Escolar Documentos
Profissional Documentos
Cultura Documentos
Psychopathology
and Developmental
Disabilities
Treating Childhood
Psychopathology
and Developmental
Disabilities
Edited by
Johnny L. Matson
Louisiana State University, Baton Rouge, LA
Frank Andrasik
University of West Florida, Pensacola, FL
Michael L. Matson
Louisiana State University, Baton Rouge, LA
Editors
Johnny L. Matson
Department of Psychology
Louisiana State University
Baton Rouge, LA 70803
225-752-5924
johnmatson@aol.com
Frank Andrasik
Department of Psychology
University of West Florida
Pensacola, FL 32514-5751
fandrasik@uwf.edu
Michael L.Matson
Department of Psychology
Louisiana State University
Baton Rouge, LA 70803
ISBN: 978-0-387-09529-5
e-ISBN: 978-0-387-09530-1
DOI: 10.1007/978-0-387-09530-1
Library of Congress Control Number: 2008931350
Springer Science + Business Media, LLC 2009
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Contents
PART I: INTRODUCTION
Chapter 1. History of Treatment in Children
with Developmental Disabilities and Psychopathology .....................
Jonathan Wilkins and Johnny L. Matson
29
55
79
107
139
183
221
vi
CONTENTS
253
287
333
373
403
435
Index ..............................................................................................
445
List of Contributors
Erna Alant
Center for Augmentative and Alternative Communication,
University of Pretoria, Pretoria 0002 South Africa, erna.alant@up.ac.za
Suman Ambwani
Department of Psychology, Dickinson College, P.O. Box 1773, Carlisle,
PA 17013, ambwanis@dickinson.edu
Lisa L. Ansel
Department of Psychology, The University of Southern Mississippi,
118 College Dr., Box 5025, Hattiesburg, MS 39406, lisaansel@gmail.com
Christopher T. Barry
Department of Psychology, University of Southern Mississippi,
Hattiesburg, MS 39406, Christopher.Barry@usm.edu
Jayne Bellando
Department of Pediatrics, University of Arkansas for Medical Sciences,
Arkansas Childrens Hospital, Little Rock, AR 72202
Asit B. Biswas
Leicestershire Partnership NHS Trust and University of Leicester,
Leicester Frith Hospital, Leicester LE3 9QF, UK, asitbiswas@yahoo.co.uk
Kathryn Dingman Boger
Department of Psychology, Boston University, Boston, MA 02215,
dingman@bu.edu
Gabrielle A. Carlson
Stony Brook University School of Medicine, Stony Brook, NY 11794,
Gabrielle.Carlson@StonyBrook.edu
Thompson E. Davis III
Department of Psychology, Louisiana State University, Baton Rouge,
LA 70803, ted@lsu.edu
vii
viii
LIST OF CONTRIBUTORS
Mark C. Edwards
Department of Pediatrics, University of Arkansas for Medical Sciences,
Arkansas Childrens Hospital, Little Rock, AR 72202
Terry S. Falcomata
Center for Disabilities and Development, Division of Pediatric
Psychology, Department of Pediatrics, Childrens Hospital of Iowa,
Iowa City, IA 52242
Suzannah Ferraioli
Douglass Developmental Disabilities Center, 151 Ryders Lane,
New Brunswick, NJ 08901, sferraioloi@gmail.com
Kate Fiske
Douglass Developmental Disabilities Center, 151 Ryders Lane,
New Brunswick, NJ 08901, katefiske@gmail.com
Ellen Flannery-Schroeder
Department of Psychology, University of Rhode Island, Kingston,
RI 02881, efschroeder@mail.uri.edu
Frederick Furniss
The Hesley Group, School of Psychology, University of Leicester,
Doncaster DN4 5NU, UK, fred.furniss@hesleygroup.co.uk
David H. Gleaves
Department of Psychology, University of Canterbury, Christchurch,
New Zealand, david.gleaves@canterbury.ac.nz
Zinoviy A. Gutkovich
Division of Child and Adolescent Psychiatry, Department of Psychiatry,
The Zucker Hillside Hospital, Glen Oaks, NY 11004, ZGutkovi@lij.edu
Heather L. Harrison
Department of Psychology, The University of Southern Mississippi,
118 College Dr., Box 5025, Hattiesburg, MS 39406,
Heather.harrison@usm.edu
Bart Hodgens
Civitan International Research Center, University of Alabama
at Birmingham
Alexis N. Lamb
Psychology Department, University of Rhode Island, 10 Chafee Rd.,
Kingston, RI 0288, anlamb@mail.uri.edu
Janet D. Latner
Department of Psychology, University of Hawaii at Manoa,
2430 Campus Road, Honolulu, HI 96822, jlatner@hawaii.edu
LIST OF CONTRIBUTORS
ix
Nicholas Long
UAMS Department of Pediatrics, College of Medicine,
University of Arkansas for Medical Sciences, Little Rock,
AR 72202, longnicholas@uams.edu
Heather J. Kadey
Munroe-Meyer Institute for Genetics and Rehabilitation,
University of Nebraska Medical Center, Omaha 68198, NE
Johnny L. Matson
Department of Psychology, Louisiana State University,
Baton Rouge, LA 70803, johnmatson@aol.com
Cryshelle Patterson
Sparks Clinics, University of Alabama at Birmingham
Cathleen C. Piazza
Munroe-Meyer Institute for Genetics and Rehabilitation,
University of Nebraska Medical Center, Omaha 68198, NE
Jessica D. Pickard
Department of Psychology, The University of Southern Mississippi,
118 College Dr., Box 5025, Hattiesburg, MS 39406, pickard_jd@yahoo.com
Joel E. Ringdahl
Center for Disabilities and Development, Division of Pediatric
Psychology, Department of Pediatrics, Childrens Hospital of Iowa,
Iowa City, IA 52242, joel-ringdahl@uiowa.edu
Henry S. Roane
Munroe-Meyer Institute for Genetics and Rehabilitation, University
of Nebraska Medical Center, Omaha 68198, NE
Martha C. Tompson
Department of Psychology, Boston University, Boston, MA 02215,
mtompson@bu.edu
Kerstin Tnsing
Center for Augmentative and Alternative Communication,
University of Pretoria, Pretoria 0002, South Africa, kerstin.tonsing@up.ac.za
Kitty Uys
Center for Augmentative and Alternative Communication,
University of Pretoria, Pretoria 0002, South Africa, kitty.uys@up.ac.za
Mary Jane Weiss
Douglas Developmental Disabilities Center Rutgers, The State University
of New Jersey, New Brunswick, NJ 08901, weissnj@rci.rutgers.edu
LIST OF CONTRIBUTORS
Jonathan Wilkins
Department of Psychology, Louisiana State University, Baton Rouge,
LA 70803, Johnmatson@aol.com
Ditza Zachor
Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
dzachor@asaf.health.gov.il
1
History of Treatment
In Children With
Developmental Disabilities
And Psychopathology
JONATHAN WILKINS and JOHNNY L. MATSON
INTRODUCTION
The history of modern child psychopathology and developmental disabilities is of fairly recent origins. However, of the two topics, intellectual
disability (ID) is the area which has received the most attention as a modern science and profession for the longest period of time.
In December of 1896 in an address to the American Psychological
Association, Lightner Witmer outlined what he descried as a scheme
for practical work in psychology. The plan had four components: 1) the
investigation of mental and moral development; 2) a psychological clinic
supplemented by a training school/hospital to treat retardation or physical
defects interfering with school progress; 3) practical work in the observation
and training of normal and retarded children; and 4) training of students for
a new profession, the psychological expert, who would examine and treat
mentally and morally retarded children, or in connection with the practice
of medicine (Witmer, 1907). Witmer discusses pedagogical treatment for
stammering and other speech defects, bad spelling, slow mental development, and motor defects. As such, these early efforts were primarily geared
toward remediation of what we would now call developmental or learning
disabilities.
This topic is followed by autism and more recently the autism spectrum disorders (ASD), followed by child psychopathology such as depression, hyperactivity, and anxiety. The area that has the briefest history is
behavioral medicine with children. There are of course various reasons for
the time when various areas of study began to emerge with children. The
purpose of this chapter is to provide an overview of these areas and major
developments that have led to the establishment of each topic as an evidence-based area of research and practice.
INTELLECTUAL DISABILITY
Intelligence testing is one of the first and best established areas of
study with children. These developments initially grew from pragmatic
considerations about how to differentiate slow learners and high achievers in
the school system. Alfred Binet of the Sorbonne pioneered a series of tests
to identify at risk school children. With his assistant Theodore Simon,
they published their new IQ test in 1905, the BinetSimon scale. In 1908,
they revised the scale, dropping, modifying, and adding tests by age level
for ages 313. The test was later renormed in the United States at Stanford
University and became the Stanford-Binet Intelligence Test which is in
wide use today.
Herbert H. Goddard translated Binets writings from French to English. He was an early proponent of IQ testing and served as Director of
Research at the Vineland Training School for Feeble-Minded Girls and
Boys. Goddard also developed the notion of subcategories of ID and used
the terms moron and imbecile for those with lower IQ, and idiot for those
with the lowest scores (Goddard, 1920). Although the terminology has
changed from these labels to mild, moderate, severe, and profound, the
recognition that marked performance differences exist in ID and that subcategories are advisable has persisted.
Lewis H. Terman, a professor at Stanford University, went beyond
Goddard in that he actually revised the test itself. Most important in
his changes were more standardized responses. He also revised the test
so that it could be used to identify gifted children as well as those with
ID. Published in 1916, the Stanford Revision of the Binet-Simon Scale
of Intelligence became the standard in the United States for assessing
IQ.
One of the unforeseen developments from the widespread acceptance
of IQ testing was the creation of a multimillion dollar testing industry
with hundreds of millions of standardized tests being given to children
yearly. A second development was the recognition that objective standardized measures could be developed using the IQ test model for a range
of developmental disabilities and forms of child psychopathology. There
was a rather long germination period relative to this later trend with most
of the innovations coming in the latter half of the 20th century. A third
related development involved treatment. Once disorders and disabilities
had been defined and identified, there was an obvious need for training
and treatment strategies.
CHILD PSYCHOPATHOLOGY
The establishment of the first juvenile court in the United States in
1899 is often considered the beginning of the child mental health movement
(Schowalter, 2000). The thrust was the treatment of juvenile delinquency
and was spearheaded by women civic leaders who established the Juvenile
Psychopathic Institute. A neurologist named William Healy headed the
institute. One of his primary accomplishments was the development of
a triad of professionals including a psychiatrist, psychologist, and social
worker. The psychiatrist typically provided treatment, the psychologist did
testing, and the social worker coordinated services and assisted parents.
As reported in many books and articles, this approach became the service model for treating children. Typically these services were provided via
community mental health clinics.
Great momentum occurred in 1963 when President John F. Kennedy
signed the Community Mental Health Centers Act mandating the construction of community outpatient facilities. The dominant treatment
paradigm during this time was psychodynamic. In many ways this
approach retarded the growth of treatments for child psychopathology and developmental disabilities. For example, children and people
with ID were described as lacking sufficient ego strength to develop
many forms of psychopathology. As recently as 1978, researchers were
debating if children could evince depression (Lefkowitz & Burton, 1978).
Similarly, major diagnostic systems such as DSM have only recently
begun to present and refine various forms of psychopathology in children (Matson, 1989).
Classical Conditioning
John Broadus Watson is credited with applying the principles of classical conditioning (first demonstrated by Pavlov) to human beings. His
research and charismatic personality led to the establishment of behaviorism (Maultsby & Wirga, 1998). Watson championed Pavlovian conditioning
as the basis for behavioral psychology, and he maintained an inflexible
adherence to its tenets in his work. Behaviorism was a response to structuralism, a movement spearheaded by E. B. Titchenor in America and
based on the ideas of Wilhelm Wundt, which focused on the passive introspection of ones mind.
Watson completely rejected the notion of consciousness and introspection, and publicly attacked them in 1913 at Columbia University
with his famous lecture, which was published under the title, Psychology as the Behaviorist Views It and later became known as the behaviorist manifesto. However, behaviorism as a movement did not become
popular in the United States until the 1920s. It was during this time,
and as a result of the involvement of American psychologists in World
War I and the publishing of Watsons Psychology from the Standpoint
of a Behaviorist in 1919, that behaviorism began to spread throughout
American psychology. Watsons text was the first to analyze human
psychological functioning in terms of behavior (Wozniak, 1997). In
the book, he conceptualized psychopathology as a failure to adjust to
change; it develops when a person holds onto old habits and associated
emotions that no longer work in the context of new situations. Watson
also pointed out that proof for his ideas was evident in the possibility of
retraining as a cure.
Watson first applied classical conditioning to a human subject in
1920 with the case study of Little Albert. In this classic study, Watson
and one of his students, Rosalie Rayner, conditioned the 11-month-old
child to have an irrational fear of a white rat by pairing the presentation of the animal with an unexpected loud noise. Watson and Rayner
(1920) also demonstrated the generalization of the conditioned fear
response as Albert had spontaneously become afraid of other furry
objects. Although they made some suggestions as to how the fear might
be unlearned, no attempt was made to then reduce Alberts fear of the
furry objects.
It wasnt until Mary Cover Jones, another one of Watsons students, that the elimination of irrational fears by induced extinction was
demonstrated. In her research, children who were already overly fearful
were treated with a combination of social imitation and counterconditioning. The feared objects were gradually presented while the children enjoyed
a preferred food. Her research was notably documented in with the case
of Peter (Jones, 1924). In this study, Jones eliminated the boys fear of a
white rabbit using counterconditioning (i.e., preferred food was presented
simultaneously with the rabbit). During treatment, the rabbit was gradually brought closer to Peter and he became more tolerant of its presence,
eventually touching the animal without fear. As a result of her work with
conditioning and fears, Jones is often cited as pioneering behavior therapy
(Goodwin, 2005).
However, Watsons ideas and the doctrine of behaviorism did not
make a large impact in the realm of psychotherapy until after World War
II (Pichot, 1989). This was largely due to the dominant forms of therapy
at the time, hypnosis and suggestion initially and later psychoanalysis;
in addition, the practitioners and proponents of behaviorism were experimental psychologists and outside the field of medicine, which handled the
treatment of neuroses at the time.
The basic principles of classical conditioning have had a far-reaching
influence on treatment strategies for children. Most of the treatments
described below are based on these principles or contain elements of classical conditioning. Classical conditioning has also been used to treat fear
and phobias of children with developmental disabilities and other learning
disorders but these studies have been sporadic (Labrador, 2004). Usually elements of classical conditioning are paired with other closely related
techniques such as exposure. A further discussion of these studies is presented in the section on behavior therapy.
Skinners research and ideas have even become an international movement, spreading to places such as Latin America in the 1960s (McCrea,
1976). Fuller (1949) was the first to demonstrate that operant principles
could be applied in a clinical setting. The sole participant in this study
was an 18-year-old male described as a vegetative idiot. Using sweetened
milk as a reinforcer, a significant increase of the target behavior (raising
his right arm to a vertical position) was demonstrated in four sessions.
Fuller was also able to show that the behavior could be extinguished by
removing the reinforcing stimulus.
A few years later in 1953, Skinner and Lindsley began applying the
principles of operant conditioning to psychiatric inpatients at a state hospital. They created what was essentially a Skinner box for humans, a
room that allowed tangible reinforcers to be dispensed depending on the
behavior performed by the inhabitant of the room (Skinner, 1954). The
psychiatric patients, who were described as catatonics, mental defectives
with delusions, paranoids, and in one case, a manic, were left alone in
the room for one hour each day. The experimenters studied the effects of
different reinforcement schedules and noted that response patterns were
similar to those of animals that had been studied previously in a similar
setting. Skinner believed that applying operant techniques in such a way
would have great motivational value and ultimately lead to positive behavior change.
From this early research with adults, Bjou and colleagues (Bjou, 1959,
1963; Bjou, Birnbrauer, Kidder, & Tague, 1966) and Barrett and Lindsley (1962) applied operant conditioning to children with ID. Ferster and
DeMyer (1961) did the same with autistic children by employing a similar apparatus to the one used by Skinner that dispensed tangible objects
when a key was pressed.
Children with developmental disabilities (especially severe ID and
autism) represent one population that has benefited greatly from the
development of operant-based treatment techniques. The efficacy of
behavioral treatments has been well documented in the literature with
this group, especially with regard to reducing the frequency and severity
of symptoms and challenging behaviors and facilitating the acquisition of
adaptive skills (Rogers, 1998). Such children are likely to evince challenging behaviors, such as aggression or self-injury, that are severe in intensity and pose a threat to self and others, and it is currently recognized
that the most effective method for treating these high-intensity behaviors
is based on the principles of operant conditioning: either via reinforcement, punishment, or a combination of the two (Pelios, Morren, Tesch, &
Axelrod, 1999).
Challenging behavior is a term that is used interchangeably with maladaptive or problem behavior and was introduced to American psychology
in the 1980s to describe problematic behaviors commonly evinced by
individuals with ID (Xeniditis, Russell, & Murphy, 2001). Over the years
these behaviors have been treated with aversive stimuli such as electric
shock (Lovaas & Simmons, 1969), water misting, exposure to aromatic
ammonia, or physical restraint. One problem, however, is that the treatment must be able to be applied consistently across settings.
Although these procedures were usually highly successful at eliminating the behaviors, there are obvious ethical implications. However, in some
cases the behavior is so severe that there is no other alternative. This is
usually the case when no consistent maintaining functions for the behavior can be identified. Azrin and Holz (1966) noted that the reason that punishment-based procedures are so effective at eliminating self-injury, for
example, is that the aversive nature of the treatment is able to overcome
whatever source of reinforcement is sustaining the behavior. Less aversive punishment techniques are still frequently employed (e.g., extinction,
time-out, response cost).
Because behaviors such as self-injury or aggression can have different functions across individuals and settings and may even vary across
situations for the same individual, selecting a potentially effective treatment can only be accomplished once the maintaining events or factors
for that behavior are understood (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982). Therefore, an important development in the use of operant
techniques in modifying maladaptive behavior in children with ID was the
increasingly pronounced role of functional assessment.
Functional assessment or analysis involves a thorough assessment
of the events preceding (antecedents) and following (consequences) the
behavior. Understanding the antecedents and consequences of a behavior
provides essential information about the reasons why a problem behavior is occurring or why a desired behavior is not occurring. Therefore,
treatments that are constructed on the basis of a careful consideration
of a target behaviors maintaining factors are more likely to be effective in
reducing or eliminating the behavior and can be just as effective as punishment (Iwata et al., 1994). A comprehensive approach for conducting a
functional analysis was first delineated by Iwata and colleagues in 1982.
In this study, the authors described four experimental conditions related
to different maintaining factors: social disapproval, academic demand,
unstructured play, and alone.
For example, the self-injurious behavior (SIB) of many children is
maintained by social reinforcement; children exhibiting this behavior have
not learned a socially appropriate way of gaining attention from adults
and have discovered that the behavior gets them the attention they desire
(e.g., parent telling them to stop). In this case, after the function of the
behavior has been identified (i.e., attention), the intervention or treatment will focus on replacing the maladaptive behavior with another, more
appropriate behavior that serves the same function (e.g., saying Come
play with me.; Iwata et al., 1994). This procedure is known as functional
communication training (FCT). The desired response is then reinforced
by providing social attention whenever the child asks appropriately and
ignoring instances where the child is engaging in the problem behavior.
In general, this procedure is referred to as differential reinforcement of
alternate behavior (DRA). Alternately, the child could be provided with
social attention anytime he or she is not engaging in the behavior, which is
known as differential reinforcement of other behavior (DRO).
More specifically, functional communication training teaches the child
to emit some type of communicative behavior that results in the same
10
11
2000). Sleep problems in particular are prevalent and usually persist into
later childhood for developmentally disabled children; additionally such
difficulties can contribute to the manifestation of other challenging behaviors during the day (Didden et al., 1998). In many cases, sleep problems
have been determined by functional assessment to be maintained and
shaped by parental attention and have thus been successfully treated with
extinction (Didden et al., 1998).
Behavior Therapy
From these operant-based techniques, behavior therapy diversified
and progressed in a rapid manner. In 1952 with his article, The Effects of
Psychotherapy: An Evaluation, Hans Eyesnick convincingly brought the
ineffectiveness of psychoanalysis to light. It was at this time that psychoanalysis began to lose its grip as a dominate therapy in the United States
and new treatments based on the principles of classical and operant conditioning began to gain popularity. One of the most influential of the new
therapies that emerged was created by Joseph Wolpe and called systematic
desensitization or reciprocal inhibition.
Systematic Desensitization
In the early 1950s, Wolpe was dissatisfied with the poor outcome
he was getting treating patients with psychoanalysis. He combined his
medical training with learning theory to create a medically credible,
non-Freudian hypothesis with regard to the origin of neurotic fears and
how to effectively treat those fears in a behaviorally informed manner
(Maultsby & Wirga, 1998). The result was a combination of deep muscle
relaxation and emotive imagery that Wolpe termed systematic desensitization. He described his theories in a landmark text published in 1958
entitled Psychotherapy by Reciprocal Inhibition. Wolpe (1958) conceptualized fears or phobias as responses that have been learned through classical
conditioning and can therefore be eliminated by applying specific counterconditioning.
In a typical session, which usually lasts one hour, the client first selfinduces a state of deep muscle relaxation. This is followed by the therapist
verbally leading him or her through a predetermined list of feared objects
or events that the client imagines starting with the least fear-inducing and
gradually moving up to the most feared object or situation. If the client
becomes noticeably anxious, he or she is told to stop imagining the object
or situation and return to establishing the state of relaxation. Exposure
to the actual feared objects is often incorporated as well. The rapid effectiveness of systematic desensitization and the large number of successful
cases surprised the field. Some of the earliest studies were conducted by
Lang and colleagues and involved using the technique to reduce fear of
snakes in college students (Lang & Lazovik, 1963; Lang, Lazovik, & Reynolds, 1965; Lazovik & Lang, 1960).
Although the effectiveness of systematic desensitization for treating
phobias and anxiety was well documented throughout the 1960s, interest
12
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15
competence in dealing with their fear of the dark (e.g., I am a brave boy/
girl. I can take care of myself in the dark.) while in a dark room was more
effective than stimulus control (e.g., repeating The dark is a fun place to
be.) and control (repeating nursery rhymes) conditions. Kane and Kendall
(1989) treated four children diagnosed with Overanxious Disorder with a
cognitive-behavioral based treatment. The cognitive component included
teaching the children to recognize their anxious feelings and bodily reactions to those emotions, clarifying their cognitions in anxiety-provoking
situations, developing strategies to cope with those situations, and evaluating the success of those strategies. The behavioral portion of the treatment included elements of modeling, in vivo exposure, relaxation training,
role play, and contingent reinforcement. Homework was also included.
The treatment was effective at reducing anxiety to within normal limits
and was maintained at three- to six-month follow-up.
Meichenbaum and Goodman (1971) were among the first to advocate the application of cognitive-behavioral techniques in the treatment of
ADHD. Since that time, a great deal of research has been directed toward
this topic (Pelham, Wheeler, & Chronis, 1998). CBT for ADHD typically
consists of weekly sessions in which the therapist works with the child on
developing cognitive techniques to help control inattention and impulsive
behavior that the child will hopefully generalize to other situations (Pelham
et al., 1998). However, the results of multiple controlled studies have not
supported the effectiveness of this approach (Abikoff & Gittelman, 1985;
Bloomquist, August, & Ostrander, 1991; Brown, Borden, Wynne, Spunt,
& Clingerman, 1987).
Cognitive-behavioral approaches have also been utilized for children
and adolescents with depression and are commonly done in group settings
(Kaslow & Thompson, 1998). Because of the initial debate on the existence of childhood depression and the fact that depression is an internalizing disorder and thus may go unnoticed, controlled studies evaluating
the effectiveness of CBT and related therapies are scarce. For the most
part, interventions for children have been modified from those available for
adults and lack a developmental framework (Kaslow & Thompson, 1998).
Stark and colleagues (Stark, Reynolds, & Kaslow, 1987; Stark, Rouse, &
Livingston, 1991) conducted some of the first controlled studies of psychosocial treatment of childhood depression.
In the first study, Stark et al. (1987) compared 12 sessions of group
therapy with a wait-list control condition in a sample of fourth- through
sixth-graders. Group therapy consisted of either a self-control intervention
that taught self-management skills or a behavior-problem solving intervention that included education and group problem solving. Compared
to the control condition, the children in the two experimental conditions
reported fewer symptoms of depression with the majority no longer meeting
criteria for depression at eight-week follow-up. However, caretaker ratings
of depression, anxiety, and self-esteem did not significantly differ among
the three conditions.
Stark et al. (1991) then expanded this procedure to 24 to 26 sessions
and included monthly family meetings that added a parent training component to help their children generalize the skills to the home. This method
16
was found to be superior to a traditional counseling approach at reducing depressive symptomatology. The efficacy of manualized approaches to
CBT with young persons suffering from depression has also been demonstrated (Lewinsohn, Clarke, Hops, & Andrews, 1990; Lewinsohn, Clarke,
Rhode, Hops, & Seeley, 1996).
Dykens (2003) suggests that specific cognitive-behavioral interventions for phobia and anxiety may be applicable for people with Williams
syndrome given the circumscribed goals and relatively short duration of
such treatments as well as the well-developed expressive language and
interpersonal skills in many individuals with the condition. However, the
application of cognitive-behavioral interventions for children with developmental disabilities awaits further investigation. Reaven and Hepburn
(2006) suggest that cognitive-behavioral treatment strategies for children
with high-functioning ASD and anxiety should include a high level of
parental involvement.
Medication
The prescription of psychotropic medication for adolescents increased
by 2.5% from 1994-2001 (Thomas, Conrad, Casler, & Goodman, 2006). In
1997, the Food and Drug Administration passed the Modernization Act,
which made it easier for off-label medications to be promoted to physicians (Buck, 2000). This, taken with the increased presence of managed
care incentives limiting the number of therapy visits, has contributed
significantly to increased reliance on psychotropic medication in treating
childhood psychopathology (Thomas et al., 2006). However, there remains
a paucity of empirical research concerning the utility of using psychotropic medication to treat developmentally disabled children with comorbid
mental health conditions.
This puts the clinician in the position of having to extrapolate
from the existing data regarding adults with ID and children of normal
development (Aman, Collier-Crespin, & Lindsay, 2000). As mentioned
above, because response to psychotropic medication may depend on
the childs developmental level, extrapolating from research on adults
can be problematic (Aman, Collier-Crespin, et al., 2000). There is no
medication for intellectual disability or ASD and medical professionals should proceed with caution before prescribing psychotropics for
children with these conditions. When such a child is being prescribed
medication for the suppression of challenging behaviors and not for
an underlying comorbid condition, the treatment may serve primarily
as chemical restraint. A summary of research on the major classes of
psychotropic medication used in the treatment of childhood psychopathology follows.
Psychostimulants
For some mental health conditions, pharmacological interventions
have been the most widely used and recommended. Since the 1970s this
has been the case with stimulant medication and ADHD (Pelham et al.,
17
2000). However, stimulant medication does not work for everyone with
ADHD (7080% of cases respond) and the long-term efficacy is questionable
(Pelham et al., 2000).
From 1980 to 2000, there were at least ten group studies examining
the effects of stimulant medication (methylphenidate and dextroamphetamine) in intellectually disabled children and adults with ADHD (Aman,
Collier-Crespin, et al., 2000). The cumulative results of this research indicate that psychostimulant medication is effective in treating symptoms
of ADHD in individuals with ID. With the exception of one instance, all of
the studies yielded statistically significant, positive results with improvements noted in the areas of managing motor overflow, attention span,
and impulsiveness along with cognitive performance, social behavior, and
independent play (Aman, Collier-Crespin, et al., 2000). However, the overall response rate in children and adolescents with ID at 54% is less than
that for those of typical development (Aman, 1996). Later research with
methylphenidate in intellectually disabled children has yielded similar
results (Pearson, Lane, et al., 2004; Pearson, Santos, et al., 2004).
Although current DSM-IV-TR diagnostic criteria preclude a comorbid
diagnosis of ADHD in children with ASD, core symptoms of ADHD such
as impulsivity, hyperactivity, and inattention are common in children with
ASD (American Psychological Association [APA], 2000; Lecavalier, 2006).
The effects of stimulant medication on symptoms of ADHD in ASD children
are mixed. For example, Stigler, Desmond, Posey, Wiegand, and McDougle
(2004) found a low rate of treatment success with a high rate of side-effects
in a retrospective review of 195 ASD children. On the other hand, Posey et
al. (2007) demonstrated that methylphenidate was superior to placebo in
66 children with ASD in alleviating primary symptoms of ADHD.
Antidepressants
Since the early 1990s, antidepressants, especially the selective serotonin
reuptake inhibitors (SSRIs), have increasingly become the treatment of
choice in treating childhood depression (Jureidini et al., 2004). Prescription
of SSRIs increased dramatically from 19982002 among adolescents aged
1518 (Delate, Gelenberg, Simmons, & Motheral, 2004). One major concern
with this trend is the efficacy and safety of these drugs with children. Of
particular concern is the risk of suicide among adolescents taking SSRIs
(Jureidini et al., 2004; Whittington et al., 2004). Treatment with tricyclics in
children has largely been abandoned due to the high frequency of adverse
side-effects and a lack of efficacy (Whittington et al., 2004). In a review of six
clinical trials comprising 477 children treated with paroxetine, fluoxetine,
sertraline, or venlafaxine, and 464 children treated with placebo, Jureidini
and colleagues (2004) found the children treated with antidepressant medication only significantly improved on 14 of 42 reported outcome measures.
In addition, a larger number of children treated with antidepressant medication experienced adverse side-effects (paroxetine) and some had to withdraw
from one of the studies as a result (sertraline).
Whittington et al. (2004) also reviewed the riskbenefit profiles of
these drugs by examining published and unpublished studies. Fluoxetine
18
Mood Stabilizers
Adolescents diagnosed with bipolar disorder are treated with the same
medications as adults with the condition; however, mixed or rapid cycling,
which adolescents tend to experience more than adults, has been associated with a poor response to lithium (Cogan, 1996). Although the expression of bipolar disorder in preadolescent children is rare and even rarer in
children with ID, a few case studies have found positive results for treatment with valproic acid (Kastner, Friedman, & Plummer, 1990; Whittier,
West, Galli, & Raute, 1995) and lithium in young people with ID (Dostal &
Zvolsky, 1970; Goetzl, Grunberg, & Berkowitz, 1977; Linter, 1987). However, lithium has also been associated with limited clinical efficacy and
adverse side-effects in this population (Kastner et al., 1990). In addition,
Komoto and Usui (1984) reported a case study in which a 13-year-old
autistic female with moderate ID and depression was effectively treated
with valproic acid.
Antipsychotics
Because the symptoms of schizophrenia do not usually manifest
themselves until late adolescence, there is very little research concerning
19
Anxiolytics
Little is known about the effects of treating childhood anxiety with
benzodiazepines with only a few controlled studies available (Simeon,
1993). The paucity of such research is likely due to SSRIs being commonly
prescribed to treat anxiety conditions among young persons (Reinblatt &
Riddle, 2007). Among those with ID, this class of drugs has been commonly used to manage challenging behaviors and treat generalized anxiety
disorders (Aman, Collier-Crespin, et al., 2000). A handful of studies has
examined the effects of benzodiazepines in treating children with ID to
mixed results (LaVeck & Buckley, 1961; Krakowski, 1963; Bond, Mandos, & Kurtz, 1989). The children in these studies were not only small in
numbers but were being treated more for behavioral problems than any
underlying anxiety disorder.
As mentioned above, anxiety conditions seem to be more prevalent
in children with ASD and have been successfully treated with behavioral
approaches. One study did find that buspirone was effective at reducing symptoms of anxiety and irritability in children and adolescents with
ASD (Buitelaar, van der Gaag, & van der Hoeven, 1998). Side-effects were
reported to be minimal except for one child who developed abnormal
involuntary movements. Werry (1999) suggests that the anxiety associated
with ASD may respond better to antipsychotic drugs than to anxiolytics.
Other Drugs
There is currently only one recommended medication for enuresis,
which is desmopressin (Jarvelin, 2000). Desmopressin is typically administered
as a nasal spray. In the past, imipramine has also been used, but research
20
Combined Therapies
ADHD
For ADHD, limitations of both pharmacological and behavioral interventions have led to the development of combination therapies consisting
of behavior modification and stimulant medication (Pelham et al., 2000).
Such treatment packages are most successful when the behavioral component includes outpatient parent training and school training or occurs
in the context of a summer treatment program (Pelham et al., 2000). In
the case of parent and school training, this helps to increase the generalizability of the treatment across settings and people.
ASD
Comprehensive early intervention treatment packages with the aims
of reducing level of impairment and improving outcome are available for children with ASD (Rogers, 1998). Better outcomes have been reported for
children enrolling in such programs before the age of five years (Fenske,
Zalenski, Krantz, & McClannahan, 1985). Other than behavioral interventions aimed at remediation of specific deficit areas, this is the only other
empirically supported treatment available for children with ASD (Rogers,
1998). However, these comprehensive programs are expensive and timeconsuming, involving a team of professionals across different settings
(home, classroom, and clinic), and in some cases, thousands of hours of
treatment over many years. According to Kabot, Masi, and Segal (2003),
for an early intervention program to be appropriate and effective it should:
begin at the earliest possible age, be intensive, include parent training,
focus on social and communication domains, contain individualized goals
and objectives, and emphasize generalization.
One example of this type of approach is the Treatment and Education
of Autistic and related Communication handicapped CHildren (TEACCH)
program established in 1966 at the University of North Carolina in Chapel
Hill. At a time when the prevailing psychodynamic model of the time was
spreading the notion that autism was the result of a lack of parental
emotional support or refrigerator mothers, TEACCH recognized parental involvement as a critical factor and incorporated parent training into
the program so that treatment strategies could be implemented in the
home. The program was demonstrated to be effective early after its inception (Schopler, Brehm, Kinsbourne, & Reichler, 1971). Ozonoff and Cathcart (1998) demonstrated that a TEACCH-based home program resulted in
three to four times greater improvement than a control group on tests of
imitation, fine and gross motor, and nonverbal conceptual skills in autistic
preschoolers.
21
CONCLUSIONS
Psychopathology is a common problem for children and adolescents,
with one prevalence study finding a rate of 36.7% of 9- to 13-year-olds meeting criteria for at least one psychiatric disorder (Costello, Mustillo, Erkanli,
Keeler, & Angold, 2003). Because the way child psychopathology is conceptualized and classified has changed from various editions of the DSM and is
still changing (Ollendick & Vasey, 1999), it is important that future trends
in treatment strive to empirically validate various treatments and not simply
assume that therapies for adult disorders will apply to children. Treatments
utilizing operant principles and elements of systematic desensitization for
reducing phobias are among the best studied and have proven thus far to be
the most effective. On the other hand, the efficacy and effectiveness of cognitive behavioral and pharmacological treatments warrants further study.
However, the trend toward establishing empirically supported treatments
for children is encouraging (Lonigan, Elbert, & Johnson, 1998).
These issues become even more critical with developmentally and
intellectually disabled populations. Taken with the finding that children with ID are at a greater risk for developing psychopathology than
the general population (Menolascino & Swanson, 1982) and present
with higher rates of depression (Matson, Barrett, & Helsel, 1988), it
is of great importance that the treatments outlined in this chapter be
validated and proven efficacious for this group. Further complicating
the issue is that major mental health problems are often undiagnosed
and untreated in individuals with developmental disabilities (Deb &
Weston, 2000).
22
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2
Applied Behavior Analysis
And The Treatment of
Childhood Psychopathology
And Developmental
Disabilities
JOEL E. RINGDAHL and TERRY S. FALCOMATA
INTRODUCTION
This chapter provides a description and examples of the use of applied
behavior analysis (ABA) in the treatment of childhood psychopathology and
developmental disabilities. This task is a daunting one given that many of
the single topics that are discussed in the following pages can, and have,
served as topics for entire chapters and texts. This limitation means we
are not able to delve into each topic in a comprehensive manner. However,
we do provide an overview of the important topics related to ABA and its
use in the treatment of childhood psychopathology and developmental disabilities. In addition, we provide a discussion of literature-based examples
for these ABA-based treatments, brief examples of generalization of treatment effects, and discussion of effectiveness.
It is important to note that ABA is not a single treatment. It is more
accurate to say that ABA represents an approach to treatment as opposed
to a specific type of treatment. This approach includes a number of treatment strategies that can be used to address the behavioral symptoms
associated with childhood psychopathology and the behavioral challenges
29
30
31
Accountable: The commitment of applied behavior analysis to effectiveness, their focus on accessible environmental variables that reliably
influence behavior, and their reliance on direct and frequent measurement
to detect changes in behavior yield an inescapable and socially valuable
form or accountability (p. 18).
Public: ABA is visible and public, explicit and straightforward
(p.18) Applied behavior analysis is transparent and there are no hidden or
unexplained treatments.
Doable: the interventions found to be effective in ABA studies are
able to be implemented by teachers, caregivers, coaches, supervisors, and
sometimes even the individuals themselves (p.19). Cooper et al. suggest
that the procedures are not prohibitively complicated or arduous (p. 19).
Empowering: ABA gives practitioners real tools that work (p. 19)
thus improving their confidence.
Optimistic: the result of practitioners having effective strategies and
the ability to detect improvements, along with literature-based examples
of success gives cause for optimism regarding the future success of behavior change programs.
Collectively, Cooper et al. (2007) summarized these dimensions and
characteristics of applied behavior analysis as the science in which
tactics derived from the principles of behavior are applied systematically
to improve socially significant behavior and experimentation is used to
identify the variables responsible for behavior change (p. 20). This reliance on systematic evaluation of the variables responsible for behavior change results in an approach to the assessment and treatment of
behavior problems that is functional, as opposed to structural. Thus, the
selected treatment, or treatment package, is based on the relationship
demonstrated between the presenting behavior of interest (i.e., out of seat
behavior) and the environment. This approach can be contrasted to an
approach that prescribes or selects treatment based on the diagnosis (e.g.,
ADHD) that is of concern. Using this functional approach, it is conceivable that the same treatment(s) could be used to address different presenting concerns and different treatment(s) might be used to address similar
presenting concerns.
32
provided for each treatment. When possible, an example is provided for both
childhood psychopathology (or disorders not associated with developmental
disabilities) and developmental disabilities. Given that the ABA approach
has been most widely used to treat the psychopathologies of children in two
broad categories (early childhood disorders such as conduct disorder, disruptive behavior disorder, and attention-deficit/hyperactivity disorder and anxiety and phobias), childhood psychopathology examples will likely fit into one
of these two categories. The developmental disabilities examples focus on the
treatment of behavioral challenges presented by individuals with developmental disabilities and autism. These challenges include, but are not limited
to (1) problems of behavioral excess such as stereotypic movement disorder,
self-injurious behavior, aggression, destruction, tantrums, and so on, and
(2) problems of behavioral deficit such as delays in language development,
difficulty with skill acquisition, and problems with academic performance.
Positive Punishment
As indicated, positive punishment involves the contingent presentation of an aversive stimulus following the target response. In application,
this approach to treatment has included any number of aversive stimuli
including, but not limited to, aversive outcomes such as electric shock
(Linscheid, Iwata, Ricketts, Williams, & Griffin, 1990), water mist (Singh,
Watson, & Winton, 1986), facial screen (Rush, Crockett, & Hagopian,
2001), aversive activities such as exercise (Kahng, Abt, Wilder, 2001), and
overcorrection (Foxx & Azrin, 1973).
Linscheid et al. (1990) described the treatment of self-injurious behavior
(SIB) exhibited by five individuals, including three individuals under the age
of 18, with developmental disabilities. It is important to note that each of the
five cases had a long-standing history of SIB that had proven unmanageable
and was severe in nature (i.e., caused significant tissue damage or put the
individual at risk of tissue damage or death). As well, the authors address
issues related to generalization, maintenance, and potential for abuse for this
particular treatment. Treatment included the contingent application of electric shock following occurrences of severe SIB. Immediate and pronounced
effects were observed for each of the five participants. Anecdotal follow-up
data suggested that no habituation had occurred for four of the five participants months after treatment was initiated.
33
Kahng et al. (2001) described the implementation of a positive punishment procedure to reduce the SIB exhibited by a 16-year-old girl. One
topography of SIB was reduced by the implementation of a noncontingent
reinforcement procedure. However, other topographies of SIB continued
to be exhibited when this treatment procedure was in place. As a second
treatment component, an aversive activity (i.e., exercise; touching toes)
was made contingent on each occurrence of all topographies of SIB. This
procedure was added to the ongoing noncontingent reinforcement program as well as a restraint fading program. Immediate reductions in SIB
were observed when this punisher was in place.
Negative Punishment
Negative punishment involves the contingent removal of a reinforcer
following occurrences of the target response. Applied examples of the procedure include response cost and timeout from reinforcement. Response
cost is the loss of a specific amount of a reinforcer following each occurrence of the target response, resulting in a decreased probability of the
response (Cooper et al., 2007).
Conyers et al. (2004) used a response cost procedure to reduce the
disruptive behavior exhibited by 25 children in a classroom setting. Specifically, the authors compared a reinforcement-based procedure (differential reinforcement of other behavior; DRO) with response cost. During
RC, each childs name was displayed on a board and 15 stars (tokens)
were placed next to each name. Disruptive behavior resulted in the loss of
a token. The remaining tokens could be traded for preferred items at the
conclusion of each session. Results of the study suggested that, although
both RC and DRO behavior were effective in reducing disruptive behavior,
the classroomwide RC procedure was more effective.
Long, Miltenberger, and Rapp (1999) incorporated response cost
into a treatment package to reduce the thumb sucking and hair pulling exhibited by a typically developing six-year-old girl. Reinforcement-based procedures were ineffective in reducing the behavior to
sufficiently low levels. Thus, a response cost contingency was added to
the reinforcement package. Specifically, the participant was able to earn
an M&M at specific time intervals for engaging in behavior other than
thumb sucking or hair pulling. When the RC component was added,
the participant was told she would lose one M&M for engaging in either
thumb sucking or hair pulling. Immediate reductions of both these target responses were observed. According to the authors, the participant
only lost access to one M&M during the first session of treatment with
the RC contingency in place. Treatment gains were maintained for 23
weeks. Corresponding decreases in problem behavior were reported by
the participants parents in the home setting.
Time out from reinforcement (TO) includes the withdrawal of the
opportunity to earn positive reinforcers or the loss of access to positive
reinforcers for a specified time, contingent on the occurrence of a behavior (p. 357). Again, the effect on behavior is decreased probability of future
occurrence (Cooper et al., 2007).
34
Kodak, Grow, and Northup (2004) used time out from reinforcement
as a component of treatment to reduce the elopement exhibited by a young
child diagnosed with ADHD. A functional analysis of the childs elopement behavior indicated it was maintained by adult attention. During
treatment, this consequence (adult attention) was provided on a scheduled basis (every 15 s). However, if the child engaged in the target response
(elopement), she was removed from the activity for 30 s and adult attention
was withheld. This combination of components resulted in a decrease in
elopement to near-zero levels.
Falcomata, Roane, Hovanetz, Kettering, and Keeney (2004) implemented a time out from reinforcement procedure to reduce the inappropriate vocalizations exhibited by an 18-year-old individual with developmental
disabilities. The researchers were able to identify a highly preferred activity (i.e., a positive reinforcer, listening to the radio), and access to this
activity was interrupted for a specified time following occurrences of the
target behavior. The timeout contingency resulted in almost immediate
reductions in problem behavior. Any number of studies could have been
included here to illustrate the effects of timeout from reinforcement in
application. The Falcomata et al. study was included because it illustrates the close relationship between RC and time out from reinforcement.
Many researchers in applied behavior analysis do not draw a distinction
between the two treatments (in fact, the title of the Falcomata et al. article
is Response cost in the treatment of ). The take-home point is that both
RC and TO involve contingent removal of positive reinforcers.
There are several concerns that go along with the use of punishment. Vollmer (2002) discussed four potential concerns regarding the use
of punishment that are often raised. First, punishment procedures can
sometimes produce negative emotional side-effects. Second, the effects of
punishment are often short-lived. Third, punishment procedures have the
potential to be abused. This risk of abuse, to some, outweighs the benefits
of some procedures. Finally, the treatment does not teach the individual
an appropriate behavior that can be used to recruit reinforcers from their
environment. Additional concerns regarding the use of punishment include
the development of escape and avoidance behavior, behavioral contrast
(i.e., an increase in the behavior targeted for punishment in the absence of
the punisher), and undesirable modeling (Cooper et al., 2007).
It is important to note that neither Vollmer (2002) nor Cooper et al.
(2007) advocate against the use of punishment procedures. Instead,
they provide discussions of some of the considerations that need to be
taken into consideration before developing and implementing a punishment-based procedure. However, for the above stated reasons, and, often
because of administrative and legal reasons, reinforcement-based strategies are typically implemented as a first step in the treatment of behavior
problems.
35
procedures often serve as the cornerstone for both simple and complex
behavior-change programs. In application, reinforcement-based procedures include such strategies as token economies, contingency contracting, and differential reinforcement. In each approach, a consequence is
identified using some sort of selection process including preference assessments, reinforcer assestsments, or functional analyses of target behavior.
The stimulus or stimuli identified via these procedures are then scheduled
for delivery contingent on the behavior targeted for increase. Delivery can
take place after each occurrence of the behavior, after a specified number of
occurrences, following the first response after a specified time interval (i.e.,
the stimuli are delivered on ratio or interval schedules), or in a deferred
manner once some behavioral criteria are met (i.e., the stimuli are delivered
as part of a token economy). In addition, a single response can be targeted
for increase, or a sequence of responses can be targeted.
Positive Reinforcement
Positive reinforcement procedures involve the contingent delivery of a
known preferred item or reinforcer contingent on a behavior targeted for
increase. When delivered on a ratio or interval schedule, the individual
must meet a particular response requirement (e.g., two responses or one
response after 10 s has elapsed) to gain access to the positive reinforcer.
This strategy is most often used when the clinical goal is the establishment
of an appropriate behavior, such as communication or task completion, or
a repertoire of appropriate behavior such as social skills or toileting.
Graff, Gibson, and Galiatsatos (2006) used a positive-reinforcement
procedure to increase the vocational and academic work completed by
four adolescents with developmental disabilities. In this study, high and
low preferred stimuli were identified via a series of preference assessments.
High preferred and low preferred stimuli were then made contingent on
completion of various vocational tasks. The results of the study demonstrated that the contingent presentation of both high and low preferred
stimuli increased the rate of vocational responses. However, contingent
presentation of the high preferred stimuli was correlated with higher, sustained response rates for each participant.
Luiselli (1991) described the use of a positive reinforcement procedure
to increase the independent feeding behavior of a boy with Lowes syndrome. Specifically, praise and access to sensory-based reinforcers (i.e.,
light and music stimulation) was provided contingent on independently
completing components of the self-feeding response. As each component
was mastered, the reinforcer was provided for the next response in the
task analysis. Results indicated that the participant exhibited acquisition
of each of the steps of the task analysis, eventually exhibiting independent
self-feeding.
Negative Reinforcement
Negative reinforcement procedures involve the contingent removal
(escape) of an aversive event, or allow the individual to postpone an aversive event (avoidance). When delivered on a ratio or interval schedule,
36
Token Economy
A token economy involves the delivery of a conditioned reinforcer (e.g.,
a token, point, or other stimulus) that can later be exchanged for another
reinforcer. According to Cooper et al. (2007), token economies consist
of three components including a list of target behavior or responses,
tokens or points that will be earned for exhibiting the target response(s),
and a menu of items or activities for which the points or tokens can be
exchanged. When implementing a token economy, considerations need to
be made regarding the conditioning of the tokens, the menu of backup or
primary reinforcers, and the schedule with which the backup reinforcers
are accessed. Breakdowns in any of these areas can reduce the effectiveness of the procedure. For example, if the tokens are not explicitly tied
to the backup reinforcer(s), they will not affect the individuals behavior.
Similarly, if the menu or backup reinforcers include nonpreferred stimuli, are arbitrarily selected (e.g., without the use of a stimulus preference
assessment), or the stimuli are only available on a very lean schedule, the
effect of the program could be limited. Token economies are often used in
large group settings such as classrooms, residential treatment centers,
and group-living environments.
37
38
hyperactivity disorder. One childs problem behavior (out of seat) was maintained by escape from task. This behavior decreased following the implementation of extinction. However, an increase in other behavior problems
(yelling, inappropriate gestures, and destruction) was observed. Using a
multiple baseline design, extinction was sequentially applied to each topography. A decrease in each topography was observed following the application of the extinction procedure. The second childs problem behavior was
maintained by social positive reinforcement (attention). When the extinction
procedure was first applied to object mouthing, that behavior decreased.
However, increases were noted for two other responses, destruction and
aggression. When extinction was implemented for each response, responding again decreased to near-zero levels.
Although these examples suggest that extinction can be an effective
approach to treatment, its use has some limitations that preclude it from
being used as the sole treatment component. First, implementing extinction can result in temporary increases in problem behavior at the outset of
treatment (i.e., extinction burst), an outcome that can be especially problematic when treatment targets behavior that has the potential to cause
injury. Second, extinction can lead to variations in response topography,
including aggressive behavior.
To further evaluate these two drawbacks, Lerman, Iwata, and Wallace
(1999) reviewed 41 data records for individuals whose treatments included
an extinction component and for whom aggression was neither a target
response nor programmed for reinforcement at any point during assessment. Their review identified extinction-induced response bursts for 39%
of the 41 reviewed cases. Similarly, Lerman et al. noted extinction-induced
aggression in 22% of the data records included in their sample. A third
drawback with extinction-only procedures is that they do not teach the
individual alternative methods to obtain the reinforcer. Each of these three
limitations can be addressed by including a differential reinforcement
component to treatment. Differential reinforcement programs include contingent reinforcement of an alternative response, or the absence of the
target response, is targeted for reinforcement, thus increasing the likelihood of an appropriate alternative behavior. This additional component
can improve the effectiveness and limit the drawbacks associated with
extinction-only procedures.
Again, looking at the data provided by Lerman et al., when the extinction-based procedure included a differential reinforcement, noncontingent reinforcement, of some antecedent manipulation as a component of
treatment, extinction bursts were evident in only 15% of cases. Similarly,
extinction-induced aggression was also only evident in 15% of cases when
extinction was accompanied by other treatment components.
39
40
in or acquisition of appropriate communication following FCT implementation. This study demonstrated the robust effectiveness of FCT because the
childrens problem behavior was maintained by different functions (both
positive and negative reinforcement), including one child whose problem
behavior was maintained by multiple functions, and the treatment effects
were observed across a longer than two-year time period.
Other DRA procedures focus on increasing appropriate behavior such
as compliance with instructions. Reed, Ringdahl, Wacker, Barretto, and
Andelman (2005) implemented differential reinforcement of alternative
behavior to increase the compliance and decrease the problem behavior
exhibited by two children with developmental disabilities. Each childs
problem behavior was maintained by escape from tasks. During treatment, compliance with the tasks resulted in a 30 s break from instruction (i.e., negative reinforcement). Problem behavior resulted in immediate
guidance through the task (i.e., extinction). For each child, compliance
increased and problem behavior was reduced relative to baseline when the
DRA treatment was in place.
41
attempting to engage in SIB. When the procedure was not in place and
restraints were removed, attempts at SIB were observed within 5 to 15
minutes. Although this study is descriptive and lacks systematic experimental control, it is included here because of the clinically significant outcomes achieved. The behavioral problems associated with LeschNyhan
syndrome are notoriously resistant to treatment, both pharmacologic
and behavioral in nature. One potential reason for this difficulty in treatment is that the reinforcers relevant to the behavior are unidentifiable or
change too often to allow for systematic evaluation. The described study
demonstrates the potential utility of arranging a differential reinforcement-based treatment when a reinforcing consequence can be identified
and manipulated.
42
43
Establishing Operations
The relationship between environment and behavior is often described
as a 3-term contingency. The three components of this contingency are
what happens prior to the response (the antecedent, or A), the behavior the individual exhibits (B), and what happens immediately following
the behavior (the consequence, or C). Often, this 3-term contingency is
denoted as A-B-C. A complete understanding of the antecedent requires
that behavior analysts take into account variables that alter the effectiveness of a stimulus as a reinforcer. The term that has historically been
used to describe this relationship between the environment and reinforcer
44
Stimulus Control
Stimulus control is demonstrated when a particular behavior is reliably occasioned by specific antecedent stimuli (Sulzer-Azaroff & Mayer,
45
46
Prompt Procedures
Cooper et al. (2007) defined prompts as supplementary antecedent stimuli intended to occasion specific responses. Whereas response
prompts (i.e., graduated guidance) target behavior, stimulus prompts target the antecedent conditions that exist prior to the occurrence of specific
behavior (i.e., antecedents). Behavior analysts use stimulus prompts as
auxiliaries to be removed over time as the intended behavior occurs more
reliably in the presence of natural stimuli (discriminative stimuli). Prompts
are often used during initial phases of treatment programs to facilitate the
acquisition of specific responses. Following acquisition, the prompts can
then be systematically faded so that naturally occurring stimuli will come
to reliably occasion the acquired behavior.
Taylor and Levin (1998) and Shabani, Katz, Wilder, Beauchamp, Taylor, and Fischer (2002) each used a prompting procedure to promote social
initiations with children with diagnoses of autism. The investigators used
a tactile prompting device located in the childrens pockets. Specifically,
the device was programmed to vibrate for 3 to 5 s whenever the investigators activated it using a remote control. The investigators initially paired
a vocal model with the tactile prompt to bring about social initiations,
and then gradually faded the vocal model as the children independently
exhibited social initiations following tactile prompts. The use of the vocal
modeling and tactile prompts resulted in high rates of social initiations
exhibited by the children across both studies.
In addition, Shabani et al. (2002) also attempted to fade the tactile
prompt with two of the three participants by systematically reducing the
frequency of the prompts over time. The results suggested that fading the
tactile prompt was partially successful for each of the particiapants as
social interactions continued, but at lower and more variable rates.
Rivera, Koorland, and Fueyo (2002) used picture prompts to promote
sight word reading with a nine-year-old boy diagnosed with a learning disability. The picture prompts, which were generated by the child himself,
were illustrated representatives of the targeted sight words. Initially, the
experimenters reviewed with the child the meaning of each of the targeted
sight words and had him generate illustrations for each of the words on
47
Choice
Another antecedent-based intervention that has been demonstrated
to be effective involves providing choice-making opportunities. Numerous
studies have shown that providing choice can serve to decrease problem
behavior and increase appropriate behavior including academic and vocational task engagement. Furthermore, choice has been conceptualized as
a functional variable (i.e., a reinforcer for appropriate behavior) in and of
itself rather than simply a means to identify highly preferred stimuli (Dunlap et al., 1994).
Dibley and Lim (1999) provided choice-making opportunities during treatment with a 15-year-old girl diagnosed with a severe intellectual
disability. Choice-making opportunities were incorporated into various
activities including meal-time routine, toileting routine, and leisure time
activities for the purpose of increasing compliance and decreasing problem behaviors. During baseline, the adolescent was prompted to engage
in each step that made up the respective activities and no choices were
incorporated. During treatment, the adolescent was prompted to engage in
each step that made up the respective activities with various opportunities
for choice embedded throughout each of the activities. For example, during
the toileting routine, the adolescent was provided with a choice between
initiating the activity immediately or following a 10-min delay, basin or
sink for hand washing, and hand-towel or hand dryer. When choices were
provided, compliance was observed at higher levels and problem behavior
was observed at lower levels when compared to baseline. These results
were consistent across each of the three targeted activities.
Dunlap et al. (1994) incorporated choice-making opportunities into
treatment programs for three young boys aged 11, 11, and 5 for the purpose of decreasing noncompliance and aggressive behavior. Two of the
children received opportunities to make choices during instructional times
in the form of menus containing several academic tasks. Choice-making
opportunities for the third child were incorporated into reading time. Specifically, the child was allowed to pick a book from an array prior to storytime. When choices were provided, each child exhibited lower levels of
noncompliance and problem behavior and task engagement was observed
at higher levels than those observed during baseline.
48
Generalization
Generalization is one of the stated characteristics of applied behavior
analysis (Baer et al., 1968). According to Cooper et al. (2007), generalization
is a broad term that refers to a number of behavior change outcomes. During
clinical application of ABA-based treatments, there is often an attempt
to expand the effects of treatment from the clinical setting to the naturalistic environment (i.e., stimulus/setting generalization). Stimulus/setting generalization refers to the occurrence of a behavior under different
conditions than which the behavior was acquired. Cooper et al. point out
that this behavior change can occur without being directly taught. However, some behavior analysts attempt to facilitate this outcome through
programming. Literature-based examples of generalization can be broken
into two broad categories. Some studies describe the naturally occurring
spread of effects across setting, time, and stimuli, whereas others describe
systematic processes to achieve generalization.
Bonfiglio, Daly, Martens, Lin, and Corsaut (2004) described the effects
of various reading interventions on the reading accuracy of a third-grade
girl. The participant was exposed to performance-based, skills-based,
and combined performance-based and skills-based reading interventions.
Each treatment was demonstrated to improve reading behavior. The effects
of treatment were noted across time and reading passages. These effects
were achieved without specific programming. The authors hypothesized
that generalization, particularly across passages, was a function (or, partially a function) of a fluency threshold.
49
EFFECTIVENESS RESEARCH
Another s tated characteristic of applied behavior analysis is effectiveness (Baer et al., 1968). Although metaanalyses regarding the effectiveness
of ABA-based treatments are difficult to identify, there are a number of
studies that review the effectiveness of ABA-based strategies in the treatment of severe behavior problems exhibited by individuals with and without developmental disabilities. These reviews and summary papers can
be placed into one of three broad categories: summaries of treatments for
behavior associated with particular disorders (e.g., autism, ADHD), summaries of treatments for specific behavior problems (e.g., SIB, aberrant
behavior, and stereotypy), and summaries of the effects of a specific treatment approach (e.g., NCR and FCT).
50
SUMMARY
We have attempted to provide an overview of the conceptual basis for
ABA-based treatments, a description of several of the more common of these
treatments, and a brief discussion of their effectiveness. Applied behavior
51
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3
Cognitive Behavior Therapy
ELLEN FLANNERY-SCHROEDER
and ALEXIS N. LAMB
INTRODUCTION
Increasingly, attention is turning to the significance of childrens mental
health. This attention results from a confluence of information sources collectively emphasizing the prevalence of childhood problems. Epidemiological estimates for the prevalence rates of childhood emotional and behavioral
disorders range between 15 and 22% (e.g., McCracken, 1992; Roberts, Attkisson, & Rosenblatt, 1998; Rutter, 1989; Kazdin & Weisz, 2003a; WHO,
2001). These rates may be underestimates as epidemiological studies often
do not include children exhibiting subclinical distress despite the fact that
these subclinical conditions have been found to be associated with significant functional impairments (e.g., Angold, Costello, Farmer, Burns, &
Erkanli, 1999). Childhood difficulties have been associated with problems
in adolescent and adult adjustment (e.g., Colman, Wadsworth, Croudace, &
Jones, 2007). Evidence exists suggesting that childhood psychopathology
has long-term social consequences including truncated educational attainment, teen parenthood, early marriage, and marital instability (e.g., Kessler, Berglund, Foster, Saunders, Stang, & Walters, 1997; Kessler, Molnar,
Feurer & Appelbaum, 2001; Kessler, Foster, Saunders, & Stang, 1995; Kessler, Walters, & Forthofer, 1998; Forthofer, Kessler, Story, & Gotlib, 1996).
Despite the evidence that a large number of children are diagnosed
or at risk for disorder, research has suggested that as few as 40% of children experiencing mental health problems receive help and only about
20% receive specialty mental health services (Burns et al., 1995). Hence,
there is a real need for easily accessed, client-acceptable, and effective
interventions for childhood mental health issues. In recent years, the child
therapy literature has grown with a profusion of empirical investigations of
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of the event, not the event itself. If ones interpretation of the situation
is not supported by the facts or reality, then the thinking is deemed distorted, irrational, or dysfunctional. One of the goals of CBT is to identify
and restructure the dysfunctional thoughts and beliefs related to ones self,
world, and future (Beck, 1970). The manner in which children think about
situations or events will determine not only their affective response but
also their behavior. These cognitive representations and resulting affect
and behavior are reciprocally determined. That is, changes in one result
in changes in the other. CBT therapists aim to educate children about this
reciprocal relationship and to heighten awareness of their cognitive processes (i.e., self-statements).
Cognition is thought of as an information-processing system with different levels, structures, and processes. Automatic thoughts, intermediate
beliefs, and schemas comprise three components of the system. Automatic
thoughts are those situation-specific self-statements that we make without deliberation or reasoning. They are closest to our conscious level of
thinking and therefore are easily accessed. Beck and colleagues (1979;
Clark, Beck, & Alford, 1999) have described characteristic errors in logic
in automatic thoughts. Sample categories of cognitive errors include magnification or minimization, overgeneralization, all-or-nothing thinking,
and personalization.
Much research evidence has demonstrated that adults and children
with psychological disorders (e.g., depression, anxiety) have a high frequency of distortions in their automatic thoughts (e.g., Bogels & Zigterman, 2000; Haaga, Dyck, & Ernst, 1991; Hollon, Kendall, & Limry,
1986; Kazdin, 1990; Kendall, Stark, & Adam, 1990; Schniering &
Rapee, 2002, 2004; Wright, Beck, & Thase, 2003). Intermediate beliefs
comprise those attitudes, rules, and assumptions that one holds (e.g.,
If I dont get an A on my math test, I am a failure.). These beliefs may
be out of conscious awareness, unspoken, and often reflect conditional
if-then thinking. Core beliefs (or schemas) represent thinking which is
absolute (e.g., I am unlovable.). These beliefs may be characterized as
global, rigid, and overgeneralized rules for interpreting ones environment (Beck, 1995, p. 16).
According to Becks (1976) content-specificity hypothesis, thought content is specific to psychological disorder or affective state. As an example,
Becks model posits that cognitive processes in depression center on loss,
hopelessness, and failure whereas cognitive processes in anxiety focus
on perceived threat, danger, and uncontrollability. Two relatively recent
studies using both community and clinic-referred samples of children and
adolescents have demonstrated support for the content-specificity hypothesis (e.g., Epkins, 2000; Schneiring & Rapee, 2004) whereas others (e.g.,
Epkins, 1996; Treadwell & Kendall, 1996; Ronan & Kendall, 1997) have
found mixed support.
Once children become adept at metacognition (i.e., thinking about
their own thinking), children are taught strategies to modify their thinking. The modification of irrational or distorted thinking occurs through
cognitive (e.g., collection of evidence against which to evaluate the
veracity of the irrational thought, Socratic questioning, problem-solving)
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or behavioral (e.g., behavioral experiments designed to test the validity of beliefs or to build skills) means. It is important to note, however,
that the reliance on cognitive versus behavioral techniques is often determined both by the nature of the disorder as well as the age of the child. As
an example, behavioral techniques may have greater utility in work with
younger children.
Contingent reinforcement is often used to enhance a childs motivation
and involvement in therapy. The process of CBT has often been described
as collaborative empiricism: therapist and child work together to form
and experimentally test hypotheses through the collection of behavioral
evidence. Together, therapist and child monitor the progress of therapy,
making necessary revisions and refinements across time.
To best fulfill the goals of cognitive behavioral therapy, one must consider the childs functioning (e.g., cognitions, affect, and behavior) within a
context. Therapists must consider biological, cultural, social, environmental factors to best understand the contextual influences impinging upon
the child. The field of developmental psychopathology has come to recognize that change involves a dynamic interplay among the individual characteristics and contextual systems (Cairns, Cairns, Rodkin, & Xie, 1998).
Recognition of these contextual systems is especially important given the
fact that children have little control over choosing and altering their environments (Erickson & Achilles, 2004).
ASSESSMENT METHODS
Numerous assessment techniques have been researched and cited
in the child assessment literature. Therapists select certain measures
and assessment tools depending on the nature of the information they
seek. For cognitive behavioral therapists, particular assessments are more
widely used than others. These include functional assessment, behavioral observations, interviews, self-report/parent-report measures, and outcome assessment techniques. The collection of information from multiple
sources known to the child provides the most accurate picture of the child,
his or her difficulties, and the surrounding systems that contribute to
these difficulties. Similarly, using multiple methods to gather information
from the child and family will result in a more thorough understanding of
the target problem (Krain & Kendall, 1999; Pellegrini, Galinski, Hart, &
Kendall, 1993). Assessment tools that differ in the means of information
access will tap into different processes. For example, behavioral observations carried out by the therapist will provide fundamentally different
information than self-report measures completed by the child and/or the
childs parents. Each of the aforementioned assessment techniques will be
discussed below.
Functional Assessment
The main goal of a functional assessment is to systematically examine
the problem behaviors exhibited by the child in order to plan the most
effective way of addressing those behaviors. Information regarding the child
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Behavioral Observations
Many of the difficulties addressed by CBTs are observable. The anxious child shows obvious signs of fear in certain situations (e.g., sweating,
shaking), the depressed child appears withdrawn and flat, and aggressive children demonstrate antagonistic behavior towards others. These
are just a few examples of overt signs characteristic of internalizing as
well as externalizing disorders. Behavioral observation relies upon close
scrutiny of these overt signs to assess how well the child or adolescent is
functioning given the target problem. Observing the child or adolescent in
session allows the therapist to witness first-hand the childs behavior and
interpersonal functioning. Observing the interactions between the child
and her family can also provide information about how significant others
in the childs life may be contributing to the development and/or maintenance of the target problem. Even brief parentchild interactions in the
therapy setting can be very informative as parents may be unaware of the
impact of their behavior on the child. Consequently, behavioral observation will provide information that interviews and self-report measures may
not. Additionally, behavioral observation can provide valuable information
when it is implemented in a more natural setting, such as a childs home
or school. Therapists can develop a greater understanding of the impact of
the targeted problem when they observe the manner in which it interferes
in every-day situations.
Interviews
Whereas observations have the unique advantage of allowing the therapist to witness first-hand certain interpersonal and/or family dynamics
that may be involved in the maintenance of the target problem, interviews
provide the therapist with historical information about the problem. During interviews, therapists have an opportunity to gain knowledge about
relationships within the family as well as child- and parent-reported
strategies for modifying behavior (Pellegrini et al., 1993). Semi-structured
interviews are recognized as being reliable and valid for making diagnoses,
and they are commonly used in CBT assessments (Clark, 2005). The CBT
therapist will not only pay attention to the childs behavior during the
interview but also to any cognitions that the child may share during the
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interview that may be contributing to the target problem. For children and
adolescents, interviews are generally conducted with both the child and
the parents, either separately or together. Interviews with both parent and
child together allow for observation of the interactions, whereas separate
interviews offer greater freedom for both parties to speak openly about the
presenting problem and surrounding issues.
Self-Report Measures
Questionnaires completed by the child or adolescent and his parents
provide yet another source of information for the therapist. For younger
children, more valuable information may be garnered from parent-report
of the childs behavior. However, when working with adolescents, there are
many self-report measures that address internal states and cognitions.
For example, certain self-report measures assess attributions regarding
the world around them (Pellegrini et al., 1993). This type of information is
generally more difficult to gather during an observation or interview and
may be quite hard for parents to report on accurately. For some children
and adolescents, self-report measures may represent a less intimidating
way to share thoughts and feelings that are otherwise too uncomfortable
to express.
Parent-report forms and teacher-report forms have significant utility
as they provide information about what occurs outside the therapy setting. Teachers and parents spend the most time with children and, as a
consequence, are invaluable sources of information about child functioning. Although behavioral observations in the school or home certainly provide useful information to the therapist, questionnaires are significantly
more cost- and time-effective. Use of these forms during the initial assessment and throughout treatment is essential in the monitoring of treatment
progress (Pellegrini et al., 1993).
Outcome Assessments
As with most types of psychotherapy, cognitive-behavioral therapy
monitors symptomatology throughout treatment to assess progress. If the
child is showing little or no progress, this may be an indication to the
therapist that either the initial conceptualization of the target problem
and corresponding contributing factors is incorrect or that the treatment
formulation may need alteration. Outcome assessments provide an objective way to evaluate the impact of treatment. Many of the aforementioned
assessments may be implemented as outcome assessments, yet certain
types may be considered more objective than others. For example, selfreport measures and other questionnaires are less likely to be biased by
the therapists expectations for treatment gains although they may be
influenced by the childs expectations.
Re-administration of structured interviews by an independent
diagnostician at the end of treatment also provides a relatively objective
indication of changes in the childs functioning as a result of receiving
services. Behavioral observations, although somewhat less objective than
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Cultural Considerations
When providing assessment or treatment services for children of different cultures, it is important to take into account both the appropriateness of the assessment measures as well as norms and expectations
inherent to the childs cultural background. Many measures that are used
commonly in CBT have not been normed on non-European-American cultures. Consequently, evaluating a childs score relative to existing norms
may be very misleading. Moreover, research has shown significant differences across cultures in the prevalence and intensity of different emotions
(Okazaki & Tanaka-Matsumi, 2006).
For example, Latin American individuals report high levels of positive
affect, whereas individuals from Asian cultures generally do not report high levels of positive affect (Okazaki & Tanaka-Matsumi, 2006). As a result, an Asian
American woman who shows low positive affect may present as depressed or
dysthymic when actually she is within the normative range given her cultural
background. Alternatively, a Latino American man who might be exhibiting
reduced affect relative to his cultural norms may not be identified as such
if he is evaluated against existing norms. In addition, more research needs
to be conducted on the reliability, validity, and utility of behavioral assessments in other cultures (Okazaki & Tanaka-Matsumi, 2006). Cultures vary
in their conceptualizations of what is considered appropriate or acceptable
behavior. Thus, therapists are urged to be cautious when assessing children
from other cultures or ethnicities. It is critical to ascertain relevant information regarding the childs cultural background before arriving at conclusions
about target problems and contributing systems.
THERAPEUTIC TECHNIQUES
Common cognitive behavioral therapeutic techniques include affective
education, cognitive restructuring, contingency management, behavioral
rehearsal, problem-solving, and self-monitoring, self-evaluation, and selfreinforcement. CBTs often use a few, many, or all of these techniques in
the conduct of therapy.
Affective Education
An important first step towards identifying and changing faulty cognitions is recognizing the emotions associated with these thoughts. Children
and adolescents often lack the insight or maturity to realize that their body
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produces physiological reactions to emotional states. For example, an anxious child might feel butterflies in her stomach when she finds herself in
an anxiety-producing situation. Instead of recognizing, for example, that
she is nervous, this child might conclude that she is sick with a stomachache. Affective education addresses this disconnect between the physical
and psychological experiences of emotional states.
Children and adolescents are often asked to reflect upon ways in
which people demonstrate their feelings. This may be done via role-playing
or charades, by drawing pictures of faces or people experiencing different
feelings, or simply jotting down a few signs that someone is angry, sad,
happy, or confused. This focus on the physical signs of emotions is applied
to the child so that the child is asked to think about what happens to his
or her body when a certain emotion is experienced. For some children, it is
helpful to either provide a drawing of a human body or have them draw a
person on which they can circle or otherwise mark the part of their body in
which they experience a somatic symptom (e.g., drawing a hammer hitting
the head to indicate the experience of headaches). Children and adolescents are encouraged to view these feelings as clues to their emotional
experience. In such a way, coping mechanisms can be put into place at
the first physiological signs of emotional distress in an effort to prevent a
worsening of the emotional and/or physical response.
Cognitive Restructuring
A key element of CBT is recognizing and altering the faulty cognitions that underlie the emotional distress. For a depressed adolescent, for
example, the maladaptive automatic thoughts might include, Im not good
at anything, and No one is ever going to like me. There are many creative
ways to help children and adolescents identify their automatic thoughts.
One way to illustrate the concept in a more concrete way for younger children is to use cartoons and to talk about the characters thought bubble
(see Kendall & Hedtke, 2006). This is a very visual way for children to
gain insight into cognitive processes. Use of cartoon characters can help
to illustrate, for example, that two people in the same situation may have
different thoughts, and, as a result, will experience different emotions
and/or behaviors. Once children have mastered the skill of identifying
their self-talk, they are taught to undergo a rational analysis of that selftalk. Is there evidence to support their thinking? Is there another way of
looking at the situation? Through this process, children are able to modify
their dysfunctional thinking from irrational to rational, and the cognitivebehavioral model then predicts a corresponding decrease in emotional and
behavioral distress.
Contingency Management
Cognitive-behavioral therapy places strong emphasis on the consequences
of behavior. In line with the fundamental principles of behavior therapy,
positive consequences will increase the frequency of behavior whereas negative
consequences will reduce the frequency. As such, contingency management
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Behavioral Rehearsal
Behavioral rehearsal is a crucial part of both cognitive and behavioral change. Behavioral rehearsal involves the simulation of situations
inside the therapy room for the purpose of skill development and practice. Thus, behavioral rehearsal can help children to utilize new ways
of responding to life situations that cause them difficulty. Once new
response patterns are trained in therapy, they are then tested out in real
world settings. Some children find it difficult to role-play; others relish
the opportunities. Clearly, the success of behavioral rehearsal is dependent upon a childs openness to engagement in the activity. Behavioral
rehearsal typically proceeds in a steplike fashion with easier to manage
situations practiced prior to more difficult ones. Corrective feedback is
provided by the therapist; however, the child is encouraged to self-monitor and evaluate her own performance as well. Often modeling of the
skill is necessary when the childs skill deficit is profound or corrective
feedback is proving ineffective. Once the child demonstrates mastery of
the skill being practiced, therapist and child move to the next more difficult situation. Homework assignments are critical to ensure that the
skill receives practice in vivo.
Problem-Solving
Bedell and Lennox (1997) have proposed a problem-solving model
that includes seven steps in the problem-solving process. The seven steps
include: (1) recognize the existence of a problem, (2) define the problem in
a goal-directed manner in which your own and others unmet wants are
identified, (3) brainstorm problem solutions without evaluation of their
possible efficacy, (4) evaluate the potential effectiveness of the alternatives generated, (5) select the best alternative or combination of alternatives, (6) implement the chosen solution, and (7) verify the effectiveness
of the chosen solution. Thus, the problem-solving process acknowledges
that there is a conflict to be addressed, and it provides a structured way
for approaching the problem.
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Results suggested that the difference in effect sizes for behavioral and
nonbehavioral treatments was not an artifact of methodological quality.
A subsequent meta-analysis by Weisz, Weiss, Han, Granger, and Morton (1995). also failed to support the Dodo bird verdict for psychotherapy with children and adolescents. Behavioral treatments again exhibited
higher effect sizes than nonbehavioral treatments, although effect sizes
in this study were somewhat more conservative than those found previously. Weisz, Weiss, et al. (1995) asserted that, because the studies used
in their meta-analysis had not been included in previous meta-analyses,
the present findings must be seen as rather strong independent evidence
of the replicability of this non-Dodo verdict (p. 461). They note, however,
that of the 150 studies involved in this meta-analysis, only 10% included
nonbehavioral treatments. Similarly, there were relatively few nonbehavioral studies in Weisz et al.s (1987) meta-analysis, thus limiting the potential generalizability of this sample to all nonbehavioral interventions.
In addition to broader meta-analyses studying the effectiveness of
behavioral versus nonbehavioral treatments, there have been numerous
studies focusing specifically on the efficacy of CBTs with children and adolescents. As Ollendick, King, and Chorpita (2006) have argued, any form of
psychotherapy used in treatment should have first been shown to be effective in randomized clinical trials (RCTs). These trials allow for comparisons
of CBT to either other forms of treatment or to control groups, and these
comparisons may provide scientific evidence supporting the effectiveness
of CBTs. CBT has been one of the most researched forms of treatment, and
over 300 RCTs have shown it to be an effective way of addressing a range
of Axis I disorders (Wright, Basco & Thase, 2006).
Over the past two decades, structured treatments, such as CBT, have
been shown empirically to be one of the more effective forms of psychotherapy (Erickson & Achilles, 2004). During the 1990s, the use of CBT
with children and adolescents was supported by the treatment outcome
literature (Braswell & Kendall, 2001). CBT has been shown to be effective
with children and adolescents with depression, anxiety, attention-deficit
difficulties, oppositionality, aggression, autism, mental retardation, low
self-esteem, poor academic skills, learning disorders, eating disorders,
and other difficulties (Braswell & Kendall, 2001; Clark, 2005; Craighead,
Craighead, Friedburg & McClure, 2002; Kazdin & Mahoney, 1994; Kendall, 1991, 2006; Reinecke et al., 2006b). In fact, CBT is considered a
probably efficacious treatment for the treatment of childhood anxiety
disorders (Kazdin & Weisz, 1998; Ollendick & King, 1998), ADHD and
depression (Ollendick et al., 2006) as well as aggression, anger, and conduct disorders (Kazdin, 2003, 2005; Larson & Lochman, 2002; Lochman,
Barry, & Pardini 2003).
Although the treatment outcome literature has shown consistent support for CBT, many clinicians claim that this research is of questionable
utility in nonlaboratory-based treatment clinics (Weisz, Donenberg, Han
& Weiss, 1995). This is due to the possibility of limited transportability of
treatment outcome results. There are many factors that may affect treatment outcome that vary between research settings and clinical practice.
First, study samples in clinical trials may not be representative of the general
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population of clinical patients. Whereas clinical clients are often seeking services, study participants are more actively recruited. In addition,
researchers aim to recruit a somewhat homogenous sample so that treatment can focus on one or two target problems, whereas clinicians may find
themselves treating a wide variety of diagnoses and difficulties. Second,
the research experimenters are not comparable to therapists in clinical
practice. They may differ in amount and type of training and supervision.
Research therapists will have undergone intensive pretherapy training on
the intervention being used in the study. Practicing clinicians, however,
rarely receive such training. Third, the manner in which treatment is
administered is unique to research settings. Study participants are not
permitted to obtain simultaneous services elsewhere, and experimenters
must strictly follow treatment protocols. In general practice, however, clinicians may use several techniques depending upon the child or adolescents responsiveness to therapy (Ollendick et al., 2006; Weisz, Donenberg,
et al., 1995).
Weisz, Donenberg, et al. (1995) assert that the meta-analyses showing
overall positive effects for psychotherapy must be considered in light of
these limitations. Only nine studies included in the broad meta-analyses
included what they call clinic therapy which involves clients, therapists,
and settings that approximate actual clinical practice. All other studies
included in the meta-analyses involved strictly research therapy. Weisz,
Donenberg, et al. (1995) calculated the effect sizes for the nine studies
involving clinic therapy and found that the mean effect size for these
studies was much lower than that of the research therapy studies.
In evaluating this difference, Weisz and colleagues identified two possible explanations. First, behavioral methods, which generally have higher
effect sizes, are more common in research therapy than in clinical practice. Consequently, the higher effect sizes might actually be due to a greater
percentage of behavioral treatments included in the research therapy
studies. If clinic therapy studies included more behaviorally based treatments, the difference in effect sizes might be reduced. Second, clients who
actively seek out treatment in clinical settings may be fundamentally different than those therapy clients who are recruited for study participation.
Recruited clients may have less complex problems, rendering them more
likely to be successful in treatment.
THERAPEUTIC RELATIONSHIP
CBT is sometimes mistakenly viewed as having little emphasis on the
quality of the therapeutic relationship. However, many CBT therapists
assert that the therapeutic relationship is one of the most essential components of treatment (e.g., Beck et al., 1979; Kendall, 1991). Most schools
of therapy view the therapeutic alliance as an important variable in treatment outcome. Most conceptualizations of alliance use Bordins (1979)
definition in which alliance is comprised of three facets: an agreement on
goals, an assignment of task(s), and the development of a bond. Cognitive-behavioral therapy clearly emphasizes each of the three facets. It has
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Therapist Characteristics
Not all therapists are created equal. As Kendall and Choudhury (2003)
note, treatments are often described as though they are equally effective
across therapists. This may be especially true of manualized treatments.
However, we know that therapists differ on a wide variety of dimensions
(e.g., energy, animation, self-disclosure, warmth, flexibility, sociability,
adherence to protocol). Therefore, it is unlikely that they impart little effect
on outcome.
Research on the importance of the therapists contributions to therapeutic alliance and outcome has been sparse (Garfield, 1997). It stands to
reason that there may be particular therapist characteristics which hasten
(or detract from) alliance and/or treatment outcomes. The importance of
investigating the role of the therapist is heightened by the difficulty in
disentangling the effects of the treatment from the effects of the therapist.
That is, true treatment effects may be obscured by therapist competency
(or incompetency) or other therapist characteristics (e.g., therapist efficacy, therapist training and supervision; Elkin, 1999).
Ackerman and Hilsenroth (2003) examined therapist characteristics
and techniques that have a positive impact on the therapeutic alliance
in therapistadult client relationships. Therapist characteristics including
being flexible, honest, respectful, trustworthy, confident, warm, interested,
and open were found to be positively correlated with therapeutic alliance.
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Child Characteristics
Child therapy outcome studies must concern themselves with those
child characteristics that may mediate or moderate outcomes. Age, gender, ethnicity, familial or cultural background, socioeconomic status, and
other child characteristics have received relatively little research attention.
Are there preferred ages or developmental stages for the effective implementation of cognitive-behavioral interventions? Durlak, Fuhrman, and
Lampman (1991) conducted a meta-analysis on the effectiveness of CBT
for children with a variety of mental health problems. The authors looked
at developmental stage as a moderator of outcome and found a larger
effect size (.92) for children at the formal operational level (age 1113)
than for children at less advanced levels (age 711, effect size = .55; and
age 57, effect size = .57). Thus, the authors conclude that children who
are more cognitively mature may be more capable of abstract thinking and
deductive reasoning, making them more likely to benefit from CBT.
Conversely, in a study examining the predictors of remission from
major depressive disorder in children and adolescents treated with CBT,
Jayson, Wood, Kroll, Fraser, and Harrington (1998) found older age to be
associated with the poorest outcomes. Similarly, in the field of anxiety
disorders, there is some evidence to suggest that younger children might
benefit more from CBT than older children, especially when the family is
involved in treatment (Barrett, Dadds, & Rapee, 1996; Hudson, Kendall,
Coles, Robin & Webb, 2002). For example, Southam-Gerow, Kendall, and
Weersing (2001) found that those children who were identified as poor
responders (retained an anxiety diagnosis posttreatment) were more likely
to be older than children in the good treatment response group (no posttreatment anxiety disorder).
Several hypotheses have been suggested to explain why younger children may do better. Older childrens disorders may be more chronic and
resistant to change or they may be more nonnormative in the course of
development, making them less well able to navigate the tasks of adolescence. Younger children may benefit more due to an increased involvement
from parents. Last, it might be the case that treatment materials commonly
used in anxiety treatment packages for youth (e.g., Coping Cat; Kendall &
Hedtke, 2006) may be more age-appropriate for younger children. If the
latter is true, it may be that interventions designed for middle childhood
may need substantial modifications prior to use with adolescents.
Gender has received limited attention as a factor in treatment outcomes
of CBT. Although gender has been identified as a significant variable in the
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CONTEXTS
As briefly discussed earlier in this chapter, a cognitive-behavioral
framework must provide explicit attention to the child in various contexts
(e.g., family, school, peer group, ethnicity, culture, religion). Numerous
researchers have proposed that the inclusion of family members (namely,
parents) in the therapeutic process is an effective means to enhance treatment success (e.g., Ginsburg, Silverman, & Kurtines, 1995; Kazdin, 1993;
Kendall, 1994; Silverman, Ginsburg, & Kurtines, 1995). Ginsburg and colleagues (1995) have described a transfer of control model in which an
expert therapist passes along knowledge, skills, and methods to the child,
either directly or from therapist to parent to child. However, they note
some blocks that may occur in this transfer process. The blocks often
involve maladaptive family processes (e.g., parental psychopathology, dysfunctional family relationships).
In order to clear the pathway to facilitate transfer of control, parental
inclusion in therapy is a necessity. Although many therapists support the
inclusion of parents, especially with young children, there remain questions regarding the degree to which and in what capacity parents should
be involved in child treatment. Are parents informants, consultants, or
co-clients? The degree of parental participation is likely to be determined
in part by child age and type of presenting problem.
Hays (2006) has noted the widespread omission of ethnic and cultural information in clinical research. Research on CBT, for example, has
almost exclusively relied on individuals with European American identities
(Hays, 1995; Iwamasa & Smith, 1996; Suinn, 2003). Thus, the success
and limitations of CBT with minority populations have not been evaluated.
Due to CBTs experimental orientation to human behavior, there may exist
an implicit assumption that CBT is value-neutral. Hays (2006) notes that
CBT is as value laden as any other psychotherapy (p. 7). In fact, CBTs
emphasis on rationality and definitions of adaptive versus maladaptive
behaviors may conflict with values and ideals prominent in other cultures
(e.g., spirituality). Training in working with diverse populations, sensitivity workshops, and consultations with experts in cultural diversity are all
necessary to ensure sensitivity.
FUTURE DIRECTIONS
Despite the apparent efficacy of CBT with children, there remain
substantial numbers of children who do not progress in treatment. Little
research has been conducted on how to address these treatment-resistant
72
cases. In the case of a less than successful outcome, are there particular
treatment techniques that may be employed? Is medication warranted?
Should frequency or length of treatment sessions be increased? Is work
with parent(s) needed? These questions will linger until treatment research
addresses how to facilitate improvement in all cases. The answers lie in
understanding the mechanisms of therapeutic action in CBT, and despite
much treatment outcome research, research on knowing how and why
CBT works remains sparse (Kazdin & Nock, 2003; Shirk & Karver, 2006).
While research on the efficacy of cognitive-behavioral interventions is
amassing, the majority of randomized clinical trials evaluating CBT have
used waitlist control conditions. Much work remains to evaluate the relative
efficacy of CBT and active control conditions. Also, much of the research has
employed CBT treatment packages. That is, most CBT treatments are comprised of several cognitive-behavioral elements (e.g., cognitive-restructuring,
homework, problem-solving training); yet little is known about the influence
of individual elements on treatment outcomes. Other methodological considerations include evaluation of CBT efficacy with youth via an examination
of clinical as well as statistical significance (e.g., Kendall, 1999; Kendall &
Grove, 1988, Kendall, Marrs-Garcia, Nath & Sheldrick, 1999). Whereas statistical significance determines the likelihood that a mean difference may
have resulted by chance, clinical significance can determine the meaningfulness of the magnitude of change. In treatment outcome research, clinical
significance may be helpful in evaluating whether deviant scores have been
returned to within normal limits on a particular assessment measure.
There is a clear call for more developmentally oriented research designs.
For example, longitudinal designs would better evaluate CBTs impact on
developmental processes and trajectories. However, longitudinal designs
bring additional considerations. Issues such as measurement equivalence
remain to be resolved (Kendall & Choudhury, 2003). In the measurement of
a particular construct across time, it is likely that several measures will be
warranted in order to ensure that the measures are developmentally appropriate. However, the comparability of these measures is at issue. For example, do the Childrens Depression Inventory (Kovacs, 1981) and the Beck
Depression Inventory (Beck,Ward, Mendelson, Mock, & Erbaugh,1961;
Beck, Steer, & Garbin, 1988) measure depression in a similar manner?
How can one evaluate depression across the span of early childhood and
into young adulthood? Longitudinal designs also afford an opportunity to
consider the indirect effects of treatment (Kendall & Kessler, 2002).
Given the long-term social and economic consequences of childhood
psychopathology, researchers should examine for treatment impacts on the
sequelae of targeted disorders (e.g., impact of childhood anxiety treatment on
adolescent or early adulthood substance use). In addition, there is a great
need to generate treatment samples from ethnically and socioeconomically
diverse populations in order to enhance treatment generalizability and transportability. Regarding the latter, there is little reason to believe that all CBTs
found efficacious in the research lab will show a corresponding efficacy in clinical settings. However, the extent to which the results of randomized clinical
trials can be applied in the real world remains to be determined by research
(Kendall & Southam-Gerow, 1995; Persons & Silberschatz, 1998; Silverman,
Kurtines, & Hoagwood, 2004; Southam-Gerow, Weisz, & Kendall, 2003).
73
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4
Parent-training
Interventions
NICHOLAS LONG, MARK C. EDWARDS,
and JAYNE BELLANDO
University of Arkansas
79
80
Gerald Pattersons (1982) research on coercive parentchild interactions offered a major contribution to the early development of parent
training. His model on reciprocal influences provided an explanation as to
how the behavior of both parents and children contribute to the escalation of child aggression and behavior problems. The model explained how
children use high rates of aversive behaviors to stimulate parental attention, and in turn, this parental attention reinforces the childrens aversive
behavior. Such parental attention can involve either giving in to the aversive behavior or using coercive tactics (e.g., nagging, yelling) in an attempt
to stop the aversive behavior.
Pattersons model also helped explain how childrens behavior simultaneously reinforces and escalates parental use of coercive tactics through
negative reinforcement. Thus his model of reciprocal influences helped
explain how childrens disruptive behavior can escalate while parent
management tactics become more punitive and coercive. Such coercive
exchanges within the home were believed to be basic training for the
development of aggression and disruptive behavior that generalizes to other
settings. The entry into this coercive cycle was considered to be ineffective
parenting, especially in regard to child compliance to parental directions
during the preschool years (McMahon & Wells, 1998).
Since its development in the 1960s, behavioral parent training has
gone through three distinct stages of development (McMahon & Forehand,
2003). The first stage, during the 1960s and early 1970s, focused on the
initial development of a parent training intervention model. The parent
training model, based on Tharp and Wetzels (1969) triadic model, utilized a
therapist (consultant) who taught the parent (mediator) to reduce the childs
(target) disruptive behavior (McMahon & Forehand, 2003). The research
conducted during this first stage was largely limited to case studies or singlecase designs. However, during this first stage, evidence was obtained that
demonstrated that, at least in the short-term, parent training interventions
could produce changes in both parent and child behaviors.
At about the same time, researchers also started to examine different
strategies (e.g., written instructions, videotaped instruction, modeling, etc.)
for teaching parents how to use specific behavior management strategies
(e.g., Flanagan, Adams, & Forehand, 1979; Nay, 1975; ODell, Mahoney,
Horton, & Turner, 1979; ODell, Krug, OQuinn, & Kasnetz, 1980). Parents could learn to effectively use specific techniques through a variety of
instructional modes. However, there was also the realization that although
parents could be taught basic behavior modification techniques through
various instructional modes, to effectively address significant child behavior problems interventions for parents needed to be more multifaceted
and take into account the complexities of parentchild interactions in the
home (Kazdin, 1985).
The second stage of parent training research, from the mid-1970s
to the mid-1980s, focused on social validity and the generalization of
treatment effects. Issues examined included whether behavior changes
observed in the clinic generalized to the home, whether improvements
were seen in behaviors other than the target behaviors (behavioral gen-
PARENT-TRAINING INTERVENTIONS
81
82
Cohen (1988) defined effect sizes as small, d = .2, medium, d = .5, and large, d = .8.
PARENT-TRAINING INTERVENTIONS
83
The largest subgroup of parent training outcome studies are those that
evaluated programs which train parents in behavioral child management
strategies to address deviant behaviors, such as aggressiveness, temper
tantrums, and noncompliance. Behavioral parent training (BPT) typically
included strategies such as differential reinforcement of other behavior,
extinction, and time-out. An early narrative review was supportive of
the efficacy of BPT with deviant behavior. Atkeson and Forehand (1978)
reviewed 24 studies which included three outcome measures (observations, parent collected data, and parent completed measures) and reported
positive results in all three outcome domains.
Serketich and Dumas (1996) conducted a meta-analysis of studies evaluating the effects of behavioral parent training program on child
antisocial behavior and parental adjustment. They analyzed 27 studies
from 1969 to 1992 that included 36 comparisons between experimental
and control groups. In these studies, 22 received some form of individually administered BPT and 13 received BPT in a group format. The
average numbers of sessions was 9.53 (SD = 4.17). This study reported
a mean effect size for overall child outcome of .86, which is considered
large (Cohen, 1988). The mean effect sizes for child outcome based on
parent, observer, and teacher were .84, .85, and .73, respectively. The
mean effect size for outcomes of parental adjustment was moderate at
.44. As a result of the favorable outcome evidence, behavioral parent
training for oppositional children has been designated by the American
Psychological Association Task Force as an empirically validated intervention (Chambless et al., 1996).
Several studies have evaluated the efficacy of BPT programs with parents of children with ADHD. Seven of eight studies which compared BPT
with no treatment reported positive findings (Anastopoulos et al., 1993;
Duby, OLeary, & Kaufman, 1983; OLeary, Pelham, Rosenberg, & Price,
1976; Pisterman et al., 1989; Pisterman et al., 1992; Sonuga-Barke, Daley,
Thompson, Laver-Bradbury, & Weeks, 2001; Thurston, 1979). However,
the effects of BPT were not found to be superior to a cognitive-behavioral
self-control therapy (Horn, Ialongo, Popovich, & Peradotto, 1987; Horn,
Ialongo, Greenbert, Packar, & Smith-Winberry, 1990) or stimulant medications (Firestone, Kelly, Goodman, & Davey, 1981; Horn et al., 1991;
Klein & Abikoff, 1997; Pollard, Ward, & Barkley, 1983; Thurston, 1979).
BPT has not been shown to enhance treatment response when combined with medications (Firestone et al., 1981; Horn et al., 1991; Klein &
Abikoff, 1997; Pollard et al., 1983). However, there is some evidence that
suggests that combining BPT with medications may allow for lower doses of
medications (Horn et al., 1991) or lead to enhanced outcomes in functioning
(social skills; improved parentchild relationships; parenting) and consumer
satisfaction (Hinshaw et al., 2000; Multimodal Treatment Study of Children
with ADHD Cooperative Group, 1999). Reviews of parent training interventions with ADHD populations have concluded that more systematic study is
needed but that existing studies provide sufficient evidence to consider parent training an effective treatment for ADHD (Chronis et al., 2004; Kohut &
Andrew, 2004; Pelham, Wheeler, & Chronis, 1998).
84
PARENT-TRAINING INTERVENTIONS
85
reductions in negative parent behaviors in a structured parentchild interaction observation compared to the control group. Other measures of child
and parent behavior and parent functioning showed improvements across
both experimental and control groups.
Cedar and Levant (1990) conducted a meta-analysis of studies that
evaluated the efficacy of the Parent Effectiveness Training program (PET;
Gordon, 1970) on the behavior and cognitive adjustment of both children
and parents. Most of the studies were doctoral dissertations rather than
peer reviewed journals. PET is based on a reflective/Rogerian approach
rather than a behavioral orientation and consists of training parents in
the use of active listening, I messages, and conflict resolution. Cedar and
Levant examined 26 studies from 1975 to 1990. Their analyses found no to
small effects on outcomes related to child attitudes and behaviors (ds = .12
& .03, respectively), small to moderate effects for child self-esteem (d = .38),
small to moderate effects on parent attitudes and behavior (ds =.41 & .37,
respectively), and large effects on outcomes related to parental knowledge
of course content (d =1.10).
Generalization Effects
It is reasonable to assume that changing parents behavior would result
in some generalization of treatment effects across time and settings and to
untreated siblings. Although there is some supporting evidence for such
generalization, confidence in the generalizability of treatment effects would
be increased with additional studies with improved methodology, such as
larger sample sizes, multiple outcome measures, and control groups.
Three of the four meta-analytic studies reviewed above evaluated the follow-up effects of parent training. The long-term effect (interval not reported)
of the PET program showed an attenuation of overall effect over time, from
small to moderate (d = .35) to small (d = .24; Cedar & Levant, 1990). Of the
23 studies that evaluated the efficacy of parent training programs on child
abuse risk factors reviewed by Lundahl, Nimer, and Parsons (2006), five
studies reported follow-up effects for child-rearing behaviors and six studies reported follow-up effects on parental attitudes and emotional adjustment. The effects were moderate for child-rearing attitudes (d =.65) and
small for emotional adjustment and child-rearing behaviors (ds =.28, .32,
respectively). Both of these reviews did not report separate follow-up effects
for studies that employed control groups at follow-up and those that did
not. Lundahl, Risser, and Lovejoy (2006) reported on the follow-up effects
(1 to 12 months post treatment) of behavioral parent training programs.
They reported the effects of those studies that employed a control group
at follow-up and those that did not. Studies that include a control group
at follow-up can provide a more accurate picture of the long-term impact.
The follow-up impact of the programs that used a control group at followup was shown to maintain in the moderate range for parent perceptions
(d =.45) and to attenuate from moderate in magnitude at post-test to small
at follow-up for child behavior (d =.21) and parenting skills (d = .25).
A couple of recent studies reported follow-up effects of BPT with physically abusive parents and parents of children with Oppositional Defiant
86
Disorder. Chaffin and his colleagues (2004) reported follow-up data (median
interval of 2.3 years) in their randomized controlled trial of a BPT program
with physically abusive parents. Forty-nine percent (49%) of parents in the
control group (standard community group intervention) had a re-report for
physical abuse at follow-up compared to 19% of parents assigned to the
BPT group. Reid, Webster-Stratton, and Hammond (2003) reported on a
two-year follow-up of 159 four- to eight-year-old children diagnosed with
Oppositional Defiant Disorder and treated with a behavioral parent training program (Incredible Years). At posttreatment, 46.2% of participants
who received parent training alone and from 55% to 59.1% who received
parent training in combination with teacher or child training, showed
clinically significant changes (defined as a 20% reduction in ratings of
behavior) at posttreatment compared to 20% of controls. At the two-year
follow-up, the percentage of participants who received the parent training
alone or in combination with teacher or child training who showed clinically significant improvements was 50%, 81.8%, and 60%, respectively. No
control group was used at this two-year follow-up.
There is some support for the generalization of behavioral parent
training treatment effects to untreated siblings. Four studies showed
significant improvements in the untreated siblings observed compliance
(Humphreys, Forehand, McMahon, & Roberts, 1978; Eyberg & Robinson,
1982) and deviant behavior (Arnold, Levin, & Patterson, 1975; Wells, Forehand, & Griest, 1980) at posttreatment. In one study, the improvements
were maintained at a six-month follow-up (Arnold et al., 1975). Eyberg
and Robinson (1982) reported significant improvements in observed parent behavior with untreated siblings and no significant reductions in the
number or intensity of negative sibling behaviors.
Two early studies failed to show generalization of treatment effects
from clinic to school settings (Breiner & Forehand, 1981; Forehand et al.,
1979). However, McNeil, Eyberg, Eisenstadt, Newcomb, and Funderburk
(1991) reported significant improvements in teacher-rated deviant behavior and observations of appropriate and compliant behaviors at school in
ten children treated with a BPT program relative to controls. In this study,
they selected subjects who showed high levels of behavior problems across
home and school settings at pretreatment and who all showed clinically
significant improvements in home behavior after treatment.
Moderator Effects
A number of child, parent, and program characteristics have been
associated with parent training outcomes, such as child age, child IQ,
familys socioeconomic status, parental social support, parental education level, parental functioning, family stress, and ethnicity (see Graziano
& Diament, 1992 for review); however, relatively little research has been
done where these characteristics have been studied as independent variables. Lundahl, Risser, and Lovejoy (2006) assessed moderator effects of
parent training in their meta-analysis. They found financial disadvantage
to be the most salient moderator of outcomes. Children and parents from
non-disadvantaged families benefited more across the child behavior, parent
PARENT-TRAINING INTERVENTIONS
87
behavior, and parental perception outcome constructs compared to disadvantaged families. They also found that marital status was a moderator
of child behavior outcomes. Studies with a higher percentage of single
parents (Number of studies (k) = 29) did not show as much change as
studies with a lower percentage of single parents (k = 16). There have been
some mixed results related to childs age and parent training outcomes in
three quantitative reviews. The Lundahl, Risser, and Lovejoy (2006) and
the Cedar and Levant (1990) meta-analyses found no relationship between
age and positive outcomes, whereas Serketich and Dumas (1996) reported
a positive relationship between age and positive outcomes.
There have been some program characteristics associated with parent
training outcomes, including the format of training and number of sessions. In their meta-analysis, Serketich and Dumas (1996) found a nonsignificant correlation between the effect size for the overall child outcome
and the format of the treatment (individual vs. group). Studies have found
individual, group, and self-administered BPT to be equally effective and
superior to a no-treatment control group (Webster-Stratton, 1984; Webster-Stratton, Kolpacoff, & Hollinsworth, 1988).
Lundahl, Risser, and Lovejoy (2006) also found no differences in effect
sizes between face-to-face and self-directed interventions. However, they
reported that among the 20 studies that treated financially disadvantaged
families, individual parent training resulted in significantly greater improvements in child and parent behavior than group parent training. There were
no differences between individual and group treatment in the parental perceptions outcome domain. Lundahl, Nimer, and Parsons (2006) found that
studies whose programs were more than 12 sessions had greater improvements in parental attitudes linked to abuse compared to programs with fewer
than 12 sessions. No differences in child-rearing behavior were found between
programs with low and high number of sessions.
88
PARENT-TRAINING INTERVENTIONS
89
parents the effective use of the skills of attending, rewarding, and ignoring.
Phase 2 involves teaching parents to give effective directions and how to
use time-out appropriately. The clinical program typically takes 812 sessions to complete. The number of sessions varies from family to family
because HNC uses a competency-based approach which requires parents
to achieve a certain level of competence with a skill before the next skill is
introduced. Details regarding the specific skills are provided below.
90
instructions to their child within the parents game. Unlike the childs
game which is used to teach Phase 1 skills and involves the parent being
nondirective, the parents game involves the parent taking direction of
the activities (e.g., the parent issues frequent instructions/commands
while directing the activity). The therapist provides feedback to the parent
regarding the directions being issued (e.g., how they could be improved).
The parent is also taught to attend to or praise their childs compliance to
their directions.
Time-out. Parents are taught a specific time-out procedure to use
with their child. The child is also informed about the time-out protocol
within the session. The therapist provides guidance to the parent in terms
of issues related to time-out. The therapist then helps the parent utilize a
clear instruction sequence that guides the parent in how to manage compliance and noncompliance to parental directions.
Standing rules. Once the parent is effectively implementing the clear
instruction sequence at home, the use of standing rules is introduced.
Standing rules are typically If then statements (i.e., rules that
specify the consequences for specific behavior). The therapist assists the
parents in developing appropriate standing rules.
Extending the skills. The therapist discusses with the parents how
they can use the skills they have been taught to manage their childs
behavior outside the home.
PARENT-TRAINING INTERVENTIONS
91
whereas the clinical HNC program is intended for parents whose children
have more significant behavior problems.
92
self-control, communication skills, problem-solving skills, and strengthening social support and self-care.
Triple P
Triple P (Positive Parenting Program) developed by Sanders (Sanders &
Ralph, 2004) is a unique parent-training program. Developed in Australia
and currently being used around the world, Triple P is a multilevel parenttraining program that targets children 212 years old. The program has
five levels. Level 1 is a universal parent information strategy that makes
general parenting information available to all parents through the use of
various strategies including tip-sheets and promotional media campaigns.
Level 2 consists of a brief one- or two-session primary healthcare-based
parenting intervention targeting children with mild behavior problems.
Level 3 is a four-session more intensive parenting intervention that targets
children with mild to moderate behavior problems. Level 4 is an eight- to
ten-session individual or group parent-training program targeting children
with more significant behavior problems. Level 5 is an enhanced behavioral family intervention program that is utilized for significant behavior
problems that are complicated by other factors (e.g., marital conflict, high
stress).
PARENT-TRAINING INTERVENTIONS
93
Encourage parenting strategies including attending to and reinforcing their childrens coping, approaching behaviors, and parental
modeling of appropriate coping behavior to their children
Teach parents self-awareness and appropriate management of their
own stress and anxiety.
94
The parent component follows along with the FRIENDS components for
the children. Barrett and Farrell (2007) have outlined the specific strategies of the parent component for each component as indicated by the
FRIENDS acronym as summarized below.
Feelings. Parents are encouraged to focus on their own responses
to fear and anxiety and on learning the skills of anxiety awareness. The
importance of accepting individual differences, particularly in response to
feelings, is discussed.
Remember to relax. Have a quiet time. Parents are taught relaxation skills
and are encouraged to practice and coach other family members. Parents are
also encouraged to ensure that the family has regular periods of quiet time.
Parents are also encouraged to reinforce relaxation practice in children. Parents are supported and encouraged to spend quality time with their children.
I can do it! I can try my best! Parents are encouraged to become aware
of their own cognitive style and how their responses to stress model optimism or pessimism to their children. Parents are encouraged to use positive
thoughts and to notice and reward their children for positive thoughts.
Parents are also asked to use positive prompts (e.g., You can do it, youve
done it before) with their children.
Explore solutions and coping step plans. Parents are taught how to
help their child develop coping step plans (based on a fear hierarchy). They
are given examples of coping step plans and rules to help ensure the success
of coping step plans.
Now reward yourself! Youve done your best! Parents are encouraged
to notice brave/confident behaviors and reward approach behaviors.
Parents are also taught to ignore complaining and avoidance behaviors.
Dont forget to practice. Parents are taught to encourage their child to
use their FRIENDS plan. They are also encouraged to role-play with their
children how to utilize the skills to handle upcoming challenges.
Smile! Stay calm for life. Parents are encouraged to help their children
recognize they have effective strategies for overcoming challenges they will
face.
PARENT-TRAINING INTERVENTIONS
95
The literature on parent training for children with developmental disorders and specifically autism has, for the most part, developed separately
from the parent training literature for areas such as disruptive behavior
disorders (Brookman-Frazee, Stahmer, Baker-Ericzen & Tsai, 2006). In
reviewing the literature on parent training and autism spectrum disorders (ASD) Brookman-Frazee and colleagues (2006) identified some general differences when compared to more traditional parent training studies
for disruptive behavior disorders. They report that parent groups for ASD
tend to be smaller and that studies often include single case examples,
single case design, and more descriptive reports. Programs for ASD tend to
include more modeling of behaviors for parents. They also tend to include
more home treatment components and fewer strictly didactic components
for parents.
The degree of parental participation varies significantly across treatment programs for ASD and other developmental disabilities. The level
of parental involvement is discussed below for some of the most popular
treatment programs for ASD.
96
PARENT-TRAINING INTERVENTIONS
97
- How to reinforce a childs attempts to respond to instructional materials or natural learning opportunities
Koegels research indicates that most parents reach criterion (80% correct
use of the motivational procedures within the natural environment) within
25 hours of training.
98
CONCLUSION
From its early development in the 1960s, parent training has made
great strides. It has grown from an intervention focused on helping parents
to address specific child behaviors to a method of intervention used for a
variety of child problems and disorders. No other psychological therapy
for children has been as extensively studied (Kazdin, 2005). Meta-analytic
reviews of the parent-training literature suggest that parent training is at
least moderately effective. These results are very favorable when compared
to the effects found for other psychotherapy approaches. Such research
findings have resulted in parent training being considered one of the relatively few empirically supported treatments for childrens externalizing
behavior problems. The use of parent training in other areas of childhood
psychopathology and developmental disorders is less well established but
is rapidly gaining support.
Unfortunately, parent training is not a panacea nor is it consistently
effective. Much work remains to be conducted to fully understand factors
that impact the effectiveness of parent training interventions. A greater
understanding is needed of how contextual factors such as ethnicity/culture, socioeconomic status, parental psychopathology, and various family
stressors relate to parent training interventions. Parent-training interventions certainly need to better address issues related to ethnicity and culture, which are known to affect parenting, if treatment outcomes are to be
maintained in our increasingly diverse society.
At this stage of the development of parent-training interventions, more
effectiveness trials are needed (the primary focus to this point in time
has been on efficacy trials) (Weisz & Kazdin, 2003). That is, there is a
PARENT-TRAINING INTERVENTIONS
99
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5
Conduct Disorders
CHRISTOPHER T. BARRY, LISA L. ANSEL,
JESSICA D. PICKARD, and
HEATHER L. HARRISON
INTRODUCTION
Disruptive behaviorsdefined here as behaviors that are associated
with diagnoses of Oppositional Defiant Disorder (ODD) or Conduct Disorder
(CD)are the most common reason for referral to mental health services for
children and adolescents (Kazdin, 2003). The behaviors that comprise these
diagnoses include argumentativeness, temper tantrums, often being angry
or resentful, lying, stealing, hurting or threatening to hurt others, cruelty
to animals, setting fires, and destruction of property (American Psychiatric
Association, 2000). Kazdin (2003) estimates conservatively that between 1.4
million to 4.2 million children in the United States meet criteria for CD alone.
Conduct problems or other externalizing behavioral difficulties constitute the
most common referral issues for children and adolescents for mental health
services (Brinkmeyer & Eyberg, 2003). The presence of these symptoms can
be detected early in childhood (Webster-Stratton & Reid, 2003), making them
amenable to treatment as long as candidates for intervention are identified
and followed through with the prescribed treatment recommendations.
ODD and CD encompass a broad array of acts, and young person
need not exhibit all, or even most, of the symptoms of ODD and CD
to warrant a diagnosis or be a candidate for intervention. Noncompliant behavior is frequently demonstrated in children with ODD or CD;
however, many parents whose children do not meet diagnostic criteria
for these disorders commonly report seeking outpatient mental health
services for noncompliance in their children (McMahon & Forehand,
2003). One of the initial symptoms of conduct problems to emerge in
children is lying (Christophersen & Mortweet, 2001). Specific behaviors
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PARENT-BASED TREATMENTS
Common Elements
That parent-based strategies are, or are part of, many of the empirically supported treatments for conduct problems speaks to the potential
influence of the youths immediate home environment in the development
of conduct problems and in the usefulness of environmental interventions
in the reduction of these problems. It is important,to note that regardless
of the specific hypothesized developmental pathway toward conduct problems for a given young person, parent-based interventions are developmentally necessary for young children who generally lack the capacity to
directly participate in treatment in lieu of their parents. Indeed, considering the potential etiological effects of contextual factors, it has been argued
that intervention for children with an early onset of conduct problems
should have parent-based treatment as its central component (Beauchaine, Webster-Stratton, & Reid, 2005).
Empirically supported parenting interventions generally target
child noncompliance and have some theoretical foundation based on
Pattersons (1982) model of coercive parentchild interactions. Specifically, parenting practices that are thought to negatively reinforce child
noncompliance (e.g., withdrawing a request/command after repeated
refusals by the child) are replaced by clear commands and immediate
negative consequences for noncompliance. Furthermore, Pattersons
model suggests that increasingly harsh parenting strategies are used as
child noncompliance increases, and such strategies are positively reinforced by the childs eventual compliance in the face of harsh parenting
or threat thereof.
Parent-based interventions seek to emphasize positive reinforcement
for compliance in the form of praise, privileges, or larger, more long-term
rewards as well as to diminish the likelihood of increasingly aversive
parenting practices by promoting the use of immediate and consistent
punishment strategies such as time-out. Response cost (i.e., removing
tokens, privileges, or points when inappropriate behavior occurs) can provide an alternative to time-out (Forehand & McMahon, 2003). However,
the improvement of parentchild interactions through the use of positive
parenting strategies (i.e., parental attention, positive reinforcement) is
emphasized before the implementation of punishment strategies for misbehavior (cf., Webster-Stratton & Reid, 2003). Such models seem warranted
in light of evidence demonstrating that increases in positive parenting
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have also targeted parental stress, parental problem-solving, and marital discord insofar as they exacerbate the childs misbehavior (Lochman, 1990). Such
factors can be addressed within the context of individual parent treatment,
couples therapy, during the course of a childs treatment for conduct problems, or in parenting groups designed for parents of children with conduct
problems. Such issues could be addressed generally in parenting groups, as
many of the empirically supported parenting interventions are group-based
and may include discussion of family issues that are often associated with
child problem behaviors. In fact, given their effectiveness, group therapy for
parents of children with externalizing problems have been touted as more
cost effective than individual parent-based treatment (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004) provided that the approach to parent training
is amenable to group work.
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involved in the planning of the contract. The rationale for the adolescents
increased involvement includes a more sophisticated understanding of the
approaches used to improve his or her behavior and family relationships,
the benefits of having the adolescent as part of the intervention process,
making the parent accountable for providing appropriate consequences
contingent upon the adolescents behavior, and making the adolescent
responsible for meeting the behavioral expectations set forth by the contract (see Barkley et al., 1999).
The second phase of this program is family-focused and deals with
the importance of improving family communication habits in reducing
the teens problematic behaviors. In addition, unreasonable beliefs (e.g.,
expectations of perfect compliance, expectations of negative outcomes if
the adolescent is granted some autonomy) are discussed as a precipitant
of many hostile adolescentparent interactions. Finally, the family members practice their communication and problem-solving skills in sessions
with direction and guidance from the therapist. Of course, a wealth of
evidence supports the effectiveness of the parenting strategies introduced
in the first part of this program, although less is known about developmental adaptations for adolescents. Recent evidence has also specifically
supported the benefits of family-based intervention such as that provided
in the second part of this program for symptoms associated with ADHD
and ODD (Anastopolous, Shelton, & Barkley, 2005).
An example of a parent-focused intervention with clear empirical support for reducing child oppositional and noncompliant behavior is PCIT
developed by Sheila Eyberg and colleagues (see Brinkmeyer & Eyberg,
2003). This program is oriented toward a variety of child acting-out behaviors ranging from talking back to authority figures to aggression and is
based on both attachment and social learning theories. More specifically, maladaptive parentchild attachment (e.g., low tolerance for child
emotional expressiveness) and patterns of escalating and aversive parentchild interactions are thought to contribute to the childs aggression,
poor coping skills, and noncompliance (Eyberg & Brinkmeyer, 2003). In
this approach, however, the parent is the agent of change in the childs
behavior. In other words, PCIT does not focus on enhancing the childs
coping skills per se.
As with many other parenting programs, PCIT begins with a focus
on child-directed interactions, a difference being that parenting skills
surrounding such interactions are modeled and practiced in vivo with
regular practice assigned between sessions as opposed to only being discussed and assigned as subsequent homework. Indeed, therapists in PCIT
serve as coaches in that they discuss and model parenting skills and
then observe the parents use of these skills in session (Brinkmeyer &
Eyberg, 2003). During child-directed interactions, the parent is charged
with praising the childs behavior, reflecting the childs statements, imitating and describing the childs play, and using enthusiasm (i.e., PRIDE
skills; Brinkmeyer & Eyberg, 2003; p. 207). In other words, the parent
is cautioned not to make commands during this time or to control the
activities in which he or she engages with the child. Instead, the parent
ignores minor misbehavior during these interactions and discontinues the
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INDIVIDUAL-BASED TREATMENTS
Common Elements
The development of individual-based treatments (i.e., those that
involve direct work with the child or adolescent) for conduct disorders
speaks to the role of the youths individual tendencies in the development and maintenance of many problem behaviors. In addition to various
familial risk factors for conduct problems, youth with such problems may
also have poor interpersonal skills as well as cognitive distortions or deficiencies (Kazdin, 2003). Many treatment programs geared directly toward
youth with conduct disorders are born out of presumed interpersonal and
intrapersonal etiological factors. For example, the individuals (perceived)
reinforcement and punishment history for a set of behaviors as well as his
cognitive appraisal of a situation and of the available consequences for a
set of behaviors may serve to shape some conduct problem behaviors such
as aggression.
Thus, individual-based treatments tend to emphasize cognitive and
behavioral strategies to reduce the frequency of problem behaviors and
to improve the youths positive coping responses to anger-provoking situations. The programs may be geared toward increasing cognitive activity
(i.e., impulse control) or altering maladaptive cognitive strategies (i.e., hostile attributional biases) that may contribute to conduct problem, including aggressive, behaviors (see Crick & Dodge, 1996; Lochman & Wells,
1996) These programs also typically include social skills training given the
social skills deficits that are often part of the clinical picture for children
with conduct problems (Kazdin, 2003) as well as social problem-solving
skills so that an individual can employ effective and prosocial behaviors in
difficult peer contexts.
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skills are then introduced to emphasize the accurate identification of problems, considering all possible courses of action, and then consideration
of the positive and negative consequences of each behavioral choice. This
problem-solving model is repeated throughout the remainder of the sessions. The program also has a significant modeling component whereby
not only do the individuals in the group learn coping skills from others
as well as model them in the group, but they also create a video illustrating the coping skills developed in the program as a sort of public service
announcement.
The final six to ten sessions focus on applying problem-solving skills
geared toward particular peer contexts, reviewing the progress of each
group member, and planning for the generalization of these skills to individuals various contexts. The group format allows for role-playing activities
that involve identifying problematic social cognitions (e.g., hostile attributional biases) and that allow practice of effective social problem-solving
skills (e.g., resistance to peer pressure; see Lochman & Wells, 1996).
A similar program to the Coping Power Program is an anger control
training program entitled the Chill Out Program (Feindler & Guttman,
1994) which has enjoyed considerable empirical support. However, this
program has been more specifically geared toward adolescents, whereas
the Coping Power Program is specifically geared toward aiding at-risk
youth in making the transition to middle school. The Chill Out Program
subscribes to the idea that adolescents lose control of their anger due to
deficits in both cognitive and behavioral skills (Feindler, Ecton, Kingsley,
& Dubey, 1986; Feindler, Marriott, & Iwata, 1984), and as such, it seeks
to rectify such deficits by focusing on the underlying cognitions (e.g., hostile attributional bias) involved in the expression of anger and impulsivity that is typically associated with these cognitive distortions (Feindler
et al., 1986).
The Chill Out Program is designed for use with adolescents aged 13 to
18 who have already demonstrated aggressive behavior in their environment. It is a highly structured program conducted in a group setting with
typically eight individuals per group. There are ten sessions, each of which
focuses on a specific skills being taught, then modeled, rehearsed through
role-play, and then applied to the natural environment. The skills taught
at the ten sessions are rules and reinforcers, relaxation, self-monitoring,
triggers, refuting aggressive beliefs, assertion techniques, self-instruction
training, problem-solving training, thinking ahead, and program review
(see Feindler & Guttman, 1994).
Feindler and others (Feindler, 1990; Lochman & Lampron, 1988) have
noted that the anger control training may only be useful for a limited
period of time immediately following treatment and not as effective longterm. In addition, it has been noted that anger control training tends to
be more effective when it is used in conjunction with other behavioral
strategies (e.g., consistent consequences for problem behaviors; Lochman
& Lampron, 1988). Another investigation demonstrated empirical support
for the Chill Out Program has also been indicated on self-report measures,
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MULTIFACETED PROGRAMS
Overview
Existing treatment approaches for child conduct disorders also include
multifaceted approaches that take either a broad multisystemic approach
(e.g., Henggeler & Lee, 2003) or have multiple related components that
target multiple recipients in multiple settings (e.g., Conduct Problems Prevention Research Group, 1992). These programs have been influential in
how treatments for conduct problems are viewed. Specifically, they have
provided evidence that youth with conduct disorders can be effectively
treated in home-based interventions (e.g., Henggeler, Schoenwald, Bordvin, Rowland, & Cunningham, 1998) and through in-school strategies
(Lochman, Lampron, Gemmer, & Harris, 1987), rather than automatically
equating conduct disorders with a need for treatment in more restrictive
environments.
For example, Multisystemic Therapy (MST; Henggeler & Lee, 2003)
has enjoyed considerable empirical support and approaches conduct
problems from a broad perspective, taking into account the influence of
the youths various contexts on her behavior problems. MST is particularly oriented toward adolescents and comprises multiple levels of treatment that include the individual, family, school, peers, and neighborhood.
Treatment is actually conducted in each of these contexts as appropriate
and feasible (see below).
The parent component of the Incredible Years Program was described
above, yet this program is an example of one with well-defined child and
teacher components. Therefore, it can function as a multifaceted program
or any combination of the three elements could be used in treatment
depending on the needs of the child and adults in his home or school
contexts. As does the parent component, the child component uses social
learning principles in developing basic coping skills as well as has an
emphasis on helping the youth set appropriate behavioral goals.
According to Webster-Stratton and Reid (2003), this program as a
whole promotes parentteacher communication and encourages parents
to become involved in monitoring the childs performance and behavior in
school. The school component is particularly geared toward classroomwide
interventions for the prevention of disruptive behaviors as opposed to targeting one specific child or a small group of children for in-school intervention. Researchers have demonstrated that the addition of parent, teacher,
and/or child components to the treatment package using The Incredible
Years Program enhances outcomes regarding the target childs conduct
problem symptoms (Webster-Stratton & Reid, 2003).
In most multifaceted programs, parents are still exposed to traditional parent-training techniques, and although the presumed cause
of the youths problems is thought to be reciprocal between the youth
and his or her contexts, the parent may still be seen as the primary
agent of change. Such as discussed below, family-based work within
these models seeks to directly target family communication and conflict, and such an emphasis is thought to be associated with decrease
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work directly with school officials regarding academic planning for the
adolescent and work with the family on ways to engage the adolescent
in positive extracurricular activities. The influence of peer affiliations
is also addressed in this intervention through discussions of friendship
choice and the influence of decisions in that domain on the youths
outcomes (see Hogue et al., 2006). A formal focus on community-based
factors is unique, even though tight control over how such extramilial
factors are implemented and the behavioral contingencies in place in
such contexts cannot be fully addressed. MDFT also seeks to address
parental risk factors for youth problems both within the intervention
(e.g., parenting skills; family communication) but also through additional resources (e.g., parental drug treatment; increasing social support; Hogue et al., 2006). An initial clinical trial of MDFT found it to be
as effective as a traditional cognitive-behavioral intervention but more
effective for the long-term maintenance of positive outcomes in the form
of reduced substance use (Liddle, 2002).
RESIDENTIAL TREATMENT
Overview
The term residential treatment has been used to describe a number
of varied approaches to intervention beyond outpatient care. We have thus
far focused our discussion on treatments that are applied in outpatient
settings, although elements of these treatments (e.g., Coping Power) could
be applied within a residential setting. Although obviously less intensive in
surroundings, outpatient treatments are not necessarily shorter in duration than residential treatments, particularly inpatient hospitalizations
(see Lyman & Barry, 2006). More restrictive than most outpatient treatment models are day treatment modelsalso referred to as partial hospitalization programswhich provide a therapeutic environment during
the day including academic instruction such that the child is not removed
from the home environment. The range of services available in these settings are broader than those often employed in outpatient settings and
include individual therapy, group therapy, psychopharmacological interventions, and classroom accommodations.
Several additional treatment models involve removal of the youth
from the home environment at least for some period of time and in that
sense, are considered residential. These placements include short term
respite care, group-home care, residential treatment centers, inpatient
hospitalization, and institutionalization (Lyman & Barry, 2006). The
specific treatment strategies within each of these models are diverse
ranging from virtually nonexistent in some respite care or group-home
settings to quite intensive in any of these settings. For instance, and
depending often on local resources, group-home care may or may not
include a formal treatment regimen conducted by trained professional.
Each of these treatment models also varies in size and scope. It should
also be kept in mind that children may be placed in residential settings
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are often effective and necessary for youth whose emotional and/or
behavioral state is dangerous to themselves or others and whose psychological difficulties seem to have some organic component. Inpatient
hospitalization is primarily focused on crisis stabilization as opposed
to long-term treatment. The usefulness and cost-effectiveness of hospitalization for conduct disorders is quite limited, although such an
approach may be warranted and effective for substance abuse problems
in particular (see Lyman & Barry, 2006).
EVIDENCE-BASED PRACTICE
The interventions discussed above, particularly the outpatient interventions with parent, child, and/or teacher components have enjoyed a
great deal of empirical support. The APA Task Force for identifying empirically supported treatments presents summaries of the treatments that
have met the criteria to be considered well established and those meeting the criteria of being probably efficacious. These empirically supported
treatments, some of which are summarized above, are discussed on the
website: www.effectivechildtherapy.com. It is expected that the attention
to, and debate concerning, evidence-based practice will only further the
efforts of professionals and the public at large to consider what works in
designing, seeking, or implementing the treatments most likely to ameliorate child conduct problem symptoms. This evidence base also serves
as the foundation for further research and innovation in the design of
interventions that might demonstrate even more effectiveness, for longer
periods of time, and/or for a broader range of youth.
With well-developed supported interventions in existence, it becomes
the charge of practitioners and training programs to make evidencebased practice the centerpiece of their work and training of treatments
for conduct disorders. For example, as noted above, empirically supported
parenting interventions generally include an emphasis on positive reinforcement and increasing positive behaviors first before an emphasis on
strategies to punish noncompliance. In part, the theoretical rationale for
such a strategy is to provide guidance to children on what to do instead
of only what behaviors not to engage in, as well as to improve the quality
of parentchild interactions (e.g., Barkley, 1997). Therefore, to emphasize
punitive strategies in parent training first would be doing so against the
preponderance of empirical evidence.
In addition to the mediating effects of positive parenting practices
resulting from parenting programs, these approaches to intervention are
also thought to be most effective through the reduction of coercive parentchild interactions and when management strategies are more clearly
and consistently associated with the childs behavior (Reyno & McGrath,
2006). Furthermore, parenting programs can be effective in not only reducing the target childs conduct problem symptoms, but also in improving
parentchild interactions, parental consistency, and even sibling behavior
(see Gardner et al., 2006). More important, it appears that the effects of
evidence-based treatments for conduct problems maintain some level of
128
positive outcomes over time (Gardner et al., 2006). The length of treatment varies with the approach and severity of the childs problems, but for
parenting interventions in particular, having a greater number of sessions
is associated with poorer outcomes, often because of poor parental adherence or performance while moving through the sequence of parent training
steps implemented in most programs (see Hogue et al., 2006).
Although fairly well-developed theoretical rationales exist for the treatment of conduct disorders through psychoanalytical perspectives (e.g.,
self-psychology; see Liberman, 2006), the evidence supporting these interventions is lacking. Unlike the approaches outlined in this chapter, selfpsychology takes a nondirective approach whereby the therapist seeks to
understand the youths subjective world view. Such an approach is likely
quite limited for young children and/or youth who have difficulty with
verbal expression. It should also be noted that verbal reasoning deficits
are often associated with child conduct disorders (Lynam & Henry, 2001;
Speltz, DeKlyen, Calderon, Greenberg, & Fisher, 1999), further calling into
question the utility of this treatment for a sizable segment of the population who exhibit conduct problems.
The presumed cause of child conduct problems from this perspective is
that of unrealistic, or immature, narcissism that developsat least in part
from inappropriate or absent parental response to child distress (Liberman,
2006). Although narcissism has been found to be related to child and adolescent problem behaviors (Barry, Frick, & Killian, 2003; Barry, Grafeman,
Adler, & Pickard, in press), it is unclear how the self-psychology approach
to assessing child narcissism would fit with current approaches to common
approaches for assessing the construct in youth and adults. The intervention
itself seeks to alter the youths unrealistic self-perceptions and to foster resilience in the face of adversity. Such goals could certainly reduce the likelihood
of acting-out behaviors, but the evidence of the presumed causal model and
the intervention itself are quite limited.
More recent efforts have sought to understand the intervening variables that indicate for whom and under what circumstances treatments
for conduct disorders are most effective. For example, Beauchaine and colleagues (2005) examined the short-term treatment outcomes for children
with an early onset of conduct problems. They found that parental risk factors (i.e., drug abuse, marital discord, maternal depression) and child risk
factors (e.g., comorbid internalizing problems) influenced treatment outcomes. For example, although children with comorbid internalizing problems presented with higher externalizing problems than children without
internalizing problems, the rate of improvement of the former group was
greater. That is, children and families who present with multiple risk factorsthus complicating the clinical picturecan still, and often do, benefit greatly from intervention targeting parenting skills and child conduct
problems. Kazdin and Whitley (2006) similarly demonstrated that children
with comorbid presentations exhibited the most change in response to
intervention and outcome symptom levels equivalent to children with a
single primary clinical problem.
Of course, clients presenting for treatment of child conduct disordersor
any other clinical issue for that mattervary in the degree to which they
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present with other factors that might complicate treatment planning and
call into question the applicability of evidence-based treatments. With the
influence of such risk factors (e.g., comorbidity) on the severity of the childs
presentation and response to intervention having been demonstrated (see
Beauchaine, Gartner, & Hagen, 2000; Kazdin & Whitley, 2006), it is clearly
indicated that interventions are not one-size-fits-all. Recent efforts to address
issues surrounding the influences of comorbidity and other indices of case
complexity (e.g., low SES) only serve to inform practitioners of the potential
benefits of many evidence-based interventions as well as instances in which
further examination and innovation are needed.
The design of interventions in terms of their target recipients and settings does seem to influence the specific conduct problem behaviors that
are affected. In particular, for families of children with conduct problems,
a parent-based component is essential for reducing the childs symptoms,
whereas teacher-based interventions appear to be particularly useful for
reducing disruptive classroom behaviors (see Beauchaine et al., 2005).
Based on the performance of standalone in relation to combined interventions, it has been argued that for young children in particular, parenting
interventions should be the front-line intervention for younger children
with supplemental teacher- or child-based interventions as indicated
(Beauchaine et al., 2005).
However, research cited above has demonstrated the benefits of adding components of treatment compared to a single intervention approach.
In addition, for older children and adolescents, it may be necessary to
include a direct intervention with the young person, considering parent
and teacher interventions as supplemental. Even with the most comprehensive approach to intervention involving all important systems or contexts, conduct problems remain difficult to treat. As noted by Beauchaine
and colleagues (2005), treatment nonresponders are of concern for practitioners and researchers, but they also are the basis of all advancements
in treatment design. That is, moderators of treatment outcome for youth
with conduct disorders are variables that are present at the outset of treatment. Therefore, awareness of the variables that appear to predict treatment response allows for the selection of the most appropriate treatment
for the presenting child.
The age of the child is one such variable in regard to treatment for
conduct problems, not only in terms of with whom treatment is performed but also with the general expectation that earlier intervention
increases the likelihood of meaningful reduction in conduct problems
(see Webster-Stratton & Reid, 2003). The youths developmental level
and developmental trajectory of problem behaviors is a similarly important consideration. For example, a preschool- or early school-aged child
would likely not comprehend the cognitive coping strategies that are
the bedrock of treatment approaches such as Coping Power or PSST.
Likewise, older but developmentally delayed youth would likely benefit less from such cognitive strategies than those that emphasize clear
behavior-consequence contingencies. Another such variable may be the
level of perceived social support experienced by families going through
treatment (Dadds & McHugh, 1992).
130
CONDUCT DISORDERS
131
are implemented. A child factor that has been associated with poorer treatment outcomes is the presence of psychopathy-linked characteristics, or
callous-unemotional (CU) traits (Hawes & Dadds, 2005). More specifically,
Hawes and Dadds (2005) found that CU traits were associated with poorer
outcomes among children with ODD following parent training, even when
controlling for parental education, child age, and parental adherence to
treatment. CU traits include a relative lack of empathy and guilt as well as
flat affect (see Frick, Bodin, & Barry, 2000).
Researchers have found that CU traits moderate the relation between
parenting practices and conduct problems (Wootton, Frick, Shelton, & Silverthorn, 1997; Oxford, Cavell, & Hughes, 2003), thus perhaps predicting
the attenuated effects of parenting interventions for the conduct problems of children with these traits. CU traits are particularly important to
understand in light of intervention planning and design given the association of these features with particularly severe, varied, and persistent child
conduct problems (Barry et al., 2000; Christian et al., 1997). Researchers in this area suggest that children with this interpersonal style tend
to be insensitive to punishment cues in laboratory situations (OBrien &
Frick, 1996) and to respond more to rewards than to punishments such as
time-out (Hawes & Dadds, 2005). Thus, it is imperative that pretreatment
assessments consider the presence of CU traits and that interventions
be developed that effectively address the unique presentation of conduct
problem symptoms for this subset of youth.
CONCLUSIONS
Limited, although emerging, research has examined the effectiveness
of adaptations of existing interventions for conduct problems. Bierman
and colleagues (2006) have noted that individualized interventions are
quite appealing but that the evidence regarding these adaptations is limited. Greene and colleagues (2004) have referred to such adaptations as
indispensable (p. 1163), and some treatment approaches (e.g., collaborative problem-solving) do not prescribe a particular topic or coverage of a
specific skill to a particular sequence of sessions.
Given the advocacy of evidence-based practice in psychology, not just
for treating child conduct disorders, and the evidence in support of these
interventions relative to usual clinical practice (Weisz, Jensen-Doss, &
Hawley, 2006), understanding if and how adapted treatment plans may be
useful is an essential question. A primary question in this regard is that of
therapist fidelity to a treatment program or protocol. The degree to which
therapists adhered to the guidelines of a particular program is unclear in
much of the research showing positive effects of treatment for conduct
disorders. On the other hand, it is unclear to what extent therapist fidelity
is necessary to achieve positive behavioral outcomes.
To further advance the knowledge, use, and effectiveness of evidencebased interventions, successful adaptations must be disseminated, and
judgments regarding the need for making adaptations must follow guidelines that can be easily documented and followed by other professionals.
132
It has been shown that the more specific the areas of functioning on which
such judgments are based, the greater likelihood of positive outcomes for
adapted interventions (Bierman et al., 2006). Therefore, a call for evidence-based practice is not to limit the flexibility of clinicians or the applicability of interventions to specific clients with conduct problems, but to
ultimately allow our field to widen the evidence base and to enhance the
services provided to the youth and families who we serve.
A similar area of inquiry is the degree to which efficacious treatments
show effectiveness for a broader range of settings, trained professionals,
and clients. The generalizability of evidence-based treatments has been
called into question based largely on the relative homogeneity of clients
participating in clinical trials and heterogeneity of clients presenting in
clinical practice settings (Dulcan, 2005; Westen, Novotny, & Thompson-Brenner, 2004). Chorpita (2003) has clearly described a number of
important practice considerations (e.g., supervision, addressing attrition,
demographics, payment options, clients prior experience with treatment,
etc.) that must be made for efficacious treatments to most readily demonstrate effectiveness.
Furthermore, an expanding body of literature has examined the
adaptability of existing interventions to clients from diverse backgrounds
(e.g., Forehand & Kotchick, 1996; Santisteban et al., 2003) or the effectiveness of interventions developed for clients from nondominant cultures
(e.g., Non-English-speaking background; Sonderegger & Barrett, 2004).
Of course, direct investigations of the outcomes for interventions with
diverse clientele are preferable to assumptions that existing treatments
for conduct problems will translate directly to diverse clientele. A complete
consideration of the strides made in these areas as well as the numerous unanswered questions for treatment and treatment outcome research
would be too extensive for the present discussion.
Because of the level of similarity among empirically supported treatments for child conduct problems, it remains unclear as to which elements
of these interventions are more or less dispensable. To address this question,
dismantling studies that incorporate multiple intervention conditions and
that include frequent assessment of processes and outcomes are necessary
(Kazdin & Nock, 2003). Such an undertaking would be daunting but could
be useful in further streamlining interventions and informing practitioners as to the key aspects of treatment on which to focus. Without extensive
research on this issue, we still remain optimistic about the current state of
treatment for youth conduct problems in that the treatment packages that
existif imparted to the practicing publichave demonstrated that they
can improve the functioning and lives of youth and their families.
Perhaps the clearest conclusion from the literature on developmental
trajectories of children with conduct disorders and the treatment of these
problems is the need for early prevention/intervention. Webster Stratton and Reid (2003) noted that the primary developmental pathway
for serious conduct problems in adolescence and adulthood appears to be
established during the preschool period (p. 224). It is has been concluded
that such effortsparticularly for the youngest childrenshould include
a parent-based or family-based perspective with attention devoted to ways
CONDUCT DISORDERS
133
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6
Treatment of
Attention-Deficit/
Hyperactivity Disorder
(ADHD)
DITZA ZACHOR, BART HODGENS, and
CRYSHELLE PATTERSON
139
140
Clinicians who diagnose and treat children with ADHD should develop
a comprehensive treatment plan that recognizes the complexity and
chronic nature of the disorder. First, a diagnosis of ADHD requires that
the child meet criteria from the Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition (DSMIV) in terms of core symptoms, onset, duration,
and functional impairment in more than one setting (American Academy
of Pediatrics, 2001). During the initial assessment, clinicians should first
obtain information regarding the nature of the childs symptoms (mostly
inattention, behavioral difficulties, etc.) and then determine the severity
of the core ADHD symptoms, existence of comorbidities, and the extent of
the impairment seen across the different environments.
Because the diagnosis of ADHD and the possible need for chronic
medical treatment may cause concerns and even anxiety for the family
and the child, it is important to provide counseling prior to initiation of
therapy. In addition, clinicians should be aware of the family expectations
from the treatment and their treatment preferences, thereby optimizing
compliance and clinical outcome.
Next, it is important to set individualized treatment goals. The American
Academy of Pediatrics (AAP) guidelines suggest several outcome measures
based on the most disabling core ADHD symptoms (e.g., decrease disruptive
behaviors, improve academic performance, improve relationship with family,
teachers, and peers and improve self-esteem). It is advisable to choose
measurable goals that can assess progress from a baseline state (American
Academy of Pediatrics, 2001).
Treatment of ADHD consists of two general categories, medication
management and behavioral treatment strategies. The following sections
describe these treatment strategies in detail, as well as the benefits of
a multimodal strategy. The multimodal approach combines the careful
medication management of ADHD with proven psychosocial interventions
such as parent education, educational intervention, and behavioral therapy
in a comprehensive approach. Throughout this chapter, frequent reference
is made to the Multimodal Treatment Study of children with ADHD (MTA),
the largest randomized clinical trial for the treatment of ADHD ever
conducted (MTA Cooperative Group, 1999a). Therefore, it merits particular
attention before discussing treatment approaches in detail.
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141
142
TREATMENT OF ATTENTION-DEFICIT
143
MEDICATION
The neurobiological basis of pharmacotherapy in ADHD has been based
on the catecholamine mechanism of action in the central nervous system
(CNS). The frontal subcortical-cerebellar circuits are rich in dopaminergic
synapses and control a set of executive functions (inhibition, working memory, set shifting, planning and sustained attention, regulation of reward
systems and arousal states; Castellanos & Tannock, 2002). The pattern
of neuropsychological deficits in ADHD might originate from deregulation
of these CNS circuits. The underlying causes of ADHD are not well understood, but there is considerable evidence indicating that dopaminergic and
noradrenergic neurotransmission are dysregulated in ADHD. Support for
this concept comes from different studies:
The action of drugs that increase the synaptic availability of dopamine
and norepinephrine on ADHD symptoms.
Animal models of ADHD (created via lesions in dopamine pathways).
Structural and functional neuroimaging studies showing that brain
regions rich in dopaminergic innervations are associated with ADHD.
Various genes coding for proteins involved in dopaminergic neurotransmission were associated with ADHD (Cheon et al., 2003; Castellano, & Tannock, 2002; Krause, Dresel, Krause, Kung & Tatsch,
2000; Solanto, 2002).
The main pharmacotherapy for ADHD has for decades been the
stimulant drugs methylphenidate and amphetamine, which are believed
to enhance neurotransmission of dopamine and epinephrine. Methylphenidate is thought to act primarily by blocking reuptake of dopamine
transporters, whereas amphetamines are thought to exert their effect by
blocking noradrenergic transporters and by facilitating neurotransmitter
release. Because ADHD symptoms of inattention and hyperactivity/impulsivity reflect possible dysregulation of the monoamines system, stimulants
are thought to normalize the function of the relevant brain regions by
enhancing the neurotransmission of dopamine and norepinephrine in
therapeutic doses.
144
Drug Name
Methylphenidate (MPH)
Maximal dose: 60 mg
Ritalin
Methylin
Duration
(Hours)
34
23 times a day
23 times a day Chewable
tablets
23 times a day d-MPH isomer
45
2 daily
46
Focalin
Amphetamine:
Dextroamphetamine
Maximal dose: 40 mg
Mixed salts of amphetamines
Maximal dose: 40 mg
DextroStat
Dexedrine
Adderall
Special Consideration
TREATMENT OF ATTENTION-DEFICIT
145
Active Ingredients
Drug Name
Methylphenidate
(MPH)
Ritalin SR
48
Ritalin LA
48
Metadate ER
Metadate CD
48
48
Methylin ER
Focalin XR
48
48
Concerta
12
Daytrana
9 wear
time
Dexedrine
Spansules
Adderall XR
68
1012
Vyvance
1012
Amphetamine:
Dextroamphetamine
Mixed salts of
amphetamines
Amphetamine prodrug:
Lisdexamfetamine
dimesylate
Special Consideration
Tablets must be swallowed whole
Maximal dose: 60 mg
Bimodal release system Capsules must
be swallowed whole or sprinkled on
applesauce
Maximal dose: 60 mg
Tablets must be swallowed whole
Capsules must be taken whole,
available in dose packs
Maximal dose: 60 mg
Tablets must be swallowed whole
d-MPH isomer
Maximal dose: 20 mg
OROS delivery system
Maximal dose: 72 mg
Transdermal patch
Maximal recommended
daily dose: 45 mg
Maximal recommended
daily dose: 40 mg
Maximal recommended
daily dose: 70 mg
146
TREATMENT OF ATTENTION-DEFICIT
147
improvements in the childrens behavior throughout the day on ADHD rating scales for three examined doses (30, 50, 70 mg) compared with placebo
(Biederman, Krishnan, Zhang, McGough, & Findling, 2007).
Modafinil is a new stimulant that is structurally and pharmacologically different from other stimulant medications for ADHD and has low
potential for abuse. Modafinil has been used to promote wakefulness for
narcolepsy. The mechanism of action is not entirely known, but it appears
that Modafinil alters the balance of gamma-aminobutyric acid and glutamate, which results in activation of the hypothalamus, and increases the
metabolic rate in the thalamus, amygdala, and hippocampus (Rugino &
Copley, 2001; Rugino & Samsock, 2003). In a double-blind placebo-controlled study in children with ADHD, one 300 mg dose of Modafinil per
day greatly improved symptoms that were rated by teachers, clinicians,
and parents. A larger dose of 400 mg did not add greater effect than
the lower dose. All the doses were well tolerated and the most common
adverse effects were insomnia, headache, decreased appetite, abdominal pains, cough, fever, and rhinitis (Turner, Clark, Dawson, Robbins, &
Sahakian, 2004).
148
before first tic onset. Some concerns exist that stimulants may increase
the risk of first-onset tics or worsening of pre-existing tics. Early reports
showed stimulants might raise the risk for tics in patients with a personal
or family history of tics (Lowe, Cohen, Deltor, Kremenitzer, & Shaywitz,
1982). These authors claimed that Tourette syndrome or tics in a child are
a contraindication to the use of stimulants. However, recent reports challenge this view and a metaanalysis of studies with high methodological
quality (double-blind placebo-controlled) revealed that there seems to be
no elevated risk of first-onset tics during stimulant treatment (Roessner,
Robatzek, Knapp, Banaschewski, & Rothenberger, 2006)
In addition, stimulants are believed to lower the threshold for seizures but a diagnosis of epilepsy is not an absolute contraindication to the
use of stimulants. Although several studies have revealed that stimulants
do not exacerbate well-controlled epilepsy, children should be monitored
closely for exacerbation of seizures while on the medication. A recent study
reported 2% seizures in a stimulant-treated group of children diagnosed
with ADHD. This rate is not exceptionally high given that an estimated 1%
of unselected children will have at least one afebrile seizure by 14 years
of age. This study found that epileptiform EEGs identified a subgroup of
children with ADHD with seizure risk of up to 20%, whereas normal EEGs
indicated minimal risk (<1%) for seizures. The risk was not attributable to
stimulant use (Hemmer, Pasternak, Zecker, & Trommer, 2001).
Stimulant drugs are controlled substances with addictive potential and
therefore parents have raised their concerns about their children being
prone to abuse and addiction after long-term treatment. Studies looking
at these questions have shown that the pharmacotherapy of ADHD has
a significant protective effect and instead of causing substance abuse
actually reduces the risk for this disorder by 50% (Wilens, Faraone, Biederman, & Guanawardene, 2003).
Recently, a warning was added to the label of Adderall XR cautioning
that misuse of amphetamines can lead to serious cardiovascular events
and to sudden death. Although these cases are rare, it is important to
verify underlying structural cardiac abnormalities, inquire about family
history of unexplained cardiac deaths before initiation of treatment with
stimulants, and provide adequate cardiac monitoring afterward. A recent
study that evaluated cardiovascular safety of mixed amphetamine salts
extended release on about 3,000 children with ADHD demonstrated both
efficacy and cardiac safety (Donner, Michaels, & Ambrosini, 2007).
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149
Nonstimulant Medications
Although 8090% of children who are diagnosed with one of the ADHD
subtypes will respond to one of the stimulant medications favorably, some
children will not show effective control of the symptoms or will be intolerant
of stimulants. Nonstimulant medications such as Atomoxetine (Strattera),
antidepressants, and alpha-adrenergic agents have shown benefit in controlling symptoms of ADHD, although the response has not been as effective as that of stimulants (Table 6.4).
Medications
Tricyclic Antidepressants
Amytriptline
Desipramine
Imipramine
Clomipramine
Nortriptyline
Clonidine
Guanfacine
Atomoxetine
Modafinil
Bupropion
Alpha 2 agonists
Others
150
The most established and extensively studied nonstimulant treatments for ADHD have been the tricyclic antidepressant group. Studies
show these medications are superior to placebo in controlling ADHD symptoms. Their use is not approved in pediatric ADHD because of their low
margin of safety, possible cardiac side effects, and the requirements for
careful monitoring of levels and adverse effects. The tricyclic antidepressants have a potential risk for serious cardiovascular adverse events (i.e.,
unexplained deaths in four children treated with desipramine), although
the link between the treatment and the events remained uncertain
(Biederman, Thisted, Greenhill, & Ryan, 1995).
Atomoxetine (Strattera), a selective norepinephrine reuptake inhibitor with no significant effect on dopamine, is another relatively new
nonstimulant approved for ADHD treatment by the Food and Drug
Administration (FDA) in children and adults. Controlled trials have
shown superiority of Atomoxetin to placebo for the treatment of ADHD
symptoms and in improving self-esteem, interpersonal and family relationships, and overall functioning (Barton, 2005). Therefore, Atomoxetine
can be an alternative for children who cannot tolerate or do not respond
to stimulants. The degree of response to atomoxetine is slightly lower
than that to stimulants and therapeutic effects may appear after several
weeks of treatment.
Advantages are the long duration of action, little or no abuse potential,
no effect on sleep, and good tolerability. In addition, atomoxetine is not
a schedule II controlled substance. The half-life of atomoxetine is about
five hours but after two to four weeks of therapy, when maximal response
is achieved, clinical effects appear to be long lasting. Tapering is necessary when discontinuing the medicine. There is no major effect on growth
with atomoxetine. In addition, atomoxetine (a weak antidepressant) may
be useful for children with comorbid anxiety, sleep disorder, or tics as
no increase in tics has been documented. The most common side effects
reported with atomoxetine use include upset stomach, decreased appetite,
nausea, dyspepsia, vomiting, tiredness, dizziness, somnolence, and mood
swings. These side effects tend to be transient occurring during initiation
and titration of the medicine. The FDA required that atomoxetine carry a
black box warning indicating the possibility of severe liver injury in rare
cases, and of increased risk of suicidal thinking in children and adolescents (http://www.fda.gov).
The group of adrenergic agonists, such as clonidine and guanfacine,
is occasionally a useful option for ADHD treatment. Both drugs are not
presently approved by the FDA for ADHD treatment but are used to augment
stimulant therapy especially to control extreme impulsivity. Clinicians
should consider treatment with agonists when ADHD is associated
with tic disorder or Tourette syndrome and especially if treatment with
stimulants makes the tics worse. A meta-analysis of clinical trials involving
clonidine (a weak blood pressure medicine) concluded that this medicine
is effective as a second-line therapy, although the clinical effect is lower
than that of stimulants. A high rate of side effects are associated with
clonidine treatment including, sedation, irritability, sleep disturbance,
blood pressure drop, hypotension (new onset blood pressure lower than
TREATMENT OF ATTENTION-DEFICIT
151
the 5th percentile for age and gender), dry mouth, and dizziness (Connor,
Fletcher, & Swanson, 1999).
Guanfacine is less sedating and has a longer duration of action than
clonidine. A randomized placebo control study of guanfacine for children
with ADHD and tic disorder found guanfacine was well tolerated, and
improvement of ADHD symptoms was similar to or better than with other
nonstimulant medications but less than with stimulant treatment (Schahil
et al., 2001). Dosing of guanfacine should start low and move upward
slowly to avoid sedative and hypotensive effects. In addition, abrupt withdrawal of guanfacine is not recommended and frequent blood pressure
monitoring is suggested.
Report of sudden deaths that have occurred after patients took
agonists with methylphenidate raised concerns about the safety of these
drugs combination. A phase III clinical trial examining the benefit of an
extended-release formulation (once daily) of guanfacine has concluded
and documented clinical significance. However, the adverse effects profile
of these new drugs needs to be further examined before their routine use
in ADHD treatment.
Bupropion, an atypical antidepressant, has modest efficacy in improving symptoms of ADHD as shown in open label and controlled small trials
(Wilens et al., 2005). Some studies suggest bupropion could be helpful for
patients with comorbid depression, bipolar disorder or substance abuse
(Wilens, Prince, Spencer, et al., 2003). The drug may exacerbate tics and
increase the threshold for seizures with increasing doses. Therefore, it is
contraindicated in children with seizure or tic disorders.
Omega-3 fatty acids are a family of long-chain polyunsaturated fatty
acids. Several natural observation studies have found lower levels of omega
3 fatty acids in persons with ADHD. Randomized controlled small studies
of enhanced dietary intake of the fatty acids have had ambiguous results.
Two studies found no improvement in ADHD-related symptoms and one
study showed improvement only in a few measures. Serious side effects were
not reported with omega-3 treatment (Hirayama, Hamazaki, & Terasawa,
2004; Richardson & Puri, 2002). The current approach is that dietary
supplementation with omega-3 fatty acids may have some theoretical beneficial
effects for children with ADHD. However, there is insufficient evidence at this
time to substantiate the efficacy and safety of this treatment.
152
TREATMENT OF ATTENTION-DEFICIT
153
154
PSYCHOSOCIAL INTERVENTIONS
Numerous interventions and therapies have been developed and touted
as effective treatments for ADHD but only three interventions have stood
the test of randomized clinical trial in controlled scientific studies and
consistently been found to provide meaningful benefits to the child with
ADHD: behavioral parent training, classroom behavior management, and
summer treatment programs (e.g., Chronis, Jones, & Raggi, 2006; Pelham &
Fabiano, 2008). These evidence-based treatment approaches are reviewed
in detail in the following sections.
TREATMENT OF ATTENTION-DEFICIT
155
also thought to be an increase in parental confidence, a reduction in parent stress, and an improvement in family relationships (Anastopoulos
et al., 1993).
Parent training is typically most effective with children 4 through 12
years of age (Anastopoulos & Farley, 2003). In addition, it can typically be
delivered in 8 to 12 sessions in a group or individual format. Sessions typically range from one hour, when conducted individually, to 90 minutes,
when conducted in a group setting. Individual behavioral parent training is thought to offer several advantages over group-based approaches,
including an increased ability to be flexible with the pace and content
of the sessions. Group sessions are, however, thought to be more costeffective, provide parents with a greater level of social support, and often
produce effects equivalent to individual parent-training sessions (Chronis,
Chako, Fabiano, Wymbs, & Pelham, 2004). Chronis and colleagues (2004)
suggest an approach to parent training which first includes all parents
being enrolled in group-based behavioral parent training with additional
individual sessions scheduled as needed for parents who do not maximally
benefit from group-based treatment or for those parents who drop out of
group-based treatment.
A variety of behavior management strategies is presented throughout the
parent training sessions. Parents are asked to practice these strategies
daily at home, at their childrens school, and in public places. Although
there are many different programs (Cunningham, Bremner, & Secord,
1997; Forehand & McMahon, 1981; Pfiffner, Mikami, Huang-Pollock,
Easterlin, Zalecki, & McBurnett, 2007) for parent training they share many
features in common. The following discussion of the specific components
of behavioral parent training will use those from the program developed by
Barkley and Anastopoulos (Barkley, 1987; Anastopoulos & Barkley, 1990;
Barkley, 1997) as a representative example.
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TREATMENT OF ATTENTION-DEFICIT
157
the first parental request. Children are allowed to cash in their points
or tokens for privileges on their list. Bonus chips/points can also be
dispensed when children follow rules/complete chores without parent
request or when children complete chores with a positive attitude. Setting up the home-reward system is often a difficult step in the parenttraining program, as parents may often feel as if they have attempted
to implement similar systems in the past with no success. Parents are
reminded of the impact of consistency with such a strategy and are also
provided additional phone support by the therapist outside the session
if necessary.
The sixth session introduces the response cost condition. It is important to note that up until this point in the program, there have been no
negative components. Parents are encouraged to begin to remove tokens
or points for noncompliance for one or two behaviors on the request list.
The response cost condition will often increase childrens levels of compliance with parental requests, as they often do not want to lose tokens or
points that they have earned. Parents are cautioned not to get into a negative behavior spiral with their child. More specifically, if a child does not
comply with a command on the third request, the parent is encouraged to
no longer remove tokens or points and instead remove privileges or institute a time out.
The seventh session covers time out in great detail. First parents
are asked to discuss their experience with the use of time out from reinforcement, in order to gauge the parents experiences with the strategy.
Although many parents often reveal that they have used their own time
out procedure unsuccessfully in the past, the therapist encourages the
parent to consider the components of this time out procedure. Parents
are asked to think of one or two more serious behaviors (i.e., hitting,
destroying property, repeated noncompliance) that would warrant the
use of time out. The components of time out are then discussed, which
include: the child serving a minimum amount of time in time out (i.e.,
one minute for one year of age); parents only approaching the time out
area when the child has been quiet for the last thirty seconds of time
out, in order to avoid reinforcing inappropriate behavior; parents reissuing the command that led the child to time out, which at times begins
the time out procedure again, if the child refuses to comply with the
command again.
The eighth session explores the use of behavior management strategies in
public places (e.g., grocery stores, department stores, libraries, churches).
The public situations are first discussed, and parents are asked to think
ahead about situations that may be potentially problematic, bringing
about difficult behavior. Next, parents are asked to set up their expectations for the situation and clearly explain these to the child. An incentive
for compliance in the situation is established, along with a negative consequence for noncompliance. The parent must have the child repeat back
the discussed expectations, reward for compliance, and punishment for
noncompliance.
The ninth session explores any issues the parent and/or child may be
having within the school domain. General education about parental rights
158
TREATMENT OF ATTENTION-DEFICIT
159
160
and classmates, and actively participate in the teaching/learning process. These tasks are often more difficult for children diagnosed with
ADHD. As a result of such difficulties, children with a diagnosis of
ADHD often deal with social rejection in the school setting (Miranda,
Jarque, & Tarraga, 2006). Thus, school-based interventions are an
important adjunct in addition to behavioral parent training and medication management (Chronis et al., 2004). Stimulants, although helpful in reducing symptoms of ADHD, have not been demonstrated to
produce long-term changes in the general academic performance or the
interpersonal functioning of children with ADHD. Pelham and Gnagy
(1999) noted that simply medicating children, without teaching them
the skills they need to improve their behavior and performance, is not
likely to improve the childrens long term prognosis (p. 226).
Classroom behavior management strategies include token economies, contingency contracting, response cost, and time out. Self-evaluation is also a strategy that has some efficacy in improving behavior
among children diagnosed with ADHD. In addition, other instructional
strategies are often effective (e.g., social skills training, task modification). These strategies are explored toward the end of this section; however, first there is a brief review of the existing literature of classroom
behavior management.
Literature
There is substantial evidence that behavioral classroom management
is a well-established intervention for children diagnosed with ADHD
(Pelham & Fabiano, 2008). Studies by Barkley et al. (2000) have
demonstrated the effectiveness of classroom behavior management
strategies. In fact, in the study conducted by Barkley and colleagues
(2000), only the groups that included a school-based component
benefitted from treatment. These authors assessed ADHD symptoms
rated by teachers, teacher-rated social skills, and independent
observations of classroom behavior. All measures showed significant
improvement relative to control conditions.
In addition, a study by Van Lier, Muthen, Van der Sar, & Crijnen,
(2004) used a behavior management game called the Good Behavior
Game, where the children earned rewards for contingent good behavior.
Teachers and children chose the norms (rules) for the classroom and
the rewards for following them. The children were divided evenly into
teams. As a result of the system, ADHD-related problems were significantly reduced. Another study by Northup et al. (1999) showed interactive effects of methylphenidate and multiple classroom contingencies.
The program consisted of four conditions (1) contingent teacher reprimands; (2) brief nonexclusory time out: child was turned away from
the desk, people, and all other activities if a specific negative behavior occurred; (3) no interaction: ignoring all student behavior; and (4)
alone: children were assigned a task alone, which they did without a
teacher present.
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161
162
TREATMENT OF ATTENTION-DEFICIT
163
children with ADHD is one where a number of individuals help to implement the program (i.e., teachers, parents, peers, identified student; Teeter,
1998). Working in this manner provides a more comprehensive approach
to problematic behavior, where the teacher is not solely responsible for
implementing programs and rewarding all classroom behavior.
Before creating a classroom program for children diagnosed with
ADHD, DuPaul and Stoner (2003, pp. 145147) suggest that the childs
treatment team consider the following issues.
(1) There should first be a thorough assessment of the presenting
problem, including a functional assessment.
(2) Children diagnosed with ADHD typically require more frequent
and specific feedback. Thus, contingencies should be delivered
in a continuous manner. Gradually, reinforcement schedules can
become less dense.
(3) The programs should be based on contingent positive reinforcement. Verbal reprimands are also effective if they are given in a
neutral, consistent, and immediate manner following the problem
behavior (Pfiffner & OLeary, 1993).
(4) When the target behavior is one that occurs during independent work
periods, task instructions should not involve more than a few steps.
The child should be asked to repeat the steps back to the teacher.
(5) Goals in the classroom should include academic products and
performance (i.e., accuracy and work completion) rather than
specific task-related behaviors (i.e., attention to task or staying in
ones seat). This is important because it promotes accurate teacher
monitoring and organizational skills. Also, these behaviors are
incompatible with inattentive and disruptive behaviors, and may
lead to a reduction in these behaviors (Pfiffner & OLeary, 1993).
(6) Preferred activities should be used as reinforcers (i.e. free choice,
access to classroom computer). Reinforcers should be rotated as
needed, in order to keep the children interested in them. A reward
menu should be created from direct questioning from the child,
regarding what he or she would like to earn. The teacher can also
observe the child engaging in his or her preferred activities in order
to create the reward menu.
(7) In order to increase the likelihood that the child will engage in
appropriate behavior during academic periods, priming is recommended. This includes the teacher reviewing a list of possible
rewards for appropriate behavior prior to beginning the academic
work. This way, the child has a clear idea of what he or she will
earn following the work period, if he or she meets the target
behavior.
(8) Finally, the intervention program must be routinely monitored and
evaluated. Changes in the contingency program could be based on
teacher-observed problems in the system. In addition, independent observers may also be enlisted to evaluate effectiveness and
fidelity of the program. Such information will help to determine
whether additional teacher training or support is necessary.
164
Token Economy
Token economies provide immediate reinforcement, specific rewards,
and potent rewards, which are often required for children diagnosed with
ADHD. In a token economy, one or more problematic behaviors are targeted for intervention. Target behaviors that focus on academic products
(i.e., completion of a specific number of problems, at a specific rate of accuracy) or specific actions (i.e., appropriate interactions with a peer) are often
appropriate. Behaviors that can be easily monitored should be selected.
In addition, the type of secondary reinforcer should be identified. These
can include poker chips, check marks, stickers on a card, or points. For
younger children, more tangible rewards are often recommended, whereas
older children may respond well to check marks or points. A token economy is not recommended for children under the age of five, rather primary
reinforcers (i.e., praise, social attention) are often suggested. The values
of target behaviors can then be determined. That is, the number of tokens
earned for completion of a target behavior is established.
The teacher and child then develop a list of rewards or privileges
for which the tokens can be exchanged. This list should include
low, medium, and high-cost items. Parents should be encouraged to
participate in this process, and also provide similar reinforcement
contingencies in the home setting. The child should then be taught the
new system. Initial targets are to be set at a level to ensure child success.
Tokens should be exchanged for classroom privileges at least once
daily. In addition, an ongoing evaluation of such a system is necessary,
where new behaviors could be added, mastered behaviors deleted, and
rewards changed or updated. A response cost (i.e., removal of tokens)
system may be incorporated when some appropriate behavior has been
achieved. The system should continue to be changed in order to promote
behavioral improvement and generalization. For example, as a child
masters a multistep task, the child should begin to receive tokens for
task completion and tokens for completion of each step should be faded
(DuPaul & Stoner, 2003).
Contingency Contracting
Another method of classroom behavior management is contingency
contracting. With this technique, there is a negotiated contractual agreement between a student and a teacher. Desired behavior and consequences
contingent on this behavior are discussed. This strategy is most effective
with children above the age of seven. In addition, a contingency contract
with children diagnosed with ADHD should not include an extended delay
between the behavior and designated consequences. Reinforcements at
the end of a work period or at the end of the school day may be most
appropriate (DuPaul & Stoner, 2003).
TREATMENT OF ATTENTION-DEFICIT
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Response Cost
Response cost includes the loss of privileges and points or tokens contingent upon negative behavior. Response cost, used in concordance with positive reinforcement procedures, is often successful. When used with positive
strategies, response cost increases on-task behavior, seatwork productivity,
and academic accuracy in children diagnosed with ADHD (DuPaul, Guevremont, & Barkley, 1992). An important point to consider when implementing
a system that includes a response cost condition is that the program should
emphasize positive aspects (i.e., earning points/tokens/stickers) over the
negative response cost component. This will be important in order to continue to motivate the child to engage in appropriate behavior.
Time Out
Time out is another type of mild punishment strategy that may be used
for the classroom. This technique involves restricting a child from positive
reinforcement. In order to be effective, this approach must be used when
there is a reinforcing environment to be removed from, when the function
of the childs behavior is to gain teacher attention, when it is implemented
immediately after the negative behavior occurs, and when the smallest
amount of time for the strategy to be effective (e.g., one to five minutes) is
used. Similar to the use of response cost strategies, time out should only
occur with ongoing positive reinforcement. Time out should only be used
if more positive and less restrictive behavioral strategies have failed to
address the negative behavior. However, more aggressive or severely disruptive behaviors should immediately result in the use of strategies such
as time out (DuPaul & Stoner, 2003).
166
Date:_____
Daily Report Card
Please rate behavior today in the areas listed below.
Use the following 1-5 ratings:
5 = excellent 4 = good 3 = fair 2 = poor 1 = very poor
Initial the box at the bottom of the column rated.
Send this card home each day! Add comments about
behavior on the back or bottom of the card.
Examples of Behaviors to be rated:
Class periods
89
910
1011
Lunch
121
12
23
1. Turned in homework/class
work
2. Began assignment with 3 or
fewer prompts.
3. Completed assignment with
80% accuracy
4. Followed Classroom Rules
Teachers initials
TREATMENT OF ATTENTION-DEFICIT
167
if the child does not meet his target behaviors in the morning, there are still
several chances for him to meet the target behavior throughout the school
day. In addition, there must be long- and short-term rewards implemented
at home for such a system to be successful. Parental involvement in a daily
report card system is essential in its success. Ongoing monitoring and evaluation is also important with such a system.
SELF-MANAGEMENT SYSTEMS
A goal for the treatment of children with ADHD is often to increase
self-control, which is quite difficult for children diagnosed with ADHD,
given their difficulties with inattention, hyperactivity, and impulsivity.
Self-management systems for ADHD include self-monitoring and self-reinforcement. These strategies are often referred to as cognitive-behavioral
interventions, given that they focus on changing cognitions and behavior.
Given the difficulties that children with ADHD have with internalization
of language, these strategies are not commonly used with this population
(Miranda et al., 2006). Research has not found these strategies to be consistently successful (Abikoff, 1985), thus, they are only briefly discussed.
Self-Monitoring
This strategy includes the observation and self-recording of instances
of target behaviors. Typically an auditory or visual cue is used to remind
the child to record her behavior at a specific time. The child would then
record the behavior on a graph on her desk. Attention-related behaviors
have been found to increase with the use of such a strategy (Barkley,
Copeland, & Sivage, 1980). However, some suggest that self-monitoring
is most effective when a child is monitoring task completion or accuracy
instead of attentive behavior.
Self-Reinforcement
With self-reinforcement, children are required to monitor, evaluate,
and reinforce their own performance. This type of system is often useful
when other more externally based systems are being faded out (Barkley,
1989). In addition, this type of strategy may be more acceptable at the
secondary level, given that children in this age range are likely to be reluctant to engage in an overt contingency management system (DuPaul &
Stoner, 2003). It is important to keep in mind that children diagnosed with
ADHD often have difficulty accurately rating their own behavior. Often
there is a tendency to remember positive behaviors rather than negative or
off-task behavior. Thus, it will be important to have a discussion with the
child regarding expectations for behavior, including what might warrant
a lower rating. The child will also need to be informed of privileges that
may be earned. The goal of such as a system is to eventually train the
child to monitor his or her own behavior, without constant feedback from
a teacher (DuPaul & Stoner, 2003).
168
Instructional Strategies
In addition to contingency management strategies, children with
ADHD also benefit from more instructional strategies in the areas of academics, learning, and study and social skills (DuPaul & Stoner, 2003).
Peer tutoring is an instructional strategy that can be helpful for children
diagnosed with ADHD. This consists of two students working together on
an academic activity, with one student providing assistance, feedback,
and/or instruction. For this strategy to be successful, it is important for
there to be a one-to-one ratio, that the instruction remain self-paced by
the learner, that there is continuous prompting, and that there is frequent
and immediate feedback about the quality of performance.
In addition, task modifications can also help to improve the performance
of children diagnosed with ADHD. This involves revising the curriculum or
aspects of it in an attempt to reduce problem behaviors. One such strategy
is choice-making, where a student chooses an academic task from two or
more options. Dunlap et al. (1994) examined this modification and found
that it resulted in reliable and consistent increases in task engagement and
a reduction in disruptive behavior. Increased task structure is also noted to
improve behavioral functioning in the classroom (Zentall & Leib, 1985).
Social skills instruction is also another important strategy for children
diagnosed with ADHD, given their difficulties with making and keeping
friends. Typically social skills training consists of role-playing a variety of
skills, such as asking questions, listening, cooperating, complimenting, and
so on. Researchers have approached social skills trainings from many fronts.
More specifically, at times the children practice the skills daily in the classroom
(Anahalt et al., 1998). Other methods include a social skills review with a peer
through a buddy system (Hoza et al., 2003). Social skills training can also be
woven into sports activities, where students practice their social skills in a
less-structured environment (Evans et al., 2004; Hoza et al., 2003).
In summary, classroom behavior management strategies include token
economies, contingency contracting, response cost, and time out. Self-evaluation and other instructional strategies have also led to some behavioral and
social improvement for children diagnosed with ADHD. Such systems should
include an individualized approach to addressing child needs, while using
data to guide the creation, implementation, and revisions of the program. The
most successful school-behavior plans for children diagnosed with ADHD are
those which include a team approach (i.e., teachers, parents, peers), where
there is adequate support and training for each member of the team. In addition, classroom behavior plans should be implemented in an ongoing manner, given the chronic nature of ADHD.
TREATMENT OF ATTENTION-DEFICIT
169
& Fabiano, 2008). More recently, convincing evidence for the treatment
efficacy of intensive summer treatment programs has been presented (Pelham & Fabiano, 2008). These programs are peer-based interventions and,
therefore, emphasize the development of social skills within an appropriate
social context. In this way, they are similar to other social skills programs
that utilize peers but these other programs have generally failed to meet
the stringent criteria for a well-established, evidence-based intervention
for ADHD (e.g., Antshel & Remer, 2005). Summer treatment programs differ from other behavioral peer interventions in terms of the intensity and
comprehensiveness of the intervention.
Summer treatment program (STP) interventions are typically daylong programs conducted for multiple weeks (e.g., five to eight weeks)
thereby delivering hundreds more hours of treatment compared to the
typical outpatient program. The intervention adopts a broad skillsbuilding approach conducted concurrently with contingency management systems such as a point or token system and time out procedures.
The focus on the development of socially important functional skills
and the use of direct observational methods during group peer interactions are hallmarks of the program.
Figure 6.2 illustrates a daily schedule for a STP with three groups.
The typical STP program is multifaceted and incorporates numerous
intervention components including social skills training, problem-solving discussions, sports skills and team membership development, academic and art instruction, contingency management systems, parent
education, and a home-based reward program (Pelham, Greiner, &
Gnagy, 2004). The programs extensive procedures have been manualized and incorporate features for daily monitoring of a broad range of
child behaviors and daily monitoring of counselors and teachers for
treatment fidelity (Pelham, et al., 2004). Because of the intensity and
comprehensive nature of the program, however, it is considerably more
difficult to implement than typical psychosocial interventions, a factor
that may currently limit its clinical utility in typical community settings
(Pelham & Fabiano, 2008).
The STP model was designed as an intensive summer day-treatment program primarily for children with ADHD and related disorders.
The model for the STP has been developed over a period of 25 years by
William Pelham, first at Florida State University, then the University of
Pittsburgh, and currently at SUNY Buffalo (Pelham et al., 2004). This
program has also been established and replicated in sites across the
country, as well as internationally (Yamashita et al., 2006). The STP
was an integral component of the psychosocial treatment package of
the Multi-modal Treatment Study, the largest randomized clinical trial
ever conducted for the treatment of ADHD (MTA Cooperative Group,
1999a). As a result of its exceptional record in clinical, training, and
research endeavors, the STP was named in 1993 as a Model Program
for Service Delivery for Child and Family Mental Health by the Section
on Clinical Child Psychology and Division of Child, Youth, and Family
Services of the American Psychological Association (Pelham, Fabiano,
Gnagy, Greiner, & Hoza, 2005).
170
Prior to 1998, the evidence base supporting the effectiveness of STPs was
relatively weak, relying primarily on uncontrolled prepost studies (Pelham &
Hoza, 1996) and analogue studies (e.g., Pelham & Bender, 1982). A number
of these earlier studies also focused on ADHD medication trials because the
STP model provides an excellent setting in which to evaluate medication
effects (e.g., Pelham, McBurnett, Milich, Murphy, & Thiele, 1990). For example, STPs have been an important site for the development of the methylphenidate transdermal patch, now approved for the treatment of ADHD by the
FDA (Pelham, Manos et al., 2005). More recently, however, attention has been
focused on the systematic and well-controlled study of the treatment efficacy
of behavioral components of STPs and establishing the empirical support for
their therapeutic potential. This is due in part to the inclusion of the STP as
a component of treatment for the MTA study.
As discussed in another section of this chapter, debate continues over
how best to interpret the results of this large multisite collaborative study
(e.g., Pelham, 1999) but the empirical support for the role of intensive
behavioral interventions such as STPs in improving the functional impairments associated with ADHD appears to be quite strong (e.g., Chronis,
Fabiano, & Gnagy, 2004). In fact, several recent studies have found that
STPs yield treatment effect sizes that are comparable to those reported for
stimulant medications.
Pelham et al. (2000), as part of the MTA study, examined the incremental effect of a well-controlled medication regimen when combined
with the intensive STP treatment across a broad range of measures,
including parent and teacher ratings, classroom observations, and
academic performance. This study differed from earlier MTA reports
because it measured treatment effects while each intervention (i.e.,
behavioral and medication) was active. In 1999, the initial report of
the MTA (MTA Cooperative Group, 1999a,b) showed large incremental effects of medication over behavioral intervention alone and small
incremental improvement for the combination of treatments over medication alone, however, it was conducted when most of the behavioral
treatment package (including the STP) had been stopped or faded.
The Pelham et al. (2000) study compared the two treatments when
both were active and found that the introduction of adjunctive stimulant
medication to an ongoing STP had no effect on the rate of improvement
and produced relatively few incremental gains on measures of acute
Morning
8:008:15
8:159:00
9:1510:15
10:3011:30
11:3012:00
11:45Noon
Afternoon
Social Skills
Soccer skills
Soccer game
Learning Center
Computer Skills
Lunch
12:151:15 Softball
1:302:30 Art/Snack
2:453:00 Yoga
4:005:00 Recess/ Departure
TREATMENT OF ATTENTION-DEFICIT
171
172
TREATMENT OF ATTENTION-DEFICIT
173
174
SUMMARY
There have been many methods and procedures highly touted as effective treatments for ADHD (e.g., Feingold, 1974) but only a handful have
stood the test of randomized and well-controlled clinical trials and replication. These are the evidence-based approaches described in this chapter, that is, medication (primarily stimulants), parent behavioral training,
classroom management strategies, and intensive peer-based interventions such as the summer treatment program that incorporate all of these
approaches in a comprehensive package. Even among these scientifically
validated approaches, it appears they are effective only when active and
may not lead to enduring changes if stopped.
Increasingly, researchers and clinicians in the ADHD field recognize
the chronic and intractable nature of this disorder as they attempt to
further develop and refine intervention methods that provide the needed
level of support and treatment on a continual and long-term basis. The
heterogeneity and variability in both the behavioral phenotype of ADHD,
its likely underlying neural bases, and the many genetic, physical,
and psychological contributing etiological factors are also increasingly
recognized as adding to the complexity of devising treatment strategies
that will apply effectively to the disorder as a whole (e.g., Nigg & Casey,
2005). It is clear that a unitary treatment approach will likely never be
the case and the continuing developments in neuroscience, molecular
genetics, and other scientific fields will likely lead to further refinements
and the identification of important ADHD subtypes, which have direct
implications for treatment.
Currently, clinicians are encouraged to carefully monitor the treatment response of each child with ADHD and consider the relative merits of a multimodal approach that incorporates some combination of the
strategies described in this chapter. Researchers are currently evaluating the critical components of the multimodal approach, in particular the
sequence with which different treatments are introduced and the relative
dose of each treatment that is required to produce the desired level of
change and sustain it over time. Parents of children with ADHD have made
it clear that the level of change they desire for their families goes beyond
the simple reduction of ADHD symptoms and includes the improvement of
functioning in all important areas of daily living.
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7
PTSD, Anxiety,
and Phobia
THOMPSON E. DAVIS III
INTRODUCTION
The treatment of childhood anxiety disorders is one of the most interesting and gratifying experiences in clinical psychology. For example, by using
techniques such as exposure to feared stimuli, a clinician can regularly effect
significant reductions of psychopathology in many youth in as little as a single
session for some disorders (e.g., specific phobias; cf., st, Svensson, Hellstrm,
& Lindwall, 2001). Moreover, the clinician is afforded the invigorating opportunity to handle and manage various stimuli (e.g., snakes, dogs, and insects)
that defy the common treatment session stereotype. Although certainly not all
anxiety disorders are so quickly amenable to treatment efforts, there has been
something of a renaissance in child anxiety treatment research since the introduction of evidence-based practices (EBPs) over a decade ago and the identification of the first empirically supported treatments (ESTs) for children.
Simultaneously, however, this attention and research is overdue and
deserved. There is an urgent need to continue child treatment research,
particularly with anxiety disorders. Based upon a recent review, it has
been estimated that between 2.4% and 23.9% of preadolescent children
have anxiety disorders depending on the disorder(s), sample, time period,
and methodologies used (Cartwright-Hatton, McNicol, & Doubleday, 2006).
Moreover, results of at least one study indicate that by 16 years of age 36.7%
of children will meet diagnostic criteria for at least one DSM-IV disorder
(i.e., Diagnostic and Statistical Manual of Mental Disordersfourth edition,
American Psychiatric Association, 1994), and that 9.9% will meet criteria for
an anxiety disorder (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003).
Anxiety disorders in children have been associated with interference
in academic endeavors (Last, Hansen, & Franco, 1997) and even include
THOMPSON E. DAVIS III Louisiana State University
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2000). Most of these fears subside with age, however, a fear of death and
danger generally persists throughout development (Gullone, 2000).
Clinical levels of fear and worry typically distinguish themselves from
this common developmental course by an undue persistence and intensity
of fearful and anxious reactions. Most fears and anxieties are presumably corrected through disconfirmatory experiences (e.g., corrective information, positive encounters, experience coping with negative encounters,
repeated exposures) in concert with increases in cognitive-developmental
capabilities. As a result, strong lingering fears and worries are typically
the subject of clinical attention. DSM-IV-TR attempts to incorporate this
developmental understanding of psychopathology through the setting of
somewhat arbitrary duration criteria for children. Depending upon the
anxiety disorder, symptoms must be present for one to six months in children before a diagnosis can be made. For example, given the normative
development of fear outlined above, psychopathological fear in children
must persist for at least six months before a diagnosis is warranted (cf.
specific phobia; DSM-IV-TR). Unfortunately, beyond this and other minor
developmental adaptations, the assessment, diagnosis, and treatment of
children is still overly influenced by theories and practices from the adult
literature, although approaches based on children are slowly emerging
(Barrett, 2000).
Depending upon how one counts disorders in the DSM-IV-TR, there
are as many as 13 broad anxiety-related diagnostic categories applicable
to children: separation anxiety disorder, panic disorder, agoraphobia, specific phobia, social phobia, obsessive-compulsive disorder, posttraumatic
stress disorder, acute stress disorder, generalized anxiety disorder, anxiety
disorder due to a medical condition, substance-induced anxiety disorder,
anxiety disorder not otherwise specified, and adjustment disorder with
anxiety or mixed with anxiety and depressed mood. Although the validity of the DSM nosology has been repeatedly challenged (e.g., Achenbach,
2005), these anxiety disorders are generally meant to capture variations in
the focus of the anxiety or fear and its maladaptive expression (e.g., social
worries, separation worries, pervasive worry). The present chapter focuses
on several disorders that have been the primary focus of research with
children (see Table 7.1).
Etiology
Even though anxiety disorders are among the most prevalent mental
health concerns in children, the various paths leading to their acquisition
have not been completely determined at this time. The literature is divided
into associative, nonassociative, and integrated accounts. Although a
detailed discussion of this debate is beyond the scope of this chapter (see
Fisak & Grills-Taquechel, 2007; Muris, Merckelbach, de Jong, & Ollendick, 2002), four pathways of acquisition have been suggested that can
work individually or in combination: acquisition by way of direct conditioning experience, acquisition by way of vicarious learning, acquisition by
way of information about the stimulus, and acquisition by nonassociative
means (Ollendick & King, 1991; Rachman, 2002).
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Description
Separation
Anxiety
Disorder (SAD)
Panic Disorder
(PD)
Specific Phobia
(SP)
The primary feature of SP is a markedly intense fear of specific identifiable objects, animals, situations, environments, and the like that evoke
an anxiety response and lead to significant avoidance and/or distress.
Social Phobia
(SoP)
The primary features of PTSD follow exposure to death or a life-threatening situation in which helplessness, fear, hopelessness, or horror were
intensely experienced. Features fall into re-experiences of the trauma,
avoidance of trauma cues and situations, numbing, and increased,
persistent physiological hyperarousal.
Generalized
The primary feature of GAD is persistent (occurring more days than not),
Anxiety
excessive, uncontrollable worry regarding myriad domains and topics
Disorder (GAD)
that is associated with intense somatic symptoms or disturbance.
In addition, the case may be that learned and innate accounts of fear and
anxiety acquisition are merely different extremes on the same continuum
(Marks, 2002). Developmental experiences and the unique predispositions
of a child may lead to an acute, innate, defensive fear or anxiety at one end
or a traditionally conditioned disorder resulting from traumatic experience
at the other. In essence, the developmental question regarding the etiology
of anxiety may be how much association to a stimulus is required given a
particular child or adolescents innate predisposition and intensity of physiological response to the stimulus (Marks, 2002).
Family
Family also plays a role in the development and maintenance of anxiety.
The child is most often seen as the patient in therapy, however, the
effects of the family environment and relational ties to its members can
have varying influences on child anxiety. The literature on the relationship between family and anxiety in children has generally focused
on parental acceptance, overcontrol or overprotection, and the parental
modeling of anxious behaviors. According to a review of nonretrospective
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Theories
Throughout a typical day discussions regularly focus on feeling a
certain way. Objectively, this feeling is a very complex event composed of
physiology, behavior, and cognition (Lang, 1979) and has been the subject
of decades of psychological theory and empiricism. Several theories of
emotion have been developed to explain the relative contributions of physiology, behavior, and cognition to an emotional response. For example, Beck
and Clark (1997) proposed a three-stage schema-based model in which
the initial perception of threat is increasingly elaborated upon through
automatic and strategic processing. Accordingly, anxiety is thought of as
a system of cognitive biases and inaccurate or excessive threat determinations. Barlow (2002) has advanced a triple vulnerability theory in which
biological, generalized psychological, and specific psychological vulnerabilities interact with stress and chance pairings of panic symptoms (i.e.,
false alarms) to produce psychopathology. Similarly, Mineka and Zinbarg
(2006) have updated the learning model by incorporating prior learning
experiences and temperament with more emphasis on social learning
and vicarious learning experiences, in addition to direct experiences and
elaborating on common misconceptions of the associative approach.
Recently, however, an information-processing approach has been demonstrated to be a particularly relevant theory for evaluating treatments for
childhood anxiety (Davis & Ollendick, 2005). Bioinformational theory is
based on an information-processing model of fear in adults, but has grown
to become a theory of the organization of emotion and emotional response,
especially as adapted and elaborated into Emotional Processing Theory
(EPT; Foa & Kozak, 1986, 1998). According to Lang, Cuthbert, and Bradley
(1998), emotions are action dispositions that are cued by the stimulation
of relevant associative networks contained in long-term memory (p. 656).
These networks differ from other knowledge structures by incorporating
direct connections to motivational components and are organized within
the broad appetitive and aversive systems (Lang et al., 1998).
Emotional networks and emotional responses can be categorized
broadly as belonging to either approach and pleasure networks or fight
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(Foa & Kozak, 1986, 1998; Lang, 1979). Therapeutic technique (e.g., exposure) may, however, necessitate the uncoupling of fear (i.e., physiologicalaffective response and verbal-cognitive response) and behavioral avoidance
(Hodgson & Rachman, 1974). Even so, the synchrony of heart rate (physiology) and subjective units of distress (cognitions) has been associated with
greater treatment benefit and desynchrony between these components with
a lack of response to treatment (Vermilyea, Boice, & Barlow, 1984).
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Developmental Psychopathology
A complete approach to treating childhood anxiety requires consideration of developmental psychopathology and the broader context of how
psychopathology interacts with the childs emotional, cognitive, and social
growth. Successful development requires negotiating myriad developmental
milestones and integrating each successive achievement into an increasingly adaptive outcome. Conversely, incomplete milestones, trauma, and
insults can impede development leading to maladaptive outcomes from the
failure to traverse developmental milestones during key sensitive and critical
periods (Ollendick & Vasey, 1999; Toth & Cicchetti, 1999). In particular, the
individual differences in any one child must be considered through notions
of equifinality (i.e., that different developmental pathways and experiences
can lead to the same outcome) and multifinality (i.e., that similar developmental pathways and experiences can lead to different outcomes).
As a result, treatment of any one disorder in any one child becomes a
complex endeavor in which the childs memories, experiences, family, relationships, traumas, responses, etc. are all integrated into unique emotional
networks that have become maladaptive and pathologized and have been
associated with unique developmental insults. For example, an older child
with a fear of separating from a parent (i.e., separation anxiety) not only
presumably suffers from a resistant and maladaptive emotional network
in need of corrective information (i.e., therapy), but has also likely suffered
from social and emotional insults associated with failing to obtain normative experiences away from the parent. Moreover, treatment for this child
may not just involve providing corrective information through child therapy
and attempting to remedy any developmental insults or deficiencies through
psychoeducation and social skills training, but also may require addressing
the context in which the psychopathology has developed and been maintained (e.g., addressing overcontrolling parental behavior). In sum, child
therapy becomes reliant on a thorough and complete assessment of the
child and family in order to plan the best treatment and attempt to remedy
any variables maintaining psychopathology.
Summary
According to bioinformational theory and EPT, pathological fear and
worry, consistent with a diagnosis of an anxiety disorder, are types of
emotional networks composed of various conceptual units. These highly
coherent conceptual units are stored in memory and represent various
aspects of the stimulus, responses to the stimulus, and knowledge about
the stimulus. Stimuli that are insufficient to fully activate the emotional
network (i.e., mildly evocative) or that activate only one or two response
components create desynchronous responding.
Therapy leading to emotional processing can be most effective when
there is a concordant pattern of emotional responding and access to the
entire emotional network is achieved. This is typically best achieved through
exposure (e.g., Kendall et al., 2005). With network activation, erroneous
associations and beliefs, avoidant behaviors, and intense physiological
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ASSESSMENT
Evidence-Based Assessment (EBA)
Given that anxiety can be thought of as resistant networks of exaggerated emotional responses (Foa & Kozak, 1986, 1998), it follows that
an assessment should include a thorough evaluation of the emotion and
the components of the anxiety responsenamely, physiology, behavior,
and cognitionin addition to the overall subjective emotional experience
(Davis & Ollendick, 2005). Current evidence-based guidelines with children
include a variety of techniques: (1) using structured or semi-structured
diagnostic interviews in addition to open clinical interviews to determine
the presence or absence of anxiety disorders, (2) using rating scale information from multiple-informants to quantify symptoms and monitor treatment progress, and (3) using direct observation or behavioral avoidance
tasks to offer additional information and assist in planning for treatment,
especially when exposure is to be used (Silverman & Ollendick, 2005).
Some of the more widely utilized assessment instruments for childhood anxiety include the Anxiety Disorders Interview Schedule for Children
for DSM-IV, (ADIS-C/P; Silverman & Albano, 1996), the Child Behavior
Checklist and other Achenbach forms (CBCL; Achenbach, 1991), the Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan,
Stallings, & Conners, 1997), and the Revised Childrens Manifest Anxiety
Scale (RCMAS; Reynolds & Richmond, 1978; see Silverman & Ollendick,
2005 for a review of evidence-based assessment of anxiety in children).
Assessment for childhood anxiety should always utilize multiple
informants from differing environments. Within the anxiety disorders (and
childhood disorders generally) there is commonly disagreement among
reporters as to the presence, absence, and severity of disorders (e.g., Grills
& Ollendick, 2002; Jensen et al., 1999; Silverman & Ollendick, 2005). At
the same time, these disagreements are not trivial and may not represent
misconceptions on the part of the child. For example, Jensen et al. (1999)
reported that when discrepancies existed between parents and children
regarding the presence of an anxiety disorder, clinician verification suggested that both the parents and the children were equally good at accurately identifying an anxiety disorder in roughly 60% of cases.
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anesthesia was ineffectually administered (i.e., she reported being semiconscious, feeling surgical tugging, etc. but minimal pain). Discussion of
the case may converge upon panic disorder or posttraumatic stress disorder focusing on either her history or the traumatic experience; however, an accurate assessment is needed to also rule out a specific phobia
(i.e., blood-injection-injury type). Although evidence-based therapies exist
for all three diagnostic possibilities, the effective use of these therapies
hinges on obtaining an accurate diagnosis, in particular because the exposures would differ in clinically meaningful ways that could be detrimental if applied inaccurately (e.g., relaxing in the presence of the stimulus
compared to learning to apply tension or tense muscles when exposed).
Inaccurate diagnosis could lead to the incorrect, although evidence-based,
treatment of having an individual with a specific phobia (and vasovagal
syncope; i.e., propensity toward fainting) relax during exposure.
Functional Assessment
In addition, it has been pointed out that both dimensional and categorical systems do not readily address the functions of child psychopathology
(Scotti, Morris, McNeil, & Hawkins, 1996). These functions are frequently
addressed either directly or indirectly in treatment, but not reflected in
the treatment literature or in the current diagnostic systems. Even though
functional analysis has been used extensively with children with intellectual and developmental disabilities to assess problem behavior (for a
review see Hanley, Iwata, & McCord, 2003), little has been done to bring
this important behavioral assessment to other disorders.
Functional analysis involves the identification of variables that influence the occurrence of problem behavior (Hanley et al., 2003, p.147).
Problem behavior is thought to have certain functional attributes: to obtain
tangible items, escape demands, receive attention, and/or for reasons that
cannot be determined (i.e., an automatic function). These functions can be
assessed through careful and lengthy experimental sessions that carefully
alter the contingencies of a situation (e.g., experimental functional analysis; cf. Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994) or more
efficiently through interviews (e.g., Questions About Behavioral Function, QABF; cf. Matson, Bamburg, Cherry, & Paclawskyj, 1999). Although
these practices have become the gold standard of behavioral assessment
for those with disabilities, practices involving the functional assessment
and treatment of typically developing children with psychopathology have
trailed far behind (see Chapters 7, 14, and 15 in Volume 1 for a review of
behavioral assessment techniques in those with intellectual or developmental disabilities; Matson, Andrasik, & Matson, in press).
Likewise, limited attempts have been made to address the functions
of anxious behavior, and although treatments may broadly incorporate
family components they fall short of advances seen with other populations (e.g., in those with intellectual and developmental delays). Even so,
functional analysis has become more common in the assessment of school
refusal/phobia in children (e.g., Kearney & Silverman, 1993). Also, cognitive-behavioral functional analysis has become a common practice prior to
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Implementation
Exposure can be conducted via two media. In vivo exposure involves
actually exposing an individual to an evocative stimulus and is contrasted
with imaginal exposure (also called in vitro exposure) which involves
the individual imagining the stimulus. Bioinformational and emotional
processing theories would generally advocate the use of in vivo exposure
so as to activate more of the emotional network; however, the nature of the
anxiety disorder, the safety and well-being of the individual, and the availability of stimuli must also be considered.
For example, in vivo exposure may be better suited to specific fears,
the characteristics surrounding a traumatic event (e.g., the setting and
environment), and easily obtained and manageable stimuli (e.g., dogs).
This is in comparison to, for example, myriad generalized worries, the
actual traumatic occurrence (e.g., assault), and more unique or prohibitive
stimuli (e.g., finding tall buildings in rural areas for fear of heights or the
prohibitive cost and lack of access for fear of air travel) for which imaginal
exposure may be more appropriate. Finally, a combined approach can be a
viable alternative in which imaginal exposure can be used to supplement,
accentuate, and amplify the effects of in vivo techniques.
Exposure has also been administered in two doses in the literature:
either all at once or gradually. Exposure can be administered all at once
in procedures termed flooding (in vivo) or implosion (imaginal). Flooding and implosion involve exposure to the most challenging or evocative
presentation of a stimulus or situation all at once. For example, an individual phobic of heights would be taken to the top of a very tall building
or guided to imagine being on such a building. By contrast, gradual exposure involves using either in vivo or imaginal techniques to slowly guide
an individual through a hierarchy of increasing fear or anxiety. Using the
same examples, graduated in vivo exposure may involve gradually progressing from exposure at the second floor of a building to the third and
so forth whereas imaginal exposure may involve envisioning the same.
Currently, consensus exists that flooding or implosion may be needlessly
aversive, whereas a graduated approach is more humane, inviting, and
less of a threat to motivation and possible attrition, especially with children (Kendall et al., 2005).
Another question relevant to the use of exposure therapy is the dosing
or schedule for any particular dose. The literature is mixed and unclear at
this point as to whether a massed or spaced approach to exposure is preferred, especially with children. Is exposure best administered all in a single session of extended duration, or across several sessions with little time
between exposures (i.e., massed exposure), or during trials more approximating the typical one-hour weekly session across multiple weeks (i.e., spaced
sessions akin to most manualized treatments)? Although controversial, the
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adult literature can be construed as supporting a massed approach or minimizing the intervals between exposures (e.g., Chaplin & Levine, 1981; Foa,
Jameson, Turner, & Payne, 1980; Lang & Craske, 2000).
Even so, at the very least no support has been found for needlessly
spacing sessions (Chambless, 1990; Herbert, Rheingold, Gaudiano, &
Myers, 2004; Lang & Craske, 2000). In children, one study was identified
that examined massed and spaced exposure. Davis, Rosenthal, and Kelley (1981) found that children receiving three hours of massed exposure
therapy using actual stimuli (i.e., as opposed to approximations/toys) had
superior outcomes to those children receiving exposure therapy in three
weekly one-hour doses.
Similarly, st et al. (2001) found that children responded well to a threehour massed intervention for specific phobia, although they did not make
comparisons to spaced exposures. Moreover, most children reported that the
treatment had gone as they had expected it would (75.4%) and were satisfied
with the intervention (82.1%; Svensson, Larsson, & st, 2002). Accordingly,
it seems that children are at least capable of participating in massed treatment and that they may not find it unduly cruel or aversive. It may be more
effective than spacing sessions. Currently, best practice may come down to
a combination of the anxiety disorder(s) to be treated, current EST manuals
and formats, clinical judgment, and patient and parent choice.
Mechanisms of Change
Although exposure is easily defined in the most basic of terms, questions
remain as to what aspects or mechanisms of change in exposure impart
therapeutic benefit. Several potential mechanisms have been advanced:
such as counterconditioning, habituation, extinction, cognitive change, and
the development of coping skills (Kendall et al., 2005; Tryon, 2005). These
various mechanisms of change are theoretically wed to different therapeutic
interventions, but may occur to varying degrees in all exposure therapies
whether acknowledged or not. Even so, only one study has even examined
potential mediators of outcome, although any of the RCTs reviewed below
could have (Treadwell & Kendall, 1996; for a review see Prins & Ollendick,
2003). As a result, the review that follows focuses on the main ESTs for
childhood anxiety disorders and the degree to which these therapies target various components of the emotional response. The reader is reminded,
however, that even though many interventions are decades old, little effort
has been made to resolve the disconnect between theory and research that
would better elucidate mechanisms of change (cf. Davis & Ollendick, 2005).
200
201
202
203
204
questions to ask and that the primary goal is better patient care through
the decision on whether a particular treatment has sufficient empirical validation to warrant its dissemination for widespread clinical training
and implementation (Task Force, 1995, p. 3).
This goal of setting the agenda for dissemination, training, and patient
care necessitates that a high standard be used for determining empirical
status. This emphasis is especially urgent given that even recent examinations of the literature continue to indicate that EBTs for youth produce
better outcomes than care as usual, even in those with severe levels of
psychopathology (Weisz, Jensen-Doss, & Hawley, 2006). Unfortunately,
as it stands, the evidence-based movement has become mired in political
debate and efforts to obtain the prize of EST status (Rosen & Davison,
2003) at the expense of the original intentions of disseminating and training the best practices for treating children.
Subsequently, the following review focuses on RCTs for anxiety disorders in children using the original criteria (cf. Task Force, 1995; Chambless
et al., 1996, 1998) in an effort to determine those treatments for which the
most rigorous evidence has accrued. An emphasis is placed on studies that
either verify diagnostic status in their samples or where a specific diagnosis
or diagnostic category can be reasonably assumed through a preponderance
of the clinical assessment evidence and sample description (cf. Chambless
& Ollendick, 2001). Studies were excluded from the review if they did not
clearly indicate randomization of participants to a condition, did not specify
even the most basic characteristics of the sample (e.g., age, male vs. female),
assessed and treated symptoms that could not be verified as in the clinical
range and/or indicative of a particular anxiety disorder (e.g., test anxiety
or social isolation studies), and/or had equivalent results between or among
conditions but insufficient power to detect differences and invoke the EST
equivalence criterion (cf. Kazdin & Bass, 1989). Moreover, as little research
has attempted to isolate ESPs, this review focuses on identifying ESTs with
the most support in the extant literature.
Finally, in addition to reporting overall empirical status for the treatments reviewed, a componential analysis is presented of the effects of
treatment on the components of the emotional response (cf. Davis & Ollendick, 2005). Specifically, outcome data are examined and the effects of
treatment on the subjective experience, physiological response, behavioral response, and cognitive response of the emotion are categorized using
EST criteria guidelines. Outcome data for this analysis need also not be
in any one strict form or use a single type of informant or medium. For
example, the behavioral component could be examined using a behavioral task, observational coding, self-report, or parent-report. The results of
these reviews are summarized in Tables 7.2 and 7.3. Table 7.2 shows the
evidence from each study leading to the conclusions regarding empirical
support, and Table 7.3 indicates the actual levels of support merited for a
particular treatment for a particular disorder.
To date, no published RCTs with children that met these review
criteria were identified for Panic Disorder/Agoraphobia (see Ollendick,
1995 for results of a multiple-baseline design study), separation anxiety
205
Study
Specific Phobia
ISD vs. W-L
Cornwall
et al.
(1996)
ICBT vs. EMDR
Muris et al.
(1997)
ICBT vs. EMDR vs. Psychological Placebo
Muris et al.
(1998)
st et al.
(2001)
Social Phobia
I+GBT vs. Psychological Beidel et al.
Placebo
(2000)
GCBT vs. GCBT+Par vs. Spence et al.
W-L
(2000)
GCBT vs. W-L
Gallagher
et al.
(2004)
Obsessive-Compulsive Disorder
ICBT vs. Med
de Haan
et al.
(1998)
Physiology
Behavior
Cognition
Subjective
NR
TX > W-L
TX > W-L
ns
CBT > TX
CBT > TX
CBT > TX
ns
TX > Placebo
NR
TX > Placebo
ns
TX > W-L
TX > W-L
NR
*
NR
NR
NR
NR
NR
*
=
ns
ns
NR
ns
ns
TX > W-L
CBT > TX
ns
NR
TX > W-L
TX > W-L
NR
TX >
W-L
*
POTS (2004)
Barrett et al.
(2004)
ns
(continued)
206
Kendall et al.
(1997)
Barrett
(1998)
King et al.
(1998)
Silverman et
al. (1999)
FlannerySchroeder
et al.
(2000) NR
Shortt et al.
(2001)
Ginsburg et
al. (2002)
Muris et al.
(2002)
Nauta et al.
(2003)
Spence et al.
(2006)
NR
TX > W-L
TX > W-L
TX > W-L
ns
NR
TX > W-L
TX > W-L
TX > W-L
NR
TX > W-L
TX > W-L
TX >
W-L
TX > W-L
TX > W-L
NR
TX > W-L
TX > W-L
TX > Placebo
TX > Placebo
NR
Key: * = not measured, = = groups were equivalent, Com = Community Care/Treatment as usual, E/
RP = exposure with response prevention, G = group, I = individual, Med = medication, NR = component
was measured but not reported (e.g., a total score was reported but not a subscale containing the needed
information), ns = no significant differences, Par = parents involved with treatment, TX(s) = treatment or
treatments, SD = systematic desensitization, W-L = wait-list control.
207
Overall Status
Physiology
Behavior
Cognition
Experimental
Probably
Efficacious
Exper
Exper
Exper
Prob
Exper
Exper
Exper
Prob
Probably
Efficacious
Probably
Efficacious
Exper
Prob
Exper
Prob
Exper
Exper
Exper
Prob
Obsessive-Compulsive Disorder
CBT
Well Established
Exper
Exper
Exper
Exper
Exper
Prob
Exper
Prob
Exper
Prob
Prob
Well Est
Specific Phobia
SD
CBT
Social Phobia
BT
CBT
Subjective
Key: BT = behavior therapy, CBT = cognitive-behavioral therapy, Exper = experimental empirical status,
Prob = probably efficacious empirical status, Well Est = well established empirical status, SD = systematic
desensitization.
208
209
210
Childhood Anxieties
Frequently, studies in this category compared CBT to CBT with an
alteration (i.e., group vs. individual format, child and parent or family
treatment vs. child treatment) and/or to wait-lists. CBT to CBT comparisons
were often difficult to separate and appeared to suffer from insufficient
power to obtain differences (cf. Kazdin & Bass, 1989). As a result, general impressions of outcomes are conservatively reported in an attempt
to summarize frequently inconsistent (e.g., mother vs. father vs. child vs.
clinician reports) or vacillating results (e.g., changes in the superiority of
a group from post to follow-up to later follow-up). Moreover, preference
in interpreting outcomes was given to the results of diagnostic depictions
and widely used measures (e.g., CBCL, RCMAS, FSSC-R).
Excluding some studies where results generally appeared to be equivalent (e.g., Manassis et al., 2002), 12 RCTs were identified and examined.
As a whole, well-established status for CBT with children is warranted as
Ginsburg and Drake (2002) and Muris, Meesters, and van Melick (2002)
all found CBT superior to a psychological placebo intervention. Moreover,
the 10 additional studies included for review found CBT superior to varying wait-list conditions in every instance (see Tables 7.2 and 7.3; Barrett,
211
212
213
inclusion). Although this approach led to results that are generally more
conservative than those of previous EST reports and reviews, it is believed
these more accurately reflect the state of the science in treating psychopathology. For example, as previously mentioned, Menzies and Clarke (1993)
was used to suggest probably efficacious status for exposure (cf. Chambless et al., 1998) for water phobia (Menzies & Clarke, 1993), but also did
so using arguably analogue participants who on average at pretreatment
could at least proceed down to about neck depth in a pool, if not farther
with hesitation.
A developmental approach to childhood anxiety disorders and their
treatment is also needed. Future researchers should aspire to move RCTs
toward a more developmentally sensitive and informed model, compared
to the continuing downward extension of adult treatments (Barrett, 2000).
Such work can be advanced by examining moderators and mediators of
treatment, and has begun by examining various treatment techniques
designed to target potential etiological and maintenance factors of anxiety
particular to children (e.g., family treatment in Barrett et al., 1996) and
by examining the effects of CBT for anxiety on those with severe intellectual, emotional, and developmental delays (e.g., Davis, Kurtz, Gardner,
& Carman, 2007). However, the study of the effects of childhood anxiety on development and of the ability of treatments to remediate psychopathological developmental insults is also necessary. A developmentally
appropriate approach involves moving beyond a mere diagnostic assessment to incorporate outcome measures of the entire emotional response
and indicators of a childs developmental functioning and trajectory. This
observation points to a gap in the current treatment literature: the need
to consider factors beyond psychopathology including a childs emotion
regulation, progression through developmental milestones and developmental capabilities, and overall environment (Southam-Gerow & Kendall,
2000, 2002).
In sum, research into the treatment of childhood anxiety disorders has
blossomed over recent years with cognitive-behavioral EBTs at the forefront.
Although this renaissance has led to the development and study of elegant
therapies, controversy still surrounds their evaluation and study. Future
research should focus on the mechanisms of change and moderators of
outcome (i.e., for what individuals does treatment work or is treatment
most effective?). The various refinements and formats of CBT for childhood anxiety will likely prove beneficial considering the equifinality and
multifinality of psychopathology. Given the heterogeneity of pathways to
childhood anxiety, it is likely that specialized treatments addressing these
moderating and mediating variables will be ideal (e.g., cognitive-behavioral
family interventions for families in which anxious functional behavior is
reinforced or individual CBT for children from chaotic families for whom
little familial support of treatment procedures exists). These more complex
questions of applicability of ESTs (i.e., treatment effectiveness) are likely to
be ones of greater interest to practitioners and critics of EBP.
In closing, a framework for future EBP progress is offered using the
following circular process: (1) planners of RCTs should actively attempt
to address weaknesses pointed out in the literature, (2) active treatment
214
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220
8
Treatment
Strategies for
Depression in Youth
MARTHA C. TOMPSON and
KATHRYN DINGMAN BOGER
Boston University.
221
222
223
224
and support in negotiating the outside world, adolescents are shifting their
focus from family to peers as the primary unit of socialization.
During adolescence, youths begin to increasingly attend to environmental information from their peers, leading to higher levels of peer-related
stress (Rudolph & Hammen, 1999; Wagner & Compas, 1990). Adolescents
advanced cognitive perspective-taking abilities also cause social comparisons to become a central means of evaluating their self-worth (Stark,
Sander, & Hauser, 2006). Effective treatment strategies should therefore
be tailored to the specific socialization needs and cognitive capacities of
youth at different developmental stages.
Adolescent depression frequently presents with comorbid conditions.
Indeed, research suggests that upwards of half of the youth with diagnosable depression also meet criteria for another Axis I disorder (Lewinsohn,
Rohde & Seeley, 1998). Comorbidity may be even higher in younger children (Kovacs, 1996). Common comorbidities include anxiety disorders and
attention deficit disorders in both preadolescent and adolescent youth,
as well as substance abuse during adolescence (Kovacs, 1996). Risk for
depression may be particularly heightened in individuals with Aspergers
syndrome, Autism and associated development disabilities (Ghaziuddin,
Ghaziuddin, & Greden, 2002; Matson & Nebel-Schwalm, 2007; Saulnier
& Volkmar, 2007), and there is a strong need to enhance strategies for
assessing depression in these individuals (Matson & Nebel-Schwalm,
2007). Knowledge of the disorders that both parallel and likely contribute
to and interact with youth depression is crucial to understanding childrens ongoing depression and psychosocial difficulties.
Familial processes are also key factors associated with youths risk
and vulnerability to depression. Parental psychopathology has often been
associated with youth depression (Beardslee, Versage, & Gladstone, 1998).
Research suggests that children of depressed parents are three times
more likely to develop depression than children of nondepressed parents
(Downey & Coyne, 1990). Findings from multiple studies also show that
children of depressed parents have higher rates of depression diagnosis,
recurrence, and chronicity than those of nondepressed parents (Hammen, Burge, Burney, & Adrian, 1990; Wickramaratne & Weissman, 1998;
Beardslee, Keller, Lavori, Staley, & Sacks, 1993; Billings & Moos, 1986;
Lee & Gotlib, 1991).
In addition to the genetic and biological risk factors that may account
for these associations, psychosocial factors in families may also contribute (Goodman & Gotlib, 2002). First, parental depression may affect the
parents ability to effectively care for the child (Downey & Coyne, 1990).
Observational data show that mothers who are depressed exhibit more
sad and irritable affect than nondepressed mothers during interactions
with their children (Cohn, Campbell, Matias, & Hopkins, 1990; Hops et
al., 1987; Radke-Yarrow & Nottelmann, 1989). Second, parental depression may increase stress within the family, thereby affecting the childs
stress level. For example, children of depressed mothers report more episodic and chronic stressors than those of nondepressed mothers (Adrian
& Hammen, 1993). Taken together, these studies underscore the need to
understand the complex role of the family in the etiology and maintenance
225
of youth depression. Such understanding should inform treatment planning in terms of determining the target of treatment (child, parents, both)
and the most appropriate treatment strategies (medication, family-focused
treatment, or individual treatment).
Researchers have indicated that stress is one of the predominant pathways to the development of and manifestation of youth depression (Stark,
Sander, & Hauser. 2006, Stark et al., 2005). Knowledge of the role that
stress plays in the youths environment is therefore crucial in designing
and implementing effective treatments. In terms of the etiology of youth
depression, the diathesis-stress model posits that stress activates underlying vulnerabilities to produce the disorder (Monroe & Simons, 1991).
There has been some research to suggest that youths maladaptive cognitions are the diathesis in this model. For example, research by Rudolph
and colleagues (Rudolph, Kurlakowsky, & Conley, 2001) shows youth
stress to be a precursor to control-related beliefs that are then associated
with higher levels of depressive symptoms.
In addition to its causal role, stress may also contribute to the maintenance of depression. Depressed youth report more negative life events
and chronic stress on both questionnaires (Compas, 1987) and on objective ratings of stress based on life stress interviews (Garber & Robinson,
1997; Hammen, 2002). Families of depressed youths even report high levels of stress and negative life events (Hammen, 2002). Childhood depression is particularly associated with negative interpersonal events (such
as conflicts with peers) (Monroe, Rohde, & Seeley, 1999) and events that
are caused by the depressed youth himself or herself (such as failure in a
class; Rudolph et al., 2000). Comparisons between depressed children and
those with externalizing disorders show that depressed children report
more dependent, interpersonal stress than children with externalizing disorders. However, no differences emerge between the groups on independent life stress (Rudolph et al., 2000).
Other research has shown that some stressors that are independent
of the childs control are associated with depressive symptoms in children. For example, researchers indicate that children in families with
less money are relatively more likely to experience depressive symptoms
(as indicated by teacher reports) than those with more money (Aber,
Brown, & Jones, 2003). In addition to experiencing heightened stress,
depressed children and adolescents are also more likely to use avoidant
coping strategies to manage stress (Chan, 1995). Conversely, childrens
use of more adaptive coping strategies for managing stressors is associated with fewer depressive symptoms (Jeney-Gammon, Daugherty, &
Finch, 1993). In response to the powerful role of stress and coping in
youth depression, key components of certain evidence-based treatments,
such as Interpersonal Psychotherapy for Depressed Adolescents (IPT-A;
Mufson et al., 1999, 2004), include careful assessment of negative situations and problems as well as the implementation of coping strategies and
skills for managing them.
Cultural background is another key factor that relates to the manifestation of youth depression and its treatment. Existing research on ethnicity and depression indicates that various racial groups experience differing
226
227
experiencing high levels of depressive symptoms and reviews six interventions all of which are cognitive behavioral in their approach.
Maladaptive Cognitions
As illustrated in Tables 8.1 and 8.2 cognitive behavioral interventions have been more thoroughly investigated than any other intervention
approach for adolescent depression. The specific cognitive interventions
used have varied across treatment studies. These studies have compared
cognitive behavioral treatment with different conditions, examined its
delivery in different formats (group vs. individual), looked at longer-term
follow-ups, and examined the role of parallel parent groups in enhancing
treatment efficacy.
Of the 12 studies of diagnosed depressed youth that included a cognitive behavioral treatment condition, nine support the superiority of CBT
in comparison to control conditions. The efficacy of cognitive-behavioral
interventions has been demonstrated when compared to wait-list or nointervention conditions in three studies. CBT showed superiority in all
studies comparing it to wait-list control (Clarke, Rohde, Lewinsohn, Hops,
& Seeley 1999; Lewinsohn, Clarke, Hops, & Andrews, 1990; Rosello & Bernal,
1999), but in only one of the three studies comparing it to usual care
(Asarnow et al., 2005).
In one of the studies in which CBT did not show an advantage (Clarke
et al., 2005) the usual care consisted primarily of medication (SSRI) intervention. Both studies (Clarke et al., 2002; 2005) underscore the importance of understanding what participants are receiving in usual care
conditions.
Five studies have compared CBT to other psychosocial treatments, and
it has been shown to be superior to systemic family therapy, supportive
therapy (Brent et al., 1997), relaxation training (Wood, Harrington, & Moore,
1996), and life skills training (Rohde, Clarke, Mace, Jorgensen, & Seeley,
2004). However, in one study comparing it to Interpersonal Therapy (IPT),
IPT had a larger effect size and greater enhancements in social functioning
and self-esteem (Rosello & Bernal, 1999).
In the three studies that included medication arms, one was not
designed to compare the two interventions (Asarnow et al., 2005), one
found medication alone to be superior to CBT (TADS team, 2004), and one
found CBT to be superior to medication intervention (Melvin et al., 2006).
In the study by Asarnow and colleagues (2005) 418 adolescents in primary
care settings (ages 1321) were randomly assigned to a six-month quality
improvement intervention or usual care. Those in the quality improvement intervention had access to a care manager, who educated them about
depression and treatment options, and participants could select medication or CBT treatments. Although the study was not designed to evaluate
the relative efficacy of CBT and medication, the quality improvement intervention overall was associated with significantly lower depressive symptoms, and adolescents were somewhat more likely to prefer CBT.
In the study conducted by Melvin and colleagues (2006) 73 adolescents (ages 1218) were randomly assigned to the CBT alone, medication
Subjects
Ages
13-21
(n=418)
Ages
13-18
(n=107)
Ages
14-18
(n-=123)
Ages
13-18
(n=88)
Reference
Asarnow, Jaycox,
Duan,
LaBorde, Rea,
Murray, et al.,
2005
Brent, Holder,
Kolko, Birmaher,
Baugher,
Roth, et al., 1997
Clarke, Rohde,
Lewinson, Hops,
& Seeley, 1999
Clarke, Hornbrook,
Lynch, Polen,
Gale, OConner,
et al., 2002
Diagnosis of DSMIIIR
MDD and/or DD
based on the K-SADS
interview
Diagnosis of MDD or DD
based on the
K-SADS interview
Diagnostic/
Risk Assessment
Group
Group
Family
Individual
Individual
Treatment
Format(s)
(1) Adolescent
Coping with
Depression
Course (CWD-A)
(2) CWD-A with
nine-session
parent group
(3) Wait list control
(1) Systematic
Behavior Family
Therapy
(2) CBT
(3) Supportive
therapy
Intervention Type(s)
Immediate;
12 months;
24 months
Immediate;
12 months;
24 months
Immediate
Immediate
Post-treatment
Assessment
Impact of Treatment
Table 8.1. Randomized Clinical Interventions Trials for Adolescents with Diagnosed Depression
Ages
12-18
(n=152)
Ages
13-17
(n=32)
Ages
13-17
(n = 66)
83%
female
Ages
14-18
(n = 59)
Diamond, Reis,
Diamond, Siqueland, & Isaacs,
2002
Lewinsohn., Clarke,
Hops & Andrews,
1990
Diagnosis of major,
minor, or intermittent
depression based on
K-SADS interview with
mother and adolescent
Diagnosis of MDD or
DD based on K-SADS
Interview
Diagnoses of DSMIIIR
MDD based on the
K-SADS
Diagnoses of DSMIV
MDD based on the
K-SADS-PL interview
Group;
Family
Group
Family
Individual
(1) Therapeutic
Support Group
(TSG) vs.
(2) Social Skills
Group (SSG)
Immediate;
1 month;
6 months;
12 months;
24 months
Immediate;
9 Months
Immediate;
6 months
Immediate;
26 weeks;
52 weeks
(continued)
Subjects
Ages
12-18
(n=73)
Ages
12-18
(n=48)
Ages
12-18
(n=63)
Ages
14-19
(n = 18)
Reference
Mufson, Weissman,
Moreau, &
Garfinkel, 1999
Mufson, Dorta,
Wickramaratne,
Nomura, Olfson,
& Weissman,
2004
Reed, 1994
Clinician diagnosis of
MDD or DD
DSMIV diagnosis of
MDD, DD, adjustment disorder with
depressed mood,
or DDNOS and
HAMD10 and a
C-GAS score65
Clinician diagnosis of
MDD based on the
HRSD
Diagnosis of DSMIV
MDD, DD, or DDNOS
based on the K-SADS
Diagnostic/
Risk Assessment
Group
Individual
Individual
Individual
Treatment
Format(s)
(1) IPT-A
(2) Treatment as
usual
(1) Interpersonal
psychotherapy
for depressed
adolescents
(IPT-A)
(2) Clinician
monitoring
(1) CBT
(2) Antidepressant
medication
(Sertraline)
(3) Combined CBT
and medication
Intervention Type(s)
Immediate;
6-8 weeks
Immediate
Immediate
Immediate;
6 months
Post-treatment
Assessment
Impact of Treatment
Ages
13-18
(n=71)
Ages
12-17
(n=439)
Ages 8-17
(n=56)
Vostanis, Feehan,
Grattan, & Bickerton, 1996
Wood, Harrington, &
Moore, 1996
DSMIV diagnosis of
MDD based on the KSADS-PL
DSMIV diagnoses of
MDD and Conduct
Disorder based on the
K-SADS-E-5
Individual
Individual
Individual
Individual
Group
(1) CBT
(2) IPT
(3) Wait list control
(1) CWD-A
(2) Life skills
tutoring/control
Immediate;
6 months
Immediate;
9 months
Immediate
Immediate;
3 months
Immediate;
6 months;
12 months
Note: MDD = Major Depressive Disorder; DD = Dysthymic Disorder; DDNOS = Depressive Disorder Not Otherwise Specified; K-SADS = Schedule for Affective Disorders
and Schizophrenia for School-Aged Children; BDI = Beck Depression Inventory; CDI = Childrens Depression Inventory; GAF = Global Assessment of Functioning Scale;
CES-D = Center for Epidemiologic Studies - Depression Scale; CDRS-R = Revised Childrens Depression Rating Scale; RADS = Reynolds Adolescent Depression Scale; BID =
Bellevue Index of Depression.
Ages
9-17
(n = 48)
Ages
13-17
(n=91)
Rohde, Clarke,
Mace, Jorgensen
& Seeley, 2004
Symptomatic
adolescent
offspring (CESD>24) of recently
depressed
parents, assessed
using the F-SADS
Contact with social
services within
the previous
2 years; Mood
and Feelings
depression
questionnaire23
9th and
10th
graders
(n=150)
Ages
13-19
(n=94)
Clarke, Hawkins,
Murphy,
Scheeber,
Lewinsohn, &
Seeley, 1995
Clarke, Hornbrook,
Lynch, Polen,
Gale, Beardslee,
et al., 2001
Kerfoot, Harrington,
Harrington,
Rogers, &
Verduyn, 2004
Ages
14-18
(n=22)
Ackerson, Scogin,
McKendree-Smith,
& Lyman, 1998
CDI10 and
HRSD10
Subjects
Reference
Diagnostic/Risk
Assessment
Individual
Group
Group
Selfadministered
Treatment
Format(s)
(1) Cognitive
Bibliotherapy
(reading
Feeling Good)
and weekly
monitoring
phone calls
(2) Delayedtreatment
control
(1) CWD-A
(2) No intervention
Intervention Type(s)
17 weeks
after initial
assessment;
33 weeks
after initial
assessment
Immediate;
12 months;
24 months
Immediate;
6 months;
12 months
Immediate;
1 month
Post- intervention
Assessment
Impact of Treatment
Table 8.2. Randomized Clinical Interventions Trials for Adolescents with Depression Symptoms or Risk Factors for Depression
Ages
14-17
(n=25)
9th-12th
graders
(n=30)
CDI15 on two
administrations
and elevated
score on
semistructured
interview focusing
on depressive
symptoms
(1) BDI score > 11;
(2) RADS > 71;
(3) BID > 20;
(4) no other current
treatment
Group
Group
(1) CBT
(2) Relaxation
Training
(3) Wait-list control
(1) Rational-emotive
(2) No treatment
Immediate;
5 weeks
Immediate;
8 weeks
234
235
236
reduced time to recovery in symptomatic youth but failed to prevent recurrence. Alternatively, in a small pilot study, Kroll, Harrington, Jayson, Fraser, and Gowers (1996) found much lower rates of relapse among youth
receiving continuation CBT compared to an historical control group. Overall, the degree to which CBT interventions are sustained over time is not
clear, and future studies need to include substantial follow-up periods.
Finally, two studies have examined the role of parent involvement in
cognitive behavioral therapy. Both studies compared the Adolescent Coping with Depression (CWD) course alone both to a waitlist control group
and to CWD supplemented with cognitive behavioral training for parents.
In both studies treated groups had higher rates of recovery from depression and greater reductions in depressive symptoms. However, there was
not strong support for the addition of parental involvement. One of these
studies found no difference between CWD alone and CWD with the supplemental parent group (Clarke et al., 1999), and the other revealed only
a slight trend for the adolescent-parent condition to outperform the adolescent-only condition (Lewinsohn et al., 1990). Thus, while it is generally
agreed that parent involvement in youth treatments is important, extensive parent involvement in the delivery of cognitive behavioral interventions is not supported.
Interpersonal Functioning
Therapies focused on enhancing interpersonal functioning vary widely
and include group-based social skills training, individually based Interpersonal Psychotherapy, and family-based interventions. Although they
share common goals of improving interpersonal relationships, decreasing
social isolation, and enhancing interpersonal skills, these interventions
vary greatly in their formats, techniques, and foci.
Two studies examining the efficacy of social skills training for depressed
adolescents have yielded mixed results. First, Fine, Forth, Gilbert, and
Haley (1991) compared a 12-session social skills training group to a therapeutic support group. Although both groups had improved significantly
posttreatment, contrary to expectation, the therapeutic support group was
superior in reducing depressive symptoms to the nonclinical range. Second, Reed (1994) compared social skills training to an attention placebo
control condition. Although participants in the overall skills group showed
a greater improvement in clinicians ratings, there were significant gender
effects with boys showing some improvements and girls deteriorating. The
small sample size in this study (18 participants) makes it is difficult to
draw firm conclusions. Overall, the limited available data do not suggest
that social skills training alone is an efficacious treatment for adolescent
depression.
Three studies have examined Interpersonal Psychotherapy (IPT) for
the treatment of adolescent depression and all show strong support for
this intervention. In IPT clinicians focus on reducing depressive symptoms and enhancing interpersonal functioning using an active collaborative approach and focusing on one or two primary interpersonal problem
areas. In an initial study, Mufson and colleagues (Mufson, Weissman,
237
238
(81% vs. 47%) from depression; these recovery rates were maintained at
six-month follow-up.
Overall, interventions that focus on interpersonal functioning appear
promising in the treatment of adolescent depression. However, the appropriate role of family involvement has yet to be clarified in treating depression during this developmental period, and clinicians tread a difficult path
in balancing the need to enhance family support and functioning while
supporting the adolescents burgeoning autonomy.
Preadolescent Depression
Although an increasingly well-developed literature exists on treatment
of adolescents with depression, far less exists to guide the treatment of
preadolescents with depression. In fact, we found only one study in the
literature that included any children younger than 8 years of age. Furthermore, as illustrated in Table 8.3, the few published studies of preadolescents focused on those with high levels of depressive symptoms, and not
one study has exclusively targeted preadolescents with diagnosed clinical depression. Two studies included some children 12 years of age and
younger with depressive diagnoses in their samples (Wood, Harrington, &
Moore, 1996; Vostanis, Feehan, Grattan, & Bickerton, 1996), but neither
included separate analyses of these groups, precluding an examination
of treatment effects in younger children. One study included only eight
prepubertal subjects (Wood, Harrington & Moore, 1996), and the other,
although they did not administer a measure of pubertal status, included
six 12-year-old participants and 13 participants under the age of 12 years
(Vostanis, Feehan, Grattan, & Bickerton, 1996; Vostanis, personal communication, February 2007). Although a few treatment development studies have been conducted with diagnosed school-aged youth (Flory, 2004;
Kaslow et al., 2002; Tompson et al., 2007) much work remains to be done
in this area.
Unlike the studies examining treatments with adolescents, those
conducted with preadolescents frequently include cognitive behavioral
interventions that are also strongly focused on improving interpersonal
functioning. Most of the studies have focused on cognitive-behavioral and
skills-building interventions and have been delivered in a group format.
As illustrated in Table 8.3, in all examined treatments, group formats
allow practice of skills and interventions are designed to be active and
interactive. Indeed, most often the cognitive-behavioral components are
part of a larger skills-building package. Skills targeted include problemsolving, self-monitoring, and social abilities. For example, Asarnow and
colleagues (Asarnow, Scott, & Mintz, 2002) include a segment on building
friendships that specifically targets the developmental social challenges of
late-elementary and middle-school youth. Thus, these cognitive-behavioral
interventions are frequently heterogeneous and broad-based.
In terms of efficacy, in eight of nine intervention studies, treated groups
showed significant improvements over untreated groups in reduction of
depressive symptoms (Asarnow et al., 2002; Butler, Meizitis, Friedman,
& Cole, 1980; DeCuyper, Timbremont, Braest, Backer, & Wullaert, 2004;
4th-6th
graders
(n=23)
5th-6th
graders
(n=56)
Ages
10-12
(n=20)
Ages
10-13
(n=143)
Butler, Miezitis,
Friedman, &
Cole, 1980
De Cuyper,
Timbremont,
Braet, De Backer,
& Wullaert, 2004
Jaycox, Reivich,
Gillham, &
Seligman, 1994;
Gillham, Reivich,
Jaycox, &
Seligman, 1995
Subjects
Reference
Diagnostic/Risk
Assessment
Group
Group
Group
Group
Treatment
Format(s)
(1) Cognitive
(2) Social ProblemSolving
(3) Combined
(both above
treatments)
(4) Wait-list control
(5) No participation
control
Intervention Type(s)
Immediate;
6 months;
12 months;
18 months;
24 months
Immediate;
4 months;
12 months
Immediate
Immediate
Post-intervention
Assessment
(continued)
Impact of Treatment
Table 8.3. Randomized Clinical Interventions Trials for Preadolescents with Depression
Subjects
Ages
10-14
(n=68)
Grades
KG- 4
(n=135)
Ages
7-11
(n=31)
Reference
Kahn, Kehle,
Jensen, & Clark,
1990
King &
Kirschenbaum,
1990
CDI 19 CDRS-R
40
Multistage Gating:
Stage 1: CDI>14;
RADS>71. Stage
2: Reassessment 1
month later with
CDI and RADS.
Stage 3: Interview,
BDI>19. No
other depression
treatment
Children who scored
above a cutoff
on the Activity
Mood screening
questionnaire
Diagnostic/Risk
Assessment
Group
Group
Group
Treatment
Format(s)
Intervention Type(s)
Immediate;
3 months
Immediate
Immediate;
1 month
Post-intervention
Assessment
Impact of Treatment
3rd-6th
graders
(n=48)
Weisz, Thurber,
Sweeney, Proffitt,
& LeGagnouz,
1997
CDI10 and/or
identified by
teachers/counselor
as depressed; and
CDRS-R interview
score 34
CDI scores>12 on 2
administrations
(1) Behavioral
problem solving
(2) Self-control
(3) Wait-list control
Group
Group
Immediate; 9
months
Immediate; 8
weeks
Note: MDD = Major Depressive Disorder; DD = Dysthymic Disorder; DDNOS = Depressive Disorder Not Otherwise Specified ; K-SADS = Schedule for Affective Disorders and
Schizophrenia for School-Aged Children; BDI = Beck Depression Inventory; CDI = Childrens Depression Inventory; GAF = Global Assessment of Functioning Scale; CES-D =
Center for Epidemiologic Studies - Depression Scale; CDRS-R = Revised Childrens Depression Rating Scale; RADS = Reynolds Adolescent Depression Scale; BID = Bellevue Index
of Depression.
4th-5th
graders
(n=29)
242
Jaycox, Reivich, Gillham, & Seligman, 1994; Kahn, Kehle, Jenen, & Clark,
1990; King & Kirschenbaum, 1990; Stark, Reynolds, & Kaslow, 1987;
Weisz et al., 1997). One study found no difference between children treated
with social competence therapy, attention control, and no treatment, as
all groups showed improvement over time (Liddle & Spence, 1990). In contrast, of the five studies comparing different treatments, only two showed
group differences. Both Butler and colleagues (1980) and Stark and colleagues (1987) showed an advantage of problem-solving interventions over
both self-control and cognitive restructuring interventions, potentially
suggesting superiority of problem-solving. However, another investigation
(Jaycox et al., 1994; Gillham et al., 1995) failed to support the superiority
of social problem-solving over more cognitive-focused interventions. Thus,
although at this time studies support the overall efficacy of psychosocial
interventions for depression in preadolescent youth, they do not currently
support differences between depression-specific and more general interventions.
Although most of the studies are limited in their follow-up, focusing
only on immediate treatment effects, three studies completed evaluations
over a longer period. First, Jaycox, Gillham, and colleagues (Jaycox et al.,
1994; Gillham et al., 1995) compared five groups: a cognitive intervention, social problem-solving, a combined group, a wait-list control, and a
no-participation control. At immediate posttest, all treated groups showed
superiority to untreated groups and at two years posttreatment the differences were even more striking. Second, after comparing an 18-session
CBT protocol to wait-list, DeCuyper and colleagues (2004) followed the
school-aged participants for one year and found continued increases in
positive self-perception and decreases in both child and parent reports
of symptoms. Third, Weisz and colleagues (1997) followed school-aged
youth for nine months following a trial of Primary and Secondary Control
Enhancement Therapy, which focuses on the development of both problem-solving and cognitive restructuring skills. Group differences continued to be evident at the nine-month follow-up point.
The goal of skills-building interventions is to increase coping and
competence, and we would anticipate that such interventions may have
increasing effects over time. Indeed, these limited follow-up data suggest,
at minimum, maintenance of treatment gains and possibly enhancement
of these gains over time. Longer-term follow-up evaluations need to be
included in all studies to understand durability of intervention effects.
The role of the family in the treatment of depression in school-aged
youth remains to be clarified. Although the interventions examined at
this point have focused on group formats, several have included family
involvement (Asarnow et al., 2002; Stark, 1990). Given the embeddedness of school-aged youth within their families, there are strong reasons
to believe that family-based approaches may be particularly potent during
this developmental period. Indeed, in a study of family intervention for
childhood anxiety disorders comparing individual CBT, CBT plus family
treatment, and a wait-list control group, Barrett, Dadds, and Rapee (1996)
found a significant age effect; younger children showed better outcomes in
CBT plus family treatment whereas older children did equally well in both
243
244
245
depressive symptoms, and those with Aspergers syndrome may be at particular risk (Ghaziuddin, Ghaziuddin, & Greden, 2002; Matson & NebelSchwalm, 2007; Saulnier & Volkmar, 2007), there are no clinical trials
examining depression treatments for these special populations. Some case
studies suggest the utility of behaviorally-based approaches for individuals with mental retardation (Frame et al., 1982; Matson, 1982) and autism
spectrum disorders (Matson & Nebel-Schwalm, 2007). There is a strong
need to develop and test treatments for these populations.
Finally, although randomized clinical trials indicate efficacy for CBT
interventions for depressed youth, effectiveness trials have documented
weak effects of CBT in community settings (Clarke et al., 2002, 2005; TADS,
2004; Weisz et al., 1995). On the other hand, recent work comparing youth
receiving care in community mental-health centers to youth receiving CBT
in depression clinical trials does suggest greater benefits for the CBT-treated
youth (Weersing & Weisz, 2002). Overall, findings highlight the need to both
examine and enhance depression treatment in real-world settings.
CONCLUSIONS
Our understanding of depression in youth has advanced significantly
in the past 20 years, treatments have demonstrated efficacy, and guidelines for clinical practice have been developed. In addition to medication
strategies, interpersonal interventions and both individually based and
group-based cognitive behavioral interventions are treatment options
for depressed youth. More limited data suggest the utility of brief family
psychoeducation, and further studies are examining the utility of more
extended family interventions. However, additional research is required to
enhance and develop treatment approaches, to examine combined treatments, to delineate algorithms for making treatment decisions, and to
develop longer-term interventions aimed at preventing relapse and promoting recovery. Finally, there is a strong need to ensure that treatments
developed for the laboratory setting are available and effective for youth in
the wide range of real-world clinical settings where youth receive care.
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9
Medication Treatment
Of Bipolar Disorder In
Developmentally Disabled
Children
and Adolescents
ZINOVIY A. GUTKOVICH and
GABRIELLE A. CARLSON
INTRODUCTION
If systematic data on the treatment of bipolar disorder in children and
adolescents is meager, information on treatment of bipolar disorder in
developmentally disabled children is virtually nonexistent. Not only are
many of the challenges to diagnosing young children relevant to persons
with autism and intellectual disability of any age, but also, accumulating a sample size large enough to randomize to treatment alternatives
would require financial resources that are not likely to be forthcoming
any time soon. This chapter, then, begins with a review of the treatment of
bipolar disorder (BD) in normally developing youth, summarizes current
treatment of BD in adults with developmental disabilities (DD), and then
moves to the review of available literature on the treatment of developmentally disabled children and adolescents with BD. We conclude with our
thoughts about treatment in this vulnerable population.
253
254
255
clarify if treatment is addressing mania or depression, if the target symptoms are acute or chronic, or are characterized mainly by aggression,
mood instability, depression, insomnia, or other symptoms. The frequency,
intensity, number, and duration of periods of significant symptoms must
be captured at baseline and followed with intervention in order to determine whether intervention is having an impact. Finally, an understanding
of the environmental context of the condition is imperative: how do symptoms/behaviors change at home, in school, in residential treatments, time
of day, with and without structure, and with some people and not others.
Although people like to talk about mood swings as if they are imposed by
divine interference, they almost invariably have triggers that increase their
frequency and intensity, and moderators that decrease it.
256
studies, a global improvement measure (the child improved/worsened a little, much, very much) is also used. Both a comparison of rating scale scores
at the end of treatment between the drug and placebo groups, and the percent of people with the response rate is compared.
Although there are a growing number of such randomized, doubleblind, placebo-controlled trials in youth, most of our knowledge base
still comes from open trials. In the best of these, a thorough psychiatric/developmental assessment is done at the outset, along with severity
measures of the construct in question. At points during or at the end of
the trial, the measures are repeated so that it is possible to determine how
much change has occurred over time. Baseline and treatment measures of
adverse events are also obtained.
257
Table 9.1. Summary of the Evidence for Drugs to Treat Mania in Children and
Adolescents
Status in Bipolar Disorder
Li
Divalproex
Carbamazepine
Topiramate
Oxcarbazepine
Risperidone
Olanzapine
Quetiapine
Ziprasidone
Aripiprazole
Clozapine
Lamotrigine
258
Kowatch et al. (2005; JAACAP, 2005) closely follow guidelines for adults
with mania. There are two treatment algorithms, depending on whether
the mania presents with or without psychosis. When a child or adolescent
presents with manic or mixed symptoms without psychosis, monotherapy
is generally preferred initially, for reasons of safety. Treatment can be initiated with lithium, a sedating anticonvulsant (valproate has the most data)
or an atypical antipsychotic (such as olanzapine, quetiapine, risperidone,
and aripiprazole (soon) which currently have the most data). When the
clinical response is only partial, augmenting with a drug of a different class
(adding an atypical to a mood stabilizer or vice versa), with appropriate
dose adjustments to minimize additive side effects is recommended. If
there is no response to the initial monotherapy, switching to a drug of a
different class (from lithium to an anticonvulsant or from lithium or anticonvulsant to an atypical) is suggested. If the second agent fails to produce
a satisfactory response, the evidence in child and adolescent psychiatry
supports combined therapy.
If the manic or mixed syndrome presents with psychotic features and/or
prominent symptoms of severe agitation and aggression, it is recommended
that treatment be initiated with a combination of a mood stabilizer and an
atypical antipsychotic. Based on data from adults, when a partial response is
encountered, a mood stabilizer is usually added (i.e., three medications: an
anticonvulsant plus lithium plus an atypical.) In the case of a nonresponse
(or intolerance) to the initial mood stabilizer + atypical combination, trying
an alternative mood stabilizer (lithium for anticonvulsant non-response and
vice versa) or an alternative atypical agent can be tried.
For children and adolescents who have not responded to combinations of
treatment with three medications, clozapine is recommended. Haloperidol
has also been used as an adjunctive treatment in several trials (Kafantaris,
Coletti, Dicker, Padula, & Kane, 2001). Electroconvulsive therapy is recommended for adolescents only (Ghazziuddin et al., 2004).
Although hospitalization is not a psychiatric medication, clinical experience suggests that some children and adolescents need the structure,
decreased stimulation, or removal from stress that this intervention provides.
259
not greatly effective (Sachs et al., 2007) and there is a risk of switching
the depressed person into a manic state (Ghaemi, Hsu, Soldani, & Goodwin, 2003). Medications used to treat bipolar depression in adults include
lithium, which has some antidepressant efficacy, and most recently, lamotrigine, quetiapine, and combined fluoxetine and olanzapine (Calabrese et
al., 2005; Goodwin et al., 2004; Tohen et al., 2003).
In young people, lithium did not improve the depression of prepubertal children or adolescents with or without predictors of future bipolarity
(Geller et al., 1998; Ryan, Meyer, Dachille, Mazzie, & Puig-Antich, 1988;
Strober, Freeman, Rigali, Schmidt, & Diamond, 1992). In one open trial of
adolescent inpatients, only 30% met response criteria after 6 weeks (scores
28 and CGI improvement 2). Interpretation of the apparent treatment
response is complicated by the absence of placebo control (and depression
has a notoriously high placebo response in youth), as well as by the fact
that the major improvement in mood symptoms took place within the first
two weeks of hospitalization, itself a potent intervention.
Lamotrigine has received little study in youth. Open trials and case
series suggest some improvement in bipolar depression (Carandang Maxwell, Robbins, & Oesterheld, 2003; Chang, Saxena, & Howe, 2006; Kusumaker & Yatham, 1997). The use of lamotrigine is complicated by the need
to start with very low doses and increase gradually in order to lessen the
risk of a rare and sometimes fatal complication, Stephens-Johnson Syndrome (Messenheimer, 2002).
Unfortunately, there is a risk of precipitating a manic episode and in a
young person a risk for a bipolar course, so the doctor must weigh the risks
of precipitating a mania/hypomania/bipolar course with an antidepressant versus treating with a mood stabilizer alone (for which there is either
minimal or no data regarding effectiveness in children or adolescents) versus treating the child or adolescent with two drugs, one of which might not
be needed. The clarity of a history suggestive of a bipolar diathesis (including clear bipolar history in first-degree relatives), the reliability of parent
observation and child compliance with treatment, and family preference
should all be carefully weighed in the decision making process.
Maintenance
The consensus panel described earlier (Kowatch et al., 2005) observed
that, given the high lifetime recurrence rates in untreated BD, for patients
with the authentic disorder, medication treatment should be recommended
for the long term and that patients and families be educated to understand
both the high rate of relapse in young people as well the especially noxious
contribution of illicit drugs in perpetuating mood episodes. For patients
with less classical forms of BD, the lifetime medication recommendation
is much less clear. However, patients stable on medication are encouraged to continue treatment until completion of high school/college/trade
school, or until they are beyond an anticipated major life stressor (starting a new job, getting married, etc). Medication discontinuation should
be undertaken gradually to decrease the likelihood of rebound mania or
260
Gabapentin
A number of case reports and uncontrolled studies of gabapentin
(GP) in manic and mixed-state cognitively normal adults have suggested
261
Atypical Antipsychotics
There have been very few reports of atypical antipsychotic used in DD
adults with mania. Antonacci and Groot (2000) performed retrospective
chart review on 33 adult patients with intellectual disability and comorbid
psychiatric disorders treated with clozapine. Four patients in their sample
had Bipolar I Disorder. The study does not address outcome by diagnosis
although all patients showed clinically meaningful improvement apparently including those with BD. Side-effects were mild and transient. Buzan
et al. (1998) published a comprehensive review of the existing literature
and reported their own clinical experience with the use of clozapine in
10 adults with intellectual disability and psychiatric comorbidities. Three
patients in their sample had Bipolar I Disorder; in one of them clozaril was
discontinued after two weeks because of agranulocytosis. Two patients
with BD treated with VPA remained on clozapine and showed moderate
to marked improvement on doses of 350 mg and 650 mg with follow-up
between two to three years. The remaining patients with other disorders
including schizoaffective mania also improved.
262
Author
Sample
Size and
Age
Psychopathology
Addressed
Methodology
Results
Comments
Authors
concluded
that
overall
response
was poor
Vanstrae- N = 40
Manic
Systematic
Li alone: N = 25: 4
len and
episodes:
review of
Age
improved markedly,
Tyrer
insomnia,
published
559
5 improved partially,
(1999)
increased
case studies
years
13 showed little or
activity,
and small
16
no improvement: 2
agitacase series on
females
became worse, in 1
tion and
patients with
and 24
Li stopped because
pressure
dual diagnomales
of side effects CBZ
of speech
sis of RCBD
alone: N = 15 12 no
Depressive
and DD
improvement, in 1
episodes:
Only studCBZ stopped because
hypersomies providing
of rash, 2 had bennia, social
information
efit for epilepsy VPA.
withon individual
alone: N = 6 1 comdrawal,
cycles and
pletely remitted, 2
hypoactivindicating the
marked or significant
ity, mutelength and
improvement; 3 no
ness and
frequency of
change Li + CBZ: N
stupor
the episodes
= 10 6 no improveover one year
ment, 1 complete
were included
improvement 2 partial improvement
1 attenuation of
symptoms after addition of thyroid hormone VPA. + CBZ: N
=1; No improvement
Li + VPA: N = 1; No
improvement
King
N = 26;
Mood
Retrospective
A positive outcome
Note addiet al.
age
changes,
case series;
as evidenced by a
tion of
(2000)
1671
aggresoutcomes
decrease in hospirisperi10
sion, sleep
reported on
talizations, cycling
done to
females
disorder,
the patients
frequency, and/or
5 cases
and 4
psychosis,
with RCBD
intensity of acute
males
self-injury,
only; N = 14
symptoms was
12 with
overactivity
(age 2171)
documented in the
nonDosages and
majority of cases (12
rapid
levels when
out of 14): Respondcycling
available:
ers: VPA. only: N = 4
courses
VPA: 750 mg
VPA + R: N = 2 VPA
and 14
2500 mg,
+ CBZ: N = 1 VPA +
with
level 158
CBZ + R: N = 3 VPA +
RCBD
701 mol/L
CBZ + Li: N = 1 CBZ
(therapeu+ Li + R: N = 1
tic range
350690)
CBZ: 200
1600 mg, level
1749 mol/L
(therapeutic
range 17 to
(continued)
263
Author
Sample
Size and
Age
Psychopathology
Addressed
Methodology
Results
Comments
50 Li: 300
1350 mg,
level 0.30
1.11 mmol/L
(therapeutic
range 0.5 to
1.5)
Li = Li: CBZ = carbamazepine, VPA. = valproate, R = risperidone.
Electroconvulsive Therapy
Electroconvulsive treatment (ECT) has been used with some success
in mood disorders in DD adults. In a chart review Reinblatt et al. (2004)
reported on 20 adults, 12 of whom had mood disorders. Using strict
response criteria of a clinical improvement score of 1 or 2 (the absence
of illness or borderline illness, respectively), 66.7% of the mood disorders
group responded to ECT treatment. No side-effects were observed. A few
case reports also described psychotic patients who responded to ECT. Several other reports described patients with intellectual disability and affective symptoms who generally had a positive response to ECT.
The absence of standardized measures of symptom intensity and
treatment outcome make it impossible to compare effectiveness of one
treatment over another in all of these reports. However, the general mixture of responses again suggest that medications in the DD population are
subject to the same miracles and disappointments as they are in developmentally normal adults with this difficult form of bipolar disorder.
264
Lithium
Assessment and differential diagnosis are discussed in Volume I, Part
III, Chapter 8. Nevertheless, we have chosen to detail descriptions of children and adolescents in tables rather than simply summarizing treatment
findings so that the reader has an appreciation of the phenomenology of
patients described. More is known about lithium monotherapy in developmentally disabled young people as it is the agent that has been used
for the longest time. Tables 9.3 and 9.4 summarize early placebo-controlled lithium trials in diagnostically heterogeneous samples of children and
teens with small case series and case reports.
265
Table 9.3. Early Placebo-Controlled Trials of Lithium (Li) in Children and Adolescents with a Variety of Conditions
Author
Sample Size
and Age
Gram and
N = 18 Ages
Rafaelsen
822; 13
1972
males, 5
females;
pupils at
a special
school in
Denmark
Campbell et N = 10 Ages
al., 1972
36 inpatients
Psychopathology
Addressed
Methodology
Results
Psychosis
2 groups: Li
8-unchanged;
or profor 6 months
1 best on
nounced
then
placebo; 9
psychotic
placebo and
best on Li;
traits
vice versa;
7 worsened
7 with
Li levels
when Li
autism/
0.61.0 mEq/
stopped.
PDD; 2
L Parent/
Significant
borderteacher ratimprovement
line; 2
ings on 11
by chi square
psychosis;
items: hyper
p < 0.001
1 peror hypoactivNo patient
sonality
ity; elevated
became
disorder;
or depressed
totally free of
1 speech
mood;
symptoms;
and
anxiety;
improvement
language
obsessive
in aggression,
disorder,
behavior or
depressed/
two had
stereotypelevated
MR.
ies; speech
mood; in
disturbances;
school,
aggression to
speech disothers/self;
turbances
concentraand
tion; school
stereotypies
performance.
Severely
Children
Using global
disturbed
matched on
improvement:
prehyper- and
Li-1 with
schoolers;
hypoactivity;
marked, 4
DevelopLi compared
with slight,
mental
with chlo5 with no
quotients
rpromazine
improvement
under 60
(CPZ); 710
and 1 worse;
in 50%;
weeks for
CPZ 3 with
Mostly
each drug, 4
marked, 6
autistic/
weeks drug
with slight
PDD; 2
free between
(1 got thihyperbefore the
othixine),
kinetic, 1
crossover; Li
1 with no
organic
levels 0.25
change.
with
1.19 meq/l;
P = ns Li
withCPZ about
may have
drawing
90 mg.
improved
reaction
explosiveness, aggressiveness,
hyperactivity,
psychotic
speech
Comments
Probable
autism or
psychotic
spectrum
disorders;
no bipolar
but mood
component
important;
2 responders (age
10 and 22)
had family
history of
BD and
showed
significant
improvement in
shifts in
mood and
activity. No
significant
side effects
observed.
Margin
between
toxic and
optimal
doses
small;
improvement
didnt
outweigh
toxicity. A
very tough
population
to treat,
however.
Goetzl et al.
(1977)
Kelly et al.
(1976)
Adams et al.
(1970)
Author
N = 2 (1) 16 y.
o. adolescent boy
with mild
MR(2) 20
y.o. male
with moderate MR
N = 1 15year-old
adolescent
girl with
mild MR
N = 1 18year-old
female with
mild MR,
and chromosome
rearrangement
Number of
Patients and
Age
Depression: depressed mood, worthlessness, social withdrawal, insomnia, 20 lbs weight loss, academic
decline. Few months later mania:
pressured rambling speech, hyperactivity, awake for 34 nights, promiscuity, spending much money
on phone calls, argumentative and
aggressive.
Psychopathology Addressed
Medication Used
Table 9.4. Case Reports and Case Series About Use of Lithium (Li) Primarily in Developmentally Disabled Children and Adolescents
N = 2 1) age 9
autism/MR
Case 2: age
24
Steingard
and Biederman
(1987)
Linter
(1987)
N = 1, 12 y.o.
boy with
MR
N = 2, (1)
ages 4 y.
10 months
and (2) 5
y.o. with
autism/
MR; family
history of Li
response
Kerbeshian
et al.
(1987)
(continued)
McCracken
and
Diamond
(1988)
Author
Hospitalized
adolescents
(1) 18 y.o.
moderate
MR male (2)
17 y.o. mild
MR female
(3) 15 y.o.
moderately
retarded
female
(4) 21 y.
o. male
moderate
MR; history
of cerebral
palsy (5)
17 y.o.
severely
retarded
male
Number of
Patients and
Age
Medication Used
Psychopathology Addressed
268
ZINOVIY A. GUTKOVICH and GABRIELLE A. CARLSON
N = 1 14 y.o.
boy with
Aspergers
disorder
Frazier
et al.
(2002)
Gutkovich et al.
(2007)
270
271
Table 9.5. Two Open Trials of Valproate (VPA) in People with MR/Autism with
Affective Illness
Author
Kastner
et al.
(1993)
Sample Size
and Age
Psychopathology
Methodology
Results
Comments
Total N = 18
Inclusion
Open 2
Children:1
8 patients
with mild to
criteria:
year trial;
very much
needed
profound MR
3 of the
Assessment
improved;
additional
Children N
4 sympwith semi1 no
medications
= 2 (both F)
toms:
structured
improvement.
(CBZ, Li,
Adolescents
irritabilinterview of
Adolesverapamil,
N = 10, age
ity, sleep
caregiver;
cents: 8/10
buspirone,
1318
disturMain
improved or
or thiori(F = 3; M = 7)
bance,
outcome
very much
dazine); VPA
Adults N = 6
aggressive
measure
improved;
associated
or selfCGI-Improve2/10 - little
with lower
injurious
ment scale
improvement.
doses.
behavior,
VPA therapy
Adults: 4/6
A history of
behavioral
with levels
much or
epilepsy or
cycling
of 50 to
very much
a suspicion
125 g/ml
improved 2/6of sei(dose not
no change
zures was
reported)
or worse; No
strongly
difference in
associserum VPA
ated with
a favorable
response to
VPA
Hollander PDD with
Impulsivity/ RetrospecChild: 10
Adolescent
et al.
comorbid
aggrestive review
y.o.boy
also took
(2001)
Mood Disorsion,
of DVP in
autism, mood
fluoxetine
der (1 child),
mood
autism;
disorder NOS,
20 mg/d
3 with BP
lability
main
OCD, impulse
and
( 1 teen, 2
and 3 core
outcome
control disoralprazolam
adults)
autistic
measure
der; IQ = 87
1 mg prnv
dimenCGI-I
minimally
sions
worse
(social,
Adolescomcent: 15 y.o.
municaautism,
tion and
IQ = 55; BP;
repetitive
agitation,
behaviors)
insomnia,
impulsivity,
hyperactivity,
very much
improved VPA
level 66 g/
ml),
Adults: N
= 2 with BP
and BPNOS;
1 very much
improved;
1 no change
Whittier et
al. (1995)
Kastner and
Friedman
(1992)
Kastner et
al. (1990)
Author
Psychopathology Addressed
Medication Used
N = 1 13-yearold mentally
retarded girl
N = 3 (1)16 y.o.
(1) Irritability, aggressiveness,
(1) VPA 2750 mg/d; level (1) No further symptoms of mania. 4 episodes of
adolescent with
decreased sleep, severe fre109 g/ml; stable for
head banging due to environmental stress (2)
moderate MR
quent head banging
more than 10 months
Excellent clinical response, face gouging
and blindness (2)
(2) History of 7 years of
(2) VPA 3,000 mg/day
eliminated. Improved family relationship
13 y.o. girl with
hyperactivity, irritability,
-level 75 g/m-Follow(3) Became very calm, in good control,
profound MR,
mildly aggressive
up 7 months (3)VPA
elimination of self-injury Was able to return to
visual and hearbehavior, self-injurious
1,500 mg/day-level
foster family All 3 had failed Li trial; 2 became
ing impairment,
behavior (face gouging);
111 g/ml-Follow-up
manic on CBZ
spastic quadraworsened on Nortriptyline
8 months
paresis
(3) Severe self-injurious
(3) 8 y.o. girl with
behavior, hyperactivity,
profound MR and
irritability, distractibility,
Down syndrome
unmanageable,
Placed into RTF
N = 1 18 y.o. boy
Onset severe sleep disturbance VPA 2,750 mg/d- level
Patient failed adequate trials of Li and CBZ. Initial
with severe MR
age 4; severe self injuri111 g/ml; verapamil
response to VPA, not sustained with
and blindness
ous behavior- age 8; age 18
320 mg/d
monotherapy. Augmentation with Verapamil
increased activity level, mood
provided long-lasting effect. It is important to
lability with inappropriate
note that the patient had nonparoxismal EEG
bouts of crying
changes (general slowing)
and laughung, irritability,
hyposomnia, and severe
self-injurious behavior
Number of Patients
and Age
Table 9.6. Case Reports/Series on Use of Valproate in Developmentally Disabled Children and Adolescents with Bipolar Disorder
272
ZINOVIY A. GUTKOVICH and GABRIELLE A. CARLSON
Damore
et al.
(1998)
N = 3 Children
with fluoxetineinduced manic
symptoms
(1) 10 y.o. boy
with Asperger
Disorder, ADHD
(2) 9 y.o. boy
with Asperger
Disorder, ADHD
and OCD
(3) 9 y.o. boy
with Asperger
Disorder, meeting DSMIV
criteria for Bipolar II Disorder
274
Table 9.7. Double-Blind Trial on Use of VPA in Aggressive Youth with PDD
Author
Hellings
et al.
(2005)
Sample Size
and Age
Psychopathology
Total N = 30 Significant
children
aggresand adosion to self,
lescent
others, or
outpaproperty at
tients with
least three
ASD, 620
times per
years of
week
age (M =
20, F = 10)
average
IQ = 54.
Methodology
Results
Comment
Large placebo
response,
subject
heterogeneity, and
small group
size were
problems in
this study
275
Number of
Patients and Age
Psychopathology
Addressed
Medication
Used
Response and
Comments
Episodes
stopped Prior
trial of Li at
dose 600 mg/
day produced
no response
Depressive
episodes
stopped except
for a single
episode at
12 years 2
months of
age when she
had menarche
Patient had
first time convulsion during her fifth
depressive
episode and
second convulsion episode at
age 13 years 5
months. EEG
was abnormal. Diphenylhydantoin
60 mg/day
was added
Family history
negative in
both cases
Atypical Antipsychotics
Atypical or second-generation antipsychotic medications have not
been studied even on a small scale in developmentally disabled youth
with bipolar disorder. Two case reports (Frazier & Jackson, 2008;
Gutkovich, Carlson, Carlson, Coffey, & Wieland, 2007) describe risperidones efficacy in autism spectrum youth with bipolar disorder. On the
other hand, and very relevant for treatment of behaviors characteristic of
mania, risperidone has been studied extensively in children and adolescents with irritable and agitated behavior in autism (e.g., McCracken et
al., 2002) and has recently received FDA approval for treatment of irritability and self-injurious behavior in autism. In particular, an eight-week,
double-blind, placebo-controlled study found risperidone to be superior
to placebo for treating aggression, tantrums, and self-injury in children
276
277
8 out of 20 patients in the former and 6 out of 10 in the latter. Weight gain
and tardive dyskinesia were the main adverse events.
In general, it appears that, in the absence of specific studies on efficacy of medication for mania in DD youth, the positive responses in cognitively normal adults and teens with mania, and positive results in autistic
youth with irritability would make it likely that manic symptoms in DD
youth would also be responsive.
Electroconvulsive Treatment
Thuppal and Fink (1999) described five inpatients with mild to moderate
intellectual disability with catatonia and affective and psychotic disorders
who were treated with bilateral ECT after they failed to respond to medication trials. Affective and aggressive symptoms improved. One 18-year-old
male with moderate ID and Bipolar Disorder received 17 ECT treatments,
was discharged markedly improved. He then received four continuation
ECT treatments and then remained stable on clozapine 300 mg/day. This
is the only publication reporting treatment of an adolescent patient with
intellectual disability and Bipolar Disorder that we were able to identify
in the literature. Guze et al. (1987) reported use of ECT in treatment of
21-year-old man with bipolar depression, mild intellectual disability, and
cerebral palsy. Depressive symptoms resolved but the patient switched to
mania, which was stabilized on lithium.
278
279
CONCLUSION
Aman et al. (2000) concluded that in lieu of woeful lack of empirical
data clinicians will often be forced to extrapolate from data on adults
having intellectual disability and from typically developing children. The
best policy is probably to treat such patients cautiously, while gathering
data on the effects of such therapy.
The largely anecdotal reports we found showed effectiveness of moodstabilizing agents in people with all degrees of intellectual disability including profound ID. Nor did etiology of the developmental disorder appear to
matter (Adams, Kivowitz, & Ziskind, 1970, Kastner et al., 1990; Reid et
al., 1981; Sovner, 1991). Patients with more clearly delineated mood states
with normal interepisodic functioning (i.e., more classic bipolar disorder)
had a better response. As in normally developing adolescents, initial manifestation of the disorder often includes frank psychotic symptoms that can
be easily misdiagnosed as schizophrenia. History of depressive episode preceding mania is also common as it is documented for nondevelopmentally
disabled population. We cannot, of course, address frequency of response
to various bipolar regimens because these case reports were published
precisely because patients responded, often dramatically, to treatment.
With regard to safety of treatments, affective illnesses themselves often
cause regression (e.g., incontinence), confusion, and disorientation making it difficult to separate the toxicity of illness from the potential toxicity
of treatment.
We have reviewed somatic treatment of 191 patients with developmental disabilities and Bipolar Disorder, among them 12 children and 27
adolescents, including three double-blind trials, one single-blind trial, two
open trials, five retrospective chart reviews and the rest single case reports
or small case series.
280
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10
Treatment of Autism
Spectrum Disorders
MARY JANE WEISS, KATE FISKE,
and SUZANNAH FERRAIOLI
INTRODUCTION
This chapter provides an overview of the treatment of autism spectrum
disorders. This is both an exciting and confusing time within treatment for
autism; early identification continues to allow for more intensive and effective
early intervention, prevalence estimates of autism are suggesting increased
incidence, and claims for effective treatment abound. Consumers are faced
with myriad choices for treatment, and have difficulty navigating the claims
and opinions of professionals from multiple perspectives and disciplines.
In this chapter, we review the evidence for the effectiveness of behavior
analytic interventions for autism. We also review the evidence for nonbehavior analytic interventions. In addition, we describe interventions that
have been targeted to individuals with Aspergers syndrome, and we discuss the relevance and use of functional assessment procedures for developing effective behavior intervention plans for individuals with ASDs. We
also highlight new directions within treatment, including some social skill
interventions and information on early identification.
of New Jersey
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DTT and naturalistic methods such as incidental teaching target different deficits within autism spectrum disorders. Each methodology has
distinct advantages and unique applications. Although DTT is efficient and
effective in teaching a wide variety of skills, there is almost always a need
for additional generalization training procedures. Responsivity improves
dramatically within DTT, however, it is likely that initiation skills, requesting, and conversation may be best taught within more naturalistic methodologies.
Outcome Data
To date, a number of reports of long-term outcome with behavioranalytic intervention have been published. In the best-known study of
this type, Lovaas (1987) compared a group of children under age four
who received 40 hours of intervention per week for two or more years
with groups of children who received either fewer hours of such intervention or no intervention. Almost half of the children in the intensive
intervention group were able to be placed unassisted in regular education classes and achieved IQs in the average range. Other researchers
have documented that early intensive behavioral intervention results in
significant gains for some children (e.g., Green, Brennan, & Fein, 2002;
Smith, 1999). More research is still needed to completely understand
the effective elements and intensity levels of intervention, and how such
variables affect outcome. It is also true that outcome remains highly
variable, and that reliable predictors of outcome have not been confidently identified.
Other Directions
In recent years, behavior analytic treatment of autism has begun to
incorporate elements of rate-building to achieve fluency. Fluency has been
defined as responding accurately, quickly, and without hesitation (Binder,
1996; Dougherty and Johnston, 1996). Although fluency has been a goal
of Precision Teaching, a field within the discipline of ABA instruction that
has existed for many years and served many populations (e.g. Lindsley,
1992), it has only recently been focused on as a goal for learners with
autism (Fabrizio & Moors, 2003). Rate-building procedures are used to
build fluency in the demonstration and availability of skills.
Rate-building addresses the specific deficits and needs of learners
with autism. Many learners on the autism spectrum exhibit motor dysfluencies. Although they may be able to achieve mastery when accuracy is
used to gauge success, they may still perform the task laboriously, inefficiently, or slowly. Furthermore, many individuals with ASD demonstrate
a long latency to respond to instructions or to social initiations and bids.
Slow response times can lead to missed opportunities, especially in social
contexts (Weiss, 2001, 2005).
Rate-building procedures focus on rate of response, and utilize coaching
to build performance. Practice sessions begin as very short sprints
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Summary
The treatment of autism spectrum disorders continues to receive a
great deal of attention in the professional and lay communities. Applied
Behavior Analysis has substantial documentation of its effectiveness in
remediating the deficits associated with autism. There is no other treatment approach that even approaches ABA in terms of empirical validation,
scientific support, or confidence of findings.
Within ABA, Discrete Trial Training has been used to build core skills,
with increased emphases in recent years on using task interspersal procedures, errorless learning procedures, embedded generalization strategies, and high rates of instruction (Weiss, 2001, 2005). DTT continues to
be effective in building responsivity and in establishing a wide variety of
core skills, and is best used in combination with other ABA procedures
that target different deficits. Naturalistic ABA teaching procedures such as
Incidental Teaching facilitate generalization and increase initiation. Ratebuilding procedures may help to address problems in speed of response
and/or in latency to respond, which are critically important to ensure the
functional availability of responses in the natural environment. Furthermore, Direct Instructions foci on effective instructional design, individual assessment of progress, and scripted curricula may also benefit this
population. The use of all of these procedures provides a comprehensive
approach to addressing the diverse profiles and characteristics encountered among learners with ASDs.
NONBEHAVIORAL APPROACHES
Applied behavior analysis foundations in evidence-based principles
may be its most compelling quality to parents and practitioners. However,
the widespread implementation of interventions lacking empirical support
has been well documented (Levy, Mandell, Merhar, Ittenbach, & PintoMartin, 2003). Smith and Wick (2008) suggest that the popular medias
focus on such treatments as opposed to those that are data-driven may
contribute to this phenomenon. Their investigation of reports on alternative treatments in the media since 1990 yielded frequencies in the high
hundreds, most of which presented a positive or neutral perspective of
these therapies. Although these numbers have declined in the past few
years, parent utilization of alternative treatments that lack empirical
evidence of effectiveness for children with autism has been estimated at
74% (Hanson et al., 2006).
294
Biomedical Interventions
The Gluten-Free Casein-Free (GFCF) Diet
The rationale behind the GFCF diet stems from a variety of studies
and anecdotal reports of gastrointestinal abnormalities in children with
autism. Panksepp (1979) linked excesses of opiates in animals to the types
of social deficits and aberrant behavior observed in the autistic population. The theory further posits that inadequate digestion of gluten and
casein in individuals with autism can lead to opiatelike peptides in the
gut that are likely to seep back into the system to limit social relatedness
and cause maladaptive behaviors (the leaky gut theory). Indeed, findings
of urinary peptide abnormalities in this population (Knivsberg, Reichelt,
Hoien, & Nodland, 2003; Reichelt et al., 1981; Shattock et al,. 1990) as
well as amino acid deficiencies (Arnold, Hyman, Mooney, & Kirby, 2003)
have been documented.
As the name implies, the GFCF diet removes all gluten (a mixture of
proteins found in wheat products) and casein (a milk protein) from the
diet. Individuals on the diet must also avoid touching products containing gluten and casein (e.g., Play-Doh) that may transfer the compounds
through the skin. This is an important consideration for children in a
school setting who may encounter exposure to gluten or casein from classroom items (e.g., Play-Doh, glue) or from another student.
Data on the GFCF diet have been mixed. Evaluations of the efficacy
of this intervention are based on parent- and teacher-report (Cade et al.,
2000; Whiteley, Rodgers, Savery, & Shattock, 1999), urinary analysis of
peptides (Elder et al., 2006; Knivsberg, Reichelt, Nodland, & Hoien, 1995;
Knivsberg, Wiig, Lind, Nodland, & Reichelt, 1990), or a variety of behavioral observation scales (Elder et al., 2006; Kinvsberg et al., 1990; Lucarelli
et al., 1995). Knivsberg and colleagues randomized control trial of dietary
intervention yielded significant improvements in behavior, nonverbal
cognition, and motor difficulties.
In their 2006 review, Christianson and Ivany detail six studies that
reported significant improvements of children with autism on the GF CF
diet based on parent- and teacher-reports, urine peptide analyses, and
assessments of autistic behavior and cognitive skills. These analyses,
however, do raise some methodological concerns. Four of the studies did
not include a control group; one performed an unblinded comparison
and then based improvements on teacher and parent ratings (Whiteley
et al., 1999). Other studies have found no differences in symptom severity or urine peptides between diet and control groups (Elder et al., 2006)
295
or reported mixed results (Whiteley et al., 1999). The literature also documents frequent discrepancies between parent- and teacher-reports or
between parent-/teacher-reports and scores on standardized measures.
Other types of dietary interventions are also occasionally implemented.
The ketogenic diet (Wilder, 1921), more commonly used for individuals
with seizure disorder, is high in fat and low in carbohydrates. There is
limited preliminary evidence that the ketogenic diet may be useful in children with autism (Evangeliou et al., 2002). More general elimination diets
also exist in which children are tested for sensitivity to a variety of foods,
which are then eliminated from their diet. Frequently tested foods include
soy, milk, nuts, corn, eggs, and chocolate; these diets may elicit behavior improvements in children with autism (Torisky, Torisky, Kaplan, &
Speicher, 1993). Without more extensive controlled analyses these results
are considered very preliminary; currently the use of these types of interventions is not empirically supported.
Vitamin Therapy
It has been proposed that individuals with autism require more nutrients
than their typical peers, and that nutritional deficiency may impede normal
processing of sensory information (Rimland & Larson, 1981). Vitamin therapy involves the administration of specific compounds, most commonly vitamin B-6 (pyridoxine) and magnesium. The benefits of this intervention have
been suggested over the past 25 years for decreasing symptomatic behavior
(Barthelemy et al., 1981; Lelord, Muh, Barthelemy, Martineau, & Garreau,
1981; Martineau et al., 1989; Rimland, Callaway, & Dreyfus, 1978) and normalizing antibody deficits (Menage, Thibault, Barthelemy, Lelord, & Bardos,
1992). Ascorbic acid supplements have also resulted in decreases on abnormal sensory motor scores on a commonly used behavior measure (Dolske
et al., 1993). Opponents of vitamin therapy argue that existing literature does
not standardize dosage or units of measurements and criticize the methodology (e.g., unblinded, absence of control, lack of random assignment; Pfeiffer,
Norton, Nelson, & Shott, 1995). More recent studies have shown no benefits
of vitamin therapy in double-blind, placebo-controlled clinical trials (Findling
et al., 1997; Tolbert, Haigler, Waits, & Dennis, 1993).
Medication
Children with autism may receive medication as a supplement to other
treatments. Commonly administered medications include atypical antipsychotics (e.g., risperidone, aripiprazole), psychotropics (e.g., methylphenidate), and SSRIs (e.g., fluoxetine). These drugs are typically prescribed
to target specific behaviors such as aggression, rituals and compulsions,
and attention deficits.
Atypical Antipsychotics
Risperidone is one of the most well-studied medications currently
approved by the FDA. It is tolerated well by children as young as
296
preschool age with minimal side-effects, the most common being weight
gain, excessive appetite, and hypersalivation (Aman et al., 2005; Luby
et al., 2006; Williams et al., 2006). Several studies have suggested the
efficacy of risperidone in reducing hyperactivity and repetitive behaviors
(Barnard, Young, Pearson, Geddes, & Brien, 2002), aggression (Bernard
et al., 2002; AJP, 2005), autism severity (Luby et al., 2006) and self-injurious behaviors (Research Units on Pediatric Psychopharmocology Autism
Network, 2005), and promoting increases in communication, daily living
skills, and socialization (Williams, et al., 2006). There is also evidence
that risperidone may be more effective than alternative atypical antipsychotics (Barnard et al., 2002). Because of the lack of control in these
studies, there is a need for randomized control trials to further evaluate
the efficacy of this medication.
Secretin Therapy
Secretin is a hormone that regulates the pH balance of the stomach
and the pancreas; it was originally administered to children with autism to
alleviate gastrointestinal difficulties. Parent reports of salutary effects on
the core features of autism led to the use of secretin to directly target these
symptoms. In 1998, Hovarth and colleagues reported gains in language
and socialization in three children with autism who received one dose of
secretin therapy.
Randomized controlled trials of the effects of secretin generally suggest that there is no causal relationship between secretin and changes
in autism symptomology. Although some have reported positive results
(Kern, Miller, Evans, & Trivedi, 2002), in most cases no changes in behavior were reported (Dunn-Geier et al., 2000; Sandler et al., 1999) or concurrent benefits were observed in both treatment and placebo groups
(Handen & Hofkosh, 2005; Unis et al., 2002). In some instances, treatment groups suffered deterioration of skills (Carey, Ratliff-Schaub, Funk,
Weinle, Myers, & Jenks, 2002) and increased autism severity when paired
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Chelation
Chelation is a detoxification process created to remove heavy metals from
the body, in circumstances such as lead poisoning. Proponents of its use
with children with autism attribute its alleged efficacy to the link between
heavy metals (principally mercury) and autism symptoms (e.g., language
deficits, motor difficulties, sensory abnormalities, repetitive behaviors;
Bernard, Enayati, Redwood, Roger, & Binstock, 2001). It is purported that
the inclusion of the preservative thimerosol in the MMR and other childhood vaccines facilitates this mercury leak into the body.
Currently, there are no published clinical trials on the efficacy of chelation or any other evidence to suggest that chelation may be an appropriate
treatment for individuals with autism (Sinha, Silove, & Williams, 2006).
Further arguments suggest that the underlying theory is flawed, that the
symptoms of mercury poisoning do not mimic specific autism symptoms
(Nelson & Bauman, 2003), and that chelation has not been shown in any
instance to reverse neurological damage (Shannon, Levy, & Sandler, 2001).
Shannon and colleagues also highlight the dangers of this treatment, citing possible kidney and liver damage, and severe allergic reaction. The
recent death of a five-year-old boy during chelation therapy also cautions
against the blanket administration of this procedure (DeNoon, 2005).
Sensory-Motor Treatments
Sensory and auditory integration are posited to alleviate symptoms
that arise from abnormal processing of sensory input in individuals with
autism. There is evidence to suggest that the autistic population experiences hypo- and hyperarousal to usual sensory stimuli (Frith, 1989; Ke,
Wang, & Chen, 2004; Ornitz, 1974); these atypical processes may affect
development and account for attentional difficulties, social deficits, and
maladaptive behaviors (Ornitz, 1974).
Sensory Integration
Implementation of sensory integration therapy can vary; it may be
proprioceptive (e.g., deep pressure massage), tactile (light touching, brushing),
or vestibular (swinging, rolling, jumping). There is mixed evidence of the
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Toll, & Whitehair, 1994; Simpson & Myles, 1995b). Many more investigations
have indicated that performance with FC is largely due to facilitator influence (Kezuka, 1997; Oswald, 1994; Shane & Kearns, 1994; Perry, Bryson, &
Bebko, 1998) and that collateral improvements are unlikely (Beck & Pirovano,
1996; Myles, Simpson, & Smith, 1996a). Indeed, other methods of encouraging communication, such as the Picture Exchange Communication System,
are evidenced to be preferable (Simon, Whitehair, & Toll, 1996). FC is considered not only ineffective, but possibly harmful, and is not recommended.
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child-directed treatment; parents and therapists play with the target child
on the floor with preferred materials to promote manding, eye contact,
conversation, and other social interfaces. Greenspan and Wieder (1997)
conducted a chart review of 200 children with autism who received DIR
treatment and compared outcomes with those of children who received
traditional (unspecified) services. After two years, they found that 58% of
children were categorized as good to outstanding compared to 2% in
traditional services. Their recent 10- to15-year follow-up of the 16 most
high-functioning participants revealed long-term positive outcomes in social
and school competence, low rates of comorbid depression and anxiety,
and variable outcomes on sensory motor profiles (Wieder & Greenspan,
2005). Limitations of these studies include a nonexperimental design and
a lack of information on concurrent treatments, making it very difficult to
confidently attribute gains to the approach.
Conclusion
The widespread use of alternative nonbehavioral treatments warrants
our attention. Because these interventions are so prevalent, and because
rigorous scientific data are largely absent, additional empirical analyses
are necessary. Until more data are collected, service providers, teachers,
physicians, and parents should be aware of these treatments and of their
potential benefits, risk of harm, and possible shortcomings.
ASPERGER SYNDROME
Asperger syndrome (AS) is characterized by deficits in social behavior,
insistence on sameness, poor nonverbal language development, inappropriate affect, and stereotyped behavior (Asperger, 1944; Wing, 1981). According to the American Psychological Association (APA), differential diagnosis
of AS and autism lies in the diagnostic criterion that individuals with AS
unlike those with autismgenerally do not demonstrate communication,
language, imagination, cognitive, or self-help deficits (APA, 1997). Regardless, researchers and clinicians point out that the differentiation between
individuals with autism and AS is often unclear, and requires additional
research before a firm conclusion can be made regarding the differential
diagnosis (Barnhill, Hagiwara, Myles, & Simpson, 2000).
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Social Deficits
As indicated by Myles and Simpson (2002), AS is foremost a social
disorder (p. 132). The authors report that one of the primary differentiating characteristics of children with AS, when compared to children with
autism, is that individuals with AS desire and seek social interactions.
Difficulties in initiating and sustaining relationships, however, are evident
at an early age. Church, Alisank, and Amanullah (2000) conducted an
analysis of individuals with autism from preschool to teenage years. The
authors reported that, even in preschool, parents indicated that although
the children interacted well with adults, they had difficulty interacting
with children their age and seemed more comfortable on the periphery of
social groups. This difficulty in initiating and maintaining relationships
seemed exacerbated by difficulty reading social cues and situations and
regulating behavior. Through middle school, individuals with AS exhibit
inappropriate affect, resulting in inappropriately loud, aggressive, and
often silly behavior.
Much of the difficulty experienced by children with AS stems from
their inability to learn and understand what Myles and Simpson (2001)
term the hidden curriculum. Rules of social interaction and behavior
are learned rigidly by children with AS and are inflexibly applied to all
situations regardless of setting and audience. The ability to flexibly apply
these rules of interactionwhich is demonstrated effortlessly by typical
childrenis a skill that is never directly taught but is expected of all individuals. As a result, children with AS appear socially awkward and often
inappropriate (Myles & Simpson, 2001).
One approach for improving social skills in this population is the
development of social skills groups for children and adolescents that target appropriate behavior, recognition of verbal and nonverbal social cues
(Barnhill, Cook, Tebbenkamp, & Myles, 2002), and understanding the
hidden curriculum (Myles & Simpson, 2001). For example, Myles and
Simpson (2001) suggest that the hidden curriculum can be taught to
children with AS using a variety of methods, including direct instruction
comprised of methods such as providing a rationale for behavior, presentation of skills, modeling, evaluation, and assessment of generalizationand
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Behavioral Difficulties
Young children with AS often exhibit rigid behavioral routines and
rituals, becoming preoccupied with stereotypical body movements and inappropriate object use. Interruptions of and transitions from these routines
often result in maladaptive behavior such as tantrums (Church et al.,
1999). Many of these behaviors appear to dissipate as the children grow
older, however, they are often still evident in times of high frustration;
elementary-aged children frequently engage in behaviors such as self-talk,
humming, and pacing. These children remain extremely literal and rulebased in their interactions with others (Church et al., 1999). Managing
these restricted interests can be difficult, but promoting a predictable
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In elementary school and middle school, 96% and 76% of children, respectively, receive speech and language services to address difficulty with conversational skills, vocal regulation and modulation, and language expression.
Although these children often perform above average in academics,
the individual performance of students with AS varies widely. Griswold,
Barnhill, Myles, Hagiwara, and Simpson (2002) conducted an assessment
of children ages 6 to 17 years old with AS using the Wechsler Individual
Achievement Test and found that, whereas the aggregate score for the children fell within the average range, individual scores ranged from significantly below to significantly above average. Children with AS demonstrated
specific weaknesses in language and reading comprehension (Church
et al., 1999; Barnhill et al., 2000; Griswold et al., 2002) and mathematical
concepts and principles (Barnhill et al., 2000; Griswold et al., 2002). Such
deficits may arise from difficulties with social and communication related
tasks, literal thought and interpretation, and poor problem-solving skills
(Frith, 1991; Siegel, Minshew, & Goldstein, 1996).
These children appear to demonstrate above-average performance in tests
of nonverbal reasoning and factual recollection (Barnhill et al., 2000), as well
as reading. Teachers should note, however, that reading proficiency is not an
indicator of strong comprehension; these children often demonstrate weakness in this area (Griswold et al., 2002). In addition, they are often unable to
differentiate between general knowledge and personal thought, responding
both verbally and in writing with responses that may be incomprehensible by
a teacher due to their reliance on personal thought (Williams, 1995).
Researchers caution that knowledge of the AS diagnosis will not provide
information about specific strengths and weaknesses; rather, comprehensive
assessment must be conducted for all students (Griswold et al., 2002). Many
children with AS, because of their myriad strengths and deficits in unpredictable areas, will require individualized programs to ensure success in an
academic setting. These children may require additional explanation and
instruction, especially of abstract concepts. Care should be taken to assess
a childs comprehension of spoken and written material (Williams, 1995).
Additional supports can be implemented in the general classroom area
to increase skills in concentration, an area of difficulty for the child with AS.
A structured predictable classroom setting may increase a childs attention,
as might seating arrangements that facilitate concentration (e.g., seating near
the teacher, seating with a classroom buddy). Visual prompts for these children may be especially helpful in facilitating adherence to instruction and
smooth transitions to new activities (Williams, 1995). Visual prompts may
also be useful in improving performance in auditory tasks, as many children
with AS may have difficulty processing auditory instructions and descriptions. A lecture format may be especially difficult for a child with AS to attend
to, and additional visual strategies such as the use of role-play and videos
may make information more salient to the child (Griswold et al., 2002).
Emotional Characteristics
Of great importance in the discussion of AS is the profound impact
that the disorder has on the emotional adjustment of the individuals. As has
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been mentioned previously, unlike their peers with autism, children with
AS have a desire to develop social relationships but often fail at doing so.
These children also have the insight to understand that they are different
from others and do not fit in (Myles & Simpson, 2002). Such realizations have effects on the individuals self-esteem and self-concept and put
children, adolescents, and adults with AS at increased risk for a number
of comorbid disorders, including depression and anxiety (Barnhill et al.,
2000; Kim, Szatmari, Bryson, Streiner, & Wilson, 2000). Up to 20% of
adults with AS have experienced a period of depression at some point in
their lives (Kim et al., 2000; Tantam, 2001), but research indicates that
often these children are poor reporters of such internal states.
Barnhill et al. (2000) conducted an analysis of internalizing and externalizing problem behavior among adolescents with AS and revealed that, although
parents and teachers indicated that children were at risk for internalizing
problems, the adolescents did not report any internalizing difficulties. Such
poor insight may make it difficult to diagnose these problems in AS individuals, but the identification of these diagnoses is critical to ascertain treatment.
Much research has focused on the underlying cause of depression in
children and adolescents with AS. Recently researchers have indicated
that adolescents with comorbid AS and depression indicate a greater propensity to view situations in a way that indicates both helplessness and
hopelessness. They perceive many events as beyond their control and
take personal responsibility for the negative events in their lives (Barnhill
& Myles, 2001). Additionally, authors have found that IQ is negatively
related to this finding, in that adolescents with high IQ are less likely to
make these attributions and to instead realize the impact external situations have on ones social success (Barnhill, 2001a).
As a result of these findings, researchers have begun to examine the
use of cognitive behavior therapy (CBT)a problem-oriented therapy in
which focus is placed on psychological and environmental contributors
to emotional distressfor treatment of AS individuals with comorbid disorders. CBT places focus on the alteration of thoughts and behavior to
improve symptoms such as anxiety and depression. For example, Sofronoff, Attwood, and Hinton (2005) found that the use of a CBT package,
which included teaching children with AS to identify emotions, thought
patterns, and behavior and instructing them in ways of controlling anxiety
using a variety of coping skills and social stories, was effective in decreasing anxiety symptoms in children with AS. The treatment was most effective when paired with parental involvement in therapy.
Research in the use of CBT with individuals with AS, however, is still
emerging. In an investigation of the use of CBT in individuals with AS,
Anderson and Morris (2006) reported that only five published studies
four of which were case studieshave examined the use of CBT in individuals with AS. More research is required in this area to fully understand
the intricacies of utilizing the therapy within this population. Researchers
speculate that the highly structured format of the therapy and the focus
on the development of affect recognition and thought evaluation may be
beneficial to AS individuals suffering from comorbid disorders, especially
when enhanced by visual materials, emphasis on rules rather than on
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Functional Assessment
Iovannone, Dunlap, Huber, and Kinkaid (2003) conducted a review of
comprehensive treatments for children with autism and found that one of the
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Indirect Assessment
Functional assessments can be conducted using three types of assessment: indirect assessment, descriptive assessment, and functional analysis (ONeill, Horner, Albin, Sprague, Storey, & Newton, 1997). Indirect
methods include assessment techniques such as rating scales and interviews which require an individual who is familiar with the child to provide
information about environmental antecedents and consequences. Antecedents, or events that frequently occur before the onset of the behavior,
may include the time of day, the presence of a specific person or activity, or
inclusion in a particular setting. Consequences, or events that frequently
occur following the behavior, might include examples of positive or negative reinforcement as discussed above (e.g., access to attention, removal
of attention, etc.). The informant should also be asked to provide information about the childs current skill level and ability to communicate. All of
these responses will be helpful in informing a function-based intervention
(ONeill et al., 1997).
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Although rating forms and interviews are frequently easy and efficient
to conduct, they should not be the sole form of assessment on which treatment is based. Both rating scales and interviews are subject to bias or error
on the part of the informant and may provide unreliable results (LaRue &
Handleman, 2006; Sturmey, 1994; Zarcone, Rodgers, Iwata, Rourke, &
Dorsey, 1991). As a result, such methods of indirect assessment should
be used as a preliminary step to inform subsequent assessment and, with
very few exceptions (e.g., suicidal behavior), an intervention should not be
based solely on an indirect method of assessment.
Descriptive Assessment
In contrast to indirect methods of assessment, descriptive assessment
involves the direct observation and recording of the target behavior in the
natural environment. A frequent method of descriptive analysis is Antecedent-Behavior-Consequence (ABC) recording, in which the observer
watches the child in vivo in the natural setting and records the antecedents,
behavior, and consequences, all of which must be operationally defined
to ensure accurate recording (LaRue & Handleman, 2006; Sasso et al.,
1992). The observer is then able to calculate the conditional probability of
each antecedent and consequence by calculating the percentage of behavior episodes that were preceded by a specific antecedent and followed by a
specific consequence. The most frequent antecedent and consequence for
the behavior, or those with the greatest conditional probability, indicate a
function (e.g., escape from demand, gain access to tangible, gain access to
attention) of the behavior (LaRue & Handleman, 2006; Sasso et al., 1992).
If the data indicate a clear functional relationship between environmental
events and behavior, the descriptive analysis may be the terminal step of
the functional assessment (LaRue & Handleman, 2006).
Descriptive analysis provides more objective information about the
behavior as compared to indirect methods of assessment. By observing
the behavior in the natural environment, the observer decreases the likelihood that identification of the function of behavior is biased. Criticisms of
descriptive analyses, however, include the fact that they offer little control
over the behavior and thus one cannot assume functional relationships
between events and behavior (Sasso et al., 1992). The temporal contiguity of two events does not indicate a relationship, as the two events may
be completely unrelated and occur temporally proximate to each other
by coincidence only. In addition, many events may occur simultaneously
prior to or following the occurrence of the behavior, making observational
recording and analysis of antecedents and consequences difficult (LaRue
& Handleman, 2006).
Functional Analysis
A functional analysis evinces significantly more control over environmental events through the systematic manipulation of environmental
antecedents and consequences (Carr & Durand, 1985; Iwata, Dorsey, Slifer,
Bauman, & Richman, 1982/1994). These manipulations, referred to as
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allowed the assessment in the natural environment with control over the
environmental events controlling the behavior (Sasso et al., 1992).
Noncontingent Reinforcement
Noncontingent reinforcement is the time-based, response-independent
delivery of an activity or item that is known to be a reinforcer for the
individual (Vollmer, Marcus, & Ringdahl, 1995; Vollmer, Iwata, Zarcone,
Smith, & Mazaleski, 1993). The frequent delivery of this reinforcement
is intended to decrease an individuals motivation to engage in the challenging behavior; if he receives the reinforcing activity at a rate that is the
same or higher than that achieved by using the maladaptive behavior, his
motivation for engaging in the behavior may subsequently decrease, and
lower rates of the behavior may occur (Vollmer et al., 1993).
For noncontingent reinforcement to be effective, it is paramount that
the child receives reinforcement that is matched to the function of her
behavior. For example, if a childs noncompliance is maintained by access
to attention, a teacher might provide the child with noncontingent attention every ten minutes. Alternatively, if the noncompliance functions to
help the child escape from work tasks, the teacher may provide the child
with a noncontingent break from work every ten minutes. Researchers
have also found that the delivery of stimuli that may provide the same
sensory input as an automatically reinforced challenging behavior may
also decrease the target behavior. Again, a comprehensive assessment of
the reinforcement received from engagement in the behavior is required to
identify a form of noncontingent sensory reinforcement that may reduce
the behavior (Piazza, Adelinis, Hanley, Goh, & Delia, 2000)
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method frequently used to teach a child replacement skills. Through functional communication training, a child learns to solicit his own reinforcement using communication, be it through sign language, picture exchange,
or a verbal response (Carr & Durand, 1985). In teaching this skill, the
alternative behavior must be as efficientif not more efficientthan the
maladaptive behavior. That is, the alternative behavior must result in more
consistent, reliable reinforcement delivery than the maladaptive behavior
to result in a decrease of challenging behavior (Carr & Durand, 1985).
The advantage of functional communication training is that it puts
the child in the active role of securing reinforcement. By instructing the
child in the use of a functional communication skill, she is able to gain
access to reinforcement independently and perhaps at a more frequent
rate than might be determined by a noncontingent reinforcement schedule
(Carr & Durand, 1985). Functional communication training can be effective when used as the sole element in a behavior reduction plan (Carr &
Durand, 1985), but many researchers recommend the use of FCT in addition to other procedures (e.g., extinction) to decrease maladaptive behavior
(Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998).
Reinforcement Procedures
In addition to delivering reinforcement noncontingently or in response
to an alternative behavior, positive or negative reinforcement can also be
delivered contingently on the absence of a students behavior (Lalli et al.,
1999). Function-based reinforcement may be delivered when the child has
not engaged in the behavior for a specified period of time (Vollmer et al.,
1993) or when the child has engaged in a behavior incompatible with the
maladaptive behavior (e.g., placing hands in pockets instead of engaging
in repetitive motor movements) (Cooper, Heron, & Heward, 2007) to further increase motivation for engagement in appropriate behavior.
Extinction
One of the most critical components of behavior intervention plans
is that of extinction. Extinction refers to the elimination of reinforcement
for the maladaptive behavior, and takes place when reinforcement that
previously maintained a behavior is withheld following the occurrence of a
behavior (Iwata et al., 1994). Extinction is especially potent when combined
with other intervention components, such as functional communication
training and reinforcement procedures, because it eliminates the contingency
maintaining the behavior while the childs motivation to engage in appropriate behavior increases (Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc,
1998; Mazaleski, Iwata, Vollmer, Zarcone, & Smith, 1993).
Extinction takes on many forms, and each is specific to a different
function of behavior. For instance, in the case of behavior that is main
tained by attention, extinction would take place when attention was
withheld (i.e., planned ignoring) following the occurrence of the behavior.
For a behavior maintained by escape from demands, escape extinction
would be implemented by prompting a student through the current task
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progress in the early identification of autism spectrum disorders in toddlers, making it possible for treatment to begin at younger ages.
THEORY OF MIND
Theory of mind (ToM) refers to both the ability to understand the
presence of others mental states (e.g., beliefs, desires, intentions) and
the capacity to reasonably predict these mental states in various situations. Impairments in ToM are evident in individuals with autism, and
some argue that in these impairments lies a core deficit of autism. Recent
studies have brought into light new possible mechanisms, constructs,
and implications of ToM, thus creating an exciting new realm for future
research.
Biological Mechanisms
The prefrontal cortex (PFC) has been connected to certain core deficits
of autism, as it is implicated in the development of social, emotional, and
memory skills. Currently, researchers aim to substantiate hypotheses of
domain specificity in areas of the brain as they relate to ToM. Sabbagh
(2004) examined event-related potentials (ERP) in individuals with autism
during an emotional mental state judgment task. His results specifically
implicate the inferior frontal and anterior temporal regions of the right
hemisphere in mental state decoding. In contrast, the left PFC is associated
with executive function, inhibitory control, and the development of emotional
quality in social interactions. The PFC is also related to other constructs
related to ToM, including joint-attention and visual perspective shifting.
Sabbaghs findings suggest that the cognitive processes of ToM may
not be a result of deficits in general neural systems, but domain-specific.
Future research may focus on the need for a developmental trajectory of
cortical brain activity in individuals with autism. Sabbaghs final comments target mental state decoding as a core deficit in autism. In typical development, decoding emerges prior to reasoning; the similarities
between the cortical localizations in decoding and other ToM and social
skills processes (e.g., mental state reasoning, facial emotion recognition)
justify additional attention to this area of research.
Other investigations have targeted neural functioning to explain
ToM. A recent study of Von Economo neurons (VENs) suggests that ToM
deficits may be explicated at this level (Allman, Watson, Tetreault, &
Hakeem, 2005). VENs transmit output of the fronto-insular and anterior
cingulate cortex to the frontal and temporal cortex; they are believed to
be related to intuition, or the ability to make quick judgments in complex
social situations. Allman and colleagues suggest that VENs are especially
vulnerable to dysfunction due to their late emergence in the evolutionary development of humans. VENs may be responsible for integrating
the balance between rewards and punishments derived from a variety of
inputs in social situations, a kind of rapid cost-benefit analysis based on
expectancy and experience. Analyses of VEN location and distribution in
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the brains of individuals with autism will extend this line of investigation
and may further link specific brain abnormalities to ToM difficulties.
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processing, identifying emotions) and nonsocial domains (e.g., ambiguous figure perception, pattern recognition), suggesting that ToM is specific
to neither. To address the representational deficit theory, Sobel, Capps,
and Gopnik (2005) presented an ambiguous figure task to children with
and without autism to measure their capacity for perceptual shifts. In
typically developing children, successful perception of ambiguous figures
has been linked to ToM performance (Gopnik & Rosati, 2001). The 2005
study found no differences across diagnosis in the perception of a single
image or in the informed perception of multiple images. However, children
with autism were significantly less likely to spontaneously identify multiple images (reversal) than their typical peers. On a variety of ToM tasks,
results were mixed; in individuals with autism there was no relationship
between reversals and a false-belief task, but a correlation was present
between image reversals and discrimination between literal and nonliteral stories. Although, the results support a link between ToM and
executive functioning as opposed to specific social or representational deficits, the mixed results warrant further study.
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Sibling Research
To further the argument that ToM difficulty is a core feature of autism,
researchers have turned to typically developing siblings to examine parallel
deficits in this construct. Shaked, Gamliel, and Yirmiya (2006) presented
false-belief and strange story tasks to siblings of children with autism and
typically developing children. They found that the relationship between
receptive verbal language and performance on ToM tasks was upheld
in both sibling groups, but no significant differences in performance
were found between groups. These results were both consistent with and
contradictory to previous evidence. Longitudinal research is needed to
identify group differences across the developmental span and across other
populations with developmental disabilities, learning disorders, and
cognitive impairments.
A deficit in theory of mind is undoubtedly a fascinating feature in
individuals with autism. The ample current literature delineates many
future research directions to further examine its mechanisms, related
constructs, and the implications for individualized treatment. Because
theory of mind represents a core deficit in children with autism, remediation of these skills may have important implications for more developmentally advanced social skills (e.g., emotion recognition and interpretation,
reciprocal discourse) and possibly for academic skills as well (e.g., reading
comprehension, number sequencing). The nature of theory of mind as a
critical prerequisite skill underlines the need for future research into the
mechanisms of this phenomenon, so we can better identify the critical
components of effective interventions.
Joint Attention
Joint attention is generally defined as ones ability to use gestures or
eye contact to share an interest in or desire for an object or event with
another person.
Children with autism historically have difficulties interpreting others
eye gaze and alternating their own between a person and an object, to indicate interest. This deficit in joint attention has been the focus of numerous
studies, and there is much yet to be explained. Furthermore, joint attention is seen as a critically important social behavior that aids the development of reciprocity and social interactions.
As with ToM, the underlying processes of joint attention are subject to
much debate. At the most fundamental level, amygdala dysfunction may
be implicated in joint attention difficulties. The amygdala primarily regulates emotion processing and memory, as it relates to emotion. Researchers have also suggested that dysfunction in this area may inhibit certain
rewarding qualities of social interaction, making the individual less likely
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to generalize when taught by siblings or peers in their naturally occurring environments. Upcoming research may also investigate what types
of interventions yield robust gains; currently many methods are used to
teach joint attention (e.g., pivotal response training, discrete trial training,
video modeling, reciprocal imitation).
Lastly, there is a need for component analyses of both joint attention interventions and joint attention as an outcome. To maximize intervention benefits, it is crucial to know where these gains are occurring
and where they are not. Future studies should break down joint attention
into its bipolar components (bids vs. responses, mands vs. shared attention, dyadic vs. triadic interactions) and see where progress is observed.
These individual components may also be interesting as they may relate
to ancillary gains in social skills and generalization. It may be that certain
interventions target specific aspects of joint attention, and that gains in
those areas may have particular concurrent benefits for other skills. Furthermore, certain domains of joint attention may be more longitudinally
robust than others. These questions are all relevant to future research in
joint attention.
Early Intervention
One of the more exciting developments in recent years in ASDs has
been the ability for clinicians to diagnose ASDs at earlier ages. The earlier
identification of ASDs leads to earlier, effective treatment, and may increase
positive outcomes of intervention.
It is generally thought that autism can be diagnosed as young as 20
months (Cox et al., 1999). Early signs include limitations in eye contact,
poor reciprocity in smiling, and impaired joint attention (Robins, Fein, Barton, & Green, 2001). Poor imitation and play skills are also associated with
ASDs (Rogers et al., 2003). In general, early diagnosis has been shown to
be stable over time (Eaves & Ho, 2004; Moore & Goodson, 2003). Intensive
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SUMMARY
The treatment of Autism Spectrum Disorders has grown immensely
over the last 20 years. ABA is clearly the treatment of choice for ASDs,
with substantial and significant evidence of its effectiveness for this population. Within ABA, there is good evidence for the positive impact of discrete trial teaching and for naturalistic approaches such as incidental
teaching. Recently, there has also been interest in the potential relevance
of rate-building to achieve fluency and of direct instruction approaches
for building core academic skills. ASDs have also received a great deal of
attention from nonbehavioral treatment providers. Treatments commonly
used include biomedical interventions, sensory-motor interventions and
psychoeducational/psychosocial treatments. The majority of parents of
children with autism will use several of these approaches, despite the fact
that most lack empirical support or verification.
In recent years, there has been progress in identifying the specific
needs of and effective intervention for individuals with Aspergers Disorder. Furthermore, the technology of Functional Behavioral Assessment
has greatly improved the precise assessment of challenging behaviors, the
functions of challenging behaviors, and the link between the assessment
and the treatment of challenging behaviors.
Areas of future growth include more explication of how joint attention and perspective-taking deficits help to explain the clinical profiles of
individuals with ASDs. It is likely that our understanding of social deficits,
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and of how to have an impact upon or remediate such deficits, will improve
over time. Finally, as detection of ASDs occurs earlier and earlier, our
understanding of how to best serve the youngest group of individuals with
ASDs will likely change substantially.
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11
Treatment of
Self-injurious
Behaviour in Children
with Intellectual
Disabilities
FREDERICK FURNISS and ASIT B. BISWAS
INTRODUCTION
Definitions of self-injurious behaviour (SIB) generally describe such
behaviour as comprising nonaccidental self-inflicted acts causing damage
to or destruction of body tissue and carried out without suicidal ideation
or intent (Yates, 2004). For the clinician working with children with severe
intellectual disabilities, such behaviours are likely to be a frequent cause
for concern. Between 4% and 12% of such children exhibit SIB (Oliver,
Murphy, & Corbett, 1987), which may present as repetitive head banging
or face slapping, self-biting to the hands or other parts of the body,
removing scabs from old wounds, self-pinching or scratching, hair-pulling
and eye-poking, often presented in multiple forms in the same child. Selfinjury may emerge as early as 1113 months of age (Berkson, Tupa, &
Sherman, 2001; Hall, Oliver, & Murphy, 2001a), increases in prevalence
and severity throughout the school-age years and young adulthood (Oliver
et al. 1987), and once established in adulthood is likely to be chronic
in nature (Emerson et al., 2001). Presentation of SIB is associated with
FREDERICK FURNISS The Hesley Group, Doncaster, UK and School of Psychology,
University of Leicester. Mallard House, Sidings Court, Doncaster DN4 5NU, United Kingdom.
ASIT B. BISWAS Leicestershire Partnership NHS Trust and University of Leicester,
Leicester Frith Hospital, Groby Road Leicester LE3 9QF, United Kingdom.
333
334
335
PSYCHOPHARMACOLOGICAL TREATMENT
A variety of neurotransmitter systems, alone and in interaction, has been
implicated in self-injurious behaviour. These include the dopamine, serotonin,
opioid, and noradrenaline systems, and basic research on dysregulation of
these systems in clinical disorders and in animal models has suggested a
number of approaches to psychopharmacological treatment of SIB.
336
Atypical Antipsychotics
Clozapine, olanzapine, and quetiapine all block both D1 and D2
dopamine receptor subtypes, together with several types of 5-HT receptor
and a variety of other receptors including adrenergic receptors, whereas
risperidone blocks D2, 5-HT, and adrenergic receptors (Aman & Madrid,
1999). In a systematic review of studies using atypical antipsychotics to
treat persons with intellectual disabilities and/or autism published up
to and including 1999, Aman and Madrid (1999) identified nine studies
on children and adolescents or on mixed child/adult samples, seven on
risperidone, and one each on olanzapine and clozapine. Several of these
studies reported improvement in SIB in some participants. The majority of
these studies, however, had multiple methodological problems. All but one
were case series reports or open label studies, and in most cases participants
were taking other medications throughout the trial. Sedation and weight
gain were frequently observed and dyspepsia and hyperprolactaemia were
also reported. Since Aman & Madrids review, however, a number of bettercontrolled studies of the use of atypical antipsychotics with children with
developmental disabilities, especially of risperidone, have appeared.
Risperidone
Table 11.1 summarises the results of two recent placebo-controlled
double-blind evaluations of risperidone with children aged 512, with
I.Q.s between 36 and 84, and presenting severely disruptive behaviours,
and the subsequent open-label follow-ups. A post hoc analysis (LeBlanc et
al., 2005) of data from 163 participants in the Aman et al. (2002) and Snyder et al. (2002) studies confirmed that risperidone-treated participants
showed significantly greater decreases than placebo-treated participants
on an aggression score derived from six core aggression items on the
NCBRF, but no analysis was presented on change in a similarly derived
self-harm score.
These studies reported convincing evidence for a beneficial effect of
risperidone on behavioural difficulties in young children with moderate,
mild, or borderline levels of intellectual disability. Measures of stereotyped
behaviour and SIB have, however, frequently shown either no significant
change or changes of less significance than those shown for externally
directed aggression. Aman, Buitelaar, De Smedt, Wapenaar, & Binder
(2005), examining pooled data from these studies, showed that only one
item from the NCBRF self-injury/stereotypic subscale showed improvement with risperidone. The above studies also excluded children with a
diagnosis of pervasive developmental disorder.
An eight-week, double-blind, placebo-controlled study by Scahill et al.
(2002), however, examined the effect of risperidone (in doses between 0.5
Snyder et al.
(2002)
Aman et al.
(2002)
Study
Participants (in
parentheses: number
completing study)
NCBRF conduct
problem and most
other subscales, all
ABC subscales, BPI
aggressive/destructive
behaviour subscale:
greater improvement
with risperidone vs.
placebo.
General Outcome
Measures
(continued)
Table 11.1. Recent Evaluations of Risperidone for Behavioural Difficulties in Young Children
with Moderate-Borderline Intellectual Disabilities
77 children from
Snyder et al. (2002)
study.
Turgay,
Binder,
Snyder &
Fisman
(2002)
48-week open-label
follow-up to
Snyder et al. (2002)
Children receiving
risperidone in
double-blind phase:
all subscales of
NCBRF improved
by comparison with
double-blind baseline.
Children receiving
placebo in double-blind
phase: all subscales of
NCBRF except selfinjury/stereotyped and
self-isolated ritualistic
subscales improved
from follow-up baseline
to endpoint.
General Outcome
Measures
NCBRF self-injury/
stereotypic subscale:
improved for children
receiving risperidone
during double-blind
from double-blind
baseline to endpoint;
not improved for
children receiving
placebo in doubleblind from open-label
baseline to endpoint
NCBRF self-injury/
stereotypic subscale:
greater improvement
with risperidone vs.
placebo (smallest
subscale change)
NCBRF: Nisonger Child Behavior rating form (Aman, Tass, Rojahn, & Hammer, 1996); ABC: Aberrant Behavior Checklist (Aman, Singh, Stewart, & Field, 1985); BPI: Behavior
Problems Inventory (Rojahn, Matson, Lott, Esbensen, & Smalls, 2001).
Findling,
Aman,
Eerdekens,
Derivan
& Lyons,
(2004)
Study
Participants (in
parentheses: number
completing study)
339
and 3.5 mg/day at the end of the study) on the behaviour of 49 children
with autism (76% of whom had mildsevere intellectual disabilities) compared with 52 children receiving placebo. Participants were aged between
5 and 17 years and engaged in tantrums, aggression, SIB, or multiple
behaviour problems. Repeated assessment on the ABC irritability subscale
showed a significant group by time interaction, with a mean 57% decrease
in irritability score in the risperidone-treated group compared with a 14%
decrease in the placebo group.
The ABC stereotypy and hyperactivity subscales also showed significantly greater reductions for the risperidone than the placebo group.
Reporting of increased appetite, fatigue, and drowsiness were all significantly associated with risperidone treatment, and weight gain was significantly greater in the risperidone group. Clinical assessment using
structured scales showed no extrapyramidal symptoms in either group.
Parental reports of tremor and tachycardia were significantly associated (p = 0.06) with risperidone useage. A 16-week open label follow-up
(Research Units on Pediatric Psychopharmacology Autism Network, 2005)
of 63 children previously treated with risperidone in the double-blind trial
or given eight weeks of open-label treatment following placebo showed
small but significant increases in ABC irritability subscale score, although
the mean score remained well below the baseline level of the double-blind
phase. Participants showed a mean six-month weight increase of 5.1 kg.
A subsequent eight-week double-blind placebo-substitution phase showed
relapse rates of 13% with ongoing risperidone and 63% with placebo substitution.
Anderson et al. (2007) confirmed that although the initial increase
in prolactin levels decreased over the course of treatment, approximately
one-third of participants had values above the normal range at 22 months
of treatment. Further analyses also showed greater improvements with
risperidone than placebo on measures intended to capture some of the
core symptoms of autism, including a modified form of the Childrens
Yale-Brown Obsessive-Compulsive Scale (McDougle et al., 2005).
Shea et al. (2004) reported results from an eight-week, double-blind,
placebo-controlled trial involving 79 children, aged between 5 and 12, all
with PDD, 69% having diagnoses of autistic disorder. Forty participants
(30 of whom had mildsevere intellectual disabilities) received risperidone
and 39 (29 with intellectual disabilities) received placebo. At study endpoint all scales of the ABC showed significantly greater decreases for the
risperidone group than for the placebo group, as did the conduct problem, hyperactive, insecure/anxious, and overly sensitive subscales of the
NCBRF. There were no significant differences between groups in change
on the self-isolated/ritualistic or self-injurious/stereotypic subscales of
the NCBRF. Somnolence was reported for over 70% of the risperidone
group, but was reported to resolve in most cases (usually following dose
rescheduling or reduction). Increases in weight, pulse rate, and systolic blood pressure were all significantly greater at study endpoint for the
risperidone versus the placebo group.
Although therefore the above studies have produced evidence suggestive of a beneficial effect of risperidone on the behaviour of children with
340
341
342
explanation seems unlikely to hold for the studies involving children with
autistic spectrum disorders.
Studies employing direct observation (Zarcone et al., 2001, 2004) have
unfortunately contributed little to our knowledge of the specific effect of
risperidone on SIB owing to small numbers of participants and reporting
which collapses together differing forms of challenging behaviour. When
SIB has been a specific focus, direct observation during blinded trials of
medication for individual cases has suggested both a specific beneficial
effect of risperidone on SIB greater than that on aggression (Crosland
et al., 2003) and a negative effect (Zarcone et al., 2004). Further research
on this question is clearly warranted, both because of the mixed results
to date and because the specific role for the D1 dopamine receptor in selfinjury suggested by the 6-hydroxydopamine lesioned rat would suggest
that if this animal model has validity as a general model for SIB, then
owing to its lack of affinity for the D1 type receptor, risperidone may be a
less effective treatment for this specific behaviour than other drugs with
D1 affinity. The most efficient way forward on this issue would appear to
be for double-blind trials to employ ratings of change on specific behaviour
problems as demonstrated by Arnold et al. (2003).
343
344
SIB (e.g., Carminati, Deriaz, & Bertschy, 2006) are uncontrolled studies of the addition of SSRIs to other treatments relying on limited outcome measures. For children with developmental disabilities the lack of
evidence of effectiveness, frequent occurrence of adverse reactions, and
uncertainties about appropriate dosage (Posey et al., 2006) do not support the utility of currently available SSRIs in treatment of SIB.
Naltrexone hydrochloride
A variety of evidence has suggested dysregulation of the hypothalamicpituitary-adrenal stress system in persons with autism and others with
developmental disabilities who engage in SIB (Sandman & Touchette, 2002),
with recent interest in the pro-opiomelanocortin (POMC) system. Enzyme
cleavage converts the POMC molecule into a number of biologically active
products including the opioid -endorphin and adrenocorticotrophin (ACTH),
and in adults plasma levels of these products of the POMC molecule are
normally highly correlated. Recent studies have suggested, however, that this
normal coupling of -endorphin and ACTH is reduced following episodes of
SIB in adults with developmental disabilities (Sandman, Touchette, Lenjavi,
Marion, & Chicz-DeMet, 2003), with levels of -endorphin elevated with
respect to levels of ACTH, and that the extent of this uncoupling is related
to the extent to which occurrence of SIB is predicted by previous SIB events
rather than by other behaviours or social environmental events (Sandman
& Touchette, 2002). It has been argued that this phenomenon may indicate
that persons showing SIB experience enhanced opioid-mediated analgesia
and/or that SIB produces an opioid-induced state of euphoria.
Administration of the opiate antagonist naltrexone hydrochloride
would be expected to reduce both of the above effects. Although naltrexone may cause a number of side effects (Matson et al., 2000), research
involving both nondisabled people and those with developmental disabilities suggests that the major possible serious side effect of naltrexone use
is liver toxicity; however, signs of possible toxicity have been observed in
people without disabilities treated for addictions and using substantially
larger doses than those used to treat SIB in people with intellectual disabilities (Symons, Thompson & Rodriguez, 2004).
Reports on the effectiveness of naltrexone in treatment of SIB have
been extremely mixed (Symons et al., 2004). In contrast to much other
work on psychopharmacology of SIB, the technical quality of research into
naltrexone has been rather high; Symons et al. (2004) reviewed 27 studies from which information on individual participants could be extracted
and reported that 85% of the total of 86 children and adults treated with
naltrexone had received the drug in a double-blind study. Comparison
of quantitative measures of SIB during baseline and during naltrexone
administration showed that 47% of participants showed improvement of
50% or greater, and a further 33% showed smaller decreases, during naltrexone treatment. In addition, there is some evidence that for some people limited-term administration of naltrexone can produce reductions in
SIB which persist after the medication is withdrawn (Crews, Bonaventura,
Rowe & Bonsie, 1993; Sandman et al., 2000).
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Increases in weight and appetite, raised prolactin levels, and somnolence/sedation are frequently reported adverse events associated with risperidone treatment, although post hoc analyses suggest that the positive
effects reported for risperidone are independent of the presence/absence
of somnolence (Snyder et al., 2002; Turgay et al., 2002). Other side effects
including effects on heart rate have also been reported. In considering
the use of risperidone with children, the possible long-term health consequences of these effects warrant serious consideration. The possible
negative consequences of weight increase are obvious, and although evaluations of risperidone (e.g., Croonenberghs et al., 2005) commonly advise
clinicians to provide counselling on diet and exercise, in their open-label
study of olanzapine Handen and Hardan (2006) noted that weight gain
was observed despite provision of such counselling.
The possible long-term effects of the increases in prolactin levels associated with risperidone treatment require further study. Extrapyramidal
symptoms have been reported in up to 26% of participants in one-year
follow-ups of children using risperidone (Turgay et al., 2002), and longerterm research will be needed on the question of whether long-term use
of risperidone may be associated with development of tardive dyskinesia.
Monitoring for other less frequent adverse events such as neuroleptic
malignant syndrome remains important with the atypical antipsychotics.
Careful consideration of the likely long-term benefits and risks of risperidone use is particularly warranted given that withdrawal of risperidone
after periods of up to six months from children with autistic spectrum disorders who have been judged to respond positively to initial treatment has
been reported to be associated with deterioration in behaviour in approximately two-thirds of cases (Research Units on Pediatric Psychopharmacology Autism Network, 2005; Troost et al., 2005). Observational studies
suggest that the effects of risperidone treatment may be partially mediated
by changes in carerchild interaction related to the reduction in irritability associated with risperidone (Zarcone et al., 2001). Together with the
observation that in one-third of cases it appears that risperidone treatment can be successfully withdrawn, these observations suggest that if
risperidone is used in treatment of SIB its effects should be carefully monitored, there should be frequent review to determine whether medication
can be withdrawn without negative effects on behaviour, and prescription
of risperidone should be accompanied by behavioural interventions.
The evidence for the effect of naltrexone hydrochloride on SIB suggests that in cases where SIB is chronic and assesssment does not identify
functional relationships with social/environmental events, consideration
of naltrexone treatment may be warranted. The effects of naltrexone, however, vary dramatically across individuals, are clinically difficult to predict for the individual case, and include the potential for adverse as well
as beneficial effects on SIB. Again therefore careful monitoring of effectiveness and frequent review are appropriate where naltrexone is used in
treatment of SIB. The evidence regarding adverse events with naltrexone
is largely drawn from its use with nondisabled adults and close monitoring for possible such events is appropriate where the drug is considered
for use with children with developmental disabilities. The rationale for use
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of naltrexone suggests that its use may increase SIB-related pain and/or
decrease SIB-related euphoria, and its use has been reported to increase
signs of negative affect during SIB (Benjamin et al., 1995). Given that
some level of SIB will usually continue to occur in most cases even of successful treatment with naltrexone, and that social/environmental factors
may be implicated in the maintenance of the behaviour (Symons et al.,
2001), it is therefore both practically and ethically important that consideration of naltrexone use in cases of SIB is accompanied by behavioural
intervention.
BEHAVIOURAL TREATMENT
Rationale for Behavioural Intervention
Behavioural interventions for SIB were originally developed on the
basis of demonstrations that rates of SIB in children with developmental
disabilities could be increased by contingent social attention and reduced
when such attention was witheld contingent on SIB but available at other
times (Iwata, Roscoe, Zarcone, & Richman, 2002). Subsequent studies
have demonstrated that SIB may also be maintained by socially mediated negative reinforcement (e.g., escape from task demands). Automatic
reinforcement, that is, reinforcement produced directly by the SIB without
social mediation, has also been implicated in maintenance of SIB, and
again both positive reinforcement (e.g., sensory stimulation) and negative
reinforcement (e.g., pain blocking or attenuation) have been suggested to
be involved in individual cases (Iwata et al., 2002).
Current approaches to the behavioural treatment of SIB have been
profoundly influenced, firstly by a seminal review by Carr (1977), who
reviewed evidence suggesting that SIB could be maintained by a variety of
consequences in different individuals and argued that treatment should
therefore be individualised with respect to the function of the behaviour
for the specific individual; and secondly by a landmark article in which
Iwata, Dorsey, Slifer, Bauman, & Richman (1982) described a method for
assessing behavioural function prior to treatment planning. Iwata et al.s
(1982) method (see Vollmer, XXXX, for a detailed discussion), variously
described as experimental functional analysis (EFA) or analogue assessment, involved briefly placing clients into a variety of highly structured
social situations, each of which was designed to evoke high rates of problem behaviour maintained by specific functions. For example, one condition involved the presence of carers who interacted with the client only
consequent upon SIB; this condition was predicted to lead to high rates of
any behaviour typically reinforced by contingent carer attention.
The advent of the methodology of experimental functional analysis
led to a major shift in perspective in the treatment methods employed
in clinical research. Instead of relying on use of reinforcers and punishers empirically demonstrated to be effective but possibly unrelated to
the consequences maintaining SIB, treatment shifted to interventions
based on identification of the reinforcer maintaining SIB in the clients
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dependent on low rates of SIB in the previous session. For all three participants, rates of SIB were substantially reduced during the fixed-time
treatment sessions.
Van Camp, Lerman, Kelley, Contrucci, and Vorndran (2000) demonstrated that variable-time schedules in which interreinforcement intervals
varied randomly around a mean value were as effective as the corresponding fixed-time schedules in reducing aggression and SIB which were maintained by access to leisure materials in two people with severe intellectual
disabilities, increasing the utility of this approach for applied settings in
which rigorous fixed-time schedules might be difficult to sustain.
Kahng, Iwata, DeLeon, and Wallace (2000) further demonstrated that
the reduction in frequency with which reinforcers were delivered could be
achieved more rapidly than using the fixed-step approach of Vollmer et al.
(1993), and without compromising intervention effectiveness, by a procedure in which the interval between reinforcer delivery was adjusted based
on the mean interval between participants self-injurious behaviors.
Time-based schedules have also been used to reduce SIB maintained by socially mediated negative reinforcement. Vollmer, Marcus, and
Ringdahl (1995) treated the SIB of two young males with developmental disabilities for whom EFA had suggested that SIB was maintained by
contingent escape from instructional activities. Provision of brief breaks
from required activities on fixed-time schedules with the interval between
breaks progressively increased, dependent on rates of SIB in previous sessions, to 10 minutes for one participant and 2.5 minutes for the second,
produced substantial reductions in rates of SIB for both.
Although discussed here in terms of modifying motivational processes,
the procedures employed in the above studies may reduce problem behaviour through extinction (removing the contingency between the behaviour
and the reinforcer) and by increasing tolerance of delay to reinforcement
through the schedule thinning process (Vollmer et al., 1998). To the extent
to which these additional processes are involved, use of fixed-time schedules may produce reductions in the level of problem behaviour extending
beyond the period in which the motivating operation is modified. Where
SIB occurs extensively, however, use of fixed-time schedules may risk
maintaining the behaviour though adventitious reinforcement when SIB is
occurring immediately before a scheduled reinforcer delivery, but in such
situations briefly postponing reinforcement when a scheduled delivery
is immediately preceded by SIB should avoid this possibility (see Carr &
LeBlanc, 2006, for a thorough discussion of issues in use of FT schedules).
Where SIB is maintained by escape from or avoidance of scheduled
tasks or activities, modification of instructional activities may produce substantial reductions in the behaviour. Pace, Iwata, Cowdery, Andree, and
McIntyre (1993) produced rapid and substantial reductions in levels of SIB
for three young people with intellectual disabilities by initially completely
withdrawing demands and then gradually increasing these over sessions to
baseline levels while preventing escape from activities contingent on SIB.
Zarcone, Iwata, Smith, Mazaleski, and Lerman (1994), working with three
adults with developmental disabilities and instructional escape-maintained
SIB, demonstrated that withdrawal and progressive reintroduction of demands
350
without preventing escape for SIB was initially successful in reducing levels
of SIB, but that levels of SIB increased as the intervention progressed and
that periods of escape prevention were necessary to achieve desired levels
of control of SIB. Problem behaviours including SIB may also be reduced
by identifying specific tasks which elicit SIB and interspersing requests to
complete these among tasks less likely to elicit SIB (Horner, Day, Sprague,
OBrien, & Heathfield, 1991).
Other instructional procedures which may be helpful in reducing levels of demand-escape maintained SIB include increasing levels of reinforcement for task engagement (Hoch, McComas, Thompson, & Paone,
2002; Lalli et al., 1999), preceding demands which elicit SIB by a sequence
of demands with which the child typically cooperates (although preventing escape from the demand contingent on SIB may again be important
to the effectiveness of this approach; see Zarcone, Iwata, Mazaleski, &
Smith, 1994), increasing levels of assistance with tasks, embedding task
demands in reinforcing activities, increasing the predictability of demands,
and increasing choice of activity (Miltenberger, 2006).
Systematic evaluation of rates of SIB across activity or instructional
conditions may also enable such activities to be scheduled so as to reduce
levels of SIB. OReilly, Sigafoos, Lancioni, Edrisinha, and Andrews (2005)
found that the SIB of a 12-year-old boy with autism and intellectual disabilities, normally elevated in the task demand condition of an EFA in
comparison to other conditions, did not occur when the task demand condition was preceded successively by no interaction and play conditions.
Introduction of a similar structure (a repeating schedule of five minutes
each of no interaction, play, and task demand) into the classroom situation produced substantial reductions of SIB in the classroom which were
maintained at five-month follow-up.
Where motivating operations cannot be directly modified, it may be
possible to increase tolerance of them or neutralise their effects. McCord,
Iwata, Galensky, Ellingson, and Thomson (2001) reduced problem
behaviours (including SIB) maintained by escape from noise by programmes
involving progressive exposure to increasing noise levels accompanied by
extinction (problem behaviour did not lead to noise termination) and, in
one case, differential reinforcement for absence of problem behaviour in
the presence of noise. Horner, Day & Day (1997) found that the escapemaintained aggression and SIB of two of the three children with severe
intellectual disabilities who participated in their study occurred in response
to error correction only following earlier delay or postponement of planned
preferred activities. Implementation of individually developed calming
routines (e.g., formally rescheduling the activity and reviewing pictures
from the past) following such events reduced levels of problem behaviour
in later instructional sessions.
Even when the specific motivating operations which increase the
reinforcing value of escape from demands cannot be isolated, their relevance may be inferred by systematically rating the mood of the person
presenting problem behaviour and preceding task demands by moodenhancing activities where relevant (Carr, McLaughlin, Giacobbe-Greco,
& Smith, 2003).
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Treatment of Self-Restraint
Many individuals with intellectual disabilities who engage in selfinjurious behaviour (SIB) also engage in behaviours which may appear
to observers to represent attempts by the person to prevent themselves
engaging in SIB; such behaviours are generally referred to as self-restraint
(SR). Topographies of SR, including entangling limbs in clothes, holding one
body part with another, and seeking external mechanical restraints may be
seen in as many as 75% of those who self-injure (Oliver, Murphy, Hall, Arron,
& Leggett, 2003). Self-restraint may occur very extensively, severely limit
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face validity of Mace and Mauks subtyping of biologic SIB, there are no
well-controlled studies demonstrating selective impact of specific agents
on specific subtypes of SIB. Improvement of our ability to analyse the
dynamics of individual patterns of SIB and relate these to possible rational
pharmacotherapies remains an important goal for research (Thompson &
Symons, 1999). Meanwhile, the fact that neither current behavioural nor
psychopharmacological treatments typically eliminate established SIB,
thus requiring extended treatment, and the fact that both may produce
adverse effects, implies that both require expert management and careful
monitoring.
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360
in the form of head-hitting and/or banging in the course of the study, with
at least four of the total of seven topographies emerging apparently related
to a pre-existing stereotyped behaviour (e.g., head-hitting developing in a
child previously showing stereotyped arm-waving).
Four children engaged throughout the study in behaviour initially
observed as proto-SIB but eventually resulting in tissue damage, and
one developed proto-SIB which eventually produced tissue damage. Most
functional analyses showed undifferentiated patterns across conditions,
and some degree of responding was observed in the alone (i.e., no social
contingencies presented) condition for most behaviours evaluated, suggesting that the behaviours studied were at least partly maintained by nonsocial
variables. One participant did show a pattern of responding consistent with
positive social reinforcement of proto-SIB and SIB; this child, however, had
presented SIB on entry to the study.
Kurtz et al. (2003) reported the results of individualised experimental
functional analyses conducted on the SIB (and other problem behaviours)
of 30 children aged 10 months to 4 years 11 months (M = 2 years 9 months).
Caregivers reported the mean age of SIB onset as 17 months (range, 136
months), with head banging the first topography of SIB observed for 70%
of participants. Experimental functional analysis produced results consistent with socially mediated reinforcement in 14 cases (of 29 completed
analyses) and automatic reinforcement in 4 cases. Undifferentiated patterns of response were observed in the remaining 11 cases.
Detailed comparison of the results of these studies is difficult because
of differences in methodology and groups studied (e.g., in ability, numbers
of participants with specific diagnoses associated with presence of SIB,
population-based samples vs. clinical samples). Taken together, however,
the results of these studies suggest that, as would be expected on the
basis of studies of older children (e.g., Iwata et al., 1994), the SIB of young
children may be maintained by operant processes, with positive socially
mediated reinforcement (in contrast to negative reinforcement processes
frequently observed with older children) most often seen as the maintaining process.
Although it seems likely, however, that cases occur where social reinforcement processes have shaped SIB from stereotyped or proto-SIB
responses, it seems rather less likely that such shaping processes are initially involved in the development of SIB (although they may be involved
in subsequently increasing its severity). It seems that many young children with intellectual disabilities display proto-SIB (Hall et al., 2001a).
Furthermore, the reported age of onset of SIB appears to be similar (or
perhaps even earlier) than that of motor stereotypies and proto-SIB.
Finally, substantial numbers of young children show undifferentiated
patterns of responding in experimental functional analyses (Kurtz et al.,
2003; Richman & Lindauer, 2005). The implication for the treatment of
SIB is that although SIB clearly frequently acquires operant functions,
it may initially develop through other processes which may continue to
be important even after operant functions are acquired. Further insight
into the nature of these processes may be gained from studies of the
phenomenology of SIB.
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types of SIB has been suggested to be important in understanding selfharm in adults without intellectual disabilities, and the distinction has
been supported by factor analytic studies (Bodfish & Lewis, 2002). Treatment of choice in both behavioural and pharmacological interventions
might be expected to depend on the context of comorbidity within which
SIB is presented. Aman et al. (2005) have, for example, suggested that
risperidone may be useful primarily in treatment of impulsive rather
than compulsive forms of SIB.
363
underpinning SIB is not inconsistent with the operant hypothesis, inasmuch as establishment of aggression elicited by aversive stimulation is
particularly rapid where the aggression is also reinforced by escape from
the aversive stimulus (Azrin, Hutchinson, & Hake, 1967).
The presence of a process of elicitation underlying SIB would, however, be consistent with the clinical observation that even where bursts of
SIB are clearly provoked by an aversive environmental event, immediate
withdrawal of that event may not end the behaviour (Thompson & Caruso,
2002). The implication of Pavlovian conditioning of responses to aversive
stimulation or changes in reinforcement schedules in development and
maintenance of SIB would suggest that in addition to interventions based
on operant conceptualisations, behavioural interventions well-established
as treatments for other problems, such as graduated exposure (with or
without counterconditioning) to aversive stimuli (e.g., McCord et al., 2001)
and/or delay to reinforcement may in some cases usefully be added to
operant-based interventions. Integration of interventions based on Pavlovian principles with the established operant technology may further
enhance the effectiveness of behavioural interventions.
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12
Communication,
Language, and Literacy
Learning in Children with
Developmental Disabilities
ERNA ALANT, KITTY UYS,
and KERSTIN TNSING
INTRODUCTION
This chapter deals with communication, language, and literacy learning
in children with developmental disabilities by integrating two perspectives,
firstly that of information processing and the impact of specific impairments on information processing and interpretation of symbols used in
interaction and, secondly, the role of sociocultural factors in facilitating
learning and literacy learning. The use of augmentative and alternative
communication (AAC) strategies is discussed by means of a case study to
illustrate the interaction between individual and sociocultural factors in
intervention. A differentiation is made between engagement and interactive behavior to enhance understanding of childrens participation, and
intervention strategies based on these concepts are explored. Finally the
importance of emergent literacy is discussed with reference to the importance of the sociocultural context within which families live.
The term neurodevelopmental or developmental disabilities refers to
a heterogeneous group of disabilities that include the long-term effects of
delay and deviance as a result of some damage to the neurological processes responsible for developmental functioning (Yeargin-Allsop & Boyle,
2002). Conditions that generally are included in this group are cerebral
ERNA ALANT, KITTY UYS, and KERSTIN TNSING
Center for Augmentative and Alternative Communication University of Pretoria
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374
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throughout a lifetime. Coping with the transition from the use of language
for communication to the use of language for learning can therefore pose
significant challenges to young children who, for the first time, have, to
develop the awareness of language to enable them to identify words, play
around with sounds, and make the connection between what is spoken
and how the spoken word is represented in written form.
This metalinguistic ability or awareness of language not only requires
that the child has sufficient understanding of language as a means and
object of learning, but also requires that the child is able to think analytically about symbols used in communication. The child needs to be able to
interpret different types of information transferred via different modes of
transmission. For example, the child not only needs to listen or hear the
spoken word, but also needs to interpret the nonverbal or graphic symbols
that accompany the spoken word. When any of the sensory channels of
the child are thus impaired, the information process is modified which can
affect the young childs interpretation and experience of reality.
Message sent
via:
Message
received by
ears
eyes
touch
Sender /
Receiver
Via the
transmission
environment
Speech
Writing/typing
Signing
Gesturing
Pointing
Facial expressions
Posture and movement
Message
received by
ears
eyes
touch
Receiver /
Sender
Message sent
via:
Speech
Writing/typing
Signing
Gesturing
Pointing
Facial expressions
Posture and movement
Via the
transmission
environment
Socio-cultural environment
378
time. The mere fact that the one individual communicates a specific message
does not mean that the other cant give some feedback via facial expression
or other nonverbal and verbal means. This process of external feedback is
important to enable the communicator to adjust the messages sent to prevent
communication breakdown and facilitate effective communication.
For the typically developing child, symbolic representation begins with
speech developing from vocalization and eventually expands to include
orthography. A significant number of children with developmental disabilities, however, are exposed to the use of manual signs, graphic symbols,
or speech-generating devices as early forms of receptive and/or expressive
communication. This modified interaction process can have an impact on
the information processing demands placed on the child and thus influence the experience and meaning derived from interactions.
McNaughton and Lindsay (1995) described the impact of the use of
graphic communication symbols, for example, Bliss symbols on the symbolic representation process of the child who has little or no speech and uses
graphic symbols to supplement existing vocalizations or speech. Unlike the
child who uses speech to communicate, this child will be using graphic symbols to facilitate expression. Whereas the typically developing speaking child
will, for example, verbalise more and get the auditory and proprioceptive
feedback related to the speech act, the child using graphic symbols will be
pointing to a graphic symbol of more on a communication board to indicate
to people what is required. The feedback that the child using a communication board receives from this communication act is thus much different, as
pointing at a line drawing provides mostly visual feedback with some proprioceptive feedback from the pointing. Similarly the child who makes a manual
sign for more would get visual and proprioceptive feedback from the manual
sign used to transmit the message. The question is thus how these different
modes of communication affect information processing, language learning,
and literacy learning of the child.
Similarly, Von Tetzchner and Grove (2003) describe the asymmetry
that exists between the communication modes used for receptive language input and expressive language output in children who can hear, but
have little or no speech and use alternative modes to supplement speech.
Receiving and understanding oral language whilst not being able to use
speech to communicate can once again have an impact on language learning. In addition to the impact that the modes of communication have on
information processing and interpretation, the sociocultural environment
of the child also plays a most significant role.
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381
Case Study
Kagiso is a 4-year-old girl with a diagnosis of spastic quadriplegia.
She presents with very low tone in her trunk, and increased tone in all
four limbs. Kagiso lives with her mother, grandmother, and younger
sister in an urban township in South Africa. Her mother is unemployed. The family income consists of the grandmothers pension,
a care dependency grant received for Kagiso, and a childcare grant
received by unemployed parents. Kagiso has been attending a mainstream crche for about 1 year now. Together with her mother, Kagiso
(continued)
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383
From this case illustration, certain factors which need consideration for appropriate AAC intervention can be highlighted. Firstly, Kagisos
background and context need to be considered. She has a supportive and
involved mother, who has time to spend with her, and who is able to bring
her for regular intervention. Her mother gives input on vocabulary selection and feedback on the appropriateness of the systems and strategies.
Kagisos main communication partners include her mother, grandmother,
teacher, and classmates, and her communicative contexts are mainly
home and school. Alant (2005a), in her description of AAC intervention as
a support-based process, further elaborates on the importance of taking
cognizance of partners and contexts.
384
385
Figure 12.2. A communication board for the topic shopping, devised for a young child
with cerebral palsy living in South Africa (gloss in Northern Sotho and English).
386
learning disability who have different cognitive abilities, but have a definite gap between their expressive and receptive language ability. These
children could be severely physically impaired and thus use AAC as a permanent means of communication or could be using AAC as a temporary
means of communication until speech has sufficiently developed.
The second group is referred to as the developmental group. This
group of children displays a general delay in language development on
both a receptive and expressive level without any significant gap between
the two. Typically this would include children with cognitive disabilities
whose development is generally delayed. Intervention strategies should
thus be used to enhance receptive and expressive language skills.
The third group is referred to as the alternative language group. This
group of students has difficulty in acquiring language and communication
and is often not able to speak. They have limited ability to use symbolic
language in spite of having normal hearing abilities. This group will typically rely on AAC strategies to communicate and could include children
with severe and multiple disabilities as well as children with autism.
Although it is possible to further differentiate smaller groups in some
of the categories, differentiating the three main groupings is useful in facilitating understanding of the different roles that AAC can fulfil in intervention
with this heterogeneous group of children with developmental disabilities.
387
High
Active-engaged
Active-disengaged
Interactive
High
Engagement
behavior
Passive-engaged
Passive-disengaged
Low
Low
388
389
give information on time spent, but also the level of gains or enjoyment
derived from the experiences.
The use of purposeful activities such as play activities for young children to observe participation is not a novel concept. Play is the occupation of a child and has motivational value. A child experiences satisfaction
when engaged in a purposeful activity, which leads to sustained performance, self-reward, and intrinsic motivation. This positive cyclical process
of enjoyment through engagement contributes towards the development of
new skills, mastery of skills, and the experience of a sense of control over
the environment (Uys, Alant, & Lloyd, 2005).
Enjoyment is an abstract concept and therefore difficult to measure, but an analysis of the construct reveals measurable behaviors, that
is, attention to a task and performance on the developmental domains
(social, emotional, sensory, motor, cognitive, and communication). For
enjoyment to occur there should be a match between the childs abilities and the environmental or activity demands and the activity should be
culturally valued. Csikszentmihalyi (1990) explained in his epic research
on optimal experiences that a person would be maximally engaged in an
activity when there is a just right challenge between the abilities and the
demands. However, the demands should always be a little higher than the
skills to press for development of mastery of skills. Mastery motivation is
defined as a psychological force that stimulates an individual to attempt
independently, in a focused and persistent manner, to solve a problem or
master a skill or task which is at least moderately challenging for him or
her (Morgan, Harmon, & Maslin-Cole, 1990, p. 319).
The question arises when observing children: what elements should
be observed during play, the end product or the process of activity participation? McWilliam et al. (2001) indicated in a research study on teaching
styles and engagement, that teachers who were product-focused inhibit
learning opportunities for children and their students scored lower on
developmental scales than those children exposed to teachers who are
process-oriented. McWilliam et al. (2001) also found in their research that
preschool children (36 years) presented with more sophisticated engagement than toddlers who were performing on an unsophisticated level.
They suggest nine levels of engagement but only focused on five levels in
their most recent research: sophisticated, differentiated, focused attention, undifferentiated, and nonengaged (McWilliam, et al., 2001). Table
12.1 presents the characteristics of each level.
Two essential features in promoting child engagement seem to be the
interventionists interactive behavior and the quality of the environment.
Facilitating Interaction
Three key elements are intertwined in the learning process of young
children, these being firstly the demands presented in the environment,
secondly the childs abilities and motivational level, and thirdly, the interventionist who has to integrate these elements to facilitate participation.
Each element has the potential to be adapted or modified to suit the context.
Adaptation is viewed as an external agent necessary for changing the
390
Differentiated
behavior
Focused
attention
Unsophisticated
behavior
Nonengaged
behavior
Involves problem-solving and the child either uses changing strategies or the same strategies to solve the problem or reach the goal.
The child uses language, pretend play, sign language, drawings, etc.
that allows him or her to reflect on the past, present, and future and
construct new forms of expression through combining symbols or
signs. The child can communicate about something or someone not
physically present.
The child has a set of behaviors that permits adaptation to environmental demands and expectations. This includes active interaction
with the environment (materials, tools, and people). At this stage the
child is becoming more outcomes-focused.
Includes watching or listening for features in the environment. Paying
attention to the features is a requisite. Serious facial expression and
quieting of motor activity characterise this level. Implies selectivity
and intensity of attention.
There is no clear differentiation in the childs behavior. Behavior is
repetitive and exploratory in nature. Attention is poorly focused and
action is not aimed at a specific outcome.
The child is seemingly uninvolved in any activity and tends to be
destructive and aimless. Focus of attention seems fleeting.
391
information from all the domains to perform effectively in a social context. A deficit in one domain has a direct influence on the other domains
with subsequent impact on the general functioning. Because play is the
childs occupation, interventions main goal needs to include enjoyment
through participation to enhance mastery. Children have an internal
desire to become a master of the environment. To elicit this internal
desire, meaningful activities need to be selected to accommodate each
childs interest.
Children with developmental delays experience distress in relation to
environmental challenges, which in turn interferes with all aspects of the
learning process. These children are often unable to use learning situations optimally due to their inability to access the environment. They
can be unable to initiate new responses to environmental demands, thus
negating the process of differentiation and integration. It is against this
background that interventionists need to remain cognisant not only of
ways in which to facilitate interaction with a child, but also of the level of
engagement of the child during interaction.
Interaction between the child and the environment implies press for
mastery. Ideally the interventionist should aim to create a match between
the desire for mastery (child) and the demand for mastery (environment).
Interaction (active participation in the environment) is the pivotal point for
learning to occur. Interaction challenges the childs abilities and presses
for the improvement of behaviors indicative of development. When the
children respond to stimuli from the external environment (e.g., a play
activity), they have to use their internal abilities (systems) to interpret,
integrate, and organise the stimuli, to give meaning to it and to respond
accordingly. When these responses are effective, learning occurs and positive feedback is received from the external environment either through
the activity itself or through interaction with the adult. This internal
experience creates satisfaction, which increases self-esteem and engagement (Csikszentmihalyi, 1990).
392
393
literacy development in children who are deaf. Gioia (2001), however, found
that although literacy practices were established in the homes, shared
reading rituals between parents and their deaf children were not always
established. Although parents enjoyed reading with their children who
are deaf they experience obstacles in the reading process (HeinemannGosschalk & Webster, 2003).
Mirenda and Erickson (2000) also explored the use of AAC in facilitating literacy in children with autism. They emphasised the importance
of a sociocultural model of literacy learning and acknowledged that
the attitudes and expectations of those in the individuals immediate
environment, the availability of reading and writing materials, and the
nature of interactions between the individual and his literacy partners
are important. These partners do not only include parents or teachers,
but also siblings. Lenhart and Roskos (2003) documented the literacy
learning and interaction between two siblings in literacy activities and
found that the older sibling was significant in demonstrating literacy
skills to the younger child and that to a large extent the older sibling
shaped the young childs perception towards print and books. The role
of siblings as part of the emergent literacy process is thus acknowledged
as important in the process of literacy learning in the young child with
developmental disabilities.
Perhaps the most important strategy for enhancing the home literacy
exposure of children with developmental disabilities is an understanding of the context within which families live and their perceptions of the
importance of literacy learning of the young child. One of the first steps in
this process is to make parents aware of their own literacy routines in the
home to guide them in how to use these as a basis for further expansion.
394
Language Context
Affective context
Educational context
Examples of Questions
What are your childs favorite reading activities?
How interested are you and your family in reading?
How often do you or others in your home read in the presence
of your child with developmental disabilities?
What printed materials are available in your home?
How often does your child with developmental disabilities make
use of the above-mentioned printed material?
Is your child interested in reading activities?
Does your child own any books? How many?
Is writing or drawing something you or other members of your
family enjoy?
How often do you or others in your family write or draw at
home?
Which writing or drawing materials are readily available in your
home?
How often does your child use any of the above materials?
Is your child interested in writing and drawing activities?
When your child is involved in reading and writing activities,
does anyone else participate? Who?
Who usually initiates the reading and writing activities?
How do siblings participate in reading and writing activities
with your child with developmental disabilities?
When you or other family members read to your child, what
types of books do you usually read?
When you read with your child, what does your child usually
do?
When you read, how does your child communicate with you?
How is your child usually positioned during story reading
activities?
When you read to your child, what do you usually do?
How important do you rate the following aspects of your childs
development at present?
Ability to communicate
Ability to speak
Understanding
Use of alternative ways of communicating
Learning to read
Learning to write, etc.
Do you have any difficulties in finding suitable books to read to
your child?
Do you have any difficulty in communicating with your child?
Do you have any difficulty in determining whether your child
understands the stories you read?
395
396
Figure 12.4. Examples of symbol sets that can be used to facilitate reading through symbols.
CONCLUSION
This chapter focused on the importance of providing young children
with developmental disabilities with access to communication and literacy development by firstly understanding the impact of their impairments on their use and interpretation of symbols as well as taking heed
of the sociocultural factors that might have an impact on performance. It
also discussed communication and participation from two perspectives,
these being engagement and interaction. The mere fact that messages are
exchanged does not guarantee that meaning is derived from the context.
The ability to observe the level of engagement within the activity or situation is thus critical in understanding the participation of young children
with developmental disabilities. This approach is explored further in terms
of its application to play and emergent literacy intervention.
397
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13
Eating Disorders
DAVID H. GLEAVES, JANET D. LATNER,
and SUMAN AMBWANI
INTRODUCTION
Eating problems or irregularities are common among children and
adolescents. When the problems reach the point of being gross disturbances in eating behavior and when accompanied by some form of body
image disturbance, we enter the realm of the Eating Disorders (EDs). The
current Diagnostic and Statistical Manual of Mental Disorders (DSMIVTR;
APA, 2000) distinguishes between three primary ED types: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS). The latter refers to cases that meet some but not all the
criteria required for the diagnosis of either AN or BN. Binge-Eating Disorder
(BED) is a more recently recognized disorder that is technically a variant
of the EDNOS category (although research criteria have been developed).
There are, however, numerous possible manifestations of EDNOS other
than BED.
In earlier versions of the DSM, up to and including the Third EditionRevised (American Psychiatric Association, 1987), the EDs were listed
within the Disorders Usually First Evident in Infancy, Childhood, or Adolescence section. Given their prominence among adults as well, their own
section was created in the most recent edition. However, their origins in
childhood or adolescence should not be forgotten and they are, in many
ways, disorders of adolescence.
In this chapter, we cover these above-mentioned disorders. There are
also numerous other eating-related disorders that frequently occur in
403
404
EATING DISORDERS
405
406
having one of two types; in this instance, it is based on the type of compensatory behavior. If the person engages in self-induced vomiting or the
use of laxatives, he or she is considered to have the purging subtype. If
the person only uses excessive exercise or starvation (or similar methods),
the nonpurging type of BN would be diagnosed. There is less support for
the validity of this distinction (Gleaves et al., 2000) than there is for the
subtypes of AN described above. However, the purging type, in general,
appears to be associated with more pathology than the nonpurging type
(e.g., Willmuth, Leitenberg, Rosen, & Cado, 1988).
The DSM body image criterion for BN is less specific than for AN,
and worded only as Self-evaluation is unduly influenced by body shape
and weight (APA, 2000; p. 594). There is, however, evidence that, when
controlling for actual body size, persons with BN seem very similar to
those with AN in terms of body image (Williamson, Cubic, & Gleaves,
1993). Women with BN overestimate their current size and desire to be
excessively thin, relative to same-sized women without BN (Williamson,
Davis, Goreczny, & Blouin, 1989). However, it is no doubt also true that
their self-evaluation is overly influenced by their body image, as stated
in the criterion.
In earlier versions of the DSM, it was possible for a person to be diagnosed with both AN and BN. With the current system, BN cannot be
diagnosed if it occurs only in the context of AN. Such an individual would
be diagnosed as having the binge-eating/purging subtype of AN. There is
evidence that BN occurs on a continuum with the binge-eating/purging
subtype of AN whereas the restricting subtype is qualitatively different
from both other disorders (Gleaves et al., 2000).
EATING DISORDERS
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408
EPIDEMIOLOGY
Prevalence
Although Hoek and van Hoekens (2003) review of the ED literature
reported average prevalence rates of 0.3% (AN) and 1% (BN) for young
women, and 0.1% (BN) for young men, among at-risk women, prevalence
estimates typically range from 3% to 10% (i.e., ages 1529 years; Polivy
& Herman, 2002). The averages reported by Hoek and van Hoeken (2003)
were not specific to eating disorders among adolescents, but most of the
Table 13.4. DSMIVTR Eating Disorder Not Otherwise Specified
The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not
meet the criteria for any specific eating disorder. Examples include:
1. For females, all of the criteria for anorexia nervosa are met except that the individual
has regular menses.
2. All of the criteria for anorexia nervosa are met except that despite significant weight loss
the individuals current weight is in the normal range.
3. All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for
duration of less than three months.
4. The regular use of inappropriate compensatory behavior by an individual of normal body
weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies).
5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
6. Binge-eating disorder: recurrent episodes of binge eating in the absence if the regular
use of inappropriate compensatory behaviors characteristic of bulimia nervosa.
Note: From APA (2000, pp. 594595). Reprinted with permission from the Diagnostic and Statistical Manual
of Mental Disorders, Fourt Edition, Text Revision, (Copyright 2000). American Psychiatric Association.
EATING DISORDERS
409
410
eating and purging behaviors. Moreover, some have suggested that the
prevalence of some EDs (particularly BN) may be lower among children and
adolescents than adults for practical reasons, such as not having access
to money or privacy required for binge eating (Netemeyer & Williamson,
2001). Similarly, although AN may be more obviously detectable because
of patients extreme low weight, such detection may be more difficult when
the low weight is a manifestation of a failure to gain weight. Overall, we view
proper assessment as critical for diagnosis and treatment, and there are
many issues specific to assessment of children and adolescents with eating
problems. See Netemeyer and Williamson (2001) or Zucker et al. (2008 and
with a 2009, publication data) for a more in-depth discussion of assessment
of eating disorders among children and adolescents.
Gender Differences
As reflected by the incidence and prevalence rates, EDs typically occur
less frequently among males than among females. One possibility is that
the prevalence of AN is higher among boys than it appears to be, but is
not readily recognized due to its reputation as a stereotypically female
EATING DISORDERS
411
disorder. Thus, research examining eating disorders among men and boys
may have been limited by the tendency towards misdiagnosis, although
greater attention has been devoted to this problem in recent years.
In general, data suggest that boys with EDs typically strive for a more
muscular body ideal, rather than the thin ideal typically pursued by girls
(McCreary & Sasse, 2000; see Labre, 2002, for a review on adolescent boys
and the muscular ideal). Although EDs have been diagnosed among individuals of all sexual orientations, bisexual and homosexual orientation
may be particular risk factors for developing EDs (Austin et al., 2004). The
prevalence of homosexuality and bisexuality is higher among men with
BN than in the general population (43% versus 10%; Carlat, Camargo, &
Herzog, 1997), however, it is not clear whether this applies to adolescents.
Furthermore, athletes and other individuals for whom physical appearance and body shape are especially important (e.g., body builders) are at
a higher risk of developing BN because they need to maintain their weight
at or below specific thresholds (Carlat et al., 1997).
For boys, the following estimates are available for lifetime prevalence
rates: 6.5% (any ED), 0.2% (AN), 0.4% (BN), and 0.9% (BED) (Kjelss,
Bjrnstrm, & Gtestam, 2004). Among children and adolescents, consistently higher proportions of female than male patients present to eating
disorder treatment programs (e.g., Geist, Heinmaa, Katzman, & Stephens,
1999; Peebles, Wilson, & Lock, 2006), but there may be some gender differences in the presentation of these disorders. For instance, Geist et al.
(1999) reported that male adolescents presented with significantly lower
drive for thinness and body dissatisfaction than their female counterparts.
However, the authors noted that in the absence of adolescent male norms
on the instrument used, their results may be difficult to interpret.
In comparing a large sample (N = 959) of children and adolescents
ages 819 years in an eating disorder treatment program, Peebles et al.
(2006) reported that, compared with older adolescents (mean age = 15.6
years, SD = 1.4), younger patients (mean age = 11.6 years, SD = 1.2) were
more often male, presented at a lower percentage of ideal body weight,
and lost weight more rapidly. Specifically, in the younger sample, 16.5%
was male, whereas 7.8% of the older sample was male. In the entire sample, most of the patients were female (91.1%), and presented with EDNOS
(51.3%), although there were also large proportions presenting with AN
(35.8%) and BN (12.9%).
412
(Pernick, et al., 2006). Similarly, Granillo, Jones-Rodriguez, and Carvajal (2005) evaluated data from 1,866 adolescent Latina adolescents, ages
1120 years (median = 16), and reported fairly high prevalence rates for
various behaviors placing them at risk for the development of eating disorders, including, dietary restraint (53.3%), low BMI (<17; 2.5%), amenorrhea (5.5%), and self-reported bulimic symptoms (1.9%).
Although some researchers view eating disorders as purely Western
syndromes, increasing reports attest to the prevalence of eating psychopathology in non-Western cultures. For instance, Huon, Mingyi, Oliver, and
Xiao (2002) assessed 1219-year-old girls in various regions of China (N =
1,246). The authors found that 1.8% and 2.2% of their sample used vomiting and laxatives, respectively, in order to control their weight. NishizonoMaher, Miyake, and Nakane (2004) reported that Japanese girls (1316
years) maintain a similar distribution of drive for thinness as their Western counterparts. Similarly, a study assessing South African adolescents
and young adults (N = 895) reported that 14% of the respondents maintained high levels of maladaptive eating attitudes and behaviors, and 4.6%
reported engaging in bulimic behaviors (Le Grange, Louw, Russell, Nel, &
Silkstone, 2006). A study in the United Arab Emirates reported somewhat
higher rates of maladaptive eating attitudes and behaviors among adolescent girls (23.4%), and noted that adolescents in the older age group (16
18-year-olds) were more likely to maintain these high levels (27.8%) than
their younger counterparts (1315-year-olds; 19.2%; Eapen, Mabrouk, &
Bin-Othman, 2006).
Research in Europe also suggests that maladaptive eating attitudes
and behaviors among children and adolescents are prevalent. For instance,
a survey revealed that Danish adolescent boys and girls experience substantial dissatisfaction with their body weight: 49% of the girls and 21.5%
of the boys reported wanting to lose weight, 17.9% of the boys and 7.4%
of the girls sought weight gain, and several adolescents also endorsed
extreme weight loss behaviors, including self-starvation or fasting, using
diet pills, and inducing vomiting to lose weight (Waaddegaard & Petersen,
2002). Similarly, one study reported that 15.8% and 2.8% of Italian schoolaged female and males, respectively, exhibited high levels of maladaptive
eating attitudes and behaviors (Miotto, De Coppi, Frezza, Rossi, & Preti,
2002), and another study indicated that a large proportion of Swiss female
adolescents (62%) sought to lose weight, felt too fat (36%), and engaged in
binge eating (9.1%) and self-induced vomiting (1.6%) at least once a week.
Finally, estimates of disordered eating attitudes among children and adolescents in Croatia (Knez, Munjas, Petrovec ki, Pauc ic-Kirinc ic, & Peric,
2006) and Spain (Alonso, Rodrguez, Alonso, Carretero, & Martin, 2005)
have been remarkably similar, ranging from 7.5% to 7.8% of the sampled
populations, with a higher prevalence among females than males.
Social Class
Although EDs are seen across different social classes, early observations were that certain forms of eating dysfunction, such as AN, occurred
more commonly among women of middle to high social classes (e.g., Crisp,
EATING DISORDERS
413
Palmer, & Kalucy, 1976). Although Gard and Freeman (1996) called this
a myth, more recent data do support the observation with regard to AN
(Fisher, Schneider, Burns, Symons, & Mandel, 2001; McClelland & Crisp,
2001). Fisher et al. compared female patients treated for eating disorders at an adolescent medicine unit between the years 1980 and 1994,
and reported that among the adolescent patients (aged 919 years) who
reported parental occupation, most fell in the middle (47.9%) and upper
(44.5%) classes using the Hollingshead Four Factor Social Index, with significantly fewer falling in the lower class (7.6%). However, it still may be
the case that BN is actually more prevalent among lower socioeconomic
groups, as suggested by Gard and Freeman (1996).
Comorbidity
Eating disorders in general seem to be accompanied by a wide range
of medical and/or psychological problems. Perhaps the greatest attention
has been devoted to the co-occurrence of EDs with mood disorders (Stice,
Hayward, Cameron, Killen, & Taylor, 2000; Stice, Presnell, & Bearnman,
2001) and substance abuse disorders (Dansky, Brewerton, & Kilpatrick,
2000). For instance, in a study with adolescents, Zaider, Johnson, and
Cockell (2000) reported that individuals with dysthymia, panic, and major
depressive disorder were significantly more likely [than those without
these disorders] to have an eating disorder, and even after controlling for
the effects of other Axis I and Axis II psychopathology, dysthymia independently predicted EDs.
EDs also do appear to be highly comorbid with substance use problems
(Bulik et al., 2004), and approximately 20% to 46% of women with EDs
report a history of problems with alcohol and/or drugs (Bulik et al., 2004;
Conason, Brunstein Klomek, & Sher, 2006). Researchers have suggested
that the powerful drive for thinness that is central to eating disorders may
increase the likelihood of abusing stimulant drugs for weight-loss reasons
(Measelle, Stice, & Hogansen, 2006). Moreover, if binge eating and subsequent compensatory behaviors engender feelings of guilt, the individual
may turn to substance use to modulate his or her negative affect.
In terms of research specific to adolescents, Wiederman and Pryor
(1991) reported that approximately 1/3 of a sample of adolescents with BN
smoked tobacco and marijuana and drank alcohol at least weekly. Among
those with AN, a much lower percentage (1.7 %) reported drinking on a
weekly basis. Consistent with these data, restricting anorexics reported
less substance use than the general (nonclinical) population (Stock, Goldberg, Corbett, & Katzman, 2002). Finally, in their recent longitudinal study
with adolescent girls, Measelle et al. (2006) reported that initial eating
psychopathology predicted increases in substance abuse symptoms over
a five-year period.
EDs are also commonly associated with personality disorders. Godt
(2002) reported the comorbidity of EDs and Axis II disorders at 33%. Borderline personality disorder may be particularly common. Although variable across studies, rates of BPD and ED comorbidity often range from
4.3% to 10% for AN, and 6.2% to 28% for BN (Godt, 2002; Sansone, Levitt,
414
& Sansone, 2005). Personality disorders may also predict the development
of eating disorders (Johnson, Cohen, Kasen, & Brook, 2006).
In addition to comorbid psychological conditions, individuals with
eating disorders are prone to experience a host of significant medical
consequences and correlates, such as gastrointestinal complications,
dangerously low body weight, and dental caries. Specifically, individuals with AN are susceptible to experiencing osteoporosis and osteopenia,
cardiovascular problems, and orthopedic problems due to the combined
effects of excessive exercise and nutritional deficiencies (Agras, 2001;
Brambilla & Monteleone, 2003). Individuals with BN are likely to experience various medical complications including electrolyte imbalances,
dental problems, and cardiovascular problems (Agras, 2001; Brambilla
& Monteleone, 2003).
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416
EATING DISORDERS
417
418
Overall, the authors reported that 58% had a good outcome, 21% had an
intermediate outcome, and 21% had a poor outcome.
In another study of adolescents with AN (N = 69), Herzog, Schelberg,
and Deter (1997) reported that for 50% of the patients, there was no initial
recovery until 6 years after the inpatient treatment. The authors also noted
that whereas patients with purging behavior and social disturbances had
a relatively lower chance of recovery, those with AN-R and low serum creatinine levels were more likely to experience early recovery. In a naturalistic comparison of adolescents with AN treated as inpatients (n = 21) and
outpatients (n = 51), Gowers, Weetman, Shore, Hossain, and Elvins (2000)
reported that the outpatients demonstrated a better outcome 27 years
after initial presentation, and the primary predictor of poorer outcome was
admission to inpatient care. Although this study was not randomized and
inpatient treatment may have simply reflected greater severity, its results
suggest that caution is necessary in prescribing inpatient care (Gowers &
Bryant-Waugh, 2004).
In a naturalistic outcome study, among patients who were assessed
at an average of 4.5 years after treatment (N = 113), 72 were considered
healthy, 25 still had an eating disorder, 11 refused contact, and 5 had
died (Steinhausen & Boyadjieva, 1996). Finally, in a study comparing
inpatient and outpatient (individual and family therapy, or, group therapy,
both conditions combined with dietary counseling) treatment for adults
with AN, Crisp et al. (1991) reported that many of the patients assigned to
the inpatient treatment refused to receive this form of care and, similarly,
several individuals randomized to the no-treatment condition refused to
not seek treatment elsewhere. The authors reported that the ED symptoms
and weight improved for all three treatment groups relative to the no-treatment control; however, the methodological limitations of their research
exemplify some of the difficulties in conducting controlled investigations
of AN treatment.
To understand the experience of adolescents undergoing inpatient
treatment for AN, Colton and Pistrang (2004) conducted semi-structured
interviews with young women (N = 19) in inpatient ED units. The authors
reported that the patients maintained positive as well as negative views on
their treatment and that the views were characterized by five overarching
themes. First, participants reported feelings of confusion about their AN,
and difficulty understanding how the disorder had taken control of them.
Second, they believed that the key to their recovery was a desire and readiness to get well, not for others, but for themselves. Third, participants
discussed the advantages and disadvantages of living with other patients
with AN; whereas being with other AN patients offered support, it was also
a source of distress. Fourth, they expressed their belief that being recognized by the staff as an individual, rather than just another AN patient on
the conveyor belt was helpful. And finally, participants mentioned that
a central component of their experience involved being a collaborator in
treatment versus being treated.
In sum, most hospitalization programs for EDs are multidisciplinary
and include a mixture of treatment components. The foremost goal is to
achieve medical and nutritional stabilization, weight gain, and regular
EATING DISORDERS
419
Partial Hospitalization
In a stepped-care framework, treatment that constitutes the least
restrictive alternative, but is still believed to be helpful, is the first treatment
attempted (Davison, 2000). A form of treatment that is more intensive than
outpatient treatment but less intensive and less restrictive than inpatient
treatment is partial hospitalization. Partial hospitalization programs, also
known as day treatment programs, have the additional advantage of being
less costly than inpatient treatment programs.
Partial hospital programs often use the same treatment strategies
and have the same treatment goals as inpatient programs. A descriptive
report noted that in three typical day treatments for eating disordered
patients of all ages, these programs regularly use group meals, nutrition and cooking education groups, body image and counseling groups,
and groups that address social skills, assertiveness, family issues, and
relationships (Zipfel et al., 2002). However, because patients return
home in the evening, they spend less time on the unit. Thus, such
programs permit patients to remain in their natural environments during the course of treatment. Staying in the natural environment may
facilitate more rapid learning and generalization of therapeutic skills to
home and school settings. These programs also allow patients to continue to function in their everyday social roles and to have continued
family contact and support (Zipfel et al., 2002).
Howard and colleagues (1999) examined a number of prognostic indicators of treatment failure among 59 patients in partial hospitalization
treatment. These patients had been transferred from inpatient treatment.
Reviewing these patients charts revealed that long duration of illness
(>2.5 years), amenorrhea, and low body mass index (<19) increased the
likelihood of treatment failure and readmission to inpatient treatment
(Howard, Evans, Quintero-Howard, Bowers, & Andersen, 1999). However,
the patients examined in this study were adults, and it is possible that, for
children and adolescents, additional factors such as age of onset or level of
family conflict might influence treatment outcome in day programs.
Outcome research on day treatment programs for children or adolescents with eating disorders, and even for adults, is limited. Danziger,
Carcl, Varsano, Tyano, and Mimouni (1988) described a follow-up of 32
girls with AN in a pediatric day-treatment program that involved parents
as participants and providers in the therapy. Nine months after treatment,
the majority of cases showed a healthy restoration of weight, menses, body
image, eating and exercise habits, and social functioning.
420
Outpatient Treatment
In this section we highlight four forms of outpatient treatment for
childhood and adolescent eating disturbances. Certain caveats should be
noted, however. First, the research base concerning these treatments is
limited, due to factors such as the rarity of these disorders and the difficulty in recruiting and retaining patients in treatment trials. In addition,
several studies on AN that have found no differences between groups have
had small sample sizes. In such studies, it is important to not automatically
interpret a lack of significant differences across conditions as treatment
equivalence (Fairburn, 2005).
Family-Based Treatment
Most children and adolescents with eating disorders are treated on
an outpatient basis. The most widely researched form of outpatient treatment for childhood eating disorders is family-based therapy (FBT). Clinical
researchers at the Maudsley Hospital in the United Kingdom developed FBT
and it is based on a model of mobilizing family resources to help the family
refeed the patient (Lock, LeGrange, Agras, & Dare, 2001). This treatment
has support from well-conducted clinical studies. The recently issued APA
(2006) guidelines for the treatment of eating disorders called family treatment the most effective treatment for child and adolescent AN.
EATING DISORDERS
421
422
directed at the patient, SFT was significantly superior. Only four patients
in this study required concurrent hospitalization. In a smaller study,
these treatment formats were also compared among 18 adolescents with
AN randomly assigned to CFT or SFT (Le Grange, Eisler, Dare, & Russell,
1992). Inpatient treatment was also required during the course of treatment. Both treatments brought about clinically significant improvements
in weight and psychological functioning, with few differences between the
treatment formats.
Lock, Agras, Bryson, and Kraemer (2005) examined the ideal length and
dose of family therapy. These investigators compared the standard therapy
length of 20 sessions over 12 months to a short form of therapy offering
10 sessions over 6 months. Whereas the standard length therapy covered
all three phases of treatment, the short form of therapy primarily focused
on the first and second phases with less time for general adolescent concerns and building the family relationship. In this randomized controlled
trial, 86 adolescents with AN showed similar gains in BMI, eating disorder
psychopathology, and general psychopathology across both the short and
long treatment conditions at 12 months. Although 19 patients required
hospitalization during treatment, these were distributed evenly across
the two treatments. Patients with high levels of eating-related obsessional
thinking gained more weight in the longer treatment. Similarly, those from
nonintact families experienced greater improvements in eating psychopathology in the longer treatment.
Across the two groups at one year, 96% of patients no longer met criteria for AN, and 67% achieved a healthy BMI (>20). Thus, for the majority
of AN patients (especially those from intact families and those who are not
exceptionally high on eating-related obsessionality), a short form of FBT is
likely to be as effective as standard-length treatment. These findings were
maintained at a long-term follow-up (on average, four years), when no significant differences between the groups were found and 89% of all patients
were at a healthy weight (Lock, Couturier, & Agras, 2006).
Additional forms of family therapy have been examined as well. Geist,
Heinmaa, Stephens, Davis, and Katzman (2000) compared a family group
psychoeducation treatment and a standard family therapy among 25 adolescent girls with AN and their families. Both treatments were administered in eight sessions over four months, and psychoeducation treatment
involved education classes and professionally led discussion groups on
eating disorders (Geist et al., 2000). Both groups achieved comparable
improvements in ideal body weight, eating disorder psychopathology, and
general psychopathology. However, all patients in this study required concurrent hospitalization for medical reasons (for an average of eight weeks),
so it is difficult to attribute their improvement to the outpatient family
therapies administered.
A version of family therapy entitled Behavioral Systems Family Therapy (BSFT), has also been compared with an individual treatment, Ego
Oriented Individual Treatment (EOIT, described below under psychodynamic treatment). BSFT was similar to the Maudsley model of FBT, with a
few subtle differences. Robin and colleagues (1999) compared these treatments among 37 adolescents with AN, 16 of whom required concurrent
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423
hospitalization (11 BSFT and 5 EOIT patients). Immediately after treatment and at a 12-month follow up, patients in the BSFT group had gained
more weight. A greater proportion of BSFT patients resumed menstruation after treatment (94% vs. 64%). This difference was no longer statistically significant at follow-up, when both groups had similar rates of
menstruation recovery. However, the more rapid response of menstruation
and weight gain to family therapy suggests that BSFT was quicker acting
than individual treatment. In a disorder as medically compromising as AN,
speed of recovery can be an important consideration, and a faster-acting
treatment would generally be more advisable.
Although AN in younger children is rare, a large case series also provided recent support for the use of FBT in this population. Thirty-two
children of an average of 11.9 years showed clinically significant improvements in eating disordered thinking patterns and body weight gain following family therapy (Lock, LeGrange, Forsberg, & Hewell, 2006). These
patients closely resembled those in a comparable adolescent sample before
and after treatment. This study suggested that efficacy of FBT did not
depend on addressing issues of adolescent development, and these issues
may not be crucial to treatment, even with adolescents.
There have been no randomized controlled trials of family therapy for
adolescents with BN. The results from the adult BN subgroup examined
by Russell et al. (1987) are discouraging. However, a case series described
eight adolescents with BN treated with FBT (Dodge, Hodes, Eisler, & Dare,
1995). Standard FBT for AN was modified to address compensatory behaviors and shift the focus from weight gain to regular eating. (For a description of the treatment strategies used in FBT for adolescent BN, see Le
Grange, Lock, and Dymek, 2003). At 12 months after the start of treatment, there were significant reductions in eating pathology and in the
level of self-harm behaviors, which were initially present in half of the
patients. However, only one patient achieved a good outcome as defined by
the Morgan-Russell criteria listed earlier (Morgan & Russell, 1975). Therefore, further research is needed before recommending FBT to children or
adolescents with BN.
424
were initially recruited. Thus, the final results (apparently due in 2008)
will no doubt be a meaningful contribution to the literature. However,
because no other randomized controlled trials have been conducted for
childhood or adolescent AN or BN, its efficacy with these populations can
only be predicted based on existing data from adults. However, the established efficacy of CBT, particularly in the treatment of BN, suggests that
investigations of this treatment with adolescents and children should be
an important research priority.
CBT for AN has been tested in a small number of clinical trials. For
example, in 24 adult AN patients, Channon, de Silva, Hemsley, and Perkins
(1989) compared CBT to both behavior therapy (BT) and a low-contact
treatment administered by psychiatrists. Not surprising considering the
small sample, the three treatments did not statistically differ from each
other on outcome. All patients improved significantly on nutritional status, menstrual functioning, and body weight. However, patients had better
treatment attendance with CBT than with BT. CBT also resulted in fewer
early drop-outs in a 12-month comparison of CBT and nutritional counseling in adult AN patients following hospitalization (Pike, Walsh, Vitousek,
Wilson, & Bauer, 2003).
CBT patients remained significantly longer without relapsing (44 vs.
27 sessions); 22% versus 53% of patients relapsed in CBT versus nutritional counseling. Similarly, a comparison of CBT and dietary counseling
found a much lower drop-out rate with CBT; indeed, all patients dropped
out of dietary counseling by three months (Serfaty, Turkington, Heap, Ledsham, & Jolley, 1999). In addition, all patients refused to provide data for
a six-month follow-up. This study dramatically illustrates some of the difficulties encountered in conducting research with such a relatively treatment-resistant group of patients. In addition, Fairburn (2005) argued that
nutritional counseling without concurrent psychotherapy is not a sufficiently rigorous comparison group against which to test CBT.
Interestingly, the results of a recent study cast doubt on the superiority of CBT in a comparison to another manualized psychotherapy, interpersonal therapy (IPT), and to a nonspecific clinical management condition
providing supportive psychotherapy (McIntosh et al., 2005). Patients were
55 women (aged 1740) diagnosed with AN using a slightly higher than
usual weight criterion to define the disorder (BMI <19). Thirty percent of
all patients were considered much improved or had minimal symptoms
after treatment. However, despite the authors predictions, the nonspecific
control treatment was superior to CBT and IPT on global measures of eating disorder symptoms. Thus, there is not yet strong support for the use of
any specific individual psychotherapy for AN, even with adults (see Wilson,
Grilo, and Vitousek, 2007, for a review).
For adults with BN, CBT (Fairburn, Marcus, & Wilson, 1993) is considered the treatment of choice. For example, both the APA (2006) and also
the National Institute for Clinical Excellence (NICE, 2004) recommended
CBT as the leading evidence-based treatment for BN in their recently issued
evidence-based guidelines for the treatment of eating disorders. This was
the first time that NICE endorsed a specific psychotherapy as a treatment of choice. The efficacy of CBT for BN has been supported by strong
EATING DISORDERS
425
evidence from randomized controlled trials. CBT involves weekly individual sessions over four to five months and typically results in complete
remission in about 40% of cases (Wilson & Fairburn, 2002). Treatment
does not typically affect patients body weight. The majority of therapeutic
gains occur in the first few sessions of treatment, significantly sooner than
in comparison treatments (Wilson et al., 1999). This finding suggests that
CBT is relatively fast acting. Similarly, more patients achieved remission
by the end of CBT than by the end of IPT, although this difference leveled
off by a 12-month follow-up (Agras, Walsh, Fairburn, Wilson, & Kraemer,
2000; Fairburn, et al. 1995).
Again, although inferences can only be made from research with
adults, CBT is also established as a treatment for BED, efficacious in
reducing binge eating and associated psychopathology, even over longterm follow-up (Agras, Telch, Arnow, Eldredge, & Marnell, 1997). Generally, CBT does not produce clinically significant weight loss (Wilson, 2005)
and thus does not effectively treat the obesity often associated with BED.
Descriptive research has now documented the presence of BED among
a proportion of children presenting for obesity treatment (Decaluw and
Braet, 2003). Therefore, evaluating the effect on childhood BED of weight
control treatment and other therapies should be a research priority.
Although experts recommend CBT for adolescents with BN (NICE,
2004), it is important that age-related modifications be made to fit the adolescent patients level of development and circumstances. It is also essential that the patients family be included as appropriate. In addition, Robin
and colleagues (1998) have cautioned that patients need to have developed
certain requisite cognitive abilities to engage in this treatment: (1) the ability to think abstractly about beliefs and attitudes regarding weight, shape,
and appearance, and (2) the ability to consider alternative possibilities to
presently held beliefs and a willingness to test these alternative hypotheses. These cognitive skills are usually present by age 1415 years. Cognitive treatment strategies can be made more concrete for children who do
not yet have these skills. For example, simple behavioral experiments can
be used to disconfirm distorted beliefs. Concrete cognitive strategies such
as overt self-statements or self-instruction can be used to help patients
cope with negative automatic thoughts.
Psychodynamic Therapy
One randomized trial has examined a form of psychodynamic therapy
for adolescents with AN. The study by Robin et al. (1999), described earlier,
compared a version of family therapy to ego-oriented individual treatment
(EOIT). EOIT emphasized developing ego strength, learning coping skills,
individuating from the family, and identifying and modifying any dynamics that may be blocking eating. EOIT led to decreases similar to family
therapy in conflicts during family interactions even though sessions were
individually conducted; however, EOIT took effect less immediately than
family therapy.
Time-limited versions of psychodynamic treatment for AN have also
been tested in two studies with adults. A randomized controlled trial
426
investigated three specialized treatments and a low-contact control treatment in 84 women with AN (Dare, Eisler, Russell, Treasure, & Dodge,
2001). Focal psychoanalytic therapy addressed the meaning of the
patients symptoms in light of their history and family relationships, as
well as the effect of these symptoms on their relationships (including the
relationship with the therapist). This treatment was compared to cognitive
analytic treatment (CAT), in which components of cognitive therapy were
integrated with components of psychodynamic therapy such as interpersonal and transference issues. Family therapy was the third specialized
treatment tested in this investigation.
After 12 months, the three specialized treatments were similar in
outcome, and both focal psychoanalytic therapy and family therapy were
superior to the control treatment. However, patients did poorly in all treatments. Only 30% of patients in the three treatment groups no longer met
criteria for AN (compared to 5% of patients in the control treatment). The
study may have had insufficient power to detect differences among the
specialized treatments, and patients had a long history of illness (6.3 years
on average), indicating poor prognosis. Similarly, Treasure and colleagues
(1995) found no differences between CAT and another specialized therapy,
behavior therapy (emphasizing psychoeducational techniques), administered to 30 adult AN patients. This study, as well as that of Dare et al.
(2001), may have been underpowered. Based on the research so far, there
is no compelling evidence that psychodynamic therapy is more effective
than alternative specialized treatments for AN with adolescents or adults.
Interpersonal Therapy
IPT is a specific, time-limited form of psychodynamic treatment that
focuses on resolving interpersonal difficulties that contribute to the onset
or maintenance of the disorder. Four potential problem areas typically
constitute the focus of treatment: grief, interpersonal disputes, role transitions, and interpersonal deficits. The study discussed above, which compared CBT, IPT, and nonspecific clinical management in adult women with
AN, found IPT to be the least efficacious of these three treatments (McIntosh et al., 2005). IPT has shown similar efficacy to CBT in adults with
BN, but its benefits may be more delayed (Agras et al., 2000; Fairburn et
al., 1995). Research also supports the use of IPT for BED in adults (Wilfley
et al., 2002). As with CBT, the use of IPT for adolescents or even children
would need to be carefully modified to suit the age and maturity level of
the patient, as well as to place special emphasis on relevant family relationships. However, the lack of research on IPT for this age group suggests
that this treatment would not be an optimal choice for eating disorders in
youth.
EATING DISORDERS
427
the adult literature may or may not be appropriate. Gowers and BryantWaugh (2004) recently listed four arguments in favor of such extrapolation and five reasons why such extrapolation may not be warranted. Until
there is more research, we should proceed with caution.
Overall, the state of the research-base varies depending on which disorder and which age group is being considered. The prognosis is probably
better for children and adolescents than for adults but there is still limited
research with younger ages. The prognosis is worse for AN than for BN or
BED. Regarding AN, in a recent systematic review of randomized controlled
trials of psychosocial interventions for adolescents with AN, Tierney and
Wyatt (2005) concluded that very few conclusions could be drawn from
the small body of research. Many studies have been small and possibly
underpowered to detect differences between interventions; no published
research has included no-treatment control conditions; and most studies
lacked a follow-up assessment. Thus, there is not yet strong support for
the use of any specific intervention for AN.
For BN, there is also a notable lack of research specifically with
adolescents or children, although two randomized trials of family therapy for BN are in progress (Gowers & Bryant-Waugh, 2004). However,
the efficacy of CBT for BN among adults (whose samples often include
adolescents) has been well established, and NICE (2004) recommended
CBT as the leading evidence-based treatment for BN. They recommended that CBT be used for this group, but with age-related modifications to suit the patients level of development and circumstances, and
including the family as appropriate.
BED may have the best prognosis, although more research with children and adolescents is clearly needed. More research with other variants
of EDNOS particularly given that it is the most common ED encountered
in clinical practice. We either need more research on treatment of various
subtypes of EDNOS or more research on the transdiagnostic approach
recently described by Fairburn, Cooper, and Shafran (2003).
CONCLUDING REMARKS
The EDs are potentially life-threatening conditions that are also potentially treatable. Early detection and intervention may be the key; thus,
expertise in assessment and treatment of eating disorders is valuable
for those working with children and adolescents. However, much more
research is also needed with these age groups so that we do not have to
rely on extrapolations from the adult literature.
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14
Treatment of Pediatric
Feeding Disorders
CATHLEEN C. PIAZZA, HENRY S. ROANE, and
HEATHER J. KADEY
435
436
437
Hoch et al., 1994; Luiselli, 2000; Luiselli & Gleason, 1987); therefore,
the individual effects of the procedures on acceptance and inappropriate
behavior were not clear. In fact, a careful examination of the literature
reveals that there are no studies that we could find that clearly demonstrate the effectiveness of positive reinforcement alone with multiple
participants with severe feeding problems. For example, in a study by
Riordan, Iwata, Finney, Wohl, and Stanley (1984), inappropriate behavior
resulted in escape from bite presentations in baseline. During treatment,
participants received positive reinforcement (e.g., access to preferred
items) contingent upon consumption of presented bites; however, this
positive reinforcement contingency was paired with no differential consequences for inappropriate behavior (i.e., escape was no longer provided
for inappropriate behavior) which may have approximated escape extinction for this response.
Piazza and colleagues examined the effects of positive reinforcement and escape extinction alone and in combination on acceptance and
inappropriate behavior (Piazza, Patel, et al., 2003; Reed et al., 2004) to understand how positive reinforcement alone, escape extinction alone, and
positive reinforcement and escape extinction combined affected feeding
behavior. Piazza, Patel, et al. compared an escape condition (i.e., inappropriate behavior resulted in a 30-s break from bites of solids or liquids) to a
condition in which swallowing bites of solids or liquids resulted in differential positive reinforcement (i.e., 30-s access to a preferred toy). Levels of
acceptance of solids and liquids remained low and inappropriate behavior
remained high in both conditions.
Next, the authors added escape extinction to the differential positive
reinforcement procedure (DRA) and compared DRA plus escape extinction
to escape extinction alone. Levels of acceptance increased and inappropriate
behavior decreased in both conditions (DRA plus escape extinction and
escape extinction alone). Levels of acceptance decreased and inappropriate
behavior increased when the escape extinction procedure was removed.
These results suggest that increases in acceptance and decreases in
inappropriate behavior occurred as a result of the escape extinction
procedure, independent of the presence or absence of a differential
positive reinforcement contingency. However, inappropriate behavior and/
or negative vocalizations (e.g., crying) were lower for some participants
when treatment consisted of escape extinction and differential positive
reinforcement relative to escape extinction alone.
Reed et al. (2004) used a similar preparation to compare the effects of
noncontingent reinforcement (NCR) alone, NCR plus escape extinction, and
escape extinction alone. The results of Reed et al. were similar to those of
Piazza, Patel, et al. (2003) in that levels of acceptance increased and inappropriate behavior decreased when escape extinction was implemented,
independent of the presence or absence of NCR; however, inappropriate
behavior and/or negative vocalizations were lower for some participants
when NCR was combined with escape extinction. Thus, the results of
Piazza, Patel, et al. and Reed et al. suggested that escape extinction may
be a critical component of treatment for some individuals, but that the
addition of a positive reinforcement component (i.e., either differential or
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439
levels of consumption. However, the available empirical data from published studies do not support the notion that children demonstrate more
distress (i.e., inappropriate behavior, crying) or refusal when escape
extinction is used as treatment for feeding problems.
Careful examination of data from most studies on escape extinction
(Ahearn et al., 1996; Cooper et al., 1995; Hoch et al., 1994; Patel et al.,
2002; Piazza, Patel, et al., 2003; Reed et al., 2004) show that levels of
inappropriate behavior (e.g., crying, head turning) are much higher under
baseline conditions when treatment of the feeding problem is absent (i.e.,
the child can choose not to eat). Thus, under a choice condition (I dont
have to eat), children with feeding problems tend to have higher levels of
head turning, batting at the spoon, and crying, and lower or zero levels of
acceptance, suggesting that these baseline conditions (i.e., the child can
choose not to eat) may, in some cases, have more aversive qualities than
some treatment conditions. By contrast, when escape extinction-based
treatments are implemented, crying, head turning, and batting at the
spoon tend to decrease and levels of acceptance tend to increase, suggesting that these treatment conditions may be relatively less aversive than
the baseline conditions in which the child can choose not to eat. Another
advantage of the escape extinction treatment is that it results in learning
(i.e., the child learns a new way of behaving during meals). By contrast,
tube feedings do not provide the opportunity for learning during mealtimes.
Even though a number of investigators have shown that escape
extinction is effective as treatment for food refusal, some children may
not respond to escape extinction alone. Therefore, a number of studies
have been conducted that have evaluated the effectiveness of treatment
packages that combine escape extinction with other procedures. Kern and
Marder (1996) and Piazza and colleagues (Piazza et al., 2002) showed that
simultaneous presentation of preferred and nonpreferred foods (e.g., placing a piece of nonpreferred broccoli on a preferred potato chip) was more
effective than sequential presentation (e.g., giving the child a preferred
potato chip following consumption of a nonpreferred piece of broccoli).
Mueller, Piazza, Patel, Kelley, and Pruett (2004) and Patel, Piazza,
Kelly, Ochsner, and Santana (2001) extended the work of Kern and Marder
(1996) and Piazza et al. (2002) by demonstrating that blending (i.e., mixing)
preferred and nonpreferred foods (Mueller et al.) or liquids (Patel et al.) was
an effective method of increasing consumption of nonpreferred solids or
liquids when combined with escape extinction. The children in the Mueller et al. study consumed one or two foods (referred to as preferred foods)
and refused all other foods (referred to as nonpreferred foods). Therefore,
Mueller et al. initiated treatment by presenting a mixture consisting of
90% preferred food and 10% nonpreferred food (i.e., a 90/10 blend). The
ratio of the amount of preferred to nonpreferred foods then was altered in
10% increments (e.g., 80/20, 70/30, and 60/40 blends) when the child
consumed the previous ratio of preferred and nonpreferred food at high
levels.
Patel et al. (2001) combined a high-p sequence with escape extinction
to increase acceptance of solids and liquids for three children. A high-p
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441
for one child. The child in the Patel et al. study expelled meats but not
other types of food (i.e., fruits, vegetables, starches). Reduction of the texture of the meats resulted in low levels of expulsion and also allowed the
child to continue to advance her oral motor skills with the other foods at
a higher texture.
Packing is a behavior that may emerge simultaneous with the introduction of treatment for acceptance (Sevin, Gulotta, Sierp, Rosica, & Miller,
2002) or subsequent to treatment of other response topographies of problematic feeding behavior (Gulotta, Piazza, Patel, & Layer, 2005). Sevin et al.
used a redistribution procedure, which consisted of removing the packed
food from the childs mouth, then replacing the packed food back on the
tongue, to reduce packing. Gulotta et al. replicated and extended the findings of Sevin et al. by using the redistribution procedure to increase intake
and reduce levels of packing in four children.
Packing may be an avoidance behavior that allows the child to escape
eating by holding food in his or her mouth, or it may occur because the
child lacks the prerequisite skills (e.g., tongue lateralization and elevation)
necessary to swallow (Gulotta et al., 2005). In either case, the redistribution procedure may affect behavior by altering motivation to swallow or by
promoting the development of the swallow response. That is, redistribution may increase the childs motivation to swallow because the child then
can avoid the implementation of the redistribution procedure. The redistribution procedure may also foster skill development for other children by
approximating one of the early behaviors in the chain that is necessary for
swallowing (i.e., forming the food into a bolus and moving it back on the
tongue). Swallow facilitation (placing food on the posterior of the childs
tongue, which may elicit the swallow response; Lamm & Greer, 1988;
Hoch, Babbitt, Coe, Ducan, & Trusty, 1995) is an alternative method of
promoting the swallow response. Swallow facilitation should be used with
caution by clinicians who are trained to monitor aspiration risk.
Texture selectivity or difficulties advancing texture is another problem that is exhibited by many children with feeding problems (Munk &
Repp, 1994). Shore, Babbitt, Williams, Coe, and Snyder (1988) showed
that texture fading was effective for increasing one childs acceptance of
gradually increasing textures. Shore et al. advanced the childs texture
from pureed to chopped, while maintaining high levels of acceptance and
swallowing and low levels of packing and expulsion. Data from the other
three children in the study were less clear with respect to the necessity of
the texture fading procedure.
We rarely use texture fading in our clinical practice. We have observed
that chewing skills often do not emerge in children with feeding disorders
as we increase the texture of foods in the absence of training the child in
chewing skills. That is, many of the children we treat simply swallow the
presented bites of food without chewing, independent of the presented
texture, which is unsafe. Therefore, we do not increase the texture of food
presented during meals until we have taught the child to chew, and the
child demonstrates that he or she can masticate a variety of foods to a wet
ground or lower texture and swallow those masticated bites in a timely
manner.
442
CONCLUSIONS
Taken together, the studies reviewed above suggest that treatments
based on theories of operant conditioning appear to be effective for children
with feeding problems. This conclusion is supported by several other studies evaluating the outcomes of behaviorally based treatments (Benoit, Wang,
& Zlotkin, 2000; Byars et al., 2003; Irwin, Clawson, Monasterio, Williams, &
Meade, 2003; Kerwin, 1999). For example, Kerwin reviewed the literature on
the assessment and treatment of feeding problems. The results of Kerwins
443
analysis showed that the only treatments that have empirical support were
those based on reinforcement of appropriate eating and extinction (nonreinforcement) of food refusal. Benoit et al. compared behaviorally based
treatments with nutritional education for children with food refusal who
were G-tube dependent. Forty-seven percent of children in the behaviorally
based treatment group were weaned from their tube feedings after 15 weeks
of treatment compared to zero in the nutritional education group.
Other reports on behaviorally based treatments of groups of children
with feeding disorders have shown positive effects as well. Byars et al.
(2003) showed that a behaviorally based, intensive interdisciplinary feeding program was successful in increasing intake and decreasing G-tube
feedings for nine patients. Irwin et al. (2003) showed that children with
cerebral palsy and feeding problems improved in the number of bites
accepted, weight, and height following intensive interdisciplinary treatment combining behavioral strategies and oral motor techniques. These
summative studies, combined with those described elsewhere in this chapter, suggest that procedures based on the principles of operant behavior
have been shown to be the most effective strategies for treating children
with feeding disorders.
REFERENCES
Ahearn, W. H., Kerwin, M. L., Eicher, P. S., Shantz, J., & Swearingin, W. (1996). An
alternating treatments comparison of two intensive interventions for food refusal.
Journal of Applied Behavior Analysis, 29(3), 321332.
Anderson, C. M., & McMillan, K. (2001). Parental use of escape extinctionand differential reinforcement to treat food selectivity. Journal of Applied Behavior Analysis,
34(4), 511515.
Benoit, D., Wang, E. E. L., & Zlotkin, S. H. (2000). Discontinuation of enterostomy tube
feeding by behavioral treatment in early childhood: A randomized controlled trial.
Journal or Pediatrics, 137(4), 498503.
Byars, K. C., Burklow, K. A., Ferguson, K., OFlaherty, T., Santoro, K. A., & Kaul, A.
(2003). A multicomponent behavioral program for oral aversion in children dependent on gastrostomy feedings. Journal of Pediatric Gastroenterology and Nutrition, 37,
473480.
Cooper, L. J., Wacker, D. P., McComas, J. J., Brown, K., Peck, S. M., Richman, D.,
et al. (1995). Use of component analyses to identify active variables in treatment
packages for children with feeding disorders. Journal of Applied Behavior Analysis,
28(2), 139153.
Gulotta, C. S., Piazza, C. C., Patel, M. R., & Layer, S. A. (2005). Using food redistribution
to reduce packing in children with severe food refusal. Journal of Applied Behavior
Analysis, 38(1), 3950.
Hoch, T., Babbitt, R. L., Coe, D. A., Krell, D. M., & Hackbert, L. (1994). Contingency
contacting. Combining positive reinforcement and escape extinction procedures to
treat persistent food refusal. Behavior Modification, 18(1), 106128.
Irwin, M. C., Clawson, E. P., Monasterio, E., Williams, T., & Meade, M. (2003). Outcomes of a day feeding program for children with cerebral palsy. Archives of Physical
Medicine and Rehabilitation, 84, A2.
Kerwin, M. E. (1999). Empirically supported treatments in pediatric psychology: severe feeding problems. Journal of Pediatric Psychology, 24(3), 193214; discussion 215196.
Kerwin, M. E., Ahearn, W. H., Eicher, P. S., & Burd, D. M. (1995). The costs of eating: A
behavioral economic analysis of food refusal. Journal of Applied Behavior Analysis,
28(3), 245260.
444
Index
A
AAC. See Augmentative and alternative
communication
ABA. See Applied behavior analysis
Abbott, C., 395
ABC. See Antecedent-behavior-consequence
ABC model, of human emotions, 14
ABFT. See Attachment-based family therapy
Abolishing operation (AO), 44
Ackerman, S. J., 68
Ackerson, J., 234
Acquisto, J., 39
Active-engaged and disengaged, behavior
of children, 388
Adaptation in intervention, principles for,
390, 391
Adderall XR, 146, 148
ADHD comorbid disorders, 140
ADOS. See Autism diagnostic observation
schedule
Adrenocorticotrophin (ACTH), 344
ADVANCE parent training program, 91
Agras, W. S., 422
AIT. See Auditory integration training
Alant, E., 383, 385
Alicke, M. D., 65
Alisank, S., 301
Alternative language group, of children
with disabilities, 386
Altman, K., 40
Aman, M. G., 276, 336, 343
Amanullah, S., 301
American psychological association task
force, 83
AN. See Anorexia nervosa
Anastopoulos, A. D., 155
Andelman, M. S., 40
Anderson, G. M., 339
Anderson, S., 305
AN, inpatient psychiatric care for, 416417
Anorexia nervosa, 403405
Antecedent-based intervention, 47
Antecedent-behavior-consequence, 308
Antidepressants, 1718
Antipsychotic medication, 19
Antipsychotics, 1819
Anxiolytics, 19
Anzai, N., 416, 417
Applied behavior analysis, 7, 29, 95, 293
antecedent approaches to treatment, 43
definition, 3031
treatment approaches, 3132
consequence-based intervention
strategies, 3443
consequence-based procedures, 3234
Ardoin, S. P., 161
Argumentativeness, 107
Arnold, L. E., 342
Arvidson, H. H., 381
AS. See Asperger syndrome
Asarnow, J. R., 227, 238
Asmus, J. M., 50
Aspergers disorder, 288
Asperger syndrome, 300. See also Autism
spectrum disorders, in children
behavioral difficulties, 302303
emotional behaviour and, 304306
language and cognitive development,
303304
social deficits in, 301302
Atkeson. B. M., 83
Atomoxetine, 149, 150
Attachment-based family therapy, 237
Attention-deficit/hyperactivity disorder
(ADHD), 109, 113, 139
The American Academy of Pediatrics (AAP)
guidelines, 140
behavioral classroom management,
162164
contingency contracting, 164
daily report cards, 165167
response cost, 165
time out, 165
token economy, 164
classroom behavior management, 159160
literature, 160161
445
446
Attention-deficit/hyperactivity disorder
(ADHD) (cont.)
co-morbid disorders, and treatment, 151
and anxiety, 152153
with autism spectrum disorder (ASD),
153154
with mood disorders, 152
(DSMIV) criteria, 140
medication for, 143144
immediate release stimulant
medications, 144
stimulant medications, adverse effects
of, 147148
sustained release stimulant
medications, 145
NIMH multimodal treatment study
of, 141143
psychosocial interventions, 154
behavioral parent training, 154155
components of parent training, 155158
factors influencing treatment
effectiveness, 158159
self-management systems, 167168
summer treatment programs, 168173
titration of therapy and managing adverse
effects, 148151
treatment of, 140
Attwood, T., 305
Auditory integration training, 298
Augmentative and alternative
communication, 373
in children, 381386
intervention, in children, 386388
Autism diagnostic observation schedule, 300
Autism spectrum disorders (ASD), 4, 95
Autism spectrum disorders, in children
behavioral treatment of
discrete trial training, 289
naturalistic teaching methods, 290291
outcomes of, 291
rate-building procedures, 291292
characteristics of, 287288
developmental individual difference in,
299300
early diagnosis of, 318319
function-based behavioral intervention,
310312
future research for, 312313
nonbehavioral approaches
biomedical intervention of, 293295
medications for, 295297
psychoeducational/psychosocial
treatments for, 299
relationship development intervention, 300
sensory-motor treatments, 297299
and theory of mind, 313
biological mechanisms of, 313314
cognitive processes of, 314315
INDEX
sibling research and joint attention
processes, 316318
and social qualitities, 315316
treatment and functional assessment of
descriptive and functional analysis
of, 308310
functional assessment, 306307
indirect assessment, 307308
Ayllon, T., 40
Azrin, N. H., 9
B
Baby Sibling Research Consortium, 319
Baer, D. M., 30
Bandura, A., 201
Barkley, R. A., 155, 160
Barkley, R., 113
Barlow, D., 187
Barmish, A. J., 92, 93
Barnhill, G. P., 304, 305
Baron, P., 235
Barrett, B. H., 8
Barretto, A., 40
Barrett, P. M., 70, 242
Barry, C. T., 125
BASIC parenting training program, 91
Bauman, K. E., 347
Baumeister, A. A., 10
BD. See Bipolar disorder
Beauchaine, T. P., 128
Beauchamp, K., 46
Beck, A. T., 57, 187
Beck depression inventory, 72
BED. See Binge eating disorder
Bedell, J. R., 63
Behavioral and learning-based therapies,
development of, 7
Behavioral parent training (BPT), 80, 83
Behavioral problems, 108
Behavioral psychology, 6
Behavioral systems family therapy, 422423
Behaviorism, doctrine of, 7
Behavior management strategies, 80
Behavior problems inventory, 361
Behavioural intervention, for SIB, 347348,
356357
Benjamin, S., 345
Benzodiazepines, 19
Berkson, G., 358359
Berman, J. S., 65
Bernal, G., 237
Best Pharmaceutical Act, 256
Bidwell, R. J., 416
Binet, A., 4
BinetSimon scale, 4
Binford, R. B., 408
Binge eating disorder, 403, 407, 425
Bioinformational theory, 189
INDEX
Bipolar disorder, 253
Birnbrauer, J. S., 8
Bjornstrom, C., 409
Bjou, S. W., 8
Blanchford-Rogers, W. J., 19
BN. See Bulimia nervosa
Body mass index (BMI), 147, 404, 416, 419,
422, 424
Bohn, K., 408
Bonfiglio, C. M., 48
Bordin, E. S., 67
BPI. See Behavior problems inventory
Brent, D. A., 237
Brookman-Frazee, L., 95
Bryan, T., 298
Bryson, S., 422
BSFT. See Behavioral systems family
therapy
Bulimia nervosa, 403, 405406
Bullying, 108
Bupropion, 151
Butler, L., 242
Buzan, R. D., 261
Buzas, H. P., 40
C
Campbell, M., 19
Carolyn Webster-Strattons Incredible
Years, 112
Carr, E. G., 10, 347
Carr, J. E., 297
Carton, E. R., 243
Case-Smith, J., 298
Casey, R. J., 65
Casey, S. D., 44
CAT. See Cognitive analytic treatment
Cataldo, M. F., 37
Catecholamine, 143
Cathcart, K., 20
Cedar, B., 85
Central nervous system (CNS), 143
CFT. See Conjoint family therapy
Chaffin, M., 86
Chelation process, for autism, 297
Child characteristics, for behavioral
therapy, 6971
Childhood anxiety disorders
assessment
evidence-based assessment, 192194
functional assessment, 194195
cognitive-behavioral therapy (CBT)
catastrophic thoughts, 203
dysfunctional behavior and distress,
202
development of, 211214
empirically supported treatments
CBT, analysis of, 211
diagnostic depictions, 210
447
emotional response, effects of, 207
examination of, 205206
obsessive-compulsive disorder
(OCD), 209
physiological and cognitive components,
208
posttraumatic stress disorder (PTSD),
210
psychopathology, 204
social phobia (SoP), 208209
specific phobia (SP), 206
evidence-based treatment
modular therapy, 197
psychotherapy, 195
randomized clinical trials, 196
participant modeling (PM)
social models, 201202
reinforced practice (RP)
contingency management, 200
phobias, 201
systematic desensitization (SD)
conditioning theory, 199
traumatic exposure, 200
treatment of, 183
change mechanisms, 199
exposure, 197198
implementation, 198199
Childhood disintegrative disorder, 288
Child mental health movement, 5
Child psychopathology, 4, 5
Children, autism spectrum disorders
in, 288. See also Children with
developmental disabilities; Eating
disorders, in children; Pediatric
feeding disorders, treatment of; Selfinjurious behaviour (SIB), in children
behavioral treatment of
discrete trial training for, 289
naturalistic teaching methods, 290291
outcomes of, 291
rate-building procedures, 291292
characteristics of, 287288
developmental individual difference in,
299300
early diagnosis of, 318319
function-based behavioral intervention,
310312
future research for, 312313
nonbehavioral approaches
biomedical intervention of, 293295
medications for, 295297
psychoeducational/psychosocial
treatments for, 299
relationship development intervention,
300
sensory-motor treatments, 297299
and theory of mind, 313
biological mechanisms of, 313314
448
Children (cont.)
cognitive processes of, 314315
sibling research and joint attention
processes, 316318
and social qualitities, 315316
treatment and functional assessment of
descriptive and functional analysis
of, 308310
functional assessment, 306307
indirect assessment, 307308
Childrens aggressive outbursts, 115
Childrens anxious behavior
removing reinforcement of, 93
Childrens behavior problems
aggression and disruptive behavior, 80
psychosocial treatment for, 79
Childrens depression inventory, 72
Childrens depression rating scale-revised
(CDRS-R), 255
Children with developmental disabilities
AAC intervention in, 386388
AN in, 403405
augmentative and alternative
communication in, 381386
awareness of literacy exposure at home,
393395
BED in, 403, 407
BN in, 403, 405406
communication and information
processing in, 376378
communication and learning in, 374376
EDNOS in, 403, 407408
EDs in, 403404
emergent literacy in, 392393
empirical evidence and interventions
inpatient treatment, 416419
outpatient treatment, 420426
partial hospitalization, 419420
engagement and interaction patterns
in, 388391
epidemiology of, 408416
graphic symbols role in, 395396
literacy, communication and learning,
sociocultural aspects of, 378381
Childs disruptive behaviors., 115
Childs treatment team, factors
for consideration, 163
Child treatment models, 56
Child vs. adult therapy, 68
Chill out program, 118119
Choice-making opportunities, 47
Chorpita, B. F., 66
Choudhury, M. S., 68
Christianson, G. W., 294
Chronic behavior disorders, 270
Chronis, A. M., 155
Chu, B. C., 187
Church, C., 301303
INDEX
Clark, D. A., 187
Clarke, G., 235
Clarke, G. N., 234
Clarke, J. C., 12, 213
Clonidine, 150
CLPS. See Collaborative longitudinal
personality disorders study
Coats, K. I., 235
Cobham, V. E., 70
Cognitive analytic treatment, 426
Cognitive and behavioral strategies, for
behavior problems, 116
Cognitive behavioral approaches
general characteristics of, 56
Cognitive behavioral interventions, 72, 235
Cognitive-behavioral models
for treatment of youth, 70
Cognitive-behavioral self-control therapy, 83
Cognitive-behavioral treatments (CBTs), 14,
52, 56, 152, 305, 423425
numerous assessment techniques for
behavioral observations, 5960
cultural considerations, 61
functional assessment, 5859
interviews, 5960
outcome assessments, 6061
self-report measures, 60
therapeutic techniques for
affective education, 6162
behavioral rehearsal, 63
cognitive restructuring, 62
contingency management, 6263
problem-solving, 6364
self-monitoring, self-evaluation,
self-reinforcement, 6465
Cognitive distortions, 118
Cohen, P., 415
Coleman, P.P., 392
Collaborative longitudinal personality
disorders study, 416
Collins, R., 40
Combined therapies
ADHD, 20
ASD, 2021
Combining antecedent and consequencebased treatments, 4748
generalization, 4849
Community Mental Health Centers Act, 5
Comorbidity psychological conditions and
EDs, 413414
Compliance training skills, 8990
Conduct disorder (CD), 19, 107
array of acts in person, 107
designs of treatments for, 108
diagnosis of, 108
evidence-based practice, 127131
Individual-based treatments
common elements, 116117
INDEX
empirically supported treatments,
117119
multisystemic therapy (MST), 120
empirically supported treatments,
121123
key assumptions, 121
oppositional behaviors occurrence in, 108
parent-based treatments
common elements, 110112
empirically supported treatments,
112116
parent training, 109
psychosocial treatment vs.
pharmacological treatments, 108
residential treatment, 123127
Conduct problems, 107
Conjoint family therapy, 421422
Context-dependent and independent, in
communication, 380
Contextual emotion regulation therapy
(CERT), 243
Contingent reinforcement, 58
Contrucci Kuhn, S. A., 43
Conyers, C., 33
Cooper, J. O., 30, 31, 34, 36, 46, 48
Coping power program, 117118
Coping with depression (CWD), 236
Cornwall, E., 13, 207
Corsaut, S., 48
Cowdery, G. E., 37
Crijnen, A. A. M., 160
Croll, J., 409
Csikszentmihalyi, M., 389
Cuffe, S. P., 226
Cunningham, M. A., 23
CU traits moderating relation, 131
D
Dadds, M. R., 70
Daly, E. J., 48
Data from adults (ADA), 279
Dauber, S., 122
Davies, M., 415, 417
Davies, S., 417
Davis, A., 199
Davis III, T. E., 208
Day treatment programs. See Partial
hospitalization programs, for EDs
Deitz, S. M., 41
DeMyer, M. K., 8, 289
Denver Model, treatment for ADHD, 154
Depressive disorders, 70
Derby, K. M., 39
Desipramine, 150
Desmopressin, 19
Detheridge, C., 395
Detheridge, T., 395
Developmental disabilities (DD), 253, 373
449
Developmental group, of children with
disabilities, 386
Developmental individual difference,
299300
Developmentally disabled adolescents
bipolar disorder
carbamazepine, use of, 275
valproate, use of, 272273
Developmentally disabled children, 1
bipolar disorder
valproate, use of, 272273
lithium, use of
case reports, 266269
Developmentally disabled youth
bipolar disorder, treatment of
anticonvulsant treatment, 270
antipsychotic drug, 270
antipsychotic medications, 275
appetite and weight gain, 276
carbamazepine, monotherapy and
combined treatment, 274
electroconvulsive treatment, 277
exhibits inappropriate repetitive
vocalizations, 263
lithium, 264265
pervasive developmental disorder, 264
valproate monotherapy, 270
Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV ), 183, 287,
288, 403
Diament, D. M., 84
Dibley, S., 47
Differential attention skills, 89
Differential positive reinforcement
procedure, 437
Differential reinforcement of alternate
behavior (DRA), 9, 39, 354
Differential reinforcement of diminishing
rates (DRD), 41
Differential reinforcement of incompatible
behaviors (DRI), 40
Differential reinforcement of low rates of
behavior (DRL), 41
Differential reinforcement of other behavior
(DRO), 9, 42
Differential reinforcement programs, 38
DIR. See Developmental individual
difference
Direct instruction approach, in autism
learning, 292293
Discrete trial training, 289
Disruptive behaviors, 107
Dodo bird verdict, 65, 66
Donenberg, G. R., 67
Dopamine, 143
Dopamine, in SIB treatment, 335336
Dorsey, M. F., 347
Dostal, T., 270
450
Down syndrome, 18
Drugs pharmacologic properties, 255
DSM-IV-TR diagnostic criteria
for AN, 404
for BED, 407
for BN, 406
for eating disorder, 408
DTT. See Discrete trial training
Dumas, J. E., 83, 87
Dunlap, G., 47, 168
Dunst, C. J., 379
DuPaul, G. A., 161163
Durand, V. M., 10
Durlak, J. A., 69
Dykens, E. M., 16
E
Eating disorder not otherwise specified,
403, 407408
Eating disorders, in children, 403
comorbidity psychological conditions,
413414
costs of, 414415
ethnicity and culture, 411412
gender differences role in, 410411
inpatient treatment for children and
adolescents, 416419
outpatient treatment for children and
adolescents with, 420426
partial hospitalization programs for,
419420
social class and, 412413
EBA. See Evidence-based assessment
EDNOS. See Eating disorder not otherwise
specified
EDs. See Eating disorders
EFA. See Experimental functional analysis
Ego oriented individual treatment, 422, 425
Eikeseth, S., 49
Eisenstadt, T. H., 86
Electroconvulsive therapy, 258
Electroconvulsive treatment (ECT), 18, 263
Ellis, J., 37
Emergent literacy, in children, 392393
Emotional processing theory (EPT), 187
Empirically supported treatment (EST), 195
Emslie, G. J., 18
Engagement and interaction patterns,
in children, 388391
Enuresis, 19
EOIT. See Ego oriented individual treatment
Erickson, K. A., 393
ERP. See Event-related potentials
Escape extinction procedures,
in children, 436
Esch, B. E., 297
Establishing operation (EO), 44
Ethnicity, culture, and EDs, 411412
INDEX
Event-related potentials, 313
Evidence-based assessment, 192194
Evidence-based practices (EBPs), 183, 195
Exhibits inappropriate repetitive
vocalizations, 263
Experimental functional analysis, 347
Expressive language group, of children with
disabilities, 385386
Extinction, in behavior intervention plans,
311312
Extinction procedure, 3738
Eyberg, S., 86, 114
Eyberg, S. M., 86
Eye movement desensitization and
reprocessing (EMDR), 207
Eyesnick, H., 11
F
Fabiano, G. A., 154, 172
Fabrizio, M. A., 292
Facilitated communication, 298299
Fairburn, C. G., 408, 416, 424, 427
Falcomata, T. S., 34
Family-based therapy, 420422
Family-focused treatment (FFT), 243
FAST (Families and Schools Together) Track
Program, 122
FBA. See Functional behavioral assessment
FBT. See Family-based therapy
FC. See Facilitated communication
FCT. See Functional communication
training
Fear-inducing stimulus, 13
Feindler, E. L., 118
Ferster, C. B., 8, 289
Field, C. E., 37
Finch, Jr., A. J., 108
Fine, S., 236
Fink, M., 277
Fischer, K., 46
Fisher, M., 413
Fisher, W. W., 36, 39, 436, 442
Fixed-ratio (FR) 1 schedule, 43
Fixed-time (FT) reinforcement schedule, 44
Flory, V., 243
Fluoxetine, 17
Focalin (d-MPH), 146
Food and Drug Administration (FDA), 256
Forehand, R., 83
Forehand, R. L., 88
Forth, A., 236
Fraser, J., 69, 236
Freeman, B. J., 13
Friedman, D. L., 277
Friends for life program, 9394
Friman, P. C., 37, 40
Fueyo, V., 46
Fuhrman, T., 69
INDEX
Fuller, D. R., 381, 384
Functional behavioral assessment, 306310
Functional communication training, 9,
39, 351
in behavior intervention plans, 310311
Funderburk, B., 86
G
Galiatsatos, G. T., 35
Gamliel, I., 316
Ganz, J. B., 386
Geist, R., 411, 422
Gender differences, role in EDs, 410411
GFCF diet. See Gluten-free casein-free diet
Gibson, L., 35
Gilbert, M., 236
Gillham, J. E., 242
Gioia, B., 393
Gleaves, D. H., 408
Gluten-free casein-free diet, 294295
Goddard, H. H., 4
Gnc, A., 395
Gonzalez, N. M., 19
Goodman, J., 15
Gtestam, K. G., 409
Gowers, S., 236
Gowers, S. G., 423
Graff, R. B., 35
Granger, D. A., 66
Graphic communication symbols,
for disabilities, 378, 395396
Graziano, A. M., 84
Greenspan, S. I., 300
Grilo, C. M., 416
Griswold, D. E., 304
Group discussion with parents, videos
role, 112
Group-home care, 123
Grove, N., 378
Grow, L., 34
Guanfacine, 150151
Guided participation, in children with
developmental disabilities, 395
Guze, B.H., 277
H
Hagiwara, T., 304
Hagopian, L. P., 39, 43
Haley, G., 236
Hall, E. T., 380
Handwerk, M. L., 37
Hanf, C., 91
Hanley, G. P, 309
Han, S. S., 66
Harman, D., 380
Harrington, R., 69, 236
Hart, K. J., 108
Hays, P. A., 71
451
Healy, W., 5
Heath, S. B., 379
Hellings, J. A., 261, 270, 276
Helping the noncompliant child (HNC), 8891
Henderson, H., 37
Hepburn, S., 16
Heron, T. E., 30
Heward, W. L., 30
Hillery, J., 342
Hilsenroth, M. J., 68
Hinton, S., 305
Hispanic adolescents, 111
Hobbs, N., 126
Hoek, H. W., 408, 410
Hoff, K. E., 161
Hogansen, J. M., 415
Hogue, A., 122
Hollander, E., 270, 296
Hollingshead four factor social index, 413
Holmbeck, G. N., 70
Holz, W. C., 9
Homework assignments, 112
Houlihan, D., 49
Hovanetz, A. N., 34
Hovarth, K., 296
Human emotions, ABC model of, 14
Hunter, C. S. J., 380
Hurley, A., 270
Hwang, W. C., 187
I
IDEA. See Individuals with Disabilities
Education Act
IEP. See Individual educational plan
Imipramine, 19
Incidental teaching, 290
Individual educational plan, 306
Individuals with Disabilities Education
Act, 306
Initial MTA findings, criticism of, 142
Inpatient hospitalization, 123
Inpatient treatment, for children and
adolescents, 416419
Institutionalization, 123
Intellectual ability (IQ), 184
Intellectual disability (ID), 3, 4
Interactive behavior, in children, 387388
Interpersonal psychotherapy (IPT), 236
Interpersonal therapy, 424, 426
Interresponse time (IRT), 41
Irritability, 264
Ivany, K., 294
Iwata, B. A., 38, 50, 347
Iwata, N., 226
J
Jaffa, T., 417
Jaycox, L. H., 242
452
Jayson, D., 69, 236
Johnson, K., 292
Johnson, W. L., 10
Joint attention training and ToM, 316318
Jones, M. C., 6
Joseph, J, 415
Jureidini, J. N., 17
Juvenile bipolar disorder, 254
K
Kabot, S., 20
Kahng, S. W., 33
Kalman, S. L., 392
Kalsher, M. J., 37
Kane, M. T., 15
Karver, M., 68
Kaslow, N. J., 243
Kastner, T., 270
Kates, K., 44
Katz, R. C., 46
Kazdin, A. E., 107, 128
Keeney, K. M., 34
Kelford-Smith, A., 393
Kelley, J., 199
Kelley, M. E., 36
Kendall, P., 202
Kendall, P. C., 15, 68, 92, 93
Kennedy, N., 342
Kerfoot, M., 235
Ketogenic diet, 295
Kettering, T. L., 34
Kidder, J. D., 8
King, N. J., 66
Kjelss, E., 409
Klotz, M. L., 65
Knivsberg, A. M., 294
Knoff, H. M., 45
Kodak, T., 34
Kohlenberg, R., 14
Kolko, D. J., 171
Komoto, J., 274
Koorland, M. A., 46
Koppenhaver, D. A., 392
Kotler, L. A., 415
Kovacs, M., 243
Kowatch, R. A., 258
Kraemer, H. C., 422
Kroll, L., 69, 236
L
Lalli, J. S., 43, 44
Lampman, C., 69
Lancioni, G. E., 386
Lang, A. J., 188
Lang, P. J., 11, 190
Layng, T. V. J., 292
Lazovik, A. D., 11
Learning and communication, in children,
378381
INDEX
LeBlanc, L. A., 39
Le Grange, D., 408
Lenhart, L., 393
Lennox, S. S., 63
Lerman, D. C., 38
Lesch-Nyhan disease, in children, 335
LeschNyhan Syndrome, 40, 49
Levant, R. F., 85
Levin, L., 46
Lewinsohn, P. W., 410
Lewis, S., 13
Liddle, H., 122
Light, J. C., 393
Lim, L., 47
Linderman, T. M., 298
Lindsay, P., 378
Lindsey-Dudley, K., 416
Lindsley, O. R., 8
Linscheid, T. R., 32
Lisdexamfetamine dimesylate, 146
Literacy exposure awareness, of children,
393395
Literacy learning, in children, 379381
Living with Children program, 112
Lloyd, D. A., 226
Lloyd, L. L., 381, 384
Lock, J., 422
Long, E. S., 43
Long, T. S., 33
Lovaas, O. I., 21, 291
Lovaass treatment program for autism,
9596
Lovejoy, M. C., 82, 85, 86, 87
Luiselli, J. K., 14, 35
Lundahl, B., 82, 86, 87
Lundahl, B. W., 84, 85
Lyman, R. D., 125
M
Mace, F. C., 357
Madrid, A., 336
Magee, S. K., 37
Mangus, B., 37
Marcotte, D., 235
Marcus, B. A., 48
Martens, B. K., 48, 161
Martinsen, H., 385
Masi, W., 20
Matson, J. L., 49
Mauk, J. E., 357
McDonough, M., 342
McLeod, B. D., 187
McMahon, R. J., 88
McNaughton, S., 378
McNeil, C. B., 86
McWilliam, R. A., 386, 388, 389
Measelle, J. R., 415
Medication discontinuation, 259
Medication side-effects, bipolar, 278279
INDEX
Meichenbaum, D., 15
Melvin, G. A., 227
Menzies, R. G., 12, 213
Mesibov, G. B., 299
Metabolic syndrome, 279
Methylphenidate, 146
Miltenberger, R. G., 33
Mineka, S., 187
Mirenda, P., 393
Mistry, J., 395
Modafinil, 147
Modernization Act, 16
Mood stabilizers, 18
Moors, A. L., 292
Morris, J., 305
Morton, T., 66
Mosier, C., 395
Motivating operation (MO), 44
MPH transdermal system (MTS)
patch, 146
MTA behavioral treatment strategy, 141
MTA combined treatment strategy, 141
Mufson, L., 236
Multisystemic therapy (MST), 120
Muris, P., 207
Murphy, G., 359
Muthen, B. O., 160
Myles, B. S., 301, 304
N
Naltrexone hydrochloride, in SIB treatment,
344345
Nash, H. M., 37
National Institute for Clinical Excellence, 424
National Institute of Mental Health
(NIMH), 141
Natural environment training, 290
Naturalistic teaching methods, 290291
Natural language paradigm, 290
Nelson, III. W., 108
Nesset, R., 49
NET. See Natural environment training
Neumark-Sztainer, D., 409
Neurodevelopmental disorder, 94
Newcomb, K., 86
NICE. See National Institute for Clinical
Excellence
Nimer, J., 84, 85
NLP. See Natural language paradigm
Noncompliant behavior, 107
Noncontingent reinforcement, in behavior
intervention plans, 310
Non-Dodo verdict, 66
Non-Freudian hypothesis, 11
Nonlaboratory-based treatment clinics, 66
Nonstimulant medications, for ADHD,
149151
Nonverbal communication, for child, 10
Norepinephrine, 143
453
Normally developing adolescents, clinical
management, 254256
Normally developing children
clinical management of
BD, treatment of, 254
evidence base, evaluation, 255256
mania rating scale (MRS), 255
neurological conditions, 255
Normally developing youth
bipolar disorder, treatment for
drugs, evidence for, 257258
lifetime medication, 259260
mania/hypomania, acute treatment
of, 256258
manic depression, 258259
treatment of
atypical antipsychotic, 261263
electroconvulsive therapy, 263
gabapentin (GP), 260261
lithium, 260
rapid cycling bipolar disorder (RCBD),
262263
valproate and carbamazepine, 260
Northup, J., 34
O
Oberdorff, A. J., 36
Obler, M., 13
Olanzapine, in SIB treatment, 342, 343
Ollendick, T.H., 66, 184, 192, 193, 208
Olson, L., 49
Omega-3 fatty acids, 151
Oppositional defiant disorder (ODD), 19, 86,
107, 154
OReilly, M., 386
Osmotic release oral system (OROS), 146
st, L. G., 199
Outpatient treatment, for children and
adolescents, 420426
Overanxious Disorder, 15
Ozonoff, S., 20
P
Pace, G. M., 37
Pande, A. C., 261
Panksepp, J. A., 294
Parentchild interactions, 59, 112, 115, 117
coercive, 80
complexities of, 80
maladaptive, 81
Parent child interaction therapy (PCIT), 84,
91, 114
Parent effectiveness training program (PET), 85
Parent programs
that target developmental disorders, 9495
that target externalizing behavior
problems, 8890
that target internalizing behavior
problems, 9293
454
Parents awareness of literacy, in children
with developmental disabilities, 394
Parent training
empirical evidence of, 8788
empirical support for, 8182
generalization effects, 8586
immediate effects of, 8285
intervention model
development of, 80
empirical support for, 8182
moderator effects, 8687
overview of selected programs for, 88
subgroup of, 83
Parsons, B., 84, 85
Partial hospitalization programs, for EDs,
419420
Participation, in children, 387
Partington, J. W., 290
Pary, R. J., 18
Passive-engaged and disengaged, behavior
of children, 388
Patterson, G., 80
Patterson, G. R., 110
Pattersons model, 80
Pavlovian conditioning, 6
Pavuluri, M. N., 256
PCS. See Picture communication symbols
PDD-NOS. See Pervasive developmental
disordernot otherwise specified
PDDs. See Pervasive developmental
disorders
Pediatric feeding disorders, treatment
of, 435442
Peebles, R., 411
Pelham, W. E., 154, 170, 173
Pervasive developmental disordernot
otherwise specified, 288
Pervasive developmental disorder
(PDD), 264
bipolar disorder
in children, 264
VPA, Use of, 274
Pervasive developmental disorders, 288
PFC. See Prefrontal cortex
Phobic symptoms, 13
Phonological disorder, children with, 49
Piazza, C. C., 36, 436, 437, 439, 442
Picture communication symbols, 382, 383
Picture exchange communication
system, 290
Pillai, V., 19
Pine, D. S., 415
Pivotal response training (PRT), 9697, 290
Planned activities training (PAT), 95
Play activities, for children with
developmental disabilities, 389
Polycystic ovary syndrome (PCOS), 278
Polydipsia, 270
POMC. See Pro-opiomelanocortin
INDEX
Preadolescents depression
randomized clinical interventions trials
for, 239241
Prefrontal cortex, 313
Problem-Solving Skills Training (PSST), 119
Pro-opiomelanocortin, 344
PRT. See Pivotal response training
Pryor, T., 413
Psychiatric adverse events
in children and adolescents
activation/disinhibition/manic
symptoms, 277
suicidal behavior, 277, 278
Psychiatric disorder, 21
Psychiatric medication, 258
Psychodynamic therapy, for adolescents
with AN, 425426
Psychoeducation, 112
Psychological disorders
adults and children with, 57
Psychosocial interventions, for children, 81
Psychostimulants, 1617
Psychotherapy by Reciprocal Inhibition, 11
Psychotherapy, forms of, 65
Psychotropic medication, prescription of, 16
Punishment
negative, 3334
positive, 3233
R
Rachman, S., 189
Racusin, G. R., 243
Randomized clinical trials (RCTs), 66
bioinformational theory
developmental psychopathology, 191
emotional networks, treatment, 190
etiology, 185186
family, 186187
normative and diagnostic considerations,
184185
psychological theory, 187190
treatment, effects of, 184
Rapp, J. T., 33, 50
Raspa, M. J., 386
Rastam, M., 410
Rate-building procedures, in autism
treatment, 291292
Ray, K. P., 45
Rayner, R., 6
RDI. See Relationship development
intervention
Reaven, J., 16
Reed, G. K., 40, 437
Reed, M. K., 236
Reid, J., 120
Reinblatt, S. P., 263
Reinforcement procedures
negative, 3536
positive, 35
INDEX
Reinforcement procedures, in behavior
intervention plans, 311
Relationship development
intervention, 300
Repp, A. C., 41
Residential treatment centers, 123, 125
Retts disorder, 288
Rett syndrome, 442
Revised childrens manifest anxiety scale
(RCMAS), 192
Reynolds, W. M., 235
Richman, G. S., 347
Ridley, S. M., 386
Ringdahl, J. E., 40, 42, 47
Risley, T. R., 30
Risperidone, in autism treatment,
295296
Risperidonem, in child behavioural disorder,
336342
Risser, H. J., 82, 86, 87
Ritalin LA, 145
Ritter, B., 201
Rivera, M. O., 46
Roane, H. S., 34
Robergeau, J., 415
Robinson, E. A., 86
Rogers, S., 294
Rogoff, B., 395
Role-plays, 112
Rolider, A., 36
Romski, M., 374
Rosenthal, T., 199
Roskos, K., 393
Rossell, J., 237
Rowland, C., 375
Ruch, K. S., 43
Rudolph, K., 225
S
Sabbagh, M. A., 313
Samuolis, J., 122
Sandler, A. D., 297
Sandman, C. A., 345
Santisteban, D., 111
Savin, S. M., 408
Scahill, L., 336, 339341
Schizophrenia, symptoms of, 1819
Schlosser, R. W., 386
Schopler, E., 97, 299
Schotte, D., 13
Schwartz, J. A. J, 243
Schweigert, P., 375
Secretin therapy, for autism, 296297
Seeley, J. R., 410
Segal, M., 20
Selective serotonin reuptake inhibitors, 17,
152, 221, 296, 343
Self-injurious behavior (SIB), 9, 50
treatment of, 32
455
Self-injurious behaviour (SIB), in children
aetiology, developement and
phenomenology, 358363
behavioural interventions for, 347348,
356357
characteristics of, 333334
diagnostic subtyping of, 357358
psychopharmacological treatment for
clozapine and olanzapine in, 342343
considerations for, 345347
dopamine and serotonin in, 335336
risperidone, 336342
serotonin reuptake inhibitors in,
343345
screening and treating, 334
socially mediated positive reinforcement for
antecedent motivating operations,
348350, 353354
automatic reinforcement, 353
competing prosocial responses,
351352, 354
mechanical restraints, reduction of, 355
reinforcement elimination, 352353, 355
self-restraint treatment, 355356
Self-restraint (SR), treatment for, 355356
Seligman, M. E. P., 388
Sensory integration therapy, for autism,
297298
Separated family therapy, 421422
Serketich, W. J., 83, 87
Serotonin, in SIB treatment, 335336
Sevcik, R. A., 374
SFT. See Separated family therapy
Shabani, D. B., 46
Shaked, M., 316
Shapiro, D., 65
Shapiro, D. A., 65
Shea, S., 339
Shirk, S. R., 68
Short term respite care, 123
Sigafoos, J., 386
Sigman, M., 187
Silber, T. J., 415
Silverman, W., 184, 192, 193
Simon, T., 4
Simpson, R. L., 301, 304
Skinner, B. F., 7, 8
Skinner, C. H., 45
Skinners classification system, 290
Slifer, K. J., 347
Smith, M. L., 65
Smith, T., 293
Social class and EDs, 412413
Sofronoff, K., 305
Sovner, R., 270
Specific problem behavior, treatment of, 50
Specific treatment strategies, effectiveness
of, 50
Spence, S. H., 13, 70
456
SSRIs. See Selective serotonin reuptake
inhibitors
Stanford-Binet intelligence test, 4
Stark, K. D., 15, 242
Stepping Stones Triple P (SSTP), 98
Stereotyped behaviours and SIB, 361
Sterling, H. E., 42
Stewart, K. B., 298
Stice, E., 415
Stimulant agents
AAP guidelines recommend that, 144
adverse effects of, 147148
FDA approval for, 144
immediate release stimulant, 144
new advanced system delivery stimulants,
145147
sustained release stimulant, 145
Stimulant agents, AAP guidelines
recommend that, 144
Stimulus control approaches, 4446
Stobbart, C. L., 394
Stoner, G., 162, 163
Story, M., 409
Strattera, 149
Strattera, 150
Stremel, K., 375
Striegel-Moore, R. H., 410
Sturmey, P., 297
Substance use, behavior problem, 121
Sullivan, M. T., 39
Sulzby, E., 392
Sundberg, M. L., 290
Suveg, C., 202
Symbolic behaviors, in children, 375
Symbols, in children with developmental
disabilities, 378379
Symons, F. J., 344
Synder, R., 336
Systematic desensitization, variants of, 12
T
Tague, C., 8
Taylor, B. A., 44, 46
Taylor, C. R., 46
TEACCH program, 97
TEACCH strategy, for autism, 299
Teale, W., 392
Temper outbursts, 108
Temper tantrums, 107, 108
Terman, L. H., 4
Terwilliger, R. F., 13
Tharp, R. G., 80
The incredible years (TIY), 9192
Theory of mind
biological mechanisms of, 313314
cognitive processes of, 314315
sibling research and joint attention
processes, 316318
and social qualities, 315316
INDEX
Therapeutic relationship, 6768
Therapist characteristics, 6869
Thinning differential reinforcement
schedules, 4243
Thuppal, M., 277
Titchenor, E. B., 6
ToM. See Theory of mind
TOuCAN. See Trial of outcome for child &
adolescent anorexia nervosa
Traditional parent management strategies,
116
Treatment and education of autistic and
related communication handicapped
children (TEACCH), 20
Treatment methods, 56
behavior therapy, 11
classical conditioning, 67
cognitive behavior therapy, 1416
operant conditioning/applied behavior
analysis, 711
systematic desensitization, 1114
Trial of outcome for child & adolescent
anorexia nervosa, 423
Triple P (Positive Parenting Program), 92
Turgay, A., 276
Turner, R. J., 226
U
UCLA Young Autism Project, 154
Ultee, C. A., 12
V
Valproate (VPA), trials of, MR/autism, 271
Van der Sar, R. M., 160
van Hoeken, D., 408, 410
Van Houten, R., 36
Van Lier, P. C. A., 160
VEN. See Von Economo neurons
Vitamin therapy, in autism treatment, 295
Vollmer, T. R., 34, 48, 50
Von Economo neurons, 313
Von Tetzchner, S., 378, 385
Vyvance, 146
W
Wachs, T. D., 379
Wacker, D. P., 40
Wallace, M. D., 38
Walsh, B. T., 415
Water phobia, 12
Watling, R. L., 298
Watson, J. B., 6
Watson, T. S., 42, 45
Weak central coherence (WCC), 314
Webster-Stratton, C., 120
Wechsler Individual Achievement Test, 304
Weiss, B., 65, 66
Weisz, J. R., 6567, 223, 242
Werry, J. S., 19
INDEX
Wetzel, R. J., 80
Whitley, M. K., 128
Whittington, C. J., 17
Wick, J., 293
Wiederman, M. W., 413
Wieder, S., 300
Wilder, D. A., 46
Williamson, D. A., 408
Williams syndrome, 12, 16
Wilson, D. R., 125
Witmer, L., 3, 5
Wolf, M. M., 30
Wolpe, J., 10, 11, 199, 200
Wood, A., 69
Wood, J. J., 187
Wundt, W., 6
Y
Yirmiya, N., 316
Yoder, D. E., 392
Young mania rating scale (Y-MRS), 255
Youth depression treatments
antidepressants, 221
clinical trials, 221
critical issues in
manifestation of, 225
457
mental health service utilization, 226
meta-analysis, 223
parental psychopathology, 224
symptoms, 222
efficacy of
cognitive behavioral interventions,
234, 235
contextual emotion regulation therapy
(CERT), 243
coping with depression (CWD), 236
immediate effects, 235
interpersonal functioning, 236238
interpersonal relationships, 226
maladaptive cognitions, 227
preadolescent depression, 238
randomized clinical interventions trials
for, 228233
social problem, 242
future research, directions for, 243245
psychosocial competence, 222
Z
Zarb, J., 59
Zarcone, J. R., 340
Zinbarg, R., 187
Zvolsky, P., 270