(p. 411) Treating the Behaviorally Disordered Child
Psychosocial treatments for children are changing rapidly in concert with the expanding pace of research in child psychopathology and intervention. Despite changes in procedures, timing, and even targets of treatment within the same disorder, there are basic principles of psychotherapy that remain the same over time. This chapter describes a set of principles of effective psychosocial treatment for children with disruptive behavior that are useful to review when preparing to treat these children. The scope of this chapter is limited to children between 2 and 12 years of age whose problems are related to attention-deficit/hyperactivity disorder or disruptive behavior disorders, including oppositional defiant disorder and conduct disorder. The challenges these children and their families present to treatment are considerable. The following seven principles are designed to maximize treatment effectiveness.
To conduct effective psychotherapy with a disruptive child, the psychologist must first establish an ambiance of safety and comfort for the child in the therapeutic situation. Disruptive children may express their initial apprehensions by resistance or defiance of the unfamiliar situation in which they may not be voluntarily involved. Providing a structure for the child at the outset will reduce the child’s anxiety and help to encourage participation. With a young child, for example, reading together A Child’s First Book about Play Therapy (Nemiroff & Annunziata, 1990) may provide the 4- to 7-year-old with age-appropriate information about what takes place in psychotherapy. Older children also require age-appropriate information about the purpose and process of therapy, presented in a positive but noncoercive atmosphere of understanding and acceptance. To establish a therapeutic alliance, it is necessary to convey respect for the child and avoid any suggestion of judgment, such as siding with a third person or prematurely suggesting change.
Certain communication techniques help establish and maintain rapport. The use of paraphrasing, for example, by using either reflective or summary statements, conveys genuine interest and concern for the child. Paraphrasing also increases the child’s willingness to provide information, and it enables the psychologist to verify understanding of that information. Phrasing questions in ways that avoid leading (e.g., closed-ended questions) or blaming (e.g., “why” questions) helps the child feel at ease and increases the child’s willingness to engage. With disruptive children, key strategies for managing behavior must be used as well. The psychologist must begin at the first encounter to provide age-appropriate praise for “positive (p. 412) opposites”—behaviors that are incompatible with the child’s known problem behaviors. At the same time, it is important that the psychologist not inadvertently reinforce verbalizations of any unacceptable behavior known to be part of the child’s problem constellation. That might include, for example, not responding to a statement suspected to be untrue when it is known that lying is one of the child’s problem behaviors. In this example, by changing the subject and verifying the child’s statement later before considering the response, the psychologist can move forward productively while maintaining respect for both self and child.
Address Parent Motivation
Parent motivation is critical to a child’s therapy. It usually determines the child’s participation in treatment if only because parents generally must provide the transportation. In many additional ways, however, parent motivation remains critical to the child’s attendance and progress in treatment. Therapy is inconvenient for parents in terms of their time, schedules, routines, and pocketbook. It is even more inconvenient if the parents feel embarrassed, angry, guilty, or stressed by their child’s behavior. The sense of inconvenience is heightened for parents if they lack confidence in the effectiveness of the treatment. It is at least as essential that the psychologist motivate the parents as the child.
Parental motivation is strengthened by understanding. Before treatment begins, the psychologist needs to meet with the parents alone to review assessment results. It is important to explain the nature and likely causes of the child’s disorder (to the extent this is known) and emphasize that the disorder can be treated. The psychologist needs to describe the treatment and the expected outcomes clearly and then check the accuracy of the parents’ recall. The psychologist must also review with the parents the potential barriers to treatment participation and help them reach workable solutions before leaving. By the end of this meeting, the parents should have an understanding of the child’s disorder, how it will be treated and their own role in the child’s treatment. They should have realistic and positive expectations for the likely outcomes of treatment, and they should express motivation and commitment to follow-through.
Consider Developmental Level
Children are constantly undergoing biological, cognitive, social, and affective changes. Childhood is a disjointed period of development during which there are rapid shifts in what is deemed appropriate in children’s thinking, feeling, and behaving. Typical expressions children use in therapy would characterize maladjustment in children older or younger but have no clinical significance at the child’s present age. Psychologists who work with children must have strong academic grounding in child development and must remain up to date on the fads and trends at different ages by observing normal children with their parents and peers and by examining children’s media and other sources for developmental information.
Along with children’s general developmental progression, there is often inconsistency in their rate of development across the various developmental domains. A 12-year-old may have a developmental spurt in motor skills yet show immature emotional development. In psychotherapy, cognitive development is a critical domain because of the many therapeutic techniques that rely on specific levels of cognitive competency. Even psychologists’ perceptions of children’s intellectual functioning may be skewed based on a child’s attractiveness or verbosity. Although treatments that include a substantial cognitive component are generally better suited to school-age children than preschoolers, there are exceptions at every age. Intellectual assessment can help prevent false starts in treatment.
(p. 413) Use Assessment to Guide Treatment
In addition to cognitive functioning, children’s emotional and behavioral functioning is important to assess when selecting and implementing treatment. Many rating scales with strong reliability and validity now exist for diagnostic screening and more detailed measurement of severity within identified problem domains. Drawing upon multiple sources of information using well-standardized measures of emotional and behavioral functioning not only provides the psychologist with dependable information on the best targets for efficient intervention but also provides baseline information for tracking change.
Rating scales measuring the primary targets of intervention may be administered regularly during treatment. Monitoring change in key symptoms and behaviors has several advantages. First, it can provide feedback to the psychologist on the effectiveness of the intervention approach and can signal when a change in approach may be needed. The ratings across time can also be graphed to provide feedback for parents to reinforce their participation, particularly if based on a parent’s own ratings. Finally, ratings on standardized scales can show when targeted symptoms reach the non-problem range, indicating the need to review treatment goals and perhaps to begin preparation for termination.
Maintain Treatment Integrity
Integrity refers to the accuracy of application of the intended treatment. It can be challenging to maintain treatment integrity for a number of reasons. One reason is the inevitable “crisis” that children and families bring into treatment to obtain the psychologist’s help. There are times when the psychologist must abandon the treatment plan and provide support and crisis intervention. However, when following empirically supported protocols, the psychologist must be mindful that although dealing with the crisis will set back progress toward the established goals, it is not wise to attempt including both “therapies” in the same session. A crisis session should be devoted to the crisis, and the established treatment plan can be resumed effectively in the next session. If a family has repeated crises, it is best to refer them to another therapist for crisis management so that the treatment of the child’s disorder can be accomplished effectively.
Veering off the protocol of an evidence-based treatment, for any reason, is likely to be unproductive. These treatments are generally based on decades of research and testing of each component and its variations. Although it can be tempting to follow a hunch that some alternative procedure would work better for a particular child, a psychologist should resist doing so. After having experience with five to ten cases “by the book,” psychologists will come to trust the treatment and become proficient in tailoring its components to the needs of each individual child.
Abide by the Treatment Theory
Thoroughly understanding the theory that underlies a treatment is another critically important principle of psychotherapy. It is similar in ways to treatment integrity, but it is particularly pertinent to everything that occurs in the therapy session that is not written in the protocol. In every session, children present unique issues that psychologists must respond to. These are the times when the theory guides what is an “okay” or “not okay” response. Families become familiar with the theory guiding changes that occur by experiencing its application week after week. Without theoretical consistency in the psychologist’s responses, the confusion transferred to the child and family not only affects treatment progress but also threatens the therapeutic relationship.
Plan for Treatment Generalization
Generalization occurs when changes in the targeted behaviors lead to changes in nontargeted behaviors and in settings beyond the setting (p. 414) in which they are learned. For example, a psychologist might use parent-training sessions to target changes in child responses to parental commands. The child’s new behaviors may then generalize to compliance with teachers. To ensure lasting treatment effects, it is important to program generalization explicitly to situations beyond the therapy room. Psychologists can include generalization practice of newly learned behaviors in real-life settings during the therapy hour, although this procedure may be impractical. It is more common for the psychologist to devote the child’s last few sessions to teaching the parents how to reinforce the new behaviors at home and in public.
The principles presented in this chapter address the treatment of children with disruptive behaviors. These principles address elements important to effective treatment and include establishing a working alliance with the child and family, maintaining adherence to treatment theory and procedures, tailoring treatment to the child through careful assessment and monitoring of child progress, and programming generalization. The principles are broadly applicable to psychosocial treatments across theoretical orientation and targeted problem areas. They highlight attention to both the uniqueness of the child and family and the shared characteristics of children in treatment. By following these principles, psychologists treating children and families can heighten the likelihood of therapeutic success.
References and Readings
Boggs, S. R., & Eyberg, S. M. (2008). Positive attention. In W. O’Donohue & J.D. Fisher (Eds.), Cognitive behavior therapy: Applying empirically supported techniques in your practice (2nd ed., pp. 396–401). New York: Wiley.Find this resource:
Eyberg, S. M., Schuhmann, E., & Rey, J. (1998). Psychosocial treatment research with children and adolescents: Developmental issues. Journal of Abnormal Child Psychology, 26, 71–82.Find this resource:
Nemiroff, M. A., & Annunziata, J. (1990). A child’s first book about play therapy. Washington, DC: American Psychological Association.Find this resource:
Querido, J., Eyberg, S. M., Kanfer, R., & Krahn, G. (2001). Process variables in the child clinical assessment interview. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 75–89). New York: Wiley.Find this resource: