Munroe-Meyer Institute Department of Psychology
Holly Roberts, Ph.D.Munroe-Meyer InstituteUniversity of Nebraska Medical Center
Munroe-Meyer Institute Psychology Provide clinical services and training for a
wide variety of infant, child, and adolescent concerns Behavioral Social-emotional Physical Medical Cognitive Abilities
Munroe-Meyer Institute Psychology Services are provided
Hospitals Schools Community-based clinics throughout Nebraska
Munroe-Meyer Institute Psychology Education Training Research Clinical Services
MMI Outreach clinics Home and school visits
Typical Child Concerns academic/school problems adjustment (death/divorce) anxiety/fears attention & behavior problems feeding/eating problems habits (e.g., thumb-sucking) sleep problems toileting
Behavioral Health Clinics
Why Primary Care? Physicians as gate keepers for mental health
services
Why Primary Care? Physicians as gate keepers for mental health
services Increased continuity of care
Why Primary Care? Physicians as gate keepers for mental health
services Increased continuity of care De-stigmatizes mental health treatment
Top Three Problems Behavior-based problems (58%) Otitis Media (48%) URI (41%)
Arndorfer, R. E., Allen, K. D., Aljazireh, L. (1999). Behavioral health needs in pediatric medicine and the acceptability of behavioral solutions: Implications for behavioral psychologists. Behavior Therapy, 30,137-148.
Top Three Behavior Problems Oppositional behavior Sleep/bedtime problems ADHD
Arndorfer, R. E., Allen, K. D., Aljazireh, L. (1999). Behavioral health needs in pediatric medicine and the acceptability of behavioral solutions: Implications for behavioral psychologists. Behavior Therapy, 30,137-148.
Behavioral Approach ABC’s Functional Assessment informs treatment Empirically supported treatments
Oppositional Behavior Core issue is typically noncompliance
“KEYSTONE BEHAVIOR” How many of 10 instructions would s/he do the
first time asked? Mealtimes? Bedtime and morning routines? Public outings?
Oppositional Behavior Significant problems will not dissipate with
age 5% of 3-year olds. 68% @ 8 years
Oppositional Behavior Oppositional Defiant Disorder (DSM-IV)
6 month pattern of negative, hostile, defiant behavior with 4 of the following: Loses temper Argues with adults Blames others Etc.
Causes Impairment Not psychosis Not Conduct Disorder—Part of Spectrum
Oppositional Behavior Most parents rely on repeated:
Lecturing Reasoning Explaining Warning Threatening Yelling
Oppositional Behavior Children learn best from…
Immediate feedback from their environment--i.e., “hands on” not by lecture
by doing not from hearing
Oppositional Behavior Talking with parents:
“teaching a behavioral skill” Following instructions Coping with anger Persisting on a task Self-quieting
Parent training only supported treatment!
Oppositional Behavior Talking with parents:
“teaching a behavioral skill” Following instructions Coping with anger Persisting on a task Self-quieting
Must use two-part approach Encourage skills you want to see more often. Discourage behaviors you want to see less.
Oppositional Behavior REPETITION X CONTRAST=
BEHAVIOR CHANGE High contrast= quick (often 1 trial)
learning, requires less reps
Oppositional behavior Time-In: Encouraging use of new skill
Frequent, intermittent “bursts” of attention for average behavior Keep attention tank full
BIG reaction for demonstrating skill Enthusiasm, Touch, Praise
Oppositional Behavior Time-Out: Discouraging Problem Behavior
Misconceptions: Child must sit still Child must be sorry Child must understand
Oppositional Behavior Time-Out: Discouraging Problem Behavior
What it IS: Brief, unpleasant consequence during which there is
no access to attention or anything fun Consistent use for every occurrence of target behavior No reprimand on release
Oppositional Behavior Time-Out: Discouraging Problem Behavior
Procedure Adult-sized chair Area easy to covertly monitor 2-3 minutes Parent ends the time-out Child completes task after time-out is over
Sleep/Bedtime Problems 20-25% of 1-5 year olds Parasomnias & Dyssomnias Most common:
Difficulty settling and night time awakenings Very persistent problem: 84% still have
problems after 3 years
Behavioral Formula for Establishing Pediatric Sleep Disturbance
Repeatedly attend to child’s continuous calling out, crying, and “curtain calls”
Allow child to fall asleep in living area, then transfer him/her to bed once asleep
When child awakens at night, stay with him/her or admit them to parents’ bed until they fall back to sleep
Sleep/Bedtime Problems Basic Intervention:
Improved sleep hygiene Routines Consistent bed and wake times throughout the
week The Bedroom Teach independent sleep onset skills (drowsy
but awake)—i.e.,being alone, self-calming
Sleep/Bedtime Problems Basic Intervention:
Improved sleep hygiene Systematic ignoring---(EXTINCTION BURST)
Unmodified (“cold turkey”) With parental presence Quick check Graduated (Ferber)
Sleep/Bedtime Problems Basic Intervention:
Improved sleep hygiene Systematic ignoring Faded bedtime procedure
Establish time of sleep onset Set “window” of sleep Gradually increase time
Sleep/Bedtime Problems Basic Intervention:
Improved sleep hygiene Systematic ignoring Faded bedtime procedure Reward Program
ADHD “Attentional problems” greatest increase of all
mental health problems in PC since 1979 ADHD diagnosis a 2.3-fold increase in the
population-adjusted rate from 1990-1995 Children with ADHD use primary care more,
cost more
Top 10 Myths of ADHD10. ADHD and ADD are different disorders
9. Girls aren’t hyperactive
8. ADHD is outgrown in adolescence
7. ADHD is caused by poor parenting
6. ADHD is caused by diet (sugar, food additives)
Top 10 Myths cont. 5. There is a “cure” for ADHD
4. Taking medications for ADHD leads to drug abuse
3. Children who improve with stimulant medication (Ritalin) must have ADHD
2. If the child fails to display ADHD behaviors in the doctor’s office, then the child doesn’t have ADHD
1. It is a “medical diagnosis”
Formal Diagnostic CriteriaDSM-IV, 1994
Criterion A:Six or more symptoms from one or both of these
lists:• Inattentive Type• Hyperactive/Impulsive Type …have been present for at least 6 months.
Symptom ListsInattentive Type• fails to attend to details, makes
careless mistakes• difficulty sustaining attention in
play or work• does not listen when spoken to• does not follow through• difficulty organizing tasks• avoids task requiring sustained
mental effort• loses things needed• distracted by extraneous stimuli• often forgetful
Hyper/Impulsive Type• often fidgets hands/feet or squirms• often leaves seat when sitting is
expected• runs about or climbs excessively• difficulty playing or engaging in
leisure activities quietly• often “on the go”/ “driven by motor”• talks excessively• blurts out answers before questions
completed• difficulty awaiting turn• interrupts or intrudes on others
Formal Diagnostic CriteriaDSM-IV, 1994
Criterion B:Some of the symptoms were present before the
age of seven years.
Formal Diagnostic CriteriaDSM-IV, 1994
Criterion C:Some impairment from the symptoms is present
in two or more settings (e.g., home, and school or work).
Formal Diagnostic CriteriaDSM-IV, 1994
Criterion D:There is evidence of clinically significant
impairment in social, academic, or occupational functioning.
Formal Diagnostic CriteriaDSM-IV, 1994
Criterion E:The identified symptoms are not better
accounted for by another mental disorder.
ADHD: Assessment Information gained by qualified clinician
Behavior ratings from family Behavior ratings from the school Observation (clinic or in vivo)
Treatment Unproven/DisprovenADHD is a disorder of performance, not of skill
problem is not with “knowing what do” problem is with “doing what you know”
To be effective, treatments must be in place at the “point of performance” outpatient psychotherapy alone play therapy group classes (e.g., social skills training)
ADHD: Treatment What we KNOW works:
Drug Therapy Hundreds of studies (N > 5,000) No Support for Antidepressants and Clonidine for
young children Behavior Therapy
48 classroom studies (N > 900) 80 parent/home studies (N > 5,000)
Combined Behavioral/Drug 10 classroom studies (N > 800)
ADHD Home Programs Parent training in behavior management
Positive attending reinforcement, “time-in”
Anticipating and preventing problems Compliance training Discipline strategies
time-out job card grounding token systems
Job Card GroundingPrimarily for older children (9 and up)
create 25 to 50 job cards (15 to 30 min each) assign jobs for breaking rules child/teen is grounded until jobs completed
no TV no Telephone no allowance no going outside no contact with friends no playing with toys
School Interventions Token programs Home School Notes Classroom Accommodations
e.g., preferential seating, adjustments in testing and classwork (extra time, reading directions aloud to students)
Token Systems Program in which child (or group of
children)…. Earn tokens for engaging in a variety of
desired behaviors and, Later exchange the tokens for things they
want
Daily Home-School Note Basic components
Specific behaviors are identified & defined A school note is created Divides day into shorter segments Lists identified behaviors
Daily Home-School Note Basic components
Teacher marks note, gives feedback at end of each period
Rewards/consequences provided at home for performance at school
Student is responsible for getting note from place to place
10 Management Principles for Children w/ ADHD
Greater immediacy/frequency of consequences Use of more salient (noticeable) consequences More frequent change in rewards “Act, don’t yack” Use rewards before punishment Anticipate problems; Have a plan Keep a disability perspective Prioritize Don’t personalize the child’s problem Practice forgiveness!