Taemin Oh

ASSESSMENT & TREATMENT OF CHILDHOOD PROBLEMS

Schroeder & Gordon

CHAPTER 1 Development of Psychopathology

Transactional and/or ecological perspective of development accounts for factors within the child, family, and society that inuence the child either directly or indirectly developmental gains in each area are related to progress in others Developmental change involves: biological/genetic make up physical and social environment cultural milieu Knowledge of developmental norms is essential are the behaviors excessive or decient? choosing appropriate intervention school-age: rely on cognitive and language skills preschool age: rely on concrete, situation-specic tasks, and appropriate play activities NORMAL DEVELOPMENT (Refer to Table 1.1 on p. 6-7) Keep in mind of inter- and intra- individual differences in considering normal development especially evident during the preschool years, and persists into the school-age years varies among various areas of development Infant Development (Birth~1 Year) Main tasks: gain physiological stability develop interpersonal attachments and strategies for maintaining them regulate arousal and affect develop and gain control over motor skills communicate needs and desires explore and learn about the external world Also most rapid brain growth development is also inseparable from the childs relationship with the caregiver requires necessary stimulation and support so that the child can develop inuences which neural pathways are strengthened, remain available, or atrophy Attachment Caregiver needs to respond sensitively and promptly to the infant in order to form a secure emotional attachment more securely attached kids show more optimal development in number of areas more emotionally secure, express their feelings at age 6 more appropriate social adaptation over time, better cognitive control, more symbolic play, internal control, and better problem skills
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better emotional development, ability to offer support to others/increased self-esteem insecurely attached kids develop strategies to deal with separation attachment is not stable over time (especially in higher-risk families) parental and environmental circumstances Temperament Difcult vs Easy child Difcult: irregularity of biological functions or rhythmicity, withdrawal from novel stimuli, slow adaptation, intense responses, and predominantly negative mood Difcult children shown to develop psychological symptoms but not all of them Goodness of t: difcult children with unresponsive caregivers have higher risk for later problems than difcult children with responsive caregivers easy children with unresponsive, dysfunctional caregivers may develop problems despite being easier to care during infancy

Toddler Development (1~2 Years) Independence Autonomy and independence while still wanting to be close to the primary caregiver 1) To balance the need for closeness with exploration of the environment 2) To become increasingly independent 3) To begin to internalize parental standards 4) To gain the ability to control emotions, impulses, and behavior 5) To begin to use mental representations in play and communication Inappropriate parental responses to childrens noncompliance can lead to problems Primary question: does the childs deance represent necessary self-assertion or reect anger and disturbance? Primary task for parents: provide safe environment that ensures safety while children are exploring their environment

Preschool Development (2~4 Years) Emergence of language, self-awareness, peer relationships, and autonomy/independence Increased complexity of cognitive, play, social, and motor skills Language Development Large growth in language ability foundation for later reading skills Same kind of language experience for children in different SES classes, but more experience in high SES classes amount of talking the parents engaged in with their children was a crucial factor in the childrens later language development increased frequency of learning leads to greater language diversity, encouragement received, enhancement of verbal recall Other factors that enhance language development 1) speaking motherese - simple sentences focused on present events, slow rate of speech, paraphrasing of childs utterances 2) semantic contingency or joint attention 3) reading to the child

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4) asking or suggesting rather than demanding 5) following the childs lead during play interactions Controlling style of interaction impedes language development delays or disorders of language will impede cognitive and social development receptive or comprehension language disorders associated with psychiatric comorbidity Self-Regulation Emotional Regulation: the process of initiating, maintaining, and modulating the occurrence, intensity, or duration of internal feeling states and emotion-related physiological processes Behavioral Regulation: the ability to control emotionally driven behavior Inability to self-regulate leads to internalizing (overregulated) or externalizing (underregulated) problems Appropriate regulation related with more competent social functioning Environmental circumstances affect internal reactivity to emotion and subsequent coping behaviors

School-Age Development (5~12 Years) more complex cognitive and language skills rene ne and gross motor skills self-concept and of others become increasingly abstract and accurate Cognitive Development No longer thinks egocentrically mobile, exible, reversible and logical thought process think of possibilities that do not exist in reality Can use parental standards and rules in the absence of authority gures School/academic problems are the most common LD and ADHD most commonly associated more school problems associated with greater family dyfunction Self-Concept and Self-Esteem SC and SE become increasingly abstract and consistent SC - view of oneself SE - discrepancy between ones actual self-concept and the ideal self sense of self becomes increasingly dependent on how others perceive them LSE associated with psychiatric dxs, poor academic acheivement and peer relationship problems Peer Relations Cognitive and language development plays important role in social development representational or symbolic thinking social perspective staking language comprehension and communication skills Genetic component Developmental experience; caregiving relationships caregiver-child attachment bond related to the quality of childs peer relationships vertical and horizontal relationships vertical - attachments to indv with more knowledge and social power provides security and protection horizontal - attchmts to indv with equal amounts of social power allows elaboration of skills

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VULNERABILITY AND RESILENCE especially vulnerable to abuse, neglect and explotation also behaviorally and emotionally resilient Risk and Protective Factors can be characterized into: Established risk; genetics disorder biological risk; prenatal, drug/alcohol abuse by mother during pregnancy; low birthweight environmental risk; poor responsibility by caretaker, poverty Table 1.2 (p20) Parenting Practices Determinants of Parenting 1) characteristics of the parents developmental history psychological resources 2) characteristics of the child temperamental characteristics 3) characteristics of the environmental context of the parent-child relatnshp social support networks marital relationships homosexual parents Physical Punishment reviews of research on effects of corporal punishment report inconsistent results highly stressful for children research indicate that it is not effective over time Optimal Parenting Practices proactive parent behavior - monitoring childrens activities, provding anticipatory guidance, expressing affection toward the children, and teaching - function to prevent childrens misbehavior and thus reduce the need for parents to react punitively when chidrn behave inapptly monitoring in infancy sensitive and responsive parenting, joint attention to play activities monitoring in preschool ensure childs safety, joint attention, verbal descriptions of childs activities monitoring in school-age keeping track of school achievements, homeworks, knowing childs friends, attending extracurricular activities monitoring in adolescence knowing where and with whom the child is, tracking school achievement, attending extracurricular actvs Day Care as a Risk Factor General Effects of Day Care effects on social adjustment greater levels of aggression and noncompliance day care may give intellectually average children a head start mediated by many of the same familial and envmental fcators that inuence the devlmnt of the child Quality of daycare: Structural:

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age-appropriate caregiver-child ratios smaller group size Process: sensitivity and responsiveness to the childs needs provision of devlmtal appropriate stimulating activities Stability of care or low staff turnover PREVENTION OF PROBLEMS Parent Education Programs Parent Education: focuses on preventing the development of dysfunx child behavr Parent Training: attempts to resolve serious child disturbances Parent education should focus on specic info about child devlmt and management techniques take into account the broader personal needs of the famly members child characteristics information on the relatnshp of risk factors to child behavr guidelines for when parents should seek professinal help effective in changing mothers attitudes and behavrs in a cost-effective manner Early Intervention Programs Family focused early intervention directed at chaging parental functioning so that negative effects are minimized Successful early intervention programs: Developmental timing - early interventions are more long lasting and effective Program intensity - intensvie are more effective Direct provision of learning experiences - direct intervention show larger and longer lasting effects Program breadth and exibility - programs that use multiple methods are more effective Individual dffnces in program benets - some children show greater beneftis than others Ecological dominion and envmental maintenance of devlmnt - initial positive effects tend to diminish over time. Programs that involve parents, teachers, and other imptnt adults are likely to be more benecial Prevention of Child Abuse Prevention of Physical Abuse establishing the parents ability to cope with external demands and provide for the developmental and socialization needs of their children while reducing the barriers of stress that impose upon the family intensive group and home visit associated with effectiveness Prevention of Sexual Abuse teaching children personal safety skills Active involvement of children associated with success modeling, guided practice, reinforcement of appropriate responses Providing parents with the information they need to educate their children

CHAPTER 2 Assessment to Intervention

ISSUES OF DIAGNOSTIC CLASSIFICATION Benets of classication system
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promotion of communication among professionals translation of research in to practice documentation of the need for services as special education, for staff in a particular setting, or reimbursement of services Problems no easy way to determine when a behavior should be considered pathological high degree of overlap between various forms of psychopathology stigma associated with the label derived from classication To be useful, it needs to be simple and have explicit rules so that it can be used reliably by different raters over time Categorical Approach Problems of DSM IV criteria for many of the diagnostic categories for childhood disorders have changed with each new edition of DSM assessment process for diagnostic criteria does not always specify what instruments should be used, what informants should be included and how the rating for presence and severity of the criteria should be made no systematic method of determining the extent to which symptoms interfere with functioning reliability and validity of classications for infants and toddlers has not been adequately demonstrated how to handle problems that are subthreshold for a disorder how to discriminate one disorder clearly from another disorder how to deal with comorbidity how to determine whether disorders differe qualitatively or quantitatively from normal Particularly problematic with children difcult to determine which behaviors are transient developmental problems and which are clinically signicant Dimensional Approach Assumes that behavior occurs along a continuum allows one to describe multiple behavr patterns for a child, with cutoff scores used to determine the clinical signfcance of specfc behav fo diffn age groups takes into account a full range of child behavr Categorical vs Dimensional Approaches combination of these approaches most useful ESTIMATES OF PREVALENCE Difcult to measure because children widely vary in development and behavior Factors Including Prevalence Higher prevalence among low ses samples than in general popn boys than girls older than younger children living in urban areas single-parent associated with low intelligence and temperamental characteristics Persistence children with a severe behavr disturbance in childhood were 8x more likely than healthy childn to have a severe disturbance in adolescence

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rates of serious disorders are relatively low early year prolems are often transitory and assct with a specic develpntl period howv children with severe symptoms are highly likely to continue to have problems as they grow and develop PLANNING THE ASSESSMENT Intended purpose of an evaluation must be clearly specied determine whether there is a problem delineate the indivdls strengths and decits predict future behar or the course of the disorder classify the prblm provide guidelines for intervention get a description of the problems form an initial hypothesis Knowledge of normal devlmt and devlmntal psychopathology is required evaluation must be comprehensive consider the context of the problem A COMPREHENSIVE ASSESSMENT-TO-INTERVENTION SYSTEM CAIS focuses on the specics of the behvr of concern, charcts of the child, family, and envirmnt provides framework for choosing tests and other info-gathering methods Table 2.2 (p51) METHODS FOR GATHERING INFORMATION Initial Contact essential to have parents complete and return: a general parent questionnaire family ses, childs develmtl milestones, daycare history, school history, parents perception of the childs problem, its causes, and what theyve done so far CBCL, BASC, Eyberg Child Behavir Inventory, Parenting Stress Index a norm-referenced behavior rating scale Parent and Child Interviews Problems tendency to determine diagnoses before all relevant info is collected tendency to collect info selectively when conrming a dx lack of a systematic apprch to combining diffn types of info tendency to make dx or judgments based on what is familiar to the clinician tendency to see corrltns that are spurious or nonexistent or to miss real correlations interviews vary in degree of structure greater freedom decreases reliability more structure give global info about the existence of a DSM disorder structured interview problems reliance on DSM criteria does not allow comparison with a represenative normative sample context is not taken into account parents cannot give their perspective or description of prblms do not encourage rapport building time consuming

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structured interview advantages research purposes Unstructured interview requires prior knowledge about the nature of the specic presenting prblm allows more freedom to explore the nature and context of prblm allows clinician to begin to delineate acceptable behavrl alternatives Parent Interview gathering info about the child, family and envrmnt obtaining informed consent establishing a collaborative and supportive relationship gathering info about parental concerns, expectations, and goals assessing parental percetpions and feelings about the childs problms, concerns, and goals setting realistic goals communication about procedures that are to be used educating the parents assessing parents affective state, motivations, resources for taking an active role providing the parents with an adequate rational for proposed interventions Child interview child older than age 7 provides useful info on the childs perception of him/herself, environemnt, presenting problem, attempts to cope with and solve problems develop rapport informally assess his/her cognitive, social, and perceptual-motor skills do you know why you are here today? to make child feel more comfortable use language at or just above the childs cognitive/language level be responsible for keeping the conversation going avoid using many direct questions, leading questions, or blaming qs introduce topics of interst to the child that are developmentally appropriate use descriptive statements about the childs clothing, demeanor, activity praise the child verbally or physically use structured, concrete questions can you tell me one thing you like about school? Play provides info about their perceptions of their world, intellectual and language development, feelings, thoughts, social relationships, and current concerns and anxieties Observation of Behavior provides an objective view of the nature, antecedents and consequences of the childs behavior parent-child relationship Further Assessment School teacher questionnaires and rating scales, teacher interviews, direct observation less helpful when teachers do not observe the child across several class periods Child psychoeducational or neuropsychological eval assess intellectual, achievemnt, or organic functioning Referral to Allied Health Professionals

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Effective Communication understand the particular areas of expertise of other professionals from diffn disciplines Consultation seek / give information, training, assistance to teachers, parents Communication of Findings and Treatment Recommendations share ndings from the assessment process, present recommdations, help parents understand the ndings and recommds, and allow the parents to ask questions and express their feelings/concerns about the ndings or recs. review briey what the parents have said present ndings, with focus on strengths and weakness of the child/family possible etiologies for the problem is discussed give recommendations, along with alternative courses of action length of treatment, nancial costs give parents opportunity to express their understandings and feelings about the ndings/recs TREATMENT ISSUES Treatment Effectiveness Studies strongest support is for treatments based on knowledge of the risk factors assctd with the devlmt of emotional and behavioral problems, knowldg of the trajcties of devlmt that can lead to poor outcome, and knowledge of the types of services that have failed to meet the needs of children and families changes greater with psychotherapy than without treatments functioning of average treated child was at 76-79% of normally developing peers treatment outcome for externalizing and internalizing problems did not clearly differ Outcome in the Real World little known about the actual treatment of children in nonresearch settings only medium to low treatment effects seen in study longitudinal community-based study indicated that improvement of symptoms related to number of sessions treatment less effective in real settings use of manuals is a way to improve effect Determinants of Attrition 40-60% of families who begin treatment drop out prematurely schedule conicts cost of treatment perception shift attrition can be improved by letter writing intensive telephone contract greater focus on parents expressed needs inuencing the clients social networks must motivate parents Treatment Integrity treatment integrity checklist include the specic behavrs that the teacher or parent is expected to carry out Psychopharmacology Issues few data to support short- and long-term efcacy and safety

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children may believe they are defective because they are using meds careful assessment of these attitudes/concerns need to be made meds should be used cautiously with children should not be the sole treatment method

CHAPTER 3 Eating Problems

NORMAL DEVELOPMENT OF FEEDING BEHAVIOR Table 3.1 - Normal Feeding Devlpnt in the rst year important to expose children to many different foods that are devlpntly appropriate and varied in texture and taste inborn pref for sweet and salty, aversion to sour and bitter infants predisposed to reject novel foods - needs repeated exposure breast-fed babies experience a variety of tastes as a result of variations in mothers diets 4-6 months - solid foods, devlp oral-motor skills innate regulatory system for nutritional intake works during early years of life so that children get adequate nutrition children eat what they need parental control in the feeding context can override this regulatory system parental control associated with eating problems, weight uctuations, preoccupation with food later in life supportive eating context is important! after rst year, children develop preferences and reject novel food repeated exposure can help acceptance consistent schedule, appropriate amount, pleasant, stress-free meal setting is important EATING PROBLEMS RELATED TO INFANT FEEDING Colic most common eating problem in early infancy crying that may last 3 hours or more after feeding accompanied by pain grimaces, abdominal distension, leg extension medical problems must be ruled out before dx no one effective treatment Pica persistent eating of nonnutritive substances for a period of at least 1 month actual eating of nonfood substances, rather than just tasting or chewing pica more common in developing countries, poor, with severe mental retardation assctd with impoverished envmnt and lack of stmltn, mental retardation not related to poor nutrition danger from lead poisoning and ingestion of toxic substances intervention: parental education, social/environmental stimulation, closer supervision, behavior therapy Rumination intentional and repeated regurgitation and rechewing of food

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occurs at age of 6 months, disappears spontaneously disorder if persists for 1 month or longer possible that it is a form of oral self-stimulation that can become habitual Treatment: increase stimulation and attention, parent training in use of social reinforcement for appropriate behaviors

Failure to Thrive (FTT) dx when childs weight falls two sd below mean for age or less than the 5th percentile nonorganic failure to thrive - no medical condition 1) failure due to deciencies in the mother-child relationship 2) behavioral mismanagement and prblms with independent feeding skills difcult to distinguish causes of FTT need to take a multidimensional approach OBESITY television viewing, computers, computer games contribute to childhood obsty high-fat, low-nutrition, high-sugar products advertised on tv strong assctn btwn childhood obs and adulthood obs heaviest children become heavier over time stigmatized, lower se, more behavior problems obs adults nish fewer years of school, lower incomes, less likely to marry higher risk in low SES environments, mothers not married, lack of social support possible genetic etiology higher chance of child obs if parents are obs obs caused more by family eating and activity patterns than by genetics ASSESSMENT OF OBESITY body weight above 85th percentile for children of same age, height and gender BMI, visual assessment 1) initial contact complete physical exmintion to rule out medical conditions 2) parent and child intervw observe parent-child interaction parents eating patterns successful treatment of child dependent on parents participation 3) observation of behavior observe child and parents behvrs visiting home during mealtime or videotaping nd behavrs that may interfere with tx food diary/daily activity record (p92-93) 4) further assessment 5) referral to allied health prof medical eval consultation with nutritioninst 6) communication of ndings and treatment recom explanations of why previous methods did not work explain factors that are related to succss treatment TREATMENT OF OBESITY

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Treatments with these components effective targeting of parent as well as child weight loss diet combined with increased lifestyle and/or aerobic activity parent participation more difcult with children who has comorbid psychopathology main idea is that child must consume fewer calories and expend more energy very low fat diets are not appropriate for children fat intake should be at 30% of calories exercise should focus on aerobic focus work on reducing sedentary activity behavior modication techniques are a critical component Intervention with the Child Self-Monitoring self monitor weight everyday teach how to record, what he/she eats, how it is prepared, count calories and when and where it is eaten record activity, ecercise, date/time/place/type of exercise Stimulus Control examin childs baseline data engage in problem-solving ways to avoid these situations eating more slowly eating only in one room using smaller plates so that servings appear larger serving individual portions teach how to select appropriate foods Cognitive Restructuring Shaping Developing Alternative Behaviors Planning Ahead anticipate events and parties that will increase calorie intake reduce food intake prior to the event Assertiveness Training Relapse Prevention Intervention with the Parents parents responsible for helping the child carryout assignments at home the whole family needs to help engage the family in problem solving Intervention in the Environment help parents alter the home environment to facilitate childs weight loss planning meals, purchasing appropriate food, healthy low-calorie snacks, providing regular and consistent mealtime Changing the Consequences of the Behavior determine appropriate reinforcers for eating behavior change reinforcement for self-monitoring daily Intervention in Medical/Health Aspects

FOOD REFUSAL PROBLEMS general food refusal

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avoiding food, spitting out, gagging, vomiting, temper tantrums, crying, escaping behavrs food selectivity, nicky eating behavirs when child is presented with specic foods food phobias fear and/or anxiety symptoms in eating situations, causes association of feeding with an aversive experience inadvertent positive or negative reinforcement by caregivers of food selectivity or refusal absence of developmentally apprprt early feeding experiences, usually as a result of a medical condition ASSESSMENT OF FOOD REFUSAL PROBLEMS 1) initial contact full medical checkup and nutritional assessment food diary 2) parent and child interviews focus on childs development, behavior, medical history, feeding history, current feeding status, daily routines, family feeding history, parents response to the problem, parental/ social/environmental issues attitudes and beliefs of child about eating are assessed 3) observation of behavior 4) further assessment if the child or family presents with problems beyond those assctd with the food refusal problem 5) referral to allied health professionals 6) communication of ndings and treatment recommendations TREATMENT OF FOOD REFUSAL PROBLEMS inpatient if: poor medical/health status outpatient treatment has been attempted and has failed parent-child relationship is so impaired, or the parents probelms are severe intervention program will require medical monitoring outpatient if the childs medical status is table and paretns are supportive or intervention Changing the consequences of the Behavior Appetite Manipulation control what child eats Differential Attention presenting the child with a desired stimulus or positive reinforcer contingent on the occurrence of the appropriate specied feeding behavior, while at the same time ignoring or turning away from inappropriate responses ignoring inapprt behavir is effective when used with pstv reinforcement for alternative behaviors

CHAPTER 4 Toileting: Training, Enuresis, and Encopresis

TOILET TRAINING most children trained between 24-36 months of age, all children trained by 48 mnt
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training focused on independent, voluntary control is complete latern than training focused on biological and behavioral indices of toileting readiness trend is toward delayed toilet training 1) Determine Readiness voluntary control of sphincter muscles communicate needs verbally or by other means have the desire to control the impulse to urinate or defecate 2) no more diapers helping the child unlearn certain behaviors that were acceptable in the past 3) Regular sitting use potty chair or toilet seat ring on the toilet to decrease a childs realistic fear of falling into the toilet have the child sit on the potty chair for upto 5 minutes at the times when he or she is most likely to urinate or defecate 4) handling accidents/resistance handle accidents matter-of-factly have the child help clean up and change clothes, performing all of this in the bathroom ENURESIS Description and Prevalence involuntary urination with no known organic cause repeated urination into clothes or bed occurring at least twice a week for a min of 3 consecutive months child at least 5 years of age or the develp equivlnt nocturnal - wetting during only sleep diurnal - wetting only during waking hours nocturnal-diurnal - mixed more common in develpmntaly delayed youngsters and institutionalized children increased risk for LD, lower intell, poor school achvmnt Etiology Biological Factors organic causes - nervous system lesions, disorders in neural enervation of bladder, etc genetic factors - 75% of all children with enuresis have a rst-degree biological relative who had the disorder, twins no specic sleep stage when enuresis occur no specic sleep patterns before or during enuretic episode other factors - food alergies, developmtal delay, organic brain pathology Emotional Factors psychodynamic - enuresis result of an underlying emotional dysfunction, psychological conict, anxiety howev, most emotionally disturbed children are not enuretic Learning Factors Primary factors in etiology habit deciency, inadequate learning experiences, and inappropriate reinforcement contingencies result in the failure to learn to control the complext urination reex Biobehavioral problem physical problem but responds best to learning-based treatment approaches ASSESSMENT OF NOCTURNAL ENURESIS

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1) initial contact medical evaluation, referral rule out signicant emotional or behavrl prblms questionnaire, screening instruments ask parents to keep record of child bedtime, and wet/dry nights 2) parent and child interviews good to have child in the same room with parent during interview requires cooperation of both parts gather info on: are there behvrl or dvlmntal problems? what are the history and current status of the childs urination habits and incontinenece? is there a family history of incontinence? what is the environmental context of the problem? how have the parents handled the problem? why are they seeking help now? how does the child feel about the problem? 3) observation of behavior parent-child interaction observation how child reacts to the discussion 4) further assessment 5) referral to allied health professionals 6) communiation of ndings and treatment reccmds TREATMENT OF NOCTURNAL ENURESIS Urine Alarm child learns to avoid the aversive alarm by retaining urine by sleeping through the night or by awakening and using the bathroom success rate is 77.9% begin almost all treatment with this method because of its ease, cost, and efcacy Arousal Training uses the urine alarm but focuses on reinforcing the child for getting up an going to the bathroom. child must turn off the alarm within 3 mins, go to bathroom and urinate, return to bed and reset the alarm leads to lower relapse rate than using just the urine alarm Bladder Retention Training and Sphincter Control Exercises functional bladder capacity ability of the bladder to retain a given volume of urine without producing an urge to void goal is to increase the amount of urine in the bladder before getting the urge to urinate Dry Bed Training (DBT) 1) positive reinforcement for inhibiting urination 2) urine retention control training 3) positive practice 4) nighttime waking 5) cleanliness training 6) negative reinforcement 7) mild punishment 8) family encouragement

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9) urine alarm requires great deal of motivation and cooperation on both childs and parents ENCOPRESIS Description and Prevalence defecating in the pants or other inapprprt places at least once a month for a min of 3 months in the child at least 4 years of age or develpmtal equivl retentive encopresis - result of constipation nonretentive encopresis - poor toilet training or chronic diarrhea and irritable bowel manipulative encopresis - used by child to control the envmnt Etiology Organic Factors must distinguish from fetal incontinence - caused by structural anomalies or diseases of the bowel of sphincters and nervous system chronically constipated children contract instead of relax when attempting to defecate Emotional Factors psychiatric literature views encopresis as a symptom of sever emotional problems with psychological conict usually associated with ODD and conduct disorder; howvr not supported empirically observation that family problems are common in children with encopresis Learning Factors children may not have acquired the prerequisite skill for toileting physical condition of chronic constipation may result in a breakdown in the learned cognitive control of the bowels childs soiling may be reinforced through his or her manipulation of the env stress or anxiety may lead to impaired bowel control, with a consequent loss of successful performance of toileting behvrs ASSESSMENT OF ENCOPRESIS CAIS with focus on information pertinent to the problem encopresis ability to control defecation depends on adquate enervation of the colon and anus as well as the childs ability to relax and contract external sphincter 1) initial contact medical examination general questionnaire 2) parent and child interviews childs perception of problem and willingness to engage in tx behavioral or emotional problems? stressful life events? toilet training? current status of toileting habits and bowel movements? environmental context child and parents perception of the problem 3) observation of behavr 4) further assessment 5) referral to allied health prof 6) communication on ndings and treatment recomm TREATMENT OF ENCOPRESIS

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no well-established best treatment medical treatment - cleaning of the bowel, laxatives, dietary (ber and water), sitting schedule biofeedback intervention - strengthening of the external anal sphincters contraction, sensory discrimination training behavioral interv - reinforcement, punishment via overcorrection and cleanliness training, classical conditioning, skills-building psychotherapeutic interv - play therapy, parenting skills, parent support combination of behavioral apprchs and medical intervention is more effective than medical tx alone systematic use of suppositories and enemas as well as behavioral techncs TREATMENT PROTOCOLS FOR ENCOPRESIS Retentive Encopresis Information Sharing tell parents and children that it is not an uncommon problem and early treatment can help provide description of the digestive system Intervention with the Child Physical intervention bowel cleansing, evacuated regularly using suppositories, mineral oil, etc development of toileting skills sitting on the toilet 5-10 minutes 20 minutes after each meal diet and exercise this incrases the likelihood of a healthy GI system Intervention with the Parents provide assistance in carrying out the program develop charts and reward systems Intervention in the Environment toileting charts and rewards kept in the bathroom easy to remove clothing Changing the Consequences of the Behavior take time to nd out what are acceptable rewards and punishments for particular family and child

CHAPTER 8 Fears and Anxieties

goal is to differentiate children with clinically signicant fears and anxieties from those whose fears and anxieties are a normal part of development fear: fear reaction is seen as adaptive, person learns what is a real threat and what is an innocuous situation anxiety: emotion or mood state - negative affect, including tension and uneasiness train anxiety - relatively stable chronic anxiety that a person may exp. regardless of specic circumstances state anxiety - varying or uctuating aspects of anxiety that may change relative to a given situation worry: rehearsing possible aversive events and at the same time searching for ways to avoid them adaptive in preparing and coping for future events
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but can interfere with problem solving if excessive Table 8.1 (p265) a list of sources of fears and worries at different age levels major types of fears failure and criticism, the unknown, minor injury and small animals, danger and death, psychic/stress/medical fears children from lower ses environmnets thend to have more fears than children from middle- or high-ses settings hostile, unstable environments, lacks control of their lives ANXIETY DISORDERS Separation Anxiety Disorder only anxiety disorder rst evidenced in infancy, childhood, and adolescence onset prior to 18 years attributed to recurring and excessive anxiety about being separated from home or attachment gures preoccupied worries when separated possible that SAD represents a childs failure to make a successful transition regression to a prior level of functioning due to stressors? Generalized Anxiety Disorder excessive, unrealistic worry and anxiety about a number of areas of life restlessness, tiring easily, problems with concentrating or mind going blank, irritability, etc these symptoms in turn cause signicant distress or impairment in functioning children usually worry about quality of their work, school, social, athletic events these childrens are often overlooked because such worries can give them an image of being mature parents are pleased that the child is thinking ahead and concerned thus they wait until behaviors are causing extreme distress or are signicantly interfering with the childs social or academic functioning i have seen many friends and peers that breakdown, seemingly out of nowhere, disappear, quit school pressure from parents, extreme stress in performance seen in many immigrant children because the parents have invested so much for their education, they are more pressured to succeed school refusal TREATMENT OF ANXIETY DISORDERS behavioral and cbt interventions have greatest empirical support systematic desensitization, prolonged exposure, modelling, contingency management, etc the goal is to help the child learn to cope with the feared stimulus or anxiety-provoking situation, or learn that he or she is no longer fearful in the presence of the stimulus or situation how about the parents and other family members why is the child having these symptoms? what baggage are they carrying from the family? address the whole family or its history/patterns to determine what role the kids are playing does the child think that he/she deserves it? or its his/her responsibility to do something? are they playing the savior role in their families? all of these issues needs to be addressed for long lasting effect parents are in best position to teach the children cognitive, behavioral skills but what if they are the ones that feed the anxiety? you need to get better quickly and become successful

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theres no time to be sad and anxious get your act together

CHAPTER 9 Depression
major depressive disorder - depressive disorder that most often applies to children bipolar I disorder also relevant to children anxiety and depression show high comorbidity depression - more negative views of themselves - more worries maladaptive cycle chronic anxiety might cause depression higher rates of BPD found in those with more severe and persistent depressive symptoms dealing with a client with bpd and strong depressive symptoms was very difcult for me especially during her suicidal period - very challenging and nervewrecking however it was very rewarding Developmental Course infants separated from their primary caregivers or housed in a severely deprived environment show depressive symptoms the importance of parents and forming secure attachment seems to be a recurring theme in all childhood problems however, parents are less likely to seek mental health professionals with their infants depression expressed through behavior problems - verbalize feelings of low self-worth and hopelessness dont discount childrens depressive emotions! just because they are young work on mending p-c relationship quickly, provide them with variety of stimulants to keep them engaged and build their self-efcacy observe the p-c relationship and nd out what is going wrong Associated Features suicide runs in family when you are doing self-harm interview you must see if anyother familly members committed self harm, and how suicide is thought of as in family very nerve wrecking to do this - my boundaries broke quickly and was foolish enough to think that I was the one that needs to help her at her crisis i was very preoccupied with this and nervous for weeks peer relationships has clear association with depression perceived as less likable, and have more negative social behaviors than their nondepressed peers what came rst? bullying? or depression? bullied because they are ackward and depressed? or depressed because bullied at school? need to observe behavior at school, work with the teacher school that i talked to seemed to be on other childrens side, they thought my client was just awkward and bad - also had conduct disorder how do you help these people? so many things around them are against them parents/school/peers - all essential parts of successful therapy have given up on them
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TREATMENT no differences between treatment groups have been found (but at least better than control groups) some treatment is better than no treatment approaches that are successful for adults are probably the best place to start successful tx involves: different methods, multiple targets, higher-dose treatments Prevention childrn at high risk for depression: genetic predisposition (strong family history of dp) family risk factors (low ses, parental substance use disorders) need to work on providing support for the high risk population - community resources, social support, local churches need to play a role in this

CHAPTER 10 Disruptive Behavior

Oppositional deant disorder aggression is not a typical component, its more about noncompliance!! hostile, negative, deant bhvr toward authority gures how is criteria for diagnosis of ODD changing over time? dsm-iv for is more stringent than those of dsm-iii has to do with expectations of how children should behave? how is it different across cultures? different expectation of how children should behave, especially in relation to adult gures Conduct disorder aggression to people and amimals, destruction of property, theft or deceitfulness, and serious violation of rules basic rights of others and mjr age-appropriate societal norms or rules are violated more serious antisocial behavrs emerge later in childhood how does the parents and society contribute to childrens behavior? behaviors are (partly) learned. its directly effected. many of criminal offenders have ODD or CD. however, they can be looked as victims of society whats the role of christians then? christians dont like sin! sinners - are they forgivable? if so, what kind of sins are forgivable (understandable considering the sinners childhood?) should we forgive the parents? blame them? DEVELOPMENT OF DISRUPTIVE BEHAVIOR Noncompliance not following directions, disregarding requets or doing the opposite of what is reqstd compliance - the capacity to defer or delay ones own goals in response to the imposed goals or standards of an authority gure really similar to religious faith!
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compliant to Gods commands, following Gods will this can really turn our distaste stronger for these kids/adolescents that are noncompliant development of language - facilitates more sophisticated methods of self-regulation as a child learns to label thoughts and feelings, understand cause and effect, generate strategies for effective interaction developmental changes in mothers strategies also inuence compliance-non compliance Aggression physical, verbal, nonverbal symbolic aggression gender differences boys - higher rates of instrumental and personal aggression girls - indirect, relational aggression aggression in boys tolerated more? expected? misfortune begets misfortune if you are born with unfortunate characteristics in unfortunate environment - higher chance youll be noncompliant, aggressive and have a difcult life really important that this is taken into consideration when dealing with hard to like people Developmental Process function of the characteristics of parents, children, and environment particularly vulnerable during period of early childhood - forming affectionate bonds with signf adults parent-child relationship as the source of antisocial behavior again, a lot has to do with the parents, whether teaching style, attachment style, or other life issues therefore the Parent Training Program is very important Parent Training Program emphasizes teaching parental responsiveness and improving the quality of p-c relationship through the use of bhvrl techns rst part - train parent show to attend to and praise the childs apprt bhvr child-directed interaction second part - parent-directed interaction idea of training parents is very important however it also assumes that the parent is willing to go through the difcult, time consuming training, and also to admit their fault need to set aside period of time each day to play with child, practice parenting and etc. parent with ODD or CD children might already be used to or maintains the maladaptive family environment that make child aggressive or deant family therapy denitely needed for dysfunctional families treatment focused on identifying the issues that maintain childs deant behavior however! it needs resources! does the family have the resources and the determination to participate? how do you get a dysfunctional family to be invested in childs treatment? child is the problem not me!!!! school interventions limited evidence in efcacy in reducing antisocial behavior

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also, these children are very difcult to deal with in a large classroom of adolescents/children Prevention interventions focusing on vulnerable population over 30 months, those in the treatment group maintained level ratees of noncompliance whereas those in the cntrl group deteriorated community-based prevention program based on a model of parent management training community groups enhanced the participation of the highest risk families! good for brining dysfuncitonal familes? more likely to stay throughout treatment than individual therapies why? social support? not being the only problem makers?

CHAPTER 11 Attention-Decit/Hyperactivity Disorder

widely varying, inconsistent, poor-quality assessment, treatment, and follow-up practices in the real world over- and under- diagnosis of ADHD supervisors at internship really hasty in classifying children as ADHD parent complains a little about the childs inability to concentrate or calm down, instantly jumps to calling them ADHD clients according to dsm-iv, they must report the presence of at least six of nine problem behaviors from either symptom list for a child GENERAL CHARACTERISTICS OF ADHD there are many different types of inattention, overactivity, and impulsivity expression varies with the individual child and with situational or temporal factors developmental, medical, and neurological conditions result to adhd symptoms ex) FASD clients at internship - how do you determine whats caused by neurological damage vs other factors? how do you take into these variances when nding the right treatment? higher rates of African American children with ADHD than European American Students how much does socioeconomic status have to do with this? availability of parents? afterschool support? problems of inattention emerge by the early to middle school years academic problems brings parents attention age of onset distinguishes pervasive ADHD earlier onset - more comorbid disorders, cognitive decits, family disadvantae, persistence of problems at least into adolescence later onset - secondary to reading failure and much better outcome dx criteria in dsm-iv is not necessarily developmentally apprprt for preschoolers, adolescents, and adults more for school-aged children dx based on self-reports vs parent/teacher report depends on the expectation of parents and teacher thus its important for therapists to visit school, visit problematic environments to see the childs behavior in vivo!
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high comorbidity with ODD, CD again, misfortune begets misfortune ADHD leads to ODD diagnosis? or ODD to ADHD? expectation of how people should behave in society can put people in gutters SELF FULFILLING PROPHECY Important to build self esteem - ? self esteem before self efcacy! point out what the child is doing right however, also remember that its bloody hard for parents to raise an adhd/odd/cd child Etiology genes play an important role in adhd persists in twins and intergenerations however, dont over state this. take into account childs developmental status and environmental context! ADHD BEHAVIORS AND TRAITS MAY BE ADAPTIVE hectic family patterns? hard to concentrate environments? understimulated children? maternal alcohol consumption during pregnancy? not much data to support this however, I see a lot of FASD children who are diagnosed with ADHD at internship similar traits - doesnt know what to do if they are bored, impulsive behaviors, etc Response inhibition capacity to delay a aresponse to an immediate envirmntal event provides the foundation on which executive functioning/self-regulation develops cascading deits cannot plan, decide whats important etc. bad parenting, chaotic home environment, poverty - may have a high impact on functioning of child with ADHD BAD ENVIRONMENT? MORE DIFFICULTY work at changing/supporting childs environment, not just the symptoms developmental course - well summarized in p390 TREATMENT take into account childs and familys strengths and weaknesses sources of concern, comorbid conditons must be taken into account focus not only on current problems but areas of problem that may lead to later problems pharmacotherapy, parent training/counseling, parental and classroom applications of contingency management techniques, CBT in order to be effective, treatment must be maintained over a LONG PERIOD of time Intervention with the Child CBT - self-regulation training! : self monitoring, self-reinforcement, self-instructional teqns deals with primary decits of ADH/D needs ogoing prompting and reinforcement - over varying environments Intervention with the Parents/Changing the consequences of the behavior parent training programs how do u bring parents in chaotic environments, or uninterested parents (who are the most vulnerable population) to be invested in childs therapy??? parents needed for successful tx, but hard to bring them in for the most vulnerable popn

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Proactive approach to treatment focus on altering the environment that elicits the undesirable behavior in the rst place, rather than relying solely on medication or consequence-based intvntns however, expensive also, seems too idealistic, not realistic. need to discuss how we can make this happen in low ses, most vulnerable populations!!!

CHAPTER 13 Divorce
many more african american children experience parental separation or divorce than european american children - 76% vs 36% negative effects of divorce seen over long term - throughout adolescence and into adulthood attachment problems - repeated patterns of marriage over generations? not all children experience lasting negative effects dening factors that mediate childrens adjustments to the stresses of divorce is very important! EFFECTS OF DIVORCE ON CHILDREN some factors thought to contribute to childs poor adjustment well before a marriage actually breaks up need to look at the bigger picture! not just the current problem sources of stress parental conict ongoing parent conict clearly demonstrated to have adverse effects on adjustment, even when parents remarried children from div families in which there is little conict after the divorce do not differ in adjustment from low-conict intact families so its the conict that causes the most damage! not the divorce! if conict is going to continue it is better for children to remain in an acrimonious two parent household than to suffer divorce. If there is a shift to a more harmonious household a divorce is advantageous to both boys and girls best thing for the child is to give them non-conict environment divorce is no use if its going to be the same later on intergenerational patter? attachment of children? parent-child relationships perceived loss of one beloved parent - sometimes a real loss the more the contact with parents - the better they adjust howev, if frequent contacts are less than optimal circumstances, childs adjustment will be compromised also, the more frequent the contact, the more conict between parents remember that effects of bad parenting precedes divorce, so we cannot blame divorce as the root of all problems also, its terrible that sometimes children have to choose which parents to live with. they shouldnt have to do this... parental remarriage entirely new set of relationships
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also possible that same set of patterns will appear in the new family as therapists, we need to tackle the core problem, many years of damage done in the parents and the children Characteristics of the Child their temperament, gender, developmental status, coping styles, all inuence the outcome of divorce on children Custody and Visitation the current system is really taxing for children experience at internship showed how confusing it was for children when they were taken back and forth between parents also, parents seek therapists to determine who can keep the child my challenge will be being confrontational with the parents, telling them I will report what I see, not report what you want to be reported the primary goal of all therapy would be to provide stability and control as soon as possible for the children - same school, same room, same friends, dont need to worry about where they are going Table 13.1 - Factors that mediate childrens adjustment to parental divorce very helpful TREATMENT OF DIVORCE-RELATED PROBLEMS its almost the same as dealing with trauma - complex trauma - unsure whats going on provide or help parents provide their children with honest information about the separation and divorce that is apprpt for the childs developmental level they can cope with the truth important to tell the the reasons of separation - not the details but the major causes children need to know whats going to happen after separation gives them stability and control of whats going on group tx programs in schools therapists should not side with one parent how to balance this? I will emphasize with a dad who is left behind by his wife for another man. How can I not blame her for whats going on? look at the context, look at family history remember that I need to do whats best for the child Figure 13.1 Guidelines for communication between parents (p458) Environment if at all possible, added stress of changing homes, schools, neighborhoods, caregivers, etc should be avoided provide as much stability as much, as quickly as possible changing the consequences of the behavior emotionally supportive environment that has clearly established rules and routines helps children become increasingly competent and independent maintain this during and after divorce

CHAPTER 14 Bereavement
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difcult for parents to know what to do when children deal with death in family or other lifethreatening illnesses often tries to shield them by not talking about them or making it seem not serious/ important however, this is inevitable and they will experience it in one way or the other children in preoperational stage of development (age 2-6) incomplete understanding of concept of death death is irreversible death is universal all living functions death is caused by certain specic classes of events children who have had experience with death appear to have more mature understanding of the construct CHILDRENS ADJUSTMENT TO DEATH Short-Term versus Long-Term Reactions children who experience death are believed to be at high risk for behavioral and/or emotional problems - depression secondary losses - nancial resources, unavailability of the remaining parent, changes in their roles and responsibilities I feel strongly called for this kind of population I think I want to work with kids who are constricted/restricted from such trauma, and help them nd stability and hope I also think this kind of population is similar to immigrants, or Third Culture Kids in particular change in role - bc their parents cannot speak the new language decreased nancial resources, unavailability of parents - parents have jobs that are demanding, and pays less children themselves experience decrease in self-efcacy and self-esteem stress and pressure from parents THE TERMINALLY ILL CHILD focus on: understanding how children with life-threatening illnesses perceive death nding ways to help them cope with the invasive, lengthy and painful medical treatments children have very real understanidng of their illnesses, are sensitive to their parents stress as they deal with the childrens life-threatening illness this will be really stressful for me - just to think of working with a dying child, seems very heavy main difculty will be with the question, why does God allow such suffering? even if it has a purpose for God, if the child is struggling this much, is it the best way to do that? healthy children can think of death as punishment for wrongdoing area that needs a lot of help and devotion but will be stressful undoubtedly good coping consists of: nondefensive personal posture closeness to parents happiness with oneself freedom to express negative emotions when death is imminent, bring family and child to understanding that reality

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let them feel that it is OK to talk about death help the child express denial, anger, bargaining, depression, and acceptance give them the message: you will not be alone at death or after death you have done all you could do with your life death will not hurt parents and others will always remember you and the happy times you can say goodbye to friends and family members if you want to we dont understand why children die, and we cry because we are sad about it its OK to cry and feel sad and angry, and its OK not to want to talk about it too this kind of work will be really stressful and emotionally taxing, but really really rewarding... I wonder what role pastors can play in this... Its important that parents maintain their expectations for appropriate behavior and continue to set limits when their children exhibit inapprt behavior parents can feel guilty or sorry for the child - let them have their way I might do the same as well...

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EVIDENCE-BASED PSYCHOTHERAPIES FOR CHILDREN AND ADOLESCENTS

Weisz & Kazdin

CHAPTER 1 Introduction - Context, Background, and Goals

An evidence based intervention has: careful specication of the patient population random assignment of participants use of treatment manuals that document the procedures multiple outcome measures statistically signicant differences between treatment and comparison group after treatment replication of outcome effects, ideally by an independent investigator or research team

CHAPTER 2 Ethical Issues in Child and Adolescent Psychosocial Treatment Research

CENTRALITY OF ETHICAL ISSUES Scientic inquiry vs social obligation Boundaries between Ethical Issues and Legal Issues All research must be guided by these principles: Respect for persons Benecence Justice Guidelines and Federal Regulations Fundamental requirements potential yield of the study must be signicant in its promise of improving public health experimental design must be sound and alternate designs should be considered balance between risk and potential benets should be weighed favorably toward the participants research participants must be fully informed of the risks, benets, implications, and alternatives to participation Obtaining Informed Consent Participant must understand are free to choose whether to participate Children and Adolescents children considered vulnerable population special efforts must be made to ensure that childrens assent to participate is voluntary and they fully understand the risks and benets of participation If mental illnesses impair their judgement, must seek professional judgement Using Incentives must consider respect for the participants time and compensation for such and lack of coercion must not be unfairly distributed perceptions of risk and coercion vary enormously according to cultural norms Ensuring Condentiality investigators obligated to ensure that information collected during research is not divulged to others
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participants retain control over what is shared and to whom Subject codes, secure storage, limited access to data, disposal of unnecessary identifying information, appropriate supervision of research

CHAPTER 3 Developmental Issues and Considerations in Research and Practice

PAST WORK ON DEVELOPMENTAL ISSUES AND PSYCHOLOGICAL TREATMENTS Developmental Level and Treatment Outcome: Studies of Adolescents many of empirical studies mention developmental issues with the design and evaluation of treatments However, the studies are limited in what it includes in discussion Developmental Level and Treatment Outcomes: Meta-Analyses few researches acutally include specic measures of cognitive developmental level greater effect sizes for psychotherapy within preadolescents and adolescents compared with children CBT and other cognitive based therapies require complex, symbolic, abstract, metacognitive, consequential, and hypothetical thinking DEVELOPMENTAL LEVEL AS A MEDIATOR AND MODERATOR OF TREATMENT EFFECTIVENESS Moderator - variable that species conditions under which a given predictor is or is not related to an outcome (develpmtal level, age, gender, social class) Mediator - variable that species a mechanism by which a predictor has an impact on an outcome Developmental Level as a Moderator isolating conditions that determine when a treatment is particularly effective or ineffective (eg cogntv level) Piaget Information-processing perspective specic changes in processing capacity or efciency, knowledge base, and cognitive selfregulation account for advances in thinking social-contextual perspective developmental processes driven by the interaction btween child and social and cultural world degree to which a child has devlpt these skills will enhance or limit the potential effectiveness of treatment Change in Developmental Level as a Mediator identify possible mechanisms by which the treatment affects outcome mediator assumend to account for at least a portion of treatment effect specic developmental constructs or processs could be the focus of treatment CONSIDERATIONS OF DEVELOPMENTAL FACTORS WHEN CONDUCTING THERAPY Developmental Level and Milestones Table 3.1 (p33) Implies that therapies need to address not only the symptoms but also the normative skills that may have failed to develop

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important to distinguish between recent traumatic events vs events that occured ruing childhood remember that children develop at different rates Developmental Psychopathology concerned with variations in the course of normal development equinality - single disorder via multiple pathways multinality - different outcomes via same developmental event DIRECTIONS FOR PRACTICE AND RESEARCH Recommendations for Therapists Stay current with developmental literature Consider cultural factors Use developmentally sensitive technqs Focus on devlmtl tasks and milestones that the child is attempting to master When working with older children/adolescents, think multisystemically and consider the childrens context Help parents to become developmentally sensitive Anticipate future developmental tasks and milestones Consider the concept of equinality when conducting treatment Consider alternative models of treatment delivery

CHAPTER 5 Interventions for Anxiety Disorders in Children Using Group CognitiveBehavioral Therapy with Family Involvement
treatments for anxiety, CBT - involves parents and families in treatment process increase generalizability and sustainability of the skills learned family-based cognitive-behavioral treatment family is seen as the optimal environment for effecting change in the childs dysfunctional cognition what if the family is the cause of the childs dysfunctional cognition? the family environment creates anxiety for the child the child is abused by someone but parents do not listen to the child or tells him/her that it shouldnt be talked about more vulnerable children are less likely to have family support in therapy FCBT for anxious children: Fun Friends program follows a cognitive model, cognitive processes addressed strength based; it empowers families to make positive change in their lives and values the unique knowledge and experiences that parents, siblings and children bring to the group this seems very unrealistic in some clients that ive worked with when i asked if her parents could come to therapy, they were uncooperative and thought that it was a waste of time also parents have busy schedule, other children to take care of ultimately, they dont want to be blamed and coming into therapy makes them too vulnerable it was only a specic case for my client but that experience of brining parents to therapy was so bad that I will need to work on getting over that

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I also realize that no real long lasting effect can be achieved by working on the child alone - the whole environment needs to be addressed skills emphasized in treatment feelings, relaxing, efcacy, encourage, coping steps, calm model, nurture (reward), practice efcacy signicant decreases in anxiety found immediately after program implementation and effects maintained at 12-month and a 3-year follow-up program encourages extended family networks, such as grandparents very interesting. they can represent positive, supportive role models to young children especially when parents are not around, and doesnt have good peers around him/ her

CHAPTER 6 Treating Pediatric Obsessive-Compulsive Disorder Using Exposure-Based Cognitive-Behavioral Therapy

CBT as rst treatment of choice for pediatric OCD proper assessment and psychoeducation is essential in treatment a comprehensive evaluation of current and past OCD symptoms current OCD symptom severity and associated functional impairment comorbid psychopahtology strength of the child and family THE APPLICATION OF CBT FOR PEDIATRIC OCD confronting fear-relevant but objectively low-risk situations and allow anxiety to decrease naturally over time blocking the negative reinforcement effect of rituals or other avoidance behvr emphasize the futility of thought suppression efforts placing the extinction of reassurance under the childs control families affect and are affected by the disorder include several whole-family sessions family role is larger in younger patients EVIDENCE ON THE EFFECTS OF CBT durability - ocd is a chronic condition but studies show treatment gains up to 9 months posttreatment even after withdrawal of medication - possible that it prevents relapse tx + ssris seem to show good results

CHAPTER 7 Cognitive-Behavioral Therapy for Depression

multiple pathways to the development of a depressive disorder cognitive, neurochemical, behvioral, family functioning, emotion regulation skills, etc GOALS AND MAIN THEMES OF THE TREATMENT PROGRAM child program

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main goals and themes of ACTION treatment program: if you feel bad and you dont know why, use coping skills if you feel bad and you can change the situation, use problem solving if you feel bad and it is due to negative thoughts, change the thoughts all goals designed to activate behavior Parent training help aprents model the use of thearpeutic skills and healthier ways of thinking and reinforce their daughters use of the therapeutic strategies empathic listning and conict resolution skills, create supportive envmnt developed for girls and includes six components affective education goal setting coping skills training problem solving cognitive restructuring building a positive sense of self ACTION seems to be a great cbt model, very easy to follow and teach however, does it address peer relationships? one of the most important and stressful problem for girls EVIDENCE ON THE EFFECTS OF TREATMENT results indicate that action treatment with and without parent training is more effective than the minimal contact control condition effective for 9- to 13-year old girls

CHAPTER 9 Treating Depression in Adolescents Using Individual Cognitive-Behavioral Therapy

onset and maintenance of depression among youth fall into two categories: intraindividual cognitive and biological vulnerabilities interpersonal and environmental factors cognitive vulnerability depressed individuals have inaccurate, overly negative view of themselves, the world, and possibilities for the future - core beliefs - depressogenic schemata negative life events and family contact parental depression, p-c conict, parental divorce, low family cohesion, high levels of expressed emtion - increased risk of depression in adolescents

treatment provides psychoeducation, education on development for the adolescent teach how to identify feelings, use behavioral activities and distraction to regulate mood, and solve problems calmly and logically treatment manuals and therapist training important EVIDENCE ON THE EFFECTS OF TREATMENT good results at post treatment but no differences in depression at 2-year follow-up this is problematic if it cannot be generalized

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gives them lots of tools/skills and awareness, but it doesnt deal with any of the problems that might have lead to deprssion! bullying at school? problems with parents? siblings? how about teacher training? my experience with clients when I give them the skills and tools, they cannot use it at school because theres too much going on need the support of the teachers so that skills can be used and create self-efcacy cbt seems like a quick and effective to x problems but it does not deal with the root of the problem

CHAPTER 12 Parent-Child Interaction Therapy and the Treatment of Disruptive Behavior Disorders
oppositional deant disorder, conduct disorder dbt often cooccurs with adhd dbt account for large percentage of health care costs high risk for antisocial behavior and criminal activity in adolescence and adulthood

CONCEPTUAL MODEL UNDERLYING PCIT Pcit draws from both attachment and social learning principles authoritative parenting - combntn of nurturance, good comm., rm control acctd with fewer bhvr problems than alternative parenting styles across diverse range of clinical popn attachment theory parental warmth and responsiveness to the emotional needs of young children contribute to the develpmnt of secure working model of relationships leads to greater emotional regulation, childs desire to please and willingness to comply maladaptive parent-child attchmnt aggressive behvr, low social competence, poor coping skills, low s-e, poor peer reltns insecure parent-child attchmnt increased maternal stress, increased risk of child abuse and neglect behvr management technqs based on social learning theory improve both the parent-child relatnsp and parental behvr management skills GOALS OF PCIT warm, nurturing relationship - necessary for effective limit setting and contingency in discipline lasting change in behvrs of both parent and child rst phase of pcit is child-directed interaction (CDI) parents learn to follow childs lead in play increase parental responsiveness and estblsh a secure and nurturing reltnsp btwn p-c second phase incorporates parent-directed interaction (PDI) parents learn to lead childs behvr when needed improve parental limit setting and consistency in discipline reduce childs noncompliance, aggression and other ngtv bhvrs CHARACTERISTICS OF THERAPY PROGRAM Therapy Structure
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teaching session - therapist explains, models, and role-plays CDI or PDI skills with parents coaching session - parents practice the skills with their child while therapist coaches takes up most of session time caoch from observation room with one-way mirror with comm system frequent, brief statements that give parents immdt feedback on their CDI or PDI skills, their manner, or their effect rating scale - parents complete this before each session to monitor child bhvrs at home CONTENT OF TREATMENT SESSIONS Child-Directed Interaction (Table 12.1 dos and dont skills p181) primary rule for parents is to follow the childs lead use specic comm skills: behvr description, reection, labeled praise not use commands, questions, criticism that attempt to lead and intrude play giving attention to only positive child bhvrs parents learn to use technq of differential social attention Parent-Directed Interaction decreasing noncompliance and inapp behvrs that do not respond to ignoring or too severe to ignore rather than only following, parents learn to give effective directions, follow through with consistency and calm, predictable responses reduce parental anxiety and helps parent feel more in control parents taught to give clear, positively stated, direct commands rather than criticisms Ask me quietly rather than stop yelling How about sitting here by me? rather than please sit down parents taught to explain commands before they are given or after they are obeyed avoid arguing with the child by ignoring the childs delay tactics until the command has been obeyed (Table 12.2 - effective commands) if child obeys, parents give labeled praise for compliance thank you for listening if child disobeys, parents initiate time-out sequence never ignore noncompliance! timeout: warning, chair, and room Warning given after child rst disobeys direct command give time for child to boey when it is unclear when child intends to obey if you dont ..., then you have to go to the time-out chair if child obeys, given labeled praise and continue play Chair after 5 sec warning, child calmly and quickly taken to time-out chair wile saying you didnt do what i told you to do, so you have to sit on the time-out chair remind the child of the reason for punishment - clear connection between noncompliance to direct command and negative consequence stay here until i say you can get off - establish control of the time teach parents to ignore all negative behvr when child is on chair chair for 3mins after 3mins, you are sitting quietly on chair, are you ready to ... ? if no, begin 3 min again, explain why if yes, Fine, no extensive labeled praise, give another simple command. If child obeys, give enthusiastic labeled praise

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Room when child gets off timeout chair without permission, parent brings the child to time-out room you got off the chair before i said you could, so you have to go to the time-out room parent stays outside the room, keep close track of time 1min of quiet in room, then bring the child back to time-out chair, 3 min starts over EVIDENCE ON THE EFFECTS OF PCIT PCIT compared with wait-list controls, treatment parents interacted more positively with child and reported clinically and statistically signft improvements in childs bhvr less parenting stress and more internal locus of contorl

CHAPTER 13 The Incredible Years Parents, Teachers, and Children Training Series A Multifaceted Treatment Approach for Young Children with Conduct Disorders
odd children have a two- to threefold risk of becoming tomorrows serious violent and chronic juvenile offenders risk factors: ineffective parenting family mental health and criminal factors child biological and developmental risk factors (add, ld, language d) school risk factors peer and community risk factors (poverty, gangs) treatment limited effect when in adolescence entrenched behavirs, secondary risk factors have developed may even worsen! CHARACTERISTICS OF THE TREATMENT PROGRAM The Incredible Years Training Series targeted at children 0-13 years goal increasing positive parenting, self-condence, and p-c bonding teaching p to coach cs academic and verbal skills, persistence and sustained attention, and social and emotional devlpmt decreasing harsh discipline and increasing postv strategies improving ps problem solving, anger management, and comm. increasing family support networks and school involvement/bonding helping ps and teachers work collaboratively increasing parents involvement in cs academic-related activities at home BASIC content focus on enhancing positive p-c relationships by teaching parents to use: child-directed interactive play, academic and persistence coaching, social and emotional coaching, praise, incentive programs ps learn to set up predictable home routines and rules learn set of nonviolent discipline techns

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learn how to teach children problem-solving skills ADVANCE content broader based training model mediate negtv inuences of personal and interpersonal factors on parenting skills, promote maintenance and generalizablity personal self-control comm skills problem-solving skills for adults teaching children problem solving strengthening social support and self-care SCHOOL content teaching parents to access schools, collaborate with teachers, supervise peer relatonships Teacher training effective classroom management skills academic, persistence, social, emotional coaching with students positive relationships between t and s effective discipline strategies collaborative efforts with ps teach social skills, anger management, problem solving skills in class decrease classroom aggression EVIDENCE FOR THE EFFECTS OF TREATMENT parent training many studies examined effects study in culturally diverse population showed fewer externalizing problems, better emotion regulation, stronger p-c bonding than control children mothers showed more supportive and less coercive parenting WHO BENEFITS FROM TREATMENT AND HOW? treatment moderators marital adjustment maternal depression paternal substance abuse child comorbid anxiety depression attention problems intervention combined with training required teacher training reduces parent stress general: more treatment, the better it is

CHAPTER 14 Problem-Solving Skills Training and Parent Management Training for Oppositional Deant Disorder and Conduct Disorder
ODD: stubborn, disobedient, tantrums CD: much more severe behaviors - bullying, ghting, re setting, using a weapon, stealing, running away from home high rates of other psychiatric disorders

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(I constantly have sympathy for this population. Lots of things that have led them to what they have. However, these people are more likely to end up involved in legal system. Ultimately they are gutterized, ghettoized, and neglected) christian communities - whats our role? we are quickest to judge and blame blame the parents? but parents might also be victims of realities of society and development - where do i start?? problem-solving skills training (psst) focus on cognitive aspect - how one experiences the world generating alternative solutions to interpersonal problems consequences of ones actions identifying the means to obtain particular ends making attributions to others of the motivation for their own actions perceiving how others feel identifying expectations of the effects of ones own actions parent management training (pmt) focuses on p-c interactions and child behavior at home, school, community both treatments emphasize changing how the child responds in interpersonal situ at home, school, community and with teachers, parents, peers, siblings, and others learning-based procedures modeling, prompting/fading, shaping, pstv reinforcement, practice and repeated rehearsal, extinction, mild punishment TREATMENT PROGRAM Parent Management Training remember that its really hard to raise these children i tend to blame the parents really quickly give the empathy - it must be really hard praise them for what they tried, work together to nd a different solution taking a balanced stance between p-c is the hardest challenge for me Therapeutic Alliance the more positive the c-therapist and p-therapist alliances are during tx, the greater the thptic change of the child and improvements of parents in parenting practices ITS ABOUT THE RELATIONSHIP STUPID! Participation in Treatment barriers to participation in treatment - parent dysfunction, family stress, etc however, early droupout is not indicative of treatment failure perhaps the short work with the child - my guess is the relationship! - is really impactful for the child make those sessions count!

CHAPTER 15 Anger Control Training for Aggressive Youths

variety of negative outcomes - delinquency, substance use, conduct problems, academic difculties, poor adjustment - related to childhood aggression childhood aggression viewed as an indication of a broader based syndrome norm-violating no commonly accepted denition of aggressive behavior
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Contextual Social-Cognitive Model of Prevention childhood aggressive behavior may arise out of early contextual experiences with parents who provide hash or irritable discipline, poor problem solving, vague commands, poor monitoring of childs behavior direct effect on adolescent antisocial behavior Anger Coping and Coping Power Programs designed to prevent the development of antisoical behavior in adolescence modifying maldaptive parenting practices modifying child social information processing problems group sessions - for parents and children separately CHARACTERISTICS OF THE TREATMENT PROGRAM Anger Coping Program group format - address childrens difculties with social competence through modeling, roleplaying, group problem solving, feedback/reinforcement of childrens social behavior with peers and adult group leaders personal experience in using this group was very effective! also important factor of these groups would be social support and relationships among parents/children The Coping Power Program - Child and Parent Components parents learn ways to manage child behavior outside the home and to establish ongoing family comm structures learn additional techns that support the social-cognitive and problem-solving skills that their children in the child component i think this part of treatment is essential in reaching long-term outcomes!!! needs to address the childs environment in fundamental ways! again, need to gure out ways to bring parents into therapy hard to bring parents that are preoccupied with their struggles, daytoday living parents are essential for long-term efcacy points out importance of parent and therapist relationship? cant provide good therapy for the child if I cant get along or blame the parent. i need to work on this * also, sometimes I need to be assertive in front of parents...

CHAPTER 20 Early and Intensive Behavioral Intervention in Autism

difculties with reciprocal social interaction, verbal and nonverbal communication, and repetitive or ritualistic behavior emerge by 3 years of age, lifelong Distinguish autism from Aspergers disorder and Pervasive developmental disorder not otherwise specied aspergers - high rates of autistic bevrs without a history of cognitive, language delays pdd-nos - autistic behvrs that do not meet criteria for autism and Aspergers they are all grouped in one in dsm-iv as pervasive disorder APPLIED BEHAVIOR ANALYSIS AND EARLY INTENSIVE BEHAVIORAL INTERVENTION (EIBI)
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begins when children are 4 years or younger 20-40 hrs per week of individualized applied behavior analysis (ABA) principles of learning theory to address social problems biggest impact during the toddler and preschool years - not too behind others however, young kids dont like intensive learning! UCLA MODEL OF EIBI intended to optimize childrens functioning in all areas of devlpmt rst year of treatment, intervention takes place mainly in the childs home Discrete Trial Training (DTT) one to one interaction between the practitioner and child in a distraction-free env clear and concise instructions from the practitioner highly specic procedures for prompting and fading immediate reinforcement such as praise or a preferred toy for correct responding later with progress, switch to naturalistic instruction takes place in group settings, such as classrooms includes frequent opportunities for success Family Participation 1-2 hr intake interview with project director integral part to therapy, attends all team meetings and approve all intv procedures in advance therapists and parents take turn in implementing the childrens DTT and provides feedback for each other stage 1: establishing a teaching relationship parent-team meeting after intake interview select one action that child is likely to be successful, and request this action increase childs attentiveness and motivation in teaching situ while reducing tantrums stage 2: teaching foundational skills lasts 1-4 months focus on: receptive language skills (responding correctly to what others say) imitation of actions matching and sorting teaching self-care skills (dressing) play skills instruction in small steps stage 3: beginning communication lasts 6 months~ work on: more self-care skills (toileting) expand play skills work on expressive language imitate speech sounds, separate words, strings of words many get stuck on this stage stage 4: expanding communication and beginning peer interaction move on to abstract concepts and grammatically correct sentences UCLA model emphasizes general education classes instead of special education bc they provide more apprprt peer models and higher academic expectations stage 5: advanced communication, adjusting to school

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equally divided into individual instruction and participation group settings advanced language concepts and preacademic skills intensive work on social skills (board games, sociodramatic play) read facial expressions, nonverbal cues, nonliteral meanings key goal: to increase their ability to learn in everyday situations at home and school stage 6: termination of intervention ends as they enter elementary school repeats preschool if they need more time in catching up developmentally consider placements in behavioral classrooms for children with autism, other special education classes, classes with aide EVIDENCE ON THE EFFECTS OF EIBI studies conrm substantial gains in IQ and other areas of functioning replication studies needed directions for research larger sample sizes additional tests of EIBI in community settings greater emphasis on social skills and communication may be warranted

CHAPTER 21 Empirically Supported Pivotal Response Treatment for Children with Autism Spectrum Disorders
CONCEPTUAL MODEL UNDERLYING TREATMENT main idea: target certain core areas, get widespread collateral changes in numerous other untargeted behaviors MOTIVATION! play important role in causing widespread collateral gains increase childs learning curve improve parental and child affect decrease parental stress decrease disruptive and interfering behaviors joint attention and responsivity to multiple stimulus and self-reg of behvr Pivotal Response Treatment (PRT) focus on decreasing the presence of learned helplessness by enhancing relatnsp btwn chidrens responses and their contingent acquisition of reinforcers increases childrens subsequent likelihood, rate, and accuracy of responding decreases response latency ABA interventions + motivational strategies focus on increasing and maintaining intrinsic motivational qualities specic motivational strategies child choice, task variation, interspersal of maintenance tasks, reinforcement of response attempts, use of natural and direct reinforcement motivation to self-initiate this is absent in children with autism limited to behavior regulation contexts when motivated with PRT to self-initiate social interactions, important changes occur in numerous ways increases autonomy in children
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motivation to socialize identifying activities that are mutually reinforcing to both the children with autism and typically developing peers increased social play, higher levels of positive affect, increased levels of joint attention incorporating childrens repetitive and restricted areas of interest into age-appropriate social activities GOALS OF TREATMENT provide comprehensive intervention in areas that will increase independence and selfeducation throughout the day, without the need for constant vigilance from provider tx provided within natural, inclusive settings expertise and devotion of parents is very important practice-with-feedback format through manualized intervention PARENT EDUCATION feedback on following points use of child-selected stimulus materials provide instructional stimuli only when the child is attending giving the child input into determining the stimuli to be used during instruction direct, natural reinforcers are used whenever possible directly and functionally related to the task interspersing maintenance trials interspersing previously learned tasks with new acquisition tasks reinforcing attempts reward childrens clear, appropriate attempts to respond to instructional materials or natural learning opportunities Whats That? provides children with a self-initiation to access and acquire vocab words identify desired items (snacks, toys, etc) and use it as a motivation so that wehn children are taught this query, positive consequences follow items hidden in opaque bag, children prompted to ask whats that? children are given the item Where is it? similar motivational strategies favorite items are hidden in diffnt locations prompted to ask where is it? and parents respond using targeted preposition Whose is it? increases opportunities to learn pronouns and possessives use a variety of items that child clearly associates with a particular member of the family child is prompted to ask, whose is it? parent responds and gives the item to child, then is prompted to repeat the possessive form EVIDENCE ON THE EFFECTS OF TREATMENT empirical support for each PRT component presence of child initiations related to highly favorable outcomes PRT far more effective in producing gains in social communication, with concomitant decreases in repetitive and disruptive behvrs

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massive increases in verbal comm, movmt out of special ed classes into regular ed, children shedding autism dx

CHAPTER 23 Behavioral Treatment for Enuresis

affects social activities, embarrassment about a family secret, and diminished condence treatable - 4 months tx xes problem in about 75% of cases monosymptomatic primary enuretics (MSEs) wet only during night and has no medical problems ideal for behavioral treatment Active Avoidance Learning and the Urine Alarm regular bedwetting beyond age 4 may indicate that develmptal window for acquiring apprt skills was missed urine alarm - recreates conditions to perform an active avoidance response to inhibit urination contraction of bladder targeted maintained by negative reinforcement physiological response gets conditioned overtime Bladder Capacity and Maintenance of Dry Nights possible developmental delays in bladder capacity - cannot accommodate urine volume during night Family Involvement Full Spectrum Home Training (FSHT) demanding for family to have child waking up within the rst 4 weeks bc of urine alarm CHARACTERISTICS OF TREATMENT 1) basic urine alarm treatment 2) cleanliness training 3) retention control training 4) overlearning The Family Support Agreement parents and child complete this agreement (p.362) rule: child gets up when alarm goes off, parents never turn off the alarm for child parent instructed to have child remake the bed even if the sheets are dry Reinforcing Accomplishments and Reducing Frustrations focus on reinforcements is very important point out progress by monitoring the size of wet spots, and child responding to alarm encourage their competitive spirit in overcoming challenges parents adding other incentives is not typically a good idea Relapse Prevention and Follow-Up overlearning as a programmed relapse - 14 consecutive dry nights chance of relapse decreases with overlearning overcome a setback and their condence grows EVIDENCE ON THE EFFECTS OF TREATMENT need to use relapse prevention in addition to urine alarm effective outcomes in research samples

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