Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Monday, June 13, 2016

Taking Turns is Hard to Do

Parents of toddlers, preschoolers, even school-age children sometimes feel there is no end to the task of getting children to share and take turns. It seems to be especially difficult—and embarrassing for parents—when the child is at a party or with “rivals” of their own age. The child’s own birthday party can be the worst, as he or she sulks, pouts, and makes every effort to prevent the party guests from touching any of the presents.

I suppose I needn’t point out how hard sharing and turn-taking is for us adults? We can’t see why there should such a fuss about a toy train, but we would not care for other people to expect to sleep in our beds or “take a turn” with our spouses. A whole lot of maturation and learning has gone into our adult capacity for sharing, such as it is. Yet, somehow we believe that it’s possible for a preschooler to have such a wonderful personality and such character that he or she will cheerfully share and take turns with the most precious toys in the toybox.

Well, guess what: it’s not possible. Whoever knows how to share, has learned to do it, with help and support from older people. It did not just happen, and what’s more, it did not happen in the moments of violent jealousy that are so conspicuous, but in various quiet events that took place along the way.
Looking through some papers the other day, I came across my notes from a lecture by Lisa Poelle, the author of the excellent book Chronic biting extinguished. Among other things, Lisa was considering the situations in which toddlers bite people, and thinking about ways we might make those situations less fraught and the children less easily frustrated. She had a number of suggestions about how we can prepare children for situations where we expect them to share or take turns.

One of Lisa Poelle’s suggestions was to find everyday situations where we can model taking turns by doing it ourselves and/or talking about how it’s being done, and by offering another person a turn doing what we have been doing. So, to take some of her examples:

  1. “I’ve been stirring the batter for a long time. Would you like a turn?”
  2. “Let’s play ball. My turn to roll it…  your turn to roll it… my turn.”
  3. “Let’s put the puzzle together. I’ll do this piece… okay, your turn to do one. “
  4. “You can have a turn with the truck after Sam has it for three more minutes” (N.B. one of those three-minute egg timers can be a big help on this one).
  5. “I’m tying your sister’s shoes now. Next it will be your turn.”

A second suggestion is about helping the child know when a turn begins and ends. For example:

  1.  “You put the doll down; that was the end of your turn. Jessica picked it up for her turn. When she puts it down it will be your turn again. “
  2. Pointing out situations where characters in books or in videos take turns can also be helpful.
A third suggestion is to point out how often adults as well as children have to wait for their turn. For example:

  1. “Let’s take a number at this counter. When the man is ready to wait on us he’ll call our number. We can look at these pictures while we wait.”
  2.  “ All the cars are lined up to cross the bridge and each one gets a turn. We’ll wait for our turn before we go.”
  3. “We’ll wait for the traffic light to change before we walk across the street. When we see the little green man on the sign, that means it’s our turn to go.”

One problem preschoolers have about waiting for their turn is that they don’t have a very good idea of time. When we tell them “wait just a minute”, we might mean a real minute, or five minutes, or we might forget all about what we said--  so they don’t get much of an idea about how long they have to wait. Again, an egg timer may help with the waiting, at least by providing some distraction. Distraction may also be helpful if the waiting child can be helped to find something else to do until her turn comes around.

Can we expect children not only to share and take turns, but to be cheerful about it? Eventually we get to be skilled at these social “white lies”, where we thank people for presents we hate, or smile cheerfully as someone takes the last two chocolates instead of one or spills red wine on our cream-colored carpet. But that takes time and practice, and perhaps some adult experience with how we feel when other people are grouchy about problems. There’s no harm in trying to work with a preschooler on how to be polite when cross, but we need to remember that their basic tendency at this age is to become incensed and flounce around in a towering huff, several times a day. There is no taker of umbrage like a four-year-old! Our job, perhaps, is to avoid having our own anger triggered by  the child’s ire—and to be sure that we do not respond angrily just because we are embarrassed in front of other adults. There’s more to model for the child than just turn-taking, and being calm when someone else is mad is something we should display to children if we can manage it.


Should an Eighteen-Month-Old Be Seen by an Autism Specialist? Yellow Flags

As we all know, various Internet sites proclaim “red flags”, or behaviors of young children that may be associated with a later diagnosis of autism. Unfortunately, these “red flag” sites usually neglect to explain the considerable overlap between typical and atypical behavior, or the fact that behaviors very typical of infants can closely resemble the behavior of older children diagnosed with autism. Worried young parents see one “red flag” behavior that is characteristic of their [usually quite young] infant and convince themselves that they must find treatment at once.

But in fact, for children under the age of two or three years, atypical behaviors are only “yellow flags “, or “caution” signs, and even that only if several of them are seen. A small group of “yellow flags” in a toddler simply suggests that the child should be observed and his or her development should be watched more carefully than might usually be needed. These “yellow flags” act as a screening device that helps to focus on a small number of children of whom some are going to need special help.

                        Quite a few years ago, the British psychologist Simon Baron-Cohen (yes, brother of you-know-who!) developed a checklist to help pediatricians screen for toddlers who should be seen by an autism expert. Now, let me point out once again that these children are EIGHTEEN months old or older when screened with this checklist. They are not 12 months or 6 months, and they certainly are not 4 weeks old!  Let me also point out that one or two or even three atypical responses does not mean a diagnosis of autism; this whole thing is about finding the small number of children whose diagnosis needs a highly specialized professional examination that can rule out this particular problem for many of the kids.

So, given all that, here are some questions that might be asked a parent of an 18-month-old:

Does your child enjoy being swung, bounced on your knee, etc.?

                        Does your child like climbing upstairs or up on other things?

                        Does your child enjoy peek-a-boo and hide-and-seek?

                        Does your child ever PRETEND? (Baron-Cohen uses the Brit example of pouring                         and drinking tea, but other examples might be stirring a spoon in an empty                                                    pot, or using an electric cord as a “stethoscope” after visiting the doctor.)

                        Does your child ever point a finger to ASK for something?

                        Does your child ever point a finger to show INTEREST in something?

Can your child play with objects by rolling a toy car or building with blocks, rather than just mouthing or dropping them?

Does your child ever bring objects to you to SHOW them to you?

Notice, by the way, that some of these questions ask whether the child EVER does certain things. The fact that he or she does not do them all the time is not important, but if they are never done, that may be important.

Baron-Cohen’s list then goes on to questions for the pediatrician and what he or she has observed about the child:

During the appointment, has the child ever made eye contact with you?

If you get the child’s attention and then say “oh look!” as you point at an interesting object, does the child look where you are pointing?

If you get the child’s attention and then give him or her an object that could be used to pretend (the teacup again--  but any toy can be used ), and ask if he or she can drink the tea, stir the pot, etc., does the child do so?

If you ask the child to show you a light or other object, does the child look up at your face and then POINT?

Can the child build a tower of two or more blocks?

Once again, the issue is whether the child does most of these things a lot of the time. If he or she does, the possibility of a later diagnosis of autism is remote. If the child does not do most of the things mentioned, there may still be reasons other than autism for the problem, but it would be a good idea to see a specialist who can make sense of what is going on. Whatever the trouble may be, it may be time to seek treatment and help to move the child along developmentally as much as possible.

That was EIGHTEEN months, remember! And those flags are yellow.  
   


   

Webinar for Parents Of Children with Disruptive Behaviors 6/17/2016


Hello everybody-- I want to call your attention to a webinar for parents that will be held by the National Center on Birth Defects and Developmental Disabilities on Friday, June 17, 2016, 1-2:30 PM Eastern time. To register, go to htpps://goto.webcasts.com/starthere.jsp?ei=1105300. There is no charge for participation.

This webinar is about learning to do a parent version of behavior therapy for children whose behavior is disruptive, perhaps because of ADHD.

According to the announcement I received:


During the webinar, parents and families will learn about:
·        What is behavior therapy for young children and why it is delivered by parents; the parents’ role in fostering a healthy and positive environment for their children;
·        What parent training in behavior therapy looks like (including what programs and interventions are effective for young children with ADHD and other disruptive behaviors);
·        What they can expect when being trained in behavior therapy (setting, number of sessions, activities during sessions, homework, time to see progress, types of skills addressed in the training);
·        When medication is recommended for children with ADHD;
·        Questions to ask their primary care physician or referring clinician;
·        Questions to ask a potential parent training provider before beginning training in behavior therapy;
·        How to monitor treatment progress to decide whether or not a provider and/or treatment is a good fit for your child’s needs.

This promises to be a very helpful experience for parents who are concerned about children's disruptive behavior!

Monday, June 6, 2016

Maltreated Toddlers in Foster Care: What Can We Do for Them?

A week or so ago I had an email from a CASA (court-appointed special advocate) working in Washington State. She asked a very reasonable question: So, you say not to send young foster children for Attachment Therapy. Well, what are our options? What should we do to help them?

In reply, I sent her a journal article and suggested that she read about the Attachment and Biobehavioral Catch-up  (ABC) program directed by Dr. Mary Dozier of the University of Delaware. Dr. Dozier has spent 22 years developing this program and has reported four randomized controlled trials showing its benefits to children who have experienced serious adversity. ABC is now being implemented in 15 states and is wanted in others, but Dr. Dozier is concerned about maintaining high fidelity to the original program and must thus move more slowly than we might like.

ABC is a 10-session program, done in the home by trained coaches, which targets key child issues resulting from experiences of adversity. The focus is on parenting behavior, not on underlying attitudes or motives, and the parents may be neglecting birth parents, foster parent of toddlers, or parents who have adopted internationally. Randomized controlled trials have supported the effectiveness of ABC as done by certified coaches, with long-term positive effects for children’s development. The coach does not interact with the children, but watches and comments on the parent’s behavior.

ABC teaches and increases three basic parenting behaviors: 1) nurturance, 2) following the child’s lead, and 3) non-frightening behavior. These behaviors are not all carried out at the same time, so a challenge for a parent is deciding which kind of behavior is suitable at a given time.

Nurturance, or comforting or helping when the child needs this, is especially important for children who have experienced early adversity. Their high rate of disorganized attachment behavior shows that they have no consistent strategy for deciding whether to approach or avoid an adult caregiver, so caregivers need to be able to recognize situations and subtle communications showing a need for nurturance. When toddlers are avoidant or resistant to nurturance, caregivers tend to respond “in kind” – to feel rejected and to avoid trying to comfort the child. To increase nurturance, ABC-trained coaches actively comment in the moment by making, once a minute, positive comments on a caregiver’s nurturing behavior, like going to a child who has fallen down or picking up a child who approaches the caregiver.

Increasing parents’ nurturing behavior helps to decrease the non-nurturing behaviors that are too easily resorted to when toddlers are perceived as avoiding caregivers. These behaviors include making fun of the child, acting on unrealistic expectations of the child, deliberately letting a child get into difficulty “so he will learn”, telling the child “you’re okay, you’re not hurt” or “you’re too big to cry”, ignoring the child, or distracting the hurt child by pointing to something interesting. These actions all tell the child that the parent is saying “you don’t need me”, whereas the fact is that the child does need a nurturing caregiver and needs to identify a specific adult as actually being such a person.

Nurturing behavior involves responding to the distressed child’s needs with minimum--  or perhaps, no—signals from the child.  This behavior is different from  following the child’s lead, in which the parent responds to a child’s interest signaled by speech, gaze direction, movement, or toy play. For example, if a toddler is banging two blocks together, a caregiver might follow his lead by banging two other blocks or by putting one block forward to join in the banging, or jut by saying “bang!” each time. A caregiver is not following the child’s lead if he or she takes one of the blocks and asks the child to say what the letter on it is, or takes the blocks and starts to build a tower with them.  These parent activities have their place, but ABC tries to increase the adult’s success in identifying the child’s interest and making use of it for pleasurable communication. 

Parent behavior that does not follow the child’s lead can be “teach-y” under the wrong circumstances, bossy, intrusive, or ignoring. Of course, there are many times when a caregiver appropriately does not follow a child’s lead, especially when limits need to be set or boundaries established. The ABC goal is to increase the caregiver’s ability to follow the child’s lead when doing so is appropriate--  not when the child’s lead will take the child or others into danger.

ABC-trained parents also learn to avoid frightening behavior that makes it more difficult for a young child to stay calm and regulated. This includes intrusive behavior like grabbing or tickling. For a child who has experienced severe adversity, typical “normal” parent-toddler games like “I’m gonna get you”, the threatened tickle with a finger that goes around and around near the child’s belly, or exciting chasing and hiding, may all be inappropriately frightening. The child who still struggles with knowing whether to approach or avoid a caregiver may interpret even play at frightening behavior as a signal that this adult should be avoided if possible.   
The ultimate goal of ABC is to improve the ability of the child to stay calm and regulated in the everyday circumstances of the home. This improved regulation allows the child to learn and communicate more effectively and to have more inhibitory control. One of the ABC outcomes is that children of ABC-coached parents later have more success than controls in a laboratory test where they are shown some fascinating toys and told not to touch them by an adult who then leaves the room.


When Internet sites for foster and adoptive parents tell parents that conventional treatment “just makes a child worse”, or when they advocate highly authoritarian, intrusive, managing methods that are supposed to make maltreated children “attached” and therefore obedient, they are badly mistaken (to put it politely). Evidence-based treatments like ABC and PCIT (Parent-child Interaction Therapy) can make enormous positive differences to the lives of children and families. I hope my CASA correspondent will pass along what I told her to others and help them understand this.

Thursday, June 2, 2016

What Does Evidence-based Therapy for Children Look Like?

If you’ve never been in psychotherapy, the idea can be a pretty scary one. Revealing ourselves and our problems can seem so intimidating that we may think we’d rather just have the problems. Taking your child to psychotherapy is even scarier--  what will they do when I’m not there? What will they talk about? Will they say the problems are all my fault? Will my child learn to disrespect me? Will the therapist work against our family values? Parents may have to feel pretty desperate before they are ready to face some of the possible answers to these questions!

When people start talking about evidence-based therapies, that can be scary too. The term just means that these treatments have been systematically tested and shown to give good results, but many parents are not sure what’s evidence-based and what isn’t, or how these “scientific” methods look different from any other kind of treatment. (Maybe they even involve electric shock, some may fear.)

Fortunately, you can now have a good look at what happens in some evidence-based treatments for children, thanks to Dr. Cynthia Hartung of the University of Wyoming and her graduate students. They have made  a series of youtube presentations that describe and give examples of treatments for certain childhood problems—I found these not only informative but quite fun to watch. You will enjoy watching them yourselves, but I will give a little summary about each.


1. Cognitive-Behavioral Therapy for Adolescent Depression
by Brooke Merrow & Kendal Binion

This presentation gives an excellent discussion of the basic ideas of cognitive-behavioral therapy (CBT). This treatment is based on the very real links between thoughts, feelings, and behaviors. Changing the way people think about situations or people (including themselves) can change the feelings they have, and that in turn can change their behavior. Or things can work the other way around--  if behavior can be changed, the result can be that people think and feel differently about some aspects of their lives. Depressed behavior (like staying in bed all day) can create negative feelings and subsequent negative thoughts about the world, for example, and changing that behavior can give someone a chance to experience better feelings and more positive thoughts.


2. Coping Cat to Treat Anxiety in Children and Adolescents
by Andrea Slosser & Shira Kern
This presentation discusses treatment for the debilitating anxiety some children and adolescents experience, anxiety that interferes with many of their normal behaviors and experiences. It affects school performance, sports, friendships, and family relationships. An important point is that children’s anxiety may not be shown by restlessness or a fearful expression as we might expect, but instead may show up as irritability. Sleep problems may also occur and are likely to make parents more irritable too, as their sleep is disturbed by the child’s disturbance.  

3. Parent Management Training for Childhood Behavior Problems
by Adam Ripley & Alejandra Reyna

This presentation focuses on way parents can learn to help children whose behavior is hyperactive, oppositional, or aggressive. These children may have been diagnosed as having Oppositional Defiant Disorder (ODD), Attention Deficit Hyperactivity Disorder (ADHD), or Conduct Disorder. The point of parent management training is not to blame parents or say they have caused a child’s problems, but to call to their attention how they can respond to the child’s behavior in ways that can make “good” behavior more likely.

The basic idea is that under certain circumstances (antecedents), an unwanted behavior may occur. The consequences or results that follow that behavior will help to determine whether the behavior will happen again if the same antecedents are present (for instance, a child being teased or frustrated). To help decrease unwanted behaviors and increase wanted ones, parents need to follow the wanted behaviors by a positive reinforcement. (The video gives an excellent discussion of rewards and punishments.) Methods like time-out try to ensure that children are not accidentally rewarded for unwanted behaviors.

Of course, for any of this to work, the child must be able to do what is wanted, or to stop doing what is unwanted.


4. What is Trauma-Focused CBT for Children & Adolescents?
by Kati Lear & Sarah Steinmetz

This treatment is aimed at reducing the distress and anxiety children and families experience after a child has been exposed to trauma--  an incident in which there is extreme fear and helplessness. A recent example of such a traumatizing event is the experience of the Cincinnatti family whose three-year-old slipped into the gorilla pit at the zoo during the Memorial Day weekend of 2016. A child who experiences a very frightening event may later have “flashback” memories as if re-experiencing the incident, may have family and other relationship problems and emotional outbursts along with difficulty in obeying rules, and these problems may last over some time, with impact on the family members’ states of mind and ability to help the child. The treatment helps child and parents identify and talk about the emotions connected with the event and eventually become able to talk to each other calmly about what happened.

 I hope that readers who are concerned about child emotional problems and who are hoping for effective treatment will look at these videos (thanks, Dr. Hartung and students!) and will also have a look at www.effectivetherapy.com for further discussion of evidence-based treatments for children. Do note that these treatments are not a matter of interminable psychotherapy--  generally, they involve fewer than 20 sessions, once a week.