Assessment and Treatment of Childhood Problems

ASSESSMENT AND TREATMENT OF CHILDHOOD PROBLEMS Second Edition

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ASSESSMENT AND TREATMENT OF CHILDHOOD PROBLEMS A Clinician’s Guide SECOND EDITION

Carolyn S. Schroeder Betty N. Gordon

THE GUILFORD PRESS New York London

© 2002 The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012 www.guilford.com All rights reserved Except as noted, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number:

9 8 7 6 5 4 3 2 1

LIMITED PHOTOCOPY LICENSE These materials are intended for use only by qualified mental health professionals. The Publisher grants to individual purchasers of this book nonassignable permission to reproduce those figures and appendices for which photocopying permission is specifically provided in a note on the opening page. This license is limited to you, the individual purchaser, for use with your own clients and patients. It does not extend to additional clinicians or practice settings, nor does purchase by an institution constitute a site license. This license does not grant the right to reproduce these materials for resale, redistribution, or any other purposes (including but not limited to books, pamphlets, articles, video- or audiotapes, and handouts or slides for lectures or workshops). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications.

Library of Congress Cataloging-in-Publication Data Schroeder, Carolyn S. Assessment and treatment of childhood problems : a clinician’s guide / Carolyn S. Schroeder, Betty N. Gordon. — 2nd ed. p. cm. Includes bibliographical references and index. ISBN 1-57230-742-0 1. Behavior disorders in children—Diagnosis. 2. Behavior disorders in children—Treatment. I. Gordon, Betty N. II. Title. RJ506.B44 S37 2002 618.92'858—dc21 2002005508

To the children and families with whom we have had the privilege of working over the years and, most especially, to our grandchildren, Zoe Margaret Schroeder, Elise Capen Ederle, and Margaret McBane Gordon, and their parents, whose love, encouragement, and dedicated parenting help ensure the well-being of the next generation

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About the Authors

Carolyn S. Schroeder received her PhD in clinical psychology from the University of Pittsburgh in 1966. She is currently an Adjunct Professor at the University of Kansas, Lawrence. She previously held appointments in the Departments of Pediatrics, Psychiatry, and Psychology at the University of North Carolina at Chapel Hill. Throughout her career she has trained graduate students, interns, and postdoctoral fellows in the assessment and treatment of children and their families. She is widely recognized for the establishment of a model for psychologists’ participation in primary care pediatrics. Her publications reflect her interests in pediatric psychology, service delivery in primary care settings, and the assessment and treatment of children’s behavior problems. Betty N. Gordon received her PhD in developmental and child clinical psychology from the University of Washington, Seattle, in 1978. She is currently Associate Professor Emerita of Psychology at the University of North Carolina at Chapel Hill. She has taught graduate-level courses in child assessment and treatment and undergraduate courses in developmental psychopathology. In association with Chapel Hill Pediatric Psychology, she has been involved clinically in assessment and treatment of children for many years. Her research has focused on children who have been sexually and/or physically abused, with a primary interest in children’s memory for traumatic events.

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Preface

As with the first edition of this book, this second edition of Assessment and Treatment of Childhood Problems is based on our work in a primary health care setting. For almost 28 years our focus has been on enhancing children’s development, preventing problems, and helping parents to manage stressful life events and common but often persistent and troublesome behavior problems. The primary health care setting has provided us with a unique opportunity to follow children as they develop from birth through adulthood. We view this development as a function of the dynamic interaction among the characteristics of the child and the parents, the environment, and chance events, and understand psychopathology to be normal development gone awry. Although we recognize the importance of adolescence, the focus of this book is on the development of children ages 2–12 years and the problems that can occur during these ages. It has been 11 years since the publication of the first edition of this book and much has occurred during the intervening years. Of major importance is the emergence of the field of developmental psychopathology, with its focus on normal development and developmental variations throughout the life span. This interface between developmental psychology and clinical child psychology has greatly enhanced our understanding of when and how things can go wrong for children, and it provides guidance on developing effective preventive as well as assessment and intervention strategies. The advances of biological and genetic science have been enormous, and their influence on behavior and development has received an incredible amount of attention since the first edition was published. Theory and research in these areas have enhanced our understanding of the behavioral symptoms of problems such as depression, anxiety, and disruptive behavior disorders. We have learned, for example, that some behavioral disorders can be chronic and lifelong, thus requiring ongoing or periodic attention to maintain treatment gains. We have tried to reflect these advances in the literature reviews for each problem area, and it is our hope that this book will lead clinicians to a better understanding of the “state of the field” and will help guide them to a more empirically based approach to their work. The importance of a theoretical approach to the work of the child clinician cannot be overstated. Our thinking has been strongly influenced by behavioral, social learning, and cognitive-behavioral theorists. Approaches to assessment and intervention that reflect these orientations are emphasized. For each problem area presented, we have tried to describe treatment methods that are developmentally sensitive and have some documented efficacy for the ix

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Preface

specific problem in question. The field continues to struggle, however, with how to transfer these treatments to community-based clinics—that is, the real world. Thus, the clinician must be creative in developing intervention strategies that have not been empirically validated for the majority of children with a specific problem but may be effective for an individual child or family. A theoretical aproach to guide the selection and/or development of these strategies is of critical importance. This book reflects the importance of a collaborative relationship between the child, the clinician, and parents in assessing and treating childhood problems. The clinician’s role is multifaceted, including that of educator, advocate, service provider, and case manager. He or she provides expertise based on knowledge of developmental processes and the empirical literature related to children’s problems. Parents, on the other hand, have the primary and ultimate responsibility for their children’s well-being and bring a unique understanding of their child and family. It is through this collaboration with parents that we are often able to change the trajectory of a child’s life, by enhancing parents’ abilities to deal with the tasks of parenting and by enabling them to help their children cope successfully with the stresses of growing up in an imperfect world. In this second edition we have attempted to provide a more complete picture of the problems that can occur between ages 2 and 12 years by adding three new chapters: eating problems, depression, and attention-deficit/hyperactivity disorder. We deleted the chapter on the development of the pediatric psychology practice at Chapel Hill Pediatrics since this information has been published elsewhere (e.g., Schroeder, 1996). The book is organized into three sections, with the first section providing a foundation for understanding specific problem areas and for developing assessment and intervention strategies. Chapter 1 provides an overview of child development with an emphasis on “where things can go wrong” in the developmental process. It also covers factors that can make children more resilient, or cause them to be more vulnerable to life stresses, as well as ways to use this information in the prevention of problems. Chapter 2 focuses on issues of diagnostic classification, prevalence of problems, steps in the assessment process, and treatment issues. The Comprehensive Assessment-to-Intervention System described in this chapter is used throughout the book as the framework by which clinicians can systematically gather the information necessary to understand and intervene in the problem areas covered in later chapters. The second section of the book deals with problems that can occur in childhood: eating problems, toileting problems, habits and tics, sleep difficulties, sexuality and sexual problems, fears and anxieties, depression, disruptive behavior, and attention-deficit/hyperactivity disorder. The final section of the book covers life events that can be sources of considerable stress for many children and parents during the course of growing up: siblings, divorce, and death. For each problem area or stressful event, we provide a brief review of the literature, a guide to comprehensive assessment, specific treatment options, and a case example that illustrates the central features of the problem. Finally, in the appendices we provide descriptions of published assessment instruments as well as a number of clinical forms and rating scales that are not commercially published. Who do we hope will read this book? It is written for all professionals who provide services to children. These include not only child psychologists but also pediatricians, family physicians, child psychiatrists, nurses, social workers, guidance counselors, and trainees in all of these and other health-related fields. We would like to thank the many people at The Guilford Press who helped shepherd this work to a final completion, most especially the production staff. There are many people who by their very presence greatly influenced our work: the parents and children with whom we

Preface

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have been fortunate to work and our colleagues at Chapel Hill Pediatrics and the University of North Carolina at Chapel Hill. Our husbands encouraged us to write a second edition and provided support and understanding throughout the process. Finally, our children, Mark and Matthew (CSS), and Sarah and Andrew (BNG), have taught us a great deal about parenting and resilience. When we completed the first edition of the book in 1991, they were in college or graduate school; in 2002, at the time of the second edition, they are young adults with families of their own. They have continued to teach us about development and developmental variations as they occur in their lives and our own.

Reference Schroeder, C. S. (1996). Psychologists and pediatricians in partnership. In R. J. Resnick & R. H. Rosensky (Eds.), Health psychology through the life span: Practice and research opportunities (pp. 109–132). Washington, DC: American Psychological Association.

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Contents

PART I. THE FOUNDATION Chapter 1. Development of Psychopathology

3

Normal Development, 4 Vulnerability and Resilience, 18 Prevention of Problems, 30 Summary and Conclusions, 39

Chapter 2. Assessment to Intervention

40

Issues of Diagnostic Classification, 40 Estimates of Prevalence, 45 Planning the Assessment, 48 Assessment Case Example, 49 A Comprehensive Assessment-to-Intervention System, 50 Methods for Gathering Information, 56 Treatment Issues, 73

PART II. MANAGING COMMON PROBLEMS Chapter 3. Eating Problems

81

Normal Development of Feeding Behavior, 82 Eating Problems Related to Infant Feeding, 85 Obesity, 89 Assessment of Obesity, 90 Treatment of Obesity, 94 Case Example: Obesity, 99 Food Refusal Problems, 102 Assessment of Food Refusal Problems, 103 Treatment of Food Refusal Problems, 106 Case Example: Food Refusal Problem, 109

Chapter 4. Toileting: Training, Enuresis, and Encopresis Toilet Training, 115 Enuresis, 120 xiii

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Contents Assessment of Nocturnal Enuresis, 123 Treatment of Nocturnal Enuresis, 127 Treatment of Mixed Enuresis, 132 Treatment Protocol for Enuresis, 133 Case Example: Enuresis, 137 Encopresis, 139 Assessment of Encopresis, 142 Treatment of Encopresis, 147 Treatment Protocols for Encopresis, 149 Case Example: Encopresis, 155

Chapter 5. Habits and Tics

159

Oral Habits, 159 Trichotillomania, 163 Other Habits, 164 Tics, 165 Assessment of Habits and Tics, 171 Treatment of Habits and Tics in General, 176 Treatment for Tourette’s Disorder, 180 Case Example: From Tics to Tourette’s Disorder, 182

Chapter 6. Sleep

186

Normal Sleep States and Patterns, 186 Sleep Disturbances, 189 Assessment of Sleep Problems, 199 Treatment of Sleep Problems, 204 Case Example: Night Waking, 211 Case Example: Nightmares, 214

Chapter 7. Sexuality and Sexual Problems

217

Normal Sexual Development, 217 Sexuality Education, 222 Sexual Problems, 225 Child Sexual Abuse, 231 Assessment of Sexual Abuse, 236 Treatment of Sexual Abuse, 247 Format for Immediate Short-Term Treatment When Abuse Has Been Substantiated, 251 Treatment in Cases Involving Nonsubstantiated Abuse, 257 Case Example: Substantiated Sexual Abuse, 258

Chapter 8. Fears and Anxieties Definitions, 262 Development of Fears and Worries, 264 Anxiety Disorders, 269 General Characteristics of Anxiety Disorders, 275 Assessment of Fears and Anxieties, 280 Treatment of Anxiety Disorders, 287 Case Example: School Refusal, 297

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Contents

Chapter 9. Depression

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302

Definition and Classification, 303 General Characteristics of Depression, 305 Assessment, 315 Treatment, 322 Case Example: Subclinical Depression, 326

Chapter 10. Disruptive Behavior

331

Classification and Diagnosis, 332 General Characteristics of Disruptive Behavior Problems, 336 Development of Disruptive Behavior, 345 Assessment of Disruptive Behavior, 350 Treatment, 357 Case Example: Preschool Oppositional Behavior, 374

Chapter 11. Attention-Deficit/Hyperactivity Disorder

377

Diagnostic Criteria, 378 General Characteristics of ADHD, 381 Assessment, 393 Treatment, 402 Case Example: ADHD-C, 413

PART III. MANAGING STRESSFUL LIFE EVENTS Chapter 12. Siblings

419

Adjustment to the Birth of a Sibling, 420 Sibling Conflict, 424 Assessment of Sibling Conflict, 427 Treatment of Sibling Rivalry, 430 Case Example: Physical Conflict among Siblings, 433

Chapter 13. Divorce

440

Effects of Divorce on Children, 440 Assessment of Divorce-Related Issues, 450 Treatment of Divorce-Related Problems, 455 Case Example: Recommendations for a Child’s Living Situation, 462

Chapter 14. Bereavement

466

Children’s Understanding of Death, 467 Children’s Adjustment to Death, 468 The Terminally Ill Child, 470 Assessment of Death-Related Issues, 474 Treatment of Death-Related Issues, 477 Case Example: Death of a Parent, 480 Case Example: Death of a Sibling, 482

Appendix A. Description of Assessment Instruments Parent Rating Scales, 489 Teacher Rating Scales, 493

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Contents Child Self-Report Measures, 495 Behavioral Observation Systems, 497 Structured Interviews, 498 Attention-Deficit/Hyperactivity Disorder Measures, 499 Depression, Anxiety, and Fear Measures, 500 Parent Characteristic Measures, 502

Appendix B. Assessment Instruments B.1. B.2. B.3. B.4. B.5. B.6. B.7. B.8. B.9. B.10. B.11. B.12. B.13.

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General Parent Questionnaire, 507 Daily Log, 512 Specific Events Causing Concern, 513 Teacher Questionnaire, 514 Fear Survey Schedule for Children—Revised (FSSC-R) , 517 Screen for Child Anxiety Related Emotional Disorders (SCARED)— Child Version, 521 Screen for Child Anxiety Related Emotional Disorders (SCARED)— Parent Version, 523 Hopelessness Scale for Children, 526 Hopkins Motor and Vocal Tic Scale, 528 Children’s Eating Behavior Inventory (CEBI), 530 Child Attention Problems (CAP), 534 Academic Performance Rating Scale (APRS), 536 Therapy Attitude Inventory (TAI), 539

References

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Index

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PART

I

T H E F O U N D AT I O N

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CHAPTER 1

Development of Psychopathology

M

ost children, in the process of growing up, will have emotional and behavioral problems that are transient in nature and are due to the stresses of development and adaptation to family and societal expectations. The primary task for parents is to enhance their children’s development by helping them gain control over normal developmental events such as toilet training, fears, learning about sexuality, being told “no,” and dealing with siblings and peers. Children and parents also must sometimes cope with negative life circumstances (e.g., poverty or parental unemployment) and stressful events, (e.g., a hospitalization, a divorce, a death, or the birth of a new baby). For all of this pressure to cope, it is heartening that epidemiological studies find that over the course of any one year, only about 20% of children suffer from an emotional or behavioral problem that is severe enough to interfere with their day-to-day functioning (Nottelmann & Jenkins, 1995). The goals of the child clinician are not only to assist this group of children who have major mental health problems, but also to help the other 80% of children and their parents manage the stresses of normal growth and development. Because of their rapid growth and development, children represent a unique population. Previously, the importance given to changes in development depended to a great extent on one’s theoretical perspective. Psychoanalytic theory, for example, emphasizes the emergence of independence and psychosexual development, whereas social learning theory focuses on the development of self-control and self-efficacy. However, the failure of any one theory to explain the full complexity of development across ages and areas has led to general acceptance of a transactional and/or ecological perspective of development, which attempts to account for factors within the child, family, and society that influence the child either directly or indirectly (Campbell, 1990). Within this perspective, developmental gains in each area (social, cognitive, motor, language, etc.) are thought to be related to progress in other areas. Moreover, competence or problems in any area of development early in life are seen as setting the stage for later development. Thus developmental change (both positive and negative) is the result of the transactional dialogue among each child with his or her unique biological/genetic makeup, the physical and social environment, and the cultural milieu into which he or she is born. Mash and Terdal (1997a) point out that the child clinician must recognize “the ebb and flow of this develop3

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I. THE FOUNDATION

mental dialogue, because it has critical implications for the manner in which child behaviors are conceptualized, measured, classified, diagnosed, changed, and evaluated” (p. 22). Behaviors common at one age may be considered significant problems at another age, and many childhood problems may change both qualitatively and quantitatively as a child develops. In addition, the impact of stressful life events may vary with the child’s stage of development, the parent’s characteristics, and the social support system available to the family at that time. Knowledge of developmental norms is clearly essential for the child clinician to recognize which behaviors are excessive or deficient for children at a given developmental stage. An understanding of normal development is also important in choosing appropriate intervention techniques. Treatment of the school-age child, for example, will rely more heavily on cognitive and language skills, whereas use of concrete, situation-specific tasks and developmentally appropriate play activities will be more appropriate for the preschool child. The clinician must also have knowledge of the normal sequence of skill acquisition, in order to plan appropriate treatment for such problems as social skills deficits. In light of the importance of a developmental perspective for clinical work with children, this chapter first focuses on issues related to the normal development of children from birth to 10 years, and the factors that influence children’s later development (see Campbell, 1990, 1998, for excellent discussions of theoretical issues concerning development and behavior problems). Next, research related to the variables that contribute to the vulnerability or resilience of children is reviewed. Finally, models for prevention and early intervention are discussed.

NORMAL DEVELOPMENT General Comments The developmental tasks of children obviously change with age, and each stage of development presents unique challenges to children and parents. The ways in which significant adults help children through these difficult periods can have implications for children’s later development. A child who is having trouble with separation and individuation, for example, may have more trouble with social skills if the parents deal with separation issues in an angry or rejecting manner rather than with warmth and support. In considering normal development, the clinician should keep both inter- and intraindividual differences in mind. Individual differences in the rate of development are clearly apparent during the preschool years, and these differences often persist into the school-age years. Some children, for example, begin to speak before the age of 1, whereas other “normal” children have not acquired extensive language by age 3. Differences in physical growth become dramatically apparent in the late elementary school and early adolescent years, although each child may be developing along a normal continuum. At school age, academic standards typically reflect great differences among children. An individual child’s rate of development within various areas can vary as much as the rate of development among children. A child may be speaking in sentences at age 2 years, but may not begin hopping or skipping until much later than expected. Similarly, a child may be at the top of the class in reading, but may have difficulty participating in group play activities. Some of these inter- and intraindividual differences are primarily the result of genetic/biological factors; others seem to be more the result of environmental influences. Of course, the unique interaction of these two types of factors—the child’s and the environment’s—is what ultimately determines each child’s developmental course.

1. Development of Psychopathology

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Because many types of learning take place rapidly and simultaneously during childhood, it is common for children who are not developing normally to be identified at this time (particularly during the preschool years), often because they fail to achieve an expected developmental milestone. It is usually the general pattern of development, rather than slower development in any specific area, that alerts adults to potential problems. Toilet training, for example, may be slower and more difficult; the child may be slower to learn to dress and eat independently; and constant supervision may be needed at a time when most children are becoming independent, helpful family members. If developmental problems are not noticed during the preschool years, they will almost inevitably be identified as a child enters school, when there are increased expectations to sit quietly, pay attention, process more complex language, read, do arithmetic, and deal with difficult social situations. The following discussion focuses on issues in normal development that are most relevant to understanding how psychopathology develops in children during the periods of infancy, toddlerhood, preschool, and school age. Table 1.1 provides an overview of normal development from infancy through school age, along with the associated parental tasks. The reader is referred to Davies (1999) and DiGirolamo, Geis, and Walker (1998) for more detailed descriptions of developmental milestones. In addition, we recommend three books for parents that cover developmental issues: Your Child (Pruitt, 1998); A to Z Guide to Your Child’s Behavior: A Parent’s Easy and Authoritative Reference to Hundreds of Everyday Problems and Concerns from Birth through 12 Years (Mrazek, Garrison, & Elliott, 1993); and Child Behavior: The Classic Childcare Manual from Gesell Institute of Human Development (Ilg, Ames, & Baker, 1992).

Infant Development (Birth–1 Year) Development during the first year of life is phenomenal, and by 12 months of age infants barely resemble the beings they were at birth. The main tasks of the first year can be summarized as follows: (1) to gain physiological stability; (2) to develop interpersonal attachments and strategies for maintaining them; (2) to regulate arousal and affect; (3) to develop and gain control over motor skills; (4) to begin to communicate needs and desires; and (5) to explore and learn about the external world (Davies, 1999; DiGirolamo et al., 1998). Brain development is most rapid during the first year of life, and this development makes all other functions (sensory, perceptual, emotional, regulatory, motor, and cognitive) possible (Davies, 1999). Development during infancy is also inseparable from the child’s relationship with his or her caregiver(s). Although the child is born with certain biological prerequisites, and his or her capabilities unfold in a regular progression, simple maturation is not sufficient to ensure normal progress (Davies, 1999). The infant is born with a capacity to organize his or her experiences, for example, but is dependent on adults to determine what those experiences will be and to provide appropriate stimulation and support so that the child can profit from these experiences (Davies, 1999). The types of experiences to which the infant is exposed influence which neural pathways will be strengthened, which will remain available, and which will atrophy (Davies, 1999). Thus issues of parenting are most critical during this early time of life. Problems during infancy typically come to the attention of pediatricians rather than mental health professionals (Campbell, 1998). However, clinicians should be knowledgeable about two areas of research most related to the development of later mental health problems: attachment and temperament. Both the quality of primary caregiver–infant attachment and the child’s temperamental characteristics can potentially influence the child’s future functioning,

TABLE 1.1. Issues of Normal Development and Associated Parental Tasks Toddlers (1–2 years)

• Brain develops rapidly • Weight triples, height doubles • Develops capacity for selfregulation • Physiological regularity increases • Becomes oriented to external world: sensory integration, visual and auditory acuity • Motor skills develop: rolling, sitting, crawling, standing, walking, reach and grasp, pincer grasp, hand to mouth, eye–hand coordination

• • • • •

• Needs environmental stimulation and exploration • Engages in sensory–motor actions and experiences • Learns about contingencies • Develops object permanence • Imitates adult behavior • Repeats pleasurable experiences • Anticipates familiar events • Begins goal-directed behavior

• Intense interest in exploring the world • Explores properties and functions of objects • Observation and imitation are key to learning • Develops expectations based on memory of past • Symbolic play and thinking begin • Conscious goals and plans • Views the world egocentrically

6

Infants (0–1 years)

Preschoolers (2–4 years)

Physical/motor development Stands and walks alone • Hops, skips, and jumps Imitates motor actions • Throws ball Goes up and down steps holding on • Dresses Stands on one foot • Undresses Uses implements (crayons, spoons) • Ties shoes • Copies shapes

Cognitive development • Memory capacity develops (processing and storage in place, good recognition memory, increase in ability to use retrieval strategies) • Uses verbally mediated thinking • Understands real vs. not real • Engages in pretend play • Understands consequences and rules • Views the world egocentrically • Uses magical thinking

School-age children (5–12 years) • Slow and steady growth • Increased eye–hand coordination • Sense of body position and gross motor function permit participation in organized sports

• Attention, persistence, and goaldirectedness allow formal schooling • Increased capacity to store, retain, and retrieve new information • Improved memory skills; uses retrieval strategies • Increasingly accurate perception of reality • Reversibility—can analyze events by thinking about them • Understands cause and effect • Spurt in cognition at 7 years: Spatial and visual organization, time orientation, seriation, auditory processing • Increase in executive processes: Problem solving, sustained attention

Language development • • • • • • •

Cries or smiles to communicate Orients to sound Babbles and vocalizes Imitates vocalization Learns turn taking Looks and points Understands single words and labels • Follows simple directions by end of first year

7

• Attachment develops • Uses strategies to maintain proximity • Uses caregiver to decrease arousal and regulate affect • Smiles responsively • Initiates play interactions • Cooperates in simple games (peekaboo) • Joint attention • Beginning sense of self • Cautious with new people • Responds to parents’ limit setting by end of first year

• Imitates single words • Uses single words to communicate needs • Combines words and gestures • Vocabulary of 10–100 words • Two- or three-word sentences

• • • • • • • • •

Social/emotional Balances desires for closeness with caregiver and for independence, exploration Plays independently and in parallel with others Imitates others and role-plays daily events Becomes self-assertive Bites or hits peers Expresses needs and feelings in gestures and words Has limited internal control Recovers quickly from upset Begins to understand social expectations

• Rapid development of grammar, syntax, and pronunciation • Uses language to understand the world • Asks questions • Follows three-step commands • Uses four-word complex sentences • Relates long stories and experiences • By age 5, 1,500- to 2,000-word vocabulary; grammar similar to adults’ development • Group play begins • Develops friendships • Follows rules • Plays cooperatively • Internalizes parental standards • Interacts appropriately with adults and peers • Uses language to express feelings • Uses words to control impulses

• Expression in written language begins • Vocabulary continues to increase • Uses language to express ideas and feelings, to plan for the future and remember the past, and to solve problems

• More consistent sense of self • Increased sense of identity based on gender, race, ethnicity and personal characteristics • Self-esteem based on sense of competence and status in peer group • Uses cognition to regulate internal arousal, to delay action, to attain goals, and to control behavior • Internalizes values, norms, and rules • Can see conflicting viewpoints and tolerates ambivalence • Identifies with parents as role models • Increased identification with samesex peers

(cont.)

8

TABLE 1.1. (cont.) Infants (0–1 years)

Preschoolers (2–4 years)

School-age children (5–12 years)

Parenting • Provide opportunities for exploration and motor activities • Talk to and describe child’s actions • Ensure child’s safety • Start setting limits • Use distraction to discipline

tasks • Be an authoritative parent • Be a good role model for appropriate behavior, expression of feelings, and relationships • Provide consistent daily routines and expectations • Be a good listener • Describe child’s actions and feelings

• Be an authoritative parent • Be a good role model • Encourage and model independent problem solving • Provide consistency • Be a good listener • Monitor and supervise child’s activities and friendships

I. THE FOUNDATION

8

• Scaffold or support child’s development • Adapt to child’s ongoing development • Be sensitive and responsive to child’s cues • Provide appropriate stimulation and experiences • Follow child’s lead/engage in joint attention

Toddlers (1–2 years)

1. Development of Psychopathology

9

and problems in either area are seen as risk factors for the development of behavioral or emotional problems. Attachment The formation of “attachment”—that is, an emotional bond between the infant and his or her primary caregiver(s)—occurs gradually over the course of the first year of life. As Campbell (1998) describes, the process begins as caregivers (usually parents) respond to the infant’s signals of hunger or other distress. The infant gradually learns that his or her needs will (or will not) be met consistently, and as a result develops expectations about adult behavior relative to his or her signals. At first any adult will do, but gradually, the infant begins to discriminate between and respond differently to familiar and unfamiliar people. As development progresses (usually by 6 or 7 months), the infant begins to engage in active attempts to maintain contact with familiar people (usually parents) and becomes upset when separated from them. By the end of the first year, the attachment figure is the infant’s main source of comfort and is used as a secure base from which the infant ventures out to explore the world (Waters & Cummings, 2000). Early in this process, the key to the formation of a secure emotional attachment between the infant and caregiver(s) is the ability of a caregiver to respond sensitively and promptly to the infant’s signals of distress (i.e., crying). As the child progresses through the first year, caregivers must adapt their behavior to the child’s rapidly changing needs while continuing to be sensitive and responsive to the child’s signals and to provide support for his or her development (Davies, 1999; DeWolff & van IJzendoorn, 1997; Thompson, 2000). As Campbell (1998) states: Mothers who are sensitive to their infants’ cues and responsive across a range of situations including feeding, responsiveness to crying, early face-to-face play, and the provision of opportunities to explore, foster the development of a secure attachment relationship. Mothers who respond to their infants abruptly, who are unresponsive, or who pace their behavior to their own needs and schedules foster the development of an anxious or ambivalent attachment characterized by excessive anger, clinging, and/or avoidance behavior of the part of the infant. (p. 13)

Infants who are securely attached to their caregivers have been shown to have more optimal development in a number of areas (Campbell, 1998). Main, Kaplan, and Cassidy (1985), for example, found that children who were securely attached at 12 months were more emotionally secure and better able to express their feelings at age 6; 6-year-olds who were insecurely attached at 12 months had great difficulty discussing their feelings and had few strategies for dealing with separation. Furthermore, children with secure attachments to their caregivers show more appropriate social adaptations over time (e.g., they are more popular, make more social contact, and are more helpful to others) than children with less secure attachments do (Hartup, 1989). Patterns of cognitive functioning, including more symbolic play, more internal control, and better problem-solving skills (Matas, Arend, & Sroufe, 1978), as well as increased task mastery (Baumrind, 1971) and higher school achievement (Estrada, Arsenio, Hess, & Holloway, 1987), are also associated with early secure attachment to caregivers. The quality of early attachment relationships has likewise been found to be important in emotional development, influencing popularity, number of social contacts, ability to offer support to others, and increased self-esteem (Cassidy, 1988; Sroufe & Fleeson, 1986).

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I. THE FOUNDATION

Attachment relationships are not necessarily stable over time. Moreover, attachment is found to be less stable in higher-risk than in lower-risk families (Lamb, Thompson, Gardner, & Charnov, 1985). Attachment status probably fluctuates as a function of parental and environmental circumstances (Belsky, Campbell, Cohn, & Moore, 1996; Thompson, 2000). Thus securely attached infants may become insecure if their caregivers become less able to meet their needs because of divorce, onset of mental health problems, birth of a new baby, or other life stresses. Likewise, insecure infants may become more secure if their environments become more stable. The instability seen in some children’s attachment status may explain the inconsistency in research assessing links between quality of attachment and the later development of mental health problems (e.g., Bates & Bales, 1988). Moreover, environments that predispose children to insecure attachments also typically contain a wide range of other risk factors, so it is not always possible to determine whether adverse effects are due to poor-quality attachment or to other factors (Rutter, 1995). Nonetheless, it is reasonable to consider a disordered attachment, especially at extreme levels, as a risk factor for the development of problems later in life (Carlson, 1998; Rutter, 1995). Temperament The early work of Thomas and Chess (1977) demonstrated individual differences in “temperament,” or the behavioral style of a child’s interaction with the environment, as early as the first few weeks of life. Research in behavioral genetics suggests that many aspects of temperament may be inborn (Goldsmith, Buss, & Lemery, 1997; Plomin, 1989). Thomas, Chess, and Birch (1968) derived a cluster of traits (irregularity of biological functions or rhythmicity, withdrawal from novel stimuli, slow adaptation, intense responses, and predominantly negative mood) called “difficult temperament,” which was thought to be clinically significant. Since that time, research has demonstrated that the “difficult” infant is harder to parent and is at higher risk for developing behavior problems later in life than is the “easy” child (e.g., Bates, Maslin, & Frankel, 1985; Goldsmith et al., 1987; Kagan, 1997; Sanson, Oberklaid, Pedlow, & Prior, 1991). Moreover, an association between specific aspects of temperament and psychological symptoms has been found for school-age children. Lengua, West, and Sandler (1998), for example, reported that negative emotionality was associated with symptoms of depression, whereas impulsivity was related to conduct problems. Not all difficult children develop adjustment problems, however, and some easy children exhibit difficulties later in life. Thomas et al. (1968) introduced the concept of “goodness of fit” to account for this phenomenon. Thus difficult infants with highly stressed, unresponsive caregivers are considered at higher risk for later problems than difficult infants with responsive, sensitive, calm caregivers are (Campbell, 1990; Davies, 1999). Likewise, easy infants born into dysfunctional, highly stressed families may later develop problems, despite being easier to care for during infancy and early childhood. Goodness of fit is an important aspect of understanding the development of the caregiver– infant attachment relationship. As Campbell (1998) states, “Individual differences in the frequency and duration of crying, infant cuddliness and consolability, activity level, alertness, and self-quieting can have profound effects on parental behavior and the quality of the developing parent–infant relationship” (p. 11). The association between temperament and attachment is complex, however, with caregiver behavior and infant characteristics having both direct and indirect effects on attachment security (Susman-Stillman, Kalkoske, Egeland, & Waldman, 1996). Susman-Stillman et al. (1996), for example, found a negative relationship between in-

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fant irritability and “maternal sensitivity” (used broadly to represent a number of maternal behaviors). They argue that the influence of temperament on attachment may be particularly important when maternal sensitivity is low, whereas high maternal sensitivity may mediate the effects of infant irritability. Although various aspects of the construct of temperament (stability, measurement, definition, etc.) continue to be debated, considerable research has demonstrated the relationship between specific dimensions of temperament and other aspects of later development, such as academic skills and IQ (Palisin, 1986), social relations (Keogh & Burstein, 1988), and adjustment to preschool and kindergarten (Parker-Cohen & Bell, 1988; Skarpness & Carson, 1987). Furthermore, temperament is currently being examined as one aspect of the ability to regulate one’s emotions and impulses, and as a mediator of children’s adjustment to a variety of stressful life events (e.g., parental divorce, death of a loved one). Thus consideration of temperamental characteristics in young children is clearly important to understanding many aspects of their development. Questioning parents or other caregivers about a child’s early temperament may shed light on current problems with behavior and interpersonal relationships. A recent book for parents, Understanding Your Child’s Temperament (Carey & Jablow, 1997), may be helpful in preventing problems related to child temperament.

Toddler Development (1–2 Years) Independence The hallmark of development in the second year of life is the child’s striving for autonomy and independence, at the same time that he or she still wants to be close to the primary attachment figure. Children at this age have an intense desire to explore the world and to master new and increasingly complex experiences, but they are still almost completely dependent on their caregivers. Davies (1999) summarizes the primary tasks of the toddler period as these: (1) to balance the need for closeness with exploration of the environment; (2) to become increasingly independent; (3) to begin to internalize parental standards; (4) to gain the ability to control emotions, impulses, and behavior; and (5) to begin to use mental representations in play and communication. Like infants, toddlers are rarely referred for mental health services, although parents frequently discuss problems with their pediatricians. Nonetheless, many later adjustment problems have their origins during this early period. As an example, some amount of defiance and noncompliance is to be expected during the second year of life, and for the first time behavior management becomes an important issue for parents. It is clear that inappropriate parental responses to children’s noncompliance or defiance can exacerbate problems, to the extent that negative reinforcement cycles may develop and persist (Patterson, 1976a). Thus it is not surprising that negative and conflicted parent–child relationships during the toddler period predict continued problems at school entry and beyond (Campbell, 1990; Campbell & Ewing, 1990). Whether the child’s defiance represents the self-assertion necessary to achieve independence or reflects anger and disturbance is the primary question for professionals (Campbell, 1998). Unfortunately, many parents have trouble making this distinction. They may interpret all toddler defiance as a threat to their authority, resulting in excessive punishment; conversely, they may have trouble setting appropriate limits on the child’s behavior, for fear of stifling the child’s initiative. Toddlers have limited internal control over their behavior and impulses; this

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ability develops gradually during the preschool years, driven in part by the development of cognitive and language skills. As a result, a primary parental task is to provide external controls that ensure children’s safety while they are busy exploring their environment.

Preschool Development (2–4 Years) Child psychologists consider the preschool years (ages 2–4) to be among the most important developmental periods, because the foundation for later competence in many areas is laid during this time. The emergence of language, self-awareness, peer relationships, and autonomy/independence, as well as the increased complexity of cognitive, play, social, and motor skills, sets the stage for new and often intense interactions between the child and the environment. As a child’s capacity to interact with the environment increases, so do the problems and concerns of parents. Although most of these problems are transient, significant problems in any one developmental area can affect the development of other skills in other areas. Difficulty with language, for example, can influence cognitive development, or problems with self-control can affect self-esteem and social relationships. Because of their importance to the development of psychopathology, these two areas—language and self-regulation—are discussed in the next sections. Language Development The hallmark of development during the preschool years is the development of language. Although language obviously begins to develop during infancy, and the process continues throughout toddlerhood, the period between 2 and 6 years of age represents a time of enormous growth in children’s language abilities. Rapin (1996), in a synopsis of language development during the first 6 years of life, states that in the first year infants go from cooing vowel sounds to producing repetitive consonant–vowel syllables such as “mama” or “baba” to producing meaningful but imperfect words. In the second year, words are initially acquired one by one, and then vocabulary grows rapidly. After they acquire a few dozen single words, children start to produce two-word utterances. These utterances form the basis for grammar, which allows children to understand and produce meaningful sentences. During the third year, vocabulary increases to hundreds of words, whereas syntactic knowledge moves from the production of two-word utterances to full sentences. From then on, lanugage acquisition involves the comprehension and production of ever more complex sentences, as well as the acquisition of thousands more words. By school age, children start to master written language. Rice (1989) states that without explicit teaching, as many as 14,000 new word meanings may be acquired as children encounter them in meaningful situations and conversations; this phenomenon is the foundation for later reading skills. Moreover, preschool children begin to be able to use language to develop new cognitive skills, to facilitate their understanding of the world, to aid their remembering, to organize their thoughts, and to control their impulses (Rice, 1989). Hart and Risley (1995, 1999) have demonstrated the profound effect that parenting style has on a child’s acquisition of language. They found that children living in poverty, children born into middle-class families, and children with professional parents all had the same kinds of language experiences. Children born into homes with fewer economic resources, however, had fewer of these experiences. In other words, the amount of talking the parents engaged in with their children was a crucial factor in the children’s later language development. Increased frequency of talking provided greater language diversity, a proportional increase in the amount

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of encouragement the children received, a greater opportunity to learn symbols for names and relations, and enhancement of verbal recall. Several other factors have been shown to enhance language development. These include (1) speaking “motherese,” which consists of such features as simple sentences focused on present events, slow rate of speech with pauses at significant words, and paraphrasing of the child’s utterances; (2) semantic contingency or joint attention, which involves immediate responses to the child’s utterances, and conversing about what the child is presently interested in; (3) reading to the child; (4) asking or suggesting rather than demanding; and (5) following the child’s lead during play interactions (Hart & Risley, 1995, 1999; Rice, 1989; Saxon, 1997). One factor that may impede language development is a controlling style of interaction with the child, characterized by many commands, directives, questions, and frequent attempts to shift the child’s attention to whatever the parent is interested in. Middle-ear disease, or otitis media, which is often accompanied by fluctuating hearing loss in preschool children, is associated with delays in language development (Simon, Larson, & Lehrer, 1988; Wallace, Gravel, McCarton, & Ruben, 1988), although this association has recently been found to be mediated by the communication style of caregivers, at least among children from low-socioeconomic-status (low-SES) environments (Wallace, Gravel, Schwartz, & Ruben, 1996). Wallace et al. (1996) found that the language of caregivers of children with and without otitis media did not differ. Among those children with otitis media, however, those whose caregivers used more directives, and fewer questions and informative utterances, had lower language skills. This style of caregiver language was associated with better language skills among low-SES children who did not have otitis media. Otitis media is a significant problem when one considers that as many as 40% of preschoolers’ visits to the pediatrician involve middleear disease (Teele, Klein, & Rosner, 1984). Delays in expressive language in children as young as 1 year with chronic middle-ear infections have been reported (Wallace et al., 1988). Furthermore, a longitudinal study by Feagans, Sanyal, Henderson, Collier, and Appelbaum (1987) indicated that middle-ear disease in the preschool years was related to attentional problems in elementary school, despite the fact that the language delays had resolved. The importance of language development is demonstrated by studies indicating that language mediates cognitive and social development (e.g., Simon et al., 1988; Toppelberg & Shapiro, 2000). Thus delays or disorders of language will impede development in other areas as well. Vallance, Cummings, and Humphries (1998), for example, argue that impaired communicative competence contributes to poor social skills, which may in turn lead to externalizing or internalizing symptomatology. Any of the major categories of speech and language disorders can be seen in children as young as the preschool years, including disorders of speech (articulation, voice quality, and fluency); disorders of language (understanding the symbol system, and production of words, meanings, and grammar); and disorders of communication or pragmatics (social uses of language as a communication system) (Vetter, 1980). Disorders of language and communication (but not speech disorders) are significantly associated with psychiatric disorders in childhood (Toppelberg & Shapiro, 2000) and adolescence (Beitchman et al., 2001). Cantwell and Baker (1991) have reported that as many as 50% of children with language disorders also have psychiatric diagnoses, about equally divided among behavioral and emotional disorders. Beitchman et al. (2001), for example, found that children with language impairments at age 5 years were significantly more likely to have anxiety (primarily social anxiety) and antisocial personality disorders at age 19 years. This association appears to be strongest for children who have problems with receptive language or comprehension. For example, comprehension delays at age 3 have been found to predict behavior problems at ages

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I. THE FOUNDATION

7–11 (Silva, Williams, & McGee, 1987). In a review of 10 years of research on language disorders, Toppelberg and Shapiro (2000) conclude: “The presence of receptive or comprehension language disorders has proven to be the single most important consideration, as they are a highrisk indicator of more phonological, pragmatic, and psychiatric comorbidity, worsening social competence, and hyperactivity over the years and they are often not suspected or detected” (p. 150). Clearly, concerns about language should be referred immediately to the appropriate professionals for assessment and possible intervention. A national resource for parents of children with language problems is the American Speech–Language–Hearing Association, 10801 Rockville Pike, Rockville, MD 20852, 800-638-TALK, http://www.asha.org. Self-Regulation The expression of emotion during the preschool years is usually uninhibited, because the child is in the process of learning how to communicate emotions in socially acceptable ways. Anger is usually expressed behaviorally in response to an immediate stimulus (such as wanting a toy) by biting, scratching, or kicking, but is typically short-lived (Davies, 1999). Temper outbursts occur most often at about 2–3 years of age, and then gradually diminish during the later preschool years (Mesibov, Schroeder, & Wesson, 1977). Self-regulation (e.g., the ability to label emotions, to talk about emotions, and to use language about emotions to guide behavior) increases during the preschool years (Davies, 1999; Kopp, 1989). “Emotional regulation” is defined as “the process of initiating, maintaining, and modulating the occurrence, intensity, or duration of internal feeling states and emotion-related physiological processes” (Eisenberg, Guthrie, et al., 1997, p. 295). “Behavioral regulation” refers to the ability to control emotionally driven behavior (facial or bodily reactions, aggression, etc.). Children face many challanges in learning to regulate their emotions and behavior, including (1) tolerating frustration, (2) coping with fear and anxiety, (3) defending themselves and their property, (4) tolerating being alone. and (5) negotiating friendships (Cole, Michel, & Teti, 1994). How do children come to internalize parental standards and gain control over their emotions and their behavior? This is an important question for parents and professionals, as dysregulation is a common component of most forms of psychopathology. The inability to regulate one’s emotions is associated with behavior problems—externalizing problems for children who are underregulated, and internalizing problems for those who are overregulated (Cole et al., 1994; Eisenberg et al., 1996). Conversely, appropriate regulation is associated with more competent social functioning, both concurrently and in the future (Eisenberg, Guthrie, et al., 1997; Eisenberg, Fabes, et al., 1997). A longitudinal study of over 1,000 children by Caspi, Moffitt, Newman, and Silva (1996) exemplifies this work and highlights the importance of emotional and behavioral regulation in children’s development. In this study, children who were underregulated (i.e., who were irritable, impulsive, and lacking in persistence; had trouble sitting still; and had rough and uncontrolled behavior) at 3 years of age were more likely to qualify for a diagnosis of antisocial personality disorder and to be involved in criminal activity at 21 years of age. In contrast, overregulated or inhibited 3-year-olds were more likely to meet diagnostic criteria for depression at age 21. Controls for family SES did not change these long-term associations. Similarly, Shields and Cicchetti (2001) found that emotional dysregulation differentiated maltreated children who were either bullies or victims of bullying from maltreated children who were neither. The development of emotional regulation begins at birth with the infant’s inborn temperamental characteristics (Calkins, 1994; Kagan, 1994), especially ease and intensity of arousal

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(Rothbart, Posner, & Boylan, 1990). These characteristics set the stage for how the infant will react to incoming stimuli. Experience (particularly the responses of parents or other caregivers), however, also plays a major role in moderating the infant’s reactions (Kagan, 1994). At first, the infant is almost completely dependent on his or her caregivers for regulation. Feeding, clothing, physical comforting, provision of regular and predictable routines, sensitive responding to the infant’s signals, and prevention of excessive stimulation or frustration all help the infant maintain a steady state (Calkins, 1994; Kopp, 1982). Later, parents or other caregivers promote regulation through their interactive styles, such as responsive and contingent versus insensitive, cooperative versus intrusive or controlling, reciprocal versus unilateral, supportive versus overprotective, and accepting versus neglecting (Calkins, 1994; Kochanska, 1995). Moreover, they directly teach regulation by modeling, disciplining, and reinforcing their children (Calkins, 1994; Denham, Mitchell-Copeland, Strandberg, Auerbach, & Blair, 1997). As an example, Kochanska (1995) argues that an inductive style of discipline (i.e., reasoning) elicits the optimal level of arousal in children, allowing them to attend to and process parental messages. Conversely, power-oriented or anxiety-arousing techniques may produce overarousal in a child, interfering with the child’s ability to learn; discipline completely lacking in pressure may not arouse children enough for them to pay attention to their parents or to motivate them to change their behavior. At the same time that parents are assisting the child to regulate his or her emotions and behavior, the child is developing better cognitive and language skills. These skills are critical to the ability to self-regulate, as children learn to communicate their needs and emotions more effectively, begin to understand social situations and the need to regulate their behavior, and gain the ability to apply regulation strategies intentionally (Calkins, 1994). Toddlers can comply with simple requests in familiar, predictable situations, but do not understand the rationale for compliance and do not generalize to new situations. Thus control is entirely external to the child at this age. By 24 months of age, true self-control begins to emerge, and a child has less need for external constraints (Kopp, 1982). Self-control at this age is still largely external, however, and is tied to concrete and specific situations. Parents provide control either by manipulating the child’s environment or by providing consequences for the child’s appropriate or inappropriate behaviors (Pope, McHale, & Craighead, 1988). By 3–4 years of age, children are better able to generalize rules from situation to situation and can recognize when other people behave inappropriately. They also begin to exercise more control by talking out loud about their own behavior. Verbal mediation of behavior increases rapidly during the preschool years. By 5–6 years, this verbal control begins to be internalized. The child then tends to control his or her own behavior by following the rules to get approval from others. At about age 6, the beginnings of moral behavior appear, with the child’s own conscience controlling behavior to avoid personal guilt rather than the condemnation of others. Although 4- and 5-year-olds become quite distressed in the presence of adult emotional expression and show different styles of coping (Cummings, 1987), the accurate interpretation of others’ emotional expressions does not develop until middle childhood (Covell & Abramovitch, 1987; Strayer, 1986). Environmental circumstances also play a role in how children learn to self-regulate. Chronically stressful occurrences, such as parental divorce, death of a loved one, or child abuse, can alter a child’s internal reactivity to emotion and subsequent coping behaviors (Kagan, 1994). Thompson and Calkins (1996) argue that children in these difficult circumstances often resort to nonoptimal regulatory strategies in their efforts to adapt to stressful environmental demands. They note that in some cases (e.g., ongoing parental conflict or abuse), there simply may not be a healthy way to cope.

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School-Age Development (5–12 Years) The developmental tasks for school-age children (ages 5–12) involve the consolidation and refinement of the skills neccesary to meet the expectations of society. It is during this period that children develop new and more complex cognitive and language skills, and refine their fine and gross motor and attending skills. Socially and emotionally, they confront the challenges of dealing with increased numbers of adults and children in both structured and unstructured settings. Self-concept and the perceptions of others become increasingly abstract and consequently more accurate, leading to the development of social support networks outside the immediate family. The hallmarks of development during this period are increased cognitive skills, a more consistent and internalized sense of self, and the development of social relationships outside the home.

Cognitive Development Development of children’s cognitive skills advances rapidly during the school-age years and forms the basis for their development in other areas. From the age of about 6 onward, children no longer think egocentrically and develop increasingly mobile, flexible, reversible, and logical thought processes. By 7–8 years, children are able to use representational or internalized cognitive strategies in a systematic fashion to organize, order, and manipulate objects, numbers, and events. Later, a child is able to think of possibilities that do not exist in reality, to manipulate things mentally that are not actually present, and to see that reality is just a special case of what is possible. These advances in cognition allow for formal schooling and permit the child to master increasingly complex academic material. Moreover, increased cognitive skills allow a child better control over his or her impulses and behavior. Parental standards and rules become internalized, to the extent that the child can use these to guide behavior in the absence of authority figures. It is not surprising that school/academic problems are the most common referral concerns at this age (Campbell, 1998). The transition from preschool to elementary school is often difficult, and many children with learning and/or behavior problems are identified at this time. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994) estimates the general prevalence of learning disorders at 2–10% of school-age children; approximately 5% of students in public schools are identified as having learning disorders, which are more commonly found among boys than girls. According to DSM-IV, children with learning disorders evidence achievement in one or several academic areas (reading, writing, arithmetic, etc.) that is substantially below expectations based on their age, schooling, and intellectual abilities. Learning and behavior problems in school tend to coexist. Attention-deficit/hyperactivity disorder is most commonly associated with a learning disability (Durlak, 1992). Other associated behavior problems include aggression, social withdrawal, depression, poor self-esteem, and language and social skills deficits. Children with learning problems also tend to be rejected by their peers, and thus are vulnerable to the long-term consequences of social rejection, including delinquency, dropping out of school, and various psychiatric disturbances (Durlak, 1992). In general, school problems have been shown to vary with family circumstances; more severe problems are associated with greater family dysfunction. A fairly large number of chil-

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dren are thought to be at risk for adjustment problems in school, with estimates as high as 30% of children in the United States. Durlak (1992) estimates that about 10% of school children have adjustment problems severe enough to interfere with their progress in school. Self-Concept and Self-Esteem Self-concept and self-esteem obviously develop throughout childhood and adolescence (and probably throughout life), but they become increasingly consistent and abstract during the school-age years. “Self-concept” refers to one’s view of oneself; “self-esteem” is defined as one’s self-evaluation, or the discrepancy between one’s actual self-concept and the ideal self (Harter, 1983a). Consistent with cognitive development, preschool chldren tend to view themselves in terms of concrete attributes, such as physical characteristics and possessions. Preschoolers also tend to think of themselves in either–or terms—for instance, as “nice” or “mean,” “good” or “bad” (Pope et al., 1988). At this time, self-concept and self-esteem are largely tied to feedback from parents and other significant adults. During the elementary school years, however, children begin to think of themselves in more abstract terms, and their sense of themselves becomes increasingly dependent on how they think others (especially peers) perceive them. Self-esteem plays a critical role in social and emotional development during the middle school years. Low self-esteem is associated with a number of psychiatric diagnoses (American Psychiatric Association, 1994), and also with poor academic achievement and peer relationship problems. High self-esteem, on the other hand, has been shown to buffer the effects of stress (O’Grady & Metz, 1987). Conversely, successful coping with stressful events can also foster a sense of mastery and thus can enhance self-esteem (Brazelton & Yogman, 1986). Therefore, the association between self-esteem and other factors is somewhat circular. Campbell (1990) states that adults have many opportunities to influence children’s self-esteem. They can reward, punish, or ignore their children’s successful experiences. They can also expose their children to mildly stressful experiences and help them to cope, or they can shield them from every adversity, denying them the experience of mastery and consequent self-confidence. Peer Relations The tasks of social development are complex for school-age children (Davies, 1999). Although parents remain important sources of support, other adults and peers play an increasing role in the child’s socialization. Many aspects of socialization, such as conflict resolution, problem solving, sharing, and behavioral regulation, are worked out in the context of the peer group. Social development is dependent on many other aspects of development, particularly cognitive and language development. Reasoning about the physical world, for example, provides the basis for reasoning about the social world. Social competence is in part a function of the development of specific cognitive skills, such as representational or symbolic thinking and social perspective taking (Howes, 1987), as well as language comprehension and communication skills. Research in behavioral genetics suggests that some aspects of social competence, such as sociability and extroversion, have a substantial genetic component (Plomin, 1989). Moreover, developmental research has shown that children’s experiences in early caregiving relationships provide the basis for the development of social competence (Jacobson & Wille, 1986; Park & Waters, 1989). Jacobson and Wille (1986), for example, demonstrated that the quality

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of the caregiver–child attachment bond was related to the quality of a child’s later peer relationships: Securely attached children had happier, more harmonious, and less controlling peer relations than did insecurely attached children. Children’s friendships, as defined by reciprocity and commitment between individuals who are more or less equal, usually begin to develop during the preschool years with the onset of parallel play. Gradually play becomes more cooperative and reciprocal between 3 and 5 years of age (Howes, 1987), and by middle childhood competition becomes an important part of social relationships, especially for boys (Berndt, 1981). Children’s friendships are primarily same-sex at all ages from the preschool years through adolescence. They are based on common play interests and the attraction that emanates from similarities between self and others. In an excellent review of the development of social relationships, Hartup (1989) describes the importance of having both “vertical” relationships (i.e., attachments to individuals with greater knowledge and social power) and “horizontal” relationships (i.e., relationships in which individuals have equal amounts of social power). Whereas vertical relationships provide security and protection, horizontal relationships allow children to elaborate skills with individuals more or less similar to themselves. These relationships are seen as bidirectional, because both the children and the relationships change as a result of the interactions. As a child gets older, for example, the form of parent–child interactions changes from primarily physical to the parents’ giving verbal instructions to the parents’ sharing information. It is within the context of these relationships that the complexities of cooperation and competitiveness are mastered, and “intimacy” in social relationships is first achieved (Hartup, 1989). There is substantial evidence that having friends is a “developmental advantage” (Hartup, 1989); success with peers is associated in general with better psychological adjustment and school achievement (Campbell, 1998). Because of their intensity and equality, friendships provide optimal context for learning certain social skills, such as cooperation and intimacy. Hartup (1989) points out that although close relationships with other children may not be developmental necessities, being disliked by one’s companions is an important risk factor, because social rejection in childhood is consistently found to be related to later adjustment problems (Coie & Cillessen, 1993; Parker & Asher, 1987). Achenbach and Edelbrock (1981) report that 30–75% of children referred to guidance clinics are reported by their parents to have difficulties with peers. Given the importance of parent–child relationships in the socialization process, Putallaz (1987) suggests that intervention efforts for children with peer relationship problems should be directed at parent behavior as well as child behavior. She states that the parent–child interaction easily becomes cyclical, and if a parent does not change along with a child, the child’s original maladaptive behavioral repertoire will continue to be elicited in interactions with peers.

VULNERABILITY AND RESILIENCE Children are viewed as simultaneously extremely vulnerable and wonderfully resilient. Given their cognitive, physical, and social limitations, children are known to be especially vulnerable to adverse environmental conditions; as such, they are protected by laws against abuse, neglect, and exploitation, and provided with early intervention programs such as Head Start. On the other hand, children are also seen as behaviorally and emotionally resilient, in part because of the developmental process of continual change and adaptation that characterizes childhood. At this point, we might ask, “What makes some children more vulnerable or at risk for devel-

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opmental and/or emotional/behavioral problems?” or, conversely, “Why do some children growup to be competent and productive adults, despite having experienced conditions and stresses that are known to have adverse effects on development?” The answers to these questions are difficult. We know that children with similar histories will have different outcomes, and that children with similar outcomes may reach them by different developmental pathways (Sameroff, 1985). This suggests that a multivariate, cumulative, and dynamic approach to vulnerability and resilience, in which various factors interact over time to exacerbate or moderate the effects of adversity at any given time, may be most helpful (Gordon & Jens, 1988). Rutter (1996) points out that what contributes to psychological vulnerability for an individual child is not an isolated life event or stressor, but rather an aggregated accumulation of stressful events. Similarly, it is recognized that protective factors are also on a continuum, and that when accumulated and present across time, these factors can increase the probability of a positive outcome for children in high-risk situations (Goodyer, 1990). Thus the accumulation and interaction of risk and protective factors, and the identification of areas of strength and vulnerability at any specific point in time, are the critical foci for assessment and treatment.

Risk and Protective Factors The field of developmental psychopathology merges our knowledge of normal development with clinical child psychology in order to give us a better understanding of the interplay of risk and protective factors during the course of children’s development. “Risk factors” in persons or environments result in a heightened probability for the subsequent development of a disease or disorder (Garmezy & Masten, 1986); conversely, “protective factors” are “those attributes of persons, environments, situations and events that appear to temper predictions of psychopathology based upon an individual’s ‘at risk’ status” (Garmezy, 1983, p. 73). One way of categorizing risk factors is to view them as (1) established risk, such as a frank genetic disorder (e.g., fragile-X syndrome, Down’s syndrome); (2) biological risk, such as poor prenatal care, drug and/or alcohol abuse by the mother during pregnancy, prematurity, anoxia, and low birthweight; and (3) environmental risk, such as poor responsivity or lack of sensitivity by a caretaker to a child, low level of language stimulation, or poverty (Odom & Kaiser, 1997). Protective factors can be categorized in the same way. This section focuses primarily on environmental risk and protective factors. Research in developmental psychopathology has identified many environmental factors that directly or indirectly affect children’s resistance or vulnerability to stress (Carta et al., 2001; Rolf, Masten, Cicchetti, Nuechterlein, & Weintraub, 1990). These are summarized in Table 1.2. The clinician must also understand the complex interplay between and among these risk and protective factors. Chronic life stress, for example, is associated with increased adjustment problems among children with few protective factors available to them, but has little effect on children with greater numbers of protective factors (Cowen et al., 1997; O’Grady & Metz, 1987). Moreover, the association between risk and protective factors and adjustment appears to be stronger for boys than for girls (Garmezy & Rutter, 1985; Greenberg, Lengua, Coie, Pinderhughes, & the Conduct Problems Research Group, 1999; McBride-Murry & Brody, 1999). The socioeconomic context of growing up plays an important role in determining the vulnerability or resilience of children. Socially and economically disadvantaged children, for example, are exposed to many more negative life events, and also are more adversely affected by these negative life events than are children from more affluent families (Ackerman, Kogos,

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TABLE 1.2. Risk and Protective Factors in Child Development Risk factors

Protective factors Child characteristics

Medical problems Genetic disorders Birth complications Being male Difficult temperament Low intelligence Uneven development Extremes of activity level Attention deficit Language disorder or delay External locus of control Physical unattractiveness Being first-born Poor coping strategies Social skills deficits Insecure attachment Poor academic achievement Poor self-esteem

Good physical health Absence of genetic disorder Uncomplicated birth Being female Easy temperament High intelligence Even development Moderate activity level Developmentally appropriate attention Normal language development Internal locus of control Physical attractiveness Being later-born Flexible coping strategies Good social skills Secure attachment High academic achievement High self-esteem Family/environment characteristics

Single parent Many children Marital conflict Disagreement over child rearing Chronic poverty Poor social support network Unemployment or underemployment Inadequate child care resources Stressful life events Urban environment Chaotic home environment

Two parents Fewer children Family cohesiveness Consistent discipline Higher socioeconomic status (SES) Good individual and agency support Stable employment Adequate child care resources Low stress Rural environment Consistent, stable home environment Parent characteristics

Depression or schizophrenia Low intelligence Fewer years of education Teenage mother Insensitive/unresponsive parenting Unavailability Low self-esteem Poor parenting models Avoidance coping style (denial) Hypercritical Inappropriate developmental expectations Overly harsh or lax discipline Poor supervision of child Poor physical health Low expectations for child (behavior and academic performance)

Good psychological adjustment High intelligence More years of education Mature mother Sensitive/responsive parenting Availability High self-esteem Good parenting models Flexible coping style High nurturance/warmth Knowledge of developmental norms Authoritative discipline Close supervision and monitoring Good physical health High expectations for child

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Youngstrom, Schoff, & Izard, 1999; McLoyd, 1998; Owens, Shaw, Giovannelli, Garcia, & Yaggi, 1999). On the other hand, a number of child and parent characteristics help buffer the effects of stress, even for those children who grow up in poverty. Masten and Coatsworth (1998), summarizing the research on resilence in children, state that the two variables most consistently found to differentiate resiliant from vulnerable children are good intellectual functioning and a close relationship with a caring parental figure. Other factors include an easy-going, sociable temperament; connections to an extended family support system; supportive contacts with adults outside the family; and participation in socially acceptable extracurricular activities. Parenting that involves consistent, highly structured, age-appropriate discipline combined with warmth and sensitivity, high expectations for behavior and academic achievement, and a strong sense of parenting efficacy has also been shown to buffer the effects of risk (Cowen et al., 1997; McLoyd, 1998; McBride-Murry & Brody, 1999). The parent–child relationship is a critical factor in determining both vulnerability and resilience among children. Viewed in a broad context, this relationship is influenced by child characteristics (such as sex, intelligence level, temperament, and biological status), which interact with parental, familial, and environmental chacteristics to predict the path of development for individual children. The child-rearing practices of parents certainly constitute an important component of this configuration: Parent behavior can set the stage for children to develop and use coping skills that make them more resilient, or, conversely, can place children at increased risk for problems (Blount et al., 1989). The next section reviews the work in this area.

Parenting Practices Determinants of Parenting Current work in the area of parenting practices has focused on the determinants of parenting styles and, not surprisingly, suggests that these determinants are numerous. Belsky (1984) describes three possible sources of influence on parenting: (1) characteristics of the parents, including their genetic and environmental origins and personal psychological resources; (2) characteristics of the child, especially his or her unique temperamental profile; and (3) characteristics of the environmental context of the parent–child relationship, including sources of stress or support (such as the marital or couple relationship and social networks). He and his colleagues argue that parenting is determined by the interaction among these sources of influence (Belsky, Woodworth, & Crnic, 1996). Others (Abidin, 1989; Clarke-Stewart, 1988; Kendziora & O’Leary, 1993) propose that it is also important to understand parents’ attitudes and beliefs about child rearing, because these can be critical motivational factors; that is, they can explain why parents behave toward their children in a particular manner. Kendziora and O’Leary (1993) and Martin (1975) have summarized the various determinants of parenting, and these are shown in Table 1.3. Research related to the most important of these is discussed next. Parents’ Developmental History. The influence of the developmental histories of parents, especially their own parenting histories, on parenting styles is demonstrated most clearly in studies of abusive parents. These show that parents who were mistreated during childhood are more likely than nonmistreated parents to mistreat their own children (Belsky, 1984). But the influence of parenting history has also been demonstrated for “normal” parents (Rodriguez & Sutherland, 1999). Parenting history may have a direct effect on current parenting behavior through modeling (we treat our children as we were treated by our parents) or inverse model-

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TABLE 1.3. Predictors of Parenting Styles and Components of Dysfunctional and Optimal Parenting Predictors of parenting styles • • • •

• • •

•

Attitudes and expectations One’s own parenting models Education Characteristics of the child— conduct problems, activity level, and developmental changes Parental mental health (esp. depression) Marital relationship (esp. ongoing conflict) Social support (esp. insularity—few friends and frequent, highly aversive contact with relatives and helping agencies) Low SES

Components of dysfunctional parenting

Components of optimal parenting

• Uninvolved and not responding to child with sufficient warmth and stimulation • Overly harsh and controlling • Unable to set reasonable expectations and limits • Attends to and reinforces inappropriate behavior while not attending to appropriate behavior • Vague or attacking in communication with child • Doesn’t listen to child • Inconsistent and/or inept in handling situations that require punishment • Too gentle, lengthy, or delayed in dealing with misbehavior

• Enforces rules consistently • Has age-appropriate expectations • Reinforces appropriate behavior • Accepts and nurtures child • Models appropriate behavior • Assigns age-appropriate responsibilities • Provides developmentally appropriate stimulation • Monitors child’s activities • Provides reasons for rules/ limits

Note. The data are from Kendziora and O’Leary (1993) and Martin (1975).

ing (we are determined not to do to our children what our parents did to us) (Muller, Hunter, & Stollak, 1995; Simons, Whitbeck, Conger, & Chyi-In, 1991). Belsky (1984) argues that the influence of parenting history is more likely to be indirect; he states that “in general, supportive developmental experiences give rise to a mature, healthy personality, [one] that is then capable of providing sensitive parental care which fosters optimal child development” (p. 86). A study by Crockenberg (1987) illustrates how parenting history is important in determining current parent behavior. She found that adolescent mothers who had been rejected as children were more angry and punitive with their own children than nonrejected adolescent mothers were. The relationship between early rejection and punitive parenting practices was, however, moderated by current levels of social support: Rejected mothers with good support were less punitive than those with low levels of support. Crockenberg concluded that parenting history has an important but not necessarily a determining role in the way mothers care for their children; early negative experiences of parenting can be overcome by current supportive relationships. Parents’ Psychological Resources. Research on the effects of parental psychopathology, particularly maternal depression, on parenting behavior and child adjustment illustrates the importance of parents’ mental health status in determining how parents interact with their children. This work demonstrates that maternal depression is strongly associated with poor child adjustment. Maternal depression is relatively common among mothers of young children. In a nationally representative sample, McLennan, Kotelchuck, and Cho (2001) found that 24% of mothers of 1- to 2-year-olds and 17% of mothers of children between 2 and 3 years reported elevated depressive symptoms. Mothers who are depressed engage in a variety of negative parental behaviors: increased criticism, physical punishment, and aversive responses to chil-

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dren (Panaccione & Wahler, 1986; Webster-Stratton & Hammond, 1988); avoidance of confrontation and lack of success in controlling child behavior (Kochanska, Kuczynski, RadkeYarrow, & Welsh, 1987); and perceptions of increased child behavior deviance (Schaugnency & Lahey, 1985). The process by which maternal depression influences children’s behavior and/or development is theorized to be indirect. That is, depressed mothers perceive their children more negatively, which leads to increased criticism and punishment, resulting in child behavior problems (e.g., Forehand, Lautenschlager, Faust, & Graziano, 1986). Egeland, Kalkoski, Gottesman, and Erickson (1990) have suggested that maternal depression may indirectly affect children’s development through the home environment. Specifically, depressed mothers may be less organized and provide less stimulation than nondepressed mothers. It may also be the case, however, that the effects of depression on children are direct: Depressed mothers simply may not have the psychological resources necessary for effective parenting resulting in child behavior problems. In a longitudinal study of preschool children with behavior problems, Egeland et al. (1990) provided evidence for this direct link. They found that mothers whose levels of depressive symptomatology decreased over time had children whose functioning improved; conversely, mothers whose depression increased had children who functioned more poorly. These authors have also cited a substantial research literature linking maternal depression with non-nurturing caretaking behavior (e.g., emotional unavailability, poor communication, inconsistency, hostility, and overinvolvement). Campbell (1996) points out, however, that maternal depression and other forms of parental psychopathology often occur in a context of multiple risk factors, some or all of which may account better for children’s adjustment than parental mental health alone. Life stress and daily hassles can also have a negative influence on child adjustment by depleting the resources of parents (Crnic & Greenberg, 1990). The symptoms of irritability, sadness, hostility, and negativity found in depressed mothers are common among highly stressed parents who are not clinically depressed (Downey & Coyne, 1990). It is suggested that stress has a negative effect on parents’ mood, which leads to poor parenting and subsequent adverse child outcomes (Kendziora & O’Leary, 1993). Child Characteristics. The fact that children’s characteristics have an important impact on their relationships with their parents is well accepted. Mothers of infants born prematurely, for example, report more behavior problems in their infants and more parenting stress than mothers of full-term infants (Halpern, Brand, & Malone, 2001). Of all such characteristics that might influence the parent–child relationship, child temperament has engendered the most research. Not only are “difficult” infants more difficult to parent and “easy” infants easier to parent, but children with different temperamental characteristics also respond differently to the same environment. Crockenberg (1987), for example, demonstrated that irritable infants with angry, punitive mothers were more likely to be angry and noncompliant and to have lower self-confidence later than were easy infants with angry, punitive mothers. Child temperament alone, however, does not determine parent–child relationships. Rather, the “fit” among the unique characteristics of the child, the parent, and the environment is the critical factor in developmental outcomes. In a study of high-risk black children, McBride-Murry and Brody (1999) found that parenting protective factors, such as high expectations for child behavior and academic performance and consistent household routines, buffered the effect of difficult child temperament on the children’s ability to self-regulate their behavior. Consistent with this work, Tschann, Kaiser, Chesney, Alkon, and Boyce (1996) found that preschoolers

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with difficult temperamental characteristics who lived in families with high levels of conflict had the most adjustment problems, both externalizing and internalizing. Easy children had fewer such problems, regardless of the level of family conflict. This research highlights the most important issue for prevention and/or intervention—that is, the interplay among the child’s unique temperamental characteristics, the parents’ capabilities and resources, and the broader environment’s ability to support the child’s development within this family context. Other characteristics of children that have been shown to have an effect on parenting are (1) the presence of conduct problems, (2) activity level, and (3) developmental changes (Kendziora & O’Leary, 1993). Anderson, Lytton, and Romney (1986) demonstrated that children with conduct problems elicited more negative feedback and were more noncompliant, regardless of with whom they were interacting (i.e., their own or someone else’s mother). Similarly, increased activity level (or underactivity in some circumstances) in children has been shown to result in increased parental harshness. Finally, parents must adapt to the developmental changes in their children (McNally, Eisenberg, & Harris, 1991). Parenting practices that are appropriate for a 2-year-old, for example, are not necessarily appropriate for older children (Socolar & Stein, 1996). Social Support Networks. The extent of parents’ social support networks—or, more precisely, the match between the support desired by parents and the support they actually receive—has also been shown to influence how parents care for their children. Positive perceptions of social support are associated with parents’ physical and mental well-being, which in turn affects parenting behavior (Cutrona, 1984; Heller & Swindle, 1983). Belsky (1984) argues that social support can have both direct and indirect effects on parenting behavior. Social support (e.g., being loved by a spouse or partner) can have a beneficial effect on parents’ mental health and sense of well-being in general; it can also provide concrete resources (financial help, child care, etc.) that enhance parenting abilities. Contact with friends and family members that is desired and is positively perceived functions to moderate the stresses of parenting (Crockenberg, 1987). Marital Relationship. For currently married parents, the marital relationship can be considered a source of either support or stress. In separated or divorced families, ongoing conflict between parents may provide a significant source of stress that interferes with their abilities to care for their children adequately. Many studies have documented the relationship among marital conflict (in either divorced or intact families), negative parenting behaviors, and child problems (e.g., Shaw & Emery, 1987; Stoneman, Brody, & Burke, 1989). Other work has shown that in intact families, support from one’s spouse may be a critical factor influencing parenting behavior (Brody, Pillegrini, & Sigel, 1986; Crnic, Greenberg, Ragozin, Robinson, & Basham, 1983; Crockenberg, 1987). Most interesting is a study by Howes and Markman (1989) showing that the quality of the marital relationship before the birth of the child influences the child’s functioning 3–5 years later! Abidin (1989) argues that the only aspect of the marital relationship that is relevant to child rearing is the alliance of the parents around child-rearing issues. Belsky (1984), however, points out that the marital relationship may also have an impact on parents’ general psychological well-being, and as such may exert an indirect but important influence on parenting skills. Homosexual Parents. Another factor of interest to child clinicians is the adjustment of children raised by gay or lesbian parents. It is estimated that between 6 million and 14 million

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children have gay or lesbian parents. The majority of these children are born in the context of a heterosexual relationship in which one parent subsequently comes out as a homosexual; however, increasing numbers of lesbian and gay couples are seeking to adopt children, provide foster homes, or use artificial insemination to have children. Thus clinicians are increasingly being asked about the impact on children of living in these “nontraditional” households. Historically, the assumption was made that growing up with gay or lesbian parents would have a negative impact on children’s development in general and their psychosexual development in particular, including problems with gender identity, gender role behaviors, and especially sexual orientation. Moreover, these children were thought to be at risk for isolation from or rejection by peers, as well as a broad range of other emotional or behavioral problems. Although research addressing this question is limited, the data overwhelmingly and consistently indicate that children raised by homosexual parents are at no greater risk for these problems than are children growing up in more “traditional” households (Bailey, Bobrow, Wolfe, & Mikach, 1995; Chan, Raboy, & Patterson, 1998; Golombok & Tasker, 1996). In reviews of research related to the adjustment of children living with homosexual parents, C. J. Patterson (1992, 1997) has concluded that these children do not exhibit significant problems in their psychosexual development. They are happy with the sex to which they belong; they have no wish to be members of the opposite sex; and their interests in and preferences for activities are no different from those of other children. Furthermore, there is no evidence that the number of children raised by gay or lesbian parents who as adults identify themselves as homosexual exceeds that expected in the population at large. These children also have normal relationships both with their peers and with adults of both sexes. Finally, Patterson has found no evidence that children with homosexual parents are more vulnerable to being sexually abused, either by their parents or by the parents’ acquaintances, than are children with heterosexual parents. Not surprisingly, the quality of relationships within the family is more important than the sexual orientation of the parents in influencing children’s development (Chan et al., 1998; Patterson, 1995). If parents are open about their sexual orientation, for example, and this is accepted by other significant people, the mental health of both parents and children is improved (Patterson, 1997; Rand, Graham, & Rawlings, 1982). Children’s ability to accept their parents’ homosexuality is influenced by when they first learn about it, however. It is not surprising that children who are first told in early to middle adolescence have the most difficulty, as these children are in the process of exploring their own sexual identity (Huggins, 1989; Schulenberg, 1985). Physical Punishment The use of physical punishment as a disciplinary strategy has generated considerable controversy among both parents and professionals. Nonabusive corporal punishment is extremely common in the United States. Straus and Stewart (1999), in a survey of a nationally representative sample, found that almost all parents hit their children at some time during childhood. No fewer than 35% of parents reported hitting their infants (0 to 1 year), and the prevalence of corporal punishment increased to a peak of 94% among parents of children ages 3–4 years. Prevalence declined rapidly after age 5, but over half of the parents reported hitting their 12year-old children, and 13% said they hit their 17-year-olds! The severest form of punishment— hitting with an object (e.g., a belt or paddle)—was most common for children between the ages of 5 and 12 years (25% of parents), but physical punishment in general was most frequent

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I. THE FOUNDATION

for 2-year-olds. Physical punishment was most prevalent among African American parents, those living in the South, and parents of boys. These data were replicated by Mahoney, Donnelly, Lewis, and Maynard (2000), who also found that parents of clinic-referred children were more likely to use corporal punishment (spank with bare hand; slap arm, leg, or hand; hit on bottom with hard object; pinch; shake; slap face, head, or ears) and two to three times more likely to use severe physical aggression (hit body with hard object; throw or knock down; hit with fist or kick hard; beat up; grab neck and choke; threaten with knife or gun) with their children than were parents of nonreferred children. As in the Straus and Stewart (1999) study, the use of corporal punishment in general declined with the age of the child; however, the prevalence of severe physical aggression in particular remained stable across development. Furthermore, although their use of corporal punishment declined with child age, parents of clinic-referred adolescents were twice as likely to use corporal punishment to control their children as parents of non-clinic-referred teenagers were. The debate about corporal punishment revolves around whether or not it has harmful effects on children’s development. Reviews of research have reported inconsistent results. Some studies find an association between corporal punishment of children and a variety of adverse effects, such as aggression, depression, and later spouse abuse (e.g., Straus, Sugarman, & GilesSims, 1997; Straus & Yodanis, 1996; Turner & Finkelhor, 1996); others have found no negative effects, at least when the punishment occurs in the context of a warm, supportive parental relationship (Baumrind, 1994, 1996; Rohner, Bourque, & Elordi, 1996). Rohner et al. (1996), for example, reported that corporal punishment had an adverse affect on children’s adjustment only when it was perceived as reflecting parental rejection. In contrast, Turner and Finkelhor (1996) found a significant association between physical punishment and child distress and depression even at low levels of punishment. Moreover, the association was strongest in the context of high parental support. Despite the inconsistency among studies, it seems clear that many children experience corporal punishment as highly stressful, and that for some it results in poor adjustment and increased aggressive behavior (Turner & Finkelhor, 1996; Straus, 1991; Straus & KaufmanKantor, 1994). Moreover, the risk of escalation from corporal punishment to severe physical aggression by parents who rely on physical discipline tactics to control their children or who have particularly difficult children is high (American Academy of Pediatrics, 1998). Mahoney et al. (2000) confirmed that the more parents of clinic-referred children perceived their children as being oppositional and antisocial, the more likely they were to use physical punishment. It is possible that frustrated parents resort to physical punishment because they feel that other methods of discipline have not worked to curb their children’s aversive behavior. However, the use of physical punishment may exacerbate a child’s aggressive and antisocial behavior. Mahoney et al. (2000) argue that their results are consistent with the concept of coercive cycles that develop and escalate in the interaction between parents and children with conduct problems (Patterson, 1982; Patterson, Reid, & Dishion, 1992); this suggests that causation is probably bidirectional. Perhaps a more important question is whether corporal punishment accomplishes what parents want it to. That is, does it teach children to behave in a more appropriate manner? Spanking certainly gets children’s attention, and initially it may stop inappropriate behavior. But research suggests that it is not effective over time. The more it is used, the less effective it becomes—in part because children habituate quickly, forcing parents to punish more frequently and more harshly. Parents who spank their children tend to spank them a lot, and many continue to spank as the children grow older, suggesting that children do not learn how to behave

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as a result of physical punishment (Straus & Stewart, 1999). It is possible that this is the case because spanking does not teach children acceptable alternative behaviors; it simply teaches them what not to do (American Academy of Pediatrics, 1998). Moreover, physical punishment models an aggressive way of dealing with problems and indicates that it is OK for a bigger person to hit a smaller one. If the real issue is “How do we teach children appropriate behavior?”, learning principles suggest a number of methods that are more effective than physical punishment. These are discussed in detail in Chapter 10. Parenting practices that have been shown to promote more optimal adjustment in children are discussed next. Optimal Parenting Practices Despite the knowledge that many other factors influence children’s behavior, we know that parents remain a critical avenue through which child behavior and development are influenced. With the interrelated factors described above in mind, an important question for clinicians is “What can parents do to ensure more optimal development for their children?” Considerable research has addressed this question, and the major components of optimal parenting are summarized in Table 1.3. Baumrind (1967) first identified an association between “authoritative” parenting (warm, reasonable, nonpunitive, and firm) and positive child behavior. Conversely, overcontrolling or authoritarian discipline and undercontrolling or permissive discipline were associated with negative child behavior. Building on this work, Belsky (1984) has described the kinds of parenting at different ages that are thought to promote optimal child functioning. In infancy, cognitive and motivational competence and healthy socioemotional development are promoted by parents’ attentive, affectionate, stimulating, responsive, and nonrestrictive caregiving. For preschoolers, high levels of nurturance and affection, accompanied by firm control, foster the development of good social skills, resourcefulness, and achievement motivation. By school age, inductive reasoning, consistent discipline, and expressions of affection are positively related to self-esteem, internalized controls, prosocial orientation, and intellectual achievement. Pettit and Bates (1989) suggest that proactive parent behavior—characterized by monitoring children’s activities, providing anticipatory guidance, expressing affection toward the children, and teaching—function to prevent children’s misbehavior and thus reduce the need for parents to react punitively when children behave inappropriately. They found that in families where children were perceived as having behavior problems, mothers exhibited less proactive behavior than mothers in families with nonproblem children did. Dishion and McMahon (1998) propose monitoring as a critical skill that is relevant for parenting from infancy to adolescence, although the specific methods of monitoring will necessarily change with development. “Monitoring” is defined as “a set of correlated parenting behaviors involving attention to and tracking of the child’s whereabouts, activities, and adaptations” (p. 61). It is designed to enhance parents’ awareness of children’s activities and to communicate to children that their parents are concerned about and interested in what they are doing. Monitoring in infancy includes sensitive and responsive parenting, as well as joint attention to play activities. In the preschool years, monitoring ensures a child’s safety and can also be seen in joint attention, with verbal descriptions of the child’s activities. Monitoring a school-age child involves keeping track of school achievement, homework, and activities; knowing who the child’s friends are; and attending extracurricular activities, such as sports events, dance recitals, and school plays. During adolescence, monitoring means knowing where and with whom the child is, tracking school achievement, and attending extracurricular events in which the child is involved.

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I. THE FOUNDATION

Recent work has examined the role that fathers play in their children’s development (e.g., Amato & Rivera, 1999; Coley, 1998; Tamis-LeMonda & Cabrera, 1999). This work indicates that the involvement of fathers and father figures (stepfathers, adult male friends, and relatives) with children is increasing as more mothers join the work force. A father is more likely to be positively involved with a child if he perceives the birth of the child as a desired event, has participated in the birth process and early care of the infant, has role models for father involvement, has a good relationship with the child’s mother, and has employment that is flexible enough to allow him to spend time with the child (Aldous, Mulligan, & Bjornason, 1998; Belsky, 1998; Brown & Eisenberg, 1995; Cox, Owen, Lewis, & Henderson, 1989). Tamis-LeMonda and Cabrera (1999) have reviewed the research in this area and found that for young children, fathers’ emotional investment, attachment to children, and provision of resources are all associated with the children’s well-being. For older children, fathers’ involvement (attending school meetings and/or parent–teacher conferences) is related to children’s academic performance. Moreover, fathers are particularly important in influencing children’s socialization and academic success. Specifically, Coley (1998) found that children who perceived their fathers as warm and as providing control had fewer behavior problems in school and engaged in more prosocial behaviors with peers. Dysfunctional parenting styles of both fathers and mothers, on the other hand, are clearly associated with a variety of child adjustment problems. The characteristics of dysfunctional parenting have been described by Kendziora and O’Leary (1993) and are summarized in Table 1.3.

Day Care as a Risk Factor General Effects of Day Care Concerns about the effects of day care on the development of children have soared as increasing numbers of mothers join the work force. These concerns revolve around the question of whether day care should be considered a risk factor for children’s development. That is, have negative effects of day care on children’s development been documented—and if so, what areas of development are affected, and what factors mediate or moderate these effects? Research on the effects of day care has focused on children’s emotional, social, and intellectual development. With regard to emotional adjustment, Clarke-Stewart (1989) concludes from a comprehensive review of this research that little consistent evidence exists for detrimental effects of day care on children’s emotional adjustment, as measured by the mother– child attachment relationship. She argues that studies showing that children in day care are less securely attached to their mothers have failed to consider that Ainsworth’s Strange Situation (the most common method of measuring attachment) may not be a valid assessment method for these children; they may not perceive it as a very stressful situation and thus may not exhibit attachment behaviors. Other reviews concur with this reasoning (Hoffman, 1989; Scarr, Phillips, & McCartney, 1990; Scarr, 1998). One recent study, however, has indicated that children are particularly vulnerable to attachment problems at certain ages if they enter day care during these times (Varin, Crugnola, Molina, & Ripamonti, 1996). In this study, children who started day care between 6–12 months and 18–23 months of age had more attachment difficulties and lower tolerance for frustration than those who entered either earlier or later. Research focusing on the effects of day care on children’s social adjustment has consistently documented greater levels of aggression and noncompliance in day care children than in children raised at home (Clarke-Stewart, 1989; Haskins, 1985; Scarr et al., 1990). Other

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studies, however, suggest that these behaviors may be primarily a function of the curriculum content of the day care program or of specific activities or toys. That is, when the curriculum is modified (e.g., by teaching prosocial behaviors) or activities and toys are changed (e.g., enough trucks are provided so that each child can play with one), levels of aggression and noncompliance decrease (Finkelstein, 1982). With regard to cognitive development, Clarke-Stewart (1989) concludes that day care may give intellectually average children a “head start,” but that children reared at home catch up quickly when they enter school. Among economically and socially disadvantaged children, however, the day care experience may serve to prevent a decline in intellectual functioning that results from a lack of early intellectual stimulation (Ramey & Campbell, 1984). Research on the effects of maternal employment, which almost always involves placing children in out-of-home care, is consistent with that discussed above: No short- or long-term adverse effects of maternal employment on child adjustment have been found (Harvey, 1999). However, Clark, Hyde, Essex, and Klein (1997) demonstrated a relationship between length of maternity leave and the quality of mother–infant interactions; shorter leave was associated with less sensitive parenting. This relationship was mediated by mothers’ symptoms of depression and infant temperament. Clark et al. (1997) suggest that mothers who experience symptoms of depression, and also have infants who are more difficult to care for, may find early return to work very stressful. This stress in turn affects their relationships with their infants and places the children at risk for later adjustment problems. In summarizing research related to mothers’ working, Hoffman (1989) states that “maternal employment is not so robust a variable that it can be related to child outcomes. It operates through its effects on the family environment and the child care arrangements, and these are moderated by parental attitudes, family structure, and other variables” (p. 289). The effects of day care on children’s development thus seem to be mediated by many of the same familial and environmental factors that influence the development of any child (Howes, 1988). These include a mother’s attitudes, beliefs, and perceptions of child rearing; her general sense of well-being; the support she receives from her spouse/partner and/or her family; her level of education; and her child-related behaviors. Factors unique to working mothers and day care that influence children’s development are mothers’ feelings about working and about their child care arrangements, and, most important, the quality of the care provided (Peterson & Peterson, 1986). The quality of day care is a critical factor. Quality of care can be evaluated on two levels: structural and process. High structural quality includes (1) age-appropriate caregiver–child ratios, which are related to increased safety and better cognitive and language stimulation; and (2) smaller group size, which is related to less caregiver time spent in management tasks and more spent in social, educational, and cognitive activities. High process quality consists of (1) sensitivity and responsiveness to the children’s needs; and (2) provision of developmentally apropriate stimulating activities, both of which are associated with caregiver training. A third important aspect of quality is the stability of care or low staff turnover, which gives children the opportunity to form emotional attachments with their substitute caregivers. Quality of care is consistently related to various areas of child development (but see Scarr, 1998, for a different opinion). Moreover, the positive effects of high-quality care during the preschool years have been shown to last well into elementary school (Broberg, Wessels, Lamb, & Hwang, 1997). Burchinal and colleagues (Burchinal, Roberts, Nabors, & Bryant, 1996; Burchinal et al., 2000), for example, have found that quality of care (specifically, child–adult ratio and teacher education) is positively related to children’s cognitive, language, and com-

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munication skills during the first 3 years of life. Similarly, Volling and Feagans (1995) reported an association between quality of care and children’s social competence, nonsocial play, and positive interactions with caregivers. Furthermore, high-quality day care reduced the incidence of social problems for children who were temperamentally vulnerable (i.e., rated by their mothers as socially fearful). The effects of quality of care are thought to be most important for children who live in impoverished environments (Scarr, 1998). High-quality day care for these infants and preschoolers has been used as a form of early intervention and has been shown to improve their school achievement and social behaviors later in life (Ramey & Ramey, 1992, 1998). Sexual Abuse in Day Care Settings Parents often worry that they have placed their children at increased risk of sexual abuse by leaving them in the care of others. Finkelhor, Williams, and Burns (1988) addressed this concern through a survey of 270 day care settings across the United States in which sexual abuse was substantiated during 1983–1985; these authors concluded that in reality, young children are at greater risk of sexual abuse in their own homes than in day care settings. This study did not include informal small-scale child care operations, however, and thus it may have somewhat underestimated the risk of sexual abuse for children in day care. A study by Margolin (1991) described cases of sexual abuse by nonrelated caregivers in informal arrangements or working in unlicensed, unregistered facilities. In 31% of the sample of 325 cases, the abuse was committed by a caregiver hired by parents, often caring for a child in the parents’ own home. The perpetrators in these cases were more likely than expected to be female (36%) and adolescent (mean age was 16.9 years). Other perpetrators were adult friends of children or parents (18% of cases), relatives of caregivers (16%), ad hoc caregivers (8% of cases), live-in caregivers (8%), or parents of the children’s friends (6%). Most disturbing about these cases is the finding that parents often were extremely careless in choosing a caregiver (e.g., they had reason to believe the caregiver had a history of molesting children, left the child with someone they did not know, or left the child with someone who was intoxicated); did not attend to the child’s discomfort with or dislike of a caregiver; or did not change caregiving arrangements when the child told them about being molested. Provision of adequate and affordable day care for all families who need it is an enormous problem. Although high-quality care is available, it is costly, and many families are forced to rely on less than adequate arrangements. Moreover, the difficulty of finding any child care— much less affordable, good-quality care—is often so great that parents may be tempted to overlook signs that a child is suffering. Finkelhor et al. (1988) discuss the role that parents can play in the early detection, follow-up, and prevention of sexual abuse in day care settings. Their suggestions are summarized in Table 1.4.

PREVENTION OF PROBLEMS Children are prime targets for prevention programs, because many have not yet experienced significant damage from threats to their mental and physical health. The literature contains descriptions of a wide variety of prevention programs for children, including programs to prevent child abuse and accidents; programs to alleviate fears of medical and dental procedures; programs to prevent emotional/behavioral problems for children of divorce or chronically ill

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TABLE 1.4. What Parents Can Do to Prevent Sexual Abuse in Day Care Settings 1. Visit frequently and at irregular times (e.g., pick up the child early or drop off late). 2. Insist on free access to all areas of the day care center. Locked doors, and rules about when parents can visit, are grounds for suspicion. 3. Participate in the program as much as possible. 4. Interview people who live in or visit regularly the home of the day care provider. 5. Be equally suspicious about day care in “good” and “high-risk” neighborhoods. 6. Be alert to signs of distress in your child, and seek advice from your primary health care provider. • Persistent not wanting to go, and eagerness to leave when picked up. • Significant changes in behavior (e.g., nightmares, toileting problems, general fears, whininess) that resolve when the child is absent from day care for a period of time. • Unusual sexual behaviors. • Physical complaints (e.g., genital rashes, itching, bruising). 7. Discuss the possibility of sexual abuse with your child. • “Nothing that happens should be a secret, no matter what you are told.” • “Tell me immediately if anyone does anything mean.” • “Once you are home, you are safe. Day care staff have no power to harm families.” 8. Teach your child about appropriate and inappropriate behaviors in the bathroom. 9. Teach your child about the intimidation tactics often used to ensure children’s silence. • “If anyone threatens you in any way, tell me right away.” • “Mom and Dad are more important and powerful than any day care teacher. We will always protect you.” Note. Data from Finkelhor, Williams, and Burns (1988). Reprinted from Gordon and Schroeder (1995). Copyright 1995 by Plenum Press. Reprinted by permission.

children; parent education programs; and educational programs for disadvantaged children (Lorion, Myers, Bartel, & Dennis, 1994). Most recently, programs to prevent school-based violence by promoting social competence have been developed (Henrich, Brown, & Aber, 1999). The critical issues for any prevention program are (1) demonstration of the program’s effectiveness in actually preventing the targeted behavior(s) or disorder(s), and (2) its cost– benefit ratio. Price, Cowen, Lorion, and Ramos-McKay (1989) reviewed 300 prevention programs and summarized the components shared by programs with demonstrated effectiveness. Effective programs (1) targeted a specific group of people; (2) were designed to alter the life course trajectory of the participants (i.e., they aimed for long-term rather than short-term effects); (3) strengthened the support systems available in the family, community, and school; and (4) provided extensive, carefully designed research to document their success. Price et al. (1989) state that cost–benefit analyses are rarely done in evaluating prevention programs, despite the critical information these can provide for policy makers and taxpayers. They note two factors to consider in doing such analyses: (1) Benefits may not be apparent in the short term, but rather may increase over often lengthy periods of time; and (2) policy makers and taxpayers want to know who will gain or lose from the program, as well as the size of the gain or loss. Finally, Price et al. (1989) note that although some programs may never be completely costeffective, they may have great value in promoting human dignity or relieving human suffering. Recent work indicates that prevention programs also need to be modified in order to be most effective with children from different cultural groups or ethnic backgrounds (Podorefsky, McDonald-Dowdell, & Beardslee, 2001). The need for prevention programs for children is highlighted by the American Psychological Association Task Force on Prevention, which cites the increasing discrepancy between

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the number of children who need mental health services and the number of providers of those services (Price et al., 1989). Despite increasing interest in prevention among professionals, Rickel and Allen (1987) argue that competition between prevention and direct services for scarce resources, particularly funding and staff time, has inhibited the development of prevention programs to the extent thought to be necessary. This situation will change only when professionals concerned with the welfare of children bring knowledge from the research community to the attention of legislators and others who shape public policy (Rickel & Allen, 1987). Child clinicians can play an important role in this process by advocating on a local, state, or national level for the needs of children.

Parent Education Programs In an attempt to prevent the common problems of childhood from persisting and/or becoming increasingly severe, professionals have focused on providing parents with information about child development and training in behavior management techniques. Parent education or parent training programs have become increasingly popular, and child clinicians can play an important role by offering these programs to parents in their communities. A distinction is made between “parent education” and “parent training”: Parent education focuses on preventing the development of dysfunctional child behavior, whereas parent training attempts to resolve serious child disturbances (Schaefer & Briesmeister, 1989). Thus parent education is seen as “universal” prevention, whereas parent training is viewed as “selective” or “indicated” prevention. Both types of programs, however, share such techniques as provision of information, teaching behavioral and learning principles, building parenting and communication skills, and developing problem-solving skills. Parent training programs can be viewed broadly as the primary focus in the treatment of young children’s maladaptive behavior. The parents are in fact the ones who must carry out a sleep program or a habit reversal program, or who must change their behavior or the environment to support a child’s learning new skills or decreasing negative behavior. Moreover, many of the parent training programs that focus on teaching specific management techniques also provide parents with techniques that can foster optimal development in many areas. For example, teaching parents how to use reflective comments can foster a child’s language development and self-esteem. Teaching parents how to use time out contributes to an authoritative parenting style (warmth with firm limits). Learning to use contingent reinforcement provides a child with opportunities to develop positive self-esteem and learn new skills in other areas. Parent education has received increased attention from child clinicians. Schultz and Vaughn (1999), for example, surveyed parents attending an urban pediatric primary care clinic about their need for information. Most parents had questions about child rearing and indicated that parent handouts, parent groups, and videotapes shown in the clinic waiting room would all be desirable methods of disseminating information. What should be the focus of programs employing these methods, however? The content and theoretical views of parent education programs are extremely varied, and many do not reflect current research and thinking in child development (Dangel & Polster, 1984; Taylor & Biglan, 1998). As previously stated, it is difficult to identify specific causal mechanisms in the development of childhood disorders, and equally difficult to delineate the specific factors contributing to or mediating outcome (Campbell, 1990). We can, however, share with parents our knowledge about factors that increase vulnerability or resilience in children, including specific parenting styles and practices as outlined in Table 1.3. Teaching parents specific parenting practices that have been shown

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to increase positive parent–child interactions, and assisting parents in setting limits and providing consistent consequences for inappropriate behavior, would constitute a reasonable approach to parent education programs. To be effective, parent education programs not only should focus on specific information about child development and management techniques, but also should take into account the broader personal needs of the family members. We know, for example, that maternal depression or anxiety, a poor social support network, and marital discord are all associated with the development of behavior problems among children (Bush & Cockrell, 1987; Panaccione & Wahler, 1986; Stoneman et al., 1989). Parents with these problems are less likely to access parent education programs than are better-functioning parents. Moreover, it is important to consider child characteristics in planning for effective parent education, because children respond differently to different parenting techniques. Thus parent education programs should provide information on the relationship of these risk factors to child behavior, as well as guidelines for when parents should seek professional help. Clarke-Stewart (1988) calls for clinicians to provide parent training programs for non-clinic-referred parents that are similar to those designed for parents of behavior-disordered children, and Webster-Stratton (1982) presents evidence that such programs can be effective in changing mothers’ attitudes and behaviors in a costeffective manner. Taylor and Biglan (1998) review the components of parent training programs that have empirical support for their effectiveness. These are discussed in detail in Chapter 10. Taylor and Biglan argue that many popular parenting programs, such as Parent Effectiveness Training (Gordon, 1970) and Systematic Training for Effective Parenting (Dinkmeyer & McKay, 1976), lack any evaluation of effectiveness; some of these programs also strongly advise parents against using certain proven behavioral techniques, such as praise or time out. In contrast to these programs, Taylor and Biglan (1998) recommend several books for parents that offer empirically supported advice for parents. These include Parenting the Strong-Willed Child (Forehand & Long, 1996) and The Incredible Years: A Trouble-Shooting Guide for Parents of Children Aged 3–8 (Webster-Stratton, 1992b). We also like the following books for parents: How to Talk So Kids Will Listen and Listen So Kids Will Talk (Faber & Mazlish, 1999); The Confident Child: A Practical, Compassionate Guide (Apter, 1997); and Hyper-Parenting: Are You Hurting Your Child by Trying Too Hard? (Rosenfeld & Wise, 2000). In summary, this research indicates that the expertise is available to design and implement more effective parent education programs. Further research is needed, however, to examine the relative efficacy of different contents, teaching methods, and instructors for different samples of parents and children.

Prevention of Accidental Injuries Another form of prevention that is receiving increasing interest is the prevention of children’s accidental injuries. The normal developmental chacteristics of children (e.g., mouthing objects, high activity levels, curiosity, and exploratory behavior) place them at high-risk for injuries (Baker, O’Neill, Ginsburg, & Li, 1992). This is reflected in the very high incidence of injuries among children. Data from the National Center for Injury Prevention and Control (1999) indicate that “each year between 20–25% of all children sustain an injury sufficiently severe to require medical attention, missed school and/or bed rest.” Whether a child’s injury is considered accidental or intentional is often difficult to determine; thus data on intentional and nonintentional injuries are often combined. These two types of injury account for more childhood deaths than the next six most frequent causes of death combined. Christophersen notes

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that there has been a dramatic increase in the number of childhood deaths due to both accidents and violence over the last 50 years, in part reflecting a general increase in violence in U.S. society. The relationship between physical abuse and childhood injuries is complex. Garbarino (1988) has classified childhood injuries on a continuum from random accidents to preventable accidents to negligence to assault, although there is some overlap between these categories (e.g., injuries resulting from automobile accidents would once have been considered random accidents, but now are considered preventable). Furthermore, whether or not an injured child is reported for physical abuse is related to socioeconomic and racial factors. Specifically, black and low-SES white parents who seek medical attention for their children’s injuries are more likely to be reported for child abuse than are white parents from higher-SES backgrounds (Daniel, Hampton, & Newberger, 1983). Injuries that occur in the home are responsible for the majority of childhood deaths, and boys are more vulnerable to these injuries than girls, presumably because of behavioral differences (Christophersen, 1989). Matheny (1986), however, found that characteristics of the mother and the environment were more closely related to injuries than child characteristics were. Toddlers whose mothers were more emotionally stable, active, and energetic; whose mothers had more education; and who lived in better-organized, less cluttered homes were less vulnerable to accidental injury. Poor parenting, particularly a lack of appropriate supervision or monitoring of the child, plays a critical role in the occurrence of childhood injuries (Dishion & McMahon, 1998; Garbarino, 1988). DiLillio and Peterson (2001) outline various approaches to injury prevention, which include passage of laws requiring people to change their behavior (e.g., laws requiring use of seat belts) and passive control by redesign of products and the environment (e.g., safety caps for medicine bottles). Other successful approaches to prevention of accidental injuries have utilized principles of reinforcement. Roberts and Turner (1986), for example, rewarded parents with lottery tokens redeemable for prizes for using child safety seats, and reported significantly increased usage during a 2-week period. Still other approaches have taught parents to use standard behavior management techniques to decrease dangerous behavior in their children (Matthews, Friman, Barone, Ross, & Christophersen, 1987). Of most relevance to the child clinician is research cited by Christophersen (1989) demonstrating that information given to parents before the birth of a child is more effective in changing parents’ child-safetyrelated behavior than information given when the child is a preschooler. Parents are apparently more receptive to child-related information during pregnancy than after the child is born (when they probably are too busy and too tired to pay attention!). This suggests that other types of prevention programs for parents should begin prenatally, at which time parents could be given information designed to prevent a variety of childhood problems.

Early Intervention Programs Yet another form of prevention that interests child clinicians is the early intervention program. Early intervention programs have primarily targeted high-risk children; they include educational programs such as Head Start, model programs such as the Abecedarian Project (Horacek, Ramey, Campbell, Hoffmann, & Fletcher, 1987; Ramey & Campbell, 1984), and interventions in the family system (Heinicke, Beckwith, & Thompson, 1988). Of most concern to child clinicians is family-focused early intervention.

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Family-focused early intervention is directed at changing parental functioning so that permanent negative effects on children are minimized (Heinicke et al., 1988). This type of intervention is typically “selective” or “indicated.” Intervention can be directed at developing positive child-rearing techniques, improving parents’ abilities to cope with stress, and/or promoting children’s adaptive behaviors. The goal is not only to forestall events that are harmful to children’s development, but also to enhance the children’s ability to cope with difficulties that occur in the normal course of development (Wolfe, Edwards, Manion, & Koverola, 1988). As an example of family-focused early intervention, Sanders (1999) describes a multilevel parenting and family support program that was designed to reduce the prevalence of behavioral and emotional problems in preadolescent children. Components of the program ranged from “universal” to “indicated” prevention and included the following: 1. Media and promotional strategies, such as television and radio advertisments, newspaper columns dealing with common parenting issues, and 13 episodes of a 30-minute “infotainment” television show. 2. A brief 20-minute consultation for parents with specific concerns about a child’s behavior or development, a series of parenting “tip sheets,” and four brief videotape programs. 3. Four 20-minute sessions that presented information, and allowed parents to practice specific skills and selective use of parenting tip sheets. 4. Ten 90-minute individual sessions with home visits for some high-risk individuals, eight group sessions with follow-up telephone contact for other high-risk parents, and telephone-assisted and self-directed parent training for those who could not come to the clinic. 5. Family intervention targeted toward families with additional risk factors that did not change as a result of lower levels of intervention. Each of the components of this program has been evaluated, and all are reported to be successful in meeting their individual goals. In another example, Burns, Hoagwood, and Mrazek (1999) reported long-term (i.e., 15-year!) benefits of a prevention program targeted at highrisk pregnant women. Those who received the most intense and longest intervention (home visits every 2 weeks during pregnancy, continued home visits until a child was 24 months old, free transportation to the health care clinic, and developmental screening at 1 and 2 years of age) demonstrated the most benefit from the program. Benefits noted included less use of welfare, better education, and less drug use. In a review of 20 early intervention studies with high-risk families, Heinicke et al. (1988) found that 15 (75%) showed at least one significant positive effect. The studies reviewed included work with parents during pregnancy, immediately after a child’s birth, and ongoing sessions from the age of 1 month to school entrance. The number of sessions varied from 1 to over 1,000 contacts. Those programs producing a more pervasive effect—that is, those that influenced children’s functioning in a greater number of areas—had 11 or more contacts with each family, which began before or shortly after the birth of the child and continued for up to at least 3 months of age. Heinicke et al. (1988) concluded that this is the length of time needed to develop a trusting relationship with high-risk families and to help them identify and resolve core issues. Although this in no way means that the direct impact on the parent–child relationship is not significant, it does indicate that intervention may be primarily leveraged through

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the relationship between the intervenor(s) and the family, rather than through direct work with the child. More recently, Ramey and Ramey (1998) have summarized the early intervention research focused on improving children’s cognitive skills. Based on the results of many studies across four decades, they propose six principles that should guide development of successful early intervention programs: 1. Developmental timing. Interventions that begin earlier in a child’s life and continue longer are more effective. 2. Program intensity. Programs that are more intensive (e.g., more visits, more hours, more days per week, more weeks per year) are more effective. Moreover, parents and children who participate more regularly and actively show greater positive results. 3. Direct provision of learning experiences. Children who receive direct intervention show larger and longer-lasting benefits than do children in programs that rely on intermediary intervention, such as training parents in ways to enhance their children’s cognitive development. 4. Program breadth and flexibility. More comprehensive programs that use multiple methods to affect child development are more effective than those with a narrower focus. 5. Individual differences in program benefits. Some children will show greater benefits than others. In some cases those at highest risk benefit most, whereas in other cases the opposite is true. 6. Ecological dominion and environmental maintenance of development. Initial positive effects tend to diminish over time, to the extent that environmental supports to maintain the child’s gains are lacking. Thus programs that involve parents, teachers, and other important adults are likely to be more beneficial. The success of early intervention programs that focus primarily on children has been directly linked to parental involvement. Haskins (1989), in a review of the efficacy of preschool education programs, concluded that although model programs (those included in a national consortium of outstanding early intervention programs) and the Head Start program both have immediate positive effects on the intellectual performance and social competence of children, this effect declines for Head Start children in the first few years of public schooling. In contrast, the evidence for improvement on long-term measures of school performance (e.g., special education placement) and “life success” measures (e.g., teen pregnancy, delinquency, use of welfare, and employment) is substantial for the model programs; there is no evidence linking Head Start attendance with any of these variables. Among the outstanding features of the model programs is parent and teacher involvement, which no doubt accounts for some of these differences. Haskins (1989) describes one program that included 90-minute home visits by teachers each week!

Prevention of Child Abuse Prevention of Physical Abuse Because child physical abuse typically involves the interplay of a wide variety of risk factors, the goals of prevention programs targeted at this problem are necessarily complex. Wolfe, Repucci, and Hart (1995) state that prevention of child abuse involves “establishing the parents’ ability to cope with external demands and provide for the developmental and socialization needs of their children while reducing the barriers of stress that [im]pose upon the family”

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(p. 6). These authors reviewed research related to prevention programs for physical abuse. Programs that targeted at-risk parents were found to be effective (at least in the short term) in improving parents’ attitudes and behavior, as well as the overall adjustment of mothers. No particular approach was found to be essential, except that fairly intensive group and home visit components were associated with effectiveness. Programs that targeted new and expectant parents (including high-risk low-SES groups) were beneficial even if they provided only brief home visits, if the participants were considered to be at lower risk of abuse; high-risk participants did not benefit from less intense interventions. Programs for adolescent parents required more intensive home visits to demonstrate effectiveness. Wolfe et al. (1995) conclude that multilevel programs offering escalating services over time, depending on the needs of families, are necessary with this diverse population of parents. Programs that continue for 1–3 years and are personalized (i.e., home visits) are most successful with higher-risk parents. Moore, Armsden, and Gogerty (1998) describe an early intervention/prevention day care program for abused and high-risk children ages 1 month to 5 years. The program’s goals were to decrease the long-term adverse effects of maltreatment and to reduce the likelihood of recidivism. Parents and siblings of the targeted children also received services. The 12-year follow-up data indicated that the children who received treatment had fewer behavioral and emotional problems, more positive home environments, and better parent–child relations than a group of abused children who received community services. Furthermore, the treatment group was significantly less prone to violence, aggression, and anger, and had fewer disciplinary actions in school. Prevention of Sexual Abuse With the increase in reports of sexual abuse of children, teaching children personal safety skills has become important. Reviews of research on the effectiveness of child sexual abuse prevention programs find that in general these programs result in knowledge increases (albeit in some cases very small ones) among the participants (Davis & Gidycz, 2000; Wolfe et al., 1995). Active involvement of children is one factor that has been strongly associated with success. Some studies have found that older children benefit more from prevention, whereas others suggest that because older children may know something about sexual abuse prior to participation, they show smaller gains in knowledge than do younger participants. Other work indicates that programs for very young children (i.e., preschool and early elementary school) must be sensitive to the developmental needs of the children in order to be effective. That is, prevention programs must recognize differences in how children at various developmental levels conceptualize sexual abuse (Kolko, 1988; Repucci & Haugaard, 1989). Preschoolers, for example, have difficulty understanding that someone they love could hurt them, and they may not be able to discriminate “good” from “bad” physical contact. Younger elementary-school-age children are often unsure about the nature of sexual abuse and tend to view perpetrators as “bad people,” strangers, or someone close to their own age; preadolescent children understand that sexual abuse involves sexual touching, but view perpetrators as older “mentally ill” or “sexually deviant” people (Wurtele & Miller, 1987). Evaluation research indicates that prevention programs can be successful even for preschool children when they include such behavioral techniques as modeling, guided practice, and reinforcement of appropriate responses (Wurtele, 1990; Wurtele, Kast, Miller-Perrin, & Kondrick, 1989). Wurtele and Miller-Perrin (1992) have summarized the important components of sexual abuse prevention programs for very young children. These programs should

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focus on teaching simple rules such as protection of private parts, rather than “good touch,” “bad touch,” and “confusing touch,” as the latter concepts are beyond the capabilities of preschool children (Miller-Perrin & Wurtele, 1988). Teaching the importance of disclosure (“Tell someone”) is also considered a critical component of programs for young children, because it is unlikely that all children will be able to get away or say “No” (Kolko, 1988). Finally, the effectiveness of prevention programs for young children increases as the time, effort, and oneon-one practice that are provided increase. “Booster” sessions may be essential for maintaining effectiveness over time (Garbarino, 1988). Involving parents, in combination with teaching behavioral skills (e.g., use of role play, modeling, reinforcement to teach personal protection, recognition of exploitive situations, etc.), has been demonstrated to be a good way to approach sexual abuse prevention, especially for preschool children (e.g., Wurtele, Kast, & Melzer, 1992; Wurtele, Currier, Gillispie, & Franklin, 1991). It is important to note, however, that parents of children who are most at risk for sexual abuse (e.g., children from dysfunctional families, socially isolated youngsters) are least likely to participate in such programs. Furthermore, although parents may be willing to participate in teaching abuse prevention skills to their children, it is likely that they will need information about what to teach. For example, many parents do not know, or do not know how to tell their children, that most sexual abuse is perpetrated by someone known to the child (Wurtele et al., 1991). Providing parents with the information they need to educate their children can improve the parents’ ability to protect their children (e.g., providing better supervision, changing sleeping arrangements, checking on day care centers, etc.), as well as increase the children’s personal safety skills (Wurtele & Miller-Perrin, 1992). Moreover, parents need to know that children who have good self-esteem, problem-solving skills, and sexual knowledge are better able to protect themselves from sexually exploitive situations. It is important to recognize that even the most effective sexual abuse prevention programs do not demonstrate that all children acquire all the information and skills taught. Moreover, there is no ethical way to demonstrate that children actually use the skills they have learned in abusive situations. Fryer, Kraizer, and Miyoshi (1987a, 1987b) engaged 5- to 7-year-olds in an interesting abduction analogue situation following their participation in an abuse prevention program. A research assistant (stranger) approached each child in the school yard and asked the child to accompany him or her to a car to pick up some materials. All but four of the children who participated in the prevention program refused to go (88%), whereas only half of the controls refused. Retraining for all children plus the control group resulted in refusal by everyone but two of these four original participants. Actual abuse situations are very complex, and it is not possible to predict what children will do if and when they are confronted with such a situation. Consequently, it is important for professionals to begin targeting other aspects of the child sexual abuse phenomenon (Wolfe et al., 1995). A review of the epidemiological characteristics of child sexual abuse by Wurtele and Miller-Perrin (1992) suggests several potential targets: 1. Potential perpetrators of sexual abuse. One prevention program, for example, was designed to teach adolescents who were at risk of abusing children about the nature and causes of child sexual abuse. In addition, empathy, anger management, problem solving, decision making, and impulse control skills were taught (Committee for Children, 1989). 2. Sociocultural attitudes and beliefs. Societal attitudes about children, male socialization, sexuality, and male–female relationships contribute to a social context that supports sexual abuse of children (Wurtele & Miller-Perrin, 1992).

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3. Mass media and pornography. Although a direct connection between erotic portrayals of children and child sexual abuse has not been consistently documented (Murrin & Laws, 1990), it seems reasonable to assume that such films, advertising, and other media may contribute to an increased sexual interest in children and decreased inhibitions about sexual contacts with children.

SUMMARY AND CONCLUSIONS Given the increasing discrepancy between the number of children needing mental health services and the number of providers and funds for these services, child clinicians and researchers must begin to focus on prevention programs. Taken together, the research on parenting styles, as well as that focused on other risk and protective factors, provides guidelines for planning early intervention or prevention programs for families that can enhance children’s development. These programs are based on the assumption that if children are reached early enough, their life course trajectory can be significantly changed for the better. These programs should attempt not only to forestall harmful effects on children’s development, but also to enhance the children’s ability to cope with the difficulties that occur over the normal course of development. This presents a great challenge, given the complex interplay between risk and protective factors: Multiple risk factors may combine and potentiate each other, whereas certain protective factors may buffer the effects of risk and stress. Child biological factors and other characteristics, the social and environmental context, and parental characteristics all must be weighed in the assessment of risk and protective factors. Access to children, however, is necessarily through parents. Reviews of current early intervention programs have suggested that parental involvement in the intervention process is critical to these programs’ effectiveness in preventing child problems. Although there is much to be learned about the processes involved in parent–child interaction and the factors causing and mediating positive outcomes for children, we have the methodology, knowledge, and experience to implement more and better parent education programs, family-focused early interventions, and other prevention programs to enhance the development of children. In doing this, however, the quality of the programs and qualifications of the intervenor(s), as well as documentation of outcome relative to cost, must be carefully considered.

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CHAPTER 2

Assessment to Intervention

T

he primary task of the child clinician is to identify and treat those children who suffer from emotional and/or behavioral problems that significantly interfere with their development or functioning and are likely to persist without intervention. The first step in accomplishing this complex task is a careful assessment of the presenting problem. The assessment process helps the clinician determine which problems are clinically significant and might benefit from treatment, and which are only annoying and/or transient. The second step, intervention, is necessarily dependent on the quality of the assessment. In addition to determining whether particular behaviors are clinically significant, the assessment process must determine what factors contribute to the problem and what the target areas for intervention should be. Furthermore, a careful assessment informs the clinician about which treatment methods are developmentally appropriate for each child and family. In order to accomplish this task, the clinician must take into account the developmental level of the child; the potential biological influences on the child’s functioning; and the broader ecological factors (familial, social, and cultural) that interact with children’s characteristics. Moreover, the clinician must have knowledge of empirically validated treatment approaches, as well as of ways to document treatment progress for individual cases. In this chapter, we focus on the assessment-to-intervention process in general. First, we discuss issues of diagnostic classification, and review estimates of prevalence for childhood problems. Next, we present a comprehensive assessment-to-intervention system that is adapted to specific problems as they are covered in later chapters. Methods of assessment that we have found most useful in clinical practice are also discussed. Finally, issues central to the treatment process are covered.

ISSUES OF DIAGNOSTIC CLASSIFICATION Assessment and diagnostic classification are parts of a single process. Assessment identifies the distinguishing features of an individual case, whereas classification groups cases according to these features (Kamphaus & Frick, 1996). Some of the benefits of classification systems include (1) promotion of communication among professionals, since each system of classification defines the rules for distinguishing a particular disorder from normal functioning and facilitates reporting of data; (2) translation of research into practice, since classification allows 40

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one to determine how the features of an individudal case relate to other cases for which research has identified similiar features; and (3) documention of the need for such services as special education, for staff in a particular setting, or for reimbursement of services. In contrast to these advantages, there are inherent problems in any classification system. First, there is no clear way to determine when a behavior should be considered pathological. Second, there is a high degree of overlap between various forms of psychopathology, making categorization of cases difficult. Third, a stigma is often associated with the “label” derived from classification. The labels “mental retardation” or “attention-deficit/hyperactivity disorder” (ADHD), for example, can cause people to treat children differently from their unlabeled peers. In an attempt to deal with this problem, it has recently become standard practice to use classification labels to describe the psychological construct rather than the person (e.g., “a child with ADHD” vs. “an ADHD child”). Although the benefits of classification outweight the disadvantages, it is important that the clinician have a clear understanding of the limitations of different classification systems, that the labels or classification categories be used cautiously, and that classification be used only when there is a clear purpose for doing so (Kamphaus & Frick, 1996). Furthermore, for a classification system to be useful, it must be simple and have explicit rules so that it can be used reliably by different raters over time. It must also be meaningful—that is, valid in terms of the etiology and course of the problem, associated features, or treatment approaches.

Categorical Approach The most commonly used categorical classification system in the United States is the Diagnostic and Statistical Manual of Mental Disorders, presently in its fourth edition (DSM-IV; American Psychiatric Association [APA], 1994). (The text of DSM-IV has recently been revised [DSM-IV-TR; APA, 2000], but the basic criteria sets remain the same.) Another example of the categorical approach is the similar International Classification of Diseases, currently in its 10th revision (ICD-10; World Health Organization, 1992). In both these systems, an individual either meets or does not meet criteria for a particular disorder. The DSM system illustrates many of the problems with the categorical approach to diagnosis. First, diagnostic categories and criteria for defining each disorder are chosen by committees of mental health experts. Hence clinical experience, inferences from the existing empirical literature, and the various orientations of committee members all contribute to the categories that are finally selected for inclusion. As a result, the criteria for many of the diagnostic categories for childhood disorders have changed with each new edition of DSM; children who met the criteria for a particular diagnosis in one edition often fail to qualify for the diagnosis in the next edition, and vice versa (Achenbach, 1998). Second, the assessment process for determining the diagnostic criteria does not always specify what instruments should be used, what informants should be included, and how the rating for presence and severity of the criteria should be made (Cantwell, 1996). A related concern is that there is no systematic method of determining the extent to which symptoms interfere with children’s functioning. This is problematic because impairment of functioning is a key criterion for making a DSM diagnosis, but the evaluation of impairment is currently left to “clinical judgment” (Bird et al., 2000). A third problem with the DSM approach is that the reliability and validity of classifications for infants and toddlers has not been adequately demonstrated (DelCarmen-Wiggins & Carter, 2000). As the criteria for diagnosis became more detailed in DSM-III (APA, 1980) and later DSM editions, structured interviews designed to give yes–no answers about whether a child meets

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each criterion for each specified category or disorder became increasingly popular (McClellan & Werry, 2000). Structured interviews do not take into account the importance of such factors as the natural history, biological correlates, psychosocial correlates, familiality, and response to treatment, however (Cantwell, 1996). Cantwell (1996) also points out that individual diagnoses in DSM-IV differ widely in the extent to which empirical evidence to substantiate their external validity is available; few childhood and adolescent disorders are fully validated. The DSM-IV childhood disorders for which there is a satisfactory amount of external validation include ADHD, conduct disorder, Rett’s disorder, autistic disorder, Tourette’s disorder, obsessive– compulsive disorder, and anorexia nervosa (Cantwell, 1996). Other questions that are difficult to answer with a categorical approach to classification include (1) how to handle problems that are subthreshold or just miss the criteria or cutoff score for a disorder (the “not otherwise specified” category tends to lump together all disorders that do not meet criteria); (2) how to discriminate one disorder clearly from another disorder; (3) how to deal with comorbidity (i.e., are disorders distinct, or is there something unique about the co-occurrence?); and (4) how to determine whether disorders differ qualitatively or quantitatively from “normal” (Cantwell, 1996) . The use of the DSM classification system can be particularly problematic with children, whose ever-changing development makes it difficult to determine which behaviors are transient developmental problems and which are clinically significant (Campbell, 1990). Although DSM-IV encourages the clinician to view individuals with a particular disorder as heterogeneous and to gather information that goes beyond the diagnosis, it does not provide adequate guidelines for determining the developmental and clinical significance of the symptomatic behaviors that define a problem during early and middle childhood. In addition, although both parent–child and sibling relational problems can be coded as “other conditions that may be a focus of clinical attention” (APA, 1994, p. 675), the diversity of these problems and their importance to the diagnosis of children’s problems are not adequately taken into account (Volkmar & Schwab-Stone, 1996). Despite these difficulties, DSM-IV has the advantage of describing a variety of discrete clinical features in a single term or diagnosis that facilitates communication with others in both clinical and research work (Cantwell, 1996). This latest revision also provides the user with basic scientific information supporting the various categories, including (1) the characteristics of associated features; (2) age, gender, and cultural trends; (3) prevalence; (4) course; and (5) familial patterns (APA, 1994). In addition, there are five DSM-IV sourcebooks (e.g., Widiger, Frances, Davis, & First, 1994) that provide information on the scientific bases for the disorders. Another recently published categorical diagnostic system is the Diagnostic and Statistical Manual for Primary Care (DSM-PC; Wolraich, Felice, & Drotar, 1996), published by the American Academy of Pediatrics. The academy’s goal was to develop a comprehensive and developmentally appropriate categorical diagnostic system in order to help primary care pediatricians recognize, manage, and refer a wide spectrum of children’s behavioral and developmental problems, as well as to take into account stressful family and environmental situations (Drotar, 1999). Some of the critical underlying assumptions of the DSM-PC system include the following: (1) Symptoms are viewed along a continuum from normal variations to severe mental disorders, which is divided into clinically meaningful graduations; (2) the quality of children’s environment is recognized as having a critical impact on their mental health and is taken into account in assessing problems; (3) children’s expression of symptoms and responses to stressful environmental situations vary as a function of age and level of development; and (4) the system is based on objective data where possible and on professional consensus in cases

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where data are not yet available. In addition, the system was developed to be fully compatible with DSM-IV (APA, 1994) and ICD-10 (World Health Organization, 1992). Although this system is not yet in wide clinical use, and much research must be done to validate it, it holds promise in describing children’s problem behavior and its significance within a particular developmental and environmental context. A fourth system has been developed specifically for the youngest children: the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC 0-3) (Zero to Three, 1994). Although its reliability and validity have not yet been widely studied, the DC 0-3 shows potential for categorizing disorders in the early years, including parent–child relational disturbances.

Dimensional Approach In contrast to the categorical approach, a dimensional or multivariate approach to studying childhood problems assumes that behavior occurs along a continuum (from normal to pathological) rather than dichotomously (an individual either has or does not have a disorder), and bases classification on patterns of behavior covariation (Achenbach, 1998; Kamphaus, Petoskey, Cody, Rowe, & Huberty, 1999). Examples of dimensional systems include the Child Behavior Checklist (CBCL; Achenbach, 1991a, 1992) and the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992). In the dimensional approach, pools of items are selected for reporting behavioral and emotional problems that are felt to be important among children. These items are then scored for large normative and clinical samples as assessed by different informants (i.e., parent, teacher, child) to determine how well they discriminate between children who are considered in need of help and those who are considered relatively normal (Achenbach, 1998). Factor analysis and principal-component analysis are used to identify sets of problems that co-occur; these sets or patterns of problems are viewed as syndromes, but no assumptions are made about why they covary. Data from the normative samples provide a frame of reference for judging problems reported for individual children. Standard scores or percentiles are used to determine whether a child’s scores on each syndrome are relatively low, medium, or high compared to nonreferred peers and as reported by each of the different informant sources. Thus a dimensional system of classification allows one to describe multiple behavior patterns for an individual child, with cutoff scores used to determine the clinical significance of specific behaviors for different age groups as rated by different respondents. The use of a dimensional approach has some advantages, in that it takes into account a full range of child behavior versus just categories of disorders. It thus provides information about prevention and early intervention for emerging problems, such as depression. Moreover, it considers deviant behavior as a matter of degree rather than as being present or absent, and the inclusion of adaptive scales gives information about protective factors and optimal development (Kamphaus et al., 1999).

Categorical versus Dimensional Approaches Although there has not yet been much research comparing the DSM-IV system with the empirically derived syndromes of dimensional systems, studies with the DSM-III (APA, 1980) or DSM-III-R (APA, 1987) have shown that many common DSM diagnoses for children’s behavioral/emotional problems have counterparts among the empirically based syndromes of the CBCL (Achenbach, 1998; Chen, Faraone, Biederman, & Tsuang, 1994). Achenbach (1998)

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cautions, however, that the empirically based assessment instruments were designed to measure relatively common behavioral/emotional problems occurring during a particular period of time (i.e., the past 6 months), as reported by different informants who see the child under different conditions. The instruments are not designed to address important relational issues, age of onset, the length of time the behavior has occurred, or the behavior’s impairment of a child’s functioning, all of which are included in the DSM criteria for many disorders. The dimensional approach also is not designed to assess for extremely rare behaviors such as autism. One syndrome that has been found with the CBCL system but is not reported in the DSM system is the cross-informant “social problem syndrome” (e.g., “acts too young for age,” “too dependent,” “doesn’t get along with other kids,” “gets teased a lot,” “not liked by other kids,” “clumsy,” and “prefers being with younger children”). This syndrome appears to represent an important pattern of behavior, and there is empirical evidence to support its high heritability (Edelbrock, Rende, Plomin, & Thompson, 1995), developmental stability (McConaughy, Stanger, & Achenbach, 1992), cross-informant agreement (Sawyer, 1990), and good discrimination between referred and nonreferred children (Achenbach, 1991a, 1991b). Arend, Lavigne, Rosenbaum, Binns, and Christoffell (1996) compared the DSM approach with a dimensional one based on the CBCL and its Profile (Achenbach, 1991a, 1992). Focusing on 510 children ages 2–5 selected from pediatric primary care settings, they compared DSMIII-R (APA, 1987) diagnoses derived from semistructured parent interviews, parent questionaires, play observation, and developmental testing to parent ratings on the CBCL. The greatest convergence between the two approaches was found when there was clearly no problem. Children who received scores below the clinical cutoff on the CBCL but were given a DSM diagnosis were compared with those who scored below the CBCL cutoff but did not receive a DSM diagnosis. These two groups differed in the severity of their behavior and in the number of situations in which the behavior occurred. Arend et al. (1996) also found that children’s lack of cooperation across settings indicated a greater likelihood of more severe behavior problems resulting in a DSM diagnosis. So the addition to the CBCL parent questionnaire of questions regarding the crosssituational nature of the child’s behavior, or having both the teacher and the parent complete the CBCL, should enhance the utility of the CBCL dimensional diagnostic system in identifying children with significant problems that otherwise might be missed. It is remarkable that 28 different DSM-III-R diagnoses were used for this sample of preschoolers (Arend et al., 1996). The prevalence of behavior problems on the CBCL was 8.3%, as compared to 21.4% “probable” diagnoses (9.1% “severe”) with the DSM-III-R. These results differ from those for a sample of older children from pediatric primary care, in which use of the CBCL indicated a prevalence rate of 25% (Costello et al., 1988). The different prevalence rates for older versus younger children raise the question of the DSM categories’ ability to differentiate children’s problems during the preschool years. Although Arend et al. (1996) indicate that interviewing parents and observing a child’s behavior may provide a greater amount and richness of information with which to make a categorical diagnosis, they also point out that the utility of the diagnosis depends on the validity of the DSM-III-R diagnosis for the individual in question. This is an important cautionary note, particularly with preschool children, who exhibit a significant number of problem behaviors that are age-appropriate and transient. One must also be aware that studies identifying preschool children with the DSM versus the CBCL are very likely to represent different samples of children (i.e., clinic-referred vs. community samples) (Keenan, Shaw, Walsh, Delliquadri, & Giovannelli, 1997). Arend et al. (1996) indicate that their data do not lead them to recommend either the categorical or the dimensional approach, but it seems clear that clinical judgment regarding the presence of a signifi-

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cant problem is enhanced when information is gathered through multiple methods, from several sources, and across situations. Both the authors of the DSM-IV and the developers of dimensional approaches stress the importance of including different types of data in the assessment process, such as medical evaluation, cognitive assessment, physical assessment, parent and child interviews, and direct assessment of the child behavior (e.g., Achenbach, 1998; Bernet, 1999; Kamphaus & Frick, 1996). Research indicates that both the categorical approach and the dimensional approach to classification have problems, which should discourage exclusive reliance on one versus the other (Kamphaus & Frick, 1996). In reality, a combination of these approaches is probably most useful. For example, the categorical distinctions between severe and moderate mental retardation, and between these and normality, are useful for planning services as well as for determining etiology and prognosis. The dimensional aspect of the intelligence level, however, is a very useful indicator within both the normal and abnormal ranges for planning specific educational and rehabilitation programs. Our assessment system, which is discussed later in this chapter, uses a variety of assessment methods to obtain an understanding of the child in comparison to other children the same age. The child’s family, social and ecological factors, and the ways in which the child’s behavior is viewed by the child’s family and others in the child’s environment are also important pieces of information in our approach to assessment. This information leads to a judgment about the significance of a behavior problem and, if necessary, the appropriate areas to be considered for treatment. It can also result in the diagnosis of a specific DSM-IV disorder.

ESTIMATES OF PREVALENCE The prevalence of behavioral and emotional problems among children is difficult to determine because of the various nonstandardized criteria used to identify the presence of a particular problem, as well as the varying labels and definitions of problem behaviors. In addition, the wide developmental and behavioral variability among children from infancy to adolescence makes it difficult to say that a certain behavior or set of behaviors represents a clinical disorder except in extreme cases. Specific behaviors increase and decrease with age (Campbell, 1998). For example, fears, worries, nightmares, toileting problems, and tantrums decrease with age in preschool and school-age children. Disruptive behaviors decrease in the preschool years and increase again as children move toward adolescence. Moreover, many behaviors that might be considered symptoms of psychiatric disorders are surprisingly common in nonclinical samples of children (Campbell, 1998). Table 2.1 indicates prevalence rates for the DSM-IV disorders that have their onset during infancy, childhood, or adolescence. More generally, in a recent review of epidemiological studies conducted in various countries after 1980, Bird (1996) estimated that between 12.4% and 51.3% of children 6–18 years of age have a diagnosable disorder. When only clinically significant or severe disorders are included, estimates of prevalence drop to between 5.9% and 19.4% of children. The wide variation in these rates is thought to be due to cultural factors rather than to methodological differences among studies. In the United States, prevalence of disorders among children and adolescents in the general population is estimated at approximately 17.6%–22% (Nottelmann & Jansen, 1995). Prevalence rates for DSM diagnoses of preschool children are consistent with those for older children, although the types of disorders evidenced may vary. As noted above, Arend

46 I. THEFirst FOUNDATION TABLE 2.1. DSM-IV Disorders Usually Diagnosed in Infancy, Childhood, or Adolescence Disorders

Age of onset

Prevalence

Mental retardation Learning disorders Reading disorder Mathematics disorder Disorder of written expression Motor skills disorders Developmental coordination disorder Communication disorders Expressive language disorder Mixed receptive–expressive language disorder Phonological disorder

Birth

1%

6–9 years 6–10 years 7–? years

4% 1% Unknown

Preschool

6% of 5- to 11-year-olds

3 years Before 4 years

3–5% of school-age children 3% of school-age children

Preschool

2–3% of 6- to 7-year olds; 0.5% of 17-year-olds 1% of preadolescents; 0.8% of adolescents

Stuttering

2–7 years

Pervasive developmental disorders Autistic disorder Rett’s disorder Childhood disintegrative disorder Asperger’s disorder

Before 3 years 5–48 months Before 10 years Preschool to early school age Attention-deficit and disruptive behavior disorders Attention-deficit/hyperactivity disorder Before 7 years Conduct disorder Pre- and early adolescence Oppositional defiant disorder Before age 8—not later than early adolescence Feeding and eating disorders Pica Infancy (?) Rumination disorder 3–12 months Feeding disorder of infancy or early Before 6 years childhood Tic disorders Tourette’s disorder Before 18 years Chronic motor or vocal tic disorder Before 18 years Transient tic disorder Before 18 years Elimination disorders Encopresis At least 4 years Enuresis At least 5 years

Other disorders Separation anxiety disorder Selective mutism Reactive attachment disorder of infancy or early childhood Stereotypic movement disorder

Before 18 years Before 5 years Before 5 years All ages

Note. The data are from American Psychiatric Association (1994).

2–5 cases per 10,000 Uncommon; only females Very rare Unknown; more common in males

3–5% of school-age children 6–16% of males < 18 years 2–9% of females < 18 years 2–16% of children

Unknown Unknown 0.5–2.5% of pediatric hospital admissions 4–5 per 10,000 4–5 per 10,000 4–5 per 10,000 1% of 5-year-olds Age 5: 7% male, 3% female Age 10: 3% male, 2% female Age 18: 1% male 4% of children and adolescents Rare; <1% of children seen in mental health setting Very uncommon 2–3% of children and adolescents with mental retardation living in community settings 25% of adults with severe or profound mental retardation in institutions

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and colleagues (Arend et al., 1996; Lavigne et al., 1996) reported that 21.4% of preschool children from pediatric primary care settings had “probable” DSM-III-R diagnoses, while 9.1% had “severe” DSM disorders. The most common disorder was oppositional defiant disorder (ODD; 16.8% at all severity levels and 8.1% at the most severe level). ODD was most common among 3-year-olds, and boys were twice as likely as girls to have this diagnosis. ODD decreased in frequency between the ages of 4 and 5 years, which is consistent with other work indicating a decline in oppositional behavior between 4 and 9 years (Loeber, Lahey, & Thomas, 1991). Parent–child relational problem—which, as noted earlier, is not considered a DSM disorder per se, but a condition that may merit clinical attention—was the second most common diagnosis (4.6% at all severity levels, 1.1% most severe) and was most often diagnosed at age 2 years. In a sample of older children (5–9 years old) in pediatric primary care settings, the prevalence rate for DSM disorders was 16.8% (Briggs-Gowan, Horwitz, Schwab-Stone, Leventhal, & Leaf, 2000). Parental depression/anxiety and possible child abuse were associated independently with 2- to 3-times-higher rates of disorders. Prevalence rates for infants and toddlers have only recently received attention from the research community, most likely because few reliable and valid methods for assessment are available for this age group (DelCarmen-Wiggins & Carter, 2000). A recent survey of a representative sample of healthy births indicated that about 11.8% of parents of 2-year-olds reported clinical or subclinical levels of problems as measured by the CBCL/2-3 (Briggs-Gowan, Carter, Skuban, & Horwitz, 2001). Further, approximately 6% of parents of 1- to 2-year-olds reported clinically significant problems on the Parenting Stress Index Difficult Child scale (taken as a proxy for behavior problems in this age group).

Factors Influencing Prevalence Prevalence rates for childhood problems are much higher among low-socioeconomic-status (low-SES) samples than in the general population (Lavigne et al., 1996). A study of low-SES families indicated that 26.4% of 5-year-olds had a DSM-III-R disorder and that an additional 29.9% had a subclinical disorder (at least half of the symptoms necessary for a diagnosis) (Keenan et al., 1997). Similarly, Raadal, Milgrom, Cauce, and Mancl (1994) reported that 31% of their sample of 5- to 11-year-old low-SES children had total problem scores above the 90th percentile on the CBCL, in contrast to 18% of the normative sample for this measure. In the BriggsGowan et al. (2001) study, behavioral and emotional problems among 1- to 2-year-olds were strongly associated with economic disadvantage. Many factors other than SES are known to influence prevalence rates for childhood disturbances. Rates are higher for boys than girls, for older than younger children, for children living in urban than in rural settings, and for children from single-parent versus two-parent families. Recently, higher rates of psychiatric disorders have been associated with low intelligence and child temperamental characteristics of activity level, persistence, and timidity (Lavigne et al., 1996). Estimates of prevalence are also influenced by the perceptions of the referral persons (Campbell, 1998). Children’s problems are most often identified by parents; yet parents’ perceptions of deviance are clearly influenced by their own characteristics (e.g., depression, marital conflict, self-esteem, attitudes, and expectations.).

Persistence Another interesting epidemiological question is the extent to which problems early in childhood are likely to persist. Across a range of studies, attention-deficit and disruptive behavior disorders are the most common childhood problems reported (Bird, 1996). These conduct

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problems evidence considerable stability over time, especially for children who demonstrate more severe symptoms (Achenbach, Howell, McConaughy, & Stanger, 1995; Costello, Angold, & Keeler, 1999). Costello et al. (1999), for example, reported that children with a severe behavior disturbance in childhood were eight times more likely than healthy children to have a severe disturbance in adolescence. For children with subclinical disturbances, the risk of adolescent problems was five times greater than for healthy children, but only when the disturbance was accompanied by significant impairment in functioning. Similarly, Campbell and Ewing (1990) found that 67% of children who had conduct problems at age 6 met DSM-III criteria for an externalizing disorder at age 9. Taken together, the research on prevalence of childhood problems indicates that rates of serious disorders are relatively low. Problems in the early years are often transitory and associated with a specific developmental period, but children whose symptoms are severe and especially those who have difficulty with disruptive behaviors are highly likely to continue to have problems as they grow and develop. Biological vulnerability; environmental instability; poverty; the quality of the parent–child relationship; the number, frequency, and severity of problems; and the type of disorder all appear to contribute to the stability of these problems.

PLANNING THE ASSESSMENT The intended purpose(s) of an evaluation, including clearly specified goals and objectives, should be articulated before the assessment process begins. This will determine whether a psychiatric diagnosis is needed, what tests (if any) should be administered, who should be interviewed, whether direct observation is necessary, and whether there is a need for collaboration with allied health professionals. If the person requesting the assessment is not sure whether there is a problem, then the goal should be to determine the nature and source of the child’s difficulty, as well as to make recommendations regarding the need for treatment. In clinical practice, assessment can have multiple purposes, and these are often interrelated. We suggest that in general, the goals of assessment are to (1) determine whether there is a problem (i.e., to differentiate between normal and abnormal behavior); (2) delineate the individual’s strengths and deficits; (3) predict future behavior or the course of the disorder; (4) classify the problem; and (5) provide guidelines for intervention. Most clinical cases referred for assessment involve some combination of these purposes, and many complex cases involve all five purposes. In addition to having an understanding of the purpose(s) of an assessment referral, it is also important to get a description of the problems that have led to the referral. Enough preliminary information on the child’s functioning should be gathered to permit some initial hypotheses about what the problem is, whether it warrants an evaluation, and who is the most appropriate person to do the evaluation. We have found that a brief phone contact at the time of the referral helps determine whether an evaluation should proceed, and if so, what intake information should be gathered prior to the initial appointment. If a parent is seeking an evaluation for possible sexual abuse of a child, for example, and it emerges that the child has already been interviewed, it may not be appropriate to do another interview. Likewise, if the clinician has no expertise in the area of sexual abuse or feels that he or she could not do an objective evaluation in a particular case, then the case should be referred to someone else. Cultural issues, such as language barriers, may also indicate the need for a referral to another clinician, or at least the need for an unbiased interpreter. The nature of the problem, such as a 4-year-

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old’s sleep “problems” described as one episode of a sleep terror (see Chapter 6), may indicate that a full evaluation is not appropriate. A number of other issues should be considered before embarking on an evaluation. First, as discussed in Chapter 1, knowledge of normal development and developmental psychopathology helps the clinician place the child’s emotional and behavioral functioning within a developmental context. Hence it is important to consider developmental issues in planning the assessment process. The tests used should have good normative data for the age group of the referred child, and the assessment method should be appropriate to the child’s developmental level. (Self-reports, for example, are considered unreliable prior to age 9.) Certain behaviors occur more frequently at one age than at others, so it must be determined whether the referred behavior is an exaggeration of a normal developmental pattern or is a significant problem requiring treatment. A second issue to consider is that children who have a problem in one area of emotional or behavioral functioning are likely to have problems in other areas, particularly in the social and cognitive areas (Kamphaus & Frick, 1996). This means that the evaluation must be comprehensive enough to consider the problems most likely to be associated with the referred behavior. As an example, if the referral is for an 8-year-old’s poor reading and written language achievement, then a developmental language disorder should be considered. Similarly, if a 7-year-old is referred for problems in school that center around being overactive, disorganized, and impulsive, then learning problems should also be considered. Asking the parents about these areas in the initial interview can often give the clinician enough information to determine whether or not to pursue these hypotheses. Another area that should be considered in planning the evaluation is the context of the problem. Because children’s behavior is influenced by the psychosocial environment, it is important to determine what aspects of the environment should be assessed (e.g., parenting strategies, peer influences, or sibling relationships) and how they should be assessed (e.g., direct observation, rating scales, or family interview). Given that environmental contexts vary from child to child, the intake information should give the clinician enough information to determine what significant people in the child’s life should be asked to provide information on the problem, what context of the child’s life has the greatest impact on his or her functioning, and what is the best way to structure the assessment of family influences. If the intake information indicates that the problem is occurring only at school, for example, then gathering information from the teacher and a school observation may be indicated before the initial parent or child interview. Likewise, if a child spends significant time with a stepparent, then the stepparent’s input should be considered. In summary, evaluation of childhood problems should be viewed as a quasi-scientific, hypothesis-testing procedure that takes into account developmental psychopathology, the influences of context, and the best interests of the child (Achenbach, 1998; Kamphaus & Frick, 1996). Time and cost are also important considerations, so one must determine the most economical means of obtaining the essential information without compromising the usefulnesss of the information. The assessment process is an evolving one, so that hypotheses are made, changed, or confirmed as the information is gathered.

ASSESSMENT CASE EXAMPLE A 6-year-old girl, referred by her parents, was described as impulsive, moody, and having difficuty in school. The parents sought not only an understanding of the problem, but specific

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guidance to help their daughter make a better adjustment in the home and school, as well as with her peers. In the intake information, the parents said that several male relatives on the mother’s side of the family were mentally retarded. One of these relatives had recently been diagnosed as having a fragile-X chromosomal disorder. Prior to the initial interview, the clinician reviewed the research literature on this disorder and learned that females are carriers of the defective gene for fragile-X syndrome, and that there is a phenotype for these females. Given the description of the phenotype and the initial description of the child’s behavior, the clinician hypothesized that the child might be a fragile-X carrier. It was also hypothesized that she might have ADHD and a learning disability. Information was gathered from the parents (interview, rating scales, daily behavioral logs, observation of parent–child interaction during interviews), the teacher (rating scales, achievement and test scores), and the child (interview, direct observation, psychoeducational testing). As the assessment progressed, the child’s profile of behaviors was found to have many characteristics of the female fragile-X carrier. After discussion with the parents, the child was referred for a genetic evaluation, which indeed indicated that this was the case. The assessment process also revealed a child who met the criteria for a diagnosis of ADHD, and who was functioning cognitively in the average range with achievement scores significantly below grade expectations. Socially, she had many friends and engaged successfully in age-appropriate activities. Emotionally, she felt loved, but recognized that her impulsive behavior often created problems for herself and her family. Her parents were warm and supportive, and provided a structured yet stimulating environment. Thus the nature and cause of the child’s problems were determined and classified (fragile-X carrier status, ADHD, and a learning problem); her strengths were delineated (a desire to please, good social skills, and supportive environments at home and school); and the assessment process gave specific information for intervention strategies. Although it was predicted that the child would probably have some difficulties in the future, her many strengths made it likely that she would adapt and continue to develop successfully. Intervention strategies derived from the assessment data included changes in class placement and resource support; supportive work with the family in regard to the diagnoses; referral to a parent association for children with fragile-X syndrome; specific behavior management techniques for the parents; and brief individual work with the child to help her recognize her strengths and cope with her weaknesses. It was also understood that further assessment and intervention might be needed as the child encountered new challenges.

A COMPREHENSIVE ASSESSMENT-TO-INTERVENTION SYSTEM Given the many factors that must be taken into account in identifying the emotional and behavioral problems of children, some method of systematically collecting and organizing information during the assessment process is critical. We describe a behaviorally oriented system for assessment of children’s problems that is based on Rutter’s (1975) work. This system is referred to in this book as the Comprehensive Assessment-to-Intervention System (CAIS); it is summarized in Table 2.2. It focuses on the specifics of the behavior of concern, as well as taking into account other characteristics of the child, family, and environment that influence a child’s behavior. The CAIS also provides a framework for choosing tests and other information-gathering methods, for summarizing the assessment data, and for planning areas of intervention. Specific methods used in the assessment process are discussed later in the chapter.

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TABLE 2.2. Comprehensive Assessment-to-Intervention System (CAIS) for Child Behavioral Problems I. Clarifying the referral question. After the parent has described the problem, the clinician should be certain that he or she and the parent are thinking about the same problem. This can be done by simply reflecting what the parent has said: “It sounds like you are concerned about your child getting up in the night, as well as the different ways you and your husband are handling the situation.” II. Determining the social context. A child is referred because someone is concerned. This does not mean that the child needs treatment or that the child’s behavior is the problem. The clinician should ask: “Who is concerned about the child?” “Why is this person concerned?” “Why is this person concerned now as opposed to some other time?” The parents’ affect in describing the problem is significant: Are they overwhelmed, depressed, nonchalant? III. Assessing general areas. A. Developmental status 1. Physical/motor 2. Cognitive 3. Language 4. Social 5. Personality/emotional 6. Psychosexual B. Parent and family characteristics 1. Personality characteristics 2. Psychopathology 3. Marital status 4. Availability and use of social support 5. Parenting styles and techniques 6. Sibling relationships C. Environmental characteristics 1. Recent stressful life events 2. Socioeconomic status 3. Subcultural norms and values D. Consequences of the behavior 1. Past and present management strategies 2. “Payoff” for child 3. Impact of behavior on child, parents, and environment 4. Prognosis with and without treatment E. Medical/health status 1. Family history of medical/genetic problems 2. Chronic illnesses (e.g., otitis media) 3. Medications 4. Prenatal history, birth history, and early development IV. Assessing specific areas. A. Persistence of the behavior B. Changes in the behavior C. Severity of behavior D. Frequency of behavior E. Situation specificity F. Type of problem V. Determining the effects of the problem. A. Who is suffering? B. Interference with development

(cont.)

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TABLE 2.2. (cont.) VI. Determining areas for intervention. A. Development 1. Teaching new skills to the child 2. Providing appropriate stimulation 3. Changing the behavior by increasing or decreasing it B. Parents 1. Teaching new parenting techniques 2. Changing the emotional atmosphere 3. Treating marital problems or parent psychopathology 4. Changing parental expectations, attitudes, or beliefs C. Environment 1. Changing the cues that set off or prevent the behavior from occurring 2. Helping parents build support networks and deal with daily living problems 3. Helping child/family cope with life events D. Consequences of the behavior 1. Changing parents’ responses to the behavior 2. Changing others’ responses to the behavior 3. Changing the payoff for the child E. Medical/health status 1. Intervening in the cause of the problem 2. Treating the effect of the problem

Clarifying the Referral Question Although the need to clarify the referral question seems obvious, its importance cannot be overemphasized. The referral source may be a teacher or an agency, but it is most often a parent; therefore, the referral source is described as “the parent” in this section. After the parent has described the problem, the clinician should be certain that he or she and the parent are thinking about the same problem. Parents often have questions that are not well articulated or not initially stated. A parent’s concerns can be clarified by simply reflecting what the parent has said: “It sounds like you are worried about your child refusing to go to school, as well as the different ways you and your husband are handling the situation.” This gives the parent the opportunity to restate his or her concerns until a mutual understanding is reached. Once the issues to be addressed are clarified, the clinician must then decide which questions he or she can adequately or appropriately address, and these must be agreed upon by the parent. The information gathered in the assessment process will be useful only to the extent that there is agreement on the questions needing to be answered at the end of the process.

Determining the Social Context of the Problem Children’s behavior is greatly influenced by their psychosocial environment and can vary within and between contexts (e.g., with one parent vs. another, at school vs. home, in structured vs. unstructured activities). A child is referred because someone is concerned; however, this does not necessarily mean that the behavior of concern is deviant, that the child’s functioning is impaired, or that the child needs treatment. The clinician should clarify, “Who is concerned about this child? Why is this person concerned? And why is this person concerned now, as

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opposed to some other time?” This information not only clarifies the parent’s perception of the problem, but may also alert the clinician to other people who should be contacted or other contexts in which the child’s behavior should be assessed. If a child began having a problem when a new teacher was assigned to the class, for example, or if the child is nervous and physically sick only when he or she goes to an after-school program or visits a noncustodial parent, then these contexts obviously should be assessed. The parents’ affect in describing the problem is also significant. Are they overwhelmed, anxious, depressed, or nonchalant? Two mothers, for example, describe their 3-year-old daughters as being anxious and fearful. One mother is calm, in control of herself, and using good judgment in attempting to deal with the problem. In contrast, the other mother is extremely upset, fearful, and unable to view the problem objectively. Each of these parents presents a different focus for the assessment-to-intervention process. The family’s sociocultural characteristics can also play an important role in the planning and implementation of a treatment program. Garcia-Coll and Meyer (1993) note that questions such as the following can help the clinician get a better understanding of the parents’ perspective: “What do you think caused your child’s problem?” “Why do you think the problem started when it did?” “How does the problem affect you or your child?” “How severe do you think you child’s problem is?” “Do you expect it to have a short- or long-term course?” “What kind of treatment do you think your child should receive?” “Who can help you with treatment?” “What are the most important results that you hope your child will receive from treatment?” “What is your greatest fear about your child?” Asking parents about their expectations, hopes, and fears in coming to a mental health professional helps in gathering and interpreting the material, especially if the clinician’s recommendations are contrary to the parents’ expectations or confirm their worst fears. This information can also help the clinician develop a culturally sensitive treatment program. In some cultural contexts, for example, infants and children are expected to sleep with their parents, and this is not seen as a problem; yet cosleeping may be viewed as a major concern in another culture.

Assessing General Areas In assessing a child’s behavioral problems, the clinician should keep in mind the general areas that influence the development of behavior problems: (1) the child’s developmental status; (2) characteristics of the child’s parents or extended families; (3) environmental characteristics and events; (4) the consequences of the behavior in both a narrow and a broad sense; and (5) the child’s medical or health status. These areas are summarized in section III of Table 2.2. Developmental Status of the Child Knowledge of the child’s developmental status allows the clinician to compare the child’s behavior to that of other children of the same age or developmental level. The clinician’s job is to

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judge whether the behavior of concern is more or less than one would expect of any child at that age and in that environment. A 3-year-old child who wets the bed, for example, has a behavior that may be considered “normal” or “common” for that age, whereas a 10-year-old who wets the bed is viewed as having a significant problem. Also, the frequency of problem behaviors changes developmentally, and some behaviors improve without any intervention. Physical aggression, for example, reaches a peak during the preschool years and then naturally declines. Although physical aggression may be considered a problem at any age, its clinical significance increases with age. Thus the time when this behavior first occurs in a child’s life is as important as the behavior itself. Furthermore, the preschool years are a critical time for the identification of and intervention with children with developmental problems. It should be obvious that knowledge of normal developmental processes is critical in the assessment of these children. Characteristics of the Parents and Extended Family Although it is difficult to identify causal mechanisms in the development of childhood disorders, and equally difficult to delineate the specific factors contributing to or mediating outcome, the developmental and child clinical literature provides evidence for certain parental characteristics and parenting practices that facilitate development, as well as those that make a child more vulnerable. These are discussed in Chapter 1. Moreover, these factors affect how parents view their children. It is generally accepted, for example, that low parental tolerance, unrealistic expectations for child behavior, marital stress, and family dysfunction influence parents’ perceptions of their children’s behavior. Other work demonstrates that a mother’s perception of her child’s behavior is highly correlated with the type of environmental interactions (positive or coercive) she has just experienced (Wahler, 1980). Thus the perspective of the referring person must be taken into account. The referring person may lack information about child development in general, may have emotional problems, or may be experiencing stress, all of which can distort his or her perception of the child’s behavior. Areas that are especially important to assess include parenting styles, techniques, and models; marital status; the presence of psychopathology in parents and other family members; sibling relationships; and the availability and use of social support. Environment Recent stressful life events, SES, and subcultural norms and values provide important information about the problems the child is experiencing and the intervention strategies that may be helpful. The child’s environment provides the setting conditions for the behavior, and in some cases it may be a more appropriate focus for intervention than the behavior itself. The setting conditions can include very specific antecedents to the behavior (e.g., repeated commands, teasing, criticism, hunger), SES and other relatively stable characteristics, or major events (e.g., parental divorce, a death in the family, chronic illness, or an impending move). Consequences of the Behavior Information to be gathered about consequences includes the ways in which the parents are currently handling the behavior or emotional problem; the techniques they have tried in the

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past; the impact of the behavior on the child, parents, family, and environment; and the prognosis for the child with and without treatment. Lack of careful assessment of these factors usually leads to the parents’ responding to suggestions by saying, “Yes, but we have tried that, and it doesn’t work.” Medical/Health Status Assessment of medical/health status should include gathering information on the family’s history of medical or genetic problems, chronic illness of the child, current health and medications, prenatal history, and early development. Much of this information can be gathered in an intake interview or with a general parent questionnaire, and specific areas of concern can be followed up in the interview. As an example, a 2½-year-old boy was referred by his parents because of noncompliance, irritability, and sleep problems; the parents felt incapable of caring for him appropriately. On the intake questionnaire, the parents indicated that he had had recurrent bouts of otitis media since 13 months of age. In the interview, the parents stated that medication had not been effective in controlling the infections, and that the family physician did not believe in “elective” surgery to place tubes in the ears. Observation of the child indicated that his language skills were delayed, and that he did not always attend to language directed toward himself or others. After the clinician and parents discussed the potential negative effects of otitis media on the child’s development, the parents decided to seek a second medical opinion, which resulted in surgical insertion of tubes. The child’s emotional lability improved immediately, and a brief course of parent training resolved the remaining parent–child problems. Given the child’s dramatic behavioral improvement, the parents decided to postpone a referral to a communication specialist regarding the language delay.

Assessing Specific Areas Given that many behaviors cannot be directly observed by the clinician, it is important to get a descriptive analysis of the problem(s). Information should include the persistence of the behavior (how long has it been going on?); changes in behavior (is it getting worse?); severity (is the behavior very intense or dangerous, or low-level but “annoying?”); frequency (has the behavior occurred only once or twice, or many times?); situation specificity (does the behavior occur only at home, or in a variety of settings?); and the type of problem (is the problem a discrete behavior, or a set of diffuse problems?). Methods for doing this are described in the next section of this chapter and for specific problems in subsequent chapters.

Determining the Effects of the Problem It is important to note who is suffering from the referral problem(s). It may be that the child’s behavior is bothering one parent but not the other, or is a problem in school or with peers but not for the parents. In other cases, although the behavior may be interfering with the child’s development, it may not be seen as a problem by the parents or other adults; without intervention, however, it may lead to a poor outcome for the child. A learning disability, for example, may not be viewed as a problem by the parents, but the child is likely to suffer negative consequences in school and in future opportunities if it is left untreated.

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Determining Areas for Intervention After assessing each of the areas described above, the clinician should have a good idea of what the problem is and what additional information is needed to conceptualize it. It also should be possible at this time to formulate plans for further assessment and/or intervention strategies. Although it is not possible to answer every question and/or to intervene effectively in every situation, intervention strategies follow naturally from the assessment process if the child’s development and behavior, and the physical and sociocultural context in which he or she lives, have been examined systematically. Section VI of Table 2.2 describes intervention strategies relevant to the child, the parents, the environment, the consequences of the behavior, and the medical/health status of the child. For example, targets for change can be the child’s behaviors, feelings, thoughts, or some combination of these, with cognitive and emotional level of development guiding the choice of treatment method. The focus for treatment in the preschool years is usually the child’s behavior, with parent skills training the typical mode of treatment. As the child’s cognitive skills develop and he or she is better able to reflect on inner thoughts and feelings, thoughts and feelings become targets for intervention, with a greater reliance on cognitive-behavioral treatments. Parenting skills also may be the focus for change, but these too will change with the age of the child—from contingency management techniques in the preschool and school-age years, to negotiation techniques and communication skills in adolescence. Environmental targets for change also vary from changing the daily routines of the child or family to changing the emotional atmosphere in the home. Subsequent chapters focus on specific problems, the significant targets for change for those disorders, and methods to intervene in those areas. The CAIS framework should not be seen as rigid. Rather, it is offered as a logical and systematic way to gather and organize information, to generate and test hypotheses, and to plan intervention for children’s problems. The data can be obtained from a variety of sources and different methods. The CAIS is useful for complex cases; it also works well to assist the clinician in gathering and organizing essential information very quickly. A case example taken from a parent call-in service in a pediatric primary care setting demonstrates a brief (15- to 20minute) assessment-to-intervention process involving a 6-year-old girl who was disrupting her class in school (Schroeder, Gordon, Kanoy, & Routh, 1983). As illustrated in Table 2.3, most of the necessary information was gathered quickly by listening carefully and asking specific questions.

METHODS FOR GATHERING INFORMATION Given the complexity of children’s behavior and of the potential contributing factors to emotional and behavioral problems, it is important to use several methods for gathering information from different informants and across settings. As Kamphaus and Frick (1996) state, “the most critical component in choosing a method of assessment and in interpreting assessment data is understanding what one is trying to measure” (p. xii). According to these authors, psychological assessment is not seen as “test-driven” but as “construct-driven.” Hence it is important to be familiar with research literature on the psychological constructs that describe children’s emotional, behavioral, and social functioning. Given the uniqueness of each child and family, there is no one battery of assessment methods or tests that can be used for every case. The

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TABLE 2.3. The Assessment Process in a Brief Case Example I. Clarifying the referral question. A father called at the request of his daughter’s first-grade teacher, who was concerned that the 6-year-old girl, once or twice a week, became distraught, walked in circles, and cried inconsolably. The clinician stated, “It sounds like Jane is disrupting the class and her teacher is not able to give her or the other children the attention they need. You’re also wondering why she seems so genuinely distraught one or two times a week.” II. Determining the social context. The father indicated that he and his wife were separated and that Jane was living with him. A. Listening to affect “I had so hoped this wouldn’t happen again in Jane’s new school. I don’t know what I can do to help her.” B. Who was concerned? The teacher was concerned for both Jane and the other children. The father stated, “I have been worried about Jane for the last 2 years, but generally her teachers and I have been able to calm her down.” C. Why now? Jane just started in a new school. III. Assessing general areas. A. Developmental status “Jane is a very bright child who rarely gives any problem at home. She has friends in the neighborhood and generally likes going to school. Recently she started wetting herself during the day and having nightmares.” B. Parent and family characteristics “Her mother and I have been divorced for 3 years and went through a terrible custody battle. We still fight a lot over Jane.” C. Environmental characteristics Jane visited her mother every Wednesday and every other weekend. She hated to go, reported being left alone, and was afraid of some of her mother’s friends. D. Consequences of the behavior The father described the ways in which he had tried to deal with Jane’s upset: “I tell Jane that the court says she has to visit her mother, that she should love her mother and have a good time. I also have told her not to act up in school because it gets me in trouble.” E. Medical/health status “Although Jane has generally been healthy, in the last 3 months she has been to the doctor because of her wetting. She has complained of stomachaches and has had nightmares. I also should tell you that the department of social services investigated my ex-wife’s charges against me for sexual abuse, which were not substantiated. Recently, Jane’s doctor called the department because Jane had a number of bruises when she came home from a visit with her mother.” IV. Assessing specific areas. A. Persistence of the behavior “Jane has been upset since the divorce, 3 years ago.” B. Changes in the behavior “She has never liked to visit her mother, but in the last 3 months it has gotten to the point where I have to force her to go.” C. Severity of behavior “The night before she goes to visit her mother, she becomes very upset, doesn’t listen to me, and has a very hard time getting to sleep. Sometimes she has nightmares.” D. Frequency of behavior “These problems only seem to occur when she has to visit her mother.” (cont.)

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TABLE 2.3. (cont.) E. Situation specificity “She used to be upset only at home, but now it’s happening at school too. I also think she looks sad a lot of the time.” F. Type of problem This child’s behavior was indicative of significant emotional distress. She was beginning to exhibit a variety of problematic behaviors both at home and at school. The extent of her upset was likely to have serious consequences for her functioning and development unless immediate intervention took place. V. Determining the effects of the problem. A. Who is suffering? The child, the parents, the teacher, and other children in school. B. Interference with development The behavior was already interfering with Jane’s adjustment at school. Most importantly, the child’s emotional needs were not being met. Furthermore, she had few appropriate alternatives available to express her feelings. VI. Determining areas for intervention. The severity of this child’s behavior and the complexity of the situation warranted further evaluation and treatment. In the meantime, the father and teacher were advised to work together to provide more emotional support within the school environment on the days Jane visited her mother. The father was also advised to tell the child, ”It’s OK for you to act upset if you’re feeling bad on those days.” The father and teacher were told to give her specific ways to express her feelings, such as drawing, working with clay, or simply talking to them.

assessment methods chosen will depend on the purpose of the assessment, the nature of the behavior problem, the characteristics of the child and the family, the assessment setting, the characteristics of the assessor, and the characteristics of the available methods (Mash & Terdal, 1997b). Methods can include interviews, behavioral checklists and questionnaires, self-monitoring procedures, analogue methods, direct observation of behavior, psychophysiological recordings, social competence measures, developmental measures, anxiety hierachies, role playing, simulated problem situations, projective tests, tests of perceptual–motor functioning, sociometrics, and ecological assessment, as well as standardized tests of ability, achievement, and personality. In choosing assessment methods, the child clinician should be aware of a particular method’s empirical validity and developmental sensitivity. It is beyond the scope of this book to review all of the various methods used in the assessment of children. The interested reader is referred to Sattler (1992, 1998) and Kamphaus and Frick (1996) for in-depth discussions of interviewing techniques, rating scales, standardized tests, and assessment methods for specific disorders. Descriptions of assessment instruments we have found most useful are provided in Appendix A. This section outlines the order in which we gather the information described in the CAIS framework, with special emphasis on parent and child interviews, integrating information across informants, and the feedback conference.

Step 1: Initial Contact The initial contact is most often a telephone conversation during which the behavior or behaviors of concern are described and the referral question clarified. Knowledge gained from this contact should guide the type of information that is gathered prior to the initial interview, as

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well as who will be seen in that interview. We have found it essential to have the parents complete and return two items before the initial interview: (1) a general parent questionnaire, and (2) a norm-referenced behavior rating scale. The General Parent Questionnaire we use (see Appendix B) provides information on (1) the family’s SES; (2) the child’s developmental milestones, day care history, and school history; and (3) the parents’ perception of the child’s problem, its causes, and what they have done about it thus far. The parent rating scales that we use most frequently are the CBCL (Achenbach, 1991a, 1992); the BASC (Reynolds & Kamphaus, 1992), the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999), and the Parenting Stress Index (PSI; Abidin, 1995). Rating scales provide a broad assessment of problems, foster objectivity through the specificity of the individual items, and allow assessment across settings in a time- and cost-efficient manner. Rating scales are not interchangeable, and the clinician should be aware of the purposes, strengths, and weaknesses of individual scales. The CBCL, for example, is the most widely used parent rating scale. It covers a broad range of emotional and behavioral functioning for ages 2–3 years and 4–18 years, but it combines the constructs of anxiety and depression, and of hyperactivity and inattention, into single scales. On the other hand, the BASC takes a broad sampling of behavior at home and in the community for the preschool (4–5), child (6–11), and adolescent (12–18) age ranges; it has single scales for anxiety, depression, hyperactivity, and inattention, as well as an adaptive behavior scale. The CBCL and the BASC parent rating scales are both part of larger assessment systems that include ratings from teachers, parents, and the child, as well as direct observation. This allows similar information to be gathered from multiple informants in a reliable and valid manner. The ECBI assesses the intensity and generality of conduct problem behaviors for ages 2–16 years, as well as parental tolerance for these behaviors. The PSI assesses the child-rearing environment of children between 1 and 4 years of age. It includes a Child Domain (which assesses the qualities of the child that make it difficult for the parents to fullfill their parenting role) and a Parent Domain (which assesses sources of stress and disability related to parental functioning). This measure is one of the few ways of assessing problems in infancy. The Conners Rating Scales—Revised (Conners, 1997), another well-known battery that has been primarily used for its Hyperactivity Index (10 items that are sensitive to drug effects), has norms for children ages 3–17. This Index, however, is only norm-referenced for the short form (the Conners-48 form vs. the Conners-93 form), and the individual scales in general have limited reliability, validity, and normative data. Other information may also be requested prior to the first session, depending on the presenting problem. We may ask the parents to provide daily records of the child’s behavior, for example. Although the information requested will vary, depending on the behaviors of interest (e.g., sleep diary, feeding diary, habit diary), we have developed a general Daily Log (see Appendix B) on which parents record appropriate and inappropriate behavior and give their child a rating from 0 (“dreadful”) to 10 (“fantastic!”). On the reverse side of the form, parents record the antecedents and consequences of behaviors identified as specific problems. This record helps the parents document what the child is actually doing on a daily basis (in contrast to what they think the child is doing). The Daily Log can also be used during treatment to help parents and the clinician monitor progress. As an example, a mother called with a concern about her 3-yearold’s disruptive behavior, which she felt was “not really bad” but which her parents had told her was a significant problem. Recordings on the Daily Log during the week prior to the initial interview included such behaviors as “Kicked his grandfather in the shin,” “Scraped the new kitchen wallpaper with a knife,” and “Bit a child at day care!”

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At the time of the initial contact, we inform parents that several questionnaires or rating scales will be sent for them to complete and return to the clinic prior to their appointment. The various questionnaires and forms are described, and the importance of this information in helping us to understand the problem is discussed (e.g., “The BASC will give us information regarding how your daughter’s behavior compares to other children her age,” or “The PSI will help us understand how your son responds and interacts in his environment, as well as any stresses you are currently experiencing”). Parents are always given the option of not completing the questionnaires at this point in the assessment process if they are uncomfortable doing so. This information, however, helps the clinician plan for the initial interview by developing various hypotheses as to the nature of the problem. In this time of managed care, many clinicians may feel that this is an unnecessary, time-consuming, and expensive process that is best left until after the initial interview. We have found, however, that having this information prior to the interview not only decreases the time required for assessment, but also facilitates rapport with the parents, because we are able to focus more quickly and specifically on their concerns. Another option is to have the parents come an hour or two before the scheduled appointment to complete the forms and have them scored. The clinician then reviews them prior to the interview.

Step 2: Parent and Child Interviews The unstructured interview is the standard assessment tool for determining emotional and behavioral disorders of childhood, despite the fact that it is fraught with a number of problems. According to McClellan and Werry (2000), these problems include “(1) the tendency to determine diagnoses before all relevant information is collected; (2) the tendency to collect information selectively when confirming a diagnosis and/or to ignore information that rules out a diagnosis; (3) the lack of a systematic approach to combining different types of information; (4) the tendency to make diagnoses or judgments based on what is familiar to the clinician; and (5) the tendency to see correlations that are spurious or nonexistent or to miss real correlations” (p. 20). In recent years, structured interviews that guide the interviewer’s questions have become more popular not only for research, but also in clinical assessment. Structured interviews involve a prearranged set of questions to be asked in sequential order that usually gather information about a specific DSM disorder. These interviews can vary in the degree of structure (e.g., the interviewer can follow up on questions or not ask all of the questions), but greater freedom decreases their reliability. Although providing a more standardized format, structured interviews generally give global information about the existence of a DSM disorder, rather than specific details about a particular child, family, or peer group that are needed for planning an intervention program (Kamphaus & Frick, 1996; La Greca, Kuttler, & Stone, 2001). Other disadvantages of structured interviews are as follows: (1) Their reliance on DSM criteria does not allow comparison with a representative normative sample (given that behaviors can vary with age, this could lead to inappropriate diagnosis); (2) context is not taken into account; (3) parents cannot give their perspective or description of the problem; (4) these interviews do not encourage rapport building; and 5) they are time-consuming. Structured interviews have a clear advantage for research purposes, but clinically they should be used as only one part of a more comprehensive battery of assessment methods. A recent issue of the Journal of the American Academy of Child and Adolescent Psychiatry is devoted to a description and critique of structured interviews for children (see McClellan & Werry, 2000). The reader is referred to that issue for more information.

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In contrast to the structured interview, the unstructured interview requires prior knowledge about the nature of the specific presenting problem, which guides both the content and the process of the interview. On the basis of this knowledge, the interviewer determines what questions and follow-up questions will be asked, and what responses from the client need clarification. The unstructured interview allows the clinician more freedom to explore the nature and context of the problem, as well as the opportunity to investigate potential contributing factors, such as stimuli that may elicit the problem behaviors. Moreover, this type of interview allows the clinician to begin to delineate acceptable behavioral alternatives, as well as other potential problem areas for the child or family. Even with all of the potential pitfalls, we prefer to conduct an unstructured interview, using the CAIS framework to direct the questions asked and the information collected. We use such an interview along with other, empirically derived methods for the assessment of childhood problems. For the trained clinician, starting the assessment process with an unstructured interview promotes a collaborative relationship by letting the parents know that the clinician is interested in their perception of the presenting problem, and that the assessment process will be tailored to the particular needs of their child and family. The efficacy and efficiency of the interview are significantly improved by determining the purpose of the interview ahead of time, preparing for the interview, clarifying the purpose and parameters of the interview with the parents, and collaborating with the parents during the interview. In addition, it is important to demonstrate good interviewing and listening skills, get concrete examples of behavior, identify antecedents and consequences of the problem behaviors, avoid expectations and biases, consider alternatives to the initial impression, use other assessment methods, and delay reaching final decisions until all of the needed information is gathered (Karg & Wiens, 1998). Parent Interview The parent interview has many purposes: (1) gathering the information about the child, family, and environment that is outlined in the CAIS framework (see Table 2.2); (2) obtaining informed consent; (3) establishing a collaborative and supportive relationship; (4) gathering information about parental concerns, expectations, and goals; (5) assessing parental perceptions and feelings about the child’s problems, concerns, and goals; (6) setting realistic goals for assessment and intervention; (7) communicating with the parents about procedures that are to be used; (8) educating the parents with respect to the nature of the child’s problem, its prevalence, its prognosis, and its possible etiologies; (9) assessing the parents’ affective state, motivations for changing the situation, and resources for taking an active role in the change process; and (10) providing the parents with an adequate rationale for proposed interventions (Kamphaus & Frick, 1996; Mash & Terdal, 1997b). The initial contact helps determine who should attend this first interview. It is important to include both parents if they are both actively involved in the child’s life. If a parent calls about an impending marital separation, for example, it is critical that both parents be included in the initial interview; if one parent objects, the reasons for doing this should be explained (see Chapter 13). If the child is referred for an evaluation by someone other than the parent (e.g., courts, social service, school), it is particularly important that both parents have an opportunity to express their views on the need for the assessment and what they expect will be the result of the evaluation. If parents are unable or unwilling to participate in a joint interview, an attempt should be made to interview them separately, even if this is done by tele-

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phone. Each parent brings his or her own perspective on the problem, and also will provide information about his or her willingness to support the child’s treatment. When the referral involves a preschool child, we routinely include the child in the initial parent interview, with age-appropriate toys and activities provided to keep the child occupied. There obviously are exceptions to this (e.g., discussion of divorce issues), which are covered in the chapters on specific problems. Although some clinicians may find it difficult to include a young child in the parent interview, we find that the information being discussed is usually not new to the child. Moreover, the opportunity to observe the child and the parent–child interaction far outweighs the drawbacks. If necessary, later interviews can be conducted with the parents alone, to discuss more sensitive information or to provide information to the parents without the distraction of a particularly disruptive child. Parents of a school-age child are typically interviewed alone, before the child is seen; parents of an adolescent are first seen with the adolescent present or absent, depending on the nature of the problem.. Interviewing parents is an interactive process that sets the tone for future intervention efforts. To promote collaboration, it is important for the interviewer to create an atmosphere that puts parents at ease in discussing their child’s problems and gives them a sense of optimism that the child’s or family members’ lives can improve as a result of professional help. Characteristics of a good interviewer can contribute to a positive tone. These include warmth, empathy, a sensitive and nonjudgmental approach that respects others’ feelings and cultures, and an ability to keep the interview moving along in a smooth, purposeful fashion (Kanfer, Eyberg, & Krahn, 1992). The ability to listen is also an essential skill. Listening helps parents focus on the problem, and reflecting and paraphrasing let the parents know they have been heard (Morganstern, 1988). Recognizing the parents’ distress as they discuss areas of concern encourages them to share their fears and beliefs about a problem. It is helpful to begin the interview by briefly summarizing what is known about the situation, explaining the purpose of the interview (e.g., to get a better understanding of the parents’ concerns in order to help determine what, if any, intervention is necessary), and obtaining informed consent (e.g., limits of confidentiality, details of any assessment procedures that will be used). This gives parents some initial information about what is expected of them, as well as what they can expect from the clinician. Furthermore, it helps them to start talking about their concerns. Whereas it is important to get a thorough understanding of the nature and context of the problematic behavior, it is not possible or advisable to assess everything in the child’s or family’s background at this time. Background information is important, but the goal is to be selective in pursuing areas with particular relevance to the presenting problem. It also should be remembered that working with children almost always involves an ongoing relationship with the parents, so if a relevant area is missed initially, it is very likely to be discussed in future meetings. Problems with the information collected during parent interviews include inaccurate recall, conflicting perceptions of the child between parents, and a tendency to describe the child in unrealistically positive or negative terms (Kanfer et al., 1992). Focusing on the current situation—that is, current behavior, current child management techniques, and current family strengths and weaknesses—can help increase the reliability of parental reports. Asking for examples also helps the parents describe the problem in more concrete behavioral terms. Time should be allowed at the end of the initial interview to summarize and integrate the information gathered. A careful summary lets the parents know that their concerns have been accurately heard and gives them feedback on the clinician’s initial conceptualization of the problem. An explanation should be given for why any additional information is needed (e.g.,

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school visit, home visit, behavior rating scales, psychometric testing of the child, observations of parent–child interactions, medical evaluations) and how this information will be gathered. It is also important to talk with parents about how to prepare the child (if he or she is not included in the initial interview) for seeing the clinician. Often parents have not said anything to the child and look to the clinician to guide them on how to approach this issue. If possible, potential treatment strategies should be discussed, as well as the estimated length of time and cost for treatment. Although it may not be possible to give all of this information without further assessment, it is important that the parents have some understanding of the clinician’s thoughts regarding the need for treatment, and a sense of hope that something can be done to help them and their child. Early in the interview, the clinician should have asked about the parents’ expectations; at the end of the interview, their expectations can be discussed in relation to the gathered information. The clinician can develop a collaborative relationship with parents by sharing information with them and allowing them choices in how to proceed. Asking the parents what they think (or feel) about what they have heard, and engaging them in the process of determining the next step in the assessment process and setting treatment goals, encourage them to be part of this process and maximize the chance that they will support the child’s treatment. Child Interview Although self-reports by children prior to the age of 9 (Edelbrock, Costello, Dulcan, Kalas, & Conover, 1985) are typically unreliable, we have found that interviewing a child older than age 7 provides useful information on the child’s perception of him- or herself (e.g., wishes, fears, interests, self-concept), the environment (e.g., peers, school, family), and the presenting problem, as well as on the child’s attempts to cope with and solve personal and interpersonal problems. Other purposes of the child interview are to develop rapport (in order to facilitate the child’s engagement in and cooperation with further assessment or treatment), and to informally assess his or her cognitive, social, and perceptual–motor skills. Building rapport with a child can be difficult, because children usually are not very motivated to cooperate in the interview process. Although children typically do not refer themselves, they already know that the referral means there is some problem, and they usually assume that they are at fault. Furthermore, the assessment process is unique for most children, so they have no idea what to expect. Thus the interview must be tailored to the individual child’s developmental level and needs (Kamphaus & Frick, 1996). Various things can be done, beginning at the first contact with the child and continuing throughout the interview, to facilitate establishing a relationship with the child and gathering the needed information. Meeting the family in the waiting room gives the clinician the opportunity to observe the child’s physical appearance, mood, activity level, and parent–child interactions. Greeting the parents and child by name, with a friendly and interested tone of voice, conveys to the child that the clinician is interested in him or her and glad that the child is present. It is also important for the clinician to introduce him- or herself to the child by title and full name (e.g., “I am Dr. Carolyn Schroeder, a psychologist, and I will be talking with you and your parents today”). Inviting both the child and parents to accompany the clinician to the interview room gives the child an opportunity to see where he or she is going while still with the parents. It is often helpful at this point to comment on something the child is wearing, is doing, or has brought to the session (e.g., “I see that you have a stack of baseball cards. I hope that you will show them to me”). A good time to clarify the reason for the interview is while the

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parents are with the child—for instance, “I am glad to talk with you today, John. Your mother and dad have told me that you play on the soccer team and that you recently got a badge in Scouts. That is great. Do you know why you are here today?” Children usually say no or decline to answer this question, and parents must be asked what they have told the child. The clinician can then continue, “Your mother and dad also told me that things have not been going well for you in school, and they would like to help make things better for you. I talk to many children who have had problems in school, and I would like to help you and your parents find ways to make things better.” At this point the parents can be dismissed, letting the child know where they will be during the interview. It is important to orient the child about what to expect in the interview, including the length of the session, what the clinician and child will be doing and talking about (e.g., school, friends, what the child likes to do), and issues of confidentiality. Providing the child with age-appropriate, unstructured materials (e.g., crayons, Legos, Play-Doh) to play with while talking helps a child feel more comfortable. When appropriate, we have also given a child a choice of snacks or a drink at the beginning of an interview. We also often begin with a structured activity, such as a sentence completion or Draw-a-Person task, to help the child feel more comfortable. Querido, Eyberg, Kanfer, and Krahn (2001) note a number of communication techniques that can facilitate rapport building. The clinician should (1) use language at or just above the child’s cognitive/language level (shorter, less complex words and sentences); (2) given that most children interpret silences as disapproval, be responsible for keeping the conversation going; (3) avoid using many direct questions (these can be seen as demanding), leading questions, or blaming questions (e.g., “why” questions); (4) introduce topics of interest to the child that are developmentally appropriate (e.g., TV shows, games, activities); (5) use descriptive statements about the child’s clothing, demeanor, or activity; (6) use reflective or summary statements to help convey genuine interest in the child; (7) praise the child verbally or physically; and (8) use structured, concrete questions ( “Can you tell me one thing you like about school?” vs. “What do you like about school?”). It is also important to let children know that it is OK if they do not know something the clinician asks them about. At the end of the interview, the clinician should summarize for the child what he or she understands about what the child has said, and should ask the child whether he or she would like to tell the clinician anything else or has any questions. Letting the child know what will happen in future meetings is also important. If testing is to be done, then the tests and their purposes should be briefly described for the child. In the following chapters, child interview questions focusing on specific problem areas are presented. The reader is referred to books by Sattler (1998) and Barker (1990), as well as to articles by La Greca et al. (2001), Querido et al. (2001), and Kanfer et al. (1992), for indepth discussions of interviewing children. Play Play has an important role in the development of cognitive skills, creativity, and adjustment, and therefore can provide information about these areas (Russ, 1995). For young children, observation of independent and interactive play can provide information about their perceptions of their world, intellectual and language development, feelings, thoughts, social relationships, and current concerns and anxieties. A variety of age-appropriate toys should be available, and the degree of structure provided during the play observation should also be varied, to determine the child’s response to demands and ease in changing activities. Legos or other building

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materials, for example, provide an opportunity to observe fine motor skills, frustration level, distractibility, persistence, creativity, and the use of help. Puppets allow observation of language skills, symbolic and pretend play, emotional expression, and coping skills. A doll house allows the child to demonstrate organizational skills, perceptions of family interaction, and role play. Simple rule-governed games reveal cognitive skills, compliance, frustration tolerance, and interactive play skills. The overall patterns of behavior in play are more important than any specific behavior (e.g., aggression only during puppet play vs. aggression with all types of material).

Step 3: Observation of Behavior The direct observation of behavior is an important part of the assessment process, because it provides an objective view of the nature, antecedents, and consequences of the child’s behavior. Given the time and expense involved in doing direct observations, however, they are often excluded from the assessment process. In addition, it is often difficult to get an adequate sample of some behaviors; the recordings can be unreliable; and behavior can change when people are aware that they are being observed. Even with these difficulties, direct observations are often necessary to help the clinician understand and delineate the problem, as well as monitor the progress of treatment. After a brief description of what is involved in developing a plan for direct observation, a number of structured observational systems are discussed. Direct observations require explicitly defining the concrete target behaviors to be observed (what); selecting the most appropriate setting in which to observe the behavior (where); determining how the target behaviors will be coded (how); and deciding who will observe the target behaviors (who). Observations can be done either in the child’s natural environment (e.g., home, school), or in the clinic, a laboratory, or an analogue setting. Although the latter settings can be more controlled and reliable, the ecological validity of observing in a natural setting cannot be overestimated. The way in which a behavior is recorded depends on the target behavior (e.g., tics, sleep, on-task behavior). Methods include counting the number of times it occurs (event recording); noting the length of time the behavior occurs (duration recording); and indicating whether or not the behavior occurred during a preset time interval (time sampling). The observational recordings can be made by the child, a parent, a teacher, or an outside observer such as the clinician. Given the significance of the parent–child relationship, observation of parent–child interactions is extremely important. Several systems have been developed for structuring and recording these interactions (Eyberg, Bessmer, Newcomb, Edwards, & Robinson, 1994; Foster & Cone, 1986; Forehand & McMahon, 1981; Hops & Davis, 1995; Mash, Terdal, & Anderson, 1973). The clinic version of the Dyadic Parent–Child Interaction Coding System—II (DPICSII; Eyberg, Bessmer, et al., 1994) can be readily used by clinicians. Although the DPICS-II is typically used to code the behavior of parents and preschool children, we have also found it useful for the older children. The DPICS-II is a highly structured coding system that provides an assessment of the current level of parenting skills, the child’s responsiveness to the parent, and qualitative aspects of their interaction in three 5-minute standardized situations: (1) ChildDirected Interaction, in which the parent is instructed to allow the child to choose any activity and to play along with the child; (2) Parent-Directed Interaction, in which the parent is instructed to select an activity and to keep the child playing according to parental rules; and (3) Cleanup, in which the parent instructs the child to clean up the toys. In addition to discrete behaviors, sequences of behavior are coded: parental responses (e.g., ignores or responds) to

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the child’s defiant behavior, and child responses (e.g., complies, noncomplies, or no opportunity) to parental commands. The coding system is a continuous frequency count of all behaviors observed during the 5-minute interaction periods. Scores are reliable for trained observers and are sensitive to treatment effects (Rayfield, Monaco, & Eyberg, 1999). Training is required to code the behaviors, but the resulting data are well worth the effort. Two other commerically available observational sytems for recording classroom behavior are the BASC—Student Observation System (BASC-SOS; Reynolds & Kamphaus, 1992) and the CBCL—Direct Observation Form (CBCL-DOF; Achenbach, 1986). Both of these systems can be used in conjunction with other components of the BASC and the CBCL. The BASCSOS is a 15-minute observational system that specifies 65 target classroom behaviors. The target behaviors are grouped into 13 categories (4 categories of positive/adaptive behaviors and 9 categories of problem behaviors). A momentary time-sampling recording procedure is used, in which the 15 minutes are divided into 30-second intervals; at the end of each 30-second interval, the child’s behavior is observed for 3 seconds. The observer uses a checklist to mark each category of behavior that occurred during the 3-second observation interval. At the end of the observation period, the observer provides narrative information on the interaction between the teacher and the child. Although there are no reliability or normative data for this system, it is a simple and time-efficient method to gather information on many behaviors important to children’s functioning in school. The CBCL-DOF (Achenbach, 1986) is designed to be interpreted in conjunction with the parent, teacher, and child self-report versions of the CBCL. It provides for direct observation of a child in a classroom or group setting during a 10-minute period; three to six separate 10-minute observations are recommended for a representative sample of behavior, and these ratings are then averaged. The CBCL-DOF consists of three parts: (1) The observer writes a narrative description of the child’s behavior during a 10-minute observation period, noting the occurrence, duration, and intensity of specific problems; (2) at the end of each minute, the child’s behavior is coded as being on or off task for 5 seconds; and (3) at the end of the 10-minute period, the observer rates the child on 96 behaviors that may have been observed during the observational period, using a 4-point scale (0 = behavior was not observed to 3 = definite occurrence of behavior with severe intensity or for greater than 3-minute duration). There is a high degree of item overlap between the CBCL-DOF and the CBCL parent and teacher rating forms, so the CBCL system provides a multimodal method of assessing a child’s emotional and behavior functioning. Observers with minimal training have been shown to be reliable. Moreover, there is evidence that the Off-Task and the Externalizing scores are valid (McConaughy, Achenbach, & Gent, 1988). The reliability and validity of the Internalizing scales is weaker, however, and there are no representative norms with which to compare scores. The authors recommend that the observer use the CBCL-DOF to observe two control children of the same age and sex as the identified child—one prior to the identified child’s observation, and the other after it. These observations provide a frame of reference for interpreting the identified child’s scores. Other observational systems have been developed for peer interactions (Dodge, 1983), family interaction (Patterson, 1982), and behaviors associated with ADHD (Milich, Loney, & Landau, 1982). One can also use an individualized observational system for a particular child or type of problem. Several observational systems developed for parents to record specific child behavior are given in subsequent chapters. A child can even be asked to engage in selfmonitoring of his or her behaviors, such as aggression, talking out in class, room cleaning, going to the bathroom, fighting with siblings, eating, and so forth (Mash & Terdal, 1997b). Children

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can be trained to self-monitor their behavior accurately if they have a clear and simple observational system, are reinforced for the accuracy of their recording, and have another person to monitor their recordings (Keller, 1986). Research has also shown, however, that children change their behavior as they become more aware of it through self-monitoring (Shapiro, 1987). This could be beneficial in a treatment program, but problematic for reliability purposes. See La Greica et al. (2001) for more information on behavioral observations of children.

Step 4: Further Assessment The data from the parent questionnaire, parent rating scales, parent and child interviews, and informal or formal observation of the child should give the clinician information on the nature of the problem, as well as indicate what other information is needed to delineate the problem further and/or aid in treatment planning. For example, further assessment of the child’s behavior may be needed in the areas of intellectual, achievement, emotional, behavioral, and adaptive levels of functioning, parent–child interaction (including a home observation), school behavior (e.g., teacher rating scales, teacher interview, school observation), the marital/couple relationship, parental psychopathology, and sibling or peer relationships. We have included descriptions of tests in Appendix A that assess for some common parental problems, but these problems are often best referred to mental health professionals who deal specifically with marital/couple or adult mental health problems. Information from the school and further information about the child’s functioning are most often the foci at this stage in the assessment process, and these are briefly discussed. School Children who have a problem in one area of functioning are likely to exhibit problems in other areas. Since children spend most of their time at school, it is not uncommon for them to exhibit difficulties in academic performance, in classroom behavior, or in interactions with classmates. The school environment places a variety of demands on children (e.g., sitting quietly, keeping focused, following directions, interacting with peers), and these demands change as children progress through school. Their adaptation to this environment can have a dramatic impact on their overall psychological adjustment. The details of these difficulties can be obtained through teacher questionnaires and rating scales, teacher interviews, and direct observation in the classroom. Although teachers can provide valuable information on externalizing behaviors such as sustained attention, activity level, or disruptive behaviors, they are less helpful for internalizing problems (Loeber, Green, Lahey, & Stouthamer-Loeber, 1991); they are also less helpful when teachers do not observe the child across several class periods (Edelbrock et al., 1985). After the clinician has obtained permission to gather information from the school, a brief phone contact with a teacher can set the stage for establishing a collaborative relationship with this professional. Moreover, this conversation helps determine what information should be gathered, as well as what school resources are available to the child. Having a preschool or elementary school teacher complete a general school questionnaire (see Appendix B for an example) that provides information on demographics, academic progress, and behavior problems, plus a broad-band teacher rating scale, is a time-efficient way to gather a great deal of information. The teacher rating scales that we have found most useful are the BASC—Teacher Rating Scale (BASC-TRS; Reynolds & Kamphaus, 1992) and the CBCL—Teacher’s Report Form

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(CBCL-TRF; Achenbach, 1991b). Both of these scales assess the emotional and behavioral functioning of children in school, and, as parts of multi-informant systems, they permit comparision of behavior across informants. The BASC-TRS has forms for preschool (4–5 years), elementary school (6–11 years), and high school (12–18 years) ages, and uses a 4-point scale for rating the frequency of occurrence of behavior. It covers adaptive, emotional, and behavioral functioning, and has good normative data. The BASC-TRS includes several areas of adaptive functioning (Adaptability, Leadership, Social Skills, Study Skills), and has separate scales for Motor Hyperactivity, Attentional Difficulties, Anxiety, Depression and Withdrawal, Aggression, Conduct Problems, Somatization, and Atypicality. It also screens for learning problems that can accompany emotional and behavioral problems in children. The CBCL-TRF is designed for children between the ages of 5 and 18 years. It includes some background questions (e.g., “How well do you know him/her?”), a teacher’s rating of the child’s academic performance, and a four-item screening scale for adaptive behavior. The teacher ratings on the emotional and behavioral items are “not true,” “somewhat or sometimes true,” “very true,” or “often true” of the child. Scales include Internalizing subscales (Withdrawn, Somatic Complaints, Anxious/Depressed), Externalizing subscales (Delinquent Behavior, Aggressive Behavior), Social Problems, Thought Problems, and Attention Problems. The item content of most of the scales tends to be quite heterogeneous, which makes elevated scales difficult to interpret. Moreover, the Thought Problems scale has questionable reliability and validity. The large research base for the CBCL-TRF aids in interpretation, however. Other teacher scales that we have found useful are the Sutter–Eyberg Student Behavior Inventory—Revised (SESBI-R; Eyberg & Pincus, 1999) and scales for ADHD that are discussed in Chapter 11. Finally, when a clinician is gathering information from teachers, it is particularly important to give them feedback on the findings and recommendations. Child Further evaluation of the child may include a psychoeducational or neuropsychological evaluation to assess intellectual, achievement, or organic functioning. The reader is referred to Sattler (1992) for further information on assessment in these areas. According to a recent review of testing practices (Kamphaus, Petoskey, & Rowe, 2000), testing of children is on the increase, with a more diverse array of instruments available (especially in the area of abbreviated intelligence testing). Furthermore, the use of rating scales has increased and has supplanted the use of projective tests. As previously noted, rating scales have many advantages, including brevity, cost-effectiveness, broad coverage of problem behaviors, minimization of response set, and use by multiple informants (caregivers, teachers, and children) (Kamphaus & Frick, 1996). The reader is referred to Kamphaus et al. (2000) for a selected but extensive list of tests for children and adolescents, which includes age ranges and administration time. The area of social skills often needs further assessment. The inclusion of adaptive scales in the BASC and CBCL provides information on a child’s skill deficits, as well as on strengths that can act as protective factors for emotional and behavioral functioning. The Social Skills Rating System (SSRS; Gresham & Elliot, 1990) is a comprehensive measure of social skills, with teacher, parent, and student forms measuring a variety of social skills across settings from preschool to grade 6 (see Appendix A). The scored tests give standard scores, percentile ranks, and behavioral levels. Although the SSRS measures externalizing, internalizing, and hyperactivity problem behaviors, and the teacher form includes a rating of academic competence, the focus of this measure is clearly on social skills. It assesses the domains of cooperation, asser-

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tion, responsibility (parent form only), empathy (student form only), and self-control. Frequency of behavior is rated on a 3-point scale (“never,” “sometimes,” “very often”), and the parent and teacher forms also rate the importance of each item (“not important,” “important,” and “critical”). The importance ratings help in prioritizing behaviors for intervention. Although there is poor reliability for some of the subscales (especially the student form), and the normative samples are not described, this easy-to-use instrument is unique in its thorough measurement of this important area of development. We often use a number of self-report inventories for children, including the BASC—SelfReport of Personality (BASC-SRP; Reynolds & Kamphaus, 1992), which has forms for ages 8–11 (SRP-C) and 12–18 (SRP-A) ; the Personality Inventory for Youth (PIY; Lachar & Gruber, 1995) for ages 9–19 years; the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1985) for ages 6–19 years; the Reynolds Child Depression Scale (RCDS; Reynolds, 1989) for ages 8–12 years; the Children’s Depression Inventory (CDI; Kovacs, 1992) for ages 6–17 years; and the Multidimensional Anxiety Scale for Children (MASC; March, 1997) for ages 8–19 years. These measures are described in more detail in Appendix A. It is important to have some estimate of the child’s level of cognitive functioning in order to tailor treatment for that child, especially when cognitive-behavioral or problem-solving therapy is being considered. The Peabody Picture Vocabulary Test (Dunn & Dunn, 1997), the Kaufman Brief Intelligence Test (Kaufman & Kaufman, 1990), and Wechsler Abbreviated Scale of Intelligence (Psychological Corporation, 1999) are quick methods to gather this information. Integrating Information across Informants As might be predicted, child, parent, and teacher data are not always in agreement on the type, frequency, and severity of individual children’s problems. Meta-analyses yield a mean correlation of only r = .27 between parent and teacher reports of children’s problems (Achenbach, McConaughy, & Howell, 1987). Others have found that this level of disagreement also holds true for parents and children (Andrews, Garrison, Jackson, Addy, & McKeown, 1993). How should the clinician handle this discrepant information in trying to determine the presence of a problem? There is evidence that a simple combining scheme in which information from all sources is weighed equally (i.e., if any informant says there is a problem, it is viewed as a problem) works as well as, and even better than, more complex schemes in which different sources of information are weighed more heavily than others (e.g., teachers’ reports of inattention are given more weight than parents’) (Offord et al., 1996; Piacentini, Cohen, & Cohen, 1992). Piacentini et al. (1992), however, report that the simple scheme works best if the informants are asked to report only on information that they would ordinarily be expected to know. This implies that one informant may have better knowledge of certain behaviors than another informant; for example, teachers will know more about behaviors that occur in school (e.g., inattention) than behaviors that occur outside of school (e.g., sleep problems) (Kamphaus & Frick, 1996). In a survey of mental health professionals using different informants to assess psychopathology, Loeber, Green, and Lahey (1990) found that clinicians tended to weigh the information from adults more heavily for observable externalizing behaviors, whereas more weight was given to children’s self-reports of emotional or internalizing problems. There is growing research support for this practice (Bird, Gould, & Staghezza, 1992), even when external criteria for child, teacher, and parent reports of disruptive behavior (e.g., school suspension, police reports) are used to validate the informants differentially across behavioral domains (Loeber,

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Green, et al., 1991). In another study, using maternal history of anxiety as a way of validating informants’ reports of childhood anxiety for children ages 9–13, Frick, Silverthorn, and Evans (1994) found that teachers’ reports of anxiety were not related to maternal reports, although child reports of anxiety were always accompanied by parent reports. Parent reports not confirmed by children were systematically related to the parents’ own levels of anxiety, however, giving further support for the emphasis on children’s self-reports of internalizing problems. In addition to the type of problem being assessed, the age of the child affects the quality of the information gathered by different informants, for several reasons: (1) As a child grows older, parents have less knowledge of the child’s emotions and behaviors (Paikoff & BrooksGunn, 1991); (2) as a child moves from a single teacher to multiple teachers, teachers are likely to have less knowledge of the child’s behavior; and (3) as the child develops cognitively, he or she is better able to describe emotions and thoughts. Thus the importance of children’s selfreports increases with age, as parent and teacher reports decrease in importance (Kamphaus & Frick, 1996). Other factors affecting the validity of reports of various informants include parental adjustment, marital/couple conflict, and the conditions under which the report is completed (e.g., rushed or tired). The motivation of the informant is also a factor (e.g., a parent is seeking custody or a child does not want to admit to a problem). Many rating scales include validity scales that help detect such invalidating response sets (Kamphaus & Frick, 1996). Achenbach (1998) indicates that discrepancies between different informants are understandable, given that children display different behavior in different demand situations (e.g., at home vs. school or with one teacher vs. another), or may behave differently with one parent versus the other. One parent may not be around the child as much or may have a different tolerance threshold for a behavior, for example, whereas another parent may do something that provokes the behavior. Thus discrepancies appear to be an expected part of the assessment process, and if analyzed can provide important information about the presenting problem(s). As an aid to cross-informant comparisons, Arnold and Jacobowitz (1993) developed a computer program in which the CBCL, CBCL-TRF, and CBCL—Youth Self-Report (CBCL-YSR) data are entered for a combination of up to five respondents. The program prints separate item scores, scale scores, and profiles from each informant. The program also displays the item and scale scores for each informant side by side, so the clinician can identify specific areas of agreement and disagreement among informants. Furthermore, a cross is printed beside each score that is in the borderline clinical range, and a double cross beside each scale score that is in the clinical range. Achenbach (1998) describes a taxonomic decision tree for comparing data from multiple sources, which can be helpful in comparing the scores of multiple informants. Kamphaus and Frick (1996) also give a comprehensive system for integrating and interpreting assessment information.

Step 5: Referral to Allied Health Professionals Effective Communication If the clinician suspects that the child’s emotional and behavioral functioning is being affected by fine or gross motor deficits or by medical, language, or neurological problems, then a referral should be made to the appropriate allied health professional. The clinician must develop relationships with a variety of professionals from different disciplines who deal with children. This involves understanding and appreciating the particular areas of expertise of these professionals, as well as differences in training, experience, and expectations. Timeliness of services,

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for example, is a common barrier to effective collaboration with pediatricians. Pediatricians have a fast-paced schedule and are used to “fitting” patients into these schedules, with limited time devoted to psychosocial problems. They are often dismayed to discover that a psychological consultation may not be scheduled for weeks and then may take several weeks to complete. To collaborate effectively with pediatricians, the child clinician has to take these expectations into account without compromising standards of care. Communication is obviously a key issue in collaborating with other health professionals. It is important that both oral and written communications be timely, problem-focused, jargon-free, practical, concise, and action-oriented. Consultation Children’s problems are usually not limited to the home; therefore, consulting with other agencies is often required if a child and family are to receive the most appropriate and effective treatment. Although the term “consultation” has many meanings, in this context it refers to a person (or “consultee”) receiving assistance from another person (or “consultant”) who has special knowledge or skills that help the consultee resolve a particular problem. The consultant is responsible for providing information, training, and/or assistance to the consultee, who in turn is responsible for carrying out the agreed-upon program/actions necessary to resolve the problem. Schools are the agencies with which child clinicians must work most often. Although the focus of this book is on the individual child, consultation may focus on a special education program or on system-level issues (student absenteeism, disciplinary referrals, etc.) (Mattison, 2000). Consultation with the school about an individual child may involve simply giving a teacher information about the child’s development or recommending special services, or it may involve working with the teacher to implement a behavior program in the classroom. In developing such a program, the consultant must be aware of the teacher’s biases, skills, and time limitations. If the goal of the teacher is to have the child removed from the classroom, for example, the consultant will have a different task than if the teacher is driven by a desire to change the child’s behavior. Thus the consultation process requires many of the same tasks and skills needed for working with parents; in fact, “consultant” often describes the role that the child clinician plays with parents and children. Tasks of the consultant include creating a therapeutic alliance; developing a plan for assessing the problem(s); discussing the assessment results; negotiating intervention goals; designing an intervention; implementing the intervention plan; monitoring and evaluating progress; and programming for generalization and maintenance of therapeutic gains (Sanders, 1996). The skills needed to complete these tasks include effective interviewing skills; the translation of vague or nonspecific concerns into concrete, specific goals for change; giving a rationale for data collection; negotiating data collection methods; presenting assessment results clearly and succinctly; formulating a shared explanation of the problem; helping others to carry out the treatment; and providing constructive feedback (Sanders, 1996). Establishing a therapeutic alliance with the teacher begins with the initial contact and requires developing a plan that the teacher can actually implement in the classroom within his or her daily routine and other responsibilities. Giving the teacher an assessment or treatment plan, either orally or in writing, without including him or her in the process of assessing the behavior and developing the plan is likely to fail. It will take a consistent, goal-oriented plan to help the teacher make changes in the classroom setting, just as it does when one is working with the parents to implement behavioral and environmental changes in the home.

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The importance of providing feedback to teachers was underscored in a study by Jones, Wickstrom, and Friman (1997). When teachers were given systematic feedback on their performance in carrying out treatment programs, they increased their mean levels of effectiveness from 9–37% to 60–83%! The reader is referred to Bergan and Kratochwill (1990), Kazdin (1994), and Kratochwill, Elliot, and Rotto (1995) for further information on consultation.

Step 6: Communication of Findings and Treatment Recommendations Communicating the findings of the assessment process provides the critical link to the intervention process. Either this communication of information can motivate parents, teachers, and others to provide the treatment necessary for the child’s optimal functioning, or it can overwhelm and immobilize them. Just as the clinician should have initiated a collaborative relationship with the parents early in the assessment process, he or she should continue to foster this relationship during the meeting devoted to interpretation of the findings. This can be done by sharing information in jargon-free language, encouraging parents to ask questions and express feelings, and allowing them to make choices on how to proceed. If parents feel that their concerns and observations have not been taken seriously, then they are less likely to accept the clinician’s conceptualization of the problem and treatment recommendations. Sattler (1998) provides an in-depth discussion of the interpretive process. Briefly, he states that the purposes of the interpretative or postassessment meeting are to share findings from the assessment process, present recommendations (including alternatives), help parents understand the findings and recommendations, and allow the parents to ask questions and express their feelings/concerns about the findings or recommendations. It is important to schedule adequate time for the meeting, allowing up to 1½ hours. Anything beyond that amount of time is usually overwhelming to parents and unproductive, whereas less time may not allow sufficient coverage of the important issues. Whenever possible, it is important to have both parents attend this meeting, and to ask them whether they would like anyone else to be present (e.g., a relative or teacher). It is usually best to present the findings and recommendations first to the parents and then to the child in a separate or joint interview. If the child is seen alone, the parents should be included at the end of that interview to go over briefly what was said to the child and clarify the child’s understanding of the findings and recommendations. At the beginning of the meeting, it is important to review briefly what the parents have said about their primary concerns, what they hoped to learn from the evaluation, and what has been done to answer their concerns/questions (e.g., parent and child interviews, parent and teacher questionnaires, achievement testing, school observations). Any additional questions or concerns can also be raised at this time. The findings should then be presented, with a focus on both the strengths and the weaknesses of the child and family. It is often best to use percentile ranks when reporting test data, so that parents can understand how their child is functioning in relation to other children his or her age. Possible etiologies for the problem should also be discussed. It is important for the clinician to evaluate continually how the parents are understanding and receiving the findings, and to encourage questions or discussions. The initial interview(s) will help prepare the clinician for possible parental reactions to the findings, and thus for ways to help them deal with their feelings during the feedback meeting. After the findings of the assessment are presented, the recommendations should be given, along with possible alternative courses of action. The length of treatment and financial costs should also be discussed. Finally, the parents should be given an opportunity to express their understanding of and feelings about the findings and recommendations, as well as how they

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would like to proceed. It is particularly important to take into account how the ethnic or cultural background of the parents may affect their understanding or acceptance of the findings. They should be presented with the options to take time to think about the findings and recommendations, to seek a second opinion, to schedule another meeting, or to call the clinician if they have further questions.

TREATMENT ISSUES The need for effective treatment for children in the United States is urgent, given that approximately 20% of children (i.e., one out of every five) has a diagnosable emotional or behavioral disorder (Angold & Costello, 1995), with 5–9% of these children experiencing extreme functional impairment (Friedman, Katz-Leavy, Manderscheid, & Sondheimer, 1996). As emphasized in Chapter 1, the child clinician’s role should be not only to provide services for those children who are seriously distressed, but also to target children who are at risk for problems, and to promote the mental health of all children based on a knowledge of normal child development and developmental psychopathology (Offord, Kraemner, Kazdin, Jensen, & Harrington, 1998; Satcher, 2000). Hence clinicians are often asked to help children with varying degrees of discomfort and impairment—some whose problems are age-related but persistent and annoying (e.g., thumb sucking, sleep problems), and others whose problems have multiple determinants and occur across multiple settings (e.g., anxiety, ADHD). Determining who should receive treatment, what treatment should be given, and how that treatment should be delivered is an ongoing clinical task. Various factors affect this decision-making process, including the availability of services, reimbursement for treatment, attitudes and perceptions of the parents, and training of the therapist. Not the least important factor in making treatment decisions is matching the targeted problem(s) with the least intrusive, most effective, and most efficient treatment method(s).1 In this section, we briefly review the current state of outcome studies for different treatment methods and some of the factors that can affect the success of treatment. We then discuss issues related to the pharmacological treatment of children. Specific treatment methods that have at least some empirical basis for their effectiveness are covered in subsequent chapters that focus on particular problems.

Treatment Effectiveness Studies The types of services and treatment methods available to children and families have increased over the past several decades (Kazdin, 2000). This increase reflects our growing understanding that children exist within a family, a peer group, a school system, a community, a culture, and a specific period of history (Howard, Barton, Walsh, & Lerner, 1999), and that their behavior is influenced by all of these contexts and social situations. Intervention has been increasingly directed to treating children within their environments rather than in more restrictive settings. Although this approach has the benefit of recognizing the ineffectiveness and poten1Important

resources for parents who are seeking mental health services for their children include Behind the OneWay Mirror: Psychotherapy and Children (Fishman, 1995); It’s Nobody’s Fault: New Hope and Help for Difficult Children and Their Parents (Koplewicz, 1996); the National Information Center for Children and Youth with Disabilities (NICHCY), Box 1492, Washington, DC 20013, 800-695-0285, http://www.nichcy.org; and the Federation of Families for Children’s Mental Health, 1021 Prince Street, Alexandria, VA 22314-2971, 703-684-7710, http:// www.fcmh.org.

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tial hazards of restrictive treatment (i.e., inpatient and residential treatment centers, which consume 75% of mental health dollars), many of the new community-based alternatives have little empirical evidence to support their effectiveness. In a comprehensive review of the literature on the effectiveness of treatment for mental health disorders in children and adolescents, Burns, Hoagwood, and Mrazek (1999) found that the strongest support is for treatments based on knowledge of the risk factors associated with the development of emotional and behavioral problems, knowledge of the trajectories of development that can lead to poor outcome, and knowledge of the types of services that have failed to meet the needs of children and families. Kazdin (1996a) summarized nine meta-analytic studies covering individual, group and family therapy for children and adolescents between 1985 and 1995. He found that changes with psychotherapy were greater than changes without treatment; functioning for the average treated child was at 76–79% of that for normally developing peers. Treatment outcome for externalizing and internalizing problems did not clearly differ. Moreover, although the type of treatment (behavioral vs. nonbehavioral) did not differ consistently in effectiveness, some studies found an advantage for behavioral and cognitivebehavioral approaches. Other research has identified effective treatments for specific childhood disorders, including phobias and anxieties, ODD, conduct disorder, ADHD, and a variety of other behaviors (e.g., toileting problems and thumb sucking) (Kazdin & Weisz, 1998). Outcome in the Real World It is important to note that treatment outcome research generally includes non-clinic-referred children from homogeneous populations with treatment focused on a specific target behavior. Furthermore, the treatment typically is carried out by specially trained therapists, who often use a treatment manual. In contrast, clinic-referred children are racially, ethnically, and socioeconomically diverse, and usually have comorbid conditions. Moreover, the training of people who provide treatment in the community is diverse, and there are fiscal restraints on the intensity and duration of treatment. Little is known about the actual treatment of children in nonresearch clinic settings. In a review of nine studies in which treatment was carried out by practicing clinicians in clinic settings, Weisz and Weiss (1989) found only medium to low treatment effects. Likewise, Weiss, Catron, Harris, and Phung (1999) found little support for the effectiveness of traditional child therapy in contrast to a controlled condition of academic tutoring. Results of a recent longitudinal community-based study indicated that improvement of symptoms was related to the number of sessions (eight or more), but a similiar impact was not observed on impaired functioning (Angold, Costello, Burns, Erkanli, & Farmer, 2000). Overall, studies of mental health interventions in “real-world” clinics are very limited, but treatment has generally been found to be less effective in these settings than in research settings. Translating studies of “efficacy,” which are directed at determining whether a particular intervention works under tightly controlled conditions (i.e., clinical trials in research settings), into studies of “effectiveness,” which are aimed at determining how well a particular intervention works under the conditions in which treatment usually occurs, is an important consideration. Moreover, research must focus on determining which interventions are effective for specific problems and populations, as well as how and who will deliver these services (Ollendick & Russ, 1999). One method of transporting interventions from the research to the clinic setting is the use of the manuals developed for treatment efficacy studies. Although this appears to be a reasonable idea, it has caused a great deal of controversy. Questions have been raised about

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the effects of using manuals on the therapeutic relationship and on therapists’ ability to meet their clients’ emotional needs. There are also concerns about the extent to which manual-based treatments can deal with patients with multiple problems, restrict clinical innovation, result in the replacement of doctoral-level professionals with less trained therapists, and require more frequent and regular sessions than is common in most clinical practices (Addis, Wade, & Hatgis, 1999). In response to these concerns, Wilson (1998) argues that manual-based treatments encourage focused intervention, do not exclude the treatment of comorbid problems, facilitate training and supervision of therapists, increase dissemination to practitioners, encourage innovation, and promote professional accountability. He also indicates, however, that the current manuals need to be made more therapist-friendly in providing more practical details about their use. An important point in this discussion is that even when effective treatments are available, they are not necessarily used in clinical practice. The predominant treatments for children and families continue to be eclectic, psychodynamic, and general counseling (Kazdin, 2000; Kazdin, Siegel, & Bass, 1990). Currently it appears that in clinical practice there are unclear criteria for treatment selection; that the techniques in use are eclectic and are combined with little attention to the quality and fidelity of the treatment; and that there is little monitoring of progress (Kazdin, 2000; 1997). Improvement in these areas demands an empirically based approach, and it is likely that changes in professional training practices will have to be made if children’s needs are to be effectively met. This involves training not only in specific techniques, but also in the theoretical orientations that drive the development of effective treatments, so that their range of application can be extended. At the same time, researchers must find ways to test the effectiveness of their techniques in clinical settings (Kazdin, 2001). Determinants of Attrition Another critical issue relevant to treatment effectiveness is to determine the factors that affect treatment initiation and completion. Given that only a small percentage of families seek help for childhood psychological problems (Stouthamer-Loeber, Loeber, & Thomas, 1992), it is disturbing that the no-show rate for first appointments following the initial telephone request for services is 15–35% (Kourany, Garber, & Tornusciolo, 1990), and that 40–60% of families who begin treatment drop out prematurely (Kazdin, 1996b). Kourany et al. (1990) found that the most common reasons parents do not keep the initial appointment are schedule conflicts, the cost of the treatment, and a perception shift (i.e., the parents feel that the child’s behavior has improved or is no longer a problem). The first two barriers to treatment can be dealt with by improving service planning and providing more financial help to families; the third is more difficult. Considerable research has documented that regardless of the objective severity of the child’s problem, the parent’s perception of the child’s behavior/adjustment and of the burden this places on them is what predicts help seeking (Angold et al., 1998). In a review of studies of parental cognitions and attributions in engagement in treatment, Morrissey-Kane and Prinz (1999) found that parental beliefs about the causes of their children’s problems, perceptions about their ability to handle such problems, and expectations about the ability of therapy to help them greatly influenced their engagement in treatment. Parents with an external locus of control (i.e., a belief that their children’s problems were stable, unchangeable, and outside their influence) tended to use a more authoritarian parenting style, were more dissatisfied with treatment, perceived behavioral management strategies to be less relevant and acceptable, and had poorer treatment outcomes. Conversely, parents with an internal locus of control (i.e., a belief

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that they could exert control over their children) were more likely to remain in treatment and had more positive treatment outcomes. A number of studies indicate that parental attributions regarding treatment can be modified through such intervention strategies as letter writing (Lown & Britton, 1991), intensive telephone contact (Wenning & King, 1995), a greater focus on parents’ expressed needs (Prinz & Miller, 1994), and influencing the clients’ social networks (Pescosolido, 1996). The bottom line is that the clinician must motivate parents to sustain their commitment to treatment. The involvement of parents and other caregivers during the planning and treatment phases of therapy is essential not only to keep parents and children in treatment, but to ensure treatment effectiveness (Henggeler, 1994). Eyberg, Edwards, Boggs, and Foote (1998) suggest that to help maintain treatment effects, strategies such as booster sessions or brief contacts by telephone after treatment has ended may be helpful. Treatment Integrity A related issue that must be addressed when parents and teachers actively participate in a child’s treatment by implementing behavioral programs is the question of treatment integrity. That is, are the treatment procedures being implemented correctly and consistently? This is particularly important for children with disruptive behavior problems, given the chronicity of these problems over time and the multiple settings in which they are typically exhibited. DuPaul and Hoff (1998) suggest using a treatment integrity checklist that is completed during randomly selected treatment sessions. Such a checklist should include the specific behaviors that the teacher or parent is expected to carry out in the program (e.g., the teacher recorded points, or the parent reviewed the activities for the evening or used labeled vs. unlabeled praise). DuPaul and Hoff (1998) also offer a number of suggestions to enhance treatment integrity: (1) The person who will implement the treatment program should be included in the intervention planning process; (2) the acceptibility of the intervention strategy should be assessed prior to treatment; (3) the manipulation of antecedent conditions (e.g., allowing choices, making work periods shorter, peer tutoring) versus consequences (giving tokens) should be emphasized; (4) programs should be initially implemented for one period or part of the day; (5) behaviors that are already monitored, such as completed homework or household chores, should be targeted; (6) the entire class should be involved, rather than focusing on one student (e.g., peer tutoring); (7) available activities should be used as reinforcers; (8) regular feedback and reinforcement for accurate implementation should be provided; (9) the clinician should meet periodically with the teacher or parent to monitor progress and modify the program as needed; and (10) the clinician should work initially with the person who is most positive about program implementation and/or with behaviors that are of the greatest immediate concern. Consumer Satisfaction With the advent of managed care, another approach to treatment outcome evaluation that has become popular is consumer satisfaction. Although satisfaction and service effectiveness are often equated, there is little empirical support for this assumption (Lambert, Salzer, & Bickman, 1998). A recent study using a brief consumer satisfaction measure of parent training, parent– child treatments, and family therapy, for example, found that satisfaction with the treatment process was related to changes in parent behavior ratings, whereas satisfaction with treatment outcome was related to changes in observed child compliance (Brestan, Jacobs, Rayfield, &

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Eyberg, 1999). In this study, correlations between the Therapy Attitude Inventory (TAI; Eyberg, 1974) and behavior problem severity after treatment were not significant. Furthermore, the TAI was demonstrated to be psychometrically reliable and valid. A major strength of the study was the use of a diverse, clinic-referred sample representative of typical clinical populations of young children with conduct-disordered behavior. The TAI is reprinted in Appendix B. To summarize, successful treatment of children and their families involves developing a relationship with the parents (and others, such as teachers, when necessary); including them throughout the treatment process; and using effective treatment methods that target the child’s and family’s specific strengths, deficits, and needs. The treatment can focus on changing the child’s behavior, the parents’ behavior, the parent–child interaction, the environment, the consequences of the behavior, and/or medical issues. It thus must be focused on multiple levels of interaction with ongoing monitoring of progress. The success of treatment should be substantiated, and maintenance of those effects must also be considered in this process. Three approaches to treatment in the “real world” that have been found to be effective are as follows: 1. Home-based services, particularly multisystemic therapy with delinquent children and adolescents, have clearly documented effectiveness (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998). Multisystemic therapy is an intensive family-focused treatment that targets such risk factors as peer associations; it emphasizes parental monitoring and coordination with schools and community. 2. Treatments that provide training for foster parents to help them deal with children who have emotional and behavioral problems are effective, as are approaches involving structured therapeutic homes (Chamberlain & Reid, 1998). 3. Although the evidence is small, there are indications that intensive case management (including behavior management, service planning/coordination, and psychoeducation) can be effective (Evans, Armstrong, & Kuppinger, 1996).

Psychopharmacology Issues A review of psychoactive-medication-prescribing practices for children and adolescents in the United States highlights the increased clinical use of these medications. There are few data to support their short- and long-term efficacy and safety, however (Jensen et al., 1999; Weisz & Jensen, 1999). Furthermore, a recent report (Zito et al., 2000) on the sharp increase in the use of stimulants, antidepressants, and clonidine with preschoolers has caused even the White House to raise questions about this method of treatment (Rabasca, 2000). Only stimulant drugs have adequate data to inform their use with children.2 Although the number of efficacy and safety trials for psychotropic medications with children and adolescents is increasing, the rate of progress is slow (Jensen et al., 1999). This is of particular concern, given the lack of information on the long-term effects of these medications on developing children. Clinicians not only should be knowledgeable about the efficacy and safety of psychotropic medications, but also should be aware of parents and children’s attitudes about such medications (Rappaport & Chubinsky, 2000). Some parents are apprehensive when it is recommended 2Unfortunately,

safety and efficacy concerns are not limited to psychotropic medications. The American Academy of Pediatrics recently reported that 80% of all medications used with children lacked scientific support for their efficacy with this population (American Academy of Pediatrics, Committee on Drugs, 1996).

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that medication be used to alter their child’s mood or behavior, or they may feel that the medication should resolve all of their child’s problems. A recommendation for medication may even cause some parents to feel guilty that their child has inherited a biological basis for the problem. Likewise, children often have concerns about the effects or meaning of the use of psychotropic medications. They may believe that it is proof that they are “defective,” or that they are responsible for their family problems; they may also be frightened of the tests that monitor the medication (e.g., electrocardiograph). A careful assessment of these attitudes/concerns, and the provision of appropriate information on how the body works and why medication is thought to be needed, is essential before any drugs are prescribed. An important resource for parents who are considering medication for their children is Straight Talk about Psychiatric Medications for Kids (Wilens, 1998). To summarize, psychotropic medication should be used cautiously with children, and its use as the only treatment for children with psychiatric disorders is not warranted. To do so is to ignore the context in which a child lives and the psychosocial influences that place the child at risk for continuing problems. The interested reader is referred to Wiener (1996) and Vitiello, Bhatara, and Jensen (1999) for reviews of pediatric psychopharmacology and Werry (2001) for a thoughtful commentary on psychopharmacological treatment. The use of psychotropic medications with specific disorders is discussed in later chapters.

PART

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CHAPTER 3

Eating Problems

A

lmost all parents have difficulty feeding their children from time to time. Significant conflict between parents and children can develop around feeding, because parents are naturally very concerned about their children’s well-being and want to ensure that they eat a healthy diet. At the same time, children have an uncanny sense that this is a battle parents cannot win, and as a result often assert their independence around mealtime issues. Thus feeding necessitates shared control between parents and children (Linscheid, Budd, & Rasnake, 1995). Parents control what food is served and when it will be served, whereas children control what and how much they will eat and how they will eat it. Given the extent to which children control eating, it is not surprising that difficulties in this area are relatively common during childhood. It is estimated that from 20% to 62% of children exhibit eating problems serious enough to come to the attention of a professional (Budd & Chugh, 1998; Linscheid & Rasnake, 2001). Persistent problems that compromise health and development are seen in 1–3% of children (Dahl & Sundelin, 1986; Lindberg, Bohlin, & Hagekull, 1991). There is no reliable classification for early feeding difficulties (Linscheid & Rasnake, 2001), most likely because of the wide variety of problems seen in young children and the multiple causes for these problems. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association [APA], 1994) includes in the section on disorders of childhood only pica, rumination, and a very general category called “feeding disorder of infancy or early childhood,” which is defined as “persistent failure to eat adequately, as reflected in significant failure to gain weight or significant weight loss over at least 1 month” (p. 98). DSM-IV further specifies that this disorder cannot be attributed to any medical conditions or other mental disorders. Although this disorder is descriptive of failure to thrive (FTT), it does not include most of the eating problems likely to come to the child clinician’s attention. As an alternative, Linscheid and his colleagues (Linscheid, Budd, & Rasnake, 1995; Linscheid & Rasnake, 2001) suggest classifying feeding problems by type and cause. Types include problems with (1) developmental appropriateness of foods eaten (e.g., eating only pureed foods); (2) quantity consumed (e.g., under- or overeating); (3) mealtime behaviors (e.g., tantrums, refusals, crying); and (4) delays in self-feeding. Causes include (1) medical or genetic conditions that interfere with eating or development of feeding behaviors; (2) neuromotor delay or dysfunction, especially oral–motor problems; (3) mechani81

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cal obstruction (e.g., feeding tube); and (4) behavioral mismanagement (e.g., failure to teach appropriate eating habits). In reality, most feeding problems have multiple causes, requiring the child clinician to consult with other medical and nutritional professionals (Linscheid & Rasnake, 2001). This chapter first reviews the normal development of feeding behavior. It next briefly covers four eating problems that either occur primarily in infancy or represent dysfunctional forms of infant feeding patterns: colic, pica, rumination, and FTT. Obesity, and food refusal problems (including finicky eating and food phobias), are then discussed in greater detail. The assessment and treatment of cases in which children are or have been medically compromised are included in the section on food refusal problems. It should be noted that although case reports of anorexia nervosa in children exist (Fosson, Knibbs, Bryant-Waugh, & Lask, 1987), there is general agreement that this disorder is very rare in children under 10 years of age. Thus anorexia nervosa and bulimia nervosa are not covered here, as these are primarily problems of adolescence and beyond the scope of this book. It is important to note, however, that recent research has documented an association between mothers’ eating disorders and their children’s (especially girls’) self-reported eating disturbances (i.e., feeling too fat and engaging in weight-control behavior) at age 8 years (Jacobi, Agras, & Hammer, 2001). This finding suggests that there might be precursors for adolescent eating disorders that are important in childhood. The reader is referred to Garner and Barry (2000), Sanders, Kapphahn, and Steiner (1998), Williamson, Bentz, and Rabalais (1998), and Williamson, Womble, and Zucker (1998) for further discussion of these disorders.

NORMAL DEVELOPMENT OF FEEDING BEHAVIOR Understanding normal development of feeding patterns is critical in diagnosing and treating eating problems in young children. Table 3.1 outlines physical and behavioral development related to feeding during the first year. As can be seen in the table, there are enormous changes in children’s diet and feeding behaviors during the first year of life. Children begin life eating only one food, milk, and must gradually learn to accept a wide variety of foods. By the end of the first year, almost all normally developing children are eating many different solid foods and are able to self-feed completely independently. Infants double their weight during the first 5 months of life and triple it by the end of the first year, gaining about 12–18 pounds in this year (Hoekelman, Blatman, Brunell, Friedman, & Seidel, 1978; Smith, 1977). Moreover, the capacity of the stomach grows from about 10–20 ml at birth to 200 ml at 1 year of age. Between 1 and 2 years of age, children’s weight gain slows and their appetites decrease substantially; during the next 3–4 years, weight gain is only about 5 pounds per year. This decrease in appetite, coupled with toddlers’ emerging drive for independence and autonomy, sets the stage for a variety of feeding problems. Although feeding problems do occur during the first year (see “Eating Problems Related to Infant Feeding,” below), they are much more common during the toddler and preschool years, and parents are often most worried about their children’s eating habits at this time. In a random survey of 140 parents in a private pediatric practice, for example, 60% of parents of 2-year-olds, 30% of parents of 3-year-olds, and 50% of parents of 4-year-olds indicated that mealtimes were a problem (Schroeder, Gordon, Kanoy, & Routh, 1983). In contrast, eating was not noted as a problem by any parents of newborns to 1-year-olds.

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TABLE 3.1. Normal Feeding Development in the First Year Age

Physical development

Behavioral development

Birth

Physiological distress brought on by hunger Preference for sweet, salty Aversion for sour, bitter Sucking and rooting reflexes Extrusion reflex (tongue thrust) Stomach size = 10–20 ml

Feeding on demand Colic is common Breast-fed babies experience many new flavors

2–3 months

Nighttime feedings end Colic resolves

3–5 months

Sucking and rooting reflexes fade out New skills emerge: Reach and grasp Hand to mouth intentionally Munching

Begin solid foods Everything goes in the mouth

7–10 months

Lateralization of tongue Sitting up propped Teeth appear

Finger feeding Grabs for spoon Critical period for introducing solids

9–10 months

Pincer grasp Lateral chewing movements Can lick food from bottom lip Sitting up unpropped

Drink from spouted cup Spoon to mouth

12 months 15 months

Can use spoon and other utensils Stomach size = 200 ml Weight gain decreases to 5 pounds per year

Entirely self-feeding

Linscheid and Rasnake (2001) stress the importance of preventing feeding difficulties. They recommend that parents expose their children to many different foods that are developmentally appropriate and varied in texture and taste. During the transition from milk to solids, acceptance of new foods is shaped by an inborn preference for sweet and salty, and an aversion to sour and bitter (Birch & Fisher, 1998). Infants are also born with a predisposition to reject novel foods. Thus acceptance of new foods does not come naturally, but it can easily be shaped by repeated exposure. In this way, novel foods become familiar over time, and children tend to like and eat what is familiar (Birch & Fisher, 1998). Moreover, early experience with a wide variety of tastes and textures leads to readier acceptance of new foods later in life (Birch & Fisher, 1998). In this regard, Menella and Beauchamp (1996) note that infants who are breast-fed may have an advantage over bottle-fed babies. Breast-fed babies experience a variety of tastes as a result of variations in their mothers’ diets, whereas bottle-fed babies experience only one flavor—that of commercially prepared formula. Between 4 and 6 months of age, infants will eventually accept almost any new taste (Birch, 1990; Wren & Tarbell, 1998). This is an ideal time to introduce solid foods, as children at this age tend to put everything into their mouths anyway. Moreover, fine motor skills are developing to the extent that children can reach and grasp, and can intentionally bring things to their mouths. Children who have not been exposed to solid foods requiring chewing by 7–10 months of age may have difficulty learning to eat solids later (Illingworth & Lister, 1964). Wren and Tarbell (1998) suggest that this may result from the lack of opportunity to develop adequate

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oral–motor skills. Thus it is important for parents not to revert to pureed food if a child gags on solid food as it is being introduced; rather, they should continue presenting the child with various types of solid foods, especially “finger foods.” Parents should remain flexible while feeding their children during these early years, allowing them plenty of opportunities to exercise their developing skills despite the inevitable mess. Moreover, parents do not need to worry excessively about whether or not their children are getting proper nutrition. Based on the early “cafeteria” studies, Rozin (1990) has argued that an innate regulatory system for nutritional intake is probably operating during the first year of life to help ensure that children get adequate nutrition. That is, when presented with a variety of healthy foods and left to their own devices, children tend to eat what they need. In contrast, parental control in the feeding context (e.g., urging children to clean their plates, offering rewards for finishing everything) can override this regulatory system. A high degree of parental control is associated with eating problems (over- or undereating), weight fluctuations, and preoccupation with food later in life (Birch, 1990; Birch & Fisher, 1998). In order to ensure that a child’s internal regulatory system continues to operate efficiently, Satter (1996) states that it is the parents’ responsibility to provide a healthy array of food and a supportive eating context, whereas it is the child’s responsibility to decide what and how much to eat. Rejection of various types of food is expected after the first year, as children begin to develop stronger food preferences and their appetites decrease. Repeated exposure to rejected foods, however, increases the chances that a child will try these foods and eventually even learn to like them (Budd & Chugh, 1998). Research has shown that during the preschool years, preferences for a novel food can be changed from rejection to acceptance by presenting the food to the child 8–15 times over a period of about 2 weeks (Sullivan & Birch, 1990). In contrast, removing the rejected food and substituting a preferred food only reinforces the child’s refusal and can contribute to more significant problems in the future. Parents also must know how to teach appropriate feeding and mealtime behaviors. Guidance in simple behavioral principles can help. Parents, for example, can be good models for their children by eating a variety of healthy foods in reasonable quantities, by demonstrating appropriate eating behavior, and by engaging in a variety of enjoyable physical activities to stimulate the appetite. It is also important for parents to provide children with healthy meals and snacks on a consistent schedule, and to arrange a pleasant, stress-free setting for family meals. Moreover, parents can limit the amount of television to which their children are exposed, which will reduce their desire for low-nutrition foods. Christophersen and Hall (1978) suggest the following mealtime rules for parents and children: 1. 2. 3. 4. 5. 6. 7. 8.

Remain seated until the meal is over. Chew and swallow food with mouth closed. Use utensils when appropriate. Include children in mealtime conversation. Reward appropriate eating behavior with praise and attention. Remove food at the end of the meal. Allow between-meal snacks only if children have eaten a reasonable amount at mealtime. Use time out for breaking rules or engaging in other disruptive behaviors.

Bibliotherapy can be used to help parents in the prevention of eating problems. Two of our favorite books are Coping with a Picky Eater: A Guide for the Perplexed Parent (Wilkoff,

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1998) and American Academy of Pediatrics Guide to Your Child’s Nutrition: Making Peace at the Table and Building Healthy Eating Habits for Life (Dietz & Stern, 1999).

EATING PROBLEMS RELATED TO INFANT FEEDING Colic Colic is the most common problem related to feeding in early infancy. It is characterized by inconsolable crying that may last 3 hours or more after feeding, and is accompanied by pain grimaces, abdominal distension, and leg extension (Lyman & Hembree-Kigin, 1994). The cause of colic is not known, although it has been suggested that at least some cases result from an allergic reaction to milk (Budd & Chugh, 1998). Medical problems must be ruled out before a diagnosis of colic is made. Prevalence of colic is estimated at between 10% and 20% of infants (Hewson, Oberklaid, & Menahem, 1987). There is no one effective treatment for colic; various medications (including alcohol) have been tried, but none have been found to work consistently. Ancedotal reports from parents indicate some success with noise and/or movement (e.g., riding in the car, putting the baby on top of the clothes dryer when it is running). Colic typically lasts about 13–16 weeks and then resolves on its own with no apparent long-term negative effects, although Hewson et al. (1987) reported that some mothers indicated more feeding difficulties with their children even after colic had resolved.

Pica DSM-IV defines the essential feature of pica as “persistent eating of nonnutritive substances for a period of at least 1 month” (APA, 1994, p. 96). Pica is differentiated from mouthing in that it involves actual eating of nonfood substances, rather than just tasting or chewing (Lyman & Hembree-Kigin, 1994). Mouthing of nonfood substances is developmentally appropriate in infants and is motivated by their natural curiosity about the environment (Budd & Chugh, 1998). Indeed, at about 6–9 months of age, mouthing is a primary way of exploring the world. Pica is considered a problem if it persists past the age of 18 months, and it is surprisingly common: Lacey (1993) cites prevalence estimates ranging from 27% to 50% of black children and from 17% to 30% of white children. Pica is more common in developing versus developed countries, among the poor versus the affluent, among children versus adults, and among those with severe versus mild mental retardation (Wren & Tarbell, 1998). The etiology of pica is not well understood, but it is associated with an impoverished environment and lack of stimulation, as well as with mental retardation. It does not appear to be caused by poor nutrition, and is seen frequently in some subcultures of the United States and other countries (Lyman & Himbree-Kigin, 1994, Wren & Tarbell, 1998). Pica is considered a serious problem because of its association with lead poisoning and ingestion of other toxic substances; it is estimated that about 30% of children with pica have lead poisoning (Feldman, 1986). Moreover, children with pica are often brought to their pediatricians with bowel or intestinal obstructions or perforation (APA, 1994). Intervention for children with pica typically involves parental education regarding the hazards of eating nonfood substances, increased social and environmental stimulation, closer supervision, and behavior therapy for persistent cases. The latter involves differential reinforcement (e.g., food treats) for incompatible behaviors (e.g., playing with toys), as well as overcor-

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rection (e.g., brushing the tongue and teeth with mouthwash contingent on eating nonfood substances) (Lyman & Himbree-Kigin, 1994).

Rumination Rumination involves intentional and repeated regurgitation and rechewing of food that is not associated with a medical problem (APA, 1994). Rumination occurs occasionally in almost all infants, usually at about the age of 6 months, and typically disappears spontaneously. It becomes a disorder only if it persists for 1 month or longer, as rumination can result in significant malnutrition, dehydration, and even death; mortality rates are reported as high as 25% (APA, 1994). The prevalence of rumination disorder in the general population is not known, but it is considered rare; it is more common among children and adults with mental retardation (6–10% of the institutionalized population) (Wren & Tarbell, 1998). In addition, boys with the disorder are estimated to outnumber girls 3:l (Johnston, 1993). DSM-IV indicates that infants who engage in this behavior have a characteristic posture of straining and arching their backs and making sucking movements with their mouths. Moreover, they appear to gain pleasure from the activity, suggesting that rumination is a form of oral self-stimulation that can rapidly become habitual through inherent reinforcement and parental attention (Linscheid & Rasnake, 2001). Infants who ruminate are reported to be generally irritable and hungry, despite ingesting adequate amounts of food (APA, 1994). Moreover, rumination is reported to occur more frequently in infants who lack sufficient stimulation, have anxious or depressed caregivers, and/ or come from very stressful environments (Budd & Chugh, 1998). Current work, however, indicates that some infants who experience very postive relations with their caregivers and receive adequate stimulation are known to ruminate. Thus it appears that rumination is not a homogeneous disorder (Wren & Tarbell, 1998). Assessment of rumination disorder requires observation of rumination episodes to determine the setting conditions and consequences for the behavior, as well as parent–child interaction. Linscheid and Rasnake (2001) note, however, that it is important to consider cause and effect in observing parent–child interaction, as the mother’s behavior can be considerably altered as a result of dealing with ongoing rumination. Treatment typically involves changes in the environment to ensure that the infant receives appropriate stimulation and attention, and parent training in the systematic use of social reinforcement for behaviors incompatible with rumination (Lavigne, Burns, & Cotter, 1981). Some clinicians have reported success using an aversive stimulus contingent on ruminating, such as a squirt of lemon juice or pepper sauce, or mild electric shock for severe cases (e.g., Glasscock, Friman, O’Brien, & Christophersen, 1986; Linscheid & Cunningham, 1977; Toister, Colin, Worley, & Arthur, 1975), although the ethics of this approach have been questioned (Wren & Tarbell, 1998).

Failure to Thrive FTT is diagnosed when a child’s weight falls significantly below normal—that is, two standard deviations below the mean for age or less than the 5th percentile, when corrected for gestational age, parental growth patterns, and gender (Drotar, 1995). The term “nonorganic failure to thrive” (NOFTT) describes these characteristics in the absence of any known medical condition (Linscheid & Rasnake, 2001). Linscheid and Rasnake (2001) describe two groups of children with NOFTT: (1) infants less than 8 months of age, in whom growth failure is due to deficiencies in the mother–child relationship; and (2) children over 1 year of age, in whom

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growth failure is due to behavioral mismanagement and problems with achieving independent feeding skills. Drotar (1995) suggests that instead of differentiating organically based FTT from NOFTT, it is more appropriate to view FTT as occurring on a continuum, reflecting the interplay of environmental and physical problems of varying severity. Thus “FTT” is used in this section to refer to either type. Estimates of the prevalence of FTT suggest that it is not an uncommon disorder; rates range from 3.5% to 35% of children (Drotar, 1995; Linscheid & Bennett-Murphy, 1999). Onset is typically in infancy, although older preschoolers are occasionally seen with these characteristics. Children with FTT present with a wide variety of medical conditions, psychological and developmental deficits, and social and environmental problems. Drotar (1995) notes that it is not always easy to differentiate the cause of the disorder from the effects of malnutrition. Moreover, in cases in which a child has no clear medical condition and the parent–infant interaction is problematic, the direction of causality is not always clear. That is, a parent’s dysfunctional behavior may result from having a child who will not eat sufficient food to maintain adequate growth and development. Many factors have been implicated in the etiology of FTT, and these are summarized in Table 3.2. Drotar (1995) indicates that the behavioral and cognitive deficits seen in children with FTT often persist even after proper nutrition is assured and growth is back on track. Moreover, later academic and behavioral problems in school are documented in many

TABLE 3.2. Factors Implicated in the Etiology of FTT Area of risk

Risk factors

Characteristics of the caregiver (usually mother)

• • • • • • • • •

Characteristics of the infant

• • • • •

Characteristics of the environment

• Low financial resources, which may limit food available • Cultural, ethnic, and personal beliefs about feeding, weaning, and “healthy” diet • Being the youngest child in a large family • Isolation and lack of social support • Poor-quality home environment • Family conflict at mealtimes

Disturbed interaction with the infant Poor problem-solving abilities Lack of nutritional knowledge Improper feeding techniques Inconsistent feeding History of inadequate parenting as a child Depression or other psychological distress Excessive stress Alcoholism or drug abuse

Prematurity (up to 40% of cases) Physical illness Fussy/difficult temperament Childhood depression Weak sucking reflex or other oral–motor problems • Higher pain threshold and longer latency of response to pain

Note. The data are from Drotar (1995) and Lyman and Hembree-Kigin (1994).

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of these children. It is not possible, however, to distinguish the contribution of living in a poor environment from the contribution of early malnutrition to the persistence of these problems. Assessment and treatment of FTT necessarily involve a multidisciplinary team of professionals (see Wren & Tarbell, 1998, for an in-depth description of the roles of medical, nutritional, psychological, and other professionals). Children with FTT are often seen in an inpatient setting because of their compromised health status. Medical professionals must first rule out any contributing physical problems. The psychologist must take a multidimensional approach to assessing these complex cases, focusing on gathering information about the various risk factors shown in Table 3.2 (Wren & Tarbell, 1998). Observation of parent–infant interaction at feeding times is crucial to determine specific contingencies or feeding practices that may be contributing to the problem. It is interesting that up to 40% of these youngsters gain weight during hospitalization (Lyman & Hembree-Kigin, 1994). Although there have been few controlled studies of treatment efficacy for FTT (Drotar, 1995), intervention is typically multidimensional in focus. The needs of each family must be prioritized, and treatment must focus on meeting these needs. Typically, these families require a great deal of support, and home visits after the babies are discharged from the hospital may be required (Drotar & Sturm, 1988; Sturm & Drotar, 1989). Treatment can involve changes in the parent–child interaction, parent education about nutrition and infant development, modeling of appropriate child care and nurturing, environmental interventions to reduce parental stress, and assistance in accessing resources. Weekly home visits during pregnancy and after childbirth are reported to be important in preventing problems among low-income adolescent mothers—a group at very high risk for having infants with FTT (Olds, Henderson, Chamberlin, & Tatelbaum, 1986). Psychosocial Short Stature Psychosocial short stature (PSS), also known as psychosocial dwarfism, is a more severe and relatively rare variant of FTT. It typically begins between 2 and 4 years of age. The main criteria used to differentiate PSS from FTT are (1) deficiencies in height rather than weight; (2) onset in toddlerhood rather than infancy; and (3) documented endocrine disturbance that is environmentally induced (Wren & Tarbell, 1998). Diagnosis is dependent on demonstrating the reversibility of the symptoms when the child is removed from the home environment. Children with PSS engage in very bizarre behaviors, such as overeating, vomiting, stealing or hoarding food, eating garbage or feces, drinking out of toilets, and roaming at night in search of food. They also typically have mild mental retardation, toileting problems, disruptive behaviors, and sleep and attentional problems (Lyman & Hembree-Kigin, 1994). The etiology of PSS is thought to be a severely disturbed parent–child relationship, often involving physical, emotional, and/or sexual abuse. Thus a diagnosis of PSS will almost always entail social services intervention (Wren & Tarbell, 1998). Evaluation of treatment approaches to PSS is based entirely on case reports, so there is no empirically validated approach. Treatment typically focuses on removing the child from the “toxic” environment, placing him or her in a setting that promotes healthy growth and development, and providing the child with the opportunity to form appropriate attachment relationships (Wren & Tarbell, 1998). Rarely is it possible to allow a child to remain at home during treatment, and most children relapse when returned home even after extended (up to 1-year) placement out of the home (Lyman & Hembree-Kigin, 1994).

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OBESITY Overeating to the point of obesity is an increasing problem among children in the United States. Between 1976 and 1980 the prevalence of obesity in children was estimated to be about 17%, whereas in 1995 the rate was about 22% (Troiano, Flegal, Kuczmanski, Campbell, & Johnson, 1995). The recent increase in childhood obesity is not due to increased caloric intake (Troiano & Flegal, 1998); rather, the cause is an increase in sedentary lifestyles. Current research indicates that increased television viewing, as well as time spent with computers and computer games, contributes to childhood obesity. Gortmaker et al. (1996), for example, found that children who watched 5 or more hours of TV a day were 4.6 times as likely to be overweight as those who watched 0–2 hours per day. Television viewing contributes to obesity in a number of ways. Birch and Fisher (1998) note that 80% of food advertisements on television are for low-nutrition, high-fat, and high-sugar snacks and cereals. Moreover, children’s requests for specific foods are directly related to the frequency with which they are exposed to advertisements for these foods on TV. Concerns about pediatric obesity stem from its strong association with adult obesity and the resulting serious health and psychosocial risks. It has been estimated that approximately 36% of obese infants and up to 80% of obese children aged 10–13 years become obese adults (Charney, Chamblee, McBride, Lyon, & Pratt, 1976; Abraham & Nordsieck, 1960). In surveys of national samples from 1963 to 1994, Troiano and Flegal (1998) found that the heaviest children tended to become heavier over time. Thus it seems clear that overweight children are not likely to outgrow their excess weight. Moreover, the psychological and social consequences of obesity are significant for both children and adults (Wisniewski & Marcus, 1998). Obese children are stigmatized by peers as early as the preschool years (Cramer & Steinwert, 1998; Dietz, 1998) and tend to have lower self-esteem and more behavior problems than normalweight children (Kolody & Sallis, 1995; Myers, Raynor, & Epstein, 1998). Obese adults complete fewer years of school, have lower incomes, are less likely to marry, and are more likely to live in poverty than adults of average weight (Wisniewski & Marcus, 1998). Significant psychopathology is usually not associated with childhood obesity, however, and existing behavioral problems typically improve with weight loss (Myers et al., 1998). Risk of obesity in children is increased when they come from lower-socioeconomic-status environments, when their mothers are not married, and when social support is lacking (Gerald, Anderson, Johnson, Hoff, & Trimm, 1994). The incidence of childhood obesity also varies by age, ethnic group, and gender. Rosner, Priness, Loggie, and Daniels (1998), for example, examined body mass index (BMI, defined as weight in kilograms/height in meters squared) for a sample of 66,772 U.S. children ages 5–17. They found that obesity was more common among girls of African and Hispanic descent (9–15%) and Hispanic boys (9–12%) than among boys and girls of European or Asian descent. The percentage of children considered obese decreased with age but, with the exception of Asian youth, never fell below 5% of the 17-year-olds. Field et al. (1999) surveyed 16,114 children ages 9–14. They found that more boys than girls were overweight (26% vs. 19%), but that girls were more likely than boys to perceive themselves as being overweight. The proportion of girls who reported trying to lose weight and the incidence of binge eating among girls both increased with age. Use of laxatives and purging to control weight was greater for girls aged 13–14 years than for younger girls. There is a belief that childhood obesity is in part genetically determined. This belief is based on the fact that the risk of obesity increases if one’s parents are also obese. If one parent is obese, a child has a 40–50% chance of becoming obese; if both parents are obese, the chances

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of a child’s becoming obese is over 70% (Linscheid, 1992). A similar association has been found for adopted children, however, and genetic factors are estimated to account for only about 30% of the variance in weight. This suggests that obesity is caused more by family eating and activity patterns than by genetics (Linscheid, 1992). Fundamentally, obesity is caused by an imbalance between the intake of food and the output of energy. Lack of parental concern with or supervision of children’s eating habits, misinformation about proper diet, and maladaptive family eating practices are implicated in causing this imbalance (Lyman & Hembree-Kigin, 1994). In addition, Kohl and Hobbs (1998) argue that learned physical activity behavior patterns in children are in part responsible for obesity. They note that environmental and social factors (e.g., reduced enrollment in physical education; lack of safe places to play outdoors; and the attractiveness of television, computers, and other competing activities) have contributed to increased sedentary lifestyles among children.

ASSESSMENT OF OBESITY Obesity is defined as body weight above the 85th percentile for children of the same age, height, and gender. BMI can be used to diagnose obesity; tables of normal BMI by age and gender are shown in Rosner et al. (1998). Most clinicians, however, rely on visual assessment (i.e., a child who looks fat is fat), which has been shown to correlate highly with tricep skinfold thickness (Rauh & Schumsky, 1969). Wisniewski and Marcus (1998) provide excellent guidelines for assessment of childhood obesity; the following discussion is based in part on their work. The assessment process described here follows the steps for gathering information in accordance with the Comprehensive Assessment-to-Intervention System (CAIS; see Chapter 2). The emphasis, of course, is on those factors important in assessing and treating obesity.

Step 1: Initial Contact The first step in assessing obesity is to obtain a complete physical examination to rule out any medical condition that would preclude dietary restriction or increase in activity. Treatment of children under the age of 5 years requires ongoing monitoring by a physician and/or nutritionist to ensure adequate nutrition for growth. Parents should be asked to complete a parent questionnaire (e.g., our own General Parent Questionnaire; see Appendix B) with demographic information, as well as their view of the child’s problem and what they have been told and/or done thus far. The Child Behavior Checklist (CBCL; Achenbach, 1991a, 1992), the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992), and/or the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus 1999) screen for behavior problems that might interfere with treatment. The Parenting Stress Index (PSI; Abidin, 1995) helps identify any stresses in the marital relationship or parent problems (e.g., depression) that might make treatment more difficult or lead to premature termination of treatment. The Children’s Eating Behavior Inventory (CEBI; Archer, Rosenbaum, & Steiner, 1991) assesses behavior specific to eating problems. It is reprinted in Appendix B.

Step 2: Parent and Child Interviews The parents and child should be seen together at the first session. This allows the clinician to observe parent–child interaction, and to assess both the child’s and the parents’ willingness to

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participate in the treatment program. If a parent is also significantly overweight, his or her eating habits and attitudes toward food should be assessed. (Parents’ own eating problems may not be completely dealt with in a child-focused treatment approach, and an appropriate referral may be necessary.) Successful treatment of childhood obesity necessitates changes in the parents’ eating and exercise habits. Moreover, parents control what types of food are purchased, how food is prepared, and what types of activities children engage in; they also function as role models for eating and activity behavior. Consequently, the success of treatment is significantly diminished if the parents are not active participants along with the child. The following areas should be covered: 1. During the initial interview, the clinician should follow up on the information obtained through the screening questionnaires and explore any behavioral or developmental problems reported. 2. Parents should be questioned in detail about their attempts to control their own and/ or the child’s weight. Often these attempts are made for brief periods of time and in an unsystematic fashion. It is important to give parents information about the usefulness of previously used weight loss strategies, as well as why these strategies might not have been successful. 3. Finding out why parents are seeking help now, rather than at some other time, provides information about their attitudes toward the problem and potential compliance with treatment. Because parents play such a critical role in the success or failure of a treatment program for childhood obesity, their attitudes, beliefs, and acceptance of the treatment approach must be carefully assessed before treatment begins. 4. The child’s feelings about his or her weight should also be assessed. Furthermore, his or her attitudes and beliefs about eating should be explored, especially if the child is severely overweight, as these can inform the clinician about the potential for more serious eating disorders (Wisniewski & Marcus, 1998). 5. A series of questions can determine the child’s understanding of the benefits of being thinner: (a) “What are the bad things about being fat?”; (b) “What are the good things about being thinner?”; (c) “What difference would losing weight make for you?”; (d) “What do you imagine might change if you lost weight?”; (e) “Can you see any problems with being thinner?”; and (f) “What might be the good things about being overweight?” 6. Food and activity recording sheets should be given to the family and discussed at this session. Daily self-monitoring of food intake and activity is necessary for a baseline period of about 2 weeks, but the clinician should be aware that overweight children and adults are known to be inaccurate in estimating their intake. Sample food and activity records are shown in Figures 3.1 and 3.2, respectively. The clinician should make sure that parents and child understand how to complete these records. They should be informed that regular completion of records is highly associated with successful weight loss and maintenance of the loss.

Step 3: Observation of Behavior Observation of the parent–child interaction during the interview is useful in determining the support that the parents will give the child during treatment. In addition, observing how the child reacts to the discussion can give information on the child’s interest in treatment and/or steps that may be needed to elicit his or her cooperation with the treatment plan. Visiting the home during mealtime or videotaping several mealtimes can provide useful information. The focus of this observation should be on behaviors that may interfere with treatment (e.g., family conflict, nag-

Date

Time

Type of Food

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Food Diary Amount

Where Eaten/Behavior

Sample Mon. 4/24/00

7:30 A.M.

Pancakes with syrup; orange juice

4 pancakes; 8oz. juice Kitchen/Watching TV

11:30 A.M.

Pizza; milk

3 slices; 8oz. milk

School/With friends II. MANAGING COMMON PROBLEMS

92 FIGURE 3.1. A chart for recording daily food intake and behavior. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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Daily Activity Record Date

Time

Activity

Amount

Enjoyment

Kickball

20 minutes

Picked last for team

Walked the dog around the block

15 minutes

OK

Sample Mon. 4/24/00 10:30 A.M. 4:00 P.M.

FIGURE 3.2. A chart for recording daily activity.

From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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ging or teasing about the child’s eating) and on those that might indicate inaccuracy of food records (e.g., overly large portions, overuse of butter or salad dressing).

Step 4: Further Assessment Further psychological assessment is only necessary if other problems become evident during the assessment process.

Step 5: Referral to Allied Health Professionals A medical evaluation should be done before the initial interview with the family, in order to rule out any problems that would contraindicate a moderate decrease in calories and increase in activity. It is important to note that moderate calorie restriction does not affect children’s long-term growth and is not associated with the onset of more serious eating disorders such as anorexia nervosa or bulimia nervosa (Wisniewski & Marcus, 1998). Parents may find that a consultation with a nutritionist is helpful as they progress in treatment. Parents should be referred to an appropriate professional or agency if their own obesity is a significant problem.

Step 6: Communication of Findings and Treatment Recommendations Following the assessment session, it is important for the child clinician to share information with the parents about the child’s development and the nature of the child’s weight problem. This is particularly important, because the parents’ and child’s trust in the clinician and cooperation in the treatment process will depend on their understanding of the problem. The nature and possible etiology of the obesity should be shared with the parents and child, and they should be given a rationale for the treatment recommendations. This process often involves explanations of the value of previously attempted methods and the reasons why they did not work. Furthermore, parents can be told the factors that have been shown to be associated with successful treatment (i.e., family involvement, careful self-monitoring, and lifestyle changes).

TREATMENT OF OBESITY In contrast to treatments for many other childhood disturbances, there are treatments for childhood obesity that have been empirically demonstrated to be effective—not only in promoting weight loss, but in helping children maintaining the loss over many years. Jelalian and Saelens (1999) have reviewed studies of treatment programs targeting childhood obesity. Most of these programs involved some combination of behavior modification components, such as self-monitoring, stimulus control strategies, and contingency management. It was not possible, however, to determine which of these components were critical to successful weight loss. Jelalian and Saelens concluded that treatment programs emphasizing the following components were most effective in helping children lose weight and keep it off: (1) targeting of parent as well as child weight loss; (2) diet combined with increased lifestyle and/or aerobic activity; and (3) parent participation. Few successful treatment programs were found for children who were more than 100% overweight, or who had comorbid psychopathology. Moreover, in a recent study, specific training in problem-solving skills was not found to add significantly to a family-based treatment program (Epstein, Paluch, Gordy, Saelens, & Ernst, 2000).

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The treatment program described here is based on those reported by Epstein and his colleagues (e.g., Epstein, McCurley, Wing, & Valoski, 1990; Epstein, Myers, Raynor, & Saelens, 1998; Epstein & Squires, 1988) and Wisniewski and Marcus (1998). The child’s (and one or both parents’) weight should be measured and recorded at the start of each session. The parents and child are usually seen together to review the week’s progress, to go over homework and goals for the previous week, to discuss and problem-solve difficulties, and to assign homework and set goals for the following week. Parents and child can be seen separately as needed, and treatment can be conducted either in groups or individually.

Basic Information The fundamental message for parents and children is that the child must consume fewer calories and expend more energy in order to lose weight. A pound equals about 3,500 calories, so the balance of intake and output must be adjusted accordingly. As an example, the child must reduce the number of calories consumed by 300 a day, and increase his or her daily exercise by 200 calories a day, in order to lose 1 pound a week; any combination of lower intake versus greater output will suffice, however. In order to ensure adequate calories for growth and development, the child should never consume fewer than 1,000 calories per day (Wisniewski & Marcus, 1998). Furthermore, children have specific needs for protein, calcium, and iron, so consultation with a nutritionist or dietitian may be needed. Very-low-fat diets, which are sometimes prescribed for adults, are not appropriate for children; it is recommended that fat intake should be at about 30% of calories. Setting overall weight loss goals for children as they continue to grow is difficult. For some children, simply maintaining their current weight will be sufficient, as they will slim down as their height increases. Thus Wisniewski and Marcus (1998) suggest gradually reducing the number of calories consumed each day and gradually increasing the amount of exercise from the child’s baseline data. A decrease of about 500 calories per day from a baseline of 1,800 calories, for example, should be sufficient for a loss of 1 pound per week. Targets for weight loss can be set in 5-pound increments. As each goal is reached, a new 5-pound goal can be instituted. This enables the child to experience some success without feeling too overwhelmed with the overall task. The importance of increased exercise for weight loss cannot be overemphasized. Exercise for weight loss should be primarily aerobic, as opposed to weight lifting or calisthenics, although the latter types have their own benefits (i.e., building or toning muscle) and can be used in combination with aerobic activities. Lifestyle types of aerobic activities (e.g., walking or riding a bike to school, using stairs instead of an elevator, walking the dog) have been shown to be most effective in promoting weight loss and may be the easiest to persuade a child to engage in. A reasonable goal is at least 20 minutes of aerobic exercise three to five times a week. It is difficult to motivate obese children to become more active, in part because attitudes toward exercise change as weight increases, and children come to prefer more sedentary activities (Kolody & Sallis, 1995). Thus current work focuses on reducing sedentary activity— specifically, watching television or playing computer games—rather than on increasing exercise as the target for intervention (Epstein et al., 1995). As noted earlier, television viewing contributes to obesity in many ways: It promotes poor eating habits through commercials advocating unhealthy snack foods; children also tend to eat while watching TV; finally, if a child is watching television, he or she is not doing something more active. Research has shown that reinforcing children for reducing targeted sedentary behavior, while leaving them with the

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choice of what to do instead, contributes to a decreased preference for the specified sedentary activity (Epstein et al., 1998). In contrast, children whose targeted sedentary activities are restricted by parents come to desire those activities more over time. Providing this basic information to parents and children is usually not enough to promote weight loss (Epstein, Wing, Steranchak, Dickson, & Michelson, 1980), and the use of behavior modification techniques has been shown to be a critical component of weight loss programs for both children and adults (Epstein et al., 1998; Linscheid & Rasnake, 2001). Specific intervention strategies are discussed in the context of the CAIS (see Chapter 2), with emphasis on five areas: the child, parents, environment, consequences of behavior, and medical/health aspects.

Intervention with the Child The first step in treating childhood obesity is providing the child with accurate information about diet, exercise, and weight loss. The information outlined above can be given to the child in modified form, to ensure that the child understands it. Furthermore, the child should be engaged in setting weekly goals for calorie reduction and changes in activities. Problem solving can be used to identify the types of nonsedentary activities the child is most likely to enjoy, and to determine what foods will be eliminated to reach the calorie goal. Self-Monitoring Self-monitoring is a critical component of the weight loss program. The child should weigh him- or herself every day and record the weight. The child also must be taught to record (see Figure 3.1) everything he or she eats, how it was prepared (e.g., fried or broiled), the approximate amount and calories, and when and where it is eaten. Similarly, a record should be kept (see Figure 3.2) of all exercise engaged in, including the date, time, and place; type of exercise; duration; and whether or not the child enjoyed the activity. We have found that a simple activity monitor called a Clicker is very effective in tracking daily activity and motivating children to “keep moving.” The Clicker records the number of steps taken, miles traveled, and calories expended. A goal of 10,000 steps or clicks per day is reasonable. The Clicker can be obtained for about $30 from Optimal Health Products, 888-339-2067. Daily data on activity level, calories consumed, and weight can be graphed during the child’s weekly sessions with the clinician and will provide a visual demonstration of progress. Stimulus Control Examination of the child’s baseline data will help the clinician to identify situations that promote poor eating habits. The child can then be engaged in problem-solving ways to avoid these situations or change them so that they no longer promote the desire to eat. Other stimulus control techniques include (1) eating more slowly (e.g., putting utensils down between each bite, chewing each bite a certain number of times); (2) eating only in one room (e.g., not eating in front of the television); (3) using smaller plates so that servings appear larger; and (4) serving individual portions versus family style. Another method of stimulus control (Epstein & Squires, 1988) teaches children how to select appropriate foods. Foods that are low in calories and high in nutritional value are categorized as green or “go”; those that should be eaten in moderation are yellow or “caution”; and those that are high in calories and low in nutritional value are red or “stop.”

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Cognitive Restructuring Cognitive restructuring is a form of self-control that helps a child substitute helpful thoughts for less productive thoughts. As an example, a child who may be thinking, “I’ll never lose all this weight,” can be instructed to say instead, “I know I can lose 1 pound this week.” Cognitive restructuring requires the child to be aware of and record or verbalize his or her thoughts. Consequently, it may be more useful with older children. Shaping Shaping involves taking gradual steps to meet a larger goal. The idea of setting smaller daily or weekly goals is an example of shaping. If the child’s baseline data indicate that he or she is eating two or three high-calorie snacks each day, the goal can be to reduce this to one a day, with low-calorie snacks substituted for the other one or two. The next goal can be to eat one high-calorie snack every other day, then every three days, and so forth. Eventually, all highcalorie snacks will be eliminated. Developing Alternative Behaviors As noted above, children who are obese have often restricted their activities to sedentary ones. Such a child may be engaged in thinking of alternative activities that would promote weight loss. For instance, if television viewing or playing computer games is a predominant activity, the child can be helped to think of something else he or she could do (e.g., go outside, ride a bike, play an active game with a brother or sister, etc.). Similarly, when the times the child is most likely to snack are identified from the baseline data, activities other than eating can be substituted at these times. Planning Ahead Learning to plan ahead is an important skill for children who want to lose weight. When calorie goals for the week are set, the child can be taught to anticipate such events as birthday parties, Christmas, or special family get-togethers, so that he or she can participate without feeling left out or deprived. By reducing the amount of calories consumed in the days prior to the event, the child can then eat otherwise forbidden foods without feeling guilty or getting discouraged. Assertiveness Training The child will need to be taught how to respond to well-meaning adults who seem to have a mission to feed children. Problem-solving and role-playing these types of situations can help the child come up with reasonable responses to people who pressure him or her to eat—for example, “No, thank you, I am trying not to eat so much,” or “No, thanks, I’m not hungry right now.” Relapse Prevention Children need to be taught that everyone experiences lapses in their efforts to lose weight. The key is how these lapses are handled. A strategy for dealing with lapses might include cog-

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nitive restructuring (e.g., “Everyone makes mistakes; I am not a failure”) and a restart plan in which the child goes back to careful monitoring of calories, activity, and weight, and resets reasonable goals.

Intervention with the Parents Parents must be included in the discussions with the child of the information and strategies described above, as they will be responsible for helping the child carry out his or her assignments at home. Moreover, the clinician cannot assume that parents will know how to implement the weight loss program at home; thus several sessions focused on basic principles of behavior modification may be needed. The weight loss program can be described as a learning task for the child and parents. Basic knowledge will help the parents generalize behavioral techniques to the various situations they come across. Moreover, the clinician can help the parents problem-solve difficult situations. One difficult task that many parents have is meeting the various needs of their children, especially when one child needs to lose weight and another does not. In these cases, it is important to engage the whole family in helping the target child with the program. This will involve sacrifices from other family members, who may be asked to give up favorite desserts, at least while the target child is present. Parents can be reassured that it never hurts anyone to change to a more healthful diet and that their other children will benefit, even if they do not need to lose weight. Both parents must be in agreement with this idea. If the father, for example, insists on eating primarily meat, potatoes, and gravy, it will be difficult for the mother to prepare healthful low-calorie food for the child. Engaging the family in problem solving is an effective way to resolve these issues. The clinician should be aware, however, that these are likely to be ongoing problems; as such, they will need to be revisited from time to time.

Intervention in the Environment The clinician should help parents alter the home environment so that it facilitates the child’s weight loss. Planning meals carefully, purchasing appropriate foods, having healthy low-calorie snacks available, and providing regular and consistent mealtimes are all ways to accomplish this.

Changing the Consequences of the Behavior Parents must be involved in determining appropriate reinforcers to ensure that the child’s eating behavior changes. For instance, reinforcement for successful self-monitoring is often necessary to motivate children to do this routinely. Points can be assigned for daily recording, and traded at the end of the day (or week, for an older child) for something the child wants. Obviously reinforcers should not include food or increased television or computer time. Rather, the clinician can help the family decide on things like special activities (e.g., playing a game with Mom or Dad, having a friend sleep over, going bowling, taking dance lessons, etc.) or toys (e.g., roller skates, a baseball and glove, a basketball goalpost, etc.). Because parents (and other family members) also may need to change their eating behavior, the family members can be engaged in contracting with each other so that each member is reinforced, as the child is. Reinforcers can be given by the child to the parents, just as they provide reinforcers for the child.

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Intervention in Medical/Health Aspects As noted earlier, children under the age of 5 must be followed by a physician to ensure adequate growth during a weight loss program. If necessary, parents should have a consultation with a dietitian or nutritionist to obtain information about the specific dietary needs of children.

CASE EXAMPLE: OBESITY Step 1: Initial Contact Ms. Jones, a secretary at a local university, called at the request of her pediatrician about her 9-year-old son, Jamal, who had experienced a significant weight gain in the past 6 months. Although the mother had taken him to a nutritionist, she was having difficulty implementing the suggestions she had been given. She stated that her 11-year-old daughter, who had mild cerebral palsy, had the opposite problem—eating enough to maintain her weight. In addition, Ms. Jones indicated that she herself had always been considerably overweight and had recently developed diabetes. Jamal’s father was not involved with the family. Ms. Jones was asked to complete and mail to the clinic the General Parent Questionnaire, the ECBI, the PSI, and the CBCL, as well as to complete 5-day food and activity records for Jamal. The General Parent Questionnaire indicated a lower-middle-class family with a large extended family in the area, whose members provided considerable support. Jamal was described by his mother as an active boy with many interests, who was doing average work in school. Early developmental history indicated an uncomplicated birth and no major health issues. Jamal’s recent weight gain was of concern because of Ms. Jones’s history of obesity. Ms. Jones wondered whether the problem was hereditary or just a result of poor eating habits. On the ECBI, the mother scored Jamal well within normal limits on both frequency and intensity of disruptive behaviors. The only elevated score on the CBCL was in the area of Somatic Complaints, which included eating and some toileting problems. The Child Domain scores on the PSI were within the normal range, with the mother perceiving Jamal as a reinforcing child. On the Parent Domain, the mother had elevated scores on the Depression scale and noted physical health problems.

Step 2: Parent and Child Interviews Ms. Jones and Jamal came together for this interview. Ms. Jones presented as a large but not obese woman. She was obviously self-confident, but very worried about her son. Jamal, who was clearly considerably overweight, readily participated in the interview as he made interesting things with Legos. Ms. Jones indicated that many of her concerns about Jamal stemmed from the fact that she had been overweight as a child, and as a teenager had had difficulties with social relationships, which she felt were due to her appearance. She was worried that Jamal would experience similiar problems as he approached adolescence. She said that Jamal had not shown a weight problem prior to the recent precipitious gain, but that he had always eaten a considerable amount of food, and ate very fast. At times he ate so much so quickly that he vomited. Approximately 6 months ago, he had gained 12 pounds over a 2-month period; despite all their efforts, he was continuing to gain 2–3 pounds a month. Ms. Jones could not point to any major event or specific stress in the family that might have caused Jamal’s weight gain, but she said that Jamal had decreased his participation in physical activities that he had previ-

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ously enjoyed. Instead, he had developed an interest in playing computer games and building car models, which he usually did while watching television. She said that he was increasingly becoming the focus of teasing and jokes from his peers, and that his sister had also begun calling him such names as “Fatty” and “Porky” and teasing him at mealtimes about his eating habits. Part of the problem with trying to control Jamal’s weight was their frequent visits with the maternal grandmother, who served delicious but high-calorie meals in large quantities, and encouraged everyone to eat. In addition, most social activities for the family revolved around food. This, coupled with the need for her daughter to have a high-calorie diet and to gain weight, made meal planning and preparation overwhelming for Ms. Jones. When the clinician followed up on the indications of depression on the PSI, Ms. Jones said that she had been experiencing increasing stress at work over the past 2 years and was having difficulty coping with those stresses, in addition to the family issues. She said that she was not sleeping well and had begun eating increasing amounts of food. In the interview with Jamal alone, he indicated that he had a number of friends at school, but not as many as he had had the previous year. He described family relationships as mostly positive, but was clearly distressed about his sister’s teasing. Although he could list a great many activities that he enjoyed, he said he often felt “too tired” to engage in them. He was very interested in losing weight, but saw the only solution as “just stopping eating.”

Step 3: Observation of Behavior The food and exercise records indicated that Jamal was eating a good variety of food (mostly healthy), but was consuming two to three times the expected amount for a child his size. Exercise was limited to walking to the school bus each morning and an occasional game of basketball with his cousins. The parent–child interaction was pleasant and supportive, with open communication.

Step 4: Further Assessment Given Jamal’s social problems in school, his teacher was contacted by phone. She was asked to complete the Teacher’s Report Form of the CBCL and the Social Skills Rating Scale. Jamal’s teacher said he was a pleasant child who presented no problems in the classroom. She reported on the Social Skills Rating Scale that he had many excellent social skills, with ratings well within the expected range for children his age. His teacher felt, however, that his weight clearly bothered him, made him hesitant to engage in physical activities, and appeared to cause him to decrease his social interactions. Other children were also beginning to make comments about his weight.

Step 5: Referral to Allied Health Professionals Ms. Jones was receiving regular medical care for her diabetes. She was referred to a psychiatrist for evaluation; this resulted in a prescription for an antidepressant. Her previous consultation with the nutritionist provided a great deal of information that was used in planning a treatment program for Jamal. Jamal’s primary care physician was contacted, and she reported that Jamal was healthy. She could give no medical explanation for his sudden weight gain. She was pleased that Ms. Jones was seeking help with this problem, and the clinician agreed to provide regular feedback on Jamal’s progress.

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Step 6: Communication of Findings and Treatment Recommendations Jamal’s sister was invited to participate in the feedback session with Ms. Jones and Jamal. The family in general, and Jamal in particular, were described as having many strengths; however, they were faced with dealing with many potentially difficult health issues, primarily around eating. Although there was no known medical cause for Jamal’s weight gain, it appeared that the quantity of food he was eating, the pace at which he ate, and his lack of exercise were major contributing factors. The negative focus on weight by his sister, his peers, and even by Jamal himself were also described as making it more difficult to get this problem under control. Jamal and his mother were praised for their interest in participating in a healthy eating and exercise program. It was stressed that Jamal could not do this alone, but that the whole family had to participate in the treatment program in order for him to be successful. Although the sister’s difficulties with weight were the opposite of Jamal’s, they were seen as no less important than Jamal’s and needed to be taken into consideration in planning treatment. Treatment recommendations included developing a family meal plan that took into account everyone’s needs; increasing Jamal’s physical exercise; and weekly contact with the clinician to review food and exercise data, to help Jamal develop more appropriate eating habits, and to deal with any problems in following the plan. The basic information outlined earlier in this chapter regarding diet, exercise, and weight loss was shared with the family.

Course of Treatment On the basis of the food and activity records, weekly goals for gradual calorie reduction and increases in activity level were agreed upon. A self-monitoring system was developed, including the use of a Clicker. Jamal stated that he thought he could keep his own records, but agreed to have his mother go over these with him every evening. This gave Ms. Jones the opportunity to reinforce his progress and to problem-solve any difficulties. Rules for healthy eating habits were reviewed, and a list was prepared for the family to post on the refrigerator door. One of these was for Jamal to eat a meal over a 20-minute period of time; this was to be accomplished by eating more slowly, chewing food more times, and engaging in conversation with his mother and sister. A second rule was for all family members to avoid any negative comments about food, including teasing or nagging, at any time. The family participated in a session focused on meal planning that allowed each of them to have their individual needs and wishes regarding food met. Foods were divided into categories of green or “go,” “yellow” or “caution,” and red or “stop,” according to their relative caloric content. The family also was taught how to plan ahead for visits with the grandmother, so that her food could be enjoyed but would not disrupt their long-range goals. Suggestions included eating less the day before a visit, eating smaller amounts, and learning to say “No, thank you!” Ms. Jones was encouraged to fix special drinks for her daughter, such as smoothies or milk skakes, to help her consume enough calories. Over the course of about 6 months, Jamal slowly stabilized his weight and also began to grow taller, which ultimately resulted in more appropriate weight for height. He began to participate more in sports activities that he had previously enjoyed. His problems with constipation also decreased, although these were not focused on specifically. Ms. Jones responded well to the antidepressant, reporting that she was less distressed and sleeping better. Her weight also stabilized. At this point Ms. Jones, in agreement with the clinician, decided to terminate

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treatment sessions. The family members were encouraged to continue to monitor their food intake and activity level, and to call the clinician if needed.

FOOD REFUSAL PROBLEMS “General food refusal” is characterized by a child’s turning his or her head to avoid food, spitting out food, gagging, vomiting, and/or engaging in temper tantrums, crying, or escape behaviors when presented with all or most food. “Food selectivity” or “finicky eating” is characterized by these behaviors when a child is presented with specific foods. “Food phobias,” which are characterized by fear and/or anxiety symptoms in eating situations, fit within this category as well (Wren & Tarbell, 1998). For the sake of simplicity, all of these problems are referred to in this section as “food refusal problems.” Although there are probably multiple causes for these problems, Wren and Tarbell (1998) list three major ones: (1) the association of feeding with an aversive experience (e.g., choking, unintentional vomiting while eating, force-feeding for medical reasons); (2) inadvertent positive or negative reinforcement by caregivers of food selectivity or refusal (e.g., removing rejected food and substituting a preferred food); and (3) absence of developmentally appropriate early feeding experiences, usually as a result of a medical condition (e.g., gastroesophageal reflux, short-gut syndrome, bronchopulmonary dysplasia, or a congenital cardiac condition). Sanders, Patel, LeGrice, and Shepherd (1993) documented a coercive cycle among families with food-refusing children. They found that the children engaged in high levels of negative behaviors (e.g., complaining, noncompliance, oppositional behavior, playing with food) during mealtimes, compared with normally eating children. At the same time, the parents of the children with food refusal were noted to be more negative in their feeding practices (i.e., giving more aversive instructions and prompts to eat, and making more negative eating-related comments) than parents of typical children. Sanders et al. (1993) have described a typical sequence of parents’ coaxing and pressuring their children to eat, which is reinforced by the children’s intermittent consumption of some foods. All children reject certain foods at some time or another. Children with truly picky eating habits refuse a wider variety of foods than is considered typical and may reject all foods with a certain texture. Medically compromised children or children with mental retardation may refuse all foods. It is estimated that as many as 20–30% of children have significant food refusal problems (Bentovim, 1970; Marchi & Cohen, 1990). These problems are typically seen in combination with other food-related habits, such as eating very slowly, eating very small amounts of food, and having a low level of interest in eating (Marchi & Cohen, 1990). Moreover, research has documented that children with food refusal problems have an assortment of externalizing and internalizing behavior problems; children who have a history of early eating disturbance have more severe behavior problems than those whose eating difficulty had a later onset (Rydell, Dahl, & Sundelin, 1995). The association between early food refusal problems and later eating disorders, such as anorexia nervosa or bulimia nervosa, is not clear, although some older children are reported to present with subclinical variations of full-blown eating disorders prior to adolescence (Garner & Barry, 2000; Wren & Tarbell, 1998). In support of the connection between childhood eating problems and later eating disorders, Maloney and Ruedisueli (1993) have reported that some adolescents and adults with eating disorders recall having food refusal problems as children.

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Most children with food refusal problems eat enough to ensure adequate growth, and their problems typically resolve without treatment; parental education and guidance in using behavioral principles may be all that is necessary. Some such children, however, do not receive adequate nutrition, and in some cases physical, social, and/or emotional development is compromised. For these children, a comprehensive assessment is necessary to plan an appropriate treatment program.

ASSESSMENT OF FOOD REFUSAL PROBLEMS Assessment of children who refuse most food or exhibit picky eating is complex. Some of these children—specifically, those who have medical complications or whose growth is compromised—should be assessed in an inpatient facility where there is easy access to medical and nutritional expertise. For most of these children, however, growth and development continue on a normal course despite poor feeding habits and behavior. These children represent the bulk of those seen in an outpatient clinic, and the clinician will need to rely on parents for information and implementation of treatment recommendations. The assessment process described here again follows the steps for gathering information in accordance with the CAIS (see Chapter 2); the emphasis here is on those factors particularly important in assessing and treating food refusal problems.

Step 1: Initial Contact The first step in assessment of a food refusal problem is to make sure the child has had a complete medical checkup and a nutritional assessment. These two referrals are further discussed below (see “Step 5: Referral to Allied Health Professionals”). Parents should be asked to complete a general questionnaire (e.g., our General Parent Questionnaire; see Appendix B) with demographic information, as well as brief medical and developmental histories. Information about the parents’ perceptions of the problem and what they have been told and/or done thus far is also obtained from this questionnaire. For a child over the age of 2 years, the CBCL (Achenbach, 1991a, 1992) or the BASC (Reynolds & Kamphaus, 1992) screen for general behavioral or emotional problems; the ECBI (Eyberg & Pincus, 1999) determines the extent of problems in daily activities, as well as difficulties occurring around feeding; and the PSI (Abidin, 1995) gives information on the child’s temperament, the parents’ general levels of stress, and the quality of the marital/couple relationship. The CEBI (Archer, Rosenbaum, & Steiner, 1991) assesses specific eating behaviors (see Appendix B). In addition, parents should be asked to complete a Food Diary (see Figure 3.1) for at least a week before the initial visit, to gather specific information on the child’s eating patterns and the parents’ responses to them.

Step 2: Parent and Child Interviews Parent Interview It is important that both parents attend the initial interview. A father and mother are likely to manage feeding difficulties differently, and the clinician must be aware of their differing styles/ perceptions. We usually include the child in this interview, in order to observe the parent–

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child interactions. Some parents, however, are hesitant to discuss feeding issues with the child present; a session without the child should be scheduled for these parents, and arrangements to observe the child at another time should be made. The focus of the parent interview should be on the child’s general development and behavior; a history of the food refusal problem, as well as its current status; the environmental/ social context of the problem; and the parents’ level of stress related to the problem. Specific areas to cover include the following: 1. Development. What was the child’s birth history? Was the child premature, or were there perinatal problems? Were developmental milestones achieved normally? 2. Behavior. The screening instruments will give information in this area, and the interview should follow up on any concerns, especially noncompliance and oppositional behavior. Many children referred for food refusal problems also have problems with general noncompliance or oppositional behavior, toileting, and/or sleep problems (Budd & Chugh, 1998). The clinician must determine whether these other behavior problems should be treated first, or whether treatment of the food refusal problem will aid in the resolution of the other problems. It should be remembered that poor nutrition can affect a child’s behavior, resulting in increased irritability, for example. Given the distress that most parents experience related to feeding problems, and the parents’ desire to get help with feeding, it is usually best to focus initially on the food refusal problem unless the child is generally noncompliant. How the parents have handled behavior problems in general provides helpful information on how to structure the feeding intervention. 3. Medical history. What illnesses has the child had (e.g., chronic ear infections, asthma, seizures, chronic illness)? The child’s medical history can give clues as to past conditions that, though no longer active, may have influenced the development of poor eating habits. 4. Feeding history. A careful history of the child’s feeding behavior should be obtained. Was the child fed from breast or bottle? Did the child have colic? When was he or she weaned? When were solids introduced? How did that go? Information about the onset of the food refusal problem helps differentiate developmental from pathological problems and gives potential information on any associated events. Has the child had an aversive experience with food? Have there been changes in the child’s daily routine (e.g., starting preschool or a new school, birth of a sibling)? Have there been changes in the family routines (e.g., an illness or hospitalization, unusual absences of a parent)? 5. Current feeding status. The Food Diary (Figure 3.1) provides a good starting point for gathering information about a specific problem. Parents should be asked specifically about the child’s likes and dislikes, as this information may not be evident from the Food Diary. Other areas to assess include (a) the frequency of occurrence (has the problem increased or decreased over time?); (b) fluctuations in occurrence (is there a problem at every meal, or does it depend on such factors as who feeds the child?); (c) the place of occurrence (does the child have the problem at home, at school, or both?); and (d) the nature of the problem (what foods does the child refuse, and what does the child do when presented with various foods?). 6. Daily routines. Are meals served at regular intervals? What types and quantities of snacks does the child get and when? To what extent does the child have access to food outside regularly scheduled meals and snacks? Does the child have a regular sleep schedule? Who usually feeds the child? What do typical meals consist of? Does the child’s schedule include regular exercise? 7. Family feeding history. Do other members of the family have eating problems? Children whose mothers have a history of anorexia nervosa are at higher risk for food refusal prob-

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lems than those whose mothers have no such history (Russell, Treasure, & Eisler, 1998; Stein, Woolley, Cooper, & Fairburn, 1994). 8. Parents’ response to the problem. How do parents handle the problem? What advice have they been given? What have they tried, and for how long? What have they told the child? How is the problem affecting other family members? 9. Parental/social/environmental issues. The General Parent Questionnaire and the PSI should alert the clinician to potential contributing problems in these areas. For example, maternal depression, marital/couple conflict, birth of a sibling, and/or a hospitalization can exacerbate a feeding problem. Information about the parents’ mental and physical health status, support networks, the family’s daily routine, the home environment, and cultural or ethnic views about food and eating can shed light on what may be maintaining the problem. Other questions include these: What are the parents’ financial resources? Do they provide sufficient food? What are their attitudes toward “healthy diets”? What are their expectations for table manners? Can they tolerate some messiness as the child learns to self-feed? Child Interview Depending on the type of food refusal problem, the age of the child, and the presence of other problems, a separate interview with the child may be warranted. Generally, it is not helpful to interview preschool children alone. School-age children with food refusal problems, however, should be seen separately from their parents. The focus should be on their general adjustment to friends, school, and family, as well as their perception of the eating problem (including a description of the problem, its frequency, how their parents have viewed and handled the problem, what the children themselves have done to resolve the problem, and how they themselves view the problem). Their attitudes and beliefs about eating should also be assessed.

Step 3: Observation of Behavior Observation of parent–child interaction during feeding situations is the hallmark of assessment for food refusal problems. It is not possible to plan an appropriate intervention program without first completing this observation. It can occur in the clinic or at the home, and/or the parents can be asked to videotape a feeding session at home. If the clinician cannot make a home visit, the latter method provides useful information about the setting conditions for food refusal problems. The focus of observation should be on behaviors that interfere with eating (e.g., tantrums, crying, leaving the table, vomiting, etc.); parental behaviors that may reinforce inappropriate eating behavior; and the child’s self-feeding skills. Observational assessment of the child’s food preferences is also important. Linscheid and Rasnake (2001) note that parents often do not really know what these are (although they think they do), and that information obtained through food records may not be reliable, as parents may present the child with only those foods they think he or she prefers. They suggest that the clinician present a variety of foods to the child and allow the child to eat whatever he or she likes. The child’s response to each food is then recorded. The child will often eat foods that the parents report as disliked (Linscheid & Rasnake, 2001). If the problem involves the child’s ability to self-feed, observation of this process should be included. The focus of this observation is on the behaviors that must be learned for selffeeding to occur.

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Step 4: Further Assessment Further assessment is indicated if the child or family presents with problems beyond those associated with the food refusal problem. For example, if the child is having trouble in school or has other emotional or behavioral problems, it is important to evaluate these areas further. If there are marital/couple problems, or if there is evidence of parental psychopathology, these should be evaluated or referred for evaluation.

Step 5: Referral to Allied Health Professionals Medical conditions that can affect diet or reduce weight gain, such as food allergies, thyroid or endocrine problems, or congenital abnormalities of the gastrointestinal system, must be ruled out before treatment begins (Linscheid & Rasnake, 2001). Problems with the central nervous system that might result in oral–motor or fine motor delays must also be assessed. If any of these are present, or if the child is losing weight or not growing as expected, ongoing monitoring with a physician is necessary. In these cases, inpatient treatment should be seriously considered. Consultation from a nutritionist should be obtained in all cases. This is particularly necessary if the parents lack knowledge about appropriate nutrition for children or have unusual attitudes or beliefs about food (e.g., low-fat or vegetarian diets, excessive fears of obesity). Referral to an occupational therapist is called for in cases where the child has not developed the expected oral–motor or fine motor skills to support self-feeding.

Step 6: Communication of Findings and Treatment Recommendations The nature of the food refusal problem, the clinician’s view of the problem, and potential treatment strategies should be shared with the parents. The clinician should also discuss the implications of the problem for the child’s development in other areas (e.g., independence, mastery, growth, and general health). In the treatment of food refusal problems, the clinician is primarily a consultant to the family members, who must carry out the actual intervention program. The parents’ clear understanding of the nature of the problem and the rationale for the treatment plan is essential to gaining their trust and cooperation.

TREATMENT OF FOOD REFUSAL PROBLEMS Treatment of children’s food refusal problems will, of course, vary according to the nature of the problem. It is important to note, however, that factors related to the parents can influence the course of treatment. In many cases, it is clear that parents who seek help with their children’s eating disturbances have emotional or marital/couple problems that contribute significantly to their children’s problems. In these cases, treatment for the food refusal problem is not likely to be effective. It is best to support parents in getting help for themselves before addressing the child’s problem. The first step in treatment for food refusal problems is to decide whether treatment should occur in an inpatient or outpatient setting. Linscheid and Rasnake (2001) recommend inpatient treatment if (1) the child’s medical/health status is poor; (2) outpatient treatment has been attempted and has failed; (3) the parent–child relationship is so impaired, or the parents’ problems are so severe, that home-based treatment is likely to fail; or (4) the intervention program

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will require medical monitoring. Outpatient treatment is appropriate when the child’s medical status is stable and the parents are supportive of the intervention plan. The second step in treatment is to specify goals in clear behavioral and nutritional terms (Linscheid & Rasnake, 2001). Next, a system for measuring progress must be determined. Often this results from the baseline assessment of the child’s feeding behavior. Finally, behavioral strategies should be specified, including what the parents will do in response to the child’s expected behaviors. This information should be shared with parents as the treatment program is explained. The feeding situation lends itself easily to direct intervention using behavioral techniques, and there are many reports of successful treatment using these strategies (e.g., Linscheid, Tarnowski, Rasnake, & Brams, 1987; Luiselli & Luiselli, 1995; Turner, Sanders, & Wall, 1994; Werle, Murphy, & Budd, 1993; Williamson, Womble, & Zucker, 1998). In a recent review of treatment programs for food refusal problems, Kerwin (1999) concluded that some specific behavioral strategies are most effective. These methods include positive reinforcement of appropriate feeding responses, ignoring or guiding inappropriate responses, positive reinforcement for acceptance of food, not removing the spoon if the child refuses food, and teaching the child to swallow. Linscheid (1999) adds appetite manipulation to this list. He also argues that the clinician must be well trained in behavioral principles, in order to design an intervention program that is flexible enough to meet the specific needs of individual children and their families. Specific behavioral techniques are discussed in the context of the CAIS (see Chapter 2), with emphasis on five areas: child, parents, environment, consequences of behavior, and medical/health interventions.

Intervention with the Child Direct intervention with the child is not usually a part of treating common food refusal problems unless the child has significant physical or developmental disabilities or is seriously medically compromised. In these cases, the clinician may have to teach the child appropriate responses and model techniques for the parents before they are able to carry out the program. The clinician may also work directly with a child who exhibits symptoms of food phobia (fear and anxiety responses to food). In this case, development of fear hierarchies and systematic desensitization are likely to be components of the treatment (see Chapter 8 for a description of these methods).

Intervention with the Parents If the assessment indicates that the child has significant noncompliance or oppositional behaviors outside the eating situation, a course of behavioral parent training may be necessary before the food refusal problem is treated. Indeed, the food refusal problem may remit to some extent once the parents have achieved general control over their child’s behavior (see Chapter 10 for a description of parent training).

Intervention in the Environment The clinician should help the parents alter the feeding routine so that it facilitates the child’s desire to eat. Someone should eat with the child and the atmosphere should be pleasant with-

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out cajoling or nagging about eating. The child should be expected to eat at specified times every day, to eat in the dining room or the kitchen, and to stay seated for a snack or a meal for a set period of time. New foods should be introduced and presented on a regular basis (10 or more times) even if the child initially refuses them. Drinks such as milk or juice should usually be limited and presented only at the end of the meal.

Changing the Consequences of the Behavior Careful observational assessment of the child and parent should provide the clinician with information about where to focus treatment strategies. Various behavioral strategies have been used, and these are discussed below. The reader is also referred to Linscheid and Rasnake (2001). Appetite Manipulation A very important component of any treatment program is to ensure that the child arrives hungry for the feeding sessions. Parents should be instructed to limit the child’s access to food between sessions. Preferably, between-meal snacks should be eliminated and the child should be given only water, although some parents are not comfortable with this approach. If the child is to be given snacks, they should be presented at a consistent time and should be limited in quantity. The clinician can work with the parents to arrive at a reasonable compromise. The child’s medical condition and current weight are important considerations in determining the extent to which access to food is restricted (Linscheid & Rasnake, 2001). Differential Attention Differential attention involves presenting the child with a desired stimulus or positive reinforcer contingent on the occurrence of the appropriate specified feeding behavior (e.g., consumption of a previously refused food), while at the same time ignoring or turning away from inappropriate responses (e.g., food refusal). For instance, the parent should be instructed to present the child with a small amount of a previously refused food and to praise the child if it is accepted. If the child refuses the food, the parent should say nothing, but turn his or her head away from the child for a few seconds. The parent should then re-present the food and follow the same procedure for a specified number of times. An average of 10 presentations is necessary for children without significant problems to accept previously refused food (Budd & Chugh, 1998). It is likely, however, that parents of children with food refusal problems will need to present nonpreferred food repeatedly over several feeding sessions before it will be accepted. Removal of the refused food basically functions as negative reinforcement for the child. In other words, when the parent removes the aversive food, the probability that the child will refuse that food the next time it is presented is increased. Moreover, many parents habitually remove the refused food and substitute a preferred food, which acts as a “double whammy” of both positive and negative reinforcement. Ignoring or extinction of inappropriate behavior is effective when used with positive reinforcement for alternative behaviors, but many parents do not like this method because of the “extinction burst” (i.e., an increase in inappropriate behavior) that typically occurs when the parent begins to ignore the behavior. In some instances, however, parents can be persuaded to ignore low-level inappropriate behaviors such as dawdling if it is clear that the child is doing it to gain parental attention.

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In addition to praise, various reinforcers have been used to motivate children to eat appropriately. These include (1) presenting preferred foods contingent on eating nonpreferred foods; (2) providing pleasurable events, such as short bursts of watching television; (3) giving a desired toy for a short period of time; and (4) for older children, awarding points that can be traded for special activities. Time Out A detailed description of the use of time out is included in Chapter 10. In the feeding situation, time out should be used as a consequence for temper tantrums or other disruptive behaviors that interfere with eating. It is important to note, however, that for time out to be effective in this situation the child must be hungry.

Intervention in Medical/Health Aspects When feeding intervention is required for a child who is receiving all or most of his or her nutrition through a gastrostomy tube, and the eventual goal is to eliminate the tube, coordination of the treatment program with medical personnel is required. Behavioral techniques as described above are used in these cases, but the treatment design and implementation will be different than for children without medical needs. The reader is referred to Luiselli and Luiselli (1995) for a description of such a program. Finally, the assessment data may indicate that changes in the child’s nutritional intake may be necessary. This intervention should be coordinated with a nutritional specialist.

CASE EXAMPLE: FOOD REFUSAL PROBLEM Step 1: Initial Contact Mrs. Percy called about her 22-month-old daughter, Maggie, whom she described as healthy but eating a limited variety and only small amounts of food. She said that although Maggie ate better with her babysitter than with either the mother, father, or grandparents, it took her 45– 60 minutes to complete even a small meal. Mrs. Percy indicated that she was 5 months pregnant and quite concerned about dealing with both Maggie’s poor eating and a new baby. She said that at their pediatrician’s request, they were being seen once a month for weight checks. Maggie was reported to be in the 3rd percentile for weight and the 5th percentile for height. She had recently had a complete physical workup at a local hospital and was reported to be healthy. The attending physician had referred the family to a psychologist to deal with parent– child power struggles. The Percys were unhappy with this psychological consultation and were seeking a second opinion. Prior to the initial interview, each parent was asked to complete checklists to rule out emotional and behavioral problems (the CBCL, ECBI, and PSI). Together, they completed the General Parent Questionnaire and a 2-week Food Diary. The General Parent Questionnaire indicated that the Percys were a middle-class family, with both parents in their late 20s. Mr. Percy was a computer programmer, and Mrs. Percy was a dental hygienist who was currently working full-time at a dental practice that was a 45-minute drive from home. Maggie was their first child and was described on the questionnaires as a child with many abilities who enjoyed a variety of activities, including playing with other children, reading stories, coloring,

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and so forth. She was, however, unable to attend to eating; she was extremely distracted during meals. Mr. and Mrs. Percy saw their daughter as having a high activity level but did not think she was hyperactive, and they recognized that she liked to engage in power struggles. They felt that her eating problems resulted from her never having made the transition from the bottle to solid foods. Although she had been weaned from the bottle at 1 year of age, she had begun to eat solid foods only recently. Furthermore, she was described as never showing an interest in foods, except for her formula or milk. The parents’ responses to the rating scales were similar in most areas. On the ECBI, the mother and father had Intensity scores of 130 and 125, respectively, indicating that they perceived Maggie as engaging in more noncompliant and disruptive behaviors than most children her age. The Problem scores were 4 and 6, however, indicating that the parents did not see these behaviors as problematic. On the CBCL, both parents rated Maggie above the 98th percentile on Somatic Complaints and within the normal range on all other scales. The Somatic Complaints ratings were primarily focused on eating problems and painful bowel movements. Other problems noted on the CBCL were resisting the toilet, “too neat,” and rigidity. On the PSI Child Domain, the parents described Maggie as very moody, displaying emotional upset with changes in her routine, and having trouble calming down. The parents indicated that they experienced this as extremely stressful and did not see her as a child who gave them much pleasure. On the Parent Domain, both parents’ scores were within the average range on all scales. The 2-week Food Diary indicated that the parents and babysitter were extraordinarily detailed record keepers. Their data indicated that there was no set time for meals or snacks, and that foods consumed consisted of apple sauce, peanut butter, pudding, yogurt, canned fruit, juice, and 16–24 ounces of chocolate milk a day. Only occasional foods requiring chewing, such as hot dogs, grapes, or French toast, were noted.

Step 2: Parent and Child Interview The parents requested a 6 P.M. time for the initial interview because of their work schedules. They said that they would bring Maggie’s supper, and she could eat at the clinic as the parents and clinician were talking. A high chair was provided, but the parents said they didn’t use one at home; rather they allowed Maggie to get up and down from the table as she desired. Although Maggie said that she was not hungry, the parents put some cheese and pudding on a child-size table for her. The parents appeared to be a pleasant young couple, who were quick to say that they really had very few problems except Maggie’s refusal to eat. Although both parents indicated that they were aware of and had tried behavior management techniques, they did not think these techniques worked with their daughter. They said it was easier to give in to her demands for milk than to insist she eat the food given to her at the table. They had seen another psychologist for four sessions, but felt they had tried all the suggested techniques (limiting milk, putting her in time out, and setting a regular schedule) with limited or no success. A review of Maggie’s developmental history indicated no pre- or perinatal complications. She had been a full-term baby (weight 7 pounds 5 ounces, length 19½ inches). Maggie was described as a relatively difficult baby, who was easily upset and difficult to calm. Mrs. Percy had opted to use formula rather than breast milk because of her demanding work schedule; she returned to work 6 weeks after the birth. Pureed food and some finger foods were introduced at about 9 months of age, and although the parents continued to offer solid food,

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Mrs. Percy said Maggie was not interested in it and preferred her formula. At 12 months Maggie was weaned from the bottle, but continued to lack interest in solid food. Between 12 and 18 months, she lost 4 pounds, prompting the referral for a full medical evaluation. A review of the family’s daily routine indicated that the parents woke Maggie at 6 A.M. so they could get her ready to go to the babysitter by 7 A.M. Maggie was usually very sleepy and out of sorts in the morning, wanting to be held. She had 4–8 ounces of chocolate milk before leaving for the sitter’s home. Mr. Percy picked Maggie up at 5 P.M., and Mrs. Percy returned home between 6 and 7 P.M. Given Mrs. Percy’s work schedule, dinnertime was usually late (7:30–8:00 P.M). On weekends they tried to eat earlier. They described Maggie as cranky and demanding in the evening, and said she often refused to eat. She did, however, enjoy playing with dolls and reading books with them. Maggie was put to bed at about 8 P.M., after going through a bedtime ritual of reading stories and saying “good night” to her dolls. Although she usually went to sleep easily, she would wake three or four times during the night, demanding milk (which they gave her). On days when she did not have to go to the sitter, she would often sleep until 8 or 9 A.M. At the babysitter’s, Maggie was described as a generally happy child who liked to play with other children, but who had difficulty in making transitions from one activity to another (e.g., from playing outside to eating lunch to naptime). At lunchtime, the sitter sat with her for 30– 60 minutes, encouraging her to eat such things as macaroni and cheese, soup, and crackers. The sitter reported that Maggie usually ate an adequate lunch and liked snacks of milk and cookies. Maggie was reported to take a 1½-hour nap during the afternoon. The parents described the weekends as much calmer than the week, with a better routine for all of them than during the week, when both parents were working. The maternal grandparents were planning to move to the area shortly before the second baby’s birth, and they said they would care for both Maggie and the new baby in the parents’ home. Mrs. Percy was also planning to decrease her work to 3 days a week at that time. Mr. and Mrs. Percy said they generally agreed on most things, except for Maggie’s eating. This issue had caused increasing conflict between the two of them. Mr. Percy said he would prefer to present Maggie with food, and if she didn’t eat it, to give her nothing until the next meal. Mrs. Percy said she was extremely concerned about Maggie’s small size and felt that they should give her food and drinks whenever she requested them, in addition to encouraging her to eat at mealtimes. Although the pediatrician had reassured Mrs. Percy that Maggie was healthy, she was concerned about ensuring Maggie’s growth and development.

Step 3: Observation of Behavior Maggie was a physically small but very bright child, who eagerly explored the room, moving quickly from one activity to the next. Her language skills were excellent; she described her activities in complete sentences and asked many questions. Several times during the interview, she asked her parents for milk, which they gave her. Throughout the 1-hour interview, Maggie showed no interest in the food available, but she drank approximately 12 ounces of chocolate milk. Several times the father encouraged Maggie to have some cheese and crackers, but she refused. Parent–child interaction was pleasant but characterized by frequent commands, low expections for compliance, and many questions. The parents demonstrated considerable interest in Maggie’s activities, but did not use contingent reinforcement for appropriate behaviors. They handled Maggie’s refusals or upsets by giving in to her demands or dropping their requests.

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Step 4: Further Assessment Arrangements were made to obtain all the records from the previous hospital evaluation, and to contact the Percys’ pediatrician and the psychologist who had worked with them earlier. Medical records indicated that Maggie had received a diagnosis of NOFTT, due to poor parental management of her behavior. Although there was concern about the child’s weight, she was essentially seen as a healthy youngster. The psychologist described the family as very resistant to help, meeting every recommendation with “We’ve done that and it doesn’t work.” The psychologist felt that the family wanted a “quick fix” and did not want to explore any family issues other than Maggie’s eating. He viewed the eating difficulty as part of a general parent management problem.

Step 5: Referral to Allied Health Professionals Maggie was being followed closely by her pediatrician and had recently had a thorough physical evaluation. Prior to the beginning of the intervention, the primary care pediatrician was contacted regarding possible treatment strategies. She felt that Maggie did not need more than 16 ounces of milk per day, and that with proper management of mealtime behavior, the child would eat a wider variety of foods.

Step 6: Communication of Findings and Treatment Recommendations Information from the questionnaires and rating scales was shared with the parents. Maggie was described as a delightful youngster, who was well advanced for her age in many areas. She also was described as a child with a very strong will, and one who had learned how to get her parents to do what she wanted. The clinician expressed her belief that although transitions were likely to continue being difficult for Maggie, she could be taught to handle them better. Her distractibility and activity level were seen as appropriate for a child of her age, interests, and abilities. The parents were told that Maggie was more demanding and less adaptable than many children her age, and that although these behaviors were not uncommon among 2-year-olds, she needed to learn more appropriate ways of interacting. It was also pointed out that the parents seemed to be more tolerant of these behaviors than other parents, and that this might be inadvertently perpetuating them. Mr. and Mrs. Percy were told that Maggie’s difficult transition from milk to solid foods was problematic, and most likely had set the stage for the current eating problems. It was explained to them that most children begin to make the transition to solid food between 6 and 9 months of age. The present task was to help Maggie move to more solid foods as the milk intake was gradually decreased. This would involve setting up a regular eating schedule for a specified period of time, as well as slowly introducing foods of differing consistencies. Given Maggie’s strong-willed temperament, it was also recommended that the parents learn some techniques to increase her compliance and decrease her disruptive behavior. Mr. and Mrs. Percy seemed relieved that there was an explanation for why their daughter was having so much difficulty eating, and they readily agreed to a short-term behaviorally oriented treatment program.

Course of Treatment The parents were seen for four sessions over a 2-month period of time. Initially, the goal of treatment was to get Maggie on a consistent eating schedule and to have her eat within a rea-

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sonable period of time. For the first 2 weeks, the parents and the babysitter were instructed to give Maggie six regularly scheduled (6:30 A.M., 9:30 A.M., 12:30 P.M., 3:30 P.M., 6:30 P.M., and before bed) small meals per day, lasting no longer than 15 minutes per meal. All food would be removed at the end of each meal. They were to select foods that the child liked, and to give milk or juice only at the end of each 15-minute meal. Between these six meals, Maggie was only permitted to have water. Maggie was to sit in a high chair or on a booster seat at the table with no other distractions (TV, toys, etc.), and the parents or babysitter were to sit and eat with her. They were encouraged to comment about and praise her eating, but they were not to cajole or be negative in any way. The parents were instructed to handle demands for food between meals by telling Maggie when the next meal was scheduled and offering her water. Given the parents’ concern about Maggie’s eating, initially no restriction was put on the amount of chocolate milk or juice Maggie was allowed to have at the end of each meal. The parents kept food records during this time and mailed these to the clinic at the end of the week. After reviewing the data, the clinician called the parents for a brief consultation (primarily to reinforce them for following the recommendations). According to the food records, after 2 weeks of following this schedule, Maggie was eating at regular times and actually asking for specific food items at mealtimes. At the second session, the parents and the clinician agreed that the goals for the next 2 weeks were (1) to increase Maggie’s compliance by teaching the parents to attend, follow, and reinforce Maggie’s appropriate behavior and to decrease their commands/demands (Part I of our parent training program; see Chapter 10); and (2) to substitute regular milk for chocolate milk, as well as to decrease the amount of milk to a maximum of 16 ounces per day. The latter goal was accomplished by having the parents measure out the total amount of milk per day and giving an equal amount after each meal. She continued to be allowed to have as much water as she wanted between meals. The parents were also instructed to offer Maggie a greater variety of foods by introducing a new food about every 3 days, and to present this food on a regular basis, even if the child initially refused it. For example, baked potatoes were substituted for mashed potatoes, and pancakes for French toast. The parents continued to keep detailed food records. Since they were already using time out, they were asked to keep a record of when and how they used it. Mr. and Mrs. Percy quickly learned new parent–child interaction behaviors and began enjoying their daughter as her compliance increased. They were surprised at how much happier Maggie seemed, and reported that she was able to make transitions much more easily. Food records indicated that she was not only eating more during the mealtime, but actually requesting seconds and beginning to experiment with some new foods. At the third session, it was determined that the goals for the next 2 weeks were to teach the parents how to implement time out consistently; to manage temper outbursts and refusals appropriately; and to increase the size of the three main meals, while decreasing the other three meals to snacks of an appropriate size and quality (e.g., fruit vs. cookies). Food and time-out records continued to be kept. Maggie began to demand more food between meals, and the parents used time out if she had a temper tantrum when this was refused. Not surprisingly, she quickly began to eat more at each meal. Unfortunately, Maggie became ill with an ear infection midway through this period, and the parents allowed her to have as much milk as she wanted and to eat at random times. When the ear infection resolved, however, it was clear that they were having trouble getting her back on a regular eating schedule. At the fourth session, the possiblity of other relapses was discussed. The parents were told that the rules (regular meals, no milk between

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meals) should not be changed, but that their expectations of Maggie could be lowered (not expecting her to eat as much or as varied a diet, allowing her to eat mostly preferred foods). Mr. and Mrs. Percy felt that time out was working effectively; Maggie’s temper tantrums and moodiness had decreased. Furthermore, her nighttime wakings had stopped without further intervention, and regular visits to the doctor indicated that she was steadily gaining weight. The parents elected to have no further sessions, but said they would call if they needed further assistance. A follow-up phone call after a month indicated that Maggie was continuing to progress in her eating and behavior, despite a family vacation and the impending birth of the new baby. Over the next 6 years, Mrs. Percy periodically called or came in for a session or two regarding such issues as sibling rivalry or Maggie’s being teased by peers for her small stature.

CHAPTER 4

Toileting: Training, Enuresis, and Encopresis

TOILET TRAINING Although all parents face the task of toilet-training their children, very little research supports one method of training over another. Cultural and societal attitudes seem more important than data when it comes to deciding when a child is “ready” to be trained and choosing a training method. One early cross-cultural study found that the median age of starting regular toilet training in London was 4.6 months, in Paris 7.8 months, and in Stockholm 12.4 months (Hindley, Fillozat, Klackenberg, Nicolet-Meister, & Sand, 1965). In the United States, the suggested age at which to start training has varied from 1 (!) to 24 months, with current support for 18 months and preferably 24 months (Luxem & Christophersen, 1994). In a review of 40 years of research on toilet training, Berk and Friman (1990) concluded that (1) most children are trained between 24 and 36 months of age, and almost all children are trained by 48 months of age; (2) training focused on independent, voluntary control is completed later than training focused on biological and behavioral indices of toileting readiness; and (3) the trend as of 1990 was in the direction of later completion of training. Luxem and Christophersen (1994) indicate that this trend toward delayed toilet training and permissiveness may have begun to reverse itself, as the risk of acute infectious diarrhea and hepatitis has been increased by greater numbers of children in day care who are not toilet-trained. Whether toilet-training children earlier will increase parent–child problems related to training is not clear. Even with the more permissive delayed approach, many parents report problems with toilet training, including refusal, tantrums, emotional upsets (both parent and child), avoidance through retention of urine and/or stools, strange behaviors (e.g., extreme interest in toilets and toilet waste), and parent–child conflict (Mesibov, Schroeder, & Wesson, 1977; Schmitt, 1987). Parents’ unrealistic expectations for when their children should achieve continence may also increase parent and child stress. Shelov et al. (1981), for example, surveyed 1,435 parents and 446 physicians, and found that parents felt a child should stay dry through the night by age 2.75 years (vs. age 5.13 years for the physicians). The developmental and scientific literatures, although limited, do give us some general guidelines for toilet training. Although studies and case reports demonstrate that children can signal and withhold (for a short period) their impending bowel and bladder emptying as early as 6 months of age (Smeets, Lancioni, Ball, & Oliva, 1985; Largo & Stutzle, 1977), this does 115

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not constitute voluntary and independent toileting. It does, however, indicate the power of consistently applied behavioral reinforcement methods and the lack of support for delaying training on the basis of maturation. On the other hand, we also know that if toilet training is begun when the child is older than 26 months, it is accomplished twice as fast as if it is started when the child is younger than 2 years (Azrin & Foxx, 1974). Brazelton et al. (1999) give a detailed review of the instructions, timeliness, and medical influences affecting toilet training. The fact that most children are successfully toilet-trained during the preschool years testifies to the effectiveness of a variety of methods. Several approaches have been widely disseminated in the popular press, but few of these have empirical support. Brazelton’s (1962) approach, for example, has popular appeal but no empirical support, whereas the Foxx and Azrin (1973) method has strong empirical support but is often difficult for parents to implement without professional help. Nonetheless, the Foxx and Azrin program offers a great deal of useful information on the components of toilet training and the value of using a systematic behavioral approach to training, in terms of both time and effort. Foxx and Azrin (1973) suggest the following readiness criteria for beginning toilet training: (1) bladder control (the child consistently empties his or her bladder and stays dry for several hours); (2) physical readiness (the child picks up objects easily and walks without assistance); and (3) instructional readiness (the child understands and complies with one- and two-step directions). The program provides an intensive learning experience that emphasizes the important factors in learning how to go to the bathroom independently. These factors include (1) a stimulus-free environment (the bathroom); (2) modeling (with a baby doll); (3) a large number of trials for repeated practice (increased liquid intake); (4) attention to the component responses (undressing, sitting, etc.); (5) immediate reinforcement for correct responses with a variety of reinforcers; (6) immediate detection of incorrect responses (accidents); (7) mild punishment (cleaning up accidents); and (8) stimulus control (a distended bladder is associated with the potty). Foxx and Azrin (1973) initially demonstrated the effectiveness of this approach in a study of 34 children with a mean age of 25 months (range 20–36 months) who had previously had difficulty in becoming toilet-trained. All children were trained in an average of 3.9 hours (median time 3.5 hours; range 0.5–14 hours), with accidents decreasing to near-zero and remaining so during 4 months of follow-up. Children aged 20–25 months had a mean training time of about 5 hours, whereas children aged 26–36 months were trained in about 2.5 hours! These rapid and effective results were of interest not only to professionals but also to the public, and the dry pants procedures were published in a manual for parents called Toilet Training in Less Than a Day (Azrin & Foxx, 1974), which is still in print today. Although research has supported the effectiveness of the Foxx and Azrin (1973) approach when it is used with clinical supervision (Matson & Ollendick, 1977; Pirnstill, 1981), several studies indicate that parents have trouble using the manual without supervision. Furthermore, in follow-up, “manual-only” children may actually increase their mean number of accidents above pretreatment levels (Butler, 1976; Matson & Ollendick, 1977). In the Matson and Ollendick (1977) study, children in both the supervised and unsupervised groups also showed emotional side effects, including tantrums and avoidance behaviors. Thus the Foxx and Azrin (1973) program is not recommended without professional supervision (Christophersen & Rapoff, 1992; Kimmel, 1974). Christophersen and Purvis (2001) outline the components for successful toilet training, which include a Readiness Checklist based on Azrin and Foxx’s (1974) list of criteria for toilet training. They also include a Toilet Training Checklist, focused on what parents need to do to set the stage for training (e.g., purchase a footstool, coordinate with other caregivers, decide

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on rewards) and to deal with difficult cases. Schaefer and DiGeronimo (1997) provide a practical guide for parents on urine and bowel training, bedwetting, training resistant children, and methods for training the mentally and physcially challenged children. It is based on physiological facts and learning principles, and offers parents a choice of four effective approaches to toilet training. Working in a pediatric primary care clinic for over 27 years has given us the opportunity to work with many parents on toilet training issues. Although we do not have empirical data to support the efficacy of our approach, parents have given it strong endorsement; they indicate that for children 24 months and older, the average toilet training time is 2–4 weeks, with occasional accidents up to several months following the initial training. The goal of parents and clinicians in implementing this program should be to help children accomplish this important developmental task in a way that enhances their sense of mastery and self-confidence. This approach is summarized below.

Step 1: Determining Readiness To be successful at toilet training, a child must be able to do three things: (1) voluntarily control the sphincter muscles; (2) communicate needs verbally or by other means; and (3) have the desire to control the impulse to urinate or defecate. When they are ready to be trained, most children show a fairly regular pattern of urinating four to nine times a day. Bowel movements may occur at intervals varying from once every other day to twice daily, and at different times each day. The first step in toilet training is to determine the times when the child normally empties his or her bladder or bowel. This gives information on the child’s ability to control the sphincter muscles (increased time between wets); it also alerts the parents to the times when the child’s bladder is usually full and when he or she is most likely to have bowel movements. Parents are instructed to check the child’s diaper every 30 minutes and record D (dry), W (wet), or S (soiled) on a chart such as that shown in Figure 4.1. Parents should comment matter-of-factly to the child by saying “Oh, good, you’re dry,” or “Oh, yuck, you’re wet.” This will take some effort on the parents’ part, but the importance of gathering this baseline information before starting training should be stressed. After 3–5 days of checking, a regular pattern of wetting should be evident. Bowel movements may occur at regular intervals (e.g., every 14–18 hours) as opposed to regular times of day, or they may occur about 30 minutes after a meal. If the child does not show a regular pattern or is wet every hour, it may be best to postpone training for a month or two. Urine training is often accomplished before bowel training, given that the child has more opportunities to practice urinating in the toilet.

Step 2: No More Diapers The next step in the training process is to stop using diapers (except for naptime and at night). Toilet training involves helping the child unlearn certain behaviors that were acceptable in the past, as well as learning a complex set of new behaviors. Diapers serve as a cue to the old behaviors (urinating or defecating in a diaper). Thus even periodic use of diapers during the day can be confusing to the child, making it more difficult to break old habits and learn new ones (urinating or defecating only in the toilet). For this reason, “pull-up” diapers or heavy training pants should not be used. The child should wear regular underpants, which will make the consequences of wetting or soiling immediate and very evident (“Yuck!”). In addition, clothing that is easy to take off and put on will allow the parent to respond quickly to the child’s signals,

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Record data for any 5 consecutive days during usual waking hours. Child’s Name: ______________________________________________ Time

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

6:30 A.M. 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 12:00

NOON

12:30 P.M. 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30 7:00 7:30 8:00 FIGURE 4.1. A chart for recording baseline data in toilet training. (Parents should be given

the following directions: (1) Set a timer for 30 minutes. When it rings, check the child’s pants or diapers. (2) If dry and clean, say, “Oh, dry, good,” and mark a D on the chart. (3) If wet or soiled, say, “Oh, wet [or stinky], yuck,” and mark a W or S on the chart. (4) Do not act upset. Take your child to the bathroom and change the soiled clothes. (5) In 3–5 days you should see a regular pattern of times your child wets or soils.) From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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and will make it easier for the child to use the toilet independently. When the child is dry during the day and begins to have occasional dry naps and nights, it is time to stop using diapers completely. This approach allows the child to participate actively in gaining control over urination and defecation, without setting the expectations too high.

Step 3: Regular Sitting Parents should be advised to use a potty chair or a toilet seat ring on the toilet (one without a cup in front prevents children from hurting themselves when getting on and off the toilet), to decrease a child’s realistic fear of falling into the toilet. If the child sits on the regular toilet, support for the child’s feet (e.g., a small step stool) should be provided. If a potty chair is used, it should be kept only in the bathroom, to help the child associate toileting with the bathroom. The parents should have the child sit on the potty chair or toilet for up to 5 minutes at the times when he or she is most likely to urinate or defecate. (This information should be evident from the daily Dry Pants Chart; see Figure 4.1.) Use of a timer will help parents and child keep track of the time, and let the child know when it’s OK to get off the potty chair or toilet. A special “potty toy,” which the child plays with only while sitting on the toilet, can be used to help him or her sit happily. The parents should reward the child for sitting with praise and a star drawn on a Sitting Chart (Figure 4.2). More praise and a special sticker should be given when the child urinates or defecates in the toilet. The chart helps to record progress and reinforces successes; later, it can be used to reinforce the child for dry, clean days. Many parents reward their children by allowing them to wear fancy “grown-up” pants when they are using the toilet successfully. If the child wets the grown-up pants, he or she goes back to the thin “regular” pants until the next successful toileting.

Step 4: Handling Accidents/Resistance Because toilet training is a learning process, there are bound to be accidents. At first the child may wet his or her pants soon after getting off the potty chair or toilet, or “do some” in the potty chair or toilet and then shortly afterward “do some” more in the pants. A parent should handle accidents matter-of-factly by saying, “Oops, you’re wet [or dirty]. Let’s change. You’ll make it to the toilet next time.” The parent should have the child help clean up and change clothes, performing all of this in the bathroom. The child should then sit on the potty chair or toilet for 5 minutes to “finish up”; the parent should use the timer. Some children are very resistant to toilet training or persist in having frequent daytime accidents (wetting or soiling their pants) for 1–2 years or more after starting the toilet training process. Depending on the age of the resistant child, it may be best to delay the training process until a later date or carefully review the parent–child interaction, the environmental context, and the training process. In the absence of physical or significant emotional/behavioral problems or stress, resistance is best handled by systematically teaching good toileting habits, as well as by ensuring that the child has a proper diet, plenty of exercise, and a consistent daily routine. For most children who refuse to use the toilet to urinate and/or defecate, the toilet seems to be associated with some painful event (e.g., hard stools) or a frightening thought or experience (e.g., fear of falling into the toilet). They may even ask to use a diaper or newspaper rather than use the toilet or mess their pants. It is our experience that if children successfully use the toilet a few times, these problems quickly go away. Gradually desensitizing them to sitting on the toilet by first having them sit with their clothes or underpants on for increasing

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Sitting Chart Time to Sit

Sits Quietly—5 Minutes

Urination

Defecation

Sample As soon as awake

(star)

(sticker)

10:00 A.M.

(star)

(sticker)

FIGURE 4.2. A chart for recording sitting on the toilet. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

lengths of time (up to 5 minutes), and then having them sit without clothes at times when they don’t have to void or defecate, can often resolve the problem. However, we have found that some children need their parents to let them know that they are going to help them by holding them on the toilet and counting out loud; the children can get off when they are quiet for a count of 10. Gradually increasing the count will help them learn there is nothing to fear. For bowel movements, Christophersen and Purvis (2001) suggest using glycerin suppositories before a meal or before a bowel movement is likely to occur, and then having the child sit on the toilet. If the stools are hard, mineral oil can be used, or more fiber and water can be added to the diet to help stools become looser and more difficult to retain. It is important to note that Blum, Taubman, and Osborne (1997) did not find children with toilet refusal to have more emotional or behavioral problems than a matched group of control children had.

ENURESIS Description and Prevalence Although no fatal case has ever been reported, “enuresis,”—involuntary urination with no known organic cause—has been a nuisance for literally hundreds of years. Treatment remedies predate modern civilization, with a discussion of enuresis in the Ebers Papyrus of 550 B.C.! Enuresis was also listed as a disease in the first book of pediatrics written in English, in a section titled “Of Pyssying in the Bedde” (Glicklich, 1951). Even today, nocturnal enuresis is the most common urological complaint of children (Norgaard & Djurhuus, 1993). Although enuresis is usually not medically significant, it does cause distress for many children and their parents. The essential features of enuresis are repeated urination into clothes or bed, occurring at least twice a week for a minimum of 3 consecutive months (or causing clinically significant

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distress or impaired functioning), in a child at least 5 years of age or the developmental equivalent; the wetting cannot be exclusively due to a medical condition or drug reaction (American Psychiatric Association [APA], 1994). The wetting is usually unintentional, but occasionally it is done on purpose. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) does not specify the length of time one must be incontinent, but in the past it has been defined as lasting from 6 to 12 months. According to the DSM-IV definition, enuresis is not diagnosed until age 5, when children are expected to be consistently dry both day and night (APA, 1994). There are three subtypes of enuresis: “nocturnal” (wetting only during sleep), “diurnal” (wetting only during waking hours), and “nocturnal–diurnal” or “mixed” enuresis (APA, 1994). Children who have never been dry are described as having “primary” (vs. “secondary”) enuresis, with approximately 80–90% of bedwetting in this category (Mellon & Houts, 1995). Older prevalence studies in the United States have consistently reported that 15–20% of 5-year-olds, 5% of 10-year-olds, and about 2% of 12- to 14-year-olds experience nocturnal enuresis (Oppel, Harper, & Rider, 1968; Perlmutter, 1985). DSM-IV (APA, 1994), however, reports a much lower rate of 10% for 5-year-olds. It also reports that 5–10% (vs. previous reports of 15%) of these children will spontaneously achieve control every year from 5 to 18 years, with a prevalence rate of only 1% in adults. Despite these discrepancies in the data, bedwetting is clearly a common childhood problem that improves significantly with age alone. Fewer than 10% of children who wet the bed have physical abnormalities of the urinary tract that would lead to the symptoms of night wetting (Jarvelin, Huttenen, Seppanen, Seppanen, & Moilanen, 1990). Estimates of daytime wetting and mixed enuresis are lower than for bedwetting, ranging between 0.5% and 2% for both boys and girls at ages 6–7 years (see Friman & Jones, 1998). These two problems are uncommon for both boys and girls after 9 years of age (APA, 1994; Hjalmas, 1992). There appears to be a greater incidence of medical problems in daytime wetting (LoeningBaucke, 1997) with more urinary tract abnormalities such as incomplete bladder emptying, fractionated voiding curve, and marked structural or functional disorders (Jarvelin et al., 1990; Jarvelin et al., 1991). The prevalence of enuresis varies from country to country and among ethnic and racial groups (deJonge, 1973). Some data indicate that it is more prevalent at lower socioeconomic levels, in large families, and in families where mothers have less education (Bakwin & Bakwin, 1972). Walker (1995) points out, however, that these differences probably reflect cultural beliefs and attitudes about toilet training, as well as the amount of effort expended in the training process. Enuresis is also more prevalent among developmentally delayed youngsters and institutionalized children, whether they are of normal or subnormal intelligence (Moffatt, 1989). Biederman, Santangelo, et al. (1995) reported that children with enuresis were at increased risk for learning disability, lower intelligence, and poor school achievement, compared with children who did not wet the bed. We also know, however, that some children who are of superior intelligence have enuresis. Walker (1995) suggests that enuresis is more similar to a specific learning disability than to a lack of intellectual capacity.

Etiology Because enuresis is a heterogeneous disorder, the etiological explanations for it are varied (Mellon & Houts, 1998). The most common explanations are presented here, but both physi-

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cal and psychological/behavioral factors should be considered in determining the best course of treatment for an individual child. Biological Factors The actual incidence of organic urinary incontinence is low in children; estimates range from 1% to 3% of cases of enuresis (Forsythe & Redmond, 1974). Organic causes that have been clearly identified include various acquired and congenital nervous system lesions; disorders in the neural enervation of the bladder; structural problems of the genitourinary system; bladder or urinary tract infections; and some chronic diseases, such as diabetes, seizure disorders, or sickle cell disease (Walker, 1995). Genetic factors appear to be strong contributors to enuresis (Mikkelsen, 2001). No fewer than 75% of all children with enuresis have a first-degree biological relative who had the disorder (Bakwin, 1973). According to Bakwin, when both parents have a history of enuresis, 77% of children have enuresis; when only one parent has a history of enuresis, 44% of children are enuretic; when neither parent has a history of enuresis, only 15% of children have enuresis. Furthermore, monozygotic twins have a greater concordance for enuresis than dizygotic twins do (APA, 1994). Walker (1995) notes that children with enuresis tend to become dry at about the same age as older relatives who had the problem. Although these statistics are impressive, no specific mechanism has yet been identified to explain the inheritance of enuresis, and the data on heritability do not take into account intergenerational transmission of toilet training practices. Norgaard, Rittig, and Djurhuus (1989) conducted extensive investigations of enuresis and found that (1) children with the disorder had normal daytime bladder capacities; (2) a full bladder was necessary for enuresis to occur; (3) enuresis did not occur during any specific sleep stage; and (4) there were no specific sleep patterns before or during the enuretic episode. Gellis (1994), however, presents data supporting parental reports that these children are “deep sleepers” and are difficult to awaken: In a sleep study using electroencephalograms and auditory tones presented via earphones, enuretic children were four to five times harder to awaken than nonenuretic children. Other research suggests that many enuretic children have an excessive production of overnight urine, a small “functional bladder capacity” (i.e., a small volume of urine in the bladder triggers a response to urinate), or a combination of both (Readett, Morris, & Sergeant, 1990). These findings have led to the use of desmopressin acetate, a synthetic form of the hormone vasopressin, which stimulates the kidneys to concentrate urine and therefore decreases the volume of urine during the night. For many children, the immediate response to treatment with desmopressin is good, but continence is maintained only while the drug is being used; relapse rates when the drug is discontinued are nearly 100% (Djurhuus, Norgaard, Hjalmas, & Wille, 1992). Furthermore, other studies do not support poor nocturnal concentration of urine for enuretic children under 12 years of age, although there is some support for an exceptionally small functional bladder capacity among such children (Bath, Morton, Uing, & Williams, 1996; Evans & Meadow, 1992). Thus the link between levels of antidiuretic hormone and bedwetting, as well as the response to desmopressin, has not been established (Bath et al., 1996). Other biological factors that may contribute to enuresis are food allergies, developmental delay, and organic brain pathology (Biederman, Santangelo, et al., 1995; Walker, 1995). Although there currently is not enough evidence for allergies or organic brain pathology to be considered significant in the development of enuresis, there is some support for a maturational lag. The increased prevalence of enuresis in boys (who usually have a slower rate of develop-

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ment than girls) and the high annual spontaneous remission rate indicates that there is a developmental delay in acquiring these skills, at least in some cases (Friman & Jones, 1998). Emotional Factors Psychodynamic theory had a major impact on the study and treatment of children with enuresis in the early 20th century. Enuresis was felt to be the result of an underlying emotional dysfunction, psychological conflict, or anxiety (Pierce, 1971), or secondary to some specific psychosocial stressor (Rutter, Yule, & Graham, 1973; Feehan, McGee, Stanton, & Silva, 1990). More recent work has documented that the majority of children with enuresis do not have emotional or behavioral problems (Friman, Handwerk, Swearer, McGinnis, & Warzak, 1998). Furthermore, although enuresis is more frequent in children who do have emotional disturbance, most emotionally disturbed children are not enuretic. Enuresis has not been associated with any particular disorder, but commonly noted problems include anxiety, family conflict, immaturity, and attention-deficit/hyperactivity disorder (Biederman, Santangelo, et al., 1995; Foxman, Valdez, & Brook, 1986). There is a common belief that emotional disturbance is more likely to be associated specifically with secondary enuresis, but research does not support this view (Biederman, Santangelo, et al., 1995). At least one study has found that an emotional disturbance is more likely to be associated with enuresis if daytime wetting is present, and if the child is an older female (Wagner, Smith, & Norris, 1988). Stress that occurs during ages 2–4 years, when children are in the process of being toilettrained or have just completed training, can often result in incomplete toilet training and thus lead to enuresis. In addition, Walker (1995) points out that although there is no evidence that early, late, strict or lax toilet training relates to enuresis, these could be contributing factors. Learning Factors Learning problems appear to be primary factors in the etiology of enuresis. Learning theory suggests that habit deficiency, inadequate learning experiences, and inappropriate reinforcement contingencies result in the failure to learn to control the complex urination reflex. There is some support for the role of learning factors in the etiology of enuresis, in that children learn skills at different rates, and emotional and psychosocial factors can interfere with the learning process (Walker, 1995). Most importantly, treatment based on learning principles has proven to be the most effective long-term intervention for nocturnal enuresis, with success rates of 70–90% (Mellon & McGrath, 2000; Scott, Barclay, & Houts, 1992). Houts (1991) conceptualizes enuresis as a “biobehavioral” problem, in that it is a physical problem but responds best to learning-based treatment approaches. He speculates that conditioning or operant intervention may correct the underlying physiological mechanisms that cause and/or maintain the problem. Clearly, more research is needed to understand this linkage between the physical and behavioral aspects of the disorder. Nonetheless, this conceptualization is consistent with our approach to assessment and treatment of nocturnal enuresis.

ASSESSMENT OF NOCTURNAL ENURESIS Because nocturnal enuresis is the most common subtype of enuresis, we focus on this subtype from this point on, except for a brief mention of treatment for mixed enuresis (see below);

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when the term “enuresis” is used alone, nocturnal enuresis is meant. The assessment process for nocturnal enuresis follows the Comprehensive Assessment-to-Intervention System (CAIS; see Chapter 2), with a focus on gathering information specifically pertinent to understanding and treating this disorder.

Step 1: Initial Contact When a parent refers a child for enuresis, the clinician should first determine whether there has been a recent medical evaluation of the problem; if not, a referral should be made for such an evaluation. A urinalysis and urine culture should be part of the evaluation, since 5% of males and 10% of females have urinary tract infections that require antibiotic treatment prior to bedwetting treatment (Stansfeld, 1973). Although the incidence of organic or physiological difficulties or medications resulting in nighttime urinary incontinence is low, these must be ruled out before further assessment and treatment take place. The clinician should next rule out the presence of significant emotional or behavioral problems. This can be done by mailing a general questionnaire (e.g., our General Parent Questionnaire; see Appendix B) and screening instruments such as the Child Behavior Checklist (CBCL; Achenbach, 1991a, 1992) or the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992), the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999), and the Parenting Stress Index (PSI; Abidin, 1995) to parents. (See Appendix A for a description of these instruments.) Parents should also be asked to keep a record of the times the child goes to bed and arises, as well as the number of wet and dry nights. During this baseline period the child should be taken out of all protective clothing, including diapers, thick underwear, or rubber pants. Parents should check to see whether the child is wet before they go to bed, and, if possible, every 2–3 hours (!) throughout the night. We have found that a 7-day record is usually sufficient. Sending a form (Figure 4.3) to parents on which to keep this information ensures that the appropriate data will be obtained. All of this information should be returned and reviewed by the clinician prior to the initial interview, if at all possible.

Step 2: Parent and Child Interviews We recommend including the child, regardless of age, in the initial interview with the parents. Treatment of enuresis involves a great deal of cooperation on the child’s part, and his or her level of interest in a treatment program must be determined. In addition, children often share information about the problem that is not known by the parents. For example, do they wake up right before or after they urinate? Do they feel bladder pressure indicating the need to void? Butler, Redfern, and Forsythe (1990) have illustrated the importance of interviewing children about their perceptions of bedwetting. In a study of 55 children ages 6–14 years, successful treatment was associated with children’s perception of bedwetting as having psychosocial implications. In contrast, treatment was less successful with children who perceived bedwetting as having predominantly nonpsychological implications (e.g., bad smell, changing sheets). Resistance to change was also an important factor. Developmentally, the ability to take a psychological perspective increases with age; thus the older the child, the more likely it is that treatment will be effective. These data, however, should not be construed as meaning that treatment should not be offered to a 5- or 6-year-old

Nighttime Wetting Chart Baseline Child’s Name: _____________________________________________________________________________ Age: _________________________________ Address: _________________________________________________________________________________________________________________________ Bedtime

Time up Time i n A.M. of wet(s)

Size Small Medium Large

What did you do?

Comments

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Date/day

FIGURE 4.3. A chart for recording enuresis baseline data. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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child. If the child is not resistant to change, would like to stop bedwetting, and has a supportive family, treatment has a good chance of being successful. During the initial interview, the clinician should be particularly careful to gather the following information: 1. Are there other behavioral or developmental problems? The presence of other difficulties can be determined from the screening instruments. Problems such as oppositional behavior and noncompliance can interfere with treatment of enuresis and should be treated first. The clinician should also be alert to fears of the dark or of the toilet, which may be causing the child to avoid using the toilet at night. If there is indication of psychopathology, then it is recommended that treatment of enuresis be postponed until these problems are further evaluated and possibly treated. 2. What are the history and current status of the child’s urination habits and incontinence? Questions on the nature of these behaviors should include information on (a) daytime as well as nighttime voiding (frequency, time, and amount of wets); (b) intermittent or daily incontinence (frequency, antecedents, and consequences); (c) primary or secondary status (and, if the child was previously dry, the time and circumstances when wetting began); and (d) age, methods, and circumstances of the initial toilet training process. If the child has never been dry, special attention should be given to whether the child has learned the prerequisite skills. Information on the child’s ability to retain urine after he or she has the urge to void during the day (e.g., “When you have the urge to go to the bathroom, can you hold it for 5–10 minutes, or do you have to rush to the toilet?”) and daily frequency of voiding, as well as quantity and type of liquids consumed on a daily basis, are very helpful in determining whether there is a potential bladder capacity problem. Urinary tract infections can cause frequent urination, so a query should be made about the history of such infections. 3. Is there a family history of incontinence? A family history of enuresis is important, given the increased frequency of enuresis among children when other family members have been enuretic. A positive family history does not preclude treatment, but it may affect the parents’ attitude toward treatment (e.g., are they overindulgent or exasperated?) and the methods previously used to deal with the problem. 4. What is the environmental context of the problem? Environmental circumstances give information on potential contributors to bedwetting and possible problems in carrying out a program. These include (a) the type, amount, and time of daily fluid intake; (b) recent, unexpected, or ongoing stressful life events; (c) lack of or inconsistent bedtime rituals; (d) sleeping arrangements that make getting to the toilet difficult; (e) proximity to the bathroom; (f) temperature in the house; and (g) what the child wears to bed. 5. How have the parents handled the problem? Information on the previous attempts at treatment should be gathered in great detail. The usefulness of previously attempted techniques, as well as why some techniques might not have been successful, also should be explored. The parents’ attitudes about the toileting process, conflict over how it should be handled, and their willingness to follow through on a treatment program should be assessed at this time. 6. Why are they seeking help now? Determining why the parents are seeking help now versus some other time provides information on their attitudes toward the problem and potential compliance with treatment. Parents are a critical factor in the success or failure of a treatment program for enuresis; their attitudes, beliefs, and acceptance of a treatment approach must be carefully considered before beginning.

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7. How does the child feel about the problem? The child’s interest in resolving the problem must be assessed; again, his or her cooperation is as crucial as the parents’ in successful treatment. Butler et al. (1990) used a series of questions to determine a child’s understanding of the benefits of stopping bedwetting. These included (a) “What are the bad things about bedwetting?”; (b) “What are the good things about being dry?”; (c) “What difference would being dry make to you?”; and (d)”What do you imagine might change if you become dry every night?” Questions to determine resistance to change included “Could you see any problems in being dry?” and “What might be good about bedwetting?” They reported that when asked the latter question, one child said, “The smell will frighten off burglars!”

Step 3: Observation of Behavior Observation of the parent–child interaction during the interview is useful in determining the support that will be given by the parents to the child during treatment. In addition, observing how the child reacts to the discussion can give information on the child’s interest in treatment and/or what may be needed to elicit his or her cooperation with the treatment plan.

Step 4: Further Assessment Further psychological assessment is only necessary if other problems become evident during the assessment process.

Step 5: Referral to Allied Health Professionals As noted earlier, a medical evaluation should be done before the initial interview with the family, to rule out any organic problem or medication that could be causing nighttime urinary incontinence.

Step 6: Communication of Findings and Treatment Recommendations Following the assessment session(s), it is important for the child clinician to share information with the parents and the child about how enuresis fits into the developmental process. This is particularly important, because the parents’ and child’s trust in the clinician and cooperation in the treatment process will depend on their understanding of the problem. The nature and possible etiology of the enuresis should be discussed, and a rationale for the treatment recommendations should be given. This process often involves explanations of the value of previously attempted methods and why they did not work. In helping the parents and child determine whether or not to proceed to treatment, they also should be made aware of the spontaneous remission rates, as well as the facts that some children do not succeed in staying dry and that relapses can occur.

TREATMENT OF NOCTURNAL ENURESIS Despite early recognition of the problem and a voluminous professional and lay literature, our understanding and effective treatment of nocturnal enuresis have been slow to develop. Treatments have included everything from potions of berries and animal parts, to sleeping on spikes,

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electrical shock, and severe beating (Glicklich, 1951)! The majority of well-controlled psychological interventions began in the late 1960s with the strongest empirical support for learningbased methods (such as the urine alarm; see below) over every other type of treatment (Mellon & McGrath, 2000). Most parents initially seek help with enuresis from their pediatricians. Although a recent survey indicates that physicians are increasingly prescribing learning-based treatments, over 50% of physicians reported using medication to treat enuresis, despite its limited efficacy (Vogel, Young, & Premack, 1996). Thus, by the time parents seek help from other health professionals, a family and child have often experienced repeated failure and frustration with trying to stop the child’s bedwetting. This section discusses various treatment approaches for nocturnal enuresis, with an emphasis on behavioral treatments. For a complete review of treatment approaches, see Mellon and McGrath (2000) and Houts, Berman, and Abramson (1994).

Urine Alarm The urine alarm or bell-and-pad method of treating enuresis was first described in the literature as early as 1904 (Pfaundler, 1904), but became popular following the publication of an article by Mowrer and Mowrer (1938). The apparatus includes a urine-sensitive pad, which is placed under the child’s buttocks and is connected to a loud bell or buzzer. Urine, which contains salt and is an electrolyte, completes an electrical circuit in the pad, activating an alarm that continues to sound until manually turned off. Newer models use metal snaps that are attached to the crotch of the child’s underpants and connected to a small wristwatchtype apparatus. This can be worn on the child’s arm or attached to the shoulder of the pajamas. Figure 4.4 illustrates this device, which can be obtained from Nytone Medical Products, Inc., 2424 South 900 West, Salt Lake City, Utah 84119, 801-973-4090, www.nytone.com; or Palco Laboratories, 8030 Soquel Ave., Santa Cruz, CA 95062, 831-476-3151, www.palcolabs. com. Mowrer and Mowrer (1938) originally conceptualized the bell-and-pad method as a classical conditioning paradigm, in which the sensation of bladder distension becomes associated with the sound of the alarm. Eventually bladder distension becomes the cue for the child to wake up and go to the bathroom to urinate. This conceptualization, however, does not appear to be applicable, because most children using this method learn to sleep through the night without wetting or awakening to use the bathroom. Lovibond (1964) has suggested that an avoidance learning paradigm better explains the learning process. The child learns to avoid the aversive alarm by retaining urine and sleeping through the night, or by awakening and using the bathroom before the alarm sounds. Other factors, such as positive reinforcement from the parents, may also play an important role in treatment. The average success rate for the alarm system is 77.9% (Mellon & McGrath, 2000). Although the relapse rate within 6 months of treatment is reported to be as high as 41%, resuming treatment for a shorter length of time results in successful reconditioning for over 60% of these cases (Doleys, 1978). Several studies have shown that the relapse rate can be significantly reduced by employing overlearning (increasing the liquid intake prior to bedtime (Young & Morgan, 1972), and by using the alarm on an intermittent schedule after dryness has been achieved (Jehu, Morgan, Turner, & Jones, 1977). Moreover, increasing the volume of the alarm appears to contribute to less wetting among children who are slow to respond to treatment (Finley & Wansley, 1977).

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FIGURE 4.4. Wrist urine alarm for treatment of enuresis.

Given the empirically demonstrated effectiveness of the urine alarm system, its ease of implementation, and its relatively low cost, we begin almost all treatment for enuresis with this method. Data from the first 2 weeks of treatment provide important information about the child’s progress. Our experience and that of others (Walker, Milling, & Bonner, 1988) indicates that the size of the wet spots and then the number of wets per night should decrease during this period of time. This decrease is usually followed by intermittent dry nights for the next 2 weeks and consistent dryness in 6–8 weeks. These data, along with information gathered in the assessment process, alert the clinician to potential problems and guide the treatment program. For example, urine retention or sphincter control exercises can be added for the child who exhibits excessive frequency or urgency.

Arousal Training Arousal training (van Londen, 1989) uses the urine alarm, but instead of focusing on dry nights, it reinforces the child for getting up and going to the bathroom. To be rewarded, the child must turn off the alarm within 3 minutes after it has rung, go to the bathroom to urinate, return to bed, and reset the alarm. Parents are instructed to reward the child with two stickers if he or she follows the proper procedure when the alarm goes off, and to take one sticker away if the child does not (response cost). There is no contact with a professional in this program; rather, written material is included with the alarm when parents purchase it. In a study of 113 children between the ages of 6 and 12 years, van Londen, van Londen-Barentsen, van Son, and Mulder (1993) compared arousal training to (1) the urine alarm with written instructions to reward the child for a dry night with two stickers and to remove one sticker for a wet night

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(control group 1), and (2) the urine alarm without using any rewards or response cost (control group 2). There was no contact with a professional for any of the conditions. They found that 20 weeks after the beginning of training, the success rate was 98% for the arousal training group, which was significantly higher than that for either control group (control group 1 = 85%; control group 2 = 72%). At a 2½-year follow-up, the arousal training group was still doing significantly better (92% continent) than either of the control groups. Children in all groups, however, had relapses during the 2½ years before follow-up; 28% relapsed in the arousal training group, whereas 45% and 50% in the respective control groups relapsed. These data are impressive, especially considering that parents did the training by themselves. Although a dry bed is the ultimate goal, focusing on the prerequisite skill of getting up to go to the bathroom seems to lead to a higher success rate, a lower relapse rate, and ultimately a better outcome. Although it would be good to have more studies of this method, it can easily be incorporated into a treatment program that reinforces dry nights. Responding to the alarm and going to the bathroom can be rewarded or punished with response cost, whereas a dry night can be further reinforced and wet nights ignored.

Bladder Retention Training and Sphincter Control Exercises Some children with enuresis have been found to have a small functional bladder capacity (Bath et al., 1996). As previously stated, “functional bladder capacity” refers to the ability of the bladder to retain a given volume of urine without producing an urge to void. Children who have a small functional bladder capacity tend to have increased frequency of daytime urination, as well as a sense of urgency when they need to urinate. Increasing the amount of urine in the bladder before getting the urge to urinate is the goal of urine retention and sphincter control techniques (Miller, 1973). Although the initial studies of these techniques were promising (e.g., Paschalis, Kimmel, & Kimmel, 1972), later work has indicated that increasing functional bladder capacity alone is not sufficient or necessary to eliminate enuresis for most children (Bath et al., 1996; Doleys, 1978; Harris & Purohit, 1977). Bladder retention training may be helpful, however, if the frequency of wets or awakenings during the night does not decrease as expected. To help the child increase the amount of urine in the bladder before getting the urge to urinate, he or she is given increased liquids during the day; when the urge to urinate occurs, the child is encouraged to refrain from urinating as long as possible, usually up to 30 minutes (Christophersen & Rapoff, 1992). With practice, children can hold for several minutes to hours. Walker (1978) warns that the child should not be given excessive fluids (no more than 8–16 ounces per hour) or asked to hold beyond 1–2 hours. Another technique that has been used to strengthen the sphincter muscles and thus increase bladder capacity is sphincter control training. This involves the child’s practicing starting and stopping the stream of urine when voiding. Walker, Milling, and Bonner (1988) suggest having the child do this three to five times during each voiding and providing rewards to encourage this practice. A study using Kegel exercises, which involve dry contractions of the pelvic muscles, had 79 children with diurnal enuresis hold the contraction 5–10 seconds, relax 5 seconds, and repeat this exercise at least 10 times on three separate occasions during the day (Schneider, King, & Surwitt, 1994). These authors found that these exercises eliminated diurnal enuresis for about 60% of children, and that for 34% of the children with mixed enuresis, nocturnal enuresis was eliminated. Although there is little empirical support for bladder retention training and sphincter control training, we have found them useful when the frequency of wets or urgency does not

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decrease with other methods. Walker (1995) also reports finding them clinically useful and has developed a treatment protocol for using them (Walker, Milling, & Bonner, 1988). The systematic use of these techniques, including recording the amount of fluid consumed and the length of time the urine is held after urgency is felt, has been crucial to their successful use in our clinic. Full-spectrum home training uses the urine alarm, retention control training with monetary rewards, cleanliness training, self-monitoring of wet and dry nights, and a graduated overlearning procedure (Houts & Liebert, 1984; Mellon & Houts, 1998). Success rates for this procedure are reported to be about 80% within 8–16 weeks.

Dry Bed Training No discussion of enuresis would be complete without mentioning Azrin, Sneed, and Foxx’s (1974) dry bed training (DBT) approach to treatment of enuresis. This intervention program has generated considerable research and has been described in a self-help book, A Parent’s Guide to Bedwetting Control (Azrin & Besalel, 1979). Over the years, DBT has undergone a number of changes, but it essentially involves the use of operant conditioning principles to teach the child the responses necessary to stay dry. These include (1) positive reinforcement for inhibiting urination, (2) urine retention control training, (3) positive practice (repeatedly getting out of bed to go to the bathroom), (4) nighttime waking, (5) cleanliness training (cleaning the bed, including the mattress, for a period of up to 45 minutes), (6) negative reinforcement, (7) mild punishment (parent disapproval), (8) family encouragement, and (9) a urine alarm. Bollard and Nettlebeck (1982) examined the various components of the program and concluded that only the urine alarm produced significant effects alone. The effects of the other components were cumulative when added to the urine alarm. Thus, if the alarm alone is not working as expected, the clinician should consider what parts of DBT might be added to a particular child’s treatment program. The instructions for DBT, with an emphasis on positive practice, as used successfully in the Bath et al. (1996) study follow: First night: Have a drink. Count to 50 lying on the bed, then go to the toilet, attempt to urinate, return to bed and count to 50 again. Do this 20 times. The caretaker then wakes the child every hour and asks him or her to go to the toilet, then gives the child another drink. If at any time the child wets and the alarm goes off, he or she has to count to 50, go to the toilet, attempt to urinate, and then return to bed 20 times. Next six nights: If the child has wet the bed the night before, on going to bed, he or she starts by counting to 50, then going to the toilet, 20 times. Each time the child wets the bed during the night, he or she must count to 50 and go to the toilet 20 times. This 7-day programme can be re-used for relapse of enuresis. (Bath et al., 1996, p. 82)

Although this program has demonstrated success it does require a great deal of motivation and cooperation on both the child’s and parents’ part.

Medication Given that medication is frequently prescribed for enuresis, a brief discussion of its effectiveness is warranted. Imipramine (Tofranil), desmopressin acetate (DDAVP), and oxybutynin chloride (Ditropan) are the most frequently used drugs, although a recent review reported a decrease in the use of imipramine and an increase in the use of demopressin (Mikkelsen, 2001).

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Imipramine, commonly used for depression, appears to relax the detrusor muscle, which allows an increase in bladder volume before the reflex contractions induce voiding (Rushton, 1989). Studies indicate some success in the first week of treatment with imipramine, but there is almost always a relapse when the medication is stopped (Blackwell & Currah, 1973; Rushton, 1989). This finding and the reports of negative side effects (including death due to cardiac arrest) make this drug’s value for enuresis very limited indeed (Foxman et al., 1986). Desmopressin is a synthetic form of the hormone vasopressin, which stimulates the kidneys to concentrate urine and decreases the volume of urine during the night. The rationale for this intranasal medication is based on studies that found that vasopressin was increased in nonenuretic children at night, but not in children with enuresis. Other studies, however, have not found excessive production of urine at night in enuretic children (Bath et al., 1996; Evans & Meadow, 1992). Thus it is not clear why desmopressin is effective. It is important to note that relapse rates are very high when desmopressin is discontinued (Djurhuus et al., 1992). Furthermore, the safety of this medication is problematic. Belmaker (1986) reports it to be relatively safe for up to 6 months of use with adults, but studies with children report seizures after 3 weeks of use, water intoxication, and some more minor side effects (Donoghue, Latimer, Pillsbury, & Hertzog, 1998; Robson & Leung, 1996). In addition, desmopressin is expensive (more than $100 per month). It is, however, often prescribed when a child needs to remain dry for relatively short periods of time, such as overnight visits or camp. In combination with the urine alarm, desmopressin has been found to decrease the amount of wetting during treatment, particularly among children who present with severe wetting and those with behavioral problems (Bradbury & Meadow, 1995; Sukhai, Mol, & Harris, 1989). In a review of treatment studies, Mellon and McGrath (2000) suggest that desmopressin can be used in combination with the urine alarm to increase the success rates of treatment to near 100%. We argue, however, that a more conservative approach is warranted, and that treatment with desmopressin should be reserved for those children who do not respond to a behavioral approach. Oxybutynin is used to reduce spasms of the bladder and increase functional bladder capacity. Other literature, previously reviewed, indicates that increased bladder capacity alone is not enough to eliminate enuresis, and that this drug should not be used unless there is medical evidence of spasms of the bladder. Indeed, the sparse research on oxybutynin indicates limited effectiveness (Walker, 1995).

TREATMENT OF MIXED ENURESIS Fielding (1980) notes that children with both diurnal and nocturnal enuresis may respond more slowly to treatment of nocturnal enuresis and relapse more quickly once continence is achieved. In the absence of a physical disorder or significant emotional/behavioral problems or stress, daytime wetting is most often the result of poor toileting habits. We suggest first dealing with the daytime wetting by establishing good toileting habits, including (1) taking data on when the child wets, and having him or her sit on the toilet for 5 minutes at those times; (2) encouraging the child to empty the bladder fully; (3) cleanliness training (including cleaning him- or herself, the clothes, and the floor if wet) and having the child sit on the toilet for 5 minutes after each wet; (4) positive practice, such as having the child go to the bathroom from different

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parts of the house, yard, and neighborhood; (5) charting progress and providing rewards for dry days; and (6) supporting parents and child through regular therapist contact, however brief. Friman and Vollmer (1995) have used the urine alarm during the day when a child has trouble recognizing a full bladder or waits too long before going to the bathroom, and we have also found this helpful for daytime wetting. Sphincter control and urine retention exercises can be added if necessary to increase functional bladder capacity and the ability to sense the urge to urinate, as well as to strengthen the sphincter muscle. Once continence is established, overlearning (increased fluids) is added, and the reinforcement system is gradually faded by increasing the number of dry days necessary for rewards. When this is accomplished, if the child continues to wet the bed and wants a treatment program for the bedwetting, the urine alarm system can be used. The parents and child should be told that there may be some regression during the day, but that with continuation of good toilet habits daytime wets should decrease.

TREATMENT PROTOCOL FOR ENURESIS The specific components of a behavioral treatment program used in our clinic are described in this section. Our approach is based on information derived from the empirical literature. It involves a 1-hour initial interview and the provision of a urine alarm, followed by biweekly phone contacts and letters to the child for a period of up to 3 months. The cost is based on 2.5 hours of professional time.

Sharing Information The importance of sharing information and giving specific instructions in carrying out treatment programs for enuresis has been emphasized repeatedly in the literature (Houts, Whelan, & Peterson, 1987; Rushton, 1989; Walker, 1995). Information on the frequency of enuresis and the general stages of learning to control the urine reflex should be shared with the parents and child in simple, understandable language. Most children are not aware of the prevalence of enuresis, and they and their parents find it reassuring that they are not the “only ones” with this problem. The use of a diagram of the bladder, such the one in Figure 4.5, helps both children and parents understand the process. The clinician should begin by describing how urine from the kidney fills the bladder, which functions like a storage bag. When the bladder expands to a certain point, the muscles contract to discharge urine into the tube at the lower end of the bladder, called the urethra. The sphincter muscles close the entrance to the urethra. When the bladder is full, it becomes distended; the internal sphincter muscle then opens, and this is the signal that one has to go to the bathroom. Depending on the age of the child, one can give as brief or as long a description of this process as necessary. The point is to give the child a picture of what he or she is trying to learn to do—that is, tune in to a full bladder and tighten the outer sphincter muscle until he or she wakes up and can get to the bathroom. Once children learn how to do this, they are usually able to sleep for longer periods of time without needing to use the bathroom. Children who wet frequently (eight or more times) during the day and many times during the night should be warned that it may take them a little longer to learn to stay dry.

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FIGURE 4.5. Urinary tract system.

Intervention with the Child/Changing the Consequences of the Behavior Urine Alarm The urine alarm system can be described as a “helper” that wakes the child up as soon as he or she starts to wet. The child’s goal is to “beat the buzzer”—that is, to get up before it goes off or to sleep dry through the night. If possible, the alarm should be demonstrated on the child or a parent during the first treatment session. The snaps can be put on the outer clothing, and a drop of water placed on the cloth near the snaps will set off the alarm. At night, the alarm should be placed on the child’s wrist or pinned to the pajama shoulder with the wires running up the child’s arm, into the sleeve of the shirt, and down into the crotch of the pants; the wire can be shortened by taping a length of it together with adhesive tape. This is an important step, so there is no chance that the child will become caught up in the wire or the leads will be disconnected. The alarm can be unreliable at times, going off when it should not or not going off when it should, so it is important to keep backup alarms in the clinic. The procedure for using the alarm is as follows. Parents go to the child’s room when the alarm rings and prompt the child to go to the bathroom. The child is instructed to empty the bladder completely, change the bed, put the soiled linen in the proper container, change pajamas, and reconnect the alarm. Data are then recorded, and the child is given two stickers for following this procedure (Figure 4.6). When the alarm rings but the child fails to get out of bed, does not go to the bathroom, or does not reset the alarm, the parents should have the child give back one sticker. Parents should be instructed to do this in a calm, matter-of-fact way, without excessive praise or disappointment. The next step is to describe the typical stages of treatment. The child should initially expect to wet with the same frequency, but the wet spots should become smaller. Then the frequency of the wets will decrease, with the first wet occurring later in the night. Next, the child

Nighttime Wetting Chart Treatment Child’s Name: _____________________________________________________________________________ Age: ______________________________________ Address: _______________________________________________________________________________________________________________________________

Bedtime

Time (Wet/Beat Buzzer)

Size of Wet Small Medium Large

Beat the Go to Change Change Dispose of Buzzer Bathroom Sheets P.J.’s Wet Clothing

Sample 3-22-90/Thurs

9:00

7:00

✓

11:30 P.M.

135

4:00 A.M. 6:30 A.M.

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Date/Day

Time up i n A.M.

✓ ✓

✓

✓

✓

✓

✓

✓

✓

✓

FIGURE 4.6. A chart for recording enuresis treatment data. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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will start to “beat the buzzer” and awaken to void before actually wetting the bed. Soon the child will be waking without the alarm with greater frequency and will no longer wet the bed. Finally, the child can expect to sleep longer and longer between wakenings, and will eventually sleep through the night without needing to void until morning. The time it takes to go through this process can vary from 1 to 3 months. The clinician should carefully monitor the data to determine whether the wet spots are getting smaller and the number of wets are decreasing at an acceptable rate. The goal is to get 14 consecutive dry nights, at which time an overlearning procedure is instituted. Overlearning Procedure After 14 consecutive dry nights, an overlearning procedure is implemented, in which the child drinks 6–8 ounces of his or her favorite liquid (drinks that are diuretic, such as cola and tea, should be avoided) before bed. The child and parents should be told that this is an important step to ensure that the child has fully learned to tighten the sphincter muscle, and to get up if necessary to go to the bathroom. They should be warned that there may be some accidents, but that this is to be expected at this stage of the training. This phase of the treatment should continue until there are 14 more consecutive dry nights. Intermittent Use of the Alarm The next phase of treatment is to use the alarm on an intermittent schedule, to further strengthen the newly learned behavior of sleeping through the night dry. The child should be told that on some nights the parents will disconnect the alarm after he or she has gone to sleep. Because the child will not know when the alarm is connected, this will help him or her to learn to sleep through the night without the alarm. The parents should be asked to disconnect the alarm two nights during the first week, and then to increase the number of nights after each completely dry week until the alarm is no longer connected. The alarm should be removed at this time. The parents and child should be reminded that relapses are not unusual, but if wetting occurs more than once a month for 2 months, they should use the alarm again until the child has 30 consecutive dry nights. We find that with the use of the overlearning procedure and the intermittent alarm schedule, relapses are rare; when they do occur, reinstituting the alarm quickly resolves the problem. Supporting the child through the treatment process is important. This can be done by sending an encourging letter to the child as in the following example: Dear John, Thank you for being so prompt in sending your chart to me. Wow! You must be very pleased with yourself! Four dry nights in one week, and on the other nights the wet spots were small. Have you noticed that you are also sleeping longer before you “beat the buzzer” or wet? That is just what we want to happen. Keep up the good work. After three weeks of using the buzzer, you are already having dry nights, but remember to tell yourself to “beat the buzzer” before you fall asleep. Your mother said that you were doing a good job of remembering to start and stop your stream of urine when you have to go to the bathroom. Great! I look forward to seeing your chart this week. Enjoy your dry nights! Sincerely, Dr. Schroeder

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Intervention with the Parents The parents’ motivation to implement the treatment program is critical for success. They will need instructions on how to keep data, help in setting up a reinforcement system, and regular feedback. They also should be given addressed envelopes to mail their data charts (see Figure 4.6) to the clinic every week. The clinician should review the data, observe the course of treatment, and call the parents if necessary. A phone call at least every 2 weeks is important to support the parents and answer any questions.

CASE EXAMPLE: ENURESIS Step 1: Initial Contact Mrs. O’Dell, the single mother of a 7-year-old boy, Andrew, called the clinic regarding treatment of her son’s bedwetting. Andrew had been seen in our clinic at age 5 regarding readiness for school. An evaluation at that time indicated a verbally bright child with poor visual–motor organizational skills. A referral to an occupational therapist resulted in a diagnosis of mild dyspraxia—that is, difficulty in motor planning skills. The child had a course of treatment with the occupational therapist, went on to kindergarten, and was currently doing quite well in second grade. The child had recently had a physical examination, and the physician had indicated that there was no organic basis for the bedwetting. The physician had suggested that he be made to sleep in his soiled sheets for a minimum of 2 weeks before washing. When the child indicated that he wanted to have some friends spend the night, the physician encouraged him to do this and to be sure the friends slept in the same bed with him. Neither the mother or the child was pleased with this advice, and the mother decided that they would seek help from a psychologist. To rule out the presence of significant emotional or behavioral problems, the mother was asked to complete the General Parent Questionnaire, the CBCL, the ECBI, and the PSI. She was also asked to complete a nighttime wetting record (Figure 4.3) for 7 days prior to their appointment.

Step 2: Parent and Child Interviews Mrs. O’Dell and Andrew came in together for the initial interview. A review of the parent assessment instruments indicated that Mrs. O’Dell was a licensed practical nurse who worked the day shift at a local nursing home. She had been divorced for 4 years. Andrew was described as a well-adjusted child who had a number of close friends, was doing well in school, and preferred quiet activities (such as rock collecting, reading, and playing computer games). Mrs. O’Dell confirmed the information on the rating scales by stating that she was quite pleased with Andrew and did not feel that the bedwetting was a problem for her. The request for treatment had come because Andrew wanted to have friends over, spend the night with friends, and go to a week-long overnight camp in the summer. Bladder and bowel training during the day was started at 2½ years and completed at age 4. Andrew was initially bowel-trained and then bladder-trained. Andrew reported that he still had occasional accidents during the day when he delayed going to the bathroom because he was playing. These accidents occurred approximately once a month. The only time Andrew had ever been dry at night was when he had spent the night at his grandmother’s house 6 months ago.

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To the mother’s knowledge, no one in her or Andrew’s father’s families had a history of enuresis. There had been no major changes for this family in the last year, and the atmosphere in the home was described as calm, with regular daily routines. A younger sister, age 4, was already sleeping dry through the night.

Step 3: Observation of Behavior The nighttime wetting chart indicated that Andrew went to bed at about 8:30 P.M., had his first wet at 11 to 11:30 P.M., wet again between 3 and 5:30 A.M., and got up at 7 A.M. The size of the wets varied from medium to large. The record also indicated that Andrew would often put a blanket over the wet spot; if the wet was too large, he would change his clothes and spend the rest of the night in his mother’s bed. Andrew was attentive during the interview, and although he was initially reticent, he soon contributed information readily. Mrs. O’Dell was respectful of his input and often deferred to him in answering questions. He enjoyed the demonstration of the alarm and was enthusiastic about starting the program.

Step 4: Further Assessment No further assessment was indicated at this time.

Step 5: Referral to Allied Health Professionals The medical examination had been done prior to the initial contact.

Step 6: Communication of Findings and Treatment Recommendations The findings were summarized for Andrew and his mother, and the rationale for the specific treatment recommendations was given. They were told that wetting the bed seemed to be an isolated problem for Andrew. He was well accepted by his family, had friends, had a variety of interests, and was doing well in school; in short, all the information indicated that he was a well-adjusted child. Although Mrs. O’Dell did not consider the bedwetting as a problem for her, and in fact had done nothing about it, she was supportive of Andrew and agreed to help with the program. Andrew was clearly interested in stopping the bedwetting for legitimate reasons. Next, information was shared on bladder functioning and enuresis, and the wrist alarm system was demonstrated. Nighttime wetting data forms and stamped envelopes were given to the mother and child to complete and return on a weekly basis. Given that Andrew had periodic difficulty making it to the bathroom during the day, he was instructed to start and stop the flow of urine three to five times each time he urinated. The purpose of this was to strengthen his sphincter muscle. He was also instructed not to change his consumption of liquids before bedtime and to increase fluids during the day, so he would have more opportunities to practice sphincter control. Bladder retention training was considered, but the mother felt that Andrew was already waiting too long before going to the bathroom.

Course of Treatment In the first week, Andrew beat the buzzer one night, wet two times a night for three nights, and wet once on three nights. The size of the wets was medium to large. During the second

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week, the size of the wets was small to medium, and the time of wetting was later. He beat the buzzer on two nights, wet two times on two nights, and had three nights with one wet. In the third week, he slept dry through one night, beat the buzzer two nights, and had one small wet on each of the remaining four nights. The course of treatment was unremarkable, and within 8 weeks Andrew had 14 consecutive dry nights. Overlearning and later intermittent use of the alarm were then instituted. After a period of slight regression, Andrew had 30 days dry, 4 months from the start of treatment. He was delighted and had already begun making plans for summer camp!

ENCOPRESIS Description and Prevalence “Encopresis” is the term used for defecating in the pants or other inappropriate places (in the absence of medication effects or any organic pathology other than constipation) at least once a month for a minimum of 3 months in a child at least 4 years of age or the developmental equivalent (APA, 1994). This problem has been around for a very long time, but it has received far less attention in the scientific literature than enuresis, with most well-controlled research beginning in the 1990s. Although to date there are no well-established interventions, more information is now available to help guide the clinical treatment of encopresis (McGrath, Mellon, & Murphy, 2000). DSM-IV lists two subtypes of encopresis. The first of these is “with constipation and overflow incontinence.” Constipation is the essential feature of this subtype, which also includes poorly formed feces, continuous leakage that occurs during the day or at night, and only small amounts of feces passed during toileting. The incontinence is typically resolved with treatment of the constipation. In encopresis “without constipation and overflow incontinence,” there is no constipation, feces are normal in form and consistency, and soiling is intermittent. This second type of encopresis is thought to be associated with oppositional defiant disorder (ODD) or conduct disorder. A distinction should also be made, although it is not in the DSM-IV criteria, between children who have never achieved appropriate bowel control (“primary” encopresis) and children who develop encopresis after a period of appropriate bowel control (“secondary” encopresis) (Easson, 1960). The etiology and treatment of these cases may differ. Another useful distinction among types of encopresis is made by Walker (1978), who classifies these as follows: (1) “retentive” encopresis, which is the result of constipation; (2) “nonretentive” encopresis, which involves either poor toilet training or chronic diarrhea and irritable bowel syndrome (the apparent results of stress); and (3) “manipulative” encopresis, which is used by the child to control the environment. (Our own treatment protocols for encopresis are based on this distinction; see below.) Encopresis is thus a heterogeneous problem, and appropriate treatment will depend on a careful analysis of the problem for the individual child. There are few epidemiological studies of encopresis, and the differences among these studies in definitions, settings, and age ranges make it difficult to compare results. Estimates of occurrence range from 1.5% to 7.5% of children ages 6–12, with encopresis four to five times more common in boys than in girls (Doleys, Schwartz, & Cineinero, 1981). Encopresis and constipation account for 3% of all general pediatric visits and 25% of all pediatric gastroenterology visits (Sonnenberg & Koch, 1989) and 5.7% of all clinic referrals (Olatawura, 1973). Although there is evidence that the prevalence of encopresis declines to about 0.75% of children by age 12 (Houts & Abramson, 1990), 52–64% of medically treated children evidenced persis-

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tent constipation 3½–5 years after the intervention (Bernard-Bonnin, Haley, Belanger, & Nadeau, 1993; Staiano, Andreotti, Greco, Basile, & Auricchio, 1994). Thus this problem will persist into adolescence and adulthood for many children. It is estimated that 80–95% of children treated for encopresis have chronic constipation (Levine, 1975); 50–60% of these cases had previously been successfully toilet-trained (see Christophersen & Rapoff, 1992). In contrast, among children with constipation, 35% of girls and 55% of boys reportedly have concomitant soiling (Staiano et al., 1994). It is not surprising that approximately 25% of encopretic children are also enuretic, given the pressure that an impacted colon can put on the bladder (Levine, 1975). Common physical symptoms associated with encopresis include poor appetite, chronic abdominal pain, and lethargy (Levine, 1982), with children reporting pain as the worst consequence of constipation (Bernard-Bonnin et al., 1993). Parents rate these children as also having poorer self-esteem and more emotional and behavioral problems than other children (Bernard-Bonnin et al., 1993). Children with encopresis are found at all socioeconomic and intellectual levels (Walker, Milling, & Bonner, 1988). Abrahamian and Lloyd-Still (1984) reported that 50% of their chronically constipated patients had a positive family history for encopresis, but there is little additional support for a genetic basis for this disorder.

Etiology Organic Factors By definition, encopresis is functional in nature; however, several organic problems can cause fecal incontinence, and the clinician should distinguish these conditions from encopresis. For example, structural anomalies or diseases of the bowel or sphincters (obstructing lesions or tumors), as well as of the nervous system (myelomeningocele, spina bifida), can cause fecal incontinence. Hirschsprung’s disease, which results from an absence of both the ganglion cells and the normal peristaltic waves in one segment of the bowel, is common in children. In this disorder, fecal material becomes impacted above this segment, resulting in an enlarged colon or “megacolon.” Severe cases are usually detected shortly after birth and are corrected surgically by removing the portion of the bowel that is not functional and reconnecting the functional parts of the bowel. Some milder cases may not be discovered until much later, and it is not uncommon for these children to have only one bowel movement a month! The ratio of the incidence of Hirschsprung’s disease to that of psychogenic megacolon caused by constipation is about 1:20 (Vaughan, McKay, & Behrman, 1979). Other organic problems can result from dietary factors, allergic reactions to food, and infectious diseases of the large intestines. A study comparing the “defecation dynamics” (coordination of the reflexes and voluntary efforts necessary for stool expulsion) of healthy and chronically constipated children found that 46% of the chronically constipated children contracted instead of relaxed the external sphincter when they attemped to defecate (Loening-Baucke, Cruikshank, & Savage, 1987). Constipated children who had this abnormal anal pressure were significantly less likely to improve after conventional laxative, diet, and toilet training treatment than constipated children who did not have this problem. The authors note that further study is necessary to determine whether the inability to defecate is the result of an unconsciously altered motor behavior due to fear of pain or an anatomical abnormality of the pelvic floor.

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Emotional Factors Traditionally, the psychiatric literature has viewed encopresis as a symptom of severe emotional problems, with psychological conflict as the primary catalyst for the onset of the problem (Halpern, 1977). Although encopretic children in general have more behavioral, emotional, and social problems than children in the normal population, these problems are not usually clinically significant, and most emotionally/behaviorally disturbed children are not encopretic (Young, Brennen, Baker, & Baker, 1995). As noted above, DSM-IV indicates that encopresis without constipation and overflow incontinence is usually associated with ODD and conduct disorder; however, the empirical literature does not indicate any association with a particular disorder (Young et al., 1995). Walker (1995) makes the observation that family turmoil and conflict are common when children have encopresis. Family problems, of course, could set the stage for encopresis, but they could also be due to the stress of dealing with the soiling! A few other studies have found a subgroup of children with encopresis (between 15% and 20% of the children studied) with more extreme behavior problems (Abrahamian & Lloyd-Still, 1984; Friman, Mathews, Finney, Christophersen, & Leibowitz, 1988). It is not clear, however, whether these problems cause or are secondary to the severe constipation. Moreover, it is important to note that successful treatment typically results in improvement in various behavioral/emotional problems (Owens-Stively, 1987; Shapiro & Henderson, 1992; Young et al., 1995). Others report that a specific stressful event (such as loss of a parent, birth of a sibling, or a hospitalization) related to the onset of soiling can be identified in some cases (Abrahamian & Lloyd-Still, 1984; Levine, 1975). Although it is not surprising that emotional and behavioral problems can play a part in encopresis, and that some children with encopresis exhibit significant problems, emotional factors alone cannot account for the etiology of encopresis. It is, however, important to understand the part that child and family problems can play in the successful treatment of this disorder.

Learning Factors The empirical literature supports the view that learning principles play an important role in the etiology of encopresis (e.g., Levine & Bakow, 1976; Stark et al., 1997). Walker, Milling, and Bonner (1988) propose that (1) children may not have acquired the prerequisite skills for toileting (recognizing body cues, undressing, going to the bathroom on cue, sitting on a toilet); (2) the physical condition of chronic constipation may result in a breakdown in the learned cognitive control of the bowels; (3) a child’s soiling may be reinforced through his or her manipulation of the environment; or (4) stress or anxiety may lead to impaired bowel control, with a consequent loss of successful performance of toileting behaviors. In addition, some children develop a fear of the toilet as the result of a painful bowel movement, aggressive training techniques, punitive consequences following a soiling accident, or fearful fantasies regarding the toilet. These fears can disrupt the training process or the use of appropriate toilet habits. Certain lifestyles can also promote constipation. Some children, for example, have diets that contain little fiber and/or a predominance of dairy products, which can cause constipation. A sedentary lifestyle can also promote constipation; exercise is an important element in keeping the gastrointestinal (GI) tract working properly. Moreover, a chaotic home environment with inconsistent daily routines can lead to a breakdown in toileting habits, resulting in soiling accidents. Similarly, changes in routine can also lead to toileting

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problems. Finally, delaying toileting because a toilet is not readily accessible or because a child is embarrassed to go to the bathroom (e.g., in school) can result in constipation and/or soiling.

ASSESSMENT OF ENCOPRESIS The assessment process presented here follows the CAIS (see Chapter 2), with a focus on information pertinent to the problem of encopresis. First, the clinician must have a basic understanding of normal defecation, which involves a coordination of physiological and behavioral responses (see Figure 4.7). Schaefer (1979) and Walker, Milling, and Bonner (1988) provide the following description of the GI system and of the process resulting in constipation. The digestive process is an active one that begins when food enters the mouth and is broken down in the stomach and small intestine, with the absorption of nutrients as food is digested. Wastes reach the large intestine, where water is reabsorbed and the waste material is formed into fecal material or “stools,” which are excreted through the anus. The passage of feces through the intestinal tract is the result of a series of wave-like motions of the entire tract (“peristalsis”). Distension of the rectum by the arrival of additional fecal material creates the urge to defecate. The peristaltic action resulting in the urge to defecate is usually strongest 15–30 minutes after breakfast, but some people experience a rush after each meal. On average, three-quarters of food waste is excreted within 96 hours, but there are wide individual differences. Although most people have a bowel movement every day, about 1% of the normal population has a bowel movement fewer than three times per week or more than three times per day. The normal stool should be soft, should be moist on the outside surface, and should have a distinct shape. The ability to control defecation depends on adequate enervation of the colon and anus, as well as on the child’s ability to relax and contract the external sphincter purposively. The

FIGURE 4.7. Gastrointestinal (GI) system.

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toilet training process teaches the child to recognize and respond to the stimulation of the rectum, and then to relax the external anal sphincter voluntarily when he or she is seated on a toilet or potty chair (Walker, Milling, & Bonner, 1988). If for any reason the urge to defecate is not responded to, the fecal mass is redeposited into the lower end of the colon by reverse peristalsis. When this process is repeated many times, the normally empty rectum tends to become accustomed to the increased pressure caused by the presence of stool; consequently, the urge to defecate passes. In the meantime, the colon is constantly absorbing water from its contents, and the stool becomes hard, dry, and difficult to pass. Children are reluctant to expel hard, large stools, which are painful, and constipation may result. As fecal material continues to accumulate, the intestine becomes enlarged (“psychogenic megacolon”; see Figure 4.8) and loses its muscle tone. The intestinal wall becomes thin as a result of stretching caused by the impacted fecal material, and normal peristaltic and mass movements are not able to evacuate feces fully from the bowel. In some cases, the large intestine becomes so impacted with feces that the entire abdominal cavity is filled. With impaction, bowel function is compromised, and a chronic state of constipation results. Then, as fluid from the small intestine makes its way to the large intestine, it forms a pool above the impacted feces in the colon. This fluid material then seeps around the impacted mass and out through the anus, staining the child’s clothes with a paste-like material. Because the passage of this material is not accompanied by the usual sensation of the urge to defecate, the child does not realize that it has happened until he or she feels wetness in the rectal area or on his clothing. At other times large amounts of the impacted material may be explosively expelled, causing major soiling of the clothes. Given that neither the seepage nor the explosive bowel movements are under voluntary control, one can readily see that chronic constipation is likely to inhibit learning of bowel control or to interfere with previously learned toileting skills.

FIGURE 4.8. Megacolon: Patient training diagram. Copyright 1982 by M. D. Levine, MD. Used by permission.

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Step 1: Initial Contact The first step in assessment is a thorough examination by a physician to rule out an organic basis for the fecal incontinence and to determine whether the colon is impacted. If the child is chronically constipated, then continued collaboration with the physician is necessary to coordinate the use of cathartics. A general questionnaire (e.g., our General Parent Questionnaire; see Appendix B) and checklists to rule out emotional or behavioral problems should be sent to the parents prior to the initial interview. The CBCL (Achenbach, 1991a, 1992) or the BASC (Reynolds & Kamphaus, 1992), the PSI (Abidin, 1995), and the ECBI (Eyberg & Pincus, 1999) are recommended for this purpose. The parents should be asked to keep data on bowel and toilet activity for at least a week (Figure 4.9), and data on food and liquid intake as well as physical activity for 3 days (Figure 4.10).

Step 2: Parent and Child Interviews The child and parents should be seen together for the initial interview. The child’s perceptions of the problem and willingness to engage in a treatment program are important to assess, as is the parent–child interaction in regard to this issue. The interview should focus on the following questions: 1. Are there behavioral or emotional problems? Information from the general questionnaire and rating scales should be reviewed to rule out significant emotional or behavioral problems. We have found that even if emotional and behavioral problems are present, treating the encopresis generally helps to improve these problems. If there is significant psychopathology, noncompliance, or serious parent–child conflict, however, the clinician should investigate the possibility that the encopresis is the result of manipulation on the child’s part, and these issues should be treated before the encopresis. 2. Have there been recent stressful life events for the family or the child? A review of family history is important, with an emphasis on stressful life events (e.g., a household move, a new school, the birth of a sibling, parent separation, a hospitalization, an illness or death, etc.). The clinician should determine whether any of these events occurred close to the time the soiling started. 3. How did toilet training proceed? Parents should be asked to describe the process of toilet-training their child, including the age at which it was begun, methods used, responsiveness of the child, and the age at which both daytime and nighttime continence were achieved (if at all). Previous treatment attempts should also be described in detail. This information will help the clinician determine whether the child actually was taught and/or learned appropriate toileting skills. 4. What is the current status of toileting habits and bowel movements? A thorough review should be made of the bowel movement data. Current toileting habits (time of day, length of sits), frequency of bowel movements (children can go several times a day in small amounts and still be constipated), and nature of the stool (e.g., runny, soft, paste-like stains; hard, small stools or occasional enormous amounts that are painful or difficult to pass; or an unusual foul odor) should be noted. 5. What is the environmental context of the problem? Asking for a brief description of a typical day for the child and family is useful in getting a picture of the family’s daily routine. A

Bowel Movement Chart Baseline/Treatment Child’s Name: _____________________________________________________________________________ Age: ______________________________________ Address: _______________________________________________________________________________________________________________________________

Time

Cathartics1

In Toilet

In Pants

What Happened?

Sample

145

3-21

10:00 A.M.

"

3:00 P.M.

"

6:00 P.M.

1Cathartics:

S

✓

✓

✓

✓

✓

✓

"

✓

✓

Painful BM

✓

Mother cleaned up

4. Toileting: Training, Enuresis, and Encopresis

Date

Consistency Size Runny/ Soft/ Small Medium Large Paste-like Hard Unformed Formed

Suppository (S); Enema (E); Oral (O)—mineral oil, milk of magnesia, etc.

FIGURE 4.9. Chart for recording bowel movements during baseline and treatment. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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Diet/Exercise Record Child’s Name: _____________________________________________________________________ Day 1

Day 2

Day 3

Date/Day Breakfast

Snack

Lunch

Snack

Dinner

Snack

Exercise

Comments

FIGURE 4.10. Diet/exercise record for baseline data.

From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

chaotic environment with irregular meals or a stressful time schedule can interfere with consistent toilet practices. Does the child hide his or her underpants, which might indicate the use of punishment (Friman & Jones, 1998)? The dietary and exercise data also should be reviewed at this time, to determine whether these might be factors contributing to the problem. 6. How do the child and parents perceive the problem? The child’s beliefs, feelings, and concerns about the problem should be assessed. It is always important to ask, “Why are you seeking help now?” Treatment of encopresis requires considerable effort and vigilance on the part of both parents and child; without their full cooperation, treatment will fail. Thus it is important to assess their motivation for treatment.

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Step 3: Observation of Behavior Data on bowel habits and informal observation of parent–child interaction are usually all that are needed. If the parents report significant management problems, the clinician should engage in more systematic observation of parents and child, with the goal of identifying additional areas in need of attention or to change the treatment focus.

Step 4: Further Assessment Further assessment is necessary only if other problems are suspected. For example, it is very likely that a child presenting with manipulative encopresis will need further evaluation.

Step 5: Referral to Allied Health Professionals A physician should see the child prior to the initial interview, as noted above. Collaboration with the physician is often necessary for a child with encopresis, especially if the child is impacted and/or cathartics are used in the treatment program.

Step 6: Communication of Findings and Treatment Recommendations It is strongly recommended that the child be present to hear the findings and recommendations. In communicating the recommendations to the child and family, it is important for the clinician to give them information about the GI system and the rationale for the treatment program. The influence of encopresis on the child’s development in other areas should also be discussed. The family’s clear understanding of the problem and the proposed treatment process, including the importance of consistency in carrying out its component parts, enhances the likelihood that the parents and child will cooperate with treatment. Again, this cooperation is essential to resolving bowel problems.

TREATMENT OF ENCOPRESIS A brief review of the treatment literature is given in this section, with a focus on the most successful treatments to date. For a more comprehensive review of the literature, see McGrath et al. (2000). Encopresis is a complex, multidetermined problem for which there is no well-established “best” treatment. McGrath et al. (2000) indicate that interventions have included (1) medical treatment, which can involve initial cleaning of the bowel, ongoing use of laxatives, dietary recommendations of increased fiber and water, and a sitting schedule; (2) biofeedback interventions, which can involve strengthening of the external anal sphincter’s contraction, sensory discrimination training, and home practice of sphincter tightening and relaxation; (3) behavioral interventions, including reinforcement, punishment via overcorrection and cleanliness training, classical conditioning, skills-building techniques, and awareness training; and (4) psychotherapeutic interventions, including play therapy, parenting skills, parent support, child psychotherapy, and family therapy. For children with retentive encopresis, medical treatment that involves the use of enemas to cleanse the bowel and laxatives for ensuring regular bowel movements is almost always the first

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step in the treatment protocol. The combination of behavioral approaches and medical intervention has been demonstrated to be more effective than medical treatment alone (McGrath et al., 2000). Likewise, for children with constipation and abnormal defecation dynamics, the addition of biofeedback enhances the medical interventions’ effectiveness. Yet McGrath et al. caution that “more is not always better,” and warn that unneeded treatment strategies can result in decreasing the effectiveness of treatment. For example, if a child does not have abnormal defecation dynamics, then the addition of biofeedback can serve to decrease the focus on behavioral interventions and decrease the overall effectiveness of treatment (Cox, Sutphen, Ling, Quillian, & Borowitz, 1998). In addition, recommendations that do not include a systematic way for the family to implement them may not be helpful (e.g., dietary changes without systematic information on foods with fiber and the importance of water consumption, plus a systematic way to collect data on these changes). Thus, just as with other emotional and behavioral problems, the individual needs of the child must be taken into consideration if a treatment program is to be effective. Furthermore, effective treatment is related to a shorter duration of symptoms (Lowery, Stour, Whitehead, & Schuster, 1985), so early intervention increases the chances of complete elimination of symptoms. Failure to improve during the first 2 weeks of intervention has been found to predict nonresponse at 3 months (Cox et al., 1998). McGrath et al. (2000) also report that when a child has not evidenced a complete elimination of symptoms by 6 months after treatment, a different or a more intensive intervention should be considered. A brief review of a few successful programs for children with constipation and fecal incontinence follows. Wright (1975) has described a highly successful procedure for retentive encopresis, which includes the systematic use of suppositories and enemas as well as behavioral techniques. The first step in the program is to ensure that all fecal material is removed from the colon, usually through the use of enemas administered by the parents under a physician’s direction. Then, in the morning immediately upon awakening, the child is told to sit on the toilet and attempt to have a bowel movement. If the child produces ¼ to ½ cup of feces, he or she is praised and given a reward. If the child produces less than that amount or nothing, the parent inserts a glycerin suppository, and the child is instructed to dress, prepare for school, and have breakfast. After breakfast, the child is instructed to sit on the toilet again; if this attempt is successful, the child is given a reward, but one smaller than the one for defecating independently. If the second attempt is unsuccessful, then an enema is given. No reward is given if an enema is needed to produce defecation. At the end of the day, the child’s clothing is examined for soiling. If it is clean, the child is given another reward; if it is soiled, a mild punishment (e.g., sitting on a chair for 10 minutes) is administered. Training proceeds in this manner until the child has 2 consecutive weeks with no soiling. Then the cathartics are discontinued for 1 day of the week, and as each week is soil-free, an additional cathartic-free day is added until the child is defecating completely independently (see Walker, Milling, & Bonner, 1988, pp. 388–391, for an in-depth description of this procedure). Walker and colleagues report that when properly applied, this program has resulted in cessation of soiling in 100% of cases. We have also found this program to be the most effective method of treatment, especially for children who have had severely impacted bowels. Some physicians and parents resist using enemas and suppositories repeatedly, however. Moreover, many children who have retentive encopresis have not developed good toileting habits, or their environment does not support good toileting habits. Thus these areas will require some interventions, and these are described in the following treatment protocol section. Stark and colleagues (Stark et al., 1997; Stark, Owens-Stively, Spirito, Lewis, & Guevremont, 1990) describe a promising 6-week group treatment protocol that does not include the

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continuous use of laxatives. Their protocol uses enema cleansing, increased dietary fiber, and increased water consumption (with specific instructions and data collection), and daily toilet sitting (with behavior management strategies—differential attention, contingency management, and contracting). This approach was successful in 6 weeks for the majority of children (86%). Stark et al. (1997) note that even children who “failed” treatment showed improvement over baseline, and a number of these children benefited from either brief individual behavior therapy or anal sphincter biofeedback. These results are impressive, especially given the costeffectiveness of group treatment and the absence of laxatives after the initial bowel cleanout. Although it is not possible to determine the unique contributions of each treatment component in this study, it demonstrates the value of a combined approach with a systematic focus on a diet of increased fiber and water consumption. Biofeedback has proven to be an effective treatment for children who have increased thresholds of conscious sensation of rectal distension and for those who paradoxically tighten their external anal sphincter muscle when trying to defecate (Wald, Chandra, Chiponis, & Gabel, 1986; Loening-Baucke, 1990). This form of treatment involves exercise of the external sphincter, training in discrimination of rectal sensations, and training in synchronization of internal and external sphincter responses (Whitehead, 1992). Because it is not clear in such cases whether physical abnormalities are the cause or the result of the fecal incontinence (avoidance of defecation may be due to fear of pain), and because this form of treatment is invasive, it would seem best reserved for those cases that do not respond to standard treatment or that have a clear organic basis (Walker, 1995).

TREATMENT PROTOCOLS FOR ENCOPRESIS We have come to view encopresis as primarily a “plumbing problem” that most often requires medical intervention, as well as the teaching of appropriate toilet habits, lifestyle changes (e.g., exercise and diet), and stress reduction techniques. Thus our approach to treatment of encopresis focuses on the needs of the individual child and family and is a combination of behavioral and medical methods. It includes the following components: (1) Information is provided to the parents and child, to help change their inappropriate beliefs or attitudes about the problem and to facilitate understanding and cooperation; (2) medical, dietary, and exercise interventions are used to correct the physical problems of chronic constipation or chronic diarrhea; (3) appropriate toileting behaviors are taught or increased; (4) environmental conditions are changed to facilitate the acquisition of the correct responses; and (5) consequences for appropriate and inappropriate behaviors are changed. The particular components of a treatment protocol for retentive encopresis are described, followed by protocols for nonretentive encopresis and manipulative encopresis. Each protocol should be modified to meet the needs of the individual child.

Retentive Encopresis Information Sharing The parents and child should be told that encopresis with constipation is not an uncommon problem, and that early treatment can help to alleviate it. A brief description of the digestive system and of where the problem may lie for the particular child should be given in simple language

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appropriate to the child’s level of understanding. The use of a diagram or simple drawing (Figure 4.7) showing the GI tract, with some discussion of where things can go wrong, has proven very helpful with our parents and children. The child should be shown how constipation can cause the colon to get out of shape (Figure 4.8) and not work properly, which then results in uncontrollable seepage (the paste-like stains) or very large bowel movements. Constipation can also make it difficult to feel the urge to defecate and to empty the colon completely of feces. Finally, the appearance of normal bowel movements (large, moist, well-formed) should be described. Intervention with the Child Physical Intervention. With chronic constipation, the bowel will have to be cleansed of impacted feces with one or more enemas. Depending on how severely impacted the child is, the use of enemas may have to be repeated (Davidson, Kugler, & Bauer, 1963). The type of enema used should be one that is safe for repeated administration, such as Children’s Fleet Enemas, and enemas should always be given under the direction of a physician. Once the impacted mass is removed from the colon, it is important for the bowel to be evacuated regularly over a sufficient period of time, so that the colon can regain its normal shape and tone and begin to function properly, and bowel movements are no longer painful. Suppositories, mineral oil, lactulose, and sorbitol have each been used for this purpose. The idea is to promote several loose bowel movements daily, and then gradually decrease the use of cathartics over a period of several weeks as bowel movements come under the child’s control. The dose should be sufficient to produce one or more daily bowel movements, instead of a dose calculated by body weight or a fixed dose. In addition, the dose should produce the urge to defecate, so the child can learn to tune in to the cue. Thus finding the correct dose will take some attention. Needless to say, however, none of these products should be used without consultation with the child’s physician. Development of Toileting Skills. Many encopretic children have not learned proper toileting habits; even if they have, the onset of constipation usually disrupts these once-learned skills. It should be stressed that the colon has to be evacuated regularly in order for it to begin to function properly, and that ultimately the child must learn to take responsibility for his or her own toileting behavior by tuning in to the urge to defecate and taking the time to sit on the toilet. We suggest a regimen of sitting on the toilet for 5–10 minutes about 20 minutes after each meal (when the child is in school, he or she can sit upon returning home). A timer can be used so the child can sit independently, and the child should be given a book or special “bathroom toy” to play with only while he or she is on the toilet. It is important for the child to sit long enough to evacuate all the feces. It is also imperative that the child’s feet be firmly planted on the floor or a stool to aid in expelling feces, and that the toilet seat be comfortable. The requirement of sitting should be handled in a matter-of-fact way, and this should be practiced on a regular basis. As regularity increases, the sitting times will naturally move to the times when the child gets the urge to defecate. If the child is successful in defecating ½ cup or more of feces, then he or she does not have to sit after the next meal. Keeping a chart in the bathroom is a good way to record sitting on the toilet and successful defecation (see Figure 4.9). A star for each time the child complies with the routine, and fancy stickers for successful defecation, are good reinforcers for young children. For older children, a chart system (see Chapter 12, Figure 12.1) can be used, with points exchanged for rewards at a later time.

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A clean pants check should be instituted one to three times per day, depending on the nature of the child’s problem. Times should be chosen that allow for consistent checks—for example, after school, after dinner, or at bedtime. At this time the child should be asked to show the parent his or her underpants (this can most easily be accomplished by having the child change his or her underpants). If they are clean, a small reward (or points) should be given, as well as praise (e.g., the parent can tell the child how good he or she smells or how nice it must feel to be clean). If the underpants are soiled, the child should be required to rinse and wash them. The child should undress and wash off, standing in the bathtub; put on clean underpants and outer clothing; and then sit on the toilet for 5 minutes. This should be seen as a natural consequence of soiling and handled in a matter-of-fact way, with little or no talking. Diet and Exercise. Diet and exercise increase the likelihood of a healthy GI system, with regular and easily produced bowel movements. These factors should be discussed, along with a plan to implement the appropriate changes. The diet should be low in milk products and in foods containing large amounts of refined sugars, as these foods can promote retention and constipation. Dairy intake should be limited to about 16 ounces of milk or the equivalent per day. A balanced diet—one with a variety of vegetables, fruits, whole wheat breads, fats, and at least 6–8 glasses of water or juice—is optimal for normal bowel movements. Table 4.1 provides a list of foods and fiber point ratings (Houts & Peterson, 1986), as well as suggestions for food preparation. Points are assigned for each consumed normal portion (8 ounces or 1 cup). Stark et al. (1997) recommend 10–20 grams of fiber per day for children 2–6 years of age and 20–30 grams per day for children 7–12 years of age. Houts, Mellon, and Whelan (1988) also recommend that points be assigned for consuming water in one sitting, according to the following schedule: 8 ounces = 1 point, 12 ounces = 2 points, and 16 ounces = 3 points. This increase in water consumption is based on the observation that the combination of fiber and water is what promotes bowel movements. Points are substracted for consumption of milk products and foods containing large amounts of refined sugar (Houts & Peterson, 1986). The value of eating meals at a regular time and in a calm atmosphere, as well as the need for regular exercise, should be emphasized. The child should be engaged in some physical activity (e.g., bike riding, sports, walking) for at least an hour each day. Intervention with the Parents Parents will need not only information, but assistance in carrying out the program. Giving the parents data collection forms, helping them develop charts and reward systems, and keeping in regular contact with the parents and child will ensure the much-needed consistency in carrying out the program. In some cases, we have had parents mail in the data forms once a week, and then we call them at a set time to review the program and answer questions or concerns. For other families, we have found it necessary for the child and the parents to bring their data to the clinic for a more personal review. Intervention in the Environment The environment should be conducive to acquiring good toilet habits. All toileting activities should occur in a bathroom that is readily accessible to the child. Toileting charts and rewards should also be kept in the bathroom. Clothing should be easy to undo and remove. There should be time in the regular schedule for the child to use the toilet without feeling rushed.

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TABLE 4.1. High-Fiber Diet Food (normal serving)

Fiber point rating

Food (normal serving)

Fiber point rating

All-Bran (cereal) Bran Buds (cereal) Bran Flakes (cereal)

7

Carrots Celery Brussels sprouts Kidney beans Corn (canned or fresh) Peanut butter Cabbage Tossed salad (lettuce) Oatmeal pancakes

Raisin Bran (cereal) 40% Bran (cereal) Cracklin’ Bran (cereal) Most (cereal) Corn Bran (cereal) Honey Bran (cereal) Bran Chex (cereal)

6

Whole wheat, rye, or pumpernickel bread (1 slice) Baked potato Rutabaga Sauerkraut Lipton minestrone soup Sunflower seeds (½ cup) Potato chips (at least 10) Raw spinach

Total (cereal) Fruit and Fiber (cereal) Baked beans Nutri-Grain (cereal) Peas Brown rice

5

Apple (with skin) Turnips Pear (with skin) Popcorn Banana Squash Green beans

1

Shredded Wheat (cereal) Parsnips Sweet potatoes Broccoli Nuts (at least 10) Whole wheat spaghetti

4

More than 20 ounces of milk per day More than 2 cookies per day Cake Saltine crackers Ice cream

–1

Water consumed at one sitting 8 ounces 12 ounces 16 ounces

3

2

Points 1 2 3

Miscellaneous notes 1. Child should be encouraged to increase his or her point total each week. Rewards can be given for an increase in the number of points earned. 2. Honey and prunes have a chemical laxative effect. 3. Sufficient fluids (six to eight glasses per day), particularly water, help keep stools from becoming hard and dry. 4. Fats (butter, margarine, fried foods) aid the intestines in the evacuation of stool. 5. Give a balance of high-fiber foods and fats at each meal. 6. If mineral oil has been recommended, mix it in orange juice in a blender, then add soda water or 7-Up to it. It may also be mixed with any juice or canned fruit in heavy syrup to make it more palatable.

(cont.)

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TABLE 4.1. (cont.) Food preparation ideas 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Tossed salads. Carrot, celery, green pepper sticks, raw cauliflower—may be dipped into salad dressing. Celery with chunky peanut butter. Stewed prunes with honey. Stewed dried fruit with honey. Bran muffins with prunes or raisins served with honey. Homemade whole wheat bread with bran. Glass of warm liquid with breakfast (example: apple juice with a cinnamon stick). Fresh Horizon Bread (or other high-fiber bread) with butter and honey. Add soda water or 7-Up to any juice. Substitute whole wheat flour for white flour in baking cookies. Add ¼ to ½ cup of bran, cracked wheat, or wheat germ to cookies when baking. Add diced, dried fruit like prunes. 12. Cole slaw. 13. Popcorn. Note. Adapted from Houts and Peterson (1986). Copyright 1986 by Plenum Publishers. Adapted by permission.

Changing the Consequences of the Behavior Changing the consequences for the child’s appropriate and inappropriate behavior is usually necessary in a family with an encopretic child. The preceding sections have suggested ways to reward appropriate behavior. It is important, however, that the clinician take the time to find out what are acceptable rewards and punishments for a particular child and family, and to help them to implement these consequences effectively. The child’s attempts at training should be praised, as well as successes. Praise should not be effusive or unwarranted, and expressions of displeasure should be mild. The clinician’s frequent contact with the family can be not only supportive to the parents, but also reinforcing to both the child and the parents. Children almost always respond well to written feedback from the clinician, and we use it for cases that are particularly difficult or have long-standing problems with encopresis. The following is an example of written feedback: Dear Steve, Good work! Your latest charts tell me that you are working very hard to keep clean pants and to have bowel movements every day. Last week you only needed one suppository and no enemas! Wow! It is also good that you are eating such healthy foods and riding your bicycle or playing basketball every day. Remember that healthy food, six to eight glasses of water a day, and daily exercise will keep your body in good shape. I liked the drawing of you and your dad playing basketball. It looked like you were getting lots of points! I’ve enclosed some basketball stickers that I thought that you might like. Keep up the good work! Sincerely, Dr. Schroeder

After treatment, we recommend that cases of rententive encopresis be followed by phone on a monthly or bimonthly basis for a year. This helps prevent relapses or ensures that relapses are immediately treated.

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Nonretentive Encopresis Nonretentive encopresis is usually either a problem with poor or incomplete toilet training or a diarrheic problem Poor Toilet Training If the child is poorly trained, then focusing on teaching the child appropriate toileting skills is important (see “Development of Toileting Skills” in the treatment protocol for retentive encopresis). A glycerine suppository may be used to help establish a regular schedule and then faded as the child is able to have bowel movements independently at the specified time (Christophersen & Purvis, 2001). Careful charting of bowel movements (see Figure 4.11) is important, as well as a system for rewarding bowel movements in the toilet and consequences for soiling. Depending on the severity of the problem, a response cost system may also be used for accidents. Working with parents on noncompliance or management issues can be helpful with these cases, as can encouraging them to establish regular daily routines for the family. Diarrheic Encopresis A treatment protocol for diarrheic encopresis should include the following elements. Information Sharing. If the child is diarrheic or has irritable bowel syndrome, parents should be given information on the GI system (Figure 4.7) and told that the digestive system responds to stress in particular ways, that each child’s response is unique, and that the goal of treatment is to help the body respond in a way that decreases the likelihood of diarrhea. Intervention with the Child. The child’s physician should be consulted to determine whether antidiarrhea medications or diet modifications may be helpful. The importance of good toileting habits should be stressed, especially regular times for sitting (with charts and rewards for this behavior). Anxiety and stress play an important role in diarrheic encopresis. Reducing stress and increasing coping skills are important parts of the treatment (Walker, 1995). Both the child and the parents will need support in learning to identify stressors and to handle them more effectively. Stress reduction techniques should be chosen on the basis of the stressors that the child encounters, the age of the child, and other individual characteristics. Techniques that can be used include systematic desensitization, relaxation training, stress inoculation training, or assertiveness training. Intervention with the Parents. Problems with child compliance or management techniques should be addressed with the parents and treated concurrently with the treatment for the diarrhea. Marital/couple or family therapy should be considered if problems are found in those areas. Intervention in the Environment. It is important to have ongoing data collection regarding the possible setting events for a diarrheic episode and the consequences of the episode. This helps provide information on the potential targets for treatment. It is particularly important that daily routines for eating, sleeping, exercise, and play be followed with the least amount of disruption to the schedule.

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Changing the Consequences of the Behavior. Although reinforcement should be given for appropriate toileting, the focus should be on the importance of learning to use more appropriate skills to deal with anxieties and stresses. In addition, children should not be punished for diarrheic episodes, although they should be expected to help clean their clothing and themselves and to sit on the toilet after such episodes.

Manipulative Encopresis Manipulative encopresis is a relatively rare problem, and is usually the result of a combination of family and child behavior or emotional problems. Thus a combination of approaches must be taken to resolve it. Intervention with the Child A child who soils to manipulate the environment will need further evaluation for other behavior problems or disorders (such as ODD), as well as an assessment of the parent–child relationship and family problems. Proper toileting habits will also have to be instituted (see the treatment protocol for retentive encopresis). Intervention with the Parents Depending on the age of the child and environmental circumstances, a combination of parent–child interaction therapy to improve the parent–child relationship, behavior techniques to deal with child management issues, and family therapy to deal with communication issues may be needed to help the child learn better coping skills. These problems may have to be dealt with prior to focusing on the toileting problems. Intervention in the Environment It is particularly important for the family to have a consistent daily schedule including routines for eating, exercise, bed, and special time with the child and/or family. Family members may need help in determining how to prioritize and implement these important routines into their schedules. Changing the Consequences of the Behavior The parents should be taught consistent behavior management skills that change the reinforcers for inappropriate toileting to reinforcers for appropriate toileting habits. The parents should also provide the child with opportunities to be reinforced for successes at school, with friends, and in the family functioning.

CASE EXAMPLE: ENCOPRESIS Step 1: Initial Contact Mrs. Potter called about her 8-year-old son, Mark, who was soiling his pants one or two times a day. He had not had a physical examination within the last year, but previous medical exams had indicated that there was no physiological basis for his soiling. Mrs. Potter was referred back

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to the physician for an updated physical, and permission to contact the pediatrician was obtained. Each parent was asked to complete checklists to rule out emotional and behavioral problems (the CBCL, the ECBI, and the PSI); together, they completed the General Parent Questionnaire, a 3-day diet and exercise record (Figure 4.10), and a 7-day record of soiling that included how they handled these incidents (Figure 4.9). The General Parent Questionnaire indicated a middle-class family, with both parents in their late 40s. Mr. Potter was a supervisor at a local department store. Mrs. Potter was a former teacher who was currently a full-time homemaker. Mark was the only child of this marriage, which was the second for both parents. There were two half-siblings from the mother’s previous marriage and three from the father’s, none of whom were living in the home. The parents also indicated that although Mark was capable of achieving in school, he rarely completed his in-class work and often forgot his homework. The mother indicated that Mark’s soiling was due to laziness and not wanting to take the time to go to the bathroom. Mr. Potter felt that Mark was just slow in learning good toileting habits. The parents’ responses to the rating scales differed dramatically in a number of areas. On the ECBI, both mother and father had Intensity scores between 160 and 170, indicating that Mark engaged in many noncompliant and disruptive behaviors at a high frequency. The Problem scores, however, indicated that Mrs. Potter perceived significantly more of these behaviors as problematic (Problem score = 22) than Mr. Potter (Problem score = 6). On the CBCL, both parents indicated that Mark had only a few friends in the neighborhood; he had few chores at home, but was involved in organized sports activities in the community. Both parents rated Mark above the 98th percentile on Somatic Complaints and within the normal range on all other scales. The PSI described Mark as neither easy nor difficult; he was acceptable to both parents, but more reinforcing to the father than the mother. Mrs. Potter also had high scores (indicating problems) on the Social Isolation, Health Problems (she mentioned sleep difficulties and headaches), and Relationship with Spouse scales. Her total stress score was also very high. The father’s responses placed him within the average range on all scales, with the exception of Relationship with Spouse. The 3-day diet and exercise record indicated low levels of fiber intake, as well as high intake of refined sugar and milk products. Exercise was limited to organized sports three times a week. The 7-day record of soiling indicated that whereas Mark had small paste-like soiling one or two times a day, he had large bowel movements in his pants about once a week.

Step 2: Parent and Child Interviews Mr. and Mrs. Potter and Mark came together for this interview. The parents presented as nervous, older parents who generally appeared unhappy. Although they described Mark as a very noncompliant child, they said the reason they came for help at this time was because of complaints from Mark’s teacher about his odor. Moreover, other children were starting to tease him, and the parents were beginning to have conflicts over handling the problem. Mr. Potter felt that his wife’s nagging and pressuring Mark about his soiling were making it worse, and that if she would just leave him alone it would go away. Mr. Potter admitted, however, that he felt the soiling was interfering with Mark’s social development, as well as being an annoyance for him and for Mark. Mrs. Potter stated that Mark had essentially toilet-trained himself for urine by age 4, although he still had accidents about once a month and had never been dry at night. Bowel training had never been fully accomplished. The soiling was described as an ongoing problem, and no

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particular stressful events had occurred that might have precipitated it. The parents had tried rewards (e.g., giving Mark a new watch if he was clean for a month), spanking, and threatening to remove privileges (e.g., not allowing Mark to go to the mall, not letting him watch TV for a week, etc.). When Mark complained of stomachaches and appeared constipated, they had also used enemas at the suggestion of their pediatrician. Currently, they were making Mark change his clothes when he smelled bad, and they had sent extra clothes to be kept at the school. Mrs. Potter, as a former teacher, was quite embarrassed about Mark’s soiling at school. The daily routine at home was chaotic. Mrs. Potter got up after Mr. Potter and Mark had left in the morning. Mark ate separate meals in front of the TV. His bedtime varied considerably from night to night, and he had no regular responsibilities or chores at home. Mark appeared as a pleasant youngster who was rather lethargic and generally uninterested in the discussion. He denied any concern about soiling or feeling bad about being teased. He did, however, indicate (although rather unenthusiastically) that he would be willing to work with the psychologist to resolve the problem.

Step 3: Observation of Behavior The parent–child interaction was quite warm and reinforcing. Mark frequently asked them to look at a Legos construction and drawing that he worked on as the clinician and parents talked. Mrs. Potter, however, asked Mark many questions for which an answer was not expected, and made many requests to which Mark did not have an opportunity to comply. He seemed to tune out the mother’s demands until she raised her voice, signaling “Now is the time to listen.”

Step 4: Further Evaluation The parents were seen both individually and together to further explore marital issues and management skills. The marriage problems all focused on disagreement about handling Mark, and although there did not appear to be many parents-alone activities, both parents seemed content with their life together. Mrs. Potter felt stressed by the care of a young child, stating that she had few friends with children Mark’s age, felt uncomfortable with the younger mothers, and therefore had decreased her social activities. Mark’s teacher was contacted to discuss soiling at school, and she was asked to complete the CBCL—Teacher’s Report Form (Achenbach, 1991b) and Teacher Questionnaire (see Appendix B). Mark was also observed during a group activity, individual seatwork, and recess at school. The teacher described Mark as a quiet, generally compliant child (he did not always tune in to general directions given to the class), who was not actively disliked by other children but preferred to play alone. Although there was some teasing, she did not feel this was a major problem. She had him change clothes and wash himself at the first sign of soiling. Observations of Mark at school found a child who was quiet but participated in the group activity; was drawing instead of doing his schoolwork during individual seatwork time; and wandered around the playground at recess, but readily complied when invited to join a game.

Step 5: Referral to Allied Health Professionals A medical examination was completed prior to the initial interview. The pediatrician found Mark to be chronically constipated and recommended a course of treatment with enemas to cleanse the bowel. He also agreed to work with the psychologist in managing the problem.

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Step 6: Communication of Findings and Treatment Recommendations Following the assessment, the following information was shared with Mark and his parents. Mark was a youngster who had never learned appropriate toileting habits, had a poor diet, engaged in little exercise, and lived in an environment that provided little structure for a normal daily routine. The parents’ management skills were inconsistent at best. They provided few clear signals as to their expectations, and although threats were liberally used, they were rarely enforced. Mark appeared capable of engaging in expected developmental activities (schoolwork, personal hygiene, and social relationships), but he did not engage in any of these activities on a consistent basis. His encopresis was seen as due to long-standing, chronic constipation, which in turn was a result of poor toilet training, poor diet, lack of exercise, and inconsistent management. Treatment recommendations included sharing information about the physiology of constipation; medical intervention using enemas, suppositories, and mineral oil; diet changes; teaching good toileting habits; increasing Mark’s daily exercise; establishing a daily family routine; and parent training in management skills. The parents accepted these treatment strategies, and they were implemented simultaneously.

Course of Treatment The physician initially elected to cleanse the bowel with enemas and to try a course of treatment with mineral oil, coupled with regular times for sitting on the toilet. After 3 weeks, it was evident that this was not enough for Mark to have bowel movements on a daily basis without soiling accidents throughout the day. Thus the Wright and Walker (1976) treatment program, which ensures daily bowel movements through the systematic use of suppositories and enemas, was begun. A high-fiber diet and daily exercise (riding his bicycle, swimming with Mom, shooting baskets with Dad) were recommended as lifestyle changes. Mark was initially rewarded every day; he earned 25 cents for clean pants and 50 cents for independent bowel movements. This was gradually faded into a weekly allowance. During the first week of this program, an enema was used on 3 days, suppositories alone were used on 3 days, and Mark had a bowel movement on his own one day. During the second week only one enema and three suppositories were necessary, and Mark had 4 days of independent toileting. By the fourth week, Mark was having bowel movements every morning after breakfast without the use of suppositories or enemas. Parent training quickly brought about increased compliance and better listening skills on Mark’s part. It was strongly recommended that Mrs. Potter increase her social activities, and that she and Mr. Potter do more things as a couple. This case was followed through telephone contacts for 1 year following the completion of treatment. The parents indicated that they were not always as consistent as they should be, but generally things were going very well. On vacations Mark’s bowel movements tended to become less regular, but with the reinstitution of the normal daily routines, the problem was easily resolved. The parents and teacher reported that Mark was more energetic, had increased social interactions, was more independent, and seemed happier.

CHAPTER 5

Habits and Tics

I

n the course of growing up, most children will display at least one fixed repetitive behavior that is not always under voluntary control, called a “habit” or “tic.” For most children, these behaviors are responses to temporary physical or emotional needs and seem to help them cope with normal everyday stresses. They typically appear and disappear during the normal course of development. Almost all children, for example, are observed sucking their fists within an hour after birth, then primarily after a feeding. By the preschool years, however, most children suck only at bedtime. Similarly, the use of a transitional object (e.g., a blanket, teddy bear, or doll) increases after age 2, at just about the time when separation and individuation issues peak, whereas the need for these objects begins to decrease after the preschool years. Body rocking peaks between 9 and 17 months, when children begin to sleep for longer periods of time, but it is usually gone by 2 to 3 years of age. Similiarly, head banging peaks between 12 and 17 months. Movement tics (e.g., blinking, shoulder shrugs, etc.) become evident between 6 and 8 years of age, when demands to “sit still and learn” increase; however, these tics also diminish rather quickly for most children. “Old” habits may reappear with new stresses, such as the birth of a sibling, parental divorce, going to a new school, or the prolonged absence of a parent. Some children “hang on” to a particular habit for no apparent reason, and over time it becomes an automatic, involuntary response. These behaviors or habits are not usually symptomatic of underlying pathology, and only become problems under certain circumstances: (1) The behavior continues longer than is typical; (2) the behavior becomes severe or chronic enough to cause physical damage; and/or (3) the behavior is engaged in so frequently that it interferes with ongoing physical, social, and/or cognitive development. This chapter reviews a number of habits that have been known to create problems for children or their families, including oral habits (thumb sucking, nail biting, bruxism, etc.), hair pulling, and other behaviors (such as rituals and breath holding). Motor and vocal tics are most often transient problems; however, they can persist and/or be indicative of a more serious problem, Tourette’s disorder (TD), and thus are reviewed in some depth.

ORAL HABITS Thumb Sucking Thumb sucking (which can actually include sucking the thumbs, fingers, fists, or a pacifier) is a common behavior among children; there is evidence that some children begin to suck while 159

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in the womb! For others, 20% begin sucking their thumbs between 3 and 5 months of age, and 15% begin between 6 and 9 months of age. Only 10% begin sucking their thumbs after 9 months of age. The incidence of thumb sucking decreases with age, from 45% of all 2-year-olds to 21% of 6-year-olds and approximately 5% of 11-year-olds (Foster, 1998; Matthews, Matthews, & Leibowitz, 2001; Troster, 1994). Thus thumb sucking spontaneously remitts at the rate of approximately 5–10% per year. By age 2, sucking is primarily associated with hunger, sleep, frustration, or fatigue. By age 2½ to 3 years, it usually occurs only at night and is often associated with the use of transitional objects or with some other behavior, such as twisting or pulling the hair or ear, rubbing a cheek, or sucking on a blanket (Matthews et al., 2001). If thumb sucking occurs during the day, it is usually associated with some relaxing activity, such as watching television or listening to a story. By 5 years, most children suck their thumbs only while asleep. With the advent of pacifiers, many children prefer this method of sucking; for purposes of this discussion, sucking a pacifier is considered with the more “natural” thumb sucking. There are a number of views on the etiology of thumb sucking, including pleasurable associations with feeding, a conditioned response to tension reduction, erotic gratification, and excessive breast or bottle feeding. There is little empirical evidence to support most of these hypotheses, however (Matthews et al., 2001). Furthermore, it is clear that children who suck their thumbs do not have increased behavioral or emotional problems (Friman, Larzelere, & Finney, 1994). Actually, there appears to be some value connected to early thumb sucking: It decreases crying, makes teething easier, helps a child get to sleep, and generally acts to soothe the child. Unless it is so chronic that it interferes with the child’s involvement in other activities, thumb sucking is not viewed as a problem until dental concerns arise, usually between 4 and 6 years of age. Dental concerns include an anterior open bite, malocclusions, narrowing of the dental arches, gingivitis, and digital deformities (Brenchley, 1991). Other concerns for older children who persist in thumb sucking include an impact on their social standing with peers, who may view them as less intelligent, happy, attractive, likable, and desirable as friends (Friman, McPherson, Warzak, & Evans, 1993). Moreover, some parents find thumb sucking very annoying or offensive and can make it into a problem through negative attention. Thus concerns about thumb sucking are dependent on the severity and chronicity of the habit, as well as its effects on the parents, the child’s social acceptance, and the child’s oral structure and fingers. Several behavioral treatments have been demonstrated to be very successful in treating thumb sucking. Habit reversal is one such method (Azrin, Nunn, & Franz-Renshaw, 1980; Christensen & Sanders, 1987) and is discussed in detail later in this chapter. The effective use of a bad-tasting substance and a reward system to treat chronic diurnal and nocturnal thumb sucking was demonstrated by Friman and Leibowitz (1990) with 22 children ages 4–11. Parents coated their children’s thumbnails or fingernails with a commercially available substance, Stop-zit,1 in the morning when the children awoke, each time thumb sucking was observed during the day, and once just before bed. The reward system consisted of a grab bag with 50– 100 slips of paper on which parents had written a variety of tangible and intangible rewards (e.g., nutritious snacks, privileges, special time with parents, etc.) By 3 months, 12 children had stopped thumb sucking; after 1 year, 20 of the 22 children had ceased all thumb sucking. The parents rated the treatment as very acceptable. In previous work, Friman and colleagues 1Stop-zit

is marketed by Purepac Pharmaceutical Co. and can be purchased over the counter at most drug stores.

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(Friman, Barone, & Christophersen, 1986; Friman & Hove, 1987) have shown that although the aversive-tasting treatment alone is sufficient to reduce the thumb sucking, rewards for not sucking are important because of their positive effect on treatment acceptance. Many parents help their children give up thumb sucking by removing an associated object. Friman (1988) demonstrated the success of this approach to decreasing thumb sucking in a single-subject design by preventing the covarying response of doll holding. When the child was sucking her thumb, she always held a crocheted doll in the opposite hand. When the doll was removed (the child was told that she had outgrown it), the thumb sucking stopped almost immediately. When the doll was reintroduced, the thumb sucking increased to baseline, but after 3 days the child angrily told her parents that she was too old for the doll and no longer wanted it! All thumb sucking stopped. The use of an oral pacifier has been reduced by a variety of techniques, including simply removing the pacifier, allowing it to be used only at certain times and places, putting an aversive-tasting substance on the pacifier, and gradually decreasing the size and form of the nipple by trimming it back (McReynolds, 1972). A commonly used dental treatment for thumb sucking is an intraoral device called a “palatal crib with spurs.” With this device, insertion of the thumb in the mouth is difficult and painful. Treatment results, particularly if the device is in place for at least 6 months, are good; however, some authors also note the potential negative side effects of emotional problems and difficulties in eating and speech (Hargett, Hansen, & Davidson, 1970; Wehbe, 1982). Given these problems, dentists and most parents are understandably reluctant to use this treatment except as a last resort. In a less intrusive approach, Watson and Allen (1993) prevented thumb sucking in a 5-year-old girl by attaching a post to the child’s thumb to disrupt the tactile–kinesthetic stimulation of the thumb’s contacting the palate, which was thought to be reinforcing. The post was not painful on the thumb or in the mouth, but simply prevented the thumb’s contact with the palate. The child discontinued thumb sucking, as well as the hair pulling that covaried with the thumb sucking.

Nail Biting Nail biting (biting on or chewing the nails), and the often associated behavior of picking at nails or cuticles with fingers, are common habits of children. Parents report that 25% of children between the ages of approximtely 2½ years and 6 years bite their nails (Foster, 1998). At about age 6 there is a marked increase in nail biting, which peaks in adolescence at 45%, and then decreases to a rate of about 4.5% in adults (Peterson, Campise, & Azrin, 1994). Nail biting is primarily viewed as a learned behavior that reduces anxiety or tension or occurs when a child is trying to concentrate; it is most pronounced during periods of stress (Carson, Butcher, & Mineka, 1998). There does appear to be a familial and/or genetic component to nail biting, however, with up to two-thirds of monozygotic twins and one-third of dizygotic twins found to be concordant for nail biting (Bakwin & Bakwin, 1972). In addition to the obvious cosmetic problems, nail biting can lead to scarring and infection of the nail bed and/or cuticles; it can also create dental problems, such as the shortening of tooth roots due to excessive pressure (Peterson et al., 1994). Many behavioral approaches have been tried to treat nail biting. Habit reversal, with its emphasis on self-awareness and a competing behavior (making a fist or clenching an object), is the most effective treatment; it eliminates nail biting in 40% of cases and significantly reduces

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it (by 50% or more) in 84% of cases (Peterson et al., 1994). Although the competing response appears to be the most important treatment component in habit reversal, the best outcomes occur when the entire habit reversal program is employed (Azrin & Nunn, 1977; Azrin, Nunn, & Frantz, 1980). Other approaches to eliminating nail biting and their success rates are as follows: self-monitoring alone (15%), bitter-tasting substances (15%), competing responses alone (40–57%), and negative practice (15%) (Peterson et al., 1994).

Bruxism Bruxism involves nonfunctional contact of the teeth, such as diurnal and nocturnal grinding of the teeth, teeth clenching, gnashing, tapping, and other destructive oral habits. (Nocturnal bruxism in particular is discussed in Chapter 6.) The most common behaviors are grinding and clenching the teeth. If severe, bruxism can cause irregular and premature wear on the teeth, malocclusion, and facial damage, especially to the temporomandibular joint (Glaros & Epkins, 1995). Prevalence rates for bruxism vary from 7% to 88%, depending on how it is defined (Peterson et al., 1994). Bruxism can occur as soon as the teeth erupt, but is most frequent (15% of children) between 3 and 17 years, decreasing to 4.5% in adults. The ratio of girls to boys with bruxism is approximately 3:1 (Reding, Rubright, & Zimmerman, 1966). In addition to stress, a variety of factors may be significant in the etiology of bruxism: (1) nutritional deficiencies; (2) histamine release associated with allergies, colds, or stress; (3) hyperthyroidism; (4) neurological conditions, such as cerebral palsy and mental retardation; (5) juvenile rheumatoid arthritis; and (6) medications such as amphetamines and their derivatives (Glaros & Epkins, 1995). Bruxism does not appear to be associated with emotional or behavioral problems. The initial diagnosis of bruxism is usually made by a dentist. Effective treatments have included protective dental devices or splints, nocturnal biofeedback and the full habit reversal procedure (Peterson et al., 1994). Relapse after treatment ends is a common problem with all these approaches, however.

Other Oral Habits Other oral habits (e.g., lip picking, lip biting, lip licking, tongue sucking, tongue biting, sucking the roof of the mouth, and cheek biting) are primarily problems with children or adults who are developmentally disabled. People with Lesch–Nyhan syndrome, for example, are known to mutilate parts of their bodies (including their tongues, lips, and oral cavities) by biting. For children and adults who are developing normally, the habit reversal procedure has been demonstrated to be effective. Azrin, Nunn, and Frantz-Renshaw (1982), for example, used habit reversal successfully to treat a 9-year-old-boy who pushed and flicked his tongue on his upper teeth and the roof of his mouth while making audible flicking noises. The competing responses were clenching the teeth lightly, pressing the tongue lightly on the roof of the mouth, and keeping the lips closed. In an innovative treatment program for a bright 12-year-old boy who engaged in mutilating lip biting and face wiping on his sleeve, Lyon (1983) used tracking (selfrecording with a knitting counter), response substitution (dabbing Vaseline on lips in place of biting lips), response prevention (sandpaper attached to the wrist to deter face wiping), and relaxation training to reduce the behaviors to zero in 5 weeks and over a 7-month follow-up period.

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TRICHOTILLOMANIA Trichotillomania (TTM) is chronic hair pulling that results in baldness. Although it usually involves pulling hair from the head, hair can be plucked from eyebrows, eyelashes, and the pubic region, as well as arms, legs, and arm pits (Risch & Ferguson, 1981). In assessing TTM, it is important to rule out other factors that can cause hair loss, such as vigorous brushing, tight braids, eczema with resultant rubbing, seborrhea, and fungal infections. Alopecia areata, a disorder found in children, results in nonscarring sudden loss of hair in smooth single or multiple spots about the size of a nickel. The etiology of noninflammatory alopecia areata is unknown, but it has been shown to develop a few weeks after a severe emotional trauma (Owen & Fliegelman, 1978). TTM is easily distinguishable from alopecia areata because it presents as inflamed areas with missing and broken hair, mixed with hair that is intact with normal hair follicles. Some children mouth and/or swallow the hair, creating “hairballs” that form in the stomach and can cause significant gastrointestinal difficulties. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association [APA], 1994) lists TTM as an impulse control disorder. Criteria for its diagnosis include (1) recurrent plucking of hair that results in obvious hair loss; (2) a rising sense of tension immediately before plucking the hair or during efforts to resist the behavior; (3) gratification, pleasure, or relief when plucking the hair; (4) inability to account for the problem by another mental disorder or a medical condition; and (5) resulting clinically significant distress or impairment in the person’s level of functioning. Serious questions have been raised about whether TTM should be described as an impulse control disorder, which groups it with such serious antisocial conditions as kleptomania, pathological gambling, pyromania, and intermittent explosive disorder! Furthermore, studies indicate that younger children do not often report rising tension or an irresistible urge followed by a sense of relief; even most adolescents with this problem fail to endorse both these criteria (R. A. King et al., 1995; Reeves, Bernstein, & Christenson, 1992). Although children with TTM show subtantial numbers of comorbid problems, and have profiles similiar to those of children with obsessive– compulsive disorder (OCD), they have few obsessions or compulsions other than hair pulling (R. A. King et al., 1995). In addition, the other problems they exhibit are more in line with oppositional defiant disorder or attention-deficit/hyperactivity disorder (ADHD). Thus, although there is some evidence that TTM could be a form of OCD, there is no support that it is an impulse control disorder in children (R. A. King et al., 1995). Estimates of the prevalence of TTM vary from less than 1% in psychiatric populations (Mannino & Delgado, 1969) to about 3% in the general population (Azrin & Nunn, 1977). The disorder generally appears between 1½ and 5 years of age (Friman, Finney, & Christophersen, 1984; Swedo & Rapoport, 1991). Frequency of occurrence among boys and girls in this age group is similiar, with perhaps somewhat more boys than girls engaging in this behavior (Foster, 1998; Glaros & Epkins, 1995). TTM presents as a more complex and serious problem in older children and adolescents (typically starting at age 13) and can last for decades (Swedo & Rapoport, 1991). This older-onset group is primarily female. The etiology of TTM is largely unknown, with hypotheses ranging from neurotic conflict, depression, anxiety, or learned behavior to biologically determined “pathological grooming behaviors” related to OCD (R. A. King et al., 1995). Behavioral theories of etiology view TTM as an anxiety-reducing habit; for children, it seems to be a learned behavior that presents as a relatively isolated symptom, comparable to other habits such as thumb sucking

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or nail biting (Friman et al., 1984). Neuroimaging methods with adults indicate that structural or functional problems in the brain may play a part in the etiology of this disorder (O’Sullivan et al., 1997). Various behavioral treatment strategies have been used for TTM, including habit reversal, punishment, reinforcement, response cost, response prevention, negative practice, self-monitoring, overcorrection, and relaxation (Vitulano, King, Schahill, & Cohen, 1992). Although studies of treatment effectiveness have primarily involved single cases, there are enough good examples using single-subject designs to give guidelines for the treatment of this problematic behavior (see Watson & Sterling, 1998, for a review of this literature). Habit reversal is very effective in eliminating TTM (Elliott & Fuqua, 2000). As an example, the use of a competing response (fist clenching) plus relaxation was effective in treating a 17year-old female with a 14-year history of hair pulling and nail biting (DeLuca & Holborn, 1984). Other case studies have reported a relationship between finger sucking and hair pulling in preschoolers. Hair pulling was eliminated by preventing (taping the fingers) or punishing (putting a bad-tasting substance on the thumb) the finger-sucking response (Altman, Grahs, & Friman, 1982; Knell & Moore, 1988; Sanchez, 1979). Knell and Moore (1988) point out that although the temporal order of thumb sucking varied (it began before, simultaneously with, and after hair pulling) in these three studies, treatment of the thumb sucking eliminated hair pulling in all cases. In another example, Watson and Allen (1993) treated a 5-year-old girl with a 3-year history of severe TTM, which was observed to covary with thumb sucking. Previous failed treatment had included punishment (i.e., spanking and taking away toys), response prevention (i.e., shaving her head, taping socks and mittens over her hands), and rewards (i.e., offering rewards for not sucking her thumb or pulling her hair). In a multiple-baseline study, Watson and Allen used an aversive solution on the thumb, an alarm system to disrupt the sucking, and a circumferential thumb post designed by an occupational therapist (Allen, Flegel, & Watson, 1992) to prevent thumb sucking. The most effective and acceptable treatment (for the mother) was the thumb post, which completely eliminated the thumb sucking and the TTM over a 30-month follow-up period. In another example of successful treatment of TTM, Dahlquist and Kalfus (1984) used praise, ignoring hair loss, education in hair hygiene, response prevention at night (mittens), and a variable schedule of material rewards to stop hair pulling in a 9-year-old girl who denied pulling out her hair. Other studies have focused on improving the parent–child interaction, but have also used punishment or response prevention to eliminate the behavior (Altman et al., 1982; Massong, Edwards, Range-Sitton, & Hailey, 1980). Most of the successful treatments with children have involved either response prevention with positive reinforcement for not pulling out hair, or engaging in an incompatible behavior. Although various medications (e.g., clomipramine, desipramine, fluoxetine, naltraexone) have been used to reduce hair pulling in adults with mixed results, there have been no controlled trials with children (Baer, OsgoodHynes, & Minichiello, 1999).

OTHER HABITS Other habits that occasionally come to the attention of the child clinician include breath holding; rituals, sameness, and perfectionism; and head banging. Head banging is covered in Chapter 6; the others are discussed here.

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Breath Holding Breath holding consists of holding the breath for more than 30 seconds, with resultant signs of cyanosis and possible unconsciousness as an end to the attack. Episodes occur primarily when a child is frustrated and angry, with the onset reported to be as early as 6 months of age. Breath holding is most common at about the age of 2 years, and usually spontaneously disappears between the ages of 4 and 6 years, when periods of violent crying decrease (Matthews et al., 2001). It can occur as often as several times a day to as little as once a month. The etiology appears to be either a learned behavior that is inadvertently reinforced by parents or a genetic predisposition, with increased instances of breath holding seen in some families (Matthews et al., 2001). Parents should be reassured that these frightening breath-holding episodes are benign, and that they are best handled by ignoring the behavior (e.g., leaving the room) and reinforcing more compliant behavior.

Rituals, Sameness, and Perfectionism Young children engage in a significant number of rituals and compulsion-like behaviors, such as insisting on the “exact same” bedtime routine, wanting the same story read over and over, insisting that food be presented in the same way, or wearing only certain clothes, all of which appear to be part of their normal behavioral repertoires. Repetitive, compulsion-like behaviors usually begin at about 18–21 months, whereas the more perfectionistic behaviors appear at approximately 24 months. These behaviors significantly decrease after the preschool years. Prevalence studies estimate that in general 1–3% of children and adolescents are perfectionistic (Flament, Whitaker, Rapoport, Davies, & Zaremba-Berg, 1988; Rutter, Tizard, & Whitmore, 1970). Using a parent report questionnaire with 1,488 parents of 8-month-old to 6-year-old children, Evans et al. (1997) found a developmental trend, with a peak prevalence rate of over 75% of the 2- to 4-year-old children engaging in these behaviors. These data suggest that perfectionistic behavior and insistence on sameness serve some adaptive function for preschoolers. Kopp (1989), for example, argues that these behaviors serve a child’s emotional and social need to gain some sense of self-control and to regulate emotional states. Evans et al. (1997) suggest that they are similar to repetitive, fixed action behaviors found in other species, and therefore have biological or biochemical origins. Although ritualistic and perfectionistic behaviors may be annoying to parents, the best approach in dealing with them is to make reasonable accommodations to the child’s needs, recognizing that the behaviors will probably decrease with time. Given that ritualistic behaviors are very similar to those seen in OCD, an evaluation of the child may be appropriate if they persist in an overly rigid manner into the school-age years.

TICS It is important for the child clinician to be aware of the nature of childhood tics and to be alert to the potential diagnosis of Tourette’s disorder (TD). TD is typically first seen at about the age of 8 years, but it is often not diagnosed for several years after its actual onset. This section of the chapter covers the tic disorders as defined by DSM-IV (APA, 1994), with an emphasis on TD. A “tic” is a rapid, sudden, intermittent but recurring, nonrhythmic, stereotyped motor movement or vocalization that is usually involuntary. It may affect any part of the body and

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imitate any motor or vocal act. Tics are distinctly variable over time and in their frequency, complexity, intensity, location, and duration. They can vary from being virtually continuous to occurring only a few minutes in a day. The various types of tics are described in Table 5.1. It is important to note that complex tics (e.g., touching, tapping, repetitive phrasing) can be difficult to differentiate from compulsions. Many people with tics (particularly adults) indicate that they experience a sensory experience like an “itch,” which is relieved by the tic movement (Bliss, 1980; Levine & Ramirez, 1989). Although the etiology may be different, tics appear to occur on a continuum—ranging from mild transient problems such as throat clearing or eye blinking that last only 1–2 months, to the more severe and lifelong TD, with its waxing and waning of multiple motor and vocal tics. According to DSM-IV, tic disorders share a number of common characteristics: 1. Tic symptoms can be suppressed for minutes to hours and attenuated during an absorbing activity. 2. Tics can be exacerbated by stress, fatigue, or underlying medical illness. 3. Tics can be triggered by environmental stimuli. 4. Over varying periods of time, tics can wax and wane in severity and change anatomical location. 5. Tics are markedly diminished or absent during sleep. 6. The male–female ratio for tics is 3:1. 7. Vocal tics can occur in each disorder, except for the motor form of chronic motor or vocal tic disorder (see below). DSM-IV classifies tics into four groups of disorders: transient tic disorder, chronic motor or vocal tic disorder, TD, and tic disorder not otherwise specified (tics not meeting the criteria for a specific tic disorder). The first three of these are discussed below. Along with their unique features, all tic disorders share the same criteria for diagnosis: (1) causing significant impairment of social, occupational, or other important areas of functioning; (2) not being the result of another mental disorder or a medical condition; and (3) having an age of onset before 18 years. TABLE 5.1. Types of Tics Tic type

Examples

Simple motor

Blinking, grimacing, raising an eyebrow, puckering, mouth stretching, throwing head to the side, shrugging shoulder, shooting an elbow out, abdominal tensing, kicking leg out, tensing body

Complex motor

Making odd facial expressions, running chin down an arm, combing fingers through hair, stretching neck, shadow punching, picking at body, tapping, hopping, stomping, skipping when trying to walk, hitting self, slamming things, copropraxia (e.g., giving the finger)

Simple vocal

Coughing, “hawwwwk” noises, squeaking, “aaaaa,” “tttttuh,” throat clearing, “uh, uh, uh,” blowing across upper lip, popping sounds, snorting, gnashing teeth, swishing

Complex vocal

“Uh huh,” “you bet,” “all right,” “yeah,” palilalia (repeating one’s own words, phrases, sentences), swearing, obscene language of noises, racial or colloquial insults

Note. From Towbin and Cohen (1996). Copyright 1996 by John Wiley & Sons. Reprinted by permission.

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Transient and Chronic Tic Disorders Transient Tic Disorder A transient tic disorder is characterized by DSM-IV as involving single or multiple motor and/or vocal tics, occurring almost every day for at least 4 weeks and for no longer than 12 consecutive months. The most common form of transient tic is the eye blink or other facial tic, but the head or entire torso may also be involved. Given that this disorder is transient by definition, it is difficult to determine its exact prevalence, and there are no prospective longitudinal studies of epidemiological samples of children with transient tics. However, such tics are estimated to occur in 1–24% of children (Azrin & Nunn, 1977; Shapiro, Shapiro, Young, & Feinberg, 1988). Boys are affected two to three times more often than girls, with age of onset between 4 and 12 years; the typical onset is between 5 and 7 years (Berkow, 1992). In the Berkeley Growth Study, MacFarlane, Allen, and Honzik (1954) reported that 4% of the children evidenced tics, with a peak frequency reached at 6–7 years of age. A lower prevalence rate was found in the Isle of Wight Study (Rutter, Tizard, Yule, Graham, & Whitmore, 1976), but Rutter et al. set a relatively strict criterion that a tic had to be significantly interfering with the child’s life. Teachers in this study reported that 5–6% of school-age boys and 1–2% of school-age girls had “twitches.” Hence tics are not unusual in children, especially between the ages of 4 and 8 years. It is estimated that 24–61% of children presenting with tics will have complete remissions without treatment. Most of the remainder will improve, and only a small percentage will show no change or worsening of tics. Chronic Motor or Vocal Tic Disorder DSM-IV characterizes chronic motor or vocal tic disorder as either single or multiple motor or vocal tics, but not both, occurring throughout a period of more than 1 year, with no tic-free period of more than 3 consecutive months during this period. Chronic motor or vocal tics are estimated to occur in approximately 1.6% of the U.S. population (Shapiro et al., 1988). The rates for children, however, are higher. In a sample of 4,500 children ages 9, 11, and 13 years, Costello et al. (1996) found a prevalence rate of 3.5% for motor tics and <1% for vocal tics that lasted 3 or more months. Moreover, there is a gender difference for chronic tics in children, with the overall prevalence rates at 3–18% for boys and 0–11% for girls (Zohar et al., 1999). Chronic motor or vocal tic disorder is thought to be similar to but less severe than TD, with less variablity in the frequency and type of tics. Unlike children with TD, however, children with chronic motor or vocal tic disorder do not present simultaneously with both types of tics. In addition, vocal tics occur less frequently than motor tics in chronic tic disorder, whereas the opposite is true for TD. Etiology of Transient and Chronic Tic Disorders There is little agreement on the etiology of transient and chronic tic disorders. Psychodynamic theorists argue that tics represent repressed feelings or conflicts expressed in a symbolic manner (Cavenar, Spaulding, & Sullivan, 1979). Environmental etiologies include emotional tension (Bakwin & Bawkin, 1972) and serious home conflicts (Feldman & Werry, 1966). Some behavioral theorists assert that both chronic and transient tics are learned responses that are maintained by operant conditioning (Azrin & Peterson, 1988). Azrin and Nunn (1973) argue that tics may either start as normal reactions to physical or psychological trauma and continue

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long after the initial event, or originate from normal movements that over time gradually assume an unusual form and high frequency. These movements can then result in strengthening particular skeletal muscle groups and weakening the antagonistic muscles, thus making it harder to inhibit the tics. Genetic factors may also play an important role in the development of tics, as a family history of tics is found in 10–30% of all cases (Matthews et al., 2001). It also appears that some tics can be precipitated by phenothiazines, head trauma, and central nervous system stimulants (APA, 1994). Given the frequency of transient tics in children, it seems probable that tics and their phenotypic expression or severity arise from various interactions of developmental issues, genetic vulnerabilities, and life experiences. Most tics in children are not acccompanied by other disorders (Watson & Sterling, 1998). Like other habits, however, if the tics are frequent, intense, or persistent, they can result in social difficulties, as well as problems with attention or somatic complaints. Moreover, a recent longitudinal study found that childhood tics predicted symptoms of obsessive–compulsive disorder in adolescence (Peterson, Pine, Cohen, & Brook, 2001). Transient tics, which can be both motor and vocal, may initially be difficult to differentiate from TD. The duration of the tics (for more than one year), the progression to different tics, and a family history of tics should make a clinician suspect TD. It is estimated that approximately 5–24% of children with transient tic disorder will develop chronic motor tic disorder, followed by the emergence of vocal tics and a subsequent diagnosis of TD (Cohen, Riddle, & Leckman, 1992). Treatment of Transient and Chronic Tics Transient tics, by definition, will usually remitt without intervention. In children, chronic motor or vocal tics are usually the focus of treatment. Behavioral treatments have included contingency management (the use of positive reinforcement and punishment), relaxation training, self-monitoring (daily recording of tics), massed negative practice (voluntary repetition of a tic for the purpose of extinguishing it), and habit reversal instruction (the use of competing responses and other methods to prevent the occurrence of tics) (Peterson et al., 1994). In general, these treatments, especially habit reversal, have been shown to significantly reduce single or multiple chronic motor and vocal tics and have been successfully used with children (Peterson et al., 1994). See Watson and Sterling (1998) for a detailed review of the various behavioral techniques used with tics. Overall, the most rapid and long-lasting treatment for tics is habit reversal or some variation of this procedure, which reduces tics by up to 90% in the home environment and 80% in the clinic setting (Peterson et al., 1994). Habit reversal is based on the premise that tic behaviors are maintained by response chaining (linking a sequence of conditioned responses by reinforcement), limited awareness of engaging in the behavior, excessive practice, and social tolerance of the tics. Treatment using habit reversal is comprehensive and includes 10 different components. It is distinctive from the other behavioral approaches in its use of competing responses to prevent the occurrence of tics (Carr, 1995). The most frequently studied and used treatment approach for tics is massed negative practice (Yates, 1958), in which the patient deliberately performs the tic movement as quickly and with as much effort as possible for a specified period of time (e.g., 30 minutes) interspersed with brief rest periods (e.g., 4 minutes of exercise, 2 minutes of rest). This approach, however, is one of the least effective of the behavioral approaches, with decreases in tic rates of only about 50% (Peterson et al., 1994). Contigent negative practice in which the negative practice is engaged in only after the occurrence of the tic is somewhat more effective.

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Other techniques have been used to modify an emotional state (e.g., anxiety) that is thought to be mediating the tic behavior. A study by Mansdorf (1986) is a good example of the use of self-control techniques, assertiveness, and cognitive training to eliminate a series of facial tics in a 10-year-old boy. In 10 weekly sessions lasting 1 hour each, the child was taught assertive responses to heretofore threatening situations (e.g., requesting to join a group, handling teasing) and given self-instruction training in the form of positive self-statements (e.g., “I can say just what I want,” “I’m just as good as Nate,” “I’ll tell him just what I feel”). The one-to-one treatment with the child was supplemented by contact with the mother for general guidance and feedback. She was instructed to avoid criticizing the child for his tics and to reinforce ticfree behavior with praise. The treatment was successful within eight sessions, and the child remained tic-free after 1 year. Habit reversal and contingent negative practice are described in greater detail later in this chapter. Medication treatments are discussed in connection with the treatment of TD.

Tourette’s Disorder TD, or Gilles de la Tourette syndrome, was first described by Itard in 1825. Although it is one of the rarer tic disorders, it has received a great deal of attention because of its lifelong course and bizarre manifestations. Simple, nonpurposeful, rapid movements and noises are the hallmark of TD, but these symptoms convey only a partial view of this complex disorder and its clinical expression. According to DSM-IV, TD is characterized by both multiple motor and one or more vocal tics present at some time (but not necessarily concurrently). The tics occur many times a day (usually in bouts) nearly every day or intermittently for more than 1 year, with no tic-free period of more than 3 consecutive months during this period. The anatomical location, frequency, severity, and complexity of the tics change over time. Symptoms of TD can appear as early as 12 months of age, but typically begin at about 7–8 years, with onset in the majority of cases occurring before age 14 (Watson & Sterling, 1998). Retrospective studies indicate that the median age of onset for TD is 8 years, 7 months, but diagnosis is often delayed due to the erratic symptoms and the fact that transient tics are at their peak near this age (King, Leckman, Scahill, & Cohen, 1999). Although TD can be quite severe, most cases fall in the mild range. Family genetic studies provide evidence for a single dominant autosomal gene (Eapen, Pauls, & Robertson, 1993). As with the transient and chronic tic disorders, however, the morphology and timing of TD are probably the results of interactions among developmental, genetic, biological, psychological, and environmental factors (Sallee & Spratt, 1999). Estimates of the prevalence rates for TD vary from about 0.15% to 3.3%, depending on the characteristics of the population studied (Comings, Himes, & Comings, 1990; Kadesjo & Gillberg, 2000; Mason, Banerjee, Eapen, Zettin, & Robertson, 1998). Furthermore, TD is five to six times more common in boys than girls (Witelson, 1993). In about 50% of cases, the disorder starts with a single tic (most frequently eye blinking), but it can include other tics of the face or body and sniffing, barking, throat clearing, and other noises. Eventually all cases have involuntary movements and some vocal tics (Leckman & Cohen, 1999). There is some evidence for a cephalocaudal (head-to-toe) progression of tics, but this is not always the case. There also appears to be a progression of symptoms from simple motor tics to vocal tics, with coprolalia (vocalizing curse words and/or racial slurs) beginning from 3½ to 7½ years after the onset of motor tics (Comings & Comings, 1988). Unlike transient tics, the TD tics change in intensity and type, and the presence of throat clearing, grunts, or noises accompanied by arm or leg tics should raise suspicion of TD.

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The course of TD is usually lifelong, with periods of remission lasting for weeks or years. Symptoms seem to get worse through late adolescence or early adulthood, when they become less frequent and severe (Leckman & Cohen, 1988). Symptoms can be exacerbated during periods of high emotional stress and excitement, or when an individual is fatigued (Leckman, King, & Cohen, 1999). It is estimated that in one-third to one-half of cases, the severity of the tics is exacerbated by the administration of a central nervous system stimulant, and TD has been precipitated in an estimated 10% of children as a result of being given methylphenidate (Lipkin, Goldstein, & Adesman, 1994; Towbin & Cohen, 1996). Given the common use of this drug for ADHD, clinicians should be aware of this potential problem, especially if a child is anxious, exhibits minor tics, or has a family history of tics. Other risk factors for more severe symptoms of TD include pre- and perinatal insults, exposure to bacterial antigens provoking an autoimmune system response, withdrawal from neuroleptic drugs, heat exposure, and the presence of a range of comorbid psychiatric disorders (Leckman et al., 1999). Various other symptoms are associated with TD, including anxiety, depression and other internalizing disorders. In a study using the Child Behavior Checklist (CBCL) with 186 children ages 6–11 years with TD, Rosenberg, Brown, and Singer (1994) found that 45% had significantly elevated Total scores on the Internalizing scale. The percentages of these children having other elevated scores (T-score > 70) included 39%, Schizoid Anxious; 38%, Uncommunicative; 28%, Somatic Complaints; 30%, Depressed; and 26%, Social Withdrawal. Other studies using both parent and teacher reports have found similar results (e.g., Nolan, Sverd, Gadow, Sprafkin, & Ezor, 1996). Classmates of children with TD rate them as less popular and more withdrawn than their peers (Stokes, Bawden, Camfield, Backman, & Dooley, 1991). In contrast to parents’, teachers’, and peers’ ratings, children’s own self-reports reveal less psychopathology (Rosenberg et al., 1994). It is not clear why these children have so many internalizing problems, but King et al. (1999) hypothesize that premonitory urges with their feelings of mounting tension and anxiety can cause more distress than the tic itself. In addition, children with TD have trouble modulating their anxiety, arousal, and mood; this is problematic, since tics are exacerbated by stress, anxiety, and pleasurable excitement. From 10% to 40% of patients with TD report obsessional thoughts and exhibit compulsive behaviors and rituals (Towbin, 1988). Family interview data support the hypothesis that tic disorders and some forms of OCD are linked etiologically (Pauls & Leckman, 1986). There are also data to support a sex-influenced autosomal dominant mode of inheritance, with variable expressivity as either TD, chronic motor tic disorder, or OCD (Kurlan et al., 1986). It is difficult to determine which cases of TD will be linked with OCD, however. The co-occurrence of OCD among children with TD is less than that among adults (Frankel et al., 1986; Grad, Pelcovitz, Olson, Matthews, & Grad, 1987). It is estimated that from 40% to 90% of all patients with tic disorders have characteristics of ADHD (Kadesjo & Gillberg, 2000; Walkup et al., 1999). Some argue that ADHD is a component of tic disorders, with the ADHD symptoms preceding the onset of motor or vocal tics by 2–3 years (Walkup et al., 1999). Others view ADHD as a comorbid condition that complicates the course and management of the tic disorders, as well as the treatment of ADHD (Pauls et al., 1986). In any case, ADHD makes children with TD even more vulnerable to the stresses of development and societal expectations. Although stimulant medication is a primary treatment for ADHD, it can be problematic with comorbid TD. Gadow, Sverd, and Nolan (1992) found that stimulant medication exacerbated tics in 20–30% of children with TD, while another 10–20% experienced a decrease in tics. Others have found that low doses of methylphenidate have improved the ADHD symptoms without significantly increasing the tics (Castellanos & Rapoport,

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1993; Konkol, Fischer, & Newby, 1990). The benefits and risks of using stimulant medications for children with TD and comorbid ADHD obviously have to be carefully weighed for each child. Others have advocated a more conservative approach that focuses on changing the environment and specific behaviors (Towbin, Riddle, Leckman, Bruun, & Cohen, 1988). Children with TD are at high risk for educational problems, which is not surprising, given the primary problems implicit in the disorder itself. The potential indirect effects of impaired attention, behavioral problems, and problems with adjustment and acceptance by peers all set the stage for learning problems. In a retrospective chart review of 138 children with TD, Walkup et al. (1999) estimated that 38% experienced school difficulties or special education placement. In addition, another 22% were diagnosed with a specific learning disability (Abwender et al., 1996). Data from this and other studies indicate that learning disabilities and ADHD are strongly associated in children with TD, with math and written language skills the most likely areas of weakness. In addition, there is evidence that children with TD have significant problems in visual–motor integration and fine motor coordination (Schultz, Carter, Scahill, & Leckman, 1999). Children with TD also have a greater incidence of behavioral problems than other populations (Walkup, Rosenberg, Brown, & Singer, 1992). Diminished frustration tolerance, argumentativeness, mood lability, and periods of extreme temper or aggressive behaviors are reported to occur more frequently in children with TD (Riddle, Hardin, Ort, Leckman, & Cohen, 1988). Shame, social discomfort, and self-consciousness also frequently occur as a result of the disorder (Sallee & Spratt, 1998). Research indicates that 73–78% of these children experience teasing and 68% have trouble getting along with their classmates (Dykens, Sparrow, Cohen, Scahill, & Leckman, 1999), both of which increase the isolation from their peers. Walkup et al. (1992) found that the severity of the tic symptoms was associated with disruption in global social functioning, especially in school and social interactions; however, severity was not associated with overall or individual behavior problems. Given all the problems associated with TD, the assessment process can be complex. For most children with this disorder, assessment involves contact over time, as various problems wax and wane. Treatment for TD reflects the complexity of the disorder in including a variety of approaches. These are discussed later in this chapter.

ASSESSMENT OF HABITS AND TICS Habits or tics may present as isolated behaviors or may be part of a larger constellation of problems. Referral for clinical evaluation and treatment of a habit or tic usually indicates that the behavior has continued longer than is typical; has become severe or chronic enough to cause physical damage; or is engaged in so frequently that it interferes with ongoing physical, social, and/or cognitive development. The assessment presented here follows the Comprehensive Assessment-to-Intervention System (CAIS; see Chapter 2), with an emphasis on those factors particularly important in assessing habits and tics.

Step 1: Initial Contact Parents should be asked to complete a general questionnaire (e.g., our General Parent Questionnaire; see Appendix B). Other questionaires that should be completed by each parent include the Behavior Assessment System for Children (BASC: Reynolds & Kamphaus, 1992) or the CBCL (Achenbach, 1991a) to screen for coexisting behavioral/emotional problems; the

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Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999) to determine the level of compliance to parent requests in daily activities; and the Parenting Stress Index (PSI; Abidin, 1995) for information on the child’s temperament and the parents’ general level of stress. In addition, the parents should be asked to complete the Habit Diary (see Figure 5.1) for at least 1 week prior to the initial interview, to gather specific information on the frequency, topography, antecedents, and consequences of the behavior (e.g., tics, hair pulling, thumb sucking). It is usually best to ask the parents to gather this information at the time of day when the frequency of the behavior is likely to be at its highest level. Although the specific time and length of the observation period should be consistent each day, it should be set to fit the parents’ and child’s schedule, as this will increase the likelihood of getting consistent data. It is important to review the Habit Diary to determine whether the data represent “typical” behavior on the child’s part and “typical” responses by parents to the behavior. Gathering this information is a difficult task, especially if the child is exhibiting complex tics or the behavior is affected by environmental changes. Yet, even if the data are not entirely accurate, they give the clinician some information about the behavior and the parents’ response to it. Several rating scales have been developed to help evaluate habits and tics. In a review of the scales for tics, Walkup et al. (1992) suggest that the Hopkins Motor and Vocal Tic Scale (Walkup et al., 1992) and the Yale Global Tic Severity Scale (YGTSS; Leckman et al., 1989) are easy to use in a semistructured interview and allow for multiple informants. These two measures focus on the tics themselves and the resulting impairment, and aid in operationally defining the tics. Walkup et al. (1992) also demonstrated that both historical information and direct observation contribute significantly to the overall assessment of tic severity. Although not as detailed as the YGTSS, the briefer Hopkins Scale provides valuable information in assessment of tics, and it is included in Appendix B. A scale to aid in assessing TTM is the Psychiatric Institute Trichotillomania Scale (PITS; Winchel et al., 1992). The PITS is used in a semistructured interview and addresses the history and current status of hair-pulling behaviors (sites, severity, duration, resistance, interference, and distress). It can also be used to monitor the progress of treatment. The Nailbiting Severity Scale (Leonard, Lenane, Swedo, Rettew, & Rapoport, 1991) has been adapted from measures used to assess TTM. It consists of five items: the amount of time spent each day biting nails, intensity of the urge to bite nails, resistance exerted against nail biting, amount of distress caused by nail biting, and the extent to which nail biting interferes with the child’s functioning.

Step 2: Parent and Child Interviews It is important to have an opportunity to interview at least one parent (or both, if possible) and the child on the first contact. The child can be included in the parent interview, but there should also be an opportunity to interview the child alone. Leckman and Cohen (1999) give an outline for the clinical evaluation of tic disorders and closely related conditions. Parent Interview The parent interview should focus on the following areas: 1. Developmental history. A review of the General Parent Questionnaire will indicate questions in this area that should be followed up in the interview.

Habit Diary Child’s Name: ___________________________________________________________________________________ Date: _________________________ Behavior: _________________________________________________________________________________________________________________________

Day

Observation Time

Antecedents Behavior (What’s Happening) (Frequency or Duration)

Consequences

Comments

Sample 5–5:30 P.M.

Watching TV

Checked 6 times and thumb sucking 5/6

Told to take out of mouth

He was really tired from school and fell asleep for 10 minutes.

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Monday

FIGURE 5.1. The Habit Diary, used to record the frequency with which habits and tics occur. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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2. Medical history. Were there any prenatal, perinatal, or postnatal risk factors? For TD, Santangelo et al. (1994) found that fetal exposure to relatively high levels of coffee, alcohol, and cigarettes, as well as delivery complications (especially forceps delivery), increased the association of OCD with TD. Have there been major illnesses or hospitalizations? What are the medications the child is currently taking or has taken in the past (both prescription and nonprescription)? Has the child been evaluated by a family physician or pediatrician, dermatologist, or neurologist to rule out possible organic causes for the habit or tic? 3. Course of the behavior and current status. When was the behavior first noticed? What does it look like, and has it changed in topography (e.g., initially just thumb sucking and now thumb sucking and hair pulling), frequency, intensity, complexity, and associated disruptions? When does it occur (e.g., is it situation- or time-specific)? Are there times when it occurs more frequently (e.g., when the child is under emotional stress, concentrating, expressing anger or excitement, or in particular situations)? What events typically precede or follow the behavior? What is the parental response to the behavior? How do siblings or peers respond to the behavior? How have teachers responded to the behavior? What have parents been told about the behavior? What have they done about the behavior thus far? It is also important to get a documentation of life events that may have occurred with the onset and exacerbation of habits or tic symptoms, the stability of family life, parental coping skills, and social support available to the parents. 4. Family history. A family history of similar behavior is important in the assessment of habit and tic disorders. Whether environmental or genetic factors play a part is not always clear, but a family history of similar problems often dictates how the parents respond to the behavior. Children with tics are more likely to have parents or extended family members with a history of tics than other children. Moreover, for TD, obsessive–compulsive behaviors are also more prevalent among family members. 5. Impact of behavior or the child and parents. Is the behavior interfering with the child’s academic performance, social relationships/participation in social activities, or self-esteem? In addition, how is the child’s behavior affecting the parents? The parents’ views of the problematic behavior and the impact it is having on them, their relationship with the child, and other significant people in the child’s life are often the determining factors in seeking treatment for habits or tics. 6. Associated behaviors. Determining the presence of other behavioral or emotional problems that could be associated with or occurring simultaneously with the behavior in question is important in deciding on the advisability of treating the presenting problem or initially focusing on areas that exacerbate the problem. Other problems (e.g., a poor parent–child relationship, the child’s lack of assertiveness in a stressful situation) may make it difficult to treat a habit or tic successfully. Intervention in these areas does not mean that the habit or tic will decrease in intensity or stop, but it sets the stage for later more effective treatment of the habit or tic. For TD and tics in general, it is important to gather information on inattention, impulsivity, and motoric hyperactivity; irritability and mood lability; rituals and obsessive or compulsive symptoms; and learning problems (see Step 4 below). Child Interview As noted above, the child should be seen alone sometime during the initial contact. The focus of the interview should be on the child’s general adjustment to family, school, and friends, as well as on his or her perception of the presenting problem. Is the child aware of when and where the

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behavior occurs? Why does the child think the behavior occurs? Is the behavior a concern to the child? Does the child perceive it as interfering in his or her life? Is it being commented on by others? What has the child done to resolve the problem? What is the child’s perception of the parents’ response to the problem? Does the child want treatment for the problem?

Step 3: Observation of Behavior The Habit Diary provides initial parent observational data on the behavior. For oral habits, TTM, or breath holding, it is useful to have the parents continue to keep a record of the behavior in order to monitor progress in treatment. Additional observational methods, such as taking pictures of the nails, measuring their length, counting the number of hairs in bald spots, and recording the number of times the behavior occurs in the treatment session, can be effective ways to measure progress. Some habits, such as TTM or bruxism, can be engaged in covertly or at times that make it difficult to monitor the behavior. The clinician will have to be innovative in finding methods to gather these data. Watson and Sterling (1998), for example, have described using a soundactivated tape recorder to record a child’s nocturnal bruxism, and using a video camera to record a 2-year-old’s TTM that occurred only during sleep. During clinical interviews, children with tics can often suppress or cover up the tics, so videotaping such a child in the room without the interviewer can be helpful. The parents’ periodic use of the Hopkins Motor and Vocal Tic Scale (Walkup et al., 1992; Appendix B) can be very helpful in the assessment process as well as in charting the course of treatment.

Step 4: Further Assessment For most isolated habits, there is no need for an assessment to include standardized tests or costly in-home or school observations. For TD, the clinician should evaluate the child for visual–motor, fine motor, and learning problems; teachers and parents should be asked to fill out the appropriate Conners Rating Scales (see Appendix A) to screen for ADHD; the teacher should be asked to complete the BASC Teacher Rating Scale and the Sutter–Eyberg Student School Behavior Inventory (see Appendix A); the child should be assessed for anxiety disorders (especially OCD); and an older child should be asked to complete the self-report form of the BASC.

Step 5: Referral to Allied Health Professionals If there is any suspicion of TD, an immediate referral to a pediatric neurologist should be made. It is important for the child clinician and the neurologist to work together in the treatment and monitoring of TD. Similarly, oral habits that are causing physical damage should be referred to a dentist.

Step 6: Communication of Findings and Treatment Recommendations Findings and treatment recommendations should be discussed in the context of the CAIS (see Chapter 2), with emphasis on the area(s) in which intervention is needed (child, parents, environment, consequences of behavior, and/or medical/health aspects).

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The clinician plays an important role in sharing information about a particular habit or tic, the advisability of treatment, and the available treatment options. Although the clinician can teach the child and parent intervention strategies, the child and parent are responsible for carrying out the treatment program. Hence it is very important for them to understand the rationale and steps for successful treatment and to be committed to the treatment program. An inconsistent approach to eliminating troublesome habits or tics is sure to fail.

TREATMENT OF HABITS AND TICS IN GENERAL In the overview of the various habits and tics, a number of treatment approaches have been discussed. This section focuses on the techniques of habit reversal and contingent negative practice, which have empirical support for their effectiveness. Treatment approaches for TD in particular are outlined in a separate section.

Habit Reversal Habit reversal has been demonstrated to be an effective treatment for a variety of habits and tics (Azrin & Peterson, 1990; Peterson et al., 1994; Silber & Haynes, 1991). There is also some evidence that it can decrease the number and severity of tics in TD (Azrin & Peterson, 1990). Habit reversal requires effort on the part of the parent and child, and thus it may be necessary to specifically reinforce compliance with the program. This can be done by reinforcing the child for completing the treatment procedures, as well as reinforcing habit-free periods with a chart system and tangible rewards (e.g., money, special activities). It may also be important for the clinician to model the parent’s role in monitoring and prompting the procedures, in socially reinforcing compliant child behavior, and in helping to devise charts and select rewards (Watson & Sterling, 1998). The number, length, and type of sessions needed for successful implementation of the habit reversal procedure have varied from one 2-hour group session to 12 individual sessions lasting 1 hour each. Although the habit reversal procedure outlined by Azrin and Nunn (1973) has many components, not all of the components may be necessary in the treatment of a particular habit or tic, and several studies have attempted to simplify the procedure (e.g., Miltenberger & Fuqua, 1985). The clinician should be aware of all the specific components of the procedure as used in the original studies, however, as one or another component may be more or less useful for a particular child or situation. The components of habit reversal include awareness training (response description, response detection, early warning, situation awareness); competing-response training; relaxation training; contingency management (habit inconvenience review, social support, public display); and generalized training (including symbolic rehearsal). Awareness Training or Self-Monitoring The purpose of awareness training is to increase the child’s awareness of the frequency and severity of the habit or tic, the environmental variables influencing the behavior, and the specific movements involved in the behavior. The child and/or the parents should record the incidence of the habit or tic for a specified amount of time each day, using a wrist counter or

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notebook. The length of recording time depends on the frequency of the behavior (i.e., higherfrequency behaviors can be recorded for a shorter period of time than lower-frequency behaviors). A 10- to 30-minute recording period at the same time each day is usually sufficient for most habits, but if the child is capable of recording the habit or tic throughout the day and listing the events occurring at the time, the environmental stimuli precipitating or aggravating the tics can be identified. If continuous written recording is not possible, the child can wear a wrist counter to record the tics, or can be given a simple chart (see Figure 5.1) on which to record the behavior at different times during the day (e.g., before school, during the morning, lunch). A second part of awareness training is response description, in which the child verbally and/or physically describes the details of the habit or tic to the therapist, using a mirror or videotape if necessary. This makes the child more aware of the behavior and increases his or her motivation to stop it. A third component of awareness training is response detection, in which the therapist alerts the child to each occurrence of the habit. The child is also taught to recognize the earliest sign (early warning procedure) that the habit or tic is about to occur (e.g., touching the lips in thumb sucking or feeling the urge to engage in a tic). Finally, the child should be helped to become more aware of the situations (situation awareness training) in which the habit or tic occurs most frequently, and to identify situations associated with making it better or worse. The child can then be prepared to implement the appropriate procedures or even to practice them upon entering the situation (e.g., the child who sucks a thumb at bedtime can practice fist clenching upon going to bed). Competing-Response Training Competing-response training typically requires the person to engage in a response that is incompatible with the habit or tic, contingent on its occurrence (e.g., opening the eyes wide contingent on eye blinking, or clenching the fist contingent on thumb sucking or nail picking). Azrin (Azrin & Nunn, 1973; Azrin & Peterson, 1988) suggests that the competing response be (1) opposite to or incompatible with the habit response; (2) capable of being maintained for several minutes; (3) socially inconspicious, so that it is compatible with ongoing activities; and (4) able to strengthen the muscles antagonistic to those used when engaging in the habit behavior, and to produce a heightened awareness through tensing of the muscle. For tic movements, the isometric tensing of the muscles opposite to those involved in the tic is recommended. For example, a competing response for shoulder jerking is the isometric contraction of the shoulder depressors (to strengthen the muscles that work in opposition to the upward jerking movements). A competing response for barking is slow, rhythmic, deep breathing through the nose while keeping the mouth closed. For thumb sucking or TTM, clenching of the fists has been shown to be an effective competing response. For tics, the child should be instructed to tense the muscles just tight enough so that the tic movement cannot occur, even when he or she is instructed to attempt to perform the movement intentionally. The competing response should be engaged in for about 2 minutes whenever there is an urge to have a tic or engage in a habit, or immediately after the actual occurrence of a tic or habit. For tics, the most frequent and disruptive type should be treated first, with one training session devoted to working on each type of tic. Sharenow, Fuqua, and Miltenberger (1989) demonstrated that the contingent competing response did not have to be a response that was incompatible with the habit. For instance,

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a child could tighten a muscle not related to the habit, such as clenching the left fist contingent on a mouth twitch. Their study suggests that the competing-response intervention is essentially a mild punishment procedure. Although the small number of subjects (n = 3) should make one cautious, the potential to use competing responses that are not as obvious as others is of clinical importance. As an example of habit reversal for thumb sucking, Azrin, Nunn, and Frantz-Renshaw (1980) taught the use of a competing response (grasping and clenching the fist for 1–3 minutes), parental support for not sucking the thumb, and stimulus identification) to 18 parents and children during one 1- to 2-hour session with telephone follow-up. The immediate results were striking: Thumb sucking was eliminated in 92% of the children after 1 week, and after a 20-month follow-up period, 89% of the children had stopped thumb sucking. Relaxation Training Relaxation training is taught to reduce tension and decrease the frequency and severity of the habit or tic. A combination of methods is recommended, including progressive muscle relaxation, deep breathing, visual imagery, and self-statements of relaxation. The imagery helps the child imagine that he or she is in the ideal situation for relaxation. Practicing selfstatements to “relax” or “be calm” during relaxation exercises help the child to relax at other times upon verbalizing the “calm” statement. Deep breathing is a form of relaxation that can be easily taught to children. It is most effective when exhalation is slightly longer than inhalation (5 vs. 7 seconds) and when the child inhales and exhales slowly without pausing (Cappo & Holmes, 1984). The goal of the training is for the child to relax upon cue in stressful situations. Although relaxation has not always been found to be a necessary component of the habit reversal procedure, it may be very helpful when the habit or tic occurs in particularly stressful settings or situations. Contingency Management Contingency management is used to ensure that the child is highly motivated to carry out the treatment procedures. The first step is to increase motivation by doing a habit inconvenience review, in which the child and therapist discuss in detail the inconveniences, embarrassment, and suffering that result from the tic or habit, and the positive aspects and advantages of reducing or eliminating the behavior. Azrin and Peterson (1988) recommend that these inconveniences and positives be written on an index card so that they can be carried and reviewed frequently, as a cognitive strategy to increase the motivation to use the treatment procedures. Next, they suggest that the parents and teacher praise the child for performing the exercises and for not engaging in the tic or habit. A token or chart system can also be used to reward the young or unmotivated child more concretely. If the habit or tic occurs at a high rate, the reward system can be dependent upon not engaging in the behavior for a specified period of the day, and the time period can be gradually increased as the frequency of the behavior decreases. Azrin and Peterson (1988) further indicate that in some cases it is necessary for the parent or teacher to prompt or guide the child through the exercises. If the parent or child do not believe that the child has voluntary control over the habit, then a public display procedure can be used. This involves having family members observe the child’s ability to control the behavior in the presence of the therapist, as well as

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having them inform other significant people in the child’s life (teachers, siblings, relatives) that the behavior is under the child’s control. Generalized Training In generalized training, the child is given practice and instruction on how to control the habit or tics in everyday situations. One method for doing this is symbolic rehearsal, wherein children are asked to imagine the situations that are likely to be associated with the habit or tic and cue themselves to relax or engage in the required exercise. Also, if the child fails to detect a tic or habit response during the treatment session, the therapist prompts him or her to engage in the appropriate procedure.

Contingent Negative Practice Contingent negative practice for involuntary motor responses, tics, and stuttering is one of the most often cited treatments for tics, with reported success rates (eliminated or reduced to normal limits) of approximately 50–80% (Peterson et al., 1994). This procedure involves having a child engage in the tic rather than fighting the urge to have it. Once the tic has occurred, the child engages in contingent negative practice of the tic for a period of 30 seconds. The child is encouraged to engage in the contingent negative practice every day while at home, during which time the tic is to be repeated as exactly as possible for 30 seconds immediately after every occurrence of the tic. In some cases this method has stopped the tic behavior within a few days. According to Levine and Ramirez (1989), some plausible explanations for the behavioral change produced by contingent negative practice include the following: 1. Practicing the motor response involved in a tic increases the voluntary control over the involuntary response of a tic. This was the basis for the massed negative practice procedure used by Yates (1958). Unfortunately, in Yates’s work tics were reduced, but improvement was not always maintained over time. Contingent negative practice differs from massed negative practice in that the practice is contingent upon the tic response and is engaged in for a much shorter time (30 seconds, as opposed to 30 minutes with 1- or 2-minute rest periods every 4 minutes). 2. Contingent negative practice may be a desensitization or habituation procedure when the involuntary response (tic) is required and there are no negative social consequences. Thus it is analogous to a desensitization procedure in which anxiety-producing stimuli are presented and the child remains calm. 3. Punishment may be an active ingredient in contingent negative practice, just as it is in the competing response of habit reversal. Voluntary repetition of an involuntary response contingent upon its occurrence punishes the involuntary response immediately. 4. Paradoxical intention may play a role, given that people are required to engage in the very response that they have worked so hard to inhibit. A rule of contingent negative practice is not to fight the tic but to go with it. Levine and Ramirez (1989) state that contingent negative practice is a relatively simple, cost-effective treatment method, and has been demonstrated to generalize to situations outside the treatment setting.

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TREATMENT FOR TOURETTE’S DISORDER Treatment of TD must take into account the “whole” child, with a focus on the interaction of the biological, psychological, and social components of the disorder, rather than on any one specific behavioral manifestation (i.e., tics). There is no “prototypical” child with TD. Thus the individual child’s strengths and how they can be used to help the child cope should be a prime target for intervention. Furthermore, because the disorder is a lifelong problem, a developmental perspective to treatment must be taken. Treatment approaches should focus on the specific needs of the child and family at any particular age, including reassurance, education, and guidance; advocacy in the school; and the use of behavioral techniques, psychotherapy, and pharmacotherapy (Leckman & Cohen, 1999). The clinician’s roles are varied, including those of educator, consultant, diagnostician, therapist, and advocate. Moreover, these roles change over time as the needs of the child and family change. Treatment for TD should follow the CAIS (Chapter 2) and focus on the child, the parents, the environment, and medical/health interventions.

Intervention with the Child The child should be given information and provided support in helping him or her adjust to and cope with the effects and stresses of this complex disorder. The Tourette Syndrome Association (see the contact information provided in “Intervention with the Parents”) has a wealth of information on this disorder, and local chapters often have both child and parent groups. Support groups can be particularly helpful for children as they learn that they are not the only ones with TD, hear about ways that others have coped, and begin to understand the potential course of the disorder. As the symptoms of TD wax and wane, it is important for the clinician to be available to the child to discuss the effects of the symptoms on his or her functioning, and to determine ways to decrease the symptoms. It is also important that children develop competence and a sense of control over their lives; hence they should be involved in the treatment planning as far as is appropriate to their developmental level. The focus of treatment should not simply be on “the problem,” but also on the child’s strengths (e.g., humor, intelligence, physical attributes, optimistic attitude, ability to enjoy life), and on ways these strengths can be used to compensate for the problems and to increase a sense of competence. Therapy approaches to TD generally focus on helping the child to recognize the circumstances associated with the exacerbation of the symptoms, to understand how such circumstances arise, and to select ways to diffuse or avoid them. Behavioral treatment (including habit reversal or some of its components, as well as contingent negative practice) has been effective in treating TD, as have cognitive-behavioral approaches (Leckman & Cohen, 1999; Peterson et al., 1994). Given that TD is highly associated with other problems (e.g., OCD, anxiety, ADHD, learning disabilities), these other areas may also be foci of treatment for a given child.

Intervention with the Parents Like the child, the parents and other family members will need information on TD, its course, and potential treatment options. Support groups can be very helpful, as they encourage parents and other family members not only to understand and deal with the stresses of this disorder, but also to advocate for the child. Family members often have symptoms similar to the child’s, which can make it difficult to maintain a structured, emotionally calm environment.

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Parents should be involved in both the planning and the carrying out of any treatment program, and their own special needs must be taken into consideration. It is important to coordinate treatment with other involved health professionals (e.g., neurologist, pediatrician), so that information is shared and a team approach is taken to treatment planning. This team should always include the parents and, when appropriate, the child. An excellent book for parents is Children with Tourette Syndrome: A Parents’ Guide (Haerle, 1992). Finally, a national resource for both children and parents is the Tourette Syndrome Association, 42-40 Bell Boulevard, Bayside, NY 11361, 718-224-2999, 800-237-0717, http://www.tsa.ngh.harvard,edu/.

Intervention in the Environment The direct and indirect effects of TD on the child’s functioning in school should be of concern to the clinician. Although not all children with TD require intervention in the educational setting, many will need help in adjusting to that environment. Informing the teacher and other school personnel of the child’s unique strengths and his or her specific problems should help them to be creative and flexible in adapting the academic environment for that child. A number of modifications in school can help the child with TD to learn and to adjust more effectively (Carter, Fredine, Findley, et al., 1999): 1. Educational setting. The best environment for children with TD is one that is calm and supportive. Being in a classroom that permits freedom of physical movement when their symptoms require it, but that also offers appropriate environmental cues to guide learning, is ideal. Thus a moderate amount of structure is important. When a child’s symptoms are especially severe, it is recommended that the tic be ignored or that the child be allowed to leave the classroom without special permission and go to a place of “refuge” to continue his or her work (e.g., a resource room, the nurse’s office). 2. Reasonable goals. Giving small segments of work seems to help children with TD set reasonable goals, and prevents them from being overwhelmed by the complexity of a task or length of assignment. The focus at first should be on work completed, with a gradual increase in the quality of work. 3. Timing. Children with TD should be allowed to work at their own pace with the least amount of time pressure. The untimed administration of tests in private is especially important, as is allowing rest breaks during long examinations. All of these modifications can help reduce a child’s stress level and allow him or her to perform well. 4. Directions. Most children with TD need help with directions, and having directions repeated, underlining significant words, and sequencing steps for a task can help with this problem. 5. Alternative learning methods. The use of computers, tape recorders, and calculators can often help make the learning experience more successful. 6. Support. Informing school personnel, teachers, and peers about TD is extremely important and relieves a child of continually having to explain his or her behavior. The Tourette Syndrome Association has a number of excellent films and publications that can be used for this purpose. The clinician should be aware, however, that even with the best information and explanations, some school personnel believe that children with TD can control their behavior. Moreover, many believe that it is the result of parents’ mishandling of a child. In a recent survey of teachers, 70% had no knowledge of TD, although 50% were motivated to learn specific behavioral and teaching strategies to help children with TD; 50% felt nothing could be done

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to improve the school situation for these children (Carter, Fredine, Schultz, et al., 1999). Persistence is needed in dealing with the school environment, and sometimes a change in schools may be necessary. If a child is taking medication, it is important to provide the school with information on the potential side effects of the medication. It may also be necessary to help the teachers understand that homework assignments may need to be adjusted for a child who may be relatively symptom-free during the school day, but has explosive rates of tics at home after school.

Intervention in Medical/Health Aspects The most effective and well-investigated pharmacological agents used in the treatment of TD and chronic motor tic disorders are those that block dopaminergic receptors. Of these, haloperidol is the most commonly used neuroleptic (Erenberg, 1992; see Towbin & Cohen, 1996, for an excellent review of the risks and benefits of using pharmacological interventions). Neuroleptic medications result in 50% or more reduction in tic severity for approximately 70–80% of people with TD who take them. The negative side effects of neuroleptics are substantial, however; they include cognitive impairment, drowsiness, lethargy, constipation, dermatological reactions, extreme anxiety, social phobia, depression, tardive dyskinesia, and Parkinson-like effects (drooling, tremors, rigidity, and loss of associated movements) (Towbin & Cohen, 1996). Another drug of the same type, primozide, has received less study, and some instances of sudden death from cardiac arrest while taking it mandate repeated electrocardiograms (Towbin & Cohen, 1996). Clonidine, a non-neuroleptic drug, has also been widely used for tics. Side effects include sedation, insomnia, dizziness, dry mouth, and hypotension, however. In addition, abruptly stopping this drug can be uncomfortable (e.g., hypertension, agitation, behavior changes) and potentially harmful. Finally, clonidine is generally not as effective as the neuroleptic drugs, with as few as 38% of clonidine-treated patients having a reduction of 50% in severity of tics (Leckman & Cohen, 1991). Although stimulants have been used to counteract the side effects of neuroleptics (Towbin & Cohen, 1996), the potential problems of stimulants in exacerbating the symptoms of TD, as well as the problems of using multiple medications, make this a questionable choice of treatment. Moreover, a significant limitation of all pharmacological treatments is that up to 80% of patients discontinue the use of the medications for tics because of unwanted side effects (Peterson & Azrin, 1993). Given the adverse side effects and the high percentage of patients who discontinue the drugs, the risks and benefits of using neuroleptics should be very carefully weighed. In general, their use should be considered only for cases where the tics are significantly interfering with development or when bouts of tics are particularly severe. If medication is used, it should be stopped gradually after a period of time to determine whether it is still needed; abrupt stopping of the medication can result in increased symptoms that last for several months (Towbin & Cohen, 1996).

CASE EXAMPLE: FROM TICS TO TOURETTE’S DISORDER Step 1: Initial Contact Mrs. Fox called for an appointment for her 7-year-old son, Steve, who had exhibited a recent increase in eye blinking and head jerking. At Steve’s last physical examination, she had dis-

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cussed these behaviors with the pediatrician, who assured her that they were typical for children Steve’s age, but that they might have gotten worse because of her recent marital separation and the resultant conflict over visitation. The clinician sent Mrs. Fox the General Parent Questionnaire, the ECBI, the CBCL, the PSI, and the Habit Diary (Figure 5.1) to complete and return prior to the initial interview. The General Parent Questionnaire indicated that Mr. and Mrs. Fox had separated 4 months previously and that Mrs. Fox had returned to school for her teaching degree. The marital separation had resulted in a recent move away from the family home near her large extended family, as well as a significant decrease in income. Steve was in second grade at a local elementary school, and his 4-year-old sister was in a day care program. Steve was involved in many after-school activities and had responsibility for age-appropriate chores, which he completed without problems. Mrs. Fox’s responses to the other questionnaires indicated that Steve was a compliant child who had an easy temperament and was quite reinforcing to his mother. On the Parent Domain of the PSI, the only significant score was on the Depression scale, which Mrs. Fox later related to the separation and move. The only problems noted on the CBCL were a high frequency of tics, some worries about these, and a very high activity level.

Step 2: Parent and Child Interviews Parent Interview Mrs. Fox said that she and Steve had openly discussed his tics, and that he was as eager to resolve them as she was. She felt there was no reason not to include him in the interview. Mrs. Fox said that Steve had no significant developmental or medical problems and had not taken any medication in the recent past. Furthermore, Mrs. Fox said that no one else in the immediate family exhibited tics, although her mother had told her that one of her brothers had had similar tics at about the same age as Steve. Mrs. Fox stated that Steve had engaged in some eye blinking at about age 4, but that the frequency had decreased up until the present time. She had not noticed any vocal tics. The mother’s current concern about the tics had begun with a phone call from the teacher to ask her about them. The teacher felt that other children were beginning to notice the tics and tease Steve. The teacher was also concerned that they might begin to interfere with Steve’s ability to sustain attention. Moreover, Steve had asked his mother whether there were something he could do to stop the tics. Steve was described as physically active, but this did not bother Mrs. Fox. Because he was in an “open” classroom, his high activity level did not cause problems in school. Although he had trouble completing written assignments and attending to academic work for more than 10 minutes at a time, he was doing relatively well in school. The recent move had been difficult for all of the family, because they enjoyed close relationships with the extended family, and the children’s primary playmates had been cousins. They did, however, visit the maternal grandparents every weekend. The parents’ separation had occurred after many unhappy years of marriage, although there had been no open parental conflict prior to the separation, because Mr. Fox had spent very little time at home. Visitation problems centered around the father’s complaints that he was not able to see the children often enough, but Mrs. Fox said he refused to follow a set visitation schedule. The children did not feel they got to see enough of their father, and Mrs. Fox was at a loss as to how to increase their contact with their father.

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Child Interview Steve presented as a pleasant child who interacted freely with the clinician. He readily described family activities and said that he already had made a lot of friends in school. He said that although school was not hard, he sometimes found it difficult to work “all day.” It was hard for him to talk about his parents’ separation, and he said he wished he could see his father more often. Steve said that the family’s daily routine had not changed much since the separation, except that his mother had to study after she put them to bed at night. Steve said that he wanted to stop blinking and jerking his head because some of the children at school teased him and it embarrassed him. He also felt that the tics made it more difficult for him to complete his work in school. In addition to the tics, Steve reported increased compulsive behaviors (e.g., putting his pencil to his mouth, then laying it on the desk, before picking it up to write). During the interview Steve’s eye blinks increased when he was talking about the parental separation, and they decreased when he was involved in a game that required concentration.

Step 3: Observation of Behavior The Habit Diary, which was completed for the half hour after dinner each evening, indicated that Steve blinked 20–30 times on average and that this was often followed by head jerking. There was no specific antecedent to these behaviors; they occurred across a variety of activities, and the mother did not respond to them. Mrs. Fox later admitted that her nonresponse was the result of having made an appointment with the clinician, and that normally (but not consistently) she told Steve to stop. Mrs. Fox was asked to continue keeping track of Steve’s tics with the Habit Diary throughout treatment. During the parent interview, Steve played with cars on the floor, and his tics were quite obvious to the clinician. The mother–child interaction was positive; Mrs. Fox also proudly described Steve’s many activities, athletic skills, and good relationship with his 4-year-old sister, who was described as “fun but firy.”

Step 4: Further Assessment There were no major concerns about other areas of development at this time. The mother and teacher, however, were asked to complete the Conners Parent and Teacher Rating Scales to gather further information on possible ADHD.

Step 5: Referral to Allied Health Professionals Steve had had a recent physical examination, and at this time there was not sufficient evidence to suspect TD.

Step 6: Communication of Findings and Treatment Recommendations The following information was shared with Mrs. Fox. In general, Steve appeared to be well adjusted in school, with peers, and at home. It was felt that the recent move and parental separation might have precipitated tics, which have a high incidence at Steve’s age. It seemed important to decrease Steve’s stress with regard to visitation with his father, as well as provide him with ways to decrease the frequency of tics.

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Mrs. Fox was open to the possibility of regular and frequent visitation, and she agreed to ask Steve’s father to make an appointment with the clinician or at least to contact her by phone. Mr. Fox refused to do so, however. He said that Steve’s problems were all related to the mother’s desire to separate, and that if she would return to the marriage Steve would be fine. Mr. Fox also refused to set up a regular visitation schedule. With the clinician’s encouragement, Mrs. Fox decided on a visitation schedule that included Mr. Fox’s having the children every other weekend and at any other time with 1 day’s notice. She further agreed to transport the children to see their father one weekend a month. Mr. Fox was to let them know on the Wednesday before the weekend whether he planned to see the children. Mrs. Fox told the children about this plan; she said that she would send it in writing to their father, but that it was up to their father to carry it out. The clinician also wrote a letter to Mr. Fox encouraging him to visit the children on a regular basis. Unfortunately, over the next 4 months, Mr. Fox saw the children only 1 full day and several evenings. Because of his high activity level, Steve was not able to engage in muscle relaxation. Thus he was taught relaxation by deep breathing. He was also taught habit reversal, with the competing response of opening his eyes wide for 30 seconds after each eye blink or before entering situations that were likely to result in eye blinking. This was successful in decreasing the eye blinks to an average of 1–2 times in the 30-minute home recording period. The head jerk was also treated through habit reversal by having him tense his neck in response to each head jerk. This tic also decreased within a 2-week period to a frequency of 0–1 during the 30-minute home observation period. Both the mother and teacher indicated that they rarely observed either tic over the next 2 months. Two months after treatment ended, Mrs. Fox called to report that Steve was once again engaging in tics, but this time they involved the jerking of his arm and leg as well as eye blinking. When Steve was seen by the clinician, he was easily taught habit reversal for these new tics. Significantly, however, the mother reported that Steve would engage in the tics at a very high rate after periods of no tic behavior. Furthermore, though Steve engaged in very low levels of tics during two treatment sessions (apparently in order to please the clinician), the rate of tics increased dramatically after he left the clinic. It was also noted during the treatment sessions that Steve was clearing his throat a great deal, and he off-handedly told the clinician that “he had a tickle in his throat” and probably just needed a cough drop.” At this point the clinician began to suspect TD and referred Steve to a neurologist, who confirmed this diagnosis. The clinician had the opportunity to work with Steve and his mother over the next 4 years. During this time, Steve’s sister was also diagnosed with TD. The focus of treatment was on helping the family cope with this chronic disorder, including consultation with the school, psychoeducational evaluations of both children (the sister also proved to have a learning disability), and teaching the children coping skills (defining stressful situations, using relaxation, habit reversal, and avoidance of stressful situations). Mrs. Fox was put in contact with the Tourette Syndrome Association, and both she and the children participated in local chapter meetings. Mrs. Fox became a strong advocate for her children, and provided teachers and the children’s classmates with films and handouts describing TD.

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CHAPTER 6

Sleep

S

leep! Throughout our lifetimes this restorative activity is fought, manipulated, embraced, and finally accepted as a necessary part of our lives. The parents of infants have firsthand experience in dealing with interrupted sleep, and many go on to learn about night wakings, bedtime struggles, early risings of energetic toddlers, and the rather bizarre nocturnal occurrences (sleepwalking, sleeptalking, teeth grinding, head banging and rocking, sleep terrors, and nightmares) that are common among children. As children get older, their repertoire of nighttime behaviors expands, and parental responses evolve and become more varied. The types of sleep disturbances seen in children change with age, although sleep disturbances such as bedtime struggles, night wakings, and sleepwalking have been shown to persist over a number of years (Anders & Eiben, 1997). Thus, although sleep problems in children may be common, they do not always go away on their own. When parents request help with sleep problems, the situation has usually reached a crisis point. It is important for the child clinician to be able to help these parents and their children, as well as to be aware of the role sleep problems can play in other disorders of childhood. This chapter first reviews age differences in normal sleep states and patterns, and the types of sleep disturbances seen in children. Assessment and treatment of the most common sleep problems are then discussed.

NORMAL SLEEP STATES AND PATTERNS To understand sleep disturbances, one must first have a rudimentary understanding of the physiology and development of sleep. A mature nervous system is necessary to regulate the sleep cycle over many hours, and thus children’s sleep cycles follow a developmental course.

Sleep States and Stages The sleeping person may appear inert, but his or her sleeping state is a complex, highly organized neurophysiological process. Sleep is divided into two distinctly different states: rapideye-movement (REM) sleep and non-rapid-eye-movement (NREM) sleep (Kales, 1969). REM sleep is also called “paradoxical sleep,” because it has features of both deep sleep and light sleep. It is characterized by an irregular pulse and respiratory rate, as well as rapid eye move186

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ments. There is a dramatic increase in blood flow to the brain; the body uses more oxgyen; and brain waves resemble a mixture of waking and drowsy patterns (Parmeggiani, 1994). Although dreams and nightmares occur during REM sleep, little happens behaviorally. Muscles are very relaxed and nerve impulses are essentially blocked within the spinal cord, so the body is effectively paralyzed, although there may be small twitches of the hands, legs, or face. When a person is awakened from REM sleep, alertness returns relatively quickly. The longest and most intense REM activity occurs at the end of the sleep period, just prior to morning awakening. Thus dreaming and nightmares are more frequent in the early morning hours. NREM sleep is divided into four stages, which represent progressive levels of sleep from drowsiness to very deep sleep (Guilleminault & Anders, 1976). During the latter two stages (stages 3 and 4), breathing and heart rate become very stable, and the muscles are very relaxed. Although the person usually lies very quietly, he or she can move, often sweats profusely, and is very difficult to awaken. If the stimulus is important enough (e.g., a sick child crying), however, the person will promptly awaken but may be in a confused state for a few minutes (Kales, 1969). Mindell and Dahl (1998) point out that these deep stages of sleep are increased in proportion to the amount of awake time, sleep loss, or chronic sleep disturbance. Children have large amounts of deep sleep, which peak between 3 and 6 years (when children are giving up naps), but these gradually decrease with age (Dahl, 1996). In contrast to REM sleep, the deepest NREM sleep occurs in the first 1–3 hours after falling asleep. Arousal from the initial 1–3 hours of deep NREM sleep is very difficult for children, who will appear disoriented, confused, or cognitively slow (Mindell & Dahl, 1998). Confused partial arousals can occur during NREM sleep, resulting in sleep terrors and sleepwalking, which are most frequent in the 60– 90 minutes after the child has fallen asleep. A normal sleep cycle consists of alternating periods of NREM and REM sleep, in 60- to 90-minute cycles. Short periods of waking from REM and stage 2 of NREM sleep occur about five to seven times a night, but most people quickly return to sleep without any memory of the wakings. Ware, Orr, and Bond (2001) describe the typical sleep pattern for children. Children usually fall asleep in 10–15 minutes, reach NREM stage 4 (via stages 1–3) 5–20 minutes after falling asleep, and have the first REM period (which lasts about 5 minutes) 1–2 hours after sleep onset. The NREM-REM sleep cycle is then repeated, with later REM periods lasting 15–20 minutes. Sleep regulation changes with development. Although full-term infants have differentiated REM and NREM periods, the NREM period does not have different stages. Infants enter sleep through REM rather than NREM, spend 50% of total sleep in REM sleep (compared to 20% in adults), and have sleep cycles about 50–60 minutes long (compared to the 90–100 minutes for adults). By 2–3 months of age, the four stages of NREM sleep are differentiated; by 3 months, the infants enter NREM sleep first; and by 1 year, the time in the REM sleep state is reduced to 30%. The normal adult sleep cycle is reached by about 8 years of age (Zuckerman & Blitzer, 1981). Although there is considerable individual variability in sleep requirements, the sleep–wake cycle changes considerably with age (see Table 6.1), with the total amount of sleep gradually decreasing as the duration of each sleep period gradually increases. As can be seen in Table 6.1, total sleep decreases from 16 hours a day in the newborn (with the longest time asleep being 2–4 hours) to approximately 10 hours by age 10 years, and 8 hours by age 18 years. The average 1-year-old sleeps about 11 hours a night, with two separate daytime naps for a total of approximately 13.5 hours of sleep a day. By age 3, the average child gets 10.5 hours of sleep each night, with an additional 1.5-hour daytime nap. By age 4 or 5 years, most children in the United States sleep 11 hours each night without a daytime nap (Mindell & Dahl, 1998). Cul-

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Total amount of sleep

Sleep periods

Early infancy 3–4 months 6–8 months

16 hours 14–16 hours 12–16 hours

12 months

14 hours

24 months

13–14 hours

3 years

12–13 hours

5 years 10–12 years

11 hours 10 hours

2–4 hours 4–8 hours 8–12 hours at night 2 naps of 2 hours each 8–12 hours at night 2 naps of 1–2 hours each 11–12 hours at night 2-hour nap in P.M. 11–12 hours at night 2-hour nap in P.M. No naps No naps

ture can influence time spent in sleep, and a clinician should take this into consideration when assessing sleep problems. It has been hypothesized that the function of REM sleep is to allow us to process daytime emotional experiences, to transfer recent memories into long-term storage, to concentrate attention on one task, and to integrate newly learned material (Ferber, 1985; Zuckerman & Blitzer, 1981). NREM sleep is thought to allow restoration of the body and to regain physical strength (Hartmann, 1973). Thus we appear to live in three distinct states. In the waking state, thoughts can be translated into action so we can maintain the necessary activity for survival. In the NREM sleep state, mental processes are minimal, the body rests, and restoration occurs. In the REM sleep state, the mind is active again and dreams occur, but the body, though receiving signals, does not carry them out. Ferber (1985) suggests that REM sleep can be thought of as an intermediate state between NREM sleep and waking, in which the mind wakes up before allowing signals to be received by the body. In evolutionary terms, sudden waking from NREM sleep would leave an animal confused and unable to protect itself, whereas REM sleep would allow the animal’s brain to become more active without the accompanying body movements that could attract a predator. Once sufficiently alert, the animal would wake up fully, and the muscle “paralysis” of REM sleep would disappear. Ferber (1985) states that this checking for danger may still be relevant for humans, because we wake up after each episode of dreaming, check the environment, and (if all is well) go back to sleep. We do not usually remember these wakings. Some children, however, may not return to sleep after these wakings, perhaps sensing that something is wrong; they may need to be rocked or need to feel the closeness of a parent to go back to sleep. Dahl (1996) provides strong empirical support linking the regulation of sleep, affect, and attention. He points out that emotional disturbances (both positive and negative) can cause at least transient disruption in sleep. The link between emotional regulation and sleep regulation is amply demonstrated in mood disorders, where sleep disturbance often represents a major diagnostic symptom. Among depressed children, for example, 75% complain of insomnia and 25% have symptoms of hypersomnia during episodes of depression (Ryan et al., 1987). Altered sleep has also been associated with a number of other clinical disorders, such as anxiety dis-

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orders (Mellman & Uhde, 1989; Glod, Teicher, Hartman, & Harakal, 1997), Tourette’s disorder (Glaze, Frost, & Janovic, 1983), and attention-deficit/hyperactivity disorder (Marcotte et al., 1998). In a study of children ages 7–14 on a psychiatric inpatient unit, the children’s selfratings of depression, hopelessness, and low self-esteem were significantly correlated with an objective sleep measure indicating poorer sleep quality (Sadel et al., 1995). Although the cause–effect relationship between sleep and emotional/behavioral disorders is not known, studies and case examples indicate that treatment of sleep problems often results in a decrease of daytime behavioral problems (e.g., Dahl, 1998; Minde, Faucon, & Falkner, 1994). The connection between sleep and behavior probems is further illustrated in a study of sleep and behavior in 49 physically healthy 7- to 12-year-olds without known sleep problems (Aronen, Paavonen, Fjallberg, Soininen, & Torronen, 2000). The children wore ambulatory activity monitors on belts for 72 consecutive hours, and both parents and teachers completed the Child Behavior Checklist (CBCL). Although the parents were not aware of a sleep problem and did not report behavior problems at home, the quantity of the child’s sleep was significantly associated with the Total symptom score on the CBCL Teacher’s Report Form. It is thus important to give strong consideration to a child’s sleep patterns and behaviors during assessment and treatment of all childhood problems.

Circadian Rhythms Some understanding of the circadian rhythms that are associated with the sleep–wake cycle is necessary to treat children’s sleep problems. “Circadian rhythms” are biological cycles that repeat themselves about every 25 hours; they include patterns of sleeping and waking, activity and rest, hunger and eating, and fluctuations in body temperature and hormone release. Not only is it important for our sense of well-being that these cycles be in harmony during the day, but the ability to fall asleep and to stay asleep is closely tied to the timing of these cycles. For example, in adults, selection of bedtimes, self-rated alertness, the amount of time after falling asleep to REM onset, and the duration of the sleep period are all related to body temperature (Czeisler et al., 1981). A person falls asleep when body temperature is falling toward a daily low, and awakes as it starts rising toward a peak; it is hard to wake up when the body temperature is still low, and the person may have trouble falling asleep when the body temperature is high (Ferber, 1985). These cycles are set each day by the daily routines of arising, eating, activity, going to bed, and so on. Sleep–wake cycles can also be affected by such things as seasonal changes in the light–dark cycle, with sleep tending to increase in the winter and decrease in the summer. If the sleep–wake cycle gets out of rhythm, a person begins to feel bad. Jet lag is a good example of this. If children’s schedules are irregular, it is possible that their circadian rhythms may be off; they may want to sleep when they should be awake, and vice versa. Changing sleep routines (e.g., getting children to bed earlier, getting them up earlier, or having them sleep later in the morning) must take into account the children’s normal body rhythms, and changes must occur gradually.

SLEEP DISTURBANCES It is often difficult to understand what constitutes a sleep disorder in children, because of the many terms used to describe sleep problems and the varying definitions of what consti-

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tutes a “problem.” “Cosleeping” (child and parent sleeping together in the same bed), for example, is widely viewed as a problem, even though the definition has included activities ranging from sharing the bed for a few minutes once or twice a year to regularly sleeping in the same bed (Crowell, Keener, Ginsburg, & Anders, 1987). The significance of a problem can also vary with the population studied. Cosleeping, for example, has been found to be more common in African American families, where it is not associated with sleep problems. In European American families, however, cosleeping is associated with sleep problems (Lozoff, Wolf, & Davis, 1984). In Japan, most children consistently sleep with their parents for the first 3 years of life, with few sleep problems (Kawasaki, Nugent, Miyashita, Miyahara, & Brazelton, 1994). In contrast to the 100% all-night cosleeping in Japan, cosleeping in the United States occurs in 15% of families and usually involves intermittent and partial-night cosleeping, as a result of bedtime struggles and night wakings (Latz, Wolf, & Lozoff, 1999). Although there is compelling evolutionary and cross-cultural evidence supporting a cosleeping environment for the first few months of an infant’s life, 84% of a sample of pediatricians felt that an infant should never sleep with his or her parents (Anders & Taylor, 1994). Thus cosleeping per se is not the problem, but rather how it is perceived and then carried out. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) classifies sleep disorders into four broad categories: primary sleep disorders; sleep disorder related to another mental disorder; sleep disorder due to a general medical condition; and substanceinduced sleep disorder (American Psychiatric Association, 1994). Unfortunately, all but the first of these categories apply more to adults than children; moreover, there are no sleep disorders listed in the childhood-onset section. DSM-IV does follow The International Classification of Sleep Disorders (ICSD; Diagnostic Classification Steering Committee, 1990) in classifying its primary sleep disorders into two major categories: “dyssomnias” and “parasomnias.” Dyssomnias include difficulties in either initiating or maintaining sleep, or daytime excessive sleepiness. Parasomnias include disorders that disrupt sleep after it has been initiated, and are disorders of arousal, partial arousal, or sleep stage transitions. The ICSD categories fit well in understanding children’s sleep problems. Sleep disturbances are very common in children, with a number of surveys finding that between 20% and 30% of children between the ages of 1 and 5 years experience some type of sleep problem (mainly difficulty falling asleep and maintaining sleep) (see Anders & Eiben, 1997; Mindell & Dahl, 1998; Ottaviano, Giannotti, Cortesi, Bruni, & Ottaviano, 1996). Common problems in a survey of 218 parents of children ages 2–15 years referred for a psychiatric or pediatric consultation included sleeptalking (31%), nightmares (31%), waking at night (28%), trouble falling asleep (23%), bruxism (10%), sleep rocking (7%), and sleep terrors (7%) (Salzarulo & Chevalier, 1983). In another survey of approximately 1,000 parents of 5- to 12-year-olds, five common sleep-related complaints were reported: bedtime resistance (27%), morning wakeup problems (17%), fatigue (17%), sleep-onset delays (11%), and night waking (6.5%) (Blader, Koplewicz, Abikoff, & Foley, 1997). In this section, we first review dyssomnias, including disorders of excessive sleepiness (narcolepsy, sleep-related respiratory problems); sleep–wake schedule disorders; and disorders of initiating and maintaining sleep (bedtime struggles, night wakings, getting up early). We then review parasomnias, including nightmares, REM sleep behavior disorder, sleep rocking or head banging, sleep bruxism, sleep paralysis, and partial arousals (sleepwalking, sleep terrors, and sleeptalking).

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Dyssomnias Excessive Sleepiness Excessive sleepiness can be the result of illness, medication, depression, poor nighttime sleep, narcolepsy, or sleep apnea syndrome (Ware et al., 2001). If a child sleeps more than 2 hours longer than the average for his or her age, or requires daily naps beyond the preschool years, the child may be suffering from excessive sleepiness (Ferber, 1985). The behavioral signs of sleepiness usually include shorter attention span, reduced coordination, irritability, forgetfulness, fussiness, and general “laziness” (Ware et al., 2001). Teachers are usually the first to notice these problems, and a child is often described as performing poorly because of inattention, laziness, or overactivity. Such concerns warrant investigation of the child’s sleep patterns, especially if the child is both overactive and continuing to take naps after the age of 5 years. Viral infections and illnesses with a high fever leave a child feeling tired and sleepy, but these feelings subside as the child recovers from the illness. Some medications (such as antihistamines and drugs used to control seizures) can cause excessive sleepiness as a side effect. Inadequate sleep, poor-quality sleep, or inadequate deep sleep often result in daytime sleepiness. Depression in children can also result in excessive sleepiness, but this should be only one of a number of other behavioral symptoms. Treatment will depend on the nature and cause of excessive sleepiness. In the absence of medication or psychopathology, structuring the child’s daily routines of sleep, eating, exercise, and social activities can be helpful in decreasing this problem. Narcolepsy. In narcolepsy, sleep is distributed across 24 hours rather than occurring in a single block at night. Nighttime sleep is usually disturbed by many wakings, and short periods of uncontrollable daytime sleep occur in unstimulating or physically inactive situations (very similar to the sleep patterns of newborns). In narcolepsy, the sleep system is uncontrolled. The REM state most often begins immediately or within 10–15 minutes after falling asleep, rather than after the normal 90 minutes (Ware et al., 2001). There are also episodes of partial activation of the REM system at bedtime, on waking, and during the day. In addition to inappropriate sleepiness, other classic symptoms that occur in a significant majority of people with narcolepsy are cataplexy (sudden loss of muscle tone without loss of consciousness), hypnagogic hallucinations (dream-like imagery before falling asleep), and sleep paralysis (inability to move after waking up) (Mindell & Dahl, 1998). Narcolepsy appears to be a neurological disorder with a strong genetic component (Mindell & Dahl, 1998). It occurs at the rate of 3 per 10,000 in European Americans (Hublin et al., 1994); however, having a first-degree relative with narcolepsy increases the probability by 18 times (Guilleminault, Mignot, & Grumet, 1989). Although narcolepsy is usually first diagnosed in adults, one-third of persons with this disorder date the onset of their sleepiness to adolescence or earlier (Dahl, Holtum, & Trubnick, 1994). This suggests that the disorder often goes undiagnosed in children. In a sample of 16 cases with the onset of narcolepsy before age 13, Dahl et al. (1994) found significant associations with behavioral and emotional disturbance, as well as obesity. Only 1 out of the 16 cases had all four symptoms of narcolepsy. Ware et al. (2001) report on the recently identified narcolepsy gene in canines and mice. The gene controls the hypocretin–orexin neuropeptide system, with neurons located in the lateral and posterior hypothalamus. These findings give hope for the development of medication to treat this serious problem.

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Diagnosis of narcolepsy involves ruling out other possible problems that may cause sleepiness, determining the pattern of sleep, and documenting the appearance of REM sleep soon after sleep onset (Ware et al., 2001). The documentation of REM sleep is carried out by means of a multiple sleep latency test (MSLT), performed in a sleep laboratory. A polysomnogram (PSG) should also be performed to rule out other sleep disorders. This usually involves an overnight sleep study in which recordings of oxygen saturation, nasal and oral airflow, thoracic and abdominal respiratory movements, limb muscle activity, and an electroencephalogram are taken. Although there is no cure for narcolepsy, there is treatment in the form of medication for the various symptoms, plus a regular sleep schedule with short naps throughout the day (Ware et al., 2001). However, the medications (methylphenidate hydrochloride for sleepiness, and imipramine or other trycyclic antidepressants for muscle weakness) can result in further sleep disturbances and should be used with caution. Educating the child and family as well as teachers is also important, but many teachers refuse to acknowlege narcolepsy as a medical problem, and many families refuse counseling (Guilleminault & Pelayo, 1998). Obstructive Sleep Apnea. Obstructive sleep apnea (OSA), or the absence of breathing during sleep, can produce a sleep disturbance resulting in sleepiness during the day. Although OSA was once thought to be rare in children, Ferber, Boyle, and Belfer (1981) reported that 14% of the children seen in their sleep disorders clinic had a primary diagnosis of OSA. Once a person is asleep, the upper airway narrows or closes off so that the person cannot breathe. This interruption of breathing can last from 10 seconds to 3 minutes, with an average of 30–40 seconds (Anders & Eiben, 1997). The obstruction usually occurs in the back of the throat behind the base of the tongue, where the airway can be blocked by collapse of the walls of the throat (which are floppy in this region) and by the tongue’s falling backward (Mindell & Dahl, 1998). This results in frequent arousals from sleep, which increase the muscle tone to the neck and pharyngeal muscles, open the airway, and allow the child to resume breathing. These repeated chronic disruptions in sleep can occur up to several hundred times per night, resulting in excessive daytime sleepiness. Unlike other sleep disturbances, children with OSA cannot return to sleep following the resolution of the problem or even catch up on their sleep during the day, because the OSA is a constant component of their sleep pattern. Children with OSA present with very restless sleep, characterized by loud snoring, snorting or gasping for breath, and intervening silences. These children arouse frequently during the night, toss and turn, sweat, and can fall asleep during the day at inappropriate times (Hansen & Vandenberg, 1997). They may have morning headaches, and they are at risk for the development of hypertension. Complaints of lethargy, daytime fatigue, and extreme difficulty waking in the morning are also common (Ware et al., 2001). Due to the frequent nocturnal arousals, excessive daytime sleepiness, and hypoxia, a child with OSA can suffer from inattention, decreased academic performance, oppositionality, and restlessness (Hansen & Vandenberg, 1997). Children who present with these difficulties should be assessed for OSA on a routine basis. Hansen and Vandenberg (1997) make a strong case for including routine screening questions about sleep into background information collected on every pediatric patient. OSA in children must be taken seriously, but it should be understood that it is not the same disorder as that which causes sudden infant death syndrome (SIDS). In most SIDS cases, the stopping of breathing does not involve airway obstruction; rather, the babies simply stop breathing. See Ware et al. (2001) for an in-depth discussion of SIDS. The average age for diagnosis of OSA is 7 years (Mauer, Staats, & Olson, 1983). Although OSA should not be diagnosed without PSG, the results are often difficult to interpret, given

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the few normative studies in this age group. An MSLT is also usually done (Mindell & Dahl, 1998). The most common causes of OSA among children are enlarged tonsils and adenoids. Other risk factors are obesity, oral or facial abnormalities (such as a markedly recessed chin or repaired cleft palate), Down’s syndrome, and cystic fibrosis (Ware et al., 2001). Treatment usually involves surgery to remove the airway obstruction (Croft, Brockbank, Wright, & Swanston, 1990), with tonsillectomy and/or adenoidectomy relieving symptoms in about 70% of all cases (Mindell & Dahl, 1998). Other treatments may include weight loss or the possible use of nasal continuous positive airway pressure, which has been effective for OSA in adults (Guilleminault, Riley, Powell, Simmons, & Nino-Murcia, 1985). In more severe cases a tracheostomy, in which a tube is inserted into a hole made through the neck below the vocal cords (larynx) and into the windpipe (trachea), may be performed (Ferber, 1985). Sleep–Wake Schedule Disorders It is not until about 6 months of age that infants have sleep–wake patterns that are synchronized by the clock. Infants who are premature or have had perinatal problems tend to take longer to settle into a regular sleep–wake pattern (Moore & Ucko, 1957). Once a child has settled into a pattern, this pattern can be disturbed by a number of factors, including the inconsistency of the daily schedule, parental response to the waking child, illness, environmental changes, and emotional trauma (Ware et al., 2001). Ferber et al. (1981) reported that 9% of the patients seen at their sleep disorders clinic had schedule problems. Prime clues that a schedule problem exists are that the child is not sleepy at bedtime, gets up too early, and sleeps at irregular times. Other daily activities, such as eating or playing, are also likely to be irregular. This problem is differentiated from bedtime struggles or night wakings in that children cannot fall asleep or go back to sleep no matter what their parents do, because they are in the wake phase of the sleep–wake cycle (Ferber, 1985). A daily rhythm of waking at a specific time in the morning, napping, going to sleep at a specific time at night, eating at set times, and having activities connected with light and dark are important for the body to establish a circadian rhythm that goes along with the family’s daily living routines. A consistent daily schedule is needed to solve this circadian rhythm disturbance, and most children respond fairly quickly, usually within a few weeks. Some children have consistent schedules and still have problems with the disturbance of their total amount of sleep throughout the 24-hour period (e.g. not sleeping through the night, waking very early in the morning, having too many or too few naps, or having a normal sleep– wake cycle that is out of phase with the rest of the household). Resolving these problems involves determining the total length of time the child sleeps per day, determining what factors may be interfering with establishment of a better pattern, and gradually changing the schedule (see Ferber, 1985, for a good discussion of this problem and treatment methods). Phototherapy (administering bright light pulses at appropriate times of the day) can also be helpful in treating circadian rhythm disorders (S. S. Campbell et al., 1995). Initiating and Maintaining Sleep Bedtime problems and/or frequent night wakings during sleep are very common problems among preschool children. Frequent night wakings occur in approximately 20% of 1- to 2-yearolds, 4% of 3-year-olds, and 8% of 4-year-olds (Jenkins, Bax, & Hart, 1980; Richman, 1981; Richman, Stevenson, & Graham, 1975). Difficulties with getting to bed are also common, oc-

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curring in 12.5% of 3-year-olds and 5% of 4-year-olds. These two problems are often found together; 55% of 1- to 2-year-olds and 29% of 3-year-olds who wake in the night also have trouble going to bed (Richman, 1981; Richman et al., 1975). Developmentally, problems with night waking occur before problems with falling asleep, which in turn precede problems with going to bed (Anders, Halpern, & Hua, 1992). In a study of 100 children ages 18–36 months, Crowell et al. (1987) demonstrated a developmental progression of sleep problems in this 1½-year age span. The youngest children (18–23 months) had the least difficulty with bedtime, but 21% of this group woke in the night. In the middle age group (24–29 months), bedtime problems increased; 20% fell asleep in their parents’ arms, and 31% took more than 30 minutes to fall asleep. In the oldest group (30–36 months), both bedtime problems and night wakings increased; 16% called to their parents or came out of their rooms after being put to bed, and 24% expressed fear of the dark. It is interesting that few parents saw these problems as significant enough to seek help. The behaviors that most concerned parents were cosleeping all or part of the night; a child’s resisting being alone in such a way as to make bedtime difficult or unpleasant; and a parent’s having to hold a child until he or she fell asleep. Crowell et al. (1987) concluded that the most prominent sleep problems—going to bed and going to sleep—mirror the developmental task of separation and independence. Other work suggests that many factors (e.g., infant temperament, nutrition, physical discomfort, milk allergy, marital/couple conflict, and maternal psychopathology) contribute to the development of sleep behavior problems, and that these may not be the same factors contributing to the maintenance of the problems (Anders & Eiben, 1997). Richman (1981), for example, found that difficult temperament and difficult birth histories were associated with sleep problems, but that these associations were not evident by age 3. Atkinson, Vetere, and Grayson (1995) found that although “difficult” temperament was significantly related to sleep problems in preschoolers, the parents were also a contributing factor. Similarly, a mother’s going to a child’s room was found to be associated with continued sleep problems in children who were born prematurely (Ungerer, Sigman, Beckwith, Cohen, & Parmelee, 1983). Finally, Gaylor, Goodlin-Jones, and Anders (2001) found that an infant’s ability to self-soothe at 12 months of age predicted night waking two years later. Sleep problems do not simply “go away” with time. In a sample of 8-year-olds who were waking during the night, Richman, Stevenson, and Graham (1982) found that 40% had had the problem since at least age 3. Kataria, Swanson, and Trevathan (1987) found that 84% of children with sleep problems at 15–48 months of age continued to have problems 3 years later. Persistent sleep problems were associated with increased stress in the environment, including unusual maternal absences, accidents and injuries of the child, family illnesses, and episodes of depressed maternal mood. In addition, 30% of these children had generalized behavior problems, as compared to 19% of non-sleep-disturbed children. Pollack (1994) also documented the continuity of night wakings in a national British cohort of 5-year-olds, in which 25% were reported by parents to have sleep problems; these problems were associated with sleep problems at ages 6 months and 10 years. Furthermore, the children with night waking at age 5 were more likely to report recurrent headaches and stomachaches, to have eating and appetite problems, and to have temper tantrums. Problems with initiating and maintaining sleep can be difficult to treat for a number of reasons. First, they occur at home and at night, so they cannot be readily observed; consequently, the clinician has to rely on the parents’ reports of the problem and of whether or not treatment is effective. Second, parents are typically asked to keep records and change their

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behavior in the middle of the night, when they are least alert. Third, the therapist cannot model the desired behavior. Finally, it is hard to use positive reinforcement to encourage development of new sleep-related behavior, especially with young children (Richman, Douglas, Hunt, Landsdown, & Levere, 1985). Medication is the most widely used treatment, although this is rarely necessary (Anders & Eiben, 1997). Ounsted and Hendrick (1977) reported that by 18 months of age, 25% of 59 first-born children had been given sedatives. In spite of this wide use of sedatives or hypnotics with children, there have been very few studies of their effectiveness. There is, however, an extensive literature on the side effects of drugs in adults with insomnia; these include deterioration in the quality of sleep and drug withdrawal insomnia (Kales, Bixler, Tan, Scharf, & Kales, 1974). The studies of drug effectiveness with children are no more encouraging. In a doubleblind trial of the hypnotic drug trimeprazine tartrate, Richman (1985) found that one-third of 22 children with severe waking problems showed no improvement even on relatively high doses; improvement was only moderate in the other subjects, and no child started to sleep through the night after its use. It is interesting that although the parents reported improved sleep, their sleep records did not support their oral reports. Richman concluded that strong hypnotics have little effectiveness for most wakeful children. Ware et al. (2001) point out that sedatives or hypnotics will suppress REM sleep, deep sleep, and wakefulness. Furthermore, tolerance develops as the use of a hypnotic continues, and a higher dose is required for the same effect. Ware et al. (2001) caution that hypnotic-like drugs used in any context may produce significant sleep and behavioral disturbances. Both Ware’s group and Anders and Eiben (1997) advise against the use of drugs; if used, they should be monitored with a form such as the Sleep Diary (see below) and should only be given for a brief period of time (a few days to, at most, a few weeks). A behavioral approach is the most effective treatment for problems with initiating and maintaining sleep. This can include a variety of techniques: gradual or rapid withdrawal of parental attention (Mindell, 1999), positive reinforcement of appropriate bedtime and sleep behavior, consistent bedtimes, shaping (making a gradually earlier bedtime), and cueing (making a clear distinction between daytime and nighttime activities) (Ware et al., 2001). Seymour, Brock, During, and Poole (1989) demonstrated the effectiveness of providing parents with written information in a standardized night waking program, which involved organized bedtime routines; procedures for settling the child; and instructions for handling crying, calling out, and getting out of bed. Although there is no one solution for all sleep problems, providing information to the parents about normal patterns of sleep and determining how they can change the environment and their responses to the behavior seem to constitute the most effective approach. Treatment of these problems is further discussed later in this chapter.

Parasomnias Parasomnias are disturbances during sleep or at the transition from sleep to wakefulness; they include nightmares, REM sleep behavior disorder, sleep rocking or head banging, sleep bruxism, sleep paralysis, and partial arousals from deep sleep (sleepwalking, sleep terrors, and sleeptalking). Nocturnal enuresis has also been put in this category, but there is evidence to suggest that it is not a disturbance of sleep, and it is not discussed here (see Chapter 4). Parasomnias are most common among children; perhaps 20% of all children experience at least one of these disturbances (Ware et al., 2001). Although parasomnias get a lot of attention, they generally occur infrequently in individual children, have no clear etiology, are not associated

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with psychopathology, and usually disappear with maturation (Pargja, de Pablos, Caminero, Millan, & Dobato, 1999). Because parasomnias are so common in young children, a brief description of each disorder mentioned above is given. Nightmares Nightmares, which occur in the REM stage of sleep, are frightening dreams that wake a person and leave him or her with a feeling of profound fear and anxiety. They usually occur in the last third of the sleep period. Nightmares are very different from night terrors, which are seen in the NREM sleep; they can easily be distinguished by the lack of physical activity during the nightmares, alertness upon awakening, and the ability to recall in detail the dream content. Children are also very likely to talk about nightmares in the morning. Nightmares are very common, with reports of 10–50% of all children between the ages of 3 and 6 years experiencing them (Mindell & Dahl, 1998). This may underestimate the prevalence of nightmares, however. Using a child self-report method, Muris, Merckelbach, Gadet, and Moulaert (2000) found that 67.7% of 4- to 6-year-olds, 95.7% of 7- to 9-year-olds, and 76.3% of 10- to 12-year-olds said they had scary dreams. According to these data, many children continue to have nightmares throughout childhood. Although more children report having scary dreams in the early elementary school years than at other ages (Muris, Merckelbach, Gadet, et al., 2000), referrals for problems with nightmares are more common for preschoolers and adolescents (Ferber, 1985). Nightmares appear to reflect stresses experienced during the day, and their content represents a developmental sequence of fears and concerns. Preschool children, for example, report scary dreams about imaginary creatures, personal harm, or harm to others and animals; older children report dreaming about being kidnapped, as well as continuing to dream of imaginary creatures and personal harm or harm to others (Muris, Merckelbach, Gadet, et al., 2000). Stressful times and traumatic events can also exacerbate nightmares, and they are often associated with posttraumatic stress disorder. Support for the hypothesis that troubled sleep reflects emotional concerns is provided by case studies and in an empirical study by Dollinger, Horn, and Boarini (1988), who found nightmares to be more common among learning-disabled students who were concerned about their intellectual and academic adequacy. However, work with adults indicates no relationship between nightmares and anxiety (Wood & Bootzin, 1990). Some medications (e.g., beta-blockers and antidepressants) are associated with nightmares, and withdrawal from other medications (e.g., barbiturates, benzodiazepines) can cause nightmares (Mindell & Dahl, 1998). Almost all children will have a nightmare at some time in their lives, and 10.9% are reported to have them once a week or more (Fisher & Wilson, 1987). Frequent or persistent nightmares may reflect inordinate stress during the day and should prompt an inquiry about other problems. Whereas nightmares per se are not seen as pathological, they can result in disturbed sleep and fear of going to bed (Dollinger et al., 1988). Treatment approaches for nightmares are discussed in a later section of this chapter. REM Sleep Behavior Disorder REM sleep behavior disorder occurs as a result of an unusual lack of muscle paralysis during REM sleep, which allows the physical acting out of nightmares (Ware et al., 2001). Although

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it is rare in children, it has been reported in children as young as 22 months old (Herman, Blaw, & Steinberg, 1989; Sheldon & Jacobsen, 1998). In over half of these cases there is some identifiable neuropathology; treatment with a benzodiazepine (e.g., clonazepam) is effective in 80% of the cases. Sleep Rocking and Head Banging Rhythmical movements of a child’s body during sleep usually begin around 6 months of age. Head banging and head rolling are seen at about 9 months, with 60% of 9-month-olds engaging in these behaviors (Mindell & Dahl, 1998). These behaviors tend to decrease with age, occurring in 22% of children under 2 years but only about 5% of children after age 2; they usually disappear by age 4 (Mindell & Dahl, 1998). Rocking and head banging typically occur at sleep onset and/or during the middle of the night as the child goes back to sleep after waking up. Episodes usually last from 5 to 15 minutes, but can continue as long as 1–4 hours. Ferber (1985) states that if the rhythmical patterns are strong, last longer than 15 minutes, and recur repeatedly during the night, additional problems (such as parental attention to the behavior or, in an older child, other behavioral or emotional problems) may need to be assessed. The head banging, head rolling, and body rocking associated with blindness, mental retardation, and autism should be distinguished from these behaviors in normally developing children, who probably engage in these behaviors to soothe themselves to sleep. No treatment is suggested for a young child, but parents may be advised to pad the crib, to have the child wear a helmet, or to have the child sleep on a mattress on the floor to decrease the noise of the rocking crib or bed. Sleep Bruxism The repetitive grinding of teeth or clenching of jaws during sleep can occur at any age and is very common among children; over 50% of normal infants and 15% of children between 3 and 17 years old engage in this behavior (Mindell & Dahl, 1998; Reding, Zepelin, Robinson, Zimmerman, & Smith, 1968). Bruxism can occur while an individual is awake or asleep (see Chapter 5 for a brief discussion of the waking variety); if it is severe, may necessitate the use of a tooth-protective device. Although there is some evidence that stress may play a part in this problem, bruxism is generally benign and resolves with time (Ware et al., 2001). Persistent or severe cases resulting in headaches or jaw pain are treated with biofeedback and stress management (Mindell & Dahl, 1998). Sleep Paralysis Sleep paralysis occurs at the onset of sleep or upon awakening and is distinguished by a person’s not being able to make voluntary movements. Ware et al. (2001) explain this phenomenon as related to REM sleep when the person actually awakens, but the paralysis that accompanies REM sleep remains. Though temporary and not harmful, it can be a frightening experience, especially if it is accompanied by hallucinations. It is a problem that often runs in families. Movement can usually be restored by rapid eye movements or the touch of another person. No treatment other than reassurance is usually necessary. Sleep paralysis, however, can be associated with narcolepsy, so this association should be considered when one is evaluating either problem.

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Partial Arousals Sleepwalking, sleep terrors, and sleeptalking are all variations of partial arousals from deep sleep (NREM stages 3 and 4). Since children are in deep sleep 1–3 hours after sleep onset, these problems usually occur when a child is making the transition from these deep stages to a lighter stage of sleep or REM sleep. Most of these problems decrease with age, as the number of deep sleep stages drops off in adolescence. There is no evidence that partial arousals result from psychological problems (Auchter, 1990), but they can be precipitated by fever, sleep deprivation, stress, and some medications (e.g., lithium, prolixin, and desipramine) (Klackenberg, 1982). There may be a genetic component in sleep arousals, since there is often a family history of similar sleep problems (Mindell & Dahl, 1998). Children are not easily awakened, wake in a state of confusion, and do not remember the event in the morning. Sleepwalking. Although sleepwalking usually occurs in stage 4 of NREM sleep in the first third of the night, it can occur at other times (Fisher & Wilson, 1987). Most children sit up in bed with a glassy stare and may walk for a few seconds to several minutes. Mean age of onset is 5–6 years, and prevalence is highest in children ages 9–12 years, with rates as high as 18.5%. Most children, however, have infrequent episodes (Kales et al., 1980; Klackenberg, 1982; Fisher & Wilson, 1987). A sharp noise or standing the child on his or her feet can precipitate an episode (Broughton, 1968). Sleepwalking should be differentiated from a seizure disorder. If sleepwalking occurs in the early morning, when stage 4 sleep is less concentrated, it could suggest a seizure disorder (Ware et al., 2001). Other sleep disturbances (such as OSA, which decreases the quality of sleep) may be present and contribute to the sleepwalking. Since sleepwalking can be exacerbated by fatigue, it is important for a child to get sufficient sleep on a regular schedule. If stress or anxiety is present, then treatment of these issues may be necessary. Interrupting the partial arousal by waking the child 30 minutes before the expected sleepwalking episode (as determined from a Sleep Diary) for 1 month has also been found to eliminate the problem (Frank, Spirito, Stark, & Owens-Stively, 1997). Management of the sleepwalking episode should consist of preventing accidents, calmly leading the child back to bed, and doing nothing until the child is calm (if he or she is agitated). Sleep Terrors. Sleep terrors usually occur within 15–90 minutes of sleep onset, first appear after 18 months of age, and are most common in preschool children. Sleep terrors resolve with central nervous system maturation. They are less frequent than sleepwalking, with estimates of prevalence ranging from 1–6% of children (American Psychiatric Association, 1994). Sleep terrors are characterized by intense sudden arousal, a loud panic-stricken scream, rapid pulse and respiration, profuse perspiration, and a glassy stare; the child often has strange fears and is inconsolable (Zuckerman & Blitzer, 1981). Sleep terrors can last up to 20 minutes, although they usually end quickly, with the child becoming calm and continuing to sleep. During sleep terrors, it is difficult to awaken the child, and he or she has no memory of the episode. Although sleep terrors are not associated with psychiatric disturbance, they may be precipitated by stressful life events. They are also known to occur during an illness with a high fever (Kales, Kales, Soldatos, Chamberlin, & Martin, 1979). Parents are usually very frightened when sleep terrors occur in their children, and they should be given information and reassurance. Exacerbating factors such as sleep deprivation (which increases deep sleep), the use of stimulants such as caffeine (which can cause fragmented sleep), a chaotic sleep schedule, a stressful environment, or other sleep problems (e.g., OSA)

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should be assessed and treated. Awakening the child 30 minutes prior to the sleep terror (as determined by keeping a Sleep Diary for 1 month) also disrupts the partial arousal and eliminates the problem, as with sleepwalking (Durand & Mindell, 1999). Although they are not recommended, medications that decrease stage 4 sleep, such as benzodiazepine (e.g., diazepam) or a tricyclic antidepressant (e.g., imipramine) can temporarily improve night terrors. These medications should be stopped gradually, as abrupt withdrawal can cause a rebound in partial arousals (Mindell & Dahl, 1998). During a sleep terror episode, parents should be encouraged simply to keep the child safe, since consolation or trying to awaken him or her usually does not help. It is also not wise to discuss the sleep terror episodes in any detail with the child, since this might increase his or her fear of going to sleep. Sleeptalking. “Somniloquy,” or spontaneous speech during REM or NREM sleep, is a very common behavior, with reports in the general population as high as 50–60% (Coates & Thoresen, 1981; Fisher & Wilson, 1987). Sleeptalking appears to be associated with sleepwalking and nightmares (Fisher & Wilson, 1987) and is not associated with pathology. Although it is rarely a major problem, decreasing factors that increase partial arousals (e.g., fatigue, stress, caffeine, etc.) should improve this problem.

ASSESSMENT OF SLEEP PROBLEMS A sleep disturbance may represent an isolated problem, or it may become evident in the process of evaluating other behavioral or emotional problems. The questions regarding sleep on screening questionaires such as the CBCL (Achenbach, 1991a, 1992) or Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999) should be carefully reviewed and investigated, regardless of the presenting problem. The assessment process described here follows the steps for gathering information in accordance with the Comprehensive Assessment-to-Intervention System (CAIS) presented in Chapter 2; the emphasis here is on those factors particularly important in assessing and treating disturbances of initiating and maintaining sleep, since these are the most common sleep problems in childhood.

Step 1: Initial Contact The parents should be asked to complete a general questionaire (e.g., our General Parent Questionnaire; see Appendix B) with demographic information, as well as their view of the problem and what they have been told and/or done thus far. The CBCL screens for general behavioral/emotional problems; the ECBI determines the extent of problems in daily activities, as well as around bedtime; and the Parenting Stress Index (PSI; Abidin, 1995) gives information on the child’s temperament and the parents’ general levels of stress. A sleep questionnaire such as the Albany Sleep Problem Scale (Durand, Mindell, Mapstone, & Gernert-Dott, 1998) can also be very helpful. In addition, parents should be asked to complete a Sleep Diary (Figure 6.1) prior to the initial visit, to gather specific information on the child’s sleep pattern and the parents’ response to it. This should include napping, daytime sleepiness, bedtimes, and night awakenings over 24-hour periods for at least 1 week and preferably 2 weeks. The importance of a Sleep Diary for assessing the problem and determining the effectiveness of treatment cannot be overemphasized. When parents are tired or have had a particularly bad

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Sleep Diary Time Date Awake

Mood

Naptime

Bedtime

Time Asleep

Parent Bedtime

Night Wakings

What Did

Time Asleep

12:00 3:00 5:00

Rocked Milk Talked

12:20 3:30 5:10

Comment

Sample 6:00 A.M

Happy

1:00–3:00

9:00

10:20

11:00

200 FIGURE 6.1. Chart for recording periods of sleep. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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night, their perception of the problem is not always an accurate reflection of the actual behavior (Ferber, 1985; Richman, 1985).

Step 2: Parent and Child Interviews Parent Interview The parent interview should be developmentally appropriate and culturally sensitive, with a focus on both sleep and waking behavior. It is important that both parents attend the initial interview. A father and mother are likely to handle sleep problems differently, with a mother tending to be more nurturant (taking a child into her own bed, feeding the child at wakings) than a father (Crowell et al., 1987). It is usually best not to have the child accompany the parents to the initial interview, especially an older child (who may have his or her own perceptions of the problem, and may also be able to describe more accurately how he or she feels about the problem and handles the situation). The focus of the parent interview should be on the child’s general development and behavior; a history of the sleep problem, as well as its current status; the environmental/social context of the problem; and the parents’ level of stress. Specific questions include the following: 1. Development. What was the child’s birth history? Was the child premature, or were there perinatal risk factors? Were developmental milestones achieved normally? 2. Behavior. The screening instruments will give information in this area, and the interview should follow up on any concerns, especially noncompliance. About one-third of children presenting with sleep problems also have more generalized behavior problems (Richman, 1981). The clinician must determine whether these other behaviors should be treated first, or whether treatment of the sleep problem will aid in the resolution of the other problems. Given the impact that a sleep problem can have on the child and family, and the parents’ desire to get help with this problem, it is usually best to focus initially on the sleep problem unless the child is generally noncompliant. How the parents have handled behavior problems in general can provide helpful information on how to structure the intervention. Most sleep problems are circumscribed, and daytime behavior is not highly correlated with nighttime behavior, especially after 3 years of age (Crowell et al., 1987). It should be remembered, however, that a disturbance such as OSA can profoundly affect the child’s daytime behavior, resulting in poor school performance, inattentiveness, fussiness, poor coordination, and complaints of laziness. 3. Medical history. What illnesses has the child had (e.g., chronic ear infections, asthma, allergies, seizures, atopic eczema, other chronic illness)? A history of medication use is especially important to obtain. Is the child taking (or has he or she recently stopped taking) any medication, such as antihistamines, seizure medication, sedatives, or stimulants? Has the child ever had a head injury? Disturbed sleep has also been associated with fibromyalgia syndrome in children (Siegel, Janeway, & Baum, 1998), juvenile rheumatoid arthritis (Zamir, Press, Tal, & Tarasiuk, 1998), and autism (Tiara, Takase, & Sasaki, 1998). 4. History of the sleep problem. Information about the onset of the sleep problem helps differentiate developmental from pathological problems and gives potential information on any associated events. Have there been changes in the child’s daily routine (e.g., starting preschool or a new school, the birth of a sibling, moving to a new bed or bedroom)? Have there been changes in the family routine (e.g., an illness or hospitalization, unusual parental absence, a death, a divorce, overnight guests)?

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5. Current sleep status. The Sleep Diary provides a good starting point for gathering information on a particular problem. An important area to assess is the time of occurrence: Does the problem happen in the first or last part of the night? Are there problems with initiating sleep, night wakings, or early morning rising? For events like sleep terrors, it is important to determine the actual clock time of the events and their timing in relation to sleep onset. The clinician should also determine the frequency of occurrence (has the problem increased, and if so, in what way?) and the nature of the sleep behavior (what does the child do, and how does he or she look, while asleep?). The presence of other sleep problems should be assessed: (Does the child snore? Stop breathing? Are there other sleep-related behaviors (e.g., sleepwalking, sleeptalking, enuresis, head banging, or rocking)? What is the child’s total sleep time? How is sleep distributed over 24 hours? Is the child easily awakened? How long to sleep onset? Is the child sleepy during the day, or are there complaints about inattentiveness or laziness? Finally, is the child anxious or worried about the problem? 6. Sleep habits and schedule. It is important to get descriptions of current family sleep practices. Just as there are predictable physiological patterns of sleep, most children develop presleep behavior patterns between the ages of 2 and 5 years. These serve the purpose of calming the children and preventing sleep-related anxiety; they include such bedtime rituals as hearing a story, saying prayers, saying “good night” to stuffed animals, cuddling with a special toy, and so on. What are the bedtime demands on the child? Is the child expected to go to sleep when the house is full of activity? Are daytime activities sufficiently separated from nighttime activities? What is the temperature in the room, and is it lit? What is the bedtime schedule? Are the times unrealistic for the child’s age (too early or too late with regard to time of arising)? 7. Daytime activities. Does the child’s schedule include regular exercise, and if so, when does it occur? Are meals at regular times? Are the meals or exercise occurring too close to bedtime? What snacks are given before bed (e.g., caffeinated beverages or chocolate and sweets vs. a light snack that improves sleep)? How many naps are taken during the day, how long are they, and are they taken at regular times? There is a negative correlation between the length of daytime sleep and nighttime sleep; thus as a child moves from the 16-hour daily sleep requirement of the infant to the 10-hour requirement for the adolescent, the naps should also decrease, although the child may still have a quiet time. 8. Family sleep history. Do other members of the family have similar sleep problems? If so, what was their course, how were they treated, and how were they viewed? 9. Parents’ response to the sleep problem. How have the parents handled the problem? What advice have they been given? What have they tried, and for how long? What have they told the child? How is the problem affecting other people in the family? How anxious are the parents about the problem? Why are they seeking help now? 10. Parental/social/environmental issues. The General Parent Questionnaire and the PSI should alert the clinician to potential contributing problems in these areas. Problems such as unaccustomed parental absences, maternal depression, marital/couple conflict, hospitalization of a family member, or the birth of a sibling can precipitate or exacerbate a sleep disturbance. Information about the parents’ mental and physical health status, support networks, the family’s daily routine, and the home environment can shed light on what may be maintaining the problem. Child Interview Depending on the type of sleep problem, the age of the child, and the presence of other problems, a separate interview with the child may be indicated. Generally, it is not helpful to inter-

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view a preschool child alone; a school-age child who is having sleep problems, however, should be interviewed alone. The focus should be on the child’s general adjustment to friends, school, and family, as well as his or her perceptions of the sleep problem. Coverage of the problem should include a description of what it is, how often it occurs, how the parents have viewed and handled it, what the child has done to resolve it, and how the child views it.

Step 3: Observation of Behavior The Sleep Diary serves as the source of observational data for sleep problems. If a referral is made to a sleep disorders center, then further observation will be done in that facility. There are also new technologies that can be employed in the home, such as 24-hour ambulatory monitoring; electronic detectors in mattresses that track body movements and respiration; and portable, time-lapse, infrared videosomnography (Anders & Eiben, 1997).

Step 4: Further Assessment Further assessment is indicated if the child or family presents with problems beyond those associated with the sleep problem. If the child has trouble in school, for example, or has other emotional/behavioral problems, it would be important to further evaluate these areas. If there are marital/couple problems or if there is evidence of parental psychopathology, these should be evaluated or referred for evaluation.

Step 5: Referral to Allied Health Professionals If there are medical problems, or the child is or has been taking medication, it is important for the clinician to contact the child’s physician. If the child is taking sedatives for the sleep problem, then these should be discontinued before behavioral treatment begins. For such problems as allergies, asthma, or seizures, for which treatment often involves medication that can cause sleep problems, it may be possible to make changes in the medication, the dose, the time of dose, or the medium in which it is delivered. If the child has been taking antibiotics, for example, the sleep problems may be caused by additives in the medium in which the antibiotics are given. If there is any suspicion of narcolepsy or OSA, the child should be referred to a sleep disorder center. A referral to a sleep disorders center is also appropriate if a severe sleep problem is persistent and unresponsive to treatment.

Step 6: Communication of Findings and Treatment Recommendations In an assessment that has followed the CAIS, problems (and the focus of treatment) may have been identified in the child’s development, in the parents’ perceptions and handling of the problem, in the environment, in medical issues, and/or in the consequences of the problem for the child and family. The nature of the sleep disturbance, the clinician’s view of the problem, and possible treatment strategies should be shared with the parents. The clinician should also discuss the implications of the sleep problem for the child’s development in other areas (e.g., independence, mastery). In the treatment of a sleep disturbance, the clinician is primarily a consultant to the family members who must carry out the actual treatment program. Giving parents information on normal sleep states and patterns, with an emphasis on how their child’s

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disturbance fits into this process, can both relieve the parents’ fears about the problem and ensure their understanding of and cooperation in selecting and carrying out appropriate treatment strategies. The parents’ clear understanding of the nature of the problem and the rationale for the treatment plan is essential to gaining their trust and cooperation.

TREATMENT OF SLEEP PROBLEMS Treatment of children’s sleep disturbances will of course vary, depending on the nature of the problem. Even though many sleep problems appear topographically similar, the etiology of the problem will vary for each child and family. These individual differences must be taken into account when one is planning a treatment program. In addition, environmental influences on disturbed sleep are cumulative, so that what happens one day may not be the same the next day. Factors related to the parents can also influence the course of treatment for any problem, but this is particularly true for sleep problems. In many cases, it is clear that parents who seek help with their children’s sleep disturbances have emotional or marital/couple problems that contribute significantly to their children’s problems. In such a case, treatment for the sleep disturbance per se is not likely to be effective. A mother who is depressed, for example, or a parent who is recovering from a serious illness, is not in the best position to insist that a 2-yearold sleep in his or her own bed when the child wakes in the middle of the night. To recommend that the parent do this without consideration of the parent’s own emotional state is likely only to make the problem worse. It is best to support such a parent in getting personal help or recovering from the illness before helping the child to sleep alone. In the meantime, it is better for the parent to handle the behavior in a consistent manner, such as lying down with the child every night as the child goes to sleep or allowing the child to sleep with a member of the family. However, parents also should be encouraged to set regular and appropriate bedtime schedules with good prebed routines. Group treatment and written materials have been found useful for a number of sleep problems (Mindell, 1999). Wolfson, Lacks, and Futterman (1992), for example, used a group format to teach prospective first-time parents behavioral strategies to promote healthy, selfsufficient sleep patterns in their infants. At the ages of 6–9 weeks, the infants of the trained parents had significantly better sleep patterns than a control group. Furthermore, the parents in the training group reported less stress and a sense of greater parental competence. This section focuses on treatment approaches that are appropriate for the more common sleep disturbances: sleep–wake schedule problems; bedtime struggles and night waking; and bedtime fears and nightmares. The information needed by parents for managing other sleep problems is shown in Table 6.2. For a more in-depth discussion of treatment strategies, see Durand et al. (1998).

Sleep–Wake Schedule Problems Sleep–wake schedule problems can occur when daily routines are irregular, when a child naps at inappropriate times or for too long a time, or when the child’s normal sleep–wake schedule does not fit into the family’s routine. The parents should be given information on circadian rhythms, the average amount of sleep expected for the age of their child, the advantages and disadvantages of naps at various ages, and the importance of establishing regular routines throughout the day and night.

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TABLE 6.2. Methods for Managing Children’s Sleep Problems Sleep Problem

Treatment

Description

Dyssomnias: Difficulties in initiating or maintaining sleep or day time excessive sleepiness Sleep–wake schedule

Information

Bedtime routine

Bedtime fading

Daily routine

Bedtime struggles, night waking, or early rising

Information

Bedtime routine

Gradual extinction

Scheduled waking

Excessive sleepiness

Information

Establish daily routines Narcolepsy

Information Establish sleep schedule

Sleep apnea

Information Medical

Give information on the effect of the circadian rhythm on sleep–wake cycle, appropriate sleep for age, importance of routines appropriate to day and night. Establish a consistent, unstimulating routine beginning about 30 minutes prior to bedtime (e.g., bath, story) that always leads to bed. Find time child consistently falls asleep, then systematically make bedtime 15 minutes earlier until child is falling asleep at desired time. Establish consistent routine regarding arising, eating, exercise, activities, and bedtime to conform to night and day. Give information on appropriate sleep for age; reasons for night waking, (REM-NREM cycles); and importance of bedtime routines and of learning to fall asleep independently. Establish consistent unstimulating bedtime routine beginning about 30 minutes prior to bedtime (e.g., bath, story) that always leads to bed. Have parents check on the child after progressively longer periods of time, until child falls asleep on own. For early morning rising, wait to go to the child for progressively longer periods of time. For children with frequent night wakings, have parents wake them 60 minutes before usual awakening. This teaches them to go back to sleep on their own when aroused from deep sleep. Give information about appropriate sleep for age, after ruling out medical or psychological problems that could affect the quality of sleep (e.g., medicine, narcolepsy, sleep apnea, and depression). Eating, sleeping, exercise, and social activity routines should be consistent. Give information on the disorder and its effects on the child. Bedtimes and scheduled short naps should be consistent. Give information on the disorder, its effects on the child, and lack of relationship to SIDS. Surgery to remove airway obstruction (e.g., tonsils, adenoids). Continuous positive nasal airway pressure to keep airway open. Tracheostomy for severe cases.

Parasomnias: Problems that occur during sleep or at transition from sleep to wakefulness Nightmares

Support for child

Parents should have child describe nightmare; use a night light, and be calm but firm that nothing will happen to harm the child; and explain dreams versus reality.

(cont.)

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TABLE 6.2. (cont.) Sleep Problem

Treatment

Description

Progressive relaxation Systematic desensitization

Teach relaxation skills and pair with pleasant imagery at bedtime and upon waking in the night. Build a fear hierarchy and gradually pair items with relaxation and pleasant imagery. Have child practice at bedtime. Have the child play out fear or nightmare and take an active role in vanquishing the fear. Reward child for using coping skills and staying calm for progressively longer periods of time.

Coping skills Contingency management Sleep terrors

Information

Scheduled waking

Explain how sleep terrors fit into the sleep cycle; stress the importance of keeping the child safe and not giving details of the episode to the child. Have parents awaken child 30 minutes before usual time of night terror.

Sleeptalking

Information

Explain that sleeptalking is innocuous but that fatigue, stress, and/or caffeine can increase it.

Sleepwalking

Information

Give information about the problem and the need for accident prevention. Parents should calmly return child to bed. Have parents awaken child 30 minutes before expected episode for 1 month.

Scheduled waking Sleep paralysis

Information

Explain nature of problem and give reassurance. Parents should encourage eye blinks or give light touch to restore movement.

Rocking and head banging

Information

Explain the normal progression of the behavior and its probable causes. Have parents pad the crib, use a helmet, or have the child sleep on a mattress on the floor.

Protective measures Sleep bruxism

Information Tooth-protective device Biofeedback and stress management

Discuss possible sources of stress. Have child wear device to reduce pressure and protect teeth. Use in cases where headache or jaw pain persist.

Note. Adapted from Durand, Mindell, Mapstone, and Gernert-Dott (1998). Copyright 1998 by Plenum Publishers. Adapted by permission.

Parents should be helped to adjust the child’s schedule gradually to the family’s routine or, conversely, to reorganize the family’s routine in order to accommodate a routine for the child. Depending on the basis of the problem, changing the child’s irregular sleep patterns may involve setting up regular daily schedules for going to bed, arising, eating, and exercising; clearly separating day and night activities; and providing cues for the child when it is time to sleep by establishing bedtime routines and rituals that are not stimulating. Treatment may also involve gradually establishing later or earlier bedtimes and/or waking the child earlier from naps and in the morning. This can be done by changing the current bedtime or waking time by 15 minutes every 2 days until the desired time is reached. Establishing an appropriate sleep–

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wake schedule, or changing an inappropriate one, must occur gradually and should be accomplished over a 1- to 3-week period.

Bedtime Struggles and Night Waking For the 6- to 24-month-old who is still waking several times a night, the parents should be given information on the usual distribution of sleep at various ages, the reasons for the normal wakings every night (NREM-REM cycles), and an explanation of how the child may be relying on the parents to go back to sleep or how parental responses are maintaining the behavior. Likewise, bedtime struggles can be understood in terms of the normal but often difficult separation that going to sleep alone involves. It should be explained how good bedtime routines and rituals help decrease the child’s anxiety about going to sleep, and how parental responses can change the behavior without causing psychological problems for the child. Treatment of bedtime struggles and night wakings involves techniques that focus on helping the child learn new and more independent bedtime behaviors. This essentially involves helping the child learn the task of falling asleep on his or her own. The most successful approaches to these problems involve the following steps (Mindell, 1999): 1. The parents should establish good bedtime routines and rituals (including quiet activities, appropriate snack, a story, etc.) as ways to cue the child that it is time to sleep. 2. The child’s need for the parents should be eliminated by withdrawing parental attention after saying good night, either gradually or by extinction through totally withdrawing all attention (i.e., not talking to the child, not going back into the child’s room, and closing the door). A review of empirically tested interventions for these problems indicated that although extinction is a well-established and effective treatment, parents find it difficult to implement; they cannot tolerate the child’s crying and worry about the psychological effects on the child (Mindell, 1999). Both clinical and research data indicate, however, that there is no psychological damage to the child with this technique. France (1992), for example, found no evidence of detrimental effects on 35 children (6–24 months of age) treated with extinction for sleep problems. These children’s scores on security, emotional tension, and likability actually improved after treatment! Despite this evidence, most parents find a gradual approach more tolerable, but it is important that they be given specific instructions on how to do this and follow an agreedupon schedule of time spent with the child. As an example, if the child is used to being nursed to sleep, the first step should be to stop nursing before bed, but replace it with holding the child and reading a book or singing. The child should be put to bed just before he or she falls asleep. If the child cries when the parent leaves the room, the parent should return to the child on the schedule recommended by Ferber (1985) as shown in Table 6.3. For an older child who is capable of leaving the room, the parent should follow the schedule for closing the door as shown in Table 6.4 (Ferber, 1985). The waiting times have varied in different studies, but there is support for the efficacy of this approach. Two studies had parents wait for progressively longer periods of time, in 5-minute increments, before checking on the child. Each subsequent night the first period to wait was increased by 5 minutes, with the longest period being 20 minutes (Durand & Mindell, 1990; Mindell & Durand, 1993). The extinction method is especially appropriate for parents who have tried many techniques without success, are able to tolerate crying, or want a fast cure. It involves letting the child know that the parent will not return to the room after saying good night. If necessary, the parent should be instructed to hold the door closed until the child is quiet. A chain lock that

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TABLE 6.3. Number of Minutes to Wait before Going In to Your Child Briefly If your child is still crying Day 1 2 3 4 5 6 7

At first wait

Second wait

Third wait

Subsequent waits

5 10 15 20 25 30 35

10 15 20 25 30 35 40

15 20 25 30 35 40 45

15 20 25 30 35 40 45

Note. From Ferber (1985). Copyright 1985 by Richard Ferber, MD. Reprinted by permission. 1. This chart shows the number of minutes to wait before going in if your child is crying at bedtime or after nighttime wakings. 2. Each time you go in to your child, spend only 2 to 3 minutes. Remember, you are going in briefly to reassure him and yourself, not necessarily to help him stop crying and certainly not to help him fall asleep. The goal is for him to learn to fall asleep alone, without being held, rocked, nursed, or using a bottle or pacifier. 3. When you get to the maximum number of minutes to wait for that night, continue leaving for that amount of time until your child finally falls asleep during one of the periods you are out of the room. 4. If he wakes during the night, begin the waiting schedule at the minimum waiting time for that day and again work up to the maximum. 5. Continue this routine after all wakings until reaching a time in the morning (usually 5:30 to 7:30 A.M.) you have previously decided to be reasonable to start the day. If he wakes after that time, or if he is still awake then after waking earlier, get him up and begin the morning routines. 6. Use the same schedule for naps, but if your child has not fallen asleep after one hour, or if he is awake again and crying vigorously after getting some sleep, end that naptime period. 7. The number of minutes listed to wait are ones that most families find workable. If they seem too long for you, use the times shown on the chart in Table 6.4 (though without closing the door). In fact, any schedule will work as long as the times increase progressively. 8. Be sure to follow your schedule carefully and chart your child’s sleep patterns daily so you can monitor his progress accurately. 9. By day 7 your child will most likely be sleeping very well, but if further work is necessary, just continue to add 5 minutes to each time on successive days.

allows the child to see outside the room but not get out is often helpful in extreme cases. In our experience, simply putting the lock on the door is enough to remind the child that he or she must stay in the room. If the lock is used, the parents should be clearly instructed to unchain the door when the child is quiet or has gone to sleep. For children 2 years or older, reading a story about a child who has experienced a similar problem and what was done about it helps them understand what will happen, and also helps the parents and other caregivers be consistent in carrying out the program. We use a story called “I’ll See You in the Morning,” which is adapted from a story by Ann Spitznagel (1976) (see Table 6.5). 3. The parents should provide praise for good nighttime behavior and a sticker for each night the child goes to bed quietly and stays in bed. A sticker chart that is hung on the back of the child’s door provides extra motivation. 4. The parents should continue using the Sleep Diary to keep data. This allows them to see the progress that the child is making when it is difficult to “feel” the difference between 60 and 45 minutes of crying. The child’s sleep disturbance should resolve in a few days with this approach to treatment, but long-standing problems may take up to 3 weeks. 5. Parents may also benefit from reading Sleeping Through the Night: How Infants, Toddlers, and Their Parents Can Get a Good Night’s Sleep (Mindell, 1997) or The Sleep Book for Tired Parents: Help for Solving Children’s Sleep Problems (Huntley, 1991). Our favorite bedtime book for young children is Goodnight Moon (Brown, 1947/1991).

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TABLE 6.4. Number of Minutes to Close the Door If Your Child Will Not Stay in Bed If your child continues to get out of bed Day 1 2 3 4 5 6 7

First closing

Second closing

Third closing

Fourth closing

Subsequent closings

1 2 3 5 7 10 15

2 4 5 7 10 15 20

3 6 7 10 15 20 25

5 8 10 15 20 25 30

5 8 10 15 20 25 30

Note. From Ferber (1985). Copyright 1985 by Richard Ferber, MD. Reprinted by permission. 1. This chart shows the number of minutes to close your child’s door if he will not stay in bed at bedtime or after nighttime wakings. 2. When you get to the maximum number of minutes for that night, continue closing the door for that amount of time until he finally stays in bed. 3. Keep the door closed for the number of minutes listed, even if your child goes back to bed sooner. However, you may talk to him through the door and tell him how much time remains. 4. When you open the door, speak to him briefly if he is in bed, offer encouragement, and leave. If he is still out of bed, restate the rules, put him back in bed (if it can be done easily), and shut the door for the next amount of time listed. If he lets you put him back easily and you are convinced he will stay there, you may try leaving the door open, but if you are wrong, do not keep making the same mistake. 5. If your child wakes during the night and won’t stay in bed, begin the door-closing schedule at the minimum time for that day and again work up to the maximum. 6. Continue this routine as necessary after all wakings until reaching a time in the morning (usually 5:30 to 7:30 A.M.) previously decided to be reasonable to start the day. 7. Use the same routine at naptimes, but if your child has not fallen asleep after one hour, or if he is awake again and out of bed after getting some sleep, end that naptime period. 8. If he wakes and calls or cries but does not get out of bed, switch to the progressive routine described in Table 6.3. 9. The number of minutes listed to close the door are ones that most families find workable. However, you may change the schedule as you think best as long as the times increase progressively. 10. Be sure to follow your schedule carefully and chart your child’s sleep patterns daily so you can monitor his progress accurately. 11. Remember that your goal is to help your child learn to sleep alone. You are using the door as a controlled way of enforcing this, not to scare or punish him. So reassure him by talking through the door; do not threaten or scream. By progressively increasing the time of door closure, starting with short periods, your child does not have to be shut behind a closed door unsure of when it will be opened. He will learn that having the door open is entirely under his control. 12. By day 7 your child will most likely be staying in bed, but if further work is necessary, just continue to add 5 minutes to each time on successive days. 13. If you prefer you may use a gate instead of a closed door as long as your child can’t open or climb over it. In this case you must be out of his view during the periods of gate closure, but you can still talk to him reassuringly from another room.

Bedtime Fears and Nightmares The nature of nightmares can make some children afraid to go to bed for fear that a nightmare will recur. For other children, the content of the nightmare (monsters, etc.) is associated with going to bed and nighttime. Therefore, if a child is afraid to go to sleep, the clinician should determine whether this fear has been precipitated by nightmares. If the problem is one of nightmares, parents need to know when dreaming occurs during the sleep cycle. Parents should be made aware that nightmares can be the result of trying to understand or deal with new or frightening stimuli encountered during the day. They can then understand the need to support the child and desensitize him or her to the feared stimuli, rather than insisting that the child avoid all potentially frightening material on TV or in daily activities.

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TABLE 6.5. I’ll See You in the Morning! There once was a little girl named Susie who lived in an apartment with her mommy and little brother. Every night when her mother put her to bed, Susie would get out of bed and cry for her mommy to lie down with her. She said that she could not go to sleep without her mommy beside her. If Susie woke up in the middle of the night, she would either go to her mommy’s bed or her mommy would have to come to Susie’s bed. One night her mommy said, “This is silly. My little girl is growing up to be a big and helpful girl. She can learn to sleep by herself. It will be good for her to know that she can go to bed any time without her mommy. It will be good for everyone else, too. I can get my housework done, or take a bath, and go to bed any time I want.” So one night, Susie’s mommy told her that things would be different that night. Her mommy said: “Tonight I am going to read you a story and then say ‘Good night, I’ll see you in the morning,’ and leave the room. I am not going to come back to see you if you cry. If you come out of the room, then I will take you back and close the door until you stop crying. I am not going to talk to you until the morning. If you wake up at night I am going to take you back to your own room, and if you come out I will close the door.” Susie’s mother knew that this might be hard for her little girl, so she said, “If you go to bed quietly, I will give you a sticker, and if you stay in your room all night, I will give you another pretty sticker in the morning.” That night the mommy read Susie a story, kissed her, and said “Good night, I’ll see you in the morning!” Then when Susie cried, her mommy did not go back to the room. Susie cried harder and harder, but her mommy did not come. Susie went to find her mommy. Her mommy took her right back to the room and closed the door. Susie said to herself, “This is silly to cry. Mommy is not going to talk to me until the morning. I am OK in my bed. I will stay here until the morning.” When Susie woke in the middle of the night, she said, “I can stay in my room without Mommy. I am a big girl.” Next morning Susie’s mommy said, “You are really a big girl, and I am very proud of you.” She gave Susie a pretty butterfly sticker for staying in her room all night. Note. Details of this story can be changed to fit a child’s individual circumstances. Adapted from Spitznagel (1976) by permission of Ann Spitznagel.

Nightmares are understandable when one considers the fears children experience on a daily basis (Muris, Merckelbach, Gadet, et al., 2000). A young child is expected to have greater control over his or her behavior and to express emotions appropriately, at the same time he or she is exposed to many new and varied stimuli through social interactions, books, and television. Referrals for treatment of nightmares are common for children 4–6 years old, become less frequent at 7–9 years, and then tend to increase again during the adolescent years (mirroring the conflict and struggle of becoming more independent, as in the preschool years). Children are able to describe the content of a nightmare as soon as they can talk; however, the understanding that a dream is not real, that it is invisible to others, that it comes from within and goes on inside a person, and that it is caused by one’s own thought processes follows a developmental progression. By the age of 3–4 years, most children have some understanding of the difference between dreams and reality. By 8 years, children typically have a full understanding of dreams as thought processes (Foulkes, Hollifield, Sullivan, Bradley, & Terry, 1990). Thus treatment techniques for children who have frequent and recurrent nightmares must take into account the children’s developmental level and understanding of dreams. As an example, although the clinician may tell a 4-year-old that his or her dream is not real, it is also important to give the child concrete reassurance (e.g., hugs, a night light). For older children, a discussion of the dream and its possible basis can facilitate the development of coping skills. Although a parent and child must deal with a nightmare when it occurs, the treatment process must take into account what happens to the child during the day and help the child

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gain a sense of control over or competence in difficult situations. In some instances, the child may have been exposed to situations that are too stressful or frightening to handle. Treatment in these cases will involve removing the child from those situations (e.g., not allowing the child to watch monster movies, or stopping the physical and verbal battles to which the child is exposed in the home or the day care center). Allowing the child to describe a nightmare; having a night light that allows the child to see that nothing is in the room; and being supportive, but firmly making it clear that nothing will happen to the child, are always important. Treatment during the day can involve desensitizing the child to the frightening dream by having him or her draw pictures or finger-paint the feared object, or dressing up as the feared monster. The literature reports a number of successful treatment approaches, including teaching relaxation, using pleasant imagery, making statements about competence in regard to sleeping, and reinforcing the child for appropriate sleep behavior (Greening & Dollinger, 1989). Having the child replay the nightmare, with the child taking an active role in coping victoriously with the feared event or object in the replay, is also a good way for the child to gain a sense of competence. An excellent book that helps children cope with nightmares (and other common problems) through storytelling is Annie Stories: A Special Kind of Storytelling (Brett, 1988). One should be careful not to decrease a child’s exposure to all frightening movies or events, because part of learning to cope with fearful and stressful situations is being exposed to them in a gradual, age-appropriate fashion.

CASE EXAMPLE: NIGHT WAKING Step 1: Initial Contact Mr. and Mrs. Knight, the parents of 3-year-old Amy, called for help in getting her to sleep through the night. Mr. Knight worked as a carpenter, and Mrs. Knight did part-time work in a grocery store. Mrs. Knight explained that she was a very light sleeper, and the continual night wakings had left her exhausted. Although Mr. Knight helped in caring for Amy at night, he had a very strenuous job; the parents felt that of the two of them, he was more in need of an uninterrupted night’s sleep. Both parents indicated that their sexual relationship had been almost nonexistent since Amy’s birth, and they clearly wanted this to change. Amy’s 8-year-old sister had not presented any sleep problems, and she did not wake up when Amy cried in the night. Mrs. Knight made it clear that she would not be able to tolerate a lot of crying; this indicated that any program would have to be a gradual one. The PSI, ECBI, and CBCL scores indicated a well-adjusted child during the day and parents who were stressed. The mother reported health problems, and both parents reported marital problems and disagreement about handling the sleep problem.

Step 2: Parent Interview Amy had been born prematurely, after a complicated pregnancy that resulted in Mrs. Knight’s being confined to bed for 5 months. Amy’s sleep pattern was erratic until about age 16 months, when she slept for 8 hours during the night and took two 1½- to 2½-hour naps during the day. Her mother or father rocked her to sleep every night, and because of her early developmental history, one of them slept in the room with her. Currently, Amy was waking two to four times throughout the night, at which times her mother or father changed her diaper, gave her a drink, and held her until she fell asleep again. All of this took about 5 minutes from the time of awak-

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ening. During the day Amy was described as a happy child with a great deal of curiosity and a high activity level. A 2-week Sleep Diary (Figure 6.1) indicated that it took Amy 30 minutes on average to fall asleep at night and that she woke an average of four times per night, taking 5–10 minutes on each of these occasions to get back to sleep. The parents stated on the Sleep Diary that they tried not to respond to her nighttime cries, but within 10 minutes they would do so. They stated that it was easier to give in to her than to tolerate her crying and have a totally sleepless night. In the past they had let her cry up to 45 minutes before going to her; they had talked with her about the need for all of them to get a good night’s sleep; and they had even screamed at her in the middle of the night to stop crying. They had also talked with their pediatrician, who recommended a sedative, but they did not want to use medication. Other advice had been to “let her cry it out.” They were not able to follow this advice and were concerned about the psychological effects on Amy.

Step 3: Observation of Behavior The Sleep Diary served as the source of observational data for this case.

Step 4: Further Assessment Further assessment was not needed in this case.

Step 5: Referral to Allied Health Professionals Referral to other professionals was not necessary in this case.

Step 6: Communication of Findings and Treatment Recommendations Mr. and Mrs. Knight were told that many children who are born prematurely take a longer time to develop a regular sleep pattern, and that their parents are understandably more reluctant to allow the children to cry for any extended period of time. Amy, however, appeared to be developing normally and was at an age when she should be able to fall asleep by herself and sleep through the night without her parents. Mr. and Mrs. Knight were resistant to the idea of allowing Amy to cry herself to sleep, even though they were told that this would not result in any psychological harm to her. In fact, many children, by crying themselves to sleep, quickly learn that they are able to go to sleep independently and therefore feel better about themselves. The parents insisted on a very gradual approach, including gradually decreasing the frequency with which a parent slept in Amy’s room. The clinician voiced concerns about their staying in the room with Amy, and emphasized the need for consistency over a long period of time to make the program effective. The initial intervention program included (1) establishing a clear nighttime ritual with a story and songs; (2) reading a story to Amy that described the planned treatment with another little girl; (3) patting Amy’s back for a count of 100 initially, gradually decreasing the pats to a 1-minute back rub before saying good night; (4) not speaking to Amy after saying good night, and not talking to her during the middle of the night; (5) having a parent lie down on a cot in Amy’s room without speaking to her until she fell asleep; (6) leaving Amy after she was asleep, but returning to her room when they retired for the night; and

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(7) putting a chart with the days of the week on Amy’s bedroom door, and giving Amy a sticker for staying in her bed during each night.

Course of Treatment Treatment occurred over a 6-month period with erratic progress. Within 2 weeks Amy was going to sleep on her own, while either Mr. or Mrs. Knight sat in a rocking chair placed at the doorway of the room, reading the newspaper. Mrs. Knight continued to sleep in Amy’s room, but did not get out of bed or talk to Amy when she woke, and Amy soon went back to sleep on her own after calling out to her mother. The plan for the next 2 weeks included telling Amy that her mother would no longer sleep in Amy’s room, but if she woke she could call to her mother, who would answer but would not go into her room. Neither parent wanted to give up sitting in the rocking chair as Amy fell asleep. If Amy got out of bed, Mrs. Knight was instructed to take her back to bed but not to talk to her or sleep in her room. As noted above, Amy got a sticker for staying in her room during the night. The first night she came out twice, but by the seventh day she was calling to the parents only once per night. The parents were comfortable with this, and follow-up a month later found that Amy was continuing to call to her parents one to two times per night. They were satisfied with the procedure at that time. Several months later Mrs. Knight went away for a weekend. Amy did fine during her absence, but when she returned Amy was very clingy during the day and was described as “inconsolable” when she awoke at night. She was still going to bed on her own, with the parents sitting in the rocking chair for a few minutes, but she was waking four to five times each night and coming to the parents’ room. By the time the parents contacted the clinician, Mrs. Knight was once more sleeping in Amy’s room during the night. Given Amy’s increased insecurity, it was recommended that Mrs. Knight allow Amy to stay close by her throughout the day, even to the point of letting Amy know when she was going to another room. Mrs. Knight also continued to sleep in Amy’s room, but did not talk or interact with her in any way when she awoke. Within 3 weeks, the parents indicated that Amy was no longer clingy during the day and seemed comfortable being away from the mother. At this point, Mrs. Knight went back to sleeping in her own room, but Amy repeatedly came into their room upon awakening; on four out of seven nights, Amy spent the rest of the night in their bed or Mrs. Knight slept in Amy’s room. During one of these nights, Mr. Knight became so angry with Amy that he turned on the light, put on his coat, and walked out the front door! The parents agreed with the clinician that the gradual approach they had helped design was not working. For their sakes and Amy’s, it was agreed that a “cold turkey” approach was needed at this time. Amy evidenced no separation anxiety during the day and was clearly capable of sleeping through the night without their assistance. The parents agreed that they had to respond consistently to her if she were ever to learn to sleep on her own. The parents put a chain lock on the door, so that Amy could not get out of her room but could see into the hall. She was told that if she came out of the room after they said good night to her or during the night, she would be taken back to her room and the lock would be fastened until she was quiet and in bed. During the first and second nights, Amy only called out twice to her parents. By the third night, she was going to bed on her own and sleeping through the night without disturbing the parents. The chain lock was never fastened. At a follow-up 1 year later, Amy was continuing to sleep through the night. The parents indicated that after illnesses that required their attending to her during the night, they reminded

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Amy that she was now well and could manage on her own, and that if she did come out of her room, they would return her and fasten the lock. They never actually had to do this, however.

CASE EXAMPLE: NIGHTMARES Step 1: Initial Contact Mr. and Mrs. Moon, parents of 11-year-old Matthew, requested help in dealing with Matthew’s recurrent nightmares. Screening instruments indicated that Matthew was doing well in school, was involved in many activities, and had friends. Although he was described as a rather sensitive and serious child, they saw him as quite happy. A Sleep Diary indicated that nightmares had occurred on 11 out of the last 14 nights. Matthew went to sleep in his own bed, but after having a nightmare he slept on the floor of his parents’ bedroom or with his older brother. In the last 5 days, he had been taking longer to get to sleep at night, with repeated calling to the parents or staying up to read.

Step 2: Parent and Child Interviews Parent Interview The parents came alone for the initial interview, and a day later Matthew was seen. Mr. Moon was a security guard, and Mrs. Moon cleaned houses. Matthew, the third of four children, was described as a healthy youngster who had never been hospitalized and had received only occasional antibiotics. His parents described a sleep history of occasional night terrors from ages 4 to 6. These had seemed to occur at about the time of the maternal grandfather’s death and after a particularly difficult bout with the flu, including a very high fever. The night terrors had been especially frightening for the parents, but after talking with their pediatrician, they had been reassured. Matthew had had at least one nightmare a week during the preschool years, and only occasional nightmares up until 1 month prior to the initial contact. The nightmares during the preschool years had involved monsters chasing him and weird flying birds. The recent nightmares followed the theme of some tragic event occurring to a member of the family, with Matthew feeling helpless to stop it. There was a great deal of focus on things happening to his youngest brother, age 5. Matthew complained of feeling tired during the day and becoming increasingly upset about the thought of going to sleep and having yet another nightmare. Matthew’s parents and his older brother did not mind his coming into their rooms, but Matthew saw it as immature behavior. The parents indicated that the family situation was stable and that they were in good health. The only upsetting event that had occurred recently was that the paternal grandfather had had a heart attack 2 months previously, but he was currently at home and recovering. Child Interview In the interview with Matthew, it was interesting that he estimated having nightmares only every other night. He knew that the nightmares were not real, but said that they were still very frightening. He described fairly stimulating and enjoyable daily routines. He also described a number of situations that caused him to be either very sad or very angry. For example, there were several bullies on the school bus who were constantly teasing and pushing the younger

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children (including him and his younger brother); he was having trouble completing the requirements for a particular Scout badge; and he described his older brother as being particularly irritable with the entire family. He expressed affection toward his parents, particularly his mother, who (he felt) was treated unfairly by his older brother. At the same time, however, Matthew felt that his mother did not always treat him fairly when he got into a fight with his older brother.

Step 3: Observation of Behavior The Sleep Diary served as the source of observational data for this case.

Step 4: Further Assessment Further assessment was not needed in this case.

Step 5: Referral to Allied Health Professionals Referral to other professionals was not necessary in this case.

Step 6: Communication of Findings and Treatment Recommendations Mr. and Mrs. Moon and Matthew were told that Matthew was a chid with many strengths (good school performance, friends, and age-appropriate interests), but one who was also sensitive to injustices and to people being hurt or bullied by others. His nightmares seemed to be related to stresses that he was encountering at home from interactions with his older brother, as well as from bullies on the school bus who were particularly threatening to younger children (his 5-year-old brother rode the bus with him). Given the frequency and upsetting nature of Matthew’s nightmares, it was understandable that going to bed was unpleasant for him. It was recommended that Matthew be seen for four to six sessions to learn ways to cope with his nightmares when they occurred, as well as to learn more effective ways to deal with current and future stresses in his life.

Course of Treatment Matthew came in for four weekly appointments with the clinician. Phone contact was made with Mrs. Moon after each session. Matthew agreed to go to his parents’ room when he had a nightmare. One of them was to take him back to his room, have him describe the nightmare to them, and reassure him that all was well. He was then to write the content of the nightmare in his Sleep Diary. Matthew was taught to relax his body through first tensing his muscles and then letting them relax. As he was relaxing, he was to imagine one of two scenes that he particularly enjoyed. These were winning a basketball game, and seeing himself get physically stronger and stronger as he rode his bike and engaged in other pleasurable activities. Matthew and the clinician went over his descriptions of the nightmares and role-played them, with responses from Matthew that resulted in a victory over the scary events. Treatment also focused on the areas that were creating stress for Matthew during the day. He and the clinician took a problem-solving approach to the issue of the bullies on the bus.

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Matthew decided to ask his parents to inform the principal of his school about the bullies, and he planned to tell them to pick on someone their own size. Furthermore, he decided that if they physically attacked him, he was capable of defending himself. The family as a whole discussed sibling squabbles and agreed upon a program of time out by isolation for everyone involved if the children could not resolve the problem themselves. The older brother was also encouraged to spend more time with his own friends, both inside and outside the home. The decrease in nightmares over the next month coincided with Matthew’s having greater control over daily events, and especially with the resolution of the problem with the bullies. The principal’s investigation into this matter revealed real intimidation and physical aggression on the part of the bullies. They were suspended from riding the bus for a week. When they returned they made verbal threats to Matthew, which he handled by making the statement, “You must not feel very good about yourselves if you have to talk like that.” Matthew recognized that he might have occasional nightmares as he tried to resolve and understand daytime activities, but that when he had recurrent nightmares, it was time for him to look for and cope with stressors in his environment.

CHAPTER 7

Sexuality and Sexual Problems

F

ew topics are more difficult to discuss or engender more controversy in our society than sex, especially children and sex. Most recently, research in this area has centered around issues related to child sexual abuse. Although understanding sexual abuse is undeniably important, this narrow focus ignores other sexual problems that can arise during childhood and, if left untreated, can have a negative impact on a child’s development. Indeed, identification and treatment of sexual problems during childhood can often prevent development of adult sexual disorders that are very distressing and difficult to treat (Borneman, 1994). It is only through a broad knowledge of normal sexual development, as well as of where things can go wrong, that the child clinician can come to a complete understanding of a presenting problem involving sexuality. This chapter provides the child clinician with empirically based information about the complex area of childhood sexuality. First, what is known about normal sexual development is reviewed. This is followed by a discussion of issues related to sexuality education. Childhood sexual problems, including precocious or delayed puberty, gender identity disorder (GID), and sexually aggressive behavior, are then discussed. Finally, child sexual abuse and its assessment and treatment are reviewed in detail.

NORMAL SEXUAL DEVELOPMENT The study of sexual development is clouded by cultural attitudes and values about sexuality in general, and about children and sexuality in particular (Rosenfeld & Wasserman, 1993). Much of the work in this area has come from Europe, especially the Scandinavian countries, where attitudes toward sexuality are more permissive than they are in the United States. Thus the conclusions resulting from this work may not always apply to children in the United States, where there are significant political, societal, and ethical restrictions on our ability to gather empirical data on children’s sexual behavior and development. Moreover, methodological issues have led to inconsistencies across the results of various studies. Studies that rely on parental reports of children’s sexual behavior, for example, give lower estimates of the frequency and nature of children’s sexual experiences than studies that include self-reports. This inconsistency simply reflects the fact that much of children’s sexual behavior, particularly after the preschool years, is undiscovered by adults. Finally, the participants involved in the studies are 217

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typically white and from higher-socioeconomic-status (higher-SES) backgrounds. Thus the results may not represent the full range or frequency of sexual behaviors exhibited by children from different ethnic or SES groups. With these problems made clear, the next sections examine what is known about physical sexual development, as well as the development of sexual behaviors.

Physical Aspects of Sexual Development Although a child’s genetic sex is determined at conception, differentiation as male or female does not begin until about the sixth or seventh week of pregnancy. Fetal sexual development involves a complex interaction between genetic and hormonal processes (Money, 1994). A number of the childhood sexual problems covered in later sections of this chapter originate during these early stages of development. It is generally recognized that the physiology for sexual arousal and orgasm, and the capacity for various sexual behaviors, are present at the time of a child’s birth. We know, for example, that fetuses suck their fingers and toes, and that newborn male babies have penile erections, whereas female babies are capable of vaginal lubrication (Martinson, 1981). There are few if any physical changes in sexual development during infancy and early childhood, and no developmental milestones have been clearly identified (Tanner, 1962). The changes that occur during puberty happen over a relatively lengthy period of time (4–5 years for boys and 3–4 years for girls). These include growth of testes and penis in boys; breast development in girls; and emergence of pubic hair, and a growth spurt resulting in adult height, in both sexes.

Child Sexual Behavior Despite the lack of physical changes prior to adolescence, much important development in the psychosexual arena occurs during early childhood. It is clear that children engage in a surprising variety of overt and covert sexual behaviors. In a survey of parents of nonabused children ages 2–12 years, for example, Friedrich, Grambsch, Broughton, Kuiper, and Beilke (1991) found that although some behaviors were reported relatively rarely (e.g., puts mouth on sex parts, inserts objects in vagina/anus, imitates intercourse, masturbates with object), all of the 44 sexual behaviors listed on their questionnaire were shown by at least some children. The types of sexual behaviors that are to be expected at different ages are summarized in Table 7.1. Masturbation Masturbation is one of the most common sexual behaviors seen in young children (Ryan, 2000; Routh & Schroeder, 1981). It has been observed in infants as young as 7 months (Martinson, 1981), and there is some evidence that children as young as 2–3 years (especially males) are capable of experiencing orgasm as a result of masturbation (Gundersen, Melas, & Skar, 1981). During the first 2 years of life, masturbation appears largely related to general curiosity about one’s body. Gradually, however, children discover that genital stimulation results in particularly pleasurable sensations, and masturbation begins to take on a decidedly erotic aspect. Although there is a great deal of variation, boys are generally observed to masturbate earlier and more frequently than girls. Boys also are more likely to masturbate socially, in groups of two or more, whereas girls tend to engage in this behavior alone. Masturbation is reported by some to increase among boys and girls in the years preceding puberty, although the rates are

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TABLE 7.1. Normal Sexual Development Sexual Knowledge

Sexual Behavior Birth to 2 years

• • • •

Origins of gender identity Origins of self-esteem Learns labels for body parts, including genitals Uses slang labels

• • • • •

Penile erections and vaginal lubrication Genital exploration Experiences genital pleasure Touches own and other’s sex parts Enjoys nudity, takes clothes off in public

3 to 5 years • Gender permanence is established • Gender differences are recognized • Limited information about pregnancy and childbirth • Knows labels for sexual body parts but uses elimination functions for sexual parts

• Masturbates for pleasure, may experience orgasm • Sex play with peers and siblings: exhibits genitals, exploration of own and other’s genitals, attempted intercourse, may insert objects in genitals • Enjoys nudity, takes clothes off in public • Uses “dirty” words, especially with peers

6 to 12 years • • • •

Genital basis of gender known Knows correct labels for sex parts but uses slang Sexual aspects of pregnancy known Increasing knowledge of sexual behavior: masturbation, intercourse • Knowledge of physical aspects of puberty by age 10

• Sex games with peers and siblings: role plays and sex fantasy, kissing, mutual masturbation, simulated intercourse, playing “doctor” • Masturbation in private • Shows modesty, embarrassment: hides sex games and masturbation from adults • Body changes begin: girls may begin menstruation, boys may experience wet dreams • May fantasize or dream about sex • Interested in media sex • Uses sexual language with peers • Tells dirty jokes

13 to 18 years • • • •

Sexual intercourse Contraception Sexually transmitted diseases Date rape and sexual exploitation

• Pubertal changes continue: most girls menstruate by age 16, most boys are capable of ejaculation by age 14 • Dating begins • Sexual contacts are common: mutual masturbation, kissing, petting • Sexual fantasy and dreams • Sexual intercourse may occur in up to one-third

Note. From Gordon and Schroeder (1995). Copyright 1995 by Plenum Publishers. Reprinted by permission.

thought to be somewhat lower among girls (Rutter, 1970); others (e.g., Friedrich et al., 1991) report a decline in sexual behavior in general, and masturbation in particular, with age. It is likely that these conflicting results reflect the fact that older children are more aware of societal views about the acceptability of sexual behavior and exercise restraint in where and when they engage in these behaviors. Thus studies that rely on parental reports (such as Friedrich et al., 1991) are more likely to find decreases in masturbation and other sexual behaviors with age than those that include self-reports.

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Despite the fact that masturbation is such a common sexual behavior in children, many parents still react negatively to it and may even punish their children if they are caught touching themselves (Calderone & Johnson, 1983). Parents who accept masturbation in their preschool children may become uncomfortable with this behavior as it assumes a more adult sexual quality (Klein & Gordon, 1991). Yet there is no evidence that masturbation is harmful. Rather, it is seen by many as a viable sexual activity throughout the life span, and by some as an important developmental step in becoming reliably orgasmic in adult partner sex (Haroian, 1991). Because it is inherently pleasurable, the key clinical question regarding masturbation among children is not why they masturbate, but how much and where masturbation occurs. Clearly, masturbation that interferes with other activities or causes physical harm should be considered abnormal. In other instances, whether or not masturbation constitutes a “problem” is in large part a function of family, societal, and cultural attitudes. There is agreement among professionals that the best way to handle childhood masturbation is to teach the child where and when it is appropriate to engage in this “private” behavior (Petty, 1995). Child–Child Sexual Interaction The age at which children first become aware of sexual behavior as an interpersonal phenomenon is unclear. Obviously, cultural attitudes and values greatly influence our understanding of this issue. Nonetheless, it is common knowledge that preschool children are very curious about their own and others’ bodies, and that given the opportunity, they will engage in sexual exploration with other children. Sexual play with peers is very common among preschool and school-age children and may involve relatively adult-like sexual activities, such as genital fondling, oral–genital contact, insertion of objects in genitals, or attempts at sexual intercourse (Lamb & Coakley, 1993). In contrast, sex play between siblings appears to occur much less frequently than between friends. Estimates of the prevalence of sibling sexual encounters range from 9% (Lamb & Coakley, 1993) to 13% (Finkelhor, 1981) of children. It is likely that the lower rate of sex between siblings reflects in part the age differences that typically exist between them. Sexual encounters between siblings appear to be similar to those between friends in the types of activities involved, the motivations associated with the interactions, the ages at which they occur, and the perception of the experiences as relatively positive or normal. Although most childhood sexual experiences with peers or siblings are viewed positively, some involve coercion (persuasion, manipulation, or force) of some type. Not surprisingly, the more coercion reported, the less likely the experience is to be perceived positively (Finkelhor, 1981; Lamb & Coakley, 1993). Child–Adult Sexual Interaction Although the data on sexual play among children may not be surprising, it has also been demonstrated that nonabusive sexual encounters between children and adults are quite common. Many sensual and possibly erotic encounters between the infant and mother (and other caregivers) occur in the context of nurturant caregiving, beginning at birth and continuing throughout the early years. Indeed, these early experiences of touching and physical affection are essential for a child’s healthy development. Research also indicates that nonabusive sexual interaction occurs with surprising frequency between older children and their parents, and

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that these experiences do not necessarily have a negative or damaging effect on the children or other family members involved (Nelson, 1981; Rosenfeld, Bailey, Siegel, & Bailey, 1986; Symonds, Mendoza, & Harrell, 1981). Much of this contact is motivated by children’s curiosity about their bodies and those of others. Issues of relative power and freedom of choice appear to be important in determining how these experiences are preceived. The important clinical issue is to determine when children’s sexual interactions are developmentally appropriate and when they are inappropriate and/or abusive. The next section addresses this issue.

Normal versus Abnormal Child Sexual Behaviors Several sources are available to clinicians that are helpful in distinguishing normal sex play from that which might indicate a more serious problem. Gil (1993), for example, provides a framework that focuses assessment of sexual behaviors on such factors as differences in age, size, and relative status or authority; consistency with developmental norms; and presence or absence of coercion. Johnson and Friend (1995) provide criteria for child sexual behaviors that fall outside the norm. These include the following: 1. Sexual behaviors engaged in by children who do not have an ongoing, mutual play relationship. 2. Sexual behaviors that interfere with other aspects of the child’s life. 3. Sexual knowledge that is greater than expected for the child’s age. 4. Sexual behaviors that persist in spite of frequent requests to stop or occur in public places. 5. Behaviors that are embarrassing or annoying and elicit complaints from other children or adults. 6. Sexual behaviors that increase in intensity, frequency, or intrusiveness. 7. Sexual behaviors that are associated with negative emotions, such as fear, anxiety, intense guilt or shame, or anger. 8. Sexual behaviors that cause physical or emotional pain or discomfort to self or others. 9. Sexual behaviors that are associated with aggression, coercion, force, bribery, manipulation, or threats. Johnson and Friend (1995) also provide a very useful table of which sexual behaviors can be expected of preschool or early-elementary-school-age children, when these behaviors are of concern, and when they indicate the need for professional help. Preschool children, for example, can be expected to touch the genitals or breasts of familiar adults or children. This behavior becomes a matter of concern if the child touches the genitals or breasts of unfamiliar adults or children, or asks to be touched him- or herself. Professional help should be sought when the child “sneakily touches adults, makes others allow touching or demands touching of self” (Johnson & Friend, 1995, p. 60). Similarly, early-elementary-school-age children can be expected to “play doctor,” inspecting others’ bodies. It is of concern when a child frequently engages in this behavior or gets caught after being told “no.” Professional help should be sought when a child forces another to “play doctor” or to take his or her clothes off. Obviously, only careful assessment of children’s sexual behavior can determine whether or not it is a problem. We approach this assessment very broadly so as to view the behavior in context. Information gathered should include the specific behavior of concern, the child’s exposure to adult sexual material, the type and amount of sexuality education the child has re-

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ceived, the parents’ attitudes about sexuality, and any history of possible sexual abuse, as well as the child’s developmental, school, and social history and current status.

Sexual Knowledge The fact that children are known to engage in sexual behavior alone and in interaction with others from an early age does not necessarily mean that they have knowledge or understanding of sexual facts. Research in this area is inevitably biased by the culture in which it is conducted. It is important to note that the research reviewed in this section was primarily conducted in the United States, and therefore reflects the prevailing attitudes (considered to be relatively restrictive) in this country. Sexual knowledge that can be expected at different ages is summarized in Table 7.1. Researchers have generally found a developmental progression in children’s understanding of gender and the birth process, with younger children having incomplete and inaccurate knowledge, and older children having a more accurate understanding of these topics (Bernstein & Cowan, 1975; Slaby & Frey, 1975). Studies of the concept of gender, for example, suggest that children first understand that gender is permanent (e.g., a girl always was and always will be a girl) and only later understand that gender is determined by one’s genitalia (McConaghy, 1979). Other work indicates that even very young children can be quite knowledgeable about many aspects of sexuality (e.g., body parts and functions, gender differences), whereas knowledge about other areas (e.g., sexual intercourse, pregnancy, and birth) may be lacking even in older children (Gordon, Schroeder, & Abrams, 1990a; Waterman, 1986). Moreover, these age differences may vary depending on the area of sexuality assessed, the sex of the child, the sexual attitudes of the parents, and the SES of the family (Bem, 1989; Gordon et al., 1990a). We (Gordon et al., 1990a), for example, found that lower-SES children had less knowledge about body parts and functions, pregnancy, and abuse prevention than did middle- and upper-SES children. Bem (1989) reported that girls knew as much about genitalia at 3 years as they knew at 5 years, whereas knowledge of genitalia among boys increased gradually with age. Moreover, significantly more girls knew what “vagina” meant than did boys (58% vs. 15%), but boys and girls knew “penis” equally well. This work has been replicated by Lloyd and Stroyan (1994). The relationship between children’s sexual knowledge and their sexual behavior is complex. At least two studies (Gordon, Schroeder, & Abrams, 1990b; Gundersen et al., 1981) suggest that sexual experience does not always lead to increased sexual knowledge/understanding, although the reasons why this is the case are not clear. It is possible that the relationship between knowledge and experience are mediated by parental attitudes toward sexuality. In our (Gordon et al., 1990a) study, for example, children with less knowledge had parents who reported more restrictive attitudes toward sexuality and had engaged in less sexuality education with their children. The discrepancy between knowledge and behavior indicates that we have much to learn about how to educate children effectively about sexuality. The next section examines issues related to the topic of sexuality education (including sexual abuse prevention).

SEXUALITY EDUCATION The importance of sexuality education cannot be overemphasized. Children today are bombarded with sexual messages from films, advertising, television situation comedies and soap operas, the Internet, and even the nightly news report! Education about sexuality can help to

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put it into proper perspective, assist children in making sense out of confusing messages, and increase the chances that they will behave responsibly with regard to their own sexuality. Sexuality education in its broadest sense involves communication of attitudes, values, and feelings about being male or female, as well as teaching the anatomical parts and functions of the body. Children also must be taught the skills to enable them to make good decisions about sexuality and to recognize and avoid dangerous and/or exploitative situations. Although most parents do not talk with their children about sex until preschool or early school age, sexuality education actually begins at birth and is most appropriately thought of as a process that continues throughout one’s lifetime. Children begin to learn about sexuality as parents communicate their feelings about different body parts through caregiving behaviors (breast feeding, changing diapers, bathing, etc.). As an infant begins to exhibit exploratory sexual behaviors, parental reactions to these behaviors send clear positive or negative messages to the child about these behaviors. This early nonverbal communication sets the stage for sexual values and attitudes that will be important influences on the child’s behavior later in life. In the preschool years, parents are the primary sexuality educators for their children, even if they do not actively provide information. Thus children’s knowledge of and values about sexuality are clearly going to be related to the information provided by parents. Many parents, however, are uncomfortable discussing sexual matters with their children, and most do not discuss all aspects of sexuality. Most commonly, parents talk with children about pregnancy and the birth process, but do not discuss sexual intercourse, sexually transmitted diseases, birth control, or sexual abuse—the very topics about which children, and especially adolescents, need information. Because many parents do not provide their children with sexual information, children learn a great deal about sex from peers and the mass media. Unfortunately, this information is often inaccurate and confusing, and may even be damaging to the child’s self-perception. For a variety of reasons, many children do not initiate conversations about sex, so parents must respond to behavioral cues that their children are “ready” for sexual information. Answering children’s questions and responding to their sexual behavior in a simple, nonjudgmental manner that is appropriate to their developmental level can serve to satisfy curiosity about sex and decrease the need for sexual experimentation (Gordon & Snyder, 1983). Furthermore, provision of sexual information is actually associated with postponement of sexual activity by teenagers and more responsible sexual behavior when they do become sexually active (Coley & Chase-Lansdale, 1998). By understanding normal sexual development, parents and clinicians can more easily determine what information is needed by children as they grow and develop and understand how best to respond to children’s sexual behavior. Suggestions for what to teach children at different ages are outlined in Table 7.2. In reviewing the information in Table 7.2, one must keep in mind that it is not sufficient to teach the facts about sex; attitudes and values must also be taught. Ryan (1997b, 2000) suggests that all sexual behaviors exhibited by children, especially behaviors that appear deviant, require some adult response. Because children inevitably look to adults for guidance, failure to respond to sexual behaviors can easily be interpreted by the children as acceptance or approval. Ryan proposes that goals for sexuality education should include teaching children to (1) communicate openly about sex, (2) recognize and respond empathically to the needs of others, and (3) take responsibility for their own behavior. This can be done by nonjudgmentally describing behaviors as the children engage in them, telling the children how those behaviors make others feel, and encouraging the children to control their behavior in the future.

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TABLE 7.2. Information for Parents to Teach Children at Different Ages Birth to 2 years Body parts and functions Provide correct labels for body parts, including male or female genitalia, when child is touching or parent is pointing to each part. Provide simple information about basic body functions. Allow child to explore all his or her body parts. Gender identity Learning about gender begins at birth, when baby boys are dressed in blue and girls in pink. Parents provide guidance about this topic by their choices of toys, clothing, activities, and the behaviors of the child they choose to notice. Gender stereotypes are pervasive in our culture, but flexibility is healthy. It’s OK for boys to play with dolls and girls to play with trucks. Begin to teach the child what is special about being either a girl or boy. Sexual abuse prevention Children must first learn about body parts and functions before they can learn to protect themselves from exploitation. The best prevention at this age is close supervision. 3–5 years Body parts and functions Continue to use proper labels for body parts, including male and female genitalia. Teach child about functions of genitalia, including both elimination and reproduction. This is a good age to begin talking about sexual intercourse, as children are naturally curious about pregnancy and often have a new brother or sister. Gender identity Talk about the physical differences between boys and girls. Reinforce the idea that each child is special and has unique characteristics, including being a girl or a boy. Talk about what is special about being male or female. Sexual abuse prevention Genitalia are private parts, and no one should touch them for purposes other than health or hygiene. Children should not touch anyone else’s private parts. Explain that these rules apply to friends and relatives as well as strangers. Teach the child to say, “No, my parents told me not to do that,” and to get away if someone tries to touch his or her private parts. Teach the child to tell someone if this happens and keep telling until someone who will help is found. Have the child make a list of who to tell. Practice saying no and telling. Allow your child to say no in other situations that are uncomfortable. Children should know not to go with a stranger under any circumstances. Explain why, and make sure the child knows what a stranger is. Practice “what would you do if” role plays. Sexual behavior Don’t overreact if child is caught in sex play with another child. Use it as a “teachable moment.” Explain that insertion of objects into body openings may be harmful and is prohibited. Child should learn that masturbation is a “private” behavior. Teach about appropriate and inappropriate words. 6–12 years Body parts and functions Children should have complete understanding of sexual, reproductive, and elimination functions of body parts, including sexual intercourse. Discuss changes that will come with puberty for both sexes, including menstruation and wet dreams. Gender identity Gender identity is fixed by this age. Encourage both boys and girls to pursue individual interests and talents regardless of gender stereotypes.

(cont.)

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TABLE 7.2. (cont.) Sexual abuse prevention Discuss the child’s conceptualization of an abuser, and correct misperceptions. Identify abusive situations, including sexual harassment by peers. Practice assertiveness and problem-solving skills in troublesome social situations. Explain how abusers, including friends, relatives, and strangers, may manipulate children. Sexual behavior Talk about making good decisions in the context of potentially sexual relationships. Provide information about birth control and sexually transmitted diseases (including AIDS). 13–18 years Body parts and functions Discuss health and hygiene. Provide more information about contraceptives and sexually transmitted diseases, especially AIDS. Provide access to gynecological exam for girls if sexually active. Gender identity Although boys and girls are able to do many of the same things, reinforce the idea that there are special aspects of being male or female. Talk about the differences between girls and boys in social perception. Males tend to perceive social situations more sexually than girls and may interpret neutral cues (e.g., clothing, friendliness) as sexual invitations. Sexual abuse prevention Teach teens to avoid dangerous situations (e.g., walking alone at night, avoiding certain parts of town). Discuss dating relationships, and in particular date/acquaintance rape and its association with alcohol and drug use. Let your teenager know you are available for a ride home any time he or she is in a difficult or potentially dangerous situation. Enroll your child in a self-defense class. Sexual behavior Share your attitudes and values regarding premarital sex. Provide access to contraceptives, if necessary. Accept your teenager’s need and desire for privacy. Set clear rules about dating and curfews. Note. Gordon and Schroeder (1995). Copyright 1995 by Plenum Publishers. Reprinted by permission.

Sexuality education programs for groups of children must recognize differences in children’s cognitive development. For example, in sexual abuse prevention programs for preschool children, it is important to teach behavioral skills using participatory methods (e.g., role play, modeling, guided practice, and positive reinforcement) (Wurtele, Kast, & Melzer, 1992; Wurtele, Currier, Gillispie, & Franklin, 1991). Moreover, these programs are more successful when they involve four or more sessions (so that the information is presented in small “chunks”) and when they build in “booster” sessions for maintenance skills (Davis & Gidycz, 2000).

SEXUAL PROBLEMS Many different sexual problems are seen among children, including physical/anatomical abnormalities that have an impact on later psychological and social development; “public or semipublic behaviors that cause adults (usually the parents) embarrassment and concern because they are a departure from society’s expectations” (Haroian, 1991, p. 432); and aggressive or abusive sex. Discussion of anatomical sex abnormalities is beyond the scope of this chapter.

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The interested reader is referred to Gordon and Schroeder (2001), Money (1994), and Mazur and Dobson (1995) for further information.

Precocious or Delayed Puberty The age at which children normally reach puberty ranges from 10 to 16 years among girls and from 11 to 16 years among boys. Puberty is considered to be precocious or delayed if it occurs outside this normal range (Mazur & Cherpak, 1995; Sonis et al., 1986). The age at which puberty is reached appears to have a significant impact on adjustment, although the problems experienced as a result of delayed or precocious puberty are different for boys and girls. Boys tend to suffer more from delayed puberty, whereas girls experience more problems associated with early or precocious puberty (Rutter, 1970; Rutter & Rutter, 1993). Precocious puberty is caused by increased levels of sex steroids, which can have a variety of etiologies: (1) central nervous system lesions, such as hydrocephalus; (2) an identified syndrome, such as neurofibromatosis; (3) genetic disorders; or (4) a premature signal from the hypothalmic–pituitary biological clock (Money, 1994; Sonis et al., 1986). Most cases (up to 80%) of precocious puberty in girls are idiopathic or of unknown origin (and may be considered extreme variations of normal), whereas the majority of cases (approximately 65%) among boys involve an organic disorder, such as congenital adrenal hyperplasia (Mazur & Cherpak, 1995). Regardless of its cause, the early onset of puberty clearly interacts with other social and psychological factors in ways that have the potential to alter a child’s developmental course. For boys, distinct advantages come with early maturation. Increases in height and weight, for example, enhance boys’ abilities to compete in athletics. As a result, early-maturing boys often receive more positive feedback from adults and may be considered more attractive by their peers. These advantages result in higher self-esteem, greater self-confidence, and greater social maturity (Rekers, 1991). In contrast, boys who mature late tend to be less popular, less confident, and more withdrawn, and these effects may persist into adulthood (Rutter, 1970). For girls, the impact of the timing of puberty is quite different than it is for boys. Latematuring girls are more in step with the boys in their peer groups and thus are not as likely to experience significant adjustment problems associated with onset of puberty. In contrast, girls who mature very early are at risk for a number of behavior problems, both internalizing and externalizing (Sonis et al., 1986). Although some girls who mature early may withdraw and consequently become less popular among their peers (Rekers, 1991), others have been shown to engage in a range of precocious sexual behaviors, including sexual intercourse (MeyerBahlburg et al., 1985). The reason for this early sexual behavior may be that girls who mature early appear older than their peers and may be exposed to sexual advances that are not appropriate for their chronological age and level of social and emotional development. Treatment of precocious or delayed puberty should include a thorough medical evaluation to determine the cause and rule out dangerous conditions (e.g., a brain tumor). Hormonal therapy may be indicated to slow down or stop the process of puberty and allow for normal bone growth when onset is exceedingly premature, or to precipitate the onset of puberty when it is quite delayed (Money, 1994). Psychological intervention is likely to involve issues of selfesteem and social relations. Rekers (1991) suggests that group treatment for children with late or early sexual maturation can focus on empathy and social skills. The clinician can help parents to understand the potential lability in the children’s moods and to provide the children with opportunities for age-appropriate activities. Finally, sexuality education with an emphasis

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on the bodily changes that are occurring and the potential for sexual exploitation is essential for these children, especially those with precocious puberty.

Gender Identity Disorder The development of “gender identity”—that is, a sense of oneself as male or female, and the value one places on being a member of one’s sex—begins very early in life. Hospital personnel, parents, and families typically begin to influence the development of gender identity at birth by providing blue or pink clothing and masculine or feminine names, depending on the child’s physical sex. Same-sex preferences typically are reflected in children’s behavior (e.g., choice of toys, games, playmates, clothing) by the age of 2 years, and most children have developed at least a partial understanding of the concept of gender identity by 2–3 years (Gordon et al., 1990a; Rutter, 1970). Boys appear to develop a same-sex preference earlier and more consistently than do girls (Rutter, 1975), probably reflecting different societal attitudes toward sex-typed behaviors for boys and girls. A full understanding of gender roles (the behaviors, attitudes, and traits designated by society as male or female at any given time) typically develops between 3 and 7 years. Most children begin to engage in behaviors and hold preferences that are consistent with their physical gender by the preschool years. For some children, however, there is a significant incongruity between their biological sex and their preferred gender. These children express a firm desire to be (or a belief that they are) of the opposite sex, and are preoccupied with activities that are strongly associated with the opposite sex. They are different from children who are simply “tomboys” or “sissies,” and often receive a diagnosis of gender identity disorder (GID). Diagnostic Issues In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), the diagnostic criteria for GID include two central features: (1) powerful and persisting cross-gender identification, as manifested in a desire to be or belief that one is the opposite sex, and preferences for stereotypical cross-gender clothing, activities, playmates, and roles in fantasy or make-believe play; and (2) persisting discomfort with one’s own sex, as manifested in aversion to one’s own genitalia or sex-typed behavior, activities, or clothing. Symptoms of GID typically appear between 2 and 4 years of age (Zucker & Bradley, 1995). Many of these symptoms appear to be age-dependent, at least for boys; less is known about the course of the disorder in girls. Cross-gender behavior and explicit statements about wishing to be the opposite sex, for example, decrease with age among boys, probably because of the social stigma associated with these behaviors (Zucker, 1990a). Epidemiology Although the definitive epidemiological study remains to be done, there is some agreement that GID is a relatively rare disorder. Although instances of cross-gender behavior among preschool children are quite common, it is not known how many of these children would fulfill all the criteria for a DSM-IV diagnosis of GID (Achenbach & Edelbrock, 1983). Referral rates

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for GID are much higher for boys than for girls (6–7:1) (Bradley & Zucker, 1997; Zucker & Bradley, 1995). It may be that boys are more vulnerable to GID because masculine development is dependent on prenatal androgen secretion, whereas feminine development occurs in the absence of prenatal androgens (Money & Ehrhardt, 1972). Alternatively, the higher referral rates for boys may be due to the fact that society has less tolerance for cross-gender behavior in boys. Etiology Zucker and his colleagues (Bradley & Zucker, 1997; Zucker & Bradley, 1995; Zucker & Green, 1992) summarize the research related to various theories about the etiology of GID. They present some evidence that biological factors, particularly prenatal hormone secretion, may predispose children to problems with gender identity. Variations in prenatal hormone exposure (i.e., increases or decreases in androgens) have been shown to influence later behavior (without altering external genital structures) of both animals and humans (Money & Ehrhardt, 1972). The causes of variations in hormone secretion during pregnancy are not yet well understood, but two possibilities have been proposed. First, prenatal maternal stress during pregnancy has been linked with decreased androgen secretion and later demasculinized behavior in male offspring of rats (Ward, 1984). To date, however, no definitive studies have replicated this phenomenon in humans. Second, boys with GID are more likely than boys without GID to be later-born and to have more brothers than sisters (Blanchard, Zucker, Bradley, & Hume, 1995; Blanchard, Zucker, Cohen-Kettenis, Gooren, & Bailey, 1996). It is hypothesized that antibodies to one or more of the hormones needed for sexual differentiation (including testosterone) produced by the mother of a male fetus may reduce the biological activity of these hormones, and that this effect may increase over several pregnancies involving male fetuses (Blanchard et al., 1995). Rekers and Kilgus (1995) argue that the lack of evidence for abnormal chromosome numbers, external genitalia, and hormone levels among adults with gender disturbance indicates that the etiology of such disturbance is found in psychological development variables and social learning within the family environment, rather than in biological factors. Evidence for the role of the social environment in GID is found in studies that show successful formation of gender identity in children born with ambiguous genitalia and assigned to one sex or the other shortly after birth (Money, Devore, & Norman, 1986; Money & Norman, 1987; Quattrin, Aronica, & Mazur, 1990; but see Slijper, Drop, Molenaar, & deMuinck-Keiser-Schrama, 1998). Other research demonstrates higher rates of parental and family dysfunction for children with GID than for controls (see, e.g., Marantz & Coates, 1991). Moreover, clinical reports indicate that parents of children with GID often respond neutrally or positively to their children’s early cross-gender behavior, thus potentially increasing this behavior through differential reinforcement (Zucker & Green, 1992). Money and Russo (1979) suggest that GID results from an interaction between biological and environmental factors. Fetal sex hormones influence brain development, which subsequently mediates behavior. This process creates a predisposition to behave as a male or a female. The social environment then functions to reinforce or discourage cross- or same-gender behavior and identification. This view suggests that the co-occurrence of other forms of psychopathology with GID may be the result of the social consequences (peer rejection, social isolation, and poor self-esteem) of engaging in cross-gender behavior.

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Long-Term Prognosis Although GID is relatively rare, its significance as a clinical problem lies in the strong relationship between early cross-gender behavior and later homosexuality. This link has been shown in both prospective and retrospective studies for boys and in retrospective studies for girls (for a summary, see Bailey & Zucker, 1995). Prospective work indicates that a substantial majority (60–80%) of boys with GID have a homosexual or bisexual orientation as adults (Bailey & Zucker, 1995; Green, 1987). The association between cross-gender behavior in childhood and later homosexuality is not absolute, however: Many homosexual adults do not recall engaging in cross-gender behavior during childhood, and some children with gender disturbance do not adopt a homosexual orientation as adults. It would be reasonable to expect a similar strong association between GID and transsexualism (i.e., persistent gender identity problems in adulthood and a wish to undergo sex reassignment); however, research indicates a somewhat different picture. Although retrospective studies show that almost all adults with a transsexual orientation (both males and females) recall cross-gender behavior as children (e.g., Blanchard, Clemmensen, & Steiner, 1987), prospective studies of children with GID indicate that very few develop transsexualism as adults (Green, 1987; Money & Russo, 1979). Zucker and Bradley (1995) suggest that the transition from childhood to adolescence may be a critical time for the development of transsexualism. They note that those children who maintain a consistent cross-gender identification as they move through adolescence are most at risk for transsexualism. A recent follow-up study of adolescents with GID who had received surgery for sexual reassignment indicated no gender dysphoria and better psychological and social functioning than a control group of transsexuals who had not received such treatment (Smith, van Goozen, & Cohen-Kettenis, 2001). Transvestism (cross-dressing by heterosexual males for purposes of sexual arousal) does not appear to be related to GID. Such males typically do not have gender problems as children or as adults (Blanchard, 1990). The function of cross-dressing appears to distinguish potential transvestism from GID. Cross-dressing among gender-disturbed boys is done for the purpose of enhancing identification with the opposite sex (typically employing outer clothing), as opposed to a soothing or erotic function (typically involving female underwear) for transvestism (Zucker & Green, 1992).

Treatment Treatment of GID in children has generated considerable controversy. One view argues that treatment reinforces a sexist view of child rearing (Zucker, 1990b), and therefore it is inappropriate to try to change a child’s discordant gender identity. Others have questioned the ethics of treating GID in the attempt to prevent homosexuality (although it is not clear that treatment is effective in this regard), and argue that the treatment may in effect cause more harm than good by focusing on the idea that homosexuality is undesirable (Green, 1987). An alternative view proposes that early treatment of GID may at least alleviate the peer relationship and self-esteem problems that accompany the disorder, and may also be effective in resolving the gender identity disturbance (Rekers, Kilgus, & Rosen, 1990; Zucker, 1990b). This view supports early intervention to eliminate cross-gender behaviors and to replace them with behaviors that are consistent with a child’s physical sex. This approach may speed up the natural developmental process of cross-gender behavior (i.e., a decrease with age) and prevent the development of other forms of psychopathology that typically result from peer rejection. A third

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approach is to focus treatment on first acknowledging and affirming the child’s cross-gender preference, and then helping the child learn how to express this preference in a manner that allows for both good peer relations and a positive self-image. According to this view, crossgender behaviors are only seen as problematic in reference to where and when they are expressed. A behavioral approach to treatment of GID in children is most common (but see Soutter, 1996, and Sugar, 1995, for alternatives). This approach assumes that cross-gender behavior is learned and therefore can be changed by manipulation of the consequences for cross- and samegender behavior (Meyer-Bahlburg, 1985; Zucker, 1990b). Behavioral treatment provides opportunities and positive reinforcement for engaging in gender-appropriate behavior and choosing gender-appropriate games and toys. Verbal feedback is given about gender-appropriate and gender-inappropriate behavior, and cross-gender behavior is extinguished by ignoring (Rekers & Lovaas, 1974; Schaefer & Millman, 1981). Self-esteem enhancement focused on gender-related issues is also an important component of treatment in most cases of GID (Pope, McHale, & Craighead, 1988). For example, the clinician can instruct parents to describe positively the specific gender-related attributes of the child (e.g., “You are such a strong young man. I really appreciate your carrying in the groceries. You are getting to be just like your dad”). Parental involvement is essential to the success of treatment—both to provide the parents with insight as to their contribution to the problem (if any), and to enable them to assist with the treatment program. Parents can contribute by ensuring that the program is implemented consistently across settings and people. However, treatment of any accompanying parental or family psychopathology is essential to maximize the effectiveness of the treatment program.

Oversexualized and Sexually Aggressive Behavior Although all children display interest and curiosity about sexuality at various times during their development, some appear to be focused on and preoccupied with sexual matters beyond what is expected for their age. The behavior of these children may vary a great deal, ranging from compulsive, public masturbation to coercive or aggressive sexual interactions with other children. For the most part, however, the behavior is unresponsive to parental limit setting, interferes with other age-appropriate activities, and may indicate serious psychopathology. Sexualized behavior is often thought to be an indication that a child has been sexually abused. Indeed, many sexual behaviors (e.g., asking to engage in sex acts, putting mouth on sex parts, masturbating with objects, etc.) have been shown to occur more frequently among children who have been sexually abused than among those who have not (Friedrich et al., 1992). But not all children who exhibit these types of behavior have been sexually abused; conversely, many children who have been abused do not exhibit sexualized behavior. Nonetheless, sexualized behavior that interferes with other age-appropriate activities is a warning signal that a child may have other problems. The possibility that the child may have been sexually abused should be explored (but, if possible, without raising unnecessary concern). Sexually aggressive behaviors among children are never normal and always warrant careful assessment and treatment. These behaviors tend to be part of a larger picture of conduct problems and typically reflect significant psychopathology in a child and/or family (Friedrich, 1990). The clinical picture for children who engage in such behaviors varies according to age and gender. For instance, a history of sexual abuse has been found in almost all cases of sexu-

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ally aggressive behavior in preadolescent girls (Johnson, 1989). These girls can be distinguished from others who have been abused but do not engage in sexually aggressive behaviors, in that they have been more severely and frequently abused, have a close relationship to the perpetrators, and tend to come from very dysfunctional families that have not provided support following disclosure of the abuse (Johnson, 1989). In contrast to girls, preadolescent boys who engage in sexually aggressive behavior may or may not have a history of sexual abuse, although the majority come from dysfunctional families (Johnson, 1988). It is suspected that those boys who do not have a history of sexual abuse have been exposed to deviant sexuality of some sort. Treatment of children who engage in sexually aggressive behaviors is very complex and must necessarily be multifaceted, involving individual, group, and family intervention. A recent report differentiated five types of sexual problems on the basis of demographic, historic, diagnostic, and behavioral variables: “sexually aggressive,” “highly traumatized,” “rule-breaking,” “abuse-reactive,” and “nonsymptomatic” (Pithers, Gray, Busconi, & Houchens, 1998). Different treatment approaches were shown to be effective with different types of problems. For instance, relapse prevention was more effective than expressive therapy with children who were classified as highly traumatized, abuse-reactive, and nonsymptomatic, whereas both types of treatment were equally beneficial for children classified as rule-breaking. Neither approach to treatment was very successful with children classified as sexually aggressive. Friedrich (1990) suggests that a good place to start treatment of a sexually aggressive child is with a careful analysis of the needs and issues of the individual child and family. These can then be prioritized, and treatment can be planned to deal with each in turn. Among the treatment issues likely to be important are dealing with the child’s experience of sexual abuse (when this exists), controlling the child’s own abusive sexual behavior, and helping parents to manage the child’s behavior. Moreover, Friedrich (1990) notes that many factors can interfere with individual therapy for sexually aggressive youngsters, including a primary parental figure’s lack of support for or participation in treatment, parental failure to protect a child from further victimization, and a therapist’s unwillingness or inability to be goal-oriented and directive. Because of the co-occurrence of sexual aggression and conduct disorder, the approach outlined by Patterson, Reid, Jones, and Conger (1975) for delinquent and aggressive youth is also an appropriate model to help parents gain better control over a child’s sexual and nonsexual aggressive behaviors (see Chapter 10). Excellent detailed descriptions of other treatment approaches for sexually aggressive children are provided by Friedrich (1990) and by Gil and Johnson (1993).

CHILD SEXUAL ABUSE The professional literature on the topic of child sexual abuse is overwhelmingly large and diverse, including clinical case studies, observational studies, empirical research, and comprehensive reviews and meta-analyses. In this section, we have tried to condense this large volume of work and to focus on the issues we view as central to assessing and treating children who have been sexually abused.

Definitional Issues Although there is not yet a commonly agreed-upon definition of child sexual abuse, definitional issues are important in determining when children’s sexual experiences are part of nor-

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mal development and when they should be considered abusive. The clinician should be aware that societal attitudes toward sexual contact between children and adults will necessarily influence the behaviors that are defined as sexually abusive. Perhaps because of the attention that child sexual abuse has received in the mass media, there is a tendency on the part of parents and professionals to overinterpret as abusive many innocent encounters between adults and children that are not necessarily sexually motivated (e.g., applying ointment to the genital area or taking showers together). Similarly, children who have been exposed to sexual abuse prevention programs may be overly sensitive to innocent, incidental contact with others (such as others’ accidentally brushing against their breasts or genitalia during a game or a hug), and may report this behavior as abusive. From a practical perspective, we argue that in determining whether or not sexual abuse has occurred, clinicians should focus on understanding the specific behavior that is reported, the context in which this behavior occurs, and the intent of the participants. The relative developmental level of the participants; their status in relation to each other; and the use (or not) of coercion, manipulation, or force are also important factors in determining that any specific sexual behavior is abusive.

Prevalence Estimates of the prevalence of sexual abuse reflect definitional problems as well as differences in the populations sampled (i.e., clinical vs. community), and vary tremendously, ranging from 6% to 62% of girls and from 3% to 31% of boys (Finkelhor, 1990). Higher rates are found in studies of clinical samples and studies with broader definitions of sexual abuse. A large survey (completed in 1985) that was representative of the demographics of the U.S. Census and used a relatively broad definition of sexual abuse (i.e., contact as well as noncontact sexual behavior) reported a history of sexual abuse for 27% of women and 16% of men (Finkelhor, Hotaling, Lewis, & Smith, 1990). These rates are fairly consistent with those reported in other work when sampling and definitional issues are taken into account (see Wolfe & Birt, 1997). Although there is agreement that sexual abuse in general tends to be underreported, many suspect that prevalence rates are underestimated for boys to a greater extent than for girls, in part because boys are less likely to report abuse (Wolfe & Birt, 1997). Walker, Bonner, and Kaufman (1988) presented data from the American Association for Protecting Children indicating that the incidence of sexual abuse increases with children’s age. Among children who were sexually abused, 25% were ages 0–5, 34.3% were ages 6–11 years, and 40.6% were ages 12–17. Other work suggests, however, that the incidence of abuse actually decreases with age for boys. Faller (1989) has reported data indicating that in her sample of sexually abused boys, 58.5% were 2–5 years old, 25.3% were 6–10 years old, and 17.2% were 11–17 years old when the abuse occurred. This decrease probably reflects the increased size and strength of boys as they develop. Many other characteristics of sexual abuse have been found to differ for boys and girls. Boys are more likely than girls to be abused at a younger age, to experience anal penetration, to be physically as well as sexually abused, to be abused by multiple perpetrators who are typically outside the family, and to be forcefully abused (Watkins & Bentovim, 1992; Wolfe & Birt, 1997). It is not clear whether the prevalence of sexual abuse is actually increasing or decreasing. Bagley (1990) examined age cohorts of young adults and found that prevalence rates for retrospective reports of childhood sexual abuse increased with age, from 20.8% of 18-year-olds to 42.0% of 24-year-olds, indicating a decrease in rates of sexual abuse over time. He speculates that younger women have increasingly been exposed to media presentations about sexual abuse,

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and that this increased exposure may be contributing to an actual decline in instances of abuse. In contrast, Wyatt, Loeb, Solis, and Carmona (1999) repeated a 1984 (Wyatt, 1985) survey of women in Los Angeles County, California, and found no changes in prevalence rates over 10 years. Perpetrators Aside from the fact that perpetrators of sexual abuse are overwhelmingly male (it is estimated that women account for only about 5% of abuse among girls and 20% among boys), they are a very diverse group (Finkelhor, 1987). Although abuse by fathers and stepfathers is most common among cases reported to child protective agencies, national community samples indicate that these individuals commit no more than 7–8% of all cases of sexual abuse (Finkelhor, 1987). More frequently, perpetrators include other family members (typically uncles or brothers; 16– 42% of cases) and nonrelatives (friends, neighbors, child care workers, etc.; 32–60% of cases) (Finkelhor, 1987). Although there have been several attempts to classify perpetrators of child sexual abuse (see Wolfe & Birt, 1997), no single psychological profile distinguishes these perpetrators, and few of these individuals evidence a diagnosable mental disorder. Hall (1990) reviewed research on multiple factors that might distinguish perpetrators from others, and concluded that a history of sexual aggression was the most accurate predictor of future sexual aggression. Thus it seems more productive to examine the conditions that increase the risk of sexual abuse’s occurring. Finkelhor (1984) summarizes some of these conditions. First, the perpetrator must be motivated to relate sexually with a child. In most cases, an important emotional need (e.g., power and dominance) is satisfied by this relationship. Moreover, the perpetrator must be sexually aroused by children, and alternative, appropriate sources of sexual gratification often may be unavailable. Second, internal inhibitions must be overcome. Many factors can contribute to this, including alcohol and drug use, sexualized portrayal of children in the media, stressful life events (e.g., divorce, unemployment, etc.), emotional/psychological dysfunction, and a lack of strong community sanctions (i.e., failure to prosecute or convict offenders and weak sentencing patterns). Research has shown that perpetrators of child sexual abuse differ from other groups of men in their cognitions about sexual relations with children (Stermac & Segal, 1989), and in a lack of involvement in the early day-to-day care of their children as infants (Parker & Parker, 1986). Third, external inhibitors that would ordinarily prevent abuse from occurring must be overcome. A perpetrator must have access to a child and may gain this access through the physical or psychological absence of the mother. Finally, the child’s resistance must be overcome. Factors that can contribute to this include the perpetrator’s use of coercion or manipulation, as well as the child’s lack of knowledge of sexuality and personal safety skills, poor self-confidence, emotional distress, or physical or intellectual handicaps (Budin & Johnson, 1989; Conte, Wolf, & Smith, 1989). Current research on perpetrators of sexual abuse focuses on young offenders. It is estimated that adolescent males are responsible for up to 50% of child sexual abuse cases, and it is suspected that this estimate may underrepresent the actual incidence because of a reluctance to report these young offenders (Kempton & Forehand, 1992; Ryan, 1997a). Moreover, rates of repeated offenses among these teenagers are very high; the average number of victims reported in a national survey was 7.7, with more offenses committed by older teens (Ryan, Miyoshi, Metzner, Krugman, & Fryer, 1996; Ryan, 1997c). Consistent with research on adult offenders, the vast majority of adolescent sexual offenders are male (97.4% vs. 2.6% female)

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(Ryan et al., 1996). Child maltreatment is common in the histories of these youth, and as many as 80% report having been sexually abused (Shaw, 1999). The younger a boy is when he commits his first sexual offense, the more likely it is that he has been sexually abused (Johnson, 1988). The fact that these teenagers engage in sexual deviance versus some other form of inappropriate behavior is thought to stem from early exposure to deviant sexuality through actual sexual abuse or other inappropriate stimuli. Unfortunately, treatment for adult sexual abuse perpetrators has not been very effective. Studies of recidivism rates for incarcerated perpetrators indicate that reoffending is a very common problem even for those who have received treatment, and that reconvictions often occur years after the first offense (Hanson, Steffy, & Gauthier, 1993). Relapse prevention, a treatment model first developed for substance use disorders (Marlatt, 1982), is currently widely employed in the treatment of sexual offending (Pithers & Gray, 1996). Although use of relapse prevention with sexual abuse perpetrators makes intuitive sense, there is little research examining its efficacy with this population. There are few empirical studies of treatment for adolescent sexual offenders. A recent report (Worling & Curwen, 2000) describes a treatment program that significantly reduced recidivism rates among treated adolescents versus a nontreated control group (5.17% vs. 17.8%). Factors that may contribute to recidivism include choice of boys as victims, sexual interest in children, and a history of sexual offenses (Hanson et al., 1993; Rice, Quinsey, & Harris, 1991; Worling & Curwen, 2000). Little is known about recidivism rates for perpetrators who are not convicted or who never enter the criminal justice system. It seems likely that rates of reoffending for this population would be even higher than among those who have been imprisoned. Moreover, there are no data on rates of long-term recidivism among treated offenders.

Effects of Sexual Abuse Short-Term Effects Although some children who have been sexually abused show no harmful effects of the abuse, a great number evidence clinically significant symptoms. Research has clearly documented the fact that sexually abused children as a group have more symptoms than nonabused nonreferred children, but fewer than nonabused clinic-referred children (Kendall-Tackett, Williams, & Finkelhor, 1993). Symptoms that are seen most commonly among abused children include fears, posttraumatic stress disorder (PTSD), general behavior problems, sexualized behavior, and poor self-esteem. Of these, only PTSD and sexualized behavior differentiate sexually abused children from nonabused clinic-referred children (Wolfe & Birt, 1995, 1997). The DSM-IV (American Psychiatric Association, 1994) indicates that the central features of PTSD include (1) experiencing or witnessing an event that entailed threatened or actual death or grave injury to self or others, and responding with intense fear, helplessness, or horror; (2) reexperiencing the traumatic event (e.g., nightmares, trauma-specific reenactment in play); (3) avoiding stimuli associated with the trauma (e.g., affective numbing or lack of general responsiveness); and (4) hyperarousal (i.e., startle responses, hypervigilance, inattentiveness, irritability or anger, and/or trouble sleeping). Research consistently indicates that symptoms of PTSD are seen in many children who have been sexually abused, and are most prominent among preschool children (Kendall et al., 1993; McLeer, Deblinger, Henry, & Orvaschel, 1992). Although many sexually abused children may show some symptoms of PTSD, it is likely that a diagnosis of PTSD is appropriate only for the most severely abused children.

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Sexualized behavior is consistently found to a greater extent in sexually abused children than in nonabused nonclinical or clinical samples (e.g., Friedrich, Luecke, Beilke, & Place, 1992; Gale, Thompson, Moran, & Sack, 1988; Inderbitzen-Pisaruk, Shawchuck, & Hoier, 1992). As noted earlier, however, many children who have been sexually abused do not evidence sexualized behavior, and many nonabused children do so. Thus using sexualized behavior as an indicator of sexual abuse can result in very high rates of false positives and false negatives. Moreover, recent work suggests that boys and girls may differ in the nature of the sexual symptoms shown, with girls more likely to experience sexual anxiety and boys to be more eroticized (Feiring, Taska, & Lewis, 1999). The effects of sexual abuse are highly variable, reflecting the interaction of characteristics of the abuse itself, the functioning of the individual child and family, and community stress or support (Wolfe & Birt, 1995). As a result, no one symptom or cluster of symptoms characterizes sexually abused children, and no evidence exists for a “sexual abuse syndrome” (Berliner & Conte, 1993). More symptoms are evidenced by children whose experience of abuse has included the following factors: (1) a close relationship with the perpetrator; (2) high frequency and long duration of sexual encounters; (3) oral, anal, or vaginal penetration; and (4) use of force (Beitchman et al., 1991; Kendall-Tackett et al., 1993). Moreover, maternal support, especially at the time of disclosure, has consistently been found to be related to a child’s adjustment. This should not be surprising, as children who are caught in the midst of family turmoil surrounding the disclosure of abuse are clearly going to suffer more than children whose families provide support for them. A child’s age at the time of the abuse has also been found to be related to adjustment, with older children showing more symptoms than younger children. This finding is confounded with the frequency and duration of abuse, however, as older children are more likely to have experienced abuse over a longer period of time and more frequently than younger children. The impact of age at the onset of abuse is not known, although one could speculate that this would interact in some way with the child’s developmental stage and the particular issues typical of that stage (e.g., personal identity and relationships in adolescence, automony and control in toddlers, etc.) (Feiring et al., 1999). Furthermore, one cannot assume that children who are sexually abused as infants will not remember the abuse and thus will not evidence any symptoms. The clinical literature includes cases of children who begin to disclose abuse that occurred during infancy as they gain language and communication skills (Friedrich, 1990; Hewitt, 1994). Long-Term Effects Studies on the long-term effects of sexual abuse have been conducted with clinical populations, as well as through surveys of the general population. This research typically assesses clinical symptoms in adults who recall being sexually abused as children. Women who have been sexually abused as children evidence a variety of significant problems as adults, including increased rates of sexual dysfunction, anxiety and fears, depression, suicidal ideation/behavior, and posttraumatic stress responses (Jumper, 1995; Neumann, Houskamp, Pollock, & Briere, 1996). They may also experience higher rates of other health risk behaviors (e.g., smoking, excessive alcohol consumption, earlier age at first intercourse, increased numbers of sexual partners, and a lower frequency of Pap smears) and medical/gynecological problems than women without a history of sexual abuse (Springs & Friedrich, 1992). Women who have been sexually abused also appear to be especially vulnerable to revictimization (Collins, 1998), although revictimization may be mediated by a higher level of sexual activity and more sexual partners (Krahe, Scheinberger-Olwig, Waizenhofer, &

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Koplin, 1999). It is important to note, however, that many women who experience sexual contact in childhood do not have long-term negative effects (Rind, Tromovitch, & Bauserman, 1998). Moreover, family dysfunction is typically confounded with sexual abuse and may actually explain more of the long-range negative impact than the abuse itself (Rind et al., 1998). The data on long-term effects for male victims are less clear than those for women, largely because there tend to be fewer males included in these studies. Abused males are thought to be more likely to experience gender identity confusion and homosexual preferences than are abused women (Watkins & Bentovim, 1992; Doll et al., 1992). Like abused women, abused men have been found to have depression, suicidal feelings/behavior, low self-esteem, anxiety disorders, sexual dysfunction, and relationship difficulties at higher rates than nonabused men do (Watkins & Bentovim, 1992). There are also indications that men who are sexually abused as children are at higher risk for engaging in sexual aggression or becoming sexual abuse perpetrators, although not all such perpetrators have been abused in childhood (Watkins & Bentovim, 1992). Finally, one recent study using meta-analysis found that men tended to react less negatively to childhood sexual experiences than women did (Rind et al., 1998). Longitudinal studies are important to understanding sexual abuse, because they permit examination of the course of sequelae over time, as well as of the factors contributing to recovery. In general, the majority of child sexual abuse victims improve over time, although a substantial minority may continue to evidence significant symptoms (Oates, O’Toole, Lynch, Stern, & Cooney, 1994). Moreover, some children who are symptom-free at the time of assessment may begin to show problems at a later time (Kendall-Tackett et al., 1993; Oates et al., 1994). The relationship between treatment and later adjustment is not clear. One recent study that found a significant decrease in children’s functioning over a 2-year period indicated that treatment services were generally unavailable, and that this fact might have mediated adjustment (Calam, Horne, Glasgow, & Cox, 1998). Oates et al. (1994), however, found no relationship between therapy and adjustment outcome. It is possible that the nature of the treatment received is a critical factor in mediating adjustment. Cohen and Mannarino (1998a), for example, found that children who received cognitive-behavioral therapy improved significantly more over 6 and 12 months than did children who received nondirective supportive therapy. In a review of treatment studies, Finkelhor and Berliner (1995) found that some symptoms, such as aggressive and sexualized behavior, were particularly resistant to change. Furthermore, although some children clearly benefited from treatment, others did not. No one approach to treatment was found to be more effective than another. Factors that may mediate adjustment are family functioning, family support for the child, the child’s coping skills, and whether or not he or she appears in court (Cohen & Mannarino, 1998b; Goodman et al., 1992; Oates et al., 1994; Runyon, Everson, Edelsohn, Hunter, & Coulter, 1988; Tremblay, Hebert, & Piche, 1999). Finkelhor and Berliner (1995) conclude that it is unreasonable to expect one abusespecific treatment approach to be effective for all victims of child abuse. Rather, treatment must be targeted specifically to issues most pertinent for an individual child and family, and a variety of techniques will need to be used.

ASSESSMENT OF SEXUAL ABUSE Assessment of children who are alleged to have been sexually abused is challenging, in part because there is no way to determine with absolute certainty the truth about what happened. Moreover, once an opinion about what happened is established, it is very difficult to change.

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In the assessment of sexual abuse, the clinician functions as a “fact finder,” gathering information and making professional judgments about the meaning of those facts. The clinician must review a great deal of information to determine whether there is a pattern of factors increasing or decreasing the probability that abuse has occurred. It is imperative that the criteria used in making probability statements about abuse be made explicit, including the support for and limitations of each criterion (Berliner & Conte, 1993). To do this adequately, the clinician must have knowledge of child development (particularly sexual development), be familiar with recent research on memory and suggestibility, and be able to apply this knowledge to individual cases. Although clincially relevant aspects of the research on children’s memory and suggestibility are included in this section, a comprehensive review of this extensive literature is beyond the scope of this chapter. The reader is referred to Ceci and Bruck (1995), Gordon, Schroeder, Ornstein, and Baker-Ward (1995), and Gordon, Baker-Ward, and Ornstein (2001) for more extensive discussions of this topic. Although we believe that a “scientist–practitioner” perspective is appropriate for all clinical work, it is most critical in evaluating sexual abuse cases. As Berliner and Conte (1993) state, the clinician must recognize “that mental health professionals have no special capacity to determine whether someone is being truthful” (p. 121) and that “there is no mechanism for establishing the absolute truth, whereby it is known for sure whether or not the child was actually abused” (p. 113). Fundamentally, the judgment that a child has or has not been sexually abused is just that—a clinical judgment. We hope that this clinical judgment is based on the use of a systematic process for data collection and evaluation that is informed by relevant clinical and empirical work. We urge clinicians to adopt a “quasi-scientific” approach, examining alternative hypotheses that might explain the information gathered. Various guidelines for evaluation of suspected sexual abuse in children and adolescents have been proposed (American Academy of Child and Adolescent Psychiatry, 1997a; American Professional Society on the Abuse of Children, 1990; Lamb, 1994). The essential features of these documents are summarized in this section, with the addition of more specific information on assessment methods (e.g., using questionnaires, assessing development, etc.) and on interpreting the assessment data according to the Comprehensive Assessment-toIntervention System (CAIS; see Chapter 2).

Step 1: Initial Contact The Referral Clarifying the Referral Question. Sexual abuse cases can be referred by many different people, including parents, protective services workers, police, physicians, attorneys, and others. In assessing these cases, it is most important to clarify the referral question(s), so that the clinician and the referring person are in agreement about the focus of the assessment. The clinician must then decide which questions can reasonably be answered according to the facts of each case, and can focus the assessment carefully on only those questions. Referral for assessment of sexual abuse can potentially involve four different types of cases. Each type involves different issues, and therefore different assessment and treatment processes. The four types are as follows: 1. The clinician is asked to determine whether or not sexual abuse has occurred. In these cases, the assessment must include a structured protocol that takes into account recent em-

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pirical work on children’s memory and suggestibility, as well as the potential involvement of the child in the legal system. 2. The clinician is asked to determine whether or not sexual abuse has occurred, but the child has been interviewed regarding the alleged abuse on one or more previous occasions. This assessment must include careful review of all relevant background information including the records (ideally, verbatim transcripts) of all previous interviews. This information should be interpreted in light of current research on children’s memory and suggestibility, as well as on risk factors for sexual abuse (see Table 7.3, below). It may be neither preferable nor necessary to reinterview the child (American Professional Society on the Abuse of Children, 1990). Rather, the clinician’s opinion about the probability that the alleged abuse occurred may be based on this review of existing records. 3. Sexual abuse has been substantiated, and the clinician is asked to plan a treatment program. In these cases, the focus of the assessment is on acknowledging the abuse and determining the treatment needs of the child and family. 4. The clinician is asked to plan a treatment program for a child when abuse has not been substantiated, but the parent has continuing concern regarding the child’s behavior(s) and may even express a belief that abuse may have occurred. The focus of assessment in this instance should be on the behaviors of concern, without the assumption that abuse has occurred. It is imperative in these cases that the clinician maintain a neutral attitude toward the possibility of abuse. Gathering Background Information. Before interviewing the child and/or family, the clinician should contact all persons involved in the case to determine their roles, to find out what information has already been gathered, and to promote collaboration. This step is particularly important if the case is likely to be prosecuted, if the clinician is being asked for a second opinion, or if the clinician is asked to plan treatment and abuse has not been substantiated. In reviewing background information, however, the clinician must be neutral as to whether abuse actually occurred or not, and begin to formulate alternative explanations for the allegations. The background information to be gathered at this stage in the assessment process includes the number, type and, if possible, transcripts or recordings of prior interviews; the nature of the child’s initial disclosure (or, if there is no disclosure, the reason why abuse is suspected); behavioral changes evidenced by the child; results of any medical examinations; and a brief family and developmental history. Walker, Bonner, and Kaufman (1988) suggest that risk assessment is helpful in organizing background data. In this regard, Table 7.3 presents many of the factors associated with poor outcome in families where sexual abuse has occurred. Information about each of these factors should be gathered during the assessment and used to address such questions as whether there is a need for treatment or whether the child can safely be returned home. The presence of any one or two factors may not necessarily be of concern. Rather, the accumulation and interaction of risk factors determine outcome in most cases. Often one or both parents are not available during an investigation, because the child has been removed from the home and/or a parent is suspected of perpetrating the abuse. In these cases, information about the child’s current living circumstances should be obtained, and a plan should be made to gather information about the parents and family. Questionnaires Depending on the specific questions to be addressed and the availability of parents to complete them, questionnaires and checklists may be helpful in completing the task of gathering

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TABLE 7.3. Risk Factors Associated with Poor Outcome in Sexually Abusive Families Child risk factors Poor relationship with nonabusing parent Preexisting behavioral or emotional problems Intellectual or physical handicaps Use of threats, force, or injury to the child Abuse over a long time or many incidents

Age 13 years or older Family relationship to perpetrator Few or no friends or age-appropriate activities Court appearance without adequate preparation Long delays in legal proceedings

Nonabusing parent risk factors Failure to believe child Blaming others or child for abuse Excessive dependence on abusing spouse Inability or unwillingness to protect child Resistance to help, distrust

History of inadequate parenting Social isolation Alcohol or drug abuse Significant psychopathology Intellectual handicaps

Perpetrator risk factors Denial of abuse Blaming others or child for abuse Lack of remorse, concerns only for self History of sexual abuse of self or others History of antisocial behavior or criminal record

Significant psychopathology Alcohol or drug abuse Significant life stress and poor coping skills No normal sexual outlet History of inappropriate parenting

Social and environmental risk factors Isolated family Marital conflict or distress Single-parent family Stepparent family

Overly restrictive or permissive sexual attitudes Low socioeconomic status (SES) Environmental instability Environmental stress (e.g., unemployment)

background information. Many questionnaires specific to child sexual abuse have been developed, and the reader is referred to Wolfe and Birt (1997) for a comprehensive review. The questionnaires mentioned here are those we have found most useful in a general pediatric psychology clinic. Our General Parent Questionnaire (see Appendix B) provides information about the family constellation and the parents’ perceptions of the problem. The Child Behavior Checklist (CBCL; Achenbach, 1991a, 1992) has been used extensively in research with sexually abused children and provides information on sexual behavior, PTSD, and other emotional or behavioral problems that can corroborate the allegations of sexual abuse (e.g., Friedrich, Beilke, & Urquiza, 1988). Wolfe and Birt (1997) have used the CBCL to document PTSD symptoms by selecting items that represent DSM-IV criteria; they suggest that this measure can serve as an adjunct to the regular scoring of the CBCL. These items are shown in Table 7.4. The Child Sexual Behavior Inventory—Revised (CSBI-R; Friedrich, 1997) is useful in documenting unusual sexual behaviors. It consists of questions about specific types and frequencies of sexual behavior exhibited by children. This instrument has been standardized and validated by comparing responses of parents/caretakers of sexually abused children (ages 3– 12) with those of parents/caretakers of nonabused children of the same ages. The CSBI— Revised (CSBI-R) is described in Appendix A. In using data from these questionnaires, especially the CSBI-R, the clinician must understand that there are no empirically validated behavioral indicators of sexual abuse, including sexualized behavior (Berliner & Conte, 1993). Thus it is critical to evaluate information about

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CBCL items

Reexperiencing

9. 13. 14. 17. 47. 71. 112.

Obsessive thoughts Confused; seems in a fog Cries a lot Daydreams Nightmares Self-conscious Worries

Fears and avoidance

11. 29. 30. 31. 45. 50. 69. 111.

Clings to adults Fears certain animals, situations, or places Fears going to school Fears doing something bad Nervous, high-strung Fearful, anxious Secretive Withdrawn

Hyperarousal

3. 8. 10. 41. 56f. 86. 87. 110.

Argues a lot Can’t concentrate Can’t sit still, restless Impulsive Stomachaches Irritable Moody Trouble sleeping

Note. The data are from Wolfe and Birt (1997).

sexual behavior in light of children’s normative sexual behavior and knowledge, as well as other factors pertinent to a specific case. It is not unusual for children to be referred for assessment of sexual abuse because they are engaging in sexual behavior or expressing knowledge that is typical for their developmental stage but not recognized as such by the adults around them. For instance, two brothers, ages 3 and 5 years, were referred for assessment of suspected abuse because their grandmother caught them behind the sofa touching each other’s penises. Among children at these ages, this behavior is typical and does not necessarily indicate sexual abuse. Finally, the Parenting Stress Index (PSI; Abidin, 1995) provides preliminary information about the child’s temperamental characteristics and sources of stress for the child’s parent(s) apart from the abuse.

Step 2: Parent and Child Interviews Parent Interview The nature of the parent interview will obviously vary, depending on the purpose of the assessment. If the assessment is being conducted for purposes of investigation of sexual abuse, the initial parent interview is usually brief and the child is not present. The focus of this interview should be on the parent’s perceptions of the situation, the family’s reactions, and the way in which the abuse was initially disclosed. Details of the child’s initial disclosure are important, because this is often the most accurate account of the abuse. The clinician should determine where and how the disclosure occurred, what the child’s exact words were, and what was said

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and/or done in response. In cases in which the child has not verbally reported sexual abuse, detailed information should be gathered about the behaviors or events that led to the suspicion of abuse. In a recent case assessed in our clinic, for example, the mother had been worried about “autistic-like” behavior exhibited by her 2½-year-old daughter when she returned from visits with her father for at least 1 year prior to the referral. It was only when her daughter complained of a “sore bottom” that the mother began to suspect sexual abuse. A subsequent medical examination revealed physical evidence of vaginal penetration, but the child never verbally disclosed the abuse, even when asked directly. When the purpose of assessment is to plan a treatment program, it is important prior to the parent interview to determine if abuse has been substantiated. This is critical, because our approach to cases in which abuse has been substantiated is to interview the parent (or other primary caregiver) with the child present. In order to decrease the pressure on the child, we ask the parent or caregiver to tell us the details of the abuse, including how it was first disclosed, while checking periodically with the child to verify the information. This informs the child that it is OK to talk about sexual matters. Reactions of the parent/caregiver and other family members to the abuse should be noted as an indication of their ability to provide support for the child. The parent/caregiver should also be asked what sexuality education (if any) the child has received and what terms for sexual body parts are used by the family. When the referral is for treatment of a child who is suspected or believed (by parents or others) to have been abused but the abuse has not been substantiated, the child should not be included in any discussion of sexual abuse and should not be questioned regarding suspected abuse. Rather, the focus should be on the behaviors of concern, and the clinician should entertain hypotheses other than sexual abuse to explain these behaviors. In the course of treatment, for example, a child may disclose information about abuse when the clinician gives him or her information about sexuality. The clinician must then evaluate the child’s “disclosure” in the context of the child’s history and the events that precipitated the disclosure. In these cases, it is important to consider the possibility that the clinician has influenced a false disclosure. If the referral question concerns a parent’s ability to care for and protect the child, a separate parent interview is likely to be necessary. The parent’s “parenting models,” attitudes and values about parenting, and disciplinary practices should be assessed. Information about the child’s day-to-day functioning at home and school should also be gathered at this time, with an emphasis on changes in the child’s behavior since the abuse occurred. It is often relevant to briefly assess a parent’s sexual history, attitudes, and values, although this should be done in the absence of the child. Questions should be asked about the parent’s sexuality education and age at first sexual experience; it should also be determined whether the parent was ever molested as a child. Child Interview Taping the Interview. If the purpose of the assessment is to make a judgment of whether or not abuse has occurred, arrangements should be made prior to seeing the child and/or parents to audio- or videotape the child’s interview. Although some argue against taping the interview (in part because of the possibility of its being dissected in court), we think this record serves two very important purposes. First, it can help to minimize the number of interviews to which the child is exposed, and thus can reduce the possibility of contamination of the child’s report. Second, after the interview is completed, the clinician can review the questions asked and the

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manner in which they were asked, and objectively evaluate the child’s reponses to these questions for indications of suggestibility. Arranging the Setting. The setting in which the child will be interviewed for alleged sexual abuse should be arranged to facilitate the child’s recall. A “child-friendly” environment with age-appropriate toys and props, such as crayons and paper, a doll house, and dolls (not necessarily anatomically detailed [AD] dolls; see below) should be provided. The interview should be conducted as soon after the referral as possible, within a few days to a week at most. A speedy interview is particularly important for preschool children. Establishing Rapport. Regardless of the referral question, the clinician must establish rapport with a child before discussion of sensitive issues will be productive. It is important that the child be informed what the reason for the interview is, what will happen during the session(s), and what is expected of the child. If the purpose of assessment is investigation of abuse, the interviewer may ask the child, “Do you know why you are here today?” If no response is forthcoming (which is usually the case), the interviewer may continue, “You are here because ______ is worried that something bad [uncomfortable, yucky, etc.] might have happened to you. I talk with lots of children who have had bad things happen to them, so it’s OK for you to tell me anything you want to, but you should only tell me about things that really happened. First, I think we should get to know each other better. We can color for a while if you’d like to. Then I’ll ask you some questions. Does that sound OK?” Some general conversation about the child’s interests and accomplishments is appropriate prior to asking about the abuse (for other examples of preparation instructions, see Saywitz, Geiselman, & Bornstein, 1992). If the purpose of the assessment is to plan treatment for a child for whom abuse has been substantiated, the child is already aware of the purpose of the session, since he or she was present in the parent interview. The child simply needs to be told how the session will be conducted and what is expected of him or her. If the assessment is to plan treatment for a child for whom the abuse has not been substantiated, the child can be told, “Your parents [teachers, doctors] are concerned that you have been having trouble with sleeping [touching yourself in public, not wanting to visit Daddy, asking to look at other kids’ private parts, or whatever behavior is of concern]. I talk with lots of children who are having the same problem(s). Together we will try to understand what is troubling you and what we can do to make things better for you. Today I would like to get to know you better and ask you some questions about your school, friends, and family.” Development. Regardless of the referral question, the child’s developmental status should be assessed—formally if there appears to be some concern in this area (e.g., the child has documented learning or language problems), or informally if the child appears to be developing normally. Areas to assess include language comprehension and expression, intellectual level, memory skills, emotional status, and knowledge of sexuality. In cases involving investigation of sexual abuse, this assessment provides a framework for deciding how questions will be asked, what props will be used, and how the child’s responses will be evaluated. Yuille, Hunter, Joffe, and Saparniuk (1993) suggest that the child be asked to describe two specific past experiences (e.g., a birthday or last Christmas), the details of which can be verified by parents. This allows the interviewer to model the form of the interview (e.g., asking lots of questions) and the child to practice giving complete descriptions; however, the clinician should be aware that for children under the age of 5 years, free recall of details is more difficult than for older children.

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Specific questions, such as “Tell me one thing you got for your last birthday,” are easier for younger children to answer than open-ended questions, such as “Tell me about your last birthday.” The child’s susceptibility to suggestion can be assessed by challenging some of the child’s responses to questions about the details of such events (Wehrspann, Steinhauer, & KlajnerDiamond, 1987). The clinician could say, for example, “You didn’t really get a bicycle for your birthday, did you?”, or “Your mom said you got a doll” (when the child did not receive a doll). Dorado and Saywitz (2001) describe an intervention, called narrative improvement, designed to improve the recall of preschool children (ages 3½ to 6 years). Research indicates that this method increases the details remembered without increasing errors or false statements, but it is not known whether it is practical for use in clinical situations. The language used in the interview must be consistent with the language comprehension level of the child. This is particularly important for most preschool children, who have trouble with vocabulary, multiple-syllable words, and syntax. The clinician should check out what the child actually understands, since children often think that they know the meaning of a word or a question when in fact they do not, or have only a partial understanding. To assess the child’s understanding, the clinician should request definitions or explanations, rather than accepting “Yes” reponses to “Do you understand?” When changing the topic, the clinician must make sure the child is aware of the transition. (For suggestions on conducting a “cognitive interview,” see Geiselman, Saywitz, & Bornstein, 1993.) Regardless of the referral question, children’s knowledge of sexuality is an important area of development to assess. We assess knowledge in the following areas: body parts and functions (including sexual and nonsexual body parts), gender differences and gender identity, pregnancy and birth, sexual behavior (masturbation and sexual intercourse), and abuse prevention (e.g., “What are the private parts?”, “What should you do if someone tries to touch your private parts?”). Young children respond better to concrete stimuli, so we use pictures of nude boys and girls and nude men and women as we ask questions in these areas. AD dolls can also be used for this purpose (but see below). Assessment of sexual knowledge often elicits emotional reactions from a child who has been sexually abused, and sometimes spontaneously precipitates discussion of the child’s sexual experience. Assessment of current emotional status, as well as status prior to the suspected abuse, is important. The existence of recent emotional problems, such as unusual fears, anxiety, guilt, and poor self-esteem, can provide corroborative evidence regarding the child’s report or the parent’s suspicion of abuse. The Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (Harter & Pike, 1984) and the Self-Perception Profile for Children (Harter, 1983) are useful for assessing self-esteem. Maladaptive responses and poor coping skills can be assessed in children ages 6–15 with the Roberts Apperception Test for Children (McArthur & Roberts, 1982). Additional information can be obtained by observing the child’s play and noting unusual themes (aggression, fear, guilt, etc.), over- or underactivity, and intense or unusual reactions to ordinary stimuli. The clinician can assess the child’s general perceptions of family members through a variety of methods, and this information can be particularly informative if a family member is suspected of the abuse. With preschool children, family drawings or doll house play can be used as stimuli for discussion about what the child likes and dislikes about each person and what kinds of things they do together. Extreme or intense reactions (fear, anger, hostility, etc.) to one or more specific family members is especially important to assess. For instance, in a case we recently assessed, a 4-year-old girl was so afraid of her grandfather (who allegedly had molested her) that she could not draw a picture of him and refused to talk about

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him. At the same time, she was very open and expressed positive feelings about other family members. Questioning about Sexual Abuse. When the interview involves questions specific to sexual abuse, the clinician should begin with a brief statement that he or she does not know what happened, so it is important for the child to provide as much detail as possible. The interview should begin with open-ended questions (e.g., “Tell me about your stepfather,” “What do you like/dislike about him?”). This is important because the types of questions asked are directly related to the accuracy and completeness of the child’s recall, as well as the interviewer’s (and others’) perceptions of the credibility of the child’s report. Preschool children will require more direct and specific questions, but their responses to these questions may be difficult to interpret. In particular, “yes–no” questions are problematic for preschoolers, and the validity of their responses to such questions must be viewed cautiously (Gordon & Follmer, 1994). At some point, if the child has not volunteered information about the alleged abuse, he or she must be asked directly about the possibility that sexual abuse has occurred. The question “Has anyone ever touched your [use the child’s own label for genitalia]?” is very ambiguous, because children’s bottoms are often touched for a variety of nonabusive reasons. “Yes” responses require further clarification (e.g., “What did Dad do when he touched your bottom?”), and if none is forthcoming, these responses must be interpreted cautiously. In a case recently referred to us, a 3-year-old boy (with a history of encopresis, which had been treated with enemas and suppositories) had complained to his mother of a sore bottom. She asked him whether anyone had ever “touched his bottom,” and he responded, “Daddy poked my bottom.” The mother (who had recently separated from the father) interpreted this as possible sexual abuse; yet later, when asked to elaborate, the boy would only demonstrate that his father had touched the side of his hip with his index finger. Furthermore, it is essential that the child be questioned about a variety of people, not just the suspected perpetrator. It is not uncommon for clinicians or parents to attempt to elicit a disclosure by reading the child a book about another child who has been abused. This is not appropriate, because it introduces information that can influence the child’s report. For example, in several cases referred to us (including the case of the 3-year-old described above), the book I Can’t Talk about It (Sanford, 1986) was read to the children during the assessment process. This particular book (and, we are sure, others as well) presents detailed descriptions of a father who molested a child, and we think it has the potential to elicit a false accusation. More general books on sexuality education or sexual abuse prevention can be used during assessment or treatment in most cases. Using Anatomically Detailed Dolls. The use of AD dolls is very controversal (Everson & Boat, 1994). Concerns regarding the use of AD dolls center around two important questions: (1) Do the dolls elicit false reports of sexual abuse? (2) How are the dolls most appropriately used to assess sexual abuse? In a review of the research on AD dolls, the Anatomical Doll Task Force (American Psychological Association, 1994) concluded that clinicians should not be discouraged from using AD dolls in interviews with children who may have been sexually abused. They must be particularly cautious in the use of these dolls with preschool children, however, because the tendency for these younger children to be more suggestible may lead them to make false reports of sexual abuse when interviewed with the dolls (see a study by Bruck, Ceci, Francoeur, & Renick, described in the report of the Anatomical Doll Task Force; American Psychological Association, 1994). Furthermore, although sexualized play with AD dolls is un-

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common among nonabused children, it does happen; some children may exhibit such play even though they have not been abused (Everson & Boat, 1989; Boat & Everson, 1994). There are also data indicating that use of AD dolls in sexual abuse interviews may not facilitate preschool children’s reports of sexual abuse (DeLoache & Marzolf, 1993; Gordon et al., 1993). AD dolls are clearly not appropriately used as a diagnostic “test” of sexual abuse; their use is not standardized and has no demonstrated reliability or validity. Moreover, there is no evidence that the information gained with AD dolls is enhanced or diminished by the use of a structured protocol. In sum, therefore, it seems most reasonable to consider AD dolls as one of many possible aids in conducting clinical interviews with children who may have been sexually abused. In this regard, they may facilitate communication with children who have limited vocabulary with which to talk about sexual matters, or are too embarrassed to describe the sexual details of an abuse experience.

Step 3: Observation of Behavior Observation of the child’s behavior during the interview is a critical component of the assessment, and has been covered to some extent above. In cases where the allegation of sexual abuse is made in the context of a custody dispute, it is wise to observe the child interacting with the mother and father separately as well as together. Green (1986) suggests noting fearfulness, inhibition, or seductive behavior in the father–child interaction, and excessive clinging to the mother in the presence of the father. Further observation of parent–child interaction is indicated in cases where this is to be a focus of treatment.

Step 4: Further Assessment In cases where the person suspected of abuse is a parent, or where the referral question involves determining the adequacy of parents to care for and protect the child, it is useful to request (or conduct) a psychological evaluation of both parents. If the child clinician is not trained to do this evaluation, the family should be referred to an appropriate agency. We often make this referral at the start of the assessment process and then work with that agency to coordinate the assessments. Although there is no psychological profile that can identify perpetrators of sexual abuse, the data from this evaluation can often corroborate the clinician’s hypothesis about what might have happened. Certainly, evidence of significant psychopathology (or any of the other risk factors presented in Table 7.3) in one or both parents may raise suspicions about the possibility of abuse, whereas the absence of such findings may support an alternative hypothesis. For instance, we have seen cases (typically involving issues of parental divorce and child custody) in which the mother alleges that the father has molested the child, but the mother evidences significant psychopathology, whereas the father does not.

Step 5: Referral to Allied Health Professionals If the child has not had a complete medical examination, this should be done before or soon after the first session. Although physical evidence of sexual abuse is not frequently found, it can be critical in cases that are prosecuted. The family should be referred to a physician who has specific expertise in this type of examination. Adams (1995) outlines the various types of possible physical evidence and provides guidelines for interpreting this evidence.

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Step 6: Communication of Findings and Treatment Recommendations Evaluating the Assessment Data Before the findings of the evaluation can be communicated to parents and other professionals, the data gathered during the assessment must be evaluated. The first step is to review the audioor videotape of the child’s interview and assess each critical response in light of the stimulus that was required to elicit it. For example, was the response relatively spontaneous or heavily cued (e.g., “Tell me about Uncle Joe” vs. “Did Daddy touch your bottom?”). The clinician must also attend to the nature of the behavior (if any) described by the child. Children often describe touching (even genital touching) that is not necessarily sexually motivated on the part of the alleged perpetrator (Berliner & Conte, 1993). As an example, a single father with limited knowledge of appropriate parenting practices used a rectal thermometer to take the temperature of his 2-year-old daughter. The child later told her mother that “Daddy stuck a pen in my bottom,” and the mother promptly reported her ex-husband for sexual abuse. Finally, a judgment about the credibility of the child’s responses should be made. In addition to evaluating the possibility of a false report of sexual abuse, the clinician must consider whether the child is intentionally distorting the truth. Although most fictitious reports of sexual abuse are thought to be the result of misinterpretations on the part of parents and clinicians, cases of intentional fabrication do occur, especially among teenagers (Berliner & Conte, 1993). The American Academy of Child and Adolescent Psychiatry (1997a) outlines several possible explanations for false allegations: 1. A false allegation that arises in the mind of a parent or other adult through misinterpretation of a remark or behavior, delusion, or group contagion and is imposed on the child through suggestion or indoctrination. 2. A false allegation that originates in the child’s mind through unconscious or nonpurposeful means, such as fantasy, miscommunication, misinterpretation, or confabulation (filling gaps in memory with whatever information makes sense at the time). 3. False allegations on the part of the child that are purposeful, including deliberately lying, lying because it seems to be the best way to handle a situation, or fabricating a fantasy. 4. False allegations that involve identifying the wrong person. The child’s interview data must be reviewed in the context of the child’s and family’s history, the child’s developmental status, and the circumstances surrounding the allegation of abuse. This step is particularly important for cases in which there are also issues of divorce, custody, and visitation, because rates of false allegations of abuse are higher among these families than among intact families (33% vs. 5–8%, respectively) (Everson & Boat, 1989; Thoennes & Tjaden, 1990). Finally, and perhaps most importantly, the clinician must recognize that sometimes it is not possible to determine what (if anything) has happened. A clinician may be well intentioned in attempting to persuade a child to disclose abuse (motivated by a desire to protect the child); however, persisting in pressuring a child to disclose abuse in the face of denial greatly increases the risk of a false “disclosure.” In these cases, when the clinician is uncertain about the occurrence of abuse, the child’s safety must be considered in relation to the needs of the family and the suspected perpetrator. Organizing the background information collected according to the risk factors shown in Table 7.3 is helpful in negotiating a reasonable plan with child protective

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services for protection of the child and family. This plan should include provisions for sexuality education and abuse prevention for the child, and information for the family on the potential effects of sexual abuse. In a case where the family has many risk factors, recommendations regarding treatment or monitoring by social services may be indicated. Who Should Receive the Communication? Communication of assessment findings in sexual abuse cases is a very important part of the process. In an investigative assessment, a protective services worker or district attorney may be the appropriate person to receive the results. The importance of a written report cannot be overemphasized, as this document is likely to be used as evidence in legal proceedings. The report should contain considerable detail about the assessment process, so that the reasons why specific conclusions were reached are clear. We have found it helpful to specifically state alternative explanations regarding the allegations and provide data (if any) to support each one. Table 7.5 provides a framework for organizing the information to be included in the written report. If possible, one or both parents or the primary caregiver should receive some feedback and should be included when intervention recommendations and case management decisions are discussed. In some cases we provide parents/caregivers with a copy of the written report, but the advisability of this must be judged on a case-by-case basis. Parents/caregivers should be given general information of the impact of sexual abuse on children’s development and children’s typical reactions to sexual abuse, so that they will have some idea of what to expect. Ways of handling inappropriate behaviors, such as sexual acting out or increased irritability or fears, should also be discussed.

TREATMENT OF SEXUAL ABUSE Because children who have been sexually abused are a heterogeneous group, no single treatment protocol is appropriate for all of them. A developmental approach is essential in treating such children, however. Developmental factors influence all aspects of treatment, including the effects of abuse and prognosis for treatment, treatment issues and approaches, placement and protection decisions, and expectations for a child as a witness in legal proceedings. Because children understand the world differently at different ages, their understanding of sexual experiences is necessarily a function of their developmental level and will change as they gain new cognitive abilities. Thus a sexually abused child will probably “reprocess” his or her experience of sexual abuse as cognitive capacity increases. Furthermore, developmental issues interact with treatment issues. Trust, for example, is a critical developmental issue for preschoolers and is likely to be a focus of treatment for this age group, whereas issues involving interpersonal and intimate relationships are more important for adolescents.

Models for Treatment Planning Given the many factors that must be considered in planning and carrying out a treatment program for a sexually abused child and his or her family, it is helpful for the clinician to have a framework within which to organize the data gathered on the child and family. We have found three models to be particularly helpful in our work: the traumagenic factors model proposed

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TABLE 7.5. Framework for Organizing Assessment Data and Evaluating Alternative Explanations for Sexual Abuse Allegations Nature and context of the sexual behavior • • • •

What is the sexual behavior described? What were the conditions under which the behavior occurred? How long ago did the reported event(s) occur? What was the motivation or intent of the behavior?

Characteristics of the initial disclosure • • • • • •

Under what conditions was the disclosure made? Was the initial report spontaneous or prompted? What motivated reporting to authorities? What was the response of the parent(s), especially the mother? To what extent have parents questioned the child? What factors might have influenced the child’s report?

Subsequent interviews • • • •

How many times was the child interviewed and by whom? Were the interviews recorded? If so, are transcripts available? What factors might have influenced the child’s responses to these interviews? Did the interviewer(s) consider alternative explanations for the child’s responses?

Characteristics of the child • • • •

What is the child’s age or developmental level (language and cognitive skills, sexual knowledge)? Are there preexisting emotional, behavioral, or developmental problems? Does the child show symptoms of distress or sexualized behavior? What are the child’s life circumstances?

Characteristics of the alleged perpetrator • • • • • • • •

Is there evidence of psychopathology? Is there a history of alcohol or drug abuse? Is there evidence of significant life stress? What skills are used to cope with stress? Is there a history of sexual abuse or sexual deviance? Is there an appropriate sexual outlet? Is there a criminal record? Is there a history of antisocial behavior?

Characteristics of the family • • • • • • •

Are there divorce and/or custody issues? Is the nonabusing parent able to protect the child? Does the family have the necessary resources? Is the family socially isolated? Is there a history of inadequate parenting? What are the family’s attitudes/values about sexuality? Is there significant stress or instability?

by Finkelhor and Browne (1986); the risk factors model of Walker, Bonner, and Kaufman (1988), and the coping model developed by Friedrich (1990). Finkelhor and Browne’s (1986) model is based on four factors that help explain how children cognitively process the diverse features of sexual abuse and thus show a range of emotional and behavioral responses. The four factors are betrayal, stigmatization, traumatic sexualization, and powerlessness. There is some empirical support for this model (Mannarino, Cohen, & Berman, 1994; Mannarino & Cohen, 1996a, 1996b), and we have found it to be particularly

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helpful in understanding the child’s perceptions of the abuse experience and the resulting symptoms. These factors, and suggested treatment strategies for children at different ages, are presented later in Table 7.6. The model outlined by Walker, Bonner, and Kaufman (1988) takes a broader view in considering the factors that can influence the child’s and family’s response to sexual abuse. This model uses risk factors identified by research as associated with a child’s adjustment to sexual abuse. The characteristics of the abuser, the nonabusing family member(s), the child, and the social and situational context are assessed according to their degree of risk (none, mild, moderate, or severe) for a particular child, and these data are used to identify and plan interventions in each area. This model has been outlined previously in Table 7.3. Friedrich’s (1990) model is based on the principles of “coping” (the way one actively adapts to a stressful event or series of events, and factors that enhance the ability to cope) and “human ecology” (the way events are embedded in various social relationships). It emphasizes four areas: (1) the functioning of the child and family prior to the abuse, including the risk and protective factors present at that time; (2) the nature of the sexual abuse; (3) the response of the child, family, school, social services, and court to the discovery of the abuse; and (4) the factors that could contribute to a “sleeper effect,” or delayed onset of behavioral and emotional symptoms. This model views coping as an active process that can be influenced positively or negatively by many personal, social, and environmental variables. Factors that can increase a child’s ability to cope include the child’s disposition or temperament, family cohesion and warmth, and an external social support system. Consideration of these factors helps the clinician understand why some children are more or less affected by sexual abuse than others, and identifies areas on which to focus treatment. Each of these models can contribute to the clinician’s understanding of the different behavioral and emotional responses exhibited by sexually abused children. Any one of these models, or a combination of them, may be helpful in guiding the treatment process. We find Finkelhor and Browne’s (1986) model particularly helpful, for example, in planning a child’s individual treatment, while Walker, Bonner, and Kaufman’s (1988) and Friedrich’s (1990) models are more useful in determining where to intervene in the family and environment.

Intervention with the Child Individual Approaches In general, behavioral and cognitive-behavioral interventions have been found to be more effective than other approaches in treating children who have been sexually abused (Cohen & Mannarino, 1996, 1997, 1998a; Deblinger & Heflin, 1996; Deblinger, Lippman, & Steer, 1996; O’Donohue & Elliott, 1992). The focus of these interventions is on alleviating specific abuserelated symptoms by monitoring and modifying deviant thought processes and/or behaviors, and by increasing such skills as assertion, socialization, anxiety management, anger control, problem solving, and communication. The importance of including abuse prevention training as part of any treatment program for sexually abused children—not only to decrease revictimization, but also to provide secondary benefits in other areas (e.g., increasing self-esteem and decreasing fears)—is stressed (O’Donohue & Elliott, 1992). Strategies found to be effective in treating a variety of symptoms in nonabused children can be adapted to deal successfully with similar symptoms in children who have been sexually abused. For example, techniques such as stress inoculation training, systematic desensitiza-

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tion, and education that helps children “normalize” their emotional and behavioral reactions are advocated for the treatment of anxiety (Saunders, 1993). Group Treatment Studies of the efficacy of group treatment suggest that short-term, structured group experiences using social learning principles can be beneficial for sexually abused children, especially school-age children and adolescents (Corder, Haizlip, & DeBoer, 1990; Hoier, InderbitzenPisaruk, & Shawchuck, 1988). Moreover, clinical experience indicates that the opportunity for youngsters to share details of the abuse and receive support/confirmation of their feelings from others is important. Burke (1988, cited in O’Donohue & Elliott, 1992) reported significant reductions in depression, anxiety, and fears for both children and parents following a 6-week program that was based on social learning theory. Components of treatment included relaxation exercises, education, increasing positive reinforcement through fun activities, and role plays to teach preventive skills. Rust and Troupe (1991) also reported significantly improved self-esteem and school achievement for 25 girls ages 9–18 years, 6 months after a minimum of 6 months of group treatment. These authors used a group treatment program that encouraged honest expression of feelings, ventilation of anger, socialization training, support for court appearances, and receiving weekly reports of day-to-day functioning from each member. Berliner and Ernst (1984) describe a group treatment program for school-age children that uses a combination of discussion, education, games, and art activities to deal with issues of sexual abuse. Each of six sessions begins with a snack and a reminder of why the children are in the group (e.g., “You are all here because someone has touched you in a way that was wrong”). Next, each child tells of a pleasant event that happened during the past week; this is followed by an art activity (e.g., making name tags, offender pictures, self-portraits, family drawings, or a group mural). The leaders then conduct a discussion of a topic related to abuse (e.g., what is sexual abuse, feelings about abuse, personal safety skills, etc.). A group exercise or game ends each session.

Intervention with the Parents Sexual abuse is fundamentally a relationship problem. Thus a major focus of treatment of sexual abuse involves correcting failed adult–child relationships—and, in instances of incest, failed relationships that may span generations. Parent work in cases of incest is necessarily different from that in cases involving extrafamilial abuse, and we give a brief overview of the important issues to consider in planning treatment for these two types of cases. In a case of incest, the nonabusing parent (usually the mother) is often either overtly or covertly blamed for collusion with the perpetrator. This view can set the stage for the clinician to take a negative attitude toward the mother, and consequently to decrease her involvement in the therapeutic process. Friedrich (1990) clearly states the need for therapists to take a neutral attitude toward mothers. A therapist must be willing to understand the abuse from the mother’s perspective in order to help her cope with the situation. Factors that have been found to help mothers cope with stress include social support; access to financial resources; problem-solving skills; and a realistic, nondistorted belief system. Cohen and Mannarino (1998a) specifically targeted parents in their sexual-abuse-specific cognitive-behavioral treatment program. The goals were (1) to decrease parental emotional distress by modifying distorted attributions and perceptions; (2) to enhance parental support

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for the children by helping parents set appropriate limits and manage the children’s symptoms in a supportive manner; and (3) to provide interventions for specific inappropriate behaviors and to teach problem-solving skills. In addition to focusing on these areas, work with parents should include helping them understand what to expect as children begin to cope with the abusive experience. The book Helping Your Child Recover from Sexual Abuse (Adams & Fay, 1992) is an excellent resource. In addition, helping parents provide a safe, consistent, and predictable environment for their children is a difficult but important part of this work. In instances in which a child has ongoing contact with a perpetrator or the perpetrator acknowledges the abuse, a series of family meetings (including the perpetrator) should be held to set some ground rules for appropriate and inappropriate touching, to provide ongoing support for the child, and to monitor the situation over an extended period of time. In a case of extrafamilial abuse, the clinician is still dealing with an adult–child relationship problem, but the parent or parents are not likely to be dealing with the stress of the disintegration of the family (and thus are usually more available to support the child). Friedrich (1990) points out, however, that sexual abuse usually is not a random event; therefore, even in cases not involving incest, something sets the stage for the abuse to occur. It may be that the mother has also been abused, or that the parents were careless in making child care arrangements or neglectful in monitoring the child’s safety and well-being. Parents will need help in dealing with their guilt regarding the child sexual abuse, particularly if they have been abused themselves or have inadvertently contributed to the abuse in some way. Group treatment that includes both parents and children has been empirically demonstrated to be effective. Damon, Todd, and MacFarlane (1987) describe a structured and directive program for sexually abused preschool children and their parents. Treatment strategies include providing sexuality education and teaching personal safety skills; telling a child what happened to a perpetrator; and talking openly about the abuse. They also emphasize helping parents understand the child’s perception of the abusive event and the need to support the changes that occur during treatment (e.g., the child talks freely about sexual matters).

Intervention in the Environment Intervention in a child’s environment in a case of sexual abuse usually involves collaboration with social services professionals to ensure the child’s safety and well-being.

Intervention in Medical/Health Aspects The physical examination should indicate whether intervention is needed in this area. Obviously, the child should receive treatment for any sexually transmitted diseases he or she may have contracted. Psychopharmacological treatment for severe anxiety problems may also be considered (see Chapter 8).

FORMAT FOR IMMEDIATE SHORT-TERM TREATMENT WHEN ABUSE HAS BEEN SUBSTANTIATED Providing immediate help for a sexually abused child, so that he or she can begin to understand and deal with the abuse, is crucial to the child’s adjustment. Unfortunately, for many

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reasons, the majority of children never receive treatment or do not receive help for months after the abuse. In the hope of encouraging more clinicians to work with these children, we have developed a protocol to provide immediate and potentially time-limited treatment for children and adolescents who have been sexually abused. The protocol covers many of the critical treatment issues and helps the clinician determine the need for long-term treatment. This approach is summarized in Table 7.6. Although we have found all the components to be essential, the order in which they are included in treatment (with the exception of the first two components) is not fixed. Furthermore, the number of treatment sessions can vary, depending on the needs of the individual child. It usually takes six to eight sessions, but we have done it all in one marathon session when we had only one opportunity to see a child. It is important to note that this treatment format is only recommended for children whose sexual abuse has been substantiated. A brief discussion of treatment in cases in which abuse has not been substantiated, but in which there is ongoing concern about abuse (by parents or child protective agencies), is presented in a later section.

Setting the Stage Before any treatment is begun, a comprehensive assessment should be completed as described above. The information gathered in this first step can help the clinician plan the first contact with the child and family, as well as make decisions about whom to see, what questions to ask, what materials to have available, and how much case management is needed.

Initial Interview A child and parent or other primary caregiver are usually seen together for the initial treatment interview. If the child is in foster care, a protective service worker also often accompanies the child and should be included in the interview. Depending on the circumstances of the abuse and the status of the case, the perpetrator may also be involved in this interview (e.g., in the rare case where the perpetrator has admitted to the abuse and is willing to be involved in treatment). The primary purpose of the initial contact with the child and family is to develop rapport with the child. The clinician should explain his or her understanding of why the child and family have come to the clinic, and describe what will happen in the session. Then the parent or other caregiver is asked to tell the details of the abuse in the child’s presence (children often like to play with a toy, draw, or hold a stuffed animal as they listen), while the child periodically is asked for confirmation. This serves to acknowledge the abuse openly without placing demands on the child, and allows the clinician to begin providing the child with important information and reassurance (“Other children have told me that this has happened to them,” “It’s OK to talk about it,” “You were very brave to tell,” etc.). Having the parent describe the abuse in front of the child also takes the “secrecy” out of the abuse, so that the parent and child can discuss it more freely with each other. At this time, the clinician can also briefly discuss the parent’s or caregiver’s concerns, but it should be communicated to the child that he or she is the primary focus of the session. When possible, having one therapist for the child and another for the parent present at this initial session allows their individual needs to be more fully met. If this is not possible, it is important to arrange another time to talk specifically with the parent/caregiver to discuss the adult’s concerns, ways to support the child, and things to expect from the child. Making the child feel important and in control is a primary goal for the first treatment session, so the clinician should take considerable time to talk about the child’s interests and

TABLE 7.6. Treatment Issues and Intervention Strategies for Sexually Abused Children Stigmatization

Betrayal of trust

Powerlessness

0–6 years

• Sexuality education • Limits on sexual acting out • Reinforcement of appropriate interaction • Role plays

• Something Happened to Me (Sweet, 1981) • Reinforcement of positive characteristics • Group treatment

• Setting and keeping routines • Reinforcing independence • Providing safe environment

• Treatment of nightmares and sleep problems • Prevention skills • “What if” exercises • Role plays • Identifying feelings

7–11 years

• Sexuality education • Cognitive-behavioral techniques for assertiveness training and gaining control • Reinforcement of age-appropriate sexual behavior • Social skills training

• No More Secrets for Me (Wachter, 1983) • Liking Myself (Palmer, 1977a) • Group treatment • Age-appropriate activities

• Making a book—“Whom can I trust?” • Cognitive restructuring for depression • Teaching problem-solving skills regarding trust issues

• Prevention skills • Assertiveness training • The Mouse and the Monster, and Me (Palmer, 1977b) • Letter to abuser • Channeling aggression • Support success in school activities

12–18 years

• Sexuality education • Cognitive-behavioral techniques for assertiveness training and gaining control • Role plays of relationship skills • Social skills training • Relaxation training

• Group treatment • Age-appropriate activities

• Cognitive restructuring for depression • Group trust exercises • Using problem-solving skills regarding trust issues • Listing of people who can be trusted and why

• • • •

Prevention skills Assertiveness training Letter to abuser Role plays of relationship skills • Support success in school activities • Support independence

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Age group

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activities, play games, draw, and have fun. Using reflective comments and praise, instead of asking many questions, is essential to making the child feel comfortable. One way of communicating to the child that he or she is an important, valued person is for the clinician to keep all contracts and appointments consistently and on time. For example, the child is told that he or she can have a snack at the end of the session, or that next time the clinician will remember to bring drawing material, the clinician must be sure to keep these promises. Although the parent or caregiver is invited to stay in the room if the child wishes, the clinician must be careful not to let the adult monopolize the session. Before the child and parent/caregiver leave, they should be told what to expect in the next session, and both should be given the clinician’s card in the event that either needs to call before the next session.

Issues for Treatment The following issues are those that we feel are most important to cover with every child who has been abused, regardless of the nature of the abuse. Ideally, they are covered over a period of six to eight sessions, with parent/caregiver work occurring parallel to the child’s treatment; when time is limited, however, the clinician will have to determine how and in what order to cover the material in the time available. Sexuality Education Giving children information about sexuality helps them to protect themselves and results in a sense of power. We typically begin by assessing what a child already knows about normal sexuality (body parts and functions, private parts, sexual behaviors) and the terms he or she uses for sexual parts and functions. We then provide the child with appropriate information, keeping in mind that children who have been abused have often had precocious sexual experiences and may need information that would ordinarily be more appropriate for older children. Reading a book about sexuality often elicits further questions and comments from the child, and allows a clinician to provide reassurance and information directly related to the child’s experience of sexual abuse. Sharing the sexual information with a parent or other caregiver before the session is important, so that the clinician can clarify any concerns the adult may have about the material. It is equally important for the clinician and child briefly to review the material covered with the parent/caregiver at the end of the session. This confirms for the child that it is acceptable to talk about these things. Any concerns that the adult may have about the child’s sexual behavior can be discussed at this time, and plans can be made to handle any inappropriate sexual behavior. It is good if the sexuality education materials or book used can be sent home with the child. Feelings and Coping Skills Children’s knowledge of feelings and their ability to cope with them are dependent on their developmental status, so assessment of what they currently understand is essential prior to attempting to deal with their feelings about the sexual abuse. We often begin by making a “feelings book” in which various feelings are described and illustrated. Older children enjoy making lists of things that make them happy, sad, angry, and so on, as well as ways to cope with these feelings. Younger children can cut out pictures depicting various feelings and paste them on each page. They then can be taught what to do when they feel angry, sad, afraid, and so

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forth. Adolescents often like to draw pictures of themselves with different feelings represented by different colors, and then talk about situations that give them those feelings and ways to cope with the feelings. Various techniques are effective in helping a youngster deal with feelings about the perpetrator. As an example, a 6-year-old girl who was not able to talk about her feelings demonstrated them each week in doll play. Then the clinician wrote a short story dealing with each issue to read to her the following week. An older child often finds it helpful to dictate or write a letter to the perpetrator (which can be sent or unsent, depending on the circumstances). A youngster usually wants to know, and should be told, what has happened to the perpetrator. The clinician should not appear surprised to hear concern or affection expressed for the perpetrator. Especially in an incest case, the child has to be helped to understand that he or she can have both negative and positive feelings toward the perpetrator, but that the behavior of the perpetrator was wrong and not the child’s fault. Personal Safety Skills Teaching sexually abused children self-protection skills is essential to restoring a sense of personal control and power. Children should be provided with the opportunity to practice skills in role-play situations. The importance of telling someone should be recognized, and a list should be made of people the child should tell. Children also should be told that it is not their fault if they cannot get away or make someone stop hurting them. The important thing is to tell someone, so that the person can be made to stop hurting them. Parent/Caregiver Work Some time should be set aside after each session with the child to talk with a parent or other caregiver. The parent/caregiver is given basic instruction in parenting skills, or at least help in appropriately managing the behavioral sequelae of the abuse, as needed. We provide adults with information about normal sexuality and abuse prevention skills, usually sending home material used in treatment with the children. Parents/caregivers who are extremely upset, to the extent that they are temporarily unable to meet the children’s needs, may need separate sessions in which they can express and work through their feelings about the abuse and receive support. If one-way mirrors are available, allowing parents to observe their child’s sessions can help them come to terms with the abuse. Finally, most parents appreciate help with the many decisions that must be made, especially if the case will be prosecuted. Preparation for Court Although testifying in court can be a very stressful experience for children, many children with whom we have worked have found it actually beneficial, especially if a child’s testimony is believed and a perpetrator is found guilty. Good preparation helps children and parents/ caregivers handle the experience as well as possible. Both adults and children need to know what to expect from a court appearance. A visit to the courtroom should be arranged some time shortly before the the start of a trial; the child should be told who will be there, where these people will sit, what will happen and in what order, and what is expected of the child. In the weeks prior to the trial, the child can be prepared to testify by role-playing various situations that are likely to occur during the trial. Having the child assume a variety of roles (includ-

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ing those of the judge, the prosecutor, and a witness) helps to develop a sense of control and relieve anxiety. The actual incident of abuse under examination should not be used as content for these role plays, lest the clinician be accused of biasing the child’s testimony. For example, role plays of the child’s being a witness to a car accident or a shoplifting incident can be used. There are a few books available for children about being a witness at a trial (Anderson & Finne, 1986; Beaudry & Ketchum, 1987). We have found, however, that “homemade” books with simple line drawings that are specific to an individual child’s experience are just as effective. The parent/caregiver and child should be aware that the adult may not be allowed into the courtroom during the child’s testimony. Another person who is well known and liked by the child (a teacher, family friend, neighbor, social worker, etc.) should be designated as a special support person and should sit in the front of the courtroom where the child can see him or her. The child should also be prepared for either a “guilty” or “not guilty” decision by the jury. It is likely that the child will have ambivalent feelings about a “guilty” verdict, especially if the perpetrator is a family member, and these feelings should be explored. In the case of a “not guilty” verdict, the child needs to know that this does not mean the abuse did not happen, and that the clinician still believes the child.

Indicators for Longer-Term Treatment Although the above-described treatment program is sufficient for many children and provides a good starting place for most cases of sexual abuse, some children will continue to need treatment beyond the six to eight sessions. The clinician must assess the status of each child and family at the end of these sessions, taking into account factors that have been identified in the empirical literature as contributing to the need for longer-term treatment (see Chapter 2). Factors shown to be associated with poorer adjustment for sexually abused children include (1) the duration and severity of the abuse (longer duration means a poorer prognosis); (2) parental denial of the abuse; (3) environmental instability; and (4) ongoing emotional, behavioral, or learning problems. Older children (especially adolescents) are likely to need longer treatment, because they are aware of the implications of the abuse for their own developing social and sexual relationships. Furthermore, the longer the abuse has gone on, the more likely the child is to have suffered damage to self-esteem and personal identity—both key issues in adolescent development. Similarly, abuse involving anal, oral, or genital penetration, or abuse that results in injury to the child, is related to poorer adjustment. Parents who deny the possibility of abuse in spite of a child’s disclosure of abuse, or who minimize the potential negative effects, make it difficult for the child to feel accepted and safe. These parents will need help in understanding the reasons for their denial (we have found that many of these parents were themselves molested as children and have not come to terms with their own experience) and in meeting the child’s needs for emotional support. The child also will need additional help in dealing with this lack of support and the poor parent–child relationship. If a parent also has significant psychopathology, especially depression (which may have been present before the abuse was disclosed), then the child is likely to need ongoing help in learning to cope with a dysfunctional parent. Children who live in unstable environments, especially those who are in foster care, experience considerable stresses in addition to the experience of sexual abuse and will need ongoing help in coping with these stresses. Children who have other problems that either predate or result from the abuse will need further treatment focused specifically on these problems. Finally, we have found that most children need “booster” sessions from time to time as they

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progress through developmental stages. With increasing cognitive skills, children come to a different, more complex understanding of their experience and often have new questions or concerns about the abuse.

TREATMENT IN CASES INVOLVING NONSUBSTANTIATED ABUSE A clinician is often asked to treat children for sexual abuse, even though one or more previous investigations have not determined that abuse has occurred. (This work should not be confused with a referral for a second opinion on whether or not the child has been abused.) Such a referral may be due to a child’s inability to tell about the abuse due to age or disability, an unwillingness to disclose this information, or the fact that no abuse has occurred. The referral can also result from parental conflict, especially when heated divorce and custody proceedings are involved. A thorough review of all pertinent background information—including previous investigations by the legal or social service systems, interviews by other mental health professionals, and medical records—should be done prior to seeing the child. (See Chapter 13 for discussion of the assessment process with referrals involving divorce issues.) In providing treatment for a child for whom abuse has not been substantiated, the clinician must be very careful to take a neutral position regarding the possibility of abuse, and to focus instead on the specific behaviors of concern. It is important not to question the child repeatedly about sexual abuse, or to use books that describe a child being abused or being afraid to tell about abuse. These books often contain detailed information that is highly suggestible, especially to young children, and increase the risk of a false allegation. When the child is treated as if he or she may or may not have been sexually abused, any disclosure that may occur during the treatment process can be viewed more objectively. In addition to treating specific child behaviors, the clinician should assess the child’s knowledge of sexuality, and should provide sexuality education and personal safety information to both the child and parents. It may also be important to work with the parents to determine why they are worried about sexual abuse and to consider alternative explanations for their concerns. Many clinicians unintentionally encourage a persistent concern about sexual abuse by telling parents that although abuse cannot be substantiated, “red flags” suggesting that abuse could have occurred are present. In fact, there are no valid “indicators” for sexual abuse (Berliner & Conte, 1993). If the clinician is concerned about the possibility of abuse, his or her approach should be to help the child gain information about sexuality and personal safety in the absence of material suggesting sexual abuse. If one parent is concerned that the other parent is abusing the child, it is critical to include the suspected parent in the treatment process. In the presence of both child and parent, specific ground rules for appropriate and inappropriate touch should be set; the child should be instructed to tell the therapist and/or parents about any situations that make him or her uncomfortable; and the situation should be closely monitored for up to a year (Hewitt, 1991). Clinicians can also put themselves in a position of “looking for abuse” in the course of treatment by not doing a thorough review of previous work with a child and family, relying solely on the information presented by the concerned parent, or aligning themselves with one parent against the other. We recently worked on a case that illustrates this clinical pitfall. Two boys, ages 4 and 6, were interviewed 36 times over a 2-year period by 13 different individuals (!) and had repeatedly denied abuse by their father. Despite this evidence, the mother took

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the children to a therapist who provided individual and group treatment for “sexual abuse.” Although she was aware that the parents were in the middle of a heated divorce, the therapist did not review the previous work done with these children (which included a very thorough psychological evaluation of the children and both parents, indicating significant psychopathology for the mother but not for the father); nor did she ask to meet with the father. The therapist aligned herself with the mother, who believed that the children were being sexually abused by their father. Her therapeutic work consisted of reading highly suggestive stories about children who had been abused, including them in discussions with other children in group treatment about sexual abuse, and persistent encouragement to “tell what happened to them.” It was not surprising that after 10 sessions, the children “disclosed” that their father had abused them! Fortunately, abuse charges were not brought against this father, but the damage done to these children and their relationship with their father was devastating.

CASE EXAMPLE: SUBSTANTIATED SEXUAL ABUSE Step 1: Initial Contact The district attorney called to request treatment and possible court preparation for two brothers, ages 9 and 5. Two weeks prior to this contact, the 9-year-old, John, had told his maternal grandmother, Mrs. Comfort, that his father had been sexually abusing him and his little brother, Jimmy. John described oral and anal sex as well as mutual masturbation, and reported that his father had said he would kill John, his brother, and his grandmother if he told. This child had recently returned home from a 6-month inpatient stay for severe depression. During hospitalization, no one had asked him about the sexual abuse, nor did he tell anyone. He told his grandmother that he “got better” so he could come home to protect his little brother from his father. Mrs. Comfort took the child to the department of social services, and an investigation substantiated the abuse. The two boys had been living with their father, who was a local magistrate, and their stepmother. The boys’ mother had died 2 years previously. Given the father’s position in the community and the lack of evidence for abuse of Jimmy, he remained in the home while John was placed in the custody of Mrs. Comfort. The department of social services asked that the 5-year-old be brought to the clinic, which was in a neighboring county, for medical and psychological evaluation. The stepmother brought Jimmy, who was found to have anal lacerations and venereal disease. During the course of this evaluation, the stepmother admitted that the father had indeed abused the children and had been doing so over a long period of time. Both children were then placed in the custody of Mrs. Comfort, and the father was charged with sexual abuse but released on bail. Although he was not a lawyer, the father planned to defend himself in court. The purposes of the referral were to determine the emotional status of both children, to provide the children and the grandmother with short-term treatment, and to determine the probable effects on the children of going to court to testify against their father, who would be cross-examining them. The children’s teachers and Mrs. Comfort were asked to complete the version of the CBCL in use at that time (Achenbach & Edelbrock, 1983). Prior to the initial interview, phone calls were also made to each of the boys’ teachers to determine their academic and social functioning within the school setting. Both boys had significantly high scores on the Internalizing scales of the CBCL, with significant fears and physical complaints. They were reported, however, to

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be well liked by their peers and “no problem” to their teachers. The teachers indicated that the boys often came to school very tired, appeared sad, and on many days did not want to join in on academic tasks or social activities. They had noticed a dramatic improvement in the boys’ affect, alertness, and willingness to participate in activities in the short time since they had begun living with their grandmother.

Step 2: Caregiver and Child Interviews Caregiver Interview Mrs. Comfort, the social worker, and both boys were present for the initial interview. The social worker, at Mrs. Comfort’s request, related what had been done and what was known about the abuse. The boys were given some toys to play with during the interview. As they were playing, they often added information to the social worker’s report. Both boys expressed a great deal of anger at their father, but they were also quite fearful that he would come to the grandmother’s house and kill all of them. Mrs. Comfort assured them that the house was secure and that she was quite capable of protecting them. She transported the children to and from school, and outside of school they rarely left her side. Because they were both having nightmares, she also allowed them to sleep with her. Mrs. Comfort presented as a warm, loving, supportive person who had struggled, against the father’s wishes, to keep contact with her grandchildren since the death of her daughter. Child Interviews The boys were seen separately for their initial interviews. John was able to share difficult information easily. He described with great sadness the death of his mother, who had been rushed to the hospital in a diabetic coma. John felt she had protected him from his father. It was after her death that the father began to abuse him. Until he was hospitalized, John did not feel that his younger brother had been abused. He found it difficult to discuss the specifics of the abuse, and he was not pressured to do so. Although John was afraid of what his father might do, he said he felt safe both at school and when he was with his grandmother. He obviously was relieved by having told about the abuse and was able to express his anger toward his father, despite his fear of him. Although he admitted it would be “scary,” John stated that he wanted to testify in court so that his father would never be able to do this again. Assessment of John’s knowledge of sexuality revealed that he used slang terms for sexual body parts and was very knowledgeable about adult sexual behavior. He also knew about private parts and was forceful in stating that he would tell his grandmother or teacher if anyone tried to touch his private parts. Five-year-old Jimmy refused to separate from his grandmother; as a result, she was included in this session. Jimmy was active and easily distracted by any noise or sudden movement on the part of the clinician. He was reluctant to talk about his father, but stated that he missed being at home and playing with his toys. In playing with the doll house, Jimmy carefully avoided including the father doll in his play. When the clinician introduced the father doll, he turned away and refused to continue his play. Attempts to get him to play with family dolls resulted in his hiding behind a chair and refusing to come out until the father doll was put away. Assessment of knowledge of sexuality indicated that Jimmy had slang terms for sexual body parts and did not know about private parts or what to do if someone tried to touch them. He

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also did not have any knowedge of adult sexual behavior, pregnancy, or birth. It was significant that he became very quiet or left the table when he saw pictures of nude adult males or males engaging in child care activities (bathing, putting to bed, etc.).

Step 3: Observation of Behavior Only observations during clinic sessions were done in this case.

Step 4: Further Assessment Additional assessment of emotional status in order to determine the need for longer-term treatment was done as part of the immediate treatment process.

Step 5: Referral to Allied Health Professionals The boys had already had a medical evaluation, and Jimmy was being treated for venereal disease.

Step 6: Communication of Findings and Treatment Recommendations Prior to beginning treatment, the clinician met with Mrs. Comfort and the social worker to summarize the assessment findings. They were told that John appeared to be resilient and was using a lot of good skills to cope with a very difficult situation. He felt well loved and protected by his grandmother, and was clearly very attached to his brother. Jimmy, on the other hand, was seen as emotionally vulnerable, with few coping skills available with which to deal with the trauma. Unlike John, he needed a great deal of support from his grandmother. Mrs. Comfort was described as having a good grasp of the children’s needs and interacting with them in a very appropriate manner. The boys obviously cared for her, were affectionate with her, and responded well to her requests and discipline. In a phone call, the district attorney was told that although John was frightened, he was willing to testify against his father; the clinician felt that with support and preparation, he was emotionally capable of dealing with the legal process. Although the district attorney was told that the younger boy was not as well able to handle court as his brother, he was eventually required to appear.

Course of Treatment John and Jimmy were seen together for treatment, and Mrs. Comfort participated in the last 15 minutes of each 1-hour session. The course of six sessions followed the short-term treatment program outlined earlier in this chapter. The children made “feelings books” to identify and talk about feelings and to learn appropriate ways to express their feelings. They also were engaged in a sexuality education program that taught them the correct names for body parts and functions, their private parts and who may touch them and when, and personal safety skills. During this time, both boys were able to talk more openly about the abuse and to give details of what had happened to them, how they felt, and what they would do in the future if anyone tried to abuse them. Mrs. Comfort had a good support system in the community and was handling the situation well. She needed little help from the clinician. She was given books on sexuality education

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and abuse prevention, as well as the children’s “feelings” exercises to take home so that she could talk with the boys about them throughout the week. She was also given information on sexual abuse and its effects on children. The clinician supported her good parenting skills.

Court Preparation Although both children were prepared to testify in court, it was felt that only John would be able to do so. With treatment, Jimmy was able to talk about his father and the abuse, but he still demonstrated significant fear about potential interactions with his father. This was particularly significant in this case, because the father would be cross-examining the boys. The district attorney met with both children, described to them what would happen in court, and took them to visit the actual courtroom in which the trial would take place. Preparation in the clinic involved the use of role play to practice court procedures, and a booklet was written for the boys to describe what would happen and what would be expected of them. The clinician was very careful not to tell them what to say. The children knew that the therapist and their grandmother would be in the courtroom with them, and that they could look to them for reassurance. The children were also prepared for the possibility that their father might not be convicted. They were told that this would not mean he had not been abusive, but rather that the court would not punish him for this. With the support of the department of social services, Mrs. Comfort had already engaged a lawyer to help her take permanent custody of the children, regardless of the outcome of the trial. John was able to testify, although he was visibly upset with his father’s cross-examination and the attempts to confuse him. Jimmy clung to the district attorney; although he was allowed to sit on the courtroom floor rather than in the witness box, he was not able to talk. Nonetheless, the father was found guilty and sentenced to two consecutive life terms. Given the trauma these boys had experienced, and their unresolved issues regarding the death of their mother, both children were referred for further treatment.

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CHAPTER 8

Fears and Anxieties

W

e all experience fear and anxiety as normal emotions at some times during our lives. These emotions serve to elicit behaviors essential to survival, and can also increase the motivation for learning adaptive skills. The stimuli that provoke fear and anxiety change with development in a way that corresponds to a child’s increasing cognitive and physical abilities and the consequent new experiences. These emotions are such a “normal” part of a child’s life that even excessive fears or anxieties are often not brought to the attention of mental health professionals until they seriously interfere with the child’s functioning or the parents’ lives. The past 10 years have brought increased knowledge about anxiety disorders in children, but the empirical literature continues to be sparse in regard to the etiology, assessment, and treatment of children with these symptoms. Children tend to have fewer anxiety disorders than adolescents and adults, but children who have anxiety disorders typically have multiple problems and often live with parents who themselves suffer from psychiatric symptoms. Furthermore, anxiety disorders in children persist longer than previously thought, and a child who has had one episode of an anxiety disorder is at high risk for further episodes. Depression often occurs along with anxiety disorders, and this further increases the risks for these children. The goal of the child clinician is to differentiate children with clinically significant fears and anxieties from those whose fears and anxieties are a normal part of development. In addition, a number of children who exhibit subclinical levels of anxiety symptoms may be experiencing such marked distress that treatment is warranted. This chapter first briefly reviews the definitions and developmental aspects of fear, anxiety, and worry. Next, the classification, prevalence, and nature of the most common anxiety disorders experienced by children are discussed. Finally, what is known about the assessment and treatment of these disorders is presented.

DEFINITIONS Although fear, anxiety, and worry, have been studied for decades, there is no clear consensus on how to define or conceptualize them, and the three are often used interchangeably. The terms “anxiety,” “fear,” and “worry” are hypothetical constructs reflecting subjective events that must be inferred by behavioral signs, physiological responses, and self-reports. 262

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Fear “Fear” is defined as an emotion that functions to alarm or prepare the person to make a “fightor-flight” response by activating the autonomic nervous system, which responds with such physiological sensations as sweating, trembling, muscle tension, gastrointestinal distress, rapid breathing, and pounding heart; attention is focused on either escaping the situation or fighting the potential threat (Barlow, Chorpita, & Turovsky, 1996). These responses fade with the disappearance of the perceived or real threat. The fear reaction is seen as adaptive, and with experience, a person learns what is a real threat and what is an innocuous situation or stimulus. Cognitive development affects an individual’s perception and understanding of what is perceived as a threat. Children, for example, respond with an alarm reaction to different stimuli and situations as they develop (e.g., loud noises at 6 months, fear of strangers at 7–8 months, large approaching objects at 2 years, the dark at 3 years, ghosts at 6 years, and minor injuries at 6–12 years).

Anxiety In contrast to the immediate alarm reaction of fear, “anxiety” is an emotion or mood state characterized by negative affect, including tension and uneasiness; feelings of apprehension; and worry that some future negative event, situation, or misfortune will occur (Barlow, 2002). The physiological symptoms that occur with anxiety include fidgeting, increased heart rate, and muscle tension. Anxiety is thought to assist in planning or managing future events (e.g., motivating a child to study for an exam or enhancing performance in various situations). Some people appear to be predisposed to experience anxiety in response to a wide range of stimuli, whereas others have less frequent and more transitory moments of anxiety that fluctuate in duration and intensity. Spielberger (1972) has described these two different conditions as “trait” and “state” anxiety. Trait anxiety is defined as relatively stable chronic anxiety that a person may experience regardless of specific circumstances; thus, the person may preceive a wide range of stimulus situations as dangerous or threatening. State anxiety refers to varying or fluctuating aspects of anxiety that may change relative to a given situation. The two constructs are not independent: A person with high trait anxiety will react more often with a state anxiety response that includes the aforementioned feelings of tension, apprehension, and activation of the autonomic nervous system.

Fear versus Anxiety The distinction between fear and anxiety lies in the interpretation of threat as immediate versus sometime in the future, and in the nature of the physiological response as an alarm reaction versus an elevated level of tension and apprehension. Given that fear and anxiety are hypothetical constructs inferred from self-reports, physiological monitoring, and behavioral observations, and that they share many characteristics, it has long been debated whether they are two distinct constructs or manifestations of the larger, more diffuse construct of “negative affect” (Albano, Causey, & Carter, 2001). Both fear and anxiety, like other emotions, are thought to have three distinct but highly interrelated components: (1) cognitive or subjective reactions that involve all the thoughts, images, beliefs, and attributions about the situation and its expected outcomes, which are expressed as distress, discomfort, or terror; (2) motoric or behavioral reactions, such as avoid-

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ance, escape or tentative approach, crying, clenched jaw, urgent pleas for help, walking rituals, and immobility; and (3) physiological reactions, such as heart palpitations, profuse sweating, rapid breathing, muscle tension, uneasiness, sleep disturbance, and poor concentration (Barrios & Hartmann, 1997). Implicit in this three-component view of anxiety and fear are potential variations in the individual expression of the subjective, physiological, and motoric responses. Two children who are suffering from school refusal, for example, may react very differently. One child may begin to exhibit somatic complaints and crying the night before school, whereas the other child’s response may be to enter school reluctantly but refuse to participate in any activities. In addition, given the varying task demands of different situations, an anxious child’s response can vary across settings. An anxious child may respond to a social situation, for example, by refusing to interact with anyone and having thoughts of going crazy. In contrast, he or she may blank out when called on in school, exhibiting trembling, stuttering, and tearing of eyes (Barrios & Hartmann, 1997).

Worry The construct of “worry” complicates our understanding of fear and anxiety. This is of some importance, given that worry is a central component of several Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) anxiety disorders found in children. In contrast to anxiety, which is thought to be a complex emotional response involving cognitive, physiological, and motoric components, worry is viewed as a cognitive component of anxiety (Barlow, 2002; Vasey & Daleiden, 1994). It involves thoughts or images that are related to possible negative or threatening outcomes. These thoughts or images are difficult to control and can be quite intrusive. Just as fear is viewed as a special state of the biological alarm system, worry is seen as a special state of the cognitive alarm system that prepares the individual to anticipate possible future dangers. Worry involves rehearsing possible aversive events and at the same time searching for ways to avoid them. This problem-solving function is seen as adaptive in preparing for and coping with future events, but if it is excessive it can actually interfere with the problem-solving process (Matthews, 1990). Recent studies provide empirical support for the hypothesis that in children, worry and anxiety are significantly related but independent constructs (Muris, Meesters, Merckelbach, Sermon, & Zwakhalen, 1998; Silverman, La Greca, & Wasserstein, 1995).

DEVELOPMENT OF FEARS AND WORRIES Fears and worries are common phenomena for children and adolescents, with 10 or more expressed at any given time in their development (Muris et al., 1998; Ollendick, 1983). Although they have been measured by a number of different methods (e.g., adult retrospective reports, child interviews, fear survey schedules), patterns of fears and worries clearly change over the course of development, reflecting a maturation of cognitive processes. A summary of common fears and worries exhibited at different ages is shown in Table 8.1.

Development of Fears Research on fears in the general population of children has lead to a detailed understanding of normal fear experiences, including the ways in which they change with maturation and demo-

8. Fears and Anxieties TABLE 8.1. Sources of Fears and Worries at Different Age Levels Age

Sources of fear or worry

0–6 months

Loud noises Loss of support Excessive sensory stimuli

6–9 months

Strangers Novel stimuli (masks) Heights Sudden or unexpected stimuli (e.g., noise, bright light)

1 year

Separation from caretakers Strangers Toilets

2 years

Auditory stimuli (e.g., trains and thunder) Imaginary creatures Darkness Separation from caretakers

3 years

Visual stimuli (e.g., masks) Animals Darkness Being alone Separation from caretakers

4 years

Auditory stimuli (e.g., fire engines, sirens, noises) Darkness Animals Parents leaving at night Imaginary creatures Burglars

5 years

Visual stimuli Concrete stimuli (e.g., injury, falling, dogs) “Bad” people Separation from caretakers Imaginary creatures Animals Personal harm or harm to others

6 years

Auditory stimuli (e.g., angry voices, thunder) Imaginary creatures Burglars Sleeping alone Personal harm or harm to others Natural disasters (e.g., fire, floods) Animals Dying or death of others

7–8 years

Imaginary creatures Staying alone Personal harm or harm to others Media exposure to extraordinary events (e.g., bombings, kidnappings) Failure and criticism Medical and dental procedures Dying or death of others Frightening dreams or movies Animals (cont.)

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TABLE 8.1. (cont.) Age

Sources of fear or worry

9–12 years

Failure and criticism (e.g., school evaluation) Rejection Peer bullying or teasing Kidnapping Dying or death of others Personal harm or harm to others Illness

13–18 years

Social alienation Failure Embarrassment or humiliation Injury or serious illness Natural and human-made disasters (e.g., economic and political concerns) Death and danger

Note. The data are from Gullone (1999), Miller (1983), and Muris, Merckelbach, Gadet, and Moulaert (2000).

graphic differences in their content (Gullone, 1999). The major types of fears have been fairly consistently clustered into five categories: failure and criticism, the unknown, minor injury and small animals, danger and death, and psychic/stress/medical fears (Burnham & Gullone, 1997). In a recent review, Gullone (1999) summarizes the developmental progression of fears and their demographic characteristics. By the end of the first year, the increase in fears of strange persons, strange objects, and heights reflects a cognitive maturation in both the capacity to remember and the ability to distinguish the familiar from the unfamiliar. By the early preschool years, fears are quite concrete in nature and reflect present experiences, such as fear of animals, the dark, or being alone. An increase in fears that are more abstract, imaginary, and anticipatory in nature, such as fears of evaluative or social situations, bodily injury, illness, and school, is seen in the elementary school years. Adolescent fears reflect the increased maturation of cognitive processes, with more global fears (including economic and political concerns) predominating. It is interesting that fears of death and danger (e.g., getting lost in a strange place, burglars, being hit by a car, fire, earthquakes, etc.) are consistently among the most commonly reported from early childhood through late adolescence (Gullone, 1999). In a recent study in which children ages 11–18 years were asked to list their three greatest fears, however, the item listed most frequently was spiders (Lane & Gullone, 1999)! Sex differences in fears have been reported; girls report a greater number of fears than boys in all of the major fear categories. The items that most strongly discriminate boys from girls include rats, spiders, snakes, mice, creepy houses, being alone, and having bad dreams, which suggests that differences between boys and girls are influenced by gender role stereotyping (Gullone & King, 1993). Girls, especially those who are older, also consistently report a greater fear intensity than boys. When age differences in the frequency and intensity of fears are found, they mostly indicate a decrease with age; younger children (8–10 years) have more fears than older children (11–13 years) or adolescents (14–16 years) (King, Ollier, et al., 1989). Socioeconomic status (SES) also affects the number and content of fears reported by children. Children from low-SES environments tend to have more fears than children from middle- or high-SES settings. Moreover, the content of the fears of low-SES children suggests a basis in immediacy and reality for these fears. Children from low-SES environments, for example, perceive their environments as more hostile and dangerous, and report fears of ani-

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mals, strange people, being abandoned by parents, death, violence, and police officers (Gullone, 1999). In contrast, heights and ill health are more characteristic fears of middle- and upperSES children. Culture also has been found to affect the number, content, pattern, and intensity level of fears. In a study of children ages 7–11 years from four cultures, Ollendick, Yang, King, Dong, and Akande (1996) reported that children and adolescents from Nigeria and China (countries that tend to stress greater self-control, emotional restraint, and compliance with social rules) reported higher levels of social-evaluative and safety fears than youth from America or Australia. Not surprisingly, exposure to specific fear-producing stimuli in the environment also affects the content of the fears evidenced by youth in different countries. A large percentage of American and Australian youth, for example, reported fears of burglars breaking into their homes or of getting lost in strange places, whereas an equally high percentage of Nigerian and Chinese youth expressed fears of electricity and potentially dangerous animals (e.g., bears in China and snakes in Nigeria). Other fears were specific to each country (e.g., looking foolish in America, guns in Australia, ghosts in China, and deep water or the ocean in Africa). Interestingly, rates of fears remained high across all ages and all fear levels among Nigerian children. In contrast, American and Australian youth expressed decreasing numbers of fears with age. Among Chinese youth, the greatest number of fears occurred between 11 and 13 years (the period when decisions are made regarding higher education).

Development of Worries There have been only a few studies on worry in the general population of children, but this work is quite informative about the nature, frequency, and intensity of worry, as well as its relationship with anxiety. Worrisome thoughts become prominent after age 7 years, and the content of the worries shows a developmental progression (Muris, Merckelbach, Gadet, & Moulaert, 2000; Vasey, Crnic, & Carter, 1994). Just as children express many fears, they also report a considerable number of worries; 70% of primary school children report 10 or more things about which they worry (Orton, 1982). Threats to their well-being constitute a predominant worry across age (Silverman et al., 1995), although the specific content of the worries is closely linked to level of development. Preschoolers worry about imaginary and supernatural threats. This worry decreases for 5- to 6-year-olds, who worry more about threats to their physical well-being. Over 8 years of age, worries about behavioral competence, social evaluation, and psychological well-being take the forefront (Vasey & Daleiden, 1994). Vasey and Daleiden note that children’s worries become increasingly complex after the age of 8, due to their increased ability to reason about future possibilities, to consider multiple threatening outcomes, and to elaborate potential negative consequences. The increased opportunity to experience aversive experiences also plays a role in the worries expressed by children as they develop. In an entire elementary school sample from second through sixth grades, Silverman et al. (1995) found that the three most common types of worries in children ages 7–12 involved school, health, and personal harm. Although worry about physical harm or attack by others was the most frequent worry reported by children at all ages and one of the most intense, the children rated these events as low in occurrence. Thus, just as anxious children tend to worry about events that rarely or never occur (American Psychiatric Association [APA] 1994), non-clinicreferred children also worry intensely about low-frequency events even though they realize that they are not likely to occur. Other frequent worries reported were social in nature. These included worries about classmates’ rejecting, excluding, or ignoring them; friends’ betraying

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them; and conflicts between parents or among family members. There were few age-related differences in reported worries. Girls of European and Hispanic descent had more worries than boys; no differences were found for African American boys and girls, who overall had a greater number and higher intensity of worries than the other children. Silverman et al. (1995) also found that highly anxious children could be discriminated from less anxious children on various worry parameters (number, intensity, and ratings of event frequency). This is important, given DSM-IV’s assumption that worry is integral to the clinical picture of anxiety. Another study on children’s worries done in the Netherlands (Muris et al., 1998) found that children ages 8–13 years, reported worrying 2–3 days a week, and that worrying was accompained by modest levels of anxiety and interference with functioning. Worries were also described as persistent and difficult to control. Strategies used to control the worries included using some activity to distract themselves (55.6%), thinking about more pleasant things (37.6%), and discussing the worry with someone else (8.3%). Only about 30% of the children could relate their worries to a specific threatening or aversive event. A strong positive relationship was found between trait anxiety and the frequency of worry.

Source of Fears, Worries, and Scary Dreams Like fears and worries, scary dreams are common in children and are thought to be another expression of anxiety. A recent study by Muris, Merckelbach, Gadet, and Moulaert (2000) examined the developmental pattern of scary dreams, fears, and worries in children ages 4–12 years, and the extent to which conditioning, modeling, and negative information contributed to the etiology of these behaviors. Scary dreams followed a pattern of development similiar to fears: they were common in the 4- to 6-years-olds and the 11- to 12-year-olds, but were most prominent at 7–9 years. By contrast, worries increased systematically with age. Although the prevalence of some specific types of fears, worries, and dreams changed across age groups (e.g., the frequency of fears and scary dreams about imaginary creatures decreased with age, whereas worry about test performance increased with age), the most intense fears, worries, and scary dreams remained relatively stable across age levels. Scary dreams focused on imaginary creatures, personal harm or harm to others, and being kidnapped (dreams about animals vs. kidnapping were more prominant in the 4- to 6-year-olds). Information (e.g., books, the mass media, people) was found to be the most commonly reported pathway for scary dreams, with almost 70% of the children reporting that they had scary dreams about something they had seen on television. Negative information (55%) was also found to be involved in the etiology of the children’s main fears, with conditioning experiences reported for 33% and modeling for 25% of the children. This is different from a study by Ollendick and King (1991), which indicated that 88.8% of the children reported negative information as being the source of the fear. For worries, the most common pathways were a conditioning experience (58%) and negative information (33%). An important finding of this study was a significant difference in the content and origins of the children’s fears, worries, and scary dreams, suggesting that they may reflect separate phenomena. In summary, fears, worries, and anxiety are quite common among children of all ages. They tend to vary in their expression as a function of age; in number as a function of age and gender; and in foci as a function of age, gender, ethnic, and cultural differences, and SES. Distressing fears and anxiety can also have a significant impact on children’s personal and social functioning. In a study of 648 youth ages 12–17 years, for example, Ollendick and King (1994) found that 60% reported that their fears or anxieties caused high levels of daily inter-

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ference with their participation in desired or required activities, and an additional 20% reported moderate levels of daily interference.

ANXIETY DISORDERS Our understanding of anxiety disorders has evolved over the past 15–20 years, due, in part, to the increased specificity of the DSM classification system. The DSM-IV (APA, 1994) indicates that the symptoms associated with anxiety are consistent across children, adolescents, and adults, although the specific manifestations of these disorders may reflect developmental differences. A number of changes in the classification of children’s anxiety disorders have been made in DSM-IV. DSM-III-R’s avoidant disorder of childhood is now considered to be a form of social phobia, and DSM-III-R’s overanxious disorder of childhood (OAD) is subsumed under generalized anxiety disorder (GAD). Separation anxiety disorder (SAD) is now the only anxiety disorder first evidenced in infancy, childhood, and adolescence in DSM-IV. The other anxiety disorders listed in DSM-IV (specific phobia, social phobia, obsessive–compulsive disorder [OCD], panic disorder, agoraphobia, posttraumatic stress disorder [PTSD], and anxiety disorder not otherwise specified) can be diagnosed regardless of age. SAD, GAD, and specific phobia are typically far more prevalent among children than the other disorders. The DSM-IV symptoms of the anxiety disorders that have been examined in children are presented in Table 8.2. Research in this area is confusing because many studies combine the various types of anxiety disorders, whereas others examine the characteristics of only one specific type. Below, we describe the types of anxiety disorders most common in children, including SAD, GAD, and phobias. Epidemiological data for these disorders are summarized in Table 8.3. The characteristics of anxiety disorders in general are presented in a later section.

Separation Anxiety Disorder SAD has retained its status as a DSM disorder of childhood, because its age of onset is prior to 18 years. All the features associated with SAD can be attributed to recurring and excessive anxiety about being separated, either permanently or temporarily, from one’s home or from one’s attachment figures (i.e., parents or other primary caretakers). Crying or other excessive distress in anticipation of, or at the time of, separation is typical. Moreover, when away from the home or parents, the child often needs to know the parents’ whereabouts and to stay in touch with them (e.g., by phone). When children with SAD are separated from parents, they are often preoccupied with morbid worries that something terrible will happen to their parents, or that something will happen to themselves to cause a separation, such as being kidnapped or lost. Homesickness to the point of misery and panic often occurs when away from home, and the yearning to return home interferes with participation in activities. The anxiety reaction seen in SAD is considered clinically significant when it is beyond that which is expected for a child’s level of development, is significant enough to interfere with a child’s functioning or well-being, and lasts for a period of at least 4 weeks (APA, 1994). The expression of SAD can vary with age (Francis, Last, & Strauss, 1987). Young children with SAD have more symptoms than older children with this disorder. Children ages 5– 8 years most commonly report unrealistic worry about harm to attachment figures and engage in school refusal. Among the youngest children, shadowing behavior (i.e., closely following a parent throughout the day or frequently checking on a parent’s whereabouts) may be the major

270 II. MANAGING COMMON PROBLEMS TABLE 8.2. Symptoms Associated with DSM-IV Anxiety Disorders Symptoms

GAD

SAD

OCD

PD

PH

PTSD

Worry • • • • •

About work About school performance About relationships with others About someone close to them being harmed or dying About being separated from someone they are close to or a significant person

× × × × ×

Recurring experiences • Recurrent and persistent thoughts, impulses, images, or behaviors • Persistent reexperiencing of traumatic event

× ×

Actual or perceived physical symptoms • • • • • • • • • • • • • • • • • • • • •

Restlessness Being easily fatigued Difficulty concentrating Irritability Muscle tension Sleep disturbance—insomnia, too much sleep, or restless sleep Pounding heart or accelerated heart rate Sweating for no obvious reason Trembling or shaking Shortness of breath or feelings of smothering Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy, lightheaded, or faint Numbness or tingling sensations Chills or hot flashes Hypervigilance Sleep problems Irritability Exaggerated startle response Concentration problems

× × × × × ×

×

× × × × × × × × × × × × × × ×

Fears and/or phobias • • • • •

Fear of losing control Fear of dying Fear when separated or in anticipation of separation Fear of being home alone without adults present Fear of being in a social situation where there are unfamiliar people • Fear related to an object or situation (e.g., heights, animals, flying, blood) • Persistent avoidance of stimuli associated with trauma

× × × × ×1 ×2 ×

Other symptoms • Refusal to go to school or to participate in outside activities because of separation • Nightmares about being separated from others • Refusal to sleep away from home or insistence on sleeping near someone they are close to • Feelings of unreality or being detached from themselves • Consistent failure to speak in social situations, despite speaking in other situations

× × × × ×3

Note. GAD, generalized anxiety disorder/overanxious disorder; SAD, separation anxiety disorder; OCD, obsessive– compulsive disorder; PD, panic disorder; PH1, social phobia; PH2, specific phobia; PH3, selective mutism. Adapted from Laurent and Potter (1998). Copyright 1998 by Plenum Publishers. Adapted by permission.

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TABLE 8.3. Epidemiological Data for Anxiety Disorders Prevalence Disorder

Boys/girls

Clinic

Community

SAD

4%

4–13%

GAD

14–58%

3–7%

8.8–13.4 yrs

Girls = boys Girls = boys

15%

1–9%

X| = 11.3 yrs

Girls < boys Girls > boys

2–13%

X| = 8.4 yrs

Girls > boys Girls > boys

Social phobia Specific phobia All anxiety disorders

39–42%

Age of onset

Clinic

Community

>6 yrs; X| = 7.5 yrs Girls > boys Girls = boys

6–18% (7.5% at 11 yrs, 10.7% at 15 yrs)

Note. The data are from Anderson, Williams, McGee, and Silva (1987); Kashani and Orvaschel (1990); Last, Strauss, and Francis (1987); Last, Hersen, Kazdin, Finkelstein, and Strauss (1987); Last, Perrin, Hersen, and Kazdin (1992); Strauss and Last (1993).

feature. These children may demand that someone stay with them until they fall asleep, or insist on sleeping with parents or siblings. Young children with SAD also often have associated fears, such as nightmares involving separation. Prepubertal children (9–12 years) evidence withdrawal, apathy, sadness, and poor concentration when separated from their parents. School refusal may be seen in complaints of illness or tantrums when it is time to depart for school, and children may leave school during the day to return home. Adolescents (13–16 years) with SAD evidence more somatic complaints on days involving separation, and school refusal is common. They may also refuse to participate in activities that involve extended separation from parents, including going to camp, overnight stays with friends, or day excursions with peers. Overall, school refusal is exhibited by three-fourths of children with SAD. Although SAD can be seen at any age up to young adulthood, it is most often diagnosed in prepubertal children (i.e., about 8 years of age) (Kashani & Orvaschel, 1990). When it begins before age 6, it is considered “early-onset” (APA, 1994). The onset of SAD is often acute and precipitated by a stressful life event, such as a death, a move, or a change of school. It can also correspond to developmental transitions, such as entering school for the first time, or beginning middle or junior high school (Albano, Chorpita, & Barlow, 1996). A child can have periods of exacerbation and remission of the symptoms over several years. Reccurrence appears to be tied to such events as prolonged illness, school holidays, or periods of increased demands and stress (Albano et al., 2000). Given that separation anxiety is normal from about 9 to 18 months of age, it is possible that SAD represents a child’s failure to make a successful transition from this developmental phase, or that it involves a regression to a prior level of functioning in the face of stressors (Fischer, Himle, & Thyer, 1999). There is some evidence that SAD may be a precurser to the subsequent development of panic disorder or agoraphobia in adulthood (Silove et al., 1995). Others have suggested that SAD is a childhood version of panic disorder or agoraphobia and thus shares etiological pathways with these disorders, including familial transmission (Abelson & Alessi, 1992). Evidence for this includes increased rates of SAD in children of women with anxiety and depressive disorders, as well as increased rates of SAD among siblings of children with SAD (Last & Beidel, 1991). Albano et al. (1996) also found that children with SAD are at considerable risk for developing social phobia, in which the anxiety-provoking stimuli are clearly related to social situations involving exposure to unfamiliar people or embarrassing situations.

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Generalized Anxiety Disorder Although the diagnostic criteria for GAD are slightly different from those for DSM-III-R OAD, research indicates no significant difference between the two diagnoses (Kendall & Warman, 1996; Tracey, Chorpita, Douban, & Barlow, 1997), so it appears that past research on OAD can be generalized to current and future research on GAD in children. The core feature of GAD is excessive, unrealistic worry and anxiety about a number of areas of life. Furthermore, the worry and anxiety are not limited to a feature of one of the other anxiety disorders, such as being embarrassed in public (social phobia) or being away from home or close relatives (SAD). The excessive worry/anxiety must be difficult to control and must be present for more days than not for at least 6 months. For a DSM-IV diagnosis of GAD, there must also be evidence of at least one of the following physiological symptoms: restlessness, tiring easily, problems with concentrating or mind going blank, irritibility, muscle tension, and sleep disturbance. Although other somatic complaints (e.g., headaches, stomachaches, sweating) are not required for a diagnosis, they are quite common in children with GAD. The various symptoms must cause significant distress or impairment in important areas of functioning. The onset of GAD may be sudden or gradual, and often symptoms are exacerbated by stress. Children with GAD usually worry excessively about the quality of their work or about their performance in social, academic, or athletic events, even when their performance is not being evaluated. They are often perfectionistic and redo a task numerous times before believing it is acceptable. There also can be an excessive need for reassurance, as exhibited in their not being able to complete a project or homework without continuous feedback that they are doing a good job. Children with GAD also often have a preoccupation with an adult figure who seems “mean” or critical to them (Albano et al., 2001). Worries about the past, the future, and catastrophic events such as earthquakes or nuclear war are common. In addition, children with GAD may be excessively self-conscious, so they tend to avoid age-appropriate activities such as social or sport events. It is interesting that in a clinical sample, OAD was more prominent in European American children from middle- and upper-SES families than among African American and low-SES children (Last, Hersen, Kazdin, Finkelstein, & Strauss, 1987); this is similar to the findings on the development of worry in the normal population. Children with GAD are often overlooked, because their anxieties about meeting deadlines and adhering to rules, as well as their inquiries about the dangers of situations, can give them the appearance of being “mature.” Thus parents and teachers do not always recognize when these behaviors are excessive for a young child (Kendall, Krain, & Treadwell, 1999). In addition to these desirable behaviors, children with GAD do not often present with disruptive behaviors. It is therefore not uncommon for parents to wait for treatment until the behaviors are causing extreme distress or are significantly interfering with the child’s social or academic functioning. Developmental differences have been found for OAD: Younger children (5–11 years) are more likely to have concurrent SAD or attention-deficit/hyperactivity disorder (ADHD), and older children (12–19 years) have higher levels of anxiety and depression in general, as well as more frequent comorbidity with major depressive disorder or specific phobia (McGee et al., 1990). Others have found that children with a primary diagnosis of GAD are also likely to have a secondary diagnosis related to social anxiety (Albano et al., 1996; Beidel, 1991; Last, Hersen, Kazdin, Finkelstein, & Strauss, 1987). For many children, the symptoms of OAD are reported to remit over time (Last, Perrin, Hersen, & Kazdin, 1996). Last et al. (1996) found that 80% of children originally diagnosed with OAD did not meet the criteria at a 3- to 4-year follow-up

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assessment. These children did, however, show a relatively high likelihood (35%) of developing a new psychiatric disorder at follow-up. In contrast, over 50% of a sample of nonreferred children and adolescents who were initially diagnosed with severe OAD were rediagnosed with the same disorder 2½ years later (Cohen, Cohen, & Brook, 1993). Thus, although GAD appears to remit for many children, a sizable number of children continue to suffer from it or other, more specific anxiety disorders.

Phobias Social Phobia Social phobia (also called social anxiety disorder) is currently among the most common anxiety disorders, and there is some evidence that it may be increasing (Heimberg, Stein, Hiripi, & Kessler, 2000; see Kashdan & Herbert, 2001, for a comprehensive review). It affects as many as 13% of individuals at some time during their lifetimes (Kessler et al., 1994). In one study, 7.6% of children and 3.7% of adolescents met DSM-III-R criteria for social phobia (Shaffer et al., 1996). It is thought that the majority of children with social phobia go undiagnosed unless the disorder progresses to the point that the child refuses to attend school (Beidel & Morris, 1995). The age of onset for social phobia is relatively early, with some children being diagnosed as young as 8 years (Beidel & Turner, 1998). Moreover, most adults with social phobia cannot recall a time when social anxiety was not present in their lives (Heimberg, Stein, Hiripi, & Kessler, 2000). The key feature of social phobia is a strong, irrational fear in the presence of social or performance situations in which a person is exposed to possible scrutiny by others and fears that he or she may do something that will be humiliating or embarrassing (e.g., not being able to talk while speaking in public, choking on food in public, vomiting in front of others, etc.). Children with social phobia exhibit marked anticipatory anxiety when they must enter the social situation of concern, have high anxiety in the situation, and avoid the situation if at all possible. Although adolescents and adults usually recognize that their fear is excessive or unreasonable, children may not view it as such (APA, 1994). Social phobia can be of a “generalized” type (i.e., fear that occurs across most social situations, including public and interpersonal), or it may be more specific (i.e., fear in a particular situation, such as parties or club meetings). For a child to be diagnosed with social phobia, the symptoms must persist for at least 6 months; there must be evidence that the child has the capacity for social relationships with familiar people; and the social anxiety must occur in peer settings, not just in interactions with adults. The average age of onset for clinic-referred children with social phobia ranges from 11 years, 3 months to 12 years, 3 months (Last, Perrin, Hersen, & Kazdin, 1992). In a study comparing 50 children with social phobia (7–13 years; mean age 10.1 years) to 22 normal control children, Beidel, Turner, and Morris (1999) found that the children with social phobia suffered substantial emotional distress and impairment in their daily social, academic, and family functioning. The behaviors they exhibited, however, were not ones that would readily lead teachers or parents to seek help for them. They tended to have few friends, were extremely lonely, and avoided extracurricular activities. They had high levels of anxiety in general, and a substantial number of moderately distressing specific fears. Somatic complaints of headaches and stomachaches were common; in extreme cases, school refusal and selective mutism were present. These children also had poor social skills, as might be expected from their avoidance of childhood activities involving peers. Early social isolation may actually pre-

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vent such children from acquiring social skills (Turner, Beidel, Borden, Stanley, & Jacob, 1991) and increase their negative/avoidant coping style. Beidel et al. (1999) also found that children with social phobia were at high risk for developing other disorders (60%), with 36% of this sample having another anxiety disorder (typically SAD, GAD, or specific phobia). Social phobia and SAD seem to co-occur in both clinical and community groups, particularly for children ages 8–12 years, with adolescents reporting more social phobia than SAD symptoms (Compton, Nelson, & March, 2000). Compton et al. also found that European American children endorsed more symptoms of social phobia than African American children, who had more SAD symptoms. Social phobia is thought to result from a combination of biological and psychological vulnerabilities and life stresses or traumatic events (Kashdan & Herbert, 2001). Specifically, concordance rates of 24.4% for monozygotic versus 15.3% for dizygotic twins have been reported (Kendler, Neale, Kessler, Heath, & Eaves, 1992). Moreover, the temperamental style of behavioral inhibition (shyness, social inhibition, and avoidance) in infancy and early childhood may be a precursor to social phobia (Schwartz, Snidman, & Kagan, 1999; Stemberger, Turner, Beidel, & Calhoun, 1995). Environmental events that may contribute to the development of social phobia include high levels of parental criticism and control, peer rejection and victimization, and operant conditioning following a bad experience in a social situation (Hofmann, Ehlers, & Roth, 1995; LaGreca & Lopez, 1998; Whaley, Pinto, & Sigman, 1999). A cycle of negative thoughts, feelings, and behaviors, particularly skills and/or performance deficits are implicated in the maintenance of social phobia (Hopko, McNeil, Zvolensky, & Eifert, 2001; Kashdan & Herbert, 2001). Specific Phobia The core feature of specific phobia (formerly DSM-III-R simple phobia) is excessive fear in the presence of, or anticipation of, a circumscribed object or event. The fears expressed are persistent and maladaptive, lead to the avoidance of the feared object, and are perceived as uncontrollable by a child (Silverman & Carmichael, 1999). The fear is out of proportion to reality, but children may not view their fear as excessive or unreasonable. For a child, a diagnosis of specific phobia requires that the phobia must have lasted for at least 6 months, be non-age-specific, and significantly interfere with the child’s functioning. For some children, the fear may be ageappropriate but so excessive that it interferes with their functioning and thus warrants treatment. Phobias can occur at an early age, are evident in both children and adolescents, and are not necessarily tied to traumatic precipitating events (Muris, Merckelbach, Gadet, & Moulaert, 2000). Common phobias in childhood involve animals, storms, darkness, needles, and high places (Silverman & Rabian, 1993). The level of fear usually varies with the proximity of the feared object or situation and the degree to which escape is limited. The focus of the fear may be anticipated harm from some aspect of the specific object or situation (e.g., fear of dogs because of concerns about being bitten). Fears may also involve concerns about panicking or losing control when exposed to the feared object or situation (e.g., blood and injury may cause the person to worry about fainting) (APA, 1994). School Refusal Although it is not listed in DSM-IV, one of the most common symptoms exhibited by anxious and fearful children is refusal to go to school (see King & Bernstein, 2001, for a comprehen-

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sive review). Such terms as “truancy” and “school phobia” were previously used to describe this behavior, but neither of these terms fully captures the range of behavors leading to or maintaining refusal to go to school. “School refusal” is now the term most commonly used to describe these children. Kearney and Silverman (1993, 1996) identify the characteristic behaviors related to school refusal through the use of empirically derived criteria. School refusal is viewed as constituting a spectrum that includes rarely missing school but attending under duress, as well as always missing school. Specifically, school refusal refers to the behavior of youth ages 5–17 years who (1) are completely absent from school; (2) initially attend, then leave school during the school day; (3) go to school, following behavior problems such as tantrums in the morning; and/or (4) display unusual distress during school days that leads to regular pleas for future nonattendance (Kearney & Silverman, 1996). School refusal is of some significance because school attendance is mandated by law (King & Bernstein, 2001) and refusal to attend school affects the child and his or her family in a variety of ways, including family conflict and disruption, academic problems, reduced social interaction, delinquency, anxiety/depression, and the economic consequences of dropping out of school (N. J. King, Ollendick, & Tonge, 1995). Although children at any age may exhibit school refusal, the problem peaks at times of transitions to new schools (Kearney & Albano, 2000). Prevalence rates for school refusal are estimated at 5% of all clinic referrals, 1–10% of school-age children and it is equally common among boys and girls (King & Bernstein, 2001; N. J. King, Mietz, Finney, & Ollendick, 1995). To help in the classification, assessment, and treatment of school refusal, Kearney and Silverman (1993, 1996) have proposed a functional-analytic model to explain the behavior. The problem is hypothesized to occur for one or more of the following four reasons: (1) avoidance of situations or activities arousing negative affect (e.g., anxiety, fear, depression); (2) escape from aversive social and evaluative situations (e.g., oral reports, tests, social anxiety due to peer evaluation); (3) attention seeking (e.g., secondary gains of separation anxiety); and (4) possible tangible reinforcement (e.g., hanging out with friends, working, sleeping late). Children refusing for the first or second reason are motivated by a negative reinforcement paradigm, whereas refusal for the third or fourth reason is maintained by a positive reinforcement paradigm. It is possible for a child’s school refusal to be maintained by two or more of these factors. This approach to understanding and classifying school refusal also leads directly to treatment methods that are specific to the individual child’s problem (Kearney & Silverman, 1990, 1999; Kearney & Albano, 2000; see Table 8.4). Anxiety about attending school appears to stem primarily from separation problems or from excessive fear about some aspect of the school (i.e., a genuine school phobia) (Last, Hersen, Kazdin, Francis, & Grubb, 1987a, 1987b). Last and colleagues found that children with school phobia were more likely than those with SAD to present with school avoidance (100% vs. 73%). Other evidence indicates that specific anxiety disorders in parents predict an increased prevalence of specific anxiety disorders in school-avoidant children (Bernstein et al., 1997): Children presenting with phobic school-avoidant behavior are likely to have parents with specific and/or social phobia, whereas children who are school-avoidant due to SAD are more likely to have parents with panic disorder and/or agoraphobia.

GENERAL CHARACTERISTICS OF ANXIETY DISORDERS Costello and Angold (1995) have summarized the findings of recent research on the characteristics of anxiety disorders in community and school samples as follows: (1) Children self-

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TABLE 8.4. A Functional Model for Prescriptive Treatment of School Refusal Reason for school refusal

Prescriptive treatment

To avoid stimuli that provoke negative affect (crying, stomachaches, distress)

Somatic control exercises and gradual reexposure to the school setting to reduce physical symptoms and anticipatory anxiety

To escape aversive social and evaluative situations

Role play and cognitive therapy to build social skills and reduce social anxiety

To get attention

Parent training in contingency management to establish clear parental commands, regular evening and morning routines, and consequences for compliance and noncompliance

For positive tangible reinforcement

Family contingency contracting to increase rewards for attending school and decrease rewards for missing school

Note. The data are from Kearney and Albano (2000) and Kearney and Silverman (1990).

report symptoms associated with anxiety disorders much more frequently than parents report them about their children; (2) the prevalence of anxiety disorders seems to increase with age, except for SAD, which decreases with age; and (3) more girls than boys have anxiety disorders in nonclinical samples. Symptoms of anxiety appear to be persistent among both community and clinic-referred children. In first-grade children, for example, those whose self-ratings placed them in the top third with respect to anxious symptoms were nearly twice as likely as their peers still to be placed in the top third when reassessed in the fifth grade (Ialongo, Edelsohn, Werthamer-Larsson, Crockett, & Kellam, 1995). In a 3- to 4-year prospective study of children from an anxiety disorders clinic, an anxiety disorder (persistent, recurrent, or new) was present at follow-up in 35–42% of the 84 patients who initially had such a disorder (Last et al., 1996). Specifically, 19% continued to experience their previous primary anxiety disorder, 7.8% had a recurrence, and 15.5% had new anxiety disorders. Approximately two-thirds of the children who recovered did so within the first year of follow-up; the symptoms of children with OAD took longer to remit. It is interesting that age of onset was inversely related to the length of time to remission. Persistence of specific anxiety disorders has also been documented. In a community sample of 9- to 18-year-olds, Cohen, Cohen, and Brook (1993) found that the probability of OAD’s recurring at a 2½-year follow-up assessment was 23%. Studies of OCD also indicate that this condition is quite persistent, with 43–50% continuing to exhibit OCD over 2–7 years (Berg et al., 1989; Leonard et al., 1993). In addition, Woodward and Fergusson (2001) found that youngsters who have anxiety disorders are, as adults, at increased risk of anxiety disorders, depression, illicit drug dependence, and education underachievement. Taken together, these data indicate that one episode of an anxiety disorder represents a risk for further episodes of the same general type of disorder (Cohen, Cohen, & Brook, 1993; Kovacs, 1996). This persistence is remarkable, given the changes in cognition, social and interpersonal roles, extrafamilial contacts, and so forth that take place during the transition from childhood to adolescence to young adulthood. Thus the persistence of anxiety disorders is thought to be linked to something intrinsic to the individual, such as negative affect, which is an aspect of temperament and quite stable over time (Fox, 1994).

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The impact of anxiety on children’s functioning is considerable. These children exhibit impaired peer relations, higher levels of depression, poorer self-concepts, attention problems, and teacher-reported deficits in academic performance. It is also important to note that children with anxiety disorders are as disliked by their peers as are children with conduct disorders, and they also tend to be socially neglected by their classmates (Ollendick & King, 1994; Strauss, Lahey, Frick, Frame, & Hund, 1988). These factors place them at increased risk for further interpersonal problems.

Comorbidity The comorbidity of anxiety disorders with other psychiatric disorders is significant. The cooccurrence of more than one anxiety disorder is especially high. Last et al. (1992) reported that the lifetime rate of a specific anxiety disorder’s occurring with any other anxiety disorder was between 65% and 95%. This was two to three times more likely than their association with depression (22–44%) or disruptive behavior disorders (8–27%). Reviews of the literature indicate that anxiety disorders typically have an onset prior to disruptive behavior disorders, which have an onset before depression (Kovacs & Devlin, 1998). This could explain, in part, the high comorbidity rate of anxiety with other childhood disorders. Depression The importance of comorbidity, particularly depression, in the outcome of children with anxiety disorders is highlighted in a study by Last, Hansen, and Franco (1997). In an 8-year prospective study, follow-up data were collected on 101 adults with a history of diagnosed childhood anxiety disorders. They found that individuals who did not have comorbid depression in childhood were functioning relatively similarly to normal controls once they reached aduthood, whereas those with previous comorbid depression continued to experience considerable adjustment difficulties. Children with comorbid anxiety and depression are older at age of evaluation and have more severe anxiety symptoms than those with an anxiety disorder or a depressive disorder alone (Kovacs, Gatsonis, Paulauskas, & Richards, 1989). Furthermore, the anxiety disorder precedes the depressive disorder about two-thirds of the time. It is not clear, however, whether anxiety actually causes depression or whether the psychosocial sequelae of the anxiety disorder place a child at risk for depression (Seligman & Ollendick, 1998). There is considerable overlap in the symptoms of anxiety and depression, and much effort has gone into differentiating the two types of disorders (see Chapter 9). Laurent, Landau, and Stark (1993) used conditional probabilities to examine the most efficient inclusion and exclusion critieria for the differential diagnosis of depressive and anxiety disorders in children. They found that symptoms describing worries, especially worries about future events and academic competence, served as the most efficient inclusion criteria for anxiety disorders. Given that the DSM-III-R symptoms associated with anxiety (other than worry) did not differentiate children with anxiety from those with depression, they concluded that the DSM-III-R symptoms associated with anxiety and depression were both indicative of general distress or the broader construct of negative affect. Thus anxiety and depression are neither totally unitary nor separate constructs. Factor-analytic research does indicate that anxiety and depression share a common component, high negative affect (i.e., symptoms of general distress), but are also differentiated by two distinct factors. High physiological arousal is specific to anxiety, and low positive affect

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(anhedonia) is specific to depression (Joiner, Catanzaro, & Laurent, 1996; Jolly & Dykman, 1994; Murphy, Marelich, & Hoffman, 2000). This reflects the theory that mood structure is best described by two personality dispositions: negative and positive affect (Watson & Tellegen, 1985). Negative affect has pervasive influences on mood, self-concept, and world view. Positive affect reflects an individual’s level of pleasurable engagement with the environment (Watson, Clark, & Tellegen, 1988). The ability or skills to modulate or control emotional or affective arousal are acquired gradually throughout infancy and childhood, and may be further modified in later years (Fox, 1994). Given that emotional regulation skills (including arousability) are a function not only of biological mechansims but also of behavioral, social, and cognitive processes (Calkins, 1994; Thompson, 1994), their acquisition and maintenance are constrained by developmental age. This might help explain the low incidence of mood disorders in preschool children and the fact that anxiety disorders precede mood disorders. Attention-Deficit/Hyperactivity Disorder ADHD is also frequently comorbid with anxiety disorders. It is estimated that up to 22% of elementary school children and as many as 50% of adolescents with anxiety disorders have comorbid ADHD (Biederman, Newcorn, & Sprich, 1991). The co-occurrence of anxiety and ADHD seems to reduce the level of impulsiveness in these children significantly, compared to children with ADHD and without anxiety, although the former remain more impulsive than normal children. The comorbidity of anxiety and mood disorders with ADHD is often associated with a history of greater family and personal stress, greater parental symptoms of mood and anxiety disturbance, and reduced responsiveness to stimulant medication (see Jensen, Martin, & Cantwell, 1997, for a review).

Etiology The etiology of anxiety disorders in general is not clearly understood. A combination of genetic and familial factors with environmental events, learning factors, and cognitions appears to contribute to the development of anxiety; of course, the relative influence of these factors varies for the individual child. The primary theories of etiology are summarized here. Learning Theories The learning-based theory that best explains the etiology of phobias is that of Rachman (1977). Rachman proposed three prime pathways for fear acquisition: conditioning, vicarious exposure, and transmission through information and instructions. Previously cited studies on the development of fears and worries are consistent with these pathways for children. Ollendick and King (1991), for example, found that vicarious learning and instructional factors were the most influential pathways for 10 highly prevalent fears reported by 9- to 14-year-olds. These indirect sources, however, were also combined with direct conditioning experiences. Similarly, Muris, Merckelbach, Gadet, and Moulaert (2000) found that information was the most commonly reported pathway for scary dreams. Primary fears were influenced by negative information, conditioning experiences, and modeling. The fact that stressful life events are associated with anxiety is also consistent with learning theory. In a study of child and adolescent twins, for example, Eley and Stevenson (1998) found that experiencing situations involving threat or

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danger occurred more often for anxious children than for either their nonanxious cotwins or other nonanxious children. Thus learning experiences appear to play a significant role in the development of fears. However, learning theory alone cannot fully explain the etiology of the various anxiety disorders or show why certain people are more vulnerable than others to developing these disorders. Cognitive Factors Maladaptive cognitions are thought to play a significant role in the etiology and maintenance of fears and anxieties. Indeed, cognitive distortions characterized by misperceptions, exaggerations, or overattending to environmental threat are more prevalent in fearful and anxious children than in other youngsters (Kendall & Chansky, 1991; N. J. King, Mietz, et al., 1995). Kendall et al. (1999) explain the interrelationship between cognitions and behavior. They indicate that repetitions of behavioral events and the related cognitive processes result in some degree of consistency in these events and processes. With the accumulation of a history of behavioral events, a child begins to have anticipatory cognitions (expectancies). If children have early anxiety-provoking experiences, they may develop distorted cognitive schemas, involving negative or unrealistic expectations for future events. The emotional intensity related to a behavioral event can also influence the associated cognitions, with high emotional intensity exerting a greater influence. Given that cognitive processes develop over time, and that the development of fears has been shown to be related to cognitive maturation (Gullone, 1999), this explanation has some heuristic value. There is also some research to support it. Several cognitive factors that could influence the thinking of fearful and anxious children have been studied (e.g., Chorpita, Albano, & Barlow, 1996), including cognitive interpretative style (i.e., how a situation is perceived), causal attribution (e.g., “This is overwhelming”), attentional bias (i.e., what aspect of the situation is focused on), and problem solving. In a study of cognitive interpretive style, for example, Barrett, Rapee, Dadds, and Ryan (1996) found that children with specific and social phobias perceived more threat in ambigious situations than non-clinic-referred children, but less threat than children diagnosed with oppositional defiant disorder. When asked to problem-solve what they would do in specific physical and social situations, children with specific phobia gave more avoidant solutions to physical situations than children with any other type of disorder, whereas children with social phobia tended to be more avoidant in social situations. Thus cognitive distortions clearly play a significant role in fear and anxiety disorders and have implications for treatment, but it is not clear how cognitions vary with development and whether their role in phobias and other anxiety disorders is the result or the cause of the anxiety. Familial/Biological/Genetic Factors There is considerable evidence for a genetic component in the etiology of anxiety. First, the rate of anxiety disorders has been found to be higher in children of adults with anxiety disorders (Last, Hersen, Kazdin, Orvaschel, & Perrin, 1991). Furthermore, in a review of behavioral genetic studies, Eley (1999) found evidence for a genetic influence on anxiety in childhood, accounting for approximately one-third of the variance in most cases. The genetic contribution appears to increase with age, with girls evidencing greater heritability than boys. Lesch et al. (1996) found an association between a marker in the promoter of the serotonin transport gene and the emotional triad of anxiety, depression, and neuroticism, indicating that a specific

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genetic marker is associated with both anxiety and depression. Further research on children with “pure” cases of anxiety or depressive disorders, and those who have comorbid anxiety and depressive disorders, will give more information on the behavioral phenotypes of this gene. Other work has found genetic contributions for particular anxiety disorders. For example, there appears to be a greater contribution of genetic factors in the etiology of specific phobia than for the more general social phobia (Kendler, Neale, Kessler, Heath, & Eaves, 1992). Work by Kagan, Reznick, and Snidman (1988) suggests that certain individuals have a biological trait called “behavioral inhibition” (BI) that predisposes them to the development of pathological conditions, particularly when they are exposed to certain experiences and environmental stimuli (Biederman et al., 1993a). BI refers to the temperamental propensity to react with inhibition to both social and nonsocial novel situations (Van Ameringen, Mancini, & Oakman, 1998). It is estimated that approximately 10–20% of European American infants are born with this temperamental predisposition (e.g., Biederman et al., 1993a, 1993b). Children with high BI have higher rates of all types of anxiety disorders, especially phobias, than uninhibited children (see Turner, Beidel, & Wolff, 1996, for a review). Furthermore, BI appears to be most closely associated with phobias that are social or social-evaluative in nature. Despite these associations, however, the presence of behavioral inhibition is neither necessary nor sufficient for developing an anxiety disorder, but may serve to increase a child’s vulnerability to anxiety as well as to specific types of fears (Bohlin, Bengstgard, & Andersson, 2000). Manassis and Bradley (1994) describe a transactional model for the development of anxiety that attempts to integrate various causal mechanisms. Using the example of social phobia, they suggest that the development of social phobia in children is the result of a sequential process that begins with an inborn temperamental inhibition, which then leads to an insecure attachment between the mother and child due to the child’s highly reactive and difficult-to-soothe qualities. This pattern of insecure–anxious attachment then leads the child to react in ways that causes difficulties in other relationships, with the result that the child ultimately withdraws from peer interaction. The child’s withdrawal, in turn, decreases the opportunities to develop the social skills needed to form supportive relationships. Thus, although biological factors set the stage for this progression, the mediating roles of attachment, parent–child interactions, and experience are also important.

ASSESSMENT OF FEARS AND ANXIETIES Given the frequency of fears and anxieties in children, how does one distinguish a normal, developmental fear or anxiety from a clinically significant phobia or other anxiety disorder? Although DSM-IV (APA, 1994) provides criteria for each of the anxiety disorders experienced by children, it is also important to systematically evaluate the nature of the specific fear- or anxiety-based symptoms, including the intensity and frequency of the behavioral and physiological reactions, the content of the fear or anxiety, its persistence, its developmental timing, and the familial and environmental circumstances that could have precipitated and/or are maintaining it. Clinically significant anxiety disorders have some characteristics in these areas that make them distinguishable from more age-related, transient fears and anxieties (APA, 1994): 1. Intensity. The intensity of the child’s reaction is out of proportion to the actual threat or demands of the situation. For example, a child who cries uncontrollably the entire time he

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or she is in school, or starts vomiting every morning before school, should be assessed for a phobia or other anxiety disorder. 2. Frequency. The fear reaction or anxious symptoms occur with increased frequency and cannot be explained or reasoned away. No amount of reassurance seems to help, and reassurance often actually makes the situation worse. 3. Content. The child’s fear or worry is usually focused on a nonthreatening situation or stimulus that is not likely to cause harm. This could include such things as the toilet, dogs, or thunder, and worries about vomiting or being separated from parents. 4. Spontaneity. The reaction appears spontaneous and beyond the voluntary control of the child. For example, a child becomes distraught at the news that a thunderstorm might occur that day. 5. Avoidance. The fear reaction leads to the avoidance of or escape from the feared stimuli. A child who refuses to leave the house if there is a chance of rain, or a child shadowing a parent all day so as not to be separated or refusing to go to school, are examples. 6. Stage of development. The fear or worry is not specific to a child’s age or stage of development. For example, an adolescent may refuse to spend the night away from home, or a school-age child may refuse to use public toilets. 7. Nonadaptive and persistent nature. The reaction of the child is not adaptive and is persistent; thus the child does not learn more effective ways to deal with the situation or feared stimuli. For example, the child’s clinging to the parent does not allow the child to learn to gain control over his or her anxiety and adapt to the environment. 8. Interference. The degree to which the child’s reaction interferes with the child’s or family’s functioning is an important criteria for making a DSM-IV diagnosis and determining the family’s motivation for treatment. Clinical levels of anxiety or fear reactions can interfere with social relationships and activities, academic performance, and family functioning. A number of risk factors are associated with childhood anxiety, and these must be taken into consideration when one is determining the effect of the anxiety on the child’s functioning (see Table 8.5). Impaired functioning in an anxious child is significantly correlated with maternal reports of conduct problems, maternal phobic anxiety, a history of developmental difficulties in the child, and the presence of psychosocial adversity related to family composition and size (Manassis & Hood, 1998). The last factor suggests that the stress of living in a single-parent, divorced, reconstituted, or unusually large family (regardless of SES) may be difficult to manage for some anxious children. Certain types of anxiety disorders also appear to increase the level of impairment; children with social phobia are more severely affected than those with DSM-III-R OAD (Beidel et al., 1999). Others have found that panic disorder and social phobia are more impairing than other anxiety disorders (Last et al., 1992). Poor social adaptation during the preschool years also has been shown to be a robust predictor of anxiety (and depressive) disorders in kindergarten children. Further, children with high BI have higher rates of anxiety disorders (Biederman et al., 1993a), especially in combination with restrictive parental control (Messer & Beidel, 1994). In addition to overly permissive or restrictive parenting, an anxious parenting style is a strong predictor of anxiety symptoms in children (Barrett, Rapee, et al., 1996). Anxious parenting appears to promote anxious cognitions and avoidance behavior in children. Barrett and colleagues also found that parental rejection played a significant role in the development of anxiety symptoms.

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II. MANAGING COMMON PROBLEMS TABLE 8.5. Risk Factors Associated with Anxiety Disorders in Children Child risk factors Developmental problems Conduct problems Poor social adaptation

High behavioral inhibition (BI) Insecure attachment Bereavement Parent risk factors

History of anxiety disorders Permissive parenting (younger children) Restrictive parenting (older children)

Parental rejection Anxious parenting

Environmental risk factors Family composition (single, divorced, reconstituted) Large family

Dangerous neighborhood Low socioeconomic status (SES)

Parental psychopathology (especially anxiety disorders) is another risk factor for a child’s developing an anxiety disorder. Several factors have been shown to mediate this association. These include insecure attachment (Armsden, McCauley, Schumaker, Greenburg, Burke, & Mitchell, 1990), inconsistent and restrictive parenting styles (Kohlmann, Schumacher, & Streit, 1988), and childhood bereavement (Goodyer & Altham, 1991). It is important to note, however, that these mediating factors, and parental psychopathology itself, have also been shown to influence the development of a range of disorders in children; thus they are not specific to anxiety. Symptomatology of anxiety can range from mild distress (crying, tantrums, hand wringing) to overwhelming, incapacitating fear or anxiety. Barrios and Hartmann (1997) give a partial, but extensive, list of children’s motoric, physiological, and subjective responses to fears; this can be helpful to the clinician in understanding the wide variation of symptoms. Furthermore, children often present with more than one anxiety disorder, or with other disorders that may be secondary to the anxiety but have a major impact on treatment. If oppositional defiant behavior is present, for example, it may interfere with the treatment of the anxiety disorder and therefore will have to be the initial focus of treatment. Sorting this out is part of the assessment process for all disorders, but it is particularly important for anxiety disorders, since anxiety is associated with many of the other childhood disorders (Manassis & Monga, 2001). Various rating scales give specific information about the presence and content of anxieties/fears. Several of these scales also measure somatic symptoms and/or are helpful in monitoring the individual child’s progress in treatment. The reader is referred to Barrios and Hartmann (1997) and Bernstein, Borchardt, and Perwien (1996) for lists of rating scales for anxiety disorders, as well as to Appendix B for copies of the rating scales we have found most useful. For example, the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al., 1997, 1999; see Appendix B) is particularly helpful in sorting out the DSM categories of anxiety disorders. It has child self-report and parent report forms with 41 items each, which assess five factors: Panic/Somatic, Generalized Anxiety, Separation Anxiety, Social Phobia, and School Phobia. The SCARED differentiates between children with and without anxiety disorders, as well as among the specific anxiety disorders. A recent revision of the SCARED that includes a Traumatic Stress Disorder scale has garnered strong support for its use as an initial screen for detecting children who have been confronted with traumatic life events and are at risk for developing PTSD (Muris, Merckelbach, Korver, & Meesters, 2000).

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Two other widely used scales are the Fear Survey Schedule for Children—Revised (FSSC-R; Ollendick, 1983; see Appendix B) and the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1985; see Appendix A). The RCMAS does not have good discriminative validity in distinguishing anxiety from depression, and thus it is best used as a symptom inventory and a global measures of distress (Last, 1993; Stark & Laurent, 2001). The reader is referred to the American Academy of Child and Adolescent Psychiatry practice guidelines for further information on the assessment of anxiety disorders (American Academy of Child and Adolescent Psychiatry, 1997b). The assessment process outlined below follows the Comprehensive Assessment-to-Intervention System (CAIS) framework presented in Chapter 2, with particular focus on issues relevant to anxiety problems.

Step 1: Initial Contact The parents should be asked to complete and return prior to the initial interview a general questionnaire (e.g., our General Parent Questionnaire; see Appendix B), plus a broad band behavior questionnaire such as the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992) to screen for current behavioral/emotional problems and to give the clinician information on the extent to which the child’s fears/anxieties are greater than those of other children the same age. The BASC, with its separate scales for Anxiety and Depression, is recommended over the Child Behavior Checklist (CBCL; Achenbach, 1991a, 1992) which has a combined Anxious/Depressed scale. The Parenting Stress Index (PSI; Abidin, 1995) provides information about the child’s temperament, the parents’ general level of stress, and their attachment to the child—all important areas for the assessment of anxiety. The FSSC-R (Ollendick, 1983) provides information on the number, severity, and types of fears that a child experiences, and gives a rating of the child’s fears in relation to other children the same age. Having the parents keep a Daily Log (see Chapter 2 and Appendix B) of the child’s behavior provides information on the child’s daily activities, which can show whether fear or anxiety is interfering with the child’s functioning. The reverse side of the Daily Log, the Specific Events Causing Concern chart (see Appendix B), records the antecedents, behavior, and consequences of specific instances of observed fear and anxiety. This chart can be very helpful in guiding the interview and also in measuring the effects of treatment. Depending on the age of the child, either the child or the parents can be asked to complete the Mood Diary (see Chapter 9). The Daily Log and the Mood Diary should be kept for a week prior to the initial appointment.

Step 2: Parent and Child Interviews Parent Interview Including a child in the initial interview with a parent, regardless of age, has the advantage of clarifying discrepant views of the problem; it also provides an opportunity for observation of the parent–child interaction. If the parent feels that a joint interview would be unsatisfactory for either the parent or the child, then the child should be seen at a later time. (It is usually not wise to leave an anxious or fearful child alone in the waiting room during a parent’s first interview!) Information should be gathered in the following areas: 1. Behavior. The parent and child should be asked their perceptions of the problems as well as to define the specific problem behavior. The focus should be on the specific manifes-

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tation of the fear or anxiety (avoidant behavior, agitated behavior, specific worries, etc.); the onset and development of the symptoms, including frequency, intensity, duration, persistence, and situation specificity; and the antecedents and consequences of the anxiety- or fear-related behavior. Social and familial reinforcers of the symptoms should be particularly noted. The clinician should also determine whether there are conditions under which the fear is not exhibited. A child may not show fear of the dark when he or she is with a sibling or parent, for example. The impact of the symptoms on the daily life of the child and family, as well as potential comorbid conditions, should be reviewed as well. It is important to assess events or meanings associated with the fear or anxiety responses and the child’s coping strategies. Fear of going to bed, for example, may be associated with fear of ghosts, fear of a recurrent nightmare, or fear that the parents may leave the child. The fear may also be maintained by the child’s coping strategies (e.g., avoidance, escape, immature or dependent behaviors). Questions regarding who is concerned about the behavior, whether the child wants help, and whether the parents’ expectations for the child are too high are especially important in the assessment of anxiety disorders. 2. Child functioning. The child’s academic, athletic, social, and behavioral functioning should be explored. Problems with family members (e.g., intense sibling conflict), peers, and academic work should be noted, as well as the child’s coping strategies and support networks. 3. Developmental and medical history. The child’s history of temperamental problems, stranger and separation responses, and early fears should be considered. A review of the child’s general pattern of coping with sleep, toileting, eating, and child care can give further information about the child’s response to everyday events. A medical history should include information about visits to the physician for anxiety symptoms, medications, and medical conditions. A number of physical conditions may produce anxiety symptoms, including (a) reactions to caffeine, psychostimulants, sedatives/hypnotics, inhalants, and neuroleptics; (b) central nervous system problems, including partial seizures, lesions of the limbic system and frontal lobes, and postconcussion syndrome; (c) metabolic and endocrine disorders, including hypoglycemia, hyperthyroidism, carcinoid tumor, and hypocalcemia; and (d) cardiac problems, such as mitral valve prolapse, arrhythmias, and valvular diseases causing palpitations. 4. Family and environment. Changes in the environment or the child’s attachment figures (e.g., death of a grandparent) can precipitate problems with anxiety; recent changes in the family situation or changes at the time of symptom onset should be explored. Environmental stressors such as a disorganized home, neglect, and exposure to danger or violence (including apparently innocuous events, such as bullies on the school bus) can also precipitate anxiety symptoms. What are the parenting styles and the family coping styles? Permissive childrearing practices are often associated with anxiety in younger children, whereas intrusive and restrictive practices tend to increase anxiety in older children. Have the parents been rejecting or overly anxious in their rearing practices? Furthermore, the use of punishment, force, or criticism is not effective with children who are fearful or anxious. It is also important to gather information on the extent to which the family members have changed their routines to accommodate the problem or protect the child from exposure to the feared stimulus or anxietyprovoking stimuli, as well as the extent to which the problem interferes with the child’s and/or family’s activities. 5. Efforts to help the child. Finding out what has been done thus far to help the child and how the child has responded to these efforts gives information on the family’s attitudes toward certain treatment strategies, as well as efforts that may have inadvertently strengthened the

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fear or anxiety (e.g., not allowing the child to watch any TV shows or movies with imaginary figures, or repeatedly insisting that the child participate in anxiety-arousing or fearful situations with little or no support). 6. Family and community resources. Parents are often ambivalent about having a child confront a feared stimulus, and most children will not want to do this. The clinician should try to determine who in the family is best suited to help the child through the treatment process, in addition to how well the family will be able to carry out a particular procedure. Depending on the specific fear or anxiety, the clinician should also determine what support can be offered by neighbors, school personnel, or other community resources. This is particularly important for school refusal, where specific information should be gathered on what the parents’ relationship to the school is like and what has been done to help the child at school. 7. Family history. What is the medical and psychiatric history of the parents and family members? Emphasis should be placed on anxiety disorders, mood disorders, tic disorders, suicidal behavior, substance use disorders, and ADHD. Is there a family history of medical conditions that may present as anxiety disorders? Child Interview Because the child has the best understanding of his or her anxiety or fear, an interview with the child is imperative. Structured interviews are not always feasible in clinical practice, and we use a semistructured interview based on the CAIS (see Chapter 2). Although interviews are used primarily to assess the subjective/cognitive domain, they can also be used to assess the other domains through general and specific questions (e.g., “How does your body feel when you think of going to school?” or “Does your heart race [or do you sweat] when you are asked to step into an elevator?” or “What do you do to avoid oral reports?”). The clinician should remember that anxious children tend to respond better to specific questions than to open-ended questions (Ollendick & Francis, 1988). The child’s cognitive-developmental level, verbal skills, and compliance should generally be assessed. The child interview also gives the clinician an opportunity to observe the child’s emotional reactions, as well as to get the child’s subjective description of the fear or anxiety. It is important to ask the child about the nature of the distressing behavioral, physiological, and/or cognitive responses that result from the actual or anticipated exposure to the feared stimulus or situation. Determining the response (e.g., avoidance, increased heart rate, diffuse muscle tension, maladaptive thoughts and images) will have a direct impact on the treatment strategy selected. The use of one or more self-report measures can be helpful in determining this information in a structured and systematic manner (e.g., the RCMAS, the SCARED). The scale(s) chosen will depend on the specific symptoms of the child. Two other self-report questionnaires provide specific information on the negative affectivity of self-statements and the child’s perceived ability to cope with personally identified anxious situations: the Negative Affect Self-Statement Questionnaire (Ronan, Kendall, & Rowe, 1994) and the Coping Questionnaire (Kendall, 1996). The latter has child, mother, and father versions. Another method for assessing children’s experience of fear or anxiety is a “fear thermometer” (with 0 representing no fear and the top of the thermometer, 10, representing extreme fear or anxiety). Fear thermometers are not very reliable, but asking the child to rate the intensity of his or her fears does allow the clinician to establish a fear hierarchy and enable the child to distinguish among different levels of fear. The child should be asked to rate cognitions or thoughts (“what you are thinking”), behaviors (“what you do”), and physiological responses (“how

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your body feels”) separately on the thermometer. A drawing of the thermometer is helpful for younger children. The clinician can also give young children a concrete way to describe fear or anxiety (e.g., “It feels a lot or just a little like bees or butterflies”), or can have them draw a picture of themselves and indicate how different parts of their body feel by giving colors to their feelings.

Step 3: Observation of Behavior In an extensive review of performance-based measures (e.g., BI, measures of attachment, and behavioral avoidance tests) and their utility for measuring childhood anxiety, Vasey and Lonigan (2000) concluded that none of the current measures possess sufficient documented clinical utility. Observation of the child’s behavior in analogue situations, however, can be very helpful. For example, a behavioral avoidance test has been used with specific phobias. In this procedure, the child is placed in a setting that contains the feared stimulus, and then performs a series of graduated tasks that call for approaching and interacting with the feared object (Barrios & Hartmann, 1997; Kendall, 1994). Behavioral avoidance tests have been used to assess children’s motor reactions to medical procedures, school-related events, strangers, and water, among other things. Other analogue observations may involve setting up anxiety-provoking situations in the clinic and observing the child’s behavioral response. For example, with the parents’ consent, the child can be left alone in an exam room or waiting room while a parent and the clinician observe to determine whether the child’s behavior is similar to natural situations (Fischer et al., 1999). Parent–child interactions can also be observed systematically in clinic analogue situations. Although they have their shortcomings, analogue observations are straightforward and allow assessment of multiple motor responses, as well as subjective responses. Given the varying stimuli or circumstances that can provoke the specific fear or anxiety and the differences in the behavioral responses to these situations, it is generally best for the clinician to develop an observation sheet on which the individual child, parent, or teacher can monitor the behavior of interest (e.g., the time between when the parent brings the child to school and departs, number of minutes to fall asleep, avoided or delayed behaviors). Using such a sheet, the clinician also can observe the child’s behavior in natural settings (home, school, and community) and record the targeted behavior.

Step 4: Further Assessment A psychoeducational assessment is needed in a case of school-related fears when there is a question about the child’s actual abilities and performance level. A measure such as the Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984) may also be useful if there is a question about the child’s overall level of adaptive functioning. Assessment of social skills may be indicated, and the Social Skills Rating System (Gresham & Elliot, 1990) can be completed by parent, teacher, and child. Systematically observing the parent–child interaction (see Chapters 2 and 10) is always an important part of the assessment process, since the parents will play a significant role in the treatment process, and their behavior may be a target for intervention. Furthermore, if the parents or siblings are also exhibiting significant fears or symptoms of anxiety, these should be addressed by the clinician or referred for further evaluation.

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Step 5: Referral to Allied Health Professionals The child should have had a physical exam within the last year, and the clinician should consult with the physician regarding the child’s health and the behaviors of concern. A referral to a child psychiatrist for psychotropic medication is indicated only in extreme cases.

Step 6: Communication of Findings and Treatment Recommendations As with all childhood problems, it is important to share information with the parents about the child’s development and the way in which the particular behavior/emotion fits into the developmental process. This can then lead to discussion of the clinician’s hypothesis regarding how a particular fear or anxiety became established and/or what is maintaining it, and, if indicated, effective ways of treating the problem. The parents and child should be included in the choice of treatment; thus the various treatment options should be presented, with a discussion of their advantages and disadvantages. Unless there is some unusual circumstance, the child should be included in this initial discussion. If the child is not included, a follow-up discussion should occur with the child and parents together. The parents’ and child’s trust in the clinician is very important in the treatment of fears and anxieties, and their cooperation and collaboration in the treatment process will depend on their understanding of the problem and the various treatment options.

TREATMENT OF ANXIETY DISORDERS Despite the fact that anxiety disorders are among the most common disorders of childhood, relatively few empirical studies examine the effectiveness of approaches to their treatment. Methods with the greatest empirical support are behavioral and cognitive-behavioral interventions (Ollendick & King, 1998). These techniques include systematic desensitization, prolonged exposure, modeling, contingency management, cognitive-behavioral therapy (CBT), thought stopping, or a combination of two or more of these treatments. Generally, the goal of treatment is to help the child learn to cope with the feared stimulus or anxiety-provoking situation, or learn that he or she is no longer fearful in the presence of the stimulus or situation. Although all of the aforementioned treatments have been used with a wide range of fears and anxieties, certain procedures have been used predominantly for particular types of fears or anxieties. For example, systematic desensitization has been used most frequently for fears and anxieties related to small animals, nighttime, and test taking, whereas prolonged exposure is used to treat obsessions and compulsions, as well as fears/anxieties related to school, physical harm, or contamination. Modeling treatments have been used to help children deal with small animals and stressful medical or dental procedures. CBT combines a number of treatment procedures and has been used to treat a range of anxieties that focus on school, social situations, and separation issues. There is also some evidence that school-based interventions may be more successful than clinic-based treatment for social anxiety (Masia, Klein, Stroch, & Corda, 2001). As with the selection of any clinical intervention, the clinician must take several factors into consideration when selecting a treatment approach for the anxious or fearful child, including the nature of the fear/anxiety and its stimulus, the characteristics of the child and parent, cost-effectiveness, and ethical considerations. For example, a highly anxious child or parent

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is not likely to accept a prolonged exposure treatment method; however, if time is of the essence (e.g., the child must undergo surgery), this may be the method of choice. In some cases, the parents, not the child, may be the focus of treatment. Research has indicated, for example, that poor treatment outcome is associated with parental psychopathology (e.g., depression, hostility, and paranoia) and family dysfunction (Berman, Weems, Silverman, & Kurtines, 2000; Crawford & Manassis, 2001). The parents’ pathology, however, had less effect on adolescents’ than on younger children’s treatment, and also had less effect when the parents and children were treated in groups versus an individual format (Berman et al., 2000). These researchers also found that children who had a depressive disorder and high trait anxiety had poorer treatment outcomes. In these cases, Berman et al. (2000) suggest that both the anxiety symptoms and the depressive symptoms be treated simultaneously. Although the number of treatment sessions for the most common anxiety disorders ranges from 4 to 18 (Kendall, 1994; March, Amaya-Jackson, Murray, & Schulte, 1998; King et al., 1998; Ollendick, 1979; Silverman et al., 1999), the child may need periodic booster sessions, particularly in periods of stress or transition. The treatment procedures presented here follow the CAIS framework (see Chapter 2), with interventions that focus primarily on the child, the parents, the environment, consequences of the behavior, and medical/health areas.

Intervention with the Child Systematic Desensitization Wolpe (1958) developed systematic desensitization, which is based on the view that fears and phobias are classically conditioned responses and that they can be unlearned through specific counterconditioning procedures. The standard systematic desensitization treatment consists of the following sequence of activities: (1) selecting and training the child to engage in a response that is incompatible or antagonistic to the fear response (e.g., muscle relaxation); (2) having the child rank-order, from least to most distressing, a series of scenes depicting the feared stimulus (fear hierarchy); and (3) gradually having the child imagine the feared scenes while engaged in the incompatible response (e.g., being relaxed). The pairing of the relaxed state with images of the feared object begins with the least distressing scene and ends with the most distressing scene, with progression through the series contingent upon imagining a scene without significant discomfort (King, Hamilton, & Ollendick, 1988). The incompatible response used most often is muscle relaxation, but laughter (e.g., having the child imagine the feared monster dressed in red flannel underwear!), playing with toys or games, eating a favorite food, or interacting with a special person can also be used with children. Vicarious desensitization (in which the child observes another child receiving desensitization), group desensitization, and real-life or in vivo desensitization (desensitization carried out with the actual feared stimulus or situation) are all effective, though in vivo training is the most effective treatment (Ollendick & King, 1998). In vivo training has the added benefit of incorporating actual practice or skill training with the graduated pairing of the incompatible response and the fear-producing stimuli. In setting up the real-life situation, however, the clinician must be sure to have control over the feared stimuli (e.g., a cooperative dentist, a friendly but slow dog). If real-life exposure is not feasible, imagery should proceed by having the child relax (specific muscle relaxation training procedures have been developed for use with children—e.g., King et al., 1988), then imagine the least feared scene for 10–15 seconds. When no anxiety is evoked, the child can move up the hierarchy. Pictures or slides can be used to help with the imagery. Systematic desensitiza-

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tion is an active, cognitively mediated process of learning to cope with anxiety (Goldfried, 1971), so the clinician should encourage the child to apply relaxation or other learned coping skills to tolerate the feared image or real situation for longer and longer periods of time. Thus one should not immediately remove the fear-producing stimulus, but should help the child cope with it for increasingly longer periods of time. An example of this approach was given in a study with 3- to 6-year-olds who had dental phobias (Allen & Stokes, 1987). The children were negatively reinforced to be calm in the dental chair by being allowed to escape after increasingly longer periods of calm behavior. The new coping skill, calmness, was then positively reinforced. Systematic desensitization is especially useful when phobic reactions involve a high level of physiological reactivity and extreme avoidance, or in cases where it is not advisable to use more confrontational methods. It is not the treatment of choice for phobias that are due primarily to a lack of skills (e.g., a water phobia in a child who does not know how to swim), since it does not provide the child with detailed instructions on the proper way to interact with the feared stimulus (Barrios & Hartmann, 1997). Nor should it be used for fears that are being inadvertently reinforced by others without changing the reinforcement patterns. A variation of systematic desensitization developed by Lazarus and Abramowitz (1962) is emotive imagery. The term “emotive imagery” is used to describe “those classes of imagery which are assumed to arouse feelings of self-assertion, pride, affection, mirth and similiar anxietyinhibiting responses” (p. 191). The therapist evokes these images by incorporating the child’s hero image (e.g., Batman, Care Bears, a rock star) into a fantasy or exciting story that includes the child. Through emotive imagery, the therapist induces positive affect and gradually introduces items from the fear hierarchy into the narrative. Positive feelings created by the story serve to inhibit feelings of anxiety that may be elicited by the fear-related stimuli. Imagery scenes should be tailored to the child’s age, should incorporate the child’s existing fantasies and cognitions, and should include language that the child has used to describe his or her fears. The therapist also must be alert to nonverbal cues (facial expression, muscle tension) that may indicate anxiety, so that the scene can be continued until there is no evidence of anxiety. This procedure involves developing an anxiety hierarchy, determining a hero and theme the child enjoys, and interweaving the feared stimuli into scripts in a graduated fashion. The script can also be incorporated into in vivo desensitization by having the story bring the child in actual confrontation of the feared stimuli (e.g., the child pretends to be Batman’s sidekick, Robin, as they carry out a mission in a room that becomes increasingly darker). Although experimental evidence is not extensive at this time (Ollendick & King, 1998), this method has been used successfully with children as young as age 4 and is especially successful with nighttime fears (King, Cranstoun, & Josephs, 1989). Systematic desensitization techniques are especially applicable to fears that are symbolic (fear of monsters or fear of nuclear war) or when the feared stimulus is readily available and approachable in stages (elevators, animals). Not all fears, however, lend themselves to being segmented into a hierarchy, and it may be difficult for some children (especially young children) to use imagery or relaxation technqiues. High levels of motivation and cooperation are also necessary for this treatment method. Prolonged Exposure In contrast to the gradual approach of systematic desensitization, prolonged exposure forces the child to confront the feared stimulus immediately and remain in its presence until the anxiety level decreases or dissipates. Variations of this procedure include flooding, in which the child

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is faced with an intense, extended experience of the actual fear stimulus or an imaginal representation of the feared stimulus; implosion, in which the child is repeatedly presented with an unrealistic and horrific scenerio involving the feared stimulus until he or she is no longer fearful or anxious; and reinforced practice, in which the child is reinforced for remaining in the presence of the feared stimulus for progressively longer periods of time. None of these procedures instructs the child how to interact adaptively with the feared stimulus. For obvious reasons, implosion is rarely used with children. Flooding has been used with children who have separation anxiety centering primarily around day care or school attendance, requiring the child to remain at day care or school for the usual period of time. A plan to accomplish this is worked out with the school; the child is then told the plan and informed that he or she is expected to stay in the school. The child’s complaints and attempts to leave are handled kindly but firmly. The clinician must determine, along with the parents and teacher, whether the child (or parents) can be expected to handle being separated without being overwhelmed. The use of prolonged exposure (“sink or swim”) techniques requires that the parents and child will be able to tolerate high levels of fear and/or anxiety as the child is exposed to the feared stimulus or situation. There are also some ethical concerns, given that it is usually a parent who chooses this technique for the child, and escape from the situation is eliminated. If time is of concern, however, or if more gradual approaches have not worked, then one of these techniques may be the treatment of choice. Modeling Modeling treatments for fears and anxieties are based on an observational learning paradigm and consist of having the frightened child observe another person (preferably a child) interacting adaptively with the feared stimulus. Both live and filmed models are effective with anxious and fearful children; the combination of live modeling with assisted participation by the child (participant modeling—see below) is the most effective technique (Ollendick & King, 1998). Modeling provides a number of important therapeutic features for the fearful child: (1) vicarious extinction of the feared response by observing a model engage in this response without negative consequences; (2) the acquisition of information about the feared stimulus and coping strategies to deal with it effectively; and (3) response facilitation, which results in engaging in the expected behavior. One of the best features about modeling is that it provides an opportunity for the child to learn skills to deal effectively with a feared situation. However, if skill acquisition is to be a major goal of modeling, then a list of desired skills should be made so that they can be systematically demonstrated, practiced, and reinforced (King et al., 1988). A graduated exposure to the feared stimulus or situation can also be part of the modeling program. As noted above, participant modeling involves direct contact between a model and a child observer, with the model guiding the child through the steps involved in confronting the feared stimulus and offering immediate feedback and reinforcement. For example, the model may be initially reluctant to enter a swimming pool, but then may comply and say, “That wasn’t so bad after all.” Symbolic modeling, in the form of stories that describe models coping with feared stimuli, is also effective. We have successfully used a story from the book Annie Stories: A Special Kind of Storytelling (Brett, 1988) to help children cope with general fears and nightmares. In a review of the literature on modeling procedures with children, Barrios and O’Dell (1998) note that a number of variables are related to treatment outcome: the child’s age, selfcontrol, and defensiveness; the similarity of the child to the model; and the anxiety of the par-

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ents toward the feared stimulus. Older children benefit more than younger ones from this treatment, as do children who have high levels of self-control and low defensiveness. In addition, the more closely the child resembles the model in terms of age, fear level, and previous experience with the feared stimulus, the greater the probability of a positive outcome. Finally, the less fearful a parent is of the stimulus the child fears, the more likely the child will benefit from modeling treatment. This technique is quite acceptable to most children and parents and is applicable to a range of fears and anxieties, particularly fears of dental or medical procedures, as well as of animals or water. Cognitive-Behavioral Approaches The premise of CBT is that behavioral responses are mediated by cognitions (Kendall & Gosch, 1994). Therefore, maladaptive behavior is thought to be the result of maladaptive cognitions; if the maladaptive cognitions are changed, the maladaptive behavior should also change. Indeed, the literature suggests that worry is the symptom that most clearly identifies anxious children (Laurent & Potter, 1998), and that children with phobias and other anxiety disorders engage in off-task thoughts, more negative self-evaluations, and fewer positive self-evaluations (Beidel & Turner, 1988; Warren, Ollendick, & King, 1996). Thus it is logical that therapy for children suffering from anxiety disorders should focus on cognitions related to anxiety. CBT combines the techniques of behavior therapy with an emphasis on thought processes. CBT for anxiety disorders in children focuses on altering maladaptive perceptions, thoughts, images, and beliefs by manipulating and restructuring these distorted cognitions. Kendall (1994) has developed a CBT program for anxious children, and its effectiveness has been empirically demonstrated, albeit with a limited number of studies (Ollendick & King, 1998). The reader is referred to Kendall et al. (1992) and Silverman and Kurtines (1996) for an in-depth review of these techniques. CBT as described by Kendall et al. (1992) consists of four components: teaching the anxious child (1) to identify or be aware of feelings and physical symptoms that are due to anxiety; (2) to become familiar with and evaluate what he or she is thinking in an anxiety-provoking situation; (3) to develop problem-solving skills, such as making a coping plan and modifying anxious thoughts, to deal with these situations; and (4) to evaluate and reward him- or herself for nonanxious behavior in an anxiety-producing situation. The intervention program uses a combination of behavioral and cognitive techniques over the course of 16 sessions. The first 8 sessions are aimed at developing the necessary skills for children to overcome the anxiety, and the last 8 sessions are used to practice the skills in anxiety-provoking situations. Kendall (1990) has developed a workbook, called the Coping Cat Workbook, that can be used in conjunction with the CBT program. Kendall and his colleagues (Kendall, 1994; Kendall & SouthamGerow, 1996) demonstrated the effectiveness of this program with children who had a variety of anxiety disorders; treatment gains were maintained over 1- and 3-year follow-up periods. These techniques were also used in 12 weekly group CBT sessions (Mendlowitz et al., 1999; Silverman et al., 1999) and in a family-based program (Shortt, Barrett, & Fox, 2001). March and Mulle (1995) have developed a manual-based CBT approach for the treatment of OCD, which has received some preliminary support for its effectiveness. Other research indicates that CBT is equally effective for children with comorbid diagnoses as for those with anxiety alone (Kendall, Brady, & Verduin, 2001). Further, adaptations of CBT (including social skills training, peer generalization experiences and in vivo exposure) have been demonstrated to be effective in treating social phobia (Beidel, Turner, & Morris, 2000). In general, factors identified as contributing to less effective treatment are greater parent- and teacher-reported in-

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ternalizing symptoms, higher levels of maternal depressive symptoms, and older child age (Southam-Gerow, Kendall, & Weersing, 2001). Helping children recognize the signs of anxiety during the treatment sessions, and having them do homework outside the therapy sessions, help them practice the newly learned skills. These features plus the involvement of the parents in the treatment increase the likelihood of generalization beyond the treatment sessions. Indeed, most studies using CBT with anxious children have demonstrated that the skills actually improved in the 12 months following treatment (Barrett, Dadds, & Rapee, 1996; Silverman et al., 1999). A recent 6-year follow-up of anxious children treated with CBT found that 85.1% no longer met criteria for any anxiety disorder (Barrett, Duffy, Dadds, & Rapee, 2001). CBT has also been shown to be an effective prevention and early intervention approach for children who exhibit mild to moderate anxiety problems (Dadds et al., 1999). A group CBT program modeled after Kendall’s (1994), which also included a family component, was carried out in a school setting with 128 children and compared to a no-treatment group. CBT was effective in decreasing the development of serious anxiety disorders in a 2-year follow-up; 20% more of the children in the treatment group had few or no problems than those in the notreatment group. Predictors for poor outcome at the 2-year follow-up were more severe initial symptoms. It is interesting, however, that all children showed improvement in anxiety symptoms over time, regardless of their intervention status; this suggests that anxiety in children naturally improves over time (Last et al., 1996). CBT uses a combination of technques and there are few drawbacks in its use, particularly given its effectiveness in groups for both children and parents. This self-management technique does, however, require that the child have certain abilities regarding abstraction, intellect, and memory, and be able to learn data-collecting skills. A relatively high level of self-control is also needed to use the skills independently. Thought Stopping Thought stopping is a self-management technque developed by Wolpe (1958), and although it has little or no empirical support, clinical reports indicate its potential effectiveness. A case report by Campbell (1973) demonstrates the technique as well as its potential power with children. Campbell treated a 12-year-old boy who was experiencing distressing and persistent negative thoughts related to the violent death of a younger sister 1 year earlier. The child spent so much time ruminating about the experience that he stopped eating and sleeping, and performed poorly in school. Campbell trained the boy to evoke a negative thought and then to stop the thought pattern by counting backward from 10 to 1 as rapidly as possible. After counting, the child was to imagine a preselected pleasant scene. The boy was then instructed to use this technique (including a subvocal “No!”) every time he began to think of the negative experience, and to practice it every night before he went to bed. Within 4 weeks the boy was free of the negative thoughts; he was also able to talk about his sister without undue distress. We have found thought stopping to be very effective for children who engage in excessive fantasy about a situation that is out of their control (e.g., wishing divorced parents would reunite or wishing they could move back to an old neighborhood), or who ruminate about a past event to such an extent that it interferes with effective coping (e.g., worrying about an upsetting interaction with a teacher or peer). Some children indicate that they like to think about a particular event or situation to some extent, but they find it difficult to stop these thoughts. Others are afraid that if they stop worrying, the feared event will occur. We have successfully

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decreased the intrusive nature of the worry or unproductive thoughts by having a child worry for a set period of time each day. The child is told, for example, “After school you are to go to your room and think about your parents’ remarrying for 30 minutes.” A timer is used, and the child is told not to engage in any other activity until it rings. If something interferes with doing this (e.g., a Scout meeting), then the child must wait until the next day for the worry time. During the day, children are to observe when they worry, and immediately say “No!” and count backward from 10 to 1. They are to remind themselves that they will have time to worry later and there is no use upsetting themselves now. Furthermore, they are to focus their attention on whatever they are currently doing. We have found that children are soon calling the therapist to ask whether the timer can be set for shorter periods of time! The punishment (i.e., counting backward) appears to decrease the negative thoughts, which then allows more appropriate thoughts to increase. Thought stopping obviously requires high levels of motivation and cooperation on a child’s part.

Intervention with the Parents Parents play an important role in the treatment of a child with an anxiety disorder, since they are usually in the best position to teach and reinforce more adaptive responses on the child’s part. Often parents can effect changes in the child’s behavior simply through gaining a better understanding of the child’s anxious or fearful behavior and learning effective ways to help the child learn to cope with the feared situation. Other parents may actually be contributing to the anxious behavior by reinforcing or punishing it, or having expectations for the child that are too high or too low. Thus their behavior management techniques or parent–child interactions may be the focus for treatment. The parents’ own problems (e.g., depression, anxiety) can also interfere with the child’s treatment, as noted earlier. Any such issues must be identified, and the parents must be helped to deal with them. If there is marital/couple or family conflict, these problems need to be targeted for treatment before the child’s symptoms will improve. Books written for parents of anxious children include Keys to Parenting Your Anxious Child (Manassis, 1996) and SOS! Help for Emotions: Managing Anxiety, Anger, and Depression (Clark, 1996). National resources include the Anxiety Disorders Association of America, 11900 Parklawn Drive, Suite 100, Rockville, MD 20852, 301-231-9350, http://www.adaa.org; and the Obsessive Compulsive Foundation, P.O. Box 70, Milford, CT 06460, 203-878-5669, http://pages.prodigy.com/a/willen/ocf.htm/. The importance of planned, systematic involvement of parents in treatment is demonstrated in a number of studies using CBT for children with anxiety. Barrett, Dadds, and Rapee (1996), for example, described the addition of a family component to a 12-week CBT program for children. The family component emphasized methods for empowering parents and children by forming an “expert team” with them, whereby the parents were trained to reward courageous behavior (verbal praise, privileges, and tangible rewards) and to extinguish excessive anxiety in children (parents listened to initial complaints and then encouraged coping strategies, with no further response to complaints). Parents were also taught to deal with their own emotional upsets, to gain awareness of their own anxiety responses in stressful situations, and to model problem-solving responses to feared situations. At the end of treatment, 84% of the children in the CBT-plus-family-intervention group no longer met criteria for an anxiety disorder, compared to 57% of the children in the CBT-only treatment. Both groups improved further at 6- and 12-month follow-ups, with CBT plus family intervention still superior to the CBT-alone condition (95.6% vs. 71.4%)!

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The importance of involving parents in their child’s treatment was also recently demonstrated in a study of group treatment (Mendlowitz et al., 1999). Children ages 7–12 years with anxiety disorders were assigned to parent-only, child-only, and parent-and-child groups. Treatment took place over 12 sessions, with the parents using the book Keys to Parenting Your Anxious Child (Manassis, 1996). Group exercises, group problem solving, and homework assignments were used to assist parents in teaching and reinforcing their children. Although children in all three groups had significantly reduced anxiety symptoms and improved coping skills, children in the parent-and-child intervention used more active coping strategies. Moreover, parents in this group reported significantly greater improvement in their children’s emotional well-being than did parents in the other conditions. In a similar study, Silverman et al. (1999) had children and parents meet separately for 40 minutes and jointly for 15 minutes for 12 weekly sessions. The 56 children (ages 6–16) in the study were diagnosed with social phobia or either OAD or GAD. Contingency management (see “Changing the Consequences of the Behavior,” below) and contracting procedures were used to facilitate each child’s exposure to increasingly anxiety-provoking situations, followed by cognitive self-control training (Silverman & Kurtines, 1996). At the end of treatment, 64% of the children in the group CBT condition no longer met criteria for an anxiety disorder (compared to 13% on the waiting list), and treatment gains continued to improve, with 76% no longer meeting criteria at the 12-month follow-up.

Intervention in the Environment The environment plays an important part in the development as well as the maintenance of fears. When children’s fears or anxieties become extreme, parents are often inclined to have the child completely avoid the feared situation or stimulus (e.g., to forbid all scary movies or not allow them to participate in certain activities). These actions have the potential to reinforce the fear or anxiety, and also decrease the child’s opportunities to learn how to deal more effectively with the situation. Parents should be helped to set appropriate limits on television, movies, and video games, and to find ways to help the child cope with upsetting information. For example, the parent can sit with the child and comment on certain TV shows, or can describe his or her own fears or anxieties and the methods used to cope with them. Certain environments are more dangerous than others (e.g., low-SES housing projects), and children with excessive fears about their safety or the inherent dangers in those situations can be given a greater sense of control by teaching them what to do and how to protect themselves in dangerous situations. Natural disasters such as hurricanes can cause children to react with symptoms of PTSD or anticipatory anxiety/worry (Shannon, Lonigan, Finch, & Taylor, 1994), which can be very debilitating and interfere with the children’s functioning. The diagnostic criteria for PTSD have been described in connection with child sexual abuse in Chapter 7, but hurricanes and other life-threatening events can result in PTSD as well. After Hurricane Andrew, 30% of 568 children who experienced the storm reported severe or very severe levels of PTSD symptomatology (La Greca, Vernberg, Silverman, Vogel, & Prinstein, 1994; Vernberg, La Greca, Silverman, & Prinstein, 1996). At a follow-up 10 months after this disaster, 12% of the children continued to exhibit severe to very severe levels of PTSD, and 18% of the children continued to experience all three PTSD symptom clusters (reexperiencing, avoidance, and hyperarousal). Children who experienced high levels of support from significant others during the 3 months following the disaster had fewer symptoms, whereas the use of negative coping strategies (i.e.,

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blaming self or others, yelling, screaming, and getting mad) best predicted persistent PTSD symptoms. Thus finding ways to provide social support and to increase effective coping strategies after natural disasters and other traumatic events, as well as recognizing that these will be needed over time, may help these children.

Changing the Consequences of the Behavior Contingency management procedures are based on operant conditioning principles and attempt to alter anxious and fearful behavior by manipulating the external events that follow the children’s anxious/fearful reactions. Contingency management is based on the premise that the acquisition of an approach response to the feared stimulus or fear-producing situation is sufficient, and that anxiety reduction per se is not necessary (Ollendick & King, 1998). Shaping, positive reinforcement, response cost, and extinction are the most frequently used contingency management procedures to reduce phobic behavior. Essentially, this approach involves reinforcing graduated and repeated practice in approaching the actual feared stimulus. These procedures were among the first to be systematically studied in children with phobias and have earned the status of “well-established” (Ollendick & King, 1998). In a study involving 48 children (ages 3–8 years) with water phobias, for example, Menzies and Clarke (1993) demonstrated the effectiveness of reinforced practice alone in comparison to live modeling, live modeling plus reinforced practice, or a control group. It is interesting that the addition of modeling did not add to the effectiveness of reinforced practice. The systematic use of reinforcement involves specifying a target behavior, determining a naturally occurring reinforcer, and making reinforcement contingent on the occurrence of the targeted behavior. It is important that the behavior is readily observable, and that both the child and parent understand how and when the behavior is to be reinforced. It is also important to fade the reinforcement gradually as the target behavior becomes more robust. The use of a chart and token reinforcement system that specifies the desired behavior and the rewards is often the best way to ensure that the reinforcement is given in a systematic manner. For a child who is fearful of the dark, for example, a chart can specify going to bed within a certain number of minutes after being told to do so, not complaining about bedtime, and staying in his or her own bed all night. Points are given for successfully engaging in these behaviors and are traded for desired rewards. The child’s behavior can also be shaped by rewarding successive approximations to the final desired behavior. Reinforcing the child for staying in the feared situation or near the feared stimulus helps the child learn that there is nothing to fear, teaches more adaptive behavior (i.e., the targeted behavior), and reinforces coping strategies. Positive reinforcement is an integral part of almost every treatment program for fears and anxieties, but its effectiveness when used alone should not be ignored, especially when the fear or anxiety is circumscribed. As demonstrated by Barrett, Dadds, and Rapee (1996) and Silverman et al. (1999), teaching parents to use contingency management can make a substantial difference in the effectiveness of other treatment approaches.

Intervention in Medical/Health Aspects Literature reviews on the pharmacological treatment of anxiety conclude that, with the exception of clomipramine and fluoxetine for the treatment of OCD and the benzodiazepines for

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panic disorder, the efficacy of pharmacological treatment for children with anxiety disorders is unclear (Birmaher et al., 1994; King & Bernstein, 2001; Kutcher, Reiter, Gardner, & Klein, 1992). Given the abuse risk and the potential side effects, the use of psychoactive medications in children and adolescents remains controversial (Waterman & Ryan, 1993). Fluoxetine (a selective serotonin reuptake inhibitor) has been shown to be effective with children with DSM-III-R OAD, social phobia, and SAD. In a study with 21 children and adolescents (ages 11–17 years), fluoxetine treatment for up to 10 months was found to provide moderate to marked improvement in anxiety symptoms for 81% of the children (Birmaher et al., 1994). This is of particular interest, in that these children were reported to be unresponsive to previous psychopharmacological and psychotherapeutic interventions, although the nature of these treatments was not specified. Sertraline has recently been shown to be effective in treating social anxiety in some children and adolescents (Compton et al., 2001). Compton et al. found that 5 of 14 children could be classified as “responders” and 4 of 14 as “partial responders”; self-report and behavioral measures of anxiety significantly improved to within the normal range. Despite these promising results, further research is needed because of the small sample size. Children with comorbid depression and anxiety disorders usually have more severe symptoms, and their treatment is more difficult. In an 8-week randomized double-blind trial with 47 adolescents with comorbid anxiety and depression, Bernstein et al. (2000) compared CBT plus imipramine to CBT plus placebo for school refusal. The youth in the CBT-plus-imipramine group had a significantly greater return-to-school rate than the CBT-plus-placebo group (54.2% vs. 27.6%). Anxiety and depressive symptoms decreased significantly in both groups, with depressive symptoms showing a significantly faster rate of decline in the CBT-plus-imipramine group. A follow-up study indicated, however, that a substantial number of these youths continued to meet criteria for anxiety and/or depressive disorders one year after treatment (Bernstein, Hektner, Borchardt, & McMillan, 2001). These data suggest that imipramine might be added to the treatment regimen if the goal is more immediate school attendance, but that monitoring of progress over a relatively lengthy period of time is essential for maximizing treatment effectiveness. In general, given the effectiveness of current behavioral treatments and CBT, these treatments should be the first choice for most phobias or other anxiety disorders. At the present time, only unresponsive cases with severe symptoms should be considered for drug therapy.

Treatment of School Refusal Given that school refusal is associated with a number of the anxiety disorders, and that the formulation of its treatment by Kearney and Silverman (1999; see Table 8.4, presented earlier) is a blueprint for the treatment of not only anxiety disorders but other childhood disorders, a special section is devoted here to its treatment. School refusal can be precipitated by many different factors, such as change of school, death of a parent, illness, hospitalizations, or an accident, as well as academic failure, a mean teacher, bullying by other children, or fear of ridicule or failure. It can be maintained by negative reinforcement of a child’s anxious or avoidant behavior and/or by positive reinforcement for staying out of school (Kearney & Silverman, 1999). Early treatment of school refusal focused little on what maintained the behavior; the treatments of choice were immediate return to school and reinforcement for staying in school (e.g., Kennedy, 1965).

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Although a quick return to school continues to be a top priority in treating this problem, Kearney and Silverman (1999) have demonstrated that treatment based on a functional analysis of the individual child’s behavior can be the most effective way to choose a treatment for the problem. Furthermore, Kearney and Albano (2000) have developed an assessment scale, the School Refusal Assessment Scale (SRAS; Kearney & Silverman, 1993), designed to assess the relative strength of the four functional conditions of school refusal (see Table 8.4). There are versions of the SRAS for the child, mother, and father; when the scores from the respondents are averaged, the most effective treatment can be assigned in accordance with the highest mean SRAS score. Using their functional model of school refusal behavior, Kearney and colleagues have designed prescriptive treatments based on SRAS ratings for each functional condition of school refusal, and these are shown in Table 8.4 (Kearney & Albano, 2000; Kearney & Silverman, 1990). Kearney and Silverman (1999) demonstrated the preliminary validity of this approach with eight children who had acute school refusal. Four children were assigned to prescriptive treatments based on the child and parent SRAS ratings, and four were assigned to nonprescriptive treatment. Treatment with the nonprescriptive methods actually led to increased time out of school and increased ratings of depression and anxiety. In contrast, the prescriptive treatments substantially decreased these problems. The value of this work cannot be overemphasized, given that it gives the clinician a way to determine the most effective treatment approach for a particular child with a particular problem. CBT has also been shown to be effective in treating school refusal (King et al., 1998). The general success of CBT that includes graduated in vivo exposure to the school setting and methods to teach children specific coping skills makes this a seemingly worthwhile treatment for school refusal. Although it is effective, not all of the component parts of the program may be necessary. In a study comparing 12 individual hourly sessions of CBT to 12 hourly sessions of an educational/support group, for example, Last, Hansen, and Franco (1998) found both treatments to be equally effective. Moreover, treatment gains were maintained or increased in both groups at a 4-week follow-up. The children in the educational/support therapy were given information to help them overcome their difficulties in attending school, but they were not given direct instructions to return to school, nor were they taught specific coping strategies. Supportive therapy involved encouraging the children to talk about their fears and helping them distinguish among fear, anxiety, and phobia. The information presented appeared to give the children the tools to approach school gradually, and being able to identify maladaptive thinking (but not how to modify it) was enough to encourage them to use more adaptive coping. Thus the specific structured approach to school reentry used in CBT did not seem to be necessary. In fact, the high dropout rate in the CBT treatment condition (16%) suggests that children in the education/support group were more comfortable in determining their own rate of school reentry. These results also indicate, however, that the school refusal of these children may have been primarily negatively reinforced (decrease of anxiety by avoiding school) rather than positively reinforced (reward for staying out of school).

CASE EXAMPLE: SCHOOL REFUSAL Step 1: Initial Contact Kenny, age 7, was referred by his pediatrician after complaints of leg paralysis, stomach pains, and headaches were found to have no organic basis. These psychosomatic complaints had begun

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2 weeks prior to the initial contact, and Kenny’s parents, Mr. and Mrs. Shy, were having great difficulty in getting him to go to school, although the doctor had reassured him that he was fine. Kenny and his mother were seen the day after the initial contact, and thus questionnaires were not completed prior to the first interview.

Step 2: Parent and Child Interviews Parent Interview Kenny and his mother were seen together for the initial interview. Mrs. Shy presented as a warm, nurturing person who was obviously very worried about her son and said that she still wondered whether his pains had a physical basis. She stated that she was a full-time wife and mother, and that her husband was a university professor. Kenny was the youngest of three children, with a brother age 10 and a sister age 13. Mrs. Shy indicated that neither of her other children had exhibited any unusual fears or anxieties, but that she herself was always hesitant to join new groups and preferred being with her family and close friends. She stated that all of the children (including Kenny) did well in school, were involved in after-school activities, and had satisfactory relationships with friends. Kenny, however, tended to enjoy a small circle of friends and had always been reluctant to play with unknown children. Up until this time, Kenny had been healthy, was currently taking no medications, and had not taken any medication for the past 7 weeks. Shortly before the referral, the family had moved two blocks into a larger home. Everyone was pleased with the location, and Kenny had his own room for the first time, which he said he enjoyed. When asked whether any other events had recently occurred in the family, after some thought the mother recalled that 3 weeks ago, she had gone to the hospital for day surgery to remove a cyst. She felt that perhaps Kenny’s problems had begun at that time and had progressively gotten worse. Currently he became upset at bedtime, saying that he did not want to go to school in the morning. He was also having difficulty getting out of bed in the morning (he said he couldn’t walk, his stomach had shooting pains, and his head hurt). After the physical examination, Mr. and Mrs. Shy had tried to insist that he go to school. Kenny’s teacher had recommended that Mrs. Shy stay with Kenny for a half hour in the morning and return to have lunch with him every day. This worked fairly well the first week, but during the second week it seemed to make matters worse; Kenny clung to his mother when she tried to leave the class in the morning, and the teacher said that shortly before lunch, he became agitated and worried that his mother might not show up. In the last week, Mrs. Shy had stayed three afternoons in his classroom helping the teacher. Although the mother reported no other behavioral or emotional problems for Kenny, she and Mr. Shy were asked to complete the General Parent Questionnaire, the BASC, and the PSI. Mrs. Shy was also given a Daily Log and Specific Events Causing Concern chart to keep track of Kenny’s behavior for the following week. The BASC scores were within the normal range on all scales except for the Anxiety scale, which was significantly elevated. The scores on the PSI indicated that Kenny’s parents saw him as an easy-going child who was very reinforcing to the parents but significantly overly attached to the mother. Child Interview Kenny easily separated from his mother, who indicated she would wait in the waiting room, and readily engaged in activities with the clinician. He drew a picture of himself and was asked

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to show where he hurt. He chose a red crayon to illustrate a hot, burning pain in his leg when he awoke in the morning; a green crayon with red streaked through it to show his stomach pain; and a black crayon to show the pain in his head. He said he had these pains only in the morning and then, as an afterthought, said he also felt some of them when he went to bed at night. He was not sure when and how the pains went away, but he was not feeling them at the present time. He said he enjoyed his teacher, liked his classmates, and usually got all A’s and B’s in school. However, he said he had not been able to do much work in the last 2 weeks, because he felt so bad and only felt good when his mother was in school with him or when he was home. Kenny was helped to complete the State–Trait Anxiety Inventory for Children (Spielberger, 1973), which indicated very high scores on the Trait Anxiety scale. In other words, Kenny was a child who tended to react to a variety of stimuli with an anxious or fearful response. Kenny said that he wanted to go to school and he couldn’t explain it, but he just felt awful when he left home. He had no trouble going to Boy Scouts or Little League.

Step 3: Observation of Behavior The Daily Log that the mother kept over the next week indicated only minor complaints about going to school, but anxiety when Kenny did not know where his mother was going to be or when she went out at night. Kenny was pleasant during the interview with his mother, but chose to sit on the floor beside his mother and to play independently with toys. He exhibited no observable signs of anxiety, even when specific fear situations were discussed and questions about his behavior were directed to him.

Step 4: Further Assessment The Roberts Apperception Test for Children was administered. Kenny’s responses to this measure indicated a child with high anxiety and poor coping skills.

Step 5: Referral to Allied Health Professionals No referral to another health professional was needed, as Kenny had been seen by his pediatrician recently.

Step 6: Communication of Findings and Treatment Recommendations Given the nature of Kenny’s problem of school refusal, a treatment plan was developed during the initial interview. Mrs. Shy and Kenny were told that although more information needed to be gathered, it was important for everyone to help Kenny feel better as soon as possible. The clinician reviewed Kenny’s many strengths and indicated that it was not unusual for some children his age to have worries or scary feelings about leaving home, especially after a move or when someone in the family had been in the hospital. The clinician communicated optimism about resolving the problem, with some effort on everyone’s part. It was strongly recommended that Kenny be helped to get back to school as soon as possible. Kenny and his mother agreed to a reward system that specified the steps to get back to school, and rewards for completing these steps (see Figure 8.1). Kenny thought it would be hard to get all the points, but he was willing to try, and Mrs. Shy was relieved to have a specific plan of action. Kenny was to go to school as usual on the school bus; his mother was not to accompany him or have lunch with

Behavior

Pts. 1

Eating breakfast and being ready for the bus on time

1

No crying or fussing when leaving for school

2

Staying in school all day

1

Happy day report from teachers

1

Report on two good things that happened in school

1 1

No tears or fussing at bedtime

1

BONUS

1

Total points Possible points per week

Tuesday

Wednesday

Thursday

Friday

Sun. Nite

10 50

1st Prize 85% (43–50) _________ (Dinner out, friends spend the night, or go to movie with friends) 2nd Prize 75% (38–42) _________ (Rent video) 3rd Prize 65% (33–37) _________ (Trip to frozen yogurt shop) FIGURE 8.1. A record chart for a reward system in the treatment of school refusal. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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Getting up in the morning when called without fuss

Monday

300

Going Back to School Chart

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him; and he was to return home on the bus. Mrs. Shy agreed to ask the teacher, who had been quite supportive thus far, to keep Kenny in school. If he was too sick to remain in class, he was to be sent to the nurse’s office until the end of the day. Points for engaging in the appropriate behavior were exchanged each week for having friends spend the night and family activities that Kenny thoroughly enjoyed (e.g., dinner out, a picnic in the park, etc.). All of the steps were carefully written down and agreed upon by both Kenny and his mother. Mrs. Shy was told to call the clinician if she had any difficulty in getting Kenny to school. She felt that her husband would help, and Kenny indicated that he “could make it.” The clinician agreed to call Mrs. Shy the following evening to make any necessary changes in the program. After the initial interview, the clinician called Kenny’s pediatrician to share her findings and recommendations.

Course of Treatment Kenny returned to school the next day, and within a week was earning all of his points on the chart. He said that he was feeling a lot better. It was clear from the assessment data, however, that Kenny would benefit from further treatment. Both parents were asked to come in for a feedback session. In this session, the parents were told that Kenny was a child who obviously had many strengths, particularly a warm and loving relationship with his family; however, he also appeared to be prone to react to various stimuli in an anxious manner. Given the many stresses of childhood, it was recommended that he enter into some preventive treatment that would help him learn to cope with these stresses more effectively. Specifically, he would be helped to identify a wide range of emotional responses and the situations in which these emotions occurred; to develop skills to cope effectively with his anxious or fearful responses, especially in response to separation from his family; and to become more self-sufficient. The parents agreed with this recommendation, and in subsequent sessions Kenny was taught problemsolving skills. (These are illustrated in Chapter 14, Table 14.1.) Mrs. Shy also agreed to two sessions to discuss how she might best prepare Kenny for new situations, in order to prevent anxious behavior in the future. She was advised to inform him of events well ahead of time; to allow him to engage in increasingly mature and independent behavior; to encourage more activities apart from the family; and to present a rather casual “I know you can do it” response, rather than a concerned or solicitous one. Kenny responded well to this treatment approach, which was carried out over the next 4 weeks. Not unexpectedly, he returned to the clinic at age 10 when his grandfather died, and at age 12 when he was about to enter junior high school. On the first occasion, his mother requested the appointment because she could see that Kenny was having a difficult time with the death and was becoming increasingly clingy. On the second occasion, Kenny asked for the appointment on his own. Treatment at each of these times consisted of three to six sessions, focused on his developing age-appropriate coping skills. Kenny indicated that stresses were getting easier for him to manage, given that he was more aware of when he was beginning to feel anxious or fearful and was developing a number of techniques to deal with these situations (relaxation, self-instruction, modeling of peers).

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CHAPTER 9

Depression

A

fter years of controversy about whether or not it is possible for preadolescent children to experience depression, professionals have finally agreed that some young children do indeed suffer from this problem. Moreover, they exhibit symptoms that are strikingly similar (although not identical) to those of adolescents and adults with depression, dispelling the myth that depression is “masked” in the juvenile population (Milling, 2001). Research in the area of childhood depression has increased dramatically in the last 20 years, but substantial questions about its nature, causes, and treatment remain. Although relatively rare, childhood depression is a very complex disorder, as reflected in the extent to which its presentation is influenced by developmental factors, the degree to which it is associated with other disorders, and the negative and long-lasting impact it has on all areas of psychosocial functioning (Geller, Zimerman, Williams, Bolhofner, & Craney, 2001). As Kazdin and Marciano (1998) note, “Depression, from our perspective, consists of a pervasive disorder that encompasses diverse characteristics and domains of functioning well beyond mood-related symptoms” (p. 212). Although the functioning of children who experience depression can be significantly impaired in many different areas, a majority of these children do not come to the attention of mental health professionals (Wu et al., 1999). Moreover, for those who do receive mental health services, few treatments have been empirically validated for effectiveness, safety, and practicality (Kaslow & Thompson, 1998). One of the most difficult problems in the area of childhood depression is definitional. The term “depression” can describe a wide variety of manifestations. It is often used to denote either a single symptom (i.e., depressed mood or sad affect), or a cluster of symptoms (behaviors and emotions, including depressed mood) that reflect several clinically significant disorders described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSMIV; American Psychiatric Association [APA], 1994; Compas, 1997). Clearly, how depression is defined influences our interpretation of the epidemiological research, as well as our understanding of the nature, etiology, and course of this disorder. Thus this chapter begins with a discussion of issues related to the definition and classification of childhood depression. Its comorbidity with other disorders, as well as its prevalence, developmental course, associated features, and etiology, are then reviewed. Finally, issues related to its assessment and treatment are discussed.

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DEFINITION AND CLASSIFICATION DSM-IV does not include depression in the disorders of childhood. Rather, it is encompassed in the section on adult mood disorders. Kazdin and Marciano (1998) cite research indicating that the criteria for diagnosing adult depression are valid for use with children. They note, however, that irritability is more likely than depressed mood to be seen among depressed children, and that suicidal behavior (ideation, attempts) is rare among children, although it increases dramatically in adolescence. Moreover, children are more likely to present with somatic complaints, separation anxiety, phobias, increased guilt, low self-esteem, and behavior problems than are adolescents or adults (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996; Hooks & McCauley, 1998). Symptoms most common at different ages are summarized in Table 9.1. The depressive disorder that most often applies to children is major depressive disorder (MDD) or a subclinical form of MDD. According to DSM-IV, a formal diagnosis of MDD requires one or more episodes of at least 2 weeks during which the child evidences a change in functioning that includes depressed mood and/or irritability; the loss of interest or pleasure in most activities; or both of these symptoms. In addition, the child must experience at least four of the following symptoms nearly every day and must evidence significant impairment in important areas of functioning: (1) significant loss of weight or failure to gain weight as expected; (2) sleep disturbance (insomnia or hypersomnia); (3) psychomotor retardation or agitation; (4) fatigue or decreased energy; (5) worthless feelings or inappropriate or excessive guilt; (6) lessened ability to think, concentrate, or make decisions; and (7) recurring thoughts about death, suicidal ideation, a suicide attempt, or a specific plan for committing suicide (APA, 1994). In addition to MDD, the presence of bipolar I disorder (BPD) among children is currently receiving considerable research interest. BPD is a mood disorder characterized by one or more manic episodes, which include three or more of the following symptoms: (1) grandiosity or excessive self-esteem; (2) lessened need for sleep; (3) unusual talkativeness; (4) racing thoughts; (5) distractibility; (6) psychomotor agitation or increase in goal-directed activity; and (7) excessive engagement in high-risk pleasurable activities, including hypersexuality not associated with sexual abuse (APA, 1994; Geller et al., 2000). A diagnosis of BPD may be given after a single manic episode occurs, but manic episodes usually alternate with major depressive episodes as described above, or with so-called “mixed” or “hypomanic” episodes (APA, 1994). BPD is difficult to diagnose in children because of its very low frequency; because the symptoms of a manic episode are similar to those of attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD); and because there are developmental differences in the manifestation of BPD. Hooks and McCauley (1998) note that children with BPD frequently present with labile (rather than persistent cyclical) changes in mood and activity level, and that they are more likely to be irritable and belligerent than euphoric. Reckless or driven behavior often takes the form of behavior problems typical of CD, such as school problems, fighting, dangerous play, and sexual acting out. Moreover, grandiosity can be difficult to distinguish from childhood fantasy and imaginary play. DSM-IV provides several other diagnostic categories that include depressive symptoms, are applicable to children, and should be considered in making a diagnosis of childhood depression. These are summarized by Kazdin and Marciano (1998).

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TABLE 9.1. Developmental Phenomenology of Childhood Depressive Symptoms Preschoolers (2–5 years)

Early elementary school age (6–8 years)

Middle school age (9–12 years)

Adolescence (13–18 years)

• Lethargy • Feeding and sleep disturbances • Irritability • Sad or expressionless faces • Decreased affective responsivity • Decreased attention • Decreased curiosity • Increased frowning and crying • Increased clinging

• Lethargy • Feeding and sleep disturbances • Irritability • Anger • Sad facial expression • Labile mood • Somatic complaints • Excessive crying • Hyper- or hypoactivity • Decreased socialization • Tantrums • Separation anxiety • Anhedonia (lack of interest in daily activities) • Aggression • Somatic complaints • Increased clinging

• • • • • • • • •

• Lethargy • Irritability • Expressions of hopelessness and self-deprecation • Low self-esteem • Depressed mood • Sad expression • Aggression • Guilt • Poor school performance • Phobias • Separation anxiety • Suicidal ideation • Hallucinations • Self-destructive behaviors • Somatic complaints • Enuresis

• • • • •

Note. The data are Schwartz, Gladstone, and Kaslow (1998).

• • • •

Lethargy Sleep problems Irritability Prolonged unhappiness Poor school performance Accident-proneness Phobias Separation anxiety Attention-seeking behaviors Decreased socialization Somatic complaints Enuresis Psychomotor agitation

• • • • • • • • • •

Somatic complaints Social withdrawal Hopelessness Irritability Expressions of pessimism, worthlessness, and apathy Increased suicide attempts Substance abuse Eating disorders Antisocial behavior Restlessness Temper tantrums Running away Anhedonia Hypersomnia Weight change (loss or gain)

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Infants and toddlers (0–24 months)

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• Dysthymic disorder (DD). DD is characterized by at least 1 year of depressed mood or irritability that occurs most of the day and on most days. DSM-IV requires two or more of the following symptoms: (1) overeating or poor appetite; (2) sleep disturbance (insomnia or hypersomnia); (3) fatigue or decreased energy; (4) low self-esteem; (5) poor concentration or indecisiveness; and (6) feelings of hopelessness (APA, 1994). • Cyclothymic disorder. Cyclothymic disorder involves less severe symptoms of a depression and mania that do not meet criteria for MDD or BPD. Symptoms must be present for at least 1 year, and the child must not be symptom-free for 2 months at a time. • Separation anxiety disorder. Many of the symptoms of depression (sadness, sleep disturbance, social withdrawal) may appear as part of fear of separation from loved ones (see Chapter 8). • Substance-induced mood disorder. Depressive (or manic) symptoms may occur as a result of drug abuse, medication, or exposure to toxins. • Adjustment disorder with depressed mood. Depressive symptoms may occur in reaction to specific psychosocial stressors (divorce, serious illness, school failure, etc.). • Bereavement. Bereavement is similar to adjustment disorder with depressed mood, but specifically related to loss of a loved one. Symptoms must remain well beyond the usual period of adjustment (see Chapter 14). Although many disorders seen in youth clearly involve depressive symptoms, the fact remains that MDD, and depression that resembles MDD but does not meet full DSM-IV criteria for it, are the forms of depression most commonly seen in children. Therefore, the term “depression” is used in the remainder of this chapter to mean either of these two forms unless otherwise specified.

GENERAL CHARACTERISTICS OF DEPRESSION Comorbidity Depression has one of the highest rates of comorbidity with other psychiatric disorders (Kovacs, 1996; Milling, 2001). In their review, Kazdin and Marciano (1998) state that estimates of comorbidity rates are typically about 40–50%, but can be as high as 80–95%. Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al. (1996) note that childhood depression is most commonly associated with anxiety disorders (30%–80%); with CD, oppositional defiant disorder, and ADHD (10–80%); and, in adolescents, with substance abuse (20–30%). With the exception of substance abuse, these high percentages have led to questions about whether these disorders are truly separate and distinct, or merely reflect the fact that many symptoms of depression overlap with those of anxiety disorders, CD, and ADHD. Anxiety Disorders Research that examines the comorbidity of depression and anxiety through factor-analytic methods has focused on this question (Joiner & Lonigan, 2000; Murphy, Marelich, & Hoffman, 2000; Seligman & Ollendick, 1998; Wadsworth, Hudziak, Heath, & Achenbach, 2001). Taken together, this work indicates that anxiety and depression share a component called “negative affect,” but also have distinct features. “Pure” anxiety disorders are characterized by chronic

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high arousal, whereas “pure” depressive disorders are characterized by chronic low positive affect or anhedonia. Stark, Humphrey, Laurent, Livingston, and Christopher (1993) were able to distinguish depressed from anxious children on the basis of their negative cognitions. Children with depression expressed a more negative view of themselves, the world, and the future than did those with anxiety. Another distinguishing feature is that anxious children express more symptoms describing worries, especially about future events and competence (Laurent, Landau, & Stark, 1993). In a recent review, Seligman and Ollendick (1998) state that although risk factors do not differentiate anxiety and depression (indeed, with the exception of a family history of depression, they tend not to be specific to any particular type of psychopathology), anxiety typically precedes the onset of depression. They speculate that chronic anxiety may actually cause depression through its impact on the psychosocial functioning of the child, although they are careful to note that there is not yet sufficient empirical evidence to support this idea. Consistent with this work, Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al. (1996) note that MDD is most likely to emerge after the appearance of any comorbid disorder, with the exception of substance abuse. Conduct Disorder Considerable evidence supports the argument that children with comorbid MDD and CD represent a distinct etiological group (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996; Harrington, Rutter, & Fombonne, 1996). Birmaher and colleagues note that when compared with children who are depressed without conduct problems, these youngsters tend to have poorer short-term outcomes, fewer recurrences of depression, more suicide attempts, a greater likelihood of criminal behavior in adulthood, and a favorable response to placebo versus antidepressant medication. Moreover, the conduct problems exhibited by these children tend to persist even after the episode of depression has remitted. Meller and Borchardt (1996) found that children with MDD alone could be differentiated from those with a combination of MDD and CD on the basis of several factors. First, anxiety tended to occur significantly more often in MDD alone than in MDD plus CD. Second, children with MDD and CD were more likely than those with MDD alone to have witnessed family violence, to have engaged in illegal behavior, to be impulsive, and to have first-degree relatives who had substance use disorders. Meller and Borchardt (1996) suggest that the presence of anxiety may moderate symptoms of CD—a conclusion that is consistent with research on the comorbidity of conduct problems and anxiety (Walker et al., 1991; see Chapter 10). Attention-Deficit/Hyperactivity Disorder As described in DSM-IV, ADHD and depression share some symptoms, suggesting that they may not be distinct disorders. In a recent review of studies examining the comorbidity of depression and ADHD, however, Faraone and Biederman (1997) concluded that the co-occurrence of these two disorders was not due to overlap in symptomatology. It is not clear, however, whether the two have a common etiology, as ADHD and depression both have clear genetic components and common family-related risk factors (although these risk factors tend not to be specific for any type of psychopathology). Faraone and Biederman (1997) speculate that the differences between ADHD with and without depression may be due to nonfamilial environmental circumstances (e.g., social and academic failure, life stress). The reader is referred to Chapter 11 for further discussion of ADHD.

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Bipolar I Disorder Although BPD is not usually comorbid with childhood depression, between 6% and 31% of depressed youngsters eventually develop BPD (Hooks & McCauley, 1998; Kovacs, 1996). It typically develops after two to four major depressive episodes and within 4 years of the onset of depression (Kovacs, 1996). Higher rates of BPD are found in those with more severe and persistent depressive symptoms. Three features have been identified that may predict eventual onset of BPD: (1) rapid and early onset of depression, accompanied by psychomotor retardation and psychotic features; (2) a strong family history of mood disorders, especially BPD; and (3) hypomania in response to antidepressant medication (Kovacs, 1996; Strober & Carlson, 1982). The comorbidity of BPD and the attention-deficit and disruptive behavior disorders (especially ADHD; see Chapter 11) is extremely high, and the distinction between these disorders is difficult to make (Chang, Steiner, & Ketter, 2000; Weller, Weller, & Fristad, 1995). Wozniak and her colleagues (Wozniak, Biederman, Kiely, et al., 1995; Wozniak, Biederman, Mundy, Mennin, & Faraone, 1995) reported that 94% of two different samples of preadolescent children with BPD also met the criteria for ADHD. This high rate of co-occurence is not surprising, since there is considerable overlap between the symptoms of the two disorders— specifically, hyperactivity and distractibility. Moreover, episodes of mania closely resemble the symptoms of ADHD. Wozniak, Biederman, Kiely, et al. (1995) noted that all of the children in their sample with both BPD and ADHD manifested clinical features of both disorders. These included comorbid MDD, psychosis, poor functioning, and hospitalization for BPD, and disruptive disorders, tic disorders, multiple anxiety disorders, and learning disabilities for ADHD. Moreover, Wozniak, Biederman, Mundy, et al. (1995) found significant comorbidity between BPD and ADHD among the relatives of children with BPD. They concluded that the comorbidity between the two disorders was “real” as opposed to “spurious” (i.e., based on overlap in symptoms), and that many children with BPD may also meet criteria for a diagnosis of ADHD, although they often may be misdiagnosed because of the similarity of the two disorders. Geller et al. (2000) recommend that the diagnosis of BPD include elation and/or grandiosity as features of mania, in order to differentiate BPD from ADHD. Chang et al. (2000) suggest the need to consider antecedent conditions in the diagnosis of BPD, since it is often preceded by conduct problems and/or ADHD. Indeed, they cite the risk factors for development of BPD as including attentional and behavioral problems (plus a parent with BPD). Although children with mania present with many of the same symptoms as children with ADHD, a chronic (ADHD) versus episodic (mania) course, relative absence of abnormally expansive or elevated mood and psychotic features in ADHD, and family history (50% of children with mania present with a positive family history of depression, whereas no such relationship exists for ADHD) are the clinical features most useful for differentiating ADHD from mania. The Mania Rating Scale (Young, Biggs, Ziegler, & Meyer, 1978) is also helpful in differentiating the two conditions in preadolescent children (Fristad, Weller, & Weller, 1992). Children with mania receive significantly higher total scores on this measure than do those with ADHD, and there is virtually no overlap between the two groups (i.e., children with mania receive scores of 14–39 on the MRS, whereas children with ADHD receive scores of 0–12).

Dysthymic Disorder Comorbidity between MDD and DD is very high, and when the two occur together, it is often called “double depression.” DD is thought to be a precursor or risk factor for MDD. As many

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as 70% of children with DD go on to develop MDD within 2–3 years after the onset of DD (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996). Moreover, the co-occurrence of MDD and DD is a good predictor of the number of recurrences and the persistence of depression into adulthood. In contrast to the work regarding co-occurrence of depression with anxiety disorders, CD, and ADHD, Goodman, Schwab-Stone, Lahey, Shaffer, and Jensen (2000) argue that there is not sufficient empirical data to view MDD and DD as separate disorders. They found that children with MDD and DD did not differ on sociodemographic, clinical, family, and life events variables, and concluded that children with both MDD and DD are simply more severely impaired than those with one or the other diagnosis. Regardless of whether these various comorbid disorders represent separate problems, it is clear that children with depression and one or more co-occurring problems have a much more negative prognosis than those who manifest depression alone (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996). Depressed children with comorbid conditions are at increased risk for longer duration and greater recurrence of depressive episodes; more suicide attempts; and poorer functioning, response to treatment, and utilization of mental health services. Indeed, Kazdin and Marciano (1998) note that the critical issue in understanding childhood depression is not comorbidity per se. Rather, the presence of subclinical symptoms that reflect other disorders but may not meet clinical criteria for diagnosis is a key issue. Steele, Armistead, Forehand, and the Family Health Project Research Group (2000) suggest that these subclinical symptoms may be particularly important in the assessment and treatment of African American children, providing clues to the need for early intervention for depression. Subclinical symptoms that may be indicators of depression include distortions in cognitive processes, problems with social relations, academic dysfunction, and other school problems (e.g., truancy, grade repetition, and not doing homework) (Kazdin & Marciano, 1998).

Prevalence Estimates of the prevalence of MDD in community samples range from 0.4% to 2.5% for preadolescents and from 0.4% to 8.3% for adolescents (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996), but have been noted to be as high as 30% in community samples (Compas, 1997). Rates for DD are similar, ranging from 0.6% to 1.7% for children and 1.6% to 8.0% for adolescents. The prevalence of other depressive disorders among children, including BPD, is extremely low. Although depression appears to be a relatively rare disorder among children, its prevalence increases with age, with as many as 20% of preadolescents and 65% of teenagers reporting subclinical symptoms of depression (Achenbach, 1991a; Hook & McCauley, 1998) and as many as 30% with symptoms of major depression or dysthymia (Falment, Cohen, Choquet, Jeammet, & Ledoux, 2001). Moreover, there is a lifetime prevalence of 15–20% for adolescents and adults. It is likely that these rates underestimate the actual prevalence of depression in children, for several reasons. First, many children show significant internalizing symptoms and impairment of functioning, but do not meet formal criteria for a diagnosis of MDD. Second, self-reports of depression provide much higher estimates of the numbers of children who are suffering than do parent or teacher reports. Finally, the actual diagnosis of depression in children is very difficult because of developmental differences in its presenta-

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tion. Recent reviews (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996; Kazdin & Marciano, 1998) note that the prevalence rates for mild and moderate depressions are increasing, and that depressive disorders are being diagnosed at younger ages. The cause of this increase is not known, but Birmaher and colleagues (1996a) speculate that it is due to environmental (e.g., changes in lifestyle, increased stresses) rather than genetic factors.

Developmental Course Schwartz, Gladstone, and Kaslow (1998) review the developmental phenomenology of depressive symptoms in infancy and childhood (see Table 9.1). They note that despite the fact that distressed infants are incapable of self-reflection, they exhibit symptoms that are remarkably similar to those of older depressed children and adults. These features resemble those described by Bowlby (1981) and Spitz (1946) in their observations of infants separated from their primary caregivers or housed in a severely deprived environment. Depression is difficult to diagnose during the preschool years, because these children cannot yet verbalize their feelings or inner experiences, and there is a lack of reliable and valid measures for assessment (Kashani, Allan, Beck, Bledsoe, & Reid, 1997; Schwartz et al., 1998). Parents may notice symptoms, but tend to report them to pediatricians rather than mental health professionals. Kashani et al. (1997) found that by using a combination of sources of information (parents, teachers, child selfreport, and observation) they were able to successfully diagnose depression in 2- to 6-yearolds. Moreover, Mesman and Koot (2000a) found that teacher reports (based on the Teacher’s Report Form of the Child Behavior Checklist [CBCL-TRF]; Achenbach, 1991b) of problems in the affective, social, and academic areas for 4- to 5-year-old children predicted depression at age 10–11 years. It is interesting that parents’ ratings on the parent version of the CBCL were not predictive of later depression in their children. Depression in the early elementary school years is often expressed through behavior problems, whereas older preadolescents may begin to verbalize feelings of low self-worth and hopelessness. Suicidal behavior begins to increase at this age, but sleep and eating problems are less likely than in younger or older children. School and peer relationship problems are common after the age of 6. The onset of MDD is reported to be most likely after age 10 years; the modal age of onset is 11–12 years (Kazdin & Marciano, 1998; Milling, 2000). Earlier onset for less severe depression (i.e., DD) is noted, with the modal age of onset about 7–8 years (Milling, 2000). In childhood, boys and girls appear to be at similar risk for depression, whereas adolescent girls are at least twice (and perhaps as much as five times) as likely to develop MDD as are adolescent boys (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996; Kazdin & Marciano, 1998). Moreover, adolescent girls are more likely to experience more severe depression and are at greater risk for recurrence of depressive episodes than boys (Hooks & McCauley, 1998). However, Kovacs (2001) reported no evidence for gender differences in either symptoms or course of depression in a clinic referred sample of children aged 11 years through the adolescence. The short-term prognosis for children with depression is relatively good. Episodes of MDD are typically short-lived, lasting between 5 and 9 months, and over 90% of cases of MDD have remission within 1–2 years (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996; Kovacs, 1996). In contrast, episodes of DD last much longer, with an average length of about 4 years.

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In contrast to the short-term outlook, the long-term prognosis for childhood depression is guarded at best. Kazdin and Marciano (1998) note that even when a depressive episode remits, children are likely to continue to experience subclinical symptoms of depression. Moreover, the relapse rate for children who have had one depressive episode is very high, and this rate increases with the number of recurrent episodes experienced. Estimates of rates of recurrence range from 40% within 2 years to as high as 70% within 5 years (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996; Kazdin & Marciano, 1998; Kovacs, 1996). Most children who experience at least one recurrence of depression can be expected to continue to experience depression during adolescence and adulthood. Indeed, Harrington et al. (1996) reported that 84% of clinic-referred children with an operationally defined depressive syndrome, as compared to only 44% of children without such a syndrome, evidenced a similar syndrome as adults. They note, however, that the converse is not true; the majority of adults with depression do not have a history of childhood depression. The presence of any comorbid condition increases the risk of persistent depression and significant impairment later in life. Other predictors of recurrence and degree of impairment include early onset, severity of symptoms, a parental history of depression, and multiple stressors in the home.

Associated Features In addition to the primary depressive symptoms, children with depression often evidence a constellation of associated problems. Because these are important for assessment and treatment, they are briefly reviewed. Suicide The rate of suicide is relatively low among young children; among 5- to 14-year-olds it is estimated to be 0.5 per 100,000 in the United States (National Center for Health Statistics, 1992). Suicide attempts are fairly frequent, however, with rates estimated at 14.4 attempts for every completed suicide in 10- and 11-year-olds (Andrus et al., 1991). Moreover, as many as 32% of children and adolescents with depression have attempted suicide. Studies have shown that children who evidence suicidal ideation and attempts are at high risk for repeated attempts even if they receive treatment (Pfeffer, Hurt, et al., 1994), and the majority (68%) of these make more than one attempt (Kovacs, Goldston, & Gatsonis, 1993). Children who have more severe depressive symptoms are at greatest risk. In a follow-up study of child psychiatric inpatients, Pfeffer, Hurt, et al. (1994) found that those who were treated with antidepressants for longer periods of time were in fact at highest risk of suicide attempts. Childhood depression is also a risk factor for adult suicide. Harrington et al. (1994), for example, found that 32% of their sample of 60 depressed children attempted suicide at least once during adulthood, compared to 12% of the nondepressed psychiatric controls. Moreover, 63% of those who attempted suicide once made at least one further attempt. CD was also a risk factor for adult suicide, but not when it was comorbid with depression. Factors not associated with increased risk of suicide were gender, race, socioeconomic status (SES), and childhood anxiety. Other work indicates that some combination of impulsivity, low self-esteem, child abuse and neglect, high levels of turbulence in the home, and parental models for self-destructive behavior may increase the likelihood of suicide in children (McDowell & Stillion, 1994).

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Suicide also tends to run in families. Pfeffer, Normandin, and Kakuma (1994) have cited a concordance rate of 17.7% for monozygotic twins versus 0% for dizygotic pairs. Moreover, these researchers found that among children who had attempted suicide, 50% of the mothers had also done so. They also found very high rates of antisocial personality disorder, assaultive behavior, and substance abuse among first-degree relatives (primarily fathers) of children who had either thought about or attempted suicide. This work indicates that suicidal behavior and conduct problems should be assessed in parents of depressed children. School and Academic Problems Although school and academic problems are not specific to childhood depression, it is not surprising that depressed children often present with these difficulties. It is not known whether school problems are antecedents or consequences of depression, however. Considerable work has documented a variety of memory and information-processing impairments among adults with depression (Lauer et al., 1994). Less work has been done with children, but Garber and Kaminski (2000) cite studies demonstrating deficits in complex reasoning and problem-solving tasks. Lauer et al. (1994) demonstrated memory deficits (i.e., immediate recall and metamemory) in depressed children. Depressed children were also more likely to overestimate their memory abilities. Furthermore, Lauer et al. found that severity of depression was significantly associated with the occurrence of these deficits. This work suggests that the school and academic problems actually may be caused by the depression via reduced cognitive skills. But, clearly, poor school performance is likely to exacerbate preexisting depression as well. Peer Relationships There is a clear association between peer relationships and depression. Depressed children are more likely to be rejected by their peers, are perceived as less likable, and have more negative social behaviors than their nondepressed peers (Schwartz et al., 1998). The relationship between these two factors is somewhat circular, however (Ollenburg & Kerns, 1997). That is, depression can interfere with the formation and maintenance of friendships; conversely, rejection by peers and other social problems can conceivably cause or exacerbate symptoms of depression. The results of longitudinal studies suggest that children experience poor peer relations before they become depressed. Vernberg (1990), for example, found that less closeness to a friend and more peer rejection predicted increases in depressive symptoms over time in young adolescents. Similarly, Kupersmidt and Patterson (1991) reported that rejection by peers in second grade predicted depressive symptoms in girls 2 years later. There is also evidence that the association between peer relations and depression is different for boys and girls. Ollenberg and Kerns (1997) found that unpopular fifth- and eighthgrade girls were more likely to evidence depressive symptoms than were unpopular boys, whereas poor friendship quality was equally predictive of depression for boys and girls. Although the direction of effects was not assessed, these results suggest that girls place more value on being popular than boys do. Other work with younger children is consistent with these results (Bowen, Vitaro, Kerr, & Pelletier, 1995). Taken together, this work highlights the importance of close friendships for children’s emotional adjustment and suggests that the association between peer relationship problems and depression may be different for girls and boys.

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Cognitive Distortions Considerable work with adults has consistently documented a negative attributional bias that differentiates those who are depressed from those who are not. Other work suggests that negative attributional biases are also present among depressed children (Garber & Kaminski, 2000; Schwartz et al., 1998). Moreover, longitudinal studies indicate that these cognitive distortions remain even after a depressive episode has remitted (e.g., Nolen-Hoeksema, Girgus, & Seligman, 1992). Taken together, this work clearly indicates that childhood depression is associated with low self-esteem, high self-criticism, a perceived lack of control over negative events, and negative styles of interpreting information and coping with stress (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996). Dodge (1993) presents a comprehensive review of the work on cognitive distortions and concludes that they are found in all phases of information processing among depressed children. Moreover, he demonstrates that children with depression and children with conduct problems consistently show different styles of cognitive distortion. For example, depressed children attend to and recall negative self-referent words more than positive words, whereas the opposite pattern is true for nondepressed children. In contrast, children with conduct problems are biased toward attending to and encoding hostile cues, and tend to interpret neutral information as hostile. Other work has identified a style of coping called “learned helplessness” (Seligman, 1975) that characterizes individuals with depression. Learned helplessness includes lack of persistence and motivation, passivity, the inability to generate effective solutions for problems, and a pessimistic attitude regarding the ability to cope. Moreover, individuals with learned helplessness tend to believe that they are responsible for negative events, whereas responsibility for positive events is attributed to external sources (Abramson, Metalsky, & Alloy, 1989). Several reviews have concluded that attributional style and depression are strongly associated in children (Dodge, 1993; Gladstone & Kaslow, 1995; Joiner & Wagner, 1995). Those with internal, global, and stable attributions for stressful or negative events are more likely to be depressed. Similarly, higher levels of depressive symptoms are associated with external, unstable, and specific attributions for positive events. Longitudinal studies indicate that when this attributional style is persistent, it may predict the onset of depression when the child experiences a stressful life event (Dodge, 1993). Moreover, there is some evidence that this attributional style may be specific to depression, rather than characteristic of many different types of psychopathology (Dodge, 1993). It is not clear how learned helplessness and other cognitive distortions develop, and whether they precede or are consequences of depression. Parenting style is thought to play an important role. Nolen-Hoeksema, Wolfson, Mumme, and Guskin (1995) demonstrated that the severity and persistence of mothers’ depression was related to increased hostility and criticism in interaction with their children. Moreover, children whose mothers were more seriously depressed were more likely to exhibit behavior consistent with learned helplessness. Other work indicates that the learned helplessness style is persistent across childhood, and is associated with problems in several domains (e.g., lower school achievement, less popularity with peers, and increased depressive symptoms) (Nolen-Hoeksema et al., 1992; Pettit, Dodge, & Brown, 1988). It seems obvious that early and persistent parental criticism or rejection plays an important role in the development of cognitive distortions, but it is likely that other factors are important as well. Dodge (1993), for example, suggests that “the origins of these mental processes include both early environmental experiences and genetic or acquired biological predispositions” (p. 579).

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Etiology Genetic Factors Although the role of environment cannot be dismissed entirely, considerable evidence indicates that depression in children is highly heritable. Depression clearly runs in families, and close relatives of individuals with depression are more likely to have the disorder than unrelated individuals (Jones, Forehand, & Neary, 2001; Kazdin & Marciano, 1998). In general, children of depressed parents are three times more likely to experience depression at some point during their lifetimes than are children of nondepressed parents (Wickramaratne, Greenwald, & Weissman, 2000). The risk of depression in offspring increases when both parents are depressed and when parents have early-onset and recurrent episodes of depression (Mufson, Weissman, & Warner, 1992; Warner, Mufson, & Weissman, 1995). In a recent review of genetic research, Eley (1999) estimated an effect size ranging from 0.5 to 0.7, depending on the informant; higher estimates of heritability were found for self-reports than for parental reports. Other work suggests that genetic factors may be more influential in adolescent-onset than in childhood-onset depression (Thapar & McGuffin, 1994). Shared environment (i.e., environmental factors that make individuals look more similar) is thought to play a negligible role in the etiology of depression, except in very severe cases (Eley, 1999; but see Thapar & McGuffin, 1994). Nonshared environmental factors (e.g., differences in the way parents treat one child vs. another), however, are significant contributers to the variance in measures of depression (Eley, 1999). Kendler (1995) suggests that individuals at high genetic risk (i.e., those with depressed parents) may be more vulnerable to environmental risk factors than those with low genetic risk. In their review, Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al. (1996) argue that what may be inherited is a vulnerability or predisposition to depression, and that environmental stressors are required for the expression of the disorder. Since adolescents, in general, typically experience more stress (concurrent and cumulative) than younger children, this would explain the higher estimates of heritability for these older youngsters. Biological Factors Several biological markers have been found to differentiate adults with depression from nondepressed adults. These include hyposecretion of growth hormone, dysregulation of the hypothalamic–pituitary–adrenal axis, dysregulation of the serotonergic function, and sleep disturbance. In general, however, the results of research examining these markers in depressed children have been inconsistent (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996; Milling, 2000). Current theories view depression as a disorder of emotional regulation that is exacerbated during periods of intense stress. Indeed, Dawson, Hessl, and Frey (1994) cite research indicating that depressed adults evidence permanently elevated levels of cortisol. Despite the inconsistency of data on biological markers of depression for children, Dawson et al. (1994) present an intriguing theory of the influence of these and other possible biological factors in the development of childhood depression. They argue that early environmental experience (including intrauterine) may have an impact on the biochemistry and microarchitecture of the developing brain—in particular, the frontal lobe, which is important in the regulation and expression of emotion. Critical periods for the development of depression in children are thought to be during pregnancy and between 6 and 18 months of age. Mothers who are depressed during pregnancy, for example, may expose the fetus to an abnormal hormonal and physiological environment, as well as influences from other risk factors (such as

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malnutrition, smoking, or drug use). The results of research on neonatal infants with depressed mothers provides support for this idea. These infants tend to be less active, less socially responsive, and fussier than neonatal infants of nondepressed mothers (Field et al., 1985; Zuckerman, Als, Bauchner, Parker, & Cabral, 1990). Moreover, somewhat older infants of depressed mothers are more withdrawn, are less active, have diminished positive affect, and have difficulty sustaining attention and interest in challenging tasks (Field et al., 1985; Zahn-Waxler, Cummings, McKnew, & Radke-Yarrow, 1984). Significant differences between depressed and nondepressed mothers in mother–infant interactions have been clearly documented (e.g., Carter, Garrity-Rokous, Chazan-Cohen, Little, & Briggs-Gowan, 2001; Field, 1992; see Kaslow, Deering, & Bacusin, 1994, for a review). Moreover, as early as 3–6 months of age, infants of depressed mothers consistently demonstrate higher arousal indicating greater stress reactions (i.e., increased heart rate and decreased vagal tone) when they are interacting with their mothers. Most interestingly, this pattern persists when the infants of depressed mothers are paired with nondepressed strangers (Field et al., 1985). Behavioral observations do not differentiate infants of depressed mothers from those whose mothers are not depressed. Dawson et al. (1994) argue that infants of depressed mothers experience social interaction as stressful even when they appear less expressive outwardly. Moreover, they suggest that this chronic experience of stress/arousal during infancy results in “ontogenetic sculpting” of neural networks; that is, brain synapses are systematically eliminated or enhanced on the basis of experience. The period of 6–18 months is thought to be a critical period, because it is the time when attachment relationships and emotional regulation develop. Moreover, it appears to be a time of especially rapid growth of the frontal lobe (Chugani, 1994). At this age, Dawson et al. (1994) suggest that infants may be more vulnerable to the influence of their mothers’ depression, resulting in an increased likelihood of insecure attachment. It is interesting that maternal depression during this period is predictive of behavior problems and lower intellectual functioning in preschool children, even when the mothers’ depression has remitted prior to the preschool years (Sharp et al., 1995; Wolkind, Zajicek-Coleman, & Ghodsian, 1980). Family Factors Numerous factors related to family functioning have been associated with childhood depression. Various reviews of these factors (Birmaher, Ryan, Williamson, Brent, Kaufman, Dahl, et al., 1996; Kaslow et al., 1994; Kazdin & Marciano, 1998; Schwartz et al., 1998) cite evidence that children are more likely to experience depression when their parents are divorced and/or they live with a single parent; when they come from low-SES environments; and when they experience a very high number of negative life events, especially losses. Moreover, families of depressed children are characterized by increased levels of parent–child conflict, and especially by marital/couple conflict around child-rearing issues. Mothers who are depressed perceive their children to be more difficult to parent than nondepressed mothers do. They have also been shown to have problematic parenting styles, including difficulties in the communication and expression of affect; inconsistent and negative disciplinary methods; and increased controlling, critical, and rejecting interactions with their children. Sibling relationships also appear to be important in understanding childhood depression. Although sibling relations among depressed children are generally characterized as poor (Kaslow et al., 1994), good relations with a brother or sister may mediate the effects of other risk factors on the development of depression (Cicirelli, 1989; Huntley & Phelps, 1990).

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Despite considerable research on the associations between childhood depression and family variables, it is not clear that any of these factors are specific to depression. That is, they appear to be risk factors for the development of many different types of psychopathology (Goodman et al., 1998). Thus they are important to assess, but do not necessarily contribute to our understanding of the etiology of depression per se. A Transactional Model A transactional perspective provides a framework for integrating many of the factors described previously to explain the development of depression in children (see Chapter 1). Cicchetti and Toth (1998), for example, conceptualize depression as a heterogeneous condition that may be reached by a multitude of developmental pathways involving the ongoing interplay among characteristics of the child, family (especially the primary caregiver), and environment. Thus diverse outcomes may result from the same set of risk factors, and, conversely, the same outcome may result from very different variables. Like Dawson et al. (1994), Cicchetti and Toth (1998) suggest that homeostatic regulation (e.g., affect regulation, attention, and arousal) very early in infancy may have important implications for later development in many diverse areas (e.g., attachment relations, self-system, peer relations). In this regard, they suggest that difficult temperamental characteristics may set the stage for deviant development in infants. Indeed, for infants of depressed parents, difficulties in homeostatic regulation are seen as early as the neonatal period. This, in combination with a parent whose caregiving skills are compromised by depression, leads to the formation of an insecure attachment relationship; it may also play a role in the development of the cognitive distortions that are characteristic of depressed youngsters. Dodge (1993) argues that cognitive distortions are important in the etiology of depression, in the sense that they may precipitate a depressive episode in an already vulnerable child. As the child grows and develops, these early difficulties on the part of both the parent and child are compounded; in the presence of environmental risk factors, they are likely to result ultimately in the development of psychopathology, including but not limited to depression. The important point for the clinician is that although the various risk factors may not be specific to any one type of psychopathology, they are important for assessment because they provide clues as to the potential focus of treatment.

ASSESSMENT It should be evident from the review presented above that the assessment of depression in children is a difficult but very important process. It is difficult because parents may not recognize the seriousness of their child’s problems or, conversely, may overstate them. Moreover, the lack of agreement among parents, teachers, and children on measures of depression is considerable. Although it is critically important for clinicians to use multiple methods to gather information from multiple sources, this process typically results in having to reconcile very discrepant information from the different informants. Renouf and Kovacs (1994) suggest that the child’s age and the presence of maternal depression should be taken into account when integrating inconsistent information. Older children are more reliable reporters than younger children; self-report measures are not helpful before the age of about 8 years. Consistent with a generally negative outlook among depressed adults, if the mother is depressed herself, she is likely to overstate the child’s symptoms regardless of the child’s age. Other types of maternal

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psychopathology do not seem to have the same effect. Other factors, such as SES, gender, and the child’s social-cognitive and verbal abilities, do not seem to be related to agreement between mother and child (Renouf & Kovacs, 1994). Many checklists, rating scales, and structured and semistructured interviews are available for assessing depression in children. The interested reader is referred to Milling (2000), Kazdin and Marciano (1998), and Compas (1997) for comprehensive reviews of these instruments. Diagnostic interviews such as the Child Assessment Schedule (Hodges, Cools, & McKnew, 1989) or the Diagnostic Interview Schedule for Children, Version IV (Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000) are helpful in arriving at a DSM diagnosis, but there are several reasons not to use them (Schwartz et al., 1998): (1) They require extensive training in order to be used effectively; (2) they are time-consuming to administer; (3) children younger than 10 years are not reliable informants; and (4) there is little agreement between information obtained from parents and child. We follow the Comprehensive Assessment-to-Intervention System (CAIS) framework presented in Chapter 2, which enables the clinician to gather the necessary information systematically and efficiently. The CAIS framework as applied to assessment of depression is outlined next.

Step 1: Initial Contact At the time of the initial referral, parents should be asked to complete general questionnaires (e.g., our General Parent Questionnaire; see Appendix B) giving demographic information and their perception of the problem. A standardized questionnaire specific to child problems, such as the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992), allows the clinician to judge the severity of the child’s problem(s) relative to other children the same age. The BASC has scales for both Depression and Anxiety, which make it the instrument of choice in screening for depression. Furthermore, its Adaptability scale can be helpful in determining the child’s ability to adapt to changes in the environment. The CBCL (Achenbach, 1991a) has a single Anxious/Depressed scale, and thus it does not differentiate between anxiety and depression. Rather, it provides a measure of the severity of internalizing problems in general (Wadsworth, Hudziak, Heath, & Achenbach, 2001). The items reflecting loneliness and withdrawal, but not depressed mood, appear to be the most accurate. It is important to have both parents complete each measure, as there are often significant differences between a mother’s and father’s perceptions of the severity and frequency of a child’s problems. This is particularly true when one or the other parent is depressed. Parents of children under age 12 years should complete the Parenting Stress Index (PSI; Abidin, 1995) to provide information about the marital/couple relationship, parental depression, child temperament, and life stresses. Abidin and colleagues (Abidin & Brunner, 1995; Abidin & Konold, 1999) have developed a parent questionnaire called the Parenting Alliance Inventory, which is designed to assess the aspect of the marital/couple relationship most specifically related to parenthood and child rearing (see Chapter 13).

Step 2: Parent and Child Interviews Parent Interview During the initial contact, the clinician can decide whether the child should be included in the interview with parents. In general, however, it is probably best to see a depressed child sepa-

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rately (Hooks & McCauley, 1998). It is important that both parents attend the initial interview whenever possible, since (as noted above) a father and mother often have very different perceptions of a child’s problems. The parent interview necessarily covers a great deal of information, and the clinician should allow 1½ to 2 hours for this first appointment. The following areas should be assessed: 1. Developmental history and current status. The clinician should focus on the child’s early development, particularly in regard to issues of temperament. Although it is important to keep in mind that depressed mothers typically perceive their infants as being more difficult (Mayberry & Affonso, 1993), it is not known whether this is because their infants truly are more difficult to care for or because the mothers are depressed. Specifically, negative affect, high or low threshold of arousal, high activity level, and physiological irregularity are important. Specific questions about the presence or absence of symptoms listed in Table 9.1 that are associated with the child’s age should be asked. If a DSM-IV diagnosis of MDD is of concern, the clinician should ask parents whether or not their child exhibits the DSM-IV symptoms listed earlier in this chapter. Does the child, for example, complain that nothing goes right, no one understands, or there is nothing right about him- or herself? Does the child exhibit enthusiasm for anything? Does the child have trouble making decisions? Is the child proud of anything? Does the child appear tired or sluggish? The child’s early and current medical history should also be explored, with particular attention paid to any medications the child may be taking that might induce depressed affect. Furthermore, parents should be asked about any changes in sleep or eating patterns, and especially changes in weight (gain or loss, or failure to gain normally for younger children). Questions focused on the extent to which the child’s functioning is impaired in different areas (e.g., sibling and peer relations, school and academic work) are also important. Preliminary information about these areas can be obtained from the General Parent Questionnaire, and any concerns should be followed up during this interview. Documentation of any possible comorbid conditions is essential in dealing with depression. Information gathered from the BASC can provide a starting place for this process. It is especially important to ask about symptoms of ADHD, anxiety, disorders, CD, and BPD, to differentiate these problems from depression. 2. Parent and family characteristics. Information gathered from the screening instruments can provide a basis for discussion of these issues. If, for example, parental depression or marital/couple conflict appear to be problems, these should be addressed specifically. If the mother or father is currently depressed or has had depression in the past, it is important to determine the age of onset, as this is a good predictor of the potential prognosis for the child; in particular, early-onset depression in mothers predicts the persistence and severity of child depression. In addition to asking about any suicidal behavior exhibited by the child, specific questions should be asked about suicide, suicide attempts, and suicidal ideation in the parents or close relatives as this is closely related to child suicidal behavior. The presence of other forms of psychopathology (especially antisocial personality disorder or substance use disorders) in the parents or close relatives also should be queried. 3. Parenting styles and techniques. General information about the parents’ attitudes and expectations for themselves as parents and for their children informs the clinician about aspects of the parent–child relationship that will influence the parents’ abilities to follow through with treatment. The clinician should be particularly alert for indications of overly high expectations, excessive criticism, and lack of positive reinforcement. Asking parents about their own parenting history is often illuminating.

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4. Recent and ongoing stresses. A simple question such as “Has anything happened in your family lately that might be related to your child’s problems?” often reveals important information. Early or recent onset of negative life events—especially those involving loss of a loved one—is an important area to address, as these may have precipitated the onset of depression. Furthermore, ongoing chronic stresses (e.g., financial problems, stressful family relationships, etc.) have an important influence on the child’s affect and mood. Finally, the parents should be asked about sources of support that are available to themselves and to the child. Child Interview An interview with the child alone is essential in assessing depression. The form and content of this interview will obviously depend on the child’s age and/or developmental level. The basics of a general child interview are described in Chapter 2, and these can be adapted to include greater emphasis on emotions. Specific questions should be asked about suicidal ideation and behavior, as parents often are not aware of this. The clinician can also observe a child of any age for symptoms of tearfulness/crying or experiencing normal situations as overwhelming or aversive. If the child is over 8 years of age, it is useful to have him or her complete a general rating scale such as the BASC Self-Report of Personality, as well as a more specific scale such as the Children’s Depression Inventory (CDI; Kovacs, 1992). The CDI is the most widely used selfreport measure for childhood depression, and its psychometric properties are described in Appendix A. The scale should be completed on two separate occasions about 1–2 weeks apart, to differentiate persistent from transient depression (Compas, 1997). A new self-report measure called the Internalizing Symptoms Scale for Children (ISSC; Merrell & Walters, 1998) shows better reliability over time. The ISSC consists of 48 items that fall into two factors: Negative Affect, which reflects both anxiety and depression, and Positive Affect, which is specific to depression (Michael & Merrell, 1998). Self-esteem should be assessed with a measure such as the Self-Perception Profile for Children (Harter, 1983b) for ages 8–12 or the Piers–Harris Children’s Self-Concept Scale—Revised (Piers, 1985) for ages 8–18 years (see Appendix A). The assessment of self-esteem in preschool children is difficult, and there are few if any acceptable measures. Fantuzzo, McDermott, Manz, Hampton, and Burdick (1996) reported that the Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (Harter & Pike, 1984) lacked construct validity, and that the majority of the 4-yearolds they tested did not understand the concepts necessary to respond to the items appropriately and accurately. In addition to these measures, the child should be instructed on how to keep a daily Mood Diary on which mood (happy, mad, sad, etc.) is rated on a 10-point scale from 1 = “very little” to 10 = “a lot,” along with notes about specific stressors or daily hassles (Figure 9.1). This diary gives the clinician information about day-to-day changes in mood and about events that may particularly bother the child; it also provides a way of evaluating progress in treatment. A Daily Activities Diary (see Figure 9.2) provides baseline information about the child’s typical activities and indicates where changes need to be made (e.g, increasing pleasurable or social activities, decreasing use of video games or other solitary activities).

Step 3: Observation of Behavior Direct observation of the parent–child interaction is always useful. For younger children, the situation described in Chapter 10, in which parents and child play together as they would at

Mood Diary

Experiences: Pleasant = P, Unpleasant = U

Time

Where I was

How I felt (happy, mad, sad); 1 = very little, 10 = a lot

What I said to myself

What I did

Sample Kids teased me U

8 A.M.

At school

Sad

8

I am so dumb, nobody likes me

Went to class and read a book

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FIGURE 9.1. Mood Diary for assessment of childhood depression. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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Saturday Day ______________

Time

Where was I?

What was I doing? Sample

Morning

At home

Sleeping

Afternoon

At home

Playing video games

Evening

At home

Watching TV

Day ______________

Time

Where was I?

What was I doing?

Where was I?

What was I doing?

Where was I?

What was I doing?

Where was I?

What was I doing?

Morning Afternoon Evening Day ______________

Time Morning Afternoon Evening Day ______________

Time Morning Afternoon Evening Day ______________

Time Morning Afternoon Evening

FIGURE 9.2. Daily Activities Diary for assessment of childhood depression.

From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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home, is suitable. For older children, a problem-solving task is appropriate (Garber & Kaminski, 2000). Parents and child independently complete a checklist of common sources of conflict, such as doing homework, completing chores, enforcing curfews, or fighting with siblings. The clinician then chooses one or two areas of conflict indicated by both parents and child, and asks them to discuss and resolve the situation. Observation of this interaction does not need to involve formal coding, but should focus on the extent to which the family expresses positive versus negative affect, level of criticism or praise, problem-solving skills, and conflict resolution.

Step 4: Further Assessment A teacher interview is a critical component of assessment for childhood depression. Teachers’ ratings of depression are often more accurate than those of parents, for several reasons (Mesman & Koot, 2000b). First, teachers, unlike parents, rarely have psychopathology that would interfere with their objective perception of the child. Second, teachers can compare the child’s behavior to that of many other children the same age, which enhances their ability to notice deviance. Third, teachers have more opportunity to observe social and academic problems, and these are often good indicators of depression. Permission to contact the teacher should be obtained during the parent interview, and the BASC—Teacher Report Form (Reynolds & Kamphaus, 1992) should be sent out. The use of this measure allows comparison of parents’ and teacher’s ratings of the child. The Internalizing items on the CBCL-TRF (Achenbach, 1991b), however, have been shown to correspond to children’s self-reports of depression both concurrently and predictively (Mesman & Koot, 2000a, 2000b). Mesman and Koot also found that the Externalizing items “demands attention,” “jealous,” and “screams” were related to child depression. Social and school-related behaviors of note included “fails to finish assignments,” “difficulty learning,” “is teased,” and “is not liked.” An interview with the teacher, either in person or by phone, should be scheduled to follow up on this information. Psychoeducational evaluation is indicated if the child is experiencing academic problems; this should include evaluation of intellectual as well as academic functioning. Depending on the nature of the individual child’s specific problems, further assessment of associated features may be useful. The many child self-report measures focused on these areas are reviewed by Kazdin and Marciano (1998). Since feelings of hopelessness are strongly associated with suicidal behavior, however, this might be an area to target specifically (Callahan, Panichelli-Mindel, & Kendall, 1996). The Hopelessness Scale for Children was developed to assess whether children view future positive events as likely (Kazdin, Rodgers, & Colbus, 1986; see Appendix B). Scores on this measure are correlated with depression, suicidal ideation and behavior, and low self-esteem. Attributional style can be assessed with the Nowicki–Strickland Locus of Control Scale for Children (Nowicki & Strickland, 1973). Parents can also be asked to complete questionnaires such as the Dyadic Adjustment Scale (Spanier, 1976; Spanier & Thompson, 1982) and the Beck Depression Inventory—II (Beck, Steer, & Brown, 1996) to further assess marital/couple relations and parental depression. These measures are described in Appendix A.

Step 5: Referral to Allied Health Professionals Depending on the severity of the child’s depressive symptoms and the family history of depression, the clinician should refer the family to an appropriate professional for assessment of a possible medication trial if this is relevant. Furthermore, the clinician should be alert to the

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possibility that ADHD or anxiety is present along with depression; if this is the case, the comorbid disorder will also need to be addressed in treatment. If the child has not had a recent physical examination, he or she should be referred to the pediatrician to rule out medical conditions that are associated with depressed affect, such as endocrine disorders, chronic infectious states, chronic inflammatory diseases, and neurological conditions affecting the central nervous system. Finally, if either parent is experiencing depressive symptoms and is not already receiving treatment, he or she should be referred to a psychiatrist.

Step 6: Communication of Findings and Treatment Recommendations The clinician’s relationship with the family begins with the first contact, but the interpretive interview, when the evaluation findings are explained, is very important. As long as the parent–child relationship is reasonably good, this interview should include both parents and the child. The clinician’s understanding of the nature, etiology, and severity of the child’s depression, as well as potential treatment approaches, should be discussed. A clear understanding of these issues, as well as how the depression fits into the child’s developmental picture, will help the parents and child begin to trust the clinician and maximize the possibility of their cooperation with treatment. Some discussion of the prognosis for the child’s problems is also warranted, although this must be done carefully to avoid creating or exacerbating a sense of hopelessness in either the parents or the child. When there is a strong family history of depression, the genetic implications of the disorder may be discussed. Moreover, the recurrent nature of depression should be stressed, along with the need for ongoing (and perhaps even lifelong) treatment.

TREATMENT Treatment of childhood depression is obviously complex and difficult. Most approaches to intervention with children have been derived from those found to be successful in treating adults with depression. The effectiveness of these approaches for children, however, has not been documented empirically. In general, research indicates that youth treated with various approaches show improvement relative to control groups, but no differences between treatment methods have been found (Kaslow & Thompson, 1998). Moreover, most studies do not include clinic-referred children, so it is not known whether these treatments are effective with more severe depression. Stark et al. (1996) suggest that treatment of childhood depression is often not successful in part because, as in treatment of an adult, the child is often the sole focus of treatment. They argue that because of developmental factors, intervention with depressed children must also target the children’s environmental setting (e.g., parents and family) and psychosocial stressors (e.g., peer rejection, school problems). Research that examines factors related to a poor response to treatment is consistent with this argument. Poor response is associated with severity of depression; comorbid conditions, especially anxiety; lack of support for parents and child; parental psychopathology; high levels of family conflict; high rates of stressful life events; and low SES (Birmaher, Ryan, Williamson, Brent, & Kaufman, 1996; Geller, Todd, Luby, & Botteron, 1996). In summarizing the results of the treatment effectiveness literature, the authors of several recent reviews have concluded that (1) some treatment is better than no treatment, and (2) approaches that are successful for adults are probably the best place to start (Birmaher,

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Ryan, Williamson, Brent, & Kaufman, 1996; Kazdin & Marciano, 1998; Milling, 2000). Successful treatment involves combinations of methods, multiple targets, and higher-“dose” (i.e., longer rather than shorter-term) treatments. Moreover, when comorbid disorders are present, these must be targeted specifically; clinicians should not assume that they will be alleviated as the depression is treated. Clinicians also must consider the high probability of relapse and incorporate maintenance interventions into their treatment plans. Indeed, Kazdin and Marciano (1998) argue that treatment for childhood depression is best conceptualized in terms of either (1) a “continuing care” model, in which the acute problem is treated, and then intervention is modified to provide maintenance rather than terminated; or (2) a “dental care” model, in which the initial episode is treated and the child returns for “checkups” every 3 months or so, with further treatment as necessary. With this in mind, we now present specific methods for intervention with the child and parents, and in the environmental and medical areas. Finally, recent efforts at prevention of depression among high-risk children are discussed.

Intervention with the Child Treatment of a child with depression can be provided individually or in a group setting. Both approaches have advantages and disadvantages, and many intervention programs include both. In individual therapy, the clinician has a better opportunity to understand the child’s unique issues, thoughts, and feelings; in the group setting, the child can practice new skills and behaviors with peers. The following approaches are among the most common used in treatment with a depressed child. Each will have to be adapted to fit the individual child’s developmental level. Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) focuses on the child’s persistent cognitive distortions. The behavioral aspect targets increasing pleasurable activities and changing specific response repertoires. CBT has been shown to be somewhat more effective than traditional counseling in reducing depressive symptoms in non-clinic-referred children older than 9 years (Kaslow & Thompson, 1998). Stark et al. (1996) describe a comprehensive CBT program for depressed children. Specific components of this program include the following: 1. Affective education. The child is taught about the nature and functions of emotions, and the link among thoughts, feelings, and behavior. The goal is to use emotions as a cue to use coping strategies. Various games about feelings can be used (e.g., the Talking, Feeling, Doing Game; available from Creative Therapeutics, 155 County Road, Cresskill, NJ 07626; see also Stark, 1990). With younger children, we jointly create a “feelings book,” consisting of various activities related to understanding and controlling feelings. For example, each emotion has its own page, on which the things that make a child feel that way (mad, sad, happy, etc.) are listed. Pictures reflecting each emotion are drawn or cut out of magazines and pasted on the page. Ways of coping with negative emotions are discussed. 2. Activity planning. The child’s positive experiences are increased through the scheduling of pleasurable activities. These can be discussed and planned during the child’s session, and parental permission and support are obtained later. 3. Problem solving. The child is helped to develop a problem-solving approach to life, and is taught specific problem-solving skills (identifying the problem, generating alternative

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solutions, evaluating the possible consequences of each alternative, choosing one solution to try, and enacting the plan). 4. Social skills training. As another means of decreasing maladaptive behavior, the child is taught such skills as assertiveness, communication, conflict resolution, and accepting and giving feedback. 5. Self-instructional training. The child is taught to self-monitor thoughts and feelings, and to use self-talk to alter automatic negative thoughts (e.g., “I can do this” vs. “I am no good at this”). Programs in self-instructional training described by Meichenbaum (1977) and Kendall (1994) are widely used. 6. Relaxation training. The child is taught relaxation techniques combined with positive imagery as a way of coping with difficult situations. 7. Cognitive restructuring. The child is helped to change negative self-evaluations and cognitive distortions by self-monitoring pleasant events and emotions, setting reasonable goals and standards, challenging misattributions, and learning more adaptive thought processes. CBT is obviously most appropriate for older children; indeed, no studies reported in the literature thus far have included children under the age of 9 years. However, we have found that with adaptations, some components of CBT can be used with younger elementary school children.

Intervention with the Parents A recent review (Asarnow, Jaycox, & Tompson, 2001) indicated that family-focused interventions for childhood depression have both advantages and disadvantages. Among parents who participate, most routinely express satisfaction with brief family interventions and demonstrate increased knowledge of childhood depression. On the other hand, there is little data to support the effectiveness of family interventions on reducing children’s depressive symptoms, and they are often cited as a reason for refusal of treatment. Because individual treatment is less likely to be effective for preschool and early elementary school children, intervention for a young child is best focused on helping the parents change the child’s environment (Barrett, Dadds, & Rapee, 1996). Observation of parent–child interaction should indicate whether the parents would benefit from parent management training. The parent training program used in our clinic is described in detail in Chapter 10. Many aspects of the program are appropriate for parents of depressed children, including the focus on increasing the child’s experience of positive interactions with parents, increasing parents’ use of positive reinforcement, and teaching them positive approaches to discipline. Parent management training tends to reduce parent–child conflict and may also decrease depressive symptoms in parents. Other targets for intervention with parents include anger control training, for those who have difficulty controlling their own emotions, communication and negotiation skills; and problem-solving skills (Stark et al., 1996). Finally, there are several national organizations that may be helpful for parents. These include the Child and Adolescent Bipolar Foundation, 1187 Wilmette Avenue PMB#331, Wilmette, IL 60091, 847-256-8525, http://www.cabf.org; the National Depressive and Manic–Depressive Association, 730 North Franklin Street, Suite 501, Chicago, IL 60610, 800-826-3632, http: //www.ndmda.org; the Depressive and Related Affective Disorders Association, Meyer 3-181, 600 North Wolfe Street, Baltimore, MD 21287-7381, 410-955-4647, http://www.med.jhu.edu/ drada; and the National Foundation for Depressive Illness, P.O. Box 2257, New York, NY 10116, 800-248-4344, http://www.depression.org.

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Intervention in the Environment School consultation is likely to be necessary in working with depressed children and can be a very effective method of treating depression in children. Moreover, school-based interventions are becoming increasingly popular, in part because this is often the only intervention available to some children (Wu et al., 1999). Teachers, counselors, and other personnel can be made aware of the child’s problems, and their assistance with the child’s treatment program can be solicited. Possible interventions include temporarily reducing the demands of the academic program; providing additional support and encouragement for completing assignments; encouraging the child to use the coping skills taught during his or her therapy sessions; and helping the child think positively about situations in the classroom or with peers (Stark et al., 1996). Periodic monitoring of the child’s progress through teacher rating scales should be built into the child’s program, and feedback should be given to the teacher as appropriate.

Intervention in Medical/Health Aspects The decision to refer a child for possible medication treatment of depression is a difficult one. Various factors must be considered, including the severity, persistence, and recurrence of the child’s symptoms; the child’s response (or lack of response) to psychosocial interventions; the probability that the child and parents will be compliant with medication instructions (this is a major problem with depressed adolescents!); the presence of comorbid conditions, such as ADHD and anxiety, that might respond to medication; the cost–benefit ratio in terms of potential main effects versus side effects; and the parents’ and child’s feelings about medication (Hughes et al., 1999). Sommers-Flanagan and Sommers-Flanagan (1996) propose the following guidelines for referring a child for medication: (a) The youth is depressed despite the absence of clear environmental determinants (e.g., family conflict, divorce, etc.); (b) the depressive symptoms are severe and have strong physiological components (e.g., sleep disturbance, somatic complaints, appetite changes and associated weight loss or gain); (c) treatment response is lacking after 10 to 15 sessions of psychotherapy, family therapy, or cognitive-behavioral therapy: and (d) the patient expresses a clear preference for medication treatment over psychosocial interventions. (p. 151)

Pharmacological treatment of children with depression has increased dramatically since the introduction of the selective serotonin reuptake inhibitors (SSRIs; e.g., fluoxetine [Prozac], sertraline [Zoloft], paroxetine [Paxil]). Indeed, prescriptions for SSRIs written for children under the age of 5 years increased over 500% between 1996 and 1997 (Hoar, 1998)! Unfortunately, this practice is not based on research demonstrating the effectiveness of these medications for children (Eisenberg, 1996; Wagner & Ambrosini, 2001). Double-blind, placebo-controlled studies of the tricyclic antidepressants (TCAs; e.g., imipramine [Toframil]) typically report a response rate between 60% and 80%, but no difference between placebo and medication (Birmaher, Ryan, Williamson, Brent, & Kaufman, 1996). Birmaher and colleagues speculate that developmental factors (e.g., differences in the rate at which these drugs are metabolized, or differences in the manifestation of depression in children) may account for their effectiveness with adults but not with children. These authors also note that blood plasma levels of these drugs may have to be carefully monitored in order to ensure a positive response. Research with the SSRIs is more promising than that with TCAs, but is not yet sufficient to serve as a basis for strong recommendations (see Wagner & Ambrosini, 2001, for a review). Nonethe-

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less, a consensus conference was held recently to develop guidelines for physicians’ use of drug treatment for children with depression (Hughes et al., 1999). These guidelines provide stepby-step decision trees that provide for the systematic evaluation of medication trials. Clinicians who collaborate with medical professionals in their work with depressed children should make sure that these professionals receive a copy of these guidelines.

Prevention Although prevention programs for childhood depression have not received much attention in the professional literature, there are indications that this is a potentially promising area. Children at high risk for depression can be identified on the basis of many factors, including a genetic predisposition as indicated by a strong family history of depression, and family risk factors (e.g., parental depression, low SES, or parental substance use disorders) (Kazdin & Marciano, 1998). Furthermore, specific developmental periods that increase the risk for the onset of depression in vulnerable youngsters have been identified. These include late childhood to early adolescence, when the prevalence of depression increases substantially; and times of transition, such as school entry, when the demands on a child may increase beyond his or her ability to cope. In general, research that involves school-based intervention programs indicates that although any type of treatment (e.g., CBT, problem solving) may be effective, the intervention must be relatively intense (i.e., many sessions over a long period of time) in order to be effective in preventing depression (Clarke et al., 1995; Jaycox, Reivich, Gillham, & Seligman, 1994). Intensive treatment may provide an “inoculation” effect, wherein the participants continue to improve after treatment has ended (Jaycox et al., 1994). Little work has addressed the other end of the developmental spectrum (i.e., infants and depressed mothers), although this too is a promising area of research, in part because of the documented negative effects of postnatal depression on children’s development (e.g., Sharp et al., 1995). Hart, Field, and Nearing (1998), for example, examined the effectiveness of a brief prevention program for mothers experiencing postpartum depression. The intervention consisted of having the mothers watch administration of the Neonatal Behavioral Assessment Scale (Brazelton & Nugent, 1995) shortly after their infants were born, while the clinician commented on the infants’ responses and skills. The mothers were then taught to administer a parent version of this scale, the Mother’s Assessment of the Behavior of Her Infant (Field, Dempsey, Hallock, & Schuman, 1978), and were instructed to administer the test at 1-week intervals for 1 month. At 1 month of age, the infants in the intervention group were found to perform more optimally in the areas of social interaction and state organization than the control infants. Although the long-term effectiveness of this simple intervention is not known, it shows promise as a costeffective method that may provide a base for the accumulation of positive effects. Other work in this area indicates that intervention must be relatively intense, targeting multiple aspects of the parenting process (Gelfand, Teti, Seiner, & Jameson, 1996); again, however, the possibility of an inoculation effect with very young children is interesting and warrants further research.

CASE EXAMPLE: SUBCLINICAL DEPRESSION Step 1: Initial Contact Mrs. Silver called regarding her 9-year-old daughter, Julie, who had increasing complaints about not having friends, anxiety about her performance in school, and a general level of

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unhappiness. The family had been seen previously when Julie was 4 years old. At that time, Mr. Silver had just begun a prison sentence for selling drugs, and the mother was solely responsible for running the family business and caring for Julie. Both parents had a history of drug and alcohol abuse. Julie was their only child, born when the parents were in their late 30s. Julie’s developmental history was not significant, and Mrs. Silver reported that she had not used drugs or alcohol during her pregnancy. Mrs. Silver’s primary concerns at that time were that Julie had regressed in the 6 months since her father had been in prison and wanted to be treated like a baby, including being bottle-fed, using diapers, clinging to her mother throughout the day and sleeping with her at night. Toilet training had not yet been accomplished. Mrs. Silver reported little interest in playing or interacting with Julie, and in fact said she wasn’t sure how to do this. Treatment at that time had included (1) parent–child interaction training to improve the parent–child relationship; (2) structuring a daily routine, including a regular bedtime; (3) encouraging increased contact with other mothers and children; and (4) a toilet training program. Within 6 weeks, both mother and child had responded well to treatment. Julie was toilet-trained, sleeping in her bed at night, and playing with other children. Prior to seeing the parents regarding the current concerns, the clinician sent them the CBCL, the PSI, and a Daily Log (see Appendix B) to complete. Scores on the CBCL for both parents were in the subclinical range on the Anxious/Depressed, Social Withdrawal, and Somatic Complaints scales. On the PSI, the parents described Julie as having poor adaptability, and as being very moody and demanding. Parents both reported being depressed, in poor health, and not enjoying their relationship with Julie. They perceived their marriage as being within normal limits, but not “great.” Data on the Daily Log indicated that Julie was very irritable and had frequent tantrums, particularly over going to bed, getting up in the morning, and going to school.

Step 2: Parent and Child Interviews Parent Interview The parents were seen alone for the initial interview in order to explore the current family situation and their health status. Mr. Silver reported that he had finished his prison sentence 4 years ago and returned to running the family business. Both parents indicated that they were still drinking and using drugs, but they felt this was under control. They reported drinking about 6–8 ounces of alcohol each at night after Julie was put to bed. Both parents described a significant level of depression and indicated that two paternal uncles were on medication for depression. Although they did not report specific marital conflict, neither of them felt they were getting much support from each other. They also reported some financial concerns regarding their business. The Silvers were living in an isolated part of the county with no neighbors, and Julie was in the fourth grade at the local public school. The parents described Julie as a bright youngster who began having significant problems with schoolwork at the beginning of the current school year. She refused help with her homework and would have tantrums if forced to do it. Furthermore, she was very perfectionistic about her work, often taking an hour to complete a simple assignment. Of greater concern to them than the schoolwork, however, were Julie’s complaints that no one liked her, her belief that she wasn’t good at anything, and her increased guilt about anything that happened (regardless of her actual involvement). She also was having nightmares

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and difficulty getting to sleep at night. Moreover, she frequently complained about stomachaches, headaches, and various other somatic problems. Although Julie complained about not having friends, the parents often saw her playing or talking with other children when they picked her up at school. School problems primarily centered around completing written assignments and organizing reports or projects. Mr. and Mrs. Silver had talked to the teacher, but no specific suggestions had been given to them, and they felt they did not know how to proceed. The parents did not want the clinician to talk with the teacher unless Julie felt OK about it. The family’s daily routine was rather chaotic. The mornings were reported to be unpleasant, with the parents yelling, Julie having problems waking up and getting ready for school, and the father being angry about being late for work. Julie rarely ate breakfast, but would take something to eat in the car on the way to school. She often forgot her books and homework. Mrs. Silver picked her up every day after school, and although Julie initially seemed happy to be home, her afternoons were spent either complaining about things or watching television. The family did not eat together on a regular basis because Mr. Silver was often late, and on many days Julie did not have dinner until 7:30 P.M. Bedtime was also a struggle. Frequent nightmares resulted in Julie’s requesting to sleep with her parents. Julie rarely had any friends over and did not visit anyone else. She had no after-school activities. Likewise, the parents engaged in no community activities and had limited social contact with others. Child Interview Julie was a bright, highly verbal youngster who appeared unkempt and disheveled. She understood that her parents were concerned about her schoolwork and her behavior at home. Although she felt that she should be able to do better in those situations, and felt guilty for causing her parents problems, she did not know what she could do to make things better. She did, however, say that she wanted to talk with the therapist and wanted things to be better for everyone. She said that she was having problems with friends at school and that no one liked her. She described somatic complaints, poor frustration tolerance, and in general great loneliness both at home and at school. The CDI was administered. Julie received a score of 19, which was in the subclinical range. Her highest score was on the Anhedonia scale, where she reported social problems, not having fun at school, trouble sleeping, loneliness, and worries. She denied having specific reading or writing problems, but said it was harder for her to get things organized and to get her thoughts onto paper. She felt she “just couldn’t do anything right.”

Step 3: Observation of Behavior Observation of the parents and child took place in the waiting room and during a problemsolving situation (e.g., planning a family vacation). Julie tended to be overcontrolling, and the parents were permissive but often expressed anger and frustration in their responses to her. They felt that this behavior was typical of their interactions at home.

Step 4: Further Assessment The parents and Julie agreed that the therapist could talk with her teacher by phone, but they did not want a school visit. The teacher was contacted and agreed to complete the CBCL-TRF

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and the Social Skills Rating Scale (SSRS). The teacher’s ratings on the CBCL-TRF indicated significantly high scores on the Anxious/Depressed and Somatic Complaints scales, and subclinical levels of problems in the social area. Scores on the SSRS indicated that Julie was often neglected by the other children and did not know how to make friends. The teacher said that in addition to the problems noted on the rating scales, she was quite concerned about Julie’s attentional skills (problems with following directions). She described Julie as not seeming to understand what was expected of her. She rarely completed assignments and had organizational problems with long-term projects. The teacher thought that a psychoeducational evaluation was needed, and the clinician agreed that this would be important to get a better understanding of Julie’s problems. The parents elected to have the evaluation done privately. The results of this evaluation indicated that Julie was in the high average range of intelligence and had average academic skills, but was having auditory memory and sequencing problems.

Step 5: Referral to Allied Health Professionals The results of the psychoeducational evaluation prompted a referral to a communication/language specialist, who found that Julie had a moderate auditory processing dysfunction that could definitely be interfering with her ability to understand oral directions. Specific recommendations were made for modifications in the classroom (e.g., preferential seating, having instructions given in writing as well as orally).

Step 6: Communication of Findings and Treatment Recommendations It was explained to the parents that their concerns regarding Julie appeared to be the result of a number of factors. Her auditory processing problems did indeed make it difficult for her to understand and follow through with the more complex tasks that are presented in fourth grade. Although she had adequate academic skills, she was not performing at the level that would be expected from her abilities, and was in danger of falling farther behind. Thus her concerns and worries about school performance were based on real problems. She was described as an “exquisitely” lonely child in an adult world. Her lack of contact with friends outside the school setting and engagement in social activities limited her opportunity to develop social skills and have friendships. Furthermore, Julie was described as a child who tended to look at the world, herself, and life in a negative way and worried more than other children her age, yet felt there was little she could do about it. Although she was not experiencing MDD at this time, it appeared that over the past 2–3 years she had generally been unhappy, irritable, and not fully involved in any activities. This pattern of behavior, in combination with the family history of depression, placed her at high risk for MDD in the future. It was acknowledged that dealing with Julie’s behavior had been difficult for the parents. However, they also seemed to be having some problems of their own with feelings similar to Julie’s, which made it even more difficult for them to set appropriate routines and limits for her and to provide social opportunities. It was recommended that Julie receive individual tutoring for her learning/organizational problems, that she have individual treatment to help her learn to cope more effectively, and that she participate in a social skills group. It was also recommended that the parents seek help for their own depressive feelings and their ongoing problems with alcohol and drug use.

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Course of Treatment Julie was seen for eight sessions of CBT, with the goals of helping her to understand the relationship among thoughts, feelings, and behavior; to identify and modify her distorted cognitions; and to learn more effective ways of coping with stress. Julie kept a Mood Diary to chart her progress in applying her new skills. Concurrent parent sessions centered around developing structured routines at home, behavior management skills, and age-appropriate expectations for Julie. They were also encouraged to enroll her in at least two after-school activities that Julie would enjoy, and to invite her friends to their home. At the end of the individual sessions, the CDI was readministered and Julie received an overall score of 9, well within the normal range. At this point Julie joined a social skills group to learn more effective strategies for making and maintaining friends. She thoroughly enjoyed this experience, and both she and her parents reported her using these skills to make friends. The parents did seek treatment for themselves, and both were placed on antidepressant medication. This was somewhat problematic, however, as they continued to consume alcohol (although at a reduced level). Given Julie’s risk for MDD, it was agreed that she should have follow-up sessions every 4–6 months, with particular emphasis on times of transition that were likely to be difficult for Julie. The parents indicated that they planned to continue their own treatment. They both understood that Julie’s progress was in large measure dependent on them and their ability to provide the nurturance, structure, and stimulation that a child her age needed.

CHAPTER 10

Disruptive Behavior

A

major child-rearing goal for parents is the socialization of their children. As part of this process, parents must teach their children to cope with the ongoing and various stresses of life in socially acceptable ways. As children become more autonomous and independent, their desires and frustrations often come into conflict with those of their parents; the result is typically a display of negative or disruptive behavior on the part of the children (and often also the parents!). These disruptive behaviors are usually transient and considered “normal” at certain ages (e.g., toddler temper tantrums or adolescent rebellion). Some children, however, exhibit disruptive behaviors with greater intensity and/or frequency than would be expected. Moreover, these behaviors may persist or escalate throughout childhood and adolescence and even into adult life. Thus a considerable problem for clinicians is determining when disruptive behaviors exhibited by children referred for treatment are “normal” and likely to be transient, and when they are clinically significant and likely to persist or become more severe. The term “disruptive behavior” embraces a diverse set of behaviors that includes temper tantrums, excessive whining or crying, demanding attention, noncompliance, defiance, aggressive acts against self or others, stealing, lying, destruction of property, and delinquency. Children exhibiting a pattern of these behaviors have been variously labeled as “acting out,” “externalizing,” “oppositional,” “noncompliant,” “antisocial,” or “conduct-disordered.” Disruptive behaviors of one sort or another are the most frequent causes for concern among parents of normally developing children. In a random sample of parents from a primary health care setting, for example, negative behavior (defined as “won’t listen to parents, doesn’t obey, has tantrums, bossy and demanding, cries, whines”) was found to be a significant problem by 50–80% of parents of children ages 2–4 and 7–10 (Schroeder, Gordon, Kanoy, & Routh, 1983). Moreover, some form of disruptive behavior is the primary problem for a substantial percentage of the children referred for mental health services. This chapter focuses on research related to the classification and diagnosis of disruptive behavior disorders; their prevalence, comorbidity, persistence, and etiology; the normal developmental course and correlates of disruptive behavior; and issues and methods for assessment and treatment (including prevention). In the section on treatment, research on the efficacy of parent–child interaction training and other approaches to disruptive behavior is reviewed, and the program used in our clinic for young children with disruptive behavior problems is described. 331

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CLASSIFICATION AND DIAGNOSIS Classification of disruptive behavior disorders has taken many forms over the years. The categorical approach, represented here by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), focuses on specific symptoms as criteria for diagnosis of a disorder. Dimensional approaches, which use factor-analytic methods to determine clusters of behaviors, focus more on the characteristics of the deviant behavior and/or its age of onset. Each of these approaches to classification of conduct problems is briefly discussed.

Categorical Classification: The DSM-IV Approach DSM-IV (American Psychiatric Association [APA], 1994) includes three disorders in the group now called “attention-deficit and disruptive behavior disorders”: conduct disorder (CD), oppositional defiant disorder (ODD), and attention-deficit/hyperactivity disorder (ADHD). Although these three disorders are interrelated, we focus only on CD and ODD here. The reader is referred to Chapter 11 for an in-depth discussion of ADHD. Although CD and ODD are discussed as separate disorders here, the clinician should be aware of current theory and research suggesting that CD and ODD are linked developmentally and are consistently associated with the same risk factors (Biederman, Faraone, Milberger, Jettons, et al., 1996; Frick, 1998). Moreover, these factors, which are discussed in the section on etiology, differentiate both CD and ODD from other psychiatric disorders, including ADHD. Frick (1998) argues that differences between CD and ODD are quantitative rather than qualitative. Others (e.g., Werry, Reeves, & Elkin, 1987) suggest that ODD represents a mild form of CD, and there are considerable data to support this view. Children with CD almost always have a history of or concurrent symptoms of ODD (August, Realmuto, Joyce, & Hektner, 1999; Biederman, Faraone, Milberger, Jettons, et al., 1996). It is also true, however, that only some children with ODD develop CD later in life (Lahey & Loeber, 1994). This suggests that there are two subtypes of ODD, one of which remits during childhood, whereas the other persists and becomes more severe (Campbell, Pierce, Moore, Marakovitz, & Newby, 1996; Pierce, Ewing, & Campbell, 1999). The latter type of ODD is typically characterized by more severe behavioral symptoms and greater family dysfunction (Pierce et al., 1999). Researchers frequently do not differentiate ODD and CD, however; as a consequence, data concerning prevalence, risk factors, and stability tend to apply to either or both disorders. Oppositional Defiant Disorder Noncompliance is a critical element in the diagnosis of ODD as described in DSM-IV, whereas aggression is typically not a component of this disorder. According to DSM-IV, children with ODD exhibit a pattern of hostile, negative, and defiant behavior toward authority figures, which in young children is typically directed toward parents and in older children toward parents, teachers, and other adults. This pattern of behaviors must be evident for at least 6 months, and the child must evidence at least four of the following behaviors more frequently than would be expected for children of the same age and developmental level: (1) loses temper often; (2) argues frequently with adults; (3) often openly defies or resists complying with adults’ rules or requests; (4) often does things deliberately to annoy people; (5) frequently blames other people for his or her own misbehavior or mistakes; (6) is readily annoyed by others or touchy; (7) is often resentful and angry; (8) is frequently vindictive or spiteful (APA, 1994).

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The DSM-IV criteria for diagnosis of ODD are more stringent than those of DSM-III-R (APA, 1987), and thus define a more severely disturbed population (Angold & Costello, 1996). As a result, many children who exhibit significant disturbance may not meet the current criteria for a diagnosis. In order to include this group of children, Angold and Costello (1996) propose that only two or three of the DSM-IV criteria be required for a diagnosis of ODD. The risk of this approach is, of course, that some children exhibiting normal levels of defiant or noncompliant behavior will be diagnosed as having ODD. To deal with this problem and to operationalize how often each criterion must occur, Angold and Costello determined the frequency with which each of the DSM-IV symptoms of ODD occurred during the past 3 months in the general population, with cutoff at the 90th percentile. Based on these data, they suggest the following frequencies for clinical use: “has occurred at all during the past 3 months” for criteria 8 (spitefulness) and 5 (blaming others); “occurs at least twice a week” for criteria 6 (touchiness), 1 (loss of temper), 2 (arguing with adults), and 3 (defiance/noncompliance); and “occurs at least four times per week” for criteria 7 (anger/resentment) and 4 (annoying others) (Angold & Costello, 1996). Conduct Disorder Many of the features of ODD are seen in children with CD. DSM-IV distinguishes the two disorders by whether or not the basic rights of others and major age-appropriate societal norms or rules are violated. These two features are essential for a diagnosis of CD, and are reflected in the criterion behaviors for CD but not for ODD. Children with CD exhibit a pattern of behavior that includes aggression to people and animals, destruction of property, theft or deceitfulness, and serious violations of rules. The DSM-IV criteria for a diagnosis of CD involve a pattern of antisocial behavior lasting at least 6 months that includes at least three of the following behaviors occurring during the last 12 months, with at least 1 symptom occurring during the last 6 months: (1) frequently threatens, bullies, or intimidates others; (2) frequently starts physical fights; (3) has used a weapon at some point; (4–5) has shown physical cruelty to people or animals; (6) has stolen something with confrontation of a victim; (7) has forced another person into sexual activity; (8) has set a fire with intention to cause serious harm; (9) has intentionally destroyed property; (10) has engaged in breaking and entering; (11) lies frequently; (12) has stolen something valuable, but without confronting a victim; (13) frequently stays out at night, starting before age 13 years; (14) runs away from home; and (15) is frequently truant, starting before age 13 years (APA, 1994). Although some children are diagnosed with CD during early childhood, the more serious antisocial behaviors typical of CD usually do not emerge until later in childhood and often coincide with the beginning of adolescence (Frick & Ellis, 1999; Loeber & Lahey, 1989). Thus a diagnosis of ODD is usually much more likely than one of CD for young children. Indeed, CD is rarely seen during the preschool years, although it can appear as early as 5–6 years (APA, 1994). It is important to note that the symptoms of ODD do not necessarily disappear in children who are later diagnosed with CD. Rather, children tend to add more severe disruptive behaviors to their already extensive repertoires. DSM-IV differentiates CD into two types, based on the timing of onset. The childhoodonset type is characterized by the presence of at least one symptom of CD before age 10 years; the adolescent-onset type requires the absence of any symptoms of CD before age 10 years. This differentiation reflects the fact that although many adolescents with conduct problems show disruptive behaviors early in life, a substantial group of youngsters first exhibits such

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behaviors during adolescence (Hinshaw, Lahey, & Hart, 1993; Moffitt, 1993). Recent research attempting to validate the use of age of onset as a diagnostic criterion has been mixed. In a sample of adolescents, for example, Sanford et al. (1999) found that reliability of retrospective age-of-onset reporting over a 2- to 4-week period was poor, especially among adolescent informants. Other work has demonstrated that reliability of age-of-onset reporting decreases as the time since symptom onset increases (Angold, Erkanli, Costello, & Rutter, 1996). Once a symptom has been present for a year, reliable reporting of the onset of that symptom becomes very difficult. Moreover, Sanford et al. (1999) found that age of onset had limited predictive validity regarding the course of CD in a clinical sample of adolescents. They reported that the significant effects in symptom levels at adolescence were entirely due to baseline differences between childhood- and adolescent-onset groups. These authors argue that there is insufficient justification for clinical use of age of onset as a diagnostic factor until methods to measure it reliably have been developed. In contrast to this work, Lahey, Loeber, et al. (1998) reported that age of onset was strongly associated with levels of aggressive behavior in a large sample of children (ages 4–17 years) with conduct problems. Children with CD onset prior to age 10 years exhibited significantly more aggressive behavior than those with adolescent-onset CD. This difference did not hold for nonaggressive antisocial behaviors, however. Other work conducted over many years has consistently indicated that children who exhibit the most serious antisocial behavior initiate this behavior during childhood, whereas those who do not exhibit antisocial behavior until adolescence tend to engage in deviant behavior that is less serious and less likely to persist into adulthood (e.g., Frick, 1998; Loeber, 1988; Moffitt, Caspi, Dickson, Silva, & Stanton, 1996; Robins, Tipp, & Pryzbeck, 1991). Moffitt et al. (1996) found that adolescent boys in their “adolescent-limited” (AL) group could not be distinguished from those in the “life-course-persistent” (LCP) group on the basis of types of antisocial behaviors exhibited, although they were somewhat less violent. Rather, the LCP group described themselves in terms of personality characteristics consistent with adult antisocial personality disorder, whereas the AL group did not. This latter group seemed to represent the extremes of normal adolescent rebellion. Consistent with these data, McMahon and Wells (1998) cite research indicating that children with adolescent-onset conduct problems show no IQ or motor skills deficits, no reading problems, less family adversity, and no temperamental difficulty or other problems during infancy. In their review, McMahon and Wells (1998) state that risk factors for early-onset conduct problems include comorbid ADHD, difficult temperament, low socioeconomic status (SES) and poor parenting skills. The inconsistency in the results of research regarding age of onset most likely reflects the methodological issues of community versus clinical samples and concurrent versus retrospective reporting. Nonetheless, age of onset continues to be an important factor in understanding the nature of disruptive behavior disorders, and further discussion of this issue is included in other sections of this chapter.

Dimensional Classification There have been many attempts to cluster interrelated disruptive behaviors via multivariate statistical analyses. Frick et al. (1993) summarized these data in a meta-analysis of 60 factoranalytic studies comprising a combined sample of 28,401 children and adolescents with conduct problems. They concluded that most conduct problems could be classified within two orthogonal dimensions: “destructive–nondestructive” and “covert–overt.” This classification is illustrated in Figure 10.1. Frick et al. (1993) noted that the overt, nondestructive cluster of

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Destructive Property Damage

Aggression

Stealing Fire setting Vandalism Lying

Cruelty Assault Fighting Bullying Cruelty to animals Spite

Covert

Overt Status Offenses

Oppositional

Truancy Substance abuse Running away Curfew violations

Temper tantrums Noncompliance Arguing Annoying others Stubbornness Defying adults Touchiness Anger Nondestructive

FIGURE 10.1. Classification of disruptive behaviors.

From Frick (1998). Copyright 1998 by Ple-

num Publishers. Reprinted by permission.

behaviors reflected the DSM-IV criteria for ODD, whereas the other three clusters represented CD symptoms. In an independent sample of boys ages 6–13 years, Frick et al. found a strong relationship between these four clusters of behaviors and age. The mean age for emergence of oppositional behaviors was 6 years; mean age for aggressive behaviors was 6.75 years; mean age for property-destructive behavior was 7.25 years; and mean age for status offenses was 9.0 years. Frick (1998) asserts that these data support an age progression of conduct problems in preadolescent children. A second method of clustering conduct problems involves a child’s personality traits or dispositions. Frick and Ellis (1999) indicate that a significant subgroup of children with the childhood-onset type of CD show “callous” (use of others for own gain) and “unemotional” (lack of empathy, egocentricity) traits that are analogous to definitions of adult psychopathy. These callous–unemotional (CU) traits have been used to designate a group of adults with a severe form of antisocial personality disorder who are particularly difficult to treat (Hare, Hart, & Harpur, 1991). Frick and Ellis (1999) review research relevant to this grouping of children and conclude that among those with childhood-onset conduct problems, children with CU traits present a very different clinical picture than do those without CU traits. First, children with CD and CU traits tend to have a more severe type of disturbance, engaging in a greater variety of deviant behaviors and showing less distress regarding their own behavior. Second, the origin of disruptive behavior in children with CD and CU traits is thought to reflect low behavioral inhibition caused by underreactivity in the sympathetic arm of the autonomic nervous system. This in turn results in high levels of thrill seeking and low sensitivity to punishment. In contrast, the disruptive behavior of children with CD but without CU traits is thought to origi-

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nate through a variety of environmental factors, such as problematic parenting, low intelligence, or child abuse. Although work in this area is just beginning, subtyping on the basis of CU traits has obvious implications for prevention and treatment. It suggests that current treatment methods are likely to be more effective for children with CD and low levels of CU traits than for those with high CU traits. Furthermore, new treatment methods need to be developed that account for these characteristics. Finally, intervention with these children must begin very early in life, as CU traits strongly suggest a biological basis.

GENERAL CHARACTERISTICS OF DISRUPTIVE BEHAVIOR PROBLEMS Prevalence Prevalence of Diagnosable Disorders versus Disruptive Behavior in General Epidemiological research has shown that disruptive and antisocial behaviors are a major problem for children and parents, and result in enormous costs to society (Loeber, Burke, Lahey, Winters, & Zera, 2000; Zigler, Taussig, & Black, 1992). DSM-IV estimates the prevalence of ODD at between 2% and 16%, depending on the population sampled and the informants (i.e., parents vs. children vs. teachers) (APA, 1994). In community samples, prevalence rates for CD range from 1.8% to 16% for boys under age 18 years, and from 0.8% to 9.2% for girls (Loeber, Burke, et al., 2000). These rates represent a considerable increase from those reported in DSM-III, despite the more stringent criteria for ODD in DSM-IV (ODD, 5–7%; CD, 2–4%; APA 1980). Although these figures are alarming in themselves, they probably underestimate the extent to which children and adolescents actually engage in disruptive and antisocial behaviors. As many as 60% of 13- to 18-year-olds admit to more than one type of antisocial behavior, such as drug abuse, arson, vandalism, or aggression (Kazdin, 1995). Moffitt et al. (1996) reported that only 6% of their sample of 457 boys abstained from engaging in any antisocial behavior during adolescence. With regard to younger children, Achenbach and Edelbrock (1981) reported that 50% of 4- and 5-year-olds exhibited disobedience and 26% engaged in destruction of possessions. Finally, the prevalence of conduct problems is higher among children from low-SES environments (Loeber, Burke, et al., 2000). In an excellent review on the development of aggression, Loeber and Hay (1997) indicate that prevalence of physical aggression is highest early in life and decreases gradually throughout middle childhood, with a marked decrease between 14 and 16 years. On the other hand, prevalence of serious violence appears to increase with age, especially in adolescence. Loeber and Hay suggest that these prevalence data indicate four groups of children with disruptive behavior: (1) children whose aggressive behavior remits as they get older; (2) children whose aggression remains stable and who engage in deviant behavior at about the same level of severity either continually or intermittently; (3) children whose aggressive behavior escalates in severity and eventually becomes violent; and (4) children whose aggressive behavior originates during adolescence or early adulthood. Gender Differences Boys are more often described as engaging in disruptive behaviors, particularly noncompliance and aggression, than are girls (Campbell, 1990; Kuczynski, Kochanska, Radke-Yarrow, &

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Girnius-Brown, 1987). Similarly, more boys are diagnosed with conduct problems than girls, with the male–female ratio ranging from 2:l to 4:l (Anderson, Williams, McGee, & Silva, 1987; Offord et al., 1987). Boys with conduct problems also tend to engage in more severe and harmful behaviors than do girls with such problems (Keenan, Loeber, & Green, 1999). Among these boys, theft and aggression are the most common behaviors, whereas sexual misconduct is more frequent among girls (Kazdin, 1995). Girls are also found to engage in more indirect or relational aggressive behaviors, such as alienation, ostracism, character defamation, gossip and collusion, than are boys (Crick & Grotpeter, 1995). In contrast to these data, Pepler and Craig (1995) suggest that girls may engage in physical aggression against peers to the same extent as boys, but may hide it more effectively from adults. Although the prevalence of CD increases in adolescence for both boys and girls, the increase is more substantial for girls than for boys, reflecting the possibility of delayed onset for a substantial number of girls (Keenan et al., 1999; Offord et al., 1987). Despite these differences, the risk of antisocial personality disorder in adulthood is the same for both sexes (Zoccolillo, Pickles, Quinton, & Rutter, 1992).

Comorbidity Children with seriously disruptive behavior also often have symptoms of other psychiatric disorders, although fewer comorbid symptoms are associated with ODD than with CD (Loeber, Burke, et al., 2000). Most commonly, symptoms of ADHD and CD tend to co-occur, at least among boys; the few studies that include girls with CD have reported inconsistent results regarding the comorbidity with ADHD (e.g., Bird, Gould, & Staghezza, 1993; Faraone, Biederman, Keenan, & Tsuang, 1991). Among boys with conduct problems, it is estimated that as many as 65–90% also have ADHD (Frick, 1998). Conversely, somewhat fewer boys with ADHD also have conduct problems. Biederman, Faraone, Milberger, Jettons, et al. (1996) reported that 65% of boys who had ADHD had comorbid ODD (32% of these also had CD), and 22% had CD. Because ADHD and CD so frequently co-occur, the distinction between these two disorders is not always clear, although it has been clearly demonstrated that they have distinct etiologies and prognoses (see Chapter 11). McMahon and Wells (1998) suggest, however, that ADHD may be the “motor” that drives the development of conduct problems among some boys. There is evidence that conduct problems among children with ADHD decrease when these children are treated with stimulant medication (Hinshaw, 1991). It is important for the clinician to know, however, that children who display symptoms of both ADHD and CD are at very high risk for poor outcomes. These children have an earlier age of onset, display far more serious antisocial behaviors, and are at greater risk for delinquent behavior and antisocial personality disorder in adulthood than children with a single diagnosis of either CD or ADHD (Abikoff & Klein, 1992; Loeber & Lahey, 1989, Loeber, Burke, et al., 2000). Other psychiatric disorders that co-occur with conduct problems include anxiety disorders and depression. Recent work indicates that among preschool children, internalizing and externalizing symptoms often co-occur. Thomas and Guskin (2001) reported that 45% of their sample of 18- to 47-month-old children with disruptive behaviors also had clinically significant internalizing problems. This combination of symptoms was strongly associated with increased dysfunctional relational problems. Estimates of the co-occurrence of anxiety disorders and CD range from 22–33% in community samples to 60–75% in clinical samples (Russo & Beidel, 1994). In contrast to the combination of ADHD and CD, which typically results in a more severe form of disruptive behavior

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disorder, the presence of anxiety in children with conduct problems appears to reflect less severe disruptive behavior (although not necessarily less disturbance), at least among preadolescent children (Frick, 1998; Kamphaus & Frick, 1996). Depression and conduct problems are more likely to co-occur among girls than boys, especially during the adolescent years. In interpreting these data, however, one should note that base rates for depression are much higher for girls than boys, whereas base rates for CD are higher for boys. Nonetheless, the presence of depression in children with CD is clinically important because of an increased risk of substance abuse and suicidal ideation in this population (Cairns, Peterson, & Neckerman, 1988; Joffe, Offord, & Boyle, 1988; Loeber, Burke, et al., 2000).

Persistence The stability of disruptive behavior in children is an important clinical issue and has been widely studied. Results of this work vary, depending on whether one examines a specific behavior (such as aggression) or clusters of disruptive behaviors. In general, however, disruptive behavior tends to be quite stable over time, although the manifestation of the deviant behavior may change with age (Loeber & Hay, 1997). Almost all severely antisocial adults, for example, have long histories of disruptive behavior as children (Maugham & Rutter, 1998), and most children with CD have early histories of disruptive behaviors. Moreover, many studies have shown that aggressive preschool children tend to remain aggressive as they progress through school, although this may be true only for the more severe cases (Cairns, Cairns, Neckerman, Ferguson, & Gariepy, 1989; Heller, Baker, Henker, & Hinshaw, 1996; Kingston & Prior, 1995; Loeber & Hay, 1997). Although disruptive behavior during the preschool years is not necessarily clinically significant, children who exhibit clusters of antisocial behaviors at high rates across settings during these early years appear to be particularly at risk for an eventual diagnosis of CD and continuation of antisocial behavior into adult life (Cote, Zoccolillo, Tremblay, Nagin, & Vitaro, 2001; Loeber, 1990; Maugham & Rutter, 1998; Patterson, DeBaryshe, & Ramsey, 1989). The following studies are examples of research on the persistence of conduct problems. Campbell (1990) reported that preschool children with symptoms of ODD tended to have persistent problems; at age 9, over 60% of these children met the DSM-III criteria for attention deficit disorder (the forerunner of ADHD), CD, or ODD. Similarly, Esser, Schmidt, and Woerner (1990) found that all children described as having CD at age 8 had psychiatric problems at age 13, with the majority of them (75%) continuing to be described as having CD. In a large longitudinal community study of 1,037 children, Moffitt et al. (1996) reported that 7% of their sample consistently evidenced disruptive behavior from ages 3 through 18 years. Further analysis of these data indicated that behavior observations of disruptive behavior at age 3 predicted antisocial personality disorder and crime in adulthood (Caspi, Moffitt, Newman, & Silva, 1996). Various factors that increase the risk for persistence of conduct problems have been identified (e.g., Egan, Monson, & Perry, 1998; Kingston & Prior, 1995; Pope & Bierman, 1999; Speltz, McClellan, DeKlyen, & Jones, 1999), and these are summarized in Table 10.1. As an example, Hamalainen and Pulkkinen (1996) reported that adult criminal behavior involving property crimes was best predicted by an accumulation of behavior problems over the school years in combination with school failure, whereas violent crimes were predicted by persistent conduct problems during the school years. Loeber and his colleagues (Loeber, Green, Keenan, & Lahey, 1995; Loeber, Green, Lahey, & Kalb, 2000) have identified several factors that predict the escalation to CD among boys, including low SES, a mother’s age

TABLE 10.1. Factors Contributing to the Development and Stability of Disruptive Behaviors Adolescence

Child

Temperament • Emotional regulation • Irritability • Reactivity Hyperactivity Insecure–disorganized attachment Many disruptive behaviors

Escalation of disruptive behaviors Physical fighting Hyperactivity/ADHD Social-cognitive deficits Inflated self-esteem Language impairments School failure

Violent behavior Oversensitivity to rejection Inflated self-esteem Early school dropout

Parent

Poor responsivity Harsh, punitive discipline Inconsistent discipline Negative control strategies Age (young mother) Lack of social support Psychopathology • Depression • Antisocial personality disorder • Criminal behavior

Parenting style • Poor monitoring/supervision • Hostile • Punitive • Inconsistent • Permissive Psychopathology • Antisocial personality disorder • Criminal behavior

Parenting style • Poor monitoring/supervision • Hostile • Punitive • Inconsistent/permissive Psychopathology • Antisocial personality disorder • Criminal behavior

Environment/social

Low SES/poverty Hostile sibling relations Many life stresses Marital/couple distress Large families Poor home environment • Inadequate stimulation • Little or no play equipment • Lack of safety rules and supervision

Dangerous neighborhood Poor schools Physical deterioration of buildings Deviant peer group Available weapons Access to drugs and alcohol Peer rejection Hostile sibling relations Lack of extracurricular activities Family instability, especially divorce/separation

Dangerous neighborhood Poor schools Physical deterioration of buildings Gangs Available weapons Access to drugs and alcohol Lack of extracurricular activities

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Infancy/early childhood

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at the birth of her first child, maternal symptoms of antisocial personality disorder, a boy’s intelligence, parental substance use disorders, presence of ODD, and the number of ODD and CD symptoms. Among the CD symptoms, physical fighting was most strongly associated with persistent problems. In contrast to this work, Mahoney (2000) examined protective factors in a community sample of boys and girls from ages 10 and 13 until ages 20 and 24 years. He found that participation in extracurricular activities had a protective effect, primarily for those children (both boys and girls) at highest risk for conduct problems, but only when the peer group also participated in these activities. Despite the impressive evidence for persistence of disruptive behaviors, it is important to recognize that there is also considerable instability. This is reflected in the fact that only between 23% and 41% of severely disruptive children grow up to become antisocial adults (Loeber & Stouthamer-Loeber, 1998; Maugham & Rutter, 1998). Many preschool children desist from aggression during the transition to elementary school, presumably as they develop more mature social skills (Loeber & Hay, 1997). There is also a marked decrease in prevalence of disruptive behavior during elementary and middle school (Loeber & Hay, 1997), although more serious violent behaviors increase as children enter adolescence. Even among the most severe cases, however, the risk of developing adult antisocial personality disorder never rises above about 50% (Maugham & Rutter, 1998). This is not to say that these individuals no longer exhibit any disruptive behavior and are living happy, productive lives (although this may be true for some; see, e.g., Kokko & Pulkkinen, 2000). Rather, the behavior persists but tends to occur at subclinical levels. In an examination of the mechanisms for stability versus change in conduct problems, Maugham and Rutter (1998) point to several factors that have an important influence. The first, consisting of deficits in social information processing, has been shown to distinguish children with disruptive behavior problems from normal controls (Dodge, Bates, & Pettit, 1990). Children with conduct problems tend to search for fewer cues before interpreting social situations, to overattribute hostile intent to ambiguous situations, and to generate and select aggressive strategies for coping, compared to children without conduct problems (Matthys, Cuperus, & van Engeland, 1999; Waldman, 1996; Webster-Stratton & Lindsay, 1999). These deficits result in lower social competence and problems with social/peer relationships, such as rejection by peers, that exacerbate the children’s problems with deviant behavior; they probably also help to explain why aggressive youngsters tend to select other aggressive children as peers (Farver, 1996; Kupersmidt, Burchinal, & Patterson, 1995; Snyder, Horsch, & Child, 1997). Patterson, Reid, and Dishion (1992) suggest that the symptoms of CD (especially aggression) lead to rejection by prosocial peers, increasing the probability that a child with CD will affiliate with a deviant peer group. A study by Hektner, August, and Realmuto (2000) confirms that aggressive youngsters’ rejection by nonaggressive peers, rather than their actively seeking friends who are similarly aggressive, accounts for the association of such children with deviant peers. Affiliation with deviant peers is in turn associated with increases in aggressive and antisocial behavior, and accounts for much of the continuity between childhood problems and adolescent offending (Fergusson & Horwood, 1996). A second mechanism for stability versus change is called the “accentuation principle,” or the tendency for new and/or challenging experiences to reinforce existing deviant behavior patterns (Elder & Caspi, 1990). Maugham and Rutter (1998) suggest that the changes accompanying the onset of puberty and adolescence can be particularly challenging and have the potential for accentuation effects for some children.

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The stability of environmental risk is a third mechanism noted by Maugham and Rutter (1998) to explain the persistence of conduct problems. In childhood, environmental risk can be mediated by family factors. For example, families can move out of high-risk neighborhoods or send their children to better schools. Later in childhood and in adolescence, the individual plays a more important role in selecting and shaping his or her environment through the choices made, such as dropping out of school or engaging in early sexual relationships (both of which are associated with adverse outcomes). It is clear that deviance at one stage of development heightens the risk of deviance at the next stage. Maugham and Rutter (1998) point out, however, that some life experiences can break the cycle of escalating antisocial behavior. These experiences are called “turning points.” Maugham and Rutter argue that turning points often involve radical environmental change, and that they open up new opportunities for the individual and have marked effects on the individual’s view of him- or herself and/or others. They give as examples of turning points such factors as academic success, choice of positive spouse/partner, or association with a positive adult role model.

Etiology The causes of disruptive behavior have been widely studied, and considerable data indicate several possible developmental pathways leading to clinically significant problems. These pathways typically involve some combination of genetic or biologically based child characteristics or predispositions, parenting dysfunction, and environmental or contextual circumstances. A transactional model for the development of disruptive behavior disorders recognizes the interrelationship among multiple child, family, and environmental factors. At a very simple level, the interaction between the child’s characteristics and those of his or her parents, in some cases leading to parent–child “incompatibility,” is emphasized. At a more complex level, the influence of factors in the environmental context and antecedent events on both the child and parent and their relationship are taken into account. Although a transactional perspective is clearly most appropriate for understanding the etiology of disruptive behavior, research in each of the areas of risk (genetic, family, and environmental) is covered separately. This discussion is followed in a later section by a brief review of research related to the normal development of two types of disruptive behavior: noncompliance and aggression. Genetic or Biological Factors Research in behavioral genetics suggests that there is a substantial genetic component to adult antisocial behavior and criminality (Plomin, 1989). Similarly, recent twin and adoption studies of disruptive behavior among middle-school-age and adolescent youngsters report very high rates for heritability, ranging from 40% to 50% (e.g., Deater-Deckard & Plomin, 1999; Edelbrock, Rende, Plomin, & Thompson, 1995; Schmitz, Fulker, & Mrazek, 1995). Moreover, estimates of heritability appear to rise somewhat with the severity of the disruptive behavior (Gjone, Stevenson, Sundet, & Eilertsen, 1996). A genetic basis would explain the clear association between antisocial behavior in children and parental (especially fathers’) antisocial behavior, and the fact that this behavior appears to be stable across generations (Kazdin, 1995). Rutter et al. (1990) argue that a genetic link is more likely to be found in those cases in which the antisocial behavior persists into adulthood, whereas cases in which the antisocial behavior decreases with age are more likely to be environmentally based. A study by Schmitz

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et al. (1995) supports this notion. They found that genes accounted for 50% of the variance on the Child Behavior Checklist (CBCL) Externalizing scale for 2- to 3-year-old twins. This increased to 57% for older twins (4–18 years). Moreover, heritability accounted for 79% of the variance on the Delinquent scale for older twins. Because of this increase in heritability with age, Schmitz et al. suggest that some of the stability in disruptive behavior may be accounted for by genetics. Gender Differences. Based on the observation that boys consistently exhibit more disruptive behavior than girls, recent research examines gender differences in heritability. Eley, Lichtenstein, and Stevenson (1999) examined differential heritability rates and gender differences for aggressive versus nonaggressive antisocial behavior in twins ages 7–16 years. In general, they found that genetic factors were more influential in explaining aggressive antisocial behavior, whereas both shared and nonshared environmental factors better explained nonaggressive antisocial behavior. Genes played an equal role for boys and girls in explaining aggressive antisocial behavior. In contrast, environmental factors better accounted for nonaggressive antisocial behavior among boys, whereas genetic influences predominated for girls’ nonaggressive antisocial behavior. Temperament. Many of those involved in genetic research suggest that child temperament is a likely mediator of the high genetic influence on antisocial behavior (Caspi, Henry, McGee, Moffitt, & Silva, 1995; Moffitt, 1993). Preschool children with difficult temperaments have been shown to display more disruptive/aggressive behavior than those with more easy-going temperaments (e.g., Tschann, Kaiser, Chesney, Alkon, & Boyce, 1996). Several aspects of child temperament have been implicated in the etiology of disruptive behaviors, including emotional regulation, intense reactivity (especially to frustration), irritability and negative emotionality, resistance to control/manageability, and high approach/low avoidance (which appears to represent a propensity to engage in thrill-seeking or risk-taking behavior). Moreover, some of these specific temperamental characteristics have been linked with later disruptive behavior problems (Eisenberg et al., 2000). In a longitudinal study of children from infancy to 10 years of age, Bates, Pettit, Dodge, and Ridge (1998), for example, found that maternal ratings of infant manageability or resistance to control (including failure to comply) predicted later externalizing problems. Considerable research indicates that the temperament characteristic called “emotional regulation” is associated with the development of later aggressive and disruptive behavior problems. It is suggested that emotional dysregulation reflects a greater tendency toward behavioral activation and involvement in thrill seeking and risk taking (Rubin, Hastings, Chen, Stewart, & McNichol, 1998). In infancy, emotional regulation is reflected in the infant’s ability to be calmed when distressed. Wakschlag and Keenan (2001) found that low soothability in infancy predicted higher levels of disruptive behavioral symptoms in 2½- to 5½-year-olds. Research in the area of neurophysiology is beginning to delineate factors that may contribute to temperamental differences between children with and without disruptive behavior disorders. Among these factors are low levels of serotonin and epinephrine; high levels of testosterone; and autonomic nervous system abnormalities, such as decreased reactivity as measured by skin conductance, heart rate, and event-related potentials on electroencephalograms (Frick, 1998). As an example of this research, van Goozen, Matthys, Cohen-Kettenis, Buitelaar, and van Engeland (2000) examined children’s heart rate and skin conductance in stressful and nonstressful conditions. They found that children with disruptive behavior disorders had lower heart rate and skin conductance levels in both conditions than children without such disorders had. Moreover, the

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disruptive children had lower salivary cortisol levels (a measure of reactivity to stress) in stressful conditions. van Goozen and colleagues suggest that this difference reflects underarousal and the propensity to take risks that is often seen among disruptive children. Other work suggests that higher levels of androgens (testosterone), either prenatally or concurrently, may partly explain the increased disruptive behavior of some children (Orlebeke, Knol, & Boomsma, 1998; van Goozen, van den Ban, et al., 2000). In this regard, animal research has demonstrated a strong association between prenatal exposure to androgens and/or levels of androgen production during childhood and later aggressive behavior (Archer, 1991), although the link is less clear in humans. Frick (1998) points out that the data for these neurophysiological factors are much more consistent for adults with antisocial personality disorder than for children with conduct problems. This probably reflects the greater variability in childhood problems, and it suggests that a more consistent picture should emerge for children who evidence more severe and persistent disruptive behavior disorders. Family Factors Many factors related to family functioning have been examined as playing a causal role in the development of disruptive behavior disorders. These include parenting practices (style of discipline, warmth vs. hostility, supervision of the child), parental psychopathology (e.g., maternal depression, personality disorders, substance use disorders, and antisocial or criminal behavior), marital/couple dysfunction (e.g., divorce/separation, conflict, spouse/partner abuse), and sibling conflict. Variables in these areas undoubtedly interact with one another. Parenting practices are clearly affected by parental psychopathology and dysfunctional marital/couple relations, for example, but research has not yet identified the primary causal agent. Querido, Eyberg, and Boggs (2001), for example, found that mothers with higher levels of depressive symptomatology displayed higher rates of negative physical discipline and also reported more child conduct problems. This section focuses on parenting practices, as this factor is thought to be a critical component of the transactional model for the development of conduct problems. The other areas are covered in the “Normal Development of Disruptive Behavior” section, and the reader is referred to Chapter 1 for further discussion of the association of family risk factors and child development. Parenting Practices. Despite the strong evidence of a biological basis for antisocial behavior, genes are ultimately dependent on environmental circumstances for their expression. Moreover, parents are clearly an important avenue of influence for child development. Considerable research has examined the effects of various parenting practices on the development and persistence of conduct problems. In general, this work indicates that harsh, punitive, abusive, and/or inconsistent discipline is a significant risk factor for development and persistence of disruptive behavior disorders (Frick, 1994). Physical punishment below the level of abuse (i.e., spanking) as a specific discipline technique is also linked with later conduct problems, at least among European American families (Webster-Stratton & Hammond, 1998). The evidence is less clear for African American families, as some research indicates that physical discipline is associated with fewer problems in these families (Deater-Deckard, Dodge, Bates, & Pettit, 1996). Gunnoe and Mariner (1997) reported that spanking deterred fighting among younger children (4–7 years) and African American children, whereas it fostered fighting among older children (8–11 years) and European American children. As a result of this work, many argue

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that differences between ethnic groups in the meaning or perception of spanking are important in determining the effect this method of discipline is likely to have on the children’s behavior (Deater-Deckard et al., 1996; Gunnoe & Mariner, 1997). Links between specific parenting practices and disruptive behavior problems in a highrisk community sample of elementary school children were reported by Stormshak, Bierman, McMahon, Lengua, and the Conduct Problems Prevention Research Group (2000). They found that punitive discipline (yelling, nagging, threatening), physical aggression (hitting, beating), and spanking together predicted increased severity of oppositional, aggressive, and hyperactive behaviors among the children. Conversely, parental warmth and positive involvement were associated with decreased oppositional behavior. Parental involvement in the lives (activities, friends, schoolwork, and behavior) of their children (also termed “supervision” or “monitoring”; see Chapter 1) is a critical parenting skill that may reduce the risk of conduct problems (Kilgore, Snyder, & Lentz, 2000; Webster-Stratton & Hammond, 1998). In a study of 4-year-old Head Start children, however, Kilgore et al. (2000) found that parents who were poor at monitoring their preschool children also tended to choose poorer schools for their children, suggesting that parental supervision may interact with other environmental risk factors in the development of conduct problems. In infancy, parenting that lacks responsiveness and sensitivity has been shown to be associated with later conduct problems (Shaw, Owens, Giovannelli, & Winslow, 2001). In a study of African American children at high risk for both biological and social/environmental reasons, Wakschlag and Hans (1999) found that lack of maternal responsiveness in infancy predicted disruptive behavior problems when the children were 10 years of age, independently of other risk factors. Highly responsive parenting, on the other hand, appeared to act as a protective factor, buffering the children from the effects of living in a high-risk environment. The quality of the mother–infant attachment relationship (which is related to maternal responsivity and to the infant’s temperamental characteristics) is also associated with development of later disruptive behavior problems, especially among high-risk children (e.g., Shaw & Vondra, 1995). Shaw, Owens, Vondra, Keenan, and Winslow (1996) examined the mother– infant attachment relationship in 6- to 11-month-old high-risk infants and followed this sample for 5 years. They found that 67% of children with disorganized attachment in infancy had aggressive problems at age 5, as opposed to only 17% of securely attached infants. The association between disorganized attachment and later aggression was particularly strong for children who were rated as temperamentally difficult at age 2. Other types of insecure attachment (i.e., avoidant, resistant) predicted aggression only when one or more other risk factors (e.g., maternal depression, life stress, criminality) were present at age 2. Environmental Factors A large number of environmental factors have been implicated in the development of antisocial behavior problems. Among the most important of these is low SES or poverty, in part because it is highly correlated with a variety of other risk factors. Low SES sets up a context of multiple risk factors that have both direct and indirect effects on children’s behavior. Combinations of factors associated with low SES (such as high levels of chronic stress, single parenthood, social isolation, an inadequately stimulating home environment, and diminished resources) can contribute to symptoms of depression in mothers, which in turn adversely influence parenting practices. Moreover, low-SES neighborhoods are often dangerous for children, exposing them to role models for violence and/or substance misuse, and also are

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associated with poor schools. Consistent with the link between low SES and conduct problems are data presented by Webster-Stratton and Hammond (1998) indicating a greater prevalence of conduct problems (23–33%) among Head Start children than in the general population. Not all children growing up in these high-risk neighborhoods develop disruptive behavior disorders, however. A cumulative or multiple-risk model is proposed to account for these different developmental pathways (Greenberg, Coie, Lengua, Pinderhughes, & the Conduct Problems Prevention Research Group, 1999; Webster-Stratton & Hammond, 1998). According to this model, “the study of adjustment must be embedded in analyses of the contextual risks to which children are exposed” (Greenberg et al., 1999, p. 403). Moreover, the accumulation of risk factors in many different areas, rather than any one factor or risk in a specific area, best predicts the development of conduct problems (see Chapter 1). In an empirical test of the multiple-risk model, Greenberg et al. (1999) measured the following dimensions in a sample of high-risk kindergarten children and their families: (1) parent education and occupation; (2) child’s race; (3) number of siblings; (4) single-parent versus two-parent family status; (5) major life stresses; (6) social support; (7) family emotional expressiveness; (8) marital distress; (9) maternal depression; (10) physical environment of the home; (11) child-friendly home environment; and (12) neighborhood context. These factors were used to predict children’s internalizing and externalizing problems, social competence, and academic achievement. Results indicated that all dimensions of risk together accounted for about 18–29% of the variance in child adjustment at first grade. Perceptions of the neighborhood context was an independent predictor of children’s externalizing problems and social competence. In similar work, Myers, Scott, Burgess, and Burgess (1995) presented 10 factors that were present in 70% of a group of 25 homicidal children and adolescents: (1) family dysfunction; (2) previous violent acts toward others; (3) disruptive behavior disorder; (4) failing at least one school grade; (5) emotional abuse by a family member; (6) family violence; (7) prior arrests; (8) learning disabilities; (9) a weapon of choice versus one obtained at the scene of the crime; and (10) psychotic symptoms. Research reviewed by Shumaker and Prinz (2000) supports the validity of these risk factors. In a study of the interrelations among risk factors, Webster-Stratton and Hammond (1998) suggest that parents with many risk factors in their own backgrounds (e.g., histories of child abuse, substance abuse or dependence, criminality, depression) may be more vulnerable to the stresses associated with poverty than those who have fewer risk factors. Furthermore, they argue that the effects of low SES can be mediated by parenting skills. In other words, effective and positive parenting can overcome the negative effects of poverty.

DEVELOPMENT OF DISRUPTIVE BEHAVIOR Given the high rates of disruptive behavior seen in the normal population, and the prevalence and stability of serious conduct problems among children, the questions of how and when these disruptive behaviors originate, and why they persist and become more severe in some children while decreasing in others, are of interest. The two types of disruptive behavior that have received most attention in the empirical literature are noncompliance and aggression. This section first briefly reviews research on the development of these two behaviors; this is followed by a discussion of the developmental process that can result in normative versus clinically significant disruptive behaviors.

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Noncompliance “Noncompliance” is narrowly defined as not following directions, disregarding requests or doing the opposite of what is asked (Forehand & McMahon, 1981). In contrast, “compliance” is viewed as “the capacity to defer or delay one’s own goals in response to the imposed goals or standards of an authority figure” (Greene & Doyle, 1999, p. 133). Compliance and noncompliance are seen as soon as children have the cognitive capacity to understand parental requests and the physical capabilities to carry them out; however, noncompliance typically begins to be perceived as a problem at about 2 years of age, when children begin to assert their needs for autonomy and control. Greene and Doyle (1999) suggest that compliance actually has its origins in selfregulation during infancy, as reflected in the infant’s ability to manage discomfort, modulate arousal, and communicate his or her needs to caregivers. They point out that infants with poor emotional arousal have higher rates of noncompliance during the preschool years. Developmental research suggests that very young children may be predisposed to comply with adult commands. Rheingold, Cook, and Kolowitz (1987) found that adult commands were associated with increased enthusiasm and compliance in the play of 18- to 24-month-old children. These authors have speculated that compliance with adult commands provides children with some inherent pleasure and motivation. The state that “the achievement of fitting their actions to the words of another was enjoyable; the pleasure resided in the accomplishment” (p. 151). Although temperamental differences were not taken into account, this study suggests that given a predisposition to compliance, it should increase and persist as a behavioral style if compliance is rewarded rather than ignored or punished. Kuczynski and Kochanska (1995) suggest that harnessing children’s early disposition to cooperate, at a time when selfregulation is poorly developed, requires considerable physical assistance from parents. In other words, rather than expecting toddlers to comply, parents must help them to do so and then reinforce their children’s efforts. Other work implicates maternal responsivity in the development of individual differences in children’s compliance–noncompliance. Rocissano, Slade, and Lynch (1987) found that toddlers were more likely to comply when the mothers’ commands were consistent with the children’s ongoing activity. This study and others (e.g., Parpal & Maccoby, 1985) suggest that mothers who are able to allow their children a degree of control in the interaction by following their lead and modeling compliance to child requests have children who are more likely to be compliant to parental demands. Consistent with this work, Wahler, Herring, and Edwards (2001) suggest that child compliance follows from a pattern of social interaction in which positive social exchanges between mother and child (particularly child-initiated exchanges), rather than maternal demands and instruction, are predominant. Children’s compliance–noncompliance has also been found to be mediated by situational factors and to change with age. The development of language, for example, facilitates more sophisticated methods of self-regulation as a child learns to label thoughts and feelings, to understand cause and effect, and to generate strategies for effective interaction (Greene & Doyle, 1999). Consistent with this idea, Kuczynski et al. (1987) found developmental changes both in mothers’ strategies for gaining compliance and in children’s responses to control. As the children’s age increased, mothers relied less on distraction and more on explanations, bargaining, and reprimands. Among the children, passive noncompliance (ignoring the request) and direct defiance decreased with age, whereas negotiation increased. Results of a study by Kalpidou, Rothbaum, and Rosen (1998) are consistent with these data. They found that 18- to

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24-month-old children’s aversive noncompliance (e.g., whining, ignoring, and crying) decreased with age. Kuczynski and Kochanska (1995) differentiated parental demands on the basis of their function and content. They argued that demands for competence or more mature behavior (e.g., putting toys away, helping mother, doing household chores, caring for a sibling) would be beneficial for children. In contrast, prohibitions and demands for behavioral control would have a negative effect. In a study of toddlers and their mothers, they found that parents’ positive demands (“dos”) were associated with increased child compliance and fewer behavior problems at age 5 years, whereas prohibitions (“don’ts”) were negatively associated with later compliance and more behavior problems. Finally, Schneider-Rosen and Wenz-Gross (1990) studied 18- to 30-month-old children and found levels of compliance to be strongly related to the situations in which commands were given (e.g., free play, picking up toys, reading a book). Furthermore, compliance did not increase linearly with age. Rather, in some situations 2-year-olds were less compliant than older and younger children, and in others they were more compliant. Taken together, this work suggests the need to consider “stage-salient” issues in understanding the development of noncompliance (Cicchetti & Cohen, 1995). In other words, toddlers and preschoolers are going to assert themselves in the pursuit of autonomy. In the process of learning self-regulation, they will at times engage in highly aversive behaviors. Rather than viewing a child as “compliant” or “noncompliant,” Belsky, Woodworth, and Crnic (1996) suggest that a distinction be made between “self-assertiveness” (e.g., saying “no” or “not right now”) and “active defiance” (e.g., hitting, kicking, screaming, or having tantrums) in response to parental demands. Furthermore, parental control strategies can be viewed on several dimensions, such as simple control versus control plus guidance; psychological control versus behavioral control (Barber, Olsen, & Shagle, 1994); or control in the service of promoting behavior that is beneficial to the child or others versus control for its own sake (Kuczynski & Kochanska, 1995). Since most children are noncompliant to some extent, documenting differences between “normal” and “deviant” noncompliance is important. “Normal” child compliance to maternal commands ranges from 51% to 74% (Forehand, Gardner, & Roberts, 1978; Johnson, Wahl, Martin, & Johansson, 1973), whereas children referred to clinics for treatment of noncompliance exhibit compliance to only about 41% of parental commands (Forehand et al., 1978). Although these differences are statistically significant, there is considerable overlap between children referred for treatment and nonreferred children, especially in those studies based on behavioral observation. There is less overlap when one looks at parent questionnaire data: Parents often perceive their children as being deviant, even though behaviorally these children cannot be distinguished from normal children. Thus factors other than children’s behavior may be contributing to negative parental attitudes (Greenberg et al., 1999). Some of these factors include parental and marital/couple adjustment (Oltmanns, Broderick, & O’Leary, 1977), high parental standards (Atkeson & Forehand, 1978), social support (Greenberg et al., 1999), and aversive relationships outside the family (Wahler, 1980). Differences in parenting styles of nonreferred and clinic-referred parents have also been documented. Mothers of clinic-referred children tend to issue more commands and use more criticism than do mothers of non-clinic-referred children (Forehand, King, Peed, & Yoder, 1975). Furthermore, a clinic-referred parent frequently interrupts a child’s behavioral sequence by repeating the command, giving help, retrieving the command, and so forth, so that compliance on the child’s part is not possible. Thus, to some extent, “problem” noncompliance may

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be more a function of the parents’ behavior than the children’s characteristics. On the other hand, child characteristics clearly influence parents, suggesting that the behavior of a clinicreferred parent may reflect adaptation to an uncooperative child (Kuczynski & Kochanska, 1995; Webster-Stratton & Spitzer, 1996).

Aggression “Aggression” includes physically aggressive acts against another person (hitting, kicking, biting, fighting), verbal aggression (threats, tattling, teasing, name calling), and nonverbal or symbolic aggression (threatening gestures, chasing, making faces). Loeber and Hay (1997) have described the development of aggression. Expressions of frustration and rage are seen in very young infants, both male and female. By 3 months, an infant makes adult-like facial expressions of anger. By the second half of the first year, real angry feelings begin to be expressed as the child learns about cause and effect. After 12 months, gender differences in aggression are apparent (Weinberg & Tronick, 1997). Boys are more emotionally labile and express negative emotions at higher rates than girls. During the second and third years, temper tantrums and aggression toward peers and adults begin to be seen about equally among both boys and girls, although parents report more aggression for boys than for girls. Aggression at this age tends to be instrumental (i.e., used to obtain a desired object). Between 3 and 6 years of age, gender differences become quite marked. Boys exhibit higher rates of instrumental and personal aggression (Coie & Dodge, 1998), whereas girls tend to engage in more indirect, relational aggression (alienation, ostracism, character defamation, etc.) (Crick & Grotpeter, 1995). At this age, children with higher rates of physical aggression are also more likely to show higher rates of verbal aggression (McCabe & Lipscomb, 1988). As interpersonal skills begin to develop, typically between preschool and elementary school, aggression with peers decreases. Both boys and girls, however, continue to show high levels of aggression with siblings, especially dyads of the same gender. Although this is not necessarily seen as maladaptive, there is clear evidence that highly conflictual sibling relations increase the risk of aggression in the school setting (Stormshak, Bellanti, Bierman, & the Conduct Problems Prevention Research Group, 1996). Although adult reactions to a child’s aggressive outbursts clearly provide feedback to the child about the efficacy of aggressive behaviors, there is evidence that early peer relationships are important in teaching children to master these behaviors and to cope with the affective and other outcomes of aggressive interaction. Hartup (1989) suggests that the unique egalitarian relationship with age mates permits aggressive acts to be successful at some times and unsuccessful at other times. This balance has the effect of allowing a child to become neither excessively aggressive nor excessively permissive, and eventually contributes to a decrease in aggression. In contrast, Patterson (1976a) suggests that aggressive behavior in preschool children is initially positively reinforced (the child gets what he or she wants); however, if it continues unchecked, it is negatively reinforced (others use aggressive behavior to stop the aggressor), and this may operate to increase the aggressive behavior. Recent research has examined the cognitive skills, many of which develop in the preschool years, that are linked with aggressive behavior. First, low intelligence as well as attentional and academic problems are positively associated with aggression in boys, whereas these tend to be negatively associated for girls (Loeber & Hay, 1997). In other words, among boys, those with lower intelligence and poorer attentional and academic skills tend to be more aggressive, whereas girls with higher intelligence and better academic/attentional skills are more aggres-

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sive. Social-cognitive skills, such as alternative-solutions thinking (i.e., the generation of alternative solutions to a social problem such as conflict over a toy) and consequential thinking (i.e., the accurate recognition of the likely results of different social behaviors such as hitting), increase with age. Deficits in these areas are found more frequently among aggressive than among nonaggressive boys (e.g., Dodge & Coie, 1987). In contrast to this work, Gouze (1987) compared aggressive and nonaggressive preschool boys and demonstrated that aggressive boys generated a greater number of solutions to hypothetical interpersonal problem situations, but that these solutions were primarily aggressive. Gouze also found that the aggressive boys attended more to aggressive than to nonaggressive social interactions. She concluded that this attention is likely to affect the types of social information aggressive children take in and retain over time, with the result that these children increasingly see the social world as hostile; this further narrows their focus on the hostile or aggressive aspects of their environment and interactions.

Developmental Process Taken together, this work suggests that a complex interaction among parents, children, and peers that is a function of the characteristics of parents, children, and the environment contributes to the development of normative versus clinically significant disruptive behaviors. A developmental perspective suggests that there are critical periods in the course of development during which children are more vulnerable to adverse conditions and more likely to develop patterns of negative behaviors that have the potential to persist and become more severe with age (Loeber, 1990). The period of early childhood (between birth and about 3–4 years), when children typically first form affectionate bonds with significant adults and later begin to assert their independence, is an example. During this period, children are particularly vulnerable to disruptions in their social environment (e.g., marital separation and divorce, parental illness, physical and/or emotional neglect, or poor-quality parenting). Disruptive behavior can also develop in association with events that occur during the normal course of development. These events might include the birth of a sibling, beginning school, associating with peers, and moving from elementary to junior high school. All of these events have the potential to shift a child’s developmental path toward more maladaptive behavior. Patterson and his colleagues (Patterson, Capaldi, & Bank, 1991) have examined the parent–child relationship as the source of antisocial behavior. They argue that children’s negative behaviors are maintained and excerbated through the operation of aversive stimuli and negative reinforcement cycles. Early mother–infant conflict (due to difficult temperamental characteristics in the child, poor parenting skills in the parent, or both) may begin the coercive cycle that is so clearly seen in families of older children with antisocial behavior problems. In the coercive cycle, a child’s disruptive behavior is increased by removal of an aversive parent behavior, and vice versa. For example, the parent tells the child to pick up the toys (aversive stimulus), the child whines and cries (aversive stimulus), and the parent withdraws the request. Thus the child’s noncompliance is successful in removing the aversive stimulus and consequently is negatively reinforced. Moreover, the parent is negatively reinforced for withdrawing the request by the cessation of the child’s whining. Patterson (1986; Patterson et al., 1989) further suggests that ongoing poor management on the part of parents—characterized by ignoring or punishing the child’s prosocial behavior, and by positive or negative reinforcement of negative behavior—contributes to the child’s increasing repertoire of aversive behaviors. When the child enters school, this behavior results in rejection by peers and poor academic progress. Peer

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rejection and academic problems in turn lead to affiliation with a deviant peer group, increased problems with antisocial behavior, and possible delinquency. Patterson et al.’s (1991) theory suggests that aversive interchanges between parent and child are initiated primarily by the parent, who presents an aversive stimulus such as a command. Others have modified this view to recognize the influence of the child’s characteristics on parental behavior (e.g., Moffitt, 1993; Webster-Stratton & Spitzer, 1996). The currently accepted model describing the development of disruptive behavior disorders accounts for both parent and child characteristics, specific high-risk periods of development, environmental context, and life events that function as turning points in the developmental pathway (Greene & Doyle, 1999; Maugham & Rutter, 1998; Shaw, Bell, & Gilliom, 2000).

ASSESSMENT OF DISRUPTIVE BEHAVIOR When children are referred for help with disruptive behaviors, an important task for the clinician is to differentiate those children whose conduct problems are likely to persist from those whose difficulties are more likely to be transient. This involves careful assessment of the factors listed in Table 10.1 (Dadds, Schwartz, & Sanders, 1987; Holden, Lavigne, & Cameron, 1990; Kazdin, 1990; McMahon & Wells, 1998; Webster-Stratton, 1985a). The nature and degree of family dysfunction are of critical importance for assessment (Kamphaus & Frick, 1996); parental psychiatric adjustment, relationship instability/divorce, and especially parent socialization practices should all be assessed. Socialization practices include the extent of the parents’ involvement in their child’s activities, supervision or monitoring of the child, and discipline methods. McMahon and Estes (1997) provide detailed assessment procedures for conduct problems. Their approach involves multiple methods and informants in order to obtain a comprehensive view of the intensity, frequency and duration of the child’s behavior problems across settings and from the perspective of different individuals. Consistent with this approach, we follow the Comprehensive Assessment-to-Intervention System (CAIS) framework presented in Chapter 2, which enables the clinician to gather the necessary information systematically and efficiently. The CAIS framework as applied to assessment of disruptive behaviors is outlined next.

Step 1: Initial Contact At the time of the initial referral, parents should be asked to complete a general questionnaire giving demographic information and their perception of the problem (see our General Parent Questionnaire, Appendix B). Standardized questionnaires specific to child conduct problems, such as the CBCL (Achenbach, 1991a, 1992), the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992), and the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999), also provide essential information about the extent of the child’s behavior problems (from the parents’ point of view) relative to other children of the same age. Specific attention should be paid to the presence or absence of internalizing problems, such as anxiety or depression, as indicated on the CBCL or the BASC. It is important to have both parents complete each measure, as there are often significant differences between a mother’s and father’s perceptions of the severity and frequency of a child’s problems. A recent factor analysis of the ECBI (Burns & Patterson, 2000) determined that three factors (Oppositional Defiant Behavior toward Adults, Conduct Problem Behavior, and Inattentive Behavior) accounted

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for most of the variance on this measure. Use of these factors should enable a more fine-grained assessment of the nature of the child’s conduct problems. The Revised Conners Parent Rating Scale (Conners, 1997) can help the clinician screen for the presence of problems with attention and/or hyperactivity. Parents of children under the age of 12 should complete the Parenting Stress Index (PSI; Abidin 1995) to provide information about the marital/couple relationship, parental depression, child temperament, and life stress. Abidin and colleagues (Abidin & Brunner 1995; Abidin & Konold, 1999) have developed a parent questionnaire called the Parenting Alliance Measure (PAM), designed to assess the aspect of the marital/couple relationship most specifically related to parenthood and child rearing. Bearss and Eyberg (1998) provide data confirming the validity of this measure. They found that the PAM was significantly correlated with scores on the ECBI, whereas a more global measure of marital/couple adjustment was not. Parents can also be asked to complete questionnaires such as the Dyadic Adjustment Scale (Spanier, 1976; Spanier & Thompson, 1982) and the Beck Depression Inventory (Beck, Steer, & Brown, 1996), to assess other aspects of family functioning (see Appendix A for descriptions). The Home Situations Questionnaire (HSQ; Barkley, 1997b; again see Appendix A) gives information on the number of problem settings (e.g., playing alone, when visitors are in the home, when parents are on the telephone, at recess, when arriving at school, etc.) and the severity of the problems. The HSQ can also be used to assess changes in behavior during and after treatment. In addition, parents can be asked to keep a Daily Log of the child’s negative behaviors (see Chapter 2 and Appendix B). This record helps the clinician determine what the child is actually doing (in contrast to what the parents think he or she is doing), and gives preliminary information about the frequency and intensity of the problem behaviors. The Daily Log also provides a baseline against which to measure changes in the child’s behavior with treatment.

Step 2: Parent and Child Interviews In our clinic, a child with disruptive behavior is typically included in the initial interview with the parents. This enables the clinician to observe parent–child interaction, and it also ensures that everyone hears the same information. We have found that disruptive children have a good idea of the problems and will often offer their personal opinions about topics the parents bring up. Parents are informed of this arrangement during the initial phone contact and are asked to make a list of the child’s positive qualities and behaviors. They are asked to refer frequently to this list when talking with the clinician about the child’s troublesome behaviors; if they do not do so, the clinician asks about the child’s strengths directly. If parents are uncomfortable with the child’s being present, or if the child’s behavior is likely to be too disruptive, a separate parent interview is scheduled and the child is seen at a later time. The interview with the child is, however, begun with the parents present and with a joint discussion of the problems of concern as well as the child’s positive qualities. Parent Interview It is important that both parents attend the initial interview whenever possible. As noted above, father and mother often have very different perceptions of a child’s behavior and may handle discipline very differently (and inconsistently). The clinician should determine whether this is a source of conflict for the parents that will need to be resolved with treatment. Having both parents present at the initial interview also increases the chances that both of them will partici-

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pate in treatment. Although the presence of both parents is not always necessary for effective treatment (Martin, 1977), the cooperation and support of the absent parent are important. Single parents have been shown to have difficulty maintaining the effects of treatment over time and are also more likely to drop out of treatment prematurely (Webster-Stratton, 1985b). Webster-Stratton (1985b) suggests that single parents might be encouraged to involve a close friend, relative, or regular child care provider in the treatment process, in order to enhance effectiveness. The parent interview necessarily covers a great deal of information, and the clinician should allow 1½ to 2 hours for this first appointment. The following areas should be assessed: 1. Developmental history and current status. The clinician should focus on the child’s early development, particularly in regard to issues of control and independence, as the early years are the time when disruptive behaviors often originate. The child’s early medical history should also be explored, as parents often have difficulty providing effective and consistent discipline for children who have been seriously ill. As an example, a 4-year-old girl was unable to be tested for intellectual problems because her behavior was so out of control. Her parents admitted that they had been afraid to discipline her, because the first time they had sent her to her room for being bad, she had had a seizure! Questions should also be asked about the child’s temperamental characteristics as these were manifested during infancy and early childhood. Current developmental status is important to assess, particularly for young children. Delays in language, cognition, or other areas can exacerbate children’s disruptive behavior and also influence the focus of treatment. 2. Parent and family characteristics. Information gathered from the screening instruments provide a basis for discussion of these issues. If, for example, marital/couple conflict, maternal depression, or other types of psychopathology appear to be problems, these should be addressed directly; the clinician should assess their severity and the extent to which they are likely to interfere with treatment for the child’s problems. In some cases marital/couple conflict and parental psychological problems decrease as the child’s behavior improves, although in other cases these problems are associated with premature termination from treatment or ineffective treatment. The parents should be advised about the necessity of seeking treatment for these problems prior to or in conjunction with treatment for the child’s conduct problems. 3. Parenting styles and techniques. General information about the parents’ attitudes and expectations for themselves as parents and for their children can inform the clinician about aspects of the parent–child relationship that will affect the parents’ abilities to follow through with treatment. Asking questions about the parents’ own parenting history is often revealing. It is also critical to assess parents’ responses to their child’s behavior as it occurs in day-to-day life. Barkley (1997b) and McMahon and Estes (1997) suggest assessing specific situations (such as playing alone or with other children, mealtimes, visits to others, bedtimes, or bathtimes) that could involve misbehavior by asking parents: (a) “Is it a problem?” (b) “What does the child do?” (c) “What is your response?” (d) “What does the child do next?” (e) “What is the outcome of the interaction?” (f) “How often do problems occur in this situation?” and (g) “How do you feel about these problems?” Finally, parents may be asked to rate the severity of the problem on a scale of 1 (“no problem”) to 9 (“severe problem”). The HSQ (Barkley, 1997b) or the Daily Log can help to guide and thus shorten the interview time. Another method of getting this type of information is to ask parents to describe in detail their typical daily routines. This usually reveals the situations that are most problematic for the

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parents, and it gives the clinician the opportunity to determine what the child does and how the parents handle it. This method also reveals the “rhythm” of the family’s life and the strengths as well as the weaknesses of the child and parents. The clinician will need to ask very specific questions, such as “Who gets up first?”, “What happens next?”, “Who fixes breakfast?”, “What time is dinner usually served?”, and so on, in order to get the necessary detail. Specific questions about the antecedents and consequences of the child’s disruptive behavior should be asked. Because negative behavior is maintained, strengthened, or decreased by its consequences, identification and manipulation of these consequences will be an important aspect of treatment. Likewise, environmental conditions can set the stage for increased negative behavior (e.g., parents coming home tired and trying to fix dinner at a time when the child most needs parental attention) and can be an effective focus for treatment. Parents’ attempts to manage the child’s disruptive behaviors should be examined in detail, in order to determine the various techniques the parents have tried and their relative effectiveness. Parents will typically indicate that they “have tried everything, and it doesn’t work.” 4. Recent and ongoing stresses. A simple question such as “Has anything happened in your family lately that might be related to your child’s behavior problems?” often reveals startling and important information. It is not unusual for a parent to mention in an offhand manner that he or she has just lost a job, or an important family member has recently died. Sources of ongoing stress (financial problems, job-related stress, stressful family relationships, etc.) are likewise important to assess, as these will influence treatment effectiveness. 5. Persistence of problem behaviors. Specific information about the child’s problem behaviors is obtained when the parents are asked about a typical day (see above). However, the clinician should also assess the persistence of the behavior and the number of situations in which it occurs. Children who are exhibiting negative behavior at home but nowhere else (“street angels, house devils”) have a better prognosis than children who are having conduct problems in school and in the community as well as at home. Moreover, children for whom disruptive behavior has been a characteristic pattern for a long time will be more difficult to treat than those for whom the disruptive behavior is relatively recent. Child Interview Having the child present while the clinician talks with the parents provides an opportunity to begin observing the child’s behavior and assessing his or her perceptions of the problem vis-àvis those of the parents. Age-appropriate toys should be provided for the child, and the clinician can informally assess the child’s attention span and ability to play alone, as well as the parents’ management skills. The clinician can also begin to model appropriate methods of interacting with the child as the situation permits. A short period of time alone with the child following the interview with the parents is always a good idea, as this gives the clinician the opportunity to assess the child’s behavior with someone other than the parents, and to determine more closely the child’s perceptions of the problem and of his or her parents. An interview with the child, however, may or may not be useful with regard to content, as many children are reluctant to talk about their conduct problems (McMahon & Wells, 1998). With a child 6 years of age or older, an attempt should be made to assess the child’s perceptions of his or her role in the disruptive behavior, its consequences, and/or setting conditions. General areas to assess include family (“What do you like best about your father, mother, brother, or sister?”, “What do you like least?”), friends (“Who is your best friend?”, “What do you like to do with

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him or her?”), school (“What do you like best/least about school?”, “What is your best/worst subject?”), and personal strengths and weaknesses (“What do you like to do best/least?”, “What are your favorite games/sports?”, “What do you like best about yourself?”).

Step 3: Observation of Behavior Direct observation of the parent–child interaction is a central feature of the assessment of conduct problems, and a variety of systematic methods have been proposed. Barkley (1997b) suggests having the parent and child play together “as they would at home” for about 5 minutes, and then giving the parent a list of 10 simple tasks (e.g., “Stand up,” “Open the door,” “Take off your shoes,” “Do these math problems”) to do with the child. The observer records the parent behavior (command, repeated command), the child’s response (comply, noncomply, negative), and the parent’s reaction to the child’s behavior (attend or praise, negative) for about 10 minutes. Forehand and McMahon (1981) instruct parents to play with the child in two situations for 5 minutes each. During the “Child’s Game,” the child is allowed to determine the play activities and rules; during the “Parent’s Game,” the parents determine the rules and activities. Behavior is recorded as it occurs in 30-second intervals. Parent behaviors coded include rewards, attends, questions, commands, warnings, and time out. Child behaviors coded include compliance, noncompliance, and deviant behavior. Eyberg, Bessmer, Newcomb, Edwards, and Robinson (1994) developed the Dyadic Parent–Child Interaction Coding System—II (DPICS-II) to observe parent–child interactions on two separate days during three 5-minute situations (Child-Directed Interaction, Parent-Directed Interaction, and Cleanup) that vary in the degree of parental control required. Behaviors coded include parent and child verbalizations, vocalizations (e.g., whine, yell), positive or negative physical touch, parent commands and praise, and child compliance. This is the most comprehensive system of measuring interactions between the parent and child in the clinic setting. We use a modification of Forehand and McMahon’s (1981) observational system and the DPICS-II. We record parental commands (C), questions (Q), praise (P), and attention (A), and child compliance (CC), noncompliance (CN), and other deviant behavior (CD), as they occur in two 5-minute situations, the Child’s Game and the Parent’s Game. Age-appropriate toys are provided for younger children, whereas older children and their parents are asked to play a game together and to solve a family problem (e.g., to plan a family vacation). Figure 10.2 illustrates the data sheet we use. Although observations typically take place in the clinic, home or school observations are also useful if the clinician needs a more complete picture of the child’s functioning. In the school, the observer can simply keep a running account divided into 1-minute segments (this indicates when in the observation period a behavior occurred and for how long) of the child’s behavior and responses to it; or the observer can focus on the frequency, antecedents, and consequences of target behaviors if these are identified in advance. It is usually a good idea also to observe a randomly selected classmate, so the target child’s behavior can be evaluated relative to others in the same setting. Both the CBCL (CBCL—Direct Observation Form; Achenbach, 1986) and the BASC (BASC—Student Observation System; Reynolds & Kamphaus, 1992) also have an observation system designed for the classroom. The Revised Edition of the School Observation Coding System (REDSOCS; Jacobs et al., 1999) can be used to assess the child’s disruptive behavior in the classroom. The REDSOCS is an interval coding system that measures inappropriate, noncompliant, and off-task behaviors. A child is observed for 10 minutes on three different school days, yielding a total of 30 minutes of observation; a randomly selected classmate can also be

Disruptive Behavior Parent–Child10.Interaction Data Sheet

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Name: ____________________________________ Recorder: ______________________________ Date: _____________________________________ Time: __________________________________ Parent: Attention Praise Question Command

(A) (P) (Q) (C)

Child: Compliance Noncompliance Other deviant behavior

(CC) (CN) (CD)

P C P P C P P C P P C P P C P P C P P C P FIGURE 10.2. Data sheet for recording parent–child interaction in the clinic. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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coded with the same system. The REDSOCS categories are significantly correlated with the Sutter–Eyberg Student Behavior Inventory—Revised (SESBI-R) and the Revised Conners Teacher Rating Scale (Conners, 1997), and discriminate between children referred for school behavior problems and their randomly selected classmates. Home observations should occur at times identified as being problematic for families. Dinnertime or just before is typically a good time to observe negative behaviors. Again, a running account of the interactions is usually the most efficient method.

Step 4: Further Assessment At this point, the clinician will have a good idea of the nature and severity of the child’s conduct problems. Further assessment is needed if there are concerns about the child’s developmental status or performance in school, or about a parent’s ability to meet the demands of the treatment program. Because learning problems are positively associated with conduct problems in school-age children, psychoeducational assessment may be necessary. If the child’s behavior is a problem in school as well as in the home, permission should be obtained to contact the child’s teacher, and the Teacher Questionnaire (see Appendix B) and behavioral questionnaires such as those described in Chapter 2 should be sent out. The SESBI-R (Eyberg & Pincus, 1999), the School Situations Questionnaire (SSQ; Barkley, 1997b), the CBCL— Teacher’s Report Form (CBCL-TRF; Achenbach, 1991b), and the Revised Conners Teacher Rating Scale are particularly helpful. Descriptions of the CBCL-TRF, the SESBI-R, the SSQ, and the Revised Conners Teacher Rating Scale are included in Appendix A.

Step 5: Referral to Allied Health Professionals The clinician should be alert to the possibility of ADHD’s occurring along with conduct problems, and should refer the family to an appropriate professional for assessment of the possibility of a medication trial if this is relevant. Management of ADHD as well as the negative behaviors will be necessary in these cases. Children with conduct problems also often have significant developmental or medical problems that require the use of medication (e.g., seizures). In these cases, contact should be made with the child’s physician to discuss the proposed treatment program and to ensure appropriate coordination of medical and behavioral treatment. Finally, children who engage in severely aggressive behaviors that are potentially dangerous to themselves or others may need to be referred to an inpatient facility until their coercive behaviors are brought under better control. In these cases, behavioral management training would be recommended in conjunction with inpatient treatment or immediately following the children’s release.

Step 6: Communication of Findings and Treatment Recommendations The clinician’s understanding of the nature, etiology, and severity of the child’s negative behavior, as well as potential treatment approaches, should be discussed with the parents. A clear understanding of these issues, especially of how the negative behavior fits into the child’s developmental picture, will help the parents and child to trust the clinician and maximize the possibility of their cooperation with treatment. Some discussion about the prognosis for the child’s problem is also warranted, although this must be done carefully (particularly when the child is young) to avoid setting up a “self-fulfilling prophecy.” In some cases it is clear that

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a course of parent training will eliminate the child’s problem behaviors. In other cases, however, the prognosis is less positive. The risk factors for continuing conduct problems are well known, and these should be shared with the parents. In particular, there is little chance of a “cure” when a child is older; when the antisocial behavior has begun early in life; when it is severe, is frequent, and occurs across situations; and/or when the parents or environmental characteristics exacerbate the child’s problems. Kazdin (1987, 1995) recommends that cases of severe conduct problems be viewed from the perspective of a “chronic illness” model. Treatment can bring the behavior under sufficient control that the family can function reasonably well, but the child is likely to need continual monitoring, and the parents will need ongoing or periodic help and support from the clinician.

TREATMENT Clinical and developmental research supports the idea that contingent, appropriate parental responses to child behaviors constitute a key factor in the development and maintenance of positive child behaviors. This research has stimulated the development of programs designed to train parents in principles of social learning and in effective parent–child interaction and child management skills. This and a number of other treatment approaches for disruptive behavior, such as social skills training, cognitive skills training, family therapy, and school interventions (including early education programs), are reviewed by Horne, Glaser, and Calhoun (1999), Kazdin (1995), and Christophersen and Finney (1999). These other approaches, as well as pharmacotherapy, are discussed briefly here as they apply to intervention with the child, the parents, the environment, or medical/health issues, according to the CAIS framework. However, the primary focus of this section is on behavioral parent training, as this approach has accumulated the most proof of effectiveness. (It includes both intervention with the parents and changing the consequences of the child’s behavior—another element of the CAIS framework.) Finally, some innovative prevention programs are described.

Intervention with the Child Social Skills Training Programs Social skills training programs are based on the assumption that antisocial behaviors are learned and that faulty learning leads to deficits in the social skills necessary for interacting effectively and appropriately with others. Although social skills training does result in gains in social skills, there is no evidence that this type of treatment alone modifies antisocial behavior to a clinically significant degree (Taylor, Eddy, & Biglan, 1999). Cognitive Skills Training Programs Similarly, antisocial children have demonstrated deficits in social cognitions. They attend more to aggressive stimuli, overattribute hostile intent, lack empathy, are deficient in social problemsolving skills, and lack awareness of the consequences of their behaviors. Cognitive skills training programs are aimed at remediating these deficits. Although these programs do seem to improve social-cognitive skills, again, there is little evidence for their long-term effectiveness in reducing antisocial behavior when used alone (Hudley et al., 1998). Research by Kazdin and Wassell (2000)

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and Webster-Stratton and Hammond (1997) indicates that cognitive-behavioral skills training for children combined with parent management training is more successful across a wider range of variables at home and with peers (but not necessarily at school) than either component alone. The intervention described by Webster-Stratton and Hammond (1997) involved a comprehensive videotaped program targeting the following components: (1) controlling anger; (2) problem solving; (3) making friends; (4) coping with rejection and teasing; (5) paying attention to teachers; (6) finding alternative solutions to problems; (7) cooperating with parents and teachers; and (8) self-talk as a coping strategy. When implemented alone, this program resulted in modest improvement in children’s behavior, and Webster-Stratton and Hammond suggest that it may be useful when parents cannot or will not participate in a child’s treatment.

Intervention with the Parents/Changing the Consequences of the Behavior Behavioral Parent Training Behaviorally based parent–child interaction training programs are the most common and successful treatment approaches for disruptive behavior among young children, and most parents report significant satisfaction with these programs (Brestan & Eyberg, 1998; Patterson et al., 1992; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998; Webster-Stratton, 1993). Moreover, parent training is compatible with the current demands of the mental health care delivery system (i.e., managed care insurance) in that it is cost-efficient, time-limited, and empirically validated, and it provides for careful documentation of treatment gains (Taylor & Biglan, 1998). Parent training programs are effective whether administered individually, in groups, or by parents to themselves (Webster-Stratton, 1984; Webster-Stratton, Hollinsworth, & Kolpacoff, 1989), although brief in-person consultation with a therapist enhances the effectiveness of selfadministration (Webster-Stratton, 1992a).1 Behavioral parent training is based on the assumption that the child’s behavior (normal, deviant, or delayed) is related to past and current interactions with significant others, particularly parents, and that the behavior of these significant people must be changed in order to change the child’s behavior (Bijou, 1984). The strategies employed include objectively defining goals for treatment; teaching parents principles of social learning; using behaviorally based techniques to shape the child’s behavior; monitoring progress with systematic records and adjusting teaching accordingly; and modifying environmental conditions so that changes are maintained and generalized (Bijou, 1984). The specific process is described in the next section. In a review of research evaluating parent training programs, Kazdin (1995) concluded that the characteristics associated with good outcomes for families of children with severe conduct problems who were involved in parent training were as follows: (1) more sessions, up to 50–60 hours; (2) training in specific techniques, such as time out; (3) training in principles of social learning; (4) therapist training and skill; and (5) broad-based therapy designed to have an impact on various problems associated with conduct problems in children. In addition to these components necessary for successful treatment, Taylor and Biglan (1998) add (1) modeling and role play, versus simply reading and discussing; (2) building a collaborative relationship with parents; (3) providing sufficient structure; (4) dealing with resistance; and (5) including instruction in problem solving. 1The

parent training program developed by Webster-Stratton, The Parents and Children Videotape Series: Programs 1–10, is available for purchase. It may be ordered from Seth Enterprises, 1411 8th Ave. W., Seattle, WA 98199.

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For some families—particularly low-income, socially isolated, multiproblem families—a lack of effectiveness of parent training has been documented (Kazdin, 1987). This has led to the enhancement of parent training by combining it with other therapies designed to meet the specific needs of individual families (Taylor & Biglan, 1998). Many ways of doing this have been reported. Kazdin and his colleagues (Kazdin, Esveldt-Dawson, French, & Unis, 1987; Kazdin & Wassell, 2000), for example, combined parent training with cognitive-behavioral and problem-solving skills training for children and found this combination more effective than parent training alone in reducing antisocial behavior and increasing the children’s prosocial and overall adjustment. Sanders and McFarland (2000) combined cognitive-behavioral methods with parent training for clinically depressed mothers of children with conduct problems. The combination of treatments was found to be more effective than either treatment alone, particularly in alleviating the mothers’ depression over the long term. In addition to parent training, Griest et al., (1982) provided mothers with treatment focused on parental perceptions of child behavior, parents’ personal adjustment, marital/couple adjustment, and extrafamilial relationships. The combination of this “parent enhancement therapy” with parent training was found to be more effective in changing children’s and parents’ behavior than parent training alone. Wahler and his colleagues (Wahler, Cartor, Fleischman, & Lambert, 1993; Wahler & Dumas, 1984) combined parent–child interaction training with teaching parents how their interpretations of the child’s behavior as appropriate or inappropriate may vary in relation to their own coercive and stressful interactions with persons outside the family. This approach, called “synthesis training,” has proven effective in maintaining the behavior changes resulting from parent training in isolated, multiply stressed families. Blechman (1984) recommends three other adjunct treatment approaches dependent on the individual needs of the family. These include self-control training, for parents who have trouble with impulse control; self-sufficiency training, for parents who have problems managing the basic necessities of life; and marital/couple problem-solving training, for parents with relationship conflict. Finally, treatment involving problem solving (problem identification, generating alternative solutions, implementing solutions, and evaluating effectiveness) focused on problems other than child management has been found to enhance the long-term effectiveness of parent training for single parents (Pfiffner, Jouriles, Brown, Etscheidt, & Kelly, 1990). In addition to combining various treatment approaches to enhance effectiveness for difficult families, emphasis is currently on maintenance of treatment effects over the long term. This concern is based on the documented persistence of conduct problems and the fact that there is limited evidence for the effectiveness of parent training beyond 1 year posttreatment (Eyberg, Edwards, Boggs, & Foote, 1998; but see Taylor & Biglan, 1998). Various approaches to this problem have been taken, including strategies that are incorporated into the treatment program and those that are implemented after treatment is terminated. Eyberg and her colleagues (Eyberg & Boggs, 1998; Eyberg et al., 1998) note that in the former approach, parents have been taught to use problem-solving skills to deal with potential and actual problem situations, as well as to develop “house rules” that are discussed with the child and enforced consistently; also, the interval between sessions is gradually increased. In the latter approach, informal contacts with the therapist (phone calls, letters, etc.), support groups, and booster sessions with parents are planned. Eyberg et al. (1998) also indicate that strategies for relapse prevention that have been developed for other problems may be applied to treatment of children with conduct problems. These include identifying and preparing for high-risk situations, and recognizing and dealing with symptoms of relapse (i.e., increases in disruptive behavior) before they become severe.

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Many books have been written for parents of children with disruptive behavior problems. Our favorites include Your Defiant Child: Eight Steps to Better Behavior (Barkley & Benton, 1998), The Explosive Child (Greene, 2001), and The Difficult Child (Turecki & Tonnes, 2000). A national resource is Parents and Teachers of Explosive Kids, http://www.explosivekids.org. The Parent Training Program A highly effective program for younger children (2–8 years) used in our clinic is that developed by Hanf (1969) and modified by Eyberg and her colleagues (e.g., Querido, Bearss, & Eyberg, 2002) and others (Barkley, 1997b; Forehand & McMahon, 1981). The Parent–Child Interaction Treatment Program described by Eyberg and colleagues emphasizes teaching parental responsiveness and improving the quality of the parent–child relationship through the use of behavioral techniques. This is a two-part program. The first part trains parents how to attend to and praise their child’s appropriate behavior, with the goal of strengthening the parent–child bond, increasing positive parenting, and improving the child’s social skills. This is called Child-Directed Interaction and resembles traditional play therapy. Once this skill is polished (indeed, overlearned), parents are taught to give simple, clear commands and to use time out by isolation. This Parent-Directed Interaction phase of treatment resembles child behavior therapy; it focuses on improving parents’ expectations, ability to set limits, consistency, and fairness in discipline, and on reducing child noncompliance and other negative behavior The parents are also helped to generalize their new skills to specific problem situations, such as visiting friends or shopping. Although the program is most suited to younger children, it can be modified for older children by adding such features as token systems (Barkley, 1997b) or contingency contracting and family problem solving (Foster & Robin, 1997). The following is a brief outline of how this program is used in our clinic. For greater detail, the reader is referred to Foote, Schuhmann, Jones, and Eyberg (1998), Forehand and McMahon (1981), and Barkley (1997b). Step 1: Attending and Praising. In the first session, the clinician explains the rationale for the parent training program and presents basic social learning principles. We emphasize how children learn by drawing a diagram for parents (Figure 10.3). Simply put, behavior can be increased or decreased by providing something or taking something away. If, contingent on a specific behavior, positives are presented (positive reinforcement) or negatives are taken away (negative reinforcement), that behavior will increase. Similarly, if negatives are presented (punishment) or positives are taken away (time out, response cost), the behavior will decrease. Next, developmental expectations for children of the child client’s age are presented, with a discussion of the child’s strengths and weaknesses within this developmental framework. Specific behaviors are targeted to be increased and decreased. The parent training program is based on a system of presenting and taking away positives. The rationale for attending and praising is discussed as one way of presenting positives. There are many reasons why parents should learn to attend and praise the child’s appropriate behavior. These are described in Figure 10.4, which is a handout for parents. It should be emphasized that simply eliminating negative behaviors is never successful, because the child will find some other way (usually aversive) to gain parental attention. Teaching appropriate behaviors and behaviors that are incompatible with aversive behaviors effectively fulfills this need. Moreover, the technique of following, attending, and praising is remarkably similar to observations in the research literature of maternal responsivity or synchrony, which has been demonstrated

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Decrease Behavior

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Present

Take Away

Positive Reinforcement

Negative Reinforcement

+

–

(tokens, privileges, praise)

(nagging, yelling)

Punishment

Punishment

–

+

(yelling, spanking)

(removing privileges, logical and natural consequences, time out by isolation)

FIGURE 10.3. How children learn.

to be related to increased levels of child compliance (Rocissano et al., 1987; Wakschlag & Hans, 1999). These skills also provide the basis for active listening, which is crucial to good communication with adolescents. Teaching following, attending, and praising skills to parents also helps to break the aversive parent–child interaction cycle that is common when a child has been exhibiting high levels of disruptive behavior. Finally, parents should know that time out will not be effective unless the child’s experience is largely positive. Time out works by removing the child from opportunities to receive positive reinforcement, which is only possible if the child experiences large doses of reinforcing interactions with family members. If these interactions are largely negative, time out will be experienced as a relief by the child and may actually serve as a reinforcer for disruptive behavior. The idea behind attending is to watch the child carefully and describe enthusiastically what he or she is doing in a “play-by-play” manner (see Figure 10.4 for examples). Parents should be taught to use “labeled praise” (which specifies the desired behavior) whenever possible, as this lets the child know clearly what is acceptable behavior. Physical demonstrations of affection, such as hugs, kisses, or pats on the back, are also good ways to praise the child. The clinician should model following, attending, and praising with the child in play. The parents are then given an opportunity to try out this new skill. It is awkward and difficult for most parents at first, and the clinician should coach the parents by offering suggestions for descriptive statements or praise as appropriate and by praising their efforts. The parents must be told that behaviors described and praised will increase, so they need to be careful to ignore any behaviors that are not considered appropriate. At this point in treatment, behaviors that cannot be ignored (hitting, throwing toys, etc.) should be handled as the parents typically do; however, these behaviors also should serve to terminate the play session. Parents should be reminded not to ask questions, give any commands, or teach the child during this playtime. Questions are perceived by the child as demands, whereas commands and teaching interrupt and structure the child’s play. Because these are typical ways in which adults interact with children, parents usually need to be gently reminded about this from time to time (“Oops, that was a question! Try to restate it as a descriptor,” or “That was a command; did you really mean it?”).

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Child’s Game The goal of the “Child’s Game” is to increase your child’s appropriate and desired behavior by following, attending, and praising it. The benefits of the Child’s Game for both you and your child are many. • It will help your child learn the behaviors that you find acceptable and appropriate. If you want to stop certain behaviors, it is important to teach your child what behaviors you do want. • Following your child’s lead by attending to and praising appropriate behavior sets the stage for a pleasant, positive relationship. This will increase the likelihood that your child will naturally want to please you. • You will learn to monitor your child’s behavior more accurately, so that you can be more consistent in both rewarding good behavior and ignoring or punishing undesirable behavior. • Children learn by watching their parents. The Child’s Game will teach your child how to follow, attend, and praise behavior they like in other people. Your child may even begin to praise your behavior! • Punishment of undesirable behavior works best when there are many positive interactions with the child. A positive relationship also decreases the need for punishment! • The skills of reflective listening, along with attending and praising your child’s behavior, are ones that can be used throughout your child’s development. These skills let your child know that you are interested in what he or she is doing or thinking, and therefore your child will naturally want to share more with you. What you have to say will also become more important to your child. • Your child will feel good about him- herself, because you have let the child know what you like about him or her.

Steps for Success 1. Time Find a time every day when you can give full attention to your child. It is often best to choose a regular time of the day so that it becomes a part of your daily routine. Plan for 5 to 20 minutes. The use of a timer also helps, especially when you are first learning to follow, attend, reflect, and praise.

2. Child’s Activity Allow your child to choose the activity. Activities such as building blocks, drawing, puzzles, or Legos that allow free expression are good. Try to avoid games that require following rules such as table games. Avoid reading stories. Let your child know that this is his or her special time and that you will play with the child for the next 5 to 20 minutes. FIGURE 10.4. Parent handout for teaching self-control: Part 1—Child’s Game. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this table is granted to purchasers of this book for personal use only (see copyright page for details).

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3. Follow This simply means that you should watch closely and with interest what your child is doing. You should not be reading the newspaper or thinking about something else during this time.

4. Attend Think of yourself as a baseball announcer on the radio. You want to give an enthusiastic and detailed running commentary on your child’s activity. You can describe: • Your child’s actvity: “You are building a high tower.” “You’re driving your car very carefully.” “You’re using a red crayon and making a circle.” • Where your child is: “You are sitting on the floor.” “You are showing me your picture of a house.” “You are on your stomach checking out your tower.” • “Your child’s mood or appearance: “You are smiling.” “You are wearing a green shirt.” “You are trying very hard and being very careful.”

5. Reflective Listening This lets your child know that you are hearing and are interested in what he or the says. You can listen reflectively by: • Simply Child: Parent: Child: Parent: Child: Parent:

repeating back what the child has said: “I want a green block.” “You want a green block.” “I like playing with you.” “You like playing with me.” “I hate these blocks.” “You hate those blocks.”

• Elaborating on what the child says: Child: “I want a green block.” Parent: “You want a green block for your house.” Child: “I like playing with you.” Parent: “You are enjoying our special time.” Child: “I hate these blocks.” Parent: “You are really angry.”

6. Praise You can praise by labeling what it is you like (“I like the way you used yellow to draw the sun,” or “You are putting the cars in the box so carefully”), or you can give unlabeled praise (“Good work”). Labeled praise has the advantage of letting your child know specifically what you like and thus gives your child more information. This will take some practice, but it will get easier. Another way to praise your child is to give hugs, kisses, and smiles.

7. Ignore When your child engages in behavior that is undesirable but not harmful or destructive, withhold your attention (i.e., stop following, attending, or praising). This lets the child FIGURE 10.4. (cont.)

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8. No Questions or Commands It is very important not to ask questions (“What are you doing?”, “You are happy, aren’t you?”, What are you drawing?”) or give commands (“Give me the car, “Put this on top”). This interferes with the flow of your child’s play and structures the play unnecessarily.

9. No Teaching This is not a time to teach your child or to find out what he or she knows. It is a time to follow your child’s lead, so that you can see how much your child does know and can do by him- or herself!

10. Parent Participation It is important that your child’s activity is the focus of your time together. You can participate in the activity by handing your child things and imitating his or her play, but be sure to continue describing and praising what your child is doing. Be careful not to lead the activity or structure it in any way.

11. Homework Play the Child’s Game with your child every day for 5 to 20 minutes, but no less than 5 minutes. This is a time to practice the attending, reflective listening, and praising skills, but it is also a time to enjoy and get to know your child. Keep a record of each time you play the game on the attached record sheet. Remember that you can also practice using these skills throughout the day. The goal is to make them a natural part of your everyday interactions with your child. Have fun!! You can make a difference in your child’s life!! FIGURE 10.4. (cont.)

Parents should be instructed to set aside a short period of time each day to play with their child and practice attending and praising, and each session of this “Child’s Game” should be recorded on a record sheet (Figure 10.5). We recommend 15–20 minutes, although Eyberg and Boggs (1998) argue that 5 minutes is sufficient and effective. If two parents are involved in treatment, they can take turns coaching each other. If there are other children in the family or both parents work, the clinician will have to help parents determine how this special time will fit into the family schedule. Although attending and praising are practiced during special play sessions with the child, parents should be encouraged to apply this skill at other times during the day. The way to do this is to periodically (once every 30 minutes, for example) check on the child, decide whether the behavior in which he or she is engaging is appropriate, and, if so, then praise or describe it. Describing behavior during daily activities is also effective—for example, “I like the way you are staying close to me in the mall.” The handout describing the procedure (Figure 10.4) is given to the parents, as is the chart to record each time the Child’s Game is played and the child’s reaction to it (Figure 10.5). At the beginning of the next session (and all subsequent sessions), the clinician should check with the parents to determine what has happened during the preceeding week. Reviewing the parents’ Daily Log provides a structured way to do this. Parents should then each be asked to demonstrate attending and praising, and the clinician should record this behavior for

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Child’s Game Record Sheet Date

Time

Activity

Child’s Response

FIGURE 10.5. Chart for recording sessions of the “Child’s Game.” From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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about 5 minutes for each parent. The goal is to reach a rate of 10 behavioral descriptions; 10 reflective statements; 10 labeled praises; and no more than 3 questions, commands, or criticisms (Querido et al., 2002). Parents also must ignore nonharmful inappropriate behavior. The remainder of this session (and succeeding sessions until the goal is reached) should be spent coaching the parents on the use of attending and praising. The clinician should sit in an unobtrusive manner and ignore any overtures from the child. Positive feedback on how a parent is doing should be given quietly. This feedback should point out important developmental expectations for child behavior and the specific effects of the parents’ behavior on the child. The clinician should be sure to praise the parents’ efforts, especially if they are having difficulty mastering the techniques; behavior that is reinforced will increase! Some parents will need to increase their rates, whereas others may lack enthusiasm. In the latter case, the clinician will need to model enthusiastic statements. Step 2: Giving Good Commands and Using Time Out. The second step of the parent training program consists of teaching parents how to give good, clear, age-appropriate commands, and then to provide consistent consequences for compliance or noncompliance to those commands. Good commands have eight characteristics (Querido et al., 2002): (1) They should be direct rather than indirect (“Hang your coat up” vs. “Wouldn’t you like to hang your coat up now?”); (2) they should be positively stated (“Please hold my hand” vs. “Stop running ahead of me”); (3) they are given one at a time; (4) they should be specific or stated in a way that the child knows exactly what behavior is expected (e.g., instead of saying “Be good,” a parent should specify what is meant by “good” in the specific situation); (5) they should be age-appropriate (i.e., the parent should only ask the child to do something the child is capable of doing); (6) they should be given politely and respectfully; (7) they should be used only when necessary; and (8) reasons for the commands should be explained before the command is given or after the command is obeyed, rather than after the child refuses to obey, as this gives attention for not obeying. The procedure for using commands and using time out for noncompliance (the “Parent’s Game”) is given in Figure 10.6, which is another parent handout. Important parameters of time out are duration (1–4 minutes appears to be effective) and contingent release (time out should be terminated only after a period of quiet) (Hembree-Kigin & McNeil, 1995). In addition, the parents should be instructed to ignore any low-level annoying behavior (crying, whining, kicking the wall, complaining) that occurs while the child is in time out. A kitchen timer should be used so that both parent and child know when time out is over. If the child cries, screams, or is otherwise disruptive in time out, the timer should be reset each time this occurs. The time-out procedure should begin with a warning (i.e., “If you do not do ______, then you will have a time out”). After one and only one warning, the child is taken to a time out chair. Some children will not stay in time out, and there are four ways to deal with this behavior. These should be discussed with parents to determine which would work best for them. First, if the child gets off the chair, then the child can be taken to a time-out room. The room is only used for time out if the child gets off the chair. Second, the child can be repeatedly put back on the chair each and every time he or she leaves it. This method is effective, but takes considerable amounts of parents’ time and energy. Parents need to assess whether they can do this repeatedly without becoming unduly upset or angry. Third, the parents can be instructed to warn the child once and only once, “If you come out of time out again, I will spank you.” If the child comes out of time out again after this warning, the parents are instructed to administer two spanks on the child’s bottom, using only the fingers of one hand (Hembree-Kigin &

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Parent’s Game The goal of the “Parent’s Game” is to learn how to give commands and to punish undesirable behavior by using time out. “Time out” refers to “time away from ongoing positive reinforcement.” Most young children like to be around people, so time out from attention and ongoing activities can be an effective punishment. Time out is only effective if there are a lot of positive “time-in” opportunities.

Steps for Success 1. Give Good Commands Good commands are: • Direct (“Mary, please hang up the towel” vs. “Mary, let’s hang up the towel”). • Positively stated (“Please hold my hand” vs. “Stop running”). • Given one at a time (“John, please pick up your coat” vs. “John, you know you are to put your coat in the closet, your lunch bag in the kitchen, and your books on the table when you get home”). • Clear and concise (“I want you to sit quietly in the cart. Do not touch anything in the store” vs. “I want you to be good”). • Age-appropriate (“Get an apple out of the bowl” vs. “Get a snack from the kitchen”). • Polite and respectful (“Please hand me the brush” vs. “Give me that brush right now”). • Something the child can do immediately (“Please get ready for bed now” vs. “Tomorrow I want you to go to bed on time”). • Used only when necessary (e.g., child is jumping on the couch; “Please sit down” vs. “Say good-bye to Aunt Mary”).

2. Ask No Questions/Make No Suggestions Do not ask a question when you want your child to do something (“Would you feed the cat now?”). When you ask your child a question, you give him or her a choice, and you must be willing to accept “No” as an answer. If you give a suggestion (“Let’s go outside”), you should also be prepared to allow your child to say “No.” Be sure to give your child true choices as much as possible, but not when you want him or her to do what you say. FIGURE 10.6. Parent handout for teaching self-control: Part 2—Parent’s Game. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this table is granted to purchasers of this book for personal use only (see copyright page for details).

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3. Praise Compliance After you give a command, stop and wait 5 seconds for your child’s response (count silently, never out loud). If your child does what you want, immediately praise or attend to him or her (“I appreciate your hanging up your coat”). As you learned in the Child’s Game, you can increase compliance by giving it attention after its occurrence. You can also increase compliance by describing your child’s actions as he or she starts to obey (“I see you are picking up the blocks”).

4. Give a Warning If your child does not comply with your command after a (silent) count of 5 seconds, give a warning. Do not repeat the command. Warnings are “If–then” statements (“If you don’t pick up your coat, then you will have to sit on the chair!”). Warnings should be given in a stern voice so that your child knows that you are serious. If your child complies following a warning, immediately praise and/or attend to him or her.

5. Use Time Out If your child does not start to comply within 5 seconds after a warning, you should use time out. Time out by isolation is best carried out by putting your child in a chair facing a corner or in his or her room. Take your child firmly by the hand and place him or her on the chair. Say, “Since you did not ______ , you will have to sit in the chair [or stay in your room].” The length of time out should be 2 to 4 minutes for preschool children and about 5 minutes for school-age children. Use the same length of time out for both major and minor offenses. Do not talk to your child on the way to time out or while he or she is in time out. Completely ignore your child’s temper tantrums, shouting, protesting, or promises to behave. Go about your activities. Use a kitchen timer so the child knows he or she has to sit until the timer rings. A very important rule is that your child must sit quietly in the chair for 30 seconds before being released from time out. If your child is not quiet when the bell rings, say, “You will have to stay until you are quiet.” If you are using a chair for time out and your child gets off the chair without your permission (buttocks leave the seat or the chair is moved), immediately use one of the following procedures: • Take your child to an uninteresting and safe room, and close the door for 60 seconds. Take the child back to the chair and say, “Sit there and be quiet.” If your child still does not stay in the chair, take him or her back to the room and again close the door. Say, “You must stay here until you are quiet.” • Simply take your child back to the chair every time the child gets out of the chair. Do not talk to the child. Be prepared for 10 to 20 trips. After your child has been quiet for at least 30 seconds (preferably for the entire length of the time-out period) and the timer rings, the child may come out of time out (“You may come out now”). Repeat the command that resulted in time out. Then repeat giving a warning and time out as many times as necessary until your child complies. Be sure to praise compliance.

6. Do Not Reason with a Young Child Immediately after Misbehavior Explanations and reasoning about rules and consequences of behavior are important, especially as your child gets older, but if you reason immediately after misbehavior you FIGURE 10.6. (cont.)

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may actually increase the undesirable behavior. Reason with your child when he or she is doing something you like (“When you get ready for bed so quickly, it gives us more time to talk and read stories”).

7. Do Not Give a Command Unless You Are Prepared to Use Time Out This will help you reduce the number of demands to those that are really important! Be affectionate and praise your child for desirable behaviors that occur after the time out. When time out is not working, ask yourself the following questions: • Are you giving more than one command or warning? • Is everyone in the household who is responsible for the child using time out appropriately and consistently? • Are there plenty of opportunities to praise the child (and are you praising desired behavior)? • Is the general atmosphere in the home pleasant? • Are you falling for the “I like to go to time out” trick? Don’t be fooled! • Is your child putting him- or herself in time out? If this is happening, be sure to make your child stay there for the required length of time. • Is your child getting attention while in time out, or can he or she see the TV or other enjoyable sights? • Is the child aware of the rules? • Is time out used consistently? FIGURE 10.6. (cont.)

McNeil, 1995). The child is then placed back in time out. Fourth, a parent can hold the child in time out by kneeling behind the time-out chair and holding the child’s arms crossed in front of the child, firmly but gently. The child’s arms should never be held behind the chair, as this could result in a spiral fracture. The clinician should model the command–time-out sequence with one parent, and then have the parents take turns practicing with each other while the clinician coaches them. We typically include the child in this session and explain the new rules to him or her while the parents demonstrate. The child is usually very interested in watching Mom put Dad in time out, and the concrete demonstration helps the child understand the consequences of noncompliance. At the end of this session, parents are given the handout (Figure 10.6) describing the procedure in detail, as well as a chart on which to record all instances of time out for the coming week (Figure 10.7). They are instructed to call the clinician if they have questions or problems implementing the procedures. Some parents will need help deciding where to locate the time-out chair in their home. The best place is in a corner of a seldom-used room, such as a dining room or laundry room, where the child is out of the mainstream of family life (no TV, toys, etc.) but can be watched. Reasoning about rules and consequences with children is important, especially as they get older; as previously stated, however, parents should not do this at the time the child is misbehaving, as this will reinforce the child’s inappropriate behavior. Rather, parents can reason with the child when he or she is behaving appropriately, discussing why they like the

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Time Out (TO) Record Sheet Date

Time

Duration of TO

Reason for TO

FIGURE 10.7. Chart for recording instances of time out.

Child’s Response

From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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child’s behavior. Finally, it is important for parents to be sure to be affectionate and attend to and praise the child’s appropriate behaviors as soon as they occur after the time out is over. Succeeding sessions focus on troubleshooting the time-out procedure, generalizing the new skills to other situations, and dealing with any specific problems that have not been resolved. Parents are taught the value of anticipating troublesome situations and providing children with the rules and consequences of breaking the rules ahead of time. As new problems occur, parents are helped to problem-solve how they can apply their skills and resolve the problem on their own. Adaptations of the Program for Older Children In the parent training program described above, control is largely external. Although this is appropriate for younger children, the long-range goal is for children to internalize control. For this reason, as children grow older, it is important that they actively participate in the training. Contingency contracting using tokens or points can accomplish this goal. We suggest weekly family meetings (which can occur at the clinic until everyone is clear about how these work), during which parents and children negotiate together what behaviors or chores are expected and what the rewards/consequences will be for engaging in these behaviors or completing chores. A combination of a token system and a response cost system is implemented, wherein tokens or points are earned for appropriate behavior and taken away for inappropriate behavior. Points or tokens are accumulated and traded in at regular intervals for such privileges as having a friend stay overnight, watching extra TV, dinner out, special time with a parent, and so on. The program is reviewed and adjusted each week at the family meeting. An example of a token system for sibling rivalry is given in Chapter 12 (see Figure 12.1). The response cost method, in which tokens or points are taken away as a consequence of inappropriate behavior, has been demonstrated to be very effective in managing children’s negative behavior (Little & Kelley, 1989; McMahon & Wells, 1998), and parents perceive it as an acceptable method (Frentz & Kelley, 1986; Heffer & Kelley, 1987). Barkley (1997b) provides a detailed description of such a system. A parent training program for older children (3–12 years) with conduct problems, which has considerable empirical evidence for its effectiveness, is based on the book Living with Children (Patterson, 1975, 1976b). In this program, parents first read the book, which provides basic information on principles of behavior management. Next, parents are taught to pinpoint problem behaviors, including noncompliance. Parents are taught to track these behaviors by observing two or three of them for 1 hour per day. When they have mastered this skill, they are taught how to establish a positive reinforcement system; points, backup reinforcers, response cost, and praise are used to increase incompatible appropriate behaviors and decrease problem behaviors. A time-out procedure is then taught for use with aggression and noncompliance. Managing Stealing and Other Covert Behaviors Dealing with covert conduct problems is difficult because they often do not come to the attention of adults. Stealing is one of the most common problems among children with CD, and parent training programs are often modified to target this behavior specifically. Barth (1987) provides excellent guidelines for managing stealing. Briefly, he states that the behavior must first be clearly defined as follows: “the child’s taking, or being in possession of, anything that

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does not clearly belong to him [or her]” (p. 151). Adults (parents and teachers) are the only judges of when stealing has occurred. Parents should avoid arguing with the child about whether or not stealing has occurred. They should avoid searches, but should be vigilant and investigate any suspicious objects. Every stealing behavior must receive consequences (e.g., returning the object, performing 1–2 hours of hard work around the house). Parents should supervise their child carefully and know where he or she is at all times. They should not tempt the child by leaving money or other valuables unattended. Finally, the child should have some way of earning money so that he or she can legitimately purchase desired objects.

Intervention in the Environment Family Therapy Family therapy programs are based on the fact that children with conduct problems tend to come from dysfunctional families. The assumption is that the family is a system composed of interrelated parts. The child’s deviant behavior is thought to serve an adaptive function for the family, and thus changes in the child’s behavior will be resisted by the family. Treatment is focused on identifying the issues that maintain the child’s deviant behavior, and then teaching family members more appropriate ways to interact and communicate. Evaluation of this approach to treatment of conduct problems suggests that it can be effective if families have the resources necessary to undergo the change process and the therapists have the requisite relationship and structuring skills (Dumas, 1989; Kazdin, 1987). Szapocznik and Williams (2000) describe an empirically validated approach called “brief strategic family therapy,” which has been developed for use with high-risk cultural minority families. The goal of this approach is to “identify repetitive interactions within or between systems in the family social ecology that are unsuccessful at achieving the goals of the family or its individual members” (p. 119). Interventions are designed to be practical and problem-focused. Currently, Szapocznik, Williams, and their colleagues are concerned with providing training for therapists in the community and demonstrating the cost-effectiveness of the approach. School Interventions Treatment for children with disruptive behaviors often involves consultation with their teachers; Chapter 2 presents issues related to such consultation. Early education programs are based on the assumption that antisocial children have school and learning problems, and that early educational opportunities will reduce school failure and thus indirectly decrease the occurrence of antisocial behaviors. Unfortunately, although these programs do seem to result in academic improvement among their participants, there is only limited evidence that they are effective in reducing antisocial behavior. It should be noted, however, that these programs were not designed specifically for the purpose of preventing antisocial behavior problems, and it is possible that early intervention programs could be designed that would be more effective in reducing conduct problems, particularly in multiproblem families (see Chapter 1). The multicomponent prevention programs described below are examples of this approach.

Intervention in Medical/Health Aspects A comprehensive discussion of pharmacotherapy for conduct problems is beyond the scope of this chapter. The interested reader is referred to a recent review by Kruesi and Lelio (1996)

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for information on controlled studies, dosages, and side effects of various medications. In general, there is agreement among professionals that psychoactive medications should not be used as a first-line approach to treatment (Christophersen & Finney, 1999; Kruesi & Lelio, 1996). There have not been sufficient controlled studies of most of these medications to warrant their use with children unless other treatments have been tried and have failed and the children’s behavior is extremely serious. Nonetheless, various medications have been tried for conduct problems, and some have been shown to alleviate disruptive behavior (particularly aggressive outbursts) in some children (Kruesi & Lelio, 1996). In general, more severe but less frequent aggression is more likely to be reduced than more frequent, less severe aggression. Moreover, there is evidence that use of psychoactive medications for symptoms of comorbid conditions (e.g., stimulants such as methylphenidate, for ADHD, or antidepressants such as imipramine for depression) may also reduce disruptive behavior in some children. Other psychoactive medications that show some evidence of beneficial effects for disruptive behavior include lithium (M. Campbell et al., 1995) and risperidone (Findling et al., 2000), although both have significant side effects. Lithium is most likely to be effective with children who have severe and explosive aggression with an affective component (McMahon & Wells, 1998). It is hypothesized (but there are no relevant data) that children with conduct problems who respond to lithium may be more likely to develop later bipolar I disorder. It is important to keep in mind that the side effects of psychoactive medications can be substantial and even life-threatening. Thus comprehensive evaluation and careful analysis of the risk–benefit ratio are critical before a clinician resorts to this method of treatment. Kruesi and Lelio (1996) also strongly recommend that when medication is used, the clinician measure the child’s symptoms objectively, establish a contract for therapy with the family, engage in periodic reevaluations, and plan termination or tapered drug withdrawal.

Prevention Based on an increased understanding of the multiple factors that place children at risk for the development of conduct problems, the difficulty of successfully treating older children who engage in more severe behaviors, and an inability to reach the children at highest risk with individual treatment, recent work has emphasized the importance of prevention as an approach to intervention (Group for the Advancement of Psychiatry, 1999). Martinez and Forgatch (2001), for example, described a program for mothers who were divorcing based on the parent training model and aimed at preventing noncompliance in their sons. Results indicated that over 30 months, those in the treatment group maintained level rates of noncompliance whereas those in the control group deteriorated. Several large, multifaceted preventive intervention programs have been described, and data regarding their effectiveness is just beginning to appear in the scientific literature (e.g., Dumas, Prinz, Smith, & Laughlin, 1999; Tolan & McKay, 1996). An example of this type of program is the FAST Track Prevention Trial for Conduct Problems (Conduct Problems Prevention Research Group, 1999), which targets children who exhibit early-onset conduct problems by identifying them as they enter school. Programs focus on child factors, including emotional regulation, social-cognitive skills, and academic skills; parent factors, including use of harsh punishment, inappropriate/inconsistent discipline methods, monitoring and supervision of children’s whereabouts/friends/activities, and promoting warmth and support for children’s constructive activities; and school factors, including a classroom-administered curriculum designed to improve emotional regulation and prosocial skills for all children in each target child’s classroom. Preliminary data after 1 year indicate mod-

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erate positive effects on children’s skills (social, emotional, and academic), peer interactions, and conduct problems, as well as on various measures of parenting skills. Other prevention programs are school-based, targeting adaptive school-related behaviors (e.g., Aber, Jones, Joshua, Chaudry, & Samples, 1998; Walker, Stiller, Severson, Feil, & Golly, 1998) or community-based, targeting parenting skills (Cunningham, Bremner, & Boyle, 1995). Cunningham et al. (1995) describe a large group community-based prevention program based on a model of parent management training, which targeted children who were least likely to be engaged in individual treatment. When compared with clinic-based individual parent training, the data indicated that the community groups enhanced the participation of the highest-risk families, resulted in greater improvement in behavior problems at home, showed better maintenance of gains over a 6-month follow-up period, and were more cost-effective than individual treatment. Moreover, families assigned to individual treatment were more likely to drop out or not to enroll in treatment at all than families assigned to the group program. Webster-Stratton, Reid, and Hammond (2001) describe a prevention program for preschoolers based on the book The Incredible Years (Webster-Stratton, 1992b). This program targeted parents and teachers of Head Start children and consisted of 12 weekly sessions. Results at a 1-year follow-up assessment indicated that parents who attended more than six sessions had significantly higher positive parenting and parent–teacher bonding scores than those who attended fewer sessions or those in the control group. Moreover, the children of these mothers demonstrated fewer conduct problems in the classroom and at home. Children in the experimental group who had the highest rates of noncompliant and aggressive behavior at baseline showed greater reduction in these behaviors than did children in the control group.

CASE EXAMPLE: PRESCHOOL OPPOSITIONAL BEHAVIOR Step 1: Initial Contact Mrs. Sweet, who called at the suggestion of her friends, said that her 3½-year-old son, Henry, was causing a “few” problems and that the problems occurred primarily with her. The mother stated that she viewed much of Henry’s behavior as normal for an active, bright boy, but that recent comments from her friends and family about his escalating disruptive behavior had pushed her to talk with a professional. She asked to come in for an appointment to get some specific suggestions on handling his disruptive and oppositional behavior. She further indicated that she was hoping to get confirmation that everything was really OK with Henry. Prior to the initial interview, the parents were asked to complete the General Parent Questionnaire. They were also each asked to complete the ECBI and the PSI, and the mother was asked to keep the Daily Log for 1 week prior to the initial interview. Mrs. Sweet returned the completed forms and checklists before her appointment, so that they could be scored and reviewed by the clinician. Although Mr. Sweet completed the forms and supported his wife in seeking help, he elected not to come to the interview, since he saw it as primarily “my wife’s problem.” The General Parent Questionnaire indicated that Mr. Sweet was a construction worker and his wife was a full-time homemaker. Henry was the older of two children, having a 9-monthold sister. On the ECBI, Mrs. Sweet gave Henry an Intensity score of 189 and a Problem score of 5, indicating that she perceived Henry as engaging in a significant amount of disruptive behavor but did not consider the behavior to be problematic for her. In contrast, Mr. Sweet

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described Henry as within the normal range on both the Intensity and Problem scales. On the PSI, the responses of both mother and father were within the normal limits, with the exception that the father’s score for Child Adaptability and the mother’s score for Sense of Competence were both above the 90th percentile (high scores on the PSI are problematic). The Daily Log contained descriptions of inappropriate behaviors such as these: “Henry hit his grandfather on the shin with a baseball bat” and “Henry scraped a knife across the kitchen wall.”

Step 2: Parent and Child Interviews Mrs. Sweet and Henry came together for the initial interview. Mrs. Sweet stated that Henry’s developmental milestones were within normal limits; for example, he was speaking in sentences by 24 months. He was described, however, as being a “difficult” child from birth. Henry was cared for primarily by the mother; babysitters were limited to the occasional evening out, and no problems were reported during those times. Likewise, his three mornings a week at a preschool were problem-free, although the teachers initially reported that they had to be rather “firm”in their expectations for him. He was often invited to spend time with friends in their homes; although this went well, difficulties were reported when friends visited him. At these times, Henry was described as very active, getting into things that were forbidden and in general creating chaos. Henry’s father, who was 15 years older than the mother, thoroughly enjoyed Henry, often taking him on full-day outings with only minor problems. He felt that the mother simply was “too nice” and should be firmer with Henry. The major problems, according to Mrs. Sweet, were “not listening,” “refusing to do as requested,” and “talking back.” All of these behaviors occurred primarily with the mother, but they were beginning to occur with other people in the family. In order to determine the extent of the problems and the frequency of their occurrence, the clinician asked Mrs. Sweet to describe a typical day for Henry, from the time he got up in the morning to the time he went to bed. She described Henry as managing many routine events such as eating and bathing with ease, but when any demands were placed on him, he would refuse to comply. Mrs. Sweet spent much of her time rearranging her schedule in order to avoid confrontations. This was becoming increasingly difficult as her 9-month-old baby demanded more attention. Although she was clearly exhausted from the effort of caring for her children, she felt that this was simply part of being a mother.

Step 3: Observation of Behavior Henry appeared in the clinic wearing an army camouflage outfit, cowboy hat, and boots; he was toting two six-shooters and a toy machine gun. He greeted the clinician with “I’m going to shoot your eyes out.” The clinician responded with a firm “We don’t talk like that in my office,” to which Henry quickly responded in a contrite voice, “Oh, I’m sorry.” Observation of parent–child interaction indicated a mother who gave a high rate of noncontingent positive reinforcement, placed few demands on Henry, and tried to get compliance through reasoning. Henry placed many demands on his mother and rarely complied with her requests. However, there were also many positive interactions between Henry and his mother, and they seemed to enjoy playing together. Henry’s play was observed to be ageappropriate; interactions with the clinician after the initial negative statement were positive; and although he refused to comply with his mother’s requests to pick up the toys or change activities, he readily complied with the clinician’s requests to clean up the toys.

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On the basis of the information gathered thus far, the clinician decided that further assessment (Step 4) and referral to an allied health professional (Step 5) were not necessary.

Step 6: Communication of Findings and Treatment Recommendations In determining where things were going wrong for this mother and child, the clinician told Mrs. Sweet that Henry appeared to be in good physical health and that he was developmentally on target, but that his mother’s expectations for him and for herself were creating and maintaining much of the inappropriate behavior. Furthermore, her management techniques were actually increasing the problem behavior. The fact that the behavior occurred primarily with the mother and was just beginning to generalize to other adults close to him indicated a rather circumscribed problem. Although Mrs. Sweet indicated that she was not suffering personally from the behavior, she was told that the continuation of the behavior could only have a negative effect on their relationship and on the child’s development. The generalization of disruptive behaviors with other adults could also lead to decreased interactions with Henry, and consequently fewer opportunities for him to learn. It was recommended that both parents attend classes on child development and management, and that they both be involved with Henry in a series of treatment sessions to increase the positive parent–child interactions, to set age-appropriate limits, to increase compliance on Henry’s part, and to determine a consistent method of discipline. Mr. Sweet was asked to come in for an interview prior to giving these recommendations, so that his view of the problem could be further explored. He agreed to this as well as to the recommendations. He felt that coming to an agreement on management techniques would ultimately decrease the conflict between him and his wife over Henry’s behavior.

Course of Treatment The parent training program described in this chapter was carried out over a 6-week period, with follow-up appointments 1 and 3 months after treatment. After treatment, although Henry was described as “headstrong,” both parents felt that his behavior was acceptable and for the most part easily managed. Both parents rated him within normal limits on the ECBI and PSI.

CHAPTER 11

Attention-Deficit/ Hyperactivity Disorder

A

ttention-deficit/hyperactivity disorder (ADHD; American Psychiatric Association [APA], 1994) is the most commonly diagnosed behavioral disorder of childhood. Despite the dramatic increase in research over the past several decades and the progress made in the assessment, diagnosis, and treatment of children and adults with ADHD, there is still considerable controversy regarding this disorder. To address this controversy, the National Institutes of Health (NIH) held a consensus development conference in 1998 that brought experts in the field together to determine what is known about the disorder and provide recommendations for future research (Jensen, 2000). The panelists at the conference reached a number of important points of concensus (NIH, 2000): 1. There is evidence that ADHD, as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), is a valid disorder. However, it remains unclear whether it should be conceptualized as the far end of a “normal” continuum (i.e., reflecting an extreme manisfestation of a set of temperamental characteristics), or whether it reflects a qualitatively different syndrome from “normal” behavior. It was also noted that the DSM-IV diagnostic criteria were designed for younger children and have not been adjusted for adolescents and adults. 2. Although evidence supports the hypothesis that ADHD symptomatology has a central nervous system basis (as do all normal and abnormal behaviors, thoughts, and emotions), such brain–behavior correlations do not constitute proof that ADHD reflects a disordered biological state. In effect, we still know little about the etiology of this disorder. 3. Evidence was presented that ADHD is a severe condition with lifelong personal and societal consequences for many individuals. 4. Although both medications (principally stimulants and tricyclics) and behavior therapies are effective treatments for ADHD, the preponderance of evidence indicates that medications are somewhat more effective. Combined behavioral and pharmacological treatments may offer some modest advantages over medication alone. Furthermore, there is no conclusive evidence that careful therapeutic use of medications is harmful, and the committee refuted the notion that current levels of use of stimulants have had a substantial effect on drug abuse among high school students. 5. There are widely varying, inconsistent, and sometimes poor-quality assessment, treatment, and follow-up practices in the “real” world, probably leading to both over- and under377

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diagnosis of ADHD. Moreover, services vary widely from community to community, and access to care differs not only by geographic region but also by socioeconomic and ethnic parameters. The fragmentation of care and lack of coordination between the educational and the medical systems were also noted as contributing to less effective diagnosis and treatment. The NIH consensus findings clearly indicate that the assessment and treatment of children with ADHD are complex and challenging tasks. ADHD is a heterogeneous disorder that for many children has an onset in early childhood, is pervasive across many areas of functioning, and can persist throughout adolescence and adulthood (Barkley, 1998a). This chapter begins with a review of the current diagnostic criteria for ADHD. Next, its primary symptoms, prevalence, comorbidity, etiology, and developmental course are discussed. Finally, assessment and treatment of ADHD are addressed. The interested reader is referred to Barkley (1998a) for an in-depth discussion of ADHD, including its assessment and treatment.

DIAGNOSTIC CRITERIA The labels given to the constellation of impulsive, hyperactive, and inattentive behaviors have evolved over the years. In the last 30 years, labels have become more behaviorally descriptive, with a greater focus on the areas of attention and impulse control. In addition, DSM diagnostic classifications have become more operational by specifying the type and number of behavioral descriptors, the age of onset, and the duration of the symptoms. In ongoing attempts to refine the clinical features of the disorder, the DSM criteria for ADHD have been revised four times since 1968. Although often frustrating for clinicians and researchers, these changes in labels and criteria for diagnosis reflect our changing understanding of ADHD; new theories and research indicate that further changes will surely come about (Barkley, 1997a; Jensen, 2000). Because the DSM-IV (APA, 1994) criteria for ADHD are lengthy and complex, they are listed in Table 11.1. Based on findings from empirical research and factor analysis (e.g., Lahey et al., 1988), the two nine-item clusters reflect a bidimensional conceptualization of the disorder, with an inattention dimension and a combined hyperactivity–impulsivity dimension. These two symptom clusters are thought to be distinct in terms of their etiology, clinical course, correlates, response to treatment, and outcome (Lahey et al., 1994). The greatest risk of adverse outcome associated with ADHD is thought to reside in the hyperactivity–impulsivity symptom cluster (Barkley, 1994, 1997a; Quay, 1997). According to DSM-IV, parents and/or teachers must report the presence of at least six of nine problem behaviors from either symptom list for a child to be diagnosed with ADHD. These symptoms must be persistent, with an onset prior to 7 years of age, and a frequency greater than that expected of children of the same mental and chronological age. Furthermore, the behaviors must have cross-setting generality to demonstrate pervasiveness, and evidence of clinically significant impairment. The behaviors cannot be due to other types of mental health or learning disorders that would better explain their presence. These criteria do not, however, preclude a child from receiving an additional diagnosis, such as oppositional defiant disorder (ODD), conduct disorder (CD), a learning disorder, a depressive disorder, or an anxiety disorder—all of which overlap substantially with ADHD. The DSM-IV critieria acknowledge individual differences in the ways that children exhibit the various symptoms. Some children may have more difficulty with sustained attention in tasks or play activities, or may be easily distracted; other children may have more difficulty

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TABLE 11.1. DSM-IV Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder (ADHD) A. Either (1) or (2): (1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Inattention (a) often fails to give close attention to details or makes careless mistakes in school work, work, or other activities (b) often has difficulty sustaining attention in tasks or play activities (c) often does not seem to listen when spoken to directly (d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) (e) often has difficulty organizing tasks or activities (f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) (g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) (h) is often easily distracted by extraneous stimuli (i) is often forgetful in daily activities (2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity (a) often fidgets with hands or feet or squirms in seat (b) often leaves seat in classroom or in other situations in which remaining seated is expected (c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feeling of restlessness) (d) often has difficulty playing or engaging in leisure activities quietly (e) is often “on the go” or often acts as if “driven by a motor” (f) often talks excessively Impulsivity (g) often blurts out answers before questions have been completed (h) often has difficulty awaiting turn (i) often interrupts or intrudes on others (e.g., butts into conversations or games) B. Some hyperactive–impulsive or inattentive symptoms that caused impairment were present before age 7 years. C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). (cont.)

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TABLE 11.1. (cont.) Code based on type: 314.01 Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months 314.00 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months 314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive– Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “In Partial Remission” should be specified. Note. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

with overactivity, taking turns, or following rules. DSM-IV attempts to decrease the heterogeneity of ADHD by subtyping the disorder into three major categories: “ADHD, combined type” (ADHD-C); “ADHD, predominantly inattentive type” (ADHD-I); and “ADHD, predominantly hyperactive–impulsive type” (ADHD-H/I). Two other DSM-IV categories have primary bearing on the diagnosis of adolescents and adults. “ADHD in partial remission” is used when a person has problems resulting from ADHD symptoms that do not meet criteria for any of the above-described subtypes, but were part of a documented ADHD diagnosis at an earlier point in time. “ADHD not otherwise specified” applies when an earlier history of ADHD cannot be established with any degree of certainty. Barkley (1997c) suggests that an additional category be added to include children who meet criteria for ADHD after the age of 6 years as a result of central nervous system disease or trauma. This could be referred to as “acquired ADHD secondary to______,” with the known etiology specified in the blank. This category would recognize the disability of these children, but would distinguish them from the vast majority of children with ADHD described in the research literature. The DSM-IV field trials (Lahey et al., 1994) showed clinically meaningful differences among the ADHD subtypes. Children with ADHD-I were more likely to be female, and were significantly older than those with ADHD-C. These latter children were in turn significantly older than the children with ADHD-H/I. Children with ADHD-C were more psychosocially impaired, and those with ADHD-C and ADHD-I both had higher rates of academic impairment than those with ADHD-H/I. Consistent with these data, others have reported that the children with ADHD-C are more severely impaired in many assessed domains: internalizing behavior, externalizing behavior, social functioning, and academic performance (Gaub & Carlson, 1997a; Paternite, Loney, & Roberts, 1995). In addition, Gaub and Carlson (1997a) found that the children with ADHD-I had impairments in most domains, but fewer externalizing behaviors and more appropriate behaviors than those with ADHD-H/I or ADHD-C. In a study that examined 413 consecutive referrals to an outpatient clinic, Faraone, Biederman, Weber, and Russell (1998) found that 301 children (74%) met criteria for DSM-IV ADHD. Moreover, among these, 185 (61%) had ADHD-C, 89 (30%) had ADHD-I, and 27 (9%) had ADHD-H/I. Significant psychiatric differences were found among the three subtypes. Children with ADHD-C had higher rates of CD, ODD, bipolar I disorder, language disorders, and tic disorders than those with the other two subtypes. Although there were few differences between the children with ADHD-H/I and ADHD-I, the latter group had higher rates of comorbid major depressive disorder. Community-based studies using teacher reports have

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found similar significant differences among the three subtypes (Baumgaertel, Wolraich, & Dietrich, 1995; Wolraich, Hannah, Pinock, Baumgaertel, & Brown, 1996). Moreover, Lahey, Pelham, et al. (1998) validated the three subtypes for preschool children. They found that each subtype differed consistently from the others on a wide range of social and academic factors. The DSM-IV system of classification is primarily used in North America, whereas the International Classification of Diseases, 10th revision (ICD-10; World Health Organization, 1993) is used in Europe and many other parts of the world. Although the ICD-10 diagnosis corresponding to ADHD has many similiarities to the DSM-IV criteria (age of onset, duration, and developmental deviance), it also has major differences. ICD-10 has no subtyping, and only one diagnosis, “hyperkinetic disorder,” is used. This category requires six of nine inattention symptoms, three of five hyperactivity symptoms, and one of four impulsivity symptoms for a diagnosis. Furthermore, the ICD-10 diagnosis of hyperkinetic disorder is precluded by other psychopathology (e.g., a child with a diagnosis of depression cannot also be diagnosed with hyperkinetic disorder). In contrast, although some psychiatric disorders can preclude a DSM-IV diagnosis of ADHD, others can be and frequently are comorbid with ADHD. The differences between these two classification systems indicate that fewer individuals are likely to be diagnosed with hyperkinetic disorder in the ICD-10 system (Taylor, Sandberg, Thorley, & Giles, 1991). With little or no acknowledgment of the differing diagnostic criteria, the difference in prevalence rates based on DSM-IV versus ICD-10 criteria has been interpreted to mean that ADHD is “overdiagnosed” in the United States. The important point for clinicians is that any comparision between DSM-IV and ICD-10 diagnoses should be limited on the DSMIV side to ADHD-C without a comorbid disorder.

GENERAL CHARACTERISTICS OF ADHD Primary Symptoms “Inattention” refers to difficulties sustaining attention or persistence of effort to tasks, particularly those that are tedious, boring, or lengthy. Inattention can be expressed as having trouble attending or responding to tasks or play as long as others of the same age, and as being more disorganized, distracted, and forgetful than others the same age. Trouble with not concentrating, not completing tasks, frequently changing activities, being slower, not returning to a task once interrupted, and increased errors when performing boring tasks are also part of the inattention dimension. Cerebral maturation and experience both play an important role in the development of attention (Vallano & Slomka, 1998). The “hyperactivity–impulsivity” dimension refers to difficulty in controlling inappropriate impulses and inhibiting activity level to meet the demands of a situation. Behaviors along this dimension include (1) more motor activity; (2) less ability to control overflow movements; (3) fidgetiness; (4) trouble stopping an ongoing behavior; (5) talking and interrupting more; (6) trouble resisting immediate temptations and delaying gratification; and (7) responding too quickly and too often when waiting for events to occur, so that more impulsive errors are made. In essence, behavior is less governed by rules. Research supports differences in activity, impulsivity, and inattention between children with ADHD and those with learning disabilities (Barkley, DuPaul, & McMurray, 1990) or other psychiatric disorders (Halperin, Matier, Bedi, Sharma, & Newcorn, 1992). Although a great deal of research demonstrates significant group differences between children with ADHD and normal children on measures of attention span, activity level, and

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impulse control, these constructs should not be seen as unitary (for a review, see Barkley, 1997c). As Barkley points out, there are many different types of inattention, overactivity, and impulsivity, and their expression varies with the individual child and with situational or temporal factors. Task performance is affected by (1) the time of day or fatigue; (2) the increasing complexity of tasks requiring organization strategies; (3) the number of rules or demands for specific behavior versus free play; (4) situations that are highly repetitive, boring, or familiar versus those that are novel or stimulating; (5) the presence or absence of adult supervision during a task; and (6) the task’s consequences being immediate versus infrequent or delayed. Thus it is not surprising that children with ADHD show tremendous variability in their level of productivity and the accuracy of their task performance over time and in different situations. It also should be recognized that several other developmental, medical, and neurological conditions of childhood can result in symptom manifestations consistent with the diagnosis of ADHD. In addition, there are numerous ways to measure these constructs, not all of which show differences between chilren with ADHD and normal children. Likewise, research has not always demonstrated a distinction between ADHD and other psychiatric disorders on measures of these primary symptoms. Thus the clinician must be mindful of the complexity that is inherent in the ADHD construct, and must remember that it is multidimensional in nature. Moreover, it is important to note that there is no independent diagnostic test of ADHD; rather, the diagnosis must come as a result of a comprehensive clinical evaluation.

Prevalence Estimates of the prevalence for all subtypes of ADHD in school-age children range from 3% to 5% of the population (APA, 1994; Szatmari, 1992). Community samples that are based only on ADHD symptom frequency, as reported by both parents and teachers, range from 7.5% to 21.6% (Baumgaertel et al., 1995; Gaub & Carlson, 1997b). Prevalence rates for the three subtypes in a community sample were reported to be 9.9% for inattentive, 2.4% for hyperactive– impulsive, and 3.6% for combined (Nolan, Gadow, & Sprafkin, 2001). ADHD is four times more common in boys than girls in the general population, and six to nine times more common among boys in clinic-based samples (APA, 1994; Szatmari, 1992). Little is known about prevalence of ADHD at different socioeconomic levels, although a recent study reported general population rates of 39.5% for African American children (aged 3 to 18 years) versus 14.2% for European American students (Nolan et al., 2001). Furthermore, although there are fluctuations in the rates of occurrence across different countries and cultures (as might be expected with the use of different definitions and criteria), in general prevalence is relatively similiar to that reported in the United States (Barkley, 1998a). The peak period for diagnosis of ADHD is between the ages of 6 and 9, but problems can arise before the age of 3 years (Cohen, Cohen, Kasen, et al., 1993). Although some investigators have questioned the rigidly imposed DSM-IV cutoff for age of onset before 7 years (Barkley & Biederman, 1997), there is considerable evidence that that ADHD begins early in life. McGee, Williams, and Feehan (1992), for example, found that about a third of their sample of children experienced symptoms of ADHD before age 3 years; another third first showed symptoms prior to 5–6 years; and the remaining third exhibited symptoms between 6 and 7 years. Barkley (1998a) notes that problems with hyperactivity–impulsivity often arise at about 2–4 years. Moreover, these very young children are at significant risk for a variety of behavioral, social, and academic problems as they develop (DuPaul, McGoey, Eckert, & Van Brakle, 2001).

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Symptoms related to inattention emerge at about 5–7 years or when children enter school. Inattention as a primary problem typically begins by the early to middle school years (Hart, Lahey, Loeber, Applegate, & Frick, 1995; Loeber, Green, Lahey, Christ, & Frick, 1992). The relatively high rate of diagnosis during the early school years probably reflects the fact that the school setting is more demanding, less flexible, and less likely to accommodate individual differences than the home environment. Prevalence rates appear to decline during adolescence, although ADHD clearly remains a problem for many young people (Cuffe et al., 2001). Longitudinal studies indicate that ADHD persists into at least midadolescence for 40– 80% of children diagnosed during childhood (Barkley, Fischer, Edelbrock, & Smallish, 1990; Weiss & Hechtman, 1993), and that about 30% will continue to meet diagnostic criteria for ADHD into adulthood (Klein & Mannuzza, 1991; Mannuzza, Klein, Bessler, Malloy, & LaPadula, 1993). Other children who are diagnosed with ADHD in childhood continue to exhibit subclinical levels of symptoms that interfere with daily functioning, even when they no longer meet criteria for a full diagnosis (Fischer, 1997; Weiss & Hechtman, 1993). In a longitudinal study with boys, Biederman, Mick, and Faraone (2000) found that at age 19 years, 38% had a full diagnosis of ADHD; 72% showed persistence of at least one-third of the criteria for diagnosis; and 90% showed evidence of clinically significant impairment. This work clearly demonstrates that the criteria used for diagnosing ADHD can have a significant effect on estimates of prevalence rates. Some investigators (e.g., McGee et al., 1992; Willoughby, Curran, Costello, & Angold, 2000) have found that age of onset distinguishes “pervasive” ADHD (onset by ages 5–6 years) from “situational” ADHD (onset between 6 and 7 years). Children with earlier onset also have more comorbid disorders, cognitive deficits, family disadvantage, and persistence of problems at least into adolescence, whereas later-onset ADHD seems to be secondary to reading failure and to have a much better outcome (Willoughby et al., 2000). Longitudinal studies that examine changes in symptoms over time provide some insight into the basis for the decline of ADHD with age. Results of these studies indicate that the frequency of parent- and teacher-reported hyperactivity–impulsivity symptoms declines with age, especially during late childhood and early adolescence, whereas the reductions in frequency of inattention symptoms are only slight (Hart et al., 1995). Similiar findings were reported in a cross-sectional investigation using teacher rating of a nationwide community sample of children ages 5–18 years (DuPaul, Power, et al., 1997). Thus it is not surprising that the majority of the youngest children are diagnosed with ADHD-H/I, followed by ADHD-C and, as children get older, ADHD-I (Nolan et al., 2001). It is also important to remember that the DSM-IV criteria are based on what is known about school-age children with ADHD, and are not necessarily developmentally appropriate for preschoolers, adolescents, and adults. Thus the number of individuals diagnosed with ADHD over the course of development may be artificially reduced. In addition, diagnostic estimates in later years are typically based on self-report versus parent or teacher report, and this fact probably also affects estimates of prevalence. Faraone, Biederman, Feighner, and Monuteaux (2000) suggest that ADHD be recast as a norm-referenced rather than a criterion-referenced diagnosis. This would be similiar to constructs of adaptive or intellectual functioning, with different batteries for different ages. Within a single battery, a score would be considered high or low in reference to individuals of the same age. Research using this method would help answer the question of whether the prevalence of ADHD truly declines with age or whether the decline is an artifact of the DSM criteria.

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Comorbidity Between 50% and 80% of children diagnosed with ADHD also meet diagnostic criteria for other disorders, although these rates vary according to the sample studied and the method of diagnosis (Jensen, Martin, & Cantwell, 1997). The most frequently observed comorbidity is between ADHD and the other two DSM-IV “attention-deficit and disruptive behavior disorders”; ODD and CD occur in approximately 40–90% of cases of ADHD (Newcorn & Halperin, 1994; Jensen et al., 1997; see Chapter 10). Other work indicates that symptoms of CD that often co-occur with ADHD also change over time. Biederman, Mick, Faraone, and Burback (2001) reported that only 42% of ADHD cases had persistent symptoms of CD over a 4-year period. Studies of both clinic-referred and community samples find that up to 30% of the children with ADHD have a mood disorder, with major depression and dysthymic disorder most frequent (August, Realmuto, MacDonald, Nugent, & Crosby, 1996). Secondary anxiety disorders are also reported in 34% of the population with ADHD (August et al., 1996). The presence of secondary externalizing disorders increases the risk of developing a mood or anxiety disorder, with rates of depression and anxiety between 30% and 34% for children with ADHD who also have a diagnosis of ODD or CD. In contrast, among children with ADHD without ODD or CD, 3% have a mood disorder and 6% have an anxiety disorder (August et al., 1996). The high rates of comorbidity suggest the need to consider new diagnostic constructs that take into account differences in symptoms found in children with ADHD with and without various comorbid conditions (Caron & Rutter, 1991; Jensen et al., 2001; Newcorn et al., 2001). Reviews of comorbidity (Jensen et al., 1997) conclude that in addition to ADHD alone, at least three new ADHD subtypes were warranted: ADHD with disruptive behavior disorder (ADHD with ODD/CD), ADHD with an anxiety disorder (ADHD with ANX), and ADHD with both anxiety and disruptive behavior disorder (ADHD with ANX + ODD/CD). This conclusion was based on the fact that when either CD or an anxiety disorder occurs with ADHD, it interacts with and alters the diagnostic construct in terms of psychological characteristics, clinical phenomenology, clinical course, treatment, and outcome. When ADHD is comorbid with CD, neuropsychological deficits (especially in the verbal and memory domains) and outcomes (especially drug use and misuse, driving-related accidents antisocial behavior, and additional psychiatric comorbidity) appear to be worse than when either CD or ADHD appears alone (Herpertz et al., 2001; Tannock, 1998). Furthermore, there is some evidence that stimulant medication may not be as effective in reducing motoric activity in children with ADHD and aggression as in children with ADHD but without aggression. Tannock (1998) also notes that highly anxious children with ADHD have a different response to psychostimulant medication, with less robust behavioral improvement and minimal or no improvements in working memory, as well as an increased risk for side effects in comparison to nonanxious children with ADHD. Although considerable empirical work remains to be done to verify the need for new diagnostic categories, it is important to recognize that comorbid conditions do interact and affect each other in unique ways, and that there is a high rate of comorbidity in ADHD. Thus a child diagnosed with ADHD requires a comprehensive assessment to determine the presence or absence of other disorders, and these must obviously be considered in planning treatment. In addition to comorbidity with other clinical disorders, ADHD has been associated with sleep problems, academic underachievement, and poor peer relations. Although parents of children with ADHD report significant sleep problems, research has provided limited objective verification of these disturbances (Corkum, Tannock, & Moldofsky, 1998; Gruber, Sadeh, & Raviv, 2000). Recent research comparing children with ADHD to a general clinical sample

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of children found that sleep problems were more closely related to general psychopathology than to ADHD specifically (Corkum, Moldofsky, Hogg-Johnson, Humphries, & Tannock, 1999). Thus it appears that while sleep problems are common in children with ADHD, they are not a symptom of ADHD per se. Given the negative impact that sleep problems can have on the daytime functioning of a child and family (Saxby & Morgan, 1995), however, they should be assessed in children with ADHD and specifically treated if present. Children with ADHD are at high risk for difficulties in social functioning, and problems with peer relations appear to be persistent from childhood through adolescence (Bagwell, Molina, Pelham, & Hoza, 2001). This is an important area of study, given that peer rejection and social skills deficiencies in childhood have been linked to higher incidences of school maladjustment, delinquency, and later psychopathology (Parker & Asher, 1987). Children with ADHD-C appear to have more severe social problems than those with ADHD-I (Gaub & Carlson, 1997a; Lahey et al., 1994). The nature of these social problems was recently examined by comparing children with ADHD-C, children with ADHD-I, and a control group of children on parent and teacher ratings of social status and performance, self-reports of social knowledge and performance, and observations of behavior on an emotional regulation task (Maedgen & Carlson, 2000). Social functioning in the ADHD subtypes showed distinct differences. Children with ADHD-C were rated as showing more aggressive behavior, and as displaying emotional regulation characterized by high intensity and high levels of both positive and negative behavior. In contrast, children with ADHD-I were described as socially passive, as displaying deficits in social knowledge, and as evidencing no problems with emotional regulation. The children with ADHD-C appeared to understand the unwritten rules guiding emotional expression and tried to control their responses, but they had difficulty doing this. Although more research is needed to define the exact nature of the social deficits, the work to date indicates that children with either of these two subtypes of ADHD will need different behavioral interventions to alter their negative peer status. The association between academic underachievement and ADHD has been well documented (Hinshaw, 1992; Hoza, Pelham, Waschbusch, Kipp, & Owens, 2001). Approximately 25% of children with ADHD evidence specific learning disabilities, and up to 53% are described as underachievers (Frick, Kamphaus, Lahey, & Loeber, 1991). Estimates of ADHD in learningdisabled populations range from 26% to 80% (Silver, 1981). So if a child has a learning disability, he or she is at high risk for being diagnosed with ADHD, and vice versa. Significant problems center around memorizing complex information, especially when organization and deliberate rehearsal strategies are required (Douglas & Benezra, 1990). The amount of work produced is also reduced, which may contribute to underachievement (DuPaul & Stoner, 1994). Moreover, with age, the problem is only likely to increase. Of the various comorbid learning disorders seen in children with ADHD, reading disorders occur most frequently (August & Garfinkel, 1990). Language-based disabilities are also common, with difficulties primarily in organization, monitoring, and use of language rather than deficits in speech production, semantics, or syntax (Tannock, 1998). Academic problems appear to occur more often in children with either ADHD-C or ADHD-I than those with ADHD-H/I. Smaller class size, greater teacher attention, and the frequent use of contingency management methods may be needed. It is worthy of note that although children with ADHD can be found across all levels of intelligence, as a group they tend to score slightly lower on standardized intelligence tests than do normal controls (Barkley, 1997c), Whether the latter finding is due to real differences in intelligence, differences in achievement, or test taking behavior is not clear.

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Rabiner, Coie, and the Conduct Problems Prevention Research Group (2000) monitored 387 children from kindergarten through fifth grade, with standardized assessment of attention problems and reading achievement conducted at multiple time periods. They found that attention problems predicted reading achievement even after prior reading achievement, IQ, and other behavioral difficulties were controlled for. These results indicate that many inattentive children may fail to develop critical reading skills during the first grade and then have difficulty catching up to peers after this occurs, resulting in their falling farther and farther behind academically. This may be especially true for inattentive children with no obvious reading impairment when first grade begins. These children are not likely to be identified as having a learning problem, but without intervention their inattentive behavior is likely to lead to significant underachievement and a later diagnosis of learning disability. Thus it is important not only to identify children with attentional problems, but to ensure that they receive the educational assistance they will need to enhance their short- and long-term reading outcomes.

Etiology As indicated in the NIH (2000) consensus statement, the exact etiology of ADHD is not currently known. Genetic and neurobiological theories dominate the thinking in this area, and recent research provides increasing support for these positions. However, because ADHD is a heterogeneous disorder, it is not likely that one pathway will lead to ADHD for all cases. In addition, symptom severity, comorbidity, courses, and outcomes are likely to be influenced by various environmental and family factors. A brief summary of different etiologies of ADHD is presented next; the interested reader is referred to Tannock (1998) for a more in-depth review. Biological Factors Although it was initially believed that brain damage was a primary cause for ADHD, research has shown that only about 5% of cases have “hard” evidence of neurological damage (Rutter, 1977). This is currently an active area of research, however, and many studies examine neuroanatomical, neurochemical, and neurophysiological correlates of ADHD. This research demonstrates differences between children with and without ADHD in the frontal lobes, the caudate nucleus within the basal ganglia, the corpus callosum (which connects the two lobes), and related pathways between these two structures (e.g., Semrud-Clikeman et al., 2000; Castellanos et al., 1996). There is evidence, for example, that the cerebral blood flow as measured by positron emission tomography is decreased in the prefrontal regions in the brain and in the various pathways connecting these regions to the limbic system, including the caudate nucleus, in children with ADHD (Sieg, Gaffney, Preston, & Hellings, 1995). Importantly, researchers have demonstrated that these findings are reversed when stimulant medication is administered. Although this work is promising, future research is needed to determine which anatomical abnormalities have functional sequelae and how these relate to specific ADHD symptoms. Neurochemical studies have focused on the catecholamines dopamine and norepinephrine. These neurotransmitters are known to affect a variety of behaviors. There is some consensus that catecholamine dysfunction is central to ADHD, and that this dyfunction is related to more than one neurotransmitter system (Barkley, 1998a). How these problems are expressed functionally in terms of subtyping and comorbidity, as well as the specificity of the neurotransmitter, has not yet been determined. Halperin et al. (1997), for example, detected serotonin

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abnormalities in a population with ADHD, but only when co-occurring aggressive features were present. Genetic Factors There is strong empirical evidence from familial studies that genes play an important role in the etiology of ADHD. Children of parents with childhood-onset ADHD are at high risk for meeting diagnostic criteria for ADHD. Faraone, Biederman, Mennin, Gershon, and Tsuang (1996) reported that 84% of adults with ADHD who had children had at least one child with ADHD, and 52% had two or more children with ADHD. Among biological siblings, from 11% to 32% may also have the disorder. Thus in many families it is common for more than one child to have ADHD (Levy, Hay, McStephen, Wood, & Waldman, 1997). An even higher concordance exists for twins, with rates ranging from 29% to 38% for dizygotic pairs and from 51% to 82% for monozygotic pairs (Edelbrock, Rende, Plomin, & Thompson, 1995; Levy et al., 1997). Adoption studies offer further support for a genetic component of ADHD: A recent study found that 6% of adoptive parents of children with ADHD had the disorder, compared to 18% of biological parents and 3% of the biological parents of the control children (Sprich, Biederman, Crawford, Mundy, & Faraone, 2000). Results of another twin study indicated that genetic factors are important in the etiology of the two dimensions of the disorder (i.e., attention and hyperactivity–impulsivity), as well as in the covariation between them (Sherman, Iacono, & McGue, 1997). Moreover, the results of several other studies suggest that genes influence persistent ADHD more than they affect remitting ADHD. Faraone, Biederman, and Monuteaux (2000), for example, reported that the prevalence of ADHD among parents was 16.3% for adolescents with persistent ADHD and 10.8% for the adolescents with remitting ADHD; the prevalence rates of ADHD for siblings of those with persistant versus remitting ADHD were 24.4% and 4.6%, respectively. Faraone, Biederman, Mennin, and Russell (1998) also found two types of families with ADHD: those in which CD and/or bipolar I disorder occurred concurrently with ADHD, and those in which ADHD occurred without these disorders. The evidence for a genetic basis for ADHD from molecular genetic studies is inconsistent, with different genes found to be implicated in the expression of ADHD. This suggests that ADHD is not a unitary construct; rather, it consists of several disorders that have different genetic and nongenetic etiologies (Faraone, 2000). A dimensional view of the nature of ADHD might explain the apparent genetic heterogeneity of the disorder. Population-based twin studies suggest that the clinical syndrome of ADHD is influenced by the same set of genes affecting the expression of subclinical forms of the disorder. A study investigating heritability using 1,938 families with twins and siblings looked at whether a continuum (trait) or categorical (diagnostic) approach was best used to characterize ADHD and whether different cutoff criteria should be applied (Levy et al., 1997). The results suggested that ADHD is best viewed as the extreme of a continuum that varies genetically throughout the population, rather than as a disorder with discrete determinants. Thus people with many of these genes develop ADHD; people with few of them are asymptomatic; and people in between show some ADHD symptoms but may not meet diagnostic criteria for the disorder (Faraone, 2000). Jensen et al. (1997) point out the dangers of assuming that ADHD symptoms are “biological” or inborn, and argue that diagnostic approaches should take into account critical aspects of a child’s developmental status and environmental context. They state that under some circumstances ADHD behaviors and traits may be adaptive, although these are clearly mal-

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adaptive in other settings. An evolutionary perspective supports this idea. Shelly-Tremblay and Rosen (1996) assert that ADHD may have served an adaptive function at one time, and thus that individuals with these traits may have been specifically selected for survival. Other Biological Influences A number of environmental variables, including toxic or allergic reactions to food additives (such as artifical coloring or dietary sugar) and/or various allergens, have been proposed as biological causes of ADHD (e.g., Feingold, 1975). There is, however, little or no evidence to support these factors as causes for ADHD (Mattes & Gittelman, 1981; Wolraich, Wilson, & White, 1995; Trites, Tryphonas, & Ferguson, 1980). Although high blood lead levels, which are potentially harmful to children’s intellectual development, have also been suggested as a cause of ADHD, the data are inconsistent. Primary support is found for increased hyperactivity in approximately 38% of children with high blood lead levels (Binder & Matte, 1993). There is some evidence, however, that treatment to decrease the amount of lead in the blood is followed by small but reliable cognitive improvements (Ruff, Bijur, Markowitz, Ma, & Rosen, 1993). Maternal alcohol consumption and smoking have also been investigated as causes of ADHD. There are, however, no data to support an increased incidence of ADHD among children whose pregnancies were complicated by excessive maternal consumption of alcohol and/or nicotine, independently of whether or not maternal ADHD was present (Milberger, Biederman, Farone, Chen, & Jones, 1996; Streissguth, Bookstein, Sampson, & Barr, 1995). In contrast to this work, children with very low birthweight (VLBW) do appear to be at increased risk for ADHD. In a review of psychiatric symptoms among children with VLBW when they reached age 12, Botting, Powls, Cooke, and Merlow (1997) found that the main psychiatric risk was ADHD (23%, as compared to 6% in the control children). Risk for any type of psychiatric disorder was also high, however (28% for the children with VLBW, compared to 9% of the controls). Psychological Theories Recent models of ADHD focus on the cognitive processes underlying the component problems of the disorder. Two types of models have been proposed: those that pertain to the specific disorder (e.g., Barkley, 1997a), and those that attempt to account for a specific set of processes or problems (e.g., Quay, 1997; Schachar, Tannock, & Logan, 1993; Sonuga-Barke, 1994). This work has been informed in part by progress in our understanding of the functions of the prefrontal lobes, and has led to an appreciation of how this region of the brain regulates specific mental activities, which in turn regulate self-control (Barkley, 2000a). These mental activities (i.e., response inhibition, verbal working memory, nonverbal working memory, internalized emotion/motivation, and reconstitution) are called “executive functions.” One of the executive functions, response inhibition, is an area of major deficit in ADHD (Tannock, 1998). Barkley (2000a) presents the most comprehensive and elaborate theoretical model to account for the multiple symptoms of ADHD, not just response inhibition. Given that research in this area is certain to increase, a brief description of Barkley’s model is warranted. The role of response inhibition in the theoretical model of executive functions is primary. In Barkley’s model, “response inhibition” is defined as the capacity to delay a response to an immediate environmental event. Delayed responding is hypothesized to provide the founda-

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tion on which executive functioning/self-regulation develops. The model predicts that deficits in response inhibition cause secondary deficits or “cascading deficits” (e.g., greater errors and variability) in all the other executive functions. These deficits become evident in various psychological and social abilities, such as imitation/vicarious learning, rule-governed behavior, reading comprehension, emotional self-control, and both verbal and nonverbal fluency. Although much research is needed to verify this theory, it offers a framework within which to understand and further test the etiology of ADHD. Psychosocial Factors There is little empirical evidence to support a purely environmental cause of ADHD. Poor parenting, a chaotic home environment, and poverty have not been found to be “causes” of ADHD, although their impact on the functioning of a child with ADHD can be considerable (Campbell, 1995; Podolski & Nigg, 2001). Adverse family environmental factors, such as chronic and open conflict, decreased family cohesion, and exposure to maternal psychopathology, are more common among families with ADHD than control families (Biederman, Milberger, et al., 1995). In a study of parenting and family correlates of ADHD in 7- to 10-year-old children, Woodward, Taylor, and Dowdney (1998) found that the best parenting predictor for ADHD was disciplinary aggression. Although genetic and neurodevelopmental factors may be primary in the etiology of ADHD, family and social variables are likely to influence the extent to which symptoms are manifested, as well as the disorders that coexist with ADHD. Thus, for any particular child with ADHD, the influence of many factors ultimately determines his or her developmental course and outcome.

Developmental Course The developmental course of ADHD is characterized by changes in the way the problems are expressed, but not necessarily in the severity or extent of problems. A summary of ADHD behaviors most commonly exhibited at different ages is provided in Table 11.2 (see also Barkley, 1997c). Infancy The precursors of ADHD are found in infancy, as reflected in the characteristics of a difficult temperament (e.g., overactivity, intensity of emotional expression, predominantly negative mood, poor physiological regulation). Although not all children with ADHD have a history of difficult temperament in infancy, and not all children exhibiting these temperament characteristics develop ADHD, behaviors associated with a difficult temperament put these children at greater risk for ADHD than children who are more easy-going (Chamberlin, 1977). Preschool Over half of all children with ADHD exhibit behavior problems by the time they are 3 years of age (Barkley, 1997c). Moreover, all three subtypes of ADHD have been diagnosed in the preschool years (Lahey, Pelham, et al., 1998). Lahey and colleagues found that preschool children with ADHD-C were not only less popular with classmates but more actively disliked by their peers; they, as well as children with ADHD-H/I, were also more disruptive and less self-

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TABLE 11.2. Developmental Characteristics of ADHD Infants and toddlers (0–24 months)

Behvior problems • Overactivity • Impulsivity • Noncompliance • Aggression Accidental poisoning Accidental injury Delayed toilet training Preschool/day care problems • Lack of persistence • Oppositional behavior • Problems with group activities • Appears immature

Early school age (6–8 years)

Middle school age (9–12 years)

Behavior problems • Restless • Noncompliant • Conduct problems Attentional problems • Short attention span • Off task • Poor listening • Doesn’t follow directions Peer problems Requires close supervision

School problems • Underachievement (18–53%) • High error rates • Fails to complete assignments • Learning disabilities: reading and languagebased (25%) • Disruptive behaviors • Poor social skills • Poor self-control • Poor athletic skills • Peer problems Home problems • Irresponsible • Forgetful • Stealing, lying, property destruction Conduct disorder (25%) Oppositional defiant disorder (>60%) Mood disorders (30%) Anxiety disorders (34%)

Adolescence (13–18 years) Young adults Attentional problems • Poor school performance • Failure to remember assignments • Failure to complete assignments • Underachievement Conduct problems with aggression • Rebelliousness • Defiance of authority • Violation of family rules • Immature and/or irresponsible behavior • Car accidents • Drug use • Delinquency Low self-esteem Depression Poor social relations

Note. The data are from Barkley (1997c); Anastopoulos and Shelton (2001); and Du Paul, Power, et al. (1997).

Behavior problems (30–60%) • Restlessness • Inattention • Impulsivity Emotional problems • Low self-esteem • Feelings of sadness • Depression • Risk of suicide Marital/couple problems Car accidents Poor work record Substance abuse (38%) Alcohol abuse (27%) Interpersonal problems (75%) Antisocial personality disorder (23–45%)

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Difficult temperament • Overactivity • Intensity of emotional expression • Negative mood • Poor physiological regulation

Preschoolers (3–5 years)

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controlled than control children. More unintentional injuries were also reported for children with ADHD-C. Preschool children in all three ADHD subtypes were more likely to be receiving special education services for learning or behavior problems, indicating that even at this early age teachers were aware of their greater difficulties not only with behavior, but also with academic achievement. Furthermore, even when symptoms of disruptive behavior were controlled, a number of internalizing problems were significantly related to underachievement in reading and mathematics (Lahey, Pelham, et al., 1998). This is an important finding that speaks to the emotional impact of academic problems on children at even a very early age. Parents have been found to rate preschool children with ADHD as more stressful to manage, less reinforcing, more demanding, less adaptable to change, and less compatible with them (Byrne, DeWolfe, & Bawden, 1998). Parental stress and marital/couple discord also appear to increase during this time (Shelton et al., 1999), as well as symptoms of parental depression and feelings of incompetence (Byrne, DeWolfe, & Bawden, 1998). In response to negative and noncompliant behaviors with even routine daily care activities, many parents of children with ADHD use aversive, coercive, and controlling parenting stategies (Pisterman et al., 1992). Stormont-Spurgin and Zentall (1995) studied the family characteristics of 63 preschoolers who were grouped as hyperactive, hyperactive–aggressive, aggressive, or neither hyperactive nor aggressive. Compared to preschoolers with hyperactivity, preschoolers with hyperactivity plus aggression had families with more restrictive fathers, siblings who retaliated to verbal and physical aggression with verbal or physical aggression (twice as likely as in the other three groups!), and mothers who reported more physical aggression directed to their partners and more verbal aggression received from their partners. Elementary School Age If the behaviors characteristic of ADHD are excessive, the problems are likely to remain relatively stable over time from the preschool years into early formal schooling (Campbell, March, Pierce, Ewing, & Szumowski, 1991). By age 6 years, over 90% of children with ADHD have been identified as problematic by their parents or teachers (Barkley, 1997c). At this age, a lack of age-appropriate social skills is noted, along with increased peer relationship problems. Given the children’s lack of ability to follow socially appropriate rules and their problems with completing tasks, the need for constant supervision is often reported by parents during this period. Parental stress or depression also may emerge or increase at this time (Murphy & Barkley, 1996). At home, children with ADHD in the middle school years are unable to take responsibility for routine chores, need a great deal of monitoring, and their parents tend to be overly directive and negative. If there is a prior history of noncompliance and aggression, the risk for conduct problems in the community is high. At school, the children are likely to exhibit specific learning problems, and many will be labeled “underacheivers.” Peer problems increase during the middle school years; children with ADHD display problems with turn taking, interrupting conversations, and prematurely quitting activities due to boredom (Cunningham & Siegel, 1987). These behaviors tend to alienate existing friends as well as new acquaintances, and can lead to social rejection or avoidance. Peer relationship problems tend to occur more often among children with ADHD-C than among those with ADHD-I.

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Adolescence Barkley (1997c) notes that several factors can influence the outcome of a child with ADHD in adolescence. Children without associated significant aggression, comorbid mood disorders, family adversity, or peer relationship problems are likely to have problems primarily in school performance and to be termed “underachievers.” These children may have a higher chance of remission of their ADHD by adolescence (Biederman, Faraone, Milberger, Curtis, et al., 1996). On the other hand, most children who have a diagnosis of ADHD in adolescence are very likely to display extreme forms of defiance and noncompliance with rules (warranting a secondary ODD diagnosis), and are also more likely to engage in thefts and other behaviors consistent with CD (Barkley, Anastopoulos, Guevremont, & Fletcher, 1991). It should be noted, however, that children and adolescents with ADHD have an almost identical pattern of correlates in multiple domains of assessment, including psychosocial adversity and comorbidity with CD, mood disorders, and anxiety disorders (Biederman et al., 1998). Although less active, inattentive, and noncompliant by this age, adolescents may have problems with restlessness (finger tapping and leg movements), racing thoughts, and incessant talking. Adolescents with ADHD do not often report internalizing problems, but parent and teacher reports indicate they are at high risk for such emotional problems (Barkley, Anastopoulos, et al., 1991). The risk for internalizing problems is even greater for adolescents with ADHD who require special education services (Barkley, Fischer, et al., 1990), which are used by an increasing number of them (Barkley, Guevremont, Anastopdulos, & Fletcher, 1992). Furthermore, there is greater risk for school suspension. Approximately 30% of adolescents with ADHD fail to complete high school, and of those who graduate, most do not go on to college (Weiss, Hechtman, Milroy, & Perlman, 1985). Histories of repeated failure and frustration not only in academic performance, but also in social and family functioning, are very likely to contribute to these findings (Anastopoulos & Shaffer, 2001). In addition to academic and social problems, adolescents with ADHD are likely to have more frequent and intense conflicts with parents than their peers have (Barkley, Anastopoulos, Guevremont, & Fletcher, 1992). The families of these young people are also at greater risk for stress and marital/couple problems, especially if the adolescents present with features of comorbid ODD (Barkley, Anastopoulos, et al., 1992). Adolescents also report having more psychoactive substance use disorders than their parents are aware of (O’Donnell et al., 1998). Others have found that children with ADHD and severe social disability are at high risk for multiple-substance abuse (Greene et al., 1996; Greene, Biederman, Faraone, Sienna, & GarciaJetton, 1997). ADHD is also a significant risk factor for early initiation of cigarette smoking in both children and adolescents (Milberger, Biederman, Faraone, Chen, & Jones, 1997).

Adulthood Problems persist into adulthood for at least 30% of children diagnosed with ADHD. Although adults with ADHD are reported to make a better adjustment to their employment than they did to school, many continue to have significant problems that interfere with their functioning: From 23% to 45% have a diagnosis of antisocial personality disorder, 27% abuse alcohol, 75% have significant interpersonal problems, and from 30% to 66% have major behavior problems (Barkley, 1998a). In a longitudinal study of children followed from ages 9 to 26, Babinski, Hartsough, and Lambert (1999) examined the relationship among (1) childhood conduct problems; (2) two subtypes of ADHD, ADHD-I and ADHD-H/I; and (3) adult criminal activity as

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measured by official arrest records and self-report. They found that ADHD-H/I (but not ADHD-I) and early conduct problems independently, as well as jointly, predicted a greater likelihood of having an arrest record for males (but not for females). Individuals with only ADHD-H/I engaged in less serious crimes (e.g., public disorder and property crimes) than individuals with only conduct problems (e.g., assault and robbery). For females, early conduct problems increased the risk for official arrests, whereas ADHD-H/I was more predictive of self-reported crime. Not unexpectedly, the comorbidity of childhood ADHD-H/I and conduct problems consistently predicted adult arrests in all categories of crimes.

Summary In summary, ADHD places children at risk for a multitude of psychosocial difficulties across the life span. It also increases the risk of secondary or comorbid diagnoses, especially CD and ODD. Exhibiting disruptive behavior from an early age appears to be a major predictor for continuing problems. Furthermore, CD and ODD increase the risk of mood and anxiety disorders. When comorbid conditions exist, the overall severity of psychosocial impairment is greater, resulting in a far less favorable prognosis. Age has a significant impact on the prevalence of ADHD. In some cases there is significant improvement as children mature, with symptom reduction primarily in the dimension of hyperactivity–impulsivity versus the inattention dimension. For other children, problem severity increases with age, as early difficulties create later disadvantages that have cumulative consequences for learning, social relations, and selfesteem (Whalen & Henker, 1998). The clinician must also take into account the ongoing impact of interaction between the child and his or her environment. Just as with other childhood disorders, parenting strategies, parental psychopathology, family dysfunction, and socioeconomic disadvantage all play a role in the final outcome.

ASSESSMENT The assessment of ADHD is a complex and time-consuming process that must take into account many factors. These include (1) the child’s age and the part that development plays in the expression of the primary symptoms; (2) the pervasiveness of the symptoms; (3) situational variability; (4) potential comorbid disorders; (5) family and environmental factors; and (6) the impact that the behavioral symptoms are having on the child’s functioning, as well as on others in the home and at school. Thus assessment requires a variety of methods, including interviews with the parents, child, and teacher, and information from other pertinent informants; the use of both broad-band and narrow-band parent and teacher standardized child behavior rating scales and checklists, as well as parent self-report measures; direct observation of the child in natural and analogue situations; and clinic-based psychological tests. The importance of getting information from different informants, particularly the parents and teacher, cannot be overemphasized (Power, Costigan, Leff, Eiraldi, & Landau, 2001). Parents and teachers had virtually no agreement regarding DSM-IV ADHD subtypes on a structured diagnostic interview (Mitsis, McKay, Schulz, Newcorn, & Halperin, 2000)! Although parents may know that their child’s problems extend to the school setting, they are unable to indicate with any specificity the symptoms exhibited in the classroom. Without input from teachers, children are likely to be underidentified, and/or accurate identification and monitoring of target symptoms are not likely to occur.

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Given the strong association between the diagnosis of ADHD and attentional–executive deficits, neuropsychological tests are often thought to be useful in the assessment of children with ADHD (Barkley & Grodzinsky, 1994; Culbertson & Krull, 1996). Although there are documented group differences between boys with and without ADHD on some neuropsychological tests (Seidman, Biederman, Faraone, Weber, & Ouellette, 1997), recent evidence indicates that these tests have limited predictive utility for classifying individual cases with ADHD (Doyle, Biederman, Seidman, Weber, & Faraone, 2000; Rapport, Chung, Shore, Denney, & Isaacs, 2000). As an example, Doyle et al. (2000) assessed domains of functioning thought to be indirect indices of frontostriatal systems and thus important in ADHD. The measures used to test these domains were well-known clinical instruments (e.g., the Wisconsin Card Sorting Test, the Stroop Color–Word Test, an auditory continuous-performance task). Although the children with ADHD showed variable deficits on the neuropsychological tests of attention and executive functioning, neither single tests nor multiple tests used together were able to discriminate effectively between the children with ADHD and the controls. This was true both for children with ADHD who were on medication and for those who were not. Although impairments on multiple neuropsychological tests were predictive of ADHD, normal scores did not rule out the diagnosis. In addition, Reinecke, Beebe, and Stein (1999) found the Freedom from Distractibility (FFD) factor on the Wechsler Intelligence Scale for Children, Third Edition (WISC-III) to be an unreliable and invalid measure of attention for 200 children with ADHD (ages 6–11 years). Low scores on the FFD seemed to be more closely associated with the presence of a learning disablity or poor academic performance than with ADHD. Thus, although neuropsychological tests can be useful in documenting the strengths and weaknesses of a particular child, they have limited utility for diagnosis of ADHD. Given the time requirements and costs of neuropsychological tests, the routine use of these tests is not warranted at this time. The assessment of ADHD, like the assessment of all childhood problems and disorders, should not be limited to determining a diagnosis. More importantly, the assessment process should determine the specific nature of the problem(s) for an individual child, his or her strengths and weaknesses, the risk factors for significant and persistent impairment in functioning, the determination of comorbid conditions, the child’s eligibility for services, and possible intervention strategies. The interested reader is referred to Barkley (1998a) and Anastopoulos and Shelton (2001) for detailed assessment procedures for ADHD. The present discussion follows the steps for gathering information according to the Comprehensive Assessment-to-Intervention System (CAIS; see Chapter 2).

Step 1: Initial Contact At the time of the initial referral, parents should be asked to complete a general questionnaire (e.g., our General Parent Questionnaire; see Appendix B) giving demographic, developmental, and medical information, as well as their perception of the child’s problem. It is helpful to have the parents complete several standardized norm-referenced behavior checklists and rating scales prior to the initial interview, but the number of questionnaires sent out at this time or completed in the clinic before the interview should be determined by the family circumstances. Parents of children with ADHD are often likely to have their own attentional problems, and initially overwhelming them with checklists and rating scales may be counterproductive. It is important, however, to have a standardized broad-band questionnaire—such as the Child Behavior Checklist (CBCL; Achenbach, 1991a, 1992) or the Behavior Assessment System for

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Children (BASC; Reynolds & Kamphaus, 1992)—completed prior to the initial interview, since these measures alert the clinician to problems in other areas. The ADHD Rating Scale—IV (DuPaul, Power, Anastopoulos, & Reid, 1998) or the Conners Rating Scales Revised (Conners, 1997; Appendix A) are more specific scales that will be helpful for the parents to complete before the interview. A recent factor analysis (Burns & Patterson, 2000) validates the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999) as a measure of attentional problems, as well as of conduct problems and oppositional defiant behaviors. The Home Situations Questionnaire (HSQ; Barkley & Murphy, 1998; see Appendix A) assesses the number of problem settings and severity of the problems. Furthermore, having the parents keep a daily record of the child’s behaviors (e.g., our Daily Log; see Chapter 2 and Appendix B) can help the clinician determine what the child is actually doing (in contrast to what the parents think he or she is doing), and provides preliminary information about the frequency and intensity of the problem behaviors. It also provides a baseline against which to measure changes with treatment.

Step 2: Parent and Child Interviews In our clinic, a child with possible ADHD is usually included in the first interview with the parents. This enables the clinician to observe the parent–child interaction, in addition to ensuring that everyone hears the same information. We have found that children with ADHD have a good idea of their problems and will often offer their own opinions about the topics the parents bring up. If parents are uncomfortable with the child’s presence or the child’s behavior is likely to be too disruptive, a time is scheduled to interview the parents without the child, and the child is seen separately at a later date. The interview with the child, however, is begun with the parents present, and not only problems but the child’s positive qualities are discussed. Parent Interview It is important to have both parents attend the initial interview, if at all possible. A child with ADHD often behaves differently with each parent, and these differences (as well as inconsistent handling of the child) are important issues for the treatment process. Having both parents present also increases the chances that they will both participate in treatment, even if they are separated or divorced. The parent interview necessarily covers a great deal of information, and the clinician should allow 1½ to 2 hours for this first appointment, with further appointments scheduled as necessary to follow up on pertinent information presented in the initial interview. Although structured interviews have advantages in consistency of data collection (see Chapter 2), they also make it difficult to get information about the specific nature of the ADHDrelated problems for a particular child and family. We prefer a semistructured interview that follows the CAIS format and includes specific questions about the child’s development and behavior. The following areas should be assessed: 1. Behavior. ADHD problems are usually chronic, so it is important to determine what prompted the referral at this particular time and what the parents think caused the problem. This informs the clinician regarding the parents’ perceptions of the child’s problems, current family circumstances related to the problem’s severity, and the parents’ motivation for treatment. A general description of the behavior problems should be followed by specific questions that help define the problems and their functional relationships. For children with ADHD,

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it is important not only to define each specific behavior in question, its frequency, its age of onset, and its persistence, but also the situational and temporal variations in the behavior and its consequences. 2. Developmental history. The clinician should focus on the child’s early development, particuarly with regard to the child’s temperamental characteristics as they were manifested during infancy and early childhood, and to issues of control and independence. Early problems in the developmental domains of motor, language, intellectual, cognitive, academic, emotional, and social functioning could be indicators of another disorder, such as autism, mental retardation, a learning disability, or an anxiety disorder. 3. Differential diagnosis and comorbidity. Given the high rate of comorbidity in ADHD, it is important to review in a systematic way with the parents the symptom lists and other diagnostic criteria for various childhood disorders. The CBCL or BASC is helpful in determining specific areas for further follow-up. The process of diagnosing ADHD and differentiating it from other childhood disorders is a time-consuming but essential task that involves establishing the onset, course, and duration of symptoms, and then qualifying and quantifying the symptom picture. The typical age for which symptoms are reported for children with ADHD is 3½ years. This early age of onset usually differentiates it from other childhood clinical disorders, which typically are first diagnosed in older children. One must take into account, however, that this age corresponds to retrospective parental reports of early problem behaviors and not with the age of initial referral, which is typically 6–7 years. The reader is referred to Barkley and Murphy (1998) for an example of a semistructured interview to gather this information. 4. Medical history. Several medical problems, such as allergies, visual or hearing problems, lead poisoning, absence and partial complex seizures, central nervous system trauma, and hyperthyroidism, can contribute to ADHD-related behaviors. A careful medical history should be taken, including any prior or current treatment for medical problems. A history of tics for the child or biological family members should be determined, given that it might indicate the presence of Tourette’s disorder or suggest caution regarding the use of stimulant medication. Number and type of accidental injuries are also important to note, particularly if they involved a closed head injury (CHI). Research with children who had moderate or severe CHI indicated that a significant number had a premorbid diagnosis of ADHD (20%); 19% of the remaining children presented with the full ADHD criteria (except for age of onset) by the end of the first postinjury year (Gerring et al., 1998). Both the children with secondary ADHD and those with premorbid ADHD developed significantly more personality change due to CHI than those who did not have ADHD. This comorbidity of ADHD and CHI resulted in a qualitative and quantitative difference in clinical presentation, indicating greater complexity and difficulty of treatment. 5. Parent–child interactions. The nature of ADHD indicates that children will have problems complying with certain types of commands, directions, and assigned tasks. The problems usually consist of failure to finish assigned tasks or activities, particularly when they are boring, are effortful, or have no immediate consequences (Barkley, 1998a). Given that up to 60% of children with ADHD have a repertoire of oppositional, defiant, or coercive behavior, it is important to question parents about the child’s ability to comply with commands and requests in a satisfactory manner in various settings; to adhere to rules of conduct governing behavior in a variety of settings; and to demonstrate self-control or rule-following behavior appropriate to the child’s age and in the absence of adult supervision. Barkley (1998a) has developed a semi-

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structured interview format (Table 11.3) in which parents are questioned about their interactions with their child in a variety of home and public situations. If there is a problem in a particular situation, the clinician follows up with specific questions regarding the interactions that occur. This interview provides information on the type of noncompliance and aversive behaviors exhibited by the child, as well as the management style(s) typically used by the parents. If time is limited, the HSQ (which covers many of the same behaviors as the interview format) can be completed by the parents, and then one or two of the situations can then be chosen for the follow-up questions. Another way of gathering information about parent–child interaction is to ask the parents to describe in detail their typical daily routines (see Chapter 10). A focus on these behaviors can highlight differences between parental management styles or can indicate that one parent has more difficulty in managing the child than the other. The routine of daily life and its impact of the child’s behavior can also be assessed with this method. 6. Parent and family characteristics. High levels of parenting stress, marital/couple discord, and psychopathology exist among parents with children with ADHD. These problems in turn influence the frequency and severity of behavioral problems in children with ADHD (Barkley, 1997c). Screening for these problems is important, and parent self-report measures can be used for this purpose, either before or after the initial interview. A scale that we have found useful is the Parenting Stress Index (PSI; Abidin, 1995) for parents of children under the age of 12 years. It provides information about the marital/couple relationship, parental depression, child temperament, and life stress. Given the increased likelihood that parents and/or siblings also exhibit ADHD-related behaviors, it is important to question the parents about siblings’ behavior, as well as about problems similiar to their child’s problems that they themselves might have experienced during childhood or continue to experience. If there is a suspicion that a parent or a sibling may have ADHD, it is important to refer this individual for further evaluation. Many parents who have experienced problems similar to their child’s problems minimize the child’s behavior problems (e.g., “I was just like that as a kid, and I’m now doing OK”). Other parents with ADHD may complain that they are unusually sensitive or reactive to ADHD symptoms in their children. ADHD in parents can have a significant impact on the family functioning (e.g., difficulty with child supervision, overreacting to child noncompliance, trouble with organizational tasks, etc.); it can also influence the treatment of the child (e.g., high dropout rates, problems with group parent training programs, consistency; Weiss, Hechtman, & Weiss, 2000). Child Interview The child’s presence during the interview with the parents provides an early opportunity to observe the child’s behavior and to assess his or her perceptions of the problem versus the parents’ perceptions. Age-appropriate toys can be made available, and the clinician can informally assess the child’s attention span and ability to play alone; the parents’ management skills can also be noted. It is important to remember, however, that a child who exhibits nonproblematic behavior in the clinic (a new situation with novel toys) may not exhibit such behavior in other situations such as the school or home; therefore, reports by teachers and parents must be given greater weight than clinic observations. A period of time alone with the child following the interview with the parents gives the clinician the opportunity to assess the child’s behavior with a novel adult and, depending on

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TABLE 11.3. Parent Interview Format Situations to be discussed with parents

Follow-up questions for each problematic situation

General—overall interactions Playing alone Mealtime Getting dressed in morning During washing and bathing While parent is on telephone While watching television While visitors are at home While visiting others’ homes In public places (supermarkets, shopping centers, etc.) When mother is occupied with chores or activities When father is at home When child is asked to do a chore At bedtime Other situations (in car, in church, etc.)

1. Is this a problem area? If so, then proceed with questions 2 to 9. 2. What does the child do in this situation that bothers you? 3. What is your response? 4. What will the child do next? 5. If the problem continues, what will you do next? 6. What is usually the outcome of this interaction? 7. How often do these problems occur in this situation? 8. How do you feel about these problems? 9. On a scale of 0 to 10 (0 = no problem; 10 = severe problem), how severe is this problem to you?

Note. Adapted from interview used by C. Hanf of the University of Oregon Health Sciences Center. Reprinted from Barkley (1998a). Reprinted by permission.

the age of the child, to determine more closely the child’s perceptions of the problem and his or her family. For a preschool child, this may be a time to become further acquainted with the child, and to observe his or her behavior and developmental characteristics. For an older child, this session may include further inquiry about the child’s understanding of the reasons for the referral and evaluation, perceptions of the family’s functioning, additional problems the child feels he or she may have, school performance, degree of acceptance by peers and classmates, and possible changes in the family or school setting that might make life happier for the child. The child can also be asked about potential rewards and reinforcers for later use in contingency management programs. It is important to remember, however, that children below the age of 9–12 years are not very reliable in their reports of their own problems or those of their family members. This is further compounded by the frequently diminished self-awareness and impulse control typical of children with ADHD (Hinshaw, 1994). They reflect very little on the clinician’s questions, and may lie or distort information to appear in a more socially pleasing way (e.g., they have many friends, are doing well in school, and have no problems interacting with parents), although this may be in direct contrast to what their parents or teachers have reported. In general, children with ADHD tend to underreport the seriousness of their disruptive behaviors (Hinshaw, 1994). For more information on interviewing children with ADHD, see Sattler (1998).

Step 3: Observation of Behavior Direct observation of the child can provide valuable information about the child and his or her interactions with parents, teachers, and peers. A number of behavioral observation and recording systems specific to ADHD have been developed, but most of these have been used primarily for research purposes, and the training required to implement them discourages their general use. The reader is referred to Barkley (1998a) for further discussion of these methods.

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Roberts (1990) has developed a method for a clinic analogue setting that has demonstrated considerable promise. Two situations lasting 15 minutes each are used in the clinic playroom: Free Play and Restricted Academic Period. The floor of the playroom is divided into 16 squares with black tape, and there are four tables and toys in the room. In the Free Play situation the child is in the room alone and told to play freely with the toys. In the Restricted Academic Period situation, the child is requested to remain seated, to complete a series of worksheets (a task similiar to the Coding subtest of the WISC-III), and not to play with any of the toys in the room. Throughout the two 15-minute periods, observers record six behavioral categories: grid crossings, out-of-seat behavior, fidgeting, vocalization, on-task behavior, and attention shifts. Time spent touching forbidden toys and the number of worksheet items completed are also recorded during the Restricted Academic Period. This method has been shown to discriminate between aggressive and nonaggressive children with ADHD, and between children with these two types of ADHD and purely aggressive children, as well as clinical control groups. The measure is stable over time and has a significant correlation with clinicians’ ratings of hyperactivity and impulsivity. It has also been found to be sensitive to the effects of stimulant medication (Barkley, Fischer, Newby, & Breen, 1988). The CBCL and the BASC also have direct observation forms for the classroom (see Chapter 2). Although there is limited research on these forms of observation, they are easy to learn and to use, and provide useful clinical information about the child and his or her immediate peer group. Chapter 10 describes the parent–child interaction observation method used in our clinic.

Step 4: Further Assessment Teacher Interview An interview with the teacher is always needed when there is a question of ADHD, and permission to contact the child’s teacher should be obtained during the initial contact with parents. A general school questionnaire (see our Teacher Questionnaire, Appendix B), as well as both a broad-band rating scale (the teacher form of the BASC or CBCL) and specific ADHD rating scales, should be sent to the teacher to complete and return prior to the initial parent interview. This allows the clinician to discuss the results with the parents and later with the teacher during the school visit. Teacher rating scales that are more specific to ADHD-related behaviors include the Revised Conners Teacher Rating Scale (Conners, 1997); the School Situations Questionnaire (SSQ; Barkley & Murphy, 1998), which gives information on the number of problem settings and severity of the problems; the Child Attention Problems (CAP) scale (Edelbrock, 1990, cited in Barkley, 1999a; Appendix B), which is designed for teachers to give weekly information about the number and severity of attentional problems; and the Academic Performance Rating Scale (APRS; DuPaul, Rapport, & Perriello, 1991; Appendix B), which is a brief teacher-completed measure that assesses learning ability and academic performance as well as impulse control and social withdrawal. These questionnaires take a relatively short time to complete, and their importance should be emphasized in the initial phone contact with the teacher. The interested reader is referred to Barkley (1998a) and Kamphaus and Frick (1996) for discussions of other teacher rating scales for ADHD. A school visit allows the clinician to interview the teacher and assess the school environment. If such a visit is not possible, then a phone interview should be substituted. A behavioral format should be used for the teacher interview, with the focus on specific problems in the school environment (including the nature of each behavior, settings, frequency, antecedent or

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eliciting events, and consequences of the behavior). Follow-up questions derived from the teacher rating scales can be used to guide this part of the interview. The follow-up questions used to guide the parent interview (Table 11.3) can also be useful in the teacher interview. It is important to ask about the possibility of a specific learning disability. Likewise, questions regarding oppositional defiant behavior, conduct problems, and peer problems should be asked and followed up as needed.. Finally, the teacher should be asked for his or her perception of the problems, as well as for any ideas regarding what needs to be done for the child. Social Skills Deficits in social skills can be further evaluated with the Social Skills Rating System (SSRS; Gresham & Elliott, 1990; Appendix A), which has forms for teacher, parent, and child at the preschool, elementary, and secondary levels and measures a variety of social skills across settings. The teacher form of the SSRS also includes a rating of academic competence. Furthermore, the SSRS offers an integrated method of interpretation and intervention planning. Parents should be asked about the major areas of social functioning, including school, spare-time activities, peer relations, and home life. Learning Problems The CAP scale and the APRS are useful in delineating problems in learning and provide an opportunity for further follow-up questions in the teacher interview. However, given the high rate of academic underachievement and learning disabilities in children with ADHD, assessment of such children should always include intellectual and achievement testing, followed up by tests specific to problematic areas (e.g., math, reading). This assessment indicates not only a child’s general level of cognitive functioning, but the specific and overall patterns of strengths and weaknesses that may be related to classroom functioning. This testing can also help to determine a child’s eligiblity for special services. Continuous-performance tests, which measure vigilance and sustained attention, have become popular in recent years, especially to monitor response to stimulant medication (Conners, 1995; Gordon, 1983; Greenberg & Waldman, 1992). Although group differences are reported between children with ADHD and control children, when used with individual children they produce unacceptably high false-negative rates (Doyle et al., 2000). These tests, therefore, are not recommended either to evaluate children with ADHD or to monitor stimulant medication response. Parent Referral Given that parents of children with ADHD have an increased probability of ADHD or other psychiatric conditions as well as marital/couple problems, screening and/or further evaluation for these difficulties may be needed. Instruments for this purpose include the Dyadic Adjustment Scale (Spanier, 1976; Spanier & Thompson, 1982) and the Beck Depression InventoryII (Beck, Steer, & Brown, 1996) (see Appendix A for descriptions of both). If parental or family problems exist, their severity and the extent to which they are likely to interfere with the child’s treatment should be assessed. A referral for treatment of such problems should be made if necessary.

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Step 5: Referral to Allied Health Professionals It is important to determine that the child is in good health or does not have a problem that would exacerbate the symptoms of ADHD or decrease the effectiveness of treatment, so contact with the child’s physician is necessary. If medication is being considered as a treatment method (which in most instances is true), then referral to a pediatrician or psychiatrist is needed. The role of the pediatrician in the diagnosis of ADHD has received considerable attention, and there are concerns that stimulant medication is often prescribed without a proper assessment for the disorder or its possible comorbidity. Moreover, there is often little or no coordination of medical treatment with the educational system, and parent education/training and psychosocial treatment for the child are frequently overlooked when physicians diagnose and treat ADHD (NIH, 2000). The American Academy of Pediatrics (2000, 2001) has published practice guidelines for the assessment and treatment of ADHD. Although these guidelines clarify the minimal requirements for the diagnosis of ADHD, they do not take into account the specific nature of the child’s problems or the child and family’s unique strengths and weaknesses, which allow the clinician to plan the most effective intervention for the individual child. Pediatricians and family practitioners are nevertheless very important for the successful treatment of children with ADHD, and it is important to establish good relationships with them. These professionals receive the most frequent queries about ADHD, and are therefore in the best position to make appropriate referrals for further assessment and/or treatment. In addition, the demonstrated effectiveness of stimulant medication in the treatment of ADHD requires their understanding of the disorder and its most effective treatment. Sharing information about ADHD in general, as well as specific findings and recommendations for each individual child (including information about monitoring the effectiveness of stimulant medication), will ultimately support more effective assessment and treatment of children with ADHD. A referral to a neurologist should be made if Tourette’s disorder is suspected. Moreover, children with anxiety or depressive symptoms should be referred to a psychiatrist for medication recommendations and monitoring.

Step 6: Communication of Findings and Treatment Recommendations The clinician’s understanding of the nature, etiology, and severity of the child’s problems with attention, impulsivity, and overactivity, as well as potential treatment approaches, should be discussed with the parents (and with the child at his or her level of understanding). Providing the parents and child with a clear understanding of these issues, as well as how the ADHD behaviors fit into the child’s development, will help the family members trust the clinician and maximize the possibility of their cooperating with treatment. Some discussion of the child’s prognosis is also warranted, although setting up a “self-fulfilling prophecy” should be avoided. The need for continued or periodic treatment and monitoring of the child’s progress over the course of development should be stressed, as the ADHD-related problems can affect many important areas of the child’s life and rarely go away after an initial course of treatment. This is particularly true for children with ADHD-C and those who have comorbid conditions, especially ODD and CD. If parental or environmental characteristics that can exacerbate the problems are present, these should be carefully explained and recommendations for specific help in those areas offered. Just as Kazdin (1987) recommends viewing severe cases of CD from

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the perspective of a “chronic illness,” so should cases of ADHD be viewed. Treatment can bring the behavior under sufficient control that the family and child can function reasonably well, but the child is going to need continual monitoring, and the parents and teachers will need ongoing or periodic help and support from the clinician.

TREATMENT Like the assessment process, treatment of ADHD requires a multimethod and cross-situational approach that takes into account the individual child’s and family’s strengths and weaknesses. The focus of treatment is based on the areas of deficit or impairment that are most salient, the specific concerns of the referral source(s), and those areas that are most important for the child’s current and future adjustment. Comorbid conditions must also be taken into account in planning and carrying out treatment. A child with ADHD who also presents with an anxiety disorder is a very different child to treat from one who has comorbid CD or a specific learning disability. Similarly, a family with a parent who has ADHD or depression requires a different approach from that for a well-functioning and supportive family. The child’s development is another important factor in planning for treatment, with a focus not only on current problems but also on areas of weakness that without intervention could lead to later problems. Moreover, given the cross-situational nature of ADHD problems, the clinician must plan for and coordinate intervention in a number of settings. Finally, regardless of the initial recommendations, treatment involves ongoing monitoring of the child’s behavior to determine effectiveness of treatment, to maintain therapeutic gains, to plan for the generalization of treatment effects to other problems and situations, and to change programs as needed over the course of development. This process can be overwhelming for the family, and also for the clinician. Many books have been written for parents of children with ADHD. Among our favorites are Taking Charge of ADHD (Barkley, 2000b) and Attention Deficit Disorder and the Law (Latham & Latham, 1997). Support groups for parents also are often helpful. National resources include Children with Attention Deficit Disorders (CHADD), 8181 Professional Place, Suite 201, Landover, MD 20785, 800-233-4050, www.chadd.org; and Learning Disabilities Association of America (LDA), 4156 Library Road, Pittsburgh, PA 15234, 412-3411515 or 888-300-6710, http://www.ldanatl.org. Although there are many treatments for ADHD (Abikoff & Hechtman, 1996; Barkley, 1998a; Hinshaw, 1994), only a few have received adequate or preliminary empirical support. These include pharmacotherapy, parent training/counseling, parental and classroom applications of contingency management techniques, and cognitive-behavioral therapy (Pelham, Wheeler, & Chronis, 1998). Anastopoulos and Shaffer (2001) point out that none of these treatment approaches should be viewed as curative. Rather, their value lies in the reduction of ADHD-related symptoms and the improvement of related behavioral and emotional problems. When treatments are discontinued, the problem behaviors often return to pretreatment levels. Thus, to be effective in changing or ameleorating the potential negative developmental course of ADHD, treatment must be maintained over a long period of time. In the first major clinical trial to focus on a childhood disorder, the National Institute of Mental Health (NIMH) initiated a study of ADHD with six collaborating academic sites (e.g., Richters et al., 1995). The ongoing project, called the Multimodal Treatment Study of Children with ADHD (MTA), investigates an array of critical issues, including the comparative efficacy of single and combined treatments, the durability of therapeutic gains, and the opti-

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mal match of the child and treatment characteristics. The study is focusing on the relative effectiveness of 14 months of four treatments for ADHD: (1) behavioral treatment, including 35 sessions of behavioral parent training, up to 10 teacher/school consultation visits per school per school year, a 12-week classroom aide, and a summer treatment program; (2) medication management, including psychostimulant medication 7 days per week; (3) combined behavioral treatment and medical management; and (4) a community control comparison group. Children ages 7–9 years with ADHD are randomly assigned to one of the four groups and followed intensely, with major assessments after 9 months and 14 months of treatment. It will be a number of years before the final results of this study are published. Preliminary reports indicated, however, that the pharmacological interventions were more effective than behavioral treatments, and that adding behavioral treatments to medication resulted in only modest additional benefits (MTA Cooperative Group, 1999; Swanson et al., 2001; but see Conners et al., 2001). However, the children receiving intensive psychosocial treatment exhibited higher functioning and were able to take lower doses of medication. Pelham (1999) cautions that the interpretation of these results must take into account the complex design of the study, including the fact that posttreatment measures were taken while children remained actively medicated with psychostimulants, but several months after active behavioral treatment had ended and usually 4–6 months past the intensive phase of the behavioral treatment. Pelham (1999) states that if the design had been reversed (with the medication faded while behavioral treatments continued), the results would certainly have been reversed. This conclusion is supported by data from a substudy revealing that medication did not add to the effectiveness of behavioral treatment during an intensive summer treatment program. Pelham cogently presents information about the study that indicates the effectiveness of the behavioral treatment and the preference by parents for the behavioral treatments over medication-alone treatments. Greene and Ablon (2001) argue that effective behavioral treatment for ADHD requires careful matching of treatment ingredients with the specific needs of the individual child. At this point, the combination of behavioral treatment and medication is still the treatment of choice for most children with ADHD, with the acknowledgment that treatment must be ongoing to have an impact on long-term outcome. The next sections briefly cover some of the most promising treatments following the framework provided by the CAIS, including intervention with the child and parents, intervention in the (classroom) environment, changing the consequences of the child’s behavior (which can be done by both parents and teachers), and medical/health intervention. In this last section, we describe the various medications most commonly used for ADHD, and present a protocol for titration and monitoring of these drugs. The reader is referred to Barkley (1998b) and Pelham et al. (1998) for more in-depth coverage. Other chapters in this book, especially Chapters 8– 10, also discuss treatment approaches that could be useful for children with ADHD.

Intervention with the Child Cognitive-behavioral therapy approaches that emphasize self-regulation training, such as selfmonitoring, self-reinforcement, and self-instructional techniques, appear to have value for children with ADHD, since they focus on the primary deficits of ADHD (impulsivity, poor organizational skills, and difficulties with rules and regulations). They may also enhance treatment generalization beyond what would be expected of contingency management programs, and to eliminate the need for external control or reinforcement by the parent or teacher. Although initial reports indicated some potential for these methods, outcome data have been

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disappointing (Abikoff & Klein, 1992; Rapport, Chung, Shore, & Isaacs, 2001; Whalen & Henker, 1986). For the most part, children with ADHD need ongoing prompting and reinforcement, and improved behavior in one setting seldom generalizes to other settings. Children with comorbid anxiety problems may benefit from these techniques, however (see Chapter 8).

Intervention with the Parents/Changing the Consequences of the Behavior Parent Training Parent training programs for oppositional defiant behaviors are essentially the same as those that would be used for ADHD (Barkley, 1997b; Forehand & McMahon, 1981; Hembree-Kigin & McNeil, 1995). Parent training has been shown to be effective for preschoolers with symptoms of ADHD (Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001). The parent training program used in our clinic is described in detail in Chapter 10. Modification of parent training programs to improve parent–child interactions in families with ADHD include adding sessions to provide an overview of ADHD, establishing home token reinforcement systems, and teaching parents how to deal with behavior in public places (Barkley, 1997b). These programs are designed primarily for children ages 2–11 years and are best used with children who have noncompliant, defiant, and oppositional behaviors at home, in addition to the primary ADHD symptoms. They do require a certain degree of parental motivation, given that the skills learned in the clinic must be practiced and implemented in the home on a fairly consistent basis if changes are to be seen in the child’s behavior. Parental psychopathology can also interfere with the implemention of behavioral programs and might best be addressed prior to the beginning of parent training. Behavioral Interventions Children with ADHD have difficulty regulating and maintaining their behavior by its consequences, which in turn increases their problems with inhibiting, initiating or sustaining responses to tasks or stimuli; they also have difficulty adhering to rules or instructions, particularly when consequences for such behaviors are delayed, weak, or nonexistent (Barkley, 1998a). Given these difficulties, the use of techniques that exert greater control over stimulus selectivity and reinforcement have great appeal for dealing with children with ADHD. A major advantage of behavioral interventions is that parents, as well as teachers and other caretakers, can be trained to use the techniques. Moreover, they are adaptable to a variety of settings, which increases generalization of behavior and maintenance of therapeutic gains. These techniques have also been found effective in dealing with other disorders that are often comorbid with ADHD, such as CD, ODD, anxiety disorders, and mood disorders. The behavioral techniques most often used for children with ADHD are contingency management procedures, which primarily involve the use of positive reinforcement or other consequences designed to shape desired behavior. Contingency management programs involve teaching the parents (and teachers or other caretakers, as applicable) to use these techniques with a particular child and helping them implement the techniques in the child’s environment. Unfortunately, there has not been a great deal of research on the specific use of these techniques with children with ADHD, but there is some support for their effectiveness in general (e.g., Anastopoulos, Shelton, DuPaul, & Guevremont, 1993; Pisterman, McGrath, Firestone,

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& Goodman, 1989). The NIMH MTA project should shed further light on this area in terms of the specific nature of training, its effectiveness, and the extent of training needed to evidence significant changes in children with ADHD. The heterogeneity of behavior of children with ADHD makes research in this area difficult, and clinically one must adapt the most effective treatments to the individual child and family. All parents of children with ADHD (as well as any parent!), however, would benefit from understanding basic management procedures, childrearing principles, and appropriate developmental expectations. Most of the behavioral techniques have been discussed in other chapters in this book, particularly Chapter 10, and are not covered in detail here.

Intervention in the Environment/Changing the Consequences of the Behavior Techniques used in the classroom include special education classes (not discussed in detail here), antecedent-based interventions (task-related and instructional modifications, use of personal computers and other aids, and peer tutoring), and consequence-based interventions (contingency management methods, token reinforcement systems, home-based evaluation/ reinforcement programs, increased attention by teachers to child compliance, in-class timeout procedures, response cost programs, and behavioral contracts) (Barkley, 1997c). There is evidence regarding the effectiveness of these techniques in reducing classroom behavior problems and increasing academic productivity (Pelham et al., 1993; Pelham & Hinshaw, 1992). However, the extent to which these techniques bring behavior closer to “normal,” or the extent to which treatment gains are maintained after the techniques are withdrawn or the child moves on to another classroom, grade, or teacher, is not known. The preliminary results of the NIMH MTA Project (Pelham, 1999) indicate that most gains are lost after the cessation of an intervention program. Also, the extent to which these programs can be used depend on the nature of a child’s behavior problems, the characteristics of the school, and the degree of the parents’ and teacher’s commitment to implementing the methods consistently. Antecedent-Based Interventions Task-related and instructional modifications in the classroom have included (1) reducing the amount of seatwork; (2) ensuring student understanding prior to beginning a task; (3) providing extra time for the completion of tests and/or long-term assignments; (4) posting rules, with frequent reminders of expectations for rule-following behavior; and (5) teaching study skills and note-taking strategies (DuPaul & Stoner, 1994). The use of personal computers has also become more common in the classroom. Some antecedent-based interventions that have empirical support include peer tutoring (DuPaul, Hook, Ervin, & Kyle, 1995) and allowing students to choose task activities (Dunlap et al., 1994). “Classwide peer tutoring” (CWPT; Greenwood, Delquadri, & Carta, 1988) has been shown to enhance math, reading, and spelling skills for students of all achievement levels (Greenwood, 1991). It involves the following components: (1) The class is divided into two teams; (2) within each team, classmates form tutoring pairs; (3) students take turns tutoring each other; (4) tutors are provided with academic scripts (e.g., math problems with answers); (5) praise and points are contingent on correct answers; (6) errors are corrected immediately, with opportunities for practicing the correct answers; (7) the teacher monitors tutoring pairs and provides bonus points for pairs following prescribed procedures; and (8) points are tallied by individual students at the conclusion of

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each session. Tutoring sessions typically last 20 minutes, with an additional 5 minutes for charting progress and putting materials away. At the end of each week, the team with the most points is applauded by the other teams. Points are usually not exchanged for backup reinforcers. DuPaul et al. (1995) found that active engagement in tasks increased from 21.6% during baseline to an average of 82.3% when CWPT was implemented by the general classroom teacher. Furthermore, the children’s weekly posttest scores increased from an average of 55.2% to 73% for CWPT conditions, demonstrating that CWPT positively affected both attentional and academic performance. Another antecedent-based intervention more easily implemented in the classroom than CWPT is allowing the child to choose tasks independently. Dunlap et al. (1994) found that the rates of task engagement and disruptive behavior were functionally related to the manipulation of teacher-assigned versus student-chosen tasks, with the latter leading to higher levels of engagement and lower levels of disruptive behaviors. Consequence-Based Interventions Two consequence-based approaches that have been found particularly useful for children with ADHD are reinforcement contingent upon the display of appropriate behavior and response cost contingent upon off-task behavior. Token programs that target task-related attention and productivity involve (1) choosing target behaviors that are active (e.g., completion of work vs. staying in seat); (2) having the child choose a variety of preferred activities as rewards; (3) scheduling specific time periods and/or situations for program implementation; and (4) initially implementing the program for a short period each day, and then gradually increasing the time and settings in which it is used (DuPaul & Hoff, 1998). Response cost involves giving the child a set number of token reinforcers at the beginning of an activity and deducting tokens contingent on the display of inappropriate behavior (Kazdin, 1984). Rapport, Murphy, and Bailey (1982) found that a modified response cost program increased on-task behavior as much as stimulant medication did! This program involved (1) choosing active target behaviors; (2) having the child choose reinforcing activities; (3) specifying the situation in which the response cost would be used; (4) starting the work period with 0 points, with points earned periodically for engaging in the target behavior; (5) having the teacher reward the student on an interval schedule (i.e., peroidically monitoring the behavior); (6) deducting a point if the child exhibited significant off-task behavior; and (7) allowing the child to exchange his or her final net points for a certain amount of time with a preferred activity. The combination of response cost with positive reinforcement has been shown to be more effective than positive reinforcement alone in the maintenance of on-task behavior (Carlson & Tamm, 2000; Sullivan & O’Leary, 1990). In addition, the use of secondary and tangible reinforcers (tokens and activities) has been found to be more effective than teacher attention or social reinforcement alone in improving the behavior and academic performance of children with ADHD (Pfiffner, Rosen, & O’Leary, 1985). Although response cost is a mild punishment, it is usually acceptable to both students and teachers when the rate of positive reinforcers is higher than the rate of response cost (e.g., 3:1). These techniques can also be used in the home. Anhalt, McNeil, and Bahl (1998) describe another classroom-wide program, ADHD Classroom Kit: An Inclusive Approach to Behavior Management (McNeil, 1995). The components of this program have been chosen on the basis of their individually demonstrated effectiveness in changing behavior. A goal is to include the entire class in the behavior management pro-

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gram, rather than singling out the child with ADHD. The program includes consequences for appropriate and inappropriate behavior and peer-mediated interventions. Anhalt et al. (1998) provide preliminary evidence for the program’s effectiveness in increasing on-task and appropriate behaviors and decreasing disruptive behaviors for both an individual child with ADHD and her class as a whole. An Integrated Approach Rapport (1998) describes an “ideal” learning environment for children with ADHD that involves a proactive approach to treatment. This approach focuses on altering the environment that elicits the undesirable behavior in the first place, rather than relying solely on medication or consequence-based interventions to change the behavior. The classroom curriculum involves integrating personal computers, software, and instructional and training materials. Teachers act more as monitors and facilitators, and parents are regularly involved in the teaching process. This approach has heuristic value, but unfortunately it is unlikely to be implemented in any large-scale way because of its cost. At this point, its value is in describing the type of environment in which children with ADHD can best learn.

Intervention in Medical/Health Aspects The use of medication, particularly stimulants, in the treatment of ADHD increased dramatically during the 1990s (Safer, Zito, & Fine, 1996). Although a recent American Medical Association report (Goldman, Genel, Bergman, & Slanetz, 1998) states that stimulants are not being overprescribed, there is little evidence to support this assumption, and little is known about how medication for ADHD is used in community settings (Angold, Erkanli, Egger, & Costello, 2000). Given the effectiveness of drug therapy for treatment of ADHD, it is important for clinicians to work with physicians to ensure that the dose prescribed is the most appropriate for improvement of the targeted behaviors. Although physicians can learn to systematically monitor the behavioral effects of drug therapy, the NIH (2000) consensus conference clearly points out the difficulties most physicians have in doing this. In Texas, concern about the use of stimulant medication has led to the development of systematic algorithms for the use of psychopharmacology for children with ADHD with and without comorbid disorders (Pliszka et al., 2000a, 2000b). The publications resulting from this work are excellent resources, and child clinicians are encouraged to share them with the physicians with whom they work. Medications Used for ADHD The drugs most commonly used in treating children with ADHD are psychostimulants, tricyclic antidepressants, and neuroleptics (see Devney, 2001, for a review). The psychostimulants, including methylphenidate (MPH or Ritalin), dextroamphetamine (Dexedrine), and pemoline (Cylert), are the most frequently used and are prescribed to an estimated 3–6% of elementaryage children (Wilens & Biederman, 1992). Reports indicate that approximately 70–85% of children with ADHD over 5 years of age respond positively to stimulant medication (Barkley, DuPaul, & McMurray, 1991; Rapport, 1998; Wilens & Biederman, 1992). A study examining the behavioral and cognitive effects of MPH versus dextroamphetamine found that on a group level both drugs seemed to be safe and effective (Elia, Borcherding, Rapoport, & Keysor, 1991). For an individual child, however, one drug was often superior to the other, and adverse effects

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that occurred with one drug were unlikely to occur with the other. Adderall (a relatively new stimulant medication combining dextroamphetamines with amphetamines) appears to be comparable to MPH, and its behavioral effects persist longer than those of individual doses of MPH (Pliszka, Browne, Olvera, & Wynne, 2000). In a double-blind, placebo-controlled study, comparing Adderall with immediate and extended release dextroamphetamine sulfate, James et al. (2001) found that all three medications were effective when compared to placebo. Immediate-release dextroamphetamine and Adderall demonstrated earlier onset of effects, whereas the extended-release spansules showed more sustained effects over a wider range of measures. Although stimulants are not usually recommended as the first choice of treatment for preschoolers, the use of these medications with this age group has some empirical support (Byrne, Bawden, DeWolfe, & Beattie, 1998; Musten, Firestone, Pisterman, Bennett, & Mercer, 1997). In a double-blind placebo-controlled study using 0.3-mg/kg and 0.5-mg/kg doses of MPH twice a day, Musten et al. (1997) found improvements on cognitive tests of attention and impusivity, as well as in behaviors assessed by parent rating scales. No changes occurred in the children’s tendency to comply with parental requests, however, and side effects were minimal. MPH, the most commonly used stimulant, is available in doses of 5 mg, 10 mg, 20 mg, and sustained-release 20 mg (equivalent to 10 mg twice a day) for oral administration. MPH acts rapidly, producing effects on behavior 30–45 minutes after oral ingestion, with therapeutic impact peaking within 2–4 hours. Given its short behavioral half-life of 2½ hours, MPH is usually administered twice or three times daily in doses from 5 to 20 mg. A typical dose is 10 mg twice a day, regardless of age or body size (Whalen & Henker, 1998). Several studies show that body weight is unrelated to MPH response in children (Rapport & Denney, 1997; Swanson, Cantwell, Lerner, McBurnett, & Hanna, 1991). Thus, despite the guidelines for dosage by body weight in the Physicians’ Desk Reference, it appears that weight is a meaningless guideline for determining dosage. Results from the MTA study (Vitiello et al., 2001) indicate that only 17% of the 230 children for whom initial titration identified an optimal dose remained on the assigned medication and dosage throughout maintenance. Thus, for optimal pharmacological treatment of ADHD, both careful initial titration and ongoing medication management are needed. It should also be noted that children receiving combined pharmacotherapy and behavioral treatment concluded the study on lower methylphenidate doses (31.1 mg/day) than did children receiving medication management alone (38.1 mg/day) (Greenhill et al., 2001). Barkley (1997c) cites a number of the primary positive effects of stimulant medication among school-age children, including improved attention span, decreased impulsivity, diminished task-irrelevant activities (especially in structured situations), and generally decreased disruptive behavior in social situations. Secondary effects of these changes include increased compliance to commands and instructions; increased quality and quantity of academic assignments completed; improved peer interactions and increased peer acceptance; and decreased parent and teacher reprimands, supervision, and punishment. Kramer, Cepeda, and Cepeda (2001) found that methylphenidate specifically enhanced inhibitory processes involved in task switching and focusing attention on relevant responses. Thus numerous domains are potentially affected by stimulants, and it is difficult to know which domains will improve in a particular child. Moreover, gains in one area do not necessarily predict gains in another area. In general, decreases in negative behaviors are more likely than increases in positive activities, especially when complex skills such as prosocial behavior are involved. The gains resulting from medication generally fall short of “normalization”; children who respond positively to medication con-

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tinue to be distinguished from their peers by dysfunctional behavior patterns and poorer academic performance (DuPaul & Rapport, 1993; Rapport, Denney, DuPaul, & Gardner, 1994). The positive changes, however, result in smoother day-to-day interactions in different settings and with different people. Contraindications for MPH therapy include a family history of tics, a history of seizures (MPH can lower the threshold for seizures in children with such a history), glaucoma, hypertension, hyperthyroidism, documented hypersensitivity, and allergic or other adverse reactions to the drug (Rapport, 1998). Some research suggests that children with anxiety or depression do not respond well to stimulant medication (DuPaul, Barkley, & McMurray, 1994; Tannock, Ickowicz, & Schachar, 1995). Thus, if stimulant medication is not effective, a trial with tricyclic antidepressants (e.g., imipramine) may be warranted, since these drugs have been shown to have some effectiveness in ADHD (Biederman, Baldessarini, Wright, Knee, & Harmatz, 1989). Tricyclic antidepressants have also been used for children with ADHD who have a history of motor tics or who have adverse reactions to stimulants. These medications are usually given twice daily (in the morning and evening), but given that they are longer-acting than stimulants, their therapeutic effect takes longer to evaluate. Research has shown that low doses of these medications can produce increased vigilance and decreased impulsivity, as well as reductions in disruptive or aggressive behaviors (Plizska, 1987). Mood elevation may also occur. The treatment effects can diminish over time, however; therefore, antidepressants are not recommended for long-term management of ADHD. Thiruchelvam, Carach, and Schachar (2001) point out that compliance with psychopharmocological treatment of ADHD is an important component of any intervention program. In a study of 71 children with ADHD who were prescribed one of the stimulants, Thiruchelvam et al. found that only 52% adhered to the treatment program for 3 years. Factors that predicted noncompliance were teacher-rated noncompliance, fewer ADHD symptoms, and older age at baseline. Side Effects Most side effects of MPH are mild, are dose-related, fade within a few days of treatment onset, or are reversible through adjustments in the amount or timing of medication (Wilens & Biederman, 1992). Reported side effects include sleep disturbances, reduced appetite (with potential weight loss and/or growth suppression), mild elevations in heart rate and diastolic blood pressure, stomachaches, headaches, irritability, unhappiness (crying), withdrawal, constricted cognitive ability (overfocusing on certain phenomena), rebound effects, and emergence or intensification of tics and other nervous mannerisms (Barkley, McMurray, Edelbrock, & Robbins, 1989). Although there has been some concern about the development of tolerance, there is little evidence that behavioral improvements decrease over time (Whalen & Henker, 1998). Sleep problems typically consist of difficulty falling asleep (initial insomnia) and are often associated with receiving late afternoon or evening doses of MPH. Decreasing or eliminating doses in the latter part of the day usually eliminates the problem. Although there has been concern about weight loss and/or suppression of growth, MPH is not reported to compromise final height in young adults who are treated with the drug in childhood, even when there is an adverse effect on growth rate during the active treatment phrase (Gittelman-Klein & Mannuzza, 1988; Kramer, Loney, Posto, Roberts & Grossman, 2000). However, the side effects of nausea and vomiting, and higher doses of MPH are associated with adult growth decrements in some individuals (Kramer et al., 2000). An extended drug holiday during the summer months is often

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recommended to deal with this problem. Concerns about increases in blood pressure and pulse rate are also related to the use of psychostimulants. A recent study (Findling, Short, & Manos, 2001) comparing methylphenidate and Adderall found no significant cardiovascular effects for either medication at doses up to 15 mg/day or less. Few children, however, take such a small daily dose. The emergence or intensification of tics is a more serious but infrequent side effect; exacerbation of preexisting tics is estimated to occur in 13% of cases, and fewer than 1% of children with ADHD develop a tic disorder following the initiation of MPH therapy (Barkley, 1998a). A recent study of MPH indicated that a dose of 0.5 mg/kg twice a day did not cause or exacerbate tics in children with or without prior tics more often than a placebo did (Law & Schachar, 1999). Moreover, MPH has been used successfully in treating children with ADHD and a comorbid chronic tic disorder (Nolan & Gadow, 1997). Tics usually subside with discontinuation of MPH. In addition to concerns about side effects, it is important to consider a variety of other factors when referring a child with ADHD for medication. These include the child’s age, the duration and severity of the presenting problems, the history of prior treatment, parental motivation for such treatment, possible stimulant abuse by parents or other siblings living in the home, and the likelihood that the parents will administer the medication responsibly and in compliance with the physician’s directions (Barkley, 1997c). Titrating and Monitoring Medication in Children Systematic evaluation of the most effective dose of medication for an individual child can have long-reaching positive results in treating the child with ADHD. We have found that both parents and children are very receptive to such trials, as long as they are closely monitored. In fact, the trials often make the use of medication more acceptable to families. Although physicians are responsible for prescribing medications, child clinicians should understand and employ effective methods of monitoring the effects of medication on children’s behavior and should share this information with physicians. Several protocols for the titration and monitoring of stimulant medication, including the one used in the NIMH MTA study, have been published (Greenhill et al., 1996; Barkley, 1998b; Pliszka et al, 2000a, 2000b; Rapport, 1998). The doubleblind placebo-controlled protocol for MPH described in this section is based on those provided by Barkley (1998b) and Rapport (1998), and is summarized in Table 11.4. Trials of MPH should be administered in fixed doses (e.g., 5 mg, 10 mg, 15 mg, 20 mg) in the same way for every child, and should include a placebo control. This fixed protocol allows one to determine the best dose for the individual child, since some children respond better to lower doses, others do better on higher doses, and different behaviors are affected by different doses. Talking with the physician and the pharmacist ahead of time regarding the purpose of the medication trial will help a clinician to gain these professionals’ cooperation. Parents, teachers, and the child should be “blind” to the protocol, thus providing a more objective evaluation of the drug response. It is important to get baseline ratings across several domains: parent ratings of behavior at home, teacher ratings of behavior in school, records of academic performance in school, and baseline levels of physical complaints reported by the child. During the baseline and medication trial, the parents and teacher are asked to complete the same rating scales at the end of each week, reflecting the behavior for the entire week. This allows monitoring of the drug

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TABLE 11.4. Protocol for Titration and Monitoring of MPH Therapy for ADHD 1. Collect baseline data. Teachers: • School Situations Questionnaire (SSQ) • Academic Performance Rating Scale (APRS) • Disruptive Behavior Rating Scale (DBRS) Parents: • Home Situations Questionnaire (HSQ) • Disruptive Behavior Rating Scale (DBRS) • Side Effects Questionnaire (SEQ) 2. Contact physician to share information about the child and the behaviors targeted for intervention. 3. Physician contacts pharmacist. • Standard tablets of 5 mg, 10 mg, 15 mg, and 20 mg MPH and a placebo are placed in opaque gelatin capsules. • Weekly doses are put in individual containers and labeled “Week 1,” “Week 2,” etc. • One week is randomly chosen for the placebo. • Begin trial with 5 mg twice a day for 7 days. • Gradually increase dose each week (except for week of the placebo) up to 20 mg twice a day. 4. Arrange for teacher and parents to collect data weekly at the end of the week. • Provide parents and teachers with rating forms. • Remind them to give the medication at the same time every day, including weekends. • Observe behavior during the active phase of the drug (30 minutes to 3–4 hours after the child takes it). • Provide stamped, addressed envelopes for mailing data to the clinic. • Call or see parent and child every week. 5. Chart the data weekly. Teacher data Date

Dose

SSQ

APRS

Parent data DBRS

HSQ

DBRS

SEQ

Week 1 Week 2 Week 3 Week 4 Week 5 Note. The SSQ, HSQ, DBRS, and SEQ forms and normative data (means, standard deviations, and clinical cutoff scores) are all contained in Barkley and Murphy (1998). The APRS is reprinted in Appendix B.

response across settings, raters, and behavioral domains. Although some parents may not feel the need to keep the child on medication during the weekend, it is important to do this during the medication trial. It allows parents to see the changes in their child (often they do not report changes) and decreases concerns about the effects of the medication. Baseline data help determine the behaviors targeted for monitoring during the drug trial. At times a child may function better academically with a lower MPH dose, whereas a higher dose that is more effective for behavioral problems can worsen learning ability and academic performance (Kinsbourne, 1990). Given the importance of academic success for positive longterm outcomes, it is important to optimize these skills, even if it means tolerating moderate levels of disruptiveness in the classroom.

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Stimulants can affect behaviors in a number of domains (e.g., attentional, behavioral, performance), so rating scales that cover a range of behaviors in these areas should be selected. Classroom measures that are recommended include the CAP (Edelbrock, 1990) or the ADHDIV Rating Scale (DuPaul et al., 1998), the APRS (DuPaul et al., 1991), the SSQ (Barkley & Murphy, 1998), and the Side Effects Questionnaire (SEQ; Barkley & Murphy, 1998). Because neuropsychological tests (including continuous-performance tasks) do not reflect behavior and academic functioning in classroom settings, they are not adequate to monitor medication effects (Rapport et al., 2000). The HSQ (Barkley & Murphy, 1998) is an excellent rating scale for behavior in the home; it provides descriptions of compliance and leisure situations, permits the quantification of problem settings, gives mean severity ratings across settings, and has proven sensitive to medication effects. It also gives information about specific problems that may require further intervention. The ADHD-IV Rating Scale and the SEQ (Barkley & Murphy, 1998) should also be used for the parents. The SEQ should be included in baseline information, since, in general, children with ADHD report more somatic complaints than children without ADHD (Barkley, DuPaul, & McMurray, 1990). During the medication trial, parents and teachers must be instructed to rate behavior observed during the active phase of the medication (e,g., between 30 minutes and 3–4 hours after taking the medication). If the medication is given only in the morning, then the scales should reflect behavior rated up to noon. This also means that the child should take the medication at the same time every day. We have found it helpful to give the parents and teachers addressed and stamped envelopes in which to mail the data to the clinic at the end of each week. This increases the likelihood that the ratings will be completed at the required time. Telephone calls may also be necessary. All data should be charted at the conclusion of the medication trial (see Table 11.4). Monitoring the child’s response to medication, using the same rating scales as in the medication trial, is recommended every 3 months (Rapport, 1998). Educating the parents about MPH is also important, so that they have appropriate expectations for treatment outcome. Although MPH decreases variability in behavior, the child (like all children) will experience days when his or her behavior is more disruptive and academic performance is not up to expectations. Likewise, illness, family stresses, and crises can negatively affect medication response. After consultation with the physician, medication may best be temporarily discontinued at these times (Rapport, 1998). Parental compliance with the medication regimen is obviously important for treatment success. Insufficient information about the medication and its effects, the absence of an initial medication trial, and parental psychopathology can all decrease compliance. When compliance is an issue, consideration should be given to having the school administer the medication.

A Postscript on Treatment Regardless of the type of treatment provided for a child with ADHD, improvement is not usually sustained when the intervention is dropped. Moreover, learned skills often do not generalize to new or unique situations. The NIMH MTA project will ultimately provide more evidence on effective treatment. At this point, it appears that any intervention must be continued over a long period—perhaps over the entire course of a child’s school years—to ensure that the skills necessary for independent functioning are learned. In addition, Anastopoulos and Shaffer (2001) also point out that treatment for ADHD behaviors does not always affect comorbid conditions, such as depression or anxiety; nor does it help the parents deal with personal and family stresses. Other

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therapies would seem clinically appropriate for these problems, but the effectiveness of adding these to the treatment regimen for children with ADHD also requires further study.

CASE EXAMPLE: ADHD-C Step 1: Initial Contact Mrs. Ruff called about her 8-year-old son, Eddie, who was experiencing difficulties in school as well as problems at home in completing chores, following directions, and doing things independently. She described him as “spacey” and “just not with it.” The CBCL, PSI, ECBI, and General Parent Questionnaire were sent for her and Mr. Ruff to complete. The parent questionnaire indicated a middle-class family, with the mother employed as a church secretary and the father as a fireman. Eddie had one younger and two older sisters. The parents indicated that their primary concern was Eddie’s school performance. On the CBCL, both parents rated Eddie as being within the normal range on all scales except the Attention Problems scale, which was in the clinically significant range. On the ECBI, both parents rated Eddie’s frequency of problems in the high normal range, but noted significant problems in the intensity of his behaviors. On the PSI, Eddie was described as a pleasant child who was not very adaptable to change. The parents indicated some marital problems but felt competent in their parenting of Eddie, whom they both enjoyed.

Step 2: Parent and Child Interviews Parent Interview Mr. and Mrs. Ruff agreed to have Eddie included in the initial interview. The parents were very pleasant and, although concerned about Eddie, were quite supportive of him. Eddie seemed relieved to be getting some help regarding his school problems. Mrs. Ruff said that her pregnancy with Eddie was uneventful, with the exception of a long and painful delivery. Eddie was described as a sweet and calm baby, after an initial period of colic. The first problems were noticed at age 3, when Eddie had a very difficult time adjusting to the family’s move from another state. He was very unhappy in his first preschool experience, which was quite structured, and the parents took him out of school until prekindergarten. He repeated prekindergarten because of “immaturity.” He was described as very active, as having difficulty following directions, and generally as “busy.” In kindergarten he was diagnosed with a mild case of asthma; the medication for this condition tended to exacerbate his activity level. Problems with talking, fidgeting, and staying on task were noted in first grade, but he enjoyed school and the friends he made there. At the present time Eddie was in second grade and continuing to have the same problems, as well as evidencing difficulties with writing and reading. He had also become more anxious about going to school, as expressed through somatic complaints and general distress on school days. At home he was described as “hyper,” as “in constant motion,” and as having difficulty listening and sitting still. His mother said he followed directions best if eye contact was made with him before telling him what to do. Furthermore, she felt he was trying hard to be compliant and cooperative, but that he couldn’t follow through on this. She said that Eddie had a number of friends in the neighborhood and enjoyed playing sports, but lacked the required focus to play team sports. He was also described as well liked by his sisters, and as very kind and loving.

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During the interview, Eddie played quietly with cars and Legos. He often commented on what was being discussed, indicating that he hated school and loved summer best. Child Interview Eddie was quite verbal and able to describe a range of feelings. He said he felt tired and as if he was “drowning” when he was at school, but felt fine at home. Furthermore, he described himself as having trouble sleeping and not wanting to eat before going to school. On the Piers– Harris Children’s Self-Concept Scale—Revised, he indicated that he gave up easily, was not good in doing homework, was slow in finishing his work, was not an important member of his class, and felt left out. When asked what one thing he would like to change about himself, he said, “Be in the last year of college!” He also expressed a number of fears, such as nightmares, burglars, and worries about not getting his homework done.

Step 3: Observation of Behavior Five minutes of child-directed and 5 minutes of parent-directed play indicated that Eddie had a warm, supportive relationship with each parent. The parents generally followed Eddie’s lead and appeared to have difficulty placing demands on him. For example, when they told him to clean up the toys, they actually did the cleaning up as he finished playing.

Step 4: Further Assessment It was recommended that the teacher be contacted and a school visit be conducted. The teacher also rated Eddie on the teacher version of the CBCL; scores on the Attention Problems and Anxious/Depressed scales were clinically significant. On the Revised Conners Teacher Rating Scale, he was one standard deviation above the mean for Hyperactivity, two standard deviations above the mean for impulsivity, and three standard deviations above the mean for Anxiety. The teacher described Eddie as a sweet boy who had some friends, but was very sensitive to any teasing or perceived threats from the other children. He also had difficulty with written tasks and reading, but she thought this was due more to his inattentiveness and fidgeting than to a specific learning problem. The teacher did, however, question the possbility of ADHD and felt that a psychoeducational evaluation would be helpful. Eddie was not viewed as a behavior problem in the classroom. The psychoeducational evaluation indicated that Eddie was in the bright average range of intelligence, which was thought to be an underestimation, given his poor attention and motor activity throughout the testing. Eddie evidenced a moderate learning problem, with phonological coding and written language as specific deficits. Observation in the classroom indicated that Eddie was off task 80% of the time, as compared to 20% for a randomly selected peer. He was often staring out the window or was otherwise distracted when instructions were given. He completed only half of a worksheet during the 30-minute observation, compared to the other children, who completed one and a half to two pages.

Step 5: Referral to Allied Health Professionals Eddie had had a recent physical examination and was in good health despite continuing mild episodes of asthma, which were controlled by medication.

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Step 6: Communication of Findings and Treatment Recommendations Mr. and Mrs. Ruff were initially seen alone to go over the results of the psychoeducational evaluation as well as the school observation. They were told that Eddie was a child with a delightful personality and many strengths, but one who was struggling mightily to “keep his head above water in school.” The basis for his school difficulties appeared to lie in a specific learning problem with phonological coding and written language, as well as problems in controlling both his activity level and attention. His methods for coping (anxiety, tuning out) were understandable but ineffective. Although Eddie’s difficulties with controlling his impulses, focusing his attention, and exhibiting a high activity level had been present from an early age, they did not appear to interfere with his functioning until he entered the structured environment of prekindergarten. Given his pleasant personality and his eagerness to please, his problems in the learning area did not become evident until increased demands for performance were placed on him, as occurs in second grade. It was interesting that when Eddie’s problems were described, Mr. Ruff said he’d had similar problems in school, and he did not want Eddie to suffer as he had. Eddie was given a diagnosis of ADHD-C, as well as a specific learning disability. His anxiety was described as an adjustment reaction to the stress of school. Recommendations included intensive academic resource help, which was available at school, and for which his test scores qualified him. A trial of medication was discussed, and the parents were encouraged to talk further with their pediatrician about the advantages and disadvantages of using medication with a child Eddie’s age. They were hesitant to use medication and felt they would like to try to make the necessary changes in the school before doing this. The third recommendation was for the parents to set a more consistent routine for Eddie at home, with clearly specified responsibilities and a reward chart for completing tasks in a timely manner. Mr. and Mrs. Ruff understood that their tendency to help Eddie by doing things for him could actually increase his sense of incompetence and decrease his opportunities to develop needed skills. Given that Eddie’s anxiety was specific to the school setting, it was decided that changing things in the classroom and helping Eddie in a more effective way with homework would be the best ways to deal with this problem. The next day, the results of the evaluation and recommendations were explained in ageappropriate language to Eddie in the presence of his mother. He seemed relieved to learn that he could get help, and was pleased that he was capable of doing the schoolwork with extra help.

Course of Treatment Eddie was given the resource help he needed in school, and the parents completed a 4-week course on parent management skills. Two months later, Mrs. Ruff called to discuss the use of medication. Although Eddie was doing much better in school and was not so anxious about his academic performance, both she and her husband had become more aware of how his inability to attend was interfering with the learning process. Mrs. Ruff was told about the value of carefully monitoring a trial of medication, and she agreed that the clinician should contact the pediatrician to set up such a trial. The pediatrician had previously received a brief report of the evaluation findings and recommendations, and she agreed that a 5-week double-blind placebo trial of MPH would be carried out. The doses were baseline, 5 mg, 10 mg, 15 mg, 20 mg and placebo. The protocol illustrated in Table 11.4 was followed. A dose of 15 mg was found to

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be superior to the other doses: Eddie’s on-task behavior improved by 87%; fidgeting, talking, and need for redirection were each 100% improved; copying errors improved 86%; and work completion showed a 64% improvement. Furthermore, Eddie’s anxiety level and self-esteem continued to improve with the medication. The parents agreed with the pediatrician that Eddie’s behavior on medication should be monitored every 3 months. They elected not to have a late afternoon dose or to medicate Eddie on weekends.

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MANAGING STRESSFUL LIFE EVENTS

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CHAPTER 12

Siblings

A

djustment to the birth of a sibling and issues of sibling conflict are among the most common concerns expressed by parents of young children (Brody & Stoneman, 1987). Eighty percent of children live with at least one sibling (Stillwell & Dunn, 1985), and it is within the often intense and close relationships between brothers and sisters that children learn important social and cognitive skills. Many argue that sibling relationships are a major influence on the development of individual differences in antisocial and prosocial behavior, as well as aspects of personality, intelligence, and achievement (Smith, 1993; Stillwell & Dunn, 1985). Research in this area has shown that various family and child factors influence children’s adjustment to a new sibling, as well as the quality of the relationship that develops between children and their brothers and sisters. Siblings influence each other’s development both directly (by modeling or differentially reinforcing appropriate or inappropriate behaviors) and indirectly (by causing stress for parents, which in turn affects parenting skills). Interactions between two siblings increase rapidly when the younger one is between 3 and 4 years of age, but remain fairly consistent in frequency after that time (Dunn, Creps, & Brown, 1996). Moreover, anger, distress, and conflict decrease as the younger sibling reaches school age (Dunn et al., 1996). This most likely reflects the children’s increased involvement with friends at school and with other activities outside the home. Sibling relationships are quite different from peer relationships, in that they are “vertical” (the participants have unequal status) rather than “horizontal” (the participants have equal status) (Brody & Stoneman, 1983; Hartup, 1989). Research has shown that there is little relationship between the behavior of children with their siblings and with peers (Berndt & Bulleit, 1985). Incidents involving conflict, for example, occur with similar frequency between siblings and between peers, but those involving physical or verbal aggression are much more frequent between siblings (Dunn & Munn, 1985, 1986a; Shantz, 1987). Moreover, siblings are less likely to use compromise or reconciliation in the resolution of conflict than are peers (Killen, 1991; Phinney, 1985). This chapter first reviews the research on how children adjust to the birth of a new sibling, and presents suggestions for intervention in/prevention of adjustment problems. Next, issues of sibling conflict are discussed; the critical assessment issues for such conflict are outlined; and suggestions for treatment of sibling rivalry are presented.

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ADJUSTMENT TO THE BIRTH OF A SIBLING The birth of a new sibling is clearly a major source of stress in the life of a young child, and the child’s reactions to this event reflect his or her efforts to cope with the stress. As Stewart, Mobley, Van Tuyl, and Salvador (1987) note, “the birth of a sibling represents a complex period of adjustment for the firstborn child” (p. 341). The relationship between young children and their new siblings is best viewed as ambivalent, because most children evidence both positive and negative reactions (Campbell, 1990). Typical negative reactions of an older child include increased confrontation with parents, anger and aggression, clinginess, separation distress and other anxious behaviors, more problems with toileting, and demands for bottles or other “regressive” behavior (Stewart et al., 1987). Moreover, the adverse effects of the birth of a new sibling are more pronounced among disadvantaged children than among those from more advantaged families (Baydar, Hyle, & Brooks-Gunn, 1997). In contrast to many parents’ complaints that an older child is aggressive toward a new baby, the child’s overt negative behavior is more often directed toward them than toward the infant (Dunn & Kendrick, 1982). Aggression in fantasy play, however, which also increases after the birth of a sibling, is more often directed at the infant (Field & Reite, 1984). The “regressive” behaviors on the part of the older sibling are best viewed as a form of imitation or mimicry—that is, a problem-solving or strategic approach by the older child to ensure that the parent will continue to care for him or her as well as the new baby (Dunn & Kendrick, 1982). On the positive side, the results of other studies indicate that increased maturity, independence, and empathy, as well as intense interest in and curiosity about the new baby, occur along with the more negative reactions (see Campbell, 1990, for a review). Moreover, longitudinal studies indicate that most of the increases in emotional difficulties seen in the older sibling are temporary (Baydar et al., 1997), although Baydar et al. did find that the self-esteem of an older child was diminished after the birth of a sibling and remained so over 4 years. Research also has documented significant changes in the relationship between parents and their first-born child following the birth of a second child. Not surprisingly, mothers spend less time with the older child after the birth of a baby, whereas fathers reciprocally increase the amount of time spent (Mendelson, Gottlieb, & Paratta, 1995). Baydar et al. (1997) found an increase in mothers’ punitive and controlling behavior toward older daughters (but not sons) following the birth of a sibling. Dunn and Kendrick (1982) not only report decreases in the amount of time mothers spend in play or conversation with their older children, but also note that these children become the primary initiators of interactions with their mothers and that these interactions are largely confrontational. Mothers also begin to place increased demands for maturity and independence on their older children, presumably for very practical reasons. Finally, Teti, Sakin, Kucera, Corns, and Eiden (1996) documented a decrease in the security of mother–child attachment after the birth of a sibling, especially for older children (2–5 years old vs. those under 2 years), although it is not known whether this change is temporary.

Factors That Influence Adjustment It is not surprising, given these changes in the mother–child relationship, that young children almost inevitably show some negative reactions to the birth of a sibling. For most children, however, these behaviors typically decrease by 4 months after the birth and have completely resolved within 1 year (Baydar et al., 1997; Stewart et al., 1987). The question of clinical im-

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portance is why some children do not make an adequate adjustment. Given that there is considerable stability during the preschool years in the quality of an older child’s behavior toward a younger sibling following an initial adjustment period (Stillwell & Dunn, 1985), the variables that influence children’s adjustment are important to understand. The factors that have been shown to play a role in an older child’s adjustment to the birth of a new sibling include the child’s temperamental characteristics, the existence of management problems prior to the birth, the child’s age at the time of the birth, the mother’s psychological well-being, the quality of the marital/couple relationship, and the manner in which the mother handles the child’s involvement with the new baby. Dunn and Kendrick (1982) found that children (especially boys) with difficult temperament characteristics (negative mood and intense emotional reactions) were more likely to show anxious, withdrawn reactions to the birth of a sibling. This reaction tended to persist over time, indicating that temperamentally difficult children have a harder time adjusting than children with more easy-going temperaments (Brody, 1998; Campbell, 1990). Parents also report that when their children are difficult to manage prior to the birth of a new baby, these problems persist and are often exacerbated by the introduction of an infant into the family (Campbell, 1990). The intensity of the child’s initial reaction to the birth of a sibling, which may be mediated by temperament, is also related to adjustment (Dunn & Kendrick, 1982). Surprisingly, however, children who react more explosively have been found to make a better adjustment than those who become withdrawn (Dunn & Kendrick, 1982). There is evidence that younger children (especially those under 18 months) have more trouble adjusting to the birth of a sibling than do older children (Vandell, 1987; but see Teti et al., 1996). Older children are more likely to be interested in helping to care for the baby, and to be involved with activities and interests outside the immediate family; thus they are less dependent on their mothers for nurturance and support. Campbell (1990) cites inconsistent evidence for the effect of the gender of the older child on adjustment. Although girls are thought to be more nurturing toward a new baby than boys, these sex differences do not appear to hold up over time (Dunn & Kendrick, 1982). Children whose mothers are greatly fatigued or depressed after the birth of the baby, or whose parents’ relations are conflicted, have more trouble adjusting to the birth of a sibling (Dunn & Kendrick, 1982; Teti et al., 1996). This probably reflects these mothers’ extra lack of availability to their older children.

Intervention/Prevention Strategies Helping young children adjust to the arrival of a new brother or sister is best viewed as preventive work, because the quality of the relationship between siblings shows some consistency over time, and children who make a good adjustment in the early months may have less trouble with sibling conflict later on. Furthermore, there are several things parents can do before a new baby is born to help prepare an older child and facilitate a good adjustment. After the baby is born, parents are most concerned about aggression directed toward the infant or “regressive”/imitative behaviors on the part of the older child, and often wonder whether the reactions their child is showing are normal or something they should be worried about. Along with this, parents typically want help in managing the older child’s behavior. Strategies for helping a child cope with a new sibling must be extrapolated from the research literature, as there are few if any studies testing the efficacy of one approach versus another. In our practice we take a behavioral approach, liberally laced with common sense!

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Preparation Parents should prepare the older child for the birth of a sibling well in advance of the expected date. How far ahead of time, of course, depends on how old the child is. Toddlers (12–18 months), who have little sense of time (past or future), may need only a few days’ or a week’s notice. Preschoolers (2–5 years), although still tied to present experience, are very curious about their environment and are likely to have noticed and asked many questions about the physical changes in their mothers. These in turn are likely to lead to such questions as “Where do babies come from?” These questions give parents the opportunity to begin to prepare the child for the new baby. Simple, concrete, but honest factual information is appropriate for even very young children, and parents should provide this information even if their child has not asked any questions. Many very good books have been written for young children about sexuality, childbirth, and welcoming a new baby into the family. Among our favorites is the series of books by Sol and Judith Gordon (Gordon, 1992a, 1992b; Gordon & Gordon, 1983, 1992). Preschool children respond especially well to information in books; they enjoy the illustrations, and reading them together with parents often sparks more questions and discussion. It is important for parents to recognize that one cannot prepare young children for the birth of a sibling (or for anything else!) in one session. For preschoolers especially, preparation is an ongoing process that should occur over many weeks in small doses. Minimizing Stress Recognizing that the birth of a new sibling is a major stressful event for a child should alert parents to minimize other sources of stress in the child’s life, so that his or her coping skills are not overwhelmed. We recommend maintaining a young child’s schedule and routine as much as possible during the time just before and after the birth. Changes such as sleeping in a bed versus the crib, moving to a new room or a new house, or starting a new preschool should be accomplished well in advance of the birth date, so that the older child has a chance to become used to the new routines. The child should be left with someone familiar and in a familiar place while the mother is in the hospital, and should be told ahead of time who will care for him or her. Furthermore, because parent–child conflict existing prior to the birth tends to escalate dramatically after the birth (Dunn & Kendrick, 1982), parents should be advised to seek help for any such problems before the new baby arrives. Many parents ask about the advisability of having the older child visit the mother and new baby in the hospital. There is evidence that these visits have at least short-term benefits in alleviating the child’s distress at separation from the mother (Vandell, 1987). There is no evidence, however, that visiting the mother in the hospital has long-term effects on the sibling relationship. Nor is there evidence that breastfeeding versus bottle feeding of the new baby influences adjustment of the older child (Vandell, 1987). When the Baby Comes Home After the new baby comes home, extensive involvement of the father, grandparents, or other adults in the care of the older child can facilitate the child’s adjustment (Mendelson et al., 1995; Vandell, 1987). The father’s involvement probably has both direct and indirect effects on adjustment. His increased involvement provides the older child with a substitute for the care and

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nurturance once provided by the mother, as well as easing the stress experienced by the mother as a result of her new responsibilities. Dunn and Kendrick (1982) suggest that a mother can foster a positive adjustment on the part of an older child by involving the child in the care of the infant, by making this care a shared experience rather than a responsibility, and by modeling respect for the infant as a person with needs and feelings. Even a very young child can be involved in the care of a new infant by fetching diapers, holding the bottle, checking on the baby, and so on. Parents can also describe the interaction of the baby and older child in a way that emphasizes the “individuality” of the infant, as well as the infant’s responsiveness to the older child. At the same time, appropriate behavior on the part of the older child can be reinforced—for example, “The baby is watching you and likes the way you are holding her so gently,” or “Look, the baby is smiling at you. He likes the way you are holding his bottle.” It is essential that parents schedule time for the older child during which they can give the child their undivided attention. Even 10 or 15 minutes a day goes a long way toward fostering adjustment. A parent handout for maximizing such “quality” time (called the “Child’s Game”) is provided in Chapter 10 (see Figure 10.4). Special treats or events that emphasize the older child’s capabilities (in contrast to the infant’s relative lack of abilities) can help to eliminate the “regressive”/ imitative behaviors. For example, going out to eat with the mother and father while the baby is left with a sitter provides an opportunity to reinforce grown-up behavior. Behavior Management Parents should provide clear consequences for aggressive behavior, whether it is directed at a parent, the infant, or both. If parents are not already using a procedure for time out by isolation, this is a good time to begin. How time out is implemented will depend on the developmental (primarily language and cognitive) level of the child. The idea, however, is to remove the child from the situation quickly and briefly, without any discussion on the part of the parent, so the child learns that physical aggression is inappropriate and will not be tolerated. A very young child can be placed briefly (e.g., 1 minute) in a playpen (without toys) or an area of the floor (preferably in a corner) marked out with masking tape. Parents should completely ignore the child during time out. At other times, parents should be taught to watch for appropriate interaction and comment on it as it occurs. In this way, they are teaching the child what they like as well as what they do not like. Time-out procedures for children over 24 months of age are described in the treatment section of Chapter 10, and a parent handout is provided in Figure 10.6. Aggression expressed in fantasy play is often a concern for parents, particularly because it is typically directed toward the infant. Parents may be worried that the child will begin to act out his or her fantasies and actually hurt the baby. This is not usually the case, however, and fantasy play provides an excellent way for the older child to express his or her very real feelings. Furthermore, young children use play to experience mastery over environmental events that they cannot really control, and as such it functions as an adaptive coping mechanism. Parents should be advised to allow aggression to be expressed in fantasy play, and to provide other outlets for the appropriate expression of angry feelings (e.g., let the child draw a picture of the baby, tear it into little pieces, and throw it in the trash!). At the same time, parents should assure the child that the baby is here to stay and that they will all learn to get along together.

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SIBLING CONFLICT The Quality of Sibling Relationships By the end of the first year after the birth of the new sibling, as the younger child becomes more mobile and curious, conflicts between siblings increase dramatically (Campbell, 1990). At first the older sibling asserts his or her dominance in the relationship, but by the end of the second year the younger child is likely to retaliate with aggression, as well as to instigate conflict by teasing and provoking the older child. Moreover, instances of tattling increase with age between 2 and 6 years (Ross & den Bak-Lammers, 1998). Observational studies of the interaction of preschool children with toddler siblings indicate that conflict occurs about seven to eight times an hour (similar to the frequency of conflict in peer interactions), but is relatively shortlived (e.g., about 30 seconds on average; Hay, Vespo, & Zahn-Waxler, 1998). Verbal or physical aggression occurs in about 25% of these incidents (Dunn & Munn, 1985, 1986a). Furthermore, mothers have been found to intervene in sibling quarrels 50–60% of the time (Dunn & Munn, 1986a; Perlman & Ross, 1997). It is no wonder that parents express concern about sibling rivalry! Tattling is a specific form of sibling conflict that begins to occur as early as 14 months and increases throughout the preschool years (den Bak & Ross, 1996; Dunn & Munn, 1985; Ross & den Bak-Lammers, 1998). In their study of children aged 2–4 years, den Bak and Ross (1996) found that tattling was primarily concerned with property damage and aggression. When parents intervened, they tended to support the victim; when parents did not intervene, the perpetrator tended to prevail. Thus young children clearly have considerable motivation to increase their tattling, as it is a very effective way to get parental attention and resolve conflict in their favor. Children perceive their relationships with siblings much more positively than observational studies would suggest. In a unique study conducted by fourth-grade children, the frequency of fights between siblings was estimated by fourth- and fifth-graders to be only 4.7 per day, with an average duration of 8.1 minutes per fight (Prochaska & Prochaska, 1985). The number of fun times was estimated to be 9.2 per day. The most common reasons for fighting given by the children were being in a bad mood, getting even, or protecting possessions or territory. In contrast to the commonly held belief that children are rivals for their parents’ love and attention, the least common reason for fighting given was to gain parental attention! There certainly are large individual differences in the quality of sibling relationships; some relationships are entirely positive, some are both positive and negative, and some are 100% negative (Dunn, 1988; Dunn & Kendrick, 1982). Furthermore, the extent to which siblings engage in cooperative, prosocial, friendly behavior appears to be independent of the extent to which they fight and argue (Dunn, 1988). On the positive side, older children often become objects of attachment for their younger siblings, offering comfort, support, and reassurance during times of distress; they also may serve as teachers, role models, or substitute caregivers (Bryant, 1992; Dunn, 1996; Jenkins, Updergraff, McHale, & Crouter, 1999). Whether or not older children are nurturant toward their younger siblings seems to depend in part on the social-cognitive skill of being able to understand the perspective of another person (Stewart & Marvin, 1984), and in fact mothers are more likely to ask more cognitively mature youngsters to care for their younger siblings. Dunn and Munn (1986b) found that sharing, helping, comforting, and cooperation were more often shown by older siblings toward their younger brothers and sisters than vice versa. More interesting, however, are the findings that prosocial behavior on the part of the older siblings was related to the development of more mature behavior in

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the younger children. Conversely, friendly behavior on the part of younger children was also related to increased frequency of prosocial behavior by the older siblings. Thus cooperative, friendly behavior on the part of one sibling appears to encourage cooperative, friendly behavior on the part of the other. Just as friendly behavior begets friendly behavior, so does aggressive behavior lead to increased aggression in sibling relationships. Patterson (1980) has shown that a younger sibling of an aggressive boy at first submits to aggressive attacks, thus negatively reinforcing the aggression and increasing its frequency of occurrence. Later the younger child learns to retaliate with aggression, and this leads to further aggression on the part of the older child. Thus, although the older child is responsible for the initial negative tone of the relationship, both children eventually contribute equally to the frequency and escalation of conflict. In a recent review, Brody (1998) argues that some conflict among siblings is not necessarily bad. Sibling conflict can allow the expression of emotions and provide practice in communication and negotiation skills. Indeed, research indicates that sibling relationships reflecting a balance between support and conflict are most likely to promote social competence (Stormshak, Bellanti, Bierman, & the Conduct Problems Prevention Research Group, 1996). When sibling relationships are heavily weighted toward conflict, however, the result is often a “training ground” for aggression, which eventually can lead to feelings of inadequacy, incompetence, and hostility (Bank, Patterson, & Reid, 1996; Dunn, Slomkowski, Beardsall, & Rende, 1994).

Factors Influencing Sibling Relations Again, the clinician is led to ask what factors are important in the development of positive versus negative relationships between siblings, and considerable research has been devoted to answering this question. Table 12.1 summarizes the factors that have been found to influence sibling relationships. Stocker, Dunn, and Plomin (1989) report that when a wider age difference (>4 years) exists between siblings, the relationship is more likely to be positive than when siblings are closer in age, although this may not be true for preschool children (Newman, 1996); Abramovitch, Corter, Pepler and Stanhope (1986) found no differences in sibling relationships among preschoolers TABLE 12.1. Factors That Influence the Quality of Sibling Relationships Source

Factor

Children

Temperament Age difference Gender differences Level of social-cognitive development

Parent–child relationship

Differential treatment Parent intervention in child conflict Lack of clear rules and expectations General child management problems

Family

Marital/couple relationship Parental mental health Life and environmental stress Emotional climate in home Family functioning

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with wide versus narrow age gaps. Furthermore, same-sex sibling dyads tend to have more positive relationships than opposite-sex dyads (Stocker et al., 1989). Other factors that are related to the quality of sibling relationships include differential maternal behavior toward the younger child, temperamental characteristics of the children, quality of the marital/couple relationship, parental adjustment, and the ways parents intervene in sibling conflicts. Although most mothers show differential behavior toward their children, this probably reflects the relative developmental status of the children. Consistent with this idea, other work has shown remarkable consistency in a mother’s behavior toward each of two children at the same age (Dunn, Plomin, & Nettles, 1985). The important factor in how differential parental treatment influences the quality of sibling relationships appears to be the children’s perceptions of unequal treatment (Brody & Stoneman, 1987; Dunn, 1988). Kowal and Kramer (1997) found that although most 11- to 13-year-old children acknowledged differential parental treatment, they did not perceive it as “unfair.” Rather, they justified it by pointing out the ways in which they and their siblings were different (e.g., age, personal attributes, needs, etc.). Preschool children, however, may find it very difficult to understand and accept that their mothers’ differential treatment of their younger siblings is in large part due to the age and developmental differences between the siblings. Indeed, Stocker et al. (1989) found that sibling relationships were more negative when a mother was more affectionate, responsive, and controlling toward the younger sibling than toward the older sibling. Sibling conflict is likely to increase when a child perceives differential parental treatment as indicating that the parent is less concerned or that the child is less lovable. This is less likely to result when parents are warm, nurturant, and attentive to all their children (Brody, 1998). Difficult temperamental characteristics of children, including high intensity of emotional response, activity level, impulsivity, and low persistence, have consistently been associated with more negative sibling relationships (Brody, 1998). Moreover, more conflict is expected when both children in a sibling dyad possess difficult temperamental characteristics (Brody & Stoneman, 1987). Stoneman and Brody (1993) demonstrated that when an older sibling had a difficult temperament, this child set the tone (largely conflictual) for the sibling relationship, regardless of the younger child’s temperament. Moreover, ratings of temperament in middle school children predict the quality of sibling relations up to 4 years later (Brody, Stoneman, & McCoy, 1994). Recent research indicates that parental behavior moderates the effects of their children’s difficult temperamental characteristics if they interact with these children in a positive, supportive manner, especially when dealing with family conflict (Brody, Stoneman, & Gauger, 1996). Marital/couple distress is also related to increased conflict between siblings, perhaps reflecting parental modeling of conflict behavior, anxiety in children caused by witnessing the parents’ conflict, or an indirect effect of marital/couple conflict on parenting skills (Dunn & Munn, 1986a). McHale and Crouter (1996) suggest that this association may be due to the increased differential treatment of siblings, which is evident when parents experience marital/ couple distress. In contrast, maternal depression (especially depression occurring as part of bipolar I disorder) has been found to be associated with lower levels of sibling conflict (Hay et al., 1998). Finally, parental behavior plays a role in the development of positive or negative sibling relationships (Brody, 1998; Siddiqui & Ross, 1999). More positive parent–child relations are associated with more positive sibling relations, and vice versa (Brody et al., 1996). Brody et al. speculate that this may be due to a modeling effect or to differences in children’s attachment security. The ways in which parents intervene in sibling conflict also are important in

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the development of positive or negative sibling relations. Siddiqui and Ross (1999) found that when parents of preschool children did not intervene, most sibling conflicts were unresolved; that is, the younger child would usually just walk away, recognizing his or her lower status in relation to the older sibling. When parents did intervene, sibling conflicts were more likely to end in reconciliation or compromise. Parents tend to intervene when the conflict is intense, when a child cries, and when conflict involves verbal or physical aggression (Perlman & Ross, 1997). Perlman and Ross reported that sibling conflicts tended to become less intense after parental intervention, with the children demonstrating more reasoning, perspective taking, and compliance. Thus, when parental intervention involves teaching conflict resolution strategies (such as compromise or reconciliation), children increase their use of these more mature strategies (Dunn & Munn, 1986a; Siddiqui & Ross, 1999). Perlman and Ross (1999) conclude that “at least for young children, parental action, rather than nonaction, provides siblings with the opportunity to learn important conflict resolution skills” (p. 699). This conclusion is consistent with the work on tattling. den Bak-Lammers and Ross (1998) found that rates of preschoolers’ tattling were not related to parental response. They suggest that children’s tattling can best be controlled by teaching them more effective strategies for dealing with their siblings, rather than by responding to tattling. This can be accomplished by intervening in their conflicts as needed, while refusing to become involved when the children seek them out.

ASSESSMENT OF SIBLING CONFLICT When parents are concerned about and seek professional help for sibling conflict, certain factors are especially important to examine during the assessment of the problem. The assessment guidelines presented here follow the Comprehensive Assessment-to-Intervention System (CAIS; see Chapter 2), with emphasis on those factors most related to sibling rivalry as outlined in Table 12.1.

Step 1: Initial Contact The first step in the assessment process is to gather information from questionnaires and checklists completed by the parents. The following should be included in assessment of sibling conflict: 1. A general questionnaire, such as our General Parent Questionnaire (see Appendix B). This gives information on the age and sex of each child in the family, on who cares for the children, and on parents’ perceptions of the problem. 2. The Parenting Stress Index (PSI; Abidin, 1995; see Appendix A for a full description). The PSI includes parents’ perceptions of the child’s temperament and information about the marital/couple relationship, parental depression, and life stress, all of which have been shown to influence sibling relationships. Both parents should be asked to complete the PSI, and it is also useful to have the Child domain completed with reference to each child about whom the parents are concerned. Hypotheses about differential parental perceptions and treatment of the children can be developed from this information. 3. The Child Behavior Checklist (CBCL; Achenbach, 1991a, 1992) or the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992), as well as the Eyberg

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Child Behavior Inventory for Children (ECBI; Eyberg & Pincus, 1999). At least one of these measures should be completed with reference to each child involved in the conflict. Information about the existence of other problems with any of the children is provided by these screening instruments. 4. Dyadic Adjustment Scale (Spanier, 1976; see Appendix A). This measure is particularly important in the assessment of sibling conflict, because marital/couple distress has been shown to affect sibling relationships, both directly and indirectly. The existence of serious problems in the parents’ relationship should lead the clinician to work to resolve these before dealing with the referral problem of sibling conflict. 5. The Beck Depression Inventory—II (Beck, Steer, & Brown, 1996; see Appendix A). This measure is particularly important to administer to parents (especially mothers) who are concerned about the adjustment of their older child to a new baby. Postpartum depression is quite common and may need to be treated before a mother will be able to deal effectively with her older child’s adjustment problems. Information on parental depression can also be obtained from the PSI. 6. The Daily Log (see Appendix B). Parents should be asked to monitor and note all instances of sibling conflict on the Daily Log. This gives the clinician excellent information about the frequency and duration of fights (are they more frequent than expected?), as well as the instances that involve physical and/or verbal aggression. It also provides information on parents’ perceptions of who is at fault, how fights are resolved, how often parents intervene, and so on. These data will provide an excellent baseline for monitoring the effectiveness of any treatment program.

Step 2: Parent and Child Interviews Parent Interview Interviewing the parents is crucial in the assessment of sibling rivalry. During the interview, in following the CAIS framework, the clinician should be particularly careful to gather the following information: 1. How do parents handle sibling conflict currently, and what methods have been tried in the past? Reviewing the data on the Daily Log with parents can help to clarify this. Having parents go over a “typical day” will reveal any particularly troublesome situations (e.g., fighting over TV, the predinner “combat hour,” etc.). 2. How did the sibling relationship develop? Parents should be asked to describe how the older child or children were prepared for the arrival of the new baby and what the adjustment period was like. Any steps parents took to ease an older child’s adjustment should also be noted. 3. What kinds of behavior do the parents model for their children? Because parents are important models for their children, the parents’ style of interaction with each other should also be observed during the interview. We have been amazed at the number of parents who are quite comfortable with a combative, argumentative interaction style in the marital/couple relationship, and at the same time complain that their children exhibit the very same style! Conveying information about the effects of parental modeling on children’s behavior to parents during the feedback conference is an important part of the treatment program for such cases.

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4. Do the children have problems with aggression/conflict in areas other than sibling interactions? Parents should be asked about the children’s peer relationships, school progress, and other activities and interests. Data from the CBCL, BASC, or ECBI can provide the basis for gathering further information in these areas. Children who are having problems in other areas of their lives are, of course, of greater concern than those whose problems occur only in the context of sibling interaction. Furthermore, a child who does not have individual interests and activities outside the family may need to be helped to develop these— both to improve his or her sense of uniqueness, and to keep him or her occupied and out of trouble! Child Interview Interviewing children in cases involving sibling rivalry is often not necessary. When done, it is best left until after the clinician has observed the children’s behavior. Children are usually unable to describe the problem in any but very global terms (e.g., “I hate him; he’s always bugging me”). Observation enables the clinician to ask more specific questions regarding the sibling interaction.

Step 3: Observation of Behavior Observation of the children together, both in the presence of parents and alone, is the next step in the assessment process. Although many clinics provide facilities for observation, observation in the home also provides useful information, because children may feel more comfortable and behave more naturally at home than in the clinic. In the parents’ absence, instances of cooperative, friendly interaction between siblings may be observed; these will enable the clinician to give parents feedback about their children’s strengths. Observing parents interacting with the children can provide information about management strategies, as well as reinforcement patterns. Parents often complain that a clinician does not actually witness instances of fighting when observing, because the children are on “their good behavior” in the presence of a stranger. Although this is often the case, valuable information about the emotional climate of the home and family relationships, potential for building positive relationships, differential parental treatment of children, and potential effective management strategies can be gained from direct observation of the children. It is a good idea to have a list of target behaviors in hand before going to the home, and then to record one’s findings during or immediately after the visit.

Step 4: Further Assessment For many cases of sibling rivalry, Steps 1, 2, and 3 will complete the assessment. The clinician should, of course, be aware of the possibility of more serious problems among the children, parents, and/or family that would require further psychological assessment.

Step 5: Referral to Allied Health Professionals Referral to another professional should be considered for problems such as marital conflict or parental depression coexisting with sibling rivalry, and the need to treat these problems prior to treating the sibling problems should be assessed.

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Step 6: Communication of Findings and Treatment Recommendations Prior to beginning treatment, the clinician should discuss his or her understanding of the nature and etiology of the sibling problems, and should provide a rationale for the proposed treatment program. The implications of sibling problems for the children’s development in other areas and their impact on family life should be discussed. As it does for any child problem, the parents’ understanding of the clinician’s view of the sibling problems will influence their motivation to cooperate with the treatment recommendations.

TREATMENT OF SIBLING RIVALRY Research Findings There has been surprisingly little research on effective treatment methods for sibling rivalry. Studies that have examined the efficacy of various interventions in reducing the frequency of sibling conflict have been primarily based on one of two theoretical perspectives. The first, an Adlerian approach espoused by Dreikurs (1964), suggests that sibling conflict is best ignored by parents because its primary function is to gain parental attention. Allowing children to solve their own fights may also have the benefit of providing opportunities for children to learn important conflict resolution skills (Brody & Stoneman, 1987), although recent work indicates that children do not learn these skills on their own (Perlman & Ross, 1997). Behavioral theory suggests that ignoring should be effective in reducing sibling conflict through the principle of extinction, and work reviewed by Brody and Stoneman (1983) indicates that this is indeed the case. The increases in sibling conflict shown among preschoolers may be a function of a random reinforcement schedule; that is, sometimes fighting gets a parental response and sometimes it does not (Perlman & Ross, 1997). An operant approach to intervention advocates the use of differential reinforcement of other behaviors (e.g., not fighting), reinforcement of specific alternative behaviors (e.g., cooperative play), and/or use of time out for fighting. Brody and Stoneman (1983) indicate that each of these methods is effective in reducing fighting. Olson and Roberts (1987) compared the use of time out with skill-building sessions (teaching problemsolving and assertiveness skills to parents and children) in reducing sibling fighting. Overall, use of time out was more effective than skills training, but these results were confounded by socioeconomic differences in the treatment groups. Nonetheless, the authors conclude that skill-building approaches may be more effective with families from higher socioeconomic class backgrounds. When children are asked what parents can do to stop their fighting, the results are discouraging. Prochaska and Prochaska (1985) found that even the methods mentioned as most effective by fourth- and fifth-graders were judged by these youngsters to decrease fighting only slightly. These methods were (1) rewards for being good; (2) being sent to one’s room, spanked, or scolded; and (3) being kept busy with fun things. Parental ignoring was judged by these children to increase fighting! When one child in a family is referred for treatment of aggressive behavior, training parents in strategies for managing the behavior of the target child often results in improvements in the behavior of other siblings as well (Brody & Stoneman, 1983; Eyberg & Robinson, 1982). This is important, because observations of target children and their siblings usually reveal few differences in their behavior. It is not known why parents seek help for one child versus another in these cases.

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Studies have also examined the inclusion of siblings in the treatment process when one child is targeted for intervention. This approach makes sense when one recognizes that although the level of conflict remains the same, children interact more and engage in significantly more cooperative and prosocial play in the absence of parents than when their parents are present (Hay et al., 1998). Siblings have successfully been taught the use of some behavior management techniques, such as differential reinforcement and extinction (Brody & Stoneman, 1983). This type of intervention is most successful when both parents and children are consistent in their use of behavioral techniques, and when parents are careful to focus equal attention on both children. In our clinic we employ a variety of behaviorally based treatment strategies for sibling conflict, the choice of which depends on our assessment of the problem. The treatment process begins with a feedback session with parents (and sometimes also with the children), during which they are given information about sibling rivalry in general and our assessment of how it operates in their family. Various strategies for treatment are discussed in the context of the CAIS framework, although some strategies clearly cut across the areas on which one can focus treatment.

Specific Treatment Strategies Intervention with the Child In many cases it is clear that the children do not have adequate problem/conflict resolution skills, and these must be directly taught. These skills include ignoring, negotiating, compromising, expressing angry feelings appropriately, and (when all else fails) walking away from the situation. Parents can be involved by actually doing the teaching or by reinforcing use of these skills at home. If conflict between two siblings occurs because one or both children are bored or do not have enough ways to express their individuality, then parents need to help the children develop outside interests and activities. Children should be encouraged to go their separate ways much of the time, and parents should not insist, for example, that the older one include the younger in all his or her activities. Similarly, older children should not be expected to provide regular child care for younger siblings. If parents need a babysitter, they should hire one or pay an older child for accepting this responsibility. Nor should older children be allowed to criticize or feel it is their responsibility to correct younger children. A reminder that this is the parent’s job may be needed. Many children referred for sibling rivalry already have good interaction skills in their behavioral repertoires. The treatment issue then becomes one of increasing the use of these skills or, conversely, decreasing use of inappropriate behaviors with siblings. This is most effectively accomplished through use of behavioral techniques. Using time out for physical or verbal aggression, regardless of who did what to whom, is always appropriate and effective. Providing rewards for appropriate behavior or the absence of negative behavior is also important. For example, children can be given a certain number of points (or a sticker, for younger children) for playing cooperatively for 30 minutes (or a longer or shorter period of time, depending on one’s assessment of what is possible). Response cost methods, in which a child loses points (or stickers) for fighting, have has been shown to be more effective than positive reinforcement alone (Sullivan & O’Leary, 1990). Books for preschool children about sibling rivalry include When the New Baby Comes, I’m Moving Out (Alexander, 1992) and The New Baby at Your House (Cole & Miller, 1998).

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Intervention with Parents Many parents who are concerned about sibling rivalry already possess good general child management skills. These parents simply need to be helped to apply these skills to the problem of sibling rivalry. Other parents must be taught basic skills, such as how to provide contingent reinforcement and how to implement time-out procedures, before they can begin to deal with sibling conflict. Parents must also model appropriate interaction. “Do as I say, not as I do” simply does not work with children! In some families, the sibling conflict is only one aspect of the conflict that consumes the entire family. In these cases, it would be futile to try to eliminate sibling rivalry before working to improve the emotional atmosphere of the household. Similarly, if the marital/couple relationship is distressed or either parent is experiencing significant psychological problems, treatment should focus on these problems before (or at least concurrently with) treatment of the sibling problem. Changing parents’ expectations, attitudes, or beliefs can be an important aspect of treatment for sibling problems. Many parents have unrealistic expectations for their children’s relationship; they may expect sharing, helping, consideration, and so on 100% of the time. These parents may be too quick to intervene in squabbles and consequently may inadvertently reinforce fighting. Teaching them to ignore low-level conflict, or instructing the children to work things out by themselves (assuming that the children have the appropriate skills), is often effective in these cases. Parents must also be clear with their children about their expectations for their behavior and the household rules (Brody & Stoneman, 1987). Telling a child, for example, to “play nicely with your brother” is not specific enough. Schaefer and Millman (1981) suggest that parents hold regularly scheduled “family councils” when everyone sits down together to clarify rules and expectations, deal with transgressions, and plan family activities. Other parents may have trouble appreciating one or both children, and thus inadvertently favor one over the other. Schaefer and Millman (1981) recommend that parents periodically ask their children whether they feel parents have a favorite. If a child consistently answers “Yes,” parents must examine their interaction with that child and ensure that he or she is getting sufficient nurturance and attention. Parents must recognize that each child is different, and that treating children equally does not mean treating them exactly the same. Rather, parents must find ways to meet each child’s unique needs for time, attention, and family resources. Older children, for example, are entitled to privileges (later bedtimes, larger allowances, etc.) that are not appropriate for younger children. Parents often find bibliotherapy helpful; our favorite books for parents include Siblings without Rivalry: How to Help Your Children Live Together So You Can Live Too (Faber & Mazlish, 1998) and Birth Order Blues: How Parents Can Help Their Children Meet the Challenge of Birth Order (Wallace, 1999).

Intervention in the Environment Assessment should reveal whether there are specific times of day or situations in which children are particularly likely to fight. In many cases, simple interventions such as rearranging the family’s schedule (e.g., having dinner an hour earlier) or taking away a particular toy can decrease fighting. Children are entitled to some privacy and should have a few personal possessions that they are not expected to share. If children have separate rooms, other children in the family can be prohibited from entering without permission. If children must share a room,

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then providing each with his or her own cupboard (with a lock, if necessary) in which to store “nonsharable” possessions can help. If prized possessions are left out of a child’s room or cupboard, then they may be declared “fair game” for the other children. In some cases, sibling conflict is exacerbated by the degree of stress the family is experiencing. Preschool children are particularly adept at engaging in their worst behavior when parents are least able to manage it. One aspect of treatment for these families might be to help them find better ways to cope with stress, and at the same time keep the children under control. For example, giving parents permission to hire a sitter and have an evening out from time to time (perhaps even “prescribing” that they do this) can help. Changing the Consequences of the Behavior Several ways to intervene in the consequences of the behavior of individual children have already been described. Some parents have found group rewards and punishments to be effective in decreasing sibling conflict. For example, if children persist in fighting, all can be sent to time out or the TV can be unplugged until they can decide which programs to watch. Conversely, all children can be rewarded for playing together cooperatively for a specified period of time. If fighting occurs, no matter who starts it, no one gets the reward. Whatever method is adopted to handle fighting, everyone who cares for the children (babysitters, grandparents, etc.) should be familiar with the procedures and asked to use them consistently. Intervention in Medical/Health Aspects Intervention in medical/health aspects is most appropriate for parents who are concerned about the adjustment of the sibling of a disabled or chronically ill child. Parents should be made aware of the unique challenges faced by children with disabled siblings, and should be encouraged to develop a special relationship with their nondisabled child. Although meeting the needs of a sick or disabled child is inevitably difficult and time-consuming, parents must also recognize and meet the needs of their other children. Many of the suggestions provided above are equally relevant for parents with both disabled and nondisabled children. This may mean scheduling special time with a nondisabled child when the disabled sibling is cared for by someone else, encouraging the nondisabled child to develop interests and activities outside the home, and facilitating the child’s participation in these activities.

CASE EXAMPLE: PHYSICAL CONFLICT AMONG SIBLINGS Step 1: Initial Contact Mrs. Battle, the mother of three boys (ages 6, 8, and 10) and a girl (age 3), sounded very desperate when she called for an appointment to discuss sibling rivalry. Her oldest two children had recently caused physical harm to each other, with one sustaining a broken foot. Questionnaires (the General Parent Questionnaire, the ECBI, the CBCL, and the PSI) were sent out for all four children and both parents were asked to complete these for each child. Mr. Battle’s ratings of all the children on the behavioral measures were well within normal limits. He did, however, note that the 6-year-old was more hyperactive, more impulsive, and less attentive, and had some difficulty understanding directions. Mrs. Battle’s ratings, conversely, indicated major conduct problems for all of the children except the 3-year-old girl.

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Both parents’ PSI ratings for the 6-year-old indicated a child with a difficult temperament, who nevertheless was quite acceptable and reinforcing to each parent. The other children’s scores were within normal limits, and Mrs. Battle noted that in viewing each child independently, she found them quite acceptable and reinforcing. Mrs. Battle’s responses on the Parent domain of the PSI indicated scores on the Depression, Relationship with Spouse, and Parent Health scales all over the 90th percentile. (High scores on the PSI are problematic.) Mr. Battle’s scores on the Parent domain were all below the 40th percentile. The General Parent Questionnaire indicated that Mr. Battle was a university professor and was well known and respected in the community. He was often involved in evening meetings, worked on Saturdays, and therefore had only limited child care responsibilities. Mrs. Battle was a homemaker who found little time for personal activities other than church. Her days and nights were totally devoted to the care of the children. According to Mrs. Battle, school and preschool reports indicated that the children were well behaved, compliant, and socially appropriate. The 6-year-old’s teacher did, however, indicate some problems with attention and following directions. The older children (the three boys) were involved in a number of community activities, including organized sports and the church children’s choir, and each had his own special friends. The youngest child, the 3-year-old girl, was described as beloved by everyone in the family and never involved in the sibling squabbles.

Step 2: Parent Interview Mrs. Battle appeared as a pleasant woman in her early 30s, who was dressed in a very casual manner (including sweatpants and running shoes). Her husband had decided not to come for the interview because he did not feel the children’s problems were significant and attributed the latest “accident” to overly rambunctious behavior. Although Mr. Battle did not approve of such behavior, he did not see it as abnormal. Mrs. Battle, on the other hand, clearly felt responsible for her children’s behavior. Mrs. Battle said that her husband was quite supportive of her seeking help and learning more effective management techniques. The mother described the three boys as being intensely loyal to each other (e.g., they fiercely stood up for each other when in group settings with other children, and often dubbed themselves “the Battle boys”). They were also described as being able to play with each other for several hours without any major upset, especially if only two of the three older children were present. School vacations, however, were described as nightmares, with the mother constantly organizing activities, refereeing squabbles, and praying for the end of each day. Mrs. Battle’s management of the sibling rivalry included reasoning with the children, acting as judge, separating the chidren, screaming at them, and trying to provide separate activities for them outside the home. None of these methods were used consistently; they varied with her mood, the time of day, and the situation. Fighting was particularly bad in the late afternoon, and she had started to feed the children earlier and earlier in the day. At the time of this appointment, the children were fed and put to bed no later than 6:30 P.M.! Consequently, her day usually began at about 5 A.M. She felt, however, that after a night away from the children she was in better shape to deal with them. The home environment was described as quite pleasant, with a bedroom for each child, a large family room, and a large outside play area (with room for swings, as well as ball playing and other activities). Mrs. Battle had help with housework and had occasional babysitters, but was primarily responsible for the running of the household, car pooling, and the social life of the family. The family’s socializing was limited primarily to activities involving the children,

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and there was little time or energy left for the parents to be alone. Mrs. Battle said she loved her husband (who was a childhood sweetheart) very much and felt that he also loved her, but the lack of support from him with regard to the children was causing considerable stress on the marriage. She excused her husband’s lack of involvement because of his many university and community responsibilities, which were seen as ultimately benefiting the family. Although money was not overly plentiful, there were certainly enough financial resources to meet their needs fully. Mrs. Battle had elected not to have more child care because she felt the children were her responsibility. Mrs. Battle indicated close connections with and support from both the maternal and paternal sides of the family, but the recent illness and subsequent death of her mother were causing her great distress. She described a very close relationship with her mother and was sorely missing her support. Mrs. Battle’s significantly high score on the PSI Parent Health scale related to difficulties with sleep, headaches, and major problems with ulcers. The sleep problems had started after her mother’s death. Althougth sibling squabbles were the norm in this family, they had become significantly worse in the last year and a half, which coincided with the period of her mother’s illness and death. No child interview was conducted in this case.

Step 3: Observation of Behavior A home visit began 30 minutes before dinner and lasted through the dinner hour. The children were told that the clinician was helping their mother figure out ways to have their family run more smoothly and happily. This observation revealed a well-organized environment with ample materials to stimulate development. The children were all bright-eyed and very interested in the observer. They made reassuring statements that things were not as bad as they seemed and that they were happy with their family. Soon, however, the normal pattern of interaction surfaced, with squabbles over who got the most milk, who got their story read first last night, and rough-housing that quickly ended in tears. Mrs. Battle used no consistent management techniques, nor did the children respond to any but her most vociferous efforts.

Step 4: Further Assessment After further discussion about the 6-year-old’s behavior, it was agreed that questionnaires should be sent to the school, and the therapist was given permission to talk directly with his teacher. Through subsequent evaluation, it was determined that this child had a mild learning disability and attention-deficit/hyperactivity disorder (ADHD). His behavior was felt to have an impact on the two older children’s behavior, and vice versa. These problems were treated simultaneously with the sibling rivalry problems.

Step 5: Referral to Allied Health Professionals Referral to other professionals was not necessary in this case.

Step 6: Communication of Findings and Treatment Recommendations This family had many strengths, including financial security, a pleasant and adequate home for the children, a supportive and caring extended family, and children who were functioning well

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with peers and in school. The 6-year-old’s difficult temperament, mild learning disability, and ADHD negatively influenced his and the other children’s relationships with each other. The stressful life events of the maternal grandmother’s death and the mother’s health problems, plus the life circumstances of the father’s work schedule and the mother’s responsibility for the four rambunctious children, had set the stage for maternal depression, marital conflict, child management problems, and sibling rivalry. In the process of filling out questionnaires, keeping Daily Logs, and talking to the child clinician, Mrs. Battle became aware of the negative factors influencing the family. Assessment of the 6-year-old’s problems also helped both parents understand and arrange to meet this child’s needs. When the child clinician discussed sibling rivalry in a developmental context, with an analysis of what factors were most likely promoting negative interactions in their home, the parents readily agreed to the recommended treatment. It was interesting that although they saw their 6-year-old son’s ADHD and other problems as adding to the conflict, they did not feel that this was a major component of the overall problem. They indicated that they had always tried to meet his special needs; they just had not realized that there were other ways to help him. They understood and accepted that some of the recommended treatment strategies were geared toward indirectly decreasing the sibling conflict.

Course of Treatment Based on this assessment of the problem, treatment was implemented in the following areas: 1. Development. Mrs. Battle was given copies of Elizabeth Crary’s books on problem solving for children (Crary, 1982–1986). These skills were explained to her, and she was instructed to read the books to the children at times when they were not fighting. 2. Parents. Mrs. Battle was referred for individual therapy to work through her grief over her mother’s death. She also joined the women’s group at her church, which involved one night out per week by herself. Mr. and Mrs. Battle agreed to participate in one social activity per week without the children. Finally, Mrs. Battle attended evening parent groups focused on sibling conflict. These groups alerted her to the fact that other families were dealing with similar problems and that her children were not terribly abnormal. She also learned much general information about sibling conflict and how other parents handled it. 3. Environment. The therapist worked with Mrs. Battle to reorganize the family’s schedule. The children’s bedtime was moved to 8 P.M., and Mr. Battle agreed to come home at 6 P.M. every night to help put the children to bed. Mrs. Battle hired a woman to come in every day at noon and stay until Mr. Battle arrived home. This woman helped with car pooling, child care, and other household jobs. The boys’ possessions were divided into those that were private and those that were to be shared. Possessions left out of their respective rooms were automatically shared. 4. Consequences. Because Mrs. Battle was afraid the boys would kill each other if she ignored their fighting, she was instructed to use one response for every squabble. This was time out by isolation for each child involved, regardless of who did what to whom. Negative comments, procrastination in going to time out, and so on were dealt with by requiring additional time in isolation for that child. A chart system was also implemented for the family, wherein the boys had to work together to earn a reward (see Figure 12.1). Points were given for cooperation between the children and accumulated over a week when they were exchanged for the reward. Fighting resulted in automatic loss of points, as well as in time out.

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Mrs. Battle was supported in carrying out this program over the next month by one faceto-face interview and weekly telephone contacts. The children initially increased their negative interactions, but Mrs. Battle, with the help of her husband, was able to be consistent in her expectations for their behavior and in providing consequences for their appropriate and inappropriate behaviors. Within a 2-week period, Mrs. Battle reported that the household had calmed down considerably. She realized that in order for things to run smoothly, she would have to continue providing a high degree of structure and consistency in her interactions with the children.

Sibling Chart Date: ______________________ Behavior

Total Possible Points

1. All chores completed

0 or 3

Saturday

Sunday

Monday

Tuesday

Wednesday

Morning

2. Positive statement

1—3

3. No TOs for fighting

0 or 3

Afternoon

438

1. All chores completed 2. Positive 30-minute activity 3. No TOs for fighting

0 or 3 1—3 0 or 3

Evening 1. Positive dinner talk

1—3

2. Share family quiet time

1—3

3. No TOs for fighting

1—3

Total

Daily—27 Weekly—189

1st prize (151—187 points) = _________________________________________________________________________________ 2nd prize (132—150 points) = _________________________________________________________________________________ 3rd prize (114—131 points) = _________________________________________________________________________________

Thursday

Friday

Key III. Morning = the time the child gets up until he goes to school, or, if school is out, then from the time child gets up to lunchtime. 1. All chores completed = all three children’s chores must be completed or the score is 0. The score is 0 or 3 points. 2. Positive statement = add 1 point for each child who says something positive to another child (e.g., “John, thanks for helping me feed the dogs”). A maximum of 3 points is possible. 3. No time outs (TOs) for fighting. The score is 0 or 3. III. Afternoon = the time the child arrives home from school to dinnertime, or, if there is no school, from lunch to dinnertime. 1. All chores completed = same as in the morning.

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2. Play a game or do an activity together for 30 minutes without fighting = 1 point for each positive interaction, up to a maximum of 3 points. 3. No TOs for fighting. The score is 0 or 3 points. III. Evening = dinner to bedtime. 1. Dinner talk = 1 point for each child who shares a positive interaction with a sibling (e.g., “1 had fun playing ball with George today”). A maximum of 3 points is possible. 2. Share a quiet time (e.g., reading or TV) with family without fighting = 1 point for each child, with a maximum of 3 points. 3. No TOs for fighting. The score is 0 or 3 points. FIGURE 12.1. A sample Sibling Chart.

Points Total possible points per day = Total possible points per week = 1st Prize (80—100% of points) = 2nd Prize (70—80% of points) = 3rd Prize (60—70% of points) =

27 189 151—187 132—150 114—131

Prize Options These were selected by parents and children. Each week they must choose the prizes they are working toward and receive the prize by 5:00 P.M. Sunday. The prizes for the week are listed on the front. 1st Prize Options Saturday morning breakfast out Go to movie Family picnic at park New game (one of four selected by children) 2nd Prize Options Rent video and popcorn $2.00 each to spend at video arcade Stay up 1 hour later on Saturday night 3rd Prize Options Dad rides bikes with them for 30 minutes Frozen yogurt $1 for Dollar Store

From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).

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CHAPTER 13

Divorce

W

ith the rapid increase in divorce rates during the last 30 years, clinicians and researchers have begun to recognize the significance of this stressful event for the development and adjustment of children. Substantial numbers of children experience parental divorce before they reach age 18; it is estimated that about one-half of marriages end in divorce, affecting approximately 1 million children each year (National Center for Health Statistics, 1995). Racial/ethnic differences have been noted in the demographics of divorce; many more African American children experience parental separation or divorce than do European American children (76% vs. 36%) (McLanahan & Bumpass, 1988). A large body of research has clearly documented that many children are negatively affected by their parents’ divorce, at least in the short term (e.g., Amato & Keith, 1991a; Chase-Lansdale, Cherlin, & Kierman, 1995; Hetherington & Stanley-Hagan, 1999). In a recent review, Hetherington, Bridges, and Insabella (1998) estimate that 20–25% of children in divorced and/or remarried families evidence significant adjustment problems; this is compared to the 10% of children from intact homes who have difficulties. Moreover, African American males appear to be most vulnerable to the adverse affects of parental separation (Jenkins & Guidubaldi, 1997). Negative effects of divorce are also seen over the long term. Many children continue to experience their parents’ divorce as a significant negative influence in their lives through adolescence and well into adulthood (Amato & Keith, 1991b; Chase-Lansdale et al., 1995; Wallerstein & Lewis, 1998). It is important to note, however, that not all children experience lasting negative effects as a result of divorce (Grych & Fincham, 1992; Hetherington et al., 1998). Many cope amazingly well with the stresses that occur in the aftermath of parental separation and function extremely competently in all aspects of their lives (Emery & Forehand, 1994). Research has thus shifted from examining the general negative effects of divorce to defining the factors that mediate children’s adjustment to the stresses of divorce and determine which children will adapt and which will continue to evidence problems.

EFFECTS OF DIVORCE ON CHILDREN Divorce is most appropriately viewed as a “transitional event,” in that it is not the divorce per se that affects the child and family, but the often prolonged process of change and adaptation that precedes and follows the divorce (Hetherington & Stanley-Hagan, 1999). It has been 440

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demonstrated that some factors (especially poor parent–child relations) that are thought to contribute to a child’s poor adjustment may exist well before a marriage actually breaks up (Amato & Booth, 1996; Kelly, 2000; Shaw, Emery, & Tuer, 1993). Other factors, such as the remarriage of one or both parents, may occur years after the original divorce. As Felner and Terre (1987) state, “the adaptation process required of family members may extend over a prolonged period during which they are confronted by a complex set of personal and environmental stressors, changes, and ‘adaptive tasks’” (p. 110). Each of these factors will interact with the characteristics of the child and family to determine how well each family member adapts. Thus the focus for clinicians is on understanding the broad context of the divorce and the various factors identified by research that mediate or moderate children’s adjustment. Hetherington and her colleagues (Hetherington & Stanley-Hagan, 1999; Hetherington et al., 1998) have proposed a risk-and-resilience model to explain the interrelatedness of the many factors that have been shown to influence children’s adjustment. They state, “All family members encounter stresses associated with marital transitions, and it may be the balance between risks and resources that determines the impact of stresses on divorced and remarried parents and their children” (Hetherington et al., 1998, p. 179). Rutter’s (1983) conceptualization of the cumulative effects of stress on coping and adaptation is also applicable to the issues of divorce. This approach indicates that in working with children of divorce, the child clinician must understand all the potential sources of stress that have been identified in the research literature, and then assess each of these for the individual child and his or her primary caregiver. Some factors—for instance, the well-documented lowered socioeconomic status of women following divorce (e.g., Duncan, 1994; Fox & Kelly, 1995; Pett, Vaughan-Cole, & Wampold, 1994)—may have indirect rather than direct effects on children’s adjustment, in that they may be mediated by other factors (Hetherington et al., 1998). Lack of adequate financial resources often leads mothers to return to work, thus becoming less available to their children, typically just at the time when the children most need their support and supervision. Moreover, economic and work-related stress can have an indirect impact on mothers’ mental health, which in turn can affect their ability to parent effectively, leading to problems in their children (Duncan, 1994; Hetherington et al., 1998). Thus the negative effects of economic distress on children’s adjustment are most likely mediated by poor parenting. Among the sources of stress that have been identified as being important to understanding children’s adjustment following parental divorce are ongoing parental conflict, parent–child relationships, parents’ remarriage, characteristics of the child (e.g., temperament, age, gender, and coping skills), and custody/visitation arrangements. Research relevant to each of these areas is briefly reviewed.

Parental Conflict It is well known that the conflict between marriage partners that often precipitates a couple’s breakup may not end with the separation. In fact, many families evidence an increase in conflict following separation and divorce. For some parents, hostility and conflict become ongoing characteristics of their interaction that may persist with undiminished intensity for years after the divorce is final. Ongoing parental conflict has been clearly demonstrated to have adverse effects on adjustment, both among children whose parents have divorced and among those whose parents remain married (Kelly, 2000; Lee, 1997). Children from divorced families in which there is little conflict after the divorce do not differ in adjustment from low-conflict intact families (Forehand, McCombs, Long, Brody, & Fauber, 1988; Hanson, 1999; Vandewater

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& Lansford, 1998). Moreover, the adjustment of children in high-conflict families is often improved following divorce (Amato, Loomis, & Booth, 1995; Jekielek, 1998), whereas children who remain in high-conflict intact families may show increases in adjustment problems over time (Morrison & Coiro, 1999). Finally, more intense conflict, especially that which involves marital violence or child maltreatment, results in higher levels of child disturbance (Ayoub, Deutsch, & Maraganore, 1999). Much of the conflict evidenced by divorced couples with children centers around childrelated issues, such as visitation, custody, discipline, and child support (Hetherington, Cox, & Cox, 1976; Johnston, Campbell, & Mayes, 1985; Johnston, Gonzalez, & Campbell, 1987). Childfocused conflict has been shown to be particularly detrimental to children’s postdivorce adjustment (Grych & Fincham, 1992). Increases in the number of cases subjected to mediation by the courts reflect attempts to address this problem (Walton, Oliver, & Griffin, 1999). Indeed, some states have mandated mediation sessions in all divorce cases involving young children. Mediation decreases the likelihood of litigation after the final divorce decree and is associated with greater satisfaction with the divorce process (Grych & Fincham, 1992). Mediation also has been shown to reduce child-reported distress and parents’ reports of their own distress, but not parents’ reports of child distress (Walton et al., 1999). Considerable research on the benefits of divorce and custody mediation has led some to conclude that it should be a mandatory first step in resolving child-related issues (Kelly, 2000). In summarizing the research related to the effects of parental conflict on children’s adjustment to address the question “Should parents remain together for the sake of the children?”, Hetherington and Stanley-Hagan (1999) conclude: “If conflict is going to continue it is better for children to remain in an acrimonious two-parent household than to suffer divorce. If there is a shift to a more harmonious household a divorce is advantageous to both boys and girls” (p. 134).

Parent–Child Relationships From the child’s point of view, the most salient and painful aspect of parental separation is the perceived loss of one beloved parent, usually the father. For many children, this loss is real; various studies have found that between 8% and 25% of noncustodial fathers have no contact with their children by 2–3 years after separation (Braver, 1998; Stephens, 1996). Moreover, contact with noncustodial fathers tends to decrease over time; within 2 years after divorce, only about 20–35% of children see their fathers as much as once a week (King, 1994; Selzer, 1998). Decreases in noncustodial father–child contact are typically attributed to ongoing conflict between the former spouses, but also occur because of such factors as lack of economic resources, relocation or remarriage of either parent, and the birth of a new baby in a new marriage (Stephens, 1996). At the same time as contact with the noncustodial parent decreases, attention from the custodial parent may also be limited because of a return to work, increased social activities, and greater responsibility for household tasks. Thus the nature of a child’s relationship with both parents following divorce is a key factor in how the child adjusts to the divorce. Early work (Jacobson, 1978; Wallerstein & Kelly, 1980) suggested that the extent to which children had access to the noncustodial parent was related to their adjustment—the more contact, the better the child’s adjustment. More recently, however, it has become clear that quantity of contact with either the custodial or the noncustodial parent is not as important as quality of the relationship and the context in which the contact occurs (Amato & Gilbreth, 1999;

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Amato & Rezac, 1994; King & Heard, 1999). Frequent, regular visits with the noncustodial father that allow feelings of closeness and active parenting and occur in a conflict-free context, and when the visiting parent is free of serious psychopathology and the custodial mother is satisfied with the level of contact, are associated with good adjustment among children (King & Heard, 1999; Lee, 1997; Stephens, 1996). Conversely, when frequent contact occurs under less than optimal circumstances, a child’s adjustment is likely to be compromised. Sadly, there is a positive relationship between frequency of contact between children and their noncustodial parents and the amount of parental conflict (Pagani-Kurtz & Deverensky, 1997). This may explain why at least one study has found that children who have no contact with the nonresident parent do about as well as those who continue to spend time with this parent (Spruijt & Ledema, 1998). The child’s relationship with the custodial parent is, of course, central to the child’s adjustment. A warm, supportive, authoritative parenting style has been shown to promote optimal adjustment among children of divorce, as well as in children of intact families (Harrist & Ainslie, 1998; Hetherington et al., 1998; Katz & Gottman, 1997; Pett, Wampold, Turner, & Vaughan-Cole, 1999). Although the parenting relationship after the separation/divorce is important, research demonstrates that there is considerable continuity in parent–child interaction prior to and following the divorce. Longitudinal studies indicate that ineffective and unsupportive parenting of children may exist many years before the parents actually divorce (Amato & Booth, 1996; Block, Block, & Gjerde, 1988). Block, Block, and Gjerde (1986) found that among boys whose parents later divorced, evidence of undercontrolled behavior (irritability, high activity, impulsivity, aggression) was present years before the parents separated. Thus the negative reactions and behaviors often seen in children (especially boys) after the divorce may have their origins in the dysfunctional parenting that occurs in the predivorce period. Indeed, preexisting problems in parent and child behaviors may explain children’s postdivorce adjustment better than the stresses related to the actual divorce may (Kelly, 2000). Changes in parent–child relationships following divorce are not inevitable, especially for children who have positive relationships with their parents prior to divorce. Deterioration of the quality of parenting often results from the changed life circumstances in which these parents find themselves. In this regard, it should not be surprising that the quality of parent–child relationships deteriorates more for fathers than for mothers following separation, reflecting the fact that in the majority of cases fathers do not have custody of their children and thus have decreased contact with them (Amato & Booth, 1996). Felner and Terre (1987) point out several factors that have been found to influence the custodial parent’s adjustment. One is the extent to which the divorce is perceived as desirable. Other stresses include decreased financial resources, conflict with the noncustodial parent, and the number of children in the family. It is also not uncommon for parents to experience significant depression following marital separation, and this obviously has an adverse impact on their ability to parent. Although it may take several years for caregiving and discipline patterns to stabilize after the disruption of divorce, longitudinal research indicates that most families reach a new equilibrium within 2 years after the separation, and that at this time many child behavior problems will decrease (Hetherington & Stanley-Hagan, 1999).

Parental Remarriage If the custodial parent remarries, an entirely new set of relationships is added to the family. Moreover, subsequent marriages are known to be less stable than first marriages, with rates of

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divorce much higher than for first marriages (Hetherington & Stanley-Hagan, 1999). Recent research indicates that children growing up in stepfamilies are at greater risk for a variety of adjustment problems than those in intact families (Hanson, McLanahan, & Thomson, 1996), although these difficulties may be mediated by the quality of a child’s relationship with his or her parents and/or stepparent, the number of marital transitions the child has experienced, and socioeconomic factors that predate the remarriage (Dunn et al., 1998; Nicholson, Fergusson, & Horwood, 1999). Hetherington (1989) reports that both boys and girls have difficulties adjusting to stepfathers during the first 2 years after remarriage. After 2 years, however, boys appear to adapt well (and appear better adjusted than boys whose mothers have not remarried), whereas girls may continue to have difficulties accepting stepfathers. Hetherington et al. (1998) suggest that stepfathers provide a degree of structure, supervision, and support to boys that is lacking in mother-custody families. In contrast, girls may have developed particularly close relationships with their mothers that are disrupted by the appearance of stepfathers. Furthermore, in contrast to intact families, close marital relationships between mothers and stepfathers and active involvement in parenting on the stepfather’s part are associated with increased parent–child conflict, especially between girls and their stepfathers. Hetherington (1989) concludes that it can be extremely difficult for stepfathers to integrate themselves into families with preadolescent girls, and that the best strategy for a new stepfather is initially to make no attempt to control a child’s behavior; rather, the stepfather should establish a good relationship with the child and support the mother in her discipline. Later, the stepfather should adopt an authoritative parenting style.

Characteristics of the Child Temperament Given the extensive work on the relationship between child temperament and the development of behavior problems, it should not be surprising that a child’s personality characteristics have been found to be related to his or her adjustment following divorce (Elder, Caspi, & Van Nguyen, 1992; Hetherington, 1991; Lengua, Sandler, West, Wolchik, & Curran, 1999). Hetherington (1989) states that the relationship between temperament and adjustment is complex. She found that temperament interacted with levels of stress and adjustment in custodial mothers to predict parent–child interaction, which in turn predicted child adjustment. When these mothers were emotionally stable and under low levels of stress, there was no difference in their reactions to temperamentally easy versus difficult children. Under conditions of high stress and/or when mothers had significant emotional problems, however, they interacted more negatively with temperamentally difficult children than with easy children. For difficult children, a linear relationship was found between stress and coping—the more stress, the less adequate coping. For easy children, the relationship was curvilinear, so that moderate amounts of stress promoted better coping than small or large amounts of stress. Lengua, Wolchik, Sandler, and West (2000) report data consistent with this work. They found that parenting style interacted with aspects of child temperament to predict adjustment. Parental rejection was more strongly related to adjustment among children with low positive emotionality (frequency of smiling, laughing, cheerfulness, and general happy mood), whereas inconsistent discipline predicted adjustment problems for highly impulsive children. Negative emotionality (frequency and

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intensity of the expression of such feelings as anger, fear, or sadness) did not interact with parenting style; rather, it independently predicted depression. Gender Another factor that has been shown to mediate the effects of divorce is a child’s gender. On the basis of considerable research, it is commonly believed that boys are more vulnerable to the negative effects of divorce than are girls, and are more likely to react with externalized or undercontrolled behavior (aggression, negative behavior, temper tantrums, etc.), whereas girls may be more vulnerable to internalizing disorders (anxiety, depression). There is, however, substantial inconsistency in the research literature regarding this issue. Some studies report significant differences in adjustment between boys and girls (e.g., Dunn et al., 1998; Hetherington, Cox, & Cox, 1985; Howell, Portes, & Brown, 1997), and others report no differences (Allison & Furstenberg, 1989; Fergusson, Lynskey, & Horwood, 1994; Johnston et al., 1987; Nicholson et al., 1999; Vandewater & Lansford, 1998). Felner and Terre (1987) suggest that gender may be more related to the pattern of response to divorce than to the severity of the reaction. They argue that boys and girls are socialized differently, and as a result develop different coping styles and abilities that may lead to the appearance of differential effects of divorce on their adjustment. In their review, Hetherington and Stanley-Hagan (1999) point out that gender differences in adjustment vary with age, time since the divorce, parenting style, and type and extent of parental conflict. The inconsistencies in findings of differential effects of divorce for boys versus girls appear to be the results of both methodological factors and a failure to account for the complexity of the divorce process (Hetherington et al., 1998). Zaslow (1988, 1989) examined many factors in a review of the research and concluded that there was evidence for boys’ being more vulnerable to adverse effects of divorce than girls when they were in the custody of their mothers and when the mothers had not remarried. These adverse effects have been shown to persist as long as 6 years after divorce (Hetherington et al., 1985). Taking a developmental perspective, Kalter, Riemer, Brickman, and Chen (1985) argue that these differential reactions to divorce are not surprising when one considers the role of fathers in the development of sons and daughters. Whereas fathers provide important models for boys throughout early development and buffer their relationships with the mothers, they are particularly important for girls just prior to and during adolescence in helping their daughters develop a sense of sexual identity and self-worth, as well as positive attitudes toward men and marriage. Hetherington and Stanley-Hagan (1999) argue that the increasing involvement of fathers following separation may contribute to the lack of gender differences. Fathers tend to be more involved with their sons than with their daughters, and thus may influence better adjustment of boys versus girls. Developmental Status Psychoanalytic theory and the idea of “critical periods” in development have led to the hypothesis that children may be more vulnerable at certain ages than at others to the adverse effects of divorce. Specifically, preschool children and adolescents are thought to be at higher risk for problems than school-age children (Wallerstein & Kelly, 1980). Preschoolers are less able to understand the causes and consequences of divorce, lack well-developed coping skills, may

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engage in more self-blame, and have greater fears of abandonment (Hetherington et al., 1998; Kott & Shoemaker, 1999). Moreover, infants and preschool children are vulnerable to higher rates of maltreatment and actual homicide by stepfathers than by biological fathers; rates of physical abuse in these young age groups are 7 times higher for stepfathers than for biological fathers, and homicide rates are 100 times higher (Daly & Wilson, 1996). Adolescents, in contrast to younger children, may be particularly sensitive to issues of sexuality and independence and may need more supervision than a single parent or a stepfamily is able to provide. Moreover, teenage girls are at higher risk of sexual abuse by stepfathers than are younger children (Daly & Wilson, 1996). Indeed, adolescence may trigger problems in children who have been otherwise functioning adequately since their parents’ divorce many years previously (Hetherington & Stanley-Hagan, 1999). The evidence for age differences in the effects of divorce on children’s functioning is inconsistent, however, with some studies finding age differences in adjustment (although not always the same ages) and others none (e.g., Chase-Lansdale et al., 1995; Howell et al., 1997). Recent work indicates that in examining age differences in adjustment, one must consider the timing of the various marital transitions (i.e., separation, divorce, remarriage) and the time of assessment relative to the ages of the children (Hetherington et al., 1998; Pagani, Tremblay, Vitaro, Kerr, & McDuff, 1998). Heinicke, Guthrie, and Ruth (1997), for example, found that when separation occurred within the first 2 years of a child’s life, the immediate impact was to enhance the parent’s responsive caregiving of the child; for older children, by contrast, the parenting relationship tended to deteriorate. When children’s understanding of divorce is examined, it is not surprising that agerelated differences are found. Pruett and Pruett (1999), for example, found that children under age 6 had many misconceptions about their parents’ divorce and that their knowledge was often inappropriate. McGurk and Glachan (1987) found that children ages 4–6 from intact families were more likely to insist that both their parents would remain parents after a divorce, regardless of whom a child lived with or whether the parents remarried. In contrast, children of this age from divorced families were more likely to believe that parenting was not continuous after divorce, but was contingent on whether the parents lived with a child, remarried, or continued to love the child. Older children in both groups clearly differentiated marital from parental relationships (i.e., spouses can be divorced but children cannot) and biological from caregiving parental relationships (i.e., parents remain parents even if they have little or no contact with the child). These results imply that older children may be able to cope better with parental divorce because of their greater understanding of the inviolate nature of parenthood. Coping Styles Recent work on children’s adjustment to divorce has focused on the different ways in which children cope with the stresses associated with marital transitions, and on the relationship among temperament, coping, and adjustment (e.g., Kott & Shoemaker, 1999). Lengua et al. (1999) argue that temperament affects how children perceive negative events (e.g., “the glass is half full” vs. “the glass is half empty”). These appraisals (mostly positive vs. mostly negative) are in turn associated with the types of coping strategies used by children and their subsequent adjustment problems. Characteristically positive appraisals are thought to enhance self-esteem and a sense of control, whereas negative appraisals are related to increased adjustment problems (Sandler, Kim-Bae, & McKinnon, 2000). Mazur, Wolchik, Virdin, Sandler, and West (1999) found that positive appraisals buffered the negative effects of stressful divorce-related events,

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whereas negative appraisals contributed to children’s self-reports of depression, anxiety, and conduct problems. Emotional regulation, a specific aspect of temperament, is emerging as a factor in predicting children’s coping with parental conflict (Crockenberg & Forgays, 1996; Davies & Cummings, 1995; Davies, Myers, & Cummings, 1996; Rotenberg, Kim, & Herman-Stahl, 1998). Davies and Cummings (1995) suggest that the ability to regulate affective states (e.g., anger, sadness, happiness, fear) influences how children perceive and react to parental conflict; children who tend to show predominantly negative affective states are more likely to be distressed by parental anger, whereas those who tend to show more positive states experience less distress. Furthermore, the more negative a child’s emotional reaction to adult conflict, the higher the child’s risk for behavior problems (Cummings & Davies, 1994). Davies et al. (1996) suggest that the parents’ resolution of conflict, as well as the child’s temperament, is important in understanding the child’s ability to cope. Hostile conflict endings appear to increase the likelihood that a child will become inappropriately involved in parental conflict by forming coalitions with one parent against the other, by proposing solutions to the conflict, or by helping with the tasks that were the initial cause of the conflict. When conflict is resolved positively, the child is less likely to engage in these ineffective coping strategies. Other research has focused on specific coping strategies used by younger and older children and their relation to child adjustment (e.g., Drapeau, Samson, & Saint-Jacques, 1999). Kurdek and Sinclair (1988), for example, found that adolescents who tended to use externalizing coping strategies (e.g., inappropriately ventilating feelings to parents or others, using drugs or alcohol, or smoking) were less well adjusted than those who used outside support strategies (e.g., talking with friends, clergy, or professionals). Johnston et al. (1985) found that younger children (ages 6–8) tried to control their parents’ disputes by actively intervening or trying to distract their parents. These younger children were also likely simply not to cope, displaying various symptoms of acute distress (hyperventilation, stomachaches, headaches, crying, asthma attacks, etc.). On the other hand, older children (ages 9–12) were more likely to take a strong stand in their parents’ fights or to take the side of one parent versus the other. Two-thirds of the children at both ages coped by avoiding the argument (blocking eyes and ears, retreating to their rooms, etc.). Avoidance was judged to be the most adaptive response in dealing with parental conflict. In contrast to these results, avoidance as a style of coping with parental divorce in general (in contrast to specific parental conflict) was found to be related to poorer adjustment, whereas active cognitive responses (changing one’s perception of a problem) and active behavioral responses (doing something about the problem) were associated with good adjustment in a study of young adolescent girls (ages 12–16) (Armistead et al., 1990). Taken together, the work on children’s coping strategies suggests that cognitive-behavioral approaches to treatment/prevention for children of divorced parents, with a focus on positive thinking and active problem solving, would be beneficial (Sandler, Pitts, & Tein, 1995; Sandler, Tein, & West, 1994).

Custody and Visitation Determining custody and visitation arrangements for divorcing families can be one of the most stressful aspects of clinical work with these families. The basis on which custody is determined has varied enormously over the years, depending on the cultural and societal values and attitudes in existence at a given time. Wyer, Gaylord, and Grove (1987) provide an excellent summary of the legal context of child custody decisions. At first, custody was determined solely on

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the basis of parental gender: Fathers had absolute rights over their children, who were viewed as property. In the late 19th and early 20th centuries, the emphasis shifted to consideration of the “best interests of the child,” and a presumption in favor of mothers was established. Awarding custody of children to their mothers was based on the “tender years” doctrine, which assumes that mothers are the appropriate custodians for young children and for girls of any age. Custody of adolescent boys was often awarded to their fathers. Currently, the emphasis in determining custody continues to be on the best interests of the child, but with less importance given to the “tender years” doctrine and without a presumption for either parent (Hysjulien, Wood, & Benjamin, 1994). Unfortunately, most states do not provide adequate guidelines for determining the child’s best interests, leaving considerable discretion in the hands of judges. The Uniform Marriage and Divorce Act (cited in Wyer et al., 1987) states that the following should be considered in determining the best interests of the child: 1. The wishes of the child’s parent or parents as to his custody; 2. The wishes of the child as to his custodian; 3. The interaction and interrelationship of the child with his parent or parents, his siblings, and any other person who may significantly affect the child’s best interest; 4. The child’s adjustment to his home, school, and community; and 5. The mental and physical health of all individuals involved. The court shall not consider conduct of a proposed custodian that does not affect this relationship to the child. (Wyer et al., 1987, p. 10)

More specifically, Weithorn and Grisso (1987) argue that many factors should be considered in determining custody. These include (1) child factors (age, sex, physical and psychological functioning, individual needs, and preferences regarding custody); (2) parent factors (age, sex, physical and psychological functioning, history of meeting the child’s needs, and current capacity to meet these needs); (3) environmental factors (characteristics of the environment and resources offered by each parent); and (4) relationship factors (relationships of the child with each parent and other important persons, such as siblings, grandparents, etc.). Clearly, child clinicians can play a role in providing information to the court concerning these areas and the specific needs of an individual child. The American Psychological Association provides guidelines for conducting child custody evaluations (APA, 1994a). Although a recent review (Bow & Quinnell, 2001) indicated that child custody evaluations have become more sophisticated and comprehensive, there remains a lack of consensus on what constitutes “the child’s best interests” (Hysjulien et al., 1994). Moreover, clinicians have been criticized for a lack of attention to empirically based research in choosing methods for assessment (Melton, Petrila, Poythress, & Slobogin, 1997). Nonetheless, reviews of the outcomes of custody evaluations indicate that they are effective in preventing the majority of disputed custody cases from going to trial (Ash & Guyer, 1984, 1986). A lengthy discussion of methods used in conducting custody evaluations is beyond the scope of this chapter; the reader is referred to Gardner (1982) and Bricklin (1995) for “cookbook” approaches to child custody evaluations, to Weithorn (1987) for consideration of the relevant ethical and professional issues, and to Hynan (1998) for a review of interview methods. From the child’s point of view, legal custody is far less important than physical custody (i.e., the person with whom the child lives) and visitation arrangements. Increasingly, parents and the legal community consider joint legal and physical custody as a viable and even desir-

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able option for divorcing families. Proponents of joint physical custody argue that this arrangement most closely resembles an intact family, fosters a continued relationship between the child and both parents, eliminates acrimonious custody disputes, and meets the parents’ needs by alleviating one parent’s feeling of being overburdened by one parent and the other’s sense of loss (Felner & Terre, 1987). On the other hand, opponents of joint physical custody contend that this arrangement forces parents to continue to interact and may actually exacerbate conflict. Furthermore, joint physical custody usually involves complex child care arrangements and frequent disruptions in the continuity of care, especially if the parents live some distance apart; these may be very stressful for the child. Finally, the child may be prevented from forming and maintaining a close attachment based on day-to-day, ongoing care by one parent (Felner & Terre, 1987). There is some research suggesting that joint physical custody may not adequately meet children’s needs. Cloutier and Jacques (1997) reported that over time there was a tendency for custody to shift toward sole custody from joint custody: About half of the children in joint custody changed custody status (i.e., went to sole custody) during the 2 years of their study. Moreover, Steinman (1981) found that although parents were generally satisfied with joint physical custody arrangements, children were significantly less positive. They expressed confusion, anxiety, fears, and feelings of being overburdened concerning their schedules and living arrangements. This was particularly true for younger children, whereas adolescents felt that joint custody simply did not meet their needs. It is important to note that most (if not all) of the studies of joint physical custody have involved families who have chosen this arrangement and are committed to making it work. Thus these parents represent a very different population from those with sole custody arrangements. In her review, Kelly (2000) concludes that there are few differences in child adjustment between sole and joint physical custody. She states, “The psychological health of the parents and the quality of the parent–child relationships remain the best predictors of children’s adjustment” (p. 970). Research examining the influence of mother versus father custody is just beginning to appear, most likely reflecting the lack of father-custody households until recently. A study by Clarke-Stewart and Hayward (1996) makes a strong case for awarding custody to fathers, at least in some cases. They found that children (especially boys) in father-custody households did significantly better on various measures of psychological functioning than did those in their mothers’ custody. Interestingly, these differences were maintained even when family income, contact with the noncustodial parent, and psychological adjustment of the custodial parent were controlled for. Clarke-Stewart and Hayward suggest that their custodial fathers had several advantages over the custodial mothers, such as higher incomes, fewer children to care for, and more available emotional support from friends and family members. Furthermore, they were self-selected custodial parents, as opposed to having been assigned by the courts to provide custody for their children. An added benefit for these children living with their fathers was that they also maintained a close relationship with their noncustodial mothers, who made a considerable effort to remain an important part of their children’s lives. Clarke-Stewart and Hayward (1996) conclude: The significance of this study for practitioners is not that it provides a blunt instrument for obtaining more custody for fathers. The positive associations obtained in the study demonstrate the benefits for children of father custody and of continued contact with both parents. . . . Practitioners wishing to apply the findings of this study can use them to encourage fathers to stay involved with their

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The issue of which custodial arrangement is best is complex. Hetherington et al. (1998) suggest that custodial mothers and fathers provide different advantages and disadvantages to their children; mothers may have more trouble with control issues, whereas fathers have more trouble with communication, self-disclosure, and supervision. Thus the presumption that any one custodial arrangement is inherently best for children is misguided and does not reflect the very real differences among families.

ASSESSMENT OF DIVORCE-RELATED ISSUES Taken together, the research on children’s adjustment to divorce provides useful guidelines for clinicians, but it indicates clearly that the circumstances and needs of individual children and families must be carefully assessed in order to provide appropriate advice and treatment. Divorce is inevitably a difficult and painful process for children no matter what their age, and parents can expect a period of adjustment lasting up to 2 years after the separation. Nonetheless, several factors stand out as being centrally related to children’s ability to adapt; these are summarized in Table 13.1. The assessment process outlined here sets the stage for intervention and is not designed for determining custody in the legal sense. However, careful attention to the assessment process and the information gathered therein can provide the clinician with the tools necessary to help parents make good decisions regarding their children’s well-being. The assessment process outlined here follows the Comprehensive Assessment-to-Intervention System (CAIS) described in Chapter 2, with an emphasis on those issues most related to divorce.

Step 1: Initial Contact To keep the focus on the best interests of the child (or children), it is important to include both parents in the initial interview. This arrangement gives each parent the opportunity to share their views and concerns, and the clinician can more readily clarify the appropriate focus of the clinical contact. Furthermore, neither parent is seen as having “an advantage” with the clinician, and the final recommendations are more likely to be seen as impartial. The parent who calls for the initial interview often wants to give the clinician his or her view of the problem on the telephone, or initially to see the clinician alone. Thus the clinician must clarify quickly how he or she proceeds with issues of separation or divorce and what services he or she can offer (e.g., setting the stage for telling children of an impending separation, providing information on children’s reactions to separation, assisting in determination of living arrangements, providing treatment for families and children of separated or divorced families, and/or doing custody evaluations for the court). If parents want a custody evaluation for the court and the clinician does not offer this service, the parents should immediately be referred to someone who does this work. Sending each parent a general questionnaire (e.g., our General Parent Questionnaire; see Appendix B) that provides demographic information, as well as information on their reason for seeking help and their perceptions of the problem, gives the clinician important information for the initial interview. In addition, having each parent complete for each child the Child

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TABLE 13.1. Factors That Mediate Children’s Adjustment to Parental Divorce Area of risk

Risk/protective factor

Characteristics of the child

• Temperament: easy (protective) vs. difficult (risk) • Age (adolescents have more difficulty) • Gender (boys have poorer adjustment, especially when father is absent • Race (adjustment is problematic for African American boys) • Preexisting behavioral or emotional problems (risk) • Higher intelligence/better academic skills (protective) • Active coping strategies (protective)

Characteristics of the parents

• Quality of parenting, especially for custodial parent (all factors below protective): • Warmth and support • Ability to monitor child’s activities • Consistency of control/supervision • Responsiveness to child’s needs • Ability to communicate clearly, especially about feelings • Quality of involvement of noncustodial parent: good (protective) vs. poor (risk) • Level and nature of parental conflict (all factors below risk): • Child’s being caught in the middle • Exposure of child to conflict • Violence or abuse • Presence of psychopathology (risk) • High levels of stress (risk) • Isolation, lack of social support (risk) • Coping skills, ability to deal with stress (protective)

Characteristics of the environment

• Adequate financial resources (protective; note that these tend to decrease more for mothers than for fathers) • Employment status, stability (protective) • Divorce-related transitions—move to new home, neighborhood, school (risk) • Quality of sibling relations: good (protective) vs. poor (risk) • Support from external family (protective) • Remarriage (varies; see text)

Behavior Checklist (CBCL; Achenbach, 1991a, 1992) or the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992), as well as the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999) and the Parenting Stress Index (PSI; Abidin, 1995), provides a wealth of information. These instruments cover a child’s overall emotional and behavioral status, involvement in activities, temperament, and compliance with daily routines, as well as parents’ stress level. Fathers and mothers do not always have the same view of their children’s behavior, and in the case of a separation, this information is especially important as a starting point in assessing each parent’s relationship with each child. Reviewing these questionnaires prior to the initial interview gives the clinician infomation on the potential problems or issues for the family. We have found that parents are increasingly seeking help prior to separation; this is ideal, because it allows the clinician to provide information and guidance that have the potential to decrease greatly both the immediate and longterm adverse effects of the separation and divorce on the children.

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Step 2: Parent and Child Interviews Parent Interview The setting for the interview with the parents is very important. Primarily, it should provide the opportunity for the parents to sit apart from each other. Because the clinician has already gathered a lot of information from both parents, it is good to begin the interview by summarizing the clinician’s understanding of the reason for the session and asking both parents to clarify this information, as well as what they hope to receive from the contact. The clinician should also let the parents know what he or she feels can be accomplished in the first session. Any conflict around these points can be dealt with immediately. After both parents have expressed their concerns, it is important to gather information about the following areas, in addition to those outlined in Chapter 2: 1. Living arrangements. Where is each parent currently living? How is the children’s time spent with each parent? How is this working? Are there plans to change the living arrangements? If so, when will these changes occur? These issues can be sources of conflict between the parents, and getting their views on what they want and why they think a particular arrangement is or is not appropriate is important. It also enables the clinician to determine whether the focus is primarily on the children’s or the parents’ needs. 2. Reasons for the separation. The reasons and events leading up to the decision to separate are very important in determining the past, current, and potential future level of conflict. Each parent’s view of these events and their reaction to them gives information on the emotional atmosphere surrounding the separation, as well as on how each parent is likely to share this information with the children. 3. What do the children know? What the children know or have been explicitly told about the separation is crucial to understanding how each child is adjusting or will adjust. Parents sometimes think that a child does not have any idea that a separation is being considered, and others who are already separated have never given a full explanation because they feel the child “already knows” or will not understand. If there is more than one child in the family, have the parents shared information with some of them but not with others? 4. Who knows about the separation? Whom the parents have told about the separation, and how these people have reacted, are important in terms of the support both parents feel they have for making this decision. These people in turn will have an influence on the child’s perception of the separation. Will the child be able to rely on them for support? Is there a chance that the child will lose contact with particular extended family members? 5. Lawyers. It is helpful to know how far the parents have gone in the legal process and who their lawyers are. This may have a direct bearing on the current and future level of conflict. 6. Financial arrangements. The current financal resources of the family, and the ways in which these will be divided or changed, are crucial to understanding children’s adjustment to separation and divorce; financial arrangements are often a significant source of stress and conflict for divorced parents, and such conflict usually affects the children as well. The clinician should determine whether a child will have to change schools (e.g., from private to public) or decrease activities due to the changing financial situation. It is also important to know whether one or both parents are using or have used the issue of child custody or visitation as a threat or bargaining factor in determining property settlement, alimony, or child support. 7. Conflict between parents. On the basis of the parents’ interaction in the interview, the clinician should be able to make some judgment about their level of conflict and how they are

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handling this with the children. Finding out when and how they talk about their own personal issues will shed light on the extent to which the children are exposed to parental conflict and the effects of the conflict on them. The PSI gives information on the level of stress each parent is experiencing. Further exploration of this information, however, is best left to a future individual session with each parent. 8. Perception of children’s adjustment. Parents should be asked how they think their children are adjusting to the separation and/or what problems they perceive in their adjustment. They should also be asked what they think would help the children adjust better to the realities of the separation. Do they feel that their interactions with a child have changed since the separation or divorce? Again, gathering specific information on the parent–child relationships, the children’s daily routines, parenting styles, and discipline techniques is usually best left to future interviews with both or each parent. Child Interview The child (or children) is almost always seen in a separate session from the parents, although the interview should begin with the child and one or both parents present to clarify the reason for the contact and indicate how the information gathered from the child will or will not be used. A child should be assured of confidentiality. If information is to be shared, the child is informed that he or she will first be told what, why, and with whom something will be shared. To this end, it is best not to talk to parents immediately after seeing a child; rather, they should be seen at a separate time, or concerns should be discussed by telephone. Furthermore, the child should be told that he or she has a choice about sharing information from the sessions with the parents, and that the child also has permission not to talk about the sessions. Saying these things to the child in the presence of the parents is important, because children of separated parents often feel pulled between their mothers and fathers; some parents have been known to pressure children to divulge the content of their sessions with the clinician, in order to gain “ammunition” to use in divorce proceedings. The child should be told the clinician’s general understanding of the family situation. It is also important to let the child know that the clinician has seen other children whose parents are separated, and that this can be a difficult time for everyone. As in other child interviews, the child should be told what to expect in the session (e.g., “Today I would like to hear about your school, your dance classes, and what you like to do. I’m also going to ask you some questions that will help me better understand your likes, dislikes, and feeling about things. We should also have time to play a game, if you like”). For preschool children, the focus will be more on gathering information through play or drawing activities, but it is equally important to let them know what to expect. Specific information gathered during this session includes (1) the child’s general level of coping; (2) his or her perception of why the parents separated; (3) the child’s understanding of what is happening or going to happen with regard to living arrangements; (4) the child’s feelings about the living arrangements; and (5) his or her worries or concerns about the separation and/or its effects on his or her life.

Step 3: Observation of Behavior Direct observation of each parent’s interaction with each child (and, if there is more than one child, all the children together) is very important for addressing specific questions about the best living arrangements or to get an understanding of a parent and child’s relationship. See

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Chapters 2 and 10 for information about observation of parent–child interaction. A home visit is often an important and necessary way to gather data about the child’s environment and family interactions. During this visit, the specific focus should be on parent–child communication: For example, does the parent attend or listen to the child? How is information shared with the child? What kind of feedback is given to the child? And, likewise, how does the child interact with and respond to the parent? The clinician should determine whether current interactions are similiar to those prior to the separation.

Step 4: Further Assessment In-depth assessment will depend on the nature of the questions being asked and the presenting problems or associated problems of the child(ren) or parents. This could involve formal psychoeducational assessment and/or further assessment of a child’s emotional and social status. Problems present prior to the separation are certain to be exacerbated with the stress of separation, and further assessment of these problems is always indicated. The assessment process for questions surrounding separation or divorce usually involves at least one individual session with each parent and several sessions with the child (or children) in question. The parent interviews should focus on their emotional status, social support network, stressors, and parenting ability.

Step 5: Referral to Allied Health Professionals Parents who have significant psychological problems, or who are in great distress over the separation or divorce, should be referred to an appropriate professional for treatment. If the parents are having difficulty resolving their conflict, they should be referred for joint counseling or divorce mediation sessions. Most schools offer divorce groups for children, and these can be very helpful in answering questions and providing support.

Step 6: Communication of Findings and Treatment Recommendations Evaluating the Assessment Data Before the findings of the evaluation can be communicated to parents and other professionals and recommendations for custody, visitation, and/or intervention made, the data gathered from multiple sources during the assessment must be integrated. This is particularly important in cases of divorce, as parents and others are likely to have very different perspectives on the child’s needs and characteristics. The first step in this process is to review the data in an unbiased manner, keeping in mind the factors that are known to be important in the long-term health of children experiencing parental separation or divorce. Table 13.1 summarizes these factors. Most important is the parents’ abilities to support one another in coparenting the child, including the extent to which they are able to protect the child from their own disputes and reinforce the other parent’s relationship with the child. A second critical factor to consider is the parents’ understanding of each child’s unique strengths and weaknesses and their abilities to meet the child’s needs even when doing so might be inconsistent with their own needs and desires. The assessment findings and recommendations should be communicated to both parents at the same time. Information about children’s adjustment to divorce, and especially the effects of ongoing parental conflict and the quality of the child’s relationship with both parents, should

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be shared with the parents. This information provides a basis for ensuring the cooperation of both parents with the proposed treatment plan. If lawyers are involved, they should be given the information at the same time, with or without the parents present. Enough time should be allowed to answer the parents’ questions, and they should be given an opportunity to meet individually with the clinician after a joint feedback conference.

TREATMENT OF DIVORCE-RELATED PROBLEMS The breakup of a family is always difficult, and the task of the child clinician is to help parents and children deal effectively with this painful process. In many ways, helping children deal with a divorce is like helping them deal with death (see Chapter 14), and as with death, there is an inevitable grieving process that must culminate in accepting the situation and learning to live with the life changes. This work is often preventive in nature; it involves offering information and advice on the factors affecting adjustment, as well as helping parents and children develop the skills necessary to cope with the changes in their lives. Given the individuality of each family’s situation and needs, the focus of treatment will vary from family to family. Various intervention strategies are discussed here in the context of the CAIS (see Chapter 2).

Intervention with the Child What to Tell a Child Research indicates that various interventions are effective in preventing adjustment problems among children whose parents have separated or divorced (e.g., Burroughs, Wagner, & Johnson, 1997; McConnell & Sim, 1999; Pedro-Carroll, Sutton, & Wyman, 1999; Wolchik et al., 1993). A primary strategy is to provide or help parents provide their children with honest information about the separation and divorce that is appropriate to each child’s developmental level. Children can cope with the truth, but are not able to manage secrets. Although a child’s age and ability level, as well as the family circumstances, will determine the specifics of this information, some general principles cut across all ages and circumstances. If possible, each child should be told by both parents a few days before the actual separation occurs. This allows the child to work through some feelings and reactions before the actual separation takes place. Preschool children are not able to appreciate future events as well as older children, so they are more likely to understand what is happening only after the separation actually occurs. Having both parents tell a child communicates the fact that this is a joint decision. Moreover, it decreases the likelihood that the child will take sides, and lets the child know that both parents will continue to be available after the separation (if this is true). Parents will be understandably upset during this time; although their emotional reactions should not detract from the specific information shared, they should be honest about their feelings. The expression of emotions (even crying) can facilitate the child’s expression of his or her own feelings. The expression of rage or uncontrolled anger by parents is not helpful, however, as this makes it more difficult for the child to feel free to express his or her feelings of sadness or anger. Children have wonderful imaginations, and their fantasies can often be more frightening than the truth about the separation. Thus it is important for them to know the causes for the separation, so they can deal with the facts yet continue to trust their parents. The details of the

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causes of the separation do not have to be shared, because children are likely to obsess over details, but the major causes should be addressed. For example, if the mother is in love with another man, this should be stated; however, giving the details of the relationship (when they met or why she loves him) is not needed or helpful. Specifically telling children that nothing they did, said, or thought had anything to do with the separation is important, because a common response of children is to assume that it is their fault. Similarly, children need reassurance that they will always have a home, will be cared for, and will be loved. It is also helpful for a child to know that the parents have told or will tell significant people in the child’s life (e.g., relatives, neighbors, and teachers) about the separation. This relieves the child of the burden of telling these people and allows the child to seek support from them. Children need to know specifically what is going to happen in the days immediately following the separation, what their living situation will be, when they will see both parents, and what will be expected of them. Even if there is some uncertainty about these arrangements, what is known should be shared with the children. A child should be told that these are things that the parents will take care of, and that they will share information as soon as decisions have been made. Being able to ask questions as often as necessary, and to get specific information, is an important way for children to begin to cope with this major disruption in their lives. Honest answers from the parents allow a child to begin to trust that the parents will look after the child’s needs and continue to care for him or her. It is often hard for children to understand that other families or children have felt the way they do, or to believe that they will ever be happy again. Thus the opportunity to talk with other children whose parents have separated, or to hear that other children have experienced separation, allows them to begin thinking creatively about their own situation and ways in which they can help themselves. Therapeutic groups in schools, which allow children to identify with peers in similar circumstances, have become a popular way to help mitigate the behavioral and emotional problems that are often the sequelae of separation or divorce. Intervention Approaches There is some empirical support for the effectiveness of group intervention programs in schools for children in kindergarten to sixth grade (Pedro-Carroll & Alpert-Gillis, 1997; Pedro-Carroll & Cowen, 1985; Pedro-Carroll, Cowen, Hightower, & Guare, 1986; Pedro-Carroll et al., 1999). Pedro-Carroll and colleagues’ groups are structured to meet the developmental needs of younger or older children. They emphasize a supportive environment to help children identify and express divorce-related feelings, clarify divorce-related issues and misconceptions, develop relevant coping skills, and promote positive perceptions of self and family. Children who participated in such groups evidenced fewer adjustment problems than did those who did not participate. Moreover, the beneficial effects on adjustment were maintained over a 2-year period. Groups that met once a week over a period of 4 months proved to be more effective than those that met twice a week for 2 months. Group treatment also provides a setting in which children can begin to deal with negative stereotyping by peers, which has been found to occur (Hoffman & Avila, 1998). King (2000) describes a similiar focus for individual treatment, with an emphasis on providing a safe and supportive environment for a child to grieve openly, express fears, feel free to express rage and anger at both parents, and then begin learning skills to cope with the situation. Bibliotherapy is another widely used intervention strategy; there are many books that identify divorce-related feelings, issues, and coping skills for children. Among our favorites are

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When Mom and Dad Divorce: A Kid’s Resource (Menendez-Aponte, 1999), Dinosaurs Divorce: A Guide for Changing Families (Brown & Brown, 1997), and The Divorce Workbook: A Guide for Kids and Families (Ives, Fassler, & Lash, 1988).

Intervention with the Parents What Parents Need to Know The role of the child clinician in cases involving marital separation is to be an advocate for the child (or children). It is important that the clinician not be viewed as “taking sides” with one parent or the other, but rather as sharing information and advice related to the best interests of a child. Parents need information about how divorce may affect their children, as well as help in determining how best to minimize the negative effects. Although parents can be supported in their own feelings about the dissolution of their marriage, they must also be helped to understand what their child(ren) will need in order to adjust to the situation. Most important, although a child may have been exposed to parental conflict before the separation, it is critical for parents to understand the deleterious effects of continued conflict on children and the need to protect the child from parental arguments. Moreover, as the research described previously indicates, successful and positive resolution of parental disagreements can help children cope (Davies et al., 1996). This often involves the use of great self-control and selfsacrifice on the part of parents, and they will need support to behave appropriately. Some parents may need individual treatment to accomplish this. Handouts that we have prepared to help parents communicate more effectively and with less conflict about child-related issues are shown in Figures 13.1 and 13.2. Each parent must learn to be responsible for his or her own relationship with the child, and even if one parent cannot support the child’s relationship with the other parent, he or she should not criticize or condemn that parent. To do so only places the child in a conflicted situation. Similarly, a mother or father does not have to defend or excuse a parent who is unreliable or irresponsible. Rather, the child should be helped to express his or her angry or hurt feelings when disappointed by that parent. Parents often must be encouraged to establish new social support systems that enable them to meet their own personal needs. It is very detrimental to children when parents rely on them for this support. Children should not be responsible for taking care of parents, and parents should be helped to separate their own needs from those of their children. Parent Groups and Bibliotherapy Parents often find that supportive groups can be a therapeutic way to share feelings and concerns, and to begin coping with the realities of their situation. Cebollero, Cruise, and Stollak (1986) described concurrent groups for mothers and children experiencing the long-term negative effects of divorce. Although the report was descriptive rather than empirical, the parents indicated that the groups were very supportive and gave them new problem-solving skills. In addition, serving as cotherapists for the children’s group gave then a better view of the divorce from their children’s perspective. Shifflet and Cummings (1999) have more recently described a two-session preventive educational program for parents, the content of which was based on their review of the literature on the effects of divorce on children. Specifically, they targeted (1) educating parents about

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Guidelines for Communication between Parents Behaviors that facilitate good communication

Behaviors that interfere with good communication

1. Stick to the subject.

1. Monopolize the conversation.

2. Be specific and clear about what you expect. 3. Be calm; show courtesy and respect for the other’s feelings and dignity. 4. Focus on giving and receiving information.

2. Nag and argue.

5. Express opinions directly. 6. Express feelings and cause of feelings (“I feel angry when you slam the door”). 7. State reasons, explanations for a specific problem. 8. Request the other’s opinion. 9. Use behavioral descriptions of problems. 10. Be willing to compromise.

3. Blame, criticize, ridicule, or threaten. 4. Engage in name calling. 5. Be stubborn or controlling. 6. Issue ultimatums or demands. 7. Interrupt. 8. Change the topic. 9. Dwell on the past. 10. Withdraw—give in or do not respond when you don’t agree. 11. Engage in mind reading or secondguessing (“You don’t watch his diet because you don’t care what I think”). 12. Focus on the negative.

It is important for you to practice these communication principles. That might seem quite difficult at the current time, but if you start with talking with each other instead of at each other, you will have made a good beginning. Remember, don’t attack the other person; attack the problem. FIGURE 13.1. Parent handout: Guidelines for communication between parents. From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this table is granted to purchasers of this book for personal use only (see copyright page for details).

the effects of parental conflict and divorce in general on children; (2) teaching parents to handle conflict more constructively; and (3) parental satisfaction with the program. Important components were the provision of child care services and a parallel program for children. Evaluation of the efficacy of the program, using a waiting-list control group, an alternative treatment (general parenting information) group, and pre–post measures, indicated that the program was effective in increasing parental knowledge and decreasing conflict behavior over time. Changes were maintained over a 2-month follow-up period. Changes in spousal behavior (although spouses were not included in the treatment groups) were noted after 2 months. Consumer satisfaction was high. Bibliotherapy as an adjunct to treatment of divorce-related problems is very useful for parents as well as for children. In addition to the books for children noted previously, several excellent books for parents give information on living arrangements, strategies for resolving

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Communication Helps Children Communication about important aspects of their lives significantly helps children learn to live, love, and play with two “separate” parents. This form helps you exchange important information about your child without placing the burden on the child as the “messenger.” Equally important, it allows each parent to have knowledge of and share in all the child’s experiences. Exchanging the form at the time of pickup/dropoff will help make the transition easier for both child and parents. For each category below, a sample entry is provided to illustrate the sort of information that can be exchanged. Date: ____________ Health Issues: Mary woke up with a fever of 101 degrees and sore throat on Saturday. We saw Dr. Lail, who took a throat culture (to rule out strep) and prescribed Tylenol until the culture is back on Monday. It will be ready by 10:00 A.M. Mary was fine the rest of the weekend, although we restricted our activities to the house. Let me know if you want me to call for the results.

School: Greg finished his science project. Looks good! Mary seemed worried about her upcoming history test (Tuesday); we went over some of the chapters, but she will probably need some more guidance.

Social/Friends: We did not have anyone over to play, given the sore throat. Greg again complained about the Scout leader and the fighting that is going on in the meetings. Do you have any suggestions on what we should do (if anything) about this?

Extracurricular Activities: Greg went to his swimming lesson on Saturday and seemed to enjoy it. Mary started talking about taking piano lessons. Is this something you support?

FIGURE 13.2. Parent handout for facilitating communication between parents.

From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this table is granted to purchasers of this book for personal use only (see copyright page for details).

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Specific Concerns: Greg seems to be having trouble with the kids on the school bus, and in general seems unhappy about his friendships. I am not sure if things are as bad as he says or if he is just upset that his best friend is not in his class this year.

Advice/Suggestions to Child: Greg and I talked about the kids in his class, and he tried to identify the ones he thinks could be friends. He was open to asking them to play with him at recess.

Important Changes in My Household (Relationships, Pets, Trips): I am going to be at my mother’s on Thursday and Friday of this week. The cat had a litter of kittens, and the kids watched the birth. They didn’t have any specific questions, but I talked with them about how the birth process. Are you using any books on sex education?

Upcoming Things to Consider: Mary is still pushing to go to camp this summer. Any plans for this?

Requested Schedule Changes/Response: I would like to take the kids to the beach on the weekend of May 10. They are off school on Friday. Could I pick them up Thursday evening instead of Friday evening?

Miscellaneous:

FIGURE 13.2. (cont.)

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conflicts, and so on. Among our favorites are Does Wednesday Mean Mom’s House or Dad’s?: Parenting Together While Living Apart (Ackerman, 1999) and How to Win as a Stepfamily (Visher & Visher, 1991).

Intervention in the Environment Familiar surroundings can help a child utilize established social support systems to begin coping with the separation (King, 2000). Thus, if at all possible, the added stress of changing homes, schools, neighborhoods, caregivers, and so on should be avoided. Likewise, daily routines, activities, chores, and expectations should be kept as normal as possible. This minimizes the stress on the child and allows him or her to learn what parts of life will remain the same and what parts will be different. Visitation schedules and living arrangements should take into account the child’s developmental level and needs for stability, as well as the child’s need for an ongoing relationship with both parents. Preschool children need environmental stability because of the challenges of developing independence and a sense of mastery and control; school-age children need stability because they are beginning to move out into the world and to experience the stresses of meeting social and academic challenges. Although shared living arrangements are common and appear to meet the needs of the parents, these shared arrangements can be confusing and stressful for children. Each family situation is unique, however, and a careful review of how a particular arrangement will meet a child’s needs apart from those of the parents is an important part of the treatment process. Introducing significant new people in the parents’ lives to the children is usually an inevitable part of the divorce process. Young children often resent sharing the time they spend with a parent; or, if they like the new person, they may feel that they are being disloyal to the other parent. For these reasons, it is often best to allow the child to establish a relationship alone with each parent before including new people in shared activities. It is, however, important for children to understand that their parents have lives separate from them.

Changing the Consequences of the Behavior An emotionally supportive environment, with clearly established rules and consistent routines, sets the stage for children to become increasingly competent and independent. It is thus important for parents to maintain expectations for each child’s behavior and continue to set limits for inappropriate behavior. Changing the expectations and consequences for appropriate and inappropriate behavior when the family is itself changing can create feelings of insecurity among children and decrease their ability to cope effectively with the situation. Children are likely to express many of their concerns and worries through inappropriate behavior or emotional lability. Thus it is important for parents to acknowledge a child’s feelings at the same time they put limits on a behavior (“I know that you want to help me, but as the parent, I am the one who will discipline your younger brother,” or “I can understand that you might be angry with Mom for being late, but you may not hit your sister”).

Intervention in Medical/Health Aspects Children whose parents are separating may have increased psychosomatic complaints; they may state, for example, that they don’t feel well enough to go to school or that they are afraid

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to sleep alone. Although it is important to have a physician attend to these physical complaints, it is often the case that such children are worried or upset about what is happening in the family. These complaints will usually decrease if children are helped to identify and communicate openly about their feelings and anxieties.

CASE EXAMPLE: RECOMMENDATIONS FOR A CHILD’S LIVING SITUATION Step 1: Initial Contact Mr. May, a city councilman and town businessman, requested an interview to discuss the current living arrangements of his 10-year-old daughter, Sarah. He stated that he was concerned that his former wife’s emotional instability was having negative effects on Sarah, and that the department of social services had investigated the mother on charges of neglect (initiated by Sarah’s teacher). Sarah had been living with her mother since the parents separated 10 months ago. In clarifying the referral question (“What is the best living arrangement for Sarah?”), the clinician indicated that the mother should be involved in this process, and that if at all possible she should be present at the initial interview. The father agreed to tell the mother of his contact with the clinician and to request her attendance at the interview. When the father called back to confirm that the mother would be coming, the General Parent Questionnaire, the ECBI, and the CBCL were sent to both parents. The responses to the ECBI and CBCL indicated that both parents perceived Sarah as a rather withdrawn and quiet child who was experiencing high levels of anxiety. The General Parent Questionnaire responses indicated that legal custody had not yet been finalized and that neither parent had consulted a lawyer. Ms. May was concerned that Sarah, as an only child, was “overly close” to her and worried too much about her mother’s well-being. Mr. May felt that Sarah’s problems centered around the mother, who had been diagnosed with depression and alcohol dependence. He also indicated that the mother used Sarah’s visits with him as a weapon to vent her anger toward him. Sarah was living primarily with her mother; although there was no visitation schedule with the father, he saw her approximately every other weekend. He was currently living with another woman who had joint physical custody of her two boys, ages 6 and 9.

Step 2: Parent and Child Interviews Parent Interview The parents arrived separately for the session, and it was apparent in the waiting room that there was a great deal of tension and hostility between them. Mr. May rarely made eye contact with Ms. May, and she talked about Mr. May as though he were not present. Mr. May stated that he had left the marriage because his wife’s drinking had destroyed their relationship. He clearly stated that his current relationship with another woman had begun several months after he had left the home. Ms. May indicated that she was very angry at her husband for leaving her, and that this anger was exacerbated when he moved in with another woman. She felt that, given his work schedule with evening appointments and weekend work, he had never been available to her as a husband or to Sarah as a father. The fact that he was now willing to take time off for Sarah’s school functions and to spend time with her made Ms. May even angrier, although she fully acknowledged the benefits of this relationship for Sarah.

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Ms. May described Sarah as a very loving child and felt that perhaps she sometimes relied “too much” upon Sarah. Ms. May added that she had been under a great deal of stress, was seeing a psychiatrist, was on medication for depression, and was also having trouble controlling her drinking. She noted that she herself had had a parent with alcoholism, and that life had always been difficult for her. She was angry at Sarah’s teacher for reporting her to the department of social services; she felt that she had done nothing wrong in allowing Sarah to stay home from school for a few “mental health” days. Mr. May readily admitted to being out of the home a great deal prior to the separation and “not being the father he should have been” to Sarah when he and his wife were living together. He stated that he had come to realize how important appropriate parenting was through observation of the woman he currently lived with. He stated that his greatest fear was that the court would take Sarah away from both him and Ms. May. Mr. May described himself as a rather serious and intense person, who up to this point had been reluctant to share his feelings or give emotional support to the people for whom he cared. He stated that he was aware of needing specific help on how best to interact with Sarah. Although money was not plentiful, finances were not a major point of dispute between Mr. and Ms. May. Mr. May stated that he was interested in doing what was best for Sarah, and that it was not his intention to “take Sarah away” from her mother. Ms. May concurred with a desire to do whatever would be in Sarah’s best interests. Neither parent had specifically asked for a custody evaluation from the courts, but the clinician had informed the father at the initial contact that she did not do such evaluations. When the clinician restated this restriction in her services, both parents indicated that they were not asking for a custody evaluation, but rather recommendations about the best living situation for Sarah at this time. They fully understood that living arrangements were ultimately their decision, but that the clinician would offer them some recommendations. Sarah’s daily routines included school, ballet lessons once a week, and close relationships with paternal and maternal grandparents. Both parents saw Sarah as easy-going and almost too adaptable to their needs. She had been told that her father was leaving the home, but no other explanation by either parent had been given to her, nor had she asked for further information. Child Interview The father and mother came with Sarah for her initial interview. With all three present, the clinician reviewed the purpose of the visit, assured Sarah of confidentiality, and briefly talked about the reasons for the separation and the mother’s seeking help for her depression and alcoholism. The father further acknowledged that he had not always been available to Sarah or her mother when he lived with them. Sarah was told that the clinician would be meeting with Sarah, her parents, and the woman who was living with the father several times over the next month, in order to determine what Sarah needed and to help the parents meet her needs. The purpose of this first interview was to develop a relationship with Sarah and to help her feel comfortable about talking about her parent’s separation. Given the parents’ description of Sarah as quiet and withdrawn, a structured game that allowed for expression of feelings was played with Sarah. (This game, which has also been mentioned in Chapter 9 as useful in treating depression, is called the Talking, Feeling, Doing Game; as noted there, it is available from Creative Therapeutics, 155 County Road, Cresskill, NJ 07626.) Sarah was initially reticent in expressing her likes, dislikes, and coping strategies for problematic situations, but she soon relaxed. After the game, Sarah was told that the clinician had talked with many children

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whose parents had separated, and that she could understand that Sarah might have questions or concerns about many things concerning the separation.

Step 3: Observation of Behavior Each parent was observed interacting with Sarah while playing a game and planning a trip. Sarah tended to follow the mother’s lead and readily agreed to all of her suggestions. The father tended to follow Sarah’s lead and encouraged her to make suggestions. Sarah seemed to enjoy being with both parents, who were physically affectionate with her.

Step 4: Further Assessment With the parents’ permission, questionnaires were sent to Sarah’s teacher, and phone contact was made with the teacher and the department of social services. The teacher described Sarah as a well-liked child who, however, was very quiet and not performing up to her potential academically. Sarah had missed 13 days of school in the last grading period and was late for school about 50% of the time. The teacher’s contacts with the mother had not changed this pattern, and the teacher had decided to call the department of social services when Sarah cried one morning, saying she was worried because her mother had passed out from drinking and had not yet recovered when she left for school. Representatives of the department indicated that although they did not want to remove Sarah from the mother’s custody, they insisted that the mother get into a program for alcohol dependence. They were monitoring the situation closely and were pleased to hear the parents had sought help for Sarah.

Step 5: Referral to Allied Health Professionals Sarah was referred to the divorce group for children at her school. The mother was already receiving appropriate help for her problems.

Step 6: Communication of Findings and Treatment Recommendations The findings and recommendations were given simultaneously to both parents. Sarah was described as an easy-going, loving child who was very confused about the current family situation and very worried about her mother’s emotional and physical well-being; she felt that if she did not stay with her mother all the time, something terrible would happen to Ms. May. Although Sarah enjoyed being with her father, this made her feel disloyal to her mother. At this point, she was not able to freely express her feelings (in fact, she could not even fully identify them). The clinician felt that Sarah was desperately in need of a united front on the part of her parents; a living arrangement that provided her with consistent care; and emotional support from, and regular contact with, both parents. Although the goal might ultimately be for Sarah to move easily between her parents, at the current time it was recommended that Sarah live with her father and visit her mother regularly. The purpose of this would be not only to provide Sarah with stability, but also to give the mother an opportunity to fully engage in and benefit from her own treatment. This arrangement would allow Sarah to see that her mother would indeed be able to take care of herself. Ms. May agreed to this arrangement almost with relief; she suggested that seeing Sarah two afternoons a week until 8 P.M. would be the best visiting schedule. It was also decided that the

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mother would call three times a week on set days, but that Sarah would not be told when the mother would be calling. This was to avoid Sarah’s worrying about her mother if she did not call. The parents agreed for Sarah to begin treatment with a focus on identifying feelings, learning to express them, and developing coping skills. The mother agreed that the clinician could keep in regular contact with her therapist and the department of social services. The father agreed to attend an evening parent group focusing on developmental issues in the elementary school years and parenting techniques.

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CHAPTER 14

Bereavement

O

ne of the most stressful life events faced by children is the death of a loved family member or their own impending death from a life-threatening illness. Death is not an uncommon problem for young children and their families. Approximately 4% of children in the United States lose a parent through death before they reach age 18, and 1.5 million children live in single-parent families because of death (U.S. Bureau of the Census, 1993). Furthermore, as survival rates for children with life-threatening illnesses improve, many young children must deal with the possibility of their own deaths, and at the same time must live with tremendous uncertainty as they undergo stressful medical treatment for their illnesses. Understandably, parents (and many professionals) have great difficulty knowing what to say to children about death, how to help them deal with the aftermath of a death in the family, or how to help them cope with life-threatening illnesses. Efforts to help children deal with death have been influenced by the widely held assumption that children cannot fully understand the concept of death, and that even if they do, it would be harmful for them to be exposed to information about death (Kastenbaum & Costa, 1977). Consequently, many professionals and parents have felt it best to shield young children from the experience of death. Children often are not told how or why a person died, are not allowed to participate in family rituals surrounding the death, and are encouraged to deny the finality of death. Even terminally ill children have faced their own deaths without help. Koocher and Gudas (1992) rightly state that the assumption of childhood naiveté regarding death probably reflects the discomfort adults have with death, rather than the reality of children’s ability to understand and cope with death. Despite parents’ efforts to shield them, children are routinely confronted with death in their day-to-day lives—through death of a pet, television programs in which people die (often quite violently), dead animals by the roadside, and/or stories and fairy tales. As a consequence, all children think about death, and concerns and questions about death are a normal part of growing up. It is important for clinicians to be aware of the empirical literature in this area, so that they are prepared to help children and parents cope with death should the occasion arise. This chapter first reviews the literature in the following areas: (1) what children understand about the concept of death; (2) how they cope with and adjust to the death of a family member; and (3) how terminally ill children cope with their own illness and possible death. Suggestions for assessment and intervention strategies are then provided. 466

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CHILDREN’S UNDERSTANDING OF DEATH The assumption that children have a limited understanding of death is based on research that ties children’s conceptions of death to Piagetian theory of cognitive development. Children in the preoperational stage (approximately ages 2–6), who are egocentric, tied to present experience, and unable to take the perspective of others, have been shown to have an incomplete understanding of four central components of a concept of death: (1) Death is irreversible (the physical body cannot be made alive again); (2) death is universal (all living things die); (3) all living functions (eating, feeling, knowing, etc.) cease at death; and (4) death is caused by certain specific classes of events (illness, old age, accidents, etc.) (Speece & Brent, 1996). Furthermore, because these young children understand the way the world works according to their own experience, death is typically conceived of in terms of sleep, separation, and injury— experiences common to all preschoolers (Koocher & Gudas, 1992; Gudas & Koocher, 2000). Children in the concrete operational stage (approximately ages 7–10) typically begin to understand the permanence of death, although death is not thought to be personally relevant; that is, they may believe that only old people die (Stambrook & Parker, 1987). Children at this age also tend to see death as externally caused (the result of a disease or injury), rather than as a biological process that affects all living things. By adolescence, with the onset of formal operational thought, death is understood completely, and abstract theological ideas may be included in teenagers’ conceptions of death (Gudas & Koocher, 2001). Other studies show, however, that children do not all follow this “expected” developmental sequence of understanding death (Koocher, 1973; White, Elsom, & Prawat, 1978). Many preoperational children, for example, demonstrate concepts of death that include irreversibility, universality, functionality, and causality, and some concrete operational children do not. Moreover, some children under 2 years of age appear to understand some aspects of the concept of death, such as the finality of death (Stambrook & Parker, 1987). By 7 years of age, research indicates that most children have a fairly complete understanding of the four components of the concept of death (Speece & Brent, 1996). Not surprisingly, children who have had experience with death appear to have a more mature understanding of the construct than their peers who are less experienced (Schonfeld & Kappelman, 1990). Reilly, Hasazi, and Bond (1983) compared children (ages 5–10) who had experienced the death of a parent, a sibling, a close relative, or a peer with children who had no experience with death; the experienced children were found to have an understanding of personal mortality that indicated a more advanced understanding of the concept of death than the inexperienced children. Furthermore, the children who had experienced death often elaborated their understanding with specific examples from their experience. Jay, Green, Johnson, Caldwell, and Nitschke (1987) argue that experience with death may have more of an impact on the death concepts of younger children than on those of older children. These researchers found that understanding of universality, irreversibility, and personal mortality was associated with the experience of death of a loved person among 3- to 6-year-old children, but older children who already had a fairly complete understanding of death did not change to a higher developmental level of understanding. To summarize, in the absence of experience with death, the development of a mature concept of death seems to depend to some extent on cognitive development. Research has shown that children’s understanding of death varies systematically with age (and presumably with cognitive-developmental level). However, for young children particularly, experience with the death of a loved family member or pet can serve to accelerate the understanding of death.

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It seems clear, therefore, that even young children may be capable of understanding information about death if it is presented in a concrete, simple fashion that takes into account their characteristic patterns of thinking and their everyday activities and experiences.

CHILDREN’S ADJUSTMENT TO DEATH Short-Term versus Long-Term Reactions Children of any age who experience death, especially that of a parent or other close relative, are believed to be at high risk for behavioral and/or emotional problems, particularly depression. Children not only experience the loss of a loved person as a result of a death in the family; when the deceased is a parent, they often also suffer secondary losses, such as reduced financial resources, unavailability of the remaining parent, and changes in their roles and responsibilities within the family (Hatter, 1996; Thompson, Kaslow, Price, Williams, & Kingree, 1998). Studies that have examined the short-term effects of parental death have found a strong association between death of a parent and increased psychological disturbances in almost all children in the weeks immediately following the death. Thompson, Kaslow, Kingree, et al. (1998), for example, reported increased emotional and behavioral problems in a sample of ethnic minority children following the death of a parent, compared with a nonbereaved peer group. Similarly, Black and Urbanowicz (1987) reported that 92% of the children in their sample showed signs of behavioral disturbance following the death of a parent. Immediate typical reactions included high anxiety, crying and moodiness, overdependence, separation problems, increased aggression, nightmares and other sleep disturbances, fear of injury, toileting problems, loss of appetite, restlessness, lack of concentration, and learning problems (Kaffman & Elizur, 1983). Other studies have documented symptoms of clinical depression and posttraumatic stress disorder (PTSD) among some children (Black & Urbanowicz, 1987; Stoppelbein & Greening, 2000). Although many of the symptoms evidenced by bereaved children immediately following a death typically decrease over 6–12 months (Black & Urbanowicz, 1987; Forehand et al., 1999), some children may continue to have significant problems. Kaffman and Elizur (Elizur & Kaffman, 1982; Kaffman & Elizur, 1983), for example, followed Israeli children who had lost their fathers in the Yom Kippur war. Eighteen months after the deaths, 50% of the children had symptoms of sufficient severity to interfere with their functioning, and 39% continued to have significant problems requiring professional help at a 42-month follow-up. The younger children’s problems included frequent denial of the finality of the death, nightmares, separation anxiety, and overly dependent and demanding behavior. Older children showed emotional restraint and social withdrawal, restlessness, increased aggression, and unexpected “exemplary” behavior.

Factors Influencing Long-Term Adjustment Many factors have been found to mediate children’s adjustment to death over the long term (Gudas & Koocher, 2000). These include the circumstances of the death, subsequent family rituals, the psychological adjustment of the child prior to the death, the functioning of the primary caregiver, the amount of stress experienced, and the available social support. Kaffman and Elizur (1983) noted in their study that a child who continued to show signs of upset typically had a mother who also was not coping well with her spouse’s death or had not given her

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child sufficient help in understanding the death. Similarly, Stoppelbein and Greening (2000) recently reported that children whose surviving parent had more symptoms of PTSD were themselves more vulnerable to these types of problems. Worden and Silverman (1993) suggest that an adult who can meet a child’s needs and provide for open discussion of the death is the most important factor in helping the child deal with grief. Recent work supports the notion that open communication can enhance bereaved children’s adjustment. Raveis, Siegel, and Karus (1999) studied 83 families with school-age children in which a parent had died of cancer during the previous 18 months. They found that the children’s perception of the surviving parent’s level of openness in communication was the best predictor of child adjustment (as measured by symptoms of depression and anxiety). In addition to the mental health and coping ability of the surviving parent, other work suggests that the gender of the child may mediate the occurrence of later problems, although whether boys or girls are more adversely affected is not clear. Worden, Davies, and McCown (1999) compared school-age children who had experienced death of a parent with a group who had experienced a sibling’s death. They found that boys were more adversely affected by death of a parent, whereas girls were more affected by the loss of a sibling, especially a sister. In contrast, Stoppelbein and Greening (2000) found that girls were more vulnerable to PTSDtype symptoms than were boys. Hence the gender of the bereaved child may interact with the child’s relationship with the deceased person in determining the type of symptoms evidenced, as well as overall adjustment. The risk for behavioral disturbance in children who have experienced the death of a sibling appears to be similar to, or only slightly lower than, that in children who have lost a parent (Worden et al., 1999). In a review of the literature, McCown and Pratt (1985) reported that from 30% to 50% of children showed behavior problems after the death of a sibling. They studied 65 children from 2 to 13 months after a sibling death and found that parents reported behavior to have worsened for 38.3% of the children. Children ages 6–11 and children whose deceased sibling had been over 2 years old had more problems than older or younger children and those whose sibling had died during infancy. Other factors found to be related to behavior problems were the place of death (home was better than in hospital), the diagnosis of a deceased child (a cardiac condition or sudden infant death syndrome was better than cancer), and the number of surviving children (more was better). In related work, Coughlan, Carr, and Fitzgerald (1998) found that mothers’ mental health status, in combination with children’s selfesteem and locus of control, best predicted the adjustment of children with a sibling who had died of sudden infant death syndrome. Recent work suggests that the nature of the death may influence children’s adjustment. Pfeffer, Karus, Siegel, and Jiang (2000) found that children with a parent who had died from suicide reported significantly more depressive symptoms than those with a parent who had died from cancer. Cerel, Fristad, Weller, and Weller (1999, 2000) reported similar results, but also noted that “suicide-bereaved” children had more psychological problems prior to parental death, in part because their families experienced more disruption (e.g., marital separation) and turmoil than did other families in which a nonsuicide death occurred. In a related study, Saldinger, Cain, Kalter, and Lohnes (1999) found no differences in long-term adjustment between children with a parent who had died suddenly and children who had had forewarning of an impending parental death. The traumatic death of a friend or relative is also associated with children’s adjustment problems, particularly PTSD-type symptoms, even though a child’s experience of the trauma may be relatively indirect (i.e., not experienced directly by the child) (McCloskey & Walker,

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2000; Nader, 1996; Pfeffer et al., 2000). These children must deal with issues of both trauma and loss. Although trauma and grief share many symptoms, the symptoms specific to trauma (e.g., hypervigilance, reexperiencing, preoccupation with aspects of the event, and avoidance of reminders) may hinder the grieving process. Thus intervention must target the trauma first and focus on grief only after these symptoms have resolved (Gudas & Koocher, 2001; Nader, 1996; Raphael & Martinek, 1997). Leenaars and Wenckstern (1996) provide principles for intervention with traumatized children. Intervention should begin as soon as possible, and at least within 24 hours. Depending on the nature of the trauma, consultation with school or civic authorities to coordinate efforts and obtain facts may be an important first step. Children should have opportunities to discuss the event and receive clarification of misconceptions and distortions. Parents should supervise the children’s access to media coverage as much as possible and should be warned to expect repetitive telling or playing out of the event as the children attempt to make sense of it (Gudas & Koocher, 2001). Finally, maintaining the children’s routines is essential to reestablishing a sense of predictability and control.

Funeral Attendance One question of great concern to parents is the extent to which children should be involved in the events that follow a death, and specifically whether or not children should attend the funeral. The clinical literature indicates some consensus that children should be given the opportunity to attend the funeral but not forced to go, and that funeral attendance may actually help a child make a better adjustment to the death. Although there has not been much controlled empirical work in this area, a few early studies (e.g., Furman, 1976; McCown & Pratt, 1985; Schowalter, 1976) reported adverse reactions among some children who attended funerals. Weller, Weller, Fristad, Cain, and Bowes (1988) described a study of 38 children ages 5–12 who had recently experienced the death of a parent. Almost all of the children (92%) attended the funeral, and the majority of parents and children reported that they were expected to and wanted to attend. Twenty-one percent of these children were reported to have had an adverse reaction (e.g., excessive crying) during the funeral. However, neither attendance at nor reactions to the funeral were associated with poor adjustment 2 months later. Interestingly, there was little agreement between parents and children on ratings of adverse reactions; that is, parents were not always aware of when their children were feeling unusually upset. Although older children were expected to go to the funeral more often than younger children, age was not a factor in determining actual attendance or adverse reactions. Koocher (1983) suggests that parents should make sure that a child’s attendance at a funeral will meet the child’s needs and not just their own. Children can be asked whether they wish to attend in a way that truly gives them a choice (“Some children would like to come to the funeral, and some children do not want to come. Which would you like to do?”). Children should, of course, be told what to expect at the funeral home or memorial service, and someone who will not be excessively upset should be available to answer questions and/or manage their behavior.

THE TERMINALLY ILL CHILD The adjustment of children with life-threatening illnesses has become a concern for clinicians in recent years, in part because of dramatic increases in survival rates among these youngsters.

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Although cancer, for example, continues to be a leading cause of death among children, approximately two-thirds of those diagnosed will survive (Lampkin, 1993). It is estimated that 1 in 1,000 young adults (ages 20—29) is a survivor of childhood cancer (Meadows & Hobbie, 1986). Whereas efforts of professionals previously were directed toward helping family members cope with the death of a child with cancer, the current focus is on (1) understanding how children with life-threatening illnesses perceive death; and (2) finding ways to help them cope with the invasive, lengthy, and often painful medical treatment necessitated by their disease and with the possibility of death.

Understanding of Illness and Death Just as bereaved children have been assumed to be naive about death, children with terminal illnesses were thought to be unaware of the seriousness of their illness. Children as young as 5 or 6 years, however, have demonstrated a very real understanding of their illness, and even younger children are sensitive to and react to the upset of their parents as they deal with the children’s life-threatening illness (Gudas & Koocher, 2001). As an example, the anxiety levels of children with cancer, in contrast to those with non-life-threatening chronic illnesses, have been shown to increase with an increase in visits to the clinic (Dokas, 1996; Spinetta & Maloney, 1975), suggesting an awareness of the severity of their illness. The idea that terminally ill children have more mature concepts of death (presumably because of having to face the possibility of their own deaths) has not been substantiated. Jay et al. (1987) examined differences in specific aspects of the understanding of death between children with cancer and healthy children. They found that among the youngest children (ages 3–6), healthy children were more likely to understand the concept of personal death than were the children with cancer (75% vs. 33% respectively). Jay et al. noted that it was not possible to determine whether the children with cancer had not actually developed the concept of personal death, or whether admitting this possibility was too anxiety-provoking for them. In the patients with cancer, the understanding of personal death, universality, and irreversibility was associated with the experience of death of a friend, parent, or other family member. Thus, as is true for healthy children, experience with death accelerates the death concepts of children with life-threatening illnesses. On the other hand, Jay et al. (1987) found that healthy children ages 3–12 were more likely to think of death as punishment for wrongdoing than were the children ages 3–12 with cancer (38% the of healthy children vs. 0% of the patients). None of the older children (ages 13–16) in either group believed this. Jay et al. concluded that children with terminal illnesses do not necessarily have more advanced concepts of death than healthy children.

Adjustment of Terminally Ill Children It would not be surprising to find increased symptoms of psychopathology among children with life-threatening illnesses. At the very least, these children are at high risk for emotional disturbances because of the disease-related stresses with which they must cope. Although some studies have found evidence of adjustment problems, such as greater anxiety or lower academic achievement among terminally ill children (Mulhern, Wasserman, Friedman, & Fairclough, 1989; Sanger, Copeland, & Davidson, 1991), others have found few differences between these children and healthy children (Allen & Zigler, 1986). This discrepancy probably reflects the fact that most children cope relatively well with a life-threatening illness,

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although some may evidence significant emotional or behavioral symptoms (Friedman, Latham, & Dahlquist, 1998; Varney, Blount, & Quiggins, 1998). As Spinetta (1982) states, the responses of children with life-threatening illnesses are best thought of as reactions to extremely stressful circumstances, rather than as evidence for functional psychopathology. These reactions are influenced by many factors, including the age and sex of a child, the number of children in a family, the family’s functioning and relationships, its religious orientation, its financial resources, the type of medical and psychosocial care provided, and the family’s communication patterns (Stehbens, 1988). The extent to which children and families are able to cope with the stresses of ongoing medical intervention and the possibility of death is a critical factor in determining the children’s adjustment. Spinetta (1978) has defined the following behaviors as evidence of good coping: (1) nondefensive personal posture, (2) closeness to parents, (3) happiness with oneself, and (4) freedom to express negative emotions. He reports that open communication on the part of the parents is directly related to evidence of good coping among the children. Other research has clearly supported this view, indicating that open communication is also related to a family’s adjustment following the death of a child (Stehbens, 1988). Kupst and Schulman (1988) found that factors other than open communication that enhance coping include the quality of the marital/couple relationship, lack of concurrent stresses, and level of family support. The existence of emotional or behavioral problems prior to the onset of the disease is also related to coping, as these are likely to become more severe as the child and family experience the stresses of the illness (Kupst & Schulman, 1988). Interestingly, the medical status of the child and duration of the child’s illness do not seem to be related to coping, although each stage of the disease (diagnosis, treatment, remission, relapse, etc.) present the child and family with unique stresses (Dokas, 1996).

Helping Children Cope In light of the fact that honest and open communication has been related to both a child’s ability to cope and a family’s adjustment before and after the child’s death, providing the child with honest information about his or her disease seems essential. Stehbens (1988) suggests that the child should be told the name of the disease, the treatments that will be necessary, and why they are necessary, in language that is appropriate to the child’s developmental level. Rando (1984) indicates that the child’s understanding of this information is dependent less on age and intellectual ability than on his or her experience with the illness. Thus assimilation of information about the disease is likely to occur over the course of the illness rather than all at one time. At first the child learns that the illness is serious and that sometimes people can die from it. Next the child learns about the various treatments, how they will be administered, and their potential side effects. Then the child experiences various treatments in the cycle of remission and relapse, and finally the child comes to understand that the treatments are finite and death is a possibility. As is true for any stressful event, helping children cope by providing them with information is a process that is carried out over time, rather than a one-time intervention. Stehbens (1988) also recommends that children be given a sense of control over the disease. Information about why certain treatments are necessary is one way of doing this. Children also can be given choices about some aspects of their treatment, and this can foster a sense of control. Finally, Stehbens (1988) advocates helping the family members maintain a future-oriented and optimistic point of view. As Rando (1984) indicates, children must be pre-

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pared for their further development as much as, if not more than, their possible death. Maintenance of home and school activities is strongly encouraged, although this is often difficult for parents to accomplish. Overprotection and overindulgence are common among parents of terminally ill children (Rando, 1984; Stehbens, 1988), in spite of the fact that maintenance of appropriate limits on behavior is important to a child’s sense of well-being and security. Rando (1984) advocates ensuring that the child continues with schoolwork during the course of the illness, either at home, in the hospital, or at school. Parents should be counseled regarding the importance of the child’s returning to school as soon as possible. School personnel should be helped to understand changes in the child’s behavioral and cognitive functioning that result from treatment of the illness. Moreover, the child’s frequent absences from school should be acknowledged, and ways to help the child cope with missed schoolwork should be discussed with the child’s teacher. Preparing children for invasive medical treatments by giving them information about the procedures can help them cope more effectively with a serious illness. Jay (1988) describes preparation as including both “sensory” and “procedural” information. Sensory information includes a description of the sensations (noises, smells, physical sensations) the child will experience during the procedure, whereas procedural information involves explaining the steps of the procedure. Information about medical procedures can be provided in a number of ways that are appropriate to the child’s developmental level, including doll play, hospital tours, puppet shows, books, and modeling films. It is important to note, however, that children have been found to have different coping styles; some actively seek out information, whereas others appear to avoid it (Peterson, 1989). Although children whose coping is categorized as “active” have been reported to experience less anxiety and make a better adjustment to medical procedures than those whose coping is “avoidant,” research has not evaluated the effectiveness of one method of providing information over another, or the issue of attempting to provide information to those children who actively avoid it. Melamed (1998) describes a variety of techniques that have been used to help children cope with invasive medical procedures. These include hypnosis, behavioral strategies (desensitization, modeling, contingency management, relaxation), and cognitive-behavioral techniques (selective attention, distraction, stress inoculation, cognitive restructuring, and coping skills training). When death is imminent, the clinician must focus on helping the child and family adapt to that reality. The “stages” of adaptation to death (denial, anger, bargaining, depression, and acceptance) derived by Kübler-Ross (1969) from her work with adults appear to apply to children as well, although these are no longer thought of as fixed stages as much as various reactions to the realization that one is dying. As such, their expression can occur in any order and at any time during the process of adaptation. If given the message that it is OK to talk about their feelings, children will express denial, anger, bargaining, depression, and acceptance both verbally and through play. Some children are very open about their fears and concerns, whereas others continue to deny the seriousness of their illness, though at the same time they show signs of great anxiety. Koocher (1983) suggests that for these latter children it is appropriate to treat the symptoms of anxiety, leaving the defenses intact. As an example, for a young child especially, anxiety is most likely related to fears of separation; therefore, a dying child should never be left alone. Spinetta (1982) suggests that children be given the following messages: (1) “You will not be alone at death or after death”; (2) “You have done all you could do with your life”; (3) “Death will not hurt”; (4) “Parents and others will always remember you and the

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happy times”; (5) “You can say goodbye to friends and family members if you want to”; (6) “We don’t understand why children die, and we cry because we are sad about it”; and (7) “It’s OK to cry and feel sad and angry, and it’s OK not to want to talk about it too.”

ASSESSMENT OF DEATH-RELATED ISSUES Given that almost all children over the age of 2 or 3 show signs of grief at the death of a family member, an important issue for parents and clinicians is to determine whether the reaction is within the normal range or evidence of psychopathology, and to differentiate normal grieving from clinical depression. Koocher and Gudas (1992) provide some guidelines for making this distinction. They state that it is important to assess the duration and intensity of the child’s reaction (although there are no real guidelines about the length of time grieving should occur). Typically, reactions decrease over several weeks after a death, but anniversaries, holidays, and other events can trigger renewed grief reactions (these should be less intense and of shorter duration than the original reaction). Other critical factors to consider are the presence of anxiety, feelings of guilt or personal responsibility, denial of feelings, and an inability to talk about the death. Koocher and Gudas (1992) also warn that the reactions of a young child are strongly influenced by behavioral contagion and social learning, as well as by the extent to which the child receives support from family members. Thus it is important to assess the reactions of parents and other family members who have contact with the child at the time of the death. Kuperman and Stewart (1981) offer guidelines for determining whether normal grief has become clinical depression. They suggest that grieving children will continue to enjoy pleasurable activities from time to time, whereas children who are depressed typically do not. Furthermore, they state that depressed children often express feelings of worthlessness, whereas lack of self-esteem is not usually seen among children who are grieving normally. When parents seek professional help for their children concerning issues of death, assessment will vary depending on whether the situation is an emergency (a parent or other family member has died suddenly) or one in which parents are anticipating an impending death. In the former situation, the clinician may not have the opportunity to send out parent questionnaires or checklists prior to the interview, but may request that parents complete them at the end of the interview if it is felt to be necessary. Regardless of the methods used, certain factors are important to examine during the assessment process. The present assessment outline follows the Comprehensive Assessment-to-Intervention System (CAIS) presented in Chapter 2, with emphasis on those factors most related to concerns about bereavement.

Step 1: Initial Contact If the clinician has the opportunity to do so, a general questionnaire (e.g., our General Parent Questionnaire in Appendix B); the Parenting Stress Index (PSI; Abidin, 1995) for parents of children under 12 years; and behavior rating scales such as the Child Behavior Checklist (CBCL; Achenbach, 1991a, 1992), the Behavioral Assessment System for Children (BASC; Reynolds & Kamphaus, 1992) or the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999) should be sent to parents to complete prior to their first appointment. Typically, all the children in the family (when there are more than one) are of concern to the parents; thus parents should be asked to complete a behavior problem measure for each child. The PSI gives infor-

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mation about sources of stress for the family apart from the death, as well as indications of parental depression. The CBCL or BASC and ECBI alert the clinician to child behavior problems that may be unrelated to the death (preexisting) or are reactions to the death, and provide guidelines for judging their seriousness relative to normal children’s behavior.

Step 2: Parent and Child Interviews Parent Interview We typically begin the parent interview with the parents alone. During this time, facts about the death are obtained, and the parents’ specific concerns are clarified. In addition, the following information should be gathered: 1. How is each parent (or the surviving parent, when a parent has died) handling the death? Because parental functioning is clearly related to child adjustment following a death, questions should be asked regarding the parents’ feelings about the death. High scores on the Depression scale of the PSI should alert the clinician to assess this possibility more fully. Other sources of stress (financial, family relationships, etc.), and the availability of emotional and other types of support for the family, are also important to determine. Parents who are isolated or who are experiencing many other worries apart from their concerns about their children are likely to have more difficulty dealing with death. 2. What questions about the death have the children asked? Information in this area will alert the clinician to the concerns of the children. Questions indicating feelings of guilt or personal responsibility, or the absence of any questions, should be noted. 3. What have the children been told regarding the death? Assessment of this issue can lead to a discussion of parental beliefs about and perceptions of death. Religious beliefs in particular must be understood and appreciated by the clinician, because treatment will need to take these into consideration. Misconceptions about children’s abilities to understand death can also be cleared up. 4. What was the relationship between each of the children and the deceased? Obviously, a child with a very close relationship with the deceased person will have a more difficult time adjusting to the death. Children who have had a conflicted relationship with the deceased person, however, may experience feelings of guilt and/or responsibility. 5. What unusual behaviors have the children exhibited? Responses to the CBCL or BASC and ECBI will provide clues as to each child’s specific problems. Further information on the frequency, intensity, duration, antecedents, and consequences of the behaviors should be gathered by questioning the parents. If it is suspected that a child might be depressed, questions should address this issue specifically. After the clinician has gathered this information, the (parent or) parents are told that the children will be invited to join the discussion, and that the clinician would like the parents to repeat some of what was said in front of the children. If a parent does not want the children to know about certain aspects of the death, the clinician can discuss the benefits and disadvantages of not sharing this information openly. Parents are asked to describe the course of events leading to the death (or, if the death is impending, the situation as it currently exists) and their concerns about the children. If a parent is not able to do this, the clinician supplies the words and asks the parent periodically whether he or she is in agree-

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ment. The purpose of this is to set the stage for open communication with the children and to relieve the children of the burden of providing the clinician with details about the death. The clinician is then free to explore the children’s feelings and worries about the death, because all the facts are out in the open. Child Interview At this point the parents are excused, and the clinician talks with the child or children alone. The purpose of this first session with the children is to get to know them better, to express sympathy about the children’s loss, and to gather information about their perceptions of the death and their current worries or concerns. The interview will, of course, vary considerably, depending on how able or willing the children are to talk about their concerns. It is appropriate to begin with a genuine expression of sympathy (“I know this is a very difficult time for you, and I am so sorry this happened”). Because parents (with the clinician’s help) have talked about the death in the children’s presence, the clinician can discuss their concerns openly (e.g., “Your mother is worried about how you are handling the death of your father. What are you most worried about?”). If the children do not respond, the clinician can say, for example, “I have talked with other children whose fathers or mothers have died, and lots of them are worried that they might have done something to cause the death. Does this ever worry you?” It is also important to gather information about other aspects of the children’s lives (school, friends, activities). This will provide the clinician with guidelines about how much support each child is likely to need. Children with lots of friends and activities are likely to have developed an extensive support network and will require less from the clinician than will isolated children.

Step 3: Observation of Behavior Observation of the parent–child interaction or the children’s behavior outside the clinic setting is generally not necessary in the assessment of death-related concerns unless there are specific questions regarding this area. In the case of a terminally ill child, observation of the child in school may lead to suggestions for interventions to address problems in that setting (peer relations, withdrawal, etc.).

Step 4: Further Evaluation In most cases, the previously described steps will complete the assessment, although further evaluation may be indicated for children with problems that existed prior to the death.

Step 5: Referral to Allied Health Professionals Parents who are experiencing significant depression should be referred to a mental health professional for counseling and/or medication. The child clinician should be aware that other family members may also need to be seen.

Step 6: Communication of Findings and Treatment Recommendations Prior to beginning treatment and often at the end of the initial interview, the clinician should provide the parents with general information about children’s understanding of death and how

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this applies to each child. The clinician should also discuss his or her understanding of the current situation and present a rationale for treatment. Research on intervention strategies for concerns about death is reviewed next, followed by a discussion of specific areas on which to focus intervention.

TREATMENT OF DEATH-RELATED ISSUES Intervention with bereaved children is largely preventive, in the sense that many of the strategies are aimed at ensuring that serious problems do not develop. Because death is such an integral part of life, talking with children about this topic should not wait until a death has occurred. Children present us with many opportunities for conversations about death and dying, and it is at these “teachable moments” that their understanding of death can be enhanced. Parents who respond openly to their children’s questions about death communicate to their children that it is OK to discuss this topic.

Research Findings There has been little empirical research on effective methods of intervention with bereaved children. Based on clinical experience, Baker, Sedney, and Gross (1992) describe the following tasks as guidelines for individual child treatment: helping the child (1) accept the reality of the death; (2) explore his or her relationship with the deceased; (2) cope with psychological pain; (4) be assured of his or her own personal safety; (5) reorganize his or her sense of personal identity; (6) return to age-appropriate activities; and (7) cope with recurrences of pain. Koocher (1983) states that children typically have several concerns that are important but often unarticulated. These include (1) “Could it happen to me? Or to my parent(s)?”; (2) “Who will take care of me?”; (3) “What is expected of me?”; (4) “Did I cause it?”; and (5) “Why did he [or she] die?” (i.e., by what means). Koocher suggests that parents and other concerned adults simply talk to children openly about the death and address these concerns by talking about how people cope with death, what happens at funerals, what people feel when someone close to them has died, and so on. For children who are having trouble coping with their grief, the task of the therapist is to help these children differentiate their own fate from that of the deceased and to come to some closure about the death. Masterman and Reams (1988) identified several issues that surfaced during the course of support groups for bereaved preschool and school-age children. These were (1) the stresses that resulted from the death, such as a surviving parent’s unavailability to a child and financial problems; (2) anger over disruptions in their lives, as well as anger toward the deceased parent; (3) fear of their own death; (4) use of fantasies or denial to explain the absence of the deceased parent; (5) physical symptoms similar to those of the parent before death; (6) a desire to be reunited with the deceased parent and suicidal ideation; and (7) a fear of being perceived as different by their peers. Anger was often expressed in externalizing behavior problems, whereas fears were expressed through exemplary behavior, separation anxiety, and school refusal. The sessions for school-age children described by Masterman and Reams (1988) lasted 1 hour each and were held once a week for 8 weeks. Each session was divided into four parts: (1) a 15-minute discussion of the previous week’s events (“Tell me about your week”); (2) a 10-minute discussion of previously assigned homework (e.g., a letter or poem to the deceased

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person); (3) a 25-minute discussion of a planned topic (e.g., describing the person who has died, telling about the funeral, etc.); and (4) 10 minutes spent in a closing game or activity (making and throwing paper airplanes was the favorite!). Sessions for preschoolers were divided into five parts, including (1) a 5-minute beginning discussion (show-and-tell); (2) 15 minutes of free play (structured through the provision of specific toys, such as a doll house, crayons and paper, puppets, a baby doll, etc.); (3) 15 minutes of therapeutic stories and role plays (how parents die, fears of dying, what it is like to be dead, etc.); (4) 15 minutes of free play; and (5) 10 minutes of closing discussion about eventual termination (each week a child crossed off one of eight houses drawn on a blackboard) and a cooperative game (e.g., rolling a ball around the circle of children). Although the effectiveness of the Masterman and Reams (1988) groups was not formally evaluated, these authors reported that parents noted a decrease in behavior problems at home and in school, as well as increased communication with their children around issues of death. The children were observed to be less angry and better able to cope with their feelings about the death. Black and Urbanowicz (1987) evaluated the effectiveness of an intervention program designed to provide support for the surviving parent and children in families where one parent had recently died. Each family was provided with six therapy sessions spaced 2–3 weeks apart; these were focused on promoting mourning (by having family members describe events that led up to the death, talk about the deceased parent, show pictures, etc.) for both the children and the surviving parent, and improving communication among family members (by modeling appropriate verbal behaviors and responses to the children’s comments and questions), especially about the death. Follow-up at 1 and 2 years indicated fewer behavioral problems among the children who received treatment, as compared with a control group of children who did not receive treatment. Parents in the treatment group also had fewer problems (continued grief, worrying, depression, suicidal thoughts, and physical health) than controls, and parental well-being was associated with fewer problems in the children. Other support groups for children are described by Bacon (1996). Various intervention strategies are now discussed in the context of the CAIS (see Chapter 2), with emphasis on the usual five areas: the child, the parents, the environment, consequences of specific behaviors, and medical/health issues.

Intervention Strategies Intervention with the Child One of the primary intervention strategies for death-related concerns is providing children with factual, honest information about death that is appropriate for their developmental level. For a young child, this means crafting the message in terms that are concrete and related to the child’s experience. Schaefer, Peretz, and Lyons (2000) offer excellent suggestions on how to explain death to children. They suggest an initial simple statement including the following elements: (1) The person has died; (2) this is very sad, and it’s OK for children to talk about how they feel; (3) the person died because something happened to his or her body (this should be clarified as appropriate); (4) “dead” means that the body stops working and no longer does any of the things it used to do; and (5) it’s OK for children to ask questions, and an adult will try to answer them. Children also need to know what will happen in the days immediately following the death, and exactly what is expected of them (who will take care of them, when and where

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the funeral or memorial service will be, etc.). Schaefer et al. (2000) also suggest avoiding the use of euphemisms such as “gone away,” “passed on,” “lost,” “left us,” or “died in his [or her] sleep,” as these can be very confusing for young children. Furthermore, they state that religious concepts (such as heaven or hell) can be confusing for children, unless they are presented within the context of ongoing religious experience and instruction. Regardless of one’s religious beliefs, children should be told that death is a biological process that happens to all living things. Because children need to experience the finality of death very concretely, helping young children grieve often involves allowing them to do things that make adults uncomfortable. Take, for instance, the case of a 2½-year-old girl (see the first case example below) who, when taken to see her mother’s body at the funeral home, repeatedly opened and shut the coffin lid while saying goodbye to her mother. Older children may act silly or laugh inappropriately because they are embarrassed or don’t know how to act. For all children, it is important to keep in mind the concerns that they are likely to have as outlined earlier in this chapter, and to address these concerns directly, even if the children do not verbalize the questions. In particular, children experiencing the death of a parent are usually worried about what will happen to them if the other parent should die, and will often ask repeated questions about this. The surviving parent needs to be prepared with a plan that can be shared with the children (“Aunt Mary will take care of you if anything happens to me”). Intervention with the Parents Because the manner in which parents handle the grief process so clearly affects children’s adjustment, it is important for the clinician to understand and support the parents in their own grieving. Parents should be given permission to express a range of emotions in front of their children, as long as they provide an explanation to the children (“I am crying because I am sad that Daddy died”). The explanation is important because young children so easily misconstrue adults’ expressions of emotion, typically blaming themselves for the adults’ tears or anger. In some cases, parents will need to be referred for individual treatment before they can deal adequately with their children’s needs. For these parents, it may be necessary to have another adult (someone the children know and trust) be responsible for the children until the parents are better able to function. Providing parents with information about how children grieve is another important intervention strategy. In many cases, helping parents understand how children at different ages understand death and what their typical concerns are, and giving them suggestions for the words to use to explain death, may be all that is needed. Parents need to be warned that the grief process in children is different from that in adults, and that as a result their children may behave as if nothing has happened (laughing, playing, running around). Although this often makes parents angry (“She doesn’t seem to care that Grandpa died”), it is normal and simply reflects the fact that children cannot focus their attention on grief for long periods of time. Furthermore, it is through play that children come to terms with the fact of death. Thus playing out death scenes or funerals, and acting as though the deceased person is still alive (e.g., talking to Grandma on the telephone), are common activities among grieving children. Parents should be encouraged to talk about the deceased person, both as he or she is remembered and as things come up in the present that remind them of that person. At the same time, it is important to remind children of the finality of death (“It’s OK to pretend to talk to Grandma, but she is really dead and we can’t see her any more”).

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Intervention in the Environment As part of the assessment, the clinician should have gathered information about children’s daily routines, and parents should be encouraged to maintain these routines as much as possible. Although it is appropriate to include children in the functions that occur following a death, it is important to have them return to their normal activities as soon as possible. Parents often ask, “How long should I keep my child out of school?” We believe that it is in a child’s best interests to return to school as soon as possible, within a few days at most. This reassures the child that life does indeed go on. Parents or another family member should inform the child’s teacher and other important adults who have contact with the child about the death, so that they can be prepared to answer questions or help the child deal with any upset. Changing the Consequences of the Behavior It is important that parents maintain their expectations for appropriate behavior and continue to set limits when their children exhibit inappropriate behavior. Changing the rules and expectations during times of family turmoil can be very unsettling for a child and increase feelings of insecurity. Household rules can be enforced and consequences can be provided for inappropriate behavior, at the same time that a parent expresses concerns for a child’s feelings (“I know you are upset/angry that Daddy died, but I cannot let you hit your sister”). Children who exhibit specific problem behaviors such as fears or sleep problems may be operating under misconceptions about the death, which will then need to be clarified. Often a behavior of concern will decrease as a child gains a better understanding of the death, but if this is not the case, then the problem behavior will need to be dealt with directly. Intervention in Medical/Health Aspects Parents often ask whether a child should be given a sedative to calm him or her down, or sleep medication to help with sleep problems. It is rare that such medications are helpful for children, although some parents may benefit from sedation themselves. Generally, it is best to attempt to manage a child’s upset by providing honest information, encouraging expressions of feelings, and providing clear consequences for inappropriate behaviors. Children sometimes present with psychosomatic symptoms following a death in the family, and these should be attended to by a physician. Often, however, these symptoms are related to unresolved anxiety and decrease as a child is allowed to communicate openly about his or her concerns.

CASE EXAMPLE: DEATH OF A PARENT Step 1: Initial Contact Mr. Graves called early one Sunday morning and said that his wife had died unexpectedly 24 hours after giving birth to their second daughter. He wanted to know how to tell his 2½-yearold daughter, Annie, about her mother’s death and was concerned about her participation in the funeral. He said that the maternal grandparents were quite religious and that public grieving was part of their belief system. The clinician offered to meet with Mr. Graves and the

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maternal and paternal grandparents, as well as the maternal aunt who had lived with the family during the first 2 years of Annie’s life. There was no time, nor was it appropriate, to gather extensive background information prior to the meeting.

Step 2: Family Interview Mr. Graves, the paternal grandmother, and the maternal aunt attended this session with the clinician. Mr. Graves, in a state of shock, described the death of his wife during the previous evening. He indicated that his greatest concern was to help Annie understand and accept her mother’s death. He had made arrangements for the baby to remain in the hospital until after the funeral. Annie was described as a strong-willed, precocious child, who had been well prepared for the birth of a sibling but had already shown some regression in toileting and sleep habits. Currently, she was sleeping with her father and was having occasional daytime toileting accidents. The maternal grandparents had been staying with the family for the past 2 weeks and had planned to stay for at least a month to help care for the new baby. The maternal aunt had lived with the family for 2 years, as noted above, but in the last 6 months had moved into her own apartment. She said that she would be able to move back into the family home immediately, and to care for the two children. Mr. Graves described conflict over the funeral arrangements. The maternal grandparents wanted an open casket and an opportunity to share their grief with friends. The paternal grandparents and Mr. Graves felt that it would be in everyone’s best interests to have a cremation and simple memorial service.

Step 3: Observation of Behavior Step 4: Further Assessment Step 5: Referral to Allied Health Professionals The third through fifth steps in the assessment process were not relevant to this case.

Step 6: Communication of Findings and Treatment Recommendations Given the family’s understandably intense emotions and the clinician’s lack of familiarity with the family members, they were offered the opportunity to hear about children’s understanding of death in general and how this might be applied to handling the current situation with Annie. They were quite open to this and understood the need for concrete, simple explanations regarding the mother’s death. After this sharing of information relevant to Annie’s understanding and acceptance of death, the family engaged in problem solving with the clinician on how best to meet both Annie’s and their own needs. It was agreed that Annie would be allowed to see her mother’s body in the funeral parlor, and that she would attend a brief church ceremony. The family did not feel it was necessary for her to go to the cemetery, and the maternal aunt offered to stay home with her. Although the paternal grandmother was concerned that open discussion and viewing of the body would make matters worse for Annie, she was able to understand that Annie would

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have many questions and concerns that could only be answered by seeing her mother’s body. All the family members were especially concerned that Annie not associate going to the hospital with death. Giving the child an opportunity for some grieving prior to her sister’s being brought home was felt to be important in distancing the mother’s death from the sibling’s birth. The family members were advised that after their initial adjustment to the mother’s death, they would need to consider their own feelings about the new baby’s arrival home. The father, grandmother, and aunt were then given several books appropriate for children Annie’s age to review. They chose Lifetimes: The Beautiful Way to Explain Death to Children (Mellonie & Ingpen, 1987), which describes death in terms of the beginning, middle, and end of life and explains that everyone has his or her own special lifetime. It was agreed that Mr. Graves and the maternal aunt would tell Annie about her mother’s death, and that everyone would be available to answer her questions in an honest and straightforward manner. Furthermore, they agreed to rely on each other when a response was too difficult for one of them or they did not have a ready answer. Mr. Graves requested that the clinician be available at the funeral home in case he or Annie needed her assistance. Two days later, Mr. Graves took Annie to the funeral home to see her mother’s body. Annie arrived looking happy and chatting nonstop about a new teddy bear her mother had given to her before she went to the hospital. Mr. Graves held her in his arms so that she could see her mother. After an initial silence, Annie stated, “But this isn’t my mother. My mother always laughs and talks with me.” Mr. Graves explained that this was only her mother’s body, and that the mother she knew had died and was no longer able to laugh or talk with her. Annie asked to touch the mother’s face, kissed her, and then asked, “Will she get awake like Sleeping Beauty?” Mr. Graves again explained that the body would never be able to move, nor would her mother become alive again. Annie then proceeded to close the casket and to reopen it, with the obvious expectation that her mother might speak to her as if in hide-and-seek; she did this a number of times, and finally her father indicated that it was time for them to say goodbye to the mother’s body. The child waved goodbye to the body and closed the casket. Although Mr. Graves had tears streaming down his face, he indicated that it was clearly helpful for his daughter to have said a final goodbye to her mother. The clinician had the opportunity to continue to work with this family from time to time over the next 2 years. Although adjustment was difficult for everyone, especially the father, the family warmly welcomed the new child. Annie continued to talk openly about her mother and her death, but eventually in a matter-of-fact way. On a home visit, for example, she showed the clinician her room and her toys, and explained that the pictures on the bulletin board were of her mother who had died.

CASE EXAMPLE: DEATH OF A SIBLING Step 1: Initial Contact Mr. Finelli called from out of state indicating that his 5-year-old daughter, Gina, had been killed by a car the previous evening. He wanted advice on how to deal with his 10-year-old daughter, Mary, who had witnessed the accident. Mr. Finelli explained that Gina had run out into the street; when she was called to come back, she darted in front of a car. She was taken to the hospital, where she later died. The body was severely disfigured, and the family did not plan to have an open casket. The burial was to occur in the home town of the maternal and paternal grandparents, where the family was visiting.

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Step 2: Parent Interview Given the time factor, the parent interview was conducted on the telephone. Mr. Finelli said that Mary not only had witnessed the accident, but had been at the hospital with the family when Gina died. He said that Mary was aware of the meaning of death, but was having difficulty expressing any emotion about the event. The parents and grandparents were openly expressing their sadness; at these times, Mary tried to reassure them that it would be all right, and then quietly disappeared to play or read by herself. Mr. Finelli indicated that this was a typical response from Mary when she was upset or under stress. He described her as a rather serious young lady who did well in school, had friends, and had enjoyed her 5-year-old sister. He was quick to add, however, that they had had their battles. They were concerned that Mary was not responding in a way that would help her adjust to Gina’s death. Mr. Finelli requested an appointment for Mary when they returned in 3 days, and also asked that the clinician offer assistance to Mary’s and Gina’s teachers and classmates. Mr. Finelli had already informed the school, the local church, and several neighbors about the death.

Step 3: Observation of Behavior Step 4: Further Assessment Step 5: Referral to Allied Health Professionals Again, the third through fifth steps in the assessment process were not relevant in this case.

Step 6: Communication of Findings and Treatment Recommendations Mr. Finelli was assured that we all must deal with death in our own way, and that Mary was handling it in the most effective way for her at this time. She was not avoiding the reality of the death, and she was able to offer solace to her parents, but she could not openly express her feelings. The parents were encouraged to include her in family rituals surrounding the burial; to continue expressing their feelings openly; and, while allowing her to be part of this process, not to force any grieving responses from her. When the clinician contacted the principal of Mary’s school, the latter indicated that she would have the girls’ teachers talk with the clinician. The principal added that the school had already planned a memorial service for Gina, and that this would be held after Mary returned. The parents had agreed to this plan. The teachers’ concerns centered around telling the children about the circumstances of Gina’s death and finding ways to help all the children in the school and their parents adjust to this tragic loss. The books How Do We Tell the Children? (Schaefer et al., 2000) and Lifetimes (Mellonie & Ingpen, 1987) were taken to the school. In discussions with the teachers and the principal, it was decided that the children and their parents would be told the circumstances surrounding Gina’s death: She had been playing in the front yard of her grandmother’s house, had run into the street to get a ball, and when called to return had not looked both ways and had run in front of a car. She had been unconscious from that time until her death several hours later and had not felt any pain. It was agreed that this factual information would decrease the number of questions to Mary and her family, as well as rumors about how the death

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occurred. The teachers were able to think of things that each grade could do to express sympathy. They planned to ask the children what they would like to do, but had several projects in mind in the event that the children could not come up with ideas. Not surprisingly, the children were very creative in finding ways to express their sympathy (e.g., drawing pictures, writing poems, and talking about and engaging in many of Gina’s favorite activities). Both Mary and her parents appreciated the outpouring of love and support for them, and indicated that it was very helpful in their acceptance of Gina’s death.

Interview and Intervention with the Child When Mary was seen by the clinician, she readily described what had happened to Gina and indicated that she was sad, but it was clear that she did not want to talk further about it. Several weeks later, the parents called to say that Mary was complaining of stomachaches and headaches, and did not want to go to school. When they allowed her to stay home, however, it was obvious that she was entirely well. A visit to the doctor found no medical reason for her physical complaints. When Mary was seen by the clinician, she said that everyone at school was being very nice to her, but they were treating her as if she were “made of glass.” She found the children’s and teachers’ continued expressions of sympathy very difficult to deal with, and she wished things would get back to the way they were before her sister’s death. The clinician engaged Mary in a discussion of the different ways in which people express their grief. She was able to describe how each of her parents, her grandparents, and she herself were expressing their grief, and could also see that people were handling the death in very different ways. The children at school were handling it by telling her how sorry they were and trying to make her feel better by being “overly kind.” The clinician and Mary then discussed how she might let the children at school know how she felt and what she needed without hurting their feelings. Through problem solving, (see Table 14.1), Mary decided TABLE 14.1. Example of Problem Solving with a Bereaved Child Problem-solving steps

Example

1. Define the problem.

“The kids want to be nice, but their sympathy and questions make me upset.”

2. Generate alternative solutions.

1. “I could change schools.” 2. “I could stay home.” 3. “I could tell them I appreciate their help, but it makes me sad to talk about Gina right now.” 4. “I could ask the teacher to tell the kids not to talk about Gina.”

3. Evaluate the alternatives.

1. “I like my school, and it would make me even sadder if I left.” 2. “I would miss my friends and not be promoted.” 3. “It would let the kids know how I feel without hurting their feelings.” 4. “It’s not that I don’t want them ever to talk about Gina, just not all the time.”

4. Choose a solution and practice it.

Mary chose solution #3.

5. Evaluate the results.

“I’ll start telling the kids on Monday, and we can talk about how it is going when I see you on Thursday.”

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on several statements that could be used in a variety of situations (e.g., “We’re sad, but we’re going to be OK,” “Thank you for your concern, but I’m finding it hard to talk about Gina’s death”). She also decided she would show the children that she was all right by actively participating in her regular activities. Mary’s physical symptoms immediately decreased, and over the next 3 months she made a good adjustment in school.

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APPENDIX A

DESCRIPTION OF ASSESSMENT INSTRUMENTS

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PARENT RATING SCALES Behavior Assessment System for Children—Parent Rating Scale (BASC-PRS; Reynolds & Kamphaus, 1992) The PRS is one of five components of the BASC. It has items and content similar to those of the BASC Teacher Rating Scale and the child Self-Report of Personality (see below). The PRS has three forms composed of similar items and scales for preschoolers (4–5 years), children (6–11 years), and adolescents (12–18 years), which take a broad sampling of a youngster’s behavior in home and community settings. It takes about 20 minutes to complete. Hand scoring is straightforward, and a computer software scoring program is available. Clinical and adaptive scales are included at each age level, and a four-choice response format (“never,” “sometimes,” “often,” “almost always”) is employed. There are three factors: (1) Externalizing (Aggression, Attention Problems, Hyperactivity, and Conduct subscales), (2) Internalizing (Atypicality, Anxiety, Withdrawal, Depression, and Somatization subscales); and (3) Adaptive (Adaptability, Leadership, and Social Skills subscales). Norm-referenced comparisons can be made for general, clinical, male, and female samples. Psychometric properties are good, with a variety of subscales useful for differential diagnosis (e.g., Attention Problems vs. Hyperactivity, and Anxiety vs. Depression). The norm-referenced adaptive scales are also very helpful. The scoring sheet highlights critical items that are of clinical importance (e.g., “I want to kill myself”). The BASC-PRS is available from American Guidance Service, Inc., Publishers’ Building, Circle Pines, MN 55014-1796, 800-3282560, www.agsnet.com. Child Behavior Checklist (CBCL; Achenbach, 1991a, 1992) The original parent report form of the CBCL is one of the four components of the CBCL system. The items and content are similar to those of the Teacher’s Report Form and the Youth Self-Report (see below). The parent CBCL has two versions, one for children 2–3 years (Achenbach, 1992) and another for children 4–18 years (Achenbach, 1991a). A 3-point response format (“not true,” “somewhat or sometimes true,” and “very true or often true”) is used for the clinical scales, whereas the adaptive scales involve open-ended questions. The CBCL takes about 10 minutes to complete. Hand scoring via templates is cumbersome, and a computer scoring program is available. There are eight clinical scales making up two global scales: Externalizing 489

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(Delinquent Behavior, Aggressive Behavior) and Internalizing (Withdrawn, Somatic Complaints, Anxious/Depressed, Social Problems, Thought Problems, Attention Problems). T-scores are calculated for Externalizing and Internalizing scores and a Total score, which is a composite of the former two scores. T-scores are not provided for adaptive items, which make them difficult to interpret. Psychometric properties are good, but the normative sample excludes children who received mental health or special education services, so it is not representative of the general population. Scores are based on gender- and age-specific norms, with no comparison to the entire normative sample. It is difficult to determine the meaning of elevated scale scores (e.g., is such a score due to anxiety or depression, or to learning problems or attention/hyperactivity), so a review of the individual items for elevated scores is recommended. The CBCL can be obtained from Thomas Achenbach, PhD, University Associates in Psychiatry, Department of Psychiatry, University of Vermont, 1 South Prospect Street, Burlington, VT 05401, 802-656-3131, www.uvm.edu. Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999) The ECBI consists of 36 common behavior problems for children 2–18 years of age. Parents rate each behavior on a 7-point Intensity scale, and also indicate whether the behavior is a problem for them. The ECBI can be completed in 5–10 minutes, requires limited reading skills, and can be scored in 5 minutes. Although complete normative data are available, clinical significance across all ages is usually determined by Intensity scores of 132 or higher and Problem scores of 15 or more. Considerable research provides evidence for the reliability and validity of the ECBI in screening for behavior problems and evaluating the effects of treatment. A recent factor analysis (Burns & Patterson, 2000) indicated separate factors for Oppositional Defiant Behavior toward Adults, Conduct Problem Behavior, and Inattentive Behavior. The ECBI is available from Psychological Assessment Resources, Inc., P.O. Box 998, Odessa, FL 33556, 800-331-8378, http://www.parinc.com. Parenting Stress Index (PSI; Abidin, 1995) The PSI provides a measure of the degree of stress in the parent–child relationship as rated by parents of children 12 years or younger. Stressors can result from characteristics of the child, the parent, and/or situational/demographic life stress. There are two forms: a 101-item long form (the standard PSI; 20–30 minutes to complete) and a 36-item short form (PSI-SR;10 minutes to complete). Parents rate items on a 5-point scale, and on the long form the scores are summed to form 13 subscale scores in two broad domains: Parent (stress that results from characteristics of the parent) and Child (stress that results from characteristics of the child). The Life Stress scale (19 items) is optional and measures stress experienced by parents outside the parent–child relationship. A Total score is obtained by adding the scores in the Parent and Child domains. In the Parent domain, items cover the areas of Depression, Attachment to Child, Restriction of Role, Sense of Competence, Social Isolation, Relationship with Spouse, and Parent Health. In the Child domain, items cover aspects of the child’s temperament (Adaptability, Demandingness, Mood, Distractibility/Hyperactivity) and the degree to which the child is Acceptable to Parent and Reinforces the Parent. The Life Stress domain focuses on such stresses as major life changes, minor daily hassles, job-related pressures, and socioeconomic conditions. Hand scoring is fairly easy, although computer software is available to score and generate a report (highly recommended). The short form has three scales based on factor analysis: Parental Distress, Parent–Child Dysfunctional Interaction, and Difficult Child. Correlations between the PSI and PSI-SR are high. Validity and reliability are good, but the

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normative data are limited. Studies have supported the use of the PSI with a range of cultural and ethnic groups. Moreover, the PSI identifies children at risk for emotional and behavioral problems, as well as parents in need of parent education or professional assistance. It has also been found useful in child custody evaluations and child abuse evaluations. It is sensitive to changes with treatment, and is therefore a good outcome measure. A major strength of the PSI and PSI-SR is the assessment of children within a systems context that leads directly to areas targeted for intervention. The PSI and PSI-SR are available from Psychological Assessment Resources, Inc., P.O. Box 998, Odessa, FL 33556, 800-331-8378, http://www.parinc.com. Stress Index for Parents of Adolescents (SIPA; Sheras, Abidin, & Konold, 1998) The SIPA was developed as an upward extension of the PSI that takes into account central issues faced by parents in dealing with adolescents (ages 11–19 years). It can be completed by parents or foster parents. The SIPA consists of 112 items; parents respond to the first 90 items on a 5-point scale ranging from “strongly disagree” to “strongly agree,” and to the final 22 items plus a Life Stress scale by circling “yes” or “no.” It requires a fifth-grade reading level and can be completed in approximately 20 minutes. Scoring/profiling usually takes an additional 5–10 minutes. The SIPA yields scores in three domains: (1) the Adolescent domain, with four subscales (Moodiness/Emotional Lability, Social Isolation/Withdrawal, Delinquency/Antisocial, and Failure to Achieve/Persevere); (2) the Parent domain, with four subscales (Life Restrictions, Relationship with Spouse/Partner, Social Alienation, and Incompetence/Guilt); and (3) Adolescent–Parent Relationship domain, which measures the perceived quality of the relationship the parent has with the adolescent, such as the degree of communication and affection between them. There is also a Life Stressors scale, which indicates the number of stressors the parent has experienced in the past year. A Total Parenting Stress Index score is a composite of all items across all domains and indicates the total stress experienced as a function of parenting a particular adolescent. Reliability and validity information is adequate; although the normative population is stratified, it represents a small sample. The establishment of normative levels of stress for parents of adolescents, however, is especially helpful in determining families that fall outside this range, as well as reassuring those parents whose stresses are considered typical. It should also be valuable in measuring treatment outcome. Further research and clinical experience are needed to determine whether the SIPA is as useful as the PSI, but it looks promising. The SIPA is available from Psychological Assessment Resources, Inc., P.O. Box 998, Odessa, FL 33556, 800-331-8378, http:// www.parinc.com. Vineland Adaptive Behavior Scales (VABS; Sparrow, Balla, & Cicchetti, 1984) The VABS measures the social and adaptive behavior of children and adolescents from birth through 18 years. There are three versions: the Classroom Edition, which is completed by teachers for children ages 3½ to 13 (244 items); the Interview Edition—Survey Form (297 items); and the Interview Edition—Expanded Form (577 items). The Interview Editions are designed for youth from birth through 18 years of age and are administered through a semistructured interview with parents or primary caregivers. The Survey Form takes 20–60 minutes to complete, whereas the Expanded Form requires 60–90 minutes. The semistructured interviewing technique used for the VABS takes time to learn. It requires organizing the interview topically, yet items are placed

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on the response form by difficulty level. Thus the interviewer must obtain adequate information about an area (e.g., Communication) to score items in that area that are scattered throughout the record form. Scoring is time-consuming, and there is a limited computer scoring program. Both interview forms cover the domains of Communication, Daily Living Skills, Socialization, and Motor Skills (for children from birth to 5 years and for older individuals with motor handicaps). There is also a Maladaptive domain, which is essentially a behavior problem checklist that assesses for severe behavior problems. Reliability and validity are very good, and the normative sample is adequate. Scores are reported as standard scores with a mean of 100 and a standard deviation of 15, and yield a profile of development relative to children the same age. Age-equivalent scores for the domains have a highly restricted range and should not be used. Although the VABS is commonly used for individuals with developmental disabilities, it has up-to-date standards for social and adaptive behavior of all children from birth through age 18. The VABS is available from American Guidance Service, Inc., Publishers’ Building, Circle Pines, MN 55014-1796, 800-3282560, www.pgsnet. com. Child Sexual Behavior Inventory—Revised (CSBI-R; Friedrich, 1997) The CSBI-R is a parent report (intended for completion by a mother or primary female caretaker) measure of sexual behavior in children ages 2–12 years. It is designed for use with children who have been or who may have been sexually abused. The test was developed in response to evidence that sexual abuse is related to the presence of precocious sexual behavior in children. Friedrich states very clearly and appropriately, however, that the CSBI-R is not a test of sexual abuse: Many children who have been abused do not exhibit these behaviors, and some children who have not been abused may do so. The CBSI-R does provide valuable information on a child’s sexual behavior and identifies children who should be further evaluated. The CSBI-R consists of 38 items that are rated on a 4-point scale from 0 (“never”) to 4 (“at least once a week”), indicating how often the behavior has been observed during the past 6 months. It takes 10–13 minutes to administer and score, and requires a fifth-grade reading level. A wide range of sexual behaviors are covered in nine major content domains: Boundary Issues, Exhibitionism, Gender Role Behavior, Self-Stimulation, Sexual Anxiety, Sexual Interest, Sexual Intrusiveness, Sexual Knowledge, and Voyeuristic Behavior. The CSBI-R has three clinical scales: (1) the CSBI-R Total scale (overall level of sexual behavior exhibited); (2) the Developmentally Related Sexual Behavior scale (sexual behaviors considered normative for the child’s age and gender); and (3) the Sexual Abuse Specific Items scale (sexual behaviors that are atypical for the child’s age and gender). T-scores are given for the clinical scales for six age– gender groups. Psychometric properties of the CSBI-R are good, including an adequate normative sample. Clinical data for children from child abuse centers are also presented. The CSBI-R is available from Psychological Assessment Resources, Inc., P.O. Box 998, Odessa, FL 33556, 800-3318378, http://www.parinc.com. Personality Inventory for Children—Revised (PIC-R; Wirt, Lachar, Klinedinst, & Seat, 1990) The PIC-R was one of the earliest parent rating scales and was patterned after the Minnesota Multiphasic Personality Inventory. Although it has a number of weaknesses that limit its usefulness, the PIC-R continues to be one of the best-known scales and is therefore included in this review. The revised edition has three versions, containing 131, 280, and 420 items, respectively. Parents of children ages 3–16 years read items presented in a booklet and put “true” or “false” responses on

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a separate score sheet. Separate norms and profiles are given for boys and girls ages 3–5 and 6–16. The hand scoring is onerous, but a computerized version and a mail-in format are available. The 420-item version can only be obtained in the computer-scored version. The 420-item form has 14 clinical scales and 2 validity scales, while the 131-item short form offers only four clinical scales. The scales were developed by either empirical or rational (expert opinion) means. Factor analysis indicated five factors: (1) Acting Out/Conduct Disorder/Externalization, (2) Cognitive Development, (3) Psychopathology/Internalization, (4) Activity Level, and (5) Somatic Concern. Although levels of reliability and validity are generally acceptable, it appears that much of the normative data were collected in the 1960s and were limited to the Minneapolis area. Race and ethnicity are not reported, and information about socioeconomic status is limited. The poor norms, the lack of a teacher form, the excessive item overlap between scales (e.g., Depression and Anxiety), the length of the test, and the complex scoring all limit the usefulness of the PIC-R, especially when there are more reliable, shorter, and useful scales available (e.g., the CBCL, the BASC). The PIC-R is available from Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, CA 90025, 800-222-2670, www.wpspublish.com.

TEACHER RATING SCALES Behavior Assessment System for Children—Teacher Rating Scale (BASC-TRS; Reynolds & Kamphaus, 1992) The TRS is part of the BASC and is similar in content and format to the BASC Parent Rating Scale (see above) and child Self-Report of Personality (see below). The TRS has three forms composed of similar items and scales for preschoolers (4–5 years), children (6–11 years), and adolescents (12–18 years), which measure multiple aspects of a youngster’s personality and behavior in the school setting. It uses a four-choice response format (“never,” “sometimes,” “often,” “almost always”) and takes about 20 minutes to complete. Hand scoring is straightforward, and a computer software scoring program is available. Items are grouped into five composite scales: Externalizing Problems, Internalizing Problems, School Problems, Other Problems (i.e., Atypicality and Withdrawal), and Adaptive Skills. Clinical and adaptive scales are included at each age level, and norm-referenced comparisons can be made for general, clinical, male, and female samples. Psychometric properties, including normative data (limited for adolescents ages 14–18) are good, with a variety of scales useful for differential diagnosis (e.g., Attention Problems vs. Hyperactivity, and Anxiety vs. Depression). Norm-referenced adaptive scales (Adaptability, Leadership, and Social Skills) are also very useful. The scoring sheets also highlight critical items that are of clinical importance (e.g., “I want to kill myself”). The TRS has a “fake bad” index (F), which helps assess the possibility that a teacher rated a child in an overly negative pattern. The BASC-TRF is available from American Guidance Service, Inc., Publishers’ Building, Circle Pines, MN 55014-1796, 800-328-2560, www.agsnet.com. Child Behavior Checklist—Teacher’s Report Form (CBCL-TRF; Achenbach, 1991b) The TRF is a component of the CBCL system and corresponds to the CBCL parent rating scale (see above) and Youth Self-Report (see below). The TRF has one form for children ages 5–18 years and takes about 10 minutes to complete. The clinical scales use a 3-point response format (“not true,” “somewhat or sometimes true,” and “very true or often true”), resulting in T-scores for Ex-

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ternalizing and Internalizing scores and a Total score, which is a composite of the former two scores. T-scores are not provided for adaptive items, which the teacher marks on a 7-point scale with higher numbers corresponding to increased problems. Psychometric properties are good, but (as with the parent CBCL) it is difficult to determine the meaning of elevated scale scores, so a review of the individual items for elevated scores is recommended. The normative sample excludes children who received mental health or special education services, so it is not representative of the general population. Scores are based on gender- and age-specific norms, with no comparison to the entire normative sample. The CBCL-TRF can be obtained from Thomas Achenbach, PhD, University Associates in Psychiatry, Department of Psychiatry, University of Vermont, 1 South Prospect Street, Burlington, VT 05401, 802-656-3131, www.uvm.edu. Sutter–Eyberg Student Behavior Inventory—Revised (SESBI-R; Eyberg & Pincus, 1999) The SESBI-R is patterned after the Eyberg Child Behavior Inventory. It consists of 38 behaviors that are problematic for teachers of children 2–16 years of age. Teachers rate each behavior on a 7-point Intensity scale (how often it occurs) and also indicate whether the behavior is a problem for them. The SESBI-R can be completed in 5–10 minutes and can be scored in 5 minutes or less. Although normative data are available, in general an Intensity score of 153 or above and a Problem score of 19 or above would be considered clinically significant. Research has provided evidence for the reliability and validity of the SESBI-R in screening for disruptive behavior problems and for evaluating the effects of treatment. The SESBI-R is available from Psychological Assessment Resources, Inc., P.O. Box 998, Odessa, FL 33556, 800-331-8378, http://www.parinc.com. Social Skills Rating System (SSRS; Gresham & Elliott, 1990) The SSRS is a comprehensive measure of social skills for children from preschool through secondary school that incorporates multiple domains and raters. There are three forms for parents and teachers (preschool, elementary, and secondary levels) and two self-report measures for children (grades 3–6 and the secondary-level grades). The number of items on a particular form varies from 34 to 57. The frequency of behavior is rated on a 3-point scale (“never,” “sometimes,” “often”), and the parent and teacher forms also indicate the importance of the behavior on a 3-point scale (“not important,” “important,” and “critical”). This allows clinicians to prioritize behaviors for intervention. The forms take 15–20 minutes to complete, and hand scoring takes approximately 10–15 minutes. Although the SSRS measures externalizing, internalizing, and hyperactivity problem behaviors, social skills are clearly the focus of the system. Domains assessed are Cooperation, Assertion, SelfControl, Empathy (student forms only), and Responsibility (parent forms only). Standard scores, percentile ranks, and behavioral-level (fewer, average, more) scores are calculated for the various domains. Although there was a large sample of children for the normative data, specific information for the parent and teacher norms is lacking. Reliability is poor for some of the scales, especially on the student forms; validity appears adequate, given that there is no widely accepted criterion for “social skills.” The SSRS, however, does provide a thorough method for assessing behaviors that are often labeled as “social skills,” and the normative data are far superior to those for other measures of social skills. Over time, the SSRS may become the criterion for establishing the validity of other measures. The SSRS is available from American Guidance Service, Inc., Publishers’ Building, Circle Pines, MN 55014-1796, 800-328-2560, www.agsnet.com.

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CHILD SELF-REPORT MEASURES Behavior Assessment System for Children—Self-Report of Personality (BASC-SRP; Reynolds & Kamphaus, 1992) The SRP is another of the five components of the BASC. Its goal is to assess a child’s or adolescent’s perceptions about school, parents, peers, and his or her behavior problems. It takes about 30 minutes to complete. There are two forms (8–11 years [SRP-C] and 12–18 years [SRP-A]), requiring a minimum third-grade reading level; short item stems with a true–false format are used, and items are linked to the parent and teacher rating scales. Hand scoring is straightforward, and a computer software scoring program is available. Norm-referenced comparisons can be made for male, female, and general samples; although there is a clinical comparison sample, it is small. There are three factors: School Maladjustment, Clinical Maladjustment, and Personal Adjustment. Two scales, Depression and a Sense of Inadequacy, did not load on any factor, perhaps reflecting their complexity. The Depression scale does correlate fairly well with other measures of depression. The BASCSRP is available from American Guidance Service, Inc., Publishers’ Building, Circle Pines, MN 55014-1796, 800-328-2560, www.agsnet.com. Child Behavior Checklist—Youth Self Report (CBCL-YSR; Achenbach, 1991c) The YSR is another component of the CBCL system. It is designed to enable youth 11–18 years of age to report on their competencies and problems, and takes about 15 minutes to complete. Its content and format are similar to those of the parent and teacher forms (i.e., a 3-point response format—“not true,” “somewhat or sometimes true,” and “very true or often true”). Hand scoring via templates is cumbersome, and a computer scoring program is available. Results are reported in T-scores for Externalizing and Internalizing scores and a Total score, which is a composite of the former two scores. Reliability is reasonable, but no content- or criterion-related validity is reported, and normative data are limited. There is a lack of differentiation between the constructs of anxiety and depression, and the assessment of school-related problems is limited. The CBCL-YSR can be obtained from Thomas Achenbach, PhD, University Associates in Psychiatry, Department of Psychiatry, University of Vermont, 1 South Prospect Street, Burlington, VT 05401, 802-656-3131, www.uvm.edu. Personality Inventory for Youth (PIY; Lachar & Gruber, 1995) The PIY is a self-report measure designed to assess emotional and behavioral adjustment, school adjustment, family characteristics and interactions, and academic ability in children and adolescents ages 9–19 years. There are two forms: a 420-item long form and an 80-item short form (CLASS) that can be used for classroom screening. The PIY is based on the PIC-R, and the majority of items are adapted from the PIC-R. Children read items presented in a booklet and put “true” or “false” responses on a separate score sheet. The scoring is straightforward, and raw scores are converted to gender-based T-scores (computer software for scoring is also available). The PIY has nine subscales that form four broad-band factor scales: Externalizing/Internalizing, Cognitive Impairment, Social Withdrawal, and Social Skills Deficit. There are also four validity scales: Validity (inattentive, oppositional, or provocative responses), Inconsistency (haphazard responses), Dissimulation (tendency to “fake bad” or malinger), and Defensiveness (tendency to “fake good” or give socially desirable

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responses). Reliability using a clinical sample is generally good for the four primary scales but lower for the subscales. At this point, it is better to base interpretation on the primary scales than on the subscales. Validity was determined by factor analysis, so the rationale for placement of some items is questionable. For example, the item “Several times I have said I wanted to kill myself” is included on the Sleep Disturbance subscale rather than on the Depression subscale. The normative data are generally good except for a very small sample of 9-year-olds, which makes interpretation for that age group questionable. Although the PIY assesses a wide variety of problems and covers a large age range, the length of the test is another deterrent to its use. The PIY is available from Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, CA 90025, 800-222-2670, www. wpspublish.com. The Piers–Harris Children’s Self-Concept Scale—Revised (Piers, 1986) The Piers–Harris Children’s Self-Concept Scale, or “The Way I Feel about Myself,” is designed to measure relatively stable self-attitudes in children ages 8–12 years. It consists of 80 items that either children read or someone reads to them. Children then indicate whether each statement describes the way they feel about themselves, using a yes–no format. The reading level is about third grade, and the scale takes about 20 minutes to complete; scoring takes an additional 10 minutes. Percentile and stanine scores are obtained for a Total score (a global measure of selfconcept) and six factor-analytically derived subscales: Behavior, Intellectual and School Status, Physical Appearance and Attributes, Anxiety, Popularity and Happiness/Satisfaction. Although this is a commonly used scale, the psychometric properties do not meet current standards, and scores for children under age 9 are questionable. The results should not be used in diagnostic decision making, but rather in forming a clinical impression. The Piers–Harris is available from Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, CA 90025, 800-2222670, www.wpspublish.com. Roberts Apperception Test for Children (RATC; McArthur & Roberts, 1982) The RATC is a projective technique that involves a child’s telling a story about a moderately ambiguous picture. It is unique among projective tests in its use of an explicit and standardized scoring system. The RATC is designed for use with children ages 6–15 and uses 27 stimulus cards depicting common situations, conflicts, and stresses in children’s lives. Eleven cards have parallel male and female versions (therefore, only 16 cards are administered to a child), and there is a supplementary set of stimulus cards featuring African American children (the main set depicts European American youngsters). Children are instructed to tell a story about each picture, and each story is scored on 16 coding categories (8 Adaptive categories, 5 Clinical categories, and 3 categories labeled Indicators). Scores used in interpretations represent the total number of times a given code was present across all stories. This allows one to determine consistent themes (high scores within a category) across stories. The scoring system has been shown to be reliable, but normative data are minimal, and there is no evidence for the validity of the scoring system. The RATC therefore should not be used in diagnostic decision making, but rather as a method of obtaining clinical impressions. The RATC is available from Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, CA 90025, 800-222-2670, www.wpspublish. com.

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BEHAVIORAL OBSERVATION SYSTEMS Dyadic Parent–Child Interaction Coding System—II (DPICS-II; Eyberg, Bessmer, Newcomb, Edwards, & Robinson, 1994) The DPICS-II is an observation system for coding parent–child interactions in the clinic during three 10-minute periods (Child-Directed Interaction, Parent-Directed Interaction and Cleanup), with the last 5 minutes of each 10-minute period used for observation recording. The DPICS-II is designed for children whose verbal skills are at least at the 2-year-old level. Five categories of behavior are recorded: (1) verbalizations (e.g., behavioral description, labeled praise, direct command, criticism); (2) vocalizations (e.g., laugh, whine); (3) physical behaviors (e.g., physical positive, destructive); (4) responses following commands (e.g., compliance, noncompliance); and (5) responses following information questions (e.g., answer, no answer). Each behavior is coded for both parents and children. The DPICS-II manual includes 26 behaviors that can be recorded, and these were selected on the basis of their theoretical relevance to conduct problems. The clinician, however, is encouraged to be flexible in the specific behaviors recorded in the observation. There is also flexibility in reporting the coding categories as individual frequencies or combined into summary variables, such as total praise (labeled praise + unlabeled praise), command ratio (direct commands/ total commands), or inappropriate behavior (whine + physical negative + yell + destructive). Recording can also be done by a paper-and-pencil system that yields frequency counts; a paper-andpencil system in which behaviors are recorded sequentially in 10-second intervals; or a computer software program that records data in real time, yielding frequencies, sequences, and reliability estimates. The choice depends on the type of data needed and the available resources. Studies have demonstrated good interobserver reliability, and the validity of the DPICS-II in differentiating referred from nonreferred children has been shown. The original DPICS was shown to be a sensitive measure of treatment outcome in the clinic and home, and the DPICS-II also appears to be a good treatment outcome measure. This relatively easy and time-efficient observation method is worth learning to use in the clinic setting. The DPICS-II manual (Eyberg, Bessmer, et al., 1994) is available from Select press, P.O. Box 9838, San Rafael, CA 94912. A coder training manual for the DPICS-II (Eyberg, Edwards, Bessmer, & Litwins, 1994) is available from Sheila M. Eyberg, Department of Clinical and Health Psychology, 1600 S.W. Archer Boulevard, Gainesville, FL 32610. Behavior Assessment System for Children—Student Observation System (BASC-SOS; Reynolds & Kamphaus, 1992) The SOS is yet another component of the BASC. It is a 15-minute school observation procedure that is divided into 30-second intervals; at the end of each interval, the child’s behavior is observed for 3 seconds. Sixty-five target behaviors are listed for observation. At the end of the observation period, the observer makes a narrative recording of the teacher and child interactions. There are no reliability or normative data, and only limited validity. Nor is there a system for recording the antecedents and consequences of the behaviors. The BASC-SOS is available from American Guidance Service, Inc., Publishers’ Building, Circle Pines, MN 55014-1796, 800-328-2560, www.agsnet.com. Child Behavior Checklist—Direct Observation Form (CBCL-DOF; Achenbach, 1986) The DOF is another component of the CBCL system. It is a direct observational procedure that involves observing a child for 10 minutes on three to six separate occasions. The observer performs

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three tasks during the 10-minute observation period: (1) A narrative description is written throughout the 10 minutes, noting the occurrence, duration, and intensity of specific problems; (2) at the end of every minute, the child’s behavior is coded as being on or off task for 5 seconds; and (3) at the end of the 10-minute period, the observer rates the child on 96 behaviors that may have been observed during the observational period, using a 4-point scale (0 = “never occurred” to 3 = “definitely occurred”). There are no norms, but it is recommended that two randomly selected children also be observed (one before and one after the target child). The Total Problems and On-Task scores have been shown to be reliable between observers and to differentiate disturbed children from those without problems. The CBCL-DOF can be obtained from Thomas Achenbach, PhD, University Associates in Psychiatry, Department of Psychiatry, University of Vermont, 1 South Prospect Street, Burlington, VT 05401, 802-656-3131, www.uvm.edu.

STRUCTURED INTERVIEWS National Institute of Mental Health (NIMH) Diagnostic Interview Schedule for Children, Version IV (DISC-IV; Shaffer, Fisher, Lusac, Dulcan, & Schwab-Stone, 2000) The DISC-IV is the most recent revision of the NIMH structured interview for children. It is designed to assess more than 30 psychiatric disorders occurring in children and adolescents. There are two parallel versions of the DISC-IV: one for parents (or knowledgeable caretakers) of 6- to 17-year-olds (DISC-IV-P), and one for direct administration to children or adolescents ages 9– 17 years (DISC-IV-Y). Information from these interviews can be combined or examined separately. There are 358 core questions, as well as 2,032 questions (plus an additional 700 optional questions) that are asked contingently on the parent’s or child’s responses. Questions are read by the interviewer, and most answers are limited to a “yes” or “no,” although there are some “sometime” or “somewhat” response options or closed-ended frequency choices. The DISC-IV assesses the presence of symptoms occurring both within the past 4 weeks and past 12 months. Administration time is approximately 70 minutes per informant for community samples and 90–120 minutes for known patients. The interview is available in both Spanish and English. The DISC-IV can be administered by “lay” interviewers after 2 or 3 days of training. Scoring is computerized. Validity and reliability are good. There are currently a number of DISC-IV derivations in development, including a Teacher DISC-IV, a Voice DISC-IV, and a Quick DISC-IV. The DISC-IV is comprehensive and is primarily used for large-scale epidemiological studies and other research. The NIMH DISC-IV is available from the Columbia DISC Development Group, New York State Psychiatric Institute, 1051 Riverside Drive, Unit 78, New York, NY 10032, 888-814-3472, www. c-disc.com. Behavior Assessment System for Children—Structured Diagnostic History (BASC-SDH; Reynolds & Kamphaus, 1992) The SDH is the fifth component of the BASC. It is a semistructured interview that provides a systematic way to gather information on social, psychological, developmental, educational, and medical factors that could be affecting a child’s behavior and adjustment. The BASC-SDH is available from American Guidance Service, Inc., Publishers’ Building, Circle Pines, MN 55014-1796, (800328-2560, www.agsnet.com.

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Clinical Interview—Parent Report Form (Barkley, 1997b; Barkley & Murphy, 1998) This semistructured interview was designed to interview parents of children with attention-deficit and disruptive behavior disorders, but covers areas pertinent to interviewing parents for any childhood disorder. Of particular value is the summary of criteria for DSM-IV diagnoses for childhood disorders; it offers a quick way to determine whether symptoms meet criteria for a disorder or comorbid disorder. The full interview can be found in Attention-Deficit Hyperactivity Disorder: A Clinical Workbook (2nd ed.) by Russell A. Barkley and Kevin R. Murphy (1998), which is available from Guilford Press, 72 Spring Street, New York, NY 10012, 212-431-9800, http://www.guilford.com.

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER MEASURES Conners Rating Scales—Revised (Conners, 1997) We have found the 10-item Conners Global Index for parents (Conners-P) and teachers (Conners-T), formerly known as the Hyperactivity Index and/or Abbreviated Conners Rating Scale, to be the most useful measures in the Conners Rating Scales system. These scales are quick to complete, can be used repeatedly, and are sensitive to the effects of stimulant medication treatment. The Conners Global Index is available from Multi-Health Systems, 908 Niagara Falls Boulevard, North Tonawanda, NY 14120-2060, 800-456-3003, www.mhs.com.

Home and School Situations Questionnaires (HSQ and SSQ; Barkley, 1997b; Barkley & Murphy, 1998) The HSQ and SSQ assess the pervasiveness and severity of children’s behavior problems across multiple home and school situations. The HSQ includes 16 different home and public situations, for each of which the parent responds “yes” or “no” whether it is a problem for the child; for each “yes,” the parent then rates the severity of the problem behavior on a 9-point scale (“mild” to “severe”). Mean number of problem situations can be calculated, as well as a mean severity rating across situations. Normative data based on a small sample are available for boys and girls ages 4–5, 6–8, and 9–11. The SSQ includes 12 different school situations to which the teacher responds, and for which scores are calculated, in the same way as the HSQ. Normative data based on a small sample are available for boys and girls ages 6–8 and 9–11. These scales can be completed and scored in less than 10 minutes, can be used repeatedly and have demonstrated sensitivity to medication effects. The HSQ and SSQ also provide information on specific target areas for intervention and treatment outcome for the individual child. The scales and normative information are included in Attention-Deficit Hyperactivity Disorder: A Clinical Workbook (2nd ed.) by Russell A. Barkley and Kevin R. Murphy (1998), which is available from Guilford Press, 72 Spring Street, New York, NY 10012, 212-431-9800, http://www.guilford.com.

Side Effects Rating Scale (SERS; Barkley & Murphy, 1998) The SERS lists 17 common side effects to stimulant medication with a 10-point rating scale from “absent” (0) to “serious” (9). The SERS can be completed by a parent, teacher, or child, and provides a good method to track the potential negative side effects of medication. It could also be used for determining the side effects of any psychotropic medication. The SERS can be found in Attention-

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Deficit Hyperactivity Disorder: A Clinical Workbook (2nd ed.) by Russell A. Barkley and Kevin R. Murphy (1998), which is available from Guilford Press, 72 Spring Street, New York, NY 10012, 212-431-9800, http://www.guilford.com.

DEPRESSION, ANXIETY, AND FEAR MEASURES Children’s Depression Inventory (CDI; Kovacs, 1992) The CDI is a self-report measure that assesses the cognitive, affective, and behavioral signs of depression in children ages 7–17 years. It has two forms: a 27-item long form taking about 15 minutes to complete, and a 10-item short form taking 5–10 minutes to complete. For each item, children select one of three alternatives that best describes themselves in the past 2 weeks; these are scored 0, 1, or 2, with higher scores indicative of more depression. Depending on the form, the CDI takes 5–10 minutes to score. Scores are totaled for all items, and T-scores are calculated. The CDI has adequate reliability and is sensitive to change, but research on its discriminative validity has been mixed. It should therefore be used in conjunction with other methods to assess for depression in children. The CDI is available from Multi Health Systems, 908 Niagara Falls Boulevard, North Tonawanda, NY 14120-2060, 800-456-3003, www.mhs.com. Reynolds Child Depression Scale (RCDS; Reynolds, 1989) The RCDS is designed to assess symptoms associated with depression for children ages 8–12. It is a downward extension of the Reynolds Adolescent Depression Scale (RADS; Reynolds, 1986), which is designed for youth ages 13–18. The scale has 29 items that use a four-choice format (“never,” “sometimes,” “a lot of the time,” “and “all of the time”) to describe how the child feels. A secondgrade reading level is required. Scoring is easy, and only percentile rank scores are given, with the use of a cutoff score discouraged. Reliability and validity are good with adequate norms, but socioeconomic status of the normative sample was not controlled. A major strength of the RCDS is its thorough assessment of depressive symptoms. The adolescent version (RADS) has similar strengths. The RCDS and the RADS are available from Psychological Assessment Resources, Inc., P.O. Box 998, Odessa, FL 33556, 800-331-8378, http://www.parinc.com. State–Trait Anxiety Inventory for Children (STAIC; Spielberger, 1973) The STAIC measures enduring tendencies to experience anxiety (Trait Anxiety) and temporal or situational variations in levels of anxiety (State Anxiety). It includes two 20-item self-report scales covering these two constructs for children ages 9–12 years, although the manual states that it can be used for younger children who are average or above in reading ability and for older children who are below average in reading ability. Test–retest reliability coefficients for the Trait Anxiety scale are moderate, but considerably higher than those for the State Anxiety scale. Psychometric properties are adequate. Norms are provided for fourth-, fifth-, and sixth-graders, but these are out of date. The STAIC is available from Consulting Psychologists Press, 577 College Avenue, Palo Alto, CA 94306, 800-624-1765, www.cpp-db.com. Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1985) The RCMAS, also called “What I Think and Feel,” measures a range of symptoms related to anxiety for children and adolescents ages 6–19 years. Reading is at the third-grade level, with directions

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read aloud for children under 9½ years. The scale has 37 items distributed among four subscales: Physiological Anxiety (10 items), Worry/Oversensitivity (11 items), Social Concerns/Concentration (7 items), and Lie (9 items). The Lie scale measures children’s tendency to portray themselves in a favorable light (e.g., to get a high score, one would have to deny ever getting angry!). The child responds “yes” or “no” to being like the described item. The Total Anxiety score is a T-score conversion of the raw score, and standard scores are given for the Total Anxiety score and for the four subscales. Psychometric properties are good (with a very reliable Total Anxiety score), and normreferenced scores are provided by gender, age, and ethnicity. The RCMAS, like the RCDS for depression, was not designed to discriminate children with anxiety disorders, but it is a very good measure of the variety of anxiety symptoms that children can experience. The RCMAS is available from Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, CA 90025, 800-2222670, www.wps.publish.com. Multidimensional Anxiety Scale for Children (MASC; March, 1997) The MASC is a self-report measure that assesses the major dimensions of anxiety in children and adolescents ages 8–19 years. The 39-item form uses a 0–3 rating scale (“never true about me,” “rarely true about me,” “sometimes true about me,” and “often true about me”). Items are read to children under 10 years or age. The MASC takes about 15 minutes to complete (fourth-grade reading level) and less then 10 minutes to score and profile. There are four major factors and six subscales: (1) Physical Symptoms (Tense/Restless and Somatic/Autonomic); (2) Social Anxiety (Humiliation/ Rejection and Public Performance Fears); (3) Harm Avoidance (Perfectionism and Anxious Coping); and (4) Separation Anxiety, a 10-item factor that was developed to monitor treatment progress, including drug treatment. T-scores are obtained for each factor and subscale, plus scores for Total Anxiety, an Inconsistency Index (random or careless responding), and an Anxiety Disorders Index (indicates need for further evaluation). Psychometric properties are good, and normative data for the general population are given for three age groups (8–11, 12–15, and 16–19), but the number of 8-year-olds is very limited. Concordance with parent reports was greatest for easily observable symptom clusters. The MASC has been shown to discriminate children with and without anxiety disorders (and, to a lesser degree, children with depression). The MASC is available from Multi-Health Systems, 908 Niagara Falls Boulevard, North Tonawanda, NY 14120-2060, 800456-3003, www.mhs.com. Social Phobia and Anxiety Inventory for Children (SPAI-C; Turner, Beidel, & Morris, 1998) The SPAI-C specifically assesses somatic symptoms, cognitions, and behavioral aspects of social phobia across a broad range of social encounters and setting in children ages 8–14. It has 26 items, some of which require multiple responses, and uses a 3-point scale to assess the frequency with which each symptom is experienced (“hardly ever,” “sometimes,” “almost always”). It requires a thirdgrade reading level, and it takes about 20 minutes to administer and 15 minutes to score and profile. T-scores are given for a Total score and Intensity scores for somatic, cognitive, and behavioral symptoms across settings. Reliability is excellent, validity is good, and the normative sample is adequate. This is a good clinical instrument to determine the salient aspects of a child’s fear, and therefore aids in the development of an appropriate treatment plan. The SPAI-C is available from Multi-Health Systems, 908 Niagara Falls Boulevard, North Tonawanda, NY 14120-2060, 800-4563003, www.mhs.com.

502

APPENDIX A

School Refusal Assessment Scale (SRAS; Kearney & Albano, 2000) The SRAS is an empirically derived assessment instrument that is based on a functional classification system of school refusal in children from kindergarten through grade 12. There are 16-item child and parent versions, with each question rated on a 7-point scale, “never” (0) to “always” (6). The SRAS takes about 10 minutes to administer and 10 minutes to score. The items were selected to measure four motivating conditions for school refusal (four items per condition): (1) avoidance of negative-affect-provoking objects or situations related to school settings (e.g., fire alarm, bus, tests; (2) escape from aversive social or evaluative situations (e.g., those leading to unsatisfying peer relationships or severe social anxiety); (3) attention getting (e.g., having tantrums in order to stay home); and (4) positive tangible reinforcement (e.g., pursuit of more rewarding experiences outside of school, such as watching television or visiting friends). Following administration, the means for each condition are calculated and ranked. The highest-scoring condition is considered the primary maintaining variable of school refusal for a particular child, although the strength of the remaining conditions is considered in the development of an appropriate treatment plan. The scale is therefore viewed as both typological (prescriptive treatment for school refusal is assigned on the basis of the highest-scoring functional condition) and dimensional (the scores on each condition are viewed as a continuum for extended treatment planning). The parent and child versions are reliable across time and between parent raters, and correlational data support the four separate functional conditions. The SRAS is also effective in selection of the most effective treatment for school refusal. (Kearney & Silverman, 1999). The SRAS is a model for the development of functional scales for prescriptive treatment of other problem behaviors. The assessment including the SRAS scales and treatment of school refusal using this approach is published in When Children Refuse School: A Cognitive-Behavioral Therapy Approach (Kearney & Albano, 2000), which includes both a parent workbook and a therapist guide. These are available from Psychological Corporation, 555 Academic Court, San Antonio, TX, 800-221-8378, www.psychcorp.com.

PARENT CHARACTERISTIC MEASURES Dyadic Adjustment Scale (DAS; Spanier, 1976; Spanier & Thompson, 1982) The DAS consists of 32 items that assess the quality of a marriage. Most items are rated on a 6-point scale; there are a few yes–no questions; and some items are rated on a 4-point scale. The DAS takes 5–10 minutes to complete, and scoring is relatively quick. Early research found that married couples differed from divorced couples on four factors (Dyadic Satisfaction, Cohesion, Consensus, and Affectional Expression) and a Total score. Means and standard deviations on the factors and total score are provided for divorced and married couples. The DAS is available from Multi-Health Systems, 908 Niagara Falls Boulevard, North Tonawanda, NY 14120-2060, 800-456-3003, www.mhs.com.

Beck Depression Inventory—II (BDI-II; Beck, Steer, & Brown, 1996) The BDI-II is an update of the original BDI, which was the “gold standard” for the measurement of depression in adults. Although some new items have been added, some old ones have been dropped, so the BDI-II still totals 21 items. For each item, the person chooses one of four statements that are arranged according to increasing levels of depression. The BDI-II takes approximately 10 minutes to complete, and scoring is relatively quick. Psychometric properties are good,

Description of Assessment Instruments

503

with scores differentiating clinical levels of depression. The BDI-II is available from Psychological Corporation, 555 Academic Court, San Antonio, TX, 800-211-8378, www.psych.corp.com. Parenting Alliance Measure (PAM; Abidin & Brunner, 1995; Abidin & Konold, 1999) The PAM is a 20-item self-report measure that assesses the degree to which parents of children ages 1–19 years believe they have a cooperative working relationship in meeting their children’s needs. Parents respond to each item on a 5-point rating scale ranging from “strongly agree” to “strongly disagree.” The PAM can be completed in less than 10 minutes; it requires a third-grade reading level; and hand scoring can be completed in less than 5 minutes. The Total score is the sum of the item scores for all 20 items, with corresponding percentiles for males and females. Psychometric properties are good. The PAM discriminates among married, separated, and divorced couples, and correlates significantly with established measures of marital satisfaction, parenting stress and style, and total child adjustment and social competence. It has also been shown to relate more to a couple’s success as parents than to the partners’ success as a couple (Bearss & Eyberg, 1998). This suggests that parents who have a strong alliance around issues of parenting can continue to nurture their children successfully after a divorce or during a conflicted marriage. The PAM is available from Psychological Assessment Resources, Inc., P.O. Box 998, Odessa, FL 33556, 800-331-8378, http://www.parinc.com.

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APPENDIX B

ASSESSMENT INSTRUMENTS

505

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APPENDIX B.1

General Parent Questionnaire Note: Please complete all information on this questionnaire. All information is treated in confidence and will not be released without your permission. Date ______________________ Form completed by ____________________________________________ Child’s full name _____________________________ [ ] Male [ ] Female

Birthdate ________________

Address ____________________________________________________________________________________ Street City County State Zip Home phone ____________ Work phone ____________ (Mother) __________ (Father) ___________ Who referred the child? _____________________________________________________________________ Name Address Child’s primary physician ___________________________________________________________________ Insurance company ___________________________ Child’s Social Security # ______-______-______

FAMILY Father’s name ____________________________________________________ Birthdate _______________ Address (if different from above) ___________________________________________________________ Occupation ____________________ Education level _________________ # of dependents ________ Mother’s name _____________________________________________ Birthdate _________________ Address (if different from above) ________________________________________________________ Occupation ____________________ Education level _________________ # of dependents ________ Date of marriage __________ Present marital status ________________________________________ With whom does the child live? [ ] Birth parents

[ ] Adoptive parents

[ ] Foster parents

[ ] Other (specify) _________________________________________ If parents are separated or divorced: Date of separation/divorce _______________________________ Who has physical custody? __________________ Who has legal custody? _______________________ List all other persons living in the home: Name Relationship to child

Present health

_____________________________

___________________________

________________________________

_____________________________

___________________________

________________________________

_____________________________

___________________________

________________________________

List any other people who care for the child a significant amount of time: Name Relationship to child (grandmother, neighbor, etc.) _______________________________________

________________________________________________

_______________________________________

________________________________________________

_______________________________________

________________________________________________

From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).

507

508

APPENDIX B

CHILD Pregnancy and birth: Any complications? [ ] Yes [ ] No; if yes, briefly explain: __________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Developmental milestones: (Ages) Sitting: ____ Walking: ____ Talking: ____ Toilet-trained: ____ Medical problems: [ ] Yes

[ ] No; if yes, briefly explain: ____________________________________

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Please list any jobs or chores your child has at home or at school—for example, feeding the dog, making the bed, safety patrol. [ ] None

How well does your child do these jobs/chores? Poor Average Great

1. ________________________________________

1

2

3

4

5

2. ________________________________________

1

2

3

4

5

3. ________________________________________

1

2

3

4

5

What are your child’s strengths? ____________________________________________________________ _____________________________________________________________________________________________ How many close friends does your child have? [ ] None

[ ] 1

[ ] 2 or 3

[ ] 4 or more

How many close friends in the neighborhood does your child have?

[ ] None

[ ] 1

[ ] 2 or 3

[ ] 4 or more

How many times a week does your child do things with them?

[ ] None

[ ] 1

[ ] 2 or 3

[ ] 4 or more

Poor 1

2

Average 3

4

Compared to other children his/her age, how does your child get along with other children?

Great 5

What are your child’s favorite recreational or extracurricular activities? __________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Comments: _________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Who generally disciplines the child? _________________________________________________________ What methods are used? ____________________________________________________________________ _____________________________________________________________________________________________ Do parents agree on methods of displine? [ ] Yes [ ] No; if no, please elaborate: _______________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Assessment Instruments

509

Indicate other relative

Other

Daughter

Son

Sister

Brother

Grandmother

Grandfather

Mother

Father

Being treated

No

Check condition and relationship of any blood relative who has or has had any of the conditions listed below:

Yes

FAMILY RECORD

Alcoholism/substance abuse Allergies Birth defects Cancer Colitis Depression Heart attack High blood pressure Kidney disease Liver disease Migraines Mental illness Seizure disorder Mental retardation Learning disorder Attention problems Suicide/suicide attempt Other Current health Family member

Living?

Age

Good Fair

Poor

If deceased, reason for death

Father Mother Brothers

Sisters

Last physical exam date: ___________________________________________________________________ Doctor’s notes: ____________________________________________________________________________ _____________________________________________________________________________________________

510

APPENDIX B

SCHOOL HISTORY Has child been enrolled in a nursery or day care? [ ] Yes [ ] No At what age? ___________ Has child attended kindergarten?

[ ] Yes [ ] No

Has child begun elementary school?

[ ] Yes [ ] No

At what age? ___________

At what age did he/she enter first grade? ________ What is present grade placement? _______ If your child has ever been to school (including nursery, kindergarten, and grade school), complete the following for all grades beginning with nursery and ending with current placement. Please indicate if your child repeated a grade or is in a special class (gifted/talented, learningdisabled, behavior-disordered, emotionally disabled, etc.). Grade

School

Comments

_________________ _________________ ___________________________________________________________ _________________ _________________ ___________________________________________________________ _________________ _________________ ___________________________________________________________ _________________ _________________ ___________________________________________________________ _________________ _________________ ___________________________________________________________ _________________ _________________ ___________________________________________________________ Current school performance (for children ages 6 and older): [ ] Does not go to school Failing

Below average

Average

Above average

a. Reading b. Writing c. Arithmetic/math d. Spelling Other academic subjects (history, science, foreign language, geography, etc. e. f. g. h.

PARENTAL CONCERNS What do you feel is your child’s main problem? _____________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

Assessment Instruments

511

What do you feel caused your child’s problem? ______________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ What have you been told by doctors, teachers, and/or others about your child’s problems? ___ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Has your child had any other mental health evaluations or treatment? _______________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ What have you done to try to deal with your child’s problem? ______________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Has any other member of your child’s immediate family had mental health treatment? _______ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Other comments: ___________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ May we contact the child’s primary physician? [ ] To receive information [ ] To give information ____________________________________________ (Signed) Parent or guardian

APPENDIX B.2

Daily Log Record a brief summary of both appropriate and inappropriate behavior each day. Give each day’s overall behavior a rating from 0 to 10, with 0 being “dreadful” and 10 being “fantastic!”

Date

Appropriate Behavior

Inappropriate Behavior

Overall Rating (0 to 10)

From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).

512

APPENDIX B.3

Specific Events Causing Concern Child’s Name: __________________________________ Initial

Date

Time

What happened?

What did you do?

Child’s reaction?

From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).

513

514

APPENDIX B APPENDIX B.4

Teacher Questionnaire Date form completed: ___________________________________ Child: __________________________________________________________________________________________ (Name) (Age) (Grade) School: _______________________________________ Address: ____________________________________ Teachers and other school personnel who work with the child: _________________________________________________

_______________________________________

_________________________________________________

_______________________________________

Director or principal: _________________________________________________________________________

BEHAVIOR INFORMATION Please rank the following on a 1–4 scale: 1 = “no problem,” 4 = “severe problem” 1

2

3

4

NA

1. Classroom behavior Interest Attention Following instructions Self-control Participation Other (please specify) 2. Relationship with teachers 3. Speech and language 4. Fine motor skills 5. Gross motor skills 6. Social skills 7. Relationship with peers 8. Reading 9. Writing 10. Arithmetic 11. Other academic skills

From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S. Schroeder and Betty N. Gordon. Copyright 2002 by The Guilford Press. Permission to photocopy this form is granted to purchasers of this book for personal use only (see copyright page for details).

514

Assessment Instruments

515

12. Homework completion/organization 13. Test performance 14. Home background 15. Intelligence level 16. Physical problem (please specify) 17. Other problems (please specify) Do you think the child is functioning at his or her age level in: Yes

No

Comments

Behavior Social adjustment with peers Social adjustment with adults Academics Please list the child’s strengths and weaknesses as you see them in the classroom. Strengths

Weaknesses

What remedial and/or behavioral techniques have been attempted with the child? Have any been helpful? (Please be as specific as possible.)

Have you had to make any special accommodations for this child? If so, please describe.

SCHOOL PERCEPTIONS/EXPECTATIONS Please list any specific questions you have concerning this child.

516

APPENDIX B

Is it your sense that other teachers and/or school professionals share a similar perception of this student? Please comment.

Is there any other information that would be helpful for us to know about this child?

Is there any other teacher/school professional with whom we should speak?

What information from our evaluation would be helpful in your planning for the child?

What is the best time to contact you? _________________ (Time)

__________________________________ (Phone number)

___________________________________________ Teacher(s) completing this form ___________________________________________ ___________________________________________ ___________________________________________ Thank you for completing this and any other attached forms.

Assessment Instruments

517

APPENDIX B.5

Fear Survey Schedule for Children—Revised (FSSC-R) The FSSC-R is an 80-item questionnaire revised from the original scale published by Scherer and Nakamura (1968). It is designed for children ages 7–18 and can also be used with children who are developmentally delayed. The FSSC-R documents both the number and intensity of fears on a 3-point scale (“none,” “some,” “a lot”). The FSSC-R is a well-normed, reliable, and valid instrument that identifies specific fears for individual children, discriminates between children exhibiting typical fears and those with excessive fears, and is a good treatment outcome measure. Name: __________________________________________ Age: _______________ Date: ________________ Directions: A number of statements which boys and girls use to describe the fears they have are given below. Read each fear carefully and put an X in the box in front of the words that describe your fear. There are no right or wrong answers. Remember, find the words which best describe how much fear you have. 1. Giving an oral report

អ None

អ Some

អ A lot

2. Riding in the car or bus

អ None

អ Some

អ A lot

3. Getting punished by mother

អ None

អ Some

អ A lot

4. Lizards

អ None

អ Some

អ A lot

5. Looking foolish

អ None

អ Some

អ A lot

6. Ghosts or spooky things

អ None

អ Some

អ A lot

7. Sharp objects

អ None

អ Some

អ A lot

8. Having to go to the hospital

អ None

អ Some

អ A lot

9. Death or dead people

អ None

អ Some

អ A lot

10. Getting lost in a strange place

អ None

អ Some

អ A lot

11. Snakes

អ None

អ Some

អ A lot

12. Talking on the telephone

អ None

អ Some

អ A lot

13. Roller coaster or carnival rides

អ None

អ Some

អ A lot

14. Gettng sick at school

អ None

អ Some

អ A lot

15. Being sent to the principal

អ None

អ Some

អ A lot

16. Riding on the train

អ None

អ Some

អ A lot

17. Being left at home with a sitter

អ None

អ Some

អ A lot

18. Bears or wolves

អ None

អ Some

អ A lot

19. Meeting someone for the first time

អ None

អ Some

អ A lot

20. Bombing attacks—being invaded

អ None

អ Some

អ A lot

21. Getting a shot from the nurse or doctor

អ None

អ Some

អ A lot

22. Going to the dentist

អ None

អ Some

អ A lot

The FSSC-R itself is from Ollendick (1983). Copyright 1983 by Pergamon Press. Reprinted by permission. The normative data, and the score means and standard deviations, are from Ollendick, King, and Frary (1989). Copyright 1989 by Pergamon Press. Reprinted by permission.

517

518

APPENDIX B

23. High places like mountains

អ None

អ Some

អ A lot

24. Being teased

អ None

អ Some

អ A lot

25. Spiders

អ None

អ Some

អ A lot

26. A burglar breaking into our house

អ None

អ Some

អ A lot

27. Flying in a plane

អ None

អ Some

អ A lot

28. Being called on by the teacher

អ None

អ Some

អ A lot

29. Getting poor grades

អ None

អ Some

អ A lot

30. Bats or birds

អ None

អ Some

អ A lot

31. My parents criticizing me

អ None

អ Some

អ A lot

32. Guns

អ None

អ Some

អ A lot

33. Being in a fight

អ None

អ Some

អ A lot

34. Fire—getting burned

អ None

អ Some

អ A lot

35. Getting a cut or injury

អ None

អ Some

អ A lot

36. Being in a big crowd

អ None

អ Some

អ A lot

37. Thunderstorms

អ None

អ Some

អ A lot

38. Having to eat some food I don’t like

អ None

អ Some

អ A lot

39. Cats

អ None

អ Some

អ A lot

40. Failing a test

អ None

អ Some

អ A lot

41. Being hit by a car or truck

អ None

អ Some

អ A lot

42. Having to go to school

អ None

អ Some

អ A lot

43. Playing rough games during recess

អ None

អ Some

អ A lot

44. Having my parents argue

អ None

អ Some

អ A lot

45. Dark rooms or closets

អ None

អ Some

អ A lot

46. Having to put on a recital

អ None

អ Some

អ A lot

47. Ants or beetles

អ None

អ Some

អ A lot

48. Being criticized by others

អ None

អ Some

អ A lot

49. Strange-looking people

អ None

អ Some

អ A lot

50. The sight of blood

អ None

អ Some

អ A lot

51. Going to the doctor

អ None

អ Some

អ A lot

52. Strange or mean-looking dogs

អ None

អ Some

អ A lot

53. Cemeteries

អ None

អ Some

អ A lot

54. Getting a report card

អ None

អ Some

អ A lot

55. Getting a haircut

អ None

អ Some

អ A lot

56. Deep water or the ocean

អ None

អ Some

អ A lot

57. Nightmares

អ None

អ Some

អ A lot

58. Falling from high places

អ None

អ Some

អ A lot

59. Getting a shock from electricity

អ None

អ Some

អ A lot

60. Going to bed in the dark

អ None

អ Some

អ A lot

61. Getting carsick

អ None

អ Some

អ A lot

Assessment Instruments

519

62. Being alone

អ None

អ Some

អ A lot

63. Having to wear clothes different from others

អ None

អ Some

អ A lot

64. Getting punished by my father

អ None

អ Some

អ A lot

65. Having to stay after school

អ None

អ Some

អ A lot

66. Making mistakes

អ None

អ Some

អ A lot

67. Mystery movies

អ None

អ Some

អ A lot

68. Loud sirens

អ None

អ Some

អ A lot

69. Doing something new

អ None

អ Some

អ A lot

70. Germs or getting a serious illness

អ None

អ Some

អ A lot

71. Closed places

អ None

អ Some

អ A lot

72. Earthquakes

អ None

អ Some

អ A lot

73. Russia

អ None

អ Some

អ A lot

74. Elevators

អ None

អ Some

អ A lot

75. Dark places

អ None

អ Some

អ A lot

76. Not being able to breathe

អ None

អ Some

អ A lot

77. Getting a bee sting

អ None

អ Some

អ A lot

78. Worms or snails

អ None

អ Some

អ A lot

79. Rats or mice

អ None

អ Some

អ A lot

80. Taking a test

អ None

អ Some

អ A lot

SCORING PROCEDURES Record 1 (“none”), 2 (“some”), or 3 (“a lot”) for each item. To determine intensity scores for each factor, sum across items within each factor. To determine total intensity scores, sum across factors. To determine frequency scores, total the number of items scored 3 across the five factors. Failure and Criticism 1 ___

15 ___

29 ___

42 ___

54 ___

66 ___

3 ___

19 ___

31 ___

44 ___

63 ___

69 ___

5 ___

24 ___

38 ___

46 ___

64 ___

80 ___

14 ___

28 ___

40 ___

48 ___

65 ___

Total ______

The Unknown 6 ___

17 ___

45 ___

56 ___

62 ___

71 ___

9 ___

36 ___

49 ___

57 ___

67 ___

74 ___

13 ___

37 ___

53 ___

60 ___

68 ___

75 ___

Total ______

Minor Injury and Small Animals 4 ___

18 ___

32 ___

39 ___

50 ___

78 ___

7 ___

25 ___

33 ___

43 ___

52 ___

79 ___

11 ___

30 ___

35 ___

47 ___

77 ___

Total ______

520

APPENDIX B

Danger and Death 10 ___

26 ___

58 ___

72 ___

20 ___

34 ___

59 ___

73 ___

23 ___

41 ___

70 ___

76 ___

Total ______

Medical Fears 8 ___

22 ___

21 ___

51 ___

Total ______ Intensity Total ______

NORMATIVE DATA

Age and sex

Frequency of fears (range = 0–74)

Intensity of fears (range = 74–222)

7–10 11–13 14–16 Boys Girls

17 13 12 10 18

139 133 129 125 144

MEANS AND STANDARD DEVIATIONS OF INTENSITY SCORES FOR CATEGORIES OF FEARS Factor

Failure and Criticism The Unknown Minor Injury and Small Animals Danger and Death Medical Fears

7–10

11–13

14–16

Boys

Girls

X|

SD

X|

SD

X|

SD

X|

SD

X|

SD

39 29 28 26 7

(8.3) (7.5) (7.5) (6.4) (2.1)

39 27 27 25 7

(7.6) (6.4) (6.4) (6.0) (2.2)

37 26 26 24 7

(7.9) (6.2) (6.1) (6.0) (2.1)

36 25 24 23 6

(7.8) (6.3) (5.8) (5.9) (2.0)

40 30 30 27 7

(7.6) (6.8) (6.6) (5.8) (2.2)

Assessment Instruments

521

APPENDIX B.6

Screen for Child Anxiety Related Emotional Disorders (SCARED)—Child Version The SCARED is a screening measure for specific types of anxiety disorders in children ages 9–18 years. There are parent and child self-report versions with 41 items each. (The parent version is given in Appendix B.7, along with a scoring key for both versions.) Responses to descriptive statements use a 0–2 rating scale (“not true or hardly ever true,” “sometimes true,” and “true or often true”). The SCARED has five factors: (1) Panic/Somatic, (2) Generalized Anxiety, (3) Separation Anxiety, (4) Social Phobia, and (5) School Phobia. Good reliability and validity are reported, with good discriminant validity both between children with and without anxiety disorders and among individual anxiety disorders. It also discriminates children with anxiety from those with depression. A recent revision of the SCARED that includes a Traumatic Stress Disorder scale has obtained strong support as an initial screen for detecting children who have experienced traumatic life events and are at risk for developing posttraumatic stress disorders (Muris, Merckelbach, Korver, & Meesters, 2000). More research needs to be done, but the SCARED is a promising scale to identify anxiety disorders in children who are referred for mental health services. Name: _______________________________________________________ Date: ________________________ Identification #: ______________________________________________ Below is a list of items that describe how people feel. For each item that describes you, please circle the 2 if the item is very true or often true of you. Circle the 1 if the item is somewhat or sometimes true of you. If the item is not true of you, please circle the 0. Please answer all the items as well as you can, even if some do not seem to concern you. 0 = Not true or hardly ever true 1 = Somewhat true or sometimes true 2 = Very true or often true 1

When I feel frightened, it is hard to breathe.

0

1

2

2

I get headaches when I am at school.

0

1

2

3

I don’t like to be with people I don’t know well.

0

1

2

4

I get scared if I sleep away from home.

0

1

2

5

I worry about other people liking me.

0

1

2

6

When I get frightened, I feel like passing out.

0

1

2

7

I am nervous.

0

1

2

8

I follow my mother or father wherever they go.

0

1

2

9

People tell me that I look nervous.

0

1

2

10

I feel nervous with people I don’t know well.

0

1

2

11

I get stomachaches at school.

0

1

2

12

When I get frightened, I feel like I am going crazy.

0

1

2

Adapted from Birmaher et al. (1997, 1999). Copyright, 1997 and 1999 by the American Academy of Child and Adolescent Psychiatry. Adapted by permission.

521

522

APPENDIX B

13

I worry about sleeping alone.

0

1

2

14

I worry about being as good as other kids.

0

1

2

15

When I get frightened, I feel like things are not real.

0

1

2

16

I have nightmares about something bad happening to my parents.

0

1

2

17

I worry about going to school.

0

1

2

18

When I get frightened, my heart beats fast.

0

1

2

19

I get shaky.

0

1

2

20

I have nightmares about something bad happening to me.

0

1

2

21

I worry about things working out for me.

0

1

2

22

When I get frightened, I sweat a lot.

0

1

2

23

I am a worrier.

0

1

2

24

I get really frightened for no reason at all.

0

1

2

25

I am afraid to be alone in the house.

0

1

2

26

It is hard to talk with people I don’t know well.

0

1

2

27

When I get frightened, I feel like I am choking.

0

1

2

28

People tell me that I worry too much.

0

1

2

29

I don’t like to be a way from my family.

0

1

2

30

I am afraid of having anxiety (or panic) attacks.

0

1

2

31

I worry that something bad might happen to my parents.

0

1

2

32

I feel shy with people I don’t know well.

0

1

2

33

I worry about what is going to happen in the future.

0

1

2

34

When I get frightened, I feel like throwing up.

0

1

2

35

I worry about how well I do things.

0

1

2

36

I am scared to go to school.

0

1

2

37

I worry about things that have already happened.

0

1

2

38

When I get frightened, I feel dizzy.

0

1

2

39

I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport).

0

1

2

40.

I feel nervous about going to parties, dances, or any place where there will be people that I do not know well.

0

1

2

41

I am shy.

0

1

2

For children ages 8–11, it is recommended to explain all questions or have them answer the questionnaire next to an adult in case they have any questions.

Assessment Instruments

523

APPENDIX B.7

Screen for Child Anxiety Related Emotional Disorders (SCARED)—Parent Version Child’s Name: ________________________________________ Date: ________________________________ Parents’ Name: ________________________________________ Identification #: ________________________ Below is a list of items that describe how people feel. For each item that describes your child, please circle the 2 if the item is very true or often true. Circle the 1 if the item is somewhat or sometimes true of your child. If the item is not true of your child, please circle the 0. Please answer all the items as well as you can, even if some do not seem to concern your child. 0 = Not true or hardly ever true 1 = Somewhat true or sometimes true 2 = Very true or often true 1

When my child feels frightened, it is hard for him/her to breathe.

0

1

2

2

My child gets headaches when he/she is at school.

0

1

2

3

My child doesn’t like to be with people he/she doesn’t know well.

0

1

2

4

My child gets scared if he/she sleeps away from home.

0

1

2

5

My child worries about other people liking him/her.

0

1

2

6

When my child gets frightened, he/she feels like passing out.

0

1

2

7

My child is nervous.

0

1

2

8

My child follows me wherever I go (he/she is like my “shadow”).

0

1

2

9

People tell my child that he/she looks nervous.

0

1

2

10

My child feels nervous with people he/she doesn’t know well.

0

1

2

11

My child gets stomachaches at school.

0

1

2

12

When my child gets frightened, he/she feels like he/she is going crazy.

0

1

2

13

My child worries about sleeping alone.

0

1

2

14

My child worries about being as good as other kids.

0

1

2

15

When my child gets frightened, he/she feels like things are not real.

0

1

2

16

My child has nightmares about something bad happening to his/her parents.

0

1

2

17

My child worries about going to school.

0

1

2

18

When my child gets frightened, his/her heart beats fast.

0

1

2

19

My child gets shaky.

0

1

2

20

My child has nightmares about something bad happening to him/her.

0

1

2

21

My child worries about things working out for him/her.

0

1

2

Adapted from Birmaher et al. (1997, 1999). Copyrights 1997 and 1999 by the American Academy of Child and Adolescent Psychiatry. Adapted by permission.

523

524

APPENDIX B

22

When my child gets frightened, he/she sweats a lot.

0

1 2

23

My child is a worrier.

0

1 2

24

My child gets really frightened for no reason at all.

0

1 2

25

My child is afraid to be alone in the house.

0

1 2

26

It is hard for my child to talk with people he/she doesn’t know well.

0

1 2

27

When my child gets frightened, he/she feels like he/she is choking.

0

1 2

28

People tell my child that he/she worries too much.

0

1 2

29

My child doesn’t like to be away from his/her family.

0

1 2

30

My child is afraid of having anxiety (or panic) attacks.

0

1 2

31

My child worries that something bad might happen to his/her parents.

0

1 2

32

My child feels shy with people he/she doesn’t know well.

0

1 2

33

My child worries about what is going to happen in the future.

0

1 2

34

When my child gets frightened, he/she feels like throwing up.

0

1 2

35

My child worries about how well he/she does things.

0

1 2

36

My child is scared to go to school.

0

1 2

37

My child worries about things that have already happened.

0

1 2

38

When my child gets frightened, he/she feels dizzy.

0

1 2

39

My child feels nervous when he/she is with other children or adults and has to do something while they watch him/her (for example: read aloud, speak, play a game, play a sport).

0

1

2

40

My child feels nervous about going to parties, dances, or any place where there will be people he/she does not know well.

0

1

2

41

My child is shy.

0

1 2

SCORING KEY (FOR BOTH CHILD AND PARENT VERSIONS) The following items are scored 0, 1, or 2. Panic/Somatic: 1 __ 6 __ 9 __ 12 __ 15 __ 18 __ 19 __ 22 __ 24 __ 27 __ 30 __ 34 __ 38 __ TOTAL __ Generalized Anxiety: 5 __ 7 __ 14 __ 21 __ 23 __ 28 __ 33 __ 35 __ 37 __ TOTAL __ Separation Anxiety: 4 __ 8 __ 13 __ 16 __ 20 __ 25 __ 29 __ 31 __ TOTAL __ Social Phobia: 3 __ 10 __ 26 __ 32 __ 39 __ 40 __ 41 __ TOTAL __ School Phobia: 2 __ 11 __ 17 __ 36 __ TOTAL __ Total Score: __

Assessment Instruments

525

COMPARISON OF ANXIETY DISORDERS WITH OTHER NONANXIETY PSYCHIATRIC DISORDERS Child Form

Anxiety Cases

Total Score Factor 1 (Panic/Somatic) Factor 2 (Generalized Anxiety) Factor 3 (Separation Anxiety) Factor 4 (Social Phobia) Factor 5 (School Phobia)

36.1 9.4 9.4 5.4 8.0 3.9

+/– +/– +/– +/– +/– +/–

Nonanxiety Cases

17.3 6.6 5.8 4.0 4.42 2.7

20.3 4.3 5.8 3.6 4.6 2.1

+/– +/– +/– +/– +/– +/–

14.8 4.3 4.4 3.7 3.7 2.0

Note: Values represent mean +/– SD.

COMPARISON OF CHILDREN WITH ANY ANXIETY DISORDER, PURE DEPRESSION, AND PURE DISRUPTIVE DISORDERS Child Form Total Score Factor 1 (Panic/Somatic) Factor 2 (Generalized Anxiety) Factor 3 (Separation Anxiety) Factor 4 (Social Phobia) Factor 5 (School Phobia)

Anxiety 36.1 9.4 9.4 5.4 8.0 3.9

+/– +/– +/– +/– +/– +/–

17.3 6.6 5.4 4.0 4.42 2.7

Note: Norms for the parent form were not reported.

Depression 22.0 4.8 6.6 3.3 5.1 2.2

+/– +/– +/– +/– +/– +/–

14.5 4.2 4.5 3.6 3.8 2.0

Disruptive 19.2 4.0 5.3 3.8 4.2 2.0

+/– +/– +/– +/– +/– +/–

15.0 4.3 4.2 3.8 3.5 2.1

526

APPENDIX B APPENDIX B.8

Hopelessness Scale for Children The Hopelessness Scale for Children measures negative expectations about the future as related to negative views of the world and of oneself for children ages 6–13. The scale consists of 16 items, each of which children identify as true or untrue for themselves. The items are written at the firstand second-grade level and are read to the child to facilitate comprehension. Factor analysis yielded two factors: (1) Future Expectations and Giving Up, and (2) Overall Happiness and Future Expectations. Psychometric properties of the test are adequate but only a clinical sample was used. Total scores at or above the 67th percentile (score ≥ 7.0) are delineated as High Hopelessness, and scores at or below the 33rd percentile (score ≤ 4.0) are delineated as Low Hopelessness. Children with High Hopelessness scores are significantly higher in depression, lower in self-esteem, and lower in self-rated social behavior, and are rated by their parents as participating in social activities and having poorer school performance, than children with Low Hopelessness scores. Scores are also related to suicidal attempts and ideation. Research did not find the high scores associated with a particular diagnosis or severity of dysfunction in general (Kazdin, Rodgers, & Colbus, 1986). Child’s Name ___________________________________________________________ Date ____________ Child’s Grade ___________________________________________________________ Age _____________ Read each sentence to the child, and circle “True” if the child thinks it is true of him or her and “False” if the child does not think it is true of him or her. 1. I want to grow up because I think things will be better.

True

False

2. I might as well give up because I can’t make things better for myself.

True

False

3. When things are going badly, I know they won’t be bad all of the time.

True

False

4. I have enough time to finish the things I really want to do.

True

False

5. Someday, I will be good at doing the things I really care about.

True

False

6. I will get more of the things in life than most kids.

True

False

7. I don’t have good luck, and there’s no reason to think I will when I grow up.

True

False

8. All I can see ahead of me is bad things, not good things.

True

False

9. I don’t think I will get what I really want.

True

False

10. When I grow up, I think I will be happier than I am now.

True

False

11. Things just won’t work out the way I want them to.

True

False

12. I never get what I want, so it is dumb to want anything.

True

False

13. I don’t think I will have any real fun when I grow up.

True

False

14. Tomorrow seems unclear and confusing to me.

True

False

15. I will have more good times than bad.

True

False

16. There’s no use in really trying to get something I want, because I probably won’t get it.

True

False

Adapted from Kazdin, Rodgers, and Colbus (1986). Copyright 1986 by the American Psychological Association. Adapted by permission.

526

Assessment Instruments

527

SCORING KEY Part I. For each item, record 1 if the response is “True” and 0 if the response is “False.” 2. __

9. __

13. __

7. __

11. __

14. __

8. __

12. __

16. __

Total Part I __

Part II. For each item, record 1 if the response is “False” and 0 if the response is “True.” 1. __

5. __

3. __

6. __

4. __

10. __

15. __ Total Part II __

Total Parts I and II __. Scores at or above 7.0 = High Hopelessness; scores at or below 4.0 = Low Hopelessness

528

APPENDIX B APPENDIX B.9

Hopkins Motor and Vocal Tic Scale The Hopkins Motor and Vocal Tic Scale allows parents and physicians to record each simple or complex tic symptom, taking into account frequency, intensity, interference, and impairment. The list of tic symptoms is individualized and modified in an ongoing fashion to reflect the patient’s current tics. The scale consists of series of linear analogue scales (10 cm) on which parents and physicians separately rate each tic (motor and/or vocal) symptom. The ends of the lines are 0 (no symptoms) and 10 (severe symptoms). Raters are instructed to divide each line roughly into five ranges: “none,” “mild,” “moderate,” “moderately severe,” and “severe.” A final rating asks parents and the physician to judge the overall severity of the tics on a scale ranging from “no symptoms” to “worst ever.” Parents make their ratings based on the tics seen in the preceding week, and the physician bases his or her ratings on observation during a clinical interview. Three final subjective scores, which reflect the overall ratings of parents, the physician, and a combination of the two, also can be obtained. The overall scores reflects a range of 1 (“no tics”), 2 (“mild”), 3 (“moderate”), 4 (“moderately severe”), and 5 (“severe”). There are no norms for the Hopkins Scale, but it correlates well with other measures of tic severity and allows the clinician to identify the multiple and specific factors that contribute to tic severity and impairment, monitor the progression of a tic, and assess the efficacy of treatment. Name: ______________________________________________

Assessment

Date: _______________________________________________

Parent

Motor

Vocal

Physician Overall For each tic listed below, place a mark on the line that would best describe its severity over the past week. MOTOR Head None Eye blinking

Mild

Moderate

Moderately Severe

Severe

0 _________________________________________________________ 10

Face ___________ 0 _________________________________________________________ 10 ________________ 0 _________________________________________________________ 10 ________________ 0 _________________________________________________________ 10 Neck ________________ 0 _________________________________________________________ 10 Shoulder ________________ 0 _________________________________________________________ 10

From Walkup, Rosenberg, Brown, and Singer (1992). Copyright 1992 by the American Academy of Child and Adolescent Psychiatry. Reprinted by permission.

528

Assessment Instruments

529

Extremities Arm ___________ 0 _________________________________________________________ 10 Fingers ________ 0 _________________________________________________________ 10 Legs ___________ 0 _________________________________________________________ 10 ________________ 0 _________________________________________________________ 10 ________________ 0 _________________________________________________________ 10 VOCAL ________________ 0 _________________________________________________________ 10 ________________ 0 _________________________________________________________ 10 ________________ 0 _________________________________________________________ 10 On the line below, place a mark which would describe how symptoms are today compared to the worst they have ever been or when totally absent. No Symptoms _____________________________________________________ Worst Ever

530

APPENDIX B APPENDIX B.10

Children’s Eating Behavior Inventory (CEBI) The CEBI is a mother report measure that assesses eating and mealtime behavior problems for children ages 2–12. It takes approximately 15 minutes to complete and 5–10 minutes to score. It consists of 40 items, with 28 items focusing on the child (food preferences, motor skills, and behavioral compliance) and 12 items focusing on the parent and family system (parental child behavior controls, cognitions and feelings about feeding one’s child, and interactions between family members). Single-parent families complete 36 items, and two-parent families with only one child complete 39 items. A weighting system is used to compensate for the omitted items. Responses regarding how often a behavior occurs are given on a 5-point intensity scale (“never,” “seldom,” “sometimes,” “often,” “always), and each item is also scored “yes” or “no” as a problem. Psychometric properties are adequate, with means and standard deviation scores given for clinic and nonclinic normative samples. Name ____________________________________________ Age ______ _________ Sex M F Years Months How Often Does This Happen? Never Seldom Sometimes Often Always Is this a problem 1 2 3 4 5 for you? 1. My child chews food as expected for his/her age

1

2

3

4

5

Yes

No

2. My child helps to set the table

1

2

3

4

5

Yes

No

3. My child watches TV at meals

1

2

3

4

5

Yes

No

4. I feed my child if he/she doesn’t eat

1

2

3

4

5

Yes

No

5. My child takes more than half an hour to eat his/her meals

1

2

3

4

5

Yes

No

6. Relatives complain about my child’s eating

1

2

3

4

5

Yes

No

7. My child enjoys eating

1

2

3

4

5

Yes

No

8. My child asks for food which he/she shouldn’t have

1

2

3

4

5

Yes

No

9. My child feeds him/herself as expected for his/her age

1

2

3

4

5

Yes

No

1

2

3

4

5

Yes

No

10. My child gags at mealtimes

From Archer, Rosenbaum, and Streiner (1991). Copyright 1991 by Plenum Publishing Corporation. Reprinted by permission.

530

Assessment Instruments 11. I feel confident my child eats enough

1

2

3

531 4

5

Yes

No

12. I find our meals stressful

1

2

3

4

5

Yes

No

13. My child vomits at mealtime

1

2

3

4

5

Yes

No

14. My child takes food between meals without asking

1

2

3

4

5

Yes

No

15. My child comes to the table 1 or 2 minutes after I call

1

2

3

4

5

Yes

No

16. My child chokes at mealtimes

1

2

3

4

5

Yes

No

17. My child eats quickly

1

2

3

4

5

Yes

No

18. My child makes foods for him/herself when not allowed

1

2

3

4

5

Yes

No

19. I get upset when my child doesn’t eat

1

2

3

4

5

Yes

No

20. At home my child eats food he/she shouldn’t have

1

2

3

4

5

Yes

No

21. My child eats foods that taste different

1

2

3

4

5

Yes

No

22. I let my child have snacks between meals

1

2

3

4

5

Yes

No

23. My child uses cutlery as expected for his/her age

1

2

3

4

5

Yes

No

24. At friend’s homes my child eats food he/she shouldn’t eat

1

2

3

4

5

Yes

No

25. My child asks for food between meals

1

2

3

4

5

Yes

No

26. I get upset when I think about our meals

1

2

3

4

5

Yes

No

27. My child eats chunky foods

1

2

3

4

5

Yes

No

28. My child lets food sit in his/her mouth

1

2

3

4

5

Yes

No

29. At dinner I let my child choose the foods he/she wants from what is served

1

2

3

4

5

Yes

No

30. My child’s behavior at meals upsets my spouse

1

2

3

4

5

Yes

No

532

APPENDIX B

31. I agree with my spouse about how much our child should eat

1

2

3

4

5

Yes

No

32. My child interrupts conversations with my spouse at meals

1

2

3

4

5

Yes

No

33. I get upset with my spouse at meals

1

2

3

4

5

Yes

No

34. My child eats when upset

1

2

3

4

5

Yes

No

35. My child says he/she is hungry

1

2

3

4

5

Yes

No

36. My child says she/he’ll get fat if she/he eats too much

1

2

3

4

5

Yes

No

37. My child helps to clear the table

1

2

3

4

5

Yes

No

38. My child hides food

1

2

3

4

5

Yes

No

39. My child brings toys or books to the table

1

2

3

4

5

Yes

No

Yes

No

If You Have Only One Child, Skip Number 40 40. My child’s behavior at meals upsets our other children

1

2

3

4

5

Please check to see that you have answered all the items. Have you circled a Yes or No for each item? Thank you.

SCORING Part I The following items are scored in a positive direction (i.e., a response of 1 is scored 1, 2 is scored 2, etc.). 3 ___, 4 ___, 5 ___, 6 ___, 8 ___, 10 ___, 12 ___, 13 ___, 14 ___, 16 ___, 17 ___, 18 ___, 19 ___, 20 ___, 22 ___, 24 ___, 25 ___, 26 ___, 28 ___, 30 ___, 32 ___, 33 ___, 34 ___, 35 ___, 36 ___, 38 ___, 39 ___, 40 ___,

Part II The following items are scored in a negative direction (i.e., a response of 1 is scored 5, 2 is scored 4, 3 is scored 3, a 4 is scored 2, and 5 is scored 1). 1 ___, 2 ___, 7 ___, 9 ___, 11 ___, 15 ___, 21 ___, 23 ___, 27 ___, 29 ___, 31 ___, 37 ___,

Assessment Instruments

533

Intensity of Eating Problems Only child ___, single parent ___, # of missing items ___, # items completed ___, Total CEBI score ___, Adjusted CEBI score ([Total CEBI score/# items completed] × 40) ________

Percentage of Problem Items # Y/N ___, # completed ___, # answered yes ___, % answered yes ___

MEANS AND STANDARD DEVIATIONS: TOTAL EATING PROBLEM SCORES AND PERCENTAGE OF ITEMS PERCEIVED TO BE A PROBLEM Nonclinic M SD Eating problem score Total sample 2- to 6-year-olds 7- to 12-year-olds Percentage of items perceived to be a problem Total sample 2- to 6-year-olds 7- to 12-year-olds

Clinic M

SD

86.65 88.08 83.93

11.54 11.73 10.74

92.52 93.00 92.07

12.57 14.27 10.85

13.26 13.40 12.97

13.26 13.32 13.22

20.86 19.49 22.14

16.65 17.84 15.51

A Total Adjusted score of 100 or greater could be considered in the clinical range. A Percentage of Problems score of 16 or greater could be considered in the clinical range.

534

APPENDIX B APPENDIX B.11

Child Attention Problems (CAP) The CAP was developed primarily for teachers to do weekly assessments of the effects of stimulant medication for children ages 6–16 years. The items were taken from the original version of the Child Behavior Checklist—Teacher’s Report Form, with five items focusing on Inattention and seven items on Overactivity. It takes less than 5 minutes to complete, with the responses of “not true,” “somewhat or sometimes true,” and “very or often true”: scored on a 0–2 point scale. Psychometrics are not reported, but the scale has been shown to be quite sensitive to stimulant drug effects. Child’s Name ______________________________________________ Child’s Age ____________________ Filled Out By ______________________________________________ Child’s Sex [ ] M

[ ] F

Directions: Below is a list of items that describe pupils. For each item that describes the pupil now or within the past week, check whether the items is Not True, Somewhat or Sometimes True, o r Very or Often True. Please check all items as well as you can, even if some do not seem to apply to this pupil. Not True

Somewhat or Sometimes True

Very or Often True

1. Fails to finish things he/she starts.

[ ]

[ ]

[ ]

2. Can’t concentrate, can’t pay attention for long.

[ ]

[ ]

[ ]

3. Can’t sit still, restless, or hyperactive.

[ ]

[ ]

[ ]

4. Fidgets.

[ ]

[ ]

[ ]

5. Daydreams or gets lost in his/her thoughts.

[ ]

[ ]

[ ]

6. Impulsive or acts without thinking.

[ ]

[ ]

[ ]

7. Difficulty following directions.

[ ]

[ ]

[ ]

8. Talks out of turn.

[ ]

[ ]

[ ]

9. Messy work.

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

10. Inattentive, easily distracted. 11. Talks too much.

[ ]

[ ]

[ ]

12. Fails to carry out assigned tasks.

[ ]

[ ]

[ ]

Please feel free to write any comments about the pupil’s work or behavior in the last week.

SCORING KEY Each item is scored 0 for Not True, 1 for Somewhat or Sometimes True, or 2 for Very or Often True. II. Inattention: 1 ___, 5 ___, 7 ___, 9 ___, 10 ___, 12 ___, Total____ II. Overactivity: 3 ___, 4 ___, 6 ___, 8 ___, 11 ___, Total____ Total Score (I + II) ____

From Edelbrock (1990, cited in Barkley, 1998a). Reprinted by permission.

534

Assessment Instruments

535

NORMATIVE CUTOFF POINTS FOR INATTENTION, OVERACTIVITY, AND TOTAL SCORES Cutoff points

Total (1,100)

Boys (550)

Girls (550)

2 4 7 9 12

0 2 5 7 10

1 2 4 6 8

0 1 2 5 7

4 7 11 15 20

1 4 8 11 16

Inattention Median 69th percentile 84th percentile 93rd percentile 98th percentile

1 3 6 8 11 Overactivity

Median 69th percentile 84th percentile 93rd percentile 98th percentile

0 1 4 6 8 Total score

Median 69th percentile 84th percentile 93rd percentile 98th percentile

2 6 10 14 19

Numbers in parentheses are sample sizes. Table entries are raw scores that fall at or below the designated percentile range. The 93rd percentile is the recommended upper limit of the normal range. Scores exceeding this cutoff are in the clinical range. All scores are based on teacher reports.

536

APPENDIX B APPENDIX B.12

Academic Performance Rating Scale (APRS) The APRS was designed to assess the effect of child behavior problems on academic productivity and accuracy in the classroom for children in grades 1 through 6. Nineteen items assess four factors: Academic Productivity (e.g., percentage of work completed), Academic Success (e.g., percentage of work completed accurately), Impulse Control (e.g., neatness of work, amount of work begun carelessly), and Social Withdrawal. The teacher responds to the items on a 5-point scale. It takes approximately 10 minutes to complete. Means and standard deviations by grade and gender are available. Psychometric properties for the APRS are good, but normative data are based on a small sample. In addition to its brevity, the value of the APRS is in its assessments of academic success and academic productivity, which are not readily available on other teacher rating scales. The APRS is also very useful in evaluating the effects of stimulant drug dosages on academic accuracy and productivity, especially when these are considered in relation to the information obtained on the Social Withdrawal factor. Although there is no scoring for Social Withdrawal, the item to check is number 19. Student ______________________________________________________ Date ______________________ Age ____________ Grade __________ Teacher _______________________________________________ For each of the below items, please estimate the above student’s performance over the past week. For each item, please circle one choice only. 1. Estimate the percentage of written math work completed (regardless of accuracy) relative to classmates.

0–49%

50–69%

70–79%

80–89%

90–100%

1

2

3

4

5

2. Estimate the percentage of written language arts work completed (regardless of accuracy) relative to classmates.

0–49%

50–69%

70–79%

80–89%

90–100%

1

2

3

4

5

3. Estimate the accuracy of completed written math work (i.e., percent correct of work done).

0–64%

65–69%

70–79%

80–89%

90–100%

1

2

3

4

5

4. Estimate the accuracy of completed written language arts work (i.e., percent correct of work done).

0–64%

65–69%

70–79%

80–89%

90–100%

1

2

3

4

5

5. How consistent has the quality of this child’s academic work been over the past week?

Consistently poor

Variable

3

More successful than poor 4

Consistently successful

1

More poor than successful 2

6. How frequently does the student accurately follow teacher instructions and/or class discussion during large-group (e.g., whole-class) instruction?

Never

Rarely

Sometimes

Often

Very often

1

2

3

4

5

7. How frequently does the student accurately follow teacher instructions and/or class discussion during small-group (e.g., reading group) instruction?

Never

Rarely

Sometimes

Often

Very often

1

2

3

4

5

5

From DuPaul, Rapport, & Perriello (1991). Copyright 1991 by the National Association of School Psychologists. Reprinted by permission.

536

Assessment Instruments 8. How quickly does this child learn new material (i.e., pick up novel concepts)?

537

Very slowly 1

Slowly 2

Average 3

Quickly 4

Very quickly 5

Poor

Fair

Average

Excellent

1

2

3

Above average 4

Poor

Fair

Average

Excellent

1

2

3

Above average 4

Poor

Fair

Average

Excellent

1

2

3

Above average 4

12. How often does the child complete written work in a careless, hasty fashion?

Never

Rarely

Sometimes

Often

Very often

1

2

3

4

5

13. How frequently does the child take more time to complete work than his/her classmates?

Never

Rarely

Sometimes

Often

Very often

1

2

3

4

5

14. How often is the child able to pay attention without you prompting him/her?

Never

Rarely

Sometimes

Often

Very often

1

2

3

4

5

15. How frequently does this child require your assistance to accurately complete his/her academic work?

Never

Rarely

Sometimes

Often

Very often

1

2

3

4

5

16. How often does the child begin written work prior to understanding the directions?

Never

Rarely

Sometimes

Often

Very often

1

2

3

4

5

17. How frequently does this child have difficulty recalling material from a previous day’s lessons?

Never

Rarely

Sometimes

Often

Very often

1

2

3

4

5

18. How often does the child appear to be staring excessively or “spaced out”?

Never 1

Rarely 2

Sometimes 3

Often 4

Very often 5

19. How often does the child appear withdrawn or tend to lack an emotional response in a social situation?

Never

Rarely

Sometimes

Often

Very often

1

2

3

4

5

9. What is the quality or neatness of this child’s handwriting?

10. What is the quality of this child’s reading skills?

11. What is the quality of this child’s speaking skills?

5

5

5

SCORING KEY The following items are scored 1 to 5 and summed for each factor. Academic Success

3__ 4__ 5__ 8__ 10__ 11__ 17__

Total__

Impulse Control 9__ 12__ 16__

Total__

Academic Productivity 1__ 2__ 3__ 4__ 5__ 6__ 7__ 13__ 14__ 15__ 18__ 19__

Total__

538

APPENDIX B

MEANS AND STANDARD DEVIATIONS BY GRADE AND GENDER

Grade

Total Score

Academic Success

Impulse Control

Academic Productivity

Girls Grade 1 M SD

67.02 16.27

23.92 7.37

9.76 2.49

44.68 10.91

M SD

72.56 12.33

26.61 5.55

10.15 2.70

47.85 7.82

M SD

72.10 14.43

25.07 6.07

10.86 2.65

47.88 9.35

M SD

67.79 18.69

24.08 7.56

10.36 2.91

44.26 11.96

M SD

73.02 14.10

26.11 6.01

10.76 2.34

48.36 9.05

M SD

74.10 14.45

26.59 6.26

10.79 2.25

48.77 9.13

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Boys Grade 1 M SD

71.95 16.09

26.86 6.18

10.67 2.82

46.48 11.24

M SD

67.84 14.86

25.24 6.15

9.56 2.72

44.30 10.76

M SD

68.49 16.96

25.26 6.53

9.27 2.67

45.61 11.89

M SD

69.77 15.83

25.35 6.50

9.83 2.77

45.71 10.22

M SD

63.68 18.04

23.14 7.31

8.69 2.82

42.40 12.47

M SD

65.24 12.39

23.75 55.90

9.05 2.35

43.59 8.19

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Assessment Instruments

539

APPENDIX B.13

Therapy Attitude Inventory (TAI) Mother ____________________________________ Father _________________________________________ (Please circle the response for each question which best expresses how you honestly feel.) I. Regarding techniques of disciplining, I feel I have learned 1. Nothing 2. Very little 3. A few new 4. Several useful techniques techniques

5. Very many useful techniques

II. Regarding techniques for teaching my child new skills, I feel I have learned 1. Nothing 2. Very little 3. A few new 4. Several useful 5. Very many techniques techniques useful techniques III. Regarding the relationship between myself and my child, I feel we get along 1. Much worse 2. Somewhat 3. The same 4. Somewhat 5. Very much than before worse than as before better than better than before before before IV. Regarding my confidence in my ability to discipline my child, I feel 1. Much less 2. Somewhat 3. The same 4. Somewhat confident less confident improved

5. Greatly improved

V. The major behavior problems that my child presented at home before the program started are at this time 1. Considerably 2. Somewhat 3. The same 4. Somewhat 5. Greatly worse worse improved improved VI. I feel that my child’s compliance to my commmands or requests is at this time 1. Considerably 2. Somewhat 3. The same 4. Somewhat 5. Greatly worse worse improved improved VII. Regarding the progress my child has made in his/her general behavior, I am 1. Very 2. Somewhat 3. Neutral 4. Somewhat 5. Very dissatisfied dissatisfied satisfied satisfied VIII. To what degree has the treatment program helped with other general personal or family problems not directly related to your child in the program? 1. Hindered 2. Hindered 3. Neither 4. Helped 5. Helped much more slightly helped nor somewhat very much than helped hindered IX. I feel the type of program that was used to help me improve the behaviors of my child was 1. Very poor 2. Poor 3. Adequate 4. Good 5. Very good X. My general feeling about the program I participated in is 1. I disliked it 2. I disliked it 3. I feel 4. I liked it very much somewhat neutral somewhat

5. I liked it very much

From Eyberg (1974; cited in Breston et al., 1999). Copyright 1974 by Sheila Eyberg, PhD. Reprinted by permission.

539

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References

Abelson, J. L., & Alessi, N. E. (1992). Discussion of child panic revisited. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 114–116. Aber, J. L., Jones, S. J., Joshua, L., Chaudry, N., & Samples, F. (1998). Resolving conflict creatively: Evaluating the developmental effects of a school-based violence prevention program in neighborhood and classroom context. Development and Psychopathology, 10, 187–213. Abidin, R. R. (1989, August). The determinants of parenting: What variables do we need to look at? Paper presented at the meeting of the American Psychological Association, New Orleans, LA. Abidin, R. R. (1995). Parenting Stress Index manual (3rd ed.). Odessa, FL: Psychological Assessment Resources. Abidin, R. R., & Brunner, J. F. (1995). Development of a Parenting Alliance Inventory. Journal of Clinical Child Psychology, 24, 31–40. Abidin, R. R., & Konold, T. R. (1999). Parenting Alliance Measure: Professional manual. Odessa, FL: Psychological Assessment Resources. Abikoff, H., & Hechtman, L. (1996). Multimodal therapy and stimulants in the treatment of children with ADHD. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 341–369). Washington, DC: American Psychological Association. Abikoff, H., & Klein, R. G. (1992). Attention-deficit hyperactivity disorder and conduct disorder: Comorbidity and implications for treatment. Journal of Consulting and Clinical Psychology, 60, 881–892. Abraham, S., & Nordsieck, M. (1960). Relationship of excess weight in children and adults. Public Health Reports, 75, 263–273. Abrahamian, F. P., & Lloyd-Still, J. P. (1984). Chronic constipation in children: A longitudinal study of 186 patients. Journal of Pediatric Gastroenterology and Nutrition, 3, 460–467. Abramovitch, R., Corter, C., Pepler, D. J., & Stanhope, L. (1986). Sibling and peers interaction: A final follow-up and a comparison. Child Development, 57, 217–229. Abramson, L. Y., Metalsky, G. I., & Alloy, L. B. (1989). Hopelessness depression: A theory-based subtype of depression. Psychological Bulletin, 96, 358–372. Abwender, D. A., Como, P. G., Kurlan, R., Parry, K., Fett, K., Cui, A. L., Plumb, S., & Deeley, C. (1996). School problems in Tourette’s syndrome. Archives of Neurology, 53, 509–511. Achenbach, T. M. (1986). Child Behavior Checklist: Direct Observation Form (rev. ed.). Burlington: University of Vermont, Department of Psychiatry. Achenbach, T. M. (1991a). Manual for the Child Behavior Checklist/4–18 and 1991 Profile. Burlington: University of Vermont, Department of Psychiatry. Achenbach, T. M. (1991b). Manual for the Teacher’s Report Form and 1991 Profile. Burlington: University of Vermont, Department of Psychiatry. Achenbach, T. M. (1991c). Manual for the Youth Self-Report and 1991 Profile. Burlington: University of Vermont, Department of Psychiatry. Achenbach, T. M. (1992). Manual for the Child Behavior Checklist/2–3 and 1992 Profile. Burlington: University of Vermont, Department of Psychiatry.

541

542

References

Achenbach, T. M. (1998). Diagnosis, assessment, taxonomy, and case formulations. In T. M. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (3rd ed., pp. 63–87). New York: Plenum Press. Achenbach, T. M., & Edelbrock, C. (1981). Behavioral problems and compentencies reported by parents of normal and disturbed children aged 4 through 16. Monographs of the Society for Research in Child Development, 46(1, Serial No. 188). Achenbach, T. M., & Edelbrock, C. S. (1983). Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: University Associates in Psychiatry. Achenbach, T. M., Howell, C. T., McConaughy, S. H., & Stanger, C. (1995). Six year predictors of problems in a national sample of children and youth: I. Cross-informant syndromes. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 336–347. Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychological Bulletin, 101, 213–232. Ackerman, B. P., Kogos, J., Youngstrom, E., Schoff, K., & Izard, C. (1999). Family instability and the problem behaviors of children from economically disadvantaged families. Developmental Psychology, 35, 258–268. Ackerman, M. J. (1999). Does Wednesday mean Mom’s house or Dad’s?: Parenting together while living apart. New York: Wiley. Adams, C., & Fay, J. (1992). Helping your child recover from sexual abuse. Seattle, WA: University of Washington Press. Adams, J. A. (1995). The role of the medical evaluation in suspected child sexual abuse. In T. Ney (Ed.), True and false allegations of child sexual abuse: Assessment and case management (pp. 231–241). New York: Brunner/Mazel. Addis, M. E., Wade, W. A., & Hatgis, C. (1999). Barriers to dissemination of evidence-based practices: Addressing practitioners’ concerns about manual-based psychotherapies. Clinical Psychology: Science and Practice, 6, 430–441. Albano, A. M., Causey, D., & Carter, B. D. (2001). Fears and anxiety in children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 291–316). New York: Wiley. Albano, A. M., Chorpita, B. F., & Barlow, D. H. (1996). Childhood anxiety disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (pp. 196–241). New York: Guilford Press. Aldous, J., Mulligan, G. M., & Bjornason, T. (1998). Fathering over time: What makes the difference? Journal of Marriage and the Family, 60, 809–820. Alexander, M. (1992). When the new baby comes, I’m moving out. New York: Dial Press. Allen, K. D., Flegel, J. H., & Watson, T. S. (1992). A thermoplast thumb-post for treatment of thumbsucking. American Journal of Occupational Therapy, 46, 552–554. Allen, K. D., & Stokes, T. F. (1987). The use of escape and reward in the management of young children during dental treatment. Journal of Applied Behavior Analysis, 20, 381–390. Allen, L., & Zigler, E. (1986). Psychological adjustment of seriously ill children. Journal of the American Academy of Child Psychiatry, 25, 708–712. Allison, P. D., & Furstenberg, F. F., Jr. (1989). How marital dissolution affects children: Variations by age and sex. Developmental Psychology, 25, 708–712. Altman, R., Grahs, C., & Friman, P. C. (1982). Treatment of unobserved trichotillomania by attention-reflection and punishment of an operant covariant. Journal of Behavior Therapy and Experimental Psychiatry, 13, 337–340. Amato, P. R., & Booth, A. (1996). A prospective study of divorce and parent–child relationships. Journal of Marriage and the Family, 58, 356–365. Amato, P. R., & Gilbreth, J. G. (1999). Nonresident fathers and children’s well-being: A meta-analysis. Journal of Marriage and the Family, 53, 43–58. Amato, P. R., & Keith, B. (1991a). Parental divorce and adult well-being: A meta-analysis. Journal of Marriage and the Family, 53, 43–58. Amato, P. R., & Keith, B. (1991b). Parental divorce and the well-being of children: A meta-analysis. Psychological Bulletin, 110, 26–46. Amato, P. R., & Rezac, S. J. (1994). Contact with nonresident parents, interparental conflict and children’s behavior. Journal of Family Issues, 15, 191–207. Amato, P. R., & Rivera, F. (1999). Paternal involvement and children’s behavior problems. Journal of Marriage and the Family, 61, 375–384. Amato, P. R., Loomis, & Booth, A. (1995). Parental divorce, marital conflict, and offspring well-being during early adulthood. Social Forces, 73, 895–915. American Academy of Child and Adolescent Psychiatry. (1997a). Practice parameters for the forensic evaluation of children and adolescents who may have been physically or sexually abused. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 423–442.

References

543

American Academy of Child and Adolescent Psychiatry. (1997b). Practice parameters for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 69S–84S. American Academy of Pediatrics. (1998). Guidance for effective discipline. Pediatrics, 101, 723–728. American Academy of Pediatrics. (2000). Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105, 1158–1170. American Academy of Pediatrics. (2001). Clinical practice guideline: Treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics, 108, 1033–1044. American Academy of Pediatrics, Committee on Drugs. (1996). Unapproved uses of approved drugs: The physician, the package insert, and the Food and Drug Administration. Subject review. Pediatrics, 98, 143–145. American Professional Society on the Abuse of Children. (1990). Guidelines for psychosexual evaluation of childhood sexual abuse in young children. Chicago, IL: Author. American Psychiatric Association (APA). (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (APA). (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychological Association. (1994a). Guidelines for child custody evaluations in divorce proceedings. American Psychologist, 49, 677–680. American Psychological Association. (1994b). Report of the anatomical doll task force. Washington, DC: Author. Anastopoulos, A. D., & Shaffer, S. D. (2001). Attention-deficit hyperactivity disorder. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 470–494). New York: Wiley. Anastopoulos, A. D., & Shelton, T. L. (2001). Assessing attention-deficit hyperactivity disorder. New York: Kluwer Academic/Plenum Publishers. Anastopoulos, A. D., Shelton, T., DuPaul, G. J., & Guevremont, D. C. (1993). Parent training for attention deficit hyperactivity disorder: Its impact on parent functioning. Journal of Abnormal Child Psychology, 21, 581–596. Anders, T. F., & Eiben, L. A. (1997). Pediatric sleep disorders: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 9–20. Anders, T. G., Halpern, L., & Hua, J. (1992). Sleeping through the night: A developmental perspective. Pediatrics, 90, 554–560. Anders, T. G., & Taylor, T. (1994). Babies and their sleep environments. Children’s Environment, 11, 123–134. Anderson, D., & Finne, M. (1986). Margaret’s story: Sexual abuse and going to court. Minneapolis, MN: Dillon Press. Anderson, J. C., Williams, S., McGee, R., & Silva, P. A. (1987). DSM-III disorders in preadolescent children. Archives of General Psychiatry, 44, 69–76. Anderson, K. E., Lytton, H., & Romney, D. M. (1986). Mothers’ interactions with normal and conduct-disordered boys: Who affects whom? Developmental Psychology, 22, 604–609. Andrews, V. C., Garrison, C. Z., Jackson, K. L., Addy, C. L., & McKeown, R. E. (1993). Mother–adolescent agreement on symptoms and diagnoses of adolescent depression and conduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 731–738. Andrus, J. K., Fleming, D. W., Heumann, M. A., Wassell, J. T., Hopkins, D. D., & Gordon, J. (1991). Surveillance of attempted suicide among adolescents in Oregon, 1988. American Journal of Public Health, 81, 1067–1069. Angold, A., & Costello, E. J. (1995). Developmental epidemiology. Epidemiologic Reviews, 17, 74–82. Angold, A., & Costello, E. J. (1996). Toward establishing an empirical basis for the diagnosis of oppositional defiant disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1205–1212. Angold, A., Costello, E. J., Burns, B. J., Erkanli, A., & Farmer, E. M. Z. (2000). The effectiveness of nonresidential specialty mental health services for children and adolescents in the “real world.” Journal of the American Academy of Child and Adolescent Psychiatry, 39, 154–160. Angold, A., Erkanli, A., Costello, E. J., & Rutter, M. (1996). Precision, reliability and accuracy in the dating of symptom onset in child and adolescent psychopathology. Journal of Child Psychology and Psychiatry, 7, 657–664. Angold, A., Erkanli, A., Egger, H. L., & Costello, E. J. (2000). Stimulant treatment for children: A community perspective. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 975–984. Angold, A., Messer, S., Stangl, D., Farmer, E., Costello, E., & Burns, B. (1998). Perceived parental burden and service use for child and adolescent psychiatric disorders. American Journal of Public Health, 88, 75–80.

544

References

Anhalt, K., McNeil, C. B., & Bahl, A. B. (1998). The ADHD Classroom Kit: A whole-classroom approach for managing disruptive behavior. Psychology in the Schools, 35, 67–80. Apter, T. (1997). The confident child: A practical, compassionate guide. New York: Bantam Books. Archer, J. (1991). The influence of testosterone on human aggression. British Journal of Psychology, 82, 1–28. Archer, L. A., Rosenbaum, P. L., & Streiner, D. L. (1991). The Children’s Eating Behavior Inventory: Reliability and validity results. Journal of Pediatric Psychology, 16, 629–642. Arend, R., Lavigne, J. V., Rosenbaum, D., Binns, H. J., & Christoffell, K. K. (1996). Relation between taxonomy and qualitative diagnostic systems in preschool children: Emphasis on disruptive disorders. Journal of Clinical Child Psychology, 25, 288–307. Armistead, L., McCombs, A., Forehand, R., Wierson, M., Long, N., & Fauber, R. (1990). Coping with divorce: A study of young adolescents. Journal of Clinical Child Psychology, 19, 79–84. Armsden, G. C., McCauley, E., Greenburg, M. T., Burke, P. N., & Mitchell, J. R. (1990). Parent and peer attachment in early adolescent depression. Journal of Abnormal Child Psychology, 18, 683–697. Arnold, J., & Jacobowitz, D. (1993). The Cross-Informant Program for the CBCL/4–18, YSR, and TRF. Burlington: University of Vermont, Department of Psychiatry. Aronen, E. T., Paavonen, J., Fjällberg, M., Soininen, M., & Törrönen, J. (2000). Sleep and psychiatric symptoms in school-age children. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 502–508. Asarnow, J. R., Jaycox, L. H., & Tompson, M. C. (2001). Depression in youth: Psychosocial interventions. Journal of Clinical Child Psychology, 30, 33–47. Ash, P., & Guyer, M. (1984). Court implementation of mental health professionals recommendations in contested child custody and visitation cases. Journal of the American Academy of Psychiatry and Law, 12, 137–148. Ash, P., & Guyer, M. (1986). The functions of psychiatric evaluations in contested child custody and visitation cases. Journal of the American Academy of Child and Adolescent Psychiatry, 25, 554–561. Atkeson, B. M., & Forehand, R. (1978). Parent behavior training for problem children: An examination of studies using multiple outcome measures. Journal of Abnormal Child Psychology, 6, 449–460. Atkinson, E., Vetere, A., & Grayson, K. (1995). Sleep disruption in young children: The influence of temperament on the sleep patterns of pre-school children. Child: Care, Health and Development, 21, 233–246. Auchter, U. (1990). Anxiety in children: An investigation on various forms of anxiety. Acta Paedopsychiatrica, 53, 78–88. August, G. J., & Garfinkel, G. D. (1990). Comorbidity of ADHD and reading disability among clinic-referred children. Journal of Abnormal Child Psychology, 18, 29–45. August, G. J., Realmuto, G. M., Joyce, T., & Hektner, J. M. (1999). Persistence and desistance of oppositional defiant disorder in a community sample of children with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1262–1270. August, G. J., Realmuto, G. M., MacDonald, A. W., Nugent, S. M., & Crosby, R. (1996). Prevalence of ADHD and comorbid disorders among elementary school children screened for disruptive behavior. Journal of Abnormal Child Psychology, 24, 571–595. Ayoub, C. C., Deutsch, R. M., & Maraganore, A. (1999). Emotional distress in children of high-conflict divorce: The impact of marital conflict and violence. Family and Conciliation Courts Review, 37, 297– 314. Azrin, N. H., & Besalel, V. A. (1979). A parent’s guide to bedwetting control. New York: Simon & Schuster. Azrin, N. H., & Foxx, R. M. (1974). Toilet training in less than a day. New York: Simon & Schuster. Azrin, N. H., & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619–628. Azrin, N. H., & Nunn, R. G. (1977). Habit control in a day. New York: Pocket Books. Azrin, N. H., & Peterson, A. L. (1988). Behavior therapy for Tourette syndrome and tic disorders. In D. J. Cohen, R. D. Bruun, & J. F. Leckman (Eds.), Tourette syndrome and tic disorders (pp. 237–256). New York: Wiley. Azrin, N. H., & Peterson, A. L. (1990). Treatment of Tourette syndrome by habit reversal: A waiting-list control group comparison. Behavior Therapy, 21, 305–318. Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Habit reversal vs. negative practice treatment of nailbiting. Behaviour Research and Therapy, 18, 281–285. Azrin, N. H., Nunn, R. G., & Frantz-Renshaw, S. (1980). Habit reversal treatment of thumb sucking. Behaviour Research and Therapy, 18, 395–399. Azrin, N. H., Nunn, R. G., & Frantz-Renshaw, S. (1982). Habit reversal vs. negative practice treatment of self-destructive oral habits (biting, chewing, or licking of the lips, cheeks, tongue, or palate). Journal of Behavior Therapy and Experimental Psychiatry, 13, 49–54.

References

545

Azrin, N. H., Sneed, T. J., & Foxx, R. M. (1974). Dry-bed training: Rapid elimination of childhood enuresis. Behaviour Research and Therapy, 12, 147–156. Babinski, L. M., Hartsough, C. S., & Lambert, N. M. (1999). Childhood conduct problems, hyperactivity– impulsivity and inattention as predictors of adult criminal activity. Journal of Child Psychology and Psychiatry, 40, 347–355. Bacon, J. B. (1996). Support groups for bereaved children. In C. A. Corr & D. M. Corr (Eds.), Handbook of childhood death and bereavement (pp. 285–304). New York: Springer. Baer, L., Osgood-Hynes, & Minichiello, W. E. (1999). Trichotillomania. In R. T. Ammerman, M. Hersen, & C. G. Last (Eds.), Handbook of prescriptive treatments for children and adolescents (2nd ed., pp. 277– 292). Needham Heights, MA: Allyn & Bacon. Bagley, C. (1990). Is the prevalence of child sexual abuse decreasing?: Evidence from a random sample of 750 young adult women. Psychological Reports, 66, 1037–1038. Bagwell, C. I., Molina, B. S. G., Pelham, W. E., & Hoza, B. (2001). Attention-deficit hyperactivity disorder and problems in peer relations: Predictions from childhood to adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1285–1292. Bailey, J. M., Bobrow, D., Wolfe, M., & Mikach, S. (1995). Sexual orientation of adult sons of gay fathers. Developmental Psychology, 31, 124–129. Bailey, J. M., & Zucker, K. J. (1995). Childhood sex-typed behavior and sexual orientation: A conceptual analysis and quantitative review. Developmental Psychology, 31, 43–55. Baker, J. E., Sedney, M. A., & Gross, E. (1992). Psychological tasks for bereaved children. American Journal of Orthopsychiatry, 62, 105–116. Baker, S. P., O’Neill, B., Ginsburg, M. J., & Li, G. (1992). The injury fact book (2nd ed.). Lexington, MA: Lexington Books. Bakwin, H. (1973). The genetics of enuresis. In I. Kolvin, R. C. MacKeith, & S. R. Meadow (Eds.), Bladder control and enuresis (pp. 73–77). Philadelphia: Lippincott. Bakwin, H., & Bakwin, R. M. (1972). Behavior disorders in children (4th ed.). Philadelphia: Saunders. Bank, L., Patterson, G. R., & Reid, J. B. (1996). Negative sibling interaction patterns as predictors of later adjustment problems in adolescent and young adult males. In G. H. Brody (Ed.), Sibling relationships: Their causes and consequences (pp. 197–229). Norwood, NJ: Ablex. Barber, B. K., Olsen, J. E., & Shagle, S. C. (1994). Associations between parental psychological and behavioral control and youth internalized and externalized behaviors. Child Development, 65, 1120– 1136. Barker, P. (1990). Clinical interviews with children and adolescents. New York: Norton. Barkley, R. A. (1994). Impaired delayed responding: A unified theory of attention deficit hyperactivity disorder. In D. K. Routh (Ed.), Disruptive behavior disorders: Essays in honor of Herbert Quay (pp. 11– 57). New York: Plenum Press. Barkley, R. A. (1997a). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65–94. Barkley, R. A. (1997b). Defiant children (2nd ed.): A clinician’s manual for assessment and parent training. New York: Guilford Press. Barkley, R. A. (1997c). Attention-deficit/hyperactivity disorder. In E. J. Mash & L. G. Terdal (Eds.), Assessment of childhood disorders (3rd ed., pp. 71–129). New York: Guilford Press. Barkley, R. A. (1998a). Attention-deficit/hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed.). New York: Guilford Press. Barkley, R. A. (1998b). Attention-deficit/hyperactivity disorder. In E. J. Mash & R. A. Barkley (Eds.), Treatment of childhood disorders (2nd ed., pp. 55–110). New York: Guilford Press. Barkley, R. A. (2000a). Genetics of childhood disorders: XVII. ADHD, Part 1: The executive functions and ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1064–1068. Barkley, R. A. (2000b). Taking charge of ADHD: The complete, authoritative guide for parents (rev. ed.). New York: Guilford Press. Barkley, R. A., Anastopoulos, A. D., Guevremont, D. G., & Fletcher, K. F. (1991). Adolescents with attention deficit hyperactivity disorder: Patterns of behavioral adjustment, academic functioning, and treatment utilization. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 752– 761. Barkley, R. A., Anastopoulos, A. D., Guevremont, D. G., & Fletcher, K. F. (1992). Adolescents with attention deficit hyperactivity disorder: Mother–adolescent interactions, family beliefs and conflicts, and maternal psychopathology. Journal of Abnormal Child Psychology, 20, 263–288. Barkley, R. A., & Benton, C. M. (1998). Your defiant child: Eight steps to better behavior. New York: Guilford Press.

546

References

Barkley, R. A., & Biederman, J. (1997). Towards a broader definition of the age of onset criterion for attention deficit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1204–1210. Barkley, R. A., DuPaul, G. J., & McMurray, M. B. (1990). A comprehensive evaluation of attention deficit disorder with and without hyperactivity. Journal of Consulting and Clinical Psychology, 58, 775–789. Barkley, R. A., DuPaul, G. J., & McMurray, M. B. (1991). Attention deficit disorder with and without hyperactivity: Clinical response to three dose levels of methylphenidate. Pediatrics, 87, 519–531. Barkley, R. A., Fischer, M., Edelbrock, C. S., & Smallish, L. (1990). The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8 year prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 546–557. Barkley, R. A., Fischer, M., Newby, R., & Breen, M. (1988). Development of a multi-method clinical protocol for assessing stimulant drug responses in ADHD children. Journal of Clinical Child Psychology, 17, 14–24. Barkley, R. A., & Grodzinsky, G. M. (1994). Are tests of frontal lobe functions useful in the diagnosis of attention deficit disorders? Clinical Neuropsychologist, 8, 121–139. Barkley, R. A., Guevremont, D. G., Anastopoulos, A. D., & Fletcher, K. (1992). A comparison of three family therapy programs for treating family conflicts in adolescents with attention-deficit hyperactivity disorder. Journal of Consulting and Clinical Psychology, 60, 450–462. Barkley, R. A., McMurray, M. B., Edelbrock, C. S., & Robbins, K. (1989). The response of aggressive and non-aggressive ADHD children to two doses of methylphenidate. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 873–881. Barkley, R. A., & Murphy, K. R. (1998). Attention-deficit/hyperactivity disorder: A clinical workbook (2nd ed.). New York: Guilford Press. Barlow, D. H. (2002). Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed.). New York: Guilford Press. Barlow, D. H., Chorpita, B. F., & Turovsky, J. (1996). Fear, panic, anxiety, and the disorders of emotion. In D. A. Hope (Ed.), Nebraska Symposium on Motivation: Vol. 43. Perspectives on anxiety, panic, and fear (pp. 251–328). Lincoln: University of Nebraska Press. Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, 64, 333–342. Barrett, P. M., Duffy, A. L., Dadds, M. R., & Rapee, R. M. (2001). Cognitive-behavioral treatment of anxiety disorders in children: Long-term (6-year) follow-up. Journal of Consulting and Clinical Psychology, 69, 135–141. Barrett, P. M., Rapee, R. M., Dadds, M. R., & Ryan, S. M. (1996). Family enhancement of cognitive style in anxious and aggressive children: Threat bias and the FEAR effect. Journal of Abnormal Child Psychology, 24, 187–203. Barrios, B. A., & Hartmann, D. P. (1997). Fears and anxieties. In E. J. Mash & L. G. Terdal (Eds.), Assessment of childhood disorders (3rd ed., pp. 230–327). New York: Guilford Press. Barrios, B. A., & O’Dell, S. L. (1998). Fears and anxieties. In E. J. Mash & R. A. Barkley (Eds.), Treatment of childhood disorders (2nd ed., pp. 249–257). New York: Guilford Press. Barth, R. P. (1987). Assessment and treatment of stealing. In B. B. Lahey & A. E. Kazdin (Eds.), Advances in clinical child psychology (Vol. 10, pp. 137–170). New York: Plenum Press. Bates, J. E., & Bales, K. (1988). The role of attachment in the development of behavior problems. In J. Belsky & T. Nezworski (Eds.), Clinical implications of attachment (pp. 253–299). Hillsdale, NJ: Erlbaum. Bates, J. E., Maslin, C. A., & Frankel, K. A. (1985). Attachment security, mother–child interaction, and temperamental predictors of behavior problem ratings at age three years. In I. Bretherton & E. Waters (Eds.), Growing points of attachment theory and research. Monographs of the Society for Research in Child Development, 50(1–2, Serial No. 209), 167–193. Bates, J. E., Pettit, G. S., Dodge, K. A., & Ridge, B. (1998). Interaction of temperamental resistance to control and restrictive parenting in the development of externalizing behavior. Developmental Psychology, 34, 982–995. Bath, R., Morton, R., Uing, A., & Williams, C. (1996). Nocturnal enuresis and the use of desmopressin: Is it helpful? Child: Care, Health and Development, 22, 73–84. Baumgaertel, A., Wolraich, M. L., & Dietrich, M. (1995). Attention deficit disorders in a German elementary school-aged sample. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 629– 638. Baumrind, D. (1967). Child care practices anteceding three patterns of preschool behavior. Genetic Psychology Monographs, 75, 43–88.

References

547

Baumrind, D. (1971). Current patterns of parental authority. Developmental Psychology Monographs, 4(1, Pt. 2). Baumrind, D. (1994). The social context of child maltreatment. Family Relations, 43, 360–368. Baumrind, D. (1996). A blanket injunction against disciplinary use of spanking is not warranted by the data. Pediatrics, 98, 828–831. Baydar, N., Hyle, P., & Brooks-Gunn, J. (1997). A longitudinal study of the effects of the birth of a sibling during preschool and early grade school years. Journal of Marriage and the Family, 59, 957–965. Bearss, K. E., & Eyberg, S. (1998). A test of the parenting alliance theory. Early Education and Development, 9, 179–185. Beaudry, J., & Ketchum, L. (1987). Carla goes to court. New York: Human Sciences Press. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation. Behrman, R., & Kliegman, R. (1998). Nelson—Essentials of pediatrics (3rd ed.). Philadelphia: Saunders. Beidel, D. C. (1991). Social phobia and overanxious disorder in school-age children. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 545–552. Beidel, D. C., & Morris, T. L. (1995). Social phobia. In J. S. March (Ed.), Anxiety disorders in children and adolescents (pp. 181–211). New York: Guilford Press. Beidel, D. C., & Turner, S. M. (1988). Comorbidity of test anxiety and other anxiety disorders in children. Journal of Abnormal Child Psychology, 16, 275–287. Beidel, D. C., & Turner, S. M. (1998). Shy children, phobic adults: Nature and treatment of social phobia. Washington, DC: American Psychological Association. Beidel, D. C., Turner, S. M., & Morris, T. L. (1999). Psychopathology of childhood social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 643–650. Beidel, D. C., Turner, S. M., & Morris, T. L. (2000). Behavioral treatment of childhood social phobia. Journal of Consulting and Clinical Psychology, 69, 1072–1080. Beitchman, J. H., Wilson, B., Johnson, C. J., Atkinson, L., Young, A., Adlae, E., Escobar, M., & Douglas, L. (2001). Fourteen-year follow-up of speech/language-impaired and control children: Psychiatric outcome. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 75–82. Beitchman, J. H., Zucker, K. J., Hood, J. E., DaCosta, G. A., Akman, D., & Cassavia, E. (1991). A review of the short-term effects of child sexual abuse. Child Abuse and Neglect, 15, 537–556. Belmaker, R. H. (1986). The use of desmopressin in adult enuresis. Military Medicine, 151, 660–665. Belsky, J. (1984). The determinants of parenting: A process model. Child Development, 55, 83–96. Belsky, J. (1998). Paternal influence and child’s well-being: Limits of and new directions for understanding. In A. Booth & A. C. Crouter (Eds.), Men in families (pp. 279–293). Hillsdale, NJ: Erlbaum. Belsky, J., Campbell, S. B., Cohn, J. F., & Moore, G. (1996). Instability of infant–parent attachment security. Developmental Psychology, 32, 921–924. Belsky, J., Woodworth, S., & Crnic, K. (1996). Troubled family interaction during toddlerhood. Development and Psychopathology, 8, 477–495. Bem, S. L. (1989). Genital knowledge and gender constancy in preschool children. Child Development, 60, 649–662. Bentovim, A. (1970). The clinical approach to feeding disorders of childhood. Journal of Psychosomatic Research, 14, 267–276. Berg, C. Z., Rapoport, J. L., Whitaker, A., Davies, M., Leonard, H., Swedo, S. E., Braiman, S., & Lenane, M. (1989). Childhood obsessive compulsive disorders: A two-year prospective follow-up of a community sample. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 528–533. Bergan, J. R., & Kratochwill, T. R. (1990). Behavioral consultation and therapy. New York: Plenum Press. Berk, L. B., & Friman, P. C. (1990). Epidemiologic aspects of toilet training. Clinical Pediatrics, 29, 278–282. Berkow, R. (Ed.). (1992). The Merck manual of diagnosis and therapy (16th ed.). Rahway, NJ: Merck, Sharp, & Dohme Research Laboratories. Berliner, L., & Conte, J. R. (1993). Sexual abuse evaluations: Conceptual and empirical obstacles. Child Abuse and Neglect, 17, 111–125. Berliner, L., & Ernst, E. (1984). Group work with preadolescent sexual assault victims. In I. R. Stuart & J. G. Greer (Eds.), Victims of sexual aggression: Treatment of children, women, and men (pp. 105–124). New York: Van Nostrand Reinhold. Berman, S. L., Weems, C. F., Silverman, W. K., & Kurtines, W. M. (2000). Predictors of outcome in exposure based cognitive and behavioral treatments for phobic and anxiety disorders in children. Behavior Therapy, 31, 713–731. Bernard-Bonnin, A.., Haley, N., Belanger, S., & Nadeau, D. (1993). Parental and patient perceptions about encopresis and its treatment. Developmental and Behavioral Pediatrics, 14, 397–400.

548

References

Berndt, T. J. (1981). Effects of friendship on prosocial intentions and behavior. Child Development, 52, 636– 643. Berndt, T. J., & Bulleit, T. N. (1985). Effects of sibling relationships on preschoolers’ behavior at home and at school. Developmental Psychology, 21, 761–767. Bernet, W. (1999). Introduction: Practice parameters for the 21st century. Journal of the American Academy of Child and Adolescent Psychiatry, 38(12, Suppl.), 15–45. Bernstein, A. C., & Cowan, P. A. (1975). Children’s concepts of how people get babies. Child Development, 46, 77–91. Bernstein, G. A., Borchardt, C. M., & Perwien, A. R. (1996). Anxiety disorders in children and adolescents: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1110–1119. Bernstein, G. A., Borchardt, C. M., Perwien, A. R., Crosby, R. D., Kushner, M. G., Thuras, P. D., & Last, C. G. (2000). Imipramine plus cognitive-behavioral therapy in the treatment of school refusal. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 276–283. Bernstein, G. A., Hektner, J. M., Borchardt, C. M., & McMillan, M. H. (2001). Treatment of school refusal: One-year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 206– 213. Bernstein, G. A., Massie, E. D., Thuras, P. D., Perwien, A. R., Borchardt, C. M., & Crosby, R. D. (1997). Somatic symptoms in anxious–depressed school refusers. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 661–668. Biederman, J., Baldessarini, R. J., Wright, V., Knee, D., & Harmatz, J. S. (1989). A double-blind placebo controlled study of desipramine in the treatment of ADD: I. Efficacy. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 777–784. Biederman, J., Faraone, S. V., Milberger, S., Curtis, S., Chen, L., Marrs,A., Ouellette, C., Moore, P., & Spencer, T. (1996). Predictors of persistence and remission of ADHD into adolescence: Results from a fouryear prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 343–351. Biederman, J., Faraone, S. V., Milberger, S., Jettons, J. G., Chen, L., Mick, E., Greene, R. W., & Russell, R. L. (1996). Is childhood oppositional defiant disorder a precursor to adolescent conduct disorder?: Findings from a four-year follow-up study of children with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1193–1204. Biederman, J., Faraone, S. V., Taylor, A., Sienna, M., Williamson, S., & Fine, C. (1998). Diagnostic continuity between child and adolescent ADHD: Findings from a longitudinal clinical sample. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 305–313. Biederman, J., Mick, E., & Faraone, S. V. (2000). Age-dependent decline of attention deficit hyperactivity disorder: Impact of remission definition and symptom subtype. American Journal of Psychiatry, 157, 816–818. Biederman, J., Mick, E., Faraone, S. V., & Burback, M. (2001). Patterns of remission and symptom decline in conduct disorder: A four-year prospective study of an ADHD sample. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 290–298. Biederman, J., Milberger, S., Faraone, S. V., Kiely, K., Guits, J., Mick, E., Ablon, J. S., Warburton, R., Reed, E., & Davis, S. G. (1995). Impact of adversity of functioning and comorbidity in children with attention deficit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1495–1503. Biederman, J., Newcorn, J., & Sprich, S. (1991). Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety and other disorders. American Journal of Psychiatry, 148, 564–577. Biederman, J., Rosenblum, J. F., Bolduc-Murphy, E. A., Faraone, S. V., Chaloff, J., Hirshfeld, D. R., & Kagan, J. (1993a). A three-year follow-up of children with and without behavior inhibition. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 814–821. Biederman, J., Rosenbaum, J. F., Bolduc-Murphy, E. A., Faraone, S. V., Chaloff, J., Hirshfield, D. R., & Kagan, J. (1993b). Behavioral inhibition as a temperamental risk factor for anxiety disorders. Child and Adolescent Psychiatric Clinics of North America, 2, 670–683. Biederman, J., Santangelo, S. L., Faraone, S. V., Kiely, K., Guite, J., Mick, E., Reed, E. D., Kraus, I., Jellinek, M., & Perrin, J. (1995). Clinical correlates of enuresis in ADHD and non-ADHD children. Journal of Child Psychology and Psychiatry, 36, 865–877. Bijou, S. W. (1984). Parent training: Actualizing the critical conditions of early childhood development. In R. F. Dangel & R. A. Polster (Eds.), Parent training (pp. 15–26). New York: Guilford Press. Binder, S., & Matte, T. (1993). Childhood lead poisoning: The impact of prevention. Journal of the American Medical Association, 269, 1679–1681.

References

549

Birch, L. L. (1990). Development of food acceptance patterns. Developmental Psychology, 26, 515–519. Birch, L. L., & Fisher, J. (1998). Development of eating behaviors among children and adolescents. Pediatrics, 101(Suppl.), 539–549. Bird, H. R. (1996). Epidemiology of childhood disorders in a cross-cultural context. Journal of Child Psychology and Psychiatry, 37, 35–49. Bird, H. R., Davies, M., Fisher, P., Narrow, W. E., Jensen, P. S., Hoven, C., Cohen, P., & Dulcan, M. K. (2000). How specific is specific impairment? Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1182–1189. Bird, H. R., Gould, M. S., & Staghezza, B. (1992). Aggregating data from multiple informants in child psychiatry epidemiological research. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 78–85. Bird, H. R., Gould, M. S., & Staghezza, B. (1993). Patterns of diagnostic comorbidity in a community sample of children aged 9 through 16 years. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 361–368. Birmaher, B., Brent, D. A., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1230–1236. Birmaher, B., Khetarpal, S., Brent, D., Cully, M., Balach, L., Kaufman, J., & Neer, S. M. (1997). The Screen for Child Anxiety Related Emotional Disorders (SCARED): Scale construction and psychometric characteristics. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 545–553. Birmaher, B., Ryan, N. D., Williamson, D. C., Brent, D. A., & Kaufman, J. (1996). Childhood and adolescent depression: A review of the past 10 years. Part II. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1575–1583. Birmaher, B., Ryan, N. D., Williamson, D. E., Brent, D. A., Kaufman, J., Dahl, R. E., Perel, J., & Nelson, B. (1996). Childhood and adolescent depression: A review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1427–1439. Birmaher, B., Waterman, G. S., Ryan, N., Cully, M., Balach, L., Ingram, J., & Brodsky, M. (1994). Fluoxetine for childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 993–999. Black, D., & Urbanowicz, M. A. (1987). Family intervention with bereaved children. Journal of Child Psychology and Psychiatry, 28, 467–476. Blackwell, B., & Currah, J. (1973). The psychopharmacology of nocturnal enuresis. In I. Kolvin, R. C. MacKeith, & S. R. Meadow (Eds.), Clinics in developmental medicine: Bladder control and enuresis (pp. 231–257). London: Heinemann. Blader, J. C., Koplewicz, H. S., Abikoff, H., & Foley, C. (1997). Sleep problems of elementary school children: A community survey. Archives of Pediatrics and Adolescent Medicine, 151, 473–480. Blanchard, R. (1990). Gender identity disorders in adult men. In R. Blanchard & B. W. Steiner (Eds.), Clinical management of gender identity disorders in children and adults (pp. 47–76). Washington, DC: American Psychiatric Press. Blanchard, R., Glemmensen, L. H., & Steiner, B. W. (1987). Heterosexual and homosexual gender dysphoria. Archives of Sexual Behavior, 16, 139–152. Blanchard, R., Zucker, K. J., Bradley, S. J., & Home, C. S. (1995). Birth order and sibling sex ratio in homosexual male adolescents and probably prehomosexual feminine boys. Developmental Psychology, 31, 22– 30. Blanchard, R., Zucker, K. J., Cohen-Kettenis, P. T., Gooren, L. J. G., & Bailey, J. M. (1996). Birth order and sibling sex ratio in two samples of Dutch gender-dysphoric homosexual males. Archives of Sexual Behavior, 25, 495–514. Blechman, E. A. (1984). Competent parents, competent children: Behavioral objectives of parent training. In R. F. Dangel & R. A. Polster (Eds.), Parent training (pp. 34–66). New York: Guilford Press. Bliss, J. (1980). Sensory experiences of Gilles de la Tourette syndrome. Archives of General Psychiatry, 37, 1343–1347. Block, J. G., Block, J., & Gjerde, P. F. (1986). The personality of children prior to divorce: A prospective study. Child Development, 57, 827–840. Block, J. G., Block, J., & Gjerde, P. W. (1988). Parental functioning and the home environment in families of divorce: Prospective and concurrent analyses. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 207–213. Blount, R. L., Corbin, S. M., Sturges, J. W., Wolfe, V. Y., Prater, J. M., & James, L. D. (1989). The relationship between adults’ behavior and child coping and distress during BMA/LP procedures: A sequential analysis. Behavior Therapy, 20, 585–601.

550

References

Blum, N. J., Taubman, B., & Osborne, M. D. (1997). Behavioral characteristics of children with stool toileting refusal. Pediatrics, 99, 50–53. Boat, B. W., & Everson, M. D. (1994). Exploration of anatomical dolls by nonreferred preschool-aged children: Comparisons by age, gender, race, and socioeconomic status. Child Abuse and Neglect, 18, 139–153. Bohlin, G., Bengtsgard, K., & Andersson, K. (2000). Social inhibition and overfriendliness as related to socioemotional functioning in 7- and 8-year-old children. Journal of Clinical Child Psychology, 29, 414– 423. Bollard, J., & Nettlebeck, T. (1982). A component analysis of dry-bed training for treatment of bed wetting. Behaviour Research and Therapy, 20, 383–390. Borneman, E. (1994). Childhood phases of maturity: Sexual developmental psychology. Amherst, NY: Prometheus Books. Botting, N., Powls, A., Cooke, R. W. I., & Merlow, N. (1997). Attention deficit hyperactivity disorders and other psychiatric outcomes in very low birth weight children at 12 years. Journal of Child Psychology and Psychiatry, 38, 931–941. Bow, J. N., & Quinnell, F. A. (2001). Psychologists’ current practices and procedures in child custody evaluations: Five years after American Psychological Association guidelines. Professional Psychology: Research and Practice, 32, 261–268. Bowen, F., Vitaro, F., Kerr, M., & Pelletier, D. (1995). Childhood internalizing problems: Predictions from kindergarten, effect of maternal overprotectiveness, and sex differences. Development and Psychopathology, 7, 481–498. Bowlby, J. (1981). Attachment and loss: Vol. 3. Loss: Sadness and depression. Harmondsworth, England: Penguin. Bradbury, K., Janicke, D. M., Riley, A. W., & Finney, J. W. (1999). Predictors of unintentional injuries to school-age children seen in pediatric primary care. Journal of Pediatric Psychology, 24, 423–433. Bradbury, M., & Meadow, S. (1995). Combined treatment with enuresis alarm and desmopressin for nocturnal enuresis. Acta Paediatrica Scandinavia, 84, 1014–1018. Bradley, S. J., & Zucker, K. J. (1997). Gender identity disorder: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 872–880. Braet, C., & VanWinkelk, M. (2000). Long-term follow-up of a cognitive behavioral treatment program for obese children. Behavior Therapy, 31, 55–74. Braver, S. L. (1998). Divorced dad: Shattering the myths. New York: Tarcher/Putnam. Brazelton, T. B. (1962). A child oriented approach to toilet training. Pediatrics, 29, 121–128. Brazelton, T. B., Christopherson, E. R., Filmer, R. B., Frauman, A. C., Gorski, P. A., Poole, J. M., Stadtler, A. C., & Wright, C. L. (1999). Instruction, timeliness, and medical influences affecting toilet training. Pediatrics, 103, 1353–1358. Brazelton, T., & Nugent, J. (1995). Neonatal Behavioral Assessment Scale (3rd ed.). London: MacKeith. Brazelton, T. B., & Yogman, M. (1986). Affective development in infancy. Norwood, NJ: Ablex. Brenchley, M. L. (1991). Is digit sucking of significance? British Dentistry Journal, 171, 357–362. Brestan, E. V., & Eyberg, S. M. (1998). Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. Journal of Clinical Child Psychology, 27, 180–189. Brestan, E. V., Jacobs, J. R., Rayfield, A. D., & Eyberg, S. M. (1999). A consumer satisfaction measure for parent–child treatments and its relation to measures of child behavior change. Behavior Therapy, 30, 17–30. Brett, D. (1988). Annie stories: A special kind of storytelling. New York: Workman. Bricklin, B. (1995). The custody evaluation handbook: Research-based solutions and applications. New York: Brunner/Mazel. Briggs-Gowan, M. J., Carter, A. S., Skuban, E. M., & Horwitz, S. M. (2001). Prevalence of social-emotional and behavioral problems in a community sample of 1- and 2-year-old children. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 811–819. Briggs-Gowan, M. J., Horwitz, S. M., Schwab-Stone, M. E., Leventhal, J. M., & Leaf, P. J. (2000). Mental health in pediatric settings: Distribution of disorders and factors related to service use. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 841–849. Broberg, A. G., Wessels, H., Lamb, M. E., & Hwang, C. P. (1997). Effects of day care on the development of cognitive abilities in 8-year-olds: A longitudinal study. Developmental Psychology, 33, 62–69. Brody, G. H. (1998). Sibling relationship quality: Its causes and consequences. Annual Review of Psychology, 49, 1–24. Brody, G. H., Pillegrini, A. D., & Sigel, I. E. (1986). Marital quality and mother–child and father–child interactions with school-aged children. Develomental Psychology, 22, 291–296.

References

551

Brody, G. H., & Stoneman, Z. (1983). Children with atypical siblings: Socialization outcomes and clinical participation. In B. B. Lahey & A. E. Kazdin (Eds.), Advances in clinical child psychology (Vol. 6, pp. 285–326). New York: Plenum Press. Brody, G. H., & Stoneman, Z. (1987). Sibling conflict: Contributions of the siblings themselves, the parent– sibling relationship, and the broader family system. Journal of Children in Contemporary Society, 19, 39–53. Brody, G. H., Stoneman, Z., & Gauger, K. (1996). Parent–child relationships, family problem-solving behavior, and sibling relationship quality: The moderating role of sibling temperaments. Child Development, 67, 1289–1300. Brody, G. H., Stoneman, Z., & McCoy, J. K. (1994). Forecasting sibling relationships in early adolescence from child temperaments and family processes in middle childhood. Child Development, 65, 771–784. Broughton, R. J. (1968). Sleep disorders: Disorders of arousal? Science, 159, 1070–1078. Brown, L. K. M., & Brown, M. (1997). Dinosaurs divorce: A guide for changing families. Boston: Little, Brown. Brown, M. W. (1991). Goodnight moon. New York: HarperCollins. (Original work published 1947) Brown, S. S., & Eisenberg, L. (Eds.). (1995). The best intentions. Washington, DC: National Academy Press. Bryant, B. (1992). Sibling caretaking: Providing emotional support during middle childhood. In F. Boer & J. Dunn (Eds.), Children’s sibling relationships: Developmental and clinical issues (pp. 55–70). Hillsdale, NJ: Erlbaum. Budd, K. S., & Chugh, C. S. (1998). Common feeding problems in young children. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 20, pp. 183–212). New York: Plenum Press. Budin, L. E., & Johnson, C. F. (1989). Sex abuse prevention programs: Offenders’ attitudes about their efficacy. Child Abuse and Neglect, 13, 77–87. Burchinal, M. R., Roberts, J. E., Nabors, L. A., & Bryant, D. M. (1996). Quality of center child care and infant cognitive and language development. Child Development, 67, 606–620. Burchinal, M. R., Roberts, J. E., Riggins, R., Zeisel, S. A., Neebe, E., & Bryant, D. (2000). Relating quality of center-based child care to early cognitive and language development longitudinally. Child Development, 71, 339–357. Burnham, J. J., & Gullone, E. (1997). The Fear Survey Schedule for Children—II: A psychometric investigation with American data. Behaviour Research and Therapy, 35, 165–173. Burns, B. J., Hoagwood, K., & Mrazek, P. J. (1999). Effective treatment for mental disorders in children and adolescents. Clinical Child and Family Psychology Review, 2, 199–254. Burns, G. L., & Patterson, D. R. (2000). Factor structure of the Eyberg Child Behavior Inventory: A parent rating scale of oppositional defiant behavior toward adults, inattentive behavior, and conduct problem behavior. Journal of Clinical Child Psychology, 29, 569–577. Burroughs, M. S., Wagner, W. W., & Johnson, J. T. (1997). Treatment with children of divorce: A comparison of two types of therapy. Journal of Divorce and Remarriage, 27, 83–99. Bush, J. P., & Cockrell, C. S. (1987). Maternal factors predicting parenting behaviors in the pediatric clinic. Journal of Pediatric Psychology, 12, 505–518. Butler, J. F. (1976). The toilet training success of parents after reading Toilet training in less than a day. Behavior Therapy, 7, 185–191. Butler, J. F., Redfern, E. H., & Forsythe, W. I. (1990). The child’s construing of nocturnal enuresis: A method of inquiry and prediction of outcome. Journal of Child Psychology and Psychiatry, 31, 447–454. Byrne, J. M., Bawden, H. N., DeWolfe, N. A., & Beattie, T. L. (1998). Clinical assessment of psychopharmacological treatment of preschoolers with ADHD. Journal of Clinical and Experimental Neuropsychology, 20, 613–627. Byrne, J. M., DeWolfe, N. A., & Bawden, H. N. (1998). Assessment of attention-deficit hyperactivity disorder in preschoolers. Child Neuropsychology, 4, 49–66. Cairns, R. B., Cairns, B. D., Neckerman, H. J., Ferguson, L. L., & Gariepy, J. L. (1989). Growth and aggression: 1. Childhood to early adolescence. Developmental Psychology, 25, 320–330. Cairns, R. B., Peterson, G., & Neckerman, H. J. (1988). Report from the social development laboratory. Journal of Clinical Child Psychology, 17, 298–309. Calam, R., Horne, L., Glasgow, D., & Cox, A. (1998). Psychological disturbance and child sexual abuse: A follow-up study. Child Abuse and Neglect, 22, 901–913. Calderone, M. S., & Johnson, E. W. (1983). The family book about sexuality (rev. ed.). New York: Bantam Books. Calkins, S. D. (1994). Origins and outcomes of individual differences in emotion regulation. In N. A. Fox (Ed.), The development of emotion regulation: Biological and behavioral considerations. Monographs of the Society for Research in Child Development, 59(2–3, Serial No. 240), 53–72.

552

References

Callahan, S. A., Panichelli-Mindel, S. M., & Kendall, P. C. (1996). DSM-IV and internalizing disorders: Modifications, limitations, and utility. School Psychology Review, 25, 297–307. Campbell, L. M., III. (1973). A variation of thought-stopping in a twelve-year-old boy: A case report. Journal of Behavior Therapy and Experimental Psychiatry, 4, 69–70. Campbell, M., Adams, P., Small, A. M., Kafantaris, V., Shell, J., Perry, R., & Overall, J. E. (1995). Lithium in hospitalized aggressive children with conduct disorder: A double-blind and placebo controlled study. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 445–453. Campbell, S. B. (1990). Behavior problems in preschool children: Clinical and developmental issues. New York: Guilford Press. Campbell, S. B. (1995). Behavior problems in preschool children: A review of recent research. Journal of Child Psychology and Psychiatry, 36, 113–149. Campbell, S. B. (1996). Introduction to the special section on young children at risk for psychopathology: Developmental and family perspectives. Journal of Clinical Child Psychology, 25, 372–375. Campbell, S. B. (1998). Developmental perspectives. In T. H. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (3rd ed., pp. 3–35). New York: Plenum Press. Campbell, S. B., & Ewing, L. J. (1990). Hard-to-manage preschoolers: Adjustment at age nine and predictors of continuing symptoms. Journal of Child Psychology and Psychiatry, 31, 871–889. Campbell, S. B., March, C. L., Pierce, E. W., Ewing, L. J., & Szumowski, E. K. (1991). Hard-to-manage preschool boys: Family context and the stability of externalizing behavior. Journal of Abnormal Child Psychology, 19, 301–318. Campbell, S. B., Pierce, E. W., Moore, G., Marakovitz, S., & Newby, K. (1996). Boys externalizing problems at elementary school age: Pathways from early behavior problems, maternal control, and family stress. Development and Psychopathology, 8, 701–719. Campbell, S. S., Eastman, C. I., Terman, M., Lewy, A. J., Boulos, Z., & Dijk, D. J. (1995). Light treatment for sleep disorders: Consensus report I. Chronology of seminal studies in humans. Journal of Biological Rhythms, 10, 105–109. Cantwell, D. P. (1996). Classification of child and adolescent psychopathology. Journal of Child Psychology and Psychiatry, 37, 3–12. Cantwell, D. P., & Baker, L. (1991). Psychiatric and developmental disorders in children with communication disorders. Washington, DC: American Psychiatric Press. Cappo, B. M., & Holmes, D. S. (1984). The utility of prolonged respiratory exhalation for reducing physiological and psychological arousal in nonthreatening and threatening situations. Journal of Psychosomatic Research, 28, 265–273. Carey, W. B., & Jablow, M. M. (1997). Understanding your child’s temperament. New York: Simon & Schuster. Carlson, C. L., & Tamm, L. (2000). Responsiveness of children with attention deficit-hyperactivity disorder to reward and response cost: Differential impact on performance and motivation. Journal of Consulting and Clinical Psychology, 68, 73–83. Carlson, E. A. (1998). A prospective longitudinal study of attachment disorganization/disorientation. Child Development, 69, 1107–1128. Caron, C., & Rutter, M. (1991). Comorbidity in child psychopathology: Concepts, issues, and research strategies. Journal of Child Psychology and Psychiatry, 32, 1064–1080. Carr, J. E. (1995). Competing responses for the treatment of Tourette syndrome and tic disorders. Behaviour Research and Therapy, 33, 455–466. Carson, R. C., Butcher, J. N., & Mineka, S. (1998). Abnormal psychology and modern life (10th ed.). New York: Addison-Wesley. Carta, J. J., Atwater, J. B., Greenwood, C. R., McConnell, S. T., McEvoy, M. A.,, & Williams, R. (2001). Effects of cumulative prenatal substance exposure and environmental risks on children’s developmental trajectories. Journal of Clinical Child Psychology, 30, 327–337. Carter, A. S., Fredine, N. J., Findley, D., Scahill, L., Zimmerman, L., & Sparrow, S. S. (1999). Recommendations for teachers. In J. F. Leckman & D. J. Cohen (Eds.), Tourette’s syndrome—tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 360–369). New York: Wiley. Carter, A. S., Fredine, N. J., Schultz, R. T., Scahill, L., Finley, D., & Sparrow, S. S. (1999). Comprehensive psychological and educational assessments. In J. F. Leckman & D. J. Cohen (Eds.), Tourette’s syndrome— tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 325– 337). New York: Wiley. Carter, A. S., Gerrity-Rokous, F. E., Chazan-Cohen, R., Little, C., & Briggs-Gowan, M. J. (2001). Maternal depression and comorbidity: Predicting early parenting, attachment security, and toddler social-emotional problems and competencies. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 18–26.

References

553

Caspi, A., Henry, B., McGee, R. O., Moffitt, T. E., & Silva, P. A. (1995). Temperamental origins of child and adolescent behaviors problems: from age three to age fifteen. Child Development, 66, 55–68. Caspi, A., Moffitt, T. E., Newman, K. L., & Silva, P. A. (1996). Behavioral observations at age 3 predict adult psychiatric disorders: Longitudinal evidence from a birth cohort. Archives of General Psychiatry, 53, 1033–1039. Cassidy, J. (1988). Child–mother attachment and the self in six-year-olds. Child Development, 59, 121–134. Castellanos, F. X., Giedd, J. N., Marsh, W. L., Hamburger, S. D., Vaituzis, A. D., Dickstein, D. P., Sarfatti, S. E., Vauss, Y. C., Snell, J. W., Lange, N., Kaysen, D., Krain, A. L., Ritchhie, G. F., Rajapakse, J. C., & Rapoport, J. L. (1996). Quantitative brain magnetic resonance imaging in attention-deficit hyperactivity disorder. Archives of General Psychiatry, 53, 607–616. Cavenar, J. O., Spaulding, J. G., & Sullivan, J. L. (1979). Child’s reaction to mother’s abortion: Case report. Military Medicine, 144, 412–413. Cebollero, A. M., Cruise, K., & Stollak, G. (1986). The long-term effects of divorce: Mothers and children in concurrent support groups. Journal of Divorce, 10, 219–228. Ceci, S. J., & Bruck, M. (1995). Jeopardy in the courtroom: A scientific analysis of children’s testimony. Washington, DC: American Psychological Association. Cerel, J., Fristad, M. A., Weller, E. B., & Weller, R. A. (1999). Suicide-bereaved children and adolescents: I. A controlled longitudinal examination. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 672–679. Cerel, J., Fristad, M. A., Weller, E. B., & Weller, R. A. (2000). Suicide-bereaved children and adolescents: II. Parental and family functioning. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 437–444. Chamberlain, P., & Reid, J. B. (1998). Comparison of two community alternatives to incarceration for chronic juvenile offenders. Journal of Consulting and Clinical Psychology, 4, 624–633. Chamberlin, R. W. (1977). Can we identify a group of children at age two who are at risk for the development of behavioral or emotional problems in kindergarten or first grade? Pediatrics, 59(Suppl.), 971–981. Chan, R. W., Raboy, B., & Patterson, C. J. (1998). Psychosocial adjustment among children conceived via donor insemination by lesbian and heterosexual mothers. Child Development, 69, 443–457. Chang, K. D., Steiner, H., & Ketter, T. A. (2000). Psychiatric phenomenology of child and adolescent bipolar offspring. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 453–460. Charney, E., Chamblee, H., McBride, M., Lyon, B., & Pratt, R. (1976). The childhood antecendents of adult obesity: Do chubby infants become obese adults? New England Journal of Medicine, 195, 6–9. Chase-Lansdale, P. L., Cherlin, A. J., & Kierman, K. E. (1995). The long-term effects of parental divorce on the mental health of young adults: A developmental perspective. Child Development, 66, 1614–1634. Chen, W. J., Faraone, S. V., Biederman, J., & Tsuang, M. T. (1994). Diagnostic accuracy of the Child Behavior Checklist scales for attention-deficit hyperactivity disorder: A receiver-operating characteristic analysis. Journal of Consulting and Clinical Psychology, 62, 1017–1025. Chorpita, B. F., Albano, A. M., & Barlow, D. H. (1996). Cognitive processing in children: Relationship to anxiety and family influences. Journal of Clinical Child Psychology, 25, 170–176. Chorpita, B. F., Albano, A. M., & Barlow, D. H. (1998). The structure of negative emotions in a clinical sample of children and adolescents. Journal of Abnormal Psychology, 107, 74–85. Christensen, A. P., & Sanders, M. R. (1987). Habit reversal and differential reinforcement of other behavior in the treatment of thumb sucking: An analysis of generalization and side-effects. Journal of Child Psychology and Psychiatry, 28, 281–295. Christophersen, E. R. (1989). Injury control. American Psychologist, 44, 237–241. Christophersen, E. R., & Finney, J. W. (1999). Oppositional defiant disorder. In R. T. Ammerman, M. Hersen, & C. G. Last (Eds.), Prescriptive treatments for children and adolescents (2nd ed., pp. 102–113). Needham Heights, MA: Allyn & Bacon. Christophersen, E. R., & Hall, C. L. (1978). Eating patterns and associated problems encountered in normal children. Issues in Comprehensive Pediatric Nursing, 3, 1–16. Christophersen, E. R., & Purvis, P. C. (2001). Toileting problems in children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 453–469). New York: John Wiley & Sons. Christophersen, E. R., & Rainey, S. K. (1976). Management of encopresis through a pediatric outpatient clinic. Journal of Pediatric Psychology, 1, 38–41. Christophersen, E. R., & Rapoff, M. A. (1992). Toileting problems in children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (2nd ed., pp. 399–411). New York: Wiley–Interscience. Chugani, H. T. (1994). Developmental aspects of regional brain glucose metabolism, behavior and plasticity. In G. Dawson & K. W. Fischer (Eds.), Human behavior and the developing brain (pp. 153–175). New York: Guilford Press.

554

References

Cicchetti, D., & Cohen, D. J. (1995). Perspectives on developmental psychopathology . In D. Cicchetti & D. Cohen (Eds.), Developmental psychopathology: Vol. 1. Theory and methods (pp. 3–22). New York: Wiley. Cicchetti, D., & Toth, S. L. (1998). The development of depression in children and adolescents. American Psychologist, 53, 221–241. Cicirelli, V. G. (1989). Feelings of attachment to siblings and well-being in later life. Psychology and Aging, 4, 211–216. Clark, L. (1996). SOS! Help for emotions: Managing anxiety, anger, and depression. Bowling Green, KY: Parents Press. Clark, R., Hyde, J. S., Essex, M. J., & Klein, M. H. (1997). Length of maternity leave and quality of mother– infant interactions. Child Development, 68, 364–383. Clarke, G. N., Hawkins, W., Murphy, M., Sheeber, L. B., Lewinsohn, L. B., & Seeley, J. R. (1995). Targeted prevention of unipolar depressive disorder in an at-risk sample of high-school adolescents: A randomized trial of a group cognitive intervention. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 312–321. Clarke-Stewart, K. A. (1988). Parents’ effects on children’s development: A decade of progress? Journal of Applied Developmental Psychology, 9, 41–84. Clarke-Stewart, K. A. (1989). Infant day care: Maligned or malignant? American Psychologist, 44, 266–273. Clarke-Stewart, K. A., & Hayward, C. (1996). Advantages of father custody and contact for the psychological well-being of school aged children. Journal of Applied Developmental Psychology, 17, 239–270. Cloutier, R., & Jacques, C. (1997). Evolution of residential custody arrangements in separated families: A longitudinal study. Journal of Divorce and Remarriage, 28, 17–33. Coates, T. J., & Thoresen, C. E. (1981). Sleep disturbances in children and adolescents. In E. J. Mash & L. G. Terdal (Eds.), Behavioral assessment of childhood disorders (pp. 639–678). New York: Guilford Press. Cohen, D. J., Riddle, M. A., & Leckman, J. F. (1992). Pharmacotherapy of Tourette’s syndrome and associated disorders. Psychiatric Clinics of North America, 15, 109–129. Cohen, J. A., & Mannarino, A. P. (1996). A treatment outcome study for sexually abused preschoolers: Initial findings. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 42–50. Cohen, J. A., & Mannarino, A. P. (1997). A treatment study for sexually abused preschool children: Outcome during a one year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1228–1235. Cohen, J. A., & Mannarino, A. P. (1998a). Interventions for sexually abused children: Initial treatment outcome findings. Child Maltreatment, 3, 17–26. Cohen, J. A., & Mannarino, A. P. (1998b). Factors that mediate treatment outcome of sexually abused preschool children: Six- and 12-month follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 44–51. Cohen, P., Cohen, J., & Brook, J. S. (1993). An epidemiological study of disorders in late childhood and adolescence: II. Persistence of disorders. Journal of Child Psychology and Psychiatry, 34, 867–875. Cohen, P., Cohen, J., Kasen, S., Velez, C. N., Hartmark, C., Johnson, J., Rojas, M., Brook, J., & Struning, E. L. (1993). An epidemiological study of disorders in late childhood and adolescence: I. Age- and genderspecific prevalence. Journal of Child Psychology and Psychiatry, 34, 851–867. Coie, J. D., & Cillessen, A. H. (1993). Peer rejection: Origins and effects of children’s development. Current Directions in Psychological Science, 2, 89–92. Coie, J. D., & Dodge, K. A. (1998). The development of aggression and antisocial behavior. In E. Damon (Series Ed.) & N. Eisenberg (Vol. Ed.), Handbook of child psychology (5th ed.): Vol. 3: Social, emotional, and personality development (pp. 779–861). New York: Wiley. Cole, J., & Miller, M. (1998). The new baby at your house. New York: Morrow. Cole, P. M., Michel, M. K., & Teti, L. O. (1994). The development of emotion regulation and dysregulation: A clinical perspective. In N. A. Fox (Ed.), The development of emotion regulation: Biological and behavioral considerations. Monographs of the Society for Research in Child Development, 59(2–3, Serial No. 240), 73–102. Coley, R. (1998). Children’s socialization experiences and functioning in single mother households: The importance of fathers and other men. Child Development, 69, 219–230. Coley, R. L., & Chase-Lansdale, L. (1998). Adolescent pregnancy and parenthood: Recent evidence and future directions. American Psychologist, 53, 152–166. Collins, M. E. (1998). Factors influencing sexual victimization and revictimization in a sample of adolescent mothers. Journal of Interpersonal Violence, 13, 2–24. Comings, D. E., & Comings, B. G. (1988). Tourette’s syndrome and attention-deficit disorders. In D. J. Cohen, R. D. Bruun, & J. F. Leckman (Eds.), Tourette’s syndrome and tic disorders (pp. 119–136). New York: Wiley.

References

555

Comings, D. E., Himes, J. A., & Comings, B. G. (1990). An epidemiologic study of Tourette’s syndrome in a single school district. Journal of Clinical Psychiatry, 51, 463–469. Committee for Children. (1989). Second step: A violence prevention curriculum. Available from Committee for Children, 172 20th Avenue, Seattle, WA 98122. Compas, B. L. (1997). Depression in children and adolescents. In E. J. Mash & L. G. Terdal (Eds.), Assessment of childhood disorders (3rd ed., pp. 197–229). New York: Guilford Press. Compton, S. N., Grant, P. J., Chrisman, A. K., Gammon, P. J., Brown, V. L., & March, J. S. (2001). Sertraline in children and adolescents with social anxiety disorder: An open trial. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 564–571. Compton, S. N., Nelson, A. H., & March, J. S. (2000). Social phobia and separation anxiety symptoms in community and clinical samples of children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1040–1046. Conduct Problems Prevention Research Group. (1999). Initial impact of the FAST Track Prevention Trial for Conduct Problems: I. The high-risk sample. Journal of Consulting and Clinical Psychology, 67, 631– 647. Conners, C. K. (1995). The Conners Continuous Performance Test. North Tonawanda, NY: Multi-Health Systems. Conners, C. K. (1997). Conners Rating Scales—Revised. North Tonawanda, NY: Multi-Health Systems. Conners, C. K., Epstein, J. N., March, J. S., Angold, A., Wells, K. C., Klaric, J., Swanson, J. M., Arnold, L. E., Abikoff, H. B., Elliott, G. R., Greenhill, L. L., Hechtman, L., Hinshaw, S. P., Hoza, B., Jensen, P. S., Kraemer, H. C., Newcorn, J. H., Pelham, W. E., Severe, J. B., Bitiello, B., & Wigal, T. (2001). Multimodal treatment of ADHD in the MTA: An alternative outcome analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 159–167. Conte, J. R., Wolf, S., & Smith, T. (1989). What sexual offenders tell us about prevention strategies. Child Abuse and Neglect, 13, 293–301. Corder, B. F., Haizlip, T., & DeBoer, P. (1990). A pilot study for a structured, time-limited therapy group for sexually abused pre-adolescent children. Child Abuse and Neglect, 14, 243–251. Corkum, P., Moldofsky, H., Hogg-Johnson, S., Humphries, T., & Tannock, R. (1999). Sleep problems in children with attention-deficit/hyperactivity disorder: Impact of subtype, comorbidity, and stimulant medication. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1285–1293. Corkum, P., Tannock, R., & Moldofsky, H. (1998). Sleep disturbances in children with Attention-Deficit/ Hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 637– 646. Costello, E. J., & Angold, A. (1995). Epidemiology. In J. S. March (Ed.), Anxiety disorders in children and adolescents (pp. 109–124). New York: Guilford Press. Costello, E. J., Angold, A., & Keeler, G. P. (1999). Adolescent outcomes of childhood disorders: The consequences of severity and impairment. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 212–128. Costello, E. J., Angold, A., Burns, B. J., Stangl, D. K., Tweed, D. L., Erkanli, A., & Worthman, C. M. (1996). The Great Smoky Mountains study of youth, goals, design, and the prevalence of DSM-III-R disorders. Archives of General Psychiatry, 53, 1129–1136. Costello, E. J., Edelbrock, C., Costello, A. J., Dulcan, M. K., Burns, B. J., & Brent, D. (1988). Psychopathology in pediatric primary care: The new hidden morbidity. Pediatrics, 82, 415–424. Côté, M. P., Zoccolillo, M. D., Tremblay, R. E., Nagin, D., & Vitaro, F. (2001). Predicting girls conduct disorder in adolescence from childhood trajectories of disruptive behaviors. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 678–684. Coughlan, B., Carr, A., & Fitzgerald, M. (1998). Factors related to the adjustment of siblings following sudden infant death. Irish Journal of Psychology, 19, 295–312. Covell, K., & Abramovitch, R. (1987). Understanding emotion in the family: Children’s and parents’ attributions of happiness, sadness, and anger. Child Development, 58, 985–991. Cowen, E. L., Wyman, P. A., Work, W. C., Kim, J. Y., Fagen, D. B., & Magnus, K. B. (1997). follow-up study of young stress-affected and stress-resilient urban children. Development and Psychopathology, 9, 565–577. Cox, D. J., Sutphen, J., Ling, W., Quillian, W., & Borowitz, S. (1998). Contribution of behavior therapy and biofeedback to laxative therapy in treatment of pediatric encopresis. Annals of Behavioral Medicine, 20, 70–76. Cox, M. J., Owen, M. T., Lewis, J. M., & Henderson, V. K. (1989). Marriage, adult adjustment and early parenting. Child Development, 60, 1015–1024. Cramer, P., & Steinwert, T. (1998). Thin is good, fat is bad: How early does it begin? Journal of Applied Developmental Psychology, 19, 429–451.

556

References

Crary, E. (1982–1986). A children’s problem solving book series: My name is not dummy; Mommy don’t go; I can’t wait; I’m lost; I want it; I want to play. Seattle, WA: Parenting Press. Crawford, A. M., & Manassis, K. (2001). Familial predictors of treatment outcome in childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1182–1189. Crick, N. R., & Grotpeter, J. K. (1995). Relational aggression, gender, and social-psychological adjustment. Child Development, 66, 710–722. Crnic, K. A., & Greenberg, M. T. (1990). Minor parenting stresses with young children. Child Development, 61, 1628–1637. Crnic, K. A., Greenberg, M. T., Ragozin, A. S., Robinson, N. M., & Basham, R. (1983). Effects of stress and social support on mothers and premature and full-term infants. Child Development, 54, 209–217. Crockenberg, S. (1987). Predictors and correlates of anger towards and punitive control of toddlers by adolescent mothers. Child Development, 58, 964–975. Crockenberg, S., & Forgays, D. K. (1996). The role of emotion in children’s understanding and emotional reactions to marital conflict. Merrill–Palmer Quarterly, 42, 22–47. Croft, C. B., Brockbank, M. J., Wright, A., & Swanston, A. R. (1990). Obstructive sleep apnea in children undergoing routine tonsillectomy and adenoidectomy. Clinical Otolaryngology, 15, 307–314. Crowell, J., Keener, M., Ginsburg, N., & Anders, T. (1987). Sleep habits in toddlers 18 to 36 months old. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 510–515. Cuffe, S. P., McKeown, R. E., Jackson, K. L., Addy, C. L., Abramson, R., & Garrison, C. Z. (2001). Prevalence of attention-deficit/hyperactivity disorder in a community sample of older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1037–1044. Culbertson, J. L., & Krull, K. R. (1996). Attention deficit-hyperactivity disorder. In R. L. Adams, O. A. Parsons, J. L. Culbertson, & S. J. Nixon (Eds.), Neuropsychology for clinical practice: Etiology, assessment, and treatment of common neurological disorders (pp. 271–330). Washington, DC: American Psychological Association. Cummings, E. M. (1987). Coping with background anger in early childhood. Child Development, 58, 976–984. Cummings, E. M., & Davies, P. T. (1994). Children and marital conflict: The impact of family dispute and resolution. New York: Guilford Press. Cunningham, C. E., Bremner, R., & Boyle, M. (1995). Large group community-based parenting programs for families of preschoolers at risk for disruptive behaviour disorders: Utilization, cost effectiveness, and outcome. Journal of Child Psychology and Psychiatry, 36, 1141–1159. Cunningham, C. E., & Siegel, L. S. (1987). Peer interactions of normal and attention-deficit disordered boys during free-play, cooperative task, and simulated classroom situations. Journal of Abnormal Child Psychology, 15, 247–268. Cutrona, C. E. (1984). Social support and stress in the transition to parenthood. Journal of Abnormal Psychology, 93, 378–390. Czeisler, C. A., Richardson, G. S., Coleman, R. M., Zimmerman, J. C., Moore-Ede, M. C., Dement, W. C., & Weitzman, E. D. (1981). Chronotherapy and resetting the circadian clocks of patients with delayed sleep phase insomnia. Sleep, 4, 1–21. Dadds, M. R., Holland, D. E., Laurens, K. R., Mullins, M., Barrett, P. M., & Spence, S. H. (1999). Early intervention and prevention of anxiety disorders in children: Results at 2–year follow-up. Journal of Consulting and Clinical Psychology, 67, 145–150. Dadds, M. R., Schwartz, S., & Sanders, M. R. (1987). Marital discord and treatment outcome in behavioral treatment of child conduct disorders. Journal of Consulting and Clinical Psychology, 55, 396–403. Dahl, R. E. (1996). The regulation of sleep and arousal: Development and psychopathology. Development and Psychopathology, 8, 3–27. Dahl, R. E., Holtum, J., & Trubnick, L. (1994). A clinical picture of child and adolescent narcolepsy. Journal of the American Academy of Child and Adolescent Psychiatry, 6, 834–841. Dahl, W. H., & Sundelin, C. (1986). Early feeding problems in an affluent society: I. Categories and clinical signs. Acta Paediatrica Scandinavica, 75, 370–379. Dahlquist, L. M., & Kalfus, G. R. (1984). A novel approach to assessment in the treatment of childhood trichotillomania. Journal of Behavior Therapy and Experimental Psychiatry, 15, 47–50. Daly, M., & Wilson, M. I. (1996). Violence against stepchildren. Current Directions in Psychological Science, 5, 77–81. Damon, L., Todd, J., & MacFarlane, K. (1987). Treatment issues with sexually abused young children. Child Welfare, 66, 125–137. Dangel, R. F., & Polster, R. A. (Eds.). (1984). Parent training. New York: Guilford Press. Daniel, J. H., Hampton, R. L., & Newberger, E. H. (1983). Child abuse and accidents in black families: A controlled study. American Journal of Orthopsychiatry, 53, 645–653.

References

557

Davidson, M., Kugler, M. M., & Bauer, C. H. (1963). Diagnosis and management in children with severe and protracted constipation and obstipation. Journal of Pediatrics, 62, 261–265. Davies, D. (1999). Child development: A practitioner’s guide. New York: Guilford Press. Davies, P. T., & Cummings, M. (1995). Children’s emotions as organizers of their reactions to interadult anger: A functionalist perspective. Developmental Psychology, 31, 677–684. Davies, P. T., Myers, R. L., & Cummings, E. M. (1996). Responses of children and adolescents to marital conflict scenarios as a function of the emotionality of conflict endings. Merrill–Palmer Quarterly, 42, 1–21. Davis, M. K., & Gidycz, C. A. (2000). Child sexual abuse prevention programs: A meta-analysis. Journal of Clinical Child Psychology, 29, 257–265. Dawson, G., Hessl, D., & Frey, K. (1994). Social influences on early developing biological and behavioral systems related to risk for affective disorders. Development and Psychopathology, 6, 759–779. Deater-Deckard, K., Dodge, K. A., Bates, J. E., & Pettit, G. S. (1996). Physical discipline among African American and European American mothers: Links to children’s externalizing behaviors. Developmental Psychology, 32, 1065–1072. Deater-Deckard, K., & Plomin, R. (1999). An adoption study of the etiology of teacher reports of externalizing problems in middle childhood. Child Development, 70, 144–154. Deblinger, E., & Heflin, A. H. (1996). Treating sexually abused children and their nonoffending parents: A cognitive behavioral approach. Thousand Oaks, CA: Sage. Deblinger, E., Lippman, J., & Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment, 1, 310–321. deJonge, D. A. (1973). Epidemiology of enuresis: A survey of the literature. In I. Kolvin, R. C. MacKeith, & S. R. Meadow (Eds.), Clinics in developmental medicine: Bladder control and enuresis (pp. 39–46). London: Heinemann. DelCarmen-Wiggins, R., & Carter, A. S. (2000). Introduction: Assessment of infant and toddler mental health: Advances and challenges. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 8–10. DeLoache, J. S., & Marzolf, D. P. (1993, March). Young children’s testimony may not be improved by using dolls to question them. Poster presented at the biennial meeting of the Society for Research in Child Development, New Orleans, LA. DeLuca, R. V., & Holborn, S. W. (1984). A comparison of relaxation training and competing response training to eliminate hair pulling and nail biting. Journal of Behavior Therapy and Experimental Psychiatry, 15, 67–70. den Bak, I. M., & Ross, H. S. (1996). I’m telling!: The content, context, and consequences of children’s tattling on their siblings. Social Development, 5, 292–309. Denham, S. A., Mitchell-Copeland, J., Strandberg, K., Auerbach, S., & Blair, K. (1997). Parental contributions to preschoolers’ emotional competence: Direct and indirect effects. Motivation and Emotion, 21, 65–86. Denney, C. B. (2001). Stimulant effects in attention deficit hyperactivity disorder: Theoretical and empirical issues. Journal of Clinical Child Psychology, 30, 98–109. DeWolff, M. S., & van IJzendoorn, M. (1997). Sensitivity and attachment: A meta-analysis on parental antecedents of infant attactment. Child Development, 68, 571–591. Diagnostic Classification Steering Committee. (1990). The international classification of sleep disorders: Diagnostic and coding manual. Rochester, MN: American Sleep Disorders Association. Dietz, W. H. (1998). Health consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics, 101(Suppl.), 518–524. Dietz, W. H., & Stern, L. (1999). American Academy of Pediatrics guide to your child’s nutrition: Making peace at the table and building healthy eating habits for life. New York: Villard. DiGirolamo, A. M., Geis, H. K., & Walker, C. E. (1998). Developmental issues. In R. T. Ammerman & J. V. Campo (Eds.), Handbook of pediatric psychology and psychiatry: Vol. I. Psychological and psychiatric issues in the pediatric setting (pp. 1–22). Needham Heights, MA: Allyn & Bacon. DiLillo, D., & Peterson, L. (2001). Prevention of childhood disorders. In C. D. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 974–988). New York: Wiley. Dinkmeyer, D., & McKay, G. (1976). Systematic training for effective parenting. Circle Pines, MN: American Guidance Service. Dishion, T. J., & McMahon, R. J. (1998). Parental monitoring and the prevention of child and adolescent problem behavior: A conceptual and empirical formulation. Clinical Child and Family Psychology Review, 1, 61–75. Djurhuus, J. C., Norgaard, J. P., Hjalmas, K., & Wille, S. (1992). Nocturnal enuresis. Scandinavian Journal of Urology and Nephrology, 143(Suppl.), 3–29. Dodge, K. A. (1983). Behavioral antecedents of peer social status. Child Develoment, 54, 1386–1399.

558

References

Dodge, K. A. (1993). Social cognitive mechanisms in the development of conduct disorder and depression. Annual Review of Psychology, 44, 559–584. Dodge, K. A., Bates, J. E., & Pettit, G. S. (1990). Mechanisms in the cycle of violence. Science, 250, 1678– 1683. Dodge, K. A., & Coie, J. D. (1987). Social information processing factors in reactive and proactive aggression in children’s peer groups. Journal of Personality and Social Psychology, 53, 1146–1158. Dokas, K. J. (1996). The cruel paradox: Children who are living with life-threatening illnesses. In C. A. Corr & D. M. Corr (Eds.), Handbook of childhood death and bereavement (pp. 89–108). New York: Springer. Doleys, D. M. (1978). Assessment and treatment of enuresis and encopresis in children. In M. Hersen, R. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 6, pp. 85–121). New York: Academic Press. Doleys, D. M., Schwartz, M. D., & Cineinero, A. R. (1981). Elimination problems: Enuresis and encopresis. In E. J. Mash & L. G. Terdal (Eds.), Behavioral assessment of childhood disorders (pp. 679–710). New York: Guilford Press. Doll, L. S., Joy, D., Bartholow, B. N., Harrison, J. S., Bolan, G., Douglas, J. M., Saltzman, L. E., Moss, P. M., & Delgado, W. (1992). Self-reported childhood and adolescent sexual abuse among adult homosexual and bisexual men. Child Abuse and Neglect, 16, 855–864. Dollinger, S. J., Horn, J. L., & Boarini, D. (1988). Disturbed sleep and worries among learning disabled adolescents. American Journal of Orthopsychiatry, 58, 428–434. Donoghue, M. B., Latimer, E. M., Pillsbury, H. L., & Hertzog, J. H. (1998). Hypoatremic seizure in a child using desmopressin for nocturnal enuresis. Archives of Pediatrics and Adolescent Medicine, 152, 290– 292. Dorado, J. S., & Saywitz, K. J. (2001). Interviewing preschoolers from low- and middle-SES communities: A test of the Narrative Elaboration Recall Improvement technique. Journal of Clinical Child Psychology, 30, 568–580. Douglas, V. I., & Benezra, E. (1990). Supraspan verbal memory in attention deficit disorder with hyperactivity, normal, and reading disabled boys. Journal of Abnormal Child Psychology, 18, 617–638. Downey, G., & Coyne, J. C. (1990). Children of depressed parents: An integrative review. Psychological Bulletin, 108, 50–76. Doyle, A. E., Biederman, J., Seidman, L. J., Weber, W., & Faraone, S. V. (2000). Diagnostic efficiency of neuropsychological test scores for discriminating boys with and without attention deficit-heperactivity disorder. Journal of Consulting and Clinical Psychology, 68, 477–488. Drapeau, S., Samson, C., & Saint-Jacques, M. (1999). The coping process among children of separated parents. Journal of Divorce and Remarriage, 31, 15–37. Dreikurs, R. (1964). Children: The challenge. New York: Hawthorne Books. Drotar, D. (1995). Failure to thrive. In M. C. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp. 516–536). New York: Guilford Press. Drotar, D. (1999). The diagnostic and statistical manual for primary care (DSM-PC), child and adolescent version: What pediatric psychologists need to know. Journal of Pediatric Psychology, 24, 369–380. Drotar, D., & Sturm, L. (1988). The role of parent–practitioner communication in the management of nonorganic failure to thrive. Family Systems Medicine, 6, 42–53. Dumas, J. E. (1989). Treating antisocial behavior in children: Child and family approaches. Clinical Psychology Review, 9, 197–222. Dumas, J. E., Prinz, R. J., Smith, E. P., & Laughlin, J. (1999). The EARLY ALLIANCE prevention trial: An integrated set of interventions to promote competence and reduce risk for conduct disorder, substance abuse, and school failure. Clinical Child and Family Psychology Review, 2, 37–53. Duncan, S. W. (1994). Economic impact of divorce on children’s development: Current findings and policy implications. Journal of Clinical Child Psychology, 23, 444–457. Dunlap, G., dePerczel, M., Clarke, S., Wilson, D., Wright, S., White, R., & Gomez, A. (1994). Choice making to promote adaptive behavior for students with emotional and behavioral challenges. Journal of Applied Behavior Analysis, 27, 505–518. Dunn, J. (1988). Sibling influences on childhood development. Journal of Child Psychology and Psychiatry, 29, 119–127. Dunn, J. (1996). Brothers and sisters in middle childhood and early adolescence: Continuity and change in individual differences. In G. H. Brody (Ed.), Sibling relationships: Their causes and consequences (pp. 31– 46). Norwood, NJ: Ablex. Dunn, J., Creps, C., & Brown, J. (1996). Children’s family relationships between two and five: Developmental changes and individual differences. Social Development, 5, 230–250.

References

559

Dunn, J., Deater-Deckard, K., Pickering, K., O’Connor, T. G., Golding, J., & ALSPAC Study Team. (1998). Children’s adjustment and prosocial behavior in step-, singleparent and nonstepfamily settings: Findings from a community study. Journal of Child Psychology and Psychiatry, 39, 1083–1095. Dunn, J., & Kendrick, C. (1982). Siblings: Love, envy, and understanding. Cambridge, MA: Harvard University Press. Dunn, J., & Munn, P. (1985). Becoming a family member: Family conflict and the development of social understanding in the second year. Child Development, 56, 480–492. Dunn, J., & Munn, P. (1986a). Sibling quarrels and maternal intervention: Individual differences in understanding and aggression. Journal of Child Psychology and Psychiatry, 27, 583–595. Dunn, J., & Munn, P. (1986b). Siblings and the development of prosocial behavior. International Journal of Behavioral Development, 9, 265–284. Dunn, J., Plomin, R., & Nettles, M. (1985). Consistency of mothers’ behavior towards infant siblings. Developmental Psychology, 21, 1188–1195. Dunn, J., Slomkowski, C., Beardsall, L., & Rende, R. (1994). Adjustment in middle childhood and early adolescence: Links with earlier and contemporary sibling relationships. Journal of Child Psychology and Psychiatry, 35, 491–504. Dunn, L. M., & Dunn, L. M. (1997). Peabody Picture Vocabulary Test—Fourth Edition. Circle Pines, MN: American Guidance Service. DuPaul, G. J., & Hoff, K. E. (1998). Attention/concentration problems. In T. S. Watson & F. M. Gresham (Eds.), Handbook of child behavior therapy (pp. 99–126). New York: Plenum Press. DuPaul, G. J., Barkley, R. A., & McMurray, M. B. (1994). Response of children with ADHD to methylphenidate: Interaction with internalizing symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 894–903. DuPaul, G. J., Hook, C. L., Ervin, R., & Kyle, K. (1995, August). Effects of classwide peer tutoring on students with attention deficit hyperactivity disorder. Paper presented at the annual convention of the American Psychological Association, New York. DuPaul, G. J., McGoey, K. E., Eckert, T. L., & VanBrakle, J. (2001). Preschool children with attention-deficit/hyperactivity disorder: Impairments in behavioral, social and school functioning. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 508–515. DuPaul, G. J., Power, T. J., Anastopoulos, A. D., & Reid, R. (1998). ADHD Rating Scale-IV. New York: Guilford Press. DuPaul, G. J., Power, T. H., Anastopoulos, A. D., Reid, R., McGoey, K. E., & Ikeda, M. J. (1997). Teacher rating of attention-deficit/hyperactivity disorder symptoms: Factor structure and normative data. Psychological Assessment, 9, 436–444. DuPaul, G. J., & Rapport, M. D. (1993). Does methylphenidate normalize the classroom performance of children with attention deficit disorder? Journal of the American Academy of Child and Adolescent Psychiatry, 32, 190–198. DuPaul, G. J., Rapport, M. D., & Perriello, L. M. (1991). Teacher ratings of academic skills: The development of the Academic Performance Rating Scale. School Psychology Review, 20, 284–300. DuPaul, G. J., & Stoner, G. (1994). ADHD in the schools: Assessment and intervention strategies. New York: Guilford Press. Durand, V. M., & Mindell, J. A. (1990). Behavioral treatment of multiple childhood sleep disorders: Effects on child and family. Behavior Modification, 14, 37–49. Durand, V. M., & Mindell, J. A. (1999). Behavioral intervention for childhood sleep terrors. Behavior Therapy, 30, 705–715. Durand, V. M., Mindell, J., Mapstone, E., & Gernert-Dott, P. (1998). Sleep problems. In T. S. Watson & F. M. Gresham (Eds.), Handbook of child behavior therapy (pp. 203–219). New York: Plenum Press. Durlak, J. A. (1992). School problems of children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (2nd ed., pp. 497–510). New York: Wiley–Interscience. Dykens, E. M., Sparrow, S. S., Cohen, D. J., Scahill, L., & Leckman, J. F. (1999). Peer acceptance and adaptive functioning. In J. F. Leckman & D. J. Cohen (Eds.), Tourette’s syndrome—tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 104–117). New York: Wiley. Eapen, V., Pauls, D. L., & Robertson, M. M. (1993). Evidence for autosomal dominant transmission in Tourette’s syndrome: United Kingdom cohort study. British Journal of Psychiatry, 162, 593–596. Easson, W.M. (1960). Encopresis: Psychogenic soiling. Canadian Medical Association Journal, 82, 624–627. Edelbrock, C. S. (1990). Child attention problems scale. Unpublished manuscript. Penn State University, University Park, Pennsylvania. Edelbrock, C. S., Costello, A. J., Dulcan, M. K., Kalas, R., & Conover, N. C. (1985). Age differences in the reliability of the psychiatric interview of the child. Child Development, 56, 265–275.

560

References

Edelbrock, C., Rende, R. D., Plomin, R., & Thompson, L. A. (1995). A twin study of competence and problem behavior in childhood and early adolescence. Journal of Child Psychology and Psychiatry, 36, 775– 785. Egan, S. K., Monson, T. C., & Perry, D. G. (1998). Social-cognitive influences on change in aggression over time. Developmental Psychology, 34, 996–1006. Egeland, B., Kalkoski, M., Gottesman, N., & Erickson, M. R. (1990). Preschool behavior problems: Stability and factors accounting for change. Journal of Child Psychology and Psychiatry, 33, 891–910. Eisenberg, L. (1996). What should doctors do in the face of negative evidence? Journal of Nervous and Mental Disease, 184, 103–105. Eisenberg, N., Fabes, R. A., Guthrie, I. D., Murphy, B. C., Maszk, P., Holmgren, R., & Suh, K. (1996). The relations of regulation and emotionality to problem behavior in elementory school children. Development and Psychopathology, 8, 141–162. Eisenberg, N., Fabes, R. A., Shepard, S. A., Murphy, B. C., Guthrie, I. K., Jones, S., Friedman, J., Poulin, R., & Maszk, P. (1997). Contemporaneous and longitudinal prediction of children’s social functioning from regulation and emotionality. Child Development, 68, 642–664. Eisenberg, N., Guthrie, I. K., Fabes, R. A., Reiser, M., Murphy, B. C., Holgren, R., Maszk, P., & Losoya, S. (1997). The relations of regulation and emotionality to resiliency and competent social functioning in elementary school children. Child Development, 68, 295–311. Eisenberg, N., Guthrie, I. K., Fabes, R. A., Shepard, S., Losoya, S., Murphy, B. C., Jones, S., Poulin, R., & Reiser, M. (2000). Prediction of elementary school children’s externalizing problems behaviors from attentional and behavioral regulation and negative emotionality. Child Development, 71, 1367–1382. Elder, G. H., & Caspi, A. (1990). Studying lives in a changing society: Sociological and personalogical explorations. In A. I. Rabin, R. A. Zucker, S. Frank, & R. A. Emmons (Eds.), Studying persons and lives (pp. 201–247). New York: Springer. Elder, G. H., Caspi, A., & Van Nguyen, R. (1992). Resourceful and vulnerable children: Family influences in stressful times. In R. K. Silbereisen & K. Eyferth (Eds.), Development in context: Integrative perspectives on youth development (pp. 165–194). New York: Springer. Eley, T. C. (1999). Behavioral genetics as a tool for developmental psychology: Anxiety and depression in children and adolescents. Clinical Child and Family Psychology Review, 2, 21–36. Eley, T. C., Lichtenstein, P., & Stevenson, J. (1999). Sex differences in the etiology of aggressive and nonaggressive antisocial behavior: Results from two twin studies. Child Development, 70, 155–168. Eley, T. C., & Stevenson, J. (2000). Specific life events and chronic experiences differentially associated with depression and anxiety in young twins. Journal of Abnormal Child Psychology, 28, 383–394. Elia, J., Borcherding, B. G., Rapoport, J. L., & Keysor, C. S. (1991). Methylphenidate and dextroamphetamine treatments of hyperactivity: Are there true nonresponders? Psychiatry Research, 36, 141–155. Elizur, E., & Kaffman, M. (1982). Children’s bereavement reactions: II. Journal of the American Academy of Child Psychiatry, 140, 23–29. Elliott, A. J., & Fuqua, R. W. (2000). Trichotillomania: Conceptualization, measurement, and treatment. Behavior Therapy, 31, 529–545. Emery, R. E., & Forehand, R. (1994). Parental divorce and children’s well-being: A focus on resilience. In R. J. Haggerty, L. R. Sherrod, N. Garmezy, & M. Rutter (Eds.), Stress, risk, and resilience in children and adolescents (pp. 64–99). Cambridge, England: Cambridge University Press. Epstein, L. H., McCurley, J., Wing, R. R., & Valoski, A. (1990). Five-year follow-up of family-based behavioral treatments for childhood obesity. Journal of Consulting and Clinical Psychology, 58, 661–664. Epstein, L. H., Myers, M. D., Raynor, M. A., & Saelens, B. E. (1998). Treatment of pediatric obesity. Pediatrics, 101(Suppl.), 554–570. Epstein, L. H., Paluch, R. A., Gordy, C. C., Saelens, B. E., & Ernst, M. M. (2000). Problem-solving in the treatment of obesity. Journal of Consulting and Clinical Psychology, 68, 717–721. Epstein, L. H., & Squires, S. (1988). The stoplight diet for children. Boston: Little, Brown. Epstein, L. H., Valoski, A. M., Vara, L. S., McCurley, J., Wisniewski, L., Kalarchian, M. A., Klein, K. R., & Shrager, L. R. (1995). Effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Health Psychology, 14, 109–115. Epstein, L. H., Wing, R. R., Steranchak, L., Dickson, B., & Michelson, J. (1980). Comparison of family-based behavior modification and nutrition education in childrood obesity. Journal of Pediatric Psychology, 5, 25–35. Erenberg, G. (1992). Treatment of Tourette’s syndrome with neuroleptic drugs. Advances in Neurology, 58, 241–243. Esser, G., Schmidt, M. H., & Woerner, W. (1990). Epidemiology and course of psychiatric disorders in schoolage children: Results of a longitudinal study. Journal of Child Psychology and Psychiatry, 31, 243–263.

References

561

Estrada, P., Arsenio, W. F., Hess, R. D., & Holloway, S. D. (1987). Affective quality of the mother–child relationship: Longitudinal consequences for children’s school-relevant cognitive functioning. Developmental Psychology, 23, 210–215. Evans, D. W., Leckman, J. G., Carter, A., Reznick, J. S., Henshaw, D., King, R. A., & Pauls, D. (1997). Ritual, habits and perfectionism: The prevalence and development of compulsive-like behavior in normal young children. Child Development, 68, 58–68. Evans, J. H. C., & Meadow, S. R. (1992). Desmopressin for bed wetting: Length of treatment, vasopressin secretion, and response. Archives of Disease in Childhood, 67, 184–188. Evans, M. E., Armstrong, M., & Kuppinger, A. (1996). Family-centered intensive case management: A step toward understanding individualized care. Journal of Child and Family Studies, 3, 55–65. Everson, M. D., & Boat, B. W. (1989). False allegations of sexual abuse by children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 230–235. Eyberg, S. (1974). Therapy Attitude Inventory. Unpublished manuscript. Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida. Eyberg, S. M., Bessmer, J., Newcomb, K., Edwards, D., & Robinson, E. (1994). Manual for the Dyadic Parent–Child Interaction Coding System-II. Social and Behavioral Sciences Documents (Ms. No. 2897). (Available from Select Press, P.O. Box 9838, San Rafael, CA 94912) Eyberg, S. M., & Boggs, S. R. (1998). Parent-child interaction therapy: A psychosocial intervention for the treatment of young conduct-disordered children. In J. M. Briesmeister & C. E. Schaeffer (Eds.), Handbook of parent training: Parents as co-therapists for children’s behavior problems (2nd ed., pp. 61–97). New York: Wiley. Eyberg, S.M., Edwards, D., Bessmer, J., & Litwins, N. (1994). The workbook: Coder training manual for the Dyadic Parent–Child Interaction Coding System-II. Social and Behavioral Sciences Documents (Ms. No. 2898). (Available from Sheila M. Eyberg, Department of Clinical and Health Psychology, 1600 S.W. Archer Boulevard, University of Florida, Gainesville, FL 32610) Eyberg, S. M., Edwards, D., Boggs, S. R., & Foote, R. (1998). Maintaining the treatment effects of parent training: The role of booster sessions and other maintenance strategies. Clinical Psychology: Science and Practice, 5, 544–554. Eyberg, S. M., & Pincus, D. (1999). The Eyberg Child Behavior Inventory and Sutter–Eyberg Student Behavior Inventory: Professional manual. Odessa, FL: Psychological Assessment Resources. Eyberg, S. M., & Robinson, E. A. (1982). Parent–child interaction training: Effects on family functioning. Journal of Clinical Child Psychology, 11, 130–137. Faber, A., & Mazlish, E. (1998). Siblings without rivalry: How to help your children live together so you can live too. New York: Avon Books. Faber, A., & Mazlish, E. (1999). How to talk so kids will listen and listen so kids will talk. New York: Avon Books. Faller, K. C. (1988). Criteria for judging the credibility of children’s statements about their sexual abuse. Child Welfare, 67, 389–401. Falment, M. R., Cohen, D., Choquet, M., Jeammet, P., & Ledoux, S. (2001). Phenomenology, psychosocial correlates, and treatment seeking in major depression and dysthymia of adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1070–1078. Fantuzzo, J. W., McDermott, P. A., Manz, P. H., Hampton, V. R., & Burdick, N. A. (1996). The Pictorial Scale of Perceived Competence and Social Acceptance: Does it work with low-income urban children. Child Development, 67, 1071–1084. Faraone, S. V. (2000). Genetics of childhood disorders: XX. ADHD, Part 4: Is ADHD genetically heterogeneous? Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1455–1457. Faraone, S. V., & Biederman, J. (1997). Do attention deficit hyperactivity disorder and major depression share familial risk factors? Journal of Nervous and Mental Disease, 185, 533–541. Faraone, S. V., Biederman, J., Feighner, J. A., & Monuteaux, M. C. (2000). Assessing symptoms of attention deficit hyperactivity disorder in children and adults: Which is more valid? Journal of Consulting and Clinical Psychology 68, 830–842. Faraone, S. V., Biederman, J., Keenan, K., & Tsuang, M. T. (1991). A family-genetic study of girls with DSMIII attention deficit disorder. American Journal of Psychiatry, 148, 112–117. Faraone, S. V., Biederman, J., Mennin, D., & Russell, R. L. (1998). Bipolar and antisocial disorders among relatives of ADHD children: Parsing familial subtypes of illness. Neuropsychiatric Genetics, 81, 108– 116. Faraone, S. V., Biederman, J., Mennin, D., Gershon, J., & Tsuang, M. T. (1996). A prospective four-year follow-up study of children at risk for ADHD: Psychiatric, neuropsychological, and psychosicla outcome. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1449–1459.

562

References

Faraone, S. V., Biederman, J., & Monuteaux, M. (2000). Toward guidelines for pedigree selection in genetic studies of attention deficit hyperactivity disorder. Genetic Epidemiology, 18, 1–16. Faraone, S. V., Biederman, J., Weber, W., & Russell, R. (1998). Psychiatric, neuropsychological, and psychosocial features of DSM-IV subtypes of attention-deficit/hyperactivity disorder: Results from a clinically referred sample. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 185–193. Farver, J. M. (1996). Aggressive behavior in preschoolers’ social networks: Do birds of a feather flock together? Early Childhood Research Quarterly, 11, 333–350. Feagans, L., Sanyal, M., Henderson, F., Collier, A., & Appelbaum, M. (1987). Relationship of middle ear disease in early childhood to later narrative and attentional skills. Journal of Pediatric Psychology, 12, 581–594. Feehan, M., McGee, R., Stanton, W. & Silva, P. (1990). A 6-year follow-up of childhood enuresis: Prevalence in adolescence and consequences for mental health. Journal of Pediatric and Child Health, 26, 75–79. Feingold, B. (1975). Why your child is hyperactive. New York: Random House. Feiring, C., Taska, L., & Lewis, M. (1999). Age and gender differences in children’s and adolescents’ adaptation to sexual abuse. Child Abuse and Neglect, 23, 115–128. Feldman, M. D. (1986). Pica: Current perspectives. Psychomatics, 27, 519–523. Feldman, R. B., & Werry, J. S. (1966). An unsuccessful attempt to treat a tiquer by massed practice. Behaviour Research and Therapy, 4, 111–117. Felner, R. D., & Terre, L. (1987). Child custody dispositions and children’s adaptation following divorce. In L. A. Weithorn (Ed.), Psychology and child custody determinations: Knowledge, roles and expertise (pp. 106–153). Lincoln: University of Nebraska Press. Ferber, R. (1985). Solve your child’s sleep problems. New York: Simon & Schuster. Ferber, R., Boyle, M. R., & Belfer, M. (1981, June). Initial experience of a pediatrics sleep disorder clinic. Paper presented at the 21st Annual Meeting of the Association for the Psychophysiological Study of Sleep, Hyannis, MA. Fergusson, D. M., & Horwood, L. J. (1996). The role of adolescent peer affiliations in the continuity between childhood behavioral adjustment and juvenile offending. Journal of Abnormal Child Psychology, 24, 205– 221. Fergusson, D. M., Lynskey, M. R., & Horwood, L. J. (1994). The effects of parental separation, the timing of separation and gender on children’s performance on cognitive tests. Journal of Child Psychology and Psychiatry, 35, 1077–1092. Field, A. E., Camargo, C. A., Taylor, C. B., Berkey, C. S., Frazier, L., Gillman, M. W., & Colditz, G. A. (1999). Overweight, weight concerns, and bulimic behaviors among girls and boys. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 754–760. Field, T. (1992). Infants of depressed mothers. Development and Psychopathology, 4, 49–66. Field, T., Dempsey, J., Hallock, N., & Schuman, H. (1978). The mother’s assessment of the behavior of her infant. Infant Behavior and Development, 16, 99–108. Field, T., Healy, B., Goldstein, S., & Guthertz, M. (1990). Behavior–state matching and synchrony in mother– infant interactions of non-depressed versus depressed dyads. Developmental Psychology, 26, 7–14. Field, T., & Reite, M. (1984). Children’s responses to separation from mother during the birth of another child. Child Development, 55, 1308–1316. Field, T., Sandberg, D., Garcia, R., Vage-Lahr, N., Goldstein, S., & Guy, L. (1985). Prenatal problems, postpartum depression, and early mother–infant interactions. Developmental Psychology, 12, 1152–1156. Fielding, D. (1980). The response of day and night wetting children and children who wet only at night to retention control training and enuresis alarm. Behaviour Research and Therapy, 18, 305–317. Findling, R. L., McNamara, N. K., Branicky, L. A., Schluchter, M. D., Lemon, E., & Blumer, J. L. (2000). A double-blind pilot study of risperidone in the treatment of conduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 509–516. Findling, R. L., Short, E. J., & Manos, M. J. (2001). Short-term cardiovascular effects of methylphenidate and Adderall. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 525–529. Finkelhor, D. (1981). Sex between siblings: Sex play, incest, and aggression. In L. L. Constantine & F. M. Martinson (Eds.), Children and sex: New findings, new perspectives (pp. 129–149). Boston: Little, Brown. Finkelhor, D. (1984). What parents tell their children about sexual abuse. In D. Finkelhor (Ed.), Child sexual abuse: New theory and research (pp. 134–149). New York: Free Press. Finkelhor, D. (1987). The sexual abuse of children: Current research reviewed. Psychiatric Annals, 17, 233– 241. Finkelhor, D. (1990). Early and long-term effects of child sexual abuse: An update. Professional Psychology: Research and Practice, 21, 325–330.

References

563

Finkelhor, D., & Berliner, L. (1995). Research on the treatment of sexually abused children: A review and recommendations. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1408–1423. Finkelhor, D., & Browne, A. (1986). Initial and long-term effects: A conceptual framework. In D. Finkelhor & Associates (Eds.), A sourcebook on child sexual abuse (pp. 180–198). Beverly Hills, CA: Sage. Finkelhor, D., Hotaling, G., Lewis, I. A.,, & Smith, C. (1990). Sexual abuse in a national survey of adult men and women: Prevalence, characteristics, and risk factors. Child Abuse and Neglect, 14, 19–28. Finkelhor, D., Williams, L. M., & Burns, N. (1988). Nursery crimes: Sexual abuse in day care. Newbury Park, CA: Sage. Finkelstein, N. (1982). Aggression: Is it stimulated by day care? Young Children, 37, 3–9. Finley, W., & Wansley, R. (1977). Auditory intensity as a variable in the conditioning treatment of enuresis nocturna. Behaviour Research and Therapy, 15, 181–185. Fischer, D. J., Himle, J. A., & Thyer, B. A. (1999). Separation anxiety disorder. In R. T. Ammerman, M. Hersen, & C. G. Last (Eds.), Handbook of prescriptive treatments for children and adolescents (2nd ed., pp. 141–154). Needham Heights, MA: Allyn & Bacon. Fischer, M. (1997). The persistence of ADHD into adulthood: It depends on whom you ask. The ADHD Report, 5, 8–10. Fisher, B. E., & Wilson, A.. E. (1987). Selected sleep disturbances in school children reported by parents: Prevalence, interrelationships, behavioral correlates and parental attributions. Perceptual and Motor Skills, 64, 1147–1157. Fishman, K. D. (1995). Behind the one-way mirror: Psychotherapy and children. New York: Bantam. Flament, M., Whitaker, A., Rapoport, J. J. L., Davies, M., & Zaremba-Berg, C. (1988). Obsessive–compulsive disorder in adolescence: An epidemiological study. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 764–771. Foote, R. C., Schuhmann, E. M., Jones, M. L., & Eyberg, S. M. (1998). Parent–child interaction therapy: A guide for clinicians. Clinical Child Psychology and Psychiatry, 3, 361–373. Forehand, R. L., Gardner, H., & Roberts, M. (1978). Maternal response to child compliance and noncompliance: Some normative data. Journal of Clinical Child Psychology, 7, 121–124. Forehand, R. L., King, H. E., Peed, S., & Yoder, P. (1975). Mother–child interactions: Comparisons of a noncompliant clinic group and non-clinic group. Behaviour Research and Therapy, 13, 79–84. Forehand, R. L., Lautenschlager, G. J., Faust, J., & Graziano, W. G. (1986). Parent perceptions and parent– child interactions in clinic-referred children: A preliminary investigation of the effects of maternal depressive moods. Behaviour Research and Therapy, 24, 73–75. Forehand, R. L., & Long, N. (1996). Parenting the strong-willed child. Chicago: Contemporary Books. Forehand, R. L., McCombs, A., Long, N., Brody, G., & Fauber, R. (1988). Early adolescent adjustment to recent parental divorce: The role of interparental conflict and adolescent sex as mediating variables. Journal of Consulting and Clinical Psychology, 56, 624–627. Forehand, R. L., & McMahon, R. J. (1981). Helping the noncompliant child: A clinician’s guide to parent training. New York: Guilford Press. Forehand, R., Pelton, J., Chance, M., Armistead, L., Morse, E., Morse, P. S., & Stock, M. (1999). Orphans of the AIDS epidemic in the United States: Transition-related characteristics and psychosocial adjustment at 6 months after mother’s death. AIDS Care, 11, 715–722. Forsythe, W. I., & Redmond, A. (1974). Enuresis and spontaneous cure rate: A study of 1129 enuretics. Archives of Disease in Childhood, 49, 259–276. Fosson, A., Knibbs, J., Bryant-Waugh, R., & Lask, B. (1987). Early onset anorexia nervosa. Archives of Diseases in Childhood, 62, 114–118. Foster, L. G. (1998). Nervous habits and stereotyped behaviors in preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 711–717. Foster, S. L., & Cone, J. D. (1986). Design and use of direct observation procdures. In A. R. Ciminero, K. S. Calhoun, & H. E. Adams (Eds.), Handbook of behavioral assessment (2nd ed., pp. 253–324). New York: Wiley. Foster, S. L., & Robin, A. L. (1997). Family conflict and communication in adolescence. In E. J. Mash & L. G. Terdal (Eds.). Assessment of childhood disorders (3rd ed., pp. 627–682). New York: Guilford Press. Foulkes, D., Hollifield, M., Sullivan, B., Bradley, L., & Terry, R. (1990). REM dreaming and cognitive skills at ages 5–8: A cross-sectional study. International Journal of Behavioral Development, 13, 447–465. Fox, G. L., & Kelly, R. F. (1995). Determinants of child custody arrangements at divorce. Journal of Marriage and the Family, 57, 693–708. Fox, N. A. (Ed.). (1994). The development of emotion regulation: Biological and behavioral considerations. Monographs of the Society for Research in Child Development, 59(2–3, Serial No. 240).

564

References

Foxman, B., Valdez, R. B., & Brook, R. H. (1986). Childhood enuresis: Prevalence, perceived impact, and prescribed treatments. Pediatrics, 77, 482–487. Foxx, R. M., & Azrin, N. H. (1973). Dry pants: A rapid method of toilet training children. Behaviour Research and Therapy, 11, 435–442. France, K. G. (1992). Behavior characteristics and security in sleep-disturbed infants treated with extinction. Journal of Pediatric Psychology, 17, 467–475. Francis, G., Last, C. G., & Strauss, C. C. (1987). Expression of separation anxiety disorders: The roles of age and gender. Child Psychiatry and Human Development, 18, 82–89. Frank, N. C., Spirito, A., Stark, L., & Owens-Stively, J. (1997). The use of scheduled awakenings to eliminate childhood sleepwalking. Journal of Pediatric Psychology, 22, 345–353. Frankel, M., Cummings, J. L., Robertson, M. M., Trimble, M. R., Hill, M. A., & Benson, D. F. (1986). Obsessions and compulsions in Gilles de la Tourette’s syndrome. Neurology, 36, 378–382. Frentz, C., & Kelley, M. L. (1986). Parents’ acceptance of reductive treatment methods: The influence of problem severity and perception of child behavior. Behavior Therapy, 17, 75–81. Frick, P. J. (1994). Family dysfunction and the disruptive behavior disorders. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 18, pp. 203–226). New York: Plenum Press. Frick, P. J. (1998). Conduct disorders. In T. H. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (3rd ed., pp. 213–238). New York: Plenum Press. Frick, P. J., & Ellis, M. (1999). Callous–unemotional traits and subtypes of conduct disorder. Clinical Child and Family Psychology Review, 2, 149–168. Frick, P. J., Kamphaus, R. W., Lahey, B. B., & Loeber, R. (1991). Academic underachievement and the disruptive behavior disorders. Journal of Consulting and Clinical Psychology, 59, 289–294. Frick, P. J., Lahey, B. B., Loeber, R., Tannenbaum, L. E., Van Horn, Y., Christ, M. A. G., Hart, E. L., & Hanson, K. (1993). Oppositional defiant disorder and conduct disorder: A meta-analytic review of factor analyses and cross-validation in a clinic sample. Clinical Psychology Review, 13, 319–340. Frick, P. J., Silverthorn, P., & Evans, C. S. (1994). Assessment of childhood anxiety using structured interviews: Patterns of agreement among informants and association with maternal anxiety. Psychological Assessment, 6, 372–379. Friedman, A. G., Latham, S. A., & Dahlquist, L. M. (1998). Childhood cancer. In T. H. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (3rd ed., pp. 435–461). New York: Plenum Press. Friedman, R. M., Katz-Leavy, J. W., Manderscheid, R. W., & Sondheimer, D. L. (1996). Prevalence of serious emotional disturbance in children and adolescents. In R. W. Manderscheid & M. A. Sonnenschein (Eds.), Mental health, United States (p. 83). Washington, DC: U.S. Government Printing Office. Friedrich, W. N. (1990). Psychotherapy of sexually abused children and their families. New York: W. W. Norton. Friedrich, W. N. (1997). Child sexual behavior inventory: Revised. Odessa, FL: Psychological Assessment Resources. Friedrich, W. N., Beilke, R. L., & Urquiza, A. J. (1988). Brief diagnostic group treatment of sexually abused boys: A comparison study. Journal of Interpersonal Violence, 3, 21–28. Friedrich, W. N., Grambsch, P., Broughton, D., Kuiper, J., & Beilke, R. L. (1991). Normative sexual behavior in children. Pediatrics, 88, 456–464. Friedrich, W. N., Grambsch, P., Damon, L., Koverola, C., Wolfe, V., Hewitt, S., Lang, R., & Groughton, D. (1992). The Child Sexual Behavior Inventory: Normative and clinical comparisons. Psychological Assessment, 4, 303–311. Friedrich, W. N., Luecke, W. J., Beilke, R. L.,, & Place, V. (1992). Psychotherapy outcome of sexually abused boys. Journal of Interpersonal Violence, 7, 396–409. Friman, P. C. (1988). Eliminating chronic thumb sucking by preventing a covarying response. Journal of Behavior Therapy and Experimental Psychiatry, 19, 301–304. Friman, P. C., Barone, V. J., & Christophersen, E. R. (1986). Aversive taste treatment of finger and thumb sucking. Pediatrics, 78, 174–176. Friman, P. C., Finney, J. W., & Christophersen, E. R. (1984). Behavioral treatment of trichotillomania: An evaluative review. Behavior Therapy, 15, 249–266. Friman, P. C., & Hove, G. (1987). Apparent covariation between child habit disorders: Effects of successful treatment for thumb sucking on untargeted chronic hair pulling. Journal of Applied Behavior Analysis, 20, 421–427. Friman, P. C., & Jones, K. M. (1998). Elimination disorders in children. In T. S. Watson & F. M. Gresham (Eds.), Handbook of child behavior therapy (pp. 239–259). New York Plenum Press. Friman, P. C., Larzelere, R., & Finney, J. W. (1994). Exploring the relationship between thumb-sucking and psychopathology. Journal of Pediatric Psychology, 19, 431–441.

References

565

Friman, P. C., & Leibowitz, J. M. (1990). An effective and acceptable treatment alternative for chronic thumband finger-sucking. Journal of Pediatric Psychology, 15, 57–65. Friman, P. C., Mathews, J. R., Finney, F. W., Christophersen, E. R., & Leibowitz, J. M. (1988). Do encopretic children have clinically significant behavior problems? Pediatrics, 82, 407–409. Friman, P. C., McPherson, K. M., Warzak, W. J., & Evans, J. (1993). Influence of thumb sucking on peer social acceptance in first-grade children. Pediatrics, 91, 784–786. Friman, P. C., & Vollmer, D. (1995). Successful use of the nocturnal urine alarm for diurnal enuresis. Journal of Applied Behavior Analysis, 28, 89–90. Friman, R. M., Handwerk, M. L., Swearer, S. M., McGinnis, J. C., & Warzak, W. J. (1998). Do children with primary nocturnal enuresis have clinically significant behavior problems? Archives of Pediatrics and Adolescent Medicine, 152, 537–539. Fristad, M., Weller, E. B., & Weller, R. A. (1992). The Mania Rating Scale: Can it be used in children? Journal of the American Academy of Child and Adolescent Psychiatry, 31, 252–257. Fryer, G. E., Kraizer, S. K., & Miyoshi, T. (1987a). Measuring actual reduction of risk of child abuse: A new approach. Child Abuse and Neglect, 11, 173–179. Fryer, G. E., Kraizer, S. K., & Miyoshi, T. (1987b). Measuring children’s retention of skills to resist stranger abduction: Use of the simulation technique. Child Abuse and Neglect, 11, 181–185. Furman, E. (1976). Commentary. Journal of Pediatrics, 89, 143–145. Gabel, S., Hegedus, A. M., Wald, A., Chandra, R., & Chiponis, D. (1986). Prevalence of behavior problems and mental health utilization among encopretic children: Implications for behavioral pediatrics. Journal of Developmental and Behavioral Pediatrics, 7, 293–297. Gadow, K. D., Sverd, J., & Nolan, E. E. (1992). Methylphenidate in hyperactive boys with comorbid tic disorder: II. Short-term behavioral effects in school settings. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 462–471. Gale, J., Thompson, R. J., Moran, T., & Sack, W. H. (1988). Sexual abuse in young children: Its clinical presentation and characteristic patterns. Child Abuse and Neglect, 12, 163–170. Garbarino, J. (1988). Preventing childhood injury: Developmental and mental health issues. American Journal of Orthopsychiatry, 58, 25–45. Garber, J., & Kaminski, K. M. (2000). Laboratory and performance-based measures of depression in children and adolescents. Journal of Clinical Child Psychology, 29, 509–525. Garcia-Coll, C. T., & Meyer, E. C. (1993). The socio-cultural context of infant development. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (pp. 56–70). New York: Guilford Press. Gardner, R. A. (1982). Family evaluation in child custody litigation. Cresskill, NJ: Creative Therapeutics. Garmezy, N. (1983). Stressors of childhood. In N. Garmezy & M. Rutter (Eds.), Stress, coping and development in children (pp. 43–84). New York: McGraw-Hill. Garmezy, N., & Masten, A. S. (1986). Stress, competence, and resilience: Common frontiers for therapist and psychopathologist. Behavior Therapy, 89, 500–521. Garmezy, N., & Rutter, M. (1985). Acute reactions to stress. In M. Rutter & L. Hersov (Eds.), Child and adolescent psychiatry: Modern approaches (2nd ed., pp. 152–176). Oxford: Blackwell Scientific. Garner, D. M., & Barry, D. (2001). Treatment of eating disorders in adolescents. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 692–713). New York: Wiley. Garner, D. M., & Garfinkel, P. E. (1979). The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 273–279. Garner, E. M., Olmsted, M.P., Bohr, Y., & Garfinkel, P.E. (1982). The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine, 12, 871–878. Gaub, M. J., & Carlson, C. L. (1997a). Behavioral characteristics of DSM-IV subtypes in a school-based population. Journal of Abnormal Child Psychology, 25, 103–111. Gaub, M. J., & Carlson, C. L. (1997b). Gender differences in ADHD: A meta-analysis and critical review. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1036–1045. Gaylor, E. E., Goodlin-Jones, & Anders, T. F. (2001). Classification of young children’s sleep problems: A pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 61–67. Geiselman, R. E., Saywitz, K. J., & Bornstein, G. K. (1993). Effects of cognitive questioning techniques on children’s recall performance. In G. S. Goodman & B. L. Bottoms (Eds.), Child victims, child witnesses: Understanding and improving testimony (pp. 71–94). New York: Guilford Press. Gelfand, D., Teti, D. M., Seiner, S. A., & Jameson, P. B. (1996). Helping mothers fight depression: Evaluation of a home-based intervention program for depressed mothers and their infants. Journal of Clinical Child Psychology, 25, 406–422.

566

References

Geller, B., Bolhofner, K., Craney, J. L., Williams, M., BelBello, M., & Gundersen, K. (2000). Psychosocial functioning in a prepubertal and early adolescent bipolar disorder phenotype. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1543–1548. Geller, B., Todd, R. D., Luby, J., & Botteron, K. N. (1996). Treatment-resistant depression in children and adolescents. Psychiatric Clinics of North America, 19, 253–267. Geller, B., Zimerman, B., Williams, M., Bolhofner, K., & Craney, J. J. (2001). Adult psychosocial outcome of prepubertal major depressive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 673–677. Gellis, W. W. (1994). Are enuretics truly hard to arouse? Pediatric Notes, 18, 113. Gerald, L. B., Anderson, A., Johnson, G. D., Hoff, C., & Trimm, R. F. (1994). Social class, social support and obesity risk in children. Child: Care, Health and Development, 20, 145–163. Gerring, J. P., Brady, K. D., Chen, A., Vasa, R., Crados, M., Bandeen-Roche, K. J., Bryan, R. N., & Benckla, M. B. (1998). Premorbid prevalence of ADHD and development of secondary ADHD after closed head injury. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 647–654. Gil, E. (1993). Age-appropriate sex play versus problematic sexual behaviors. In E. Gil & T. C. Johnson (Eds.), Sexualized children: Assessment and treatment of sexualized children and children who molest. Rockville, MD: Launch Press. Gil, E.,, & Johnson, T. C. (Eds.). (1993). Sexualized children: Assessment and treatment of sexualized children and children who molest. Rockville, MD: Launch Press. Gittelman-Klein, R., & Mannuzza, S. (1988). Hyperactive boys almost grown up: III. Methylphenidate effects on ultimate height. Archives of General Psychiatry, 45, 1131–1134. Gjone, H., Stevenson, J., Sundet, J. M., & Eilertsen, D. E. (1996). Changes in heritability across increasing levels of behavior problems in young twins. Behavior Genetics, 26, 419–426. Gladstone, T. R. G., & Kaslow, N. J. (1995). Depression and attributions in children and adolescents: A metaanalytic review. Journal of Abnormal Child Psychology, 23, 597–606. Glaros, A. G., & Epkins, C. C. (1995). Habit disorders: Bruxism, trichotillomania, and tics. In M. C. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp. 558–574). New York: Guilford Press. Glasscock, S. G., Friman, P. S., O’Brien, S., & Christophersen, E. R. (1986). Varied citrus treatment of ruminant gagging in a teenager with Batten’s disease. Journal of Behavior Therapy and Experimental Psychiatry, 17, 129–133. Glaze, D. G., Frost, J. D., & Jankovic, J. (1983). Sleep in Gilles de la Tourette’s syndrome: Disorder of arousal. Neurology, 33, 586. Glicklich, L. B. (1951). An historical account of enuresis. Pediatrics, 8, 859–876. Glod, C. A., Teicher, M. H., Hartman, C. R., & Harakal, T. (1997). Increased nocturnal activity and impaired sleep maintenance in abused children. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1236–1243. Goldfried, M. R. (1971). Systematic desensitization in training self-control. Journal of Consulting and Clinical Psychology, 37, 228–234. Goldman, L. S., Genel, M., Bergman, & Slanetz, P. J. (1998). Diagnosis and treatment of attention-deficit/ hyperactivity disorder in children and adolescents. Journal of the American Medical Association, 279, 1100–1107. Goldsmith, H. H., Buss, K. A., & Lemery, K. S. (1997). Toddler and childhood temperament: Expanded content, stronger genetic evidence, new evidence for the importance of environment. Developmental Psychology, 33, 891–905. Goldsmith, H. H., Buss, A. H., Plomin, R., Rothbart, M. K., Thomas, A., Chess, S., Hinde, R. A., & McCall, R. B. (1987). Roundtable: What is temperament? Four approaches. Child Development, 58, 505–529. Golombok, S., & Tasker, F. (1996). Do parents influence the sexual orientation of their children?: Findings from a longitudinal study of lesbian families. Developmental Psychology, 32, 3–11. Goodman, S. H., Hoven, C., Narrow, W., Cohen, P., Fielding, B., Alegria, M., Leaf, P. J., Kandel, D., Morwotz, S. M., Bravo, M., Moore, R., & Dulcan, M. K. (1998). Measurement of risk for mental disorders and competence in a psychiatric epidemiologic community survey: The National Institute of Mental Health Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study. Social Psychiatry and Psychiatric Epidemiology, 33, 162–173. Goodman, S. H., Schwab-Stone, M., Lahey, B. B., Shaffer, D., & Jensen, P. S. (2000). Major depression and dysthymia in children and adolescents: Discriminant validity and differential consequences in a community sample. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 761– 770. Goodman, G., Taub, E., Jones, D., England, P., Port, L. K., Rudy, L., & Prado, L. (1992). Introduction: Testifying in criminal court. Monographs of the Society for Research in Child Development, 57, 1–15.

References

567

Goodyer, I. M. (1990). Life experience, development and child psychopathology. Chichester, England: Wiley. Goodyer, I. M., & Altham, P. M. E. (1991). Lifetime exit events and recent social and family adversities in anxious and depressed school-age children and adolescents: I. Journal of Affective Disorders, 21, 219– 228. Gordon, B. N., Baker-Ward, L., & Ornstein, P. A. (2001). Children’s memory for personal experiences: A review of research related to testimony. Journal of Clinical Child and Family Psychology Review, 4, 157– 181. Gordon, B. N., & Follmer, A. (1994). Developmental issues in judging the credibility of children’s testimony. Journal of Clinical Child Psychology, 23, 283–294. Gordon, B. N., & Jens, K. G. (1988). A conceptual model for tracking high-risk infants and making early service decisions. Developmental and Behavioral Pediatrics, 9, 279–286. Gordon, B. N., Ornstein, P. A., Nida, R. E., Follmer, A., Crenshaw, M. C., & Albert, G. (1993). Does the use of dolls facilitate children’s memory of visits to the doctor. Applied Cognitive Psychology, 7, 459–474. Gordon, B. N., & Schroeder, C. S. (1995). Sexuality: A developmental approach to problems. New York: Plenum Press. Gordon, B. N., & Schroeder, C. S. (2001). Sexual problems of children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 495–522). New York: Wiley. Gordon, B. N., Schroeder, C. S., & Abrams, J. M. (1990a). Children’s knowledge of sexuality: Age and social class differences. Journal of Clinical Child Psychiatry, 19, 33–43. Gordon, B. N., Schroeder, C. S., & Abrams, J. M. (1990b). Children’s knowledge of sexuality: A comparison of sexually abused and nonabused children. American Journal of Orthopsychiatry, 60, 250–257. Gordon, B. N., Schroeder, C. S., Ornstein, P. A., & Baker-Ward, L. (1995). Clinical implications of research on memory development. In T. Ney (Ed.), True and false allegations of child sexual abuse: Assessment and case management (pp. 99–124). New York: Brunner/Mazel. Gordon, M. (1983). The Gordon Diagnostic System. DeWitt, NY: Gordon Systems. Gordon, R. S. (1987). An operational classification of disease prevention. In J. A. Steinberg & M. M. Silverman (Eds.), Preventing mental disorders: A research perspective (DHHS Publication No. ADM 87-1492, pp. 20–26). Washington, DC: U.S. Government Printing Office. Gordon, S. (1992a). Facts about sex for today’s youth. New York: Prometheus Books. Gordon, S. (1992b). Girls and girls and boys are boys, so what’s the difference: A nonsexist sexuality education book for children age 6 to 10 (rev. ed.). New York: Prometheus Books. Gordon, S., & Gordon, J. (1983). Raising a child conservatively in a sexually permissive world. New York: Simon & Schuster. Gordon, S., & Gordon, J. (1992). Did the sun shine before you were born?: A sex education primer. New York: Prometheus Books. Gordon, S., & Snyder, S. V. (1983). Sex education. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (pp. 1154–1173). New York: Wiley. Gordon, T. (1970). Parent effectiveness training: The tested new way to raise responsible children. New York: Plume. Gortmaker, S. L., Must, A., Sobol, A. M., Peterson, K., Colditz, G. A., & Dietz, W. H. (1996). Television viewing as a cause of increasing obesity among children in the U.S., 1986–1990. Archives of Pediatrics and Adolescent Medicine, 150, 356–362. Gouze, K. (1987). Attention and social problem solving as correlates of aggression in preschool males. Journal of Abnormal Child Psychology, 15, 181–197. Grad, L. R., Pelcovitz, D., Olson, M., Matthews, M., & Grad, G. (1987). Obsessive–compulsive symptomatology in children with Tourette’s syndrome. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 69–74. Green, A. H. (1986). True and false allegations of sexual abuse in child custody disputes. Journal of the American Academy of Child Psychiatry, 25, 449–456. Green, R. (1987). The “sissy boy syndrome” and the development of homosexuality. New Haven: Yale University Press. Greenberg, L. M., & Waldman, I. D. (1992). Developmental normative data on the Test of Variables of Attention (TOVA). Minneapolis: University of Minnesota Medical School, Department of Psychiatry. Greenberg, M. T., Lengua, L. J., Coie, J. D., Pinderhughes, E. E., & the Conduct Problems Prevention Research Group. (1999). Predicting developmental outcomes at school entry using a multiple-risk model: Four American communities. Developmental Psychology, 35, 403–417. Greene, R. W. (2001). The explosive child. New York: Quill. Greene, R. W., & Ablon, J. S. (2001). What does the MTA study tell us about effective psychosocial treatment for ADHD? Journal of Clinical Child Psychology, 30, 114–121.

568

References

Greene, R. W., & Doyle, A. E. (1999). Toward a transactional conceptualization of ODD. Clinical Child and Family Psychology Review, 2, 129–148. Greene, R., Biederman, J., Faraone, S., Ouellette, C., Penn, C., & Griffin, S. (1996). Toward a new psychometric definition of social disability in children with attention-deficit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 571–578. Greene, R., Biederman, J., Faraone, S., Sienna, M., & Garcia-Jetton, J. (1997). Adolescent outcome of boys with ADHD and social disability: Results from a four year longitudinal follow-up study. Journal of Consulting and Clinical Psychology, 65, 758–767. Greenhill, L. L., Abikoff, H. B., Arnold, L. E., Cantwell, D. P., Conners, C. K., Elliott, G., Hechtman, L., Hinshaw, S. P., Hoza, B., Jensen, P. S., March, J. S., Newcorn, J., Pelham, W. E., Severe, J. B., Swanson, J. M., Vitiello, B., & Wells, K. (1996). Medication treatment strategies in the MTA study: Relevance to clinicians and researchers. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1304–1313. Greenhill, L. I., Swanson, J. M., Vitiello, B., Davies, M., Clevenger, W., Wu, M., Arnold, L. E., Abikoff, H. B., Bukstein, O. G., Conners, C. K., Elliott, G. R., Hechtman, L., Hinshaw, S. P., Hoza, B., Jensen, P. S., Kraemer, H. C., March, J. S., Newcom, J. H., Severe, J. B., Wells, K., & Wigal, T. (2001). Impairment and deportment responses to different methylphenidate doses in children with ADHD: The MTA titration trial. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 180–187. Greening, L., & Dollinger, S. J. (1989). Treatment of a child’s sleep disturbance and related phobias in the family. In M. C. Roberts & C. E. Walker (Eds.), Casebook of child and pediatric psychology (pp. 94– 111). New York: Guilford Press. Greenwood, C. R. (1991). Classwide peer tutoring: Longitudinal effects of the reading, language, and mathematics achievement of at-risk students. Journal of Reading, Writing, and Learning Disabilities International, 7, 105–123. Greenwood, C. R., Delquadri, J., & Carta, J. J. (1988). Classwide peer tutoring. Seattle, WA: Educational Achievement Systems. Gresham, R. M., & Elliott, S. N. (1990). Social Skills Rating System. Circle Pines, MN: American Guidance Service. Griest, D. L., Forehand, R., Rogers, T., Breiner, J., Furey, W., & Williams, C. A. (1982). Effects of parent enhancement therapy on the treatment outcome and generalization of a parent training program. Behaviour Research and Therapy, 20, 429–436. Group for the Advancement of Psychiatry, Committee on Preventive Psychiatry. (1999). Violent behavior in children and youth: Preventive intervention from a psychiatric perspective. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 235–241. Gruber, R., Sadeh, A., & Raviv, A. (2000). Instability of sleep patterns in children with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 495– 501. Grych, J. H., & Fincham, F. D. (1992). Interventions for children of divorce: Towards greater integration of research and action. Psychological Bulletin, 111, 434–454. Gudas, L. S., & Koocher, G. P. (2001). Children with grief. In C. E. Walker & M. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 1046–1056). New York: Wiley. Guilleminault, C., & Anders, T. (1976). Sleep disorders in children: Part II. Advances in Pediatrics, 22, 151– 174. Guilleminault, C., Mignot, E., & Grumet, F. C. (1989). Familial patterns of narcolepsy. Lancet, ii, 1376–1379. Guilleminault, C., & Pelayo, R. (1998). Narcolepsy in prepubertal children. Annals of Neurology, 43, 135– 142. Guilleminault, C., Riley, R., Powell, N., Simmons, F. B., & Nino-Murcia, G. (1985). Obstructive sleep apnea syndrome in adolescents: Diagnosis and treatment [Abstract]. Sleep Research, 14, 159. Gullone, E. (1999). The assessment of normal fear in children and adolescents. Clinical Child and Family Psychology Review, 2, 91–106. Gullone, E., & King, N. J. (1993). The fears of youth in the 1990’s: Contemporary normative data. Journal of Genetic Psychology, 154, 137–153. Gundersen, B. H., Melås, P. S., & Skår, J. E. (1981). Sexual behavior of preschool children: Teachers’ observations. In L. L. Constantine & F. M. Martinson (Eds.), Children and sex: New findings, new perspectives (pp. 45–61). Boston: Little, Brown. Gunnoe, M. L., & Mariner, C. L. (1997). Toward a developmental–contextual model of the effects of parental spanking on children’s aggression. Archives of Pediatrics and Adolescent Medicine, 151, 768–775. Haerle, T. (Ed.). (1992). Children with Tourette syndrome: A parents’ guide. Rockville, MD: Woodbine House. Hall, G. C. N. (1990). Prediction of sexual aggression. Clinical Psychology Review, 10, 229–245.

References

569

Halperin, J. M., Matier, K., Bedi, G., Sharma, V., & Newcorn, J. H. (1992). Specificity of inattention, impulsivity, and hyperactivity to the diagnosis of attention-deficit hyperactivity disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 190–196. Halperin, J. M., Newcorn, J. H., Kopstein, I., McKay, K. E., Schwartz, S. T., Siever, L. J., & Sharma, V. (1997). Serotonin, aggression, and parental psychopathology in children with attention-deficit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1391–1398. Halpern, L. F., Brand, K. L., & Malone, A. F. (2001). Parenting stress in mothers of very-low-birth-weight (VLBW) and full-term infants: A function of infant behavioral characteristics and child-rearing attitudes. Journal of Pediatric Psychology, 26, 93–104. Halpern, W. I. (1977). The treatment of encopretic children. Journal of the American Academy of Child Psychiatry, 16, 478–499. Hamalainen, M., & Pulkkinen, L. (1996). Problem behavior as a precursor of male criminality. Development and Psychopathology, 8, 443–455. Hanf, C. (1969). A two-stage program for modifying maternal controlling during mother–child (M-C) interaction. Paper presented at the meeting of the Western Psychological Association, Vancouver, British Columbia, Canada. Hansen, D. E., & Vandenberg, B. (1997). Neuropsychological features and differential diagnosis of sleep apnea syndrome in children. Journal of Clinical Child Psychology, 26, 304–310. Hanson, R. K., Steffy, R. A., & Gauthier, R. (1993). Long-term recidivism of child molesters. Journal of Consulting and Clinical Psychology, 61, 646–652. Hanson, T. L. (1999). Does parental conflict explain why dirorce is negatively associated with child welfare? Social Forces, 77, 1283–1316. Hanson, T. L., McLanahan, S. S., & Thomson, E. (1996). Double jeopardy: Parental conflict and stepfamily outcomes for children. Journal of Marriage and the Family, 58, 141–154. Hare, R. D., Hart, S. D., & Harpur, T. J. (1991). Psychopathy and the DSM-IV criteria for antisocial personality disorder. Journal of Abnormal Psychology, 100, 391–398. Hargett, R. D., Hansen, F. G., & Davidson, P. O. (1970). Chronic thumbsucking: A second report on treatment and its psychological effects. American Journal of Orthodontics, 57, 164–178. Haroian, L. M. (1991). Sexual problems of children. In C. E. Walker & M. C. Roberts (Eds.). Handbook of clinical child psychology (2nd ed., pp. 431–450). New York: Wiley. Harrington, R., Bredenkamp, D., Groothues, C., Rutter, M., Fudge, H., & Pickles, A. (1994). Adult outcomes of childhood and adolescent depression. III: Links with suicidal behaviours. Journal of Child Psychology and Psychiatry, 35, 1309–1319. Harrington, R., Rutter, M., & Fombonne, E. (1996). Developmental pathways in depression: Multiple meanings, antecedents, and endpoints. Development and Psychopathology, 8, 601–616. Harris, L. S., & Purohit, A. P. (1977). Bladder training and enuresis: A controlled trial. Behaviour Research and Therapy, 15, 485–490. Harris, P. L. (1994). The child’s understanding of emotion: Developmental change and family environment. Journal of Child Psychology and Psychiatry, 35, 3–28. Harrist, A. W., & Ainslie, R. C. (1998). Marital discord and child behavior problems: Parent–child relationship quality and interpersonal awareness as mediators. Journal of Family Issues, 19, 140–163. Hart, B., & Risley, T. R. (1995). Meaningful differences in the everyday experience of young American children. Baltimore: Brookes. Hart, B., & Risley, T. R. (1999). The social world of children: Learning to talk. Baltimore: Brookes. Hart, E. L., Lahey, B. B., Loeber, R., Applegate, B., & Frick, P. J. (1995). Developmental changes in attention-deficit hyperactivity disorder in boys: A four-year longitudinal study. Journal of Abnormal Child Psychology, 23, 731–751. Hart, S., Field, T., & Nearing, G. (1998). Depressed mothers’ neonates improve following the MABI and a Brazelton demonstration. Journal of Pediatric Psychology, 23, 351–356. Harter, S. (1983a). Developmental perspectives on the self system. In P. M. Mussen (Series Ed.) & E. M. Hetherington (Vol. Ed.), Handbook of child psychology (4th ed.): Vol. 4: Socialization, personality, and social development (pp. 275–385). New York: Wiley. Harter, S. (1983b). Supplementary description of the Self-Perception Profile for Children: Revision of the Perceived Competence Scale for Children. Unpublished manuscript, University of Denver. Harter, S., & Pike, R. (1984). The Pictorial Scale of Perceived Competence and Social Acceptance for Young Children. Child Development, 55, 1969–1982. Hartmann, E. L. (1973). The functions of sleep. New Haven, CT: Yale University Press. Hartup, W. W. (1989). Social relationships and their developmental significance. American Psychologist, 44, 120–126.

570

References

Harvey, E. (1999). Short-term and long-term effects of early parental employment on children of the National Longitudinal Survey of Youth. Developmental Psychology, 35, 445–459. Haskins, R. (1985). Public school aggression among children with varying day care experience. Child Development, 56, 689–703. Haskins, R. (1989). Beyond metaphor: The efficacy of early childhood education. American Psychologist, 44, 120–126. Hatter, B. S. (1996). Children and the death of a parent or grandparent. In C. A. Corr & D. M. Corr (Eds.), Handbook of childhood death and bereavement (pp. 131–148). New York: Springer. Hay, D. G., Vespo, J. E., & Zahn-Waxler, C. (1998). Young children’s quarrels with their siblings and mothers: Links with maternal depression and bipolar illness. British Journal of Developmental Psychology, 16, 519–538. Heffer, R. W., & Kelley, M. L. (1987). Mothers’ acceptance of behavior interventions for children: The influence of parent race and income. Behavior Therapy, 18, 153–163. Heimberg, R. G., Stein, M. B., Hiripi, E., & Kessler, R. C. (2000). Trends in the prevalence of social phobia in the United States: A synthetic cohort analysis of changes over four decades. European Psychiatry, 15, 29–37. Heinicke, C. M., Beckwith, L., & Thompson, A. (1988). Early intervention in the family system: A framework and review. Infant Mental Health Journal, 9, 111–141. Heinicke, C. M., Guthrie, D., & Ruth, G. (1997). Marital adaptation, divorce, and parent–infant development: A prospective study. Infant Mental Health Journal, 18, 282–299. Hektner, J. M., August, G. J., & Realmuto, G. M. (2000). Patterns and temporal changes in peer affiliation among aggressive and nonaggressive children participating in a summer school program. Journal of Clinical Child Psychology, 29, 603–614. Heller, K., & Swindle, R. W. (1983). Social networks, perceived social support, and coping with stress. In R. D. Felner, L. A. Jason, J. N. Morisugu, & S. S. Farber (Eds.), Preventive psychology: Theory research, and practice (pp. 87–103). Elmsford, NY: Pergamon Press. Heller, T. L., Baker, B. L., Henker, B., & Hinshaw, S. P. (1996). Externalizing behavior and cognitive functioning from preschool to first grade: Stability and predictors. Journal of Clinical Child Psychology, 25, 376–387. Hembree-Kigin, T. L., & McNeil, C. B. (1995). Parent–child interaction therapy. New York: Plenum Press. Henggeler, S. W. (1994). A consensus: Conclusions of the APA Task Force report on innovative models of mental health services for children, adolescents, and their families. Journal of Clinical Child Psychology, 23, 3–6. Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B. (1998). Multisystemic treatment of antisocial behavior in children and adolescents. New York: Guilford Press. Henrich, C. C., Brown, J. L., & Aber, J. L. (1999). Evaluating the effectiveness of school-based violence prevention: Developmental approaches. Society for Research in Child Development: Social Policy Report, 13(3), 1–16. Herman, J. H., Blaw, M. E., & Steinberg, J. G. (1989). REM behavior disorder in a two year old male with evidence of brainstem pathology [Abstract]. Sleep Research, 18, 242. Herpertz, S., Wenning, B., Mueller, B., Qunaibi, M., Sass, H., & Herpertz-Dahlmann, B. (2001). Psychophysiological responses in ADHD boys with and without conduct disorder: Implications for adult antisocial behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1222– 1230. Hetherington, E. M. (1989). Coping with family transitions: Winners, losers, and survivors. Child Development, 60, 1–14. Hetherington, E. M. (1991). Familes, lies, and videotapes. Journal of Research on Adolescence, 1, 323– 348. Hetherington, E. M., Bridges, M., & Insabella, G. M. (1998). What matters? What does not?: Five perspectives on the association between marital transitions and children’s adjustment. American Psychologist, 53, 167–184. Hetherington, E. M., Cox, M., & Cox, R. (1976). Divorced fathers. Family Coordinator, 25, 417–428. Hetherington, E. M., Cox, M., & Cox, R. (1985). Long-term effects of divorce and remarriage on the adjustment of children. Journal of the American Academy of Child Psychiatry, 24, 518–530. Hetherington, E. M., & Stanley-Hagan, M. (1999). The adjustment of children with divorced parents: A risk and resiliency perspective. Journal of Child Psychology and Psychiatry, 40, 129–140. Hewitt, S. K. (1991). Therapeutic management of preschool cases of alleged but unsubstantiated sexual abuse. Child Welfare, 70, 59–67.

References

571

Hewitt, S. K. (1994). Preverbal sexual abuse: What two children report in later years. Child Abuse and Neglect, 18, 821–826. Hewson, P., Oberklaid, F., & Menahem, S. (1987). Infant colic, distress, and crying. Clinical Pediatrics, 26, 69–75. Hindley, C. B., Fillozat, A. M., Klackenberg, G., Nicolet-Meister, D., & Sand, E. A. (1965). Some differences in infant feeding and elimination training in five European longitudinal samples. Journal of Child Psychology and Psychiatry, 6, 179–201. Hinshaw, S. P. (1991). Stimulant medications and their treatment of aggression in children with attention deficits. Journal of Clinical Child Psychology, 20, 301–312. Hinshaw, S. P. (1992). Externalizing behavior problems and academic underachievement in childhood and adolescence: Causal relationships and underlying mechanisms. Psychological Bulletin, 111, 127–155. Hinshaw, S. P. (1994). Attention deficits and hyperactivity in children. Newbury Park, CA: Sage. Hinshaw, S. P., Lahey, B. B., & Hart, E. L. (1993). Issues of taxonomy and co-morbidity in the development of conduct disorder. Development and Psychopathology, 5, 31–50. Hjalmas, D. (1992). Functional daytime incontinence: Definitions and epidemiology. Scandinavian Journal of Urology and Nephrology, 141(Suppl.), 39–44. Hoar, W. (Ed.). (1998, September 29). Prozac Rx for children jumps 500%. Mental Health News Alert, p. 13. Hodges, K., Cools, J., & McKnew, D. (1989). Test–retest reliability of a clinical research interview for children: The Child Assessment Schedule (CAS). Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1, 317–322. Hoekelman, R. A., Blatman, S., Brunell, P. A., Friedman, S. B., & Seidel, H. M. (Eds.). (1978). Principles of pediatrics: Health care of the young. New York: McGraw-Hill. Hoffman, C. D., & Avila, A. M. (1998). Young children’s negative stereotyping of peers from divorced families. Journal of Divorce and Remarriage, 29, 67–78. Hoffman, L. W. (1989). Effects of maternal employment in the two-parent family. American Psychologist, 44, 283–292. Hofmann, S. G., Ehlers, A., & Roth, W. T. (1995). Conditioning theory: A model for the etiology of public speaking anxiety? Behaviour Research and Therapy, 33, 567–571. Hoier, T. S., Inderbitzen-Pisaruk, H., & Shawchuck, C. R. (1988). Short-term cognitive behavioral group treatment for victims of sexual abuse. Unpublished manuscript, West Virginia University, Department of Psychology, Morgantown. Holden, G. W., Lavigne, V. V., & Cameron, A. M. (1990). Probing the continuum of effectiveness in parent training: Characteristics of parents and preschoolers. Journal of Clinical Child Psychology, 19, 2–8. Hooks, M. Y., & McCauley, E. (1998). Affective disorders. In R. T. Ammerman & J. V. Campo (Eds.), Handbook of pediatric psychology and psychiatry: Vol. 1. Psychological and psychiatric issues in the pediatric setting (pp. 266–286). Needham Heights, MA: Allyn & Bacon. Hopko, D. R., McNeil, D. W., Zvolensky, M. J., & Eifert, G. H. (2001). The relation between anxiety and skill in performance-based anxiety disorders: A behavioral formulation of social phobia. Behavior Therapy, 32, 185–207. Hops, H., & Davis, B. (1995). Methodological issues in direct observation: Illustrations with the Living in Familial Environments (LIFE) coding system. Journal of Clinical Child Psychology, 24, 193–203. Horacek, H. J., Ramey, C. T., Campbell, F. A., Hoffmann, K. P., & Fletcher, R. H. (1987). Predicting school failure and assessing early intervention with high-risk children. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 758–763. Horne, A. M., Glaser, B. A., & Calhoun, G. B. (1999). Conduct disorders. In R. T. Ammerman, M. Hersen, & C. G. Last (Eds.), Prescriptive treatments for children and adolescents (2nd ed., pp. 84–101). Needham Heights, MA: Allyn & Bacon. Houts, A. C. (1991). Nocturnal enuresis as a biobehavioral problem. Behavior Therapy, 22, 133–151. Houts, A. C., & Abramson, H. (1990). Assessment and treatment of functional childhood enuresis and encopresis: Toward a partnership between health psychologists and physicians. In S. B. Morgan & T. M. Okwumabua (Eds.), Child and adolescent disorders: Developmental and health psychology perspectives (pp 47–103). Hillsdale, NJ: Erlbaum. Houts, A. C., Berman, J. S., & Abramson, H. A. (1994). The effectiveness of psychological and pharmacological treatments of nocturnal enuresis. Journal of Consulting and Clinical Psychology, 62, 737–745. Houts, A. C., & Liebert, R. M. (1984). Bedwetting: A guide for parents and children. Springfield, IL: Thomas. Houts, A. C., Mellon, M. W., & Whelan, J. P. (1988). Use of dietary fiber and stimulus control to treat retentive encopresis: A multiple baseline investigation. Journal of Pediatric Psychology, 13, 435–446. Houts, A. C., & Peterson, J. K. (1986). Treatment of retentive encopretic child using contingency management and diet modification with stimulus control. Journal of Pediatric Psychology, 11, 375–383.

572

References

Houts, A. C., Whelan, J. P., & Peterson, J. K. (1987). Filmed versus live delivery of full-spectrum home training for primary enuresis: Presenting the information is not enough. Journal of Consulting and Clinical Psychology, 55, 902–906. Howard, K. A., Barton, C. E., Walsh, M. E., & Lerner, R. M. (1999). Social and contextual issues in intervention with children and families. In S. W. Russ & T. H. Ollendick (Eds.), Handbook of psychotherapies with children and families (pp. 45–66). New York: Kluwer/Plenum. Howell, S. H., Portes, P. R., & Brown, J. H. (1997). Gender and age differences in child adjustment to parental separation. Journal of Divorce and Remarriage, 27, 141–158. Howes, C. (1987). Social competence with peers in young children: Developmental sequences. Developmental Review, 7, 252–272. Howes, C. (1988). Relations between early child care and schooling. Developmental Psychology, 24, 53–57. Howes, P., & Markman, H. J. (1989). Marital quality and child functioning: A longitudinal investigation. Child Development, 60, 1044–1051. Hoza, B., Pelham, W. E., Waschbusch, D. A., Kipp, H., & Owens, J. S. (2001). Academic task persistence of normally achieving ADHD and control boys: Performance, self-evaluations, and attributions. Journal of Consulting and Clinical Psychology, 69, 271–283. Hublin, C., Kaprio, J., Partinen, M., Koskenvuo, M., Keikkila, K., Koskimies, S., & Guilleminault, C. (1994). The prevalence of narcolepsy: An epidemiological study of the Finnish twin cohort. Annals of Neurology, 35, 709–716. Hudley, C., Britsch, B., Wakefield, W. D., Smith, T., Demorat, M., & Cho, S. (1998). An attribution retraining program to reduce aggression in elementary school students. Psychology in the Schools, 35, 271– 282. Huggins, S. L. (1989). A comparative study of self-esteem of adolescent children of divorced lesbian mothers and divorced heterosexual mothers. In F. W. Bozett (Ed.), Homosexuality and the family (pp. 123–135). New York: Harrington Park Press. Hughes, C. W., Emslie, G. J., Crismon, M. L., Wagner, K. D., Birmaher, B., Geller, B., Pliszka, S. T., Ryan, N. D., Strober, M., Trivedi, M. H., Topriac, M. G., Sedillo, A., Llana, M. E., Lopez, M., Rush, A. J., & the Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder. (1999). The Texas Children’s Medication Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1442–1454. Huntley, D. K., & Phelps, R. E. (1990). Depression and social contacts of children from one-parent families. Journal of Community Psychology, 18, 66–72. Huntley, R. (1991). The sleep book for tired parents: Help for solving children’s sleep problems. Seattle, WA: Parenting Press. Hynan, D. J. (1998). Interviewing children in custody evaluations. Family and Conciliation Courts Review, 36, 466–478. Hysjulien, C., Wood, B., & Benjamin, G. A. H. (1994). Child custody evaluations: A review of methods used in litigation and alternative dispute resolution. Family and Conciliation Courts Review, 32, 466–489. Ialongo, N., Edelsohn, G., Werthamer-Larsson, L., Crockett, L., & Kellam, S. (1995). The significance of self-reported anxious symptoms in first grade children: Prediction to anxious symptoms and adaptive functioning in fifth grade. Journal of Child Psychology and Psychiatry, 36, 427–437. Ilg, F. L., Ames, L. B., & Baker, S. M. (1992). Child behavior: The classic childcare manual from Gesell Institute of Human Development (rev. ed.). New York: Harper Perennial Library. Illingworth, R. S., & Lister, J. (1964). The critical or sensitive period, with special reference to certain feeding problems in infants and children. Journal of Pediatrics, 65, 834–851. Inderbitzen-Pizaruk, H., Shawchuck, C. R., & Hoier, T. S. (1992). Behavioral characteristics of child victims of sexual abuse: A comparison study. Journal of Clinical Child Psychology, 21, 14–19. Ives, S. B., Fassler, D., & Lash, M. (1998). The divorce workbook: A guide for kids and families. Burlington, VT: Waterfront Books. Jacobi, C., Agras, W. S., & Hammer, L. (2001). Predicting children’s reported eating disturbances at 8 years of age. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 364–372. Jacobs, J., Bogg, S., Eyberg, S. M., Edwards, D., Durning, P., & Querido, J. (1999). Reliability and validity of the Revised Edition of the School Observation Coding System (REDSOCS). Unpublished manuscript, University of Florida. Jacobson, D. (1978). The impact of marital separation/divorce of children: I. Parent–child separation and child adjustment. Journal of Divorce, 1, 341–360. Jacobson, J. L., & Wille, D. E. (1986). The influence of attachment pattern on developmental changes in peer interaction from the toddler to the preschool period. Child Development, 57, 338–347.

References

573

James, R. S., Sharp, W. S., Bastain, T. M., Lee, P. P., Walter, J. M., Czarnolewski, M., & Castellanos, F. X. (2001). Double-blind, placebo-controlled study of single-dose amphetamine formulations in ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1268–1276. Jarvelin, M. R., Huttunen, N., Seppanen, J., Seppanen, U., & Moilanen, I. (1990). Screening of urinary tract abnormalities among day and night wetting children. Scandinavian Journal of Urology and Nephrology, 24, 181–189. Jarvelin, M. R., Moilanen, I., Kangas, P., Moring, K., Vikevainen-Tervonen, L., Huttunen, N. P., & Seppanen, J. (1991). Aetiological and precipitating factors for childhood enuresis. Acta Paediatrica Scandinavia, 80, 361–369. Jay, S. M. (1988). Invasive medical procedures: Psychological intervention and assessment. In D. K. Routh (Ed.), Handbook of pediatric psychology (pp. 401–425). New York: Guilford Press. Jay, S. M., Green, V., Johnson, S., Caldwell, S., & Nitschke, R. (1987). Differences in death concepts between children with cancer and physically healthy children. Journal of Clinical Child Psychology, 16, 301–306. Jaycox, L. H., Reivich, K. J., Gillham, J., & Seligman, M. E. P. (1994). Prevention of depressive symptoms in school children. Behaviour Research and Therapy, 32, 801–816. Jehu, D., Morgan, R., Turner, R., & Jones, A. (1977). A controlled trial of the treatment of enuresis in residential homes for children. Behaviour Research and Therapy, 15, 1–16. Jekielek, S. M. (1998). Parental conflict, marital disruption and children’s emotional well-being. Social Forces, 76, 905–936. Jelalian, E., & Saelens, B. E. (1999). Empirically supported treatments in pediatric psychology: Pediatric obesity. Journal of Pediatric Psychology, 24, 223–248. Jenkins, J. E., & Guidubaldi, J. (1997). The nature–nurture controversy revisited: Divorce and gender as factors in children’s racial group differences. Child Study Journal, 27, 145–160. Jenkins, S., Bax, M., & Hart, H. (1980). Behavior problems in preschool children. Journal of Child Psychology and Psychiatry, 21, 5–17. Jenkins, T. C., Updergraff, K. A., McHale, S. M., & Crouter, A. C. (1999). Older siblings as socializers of younger siblings’ empathy. Journal of Early Adolescence, 19, 176–198. Jensen, P. S. (2000). Commentary: The NIH ADHD consensus statement: Win, lose, or draw. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 194–197. Jensen, P. S., Bhatara, V. S., Vitiello, B., Hoagwood, K., Feil, M., & Burke, L. B. (1999). Psychoactive medication prescribing practices for US children: Gaps between research and clinical practice. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 557–565. Jensen, P. S., Hinshaw, S. P., Kraemer, H. C., Lenora, N., Newcorn, J. H., Abikoff, H. B., March, J. S., Arnold, L. E., Cantwell, D. P., Conjners, C. K., Elliott, G. R., Greenhill, L. L., Hechtman, L., Hoza, B., Pelham, W. E., Severe, J. B., Swanson, J. M., Wells, K. C., Wigal, T., & Vitiello, B. (2001). ADHD comorbidity findings from the MTA study: Comparing comorbid subgroups. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 147–158. Jensen, P. S., Martin, B. A., & Cantwell, D. P. (1997). Comorbidity in ADHD: Implications for research, practice, and DSM-IV. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1065– 1079. Joffe, R. T., Offord, D. R., & Boyle, M. H. (1988). Ontario Child Health Study: Suicidal behavior in youth aged 12–16 years. American Journal of Psychiatry, 145, 1420–1423. Johnson, S. M., Wahl, G., Martin, S., & Johansson, S. (1973). How deviant is the normal child?: A behavioral analysis of the preschool child and his family. In R. D. Rubin, J. P. Brady, & J. D. Henderson (Eds.), Advances in behavior therapy (Vol. 4, pp. 37–54). New York: Academic Press. Johnson, T. C. (1988). Child perpetrators: Children who molest other children, preliminary findings. Child Abuse and Neglect, 12, 219–229. Johnson, T. C. (1989). Female child perpetrators: Children who molest other children. Child Abuse and Neglect, 13, 571–585. Johnson, T. C.,, & Friend, C. (1995). Assessing young children’s sexual behaviors in the context of child sexual abuse evaluations. In T. Ney (Ed.), True and false allegations of child sexual abuse: Assessment and case management (pp. 49–72). New York: Brunner/Mazel. Johnston, J. M. (1993). Phenomenology and treatment of rumination. Child and Adolescent Psychiatric Clinics of North America, 2, 93–107. Johnston, J. R., Campbell, L. E. G., & Mayes, S. S. (1985). Latency children in post-separation and divorce disputes. Journal of the American Academy of Child Psychiatry, 24, 563–574. Johnston, J. R., Gonzalez, R., & Campbell, L. E. G. (1987). Ongoing post divorce conflict and child disturbance. Journal of Abnormal Child Psychology, 15, 493–509.

574

References

Joiner, T. E., Catanzaro, S. J., & Laurent, J. (1996). Tripartite structure of positive and negative affect, depression and anxiety in child and adolescent psychiatric inpatients. Journal of Abnormal Psychology, 105, 401–409. Joiner, T. E., & Lonigan, C. J. (2000). Tripartite model of depression and anxiety in youth psychiatric inpatients: Relations with diagnostic status and future symptoms. Journal of Clinical Child Psychology, 29, 372–382. Joiner, T. E., & Wagner, K. D. (1995). Attribution style and depression in children and adolescents: A metaanalytic review. Clinical Psychology Review, 15, 777–798. Jolly, J. B., & Dykman, R. A. (1994). Using self-report data to differentiate anxious and depressive symptoms in adolescents: Cognitive content specificity and global distress. Cognitive Therapy and Research, 18, 25–37. Jones, D. J., Forehand, R., & Neary, E. M. (2001). Family transmission of depressive symptoms: Replication across Caucasian and African American mother–child dyads. Behavior Therapy, 32, 123–138. Jones, K. M., Wickstrom, K. G., & Friman, P. C. (1997). The effects of observational feedback on treatment integrity in school-based behavioral consultation. School Psychology Quarterly, 12, 316–326. Jumper, S. (1995). A meta-analysis of the relationship of child sexual abuse to adult psychological adjustment. Child Abuse and Neglect, 19, 715–728. Kadesjo, B. & Gillberg, C. (2000). Tourette’s disorder: Epidemiology and comorbidity in primary school children. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 548–555. Kaffman, M., & Elizur, E. (1983). Bereavement responses of kibbutz and non-kibbutz children following death of father. Journal of Child Psychology and Psychiatry, 24, 435–442. Kagan, J. (1994). On the nature of emotion. In N. A. Fox (Ed.), The development of emotion regulation: Biological and behavioral considerations. Monographs of the Society for Research in Child Development, 59(2–3, Serial No. 240), 7–24. Kagan, J. (1997). Temperament and the reactions to unfamiliarity. Child Development, 68, 139–143. Kagan, J., Reznick, J. S., & Snidman, N. (1988). Biological bases of childhood shyness. Science, 240, 167–171. Kales, A. (Ed.). (1969). Sleep: Physiology and pathology. Philadelphia: Lippincott. Kales, A., Bixler, E. O., Tan, T. L., Scharf, M. B., & Kales, J. D. (1974). Chronic hypnotic drug use: Ineffectiveness, drug withdrawal insomnia and dependence. Journal of the American Medical Association, 5, 573–577. Kales, A., Soldatos, C., Bixler, E., Ladda, R., Charney, D., Weber, G., & Schweitzer, P. (1980). Hereditary factors in sleepwalking and night terrors. British Journal of Psychiatry, 137, 111–118. Kales, J. D., Kales, A., Soldatos, C. R., Chamberlin, K., & Martin, E. D. (1979). Sleepwalking and night terrors related to febrile illness. American Journal of Psychiatry, 136, 1214–1215. Kalpidou, M. D., Rothbaum, F., & Rosen, K. S. (1998). A longitudinal study of mothers’ and preschool children’s aversive behaviors during dyadic interactions. Journal of Genetic Psychology, 159, 103–116. Kalter, N., Riemer, R., Brickman, A., & Chen, J. W. (1985). Implications of parental divorce for female development. Journal of the American Academy of Child Psychiatry, 24, 538–544. Kamphaus, R. W., & Frick, P. J. (1996). Clinical assessment of child and adolescent personality and behavior. Needham Heights, MA: Allyn & Bacon. Kamphaus, R. W., Petoskey, M. D., Cody, A. H., Rowe, E. W., & Huberty, C. J. (1999). A typology of parent rated child behavior for a national U.S. sample. Journal of Child Psychology and Psychiatry, 40, 607– 616. Kamphaus, R. W., Petoskey, M. D., & Rowe, E. W. (2000). Current trends in psychological testing of children. Professional Psychology: Research and Practice, 31, 155–164. Kanfer, F., Eyberg, S. M., & Krahn, G. L. (1992). Interviewing strategies in child assessment. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (2nd ed., pp. 49–62). New York: Wiley– Interscience. Karg, R. S., & Wiens, A. N. (1998). Improving diagnostic and clinical interviewing. In G. P. Koocher, J. C. Norcross, & S. S. Hill III (Eds.), Psychologists’ desk reference (pp. 11–14). New York: Oxford University Press. Kashani, J. H., Allan, W. D., Beck, N. C., Bledsoe, Y., & Reid, J. C. (1997). Dysthymic disorder in clinically referred preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1426–1433. Kashani, J. H., & Orvaschel, H. (1990). A community study of anxiety in children and adolescents. American Journal of Psychiatry, 147, 313–318. Kashdan, T. B., & Herbert, J. D. (2001). Social anxiety disorder in childhood and adolescence: Current status and future directions. Clinical Child and Family Psychology Review, 4, 37–61.

References

575

Kaslow, N. J., Deering, C. G., & Bacusin, G. R. (1994). Depressed children and their families. Clinical Psychology Review, 14, 39–59. Kaslow, N. J., & Thompson, M. P. (1998). Applying the criteria for empirically supported treatments to studies of psychosocial interventions for child and adolescent depression. Journal of Clinical Child Psychology, 27, 146–155. Kastenbaum, R., & Costa, P. T. (1977). Psychological perspectives on death. Annual Review of Psychology, 28, 225–249. Kataria, S., Swanson, M. C., & Trevathan, G. E. (1987). Persistence of sleep disturbances in preschool children. Journal of Pediatrics, 110, 642–646. Katz, L. F., & Gottman, J. M. (1997). Buffering children from marital conflict and dissolution. Journal of Clinical Child Psychology, 26, 157–171. Kaufman, A. S., & Kaufman, N. L. (1990). Kaufman Brief Intelligence Test. Circle Pines, MN: American Guidance Services. Kawasaki, C., Nugent, J. K., Miyashita, H., Miyahara, H., & Brazelton, T. B. (1994). The cultural organization of infants’ sleep. Children’s Environments, 11, 135–141. Kazdin, A. E. (1984). Behavior modification in applied settings (3rd ed.). Homewood, IL: Dorsey Press. Kazdin, A. E. (1987). Treatment of antisocial behavior in children: Current status and future directions. Psychological Bulletin, 102, 187–203. Kazdin, A. E. (1990). Premature termination from treatment among children referred for antisocial behavior. Journal of Child Psychology and Psychiatry, 31, 415–425. Kazdin, A. E. (1994). Behavior modification in applied settings (5th ed.). Pacific Grove, CA: Brooks/Cole. Kazdin, A. E. (1995). Conduct disorders in childhood and adolescence. Newbury Park, CA: Sage. Kazdin, A. E. (1996a). Developing effective treatments for children and adolescents. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 9–18). Washington, DC: American Psychological Association. Kazdin, A. E. (1996b). Dropping out of child therapy: Issues for research and implications for practice. Clinical Child Psychology and Psychiatry, 1, 133–156. Kazdin, A. E. (1997). A model for developing effective treatments: Progression and interplay of theory, research, and practice. Journal of Clinical Child Psychology, 26, 114–129. Kazdin, A. E. (2000). Psychotherapy for children and adolescents: Directions for research and practice. New York: Oxford University Press. Kazdin, A. E. (2001). Bridging the enormous gaps of theory with therapy research and practice. Journal of Clinical Child Psychology, 30, 59–66. Kazdin, A. E., Esveldt-Dawson, K., French. N. H., & Unis, A. S. (1987). Effects of parent management training and problem-solving skills training combined in the treatment of antisocial child behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 416–424. Kazdin, A. E., & Marciano, P. L. (1998). Childhood and adolescent depression. In E. J. Mash & R. A. Barkley (Eds.), Treatment of childhood disorders (2nd ed., pp. 211–248). New York: Guilford Press. Kazdin, A. E., Rodgers, A., & Colbus, D. (1986). The Hopelessness Scale for Children: Psychometric characteristics and concurrent validity. Journal of Consulting and Clinical Psychology, 54, 241–245. Kazdin, A. E., Siegel, T. C., & Bass, D. (1990). Drawing upon clinical practice to inform research on child and adolescent psychotherapy: A survery of practitioners. Professional Psychology: Research and Practice, 21, 189–198. Kazdin, A. E., & Wassell, G. (2000). Therapeutic changes in children, parents, and families resulting from treatment of children with conduct problems. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 414–420. Kazdin, A. E., & Weisz, J. R. (1998). Identifying and developing empirically supported child and adolescent treatments. Journal of Consulting and Clinical Psychology, 66, 19–36. Kearney, C. A., & Albano, A. M. (2000). When children refuse school: A cognitive behavior therapy approach. Therapist’s guide. San Antonio, TX: Psychological Corporation. Kearney, C. A., & Silverman, W. K. (1990). A preliminary analysis of a functional model of assessment and treatment for school refusal behavior. Behavior Modification, 14, 340–366. Kearney, C. A., & Silverman, W. K. (1993). Measuring the function of school refusal behavior: The School Refusal Assessment Scale. Journal of Clinical Child Psychology, 22, 85–96. Kearney, C. A., & Silverman, W. K. (1996). The evolution and reconciliation of taxonomic strategies for school refusal behavior. Clinical Psychology: Science and Practice, 3, 339–354. Kearney, C. A., & Silverman, W. K. (1999). Functionally based prescriptive and nonprescriptive treatment for children and adolescents with school refusal behavior. Behavior Therapy, 30, 673–695.

576

References

Keenan, K., Loeber, R., & Green, S. (1999). Conduct disorder in girls. Clinical Child and Family Psychology Review, 2, 3–20. Keenan, K., Shaw, D., Walsh, B., Delliquadri, E., & Giovannelli, J. (1997). DSM-III-R disorders in preschool children from low-income families. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 620–627. Keller, H. R. (1986). Behavioral observation approaches to personality assessment. In H. M. Knoff (Ed.), The assessment of child and adolescent personality (pp. 353–390). New York: Guilford Press. Kelly, J. B. (2000). Children’s adjustment in conflicted marriage and divorce: A decade review of research. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 963–973. Kempe, C. H., & Helfer, R. E. (1972). Helping the battered child and his family. Philadelphia: Lippincott. Kempton, T., & Forehand, R. (1992). Juvenile sex offenders: Similar to, different from other incarcerated delinquent offenders? Behavior Research and Therapy, 30, 533–536. Kendall, P. C. (1990). Coping cat workbook. (Available from P. C. Kendall, Department of Psychology, Temple University, Philadelphia, PA 19122) Kendall, P. C. (1994). Treating anxiety disorders in children: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 62, 100–110. Kendall, P. C. (1996). The Coping Questionnaire. (Available from P. C. Kendall, Department of Psychology, Temple University, Philadelphia, PA 19122) Kendall, P. C., Brady, E. U., & Verduin, T. L. (2001). Comorbidity in childhood anxiety disorders and treatment outcome. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 787– 794. Kendall, P. C., & Chansky, T. E. (1991). Considering cognition in anxiety disordered children. Journal of Anxiety Disorders, 5, 167–185. Kendall, P. C., Chansky, T. E., Kane, M. T., Kim, R. S., Kortlander, E., Ronan, K. R., Sessa, F. M., & Siqueland, L. (1992). Anxiety disorders in youth: Cognitive-behavioral interventions. Needham Heights, MA: Allyn & Bacon. Kendall, P. C., & Gosch, E. A. (1994). Cognitive-behavioral interventions. In T. H. Ollendick, N. H. King, & W. Yule (Eds.), International handbook of phobic and anxiety disorders in children and adolescents (pp. 415–438). New York: Plenum Press. Kendall, P. C., Krain, A., & Treadwell, K. R. H. (1999). Generalized anxiety disorders. In R. T. Ammerman, M. Hersen, & C. G. Last (Eds.), Handbook of prescriptive treatments for children and adolescents (2nd ed., pp. 1155–1171). Needham Heights, MA: Allyn & Bacon. Kendall, P. C., & Southam-Gerow, M. A. (1996). Long-term follow-up of a cognitive-behavior therapy for anxiety-disordered youth. Journal of Consulting and Clinical Psychology, 64, 724–730. Kendall, P. C., & Warman, M. J. (1996). Anxiety disorders in youth: Diagnostic consistency across DSM-IIIR and DSM-IV. Journal of Anxiety Disorders, 10, 453–463. Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (1993). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. Psychological Bulletin, 113, 164–180. Kendler, K. S. (1995). Genetic epidemiology in psychiatry. Taking both genes and environment seriously. Archives of General Psychiatry, 52, 895–899. Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1992a). Major depression and generalized anxiety disorders: Same genes, (partly) different environments? Archives of General Psychiatry, 49, 716–722. Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1992b). The genetic epidemiology of phobias in women: The interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia. Archives of General Psychiatry, 49, 273–281. Kendziora, K. T., & O’Leary, S. G. (1993). Dysfunctional parenting as a focus for prevention and treatment of child behavior problems. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 15, pp. 175–206). New York: Plenum Press. Kennedy, W. A. (1965). School phobia: Rapid treatment of fifty cases. Journal of Abnormal Psychology, 70, 285–289. Keogh, B. K., & Burstein, N. D. (1988). Relationship of temperament to preschoolers’ interactions with peers and teachers. Exceptional Children, 54, 456–461. Kerwin, M. E. (1999). Empirically supported treatments in pediatric psychology: Severe feeding problems. Journal of Pediatric Psychology, 24, 193–214. Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Huges, M., Eshelman, S., Wittchen, H., & Kendler, K. S. (1994). Life-time and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8–19.

References

577

Kilgore, K., Snyder, J., & Lentz, C. (2000). The contribution of parental discipline, parental monitoring, and school risk to early-onset conduct problems in African American boys and girls. Developmental Psychology, 36, 835–845. Killen, M. (1991). Social and moral development in early childhood. In W. M. Kurtines & J. L. Gewirtz (Eds.), Handbook of moral development (pp. 115–138). Hillsdate, NJ: Erlbaum. Kimmel, H. D. (1974). Review of Toilet training in less than a day: How to do it. Journal of Behavior Therapy and Experimental Psychiatry, 5, 113. King, H. E. (2001). The effect of divorce on parents and children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 1031–1045). New York: Wiley. King, N. J., & Bernstein, G. A. (2001). School refusal in children and adolescents: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 197–205. King, N. J., Cranstoun, F., & Josephs, A. (1989). Emotive imagery and children’s night-time fears: A multiple baseline design evaluation. Journal of Behavior Therapy and Experimental Psychiatry, 20, 125– 135. King, N. J., Hamilton, D. H., & Ollendick, T. H. (1988). Children’s phobias: A behavioral perspective. New York: Wiley. King, N. J., Mietz, A., Finney, L., & Ollendick, T. H. (1995). Psychopathology and cognition in adolescents experiencing severe test anxiety. Journal of Clinical Child Psychology, 24, 49–54. King, N. J., Ollendick, T. H., & Tonge, B. J. (1995). School refusal: Assessment and treatment. Needham Heights, MA: Allyn & Bacon. King, N. J., Ollier, K., Iacuone, R., Schuster, S., Bays, K., Gullone, E., & Ollendick, T. H. (1989). Child and adolescent fears: An Australian cross-sectional study using the Revised Fear Survey Schedule for Children. Journal of Child Psychology and Psychiatry, 30, 775–784. King, N. J., Tonge, B. J., Heyne, D., Pritchard, M., Rollings, S., Young, D., Myerson, N., & Ollendick, T. H. (1998). Cognitive-behavioral treatment of school-refusing children: A controlled evaluation. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 395–403. King, N. J., Tonge, B. J., Mullen, P., Myerson, N., Heyne, D., Rollings, S., Martin, R.,, & Ollendick, T. H. (2000). Treating sexually abused children with posttraumatic stress symptoms: A randomized clinical trial. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1347–1355. King, R. A., Leckman, J. F., Scahill, L., & Cohen, D. J. (1999). Obsessive–compulsive disorder, anxiety, and depression. In J. F. Leckman & D. J. Cohen (Eds.), Tourette’s syndrome—tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 43–62). New York: Wiley. King, R. A., Scahill, L., Vitulano, L. A., Schwab-Stone, M., Tercyak, K. P., & Riddle, M. A. (1995). Childhood trichotillomania: Clinical phenomenology, comorbidity, and family genetics. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1451–1459. King, V. (1994). Nonresidential father involvement and child well-being: Can dads make a difference? Journal of Family Issues, 15, 78–96. King, V., & Heard, H. E. (1999). Nonresident father visitation, parental conflict and mother’s satisfaction: What’s best for child well-being? Journal of Marriage and the Family, 61, 385–396. Kingston, L., & Prior, M. (1995). The development of patterns of stable, transient, and school-age onset aggressive behavior in young children. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 348–358. Kinsbourne, M. (1990). Testing models for attention deficit hyperactivity disorder in the behavioral laboratory. In C. K. Conners & M. Kinsbourne (Eds.), Attention deficit hyperactivity disorder (pp. 51–69). Munich, Germany: Medizin Verlag Munchen. Klackenberg, G. (1982). Somnambulism in childhood: Prevalence, course and behavioral correlations. Acta Paediatrica Scandinavica, 71, 495–499. Klein, M., & Gordon, S. (1991). Sex education. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (2nd ed., pp. 933–949). New York: Wiley. Klein, R. G., & Mannuzza, S. (1991). Long-term outcome of hyperactive children: A review. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 383–387. Knell, S. M., & Moore, D. J. (1988). Childhood trichotillomania treated indirectly by punishing thumb sucking. Journal of Behavior Therapy and Experimental Psychiatry, 19, 305–310. Kochanska, G. (1995). Children’s temperment, mothers’ discipline, and security of attachment: Multiple pathways to emerging internalization. Child Development, 66, 597–615. Kochanska, G., Kuczynski, L., Radke-Yarrow, M., & Welsh, J. D. (1987). Resolutions of control episodes between well and affectively ill mothers and their young children. Journal of Abnormal Psychology, 15, 441–456.

578

References

Kohl, H. W., & Hobbs, K. E. (1998). Development of physical activity behaviors among children and adolescents. Pediatrics, 101(Suppl.), 549–554. Kohlmann, C. W., Schumacher, A., & Streit, R. (1988). Trait anxiety and parental child-rearing behaviour: Support as a moderator variable? Anxiety Research, 1, 53–64. Kokko, K., & Pulkkinen, L. (2000). Aggression in childhood and long-term unemployment in adulthood: A cycle of maladaptation and some protective factors. Developmental Psychology, 36, 463–472. Kolko, D. J. (1988). Educational programs to promote awareness and prevention of child sexual victimization: A review and methodological critique. Clinical Psychology Review, 8, 195–209. Kolody, B., & Sallis, J. F. (1995). A prospective study of ponderosity, body image, self concept, and psychological variables in children. Journal of Developmental and Behavioral Pediatrics, 16, 1–5. Konkol, R. J., Fischer, M., & Newby, R. F. (1990). Double-blind, placebo-controlled stimulant trial in children with Tourette’s syndrome and attention deficit-hyperactivity disorder. Annals of Neurology, 28, 424. Koocher, G. P. (1973). Childhood, death, and cognitive development. Developmental Psychology, 9, 369– 375. Koocher, G. P. (1983). Grief and loss in childhood. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (pp. 1273–1284). New York: Wiley–Interscience. Koocher, G. P., & Gudas, L. J. (1992). Grief and loss in childhood. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (2nd ed., pp. 1025–1034). New York: Wiley–Interscience. Koplewicz, H. W. (1996). It’s nobody’s fault: New hope and help for difficult children and their parents. New York: Times Books. Kopp, C. V. (1982). Antecedents of self regulation: A developmental perspective. Developmental Psychology, 18, 199–214. Kopp, C. V. (1989). Regulation of distress and negative emotions: A developmental view. Developmental Psychology, 25, 343–354. Kott, L., & Shoemaker, H. M. (1999). Children of divorce: An investigation of the developmental effects from infancy through adulthood. Journal of Divorce and Remarriage, 31, 161–178. Kourany, R. F., Garber, J., & Tornusciolo, G. (1990). Improving first appointment attendance rates in child psychiatry outpatient clinics. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 657–660. Kovacs, M. (1992). Children’s Depression Inventory. North Tonawanda, NY: Multi-Health Systems. Kovacs, M. (1996). Presentation and course of major depressive disorder during childhood and later years of the life span. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 705–715. Kovacs, M. (2001). Gender and the course of major depressive disorder through adolescence in clinically referred youngsters. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1079– 1085. Kovacs, M., & Devlin, B. (1998). Internalizing disorders in childhood. Journal of Child Psychology and Psychiatry, 39, 47–63. Kovacs, M., Gatsonis, C., Paulauskas, S. L., & Richards, C. (1989). Depressive disorders in childhood: IV. A longitudinal study of comorbidity with and risk for anxiety disorders. Archives of General Psychiatry, 46, 776–782. Kovacs, M., Goldston, D., & Gatsonis, C. (1993). Suicidal behaviors and childhood-onset depressive disorders: A longitudinal investigation. Journal of the American Academy of Child Psychiatry, 32, 8–20. Kowal, A., & Kramer, L. (1997). Children’s understanding of parental differential treatment. Child Development, 68, 113–126. Krahe, B., Scheinberger-Olwig, R., Waizenhofer, E., & Koplin, S. (1999). Childhood sexual abuse and revictimization in adolescence. Child Abuse and Neglect, 23, 383–394. Kramer, A. F., Cepeda, N. J., & Cepeda, M. L. (2001). Methylphenidate effects on task-switching performance in attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1277–1284. Kramer, J. R., Lovey, J., Posto, L. B., Roberts, M. A., & Grossman, S. (2000). Predictors of adult height and weight in boys treated with methylphenidate for childhood behavior problems. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 517–524. Kratochwill, T. R., Elliot, S. N., & Rotto, P. C. (1995). School-based behavioral consultation. In A. Thomas & J. Grimes (Eds.), Best practices in school psychology III (pp. 519–538). Washington, DC: National Association of School Psychologists. Kruesi, M. J. P., & Lelio, D. F. (1996). Disorders of conduct and behavior. In J. M. Weiner (Ed.), Diagnosis and psychopharmacology of childhood and adolescent disorders (pp. 401–447). New York: Wiley. Kübler-Ross, E. (1969). On death and dying. New York: Macmillan.

References

579

Kuczynski, L., & Kochanska, G. (1995). Function and context of maternal demands: Developmental significance of early demands for competent action. Child Development, 66, 616–628. Kuczynski, L., Kochanska, G., Radke-Yarrow, M., & Girnius-Brown, O. (1987). A developmental interpretation of young children’s noncompliance. Developmental Psychology, 23, 799–806. Kuperman, W., & Stewart, M. A. (1981). Grief and depression. In S. Gabel (Ed.), Behavioral problems in childhood: A primary care approach (pp. 393–398). New York: Grune & Stratton. Kupersmidt, J. B., Burchinal, M., & Patterson, C. J. (1995). Developmental patterns of childhood peer relations as predictors of externalizing behavior problems. Development and Psychopathology, 7, 825– 843. Kupersmidt, J. B., & Patterson, C. J. (1991). Childhood peer rejection, aggression, withdrawal, and perceived competence as predictors of self-reported behaviors in preadolescence. Journal of Abnormal Child Psychology, 19, 427–449. Kupst, M. J., & Schulman, J. L. (1988). Long-term coping with pediatric leukemia: A six-year follow-up study. Journal of Pediatric Psychology, 13, 7–22. Kurdek, L. A., & Sinclair, R. J. (1988). Adjustment of young adolescents in two-parent nuclear, stepfather, and mother-custody families. Journal of Consulting and Clinical Psychology, 56, 91–96. Kurlan, R., Behr, J., Medved, L., Shoulson, I., Pauls, D., Kidd, J. R., & Kidd, K. K. (1986). Familial Tourette’s syndrome: Report of a large pedigree and potential for linkage analysis. Neurology, 36, 772–776. Kutcher, S. P., Reiter, S., Gardner, D. M., & Klein, R. G. (1992). The pharmacotherapy of anxiety disorder in children and adolescents. Pediatric Clinics of North America, 15, 41–67. Lacey, E. P. (1993). Phenomenology of pica. Child and Adolescent Psychiatric Clinics of North America, 2, 75–91. Lachar, D., & Gruber, C. P. (1995). Personality Inventory for Youth. Los Angeles: Western Psychological Services. La Greca, A. M., Kuttler, A. F., & Stone, W. L. (2001). Assessing children through interviews and behavioral observation. In C. E. Walker & M. C. Robert (Eds.), Handbook of clinical child psychology (3rd ed., pp. 90–110). New York: Wiley. La Greca, A. M., & Lopez, N. (1998). Social anxiety among adolescents: Linkages with peer relationships and friendships. Journal of Abnormal Child Psychology, 26, 83–94. La Greca, A. M., Vernberg, E. M., Silverman, W. K., Vogel, A. L., & Prinstein, M. J. (1994). Helping children prepare and cope with natural disasters: A manual for professionals working with elementary school children. Miami, FL: Authors. Lahey, B. B., Applegate, B., McBurnett, K., Biederman, J., Greenhill, L., Hynd, G. W., Barkley, R. A., Newcorn, J., Jensen, P., Richters, J., Garfinkel, B., Kerdyke, L., Frick, P. J., Ollendick, T., Perez, D., Hart, E. L., Waldman, I., & Shaffer, D. (1994). DSM-IV field trials for attention-deficit/hyperactivity disorder in children and adolescents. American Journal of Psychiatry, 151, 1673–1685. Lahey, B. B., & Loeber, R. (1994). A framework for a developmental model of oppositional defiant disorder and conduct disorder. In D. K. Routh (Ed.), Disruptive behavior disorders in childhood (pp. 139–180). New York: Plenum Press. Lahey, B. B., Loeber, R., Quay, H. C., Applegate, B., Shaffer, D., Waldman, I., Hart, E. L., McBurnett, K., Frick, P. J., Jensen, P. S., Dulcan, M. K., Canino, G., & Bird, H. (1998). Validity of DSM-IV subtypes of conduct disorder based on age of onset. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 435–442. Lahey, B. B., Pelham, W. E., Schaughency, E. A., Atkins, M. S., Murphy, H. A., Hynd, G., Russo, M., Hartdagen, S., & Lorys-Vernon, A. (1988). Dimensions and types of attention deficit disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 330–335. Lahey, B. B., Pelham, W. E., Stein, M. A., Loney, J., Trapani, C., Nugent, K., Kipp, H., Schmidt, E., Lee, S., Cale, M., Gold, E., Hartung, C. M., Willcutt, E., & Baumann, B. (1998). Validity of DSM-IV attentiondeficit/hyperactivity disorder for younger children. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 695–702. Lamb, M. E. (1994). The investigation of child sexual abuse: An interdisciplinary consensus statement. Expert Evidence, 2, 151–156. Lamb, M., Thompson, R., Gardner, W., & Charnov, E. (1985). Infant–mother attachment. Hillsdale, NJ: Erlbaum. Lamb, S., & Coakley, M. (1993). “Normal” childhood sexual play and games: Differentiating play from abuse. Child Abuse and Neglect, 17, 515–526. Lambert, W., Salzer, M. S., & Bickman, L. (1998). Clinical outcome, consumer satisfaction, and ad hoc ratings of improvement in children’s mental health. Journal of Consulting and Clinical Psychology, 66, 270– 279.

580

References

Lampkin, B. C. (1993). Introduction and executive summary. Cancer, 71, 3199–3201. Lane, B., & Gullone, E. (1999). Common fears: A comparison of self-generated and Fear Survey Schedule generated fears of adolescents. Journal of Genetic Psychology, 160, 194–204. Largo, R. H., & Stutzle, W. (1977). Longitudinal study of bowel and bladder control by day and at night in the first six years of life: II. The role of potty training and the child’s initiative. Developmental Medicine and Child Neurology, 19, 607–613. Last, C. G. (1993). Introduction. In C. G. Last (Ed.), Anxiety across the lifespan: A developmental perspective (pp. 1–7). New York: Springer. Last, C. G., & Beidel, D. C. (1991). Anxiety. In M. Lewis (Ed.), Child and adolescent psychiatry: A comprehensive textbook (pp. 281–292). Baltimore: Williams & Wilkins. Last, C. G., Hansen, C., & Franco, N. (1997). Anxious children in adulthood: A prospective study of adjustment. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 645–652. Last, C. G., Hansen, C., & Franco, N. (1998). Cognitive-behavioral treatment of school phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 404–411. Last, C. G., Hersen, M., Kazdin, A. E., Finkelstein, R., & Strauss, C. C. (1987). Comparison of DSM-III separation anxiety and generalized anxiety disorders: Demographic characteristics and patterns of comorbidity. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 527–531. Last, C. G., Hersen, M., Kazdin, A. E., Francis, G., & Grubb, H. J. (1987a). Separation anxiety and school phobia: A comparison using DSM-III criteria. American Journal of Psychiatry, 144, 653–657. Last, C. G., Hersen, M., Kazdin, A. E., Francis, G., & Grubb, H. J. (1987b). Psychiatric illness in the mothers of anxious children. American Journal of Psychiatry, 144, 1580–1583. Last, C. G., Hersen, M., Kazdin, A., Orvaschel, H., & Perrin, S. (1991). Anxiety disorders in children and their families. Archives of General Psychiatry, 48, 928–934. Last, C. G., Perrin, S., Hersen, M., & Kazdin, A. E. (1992). DSM-III-R anxiety disorders in children: Sociodemographic and clincial characteristics. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 1070–1076. Last, C. G., Perrin, S., Hersen, M., & Kazdin, A. E. (1996). A prospective study of childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1502–1510. Last, C. G., Strauss, C. G., & Francis, G. (1987). Comorbidity among childhood anxiety disorders. Journal of Nervous and Mental Disease, 175, 726–730. Latham, P. S., & Latham, P. H. (1997). Attention deficit disorder and the law (2nd ed.). Washington, DC: JKL Communications. Latz, S., Wolf, A. W., & Lozoff, B. (1999). Cosleeping in context: Sleep practices and problems in young children in Japan and the U.S. Archives of Pediatrics and Adolescent Medicine, 153, 339–346. Lauer, R. E., Giordani, B., Boivin, M. H., Halle, N., Glasgow, B., Alessi, N. E., & Berent, S. (1994). Effects of depression on memory performance and metamemory in children. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 679–685. Laurent, J., Landau, S., & Stark, K. D. (1993). Conditional probabilities in the diagnosis of depressive and anxiety disorders in children. School Psychology Review, 22, 98–114. Laurent, J., & Potter, K. I. (1998). Anxiety-related difficulties. In T. Steuart & F. M. Gresham (Eds.), Handbook of child behavior therapy (pp. 371–392). New York: Plenum Press. Lavigne, J. V., Burns, W. J., & Cotter, P. D. (1981). Rumination in infancy: Recent behavioral approaches. International Journal of Eating Disorders, 1, 70–82. Lavigne, J. V., Gibbons, R. D., Christoffel, K. K., Arend, R., Rosenbaum, D., & Binns, H. (1996). Prevalence rates and correlates of psychiatric disorders among preschool children. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 204–214. Law, S. F., & Schachar, R. J. (1999). Do typical clinical doses of Methylphenidate cause tics in children treated for attention-deficit/hyperactivity disorder? Journal of the American Academy of Child and Adolescent Psychiatry, 38, 944–951. Lazarus, A. A., & Abramowitz, A. (1962). The use of “emotive imagery” in the treatment of children’s phobias. Journal of Mental Science, 108, 191–195. Leckman, J. F. & Cohen, D. J. (1988). Descriptive and diagnostic classification of tic disorders. In D. J. Cohen, R. D. Brown, & J. F. Leckman (Eds.), Tourette’s syndrome and tic disorders: Clinical understanding and treatment (pp. 4–19). New York: Wiley. Leckman, J. F., & Cohen, D. J. (1991). Clonidine treatment of Gilles de la Tourette’s syndrome. Archives of General Psychiaty, 48, 324–328. Leckman, J. F., & Cohen, D. J. (Eds.). (1999). Tourette’s syndrome—tics, obsessions, compulsions: Developmental psychopathology and clinical care. New York: Wiley.

References

581

Leckman, J. F., King, R. A., & Cohen, D. J. (1999). Tics and tic disorders. In J. F. Leckman & D. J. Cohen (Eds.), Tourette’s syndrome—tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 23–42). New York: Wiley. Leckman, J. F., Riddle, M. A., Hardin, M. T., Ort, S. I., Swartz, K. L., Stevenson, J., & Cohen, D. J. (1989). The Yale Global Tic Severity Scale: Initial testing of a clinician-rated scale of tic severity. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 566–573. Lee, M. Y. (1997). Post-divorce interparental conflict, children’s contact with both parents, children’s emotional processes, and children’s behavioral adjustment. Journal of Divorce and Remarriage, 27, 61–82. Leenaars, A. A., & Wenckstern, S. (1996). Postvention with elementary school children. In C. A. Corr & D. M. Corr (Eds.), Handbook of childhood death and bereavement (pp. 265–283). New York: Springer. Lengua, L .J., Wolchik, S. A., Sandler, I. N., & West, S. G. (2000). The additive interactive effects of parenting and temperament in predicting adjustment problems of children of divorce. Journal of Clinical Child Psychology, 29, 232–244. Lengua, L. J., Sandler, I. N., West, S. G., Wolchik, S. A., & Curran, P. J. (1999). Emotionality and self-regulation, threat approaisal, and coping in children of divorce. Development and Psychopathology, 11, 15– 37. Lengua, L. J., West, S. G., & Sandler, I. N. (1998). Temperament as a predictor of symptomatology in children: Addressing contamination of measures. Child Development, 69, 164–181. Leonard, H. L., Lenane, M. C., Swedo, S. E., Rettew, D. C., & Rapoport, J. L. (1991). A double-blind comparison of clomipramine and desipramine treatment of severe onychophagia (nailbiting). Archives of General Psychiatry, 48, 821–827. Leonard, H. L., Swedo, S. E., Lenane, M. C., Rettew, D. C., Hamburger, S. D., Bartko, J. J., & Rapoport, J. L. (1993). A 2- to 7-year follow-up study of 54 obsessive–compulsive children and adolescents. Archives of General Psychiatry, 50, 429–439. Lesch, K. P., Bengel, D., Heils, A., Zhang-Sabol, S., Greenberg, B. D., Petri, S., Benjamin, J., Muller, C. R., Hamer, D. H., & Murphy, D. L. (1996). Association of anxiety related traits with a polymorphism in the serotonin transporter gene regulation region. Science, 274, 1527–1530. Levine, F. M., & Ramirez, R. (1989). Contingent negative practice as a homebased treatment of tics and stuttering. In C. E. Schaefer & J. M. Briesmeister (Eds.), Handbook of parent training: Parents as co-therapists for children’s behavior problems (pp. 38–59). New York: Wiley. Levine, M. D. (1975). Children with encopresis: A descriptive analysis. Pediatrics, 56, 412–416. Levine, M. D. (1982). Encopresis: Its potentiation, evaluation, and alleviation. Pediatric Clinics of North America, 29, 315–330. Levine, M. D., & Bakow, H. (1976). Children with encopresis: A study of treatment outcome. Pediatrics, 58, 845–852. Levy, F., Hay, D. A., McStephen, M., Wood, C., & Waldman, I. (1997). Attention-deficit hyperactivity disorder: A category or a continuum? Genetic analysis of a large-scale twin study. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 737–744. Lindberg, L., Bohlin, G., & Hagekull, B. (1991). Early feeding problems in a normal population. Internationl Journal of Eating Disorders, 10, 395–405. Linscheid, T. R. (1992). Eating problems in children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (2nd ed., pp. 451–473). New York: Wiley–Interscience. Linscheid, T. R. (1999). Commentary: Response to empirically supported treatments for feeding problems. Journal of Pediatric Psychology, 24, 215–216. Linscheid, T. R., & Bennett-Murphy, L. (1999). Feeding disorders of infancy and early childhood. In S. D. Netherton & C. E. Walker (Eds.), Child and adolescent psychological disorders: A comprehensive textbook (pp. 139–155). New York: Oxford University Press. Linscheid, T. R., Budd, K., & Rasnake, L. K. (1995). Pediatric feeding disorders. In M. C. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp. 501–515). New York: Guilford Press. Linscheid, T. R., & Cunningham, C. E. (1977). A controlled demonstration of the effectiveness of electric shock in the elimination of chronic infant rumination. Journal of Applied Behavior Analysis, 10, 500. Linscheid, T. R., & Rasnake, L. K. (2001). Eating problems in children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 523–541). New York: Wiley. Linscheid, T. R., Tarnowski, K. J., Rasnake, L. K., & Brams, J. S. (1987). Behavioral treatment of food refusal in a child with short-gut syndrome. Journal of Pediatric Psychology, 12, 451–459. Lipkin, P. H., Goldstein, I. J., & Adesman, A. R. (1994). Tics and dyskinesias associated with stimulant treatment in attention-deficit hyperactivity disorder. Archives of Pediatric and Adolescent Medicine, 148, 859– 861.

582

References

Little, L. M., & Kelley, M. L. (1989). The efficacy of response cost procedures for reducing children’s noncompliance to parental instructions. Behavior Therapy, 20, 525–534. Loeber, R. (1988). Natural histories of conduct problems, delinquency, and associated substance abuse: Evidence for developmental progressions. In B. B. Lahey & A. E. Kazdin (Eds.), Advances in clinical child psychology (vol. 11, pp. 73–124). New York: Plenum Press. Loeber, R. (1990). Development and risk factors of juvenile antisocial behavior and delinquency. Clinical Psychology Review, 10, 1–41. Loeber, R., Burke, J. D., Lahey, B. B., Winters, A., & Zera, M. (2000). Oppositional defiant and conduct disorder: A review of the past 10 years, Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1468–1484. Loeber, R., Green, S. M., & Lahey, B. B. (1990). Mental health professionals’ perception of the utility of children, mothers, and teachers as informants on childhood psychopathology. Journal of Clinical Child Psychology, 19, 136–143. Loeber, R., Green, S. M., Keenan, K., & Lahey, B. B. (1995). Which boys will fare worse?: Early predictors of the onset of conduct disorders in a six-year longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 499–509. Loeber, R., Green, S. M., Lahey, B. B., Christ, M. A. G., & Frick, P. J. (1992). Developmental sequences in the age of onset of disruptive child behaviors. Journal of Child and Family Studies, 1, 21–41. Loeber, R., Green, S. M., Lahey, B. B., & Kalb, L. (2000). Physical fighting in childhood as a risk factor for later mental health problems. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 421–428. Loeber, R., Green, S. M., Lahey, B. B., & Stouthamer-Loeber, M. (1991). Differences and similarities between children, mothers, and teachers as informants on disruptive child behavior. Journal of Abnormal Child Psychology, 19, 75–95. Loeber, R., & Hay, D. (1997). Key issues in the development of aggression and violence from childhood to early adulthood. Annual Review of Psychology, 48, 371–410. Loeber, R., & Lahey, B. B. (1989). Recommendations for research on disruptive behavior disorders of childhood and adolescence. In B. B. Lahey & A. E. Kazdin (Eds.), Advances in clinical child psychology (Vol. 12, pp. 221–251). New York: Plenum Press. Loeber, R., Lahey, B. B., & Thomas, C. (1991). Diagnostic conundrum of oppostional defiant disorder and conduct disorder. Journal of Abnormal Psychology, 100, 379–390. Loeber, R., & Stouthamer-Loeber, M. (1998). Development of juvenile aggression and violence. American Psychologist, 53, 242–259. Loening-Baucke, V. A. (1990). Modulation of abnormal defecation dynamics by biofeedback treatment in chronically constipated children with encopresis. Journal of Pediatrics, 116, 214–221. Loening-Baucke, V. A. (1997). Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics, 100, 228–232. Loening-Baucke, V. A., Cruikshank, B., & Savage, C. (1987). Defecation dynamics and behavior profiles in encopretic children. Pediatrics, 80, 672–679. Lorion, R. P., Myers, T. G., Bartel, S., & Dennis, A. (1994). Preventive intervention research: Pathways for extending knowledge of child/adolescent health and pathology. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 16, pp. 109–139). New York: Plenum Press. Lovibond, S. H. (1964). Conditioning and enuresis. New York: Macmillan. Lowery, S. P., Stour, J. W., Whitehead, W. E., & Schuster, M. M. (1985). Habit training as treatment of encopresis secondary to chronic constipation. Journal of Pediatric Gastroenterology and Nutrition, 4, 397–401. Lown, N., & Britton, B. (1991). Engaging families through the letter writing technique. Journal of Strategic and Systemic Therapies, 10, 43–48. Lozoff, B., Wolf, A. W., & Davis, N. S. (1985). Sleep problems seen in pediatric practice. Pediatrics, 75, 477– 483. Luiselli, J. K., & Luiselli, T. E. (1995). A behavior analysis approach toward chronic food refusal in children with gastrostomy-tube dependency. Topics in Early Childhood Special Education, 15, 1–18. Luxem, M., & Christophersen, E. (1994). Behavioral toilet training in early childhood: Research, practice, and implications. Journal of Developmental and Behavioral Pediatrics, 15, 370–378. Lyman, R. D., & Hembree-Kigin, T. L. (1994). Mental health interventions with preschool children. New York: Plenum Press. Lyon, J. B., & Vanderberg, B. R. (1989). Father death, family relationships and subsequent psychological functioning in women. Journal of Clinical Child Psychology, 18, 327–335. Lyon, L. S. (1983). A behavioral treatment of compulsive lipbiting. Journal of Behavior Therapy and Experimental Psychiatry, 14, 275–276.

References

583

MacFarlane, J. W., Allen, L., & Honzik, M. P. (1954). A developmental study of the behavior problems of normal children between twenty-one months and fourteen years. Berkeley: University of California Press. MacKeith, R. C., Meadow, S. R., & Turner, R. K. (1973). How children become dry. In I. Kolvin, R. C. MacKeith, & S. R. Meadow (Eds.), Clinics in developmental medicine: Bladder control and enuresis (pp. 3–22). London: Heinemann. Maedgen, J. W., & Carlson, C. L. (2000). Social functioning and emotional regulation in the attention deficit hyperactivity disorder subtypes. Journal of Clinical Child Psychology, 29, 30–42. Mahoney, A., Donnelly, W. O., Lewis, T., & Maynard, C. (2000). Mother and father self-reports of corporal punishment and severe physical aggression toward clinic-referred youth. Journal of Clinical Child Psychology, 29, 266–281. Mahoney, J. L. (2000). School extracurricular activity participation as a moderator in the development of antisocial patterns. Child Development, 71, 502–516. Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. In I. Bretherton & E. Waters (Eds.), Growing points of attachment theory and research. Monographs of the Society for Research in Child Development, 50(1–2, Serial No. 209), 66–104. Maloney, M. J., & Ruedisueli, G. (1993). The epidemiology of eating problems in non-referred children and adolescents. Child and Adolescent Psychiatric Clinics of North America, 2, 1–14. Maloney, M. J., McGuire, J. B., & Daniels, S. R. (1988). Reliability testing of a children’s version of the Eating Attitudes Test. Journal of the American Academy of Child and Adolescent Psychiatry, 27, 541–543. Manasses, K. (1996). Keys to parenting your anxious child. New York: Barron’s Educational Series. Manassis, K., & Bradley, S. J. (1994). The development of child anxiety disorders: Toward an integrated model. Journal of Applied Developmental Psychology, 15, 345–366. Manassis, K., & Hood, J. (1998). Individual and familial predictors of impairment in childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 428–434. Mannassis, K., & Monga, S. (2001). A therapeutic approach to children and adolescents with anxiety disorders and associated comorbid conditions. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 115–117. Mannarino, A. P., & Cohen, J. A. (1996a). Family related variables and psychological symptom formation in sexually abused girls. Journal of Child Sexual Abuse, 5, 105–119. Mannarino, A. P., & Cohen, J. A. (1996b). A follow-up study of factors which mediate the development of psychological symptomatology in sexually abused girls. Child Maltreatment, 1, 246–260. Mannarino, A. P., Cohen, J. A., & Berman, S. R. (1994). The Children’s Attributions and Perceptions Scale: A new measure of sexual abuse-related factors. Journal of Clinical Child Psychology, 23, 204–211. Mannino, F. V., & Delgado, R. A. (1969). Trichotillomania in children: A review. American Journal of Psychiatry, 26, 505–511. Mannuzza, S., Klein, R. G., Bessler, A., Malloy, P., & LaPadula, M. (1993). Adult outcome of hyperactive boys. Archives of General Psychiatry, 50, 565–576. Mansdorf, I. J. (1986). Assertiveness training in the treatment of a child’s tic. Journal of Behavior Therapy and Experimental Psychology, 17, 29–32. Marantz, S., & Coates, S. (1991). Mothers of boys with gender identity disorder: A comparison of matched controls. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 310–315. March, J. S. (1997). Multidimensional Anxiety Scale for Children (MASC). Toronto: Multi-Health Systems. March, J. S., Amaya-Jackson, L., Murray, M. C., & Schulte, A. (1998). Cognitive-behavioral psychotherapy for children and adolescents with posttraumatic stress disorder after a single-incident stressor. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 585–593. March, J. S., & Mulle, K. (1995). Manualized cognitive-behavioural psychotherapy for obsessive–compulsive disorder in childhood: A preliminary single case study. Journal of Anxiety Disorders, 9, 175–184. Marchi, M., & Cohen, P. (1990). Early childhood eating behaviors and adolescent eating disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 112–117. Marcotte, A. C., Thacher, P. V., Butters, M., Bortz, J., Acebo, C., & Carskadon, M. A. (1998). Parental report of sleep problems in children with attentional and learning disorders. Developmental and Behavioral Pediatrics, 19, 178–186. Margolin, L. (1991). Child sexual abuse by nonrelated caregivers. Child Abuse and Neglect, 15, 213–221. Marlatt, G. A. (1982). Relapse prevention: A self-control program for the treatment of addictive behaviors. In R. B. Stuart (Ed.), Adherence, compliance, and generalization in behavioral medicine (pp. 329–378). New York: Brunner/Mazel. Martin, B. (1975). Parent–child relations. In F. D. Horowitz (Ed.), Review of child development research (Vol. 4, pp. 463–540). Chicago: University of Chicago Press.

584

References

Martin, B. (1977). Brief family intervention: Effectiveness and the importance of including the father. Journal of Consulting and Clinical Psychology, 45, 1002–1010. Martinez, C. R., & Forgatch, M. S. (2001). Preventing problems with boys’ noncompliance: Effects of a parent training intervention for divorcing mothers. Journal of Consulting and Clinical Psychology, 69, 416–428. Martinson, F. M. (1981). Eroticism in infancy and childhood. In L. L. Constantine & F. M. Martinson (Eds.), Children and sex: New findings, new perspectives (pp. 23–35). Boston: Little, Brown. Mash, E. J., & Terdal, L. G. (1997a). Assessment of child and family disturbance: A behavioral systems approach. In E. J. Mash & L. G. Terdal (Eds.), Assessment of childhood disorders (3rd ed., pp. 3–68). New York: Guilford Press. Mash, E. J., & Terdal, L. G. (Eds.). (1997b). Assessment of childhood disorders (3rd ed.). New York: Guilford Press. Mash, E. J., Terdal, L. G., & Anderson, K. (1973). The Response Class Matrix: A procedure for recording parent–child interactions. Journal of Consulting and Clinical Psychology, 40, 163–164. Masia, C. L., Klein, R. G., Stroch, E. A., & Gorda, B. (2001). School-based behavioral treatment for social anxiety disorder in adolescents: Results of a pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 780–786. Mason, A., Banerjee, S., Eapen, V., Zettin, H., & Robertson, M. M. (1998). The prevalence of Tourette syndrome in a mainstream school population. Developmental Medicine and Child Neurology, 40, 292–296. Massong, S. R., Edwards, R. P., Range-Sitton, L., & Hailey, B. J. (1980). A case of trichotillomania in a three year old treated by response prevention. Journal of Behavior Therapy and Experimental Psychiatry, 11, 223–225. Masten, A. S., & Coatsworth, J. D. (1998). The development of competence in favorable and unfavorable environments. American Psychologist, 53, 205–220. Masterman, S. H., & Reams, R. (1988). Support groups for bereaved preschool and school-aged children. American Journal of Orthopsychiatry, 58, 562–570. Matas, L., Arend, R. A., & Sroufe, L. A. (1978). Continuity of adaptation in the second year: The relationship between quality of attachment and later competence. Child Development, 49, 547–556. Matheny, A. P. (1986). Injuries among toddlers: Contributions from child, mother, and family. Journal of Pediatric Psychology, 11, 163–176. Matson, J. L., & Ollendick, T. H. (1977). Issues in toilet training normal children. Behavior Therapy, 8, 549– 558. Mattes, J. A., & Gittelman, R. (1981). Effects of artificial food colorings in children with hyperactive symptoms. Archives of General Psychiatry, 38, 714–718. Matthews, A. (1990). Why worry?: The cognitive function of anxiety. Behaviour Research and Therapy, 28, 455–468. Matthews, J. R., Friman, P. C., Barone, V. J., Ross, L. V., & Christophersen, E. R. (1987). Parental management of infants: Increasing positive maternal interactions and decreasing dangerous infant behaviors. Journal of Applied Behavior Analysis, 20, 165–169. Matthews, L. H., Matthews, J. R., & Leibowitz, J. M. (2001). Tics, stereotypic movements and habits. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 338–358). New York: Wiley. Matthys, W., Cuperus, J. M., & van Engeland, H. (1999). Deficient social problem-solving in boys with ODD/ CD, with ADHD, and with both disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 311–321. Mattison, R. E. (2000). School consultation: A review of research on issues unique to the school environment. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 402–412. Mauer, K. W., Staats, B. A., & Olson, K. D. (1983). Upper airway obstruction and disordered nocturnal breathing in children. Mayo Clinic Proceedings, 58, 349–353. Maugham, B., & Rutter, M. (1998). Continuities and discontinuities in antisocial behavior from childhood to adult life. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 20, pp. 1– 47). New York: Plenum Press. Mayberry, L. J., & Affonso, D. D. (1993). Infant temperament and postpartum depression: A review. Health Care for Women International, 14, 201–211. Mazur, E., Wolchik, S. A., Virdin, L., Sandler, I. N., & West, S. G. (1999). Cognitive moderators of children’s adjustment to stressful divorce events: The role of negative cognitive errors and positive illusions. Child Development, 70, 231–245. Mazur, T., & Cherpak, R. L. (1995). Psychologic issues of adjustment in precocious, normal, delayed, and incongruent puberty. In G. A. Rekers (Ed.), Handbook of child and adolescent sexual problems (pp. 55– 80). New York: Lexington Books.

References

585

Mazur, T., & Dobson, K. (1995). Psychologic issues in individuals with genetic, hormonal, and anatomic anomalies of the sexual system: Review and treatment considerations. In G. A. Rekers (Ed.), Handbook of child and adolescent sexual problems (pp. 101–134). New York: Lexington Books. McArthur, D. S., & Roberts, G. E. (1982). Roberts Apperception Test for Children. Los Angeles: Western Psychological Services. McBride-Murry, V., & Brody, G. H. (1999). Self-regulation and self-worth of black children reared in economically stressed, rural, single mother-headed families: The contribution of risk and protective factors. Journal of Family Issues, 20, 458–484. McCabe, A., & Lipscomb, T. (1988). Sex differences in children’s verbal aggression. Merrill–Palmer Quarterly, 34, 389–401. McClellan, J. M., & Werry, J. S. (2000). Introduction: Research on psychiatric diagnostic interviews for children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 19–27. McCloskey, L. A., & Walker, M. (2000). Posttraumatic stress in children exposed to family violence and singleevent trauma. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 108–115. McConaghy, M. J. (1979). Gender permanence and the genital basis of gender: Stages in the development of constancy of gender identity. Child Development, 50, 1223–1226. McConaughy, S. H., Achenbach, T. M., & Gent, C. L. (1988). Multiaxial empirically based assessment: Parent, teacher, observational, cognitive, and personality correlates of child behavior profile types for 6- to 11-year old boys. Journal of Abnormal Child Psychology, 16, 485–509. McConaughy, S. H., Stanger, C., & Achenbach, T. M. (1992). Three-year course of behavioral/emotional problems in a national sample of 4- to 16-year-olds: I. Agreement among informants. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 932–940. McConnell, R. A., & Sim, A. J. (1999). Adjustment to parental divorce: An examination of the differences between counselled and non-counselled children. British Journal of Guidance and Counselling, 27, 245–257. McCown, D. E., & Pratt, C. (1985). Impact of sibling death on children’s behavior. Death Studies, 9, 323– 335. McDowell, E., & Stillion, J. (1994). Suicide across the phases of life. New Directions for Child Development, 64, 7–22. McGee, R., Freehan, M., Williams, S., Partridge, F., Silva, P. A., & Kelly, J. (1990). DSM-III disorders in a large sample of adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 611–619. McGee, R., Williams, S., & Feehan, M. (1992). Attention deficit disorder and age of onset of problem behaviors. Journal of Abnormal Child Psychology, 20, 487–502. McGrath, M. L., Mellon, M. W., & Murphy, L. (2000). Empirically supported treatments in pediatric psychology: Constipation and encopresis. Journal of Pediatric Psychology, 25, 225–254. McGurk, H., & Glachan, M. (1987). Children’s conception of the continuity of parenthood following divorce. Journal of Child Psychology and Psychiatry, 28, 427–435. McHale, S. M., & Crouter, A. C. (1996). The family context of children’s sibling relationships. In G. Brody (Ed.), Sibling relationships: Their causes and consequences (pp. 173–195). Norwood, NJ: Ablex. McLanahan, S., & Bumpass, L. (1988). Intergenerational consequences of family disruption. American Journal of Sociology, 51, 557–580. McLeer, S. V., Deblinger, E., Henry, D., & Orvaschel, H. (1992). Sexually abused children at high risk for post-traumatic stress disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 875–879. McLennan, J. D., Kotelchuck, M., & Cho, H. (2001). Prevalence, persistence, and correlates of depressive symptoms in a national sample of mothers of toddlers. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1316–1323. McLoyd, V. C. (1998). Socioeconomic disadvantage and child development. American Psychologist, 53, 185– 204. McMahon, R. J., & Estes, A. M. (1997). Conduct problems. In E. J. Mash & L. G. Terdal (Eds.), Assessment of childhood disorders (3rd ed., pp. 130–193). New York: Guilford Press. McMahon, R. J., Forehand, R., Griest, D. L., & Wells, K. C. (1981). Who drops out of therapy during behavioral training? Behavior Counseling Quarterly, 1, 79–85. McMahon, R. J., & Wells, K. C. (1998). Conduct problems. In E. J. Mash & R. A. Barkley (Eds.), Treatment of childhood disorders (2nd ed., pp. 111–207). New York: Guilford Press. McNally, S., Eisenberg, N., & Harris, J. D. (1991). Consistency and change in maternal child-rearing practices and values: A longitudinal study. Child Development, 62, 190–198. McNeil, C. B. (1995). The ADHD Classroom Kit: An inclusive approach to behavior management. King of Prussia, PA: Center for Applied Psychology. (Available by calling 1-800-962-1141).

586

References

McReynolds, M. T. (1972). A procedure for the withdrawal of an infant oral pacifier. Journal of Applied Behavior Analysis, 5, 65–66. Meadows, A. T., & Hobbie, W. L. (1986). The medical consequences of cure. Cancer, 58, 524–528. Meichenbaum, D. (1977). Cognitive-behavior modification. New York: Plenum Press. Melamed, B. G. (1998). Preparation for medical procedures. In R. T. Ammerman & J. V. Campo (Eds.), Handbook of pediatric psychology and psychiatry: Vol. 2. Disease, injury, and illness (pp. 16–30). Boston: Allyn & Bacon. Meller, W. H., & Borchardt, C. M. (1996). Comorbidity of major depression and conduct disorder. Journal of Affective Disorders, 39, 123–126. Mellman, T. A., & Uhde, T. W. (1989). Sleep panic attacks: New clinical findings and theoretical implications. American Journal of Psychiatry, 146, 1204–1207. Mellon, M. W., & Houts, A. C. (1995). Elimination disorders. In R. T. Ammerman & M. Hersen (Eds.), Handbook of child behavior therapy in the psychiatric setting (pp. 341–366). New York, Wiley. Mellon, M. W., & Houts, A. C. (1998). Home-based treatment for primary enuresis. In J. M. Briesmeister & C. E. Schaefer (Eds.), Handbook of parent training: Parents as co-therapists for children’s behavior problems (2nd ed., pp. 384–417). New York: Wiley. Mellon, M. W., & McGrath, M. L. (2000). Empirically supported treatments in pediatric psychology: Nocturnal enuresis. Journal of Pediatric Psychology, 25, 193–214. Mellonie, B., & Ingpen, R. (1987). Lifetimes: The beautiful way to explain death to children. New York: Bantam Doubleday Dell. Melton, G. B., Petrila, J., Poythress, N. G., & Slobogin, C. (1997). Psychological evaluations for the courts (2nd ed.). New York: Guilford Press. Mendelson, M. J., Gottlieb, L. N., & Paratta, M. (1995). Parental involvement with first born girls before and after a sibling’s birth. Canadian Journal of Research in Early Childhood Education, 4, 10–15. Mendlowitz, S. L., Manassis, K., Bradley, S., Scapillato, D., Miezitis, S., & Shaw, B. F. (1999). Cognitivebehavioral group treatments in childhood anxiety disorders: The role of parental involvement. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1223–1229. Menella, J., & Beauchamp, G. (1996). The early development of human flavor preferences. In E. Capaldi (Ed.), Why we eat what we eat: The psychology of eating (pp. 83–112). Washington, DC: American Psychological Association. Menendez-Aponte, E. (1999). When Mom and Dad divorce: A kid’s resource. St. Meinrad, IN: Abbey Press. Menzies, R. G., & Clarke, J. C. (1993). A comparison of in vivo and vicarious exposure in the treatment of childhood water phobia. Behaviour Research and Therapy, 31, 9–15. Merrell, K. W., & Walters, A. S. (1998). Internalizing Symptoms Scale for Children. Austin, TX: Pro-Ed. Mesibov, G. B., Schroeder, C. S., & Wesson, L. (1977). Parental concerns about their children. Journal of Pediatric Psychology, 2, 13–17. Mesman, J., & Koot, H. M. (2000a). Child-reported depression and anxiety in preadolescence: II. Preschool predictors. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1379–1386. Mesman, J., & Koot, H. M. (2000b). Child-reported depression and anxiety in preadolescence: I. Associations with parent- and teacher-reported problems. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1371–1378. Messer, S. G., & Beidel, D. C. (1994). Psychosocial correlates of childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 975–983. Meyer-Bahlburg, H. F. L. (1985). Gender identity disorder of childhood. Journal of the American Academy of Child Psychiatry, 24, 681–683. Meyer-Bahlburg, H. F. L., Ehrhardt, A. A., Bell, J. J., Cohen, S. F., Healey, J. M., Feldman, J. F., Morishima, A., Baker, S. W., & New, M. I. (1985). Gender identity disorder of childhood: Introduction. Journal of the American Academy of Child Psychiatry, 24, 681–683. Michael, K. D., & Merrell, K. W. (1998). Reliability of children’s self-reported internalizing symptoms over short to medium-length time intervals. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 194–201. Mikkelsen, E. J. (2001). Enuresis and encopresis: Ten years of progress. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1146–1150. Milberger, S., Biederman, J., Faraone, S. V., Chen, L., & Jones, J. (1996). Is maternal smoking during pregnancy a risk factor for attention deficit hyperactivity disorder in children? American Journal of Psychiatry, 153, 1138–1142. Milberger, S., Biederman, J., Faraone, S. V., Chen, L., & Jones, J. (1997). Attention deficit hyperactivity disorder is associated with early initiation of cigarette smoking in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 37–44.

References

587

Milich, R., Loney, J., & Landau, S. (1982). The independent dimensions of hyperactivity and aggression: A validation with playroom observations. Journal of Abnormal Psychology, 91, 183–198. Miller, L. C. (1983). Fears and anxiety in children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (pp. 337–380). New York: Wiley–Interscience. Miller, P. M. (1973). An experimental analysis of retention control training in the treatment of nocturnal enuresis in two institutionalized adolescents. Behavior Therapy, 4, 288–294. Miller-Perrin, C. L., & Wurtele, S. K. (1988). The child sexual abuse prevention movement: A critical analysis of primary and secondary approaches. Clinical Psychology Review, 8, 313–329. Milling, L. S. (2001). Depression in preadolescents. In C. E. Walker & M. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 373–392). New York: Wiley. Miltenberger, R. G., & Fuqua, R. W. (1985). A comparison of contingent versus non-contingent competing response practice in the treatment of nervous habits. Journal of Behavior Therapy and Experimental Psychiatry, 16, 195–200. Minde, K., Faucon, A., & Falkner, S. (1994). Sleep problems in toddlers: Effects of treatment on their daytime behavior. Journal of the American Academy of Child and Adolescent Psychology, 33, 1114–1121. Mindell, J. A. (1997). Sleeping through the night: How infants, toddlers, and their parents can get a good night’s sleep. New York: HarperCollins. Mindell, J. A. (1999). Empirically supported treatments in pediatric psychology: Bedtime refusal and night wakings in young children. Journal of Pediatric Psychology, 24, 465–481. Mindell, J. A., & Dahl, R. E. (1998). Sleep. In R. T. Ammerman & J. V. Campo (Eds.), Handbook of pediatric psychology and psychiatry: Vol. 1: Psychological and psychiatric issues in the pediatric setting (pp. 162– 181). Needham Heights, MA: Allyn & Bacon. Mindell, J. A., & Durand, V. M. (1993). Treatment of childhood sleep disorders: Generalization across disorders and effects on family members. Journal of Pediatric Psychology, 18, 731–750. Mitsis, E. M., McKay, K. E., Schulz, K. P., Newcorn, J. H., & Halperin, J. M. (2000). Parent–teacher concordance for DSM-IV attention-deficit/hyperactivity disorder in a clinic-referred sample. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 308–313. Moffatt, M. E. K. (1989). Nocturnal enuresis: Psychologic implications of treatment and nontreatment. Journal of Pediatrics, 114, 697–704. Moffitt, T. E. (1993). Adolescence-limited and life-course-persistent antisocial behavior: A developmental taxonomy. Psychological Review, 100, 674–701. Moffitt, T. E., Caspi, A., Dickson, N., Silva, P., & Stanton, W. (1996). Childhood-onset versus adolescentonset antisocial conduct problems in males: Natural history from ages 3 to 18 years. Development and Psychopathology, 8, 399–424. Money, J. (1994). Sex errors of the body and related syndromes: A guide to counseling children, adolescents, and their families (2nd ed.). Baltimore: Paul Brooks. Money, J., Devore, H., & Norman, B. F. (1986). Gender identity and gender transposition: Longitudinal study of 32 male hermaphrodites assigned as girls. Journal of Sex and Marital Therapy, 12, 165–181. Money, J., & Ehrhardt, A. A. (1972). Man and woman, boy and girl: The differentiation and dimorphism of gender identity from conception to maturity. Baltimore: Johns Hopkins Press. Money, J., & Norman, B. F. (1987). Gender identity and gender transposition: Longitudinal outcome study of 24 male hermaphrodites assigned as boys. Journal of Sex and Marital Therapy, 13, 75–92. Money, J., & Russo, A. J. (1979). Homosexual outcome of discordant gender identity/role in childhood. Journal of Pediatric Psychology, 4, 29–41. Moore, E., Armsden, G., & Gogerty, P. L. (1998). A twelve-year follow-up study of maltreated and at-risk children who received early therapeutic care. Child Maltreatment, 3, 3–16. Moore, R., & Ucko, C. (1957). Night waking in early infancy: Part I. Archives of Disease in Childhood, 33, 333–342. Morganstern, K. P. (1988). Behavioral interviewing. In A. S. Bellack & M. Hersen (Eds.), Behavioral assessment: A practical handbook (pp. 86–118). Elmsford, NY: Pergamon Press. Morrison, D. R., & Coiro, M. J. (1999). Parental conflict and marital disruption: Do children benefit when high-conflict marriages are dissolved? Journal of Marriage and the Family, 61, 626–637. Morrissey-Kane, E., & Prinz, R. J. (1999). Engagement in child and adolescent treatment: The role of parental cognitions and attributions. Clinical Child and Family Psychology Review, 2, 183–198. Mowrer, O. H., & Mowrer, W. M. (1938). Enuresis: A method for its study and treatment. American Journal of Orthopsychiatry, 8, 436–459. Mrazek, D., Garrison, W., & Elliott, L. (1993). A to Z guide to your child’s behavior: A parent’s easy and authoritative reference to hundreds of everyday problems and concerns from birth through 12 years. New York: Perigee Books.

588

References

MTA Cooperative Group. (1999). A 14–month randomized clinical trial of treatment strategies for attentiondeficit/hyperactivity disorder: The MTA Cooperative Group multimodal treatment study of children with ADHD. Archives of General Psychiatry, 56, 1073–1086. Mufson, L., Weissman, M. M., & Warner, V. (1992). Depression and anxiety in parents and children: A direct interview study. Journal of Anxiety Disorders, 6, 1–13. Mulhern, R. K., Wasserman, A. L., Friedman, A. G., & Fairclough, D. (1989). Social competence and behavioral adjustment of children who are long-term survivors of cancer. Pediatrics, 83, 18–25. Muller, R. T., Hunter, J. E., & Stollak, G. (1995). The intergenerational transmission of corporal punishment: A comparison of social learning and temperament models. Child Abuse and Neglect, 19, 1323–1335. Muris, P., Meesters, C., Merkelbach, H., Sermon, A., & Zwakhalen, S. (1998). Worry in normal children. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 703–710. Muris, P., Merckelbach, H., Gadet, B., & Moulaert, V. (2000). Fears, worries, and scary dreams in 4- to 12year-old children: Their content, developmental pattern, and origins. Journal of Clinical Child Psychology, 29, 43–52. Muris, P., Merckelbach, H., Korver, P., & Meesters, C. (2000). Screening the trauma in children and adolescents: The validity of the Traumatic Stress Disorder scale of the Screen for Child Anxiety Related Emotional Disorders. Journal of Clinical Child Psychology, 29, 406–413. Murphy, D. A., Marelich, W. D., & Hoffman, D. (2000). Assessment of anxiety and depression in young children: Support for two separate constructs. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 383–391. Murphy, K. R., & Barkley, R. A. (1996). Parents of children with attention-deficit/hyperactivity disorder: Psychological and attention impairment. American Journal of Orthopsychiatry, 66, 93–102. Murrin, M. R., & Laws, D. R. (1990). The influence of pornography on sexual crimes. In W. L. Marshall, D. R. Laws, & H. H. Barbaree (Eds.), Handbook of sexual assault: Issues, theories, and treatment of the offender (pp. 73–91). New York: Plenum. Musten, L. M., Firestone, P., Pisterman, S., Bennett, S., & Mercer, J. (1997). Effects of methylphenidate on preschool children with ADHD: Cognitive and behavioral functions. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1407–1415. Myers, M. D., Raynor, H., & Epstein, L. (1998). Predictors of child psychological changes during family-based treatment for obesity. Archives of Pediatric and Adolescent Medicine, 152, 855–861. Myers, W. C., Scott, K., Burgess, A. W., & Burgess, A. C. (1995). Psychopathology, biopsychosocial factors, crime characteristics and classification of 25 homicidal youths. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1483–1489. Nader, K. O. (1996). Children’s exposure to traumatic experiences. In C. A. Corr & D. M. Corr (Eds.), Handbook of childhood death and bereavement (pp. 201–220). New York: Springer. National Center for Health Statistics. (1992). Annual summary of births, marriages, divorces, and deaths: United States, 1991. Monthly Vital Statistics Report, 40(13). National Center for Health Statistics. (1995). Births, marriages, divorces, and deaths for April 1995. Monthly Vital Statistics Report, 44(4). National Center for Injury Prevention and Control. (1999). Child injury fact sheet [On-line]. Available: http: //www.cdc.gov/ncipc/factsheets/childh.htm. National Institutes of Health (NIH). (2000). National Institutes of Health consensus development conference statement: Diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD). Journal of the American Academy of Child and Adolescent Psychiatry, 39, 182–193. Nelson, J. A. (1981). The impact of incest: Factors in self-evaluation. In L. L. Constantine & F. M. Martinson (Eds.), Children and sex: New findings, new perspectives (pp. 163–174). Boston: Little, Brown. Neumann, D. A., Houskamp, B. M., Pollock, V. E., & Briere, J. (1996). The long-term sequelae of childhood sexual abuse in women: A meta-analytic review. Child Maltreatment, 1, 6–16. Newcorn, J. H., & Halperin, J. M. (1994). Comorbidity among disruptive behaviour disorders: Impact on severity, impairment, and response to treatment. Child and Adolescent Psychiatric Clinics of North America, 3, 227–252. Newcorn, J. H., Halperin, J. M., Jensen, P. S., Abikoff, H. B., Arnold, L. E., Cantwell, D. P., Conners, C. K., Elliott, G. R., Epstein, J. N., Greenhill, L. L., Hechtman, L., Hinshaw, S. P., Hoza, B., Kraemer, H. C., Pelham, W. E., Severe, J. B., Swanson, J. M., Wells, K. C., Wigal, T., & Vitiello, B. (2001). Symptom profiles in children with ADHD. Effects of comorbidity and gender. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 137–146. Newman, J. (1996). The more the merrier? Effects of family size and sibling spacing on sibling relationships. Child: Care, Health and Development, 22, 285–302.

References

589

Nicholson, J. M., Fergusson, D. M., & Horwood, J. L. (1999). Effects on later adjustment of living in a stepfamily during childhood and adolescence. Journal of Child Psychology and Psychiatry, 40, 405–416. Nolan, E. E., & Gadow, K. D. (1997). Children with ADHD and tic disorder and their classmates: Behavioral normalization with methylphenidate. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 597–604. Nolan, E. F., Gadow, K. D., & Sprafkin, J. (2001). Teacher reports of DSM-IV ADHD, ODD, and CD symptoms in school children. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 241–249. Nolan, E. E., Sverd, J., Gadow, K. D., Sprafkin, J., & Ezor, S. N. (1996). Associated psychopathology in children with both ADHA and chronic tic disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1622–1630. Nolen-Hoeksema, S., Girgus, J. S., & Seligman, M. E. P. (1992). Predictors and consequences of childhood depressive symptoms: A 5-year longitudinal study. Journal of Abnormal Psychology, 101, 405–422. Nolen-Hoeksema, S., Wolfson, A., Mumme, D., & Guskin, K. (1995). Helplessness in children of depressed and nondepressed mothers. Developmental Psychology, 31, 377–387. Norgaard, J. R., & Djurhuus, J. C. (1993). The pathophysiology of enuresis in children and young adults. Clinical Pediatrics, 34(5–9). Norgaard, J. R., Rittig, S., & Djurhuus, J. C. (1989). Nocturnal enuresis: An approach to treatment based on pathogenesis. Journal of Pediatrics, 114, 705–710. Nottelmann, E. D., & Jensen, P. S. (1995). Comorbidity of disorders in children and adolescents: Developmental perspectives. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 17, pp. 109–151). New York: Plenum Press. Nowicki, S., Jr., & Strickland, B. R. (1973). A locus of control scale for children. Journal of Consulting and Clinical Psychology, 40, 148–154. Oates, R. K., O’Toole, B. I., Lynch, D. L., Stern, A., & Cooney, C. (1994). Stability and change in outcomes for sexually abused children. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 945–953. Odom, S. I., & Kaiser, A. P. (1997). Prevention and early intervention during early childhood: Theoretical and empirical bases for practice. In W. E. McLean, Jr. (Ed.), Ellis’ handbook of mental deficiency, psychological theory, and research (pp. 137–172). Hillsdale, NJ: Erlbaum. O’Donnell, D., Biederman, J., Jones, J., Wilens, T. E., Milberger, S., Mick, E., & Faraone, S. V. (1998). Informativeness of child and parent reports on substance use disorders in a sample of ADHD probands, control probands, and their siblings. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 752–758. O’Donohue, W. T., & Elliott, A. N. (1992). Treatment of the sexually abused child: A review. Journal of Clinical Child Psychology, 21, 218–228. Offord, D. R., Boyle, M. H., Racine, Y., Szatmari, P., Fleming, J. E., Sanford, M., & Lipman, E. L. (1996). Integrating assessment data from multiple informants. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 1078–1085. Offord, D. R., Boyle, M. H., Szatmari, P., Rai-Grant, N. L., Links, P. S., Cadman, D. T., Byles, J. A., Crawford, J. W., Blum, H. M., Byrne, C., Thomas, H., & Woodward, C. A. (1987). Ontario Child Health Study: II. Six-month prevalence of disorder and rates of service utilization. Archives of General Psychiatry, 44, 832–836. Offord, D. R., Kremner, H. C., Kazdin, A. E., Jensen, P. S., & Harrington, R. (1998). Lowering the burden of suffering from child psychiatric disorder: Trade-offs among clinical, targeted, and universal interventions. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 686–694. O’Grady, D., & Metz, J. R. (1987). Resilience in children at high risk for psychological disorder. Journal of Pediatric Psychology, 12, 3–23. Olatawura, M. O. (1973). Encopresis: A review of thirty-two cases. Acta Paediatrica Scandinavica, 62, 358–364. Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse intervention. Pediatrics, 78, 65–78. Ollenburg, C. M., & Kerns, K. A. (1997). Associations between peer relationships and depressive symptoms: Testing moderator effects of gender and age. Journal of Early Adolescence, 17, 319–337. Ollendick, T. H. (1979). Fear reduction techniques with children. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 8, pp. 127–168). New York: Academic Press. Ollendick, T. H. (1983). Reliability and validity of the Revised Fear Survey Schedule for Children (FSSC-R). Behaviour Research and Therapy, 21, 685–691. Ollendick, T. H., & Francis, G. (1988). Behavioral assessment and treatment of childhood phobias. Behavior Modification, 12, 165–204.

590

References

Ollendick, T. H., & King, N. J. (1991). Developmental factors in child behavior assessment. In P. Martin (Ed.), Handbook of behavior therapy and psychological science: An integrative approach (pp. 57–72). Elmsford, NY: Pergamon Press. Ollendick, T. H., & King, N. J. (1994). Fears and their level of interference in adolescents. Behaviour Research and Therapy, 32, 635–638. Ollendick, T. H., & King, N. J. (1998). Empirically supported treatments for children with phobic and anxiety disorders: Current status. Journal of Clinical Child Psychology, 27, 156–167. Ollendick, T. H., King, H. J., & Frary, R. D. (1989). Fears in children and adolescents: Reliability and generalizability across gender, age, and nationality. Behaviour Research and Therapy, 27, 19–26. Ollendick, T. H., & Russ, S. W. (1999). Psychotherapy with children and families: Historical traditions and current trends. In S. W. Russ & T. H. Ollendick (Eds.), Handbook of psychotherapies with children and adolescents (pp. 3–15). New York: Kluwer/Plenum. Ollendick, T. H., Yang, B., King, N. J., Dong, Q., & Akande, A. (1996). Fears in American, Australian, Chinese, and Nigerian children and adolescents: A cross-cultural study. Journal of Child Psychology and Psychiatry, 37, 213–230. Olson, R. L., & Roberts, M. W. (1987). Alternative treatments for sibling aggression. Behavior Therapy, 18, 243–250. Oltmanns, T. G., Broderick, J. E., & O’Leary, K. D. (1977). Marital adjustment and the efficacy of behavior therapy with children. Journal of Consulting and Clinical Psychology, 45, 724–729. Oppel, W. C., Harper, P. A., & Rider, R. V. (1968). Social, psychological, and neurological factors associated with nocturnal enuresis. Pediatrics, 42, 627–641. Orlebeke, J. F., Knol, D. L., & Boomsma, D. I. (1998). Frequency of parental report of problem behavior in children decreases with increasing maternal age at delivery. Psychological Reports, 82, 395–404. Orton, G. L. (1982). Comparative study of children’s worries. Journal of Psychology, 110, 153–162. O’Sullivan, R. L., Rauch, S. L., Breiter, H. C., Grachev, I. D., Baer, L., Kennedy, D. N., Keuthen, N. J., Savage, C. R., Manzo, P. A., Caviness, V. S., & Jenike, M. A. (1997). Reduced basal ganglia volumes in trichotillomania measured via morphometric magnetic resonance imaging. Biological Psychiatry, 42, 39–45. Ottaviano, A., Giannotti, F., Cortesi, F., Bruni, O., & Ottaviano, C. (1996). Sleep characteristics in healthy children from birth to 6 years of age in the urban area of Rome. Sleep, 19, 1–3. Ounstead, M. K., & Hendrick, A. M. (1977). The first-born child: Patterns of development. Developmental Medicine and Child Neurology, 19, 446–453. Owen, L. G., & Fliegelman, M. T. (1978). Diseases of the hair and scalp. In S. S. Gellis & B. K. Kagan (Eds.), Current pediatric therapy (Vol. 1, pp. 504–506). Philadelphia: Saunders. Owens, E. B., Shaw, D. S., Giovannelli, J., Garcia, M. M., & Yaggi, K. (1999). Factors associated with behavioral competence at school among young boys from multi-problem low-income families. Early Education and Development, 10, 135–162. Owens-Stively, J. A. (1987). Self-esteem and compliance in encopretic children. Child Psychiatry and Human Development, 18, 13–21. Pagani, L., Tremblay, R. E., Vitaro, F., Kerr, M., & McDuff, P. (1998). The impact of family transition on the development of delinquency in adolescent boys: A nine year longitudinal study. Journal of Child Psychology and Psychiatry, 39, 489–499. Pagani-Kurtz, L., & Deverensky, J. L. (1997). Access by noncustodial parents: Effects upon children’s postdivorce coping resources. Journal of Divorce and Remarriage, 27, 43–55. Paikoff, R. L., & Brooks-Gunn, J. (1991). Do parent–child relationships change during puberty? Psychological Bulletin, 110, 47–66. Palisin, H. (1986). Preschool temperament and performance on achievement tests. Developmental Psychology, 22, 766–770. Palmer, P. (1977a). Liking myself. San Luis Obispo, CA: Impact. Palmer, P. (1977b). The mouse, the monster, and me. San Luis Obispo, CA: Impact. Panaccione, V. F., & Wahler, R. G. (1986). Child behavior, maternal depression, and social coercion as factors in quality of child care. Journal of Abnormal Child Psychology, 14, 263–278. Paregja, J. A., de Pablos, E., Caminero, A. B., Millan, I., & Dobato, J. L. (1999). Native language shifts across sleep–wake states in bilingual sleeptalkers. Sleep, 22, 243–247. Park, K. A., & Waters, E. (1989). Security of attachment and preschool friendships. Child Development, 60, 1076–1081. Parker, H., & Parker, S. (1986). Father-daughter sexual abuse: An emerging perspective. American Journal of Orthopsychiatry, 56, 531–549. Parker, J. G., & Asher, S. R. (1987). Peer relations and later personal adjustment: Are low-accepted children at risk? Psychological Bulletin, 102, 357–389.

References

591

Parker-Cohen, N. Y., & Bell, R. Q. (1988). The relationship between temperament and social adjustment to peers. Early Childhood Research Quarterly, 3, 179–192. Parmeggiani, P. L. (1994). The autonomic nervous system in sleep. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (pp. 194–203) Philadelphia: Saunders. Parpal, M., & Maccoby, E. (1985). Maternal responsiveness and subsequent child compliance. Child Development, 56, 1326–1334. Paschalis, A. P., Kimmel, H. D., & Kimmel, E. (1972). Further study of diurnal instrumental conditioning in the treatment of enuresis nocturna. Journal of Behavior Therapy and Experimental Psychiatry, 3, 253– 256. Paternite, C., Loney, J., & Roberts, M. (1995). External validation of oppositional disorder and attention deficit disorder with hyperactivity. Journal of Abnormal Child Psychology, 23, 453–471. Patterson, C. J. (1992). Children of lesbian and gay parents. Child Development, 63, 1025–1042. Patterson, C. J. (1995). Families of the lesbian baby boom: Parents’ division of labor and children’s adjustment. Developmental Psychology, 31, 115–123. Patterson, C. J. (1997). Children of lesbian and gay parents. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 19, pp. 235–282). New York: Plenum Press. Patterson, G. R. (1975). Professional guide for “Families” and “Living with children.” Champaign, IL: Research Press. Patterson, G. R. (1976a). The aggressive child: Victim and architect of a coercive system. In E. J. Mash, L. A. Hamerlynck, & L. C. Handy (Eds.), Behavior modification and families (pp. 267–316). New York: Brunner/Mazel. Patterson, G. R. (1976b). Living with children: New methods for parents and teachers (rev. ed.). Champaign, IL: Research Press. Patterson, G. R. (1980). Mothers: The unacknowledged victims. Monographs of the Society for Research in Child Development, 45(5, Serial No. 186). Patterson, G. R. (1982). Coercive family process. Eugene, OR: Castalia. Patterson, G. R. (1986). Performance models for antisocial boys. American Psychologist, 41, 432– 444. Patterson, G. R., Capaldi, D., & Bank, L. (1991). An early starter model for predicting delinquency. In D. Pepler & R. K. Rubin (Eds.), The development and treatment of childhood aggression (pp. 139–168). Hillsdale, NJ: Erlbaum. Patterson, G. R., DeBaryshe, B. D., & Ramsey, E. (1989). A developmental perspective on antisocial behavior. American Psychologist, 44, 329–335. Patterson, G. R., Reid, J. B., & Dishion, T. J. (1992). Antisocial boys. Eugene, OR: Castalia. Patterson, G. R., Reid, J. B., Jones, R. R., & Conger, R. E. (1975). A social learning approach to family intervention: Vol. 1. Families with aggressive children. Eugene, OR: Castalia. Pauls, D. L., Hurst, C. R., Kruger, S. D., Leckman, J. F., Kidd, K. K., & Cohen, D. J. (1986). Gilles de la Tourette’s syndrome and attention deficit disorder with hyperactivity. Archives of General Psychiatry, 43, 1177–1179. Pauls, D. L., & Leckman, J. F. (1986). The inheritance of Gilles de la Tourette syndrome and associated behaviors. New England Journal of Medicine, 315, 993–997. Pedro-Carroll, J. L., & Alpert-Gillis, L. J. (1997). Preventive interventions for children of divorce: A developmental model for 5 and 6 year old children. Journal of Primary Prevention, 18, 5–23. Pedro-Carroll, J. L., & Cowen, E. L. (1985). The Children of Divorce Intervention Program: An investigation of the efficacy of a school-based prevention program. Journal of Consulting and Clinical Psychology, 53, 603–611. Pedro-Carroll, J. L., Cowen, E. L., Hightower, A. D., & Guare, J. E. (1986). Preventive intervention with latency-aged children of divorce: A replication study. American Journal of Community Psychology, 14, 277–289. Pedro-Carroll, J. L., Sutton, S. E., & Wyman, P. A. (1999). A two-year follow-up evaluation of a preventive intervention for young children of divorce. School Psychology Review, 28, 467–476. Pelham, W. E. (1999). President’s message: The NIMH Multimodal Treatment Study for ADHD. Just say yes to drugs? Clinical Child Psychology Newsletter, 14, 1–10. Pelham, W. E., & Hinshaw, S. P. (1992). Behavioral intervention for ADHD. In S. M. Turner, K. S. Calhoun, & H. E. Adams (Eds.), Handbook of clinical behavior therapy (2nd ed., pp. 259–283). New York: Wiley. Pelham, W. E., Carlson, C., Sams, S. E., Vallano, G., Dixon, M. J., & Hoza, B. (1993). Separate and combined effects of methylphenidate and behavior modification on the classroom behavior of ADHD boys: Group effects and individual differences. Journal of Consulting and Clinical Psychology, 61, 506– 515.

592

References

Pelham, W., Wheeler, T., & Chronis, A. (1998). Empirically supported psychosocial treatments for attention deficit hyperactivity disorder. Journal of Clinical Child Psychology, 27, 190–205. Pepler, D. J., & Craig, W. M. (1995). A peek behind the fence: Naturalistic observations of aggressive children with remote audiovisual recording. Developmental Psychology, 31, 548–553. Perlman, M., & Ross, H. S. (1997). The benefits of parent intervention in children’s disputes: An examination of concurrent changes in children’s fighting styles. Child Development, 68, 690–700. Perlmutter, D. (1985). Enuresis. In P. D. Kelalis, L. R. King, & A. B. Belman (Eds.), Clinical pediatric urology (2nd ed., pp. 311–325). Philadelphia: Saunders. Pescosolido, B. A. (1996). Bringing the “community” into utilization models: How social networks link individuals to changing systems of care. Research in the Sociology of Health Care, 13, 171–197. Peterson, A. L., & Azrin, N. H. (1993). Behavioral and pharmacological treatments for Tourette syndrome: A review. Applied and Preventive Psychology, 2, 2231–2242. Peterson, A. L., Campise, R. L., & Azrin, N. H. (1994). Behavioral and pharmacological treatment for tic and habit disorders: A review. Journal of Developmental and Behavioral Pediatrics, 15, 430–441. Peterson, B. S., Pine, D. S., Cohen, P., & Brook, J. S. (2001). Prospective, longitudinal study of tic, obsessivecompulsive, and attention-deficit/hyperactivity disorders in an epidemiological sample. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 685–695. Peterson, C., & Peterson, R. (1986). Parent–child interaction and day care: Does quality of day care matter? Journal of Applied Developmental Psychology, 7, 1–15. Peterson, L. (1989). Coping by children undergoing stressful medical procedures: Some conceptual, methodological, and therapeutic issues. Journal of Consulting and Clinical Psychology, 57, 380–387. Pett, M. A., Vaughan-Cole, B., & Wampold, B. E. (1994). Maternal employment and perceived stress: Their impact on children’s adjustment and mother–child interaction in young divorced and married families. Family Relations, 43, 151–158. Pett, M. A., Wampold, B. E., Turner, C. W., & Vaughan-Cole, B. (1999). Paths of influence of divorce on preschool children’s psychosocial adjustment. Journal of Family Psychology, 13, 145–164. Pettit, G. S., & Bates, J. E. (1989). Family interaction patterns and children’s behavior problems from infancy to 4 years. Developmental Psychology, 25, 413–420. Pettit, G. S., Dodge, K. A., & Brown, M. M. (1988). Early family experience, social problem solving patterns, and children’s social competence. Child Development, 59, 107–120. Petty, D. L. (1995). Sex education toward the prevention of sexual problems. In G. A. Rekers (Ed.), Handbook of child and adolescent sexual problems (pp. 31–54). New York: Lexington Books. Pfaundler, M. (1904). [Demonstration of an apparatus for automatic warning of the occurrence of bedwetting]. Verhandlungen der Gesellschaft für Kinderheilpundl, 21, 219–220. Pfeffer, C. R., Hurt, S. W., Kakuma, T., Peskin, J. R., Seifker, C. A., & Nagabhairava, S. (1994). Suicidal children grow up: Suicidal episodes and effects of treatment during follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 225–230. Pfeffer, C. R., Karus, D., Siegel, K., & Jiang, H. (2000). Child survivors of parental death from cancer or suicide: Depressive and behavioral outcomes. Psycho-Oncology, 9, 1–10. Pfeffer, C. R., Normandin, L., & Kakuma, T. (1994). Suicidal children grow up: Suicidal behavior and psychiatric disorders among relatives. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 1087–1097. Pfiffner, L. H., Jouriles, E. N., Brown, M. M., Etscheidt, M. A., & Kelly, J. A. (1990). Effects of problemsolving therapy on outcomes of parent training for single-parent families. Child and Family Behavior Therapy, 12, 1–12. Pfiffner, L. H., Rosen, L. A., & O’Leary, S. G. (1985). The efficacy of an all-positive approach to classroom management. Journal of Applied Behavioral Analysis, 18, 257–261. Phinney, J. S. (1985). The structure of 5-year-olds’ verbal quarrels with peers and siblings. Journal of Genetic Psychology, 147, 47–60. Piacentini, J. C., Cohen, P., & Cohen, J. (1992). Combining discrepant diagnostic information from multiple sources: Are complex algorithms better than simple ones? Journal of Abnormal Child Psychology, 20, 51–63. Pierce, C. M. (1971). Enuresis. In A. M. Friedman & H. I. Kaplan (Eds.), The child: His psychological and cultural development (Vol. 1, pp. 203–209). New York: Atheneum. Pierce, E. W., Ewing, L. J., & Campbell, S. B. (1999). Diagnostic status and symptomatic behavior of hardto-manage preschool children in middle childhood and early adolescence. Journal of Clinical Child Psychology, 28, 44–57. Piers, E. V. (1986). Piers-Harris self-concept scale: Revised manual. Los Angeles: Western Psychological Services.

References

593

Pirnstill, B. S. (1981). Replication and evaluation of the dry pants toilet training process. Unpublished master’s thesis, University of Kansas. Pisterman, S., Firestone, P., McGrath, P., Goodman, J., Webster, I., & Mallory, R. (1992). The role of parent training in the treatment of preschoolers with attention deficit disorder with hyperactivity. American Journal of Orthopsychiatry, 62, 397–408. Pisterman, S., McGrath, P., Firestone, P., & Goodman, J. T. (1989). Outcome of parent-mediated treatment of preschoolers with attention deficit disorder with hyperactivity. Journal of Consulting and Clinical Psychology, 57, 636–643. Pithers, W. D., & Gray, A. S. (1996). Utility of relapse prevention in treatment of sexual abusers. Sex Abuse, 8, 223–230. Pithers, W. D., Gray, A., Busconi, A., & Houchens, P. (1998). Children with sexual behavior problems: Identification of five distinct child types and related treatment considerations. Child Maltreatment, 3, 384–406. Pliszka, S. R. (1987). Tricyclic antidepressants in the treatment of children with attention deficit disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 127–132. Pliszka, S. R., Browne, R. G., Olvera, R. L., & Wynne, S. K. (2000). A double-blind, placebo-controlled study of Adderall and methylphenidate in the treatment of attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 619–626. Pliszka, S. R., Greenhill, L. L., Crismon, M. L., Sedillo, A., Carlson, C., Conners, C. K., McCracken, J. T., Swanson, J. M., Hughes, C. W., Llana, M. E., Lopez, M., Toprac, M. G., & the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. (2000a). The Texas Children’s Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part I. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 908–919. Pliszka, S. R., Greenhill, L. L., Crismon, M. L., Sedillo, A., Carlson, C., Conners, C. K., McCracken, J. T., Swanson, J. M., Hughes, C. W., Llana, M. E., Lopez, M., Toprac, M. G., & the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. (2000b). The Texas Children’s Algorithm Project: Report of the Texas Consensus Conference Panel on Medication Treatment of Childhood Attention-Deficit/Hyperactivity Disorder. Part II. Tactics. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 920–927. Plomin, R. (1989). Environment and genes: Determinants of behavior. American Psychologist, 44, 105–111. Podolski, C., & Nigg, J. T. (2001). Parent stress and coping in relation to child ADHD severity and associated child disruptive behavior problems. Journal of Clinical Child Psychology, 30, 503–513. Podorefsky, D. L., McDonald-Dowdell, M., & Beardslee, W. R. (2001). Adaptation of preventive interventions for a low-income, culturally diverse community. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 879–886. Pollock, J. I. (1994). Night-waking at five years of age: Predictors and prognosis. Journal of Child Psychology and Psychiatry, 35, 699–708. Pope, A. W., & Bierman, K. L. (1999). Predicting adolescent peer problems and antisocial activities: The relative roles of aggression and dysregulation. Developmental Psychology, 35, 235–246. Pope, A. W., McHale, S. M., & Craighead, W. E. (1988). Self-esteem enhancement with children and adolescents. Elmsford, NY: Pergamon Press. Power, T. J., Costigan, T. E., Leff, S. S., Eiraldi, R. B., & Landau, S. (2001). Assessing ADHD across settings: Contributions of behavioral assessment to categorical decision making. Journal of Clinical Child Psychology, 30, 399–412. Price, R. H., Cowen, E. L., Lorion, R. P., & Ramos-McKay, J. (1989). The search for effective prevention programs: What we learned along the way. American Journal of Orthopsychiatry, 59, 49–58. Prinz, R. J., & Miller, G. E. (1994). Family-based treatment for childhood antisocial behavior: Experimental influences on dropout and engagement. Journal of Clinical and Consulting Psychology, 62, 645–650. Prochaska, J. M., & Prochaska, J. O. (1985). Children’s views of the causes and “cures” of sibling rivalry. Child Welfare, 64, 427–433. Pruett, K. D., & Pruett, M. K. (1999). “Only God decides”: Young children’s perception of divorce and the legal system. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1544–1550. Pruitt, D. B. (1998). Your child. New York: HarperCollins. Psychological Corporation. (1998). The Wechsler Abbreviated Scale of Intelligence. San Antonio, TX: Author. Putallaz, M. (1987). Maternal behavior and children’s sociometric status. Child Development, 58, 324–340. Quattrin, R., Aronica, S., & Mazur, T. (1990). Management of male pseudohermaphroditism: A case report spanning twenty-one years. Journal of Pediatric Psychology, 15, 699–709. Quay, H. C. (1997). Inhibition and attention deficit hyperactivity disorder. Journal of Abnormal Child Psychology, 25, 7–13.

594

References

Querido, J. G., Bearss, K., & Eyberg, S. M. (2002). Theory, research and practice of parent–child interaction therapy. In T. Patterson & F. Kaslow (Eds.), Comprehensive handbook of psychotherapy: Vol. 2. Cognitive-behavioral approaches. New York: Wiley. Querido, J. G., Eyberg, S. M., & Boggs, S. R. (2001). Revisiting the accuracy hypothesis in families of young children with conduct problems. Journal of Clinical Child Psychology, 30, 253–261. Querido, J. G., Eyberg, S. M., Kanfer, R., & Krahn, G. (2001). The process of the clinical child assessment interview. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 75– 89). New York: Wiley. Raadal, M., Milgrom, P., Cauce, A. M., & Mancl, L. (1994). Behavior problems in 5- to 11-year-old children from low-income families. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 1017–1025. Rabasca, L. (2000, November). APA participates in White House meeting that questions psychotropic drug use among preschoolers. Monitor on Psychology, 31(10), 48–49. Rabiner, D., Coie, J. D., & the Conduct Problems Prevention Research Group. (2000). Early attention problems and children’s reading achievement: A longitudinal investigation. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 859–867. Rachman, S. J. (1977). The conditioning theory of fear acquisition: A critical examination. Behaviour Research and Therapy, 15, 375–387. Ragan, P. W., & McGlashan, T. H. (1986). Childhood parental death and adult psychopathology. American Journal of Psychiatry, 143, 153–157. Ramey, C. T., & Campbell, F. A. (1984). Preventive education for high risk children: Cognitive consequences of the Carolina Abecedarian Project. American Journal of Mental Deficiency, 88, 515–523. Ramey, C. T., & Ramey, S. L. (1992). Early educational intervention with disadvantaged children—to what effect? Applied and Preventive Psychology, 1, 131–140. Ramey, C. T., & Ramey, S. L. (1998). Early intervention and early experience. American Psychologist, 53, 109–120. Rand, C., Graham, D. L. R., & Rawlings, E. I. (1982). Psychological health and factors the court seeks to control in lesbian mother custody trials. Journal of Homosexuality, 8, 27–39. Rando, T. A. (1984). Grief, dying and death: Clinical interventions for caregivers. Champaign, IL: Research Press. Raphael, B., & Martinek, N. (1997). Assessing traumatic bereavement and posttraumatic stress disorder. In J. P. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 337–395). New York: Guilford Press. Rapin, I. (1996). Practitioner review: Developmental language: A clinical update. Journal of Child Psychology and Psychiatry, 37, 643–655. Rappaport, N., & Chubinsky, P. (2000). The meaning of psychotropic medications for children, adolescents, and their families. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1198–1200. Rapport, M. D. (1998). Attention-deficit/hyperactivity disorder. In V. B. Van Hasselt & M. Hersen (Eds.), Handbook of psychological treatment protocols for children and adolescents (pp. 65–107). Hillsdale, NJ: Erlbaum. Rapport, M. D., Chung, K., Shore, G., & Isaacs, P. (2001). A conceptual model of child psychopathology: Implications for understanding attention deficit hyperactivity disorder and treatment efficacy. Journal of Clinical Child Psychology, 30, 48–58. Rapport, M. D., & Denney, C. B. (1997). Titrating methylphenidate in children with attention-deficit/hyperactivity disorder: Is body mass predictive of clinical response? Journal of the American Academy of Child and Adolescent Psychiatry, 36, 523–530. Rapport, M. D., Chung, K., Shore, G., Denney, C. B., & Isaacs, P. (2000). Upgrading the science and technology of assessment and diagnosis: Laboratory and clinic-based assessment of children with ADHD. Journal of Clinical Child Psychology, 29, 555–568. Rapport, M. D., Denney, C., DuPaul, G. J., & Gardner, M. J. (1994). Attention deficit disorder and methylphenidate: Normalization rates, clinical effectiveness, and response prediction in 76 children. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 882–893. Rapport, M. D., Murphy, A., & Bailey, J. S. (1982). Ritalin vs. response cost in the control of hyperactive children: A within subject comparison. Journal of Applied Behavior Analysis, 15, 205–216. Rauh, J. L., & Schumsky, D. A. (1969). Relative accuracy of visual assessment of juvenile obesity. Journal of the American Dietetic Association, 55, 459–464. Raveis, V. H., Siegel, K., & Karus, D. (1999). Children’s psychological distress following the death of a parent. Journal of Youth and Adolescence, 28, 165–180.

References

595

Rayfield, A., Monaco, L., & Eyberg, S. M. (1999). Parent–child interaction therapy with oppositional children: Review and clinical strategies. In S. W. Russ & T. H. Ollendick (Eds.), Handbook of psychotherapies with children and families (pp. 327–343). New York: Kluwer/Plenum. Readett, D. R. J., Morris, J., & Sergeant, G. R. (1990). Determinants of nocturnal enuresis in sickle cell disease. Archives of Disease in Childhood, 65, 615–618. Reding, G. R., Rubright, W. C., & Zimmerman, S. O. (1966). Incidence of bruxism. Journal of Dental Research, 45, 1198–1204. Reding, G. R., Zepelin, H., Robinson, J. E., Zimmerman, S. O., & Smith, V. H. (1968). Nocturnal teeth grinding: All-night psychophysiologic studies. Journal of Dental Research, 47, 786–797. Reeves, E. A., Bernstein, G. A., & Christenson, G. A. (1992). Clinical characteristics and psychiatric comorbidity in children with trichotillomania. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 132–138. Reilly, T. P., Hasazi, J. E., & Bond, L. A. (1983). Children’s conceptions of death and personal mortality. Journal of Pediatric Psychology, 8, 21–31. Reinecke, M. A., Beebe, D. W., & Stein, M. A. (1999). The third factor of the WISC-III: It’s (probably) not Freedom from Distractibility. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 322–328. Rekers, G. A. (1991). Development of problems of puberty and sex roles in adolescence. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (2nd ed., pp. 607–622). New York: Wiley. Rekers, G. A., & Kilgus, M. D. (1995). Differential diagnosis and rationale for treatment of gender identity disorders and transvestitism. In G. A. Rekers (Ed.), Handbook of child and adolescent sexual problems (pp. 225–289). New York: Lexington Books. Rekers, G. A., Kilgus, M. D., & Rosen, A. C. (1990). Long-term effects of treatment for childhood gender disturbance. Journal of Psychology and Human Sexuality, 3, 121–153. Rekers, G. A., & Lovaas, O. I. (1974). Behavioral treatment of deviant sex-role behaviors in a male child. Journal of Applied Behavior Analysis, 7, 173–190. Renouf, A. G., & Kovacs, M. (1994). Concordance between mothers’ reports and children’s self-reports of depressive symptoms: A longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 208–216. Repucci, N. D., & Haugaard, J. J. (1989). Prevention of child sexual abuse: Myth or reality? American Psychologist, 44, 1266–1275. Reynolds, C. R., & Kamphaus, R. W. (1992). Behavior Assessment System for Children (BASC). Circle Pines, MN: American Guidance Service. Reynolds, C. R., & Richmond, B. D. (1985). Revised Children’s Manifest Anxiety Scale, Los Angeles: Western Psychological Services. Reynolds, W. M. (1986). Reynolds adolescent depression scale. Odessa, FL: Psychological Assessment Resources. Reynolds, W. M. (1989). Reynolds Child Depression Scale. Los Angeles: Western Psychological Services. Rheingold, H. L., Cook, K. V., & Kolowitz, V. (1987). Commands activate the behavior and pleasure of 2-year-old children. Developmental Psychology, 23, 146–151. Rice, M. L. (1989). Children’s language acquisition. American Psychologist, 44, 149–156. Rice, M. E., Quinsey, V. L., & Harris, G. T. (1991). Sexual recidivism among child molesters released from a maximum security psychiatric institution. Journal of Consulting and Clinical Psychology, 59, 381–386. Richman, N. (1981). A community survey of characteristics of one- to two-year-olds with sleep disruptions. Journal of the American Academy of Child Psychiatry, 20, 281–291. Richman, N. (1985). A double-blind drug trial of treatment in young children with sleep disruptions. Journal of the American Academy of Child Psychiatry, 20, 281–291. Richman, N., Douglas, J., Hunt, H., Landsdown, R., & Levere, R. (1985). Behavioural methods in the treatment of sleep disorders: A pilot study. Journal of Child Psychology and Psychiatry, 26, 581–590. Richman, N., Stevenson, J., & Graham, P. (1975). Preschool to school: A behavioural study. London: Academic Press. Richman, N., Stevenson, J., & Graham, P. (1982). Prevalence of behaviour problems in three-year-old children: An epidemiological study in a London borough. Journal of Child Psychology and Psychiatry, 26, 272–287. Richters, J. E., Arnold, E., Jensen, P. S., Abikoff, H., Conners, C. K., Greenhill, L. L., Hechtman, L., Hinshaw, S. P., Pelham, W. E., & Swanson, J. M. (1995). National Institute of Mental Health collaborative multisite Multimodal Treatment Study of Children with Attention-Deficit Hyperactivity Disorder (MTA): I. Background and rationale. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1–14.

596

References

Rickel, A. W., & Allen, L. (1987). Preventing maladjustment from infancy through adolescence. Newbury Park, CA: Sage. Riddle, M. A., Hardin, M. T., Ort, S. I., Leckman, J. F., & Cohen, D. J. (1988). Behavioral symptoms in Tourette’s syndrome. In D. J. Cohen, R. D. Bruun, & J. F. Leckman (Eds.), Tourette’s syndrome and tic disorders (pp. 179–196). New York: Wiley. Rind, B., Tromovitch, P., & Bauserman, R. (1998). A meta-analytic examination of assumed properties of child sexual abuse using college samples. Psychological Bulletin, 124, 22–53. Risch, C. R., & Ferguson, J. M. (1981). Behavioral treatment of skin disorders. In J. M. Ferguson & C. B. Taylor (Eds.), The comprehensive handbook of behavioral medicine (Vol. 2, pp. 263–278). New York: Spectrum. Roberts, M. A. (1990). A behavioral observation method for differentiating hyperactive and aggressive boys. Journal of Abnormal Child Psychology, 18, 131–142. Roberts, M. C., & Turner, D. S. (1986). Rewarding parents for their children’s use of safety seats. Journal of Pediatric Psychology, 11, 25–36. Robins, L. N., Tipp, J., & Pryzbeck, T. (1991). Antisocial personality. In L. N. Robins & D. A. Regier (Eds.), Psychiatric disorders in America (pp. 224–271). New York: Free Press. Robinson, J. R., Drotar, D., & Boutry, M. (2001). Problem-solving abilities among mothers of infants with failure to thrive. Journal of Pediatric Psychology, 26, 21–32. Robson, W. L., & Leung, A. K. (1996). Side effects and complications of treatment with desmopressin for enuresis. Journal of the National Medical Association, 86, 775–778. Rocissano, L., Slade, A., & Lynch, V. (1987). Dyadic synchrony and toddler compliance. Developmental Psychology, 23, 698–704. Rodriguez, C. M., & Sutherland, D. (1999). Predictors of parents’ physical disciplinary practices. Child Abuse and Neglect, 23, 651–657. Rohner, R. P., Bourque, S. L., & Elrodi, C. (1997). Children’s perceptions of corporal punishment, caretaker acceptance, and psychological adjustment in a poor, biracial Southern community. Journal of Marriage and the Family, 58, 842–852. Rolf, J., Masten, A. S., Cicchetti, D., Nuechterlein, K. H., & Weintraub, S. (1990). Risk and protective factors in the development of psychopathology. New York: Cambridge University Press. Ronan, K. R., Kendall, P. S., & Rowe, M. (1994). Negative affectivity in children: Development and validation of a self-statement questionnaire. Cognitive Therapy and Research, 18, 509–528. Rosenberg, L. A., Brown, J., & Singer, H. S. (1994). Self-reporting of behavior problems in patients with tic disorders. Psychological Reports, 74, 653–654. Rosenfeld, A., Bailey, R., Siegel, B., & Bailey, G. (1986). Determining incestuous contact between parent and child: Frequency of children touching parents’ genitals in a nonclinical population. Journal of the American Academy of Child Psychiatry, 25, 481–484. Rosenfeld, A. A., & Wasserman, S. (1993). Sexual development in the early school-aged child. Child and Adolescent Psychiatric Clinics of North America, 2, 393–406. Rosenfeld, A., & Wise, N. (2000). Hyper-parenting: Are you hurting your child by trying too hard? New York: St. Martin’s Press. Rosner, B., Priness, R., Loggie, J., & Daniels, S. R. (1998). Percentiles for body mass index in US children 5 to 17 years of age. Journal of Pediatrics, 132, 211–222. Ross, H. S., & den Bak-Lammers, I. M. (1998). Consistency and change in children’s tattling on their siblings: Children’s perspectives on the moral rules and procedures of family life. Social Development, 7, 245– 300. Rotenberg, K. J., Kim, L. S., & Herman-Stahl, M. (1998). The role of primary and secondary appraisals in the negative emotions and psychological maladjustment of children of divorce. Journal of Divorce and Remarriage, 29, 43–66. Rothbart, M. K., Posner, M. I., & Boylan, A. (1990). Regulatory mechanisms in infant development. In J. T. Enns (Ed.), The development of attention: Research and theory. Dordrecht, The Netherlands: Elsevier/ North-Holland. Routh, D. K., & Schroeder, C. S. (1981). Masturbation and other sexual behaviors. In S. Gabel (Ed.), Behavior problems of childhood (pp. 387–392). New York: Grune & Stratton. Rozin, P. (1990). Development in the food domain. Developmental Psychology, 26, 555–562. Rubin, K. H., Hastings, P., Chen, X., Stewart, S., & McNichol, K. (1998). Intrapersonal and maternal correlates of aggression, conflict and externalizing problems in toddlers. Child Development, 69, 1614–1629. Ruff, H. A., Bijur, P. E., Markowitz, M., Ma, Y.-C., & Rosen, J. F. (1993). Declining blood lead levels and cognitive changes in moderately lead-poisoned children. Journal of the American Medical Association, 269, 1641–1646.

References

597

Runyon, D. K., Everson, M. D., Edelsohn, G. A., Hunter, W. M., & Coulter, M. L. (1988). Impact of legal intervention on sexually abused children. Journal of Pediatrics, 113, 647–653. Rushton, H. G. (1989). Nocturnal enuresis: Epidemological, evaluation, and currently available treatment options. Journal of Pediatrics, 114, 691–696. Russ, S. W. (1995). Play psychotherapy research: State of the art. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 17, pp. 365–391). New York: Plenum Press. Russell, G. F. M., Treasure, J., & Eisler, I. (1998). Mothers with anorexia nervosa who underfeed their children: Their recognition and management. Psychological Medicine, 28, 93–108. Russo, M. R., & Beidel, D. C. (1994). Co-morbidity of childhood anxiety and externalizing disorders: Prevalence, associated characteristics, and validation issues. Clinical Psychology Review, 14, 199–221. Rust, J. O., & Troupe, P. A. (1991). Relationships of treatment of child sexual abuse with school achievement and self-concept. Journal of Early Adolescence, 11, 420–429. Rutter, M. (1970). Normal psychosexual development. Journal of Child Psychology and Psychiatry, 11, 259– 283. Rutter, M. (1975). Helping troubled children. New York: Plenum Press. Rutter, M. (1977). Brain damage syndromes in childhood: Concepts and findings. Journal of Child Psychology and Psychiatry, 18, 1–21. Rutter, M. (1983). Stress, coping, and development: Some issues and some questions. In N. Garmezy & M. Rutter (Eds.), Stress, coping, and development in children (pp. 1–41). New York: McGraw-Hill. Rutter, M. (1995). Clinical implications of attachment concepts: Retrospect and prospect. Journal of Child Psychology and Psychiatry, 36, 549–571. Rutter, M. (1996). Stress research: Accomplishments and tasks ahead. In R. J. Haggerty, C. R. Sherrod, N. Garmezy, & M. Rutter (Eds.), Stress, risk and resiliency in children and adolescents: Processes, mechanisms, and interventions. New York: Cambridge University Press. Rutter, M., MacDonald, H., LeCouteur, A., Harrington, R., Bolton, P., & Bailey, A. (1990). Genetic factors in child psychiatric disorders: II. Empirical findings. Journal of Child Psychology and Psychiatry, 31, 39–83. Rutter, M., & Rutter, M. (1993). Developing minds: Challenge and continuity across the life span. New York: Basic Books. Rutter, M., Tizard, J., & Whitmore, K. (1970). Education, health and behavior. London: Longmans. Rutter, M., Tizard, J., Yule, W., Graham, P., & Whitmore, K. (1976). Isle of Wight studies, 1964–1974. Psychological Medicine, 6, 313–332. Rutter, M., Yule, W., & Graham, P. (1973). Enuresis and behavioural deviance: Some epidemiological considerations. In I. Kolvin, R. C. MacKeith, & S. R. Meadow (Eds.), Clinics in developmental medicine: Bladder control and enuresis (pp. 137–147). London: Heinemann. Ryan, G. (1997a). Incidence and prevalence of sexual offenses committed by juveniles. In G. Ryan & S. Lane (Eds.), Juvenile sexual offending: Causes, consequences and correction (pp. 10–18). San Francisco: Jossey-Bass. Ryan, G. (1997b). Perpetration prevention: Primary and secondary. In G. Ryan & S. Lane (Eds.), Juvenile sexual offending: Causes, consequences and correction (pp. 433–456). San Francisco: Jossey-Bass. Ryan, G. (1997c). Sexually abusive youth: Defining the population. In G. Ryan & S. Lane (Eds.), Juvenile sexual offending: Causes, consequences and correction (pp. 3–9). San Francisco: Jossey-Bass. Ryan, G. (2000). Childhood sexuality: A decade of study. Part I. Research and curriculum development. Child Abuse and Neglect, 24, 33–48. Ryan, G., Miyoshi, T. J., Metzner, J. L., Krugman, R. D., & Fryer, G. E. (1996). Trends in a national sample of sexually abusive youths. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 17–25. Ryan, N. D., Puig-Antich, J., Rabinovich, H., Robinson, D., Ambrosini, P. J., Nelson, B., & Iyengar, S. (1987). The clinical picture of major depression in children and adolescents. Archives of General Psychiatry, 44, 854–861. Rydell, A. M., Dahl, M., & Sundelin, C. (1995). Characteristics of school children who are choosy eaters. Journal of Genetic Psychology, 156, 217–229. Sadel, A., McGuire, J. P. D., Sachs, H., Seifer, R., Tremblay, A. Civeta, R., & Hayden, R. M. (1995). Sleep and psychologlcal characteristics of children on a psychiatric inpatient unit. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 813–819. Safer, D. J., Zito, J. M., & Fine, E. M. (1996). Increased methylphenidate usage for hyperactive/attention deficit disorder in the 1990’s. Pediatrics, 87, 1084–1088. Saldinger, A., Cain, A., Kalter, N., & Lohnes, K. (1999). Anticipating parental death in families with young children. American Journal of Orthopsychiatry, 69, 39–48.

598

References

Sallee, F. R., & Spratt, E. G. (1998). Tics and Tourette’s disorder. In T. H. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (3rd ed., pp. 337–353). New York: Plenum Press. Sallee, F. R., & Spratt, E. G. (1999). Tic disorders. In R. T. Ammerman, M. Hersen, & C. G. Last (Eds.), Prescriptive treatments for children and adolescents (2nd ed., pp. 261–276). Needham Heights, MA: Allyn & Bacon. Salzarulo, P., & Chevalier, A. (1983). Sleep problems in children and their relationships with early disturbances of the waking–sleeping rhythms. Sleep, 6, 47–51. Sameroff, A. J. (1985). Environmental factors in the early screening of children at risk. In W. K. Frankenburg, R. N. Emde, & J. W. Sullivan (Eds.), Early identification of children at risk: An international perspective (pp. 21–44). New York: Plenum Press. Sanchez, V. (1979). Behavioral treatment of chronic hair pulling in a two-year-old. Journal of Behavior Therapy and Experimental Psychiatry, 10, 241–245. Sanders, M. J., Kapphahn, C. J., & Steiner, H. (1998). Eating disorders. In R. T. Ammerman & J. V. Campo (Eds.), Handbook of pediatric psychology and psychiatry: Vol. 1. Psychological and psychiatric issues in the pediatric setting (pp. 287–312). Needham Heights, MA: Allyn & Bacon. Sanders, M. R. (1996). Behavioral family intervention with children. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 18, pp. 283–330). New York: Plenum Press. Sanders, M. R. (1999). Triple P-Positive parenting program: Towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children. Clinical Child and Family Psychology Review, 2, 71–90. Sanders, M. R., & McFarland, M. (2000). Treatment of depressed mothers with disruptive children: A controlled evaluation of cognitive behavioral family intervention. Behavior Therapy, 31, 89–112. Sanders, M. R., Patel, R. K., LeGrice, B., & Shepherd, R. W. (1993). Children with persistent feeding difficulties: An observational analysis of the feeding interactions of problem and non-problem eaters. Health Psychology, 12, 64–73. Sandler, I. N., Kim-Bae, L. S., & MacKinnon, D. (2000). Coping and negative appraisal as mediators between control beliefs and psychological symptoms in children of divorce. Journal of Clinical Child Psychology, 29, 336–347. Sandler, I. N., Pitts, S., & Tein, J. (1995, March). Positive cognitive restructuring in children of divorce. Paper presented at the biennial meeting of the Society for Research on Child Development, Indianapolis, IN. Sandler, I. N., Tein, J., & West, S. G. (1994). Coping, stress and the psychological symptoms of children of divorce: A cross-sectional and longitudinal study. Child Development, 65, 1744–1764. Sanford, D. (1986). I can’t talk about it. Hong Kong: Golden Honey Books. Sanford, M., Boyle, M. H., Szatmari, P., Offord, D. R., Jamieson, E., & Spinner, M. (1999). Age-of-onset classification of conduct disorder: Reliability and validity in a prospective cohort study. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 992–999. Sanger, M. S., Copeland, D. R., & Davidson, E. R. (1991). Psychosocial adjustment among pediatric cancer patients: A multidimensional assessment. Journal of Pediatric Psychology, 16, 463–474. Sanson, A., Oberklaid, F., Pedlow, R., & Prior, M. (1991). Risk indicators: Assessment of infancy predictors of preschool behavioural maladjustment. Journal of Child Psychology and Psychiatry, 32, 609–626. Santangelo, S. L., Pauls, D. L., Goldstein, J. M., Farone, S. V., Tsuang, M. T., & Leckman, J. F. (1994). Tourette’s syndrome: What are the influences of gender and comorbid obsessive–compulsive disorder? Journal of the American Academy of Child and Adolescent Psychiatry, 33, 795–804. Satcher, D. (2000). Mental Health: A report of the Surgeon General—Executive summary. Professional Psychology: Research and Practice, 31, 5–13. Satter, E. M. (1996). Internal regulation and the evolution of normal growth as the basis for prevention of obesity in children. Journal of the American Dietetic Association, 96, 860–864. Sattler, J. M. (1992). Assessment of children: Revised and updated third edition. San Diego, CA: Author. Sattler, J. M. (1998). Clinical and forensic interviewing of children and families. San Diego, CA: Author. Saunders, B. F. (1993, October). Treating symptoms of fear and anxiety in abused children. Paper presented at the Midwest Conference of Child Sexual Abuse and Incest, Middleton, WI. Sawyer, M. G. (1990). Childhood behavior problems: Discrepancies between reports from children, parents, and teachers. Unpublished doctoral dissertation. University of Adelaide, Australia. Saxby, H., & Morgan, H. (1995). Behaviour problems in children with learning disabilities: To what extent do they exist and are they a problem? Child: Care, Health and Development, 19, 149–157. Saxon, T. F. (1997). A longitudinal study of early mother–infant interaction and later language competence. First Language, 17, 271–281.

References

599

Saywitz, K. J., Geiselman, R. E., & Bornstein, G. K. (1992). Effects of cognitive interviewing and practice on children’s recall performance. Journal of Applied Psychology, 17, 744–756. Scarr, S. (1998). American child care today. American Psychologist, 53, 95–108. Scarr, S., Phillips, D., & McCartney, K. (1990). Facts, fantasies and the future of child care in the United States. Psychological Science, 1, 26–35. Schachar, R., Tannock, R., & Logan, G. (1993). Inhibitory control, impulsiveness, and attention deficit hyperactivity disorder. Clinical Psychology Review, 13, 721–739. Schaefer, C. E. (1979). Childhood encopresis and enuresis. New York: Van Nostrand Reinhold. Schaefer, C. E., & Briesmeister, J. M. (Eds.). (1989). Handbook of parent training: Parents as co-therapists for children’s behavior problems. New York: Wiley. Schaefer, C. E., & Millman, H. L. (1981). How to help children with common problems. New York: Van Nostrand Reinhold. Schaefer, C. E., & DiGeronimo, T. F. (1997). Toilet training without tears (rev. ed.). New York: Signet Books. Schaefer, D., Peretz, D., & Lyons, C. (2000). How do we tell the children?: A step-by step guide for helping children cope when someone dies (3rd ed.). New York: Newmarket Press. Scharf, M. B., & Jennings, S. W. (1988). Childhood enuresis: Relationship to sleep, etiology, evaluation, and treatment. Annals of Behavioral Medicine, 10, 113–120. Schaughency, E. A., & Lahey, B. B. (1985). Mothers’ and fathers’ perceptions of child deviance: Roles of child behavior, parental depression, and marital satisfaction. Journal of Consulting and Clinical Psychology, 53, 718–723. Scherer, M. W., & Nakamura, C. Y. (1968). Fear Survey Schedule for Children (FSS-FC): A factor analytic comparison with manifest anxiety (CMAS). Behaviour Research and Therapy, 6, 173–182. Schmitt, B. D. (1986). New enuresis alarms: Safe, successful, and child-operable. Contemporary Pediatrics, 3, 1–5. Schmitt, B. D. (1987). Toilet training refusal: Avoid the battle and win the war. In M. I. Gottleib & J. E. Williams (Eds.), Developmental–behavioral disorders: Selected topics (pp. 279–294). New York: Plenum Press. Schmitz, S., Fulker, D. W., & Mrazek, D. A. (1995). Problem behavior in early and middle childhood: An initial behavior genetic analysis. Journal of Child Psychology and Psychiatry, 36, 1443–1458. Schmitz, S., Saudina, K. J., Plomin, R., Fulker, D. W., & DeFries, J. C. (1996). Genetic and environmental influences on temperament in middle childhood: Analysis of teacher and tester ratings. Child Development, 67, 409–422. Schneider, M. S., King, L. R., & Surwitt, R. S. (1994). Kegel exercises and childhood incontinence: A new role for an old treatment. Journal of Pediatrics, 124, 91–92. Schneider-Rosen, K., & Wenz-Gross, M. (1990). Patterns of compliance from eighteen to thirty months of age. Child Development, 61, 104–112. Schonfeld, D. J., & Kappelman, M. (1990). The impact of school-based education on the young child’s understanding of death. Developmental and Behavioral Pediatrics, 11, 247–252. Schowalter, J. E. (1976). How do children and functions mix? Journal of Pediatrics, 89, 139–142. Schroeder, C. S., Gordon, B. N., Kanoy, K., & Routh, D. K. (1983). Managing children’s behavior problems in pediatric practice. In M. Wolraich & D. K. Routh (Eds.), Advances in developmental and behavioral pediatrics (Vol. 4, pp. 25–86). Greenwich, CT: JAI Press. Schuhmann, E. J., Foote, R. C., Eyberg, S. M., Boggs, S. R., & Algina, J. (1998). Efficacy of parent–child interaction therapy: Interim report of a randomized trial with short-term maintenance. Journal of Clinical Child Psychology, 27, 34–45. Schulenberg, J. (1985). Gay parenting: A complete guide for gay men and lesbians with children. Garden City, NY: Anchor Books. Schultz, J. R., & Vaughn, L. M. (1999). Brief report: Learning to parent. A survey of parents in an urban pediatric primary care clinic. Journal of Pediatric Psychology, 24, 441–445. Schultz, R. T., Carter, A. S., Scahill, L., & Leckman, J. F. (1999) Neuropsychological findings. In J. F. Leckman & D. J. Cohen (Eds.), Tourette’s syndrome—tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 80–103). New York: Wiley. Schwartz, C. E., Snidman, N., & Kagan, J. (1999). Adolescent social anxiety as an outcome of inhibited temperament in childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1008–1015. Schwartz, J. A. J., Gladstone, T. R. G., & Kaslow, N. J. (1998). Depressive disorders. In T. H. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (3rd. ed., pp. 269–289). New York: Plenum Press. Scott, M. A., Barclay, D. R., & Houts, A. C. (1992). Childhood enuresis: Etiology, assessment and current behavioral treatment. In M. Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in behavior modification (Vol. 28, pp. 83–117). Sycamore, IL: Sycamore.

600

References

Seidman, L. J., Biederman, J., Faraone, S. V., Weber, W., & Ouellette, C. (1997). Toward defining a neuropsychology of ADHD: Performance of children and adolescents from a large clinically referred sample. Journal of Consulting and Clinical Psychology, 65, 150–160. Seifer, R., Schiller, M., Sameroff, A. J., Resnick, S., & Riordan, K. (1996). Attachment, maternal sensitivity, and infant temperament during the first year of life. Developmental Psychology, 32, 12–25. Seligman, L. D., & Ollendick, T. H. (1998). Comorbidity of anxiety and depression in children and adolescents: An integrative review. Clinical Child and Family Psychology Review, 1, 125–144. Seligman, M. E. P. (1975). Helplessness: On depression, development, and death. San Francisco: Freeman. Selzer, J. (1998). Father by law: Effects of joint legal custody on nonresident fathers’ involvement with children. Demography, 35, 135–146. Semrud-Clikeman, M., Steingard, R., Filipek, P., Biederman, J., Bekken, K., & Renshaw, P. F. (2000). Using MRI to examine brain–behavior relationships in males with attention deficit disorder with hyperactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 477–484. Seymour, F. W., Brock, P., During, M., & Poole, G. (1989). Reducing sleep disruptions in young children: Evaluation of therapist-guided and written information approaches. A brief report. Journal of Child Psychology and Psychiatry, 30, 913–918. Shaffer, D., Fisher, P., Dulcan, M. K., Davies, M., Piacentini, J., Schwab-Stone, M. E., Lahey, B. B., Bourdon, K., Jensen, P. S., Bird, H. R., Canino, G., & Regier, D. A. (1996). The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): Description, acceptability, prevalence rates, and performance in the MECA study. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 865–872. Shaffer, D., Fisher, P., Lucas, C.P., Dulcan, M.K., & Schwab-Stone, M.E. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): Description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 28–38. Shannon, M. P., Lonigan, C. H., Finch, A. J., & Taylor, C. M. (1994). Children exposed to disaster: I. Epidemiology of post-traumatic symptoms and symptom profiles. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 80–93. Shantz, C. V. (1987). Conflicts between children. Child Development, 58, 283–305. Shapiro, A. K., Shapiro, E. S., Young, J. G., & Feinberg, T. E. (1988). Gilles de la Tourette syndrome (2nd ed.). New York: Raven Press. Shapiro, E. S. (1987). Behavioral assessment in school psychology. Hillsdale, NJ: Erlbaum. Shapiro, L. D., & Henderson, J. G., Jr. (1992). Brief therapy for encopresis: A case study. Journal of Family Psychotherapy, 3, 1–12. Sharenow, E. L., Fuqua, R. W., & Miltenberger, R. G. (1989). The treatment of muscle tics with dissimilar competing response practice. Journal of Applied Behavior Analysis, 22, 35–42. Sharp, D., Hay, D. F., Pawlby, S., Schmucker, G., Allen, H., & Kumar, R. (1995). The impact of postnatal depression on boys’ intellectual development. Journal of Child Psychology and Psychiatry, 36, 1315–1336. Shaw, J. A. (1999). Male adolescent sex offenders. In J. A. Shaw (Ed.), Sexual aggression (pp. 169–193). Washington, DC: American Psychiatric Press. Shaw, D. S., Bell, R. Q., & Gilliom, M. (2000). A truly early starter model of antisocial behavior revisited. Clinical Child and Family Psychology Review, 3, 155–172. Shaw, D. S., & Emery, R. E. (1987). Parental conflict and other correlates of the adjustment of school-age children whose parents have separated. Journal of Abnormal Child Psychology, 15, 269–281. Shaw, D. S., Emery, R. E., & Tuer, M. D. (1993). Parental functioning and children’s adjustment in families of divorce: A prospective study. Journal of Abnormal Child Psychology, 21, 119–134. Shaw, D. S., Owens, E. B., Giovannelli, J., & Winslow, E. B. (2001). Infant and toddler pathways leading to early externalizing disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 36–47. Shaw, D. S., Owens, E. B., Vondra, J. I., Keenan, K., & Winslow, E. B. (1996). Early risk factors and pathways in the development of early disruptive behavior problems. Development and Psychopathology, 8, 679–699. Shaw, D. S., & Vondra, J. I. (1995). Attachment security and maternal predictors of early behavior problems: A longitudinal study of low-income families. Journal of Abnormal Child Psychology, 23, 335–356. Sheldon, S. H., & Jacobsen, J. (1998). REM-sleep motor disorder in children. Journal of Child Neurology, 13, 257–260. Shelly-Tremblay, J. F., & Rosen, L. A. (1996). Attention deficit hyperactivity disorder: An evolutionary perspective. Journal of Genetic Psychology, 157, 443–453.

References

601

Shelov, S. P., Gundy, G., Weiss, J. C., McIntire, M. S., Olness, K., Staub, H. P., Jones, D. J., Haque, M., Ellerstein, N. S., Heagardy, M. C., & Starfield, B. (1981). Enuresis: A contrast of attitudes of parents and physicians. Pediatrics, 67, 707–710. Shelton, T., Barkley, R., Crosswait, C., Moorehouse, M., Fletcher, K., Barrett, S., Jenkins, L., Metevia, L. (1999). Psychiatric and psychological morbidity as a function of adaptive disability in preschool children with aggressive and hyperactive–impulsive–inattentive behavior. Journal of Abnormal Child Psychology, 26, 475–494. Sheras, P. L. (1983). Suicide in adolescence. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (pp. 759–784). New York: Wiley–Interscience. Sheras, P. L., Abidin, R. R., & Konold, T. R. (1998). Stress index for parents of adolescents. Odessa, FL: Psychological Assessment Resources. Sherman, D. K., Iacono, W. G., & McGue, M. K. (1997). Attention-deficit hyperactivity disorder dimensions: A twin study of inattention and impulsive hyperactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 745–753. Shields, A., & Cicchetti, D. (2001). Parental maltreatment and emotion dysregulation as risk factors for bullying and victimization in middle childhood. Journal of Clinical Child Psychology, 30, 349– 363. Shifflet, K., & Cummings, M. E. (1999). A program for educating parents about the effects of divorce and conflict on children: An initial evaluation. Family Relations, 48, 79–89. Shortt, A. L., Barrett, P. M., & Fox, T. L. (2001). Evaluating the FRIENDS program: A cognitivebehavioral group treatment for anxious children and their parents. Journal of Clinical Child Psychology, 30, 525–535. Shumaker, D. M., & Prinz, R. J. (2000). Children who murder: A review. Clinical Child and Family Psychology Review, 3, 97–116. Siddiqui, A. A., & Ross, H. S. (1999). How do sibling conflicts end? Early Education and Development, 10, 315–332. Sieg, K. G., Gaffney, G. R., Preston, D. F., & Hellings, J. A. (1995). SPECT brain imaging abnormalities in attention deficit hyperactivity disorder. Clinical Nuclear Medicine, 20, 55–60. Siegel, B. M., Janeway, D., & Baum, J. (1998). Fibromyalgia syndrome in children and adolescents: Clinical features at presentation and status at follow-up. Pediatrics, 101, 377–382. Silber, K. P., & Haynes, C. E. (1991). Treating nailbiting: A comparative analysis of mild aversion and competing response therapies. Behaviour Research and Therapy, 30, 15–22. Silove, D., Harris, M., Morgan, A., Boyce, P., Manicavasagar, V., Hadzi-Pavlovic, D., & Wilhelm, K. (1995). Is early separation anxiety a specific precursor of panic–agoraphobia?: A community sample. Psychological Medicine, 25, 405–411. Silva, P. A., Williams, S., & McGee, R. (1987). A longitudinal study of children with developmental language delay at age three: Later intelligence, reading and behaviour problems. Developmental Medicine and Child Neurology, 29, 630–640. Silver, L. B. (1981). The relationship between learning disabilities, hyperactivity, distractability and behavior problems. A clinical analysis. Journal of the American Academy of Child Psychiatry, 20, 285–397. Silverman, W. K., & Carmichael, D. H. (1999). Phobic disorders. In R. T. Ammerman, M. Hersen, & C. G. Last (Eds.), Handbook of prescriptive treatments for children and adolescents (2nd ed., pp. 172–192). Needham Heights, MA: Allyn & Bacon. Silverman, W. K., & Kurtines, W. M. (1996). Anxiety and phobic disorders: A pragmatic approach. New York: Plenum Press. Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F., Lumptin, P. W., & Carmichael, D. H. (1999). Treating anxiety disorders in children with group cognitive-behavioral therapy: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67, 995–1003. Silverman, W. K., La Greca, A. M., & Wasserstein, S. (1995). What do children worry about? Worries and their relation to anxiety. Child Development, 66, 671–686. Silverman, W. K., & Rabian, B. (1993). Simple phobias. Child and Adolescent Psychiatric Clinics of North America, 2, 603–622. Simon, J., Larson, C., & Lehrer, R. (1988). Preschool screening: Relations among audiometric and developmental measures. Journal of Applied Developmental Psychology, 9, 107–123. Simons, R. L., Whitbeck, L. B., Conger, R. D., & Chyi-In, W. (1991). Intergenerational transmission of harsh parenting. Developmental Psychology, 27, 159–171. Skarpness, L. R., & Carson, D. K. (1987). Correlates of kindergarten adjustment: Temperament and communicative competence. Early Childhood Research Quarterly, 2, 367–376.

602

References

Slaby, R. G., & Frey, K. S. (1975). Development of gender constancy and selective attention to same-sex models. Child Development, 46, 849–856. Slijper, F. M., Drop, S. L., Molenaar, J. C., & deMuinck-Keizer-Schrama, S. M. (1998). Long-term psychological evaluation of intersex children. Archives of Sexual Behavior, 27, 125–144. Smeets, P. M., Lancioni, G. E., Ball, T. S., & Oliva, D. S. (1985). Shaping self-initiated toileting in infants. Journal of Applied Behavioral Analysis, 18, 303–308. Smith, D. W. (1977). Introduction to clinical pediatrics. Philadelphia: Saunders. Smith, T. E. (1993). Growth in academic acheivement and teaching younger siblings. Social Psychology Quarterly, 56, 77–85. Smith, Y. L. S., van Goozen, S. H. M., & Cohen-Kettenis, P. T. (2001). Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: A prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 472–481. Snyder, J., Horsch, E., & Child, J. (1997). Peer relationships of young children: Affiliative choices and the shaping of aggressive behavior. Journal of Clinical Child Psychology, 26, 145–156. Socolar, R. R. S., & Stein, R. E. K. (1996). Maternal discipline of young children: Context belief, and practice. Developmental and Behavioral Pediatrics, 17, 1–8. Sommers-Flanagan, J., & Sommers-Flanagan, R. (1996). Efficacy of antidepressant medication with depressed youth: What psychologists should know. Professional Psychology: Research and Practice, 27, 145–153. Sonis, W. A., Comite, R., Pescovitz, O. H., Hench, K., Rahn, C. W., Cutler, G. B., Loriaux, D. L., & Klein, R. P. (1986). Biobehavioral aspects of precocious puberty. Journal of the American Academy of Child Psychiatry, 25, 674–679. Sonnenberg, A., & Koch, T. R. (1989). Physician visits in the United States for constipation: 1958 to 1986. Digestive Diseases and Sciences, 34, 606–611. Sonuga-Barke, E. J. S. (1994). On dysfunction and function in psychological accounts of childhood disorder. Journal of Child Psychology and Psychiatry, 35, 801–815. Sonuga-Barke, E. J. S., Daley, D., Thompson, M., Laver-Bradbury, C., & Weeks, A. (2001). Parent-based therapies for preschool attention-deficit/hyperactivity disorder: A randomized, controlled trial with a community sample. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 402– 408. Southam-Gerow, M. A., Kendall, P. C., & Weersing, V. R. (2001). Examining outcome variability: Correlates of treatment response in a child and adolescent anxiety clinic. Journal of Clinical Child Psychology, 30, 422–436. Soutter, A. (1996). A longitudinal study of three cases of gender identity disorder of childhood successfully resolved in the school setting. School Psychology International, 17, 49–57. Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. Journal of Marriage and the Family, 38, 15–38. Spanier, G. B., & Filsinger, E. E. (1983). The Dyadic Adjustment Scale. In E. E. Filsinger (Ed.), Marriage and family assessment: A source book for family therapy (pp. 155–168). Beverly Hills, CA: Sage. Spanier, G. B., & Thompson, L. (1982). A confirmatory analysis of the Dyadic Adjustment Scale. Journal of Marriage and the Family, 44, 731–738. Sparrow, S. S., Balla, D. A., & Cicchetti, D. V. (1984). Vineland Adaptive Behavior Scales. Circle Pines, MN: American Guidance Service. Speece, M. W., & Brent, S. B. (1984). Children’s understanding of death: A review of three components of a death concept. Child Development, 55, 1671–1686. Speece, M. W., & Brent, S. B. (1996). The development of children’s understanding of death. In C. A. Corr & D. M. Corr (Eds.), Handbook of childhood death and bereavement (pp. 29–50). New York: Springer. Speltz, M. L., McClellan, J., DeKlyen, M., & Jones, K. (1999). Preschool boys with oppositional defiant disorder: Clinical presentation and diagnostic change. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 838–845. Spielberger, C. D. (Ed.). (1972). Anxiety: Current trends in theory and research (Vol. 1). New York: Academic Press. Spielberger, C. D. (1973). Manual for the State–Trait Anxiety Inventory for Children. Palo Alto, CA: Consulting Psychologists Press. Spinetta, J. J. (1978). Communication patterns in families dealing with life-threatening illness. In O. J. Z. Sahler (Ed.), The child and death (pp. 43–51). St. Louis, MO: Mosby. Spinetta, J. J. (1982). Psychosocial issues in childhood cancer: How the professional can help. In M. Wolraich & D. K. Routh (Eds.), Advances in developmental and behavioral pediatrics (Vol. 3, pp. 51– 72). Greenwich, CT: JAI Press.

References

603

Spinetta, J. J., & Maloney, L. J. (1975). Death anxiety in the outpatient leukemic child. Pediatrics, 65, 1034– 1037. Spitz, R. (1946). Anaclitic depression. Psychoanalytic Study of the Child, 5, 113–177. Spitznagel, A. (1976). We will see you in the morning. Unpublished manuscript, Chapel Hill, NC. Sprich, S., Biederman, J., Crawford, M. H., Mundy, E., & Faraone, S. V. (2000). Adoptive and biological families of children and adolescents with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1432–1437. Springs, F. E., & Friedrich, W. N. (1992). Health risk behaviors and medical sequelae of childhood sexual abuse. Mayo Clinics Proceedings, 67, 527–532. Spruijt, E., & Ledema, J. (1998). Well being of youngsters of divorce without contact with nonresident parents in the Netherlands. Journal of Comparative Family Studies, 29, 517–527. Sroufe, L. A., & Fleeson, J. (1986). Attachment and the construction of relationships. In W. W. Hartup & Z. Rubin (Eds.), Relationships and development (pp. 51–72). Hillsdale, NJ: Erlbaum. Staiano, A., Andreotti, M., Greco, L., Basile, P., & Auricchio, S. (1994). Long-term follow-up of children with chronic idiopathic constipation. Digestive Diseases and Sciences, 39, 561–564. Stambrook, M., & Parker, K. C. H. (1987). The development of the concept of death in childhood: A review of the literature. Merrill–Palmer Quarterly, 33, 133–157. Stansfeld, W. M. (1973). Enuresis and urinary tract infection. In I. Kolvin, R. C. MacKeith, & S. R. Meadow (Eds.), Clinics in developmental medicine: Bladder control and enuresis (pp. 102–103). London: Heinemann. Stark, K. D. (1990). Childhood depression: School-based intervention. New York: Guilford Press. Stark, K. D., Humphrey, L. L., Laurent, J., Livingston, R., & Christopher, J. (1993). Cognitive, behavioral, and family factors in the differentiation of depression and anxiety disorders during childhood. Journal of Consulting and Clinical Psychology, 61, 878–886. Stark, K. D., & Laurent, J. (2001). Joint factor analysis of the Children’s Depression Inventory and the Revised Children’s Manifest Anxiety Scale. Journal of Clinical Child Psychology, 30, 552–567. Stark, K. D., Napolitano, S., Swearer, S., Schmidt, K., Jaramilo, D., & Hoyle, J. (1996). Issues in the treatment of depressed children. Applied and Preventive Psychology, 5, 59–83. Stark, L. J., Opipari, L. C., Donaldson, D. L., Danovsky, M. B., Rasile, D. A., & DelSanto, A. F. (1997). Evaluation of a standard protocol for retentive encopresis: A replication. Journal of Pediatric Psychology, 22, 619–633. Stark, L. J., Owens-Stively, J., Spirito, A., Lewis, A., & Guevremont, D. (1990). Group behavioral treatment of retentive encopresis. Journal of Pediatric Psychology, 15, 659–671. Steele, R. G., Armistead, L., Forehand, R., & the Family Health Project Research Group. (2000). Current and longitudinal correlates of depressive symptoms among low-income, urban, African American children. Journal of Clinical Child Psychology, 29, 76–85. Stehbens, J. A. (1988). Childhood cancer. In D. K. Routh (Ed.), Handbook of pediatric psychology (pp. 135– 161). New York: Guilford Press. Stein, A., Woolley, H., Cooper, S. D., & Fairburn, C. G. (1994). An observational study of mothers with eating disorders and their infants. Journal of Child Psychology and Psychiatry, 35, 733–748. Steinman, S. (1981). The experience of children in a joint-custody arrangement: A report of a study. American Journal of Orthopsychiatry, 51, 403–414. Stemberger, R. T., Turner, S. M., Beidel, D. C., & Calhoun, K. S. (1995). Social phobia: An analysis of possible developmental factors. Journal of Abnormal Psychology, 104, 526–531. Stephens, L. S. (1996). Will Johnny see Daddy this week?: An empirical test of three theoretical perspectives of post-divorce contact. Journal of Family Issues, 17, 466–494. Stermac, L. E.,, & Segal, Z. V. (1989). Adult sexual contact with children: An examination of cognitive factors. Behavior Therapy, 20, 573–584. Stewart, R. B., & Marvin, R. S. (1984). Sibling relations: The role of conceptual perspective-taking in the ontogeny of sibling caregiving. Child Development, 55, 1322–1332. Stewart, R. B., Mobley, L. A., Van Tuyl, S. S., & Salvador, R. A. (1987). The firstborn’s adjustment to the birth of a sibling: A longitudinal assessment. Child Development, 58, 341–355. Stillwell, R., & Dunn, J. (1985). Continuities in sibling relationships: Patterns of aggression and friendliness. Journal of Child Psychology and Psychiatry, 26, 627–637. Stocker, C., Dunn, J., & Plomin, R. (1989). Sibling relationships: Links with child temperament, maternal behavior, and family structure. Child Development, 60, 715–727. Stokes, A., Bawden, H. N., Camfield, P. R., Backman, J. E., & Dooley, M. B. (1991). Peer problems in Tourette’s disorder. Pediatrics, 87, 936–942. Stoneman, Z., & Brody, G. H. (1993). Sibling temperaments, conflict, warmth, and role asymmetry. Child Development, 64, 1786–1800.

604

References

Stoneman, Z., Brody, G. H., & Burke, M. (1989). Marital quality, depression, and inconsistent parenting: Relationship with observed mother–child conflict. American Journal of Orthopsychiatry, 59, 105– 117. Stoppelbein, L., & Greening, L. (2000). Posttraumatic stress in parentally bereaved children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1112–1119. Stormont-Spurgin, M., & Zentall, S. S. (1995). Contributing factors in the manifestation of aggression in preschoolers with hyperactivity. Journal of Child Psychology and Psychiatry, 36, 491–509. Stormshak, E. A., Bellanti, C. J., Bierman, K. L., & the Conduct Problems Prevention Research Group. (1996). The quality of sibling relationships and the development of social competence and behavioral control in aggressive children. Developmental Psychology, 32, 79–89. Stormshak, E. A., Bierman, K. L., McMahon, R. J., Lengua, L. G., & the Conduct Problems Prevention Research Group. (2000). Parenting practices and child disruptive behavior problems in early elementary school. Journal of Clinical Child Psychology, 29, 17–29. Stouthamer-Loeber, M., Loeber, R., & Thomas, C. (1992). Caretakers seeking help for boys with disruptive and delinquent behavior. Comprehensive Mental Health Care, 2, 159–178. Straus, M. A. (1991). Discipline and deviance: Physical punishment of children and violence and other crimes in adulthood. Social Problems, 38, 133–154. Straus, M. A., & Kaufman-Kantor, G. (1994). Corporal punishments by parents of adolescents: A risk factor in the epidemiology of depression, suicide, alcohol abuse, and wife beating. Adolescence, 29, 543–562. Straus, M. A., & Stewart, J. H. (1999). Corporal punishment by American parents: National data on prevalence, chronicity, severity, and duration, in relation to child and family characteristics. Clinical Child and Family Psychology Review, 2, 55–70. Straus, M. A., Sugarman, D. B., & Giles-Sims, J. (1997). Spanking by parents and subsequent antisocial behavior of children. Archives of Pediatric and Adolescent Medicine, 151, 761–767. Straus, M. A., & Yodanis, C. L. (1996). Corporal punishment in adolescence and physical assaults on spouses in later life: What accounts for the link? Journal of Marriage and the Family, 58, 825–841. Strauss, C. C., Lahey, B. B., Frick, P., Frame, L. L., & Hund, G. W. (1988). Peer social status of children with anxiety disorders. Journal of Consulting and Clinical Psychology, 56, 137–141. Strauss, C. C., & Last, C. G. (1993). Social and simple phobias in children. Journal of Anxiety Disorders, 7, 141–152. Strayer, J. (1986). Children’s attributes regarding the situational determinants of emotion in self and others. Developmental Psychology, 22, 649–654. Streissguth, A. P., Bookstein, F. L., Sampson, P. D., & Barr, H. M. (1995). Attention: Prenatal alcohol and continuities of vigilance and attentional problems from 4 through 14 years. Development and Psychopathology, 7, 419–446. Strober, M., & Carlson, G. (1982). Bipolar illness in adolescents with major depression: Clinical, genetic, and psychopharmacological predictors in a three- to four-year prospective follow-up investigation. Archives of General Psychiatry, 39, 549–555. Sturm, L., & Drotar, D. (1989). Prediction of weight for height following intervention in three-year-old children with early histories of nonorganic failure to thrive. Child Abuse and Neglect, 13, 19–28. Sugar, M. (1995). A clinical approach to childhood gender identity disorder. American Journal of Psychotherapy, 49, 260–281. Sukhai, R. N., Mol, J., & Harris, A. S. (1989). Combined therapy of enuresis alarm and desmopressin in the treatment of nocturnal enuresis. European Journal of Pediatrics, 148, 465–467. Sullivan, M. A., & O’Leary, S. G. (1990). Maintenance following reward and cost token programs. Behavior Therapy, 21, 139–151. Sullivan, S. A., & Birch, L. L. (1990). Pass the sugar, pass the salt: Experience dictates preference. Developmental Psychology, 26, 546–551. Susman-Stillman, A., Kalkoske, M., Egeland, B., & Waldman, I. (1996). Infant temperament and maternal sensitivity as predictors of attachment security. Infant Behavior and Development, 19, 33–47. Swanson, J. M., Cantwell, D., Lerner, M., McBurnett, K., & Hanna, G. (1991). Effects of stimulant medication on learning in children with ADHD. Journal of Learning Diability, 24, 219–230. Swanson, J. M., Kraemer, H. C., Hinshaw, S. P., Arnold, L. E., Conners, C. K., Abikoff, H. B., Clevenger, W., Daview, M., Elliott, G. R., Greenhill, L. L., Hechtman, L., Hoza, B., Jensen, P. S., March, J. S., Newcorn, H. J., Owens, E. B., Pelham, W. E., Schiller, E., Severe, J. B., Simpson, S., Vitiello, B., Wells, K., Wigal, T., & Wu, M. (2001). Clinical relevance of the primary findings of the MTA: Success rates based on severity of ADHD and ODD symptoms at the end of treatment. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 168–179.

References

605

Swedo, S. E., & Rapoport, J. L. (1991). Annotation: Trichotillomania. Journal of Child Psychology and Psychiatry, 32, 401–409. Sweet, P. E. (1981). Something happened to me. Racine, WI: Mother Courage Press. Symonds, C. L., Mendoza, M. J., & Harrell, W. C. (1981). Forbidden sexual behavior among kin. In L. L. Constantine & F. M. Martinson (Eds.), Children and sex: New findings, new perspectives (pp. 151–162). Boston: Little, Brown. Szapocznik, J., & Williams, R. A. (2000). Brief strategic family therapy: Twenty-five years of interplay among theory, research and practice in adolescent behavior problems and drug abuse. Clinical Child and Family Psychology Review, 3, 117–134. Szatmari, P. (1992). The epidemiology of attention-deficit hyperactivity disorders. Child and Adolescent Psychiatric Clinics of North America, 1(2), 361–372. Tamis-LeMonda, C. S., & Cabrera, N. (1999). Perspectives on father involvement: Research and policy. Society for Research in Child Development: Social Policy Report, 13(2), 1–25. Tannock, R. (1998). Attention deficit hyperactivity disorder: Advances in cognitive, neurobiological, and genetic research. Journal of Child Psychology and Psychiatry, 39, 65–99. Tannock, R., Ickowicz, A., & Schachar, R. (1995). Differential effects of methylphenidate on working memory in ADHD children with and without comorbid anxiety. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 886–896. Taylor, E. A., Sandberg, S., Thorley, G., & Giles, S. (1991). The epidemiology of childhood hyperactivity. London: Oxford University Press. Taylor, T. K., & Biglan, A. (1998). Behavioral family interventions for improving child-rearing: A review of the literature for clinicians and policy makers. Clinical Child and Family Psychology Review, 1, 41–60 Taylor, T. K., Eddy, J. M., & Biglan, A. (1999). Interpersonal skills training to reduce aggressive and delinquent behavior: Limited evidence and the need for an evidence-based system of care. Clinical Child and Family Psychology Review, 2, 169–182. Teele, D. W., Klein, J., & Rosner, B. (1984). Otitus media with effusion during the first three years of life and development of speech and language. Pediatrics, 74, 282–287. Teti, D. M., Sakin, J. W., Kucera, E., Corns, K. M., & Eiden, R. D. (1996). And baby makes four: Predictors of attachment security among preschool-age first borns during the transition to siblinghood. Child Development, 67, 579–596. Thapar, A., & McGuffin, P. (1994). A twin study of depressive symptoms in childhood. British Journal of Psychiatry, 165, 259–265. Thiruchelvam, D., Carach, A., & Schachar, R. J. (2001). Moderators and mediators of long-term adherence to stimulant treatment in children with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 922–928. Thoennes, N., & Tjaden, P. E. (1990). Sexual abuse and exploitation of children and adults in custody/visitation disputes. Child Abuse and Neglect, 14, 151–163. Thomas, A., & Chess, S. (1977). Temperament and development. New York: Brunner/Mazel. Thomas, A., Chess, S., & Birch, H. B. (1968). Temperament and behavior disorders in children. New York: New York University Press. Thomas, J. M., & Guskin, K. A. (2001). Disruptive behavior in young children: What does it mean? Journal of the American Academy of Child and Adolescent Psychiatry, 40, 44–51. Thompson, M. P., Kaslow, N. J., Kingree, J. B., King, M., Bryant, L. Jr., & Rey, M. (1998). Psychological symptomatology following parental death in a predominantly minority sample of children and adolescents. Journal of Clinical Child Psychology, 27, 434–441. Thompson, M. P., Kaslow, N. J., Price, A. W., Williams, K., & Kingree, J. B. (1998). Role of secondary stressors in the parental death–child distress relation. Journal of Abnormal Child Psychology, 26, 357– 366. Thompson, R. A. (1994). Emotion regulation: A theme in search of definition. In N. A. Fox (Ed.), The development of emotion regulation: Biological and behavioral considerations. Monographs of the Society for Research in Child Development, 59(2–3, Serial No. 240), 25–52. Thompson, R. A. (2000). The legacy of early attachments. Child Development, 71, 145–152. Thompson, R. A., & Calkins, S. D. (1996). The double-edged sword: Emotional regulation for children at risk. Development and Psychopathology, 8, 163–184. Tiara, M., Takase, M., & Sasaki, H. (1998). Sleep disorder in children with autism. Psychiatry and Clinical Neurosciences, 52, 182–183. Tikotzky, L., & Sadeh, A. (2001). Sleep patterns and sleep disruptions in kindergarten children. Journal of Clinical Child Psychology, 30, 581–591.

606

References

Toister, R. P., Colin, J., Worley, L. M., & Arthur, D. (1975). Faradic therapy of chronic vomiting in infancy: A case study. Journal of Behavior Therapy and Experimental Psychiatry, 6, 55–59. Tolan, P. H., & McKay, M. M. (1996). Preventing serious antisocial behavior in inner-city children: An empirically based family intervention program. Family Relations, 45, 148–155. Toppelberg, C. O., & Shapiro, T. (2000). Language disorders: A 10-year research update review. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 143–152. Towbin, K. E. (1988). Obsessive–compulsive symptoms in Tourette’s syndrome. In D. J. Cohen, R. D. Bruun, & J. F. Leckman (Eds.), Tourette syndrome and tic disorders (pp. 137–149). New York: Wiley. Towbin, K. E., & Cohen, D. J. (1996). Tic disorders. In J. M. Wiener (Ed.), Diagnosis and psychopharmacology of childhood and adolescent disorders (2nd ed., pp. 349–374). New York: Wiley. Towbin, K. E., Riddle, M. A., Leckman, J. F., Bruun, R. D., & Cohen, D. J. (1988). The clinical care of individuals with Tourette’s syndrome. In D. J. Cohen, R. D. Bruun, & J. F. Leckman (Eds.), Tourette syndrome and tic disorders (pp. 329–352). New York: Wiley. Tracey, S. A., Chorpita, B. F., Douban, J., & Barlow, D. (1997). Empirical evaluation of the DSM-IV generalized anxiety disorder criteria in children and adolescents. Journal of Clinical Child Psychology, 26, 404–414. Tremblay, C., Hebert, M., & Piche, C. (1999). Coping strategies and social support as mediators of consequences in child sexual abuse victims. Child Abuse and Neglect, 23, 929–945. Trites, R. L., Tryphonas, H., & Ferguson, B. (1980). Diet treatment for hyperactive children with food allergies. In R. Knight & D. Baker (Eds.), Treatment of hyperactive and learning disordered children (pp. 151– 166). Baltimore: University Park Press. Troiano, R. P., & Flegal, K. M. (1998). Overweight children and adolescents: Description, epidemiology, and demographics. Pediatrics, 101(Suppl.), 497–504. Troiano, R. P., Flegal, K. M., Kuczmanski, R. J., Campbell, S. M., & Johnson, C. I. (1995). Overweight prevalence and trend for children and adolescents. Archives of Pediatric and Adolescent Medicine, 149, 1085– 1091. Troster, H. (1994). Prevalence and functions of stereotyped behaviors in nonhandicapped children in residential care. Journal of Abnormal Child Psychology, 22, 79–97. Tschann, J. M., Kaiser, P., Chesney, M. A., Alkon, A., & Boyce, W. T. (1996). Resiliance and vulnerability among preschool children: Family functioning, temperament, and behavior problems. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 184–192. Turecki, S., & Tonnes, L. (2000). The difficult child. New York: Bantam. Turner, H. A., & Finkelhor, D. (1996). Corporal punishment as a stressor among youth. Journal of Marriage and the Family, 58, 155–166. Turner, K. M., Sanders, M. R., & Wall, C. R. (1994). Behavioural parent training versus dietary education in the treatment of children with persistent feeding difficulties. Behaviour Change, 11, 242–258. Turner, S. M., Beidel, D. C., Borden, J. W., Stanley, M. A., & Jacob, R. G. (1991). Social phobias: Axis I and Axis II correlates. Behaviour Research and Therapy, 32, 381–390. Turner, S. M., Beidel, D. C., & Morris, T. L. (1998). Social phobia and anxiety inventory for children. New York: Multihealth Systems. Turner, S. M., Beidel, D. C., & Wolff, P. L. (1996). Is behavior inhibition related to anxiety disorders? Clinical Psychology Review, 16, 157–172. U.S. Bureau of the Census. (1985). Statistical abstract of the United States: 1986 (10th ed.). Washington, DC: U.S. Government Printing Office. U.S. Bureau of the Census. (1993). Statistical abstract of the United States (17th ed.). Washington, DC: U.S. Government Printing Office. Ungerer, J., Sigman, M., Beckwith, L., Cohen, S., & Parmelee, A. (1983). Sleep problems of pre-term children at 3 years of age. Developmental Medicine and Child Neurology, 25, 297–304. Vallance, D. D., Cummings, R. L., & Humphries, T. (1998). Mediators of the risk for problem behavior in children with language learning disabilities. Journal of Learning Disabilities, 31, 160–171. Vallano, G., & Slomka, G. T. (1998). Attention-deficit hyperactivity disorder. In R. T. Ammerman & J. V. Campo. (Eds.), Handbook of pediatric psychology and psychiatry: Vol. 1. Psychological and psychiatric issues in pediatric settings (pp. 227–247). Needham Heights, MA: Allyn & Bacon. Van Ameringen, M., Mancini, C., & Oakman, J. M. (1998). The relationship of behavioral inhibition and shyness to anxiety disorder. Journal of Nervous and Mental Disease, 186, 425–431. Vandell, D. L. (1987). Baby sister/baby brother: Reaction to the birth of a sibling and patterns of early sibling relations. Journal of Children in Contemporary Society, 19, 13–37. Vandewater, E. A., & Lansford, J. E. (1998). Influences on family structure and parental conflict on children’s well-being. Family Relations, 47, 323–330.

References

607

van Goozen, S. H. M., Matthys, W., Cohen-Kettenis, P. T., Buitelaar, J. K., & van Engeland, H. (2000). Hypothalamic–pituitary–adrenal axis and autonomic nervous system activity in disruptive children and matched controls. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1438–1445. van Goozen, S. H. M., van den Ban, E., Matthys, W., Cohen-Kettenis, P. T., Thiussen, J. H. H., & van Engeland, H. (2000). Increased androgen functioning in children with oppositional defiant disorder: A comparison with psychiatric and normal controls. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1446–1451. van Londen, A. (1989). Arousal-training for nocturnal enuresis in children. Unpublished dissertation, University of Utrecht, Utrecht, The Netherlands. van Londen, A., van Londen-Barentsen, M. W. M., van Son, M. J. M., & Mulder, G. A. L. A. (1993). Arousal training for children suffering from nocturnal enuresis: A 2 1/2 year follow-up. Behaviour Research and Therapy, 31, 613–615. Varin, D., Crugnola, C. R., Molina, P., & Ripamonti, C. (1996). Sensitive periods in the development of attachment and the age of entry into day care. European Journal of Psychology of Education, 11, 215– 229. Varney, J. W., Blount, R. L., & Quiggins, D. J. L. (1998). Oncologic disorders. In R. T. Ammerman & J. V. Campo (Eds.), Handbook of pediatric psychology and psychiatry: Vol. 2. Disease, injury, and illness (pp. 313–346). Boston: Allyn & Bacon. Vasey, M. W., Crnic, K. A., & Carter, W. G. (1994). Worry in childhood: A developmental perspective. Cognitive Therapy and Research, 18, 529–549. Vasey, M. W., & Daleiden, E. L. (1994). Worry in children. In G. C. L. Davey & F. Tallis (Eds.), Worrying: Perspective on theory, assessment and treatment (pp. 185–207). Chichester, England: Wiley. Vasey, M. W., & Lonigan, C. J. (2000). Considering the clinical utility of performance-based measures of childhood anxiety. Journal of Clinical Child Psychology, 29, 493–508. Vernberg, E. M. (1990). Psychological adjustment and experiences with peers during early adolescence: Reciprocal, incidental, or unidirectional relationships? Journal of Abnormal Child Psychology, 18, 187–198. Vernberg, E. M., La Greca, A. M., Silverman, W. K., & Prinstein, M. J. (1996). Prediction of posttraumatic stress symptoms in children after Hurricane Andrew. Journal of Abnormal Psychology, 105, 237–248. Vetter, D. K. (1980). Speech and language disorders. In S. Gabel & M. T. Erickson (Eds.), Child development and developmental disabilities (pp. 303–320). Boston: Little, Brown. Visher, E., & Visher, J. (1991). How to win as a stepfamily. New York: Brunner/Mazel. Vitiello, B., Bhatara, V., & Jensen, P. S. (1999). Current knowledge and unmet needs in pediatric psychopharmacology. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 501–565. Vitiello, B., Severe, J. B., Greenhill, L. L., Arnold, L. E., Abikoff, H. B., Bukstein, O. G., Elliott, G. R., Hechtman, L., Jensen, P. S., Hinshaw, S. P., March, J. S., Newcorn, J. H., Swanson, J. M., & Cantwell, D. P. (2001). Methylphenidate dosage for children with ADHD over time under controlled conditions: Lessons from the MTA. Journal of American Academy of Child and Adolescent Psychiatry, 40, 188–196. Vitulano, L. A., King, R. A., Schahill, L., & Cohen, D. J. (1992). Behavioral treatment of children and adolescents with trichotillomania. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 139–146. Vogel, W., Young, M., & Primack, W. (1996). A survey of physician use of treatment methods for functional enuresis. Developmental and Behavioral Pediatrics, 17, 90–93. Volkmar, F. R., & Schwab-Stone, M. (1996). Annotation: Childhood disorders of DSM-IV. Journal of Child Psychology and Psychiatry, 37, 779–784. Volling, B. L., & Feagans, L. V. (1995). Infant day care and children’s social competence. Infant Behavior and Development, 18, 177–188. Wachter, O. (1983). No more secrets for me. Boston: Little, Brown. Wadsworth, M. E., Hudziak, J. J., Heath, A. C., & Achenbach, T. M. (2001). Latent class analysis of the Child Behavior Checklist anxiety/depression in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 106–114. Wagner, K. D., & Ambrosini, P. J. (2001). Childhood depression: Pharmacological therapy/treatment (pharmacotherapy of childhood depression). Journal of Clinical Child Psychology, 30, 88–97. Wagner, W. G., Smith, D., & Norris, W. R. (1988). The psychological adjustment of enuretic children: A comparison of two types. Journal of Pediatric Psychology, 13, 33–38. Wahler, R. G. (1980). The insular mother: Her problems in parent–child treatment. Journal of Applied Behavior Analysis, 13, 207–219. Wahler, R. G., Cartor, P. G., Fleischman, J., & Lambert, W. (1993). The impact of synthesis teaching and parent training with mothers of conduct-disordered children. Journal of Abnormal Child Psychology, 21, 425–441.

608

References

Wahler, R. G., & Dumas, J. E. (1984). Changing the observational coding styles of insular and noninsular mothers. In R. F. Dangel & R. A. Polster (Eds.), Parent training (pp. 379–416). New York: Guilford Press. Wahler, R. G., Herring, M., & Edwards, M. (2001). Coregulation of balance between children’s prosocial approaches and acts of compliance: A pathway to mother-child cooperation. Journal of Clinical Child Psychology, 30, 473–478. Wakschlag, L. S., & Hans, S. L. (1999). Relation of maternal responsiveness during infancy to the development of behavior problems in high-risk youths. Developmental Psychology, 35, 569–579. Wakschlag, L. A., & Keenan, K. (2001). Clinical significance and correlates of disruptive behavior in environmentally at-risk preschoolers. Journal of Clinical Child Psychology, 30, 262–275. Wald, A., Chandra, R., Chiponis, D., & Gabel, S. (1986). Anorectal function and continence mechanisms in childhood encopresis. Journal of Pediatric Gastroenterology and Nutrition, 5, 346–351. Waldman, I. D. (1996). Aggressive boys’ hostile perceptual and response biases: The role of attention and impulsivity. Child Development, 67, 1015–1033. Walker, C. E. (1978). Toilet training, enuresis, and encopresis. In P. R. Magrab (Ed.), Psychological management of pediatric problems (Vol. 1, pp. 129–189). Baltimore: University Park Press. Walker, C. E. (1995). Elimination disorders: Enuresis and encopresis. In M. C. Roberts (Ed.), Handbook of pediatric psychology (2nd ed., pp. 537–557). New York: Guilford Press. Walker, C. E., Bonner, B. L., & Kaufman, K. L. (1988). The physically and sexually abused child: Evaluation and treatment. Elmsford, NY: Pergamon Press. Walker, C. E., Milling, L. S., & Bonner, B. L. (1988). Incontinence disorders: Enuresis and encopresis. In D. K. Routh (Ed.), Handbook of pediatric psychology (pp. 363–397). New York: Guilford Press. Walker, H. M., Stiller, B., Severson, H. H., Feil, E. G., & Golly, A. (1998). First step to success: Intervening at the point of school entry to prevent antisocial behavior patterns. Psychology in the Schools, 35, 259– 270. Walker, J. L., Lahey, B. B., Russo, M. F., Frick, P. J., Christ, M. A., McBurnett, K., Loeber, R., StouthamerLoeber, M., & Green, S. M. (1991). Anxiety, inhibition, and conduct disorder in children: I. Relations to social impairment. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 187– 191. Walkup, J. T., Khan, S., Schuerholz, L., Paik, Y., Leckman, J. F., & Schultz, R. T. (1999). Phenomonology and natural history of tic-related ADHD and learning disabilities. In J. F. Leckman & D. J. Cohen (Eds.), Tourette’s syndrome—tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 63–79). New York: Wiley. Walkup, J. T., Rosenberg, L. A., Brown, J., & Singer, H. S. (1992). The validity of instruments measuring tic severity in Tourette’s Syndrome. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 472–477. Wallace, I. F., Gravel, J. S., McCarton, C. M., & Ruben, R. J. (1988). Otitis media and language delays at 1 year of age. Journal of Speech and Hearing Disorders, 53, 245–251. Wallace, I. F., Gravel, J. S., Schwartz, R. G., & Ruben, R. J. (1996). Otitis media, communication style of primary caregivers, and language skills of 2 year olds: A preliminary report. Developmental and Behavioral Pediatrics, 17, 27–35. Wallace, M. (1999). Birth order blues: How parents can help their children meet the challenge of birth order. New York: Henry Holt. Wallerstein, J. S., & Kelly, J. (1980). Surviving the breakup: How children and parents cope with divorce. New York: Basic Books. Wallerstein, J. S., & Lewis, J. (1998). The long-term impact of divorce on children: A first report from a 25– year study. Family and Conciliation Courts Review, 36, 368–383. Walton, L., Oliver, C., & Griffin, C. (1999). Divorce mediation: The impact of mediation on the psychological well-being of children and parents. Journal of Community and Applied Social Psychology, 9, 35–46. Ward, I. L. (1984). The prenatal stress syndrome: Current status. Psychoneuroendocrinology, 9, 3–11. Ware, J. C., Orr, W. C., & Bond, T. (2001). Evaluation and treatment of sleep disorders in children. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (3rd ed., pp. 317–337). New York: Wiley. Warner, V., Mufson, L., & Weissman, M. M. (1995). Offspring at high and low risk for depression and anxiety: Mechanisms of psychiatric disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 786–797. Warren, M. K., Ollendick, T. H., & King, N. J. (1996). Test anxiety in children and adolescents: A clinical– developmental analysis. Behaviour Change, 13, 157–170.

References

609

Waterman, G. S., & Ryan, N. D. (1993). Pharmacological treatment of depression and anxiety in children and adolescents. School Psychology Review, 22, 228–242. Waterman, J. (1986). Developmental considerations. In K. MacFarlane & J. Waterman (Eds.), Sexual abuse of young children: Evaluation and treatment (pp. 15–29). New York: Guilford Press. Waters, E., & Cummings, E. M. (2000). A secure base from which to explore close relationships. Child Development, 71, 164–172. Watkins, B., & Bentovim, A. (1992). The sexual abuse of male children and adolescents: A review of current research. Journal of Child Psychology and Psychiatry, 33, 197–148. Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063–1070. Watson, D., & Tellegen, A. (1985). Toward a consensual structure of mood. Psychological Bulletin, 98, 219–235. Watson, T. S., & Allen, K. D. (1993). Elimination of thumb-sucking as a treatment for severe trichotillomania. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 830–834. Watson, T. S., & Sterling, H. E. (1998). Habits and tics. In T. S. Watson & F. M. Gresham (Eds.). Handbook of child behavior therapy (pp. 431–450). New York: Plenum Press. Webster-Stratton, C. (1982). Long-term effects of a videotape modeling parent education program: Comparison of immediate and 1–year follow-up results. Behavior Therapy, 13, 712–714. Webster-Stratton, C. (1984). Randomized trial of two parent-training programs for families with conductdisordered children. Journal of Consulting and Clinical Psychology, 52, 666–678. Webster-Stratton, C. (1985a). Predictors of treatment outcome in parent training for conduct disordered children. Behavior Therapy, 16, 223–243. Webster-Stratton, C. (1985b). The effects of father involvement in parent training for conduct problem children. Journal of Child Psychology and Psychiatry, 26, 801–810. Webster-Stratton, C. (1992a). Individually administered videotape parent training: “Who benefits?” Cognitive Therapy and Research, 16, 31–52. Webster-Stratton, C. (1992b). The incredible years: A trouble-shooting guide for parents of children aged 3– 8. Toronto: Umbrella Press. Webster-Stratton, C. (1993). Strategies for helping early school-aged children with oppositional defiant disorders and/or conduct disorders: The importance of home–school connections. School Psychology Review, 22, 437–457. Webster-Stratton, C., & Hammond, M. (1988). Maternal depression and its relationship to life stress, perceptions of child behavior problems, parenting behaviors, and child conduct problems. Journal of Abnormal Child Psychology, 16, 299–315. Webster-Stratton, C., & Hammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65, 93–109. Webster-Stratton, C., & Hammond, M. (1998). Conduct problems and level of social competence in Head Start children. Clinical Child and Family Psychology Review, 1, 101–124. Webster-Stratton, C., Hollinsworth, T., & Kolpacoff, M. (1989). The long-term effectiveness and clinical significance of three cost-effective training programs for families with conduct-problem children. Journal of Consulting and Clinical Psychology, 57, 550–553. Webster-Stratton, C., & Lindsay, D. W. (1999). Social competence and conduct problems in young children: Issues in assessment. Journal of Clinical Child Psychology, 28, 25–43. Webster-Stratton, C., Reid, M. J., & Hammond, M. (2001). Preventing conduct problems, promoting social competence: A parent and teacher training partnership in Head Start. Journal of Clinical Child Psychology, 30, 283–302. Webster-Stratton, C., & Spitzer, A. (1996). Parenting a young child with conduct problems. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 18, pp. 1–62). New York: Plenum Press. Wehbe, M. A. (1982). An orthopaedic solution to thumbsucking. Journal of the Iowa Medical Society, 72, 412–413. Wehrspann, W. H., Steinhauer, P. D., & Klajner-Diamond, H. K. (1987). Criteria and methodology for assessing credibility of sexual abuse allegation. Canadian Journal of Psychiatry, 32, 615–623. Weinberg, M. K., & Tronick, E. Z. (1997). Maternal depression and infant maladjustment: A failure of mutual regulation. In J. Nospitz, S. Greenspan, S. Weider, & J. Osofsky (Eds.), The handbook of child and adolescent psychiatry: Vol. 1. Infants and preschoolers: Development and syndromes (pp. 177–191). New York: Wiley. Weiss, B., Catron, T., Harris, V., & Phung, T. M. (1999). The effectiveness of traditional child psychotherapy. Journal of Consulting and Clinical Psychology, 67, 82–94. Weiss, G., & Hechtman, L. T. (1993). Hyperactive children grown up: ADHD in children, adolescents, and adults (2nd ed.). New York: Guilford Press.

610

References

Weiss, G., Hechtman, L., Milroy, T., & Perlman, T. (1985). Psychiatric status of hyperactives as adults: A controlled prospective 15 year follow up of 63 hyperactive children. Journal of the American Academy of Child Psychiatry, 23, 211–220. Weiss, M., Hechtman, L., & Weiss, G. (2000). ADHD in parents. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1059–1061. Weissenberger, A. A., Leschek, E. W., & Zametkin, A. J. (2001). Case study: Sexual hyperactivity treated with psychostimulants in familial male precocious puberty. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 373–376. Weisz, J. R., & Jensen, P. S. (1999). Efficacy and effectiveness of child and adolescent psychotherapy and pharacotherapy. Mental Health Services Research, 1, 125–157. Weisz, J. R., & Weiss, B. (1989). Assessing the effects of clinic-based psychotherapy with children and adolescents. Journal of Consulting and Clincial Psychology, 57, 741–746. Weisz, J. R., Weiss, B., Han, S. S., Granger, D. A., & Morton, T. (1995). Effects of psychotherapy with children and adolescents revisited: A meta-analysis of treatment outcome studies. Psychological Bulletin, 117, 450–468. Weithorn, L. A. (Ed.). (1987). Psychology and child custody determinations: Knowledge, roles and expertise. Lincoln: University of Nebraska Press. Weithorn, L. A., & Grisso, T. (1987). Psychological evaluations in divorce custody: Problems, principles, and procedures. In L. A. Weithorn (Ed.), Psychology and child custody determinations: Knowledge, roles and expertise (pp. 157–181). Lincoln: University of Nebraska Press. Weller, E. B., Weller, R. A., & Fristad, M. A. (1995). Bipolar disorder in children: Misdiagnosis, underdiagnosis, and future directions. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 709–714. Weller, E. B., Weller, R. A., Fristad, M. A., Cain, S. E., & Bowes, J. M. (1988). Should children attend their parent’s funeral? Journal of the American Academy of Child and Adolescent Psychiatry, 27, 559–562. Wenning, K., & King, S. (1995). Parent orientation meetings to improve attendance and access at a child psychiatric clinic. Psychiatric Services, 46, 831–833. Werle, M. A., Murphy, T. B., & Budd, K. S. (1993). Treating chronic food refusal in young children: Homebased parent training. Journal of Applied Behavior Analysis, 26, 421–433. Werry, J. S. (2001). Pharmacological treatments of autism, attention deficit hyperactivity disorder, oppositional defiant disorder, and depression in children and youth: Commentary. Journal of Clinical Child Psychology, 30, 110–113. Werry, J. S., Reeves, J. C., & Elkin, G. S. (1987). Attention deficit, conduct, oppositional, and anxiety disorders in children: I. A review of research on differentiating characteristics. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 133–143. Whalen, C. K., & Henker, B. (1986). Cognitive behavior therapy for hyperactive children: What do we know? Journal of Children in Contemporary Society, 19, 123–141. Whalen, C. K., & Henker, B. (1998). Attention-deficit/hyperactivity disorders. In T. H. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (pp. 181–211). New York: Plenum Press. Whaley, S. E., Pinto, A., & Sigman, M. (1999). Characterizing interactions between anxious mothers and their children. Journal of Consulting and Clinical Psychology, 67, 826–836. White, E. A., Elsom, B., & Prawat, R. (1978). Children’s conceptions of death. Child Development, 49, 307– 310. Whitehead, W. E. (1992). Biofeedback treatment of gastrointestinal disorders. Biofeedback and Self-Regulation, 17, 59–76. Wickramaratne, P. J., Greenwald, S., & Weissman, M. M. (2000). Psychiatric disorders in the relatives of probands with prepubertal-onset or adolescent-onset major depression. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1396–1405. Widiger, T. A., Francis, A. J., Davis, W., & First, M. (Eds.). (1994). DSM-IV sourcebook (Vol. 1). Washington, DC: American Psychiatric Association. Wiener, J. M. (Ed.). (1996). Diagnosis and psychopharmacology of childhood and adolescent disorders (2nd ed.). New York: Wiley. Wilens, T. E. (1998). Straight talk about psychiatric medications for kids. New York: Guilford Press. Wilens, T. E., & Biederman, J. (1992). The stimulants. Pediatric Psychopharmacology, 15, 191–222. Wilkoff, W. G. (1998). Coping with a picky eater: A guide for the perplexed parent. New York: Fireside. Williamson, D. A., Bentz, B. G., & Rabalais, J. Y. (1998). Eating disorders. In T. H. Ollendick & M. Hersen (Eds.), Handbook of child psychopathology (3rd ed., pp. 291–305). New York: Plenum Press. Williamson, D. A., Womble, L. G., & Zucker, N. L. (1998). Cognitive behavior therapy for eating disorders. In T. S. Watson & F. M. Gresham (Eds.), Handbook of child behavior therapy (pp. 335–356). New York: Plenum Press.

References

611

Willoughby, M. T., Curran, P. J., Costello, J., & Angold, A. (2000). Implications of early versus late onset of attention deficit disorder symptoms. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1512–1519. Wilson, G. T. (1994). Behavioral treatment of obesity: Thirty years and counting. Advances in Behavior Therapy, 27, 417–439. Wilson, G. T. (1998). Manual-based treatment and clinical practice. Clinical Psychology: Science and Practice, 5, 363–375. Winchel, R. M., Jones, J. S., Molcho, A., Parsons, B., Stanley, B., & Stanley, M. (1992). The Psychiatric Institute Trichotillomania Scale (PITS). Psychopharmacology Bulletin, 28, 463–476. Wirt, R. D., Lachar, D., Klinedinst, J. K., & Seat, P. S. (1990). Personality inventory for children—1990 edition. Los Angeles: Western Psychological Services. Wisniewski, L., & Marcus, M. D. (1998). Childhood obesity. In V. B. VanHasselt & M. Hersen (Eds.), Handbook of psychological treatment protocols for children and adolescents (pp. 179–201). Mahwah, NJ: Erlbaum. Witelson, S. F. (1993). Clinical neurology as data for basic neuroscience: Tourette’s syndrome and the human motor system. Neurology, 43, 859–861. Wolchik, S. A., West, S. G., Westover, S., Sandler, I. N., Martin, A., Lustig, J. L., Tein, J., & Fisher, J. L. (1993). The children of divorce parenting intervention: Outcome evaluation of an empirically based program. American Journal of Community Psychology, 21, 293–332. Wolfe, D. A., Edwards, B., Manion, I., & Koverola, C. (1988). Early intervention for parents at risk of child abuse and neglect: A preliminary investigation. Journal of Consulting and Clinical Psychology, 56, 40– 47. Wolfe, D. A., Reppucci, N. D., & Hart, S. (1995). Child abuse prevention: Knowledge and priorities. Journal of Clinical Child Psychology, 24(Suppl.), 5–22. Wolfe, V. V., & Birt, J. (1995). The psychological sequelae of child sexual abuse. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (Vol. 17, pp. 233–263). New York: Plenum Press. Wolfe, V. V., & Birt, J. (1997). Child sexual abuse. In E. J. Mash & L. G. Terdal (Eds.), Assessment of childhood disorders (3rd ed., pp. 569–623). New York: Guilford Press. Wolfson, A., Lacks, P., & Futterman, A. (1992). Effects of parent training on infant sleeping patterns, parents’ stress, and perceived parental competence. Journal of Consulting and Clinical Psychology, 60, 41–48. Wolkind, S. N., Zajicek-Coleman, E., & Ghodsian, M. (1980). Continuities in maternal depression. International Journal of Family Psychiatry, 1, 167–182. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press. Wolraich, M. L., Felice, M. E., & Drotar, D. (Eds.). (1996). The diagnostic and statistical manual for primary care (DSM-PC), child and adolescent version. Elk Grove, IL: American Academy of Pediatrics. Wolraich, M., Hannah, J. N., Pinnock, T., Baumgaertel, A., & Brown, J. (1996). Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 319–324. Wolraich, M., Wilson, D. B., & White, J. W. (1995). The effect of sugar on behavior or cognition in children. Journal of the American Medical Association, 274, 1617–1621. Wood, J. M., & Bootzin, R. R. (1990). The prevalence of nightmares and their independence from anxiety. Journal of Abnormal Psychology, 99, 64–68. Woodward, L. J., & Fergusson, D. M. (2001). Life course outcomes of young people with anxiety disorders in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 1086–1093. Woodward, L., Taylor, E., & Dowdney, L. (1998). The parenting and family functioning of children with hyperactivity. Journal of Child Psychology and Psychiatry, 39, 161–169. Worden, J. S., Davies, B., & McCown, D. (1999). Comparing parent loss with sibling loss. Death Studies, 23, 1–15. Worden, J. W., & Silverman, P. R. (1993). Grief and depression in newly widowed parents with school-age children. Omega, 27, 251–260. World Health Organization. (1992). Mental disorders: Glossary and guide to their classification in accordance with the tenth revision of the International Classification of Diseases. Geneva: Author. World Health Organization. (1993). The ICD-10 classification of mental and behavioral disorders: Diagnostic criteria for research. Geneva: Author. Worling, J. R., & Curwen, T. (2000). Adolescent sexual offender recidivism: Success of specialized treatment and implications for risk prediction. Child Abuse and Neglect, 24, 965–982. Wozniak, J., Biederman, J., Kiely, K., et al. (1995). Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 867–876.

612

References

Wozniak, J., Biederman, J., Mundy, E., Mennin, D., & Faraone, S. V. (1995). A pilot family study of childhood-onset mania. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1577–1583. Wren, F. J., & Tarbell, S. E. (1998). Feeding and growth disorders. In R. T. Ammerman & J. V. Campo (Eds.), Handbook of pediatric psychology and psychiatry: Vol. 2. Disease, injury, and illness (pp. 133–165). Needham Heights, MA: Allyn & Bacon. Wright, L. (1975). Outcome of a standardized program for treating psychogenic encopresis. Professional Psychology, 6, 453–456. Wright, L., & Walker, C. E. (1976). Behavioral treatment of encopresis. Journal of Pediatric Psychology, 4, 35–37. Wu, P., Hoven, C. W., Bird, H. R., Moore, R. E., Cohen, P., Alegria, M., Dulcan, M. K., Goodman, S. H., Morwitz, S. M., Lichtman, J. H., Narrow, W. E., Rae, D. S., Regier, D. A., & Roper, M. T. (1999). Depressive and disruptive disorders and mental health service utilization in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1081–1090. Wurtele, S. K. (1990). Teaching personal safety skills to four-year-old children: A behavioral approach. Behavior Therapy, 21, 25–32. Wurtele, S. K., Currier, L. L., Gillispie, E. I., & Franklin, C. F. (1991). The efficacy of a parent-implemented program for teaching preschoolers personal safety skills. Behavior Therapy, 22, 69–83. Wurtele, S. K., Kast, L. C., & Melzer, A. M. (1992). Sexual abuse prevention education for young children. A comparison of teachers and parents as instructors. Child Abuse and Neglect, 16, 855–876. Wurtele, S. K., Kast, L. C., Miller-Perrin, C. L., & Kondrick, P. A. (1989). Comparison of programs for teaching personal safety skills to preschoolers. Journal of Consulting and Clinical Psychology, 57, 505–511. Wurtele, S. K., & Miller, C. L. (1987). Children’s conceptions of sexual abuse. Journal of Clinical Child Psychology, 16, 184–191. Wurtele, S. K., & Miller-Perrin, C. L. (1992). Preventing child abuse: Sharing the responsibility. Lincoln, NE: University of Nebraska Press. Wyatt, G. E. (1985). The sexual abuse of African American and European American women in childhood. Child Abuse and Neglect, 9, 507–519. Wyatt, G. E., Loeb, T. B., Solis, B., & Carmona, J. V. (1999). The prevalence and circumstances of child sexual abuse: Changes across a decade. Child Abuse and Neglect, 23, 45–60. Wyer, M. M., Gaylord, S. J., & Grove, E. T. (1987). The legal context of child custody evaluations. In L. A. Weithorn (Ed.), Psychology and child custody determinations: Knowledge, roles and expertise (pp. 3– 22). Lincoln: University of Nebraska Press. Yates, A. J. (1958). The application of learning theory to the treatment of tics. Journal of Abnormal and Social Psychology, 56, 175–182. Young, R. C., Biggs, J. T., Ziegler, V. E.,, & Meyer, D. A. (1978). A rating scale for mania: reliability, validity and sensitivity. British Journal of Psychiatry, 133, 429–435. Young, G. C., & Morgan, R. T. T. (1972). Overlearning in the conditioning treatment of enuresis. Behaviour Research and Therapy, 10, 419–420. Young, M. H., Brennen, L. C., Baker, R. D., & Baker, S. S. (1995). Functional encopresis: Symptom reduction and behavioral improvement. Developmental and Behavioral Pediatrics, 16, 226–232. Yuille, J. C., Hunter, R., Joffe, R., & Saparniuk, J. (1993). Interviewing children in sexual abuse cases. In G. S. Goodman & B. L. Bottoms (Eds.), Child victims, child witnesses: Understanding and improving testimony (pp. 95–116). New York: Guilford Press. Zahn-Waxler, C., Cummings, E. M., McKnew, D. H., & Radke-Yarrow, J. (1984). Problem behaviors and peer interactions of young children with a manic–depressive parent. American Journal of Psychiatry, 141, 236–240. Zamir, G., Press, J., Tal, A., & Tarasiuk, A. (1998). Sleep fragmentation in children with juvenile rheumatoid arthritis. Journal of Rheumatology, 6, 1191–1197. Zaslow, M. J. (1988). Sex differences in children’s response to parental divorce: 1. Research methodology and post-divorce family forms. American Journal of Orthopsychiatry, 58, 353–378. Zaslow, M. J. (1989). Sex differences in children’s response to parental divorce: 2. Samples, variables, ages, and sources. American Journal of Orthopsychiatry, 59, 118–141. Zero to Three. (1994). Diagnostic classification, 0–3: Diagnostic classification of mental health and developmental disorders of infancy and early childhood. Arlington, VA: Zero to Three/National Center for Clinical Infant Programs. Zigler, E., Taussig, C., & Black, K. (1992). Early childhood intervention: A promising preventative for juvenile delinquency. American Psychologist, 47, 997–1006. Zito, J. M., Sager, D. J., Dos-Reis, S., Gardner, J. R., Boles, M., & Lynch, F. (2000). Trends in prescribing of psychotropic medications to preschoolers. Journal of the American Medical Association, 283, 1025–1030.

References

613

Zoccolillo, M., Pickles, A., Quinton, D., & Rutter, M. (1992). The outcome of conduct disorder: Implications for defining adult personality disorder and conduct disorder. Psychological Medicine, 22, 1–16. Zohar, A. J., Apter, A., King, R. A., Pauls, D. L., Leckman, J. F., & Cohen, D. J. (1999). Epidemiological studies. In J. F. Leckman & D. J. Cohen (Eds.), Tourette’s syndrome—tics, obsessions, compulsions: Developmental psychopathology and clinical care (pp. 177–193). New York: Wiley. Zucker, K. J. (1990a). Gender identity disorders in children. In R. Blanchard & B. W. Steineer (Eds.), Clinical management of gender identity disorders in children and adults (pp. 3–23). Washington, DC: American Psychiatric Press. Zucker, K. J. (1990b). Treatment of gender identity disorders in children. In R. Blanchard & B. W. Steiner (Eds.), Clinical management of gender identity disorders in children and adults (pp. 27–45). Washington, DC: American Psychiatric Press. Zucker, K. J., & Bradley, S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York: Guilford Press. Zucker, K. J., & Green, R. (1992). Psychosexual disorders in children and adolescents. Journal of Psychology and Psychiatry, 33, 107–151. Zuckerman, B., Als, H., Bauchner, H., Parker, S., & Cabral, H. (1990). Maternal depressive symptoms during pregnancy and newborn irritability. Developmental and Behavioral Pediatrics, 11, 190–194. Zuckerman, B. S., & Blitzer, E. C. (1981). Sleep disorders. In S. Gabel (Ed.), Behavioral problems in childhood: A primary care approach (pp. 257–272). New York: Grune & Stratton.

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Index

Academic Performance Rating Scale (APRS), 399, 536–538 Academic problems attention-deficit/hyperactivity disorder, 385, 386 and depression, 311 “Accentuation principle,” 340 Accidental injuries, prevention, 33, 34 Adderall, 408 ADHD (see Attention-deficit/ hyperactivity disorder) ADHD Classroom Kit, 406, 407 ADHD, combined type developmental course, 389–393 diagnostic criteria, 378–381 peer relations, 385 ADHD, hyperactive–impulsive type developmental course, 389–393 diagnostic criteria, 378–381 prevalence, 382, 383 symptomatology, 381, 382 ADHD, inattentive type developmental course, 389–393 diagnostic criteria, 378–381 peer relations, 385 prevalence, 382, 383 symptomatology, 381, 382 ADHD Rating Scale—IV, 395, 412 Adolescent sex offenders, 233, 234 Aerobic exercise, obesity treatment, 95 Affective education, 323 Age factors (see Developmental status) Aggression developmental aspects, 348, 349 gender differences, 348 psychoactive medication, 373 siblings, 348, 425 Albany Sleep Problem Scale, 199 Alopecia areata, 163 Anatomically detailed dolls, 244, 245 Androgens disruptive behavior disorders, 343 and gender identity disorder, 228

Anger control training, parents, 324 Antidepressants (see Imipramine; Selective serotonin reuptake inhibitors) Antisocial personality disorder, 337, 338, 340–342 Anxiety, 262–301 assessment, 280–287 definition, 263, 264 development, 264–267 etiological theories, 278–280 versus fear, 263, 264 measurement instruments, 500–502 treatment, 287–301 Anxiety disorders, 269–275 assessment, 280–287, 500–502 behavioral observation, 286 biological/genetic factors, 279, 280 child interview, 285, 286 cognitive-behavioral approaches, 291, 292 cognitive factors, 279 comorbidity, 277, 278, 305, 306 conduct disorder comorbidity, 337, 338 and depression, 277, 278, 305, 306 DSM-IV symptoms, 269, 270 etiology, 278–280 general characteristics, 275–280 intervention with parents, 293, 294 learning theories, 278, 279 measurement instruments, 500– 502 medication, 295, 296 modeling procedures, 290, 291 parent interview, 283–285 persistence of, 276 risk factors, 281, 282 systematic desensitization, 288, 289 treatment, 287–301 Appetite and food refusal problems, 108 normal development, 82, 83 Arousal training, enuresis, 129, 130 Assertiveness training, obesity, 97

615

Assessment, 40–78 (see also under specific disorders) case examples, 49, 57, 58 intervention link, 50–56 methods, 56–73 planning of, 48, 49 Assessment-to-intervention system, comprehensive, 50–56 Attachment relationship (see also Insecure attachment) developmental effects, 9, 10 disruptive behavior disorders, 344 and temperament, 10, 11 Attention-deficit/hyperactivity disorder, 377–416 adolescent, 392 adult, 392, 393 anxiety disorders comorbidity, 278, 384 assessment, 393–402, 499, 500 behavioral interventions, 402–407 biological factors, 386–388 bipolar disorder comorbidity, 307 case example, 413–416 child interview, 397, 398 comorbidity, 384–386 conduct disorder comorbidity, 337, 384 depression comorbidity, 306, 384 developmental course, 389–393 diagnostic criteria, 378–381 etiology, 386–389 measurement instruments, 499, 500 medication, 402, 403, 407–413 NIMH consensus findings, 377, 378 NIMH multimodal treatment study, 402, 403 observation of behavior, 398, 399 parent interview, 395–397 persistence, 383 prevalence, 382, 383 referrals, 401 symptomatology, 381, 382 teacher interview, 399, 400 and tic disorders, 170, 171 treatment, 402–416

616 Attributional style, in depression, 312 Attrition, determinants of, 75, 76 Authoritarian parenting, 27 Autonomic underarousal, 342, 343 Awareness training, habits and tics, 176, 177 Barbiturates, 196 BASC (Behavior Assessment System for Children) attention-deficit/hyperactivity disorder, 394–395 characteristics, 59, 489, 493, 495, 497, 498 depression, 316 disruptive behavior disorders, 350 divorce, 451 encopresis, 144 enuresis, 124 fears and anxieties, 283 food refusal, 103 habits and tics, 171 obesity, 90 sibling conflict, 427 BASC—Parent Rating Scale, 489 BASC—Self-Report of Personality, 69, 495 BASC—Structured Diagnostic History, 498 BASC—Student Observation System, 66, 497 BASC—Teacher Rating Scale availability, 493 characteristics, 67, 68, 493 depression assessment, 321 Beck Depression Inventory—II description and availability, 502, 503 parental depression, 321, 428 Bedtime problems description, 193, 194 management, 207–211 Behavior Assessment System for Children (see BASC) Behavioral avoidance test, 286 Behavioral inhibition (BI), 274, 280 Behavioral interventions anxiety disorders, 287 attention-deficit/hyperactivity disorder, 402–407 encopresis, 147–149 enuresis, 134–137 food refusal problems, 107–109 obesity, 96–98 sibling adjustment, 423 thumb sucking, 160, 161 trichotillomania, 164 Behavioral observations (see Observation of behavior) Behavioral regulation, preschoolers, 14–16 Bell-and-pad method (see Urine alarm; Arousal training) Benzodiazepines anxiety disorders, 295, 296 nightmares, 196 REM sleep behavior disorder, 197 sleep terrors, 199

Index Bereavement, 466–485 adjustment to, 468–470 assessment, 474–477 case examples, 480–485 child interview, 476 funeral attendance issue, 470 interventions, 477–480 problem-solving intervention, 484, 485 referral criteria, 476 short-term versus long-term reactions, 468 support groups, 477, 478 “Best interests of the child,” 448 Betrayal of trust, and sexual abuse, 283 Bibliotherapy divorce, 456–458, 461 sibling conflict, 432 Biofeedback, encopresis, 147–149 Bipolar disorder definition, 303 comorbidity, 307 Bladder retention training, 130, 131 Body mass index (BMI), and obesity, 89, 90 Body rocking, 197, 206 Bowel movements, encopresis assessment, 144, 145 Bowel training, 117–120 Boys bereavement response, 469 delayed puberty effects, 226 divorce adjustment, 445 fears, 266 risk and protective factors, 19 sexual abuse effects, 235, 236 sexual abuse prevalence, 232 sexually aggressive behavior, 230, 231 Breath holding, 165 Bruxism, 162 behavioral observation, 175 description, 162 treatment, 162 “Cafeteria” studies, 84 Callous–unemotional traits, 335, 336 Calorie reduction, obesity treatment, 95, 96 Cancer, childhood, 470–474 Cataplexy, 191 Categorical diagnosis, 41–45 versus dimensional approach, 43– 45 disruptive behavior disorders, 332– 334 overview, 41–43 Child abuse, prevention, 36–39 (see also Sexual abuse) Child Assessment Schedule (CAS), 316 Child Attention Problems (CAP) scale, 399, 534, 535 Child Behavior Checklist (CBCL), 43–45, 59, 66–68 attention-deficit/hyperactivity disorder, 394 availability, 490, 494, 497

depression, 316 dimensional approach in, 43–45 disruptive behavior disorders, 350 divorce, 450–451 encopresis, 144 enuresis, 124 fears and anxiety, 283 food refusal, 103 habits and tics, 171 obesity, 90 posttraumatic stress disorder, 240 sexual abuse, 239, 240 sibling conflict, 427 sleep problems, 199 Tourette’s disorder, 170 Child Behavior Checklist—Direct Observation Form characteristics, 66, 497, 498 disruptive behavior disorders, 354 Child Behavior Checklist—Teacher’s Report Form characteristics, 67, 68 depression, 321 disruptive behavior, 356 Child Behavior Checklist—Youth Self Report, 495 Child custody (see Custody arrangements) Child interview, 63, 64 anxiety disorders, 285, 286 in assessment process, 63, 64 attention-deficit/hyperactivity disorder, 397, 398 bereavement assessment, 476 depression, 318 disruptive behavior disorders, 353, 354 divorce adjustment, 453 encopresis, 144, 145, 156, 157 enuresis, 124–127 habit and tic disorders, 174, 175, 184 obesity assessment, 90, 91, 99, 100 sexual abuse, 241–245, 259, 260 sleep problems, 202, 203 Child sexual abuse (see Sexual abuse) Child Sexual Behavior Inventory— Revised (CSBI-R) availability, 492 characteristics, 239, 240, 492 Childhood-onset conduct disorder, 333, 334 Children’s Depression Inventory (CDI), 69, 318 availability, 500 characteristics, 69, 500 Children’s Eating Behavior Inventory (CEBI), 530–533 food refusal assessment, 103 obesity assessment, 90 Children’s Fleet Enemas, 150 Children’s memory, sexual abuse, 237, 238 The Child’s Game, 362–365 Chronic tic disorder description, 167 etiology, 167, 168 treatment, 168, 169, 176–179

Index Circadian rhythms disorders, 193 and sleep disturbances, 189 Classification systems, 40–45 Classroom behavior, observational assessment, 66 “Classwide peer tutoring” (CWPT), 405 Clicker monitor, 96 Clinical interview, 60–65 (see also Child interview; Parent interview) Clinical Interview—Parent Report Form, 499 Clomipramine, 295 Clonazepam, 197 Clonidine, tic treatment, 182 Coding systems, behavioral observation, 65, 66 Coercive cycle, parent–child relationship, 349, 350 Cognitive-behavioral therapy anxiety disorders, 291, 292 attention-deficit/hyperactivity disorder, 403, 404 depression, 323–324 school refusal, 297 Cognitive development, 6, 16, 17 Cognitive distortions, in depression, 312 Cognitive restructuring depression, 324 obesity, 97 Cognitive skills training, antisocial behavior, 357, 358 Colic, 85 Community-based prevention, 374 Comorbidity (see under specific disorders) Competing-response training, 177, 178 Compliance–noncompliance, development, 346–348 Comprehension language disorders, 13, 14 Comprehensive Assessment-toIntervention System (CAIS), 50–56 Compulsive behavior, 165 Conduct disorder (CD), 331–376 ADHD comorbidity, 337, 384 adolescent onset, 333, 334 age-of-onset issue, 333, 334 assessment, 350–357 categorical classification, 332–334 comorbidity, 337, 338 depression comorbidity, 306, 338 dimensional classification, 334–336 DSM-IV criteria, 333, 334 and encopresis, 139 etiology, 341–345 family therapy, 372 gender differences, 336, 337, 342 observation of behavior, 354, 355 parent-training, 358–372 parenting practices link, 343, 344 prevalence, 336, 337 prevention, 373, 374 psychoactive medication, 372, 373 referral, 356

stability, 47, 48, 338–341 and temperament, 342, 343 treatment, 357–376 Conflict resolution, siblings, 427 Conners Rating Scales—Revised attention-deficit/hyperactivity disorder, 395, 499 description and availability, 499 limitations, 59 Constipation and encopresis, 139, 140, 142, 143, 150 physiology, 142, 143 Consultation, overview, 71, 72 Consumer satisfaction, 76, 77 Contingency management anxiety disorders, 295 attention-deficit/hyperactivity disorder, 404–406 habits and tics, 178, 179 in parent training programs, 371 Contingent negative practice chronic tics, 168, 179 habits and tics, 179 massed negative practice differences, 179 Continuous-performance tests, 400 Coping model, sexual abuse, 249 Coping Questionnaire, 285 Coping styles “active,” 473 “avoidant,” 473 divorce, 446, 447 terminally ill children, 472, 473 Corporal punishment, 25–27, 343, 344 Cortisol levels, disruptive behavior disorders, 343 Cosleeping, 190 Cost–benefit ratio, prevention programs, 31, 32 Court testimony case example, 261 sexual abuse, 255, 256, 261 Covert problems classification, 334, 335 informant biases, 69, 70 parent training programs, 371, 372 Cross-dressing, 229 Cross-gender behavior, 227–230 Cultural factors, and fears, 267 Custodial parent, 442, 443 Custody arrangements, 447–450 determination of, 447, 448 mother versus father, 449 Cyclothymic disorder, 305 Cylert (pemoline), 407 Daily Activities Diary, 93, 318, 320 Daily Log, 59, 512 anxiety disorders, 283 in initial assessment, 59 sibling conflict, 428 Dairy intake, encopresis, 151, 152 Day care, 28–31 quality of care in, 29, 30 as risk factor, 28–30 sexual abuse, 30, 31 Daytime wetting, 121, 132, 133

617 DC 0–3 approach, 43 Death, 466–485 (see also Bereavement) adjustment to, 468–470 children’s understanding of, 467, 468, 471 short-term versus long-term reactions, 468 “stages” in adaptation to, 473 Deep breathing, 178 Defiant behavior, toddlers, 11, 12 Delayed puberty, 226, 227 Depressed mothers (see Maternal depression) Depression, 302–330 anxiety disorders comorbidity, 277, 278, 305, 306 assessment, 315–322, 500–502 case example, 326–330 child interview, 318, 328 cognitive-behavioral therapy, 323, 324 cognitive distortions, 312 comorbidity, 305–308 definition and classification, 303– 305 developmental factors, 304, 309, 310 etiology, 313–315 family factors, 314, 315 genetics, 313 interventions with parents, 324 measurement instruments, 500– 502 medication guidelines, 325, 326 observation of behavior, 318, 321 parent interview, 316–318, 327, 328 peer relationships, 311 prevalence, 308, 309 prevention, 326 school and academic problems, 311 and sleep disorders, 188 and suicide, 310, 311 teacher interview, 321 transactional model, 315 treatment, 322–330 Desipramine, 198 Desmopressin acetate (DDAVP), 122, 131, 132 Destructive behavior, 334, 335 Developmental status, 4–18 assessment, 53, 54 and divorce effects, 445, 446 normative, 4–18 Dextroamphetamine (Dexedrine), 407, 408 Diagnostic and Statistical Manual of Mental Disorders (see DSM approach) Diagnostic and Statistical Manual for Primary Care, 42, 43 Diagnostic Classification of Mental Health . . . , 43 Diagnostic Interview Schedule for Children—IV availability, 498 characteristics, 498 depression assessment limitations, 316

618 Diapers, and toilet training, 117, 118 Diarrheic encopresis, 154, 155 Diazepan, 199 Diet encopresis, 151–153 obesity intervention, 96 Diet/Exercise Record, 146 Dietary fiber, encopresis treatment, 149, 151, 152 Differential attention technique, 108, 109 “Difficult temperament” and development, 10 disruptive behavior disorders, 342 and divorce effects, 444 parenting interactions, 23, 24 sibling conflict factor, 421, 426 and sleep problems, 194 Dimensional classification versus categorical approach, 43–45 disruptive behavior disorders, 334, 336 overview, 43–45 Direct observation (see Observation of behavior) Disciplinary strategies and child adjustment, 25–27 and disruptive behavior disorders, 343, 344 physical punishment effects, 25–27 Disorganized attachment, aggression link, 344 Disruptive behavior disorders, 331– 376 age-of-onset issue, 333, 334 assessment, 350–357 case example, 374–376 classification and diagnosis, 332– 336 development of, 345–350 etiology, 341–345 family therapy, 372 gender differences, 336, 337, 342 multiple-risk model, 345 observation of behavior, 354, 355 parent training, 358–372 parenting practices link, 343, 344 persistence, 336, 337 prevalence, 336, 337 prevention, 373, 374 psychoactive medication, 372, 373 stability, 47, 48, 338–341 and temperament, 342, 343 treatment, 357–376 Ditropan, 131, 132 “Diurnal” enuresis, 121 Divorce adjustment, 440–465 assessment, 450–455 case example, 462–465 child interview, 453 and child’s characteristics, 444– 447 and coping styles, 446, 447 and custody arrangements, 447– 450 developmental status factors, 445, 446 intervention with child, 455, 457 intervention with parents, 457–461

Index mediating factors, 440–450 and parent–child relationship, 442, 443 parent interview, 452, 453 parental conflict factor, 441, 442 and remarriage, 443, 444 risk-and-resilience model, 441 treatment, 455–462 visitation, 447–450 “Double depression,” 307 Drop-outs, from treatment, 75 Dry bed training (DBT), 131 Dry Pants Chart, 118 DSM approach, 41–43 attention-deficit/hyperactivity disorder, 378–381 dimensional approach comparison, 40–45 disruptive behavior disorders, 332– 334 overview, 41–43 Dyadic Adjustment Scale (DAS), 321, 400 description and availability, 502 parental depression, 321 sibling conflict, 428 Dyadic Parent–Child Interaction Coding System—II (DPICSII) availability, 497 characteristics, 65, 66, 497 disruptive behavior disorders, 354 Dyssomnias, 191–194 management, 205 overview, 191–194 Dysthymic disorder characteristics, 305 comorbidity, 307, 308 prevalence, 308 Early intervention programs, 34–36 disruptive behavior disorders, 372 family-focused, 34–36 guiding principles, 36 “Easy” temperament and divorce effects, 444 parenting interaction, 23, 24 Eating problems, 81–114 Ecological model (see Transactional model) “Effectiveness” studies, 74 “Efficacy” studies, 74 Emotional development, milestones, 7 Emotional regulation disruptive behavior disorders, 342 in divorce coping, 447 preschooler development, 14–16 Emotive imagery, 289 Encopresis, 139–158 anal spincters and, 147–149 assessment, 142–147 case example, 155–158 child interview, 144, 145, 155, 156 defecation, 140, 142, 143, 150 description, 139, 140 emotional factors, 141 etiology, 140–142

learning factors, 141, 142 medical treatment, 147–149 organic factors, 140, 141 parent interview, 144, 145, 155, 156 prevalence, 139, 140 subtypes, 139 treatment, 147–155 Enemas, encopresis treatment, 147– 150 Enuresis, 120–139 arousal training, 129, 130 assessment, 123–127 biological factors, 122, 123 bladder retention training, 130, 131 case example, 137–139 description, 120, 121 dry bed training, 131 emotional factors, 123 etiology, 121–123 learning factors, 123 medication, 131, 132 parent and child interviews, 124– 127 prevalence, 120, 121 sphincter control exercises, 130, 131 treatment, 127–139 urine alarm, 128–130, 134–137 Epidemiology (see Prevalence) Excessive sleepiness, 191–193 Executive functions, ADHD, 388 Exercise encopresis intervention, 151 obesity, 95, 96 Exposure technique, anxiety disorders, 289, 290 Externalizing problems, 69, 70 Extinction method food refusal problems, 108 sleep problems, 207, 208 Eyberg Child Behavior Inventory (ECBI) attention-deficit/hyperactivity disorder, 395 availability, 490 characteristics, 59, 490 disruptive behavior disorders, 350 divorce, 451 encopresis, 144 enuresis, 124 food refusal, 103 habits and tics, 171–172 obesity, 90 sibling conflict, 427–428 sleep problems, 199 Failure to thrive, 86–88 assessment and treatment, 88 etiology, 87, 88 prevalence, 87 psychosocial short stature differentiation, 88 False allegations, sexual abuse, 246 Family factors ADHD etiology, 389 depression etiology, 314, 315 Family-focused early intervention, 34–36

Index Family intervention anxiety disorders, 293 depression, 324 disruptive behavior disorders, 372 Fantasy play, in sibling adjustment, 423 FAST Track Prevention Trial for Conduct Problems, 373 Father custody, 449, 450 Fathers birth of new baby and, 420, 422– 423 child development role, 28 and divorce adjustment, 445 Fear Survey Schedule for Children— Revised (FSSC-R), 283, 517– 520 Fear thermometer, 285, 286 Fears, 262–301 versus anxiety, 263, 264 assessment, 280–287 categorization, 266 definition, 263, 264 development, 264–267 etiological theories, 278–280 sex differences, 266 socioeconomic factors, 266, 267 sources of, 268 treatment, 287–301 Feeding behavior, normal development, 82–85 Feeding problems, 81–85, 102–114 “Feelings book,” 323 Fiber diet, encopresis treatment, 149, 151, 152 Flooding, anxiety disorders, 289, 290 Fluoxetine (Prozac) anxiety disorders, 295, 296 depression, 325 Food diary, 92, 104 Food preparation, and encopresis, 153 Food refusal problems, 102–114 appetite manipulation, 108 assessment, 103–106 behavioral techniques, 107–109 case example, 109–114 differential attention technique, 108, 109 observational assessment, 105, 111 parent and child interviews, 103– 105, 110, 111 referrals, 106 treatment, 106–109 Foster parents, training programs, 77 Free Play, ADHD assessment, 399 Freedom from Distractibility factor, 394 Friend’s death, 469, 470 Friendships and depression, 311 in school-age children, 17, 18 “Functional bladder capacity,” 130 Funeral attendance, 470

Gender differences (see also Boys; Girls) ADHD, 382 aggression, 348 bereavement response, 469 conduct disorder, 336, 337, 342 depression, 309 divorce adjustment, 445 fears, 266 puberty effects, 226 sexual abuse effects, 235, 236 Gender identity age-related education in, 224, 225 development of, 227 Gender identity disorder, 227–230 diagnostic issues, 227 epidemiology, 227, 228 etiology, 228 long-term prognosis, 229 treatment, 229, 230 General Parent Questionnaire description, 59, 507–511 sexual abuse assessment, 239 Generalized anxiety disorder (GAD), 272, 273 assessment, 280–287 developmental differences, 272, 273 DSM-IV symptoms, 270 epidemiology, 271 general features, 272, 273 intervention with parents, 294 medication, 296 persistence of, 276 Generalized training, habits and tics, 179 Genetics attention-deficit/hyperactivity disorder, 387, 388 depression, 313 disruptive behavior disorders, 341, 342 Girls aggression, 348 bereavement response, 469 conduct disorder, 336, 337, 342 divorce adjustment, 445 fears, 266 precocious puberty effects, 226 risk and protective factors, 19 sexual abuse effects, 235, 236 sexual abuse prevalence, 232 sexually aggressive behavior, 230, 231 Glycerine suppository, 154 Going Back to School Chart, 300 “Goodness of fit,” 10 Grief, 466–485 (see also Bereavement) clinical depression distinction, 474 interventions, 477–480 Group treatment divorce adjustment problems, 456 sexual abuse, 250, 251 sleep problems, 204

Gastrointestinal system, and encopresis, 142, 143 Gay parents, 24, 25

Habit Diary, 172, 173 Habit reversal nail biting, 161, 162

619 overview, 176 thumb sucking, 160 tics, 168, 176 trichotillomania, 164 Habits, 159–165, 171–176 assessment, 171–176 behavioral observation, 175 case example, 182–185 overview, 159–165 parent interview, 172, 174 treatment, 176–179 Hair pulling (see Trichotillomania) Haloperidol, in Tourette syndrome, 182 Head banging, 197, 206 Head Start intervention, conduct problems, 374 Health status, assessment, 55 Heart rate, disruptive behavior disorders, 342, 343 Help-seeking, determinants, 75 Heritability depression, 313 disruptive behavior disorders, 341, 342 High-fiber diet, encopresis, 151, 152 Hirschsprung’s disease, 140 Home-based services, effectiveness, 77 Home Situations Questionnaire (HSQ) attention-deficit/hyperactivity disorder, 395, 412 description and availability, 499 disruptive behavior disorders, 351 Homosexual parents, 24, 25 Homosexuality, and gender identity disorder, 229 Hopelessness Scale for Children, 321, 526, 527 Hopkins Motor and Vocal Tic Scale, 172, 528, 529 “Hyperactivity–impulsivity” (see ADHD, hyperactive– impulsive type) Hypnagogic hallucinations, 191 Hypnotic drugs, effectiveness, 195 Imagery techniques, 288, 289 Imipramine (Tofranil) attention-deficit/hyperactivity disorder, 409 depression, 325 disruptive behaviors, 373 enuresis, 131, 132 school refusal, 296 sleep, 199 Implosion technique, anxiety disorders, 290 In vivo techniques, anxiety disorders, 288, 289 “Inattention” (see ADHD, inattentive type) Independence, toddler development, 11, 12 Infants attachment relationship, 9, 10 normal development, 5–11

620 Informants, integrating information from, 69, 70 Initiating sleep problems description, 193, 194 treatment, 194, 195, 205 Injury prevention, 33, 34 Insecure attachment developmental effects, 9, 10 disruptive behavior disorders link, 344 Intensive case management, 77 Intergenerational effects, parenting, 21, 22 Internalizing problems assessment, 69, 70, 318 informant biases, 69, 70 Internalizing Symptoms Scale for Children (ISSC), 318 International Classification of Diseases (ICD), 41 Interviews, 60–65 (see also Child interview; Parent interview) in assessment process, 60–65 with child, 64, 65 with parent(s), 61–63 Joint physical custody, 448, 449 Kegel exercises, enuresis, 130 “Labeled praise,” 361 Language development, 12–14 parenting influences, 12, 13 milestones, 7 Language disorders, 13, 14 Laxatives, encopresis treatment, 147– 149 Lead poisoning attention-deficit/hyperactivity disorder, 388 and pica, 85 Learned helplessness, and depression, 312 Learning disabilities and ADHD, 385, 386, 400 prevalence, 16 Learning factors anxiety disorders, 278, 279 encopresis, 141, 142 enuresis, 123 Lesbian parents, 24, 25 Life-threatening illness, 470–474 Lithium aggression treatment, 373 sleep treatment, 198 Maintaining sleep problems description, 193, 194 treatment, 194, 195, 205 Major depressive disorder (MDD; see also Depression) comorbidity, 305–308 developmental course, 309 DSM-IV diagnosis, 303 prevalence, 308, 309 Mania Rating Scale, 307 “Manipulative” encopresis definition, 139 treatment, 155

Index Manual-based interventions, 74, 75 Marital conflict child adjustment effects, 441, 442 and parenting, 24 sibling relationship effect, 426 “Masked” depression, 302 Massed negative practice chronic tics, 168 contingent negative practice difference, 179 Masturbation, 218–220 frequency, 218, 219 key clinical question about, 220 Maternal depression childhood depression link, 314 parent interview influence of, 317 as risk factor, 22, 23 and sibling conflict levels, 426 Maternal employment, 29 Maternal responsivity and compliance–noncompliance, 346 and parent training, 360, 361 Mealtime rules, 84 Medical status, assessment, 55 Medication (see Psychotropic medication) Megacolon, 140, 143 Methylphenidate (MPH) ADHD treatment, 402, 403, 407– 413 assessment instrument, 524, 525 contraindications, 409 disruptive behavior treatment, 373 parent and teacher ratings, 410– 412 side effects, 170, 171, 409, 410 titration and monitoring, 410–412 Tourette’s disorder link, 170, 171 Middle-ear disease, 13 Milk intake, encopresis, 151, 152 Mineral oil, and encopresis, 152 Mixed enuresis prevalence, 121 treatment, 132, 133 Modeling techniques, anxiety disorders, 290, 291 Monitoring, in optimal parenting, 27 Mood Diary, 319 anxiety disorders, 283 depression, 318, 319 Mother custody, 449, 450 “Motherese,” 13 Mothers depression in, 22, 23, 314, 317 employment, 29 responsivity, 346, 360, 361 and sibling conflicts, 426 Motor development, milestones, 6 Motor tics description, 166–168 treatment, 168, 169, 176–179, 182 Mouthing, 85 MPH (see Methylphenidate) Multidimensional Anxiety Scale for Children (MASC), 69, 501 Multimodal Treatment Study of Children with ADHD (MTA), 402, 403

Multiple sleep latency test (MSLT), 192 Muscle relaxation, 288, 289 Nail biting, 161, 162 Nailbiting Severity Scale, 172 Narcolepsy, 191, 192 description, 191, 192 diagnosis and treatment, 192, 205 Negative affect in anxiety and depression, 277, 278, 305 assessment, 285 Negative Affect Self-Statement Questionnaire, 285 Negative attributions, in depression, 312 Negative reinforcement in food refusal problems, 108 parent training perspective, 360, 361 Neuroleptics, in Tourette syndrome, 182 Neuropsychological tests, ADHD, 394 Night terrors, 198, 199 Night wakings case example, 211–214 description, 193, 194 developmental progression, 194 extinction method, 207, 208 treatment, 194, 195, 205, 207–209 Nightmares, 196 case example, 214–216 description, 196 management, 205, 206, 209–211 Nighttime Wetting Chart and encopresis, 145 and enuresis, 125, 135 Nocturnal bruxism, 197 description, 197 management, 206 observation, 175 Nocturnal enuresis assessment, 123–127 prevalence, 121 treatment, 127–139 Nonabusing parent, treatment, 250 Noncompliance, 346–348 development of, 346–348 in oppositional defiant disorder, 332, 333 prevention, 373 time-out procedure, 366 Noncustodial father, 442, 443 “Nonorganic failure to thrive,” 86, 87 Non-rapid-eye-movement sleep (see NREM sleep) “Nonretentive” encopresis, 139 definition, 139 treatment, 154, 155 Nonsubstantiated sexual abuse, 257, 258 Normal development, 4–18 Nowicki-Strickland Locus of Control Scale for Children, 321 NREM sleep description, 186–188 function, 188

Index Obesity, 89–102 assessment, 90–94 case example, 99–102 observational assessment, 91 overview, 89, 90 parent intervention, 98 prevalence, 89 referrals, 94 risk, 89, 90 treatment, 94–99 Observation of behavior (see also under specific disorders) assessment systems, 497, 498 overview, 65–67 Obsessive-compulsive disorder (OCD) DSM-IV symptoms, 270 persistence of, 276 and tic disorders, 170 and trichotillomania, 163 Obstructive sleep apnea (OAS) description, 192 diagnosis, 192, 193 treatment, 193, 205 Oppositional defiant disorder (ODD), 331–376 assessment, 350–357 case example, 374–376 categorical classification, 332, 333 comorbidity, 337, 338, 384 DSM-IV criteria, 332, 333 and encopresis, 139 etiology, 341–345 persistence, 338 prevalence, 47, 336, 337 treatment, 357–376 Oral habits, 159–162 Oral pacifier use, 161 Otitis media, 13 Outcome studies, 73–78 attrition problem, 75, 76 effectiveness versus efficacy issue, 73–75 Overlearning procedure, enuresis, 136 Oversexualized behavior, 230 Overt behavior conduct problems, 334, 335 informant biases, 69, 70 Overweight (see Obesity) Oxybutynin chloride (Ditropam), 131, 132 Pacifier use, 161 “Palatal crib with spurs,” 161 Parasomnias, 195–199 overview, 195–199 treatment, 205, 206 Parent–Child Interaction Data Sheet, 355 Parent–Child Interaction Treatment Program, 360–372 adaptation for older children, 371 covert behavior management, 371, 372 description, 360 outline of, 360–372

Parent–child relationship (see also Parenting) coercive cycle, 349, 350 divorce effects, 442, 443 Parent education, 32, 33 definition, 32 and divorce, 457, 458 encopresis, 149, 150 enuresis, 133 parent training distinction, 32 Parent Effectiveness Training, 33 “Parent enhancement therapy,” 359 Parent intervention (see also Parent training) anxiety disorders, 293, 294 divorce, 457–461 sibling conflict, 432 Parent interview, 61–63 anxiety disorders, 283–285 in assessment process, 61–63 attention-deficit/hyperactivity disorder, 395–397 childhood bereavement, 475, 476 depression, 316–318 disruptive behavior disorders, 351– 353 divorce adjustment, 452, 453 encopresis, 144, 145, 156, 157 enuresis, 124–127 food refusal assessment, 103–105, 110, 111 habit and tic disorders, 172, 174, 183 obesity, 90, 91, 99, 100 purposes, 61 sexual abuse, 240, 241, 259 sibling conflict, 428, 429 sleep problems, 201, 202 Parent referral, and ADHD, 400 Parent training, 32, 33, 358–372 adaptation for older children, 371 attention-deficit/hyperactivity disorder, 404 covert behavior management, 371, 372 definition, 32 depression, 324 disruptive behavior disorders, 358– 372 maintenance of effects of, 359 parent education distinction, 32 Parental conflict and divorce, 441, 442 and parenting, 24 sibling conflict factor, 426 Parental death adjustment to, 468, 469 case example, 480–482 short-term versus long-term reactions, 468 support groups, 477, 478 Parental informants, 69, 70 ADHD assessment, 393 in assessment process, 69, 70 internalizing versus externalizing symptoms, 69, 70 psychostimulant medication effects, 410–412 rating scales, 489–493

621 Parental psychopathology and anxiety disorders outcome, 288 depression link, 314 as risk factor, 22, 34 Parenting anxiety disorders, 281, 282 and child development, 8 coercive cycle, 349, 350 determinants, 21–25 disruptive behavior disorders factor, 343, 344, 349, 350 assessment, 352, 353 history of, 21, 22 language development influence, 12, 13 noncompliant behavior link, 347, 348 optimal practices, 27, 28 sibling conflict factor, 426, 427 vulnerability and resilience factor, 21–28 Parenting Alliance Measure (PAM) description and availability, 503 disruptive behavior disorders, 351 Parenting Stress Index (PSI), 59, 490, 491 availability, 491 characteristics, 59, 490, 491 child temperament, 490 depression, 316 disruptive behavior disorders, 351 divorce, 451 encopresis, 144 enuresis, 124 fears and anxieties, 283 habits and tics, 172 sexual abuse, 240 sibling conflict, 427 sleep problems, 199 The Parent’s Game, 366–368 Paroxetine (Paxil), 325 Partial arousals from sleep, 198, 199 Participant modeling, 290 Paxil (see paroxtine), 325 Peabody Picture Vocabulary Test, 69 Pediatricians, consultation, 71 Peer relations attention-deficit/hyperactivity disorder, 385 conduct disorder, 340 depression, 311 observational systems, 66, 67 parental relationship link, 18 school-age children complexity, 17, 18 Peer tutoring, ADHD, 405 Pemoline (Cylert), 407 Perfectionism, 165 Peristalsis, 142, 143 Perpetrator characteristics (see Sex offenders) Persistence attention-deficit/hyperactivity disorder, 383 disruptive behavior disorders, 338– 341 DSM disorders, 47, 48

622 Personality Inventory for Children— Revised (PIC-R) availability, 493 characteristics, 492, 493 Personality Inventory for Youth (PLY), 69, 495, 496 Phobias, 273–275 cognitive factors, 279 DSM-IV symptoms, 270 general features, 273–275 treatment, 287–301 Phototherapy, 193 Physical abuse childhood injuries relationship, 34 prevention, 36, 37 Physical development, milestones, 6 Physical punishment and child adjustment, 25–27 disruptive behavior disorders link, 343, 344 Pica, 85, 86 Piers-Harris Children’s Self-Concept Scale—Revised, 496 availability, 496 characteristics, 496 in depression, 318 Pimozide, 182 Play in ADHD evaluation, 319 in assessment process, 64, 65 Polysomnogram (PSG), narcolepsy, 192 Positive reinforcement anxiety disorders, 295 in food refusal problems, 108 in parent training, 360, 361 Postpartum depression, intervention, 326 Posttraumatic stress disorder (PTSD) and bereavement, 469, 470 Child Behavior Checklist items, 240 DSM-IV symptoms, 270 intervention, 294, 295, 470 sexual abuse link, 234 Potty chair, 119 Powerlessness, and sexual abuse, 253 Praise, and parent training, 360, 361, 364 Precocious puberty, 226, 227 girls versus boys, 226 treatment, 226, 227 Prenatal androgens, gender identity disorder, 228 Preschool children aggression, 348, 349 attention-deficit/hyperactivity disorder, 389–391 divorce effects, 445, 446 DSM diagnoses prevalence, 45–47 noncompliant behavior, 346–348 normal development, 6–8, 12–16 normal versus abnormal sexual behavior, 221 psychostimulant use, 408 sexuality education, 223, 224 Prevalence, 45–48 (see also under specific disorders)

Index Prevention child abuse, 36–39 critical issues, 31 disruptive behavior disorders, 373, 374 overview, 30–39 sexual abuse, 37–39, 224, 225 “Primary” encopresis, 139 Problem solving bereavement, 484, 485 depression, 323, 324 Progressive muscle relaxation, 178 Prolixin, 198 Prolonged exposure, anxiety disorders, 289, 290 Protective factors conduct problems, 340 overview, 19–39 risk factors interplay, 19–21 Prozac (see Fluoxetine) Psychiatric Institute Trichotillomania Scale (PITS), 172 Psychogenic megacolon, 143 Psychopathy, 335, 336 Psychopharmacology (see Psychotropic medications) Psychosocial short stature (PSS), 88 Psychostimulant medication (see also Methylphenidate) ADHD, 402, 403, 407–413 anxious type, 384 assessment instrument, 534, 535 Psychotropic medications anxiety disorders, 295, 296 attention-deficit/hyperactivity disorder, 402, 403, 407–413 depression, 325, 326 disruptive behavior disorders, 372, 373 general issues, 77, 78 Puberty, timing of, 226, 227 Punitive discipline and child adjustment, 25–27 and conduct disorder, 344 Questionnaires, 59, 60 (see also Assessment; specific disorders; specific questionaires) child sexual abuse, 238–240 in initial assessment, 59, 60 Rapid-eye-movement sleep (see REM sleep) Rating scales in initial assessment, 59, 60, 68 parental informants, 69, 70, 489– 493 teachers, 67, 68 Reading problems, ADHD, 385, 386 “Real-world” outcome studies, 74, 75, 77 Reassurance seeking, 272 Receptive language disorders, 13, 14 Referral question, 52, 237, 238 Referrals, 70, 71 (see also under specific disorders) Refined sugar, 151, 152 “Regressive” behaviors, 420

Reinforcement techniques anxiety disorders, 295 food refusal problems, 108, 109 obesity, 98 in parent training, 360, 361 Relapse prevention, obesity, 97, 989 Relaxation training, 178 REM sleep description, 186–188 function, 188 in narcolepsy, 191, 192 REM sleep behavior disorder, 196, 197 Remarriage effects, 443, 444 Repetitive behavior, 165 Resilience, 18–30 Response cost intervention attention-deficit/hyperactivity disorder, 406 and parent training, 371 sibling conflict, 431 Response inhibition, and ADHD, 388, 389 Restricted Academic Period, 399 “Retentive” encopresis definition, 139 treatment, 148–153 Revictimization, sexual abuse, 235, 236 Revised Children’s Manifest Anxiety Scale (RCMAS) anxiety screening, 283 availability, 501 characteristics, 500, 501 Revised Conners Parent Rating Scale, 351 Revised Conners Teacher Rating Scale, 356, 399 Revised Edition of the School Observation Coding System (REDSOCS), 354, 356 Reynolds Child Depression Scale (RCDS), 69, 500 Risk factors, 19–39 anxiety disorders, 281, 282 overview, 19–39 protective factors interplay, 19–21 sexual abuse, 238, 239, 249 treatment model, 249 Risperidone, aggression treatment, 373 Ritalin (see Methylphenidate) Ritualistic behavior, 165 Roberts Apperception Test for Children (RATC), 496 Rocking behavior, 197, 206 Ruminative disorder, 86 Sameness behavior, 165 SCARED scale, 282, 521–525 Scary dreams, 268, 278 (see also Nightmares) School-based interventions depression, 325 disruptive behavior disorders, 372, 374 divorce adjustment, 456 School behavior, assessment, 67, 68 School Observation Coding System, 354, 356 School phobia, 275

Index School problems (see Academic problems) School refusal, 274, 275 case example, 297–301 cognitive-behavioral therapy, 297 functional-analytic model, 275, 276, 297 general features, 274, 275 medication, 296 prevalence, 275 in separation anxiety disorder, 271 treatment, 296, 297 School Refusal Assessment Scale (SRAS) availability, 502 description, 297, 502 School Situations Questionnaire (SSQ) attention-deficit/hyperactivity disorder, 399 description and availability, 499 disruptive behavior, 356 Screen for Child Anxiety Related Emotion Disorders (SCARED) characteristics, 282 child version, 521, 522 parent version, 523–525 “Secondary” encopresis, 139 Secure attachment, 9, 10 Sedatives, and sleep problems, 195 Sedentary behavior, and obesity, 95 Selective serotonin reuptake inhibitors (SSRIs) anxiety disorders, 295, 296 depression, 325, 326 Self-concept development, 17 Self-esteem developmental factors, 17 enhancement of, 230 Self-instructional training, in depression, 324 Self-monitoring and assessment, 66, 67 habits and tics, 176 obesity intervention, 96 Self-Perception Profile for Children, 243, 318 Self-regulation, preschool children, 14–16 Self-report inventories, 69 Semistructured interviews, 60, 498, 499 Separation anxiety disorder (SAD), 269–271 DSM-IV symptoms, 270 epidemiology, 271 flooding treatment, 290 general features, 269, 271 medication, 296 Sertraline (Zoloft), in social anxiety, 296 Sex differences (see Gender differences) Sex hormones, and gender identity disorder, 228 Sex offenders, 233, 234 characteristics, 233, 234 classification, 233

recidivism, 234 treatment, 234 victims feelings toward, 255 Sexual abuse, 231–261 age factors in adjustment to, 235 age-related prevention information, 224, 225 assessment, 236–248 case example, 258 child interview, 241, 242, 259, 260 court testimony, 255, 256, 261 day care settings, 30, 31 definitional issues, 231, 232 false allegations, 246 group treatment, 250, 251 intervention with parents, 250, 251, 255 long-term effects, 235, 236 and treatment, 236 long-term treatment indications, 256, 257 nonsubstantiated cases, 257, 258 parent interview, 240, 241, 259 perpetrators, 233, 234 prevalence, 232, 233 prevention, 37–39, 224, 225 risk assessment, 238, 239 short-term effects, 234, 235 treatment, 247–261 models for, 247, 248 in nonsubstantiated abuse, 257, 258 Sexual behavior, 218–222 abnormal versus normal, 221, 222 adult–child nonabusive interaction, 220, 221 age-related information, 224, 225 child–child interactions, 220 normal development, 218–222 in preschoolers, 221 sexual knowledge relationship, 222 Sexual development, 217–222 Sexual problems, 225–261 Sexuality education, 222–225 age-related goals, 223–225 parents’ role, 223 preschoolers, 223, 224 programs, 225 sexually abused children, 254 Sexualized behavior, 230 description, 230 intervention strategies, 253 sexual abuse link, 234, 235 Sexually aggressive behavior, 230, 231 Shadowing behavior, 269, 271 Shaping, obesity intervention, 97 Sibling Chart, 438, 439 Sibling conflict, 419–439 aggression in, 348, 425, 430 assessment, 427–439 case example, 433–437 observation of behavior, 429 parent interview, 428, 429 peer conflict comparison, 419 treatment, 430–433 Sibling death, 469, 482–485 adjustment to, 469 case example, 482–485

623 Side Effects Questionnaire (SEQ), 412 Side Effects Rating Scale, 499, 500 Single parents, 352 Sitting Chart, 119, 120 Skin conductance, 342, 343 Sleep apnea (see Obstructive sleep apnea) Sleep bruxism, 197, 206 Sleep cycle, 187 Sleep Diary, 199, 200 Sleep paralysis description, 197 management, 206 and narcolepsy, 191 Sleep problems, 189–216 and ADHD, 384, 385 assessment, 199–204 case examples, 211–216 child interview, 202, 203 developmental progression, 194 dyssomnias, 191–194 and emotional/behavioral disorders, 188, 189 extinction method, 207, 208 group treatment, 204 observational methods, 203 parasomnias, 195–199 parent interview, 201, 202 prevalence, 190 referrals, 203 treatment, 204–211 Sleep rocking, 197 Sleep stages, 186–189 Sleep terrors description, 198, 199 management, 206 medication, 199 Sleep-wake cycle disorders, 193, 204–207 normal pattern, 187, 188 Sleeptalking, 199, 206 Sleepwalking description, 198 management, 206 seizure differentiation, 198 Social context, assessment, 52, 53 Social development, milestones, 7 Social information processing, conduct disorder, 340 Social phobia, 273, 274 assessment, 280–287 cognitive-behavioral therapy, 291 cognitive factors, 279 DSM-IV symptoms, 270 general features, 273, 274 intervention with parents, 294 medications, 296 transactional model, 280 Social Phobia and Anxiety Inventory for Children, 501 “Social problem syndrome,” 44 Social skills, assessment, 68 Social Skills Rating System (SSRS) anxiety disorders, 286 attention-deficit/hyperactivity disorder, 400 availability, 494 characteristics, 68, 69, 494

624 Social skills training antisocial behavior, 357 depression, 324 Social support, and parenting, 24 Socioeconomic status disruptive behavior disorders link, 344, 345 and DSM disorder prevalence, 47 and fears, 266, 267 Sole custody, 449 “Somniloquy,” 199 Spanking, 26, 27, 343, 344 Specific phobias DSM-IV symptoms, 270 epidemiology, 271 general features, 274 Sphincter control exercises encopresis, 147–149 enuresis, 130, 131 SSRIs (see Selective serotonin reuptake inhibitors) Stability (see Persistence) “State” anxiety, 263 State-Trait Anxiety Inventory for Children (STAIC), 500 Stealing, and parent training, 371, 372 Stepfathers child’s adjustment to, 444 physical abuse rates, 446 Stigmatization, and sexual abuse, 253 Stimulant medications (see Psychostimulant medications) Stimulus control, obesity intervention, 96 Stomach capacity, 82, 83 Stoplight diet, 96 Stop-zit, 160 Strategic family therapy, 372 Stress Index for Parents of Adolescents (SIPA), 491 Structured interviews, 60, 498, 499 Sudden infant death syndrome, 192 Suggestibility assessment, 243 sexual abuse cases, 237, 238, 243 Suicide, 310, 311 Suicide-bereaved children, 469 Support groups, bereaved children, 477, 478 Suppositories in nonretentive encopresis, 154 in retentive encopresis, 148, 150 Sutter-Eyberg Student Behavior Inventory (SESBI) availability, 494 characteristics, 68, 494 Symbolic modeling, 290 “Synthesis training,” 359 Systematic desensitization, 288, 289 Systematic Training for Effective Parenting, 33 Talking, Feeling, Doing Game, 323 Tattling control of, 427 in sibling relationships, 424, 427

Index Teacher Questionnaire, 514–516 Teachers ADHD assessment, 393, 399, 400 in assessment process, 67–70 consultation, 71, 72 depression assessment, 321 as informants, 69, 70 psychostimulant medication ratings, 410–412 rating scales, 493, 494 Television viewing, and obesity, 89, 95 Temperament attachment interactions, 10, 11 and development, 10, 11 and disruptive behavior disorders, 342, 343 and divorce effects, 444, 445 parenting interaction, 23, 24 sibling conflict factor, 421, 426 and sleep problems, 194 “Tender years” doctrine, 448 Terminally ill child, 470–474 adjustment, 471–474 coping styles, 472, 473 Testosterone, disruptive behavior, 343 Therapy Attitude Inventory (TAI), 77, 539 Thought stopping, anxiety disorders, 292, 293 Thumb sucking, 159–161 competing-response training, 177, 178 incidence, 160 treatments, 160, 161, 177, 178 Tics, 159–185 (see also Tourette’s disorder) assessment, 171–176 behavioral observation, 175 case example, 182–185 description, 165–168 etiology, 167, 168 methylphenidate side effect, 410 parent interview, 172, 174, 183 subtypes, 166 treatment, 168, 169, 176–179, 182 Time out food refusal problems, 109, 113, 114 in parent training, 361, 366, 368– 371 Tofranil (see Imipramine) Toilet seat ring, 119 Toilet training, 115–120 general guidelines, 115, 116 readiness criteria, 116, 117 resistance to, 119, 120 Token reinforcement anxiety disorders, 295 attention-deficit/hyperactivity disorder, 406 in parent training program, 371 Tourette Syndrome Association, 181 Tourette’s disorder (TD), 169–171, 180–182 case example, 182–185 description, 169–171

medication, 182 parent intervention, 180, 181 prevalence, 169 referral, 175 symptomatology, 170, 171 treatment, 180–182 “Trait” anxiety definition, 263 and treatment outcome, 288 Transactional model depression, 315 and developmental change, 3, 4 social phobia, 280 Transient tic disorder, 167, 168 Transsexualism, 229 Transvestism, 229 Trauma (see Posttraumatic stress disorder) Treatment integrity, 76 Treatment outcome (see Outcome studies) Trichotillomania (TTM), 163, 164 Tricyclic antidepressants (TCAs; see Imipramine) Trimeprazine tartrate, 195 Unstructured interviews, advantages, 61 Urine alarm, 128–130, 134–137 and arousal training, 129, 130 case example, 138, 139 intermittent use, 136 procedure, 134 Very low birthweight (VLBW), and ADHD, 388 Vicarious extinction, 290 Vineland Adaptive Behavior Scales (VABS) anxiety disorders, 286 availability, 492 characteristics, 491, 492 Vocal tics description, 166–168 treatment, 168, 169, 176–179 Vulnerability, 18–30 overview, 18–30 and parenting, 21–28 Water consumption, and encopresis, 147–149, 151, 152 Weight loss programs, 95, 96 Worry cognitive-behavioral approach, 291, 292 definition, 264 development of, 265, 267, 268 sources of, 268 thought stopping, 292, 293 Worry time, 293 Wrist urine alarm, 128, 129, 134 Yale Global Tic Severity Scale (YATSS), 172 Zoloft (sertraline), 325