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!