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Munroe-Meyer Institute Department of Psychology . Holly Roberts, Ph.D. Munroe-Meyer Institute University of Nebraska Medical Center. Munroe-Meyer Institute Psychology. Provide clinical services and training for a wide variety of infant, child, and adolescent concerns Behavioral

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Munroe meyer institute department of psychology

Munroe-Meyer Institute Department of Psychology

Holly Roberts, Ph.D.

Munroe-Meyer Institute

University of Nebraska Medical Center


Munroe meyer institute psychology

Munroe-Meyer Institute Psychology

  • Provide clinical services and training for a wide variety of infant, child, and adolescent concerns

    • Behavioral

    • Social-emotional

    • Physical

    • Medical

    • Cognitive Abilities


Munroe meyer institute psychology1

Munroe-Meyer Institute Psychology

  • Services are provided

    • Hospitals

    • Schools

    • Community-based clinics throughout Nebraska


Munroe meyer institute psychology2

Munroe-Meyer Institute Psychology

  • Education

  • Training

  • Research

  • Clinical Services

    • MMI

    • Outreach clinics

    • Home and school visits


Typical child concerns

Typical Child Concerns

  • academic/school problems

  • adjustment (death/divorce)

  • anxiety/fears

  • attention & behavior problems

  • feeding/eating problems

  • habits (e.g., thumb-sucking)

  • sleep problems

  • toileting


Behavioral health clinics

Behavioral Health Clinics


Why primary care

Why Primary Care?

  • Physicians as gate keepers for mental health services


Why primary care1

Why Primary Care?

  • Physicians as gate keepers for mental health services

  • Increased continuity of care


Why primary care2

Why Primary Care?

  • Physicians as gate keepers for mental health services

  • Increased continuity of care

  • De-stigmatizes mental health treatment


Top three problems

Top Three Problems

  • Behavior-based problems (58%)

  • Otitis Media (48%)

  • URI (41%)

    Arndorfer, R. E., Allen, K. D., Aljazireh, L. (1999). Behavioral health needs in pediatric medicine and the acceptability of behavioral solutions: Implications for behavioral psychologists. Behavior Therapy,30,137-148.


Top three behavior problems

Top Three Behavior Problems

  • Oppositional behavior

  • Sleep/bedtime problems

  • ADHD

    Arndorfer, R. E., Allen, K. D., Aljazireh, L. (1999). Behavioral health needs in pediatric medicine and the acceptability of behavioral solutions: Implications for behavioral psychologists. Behavior Therapy,30,137-148.


Behavioral approach

Behavioral Approach

  • ABC’s

  • Functional Assessment informs treatment

  • Empirically supported treatments


Oppositional behavior

Oppositional Behavior

  • Core issue is typically noncompliance

    “KEYSTONE BEHAVIOR”

    • How many of 10 instructions would s/he do the first time asked?

    • Mealtimes?

    • Bedtime and morning routines?

    • Public outings?


Oppositional behavior1

Oppositional Behavior

  • Significant problems will not dissipate with age

    • 5% of 3-year olds. 68% @ 8 years


Oppositional behavior2

Oppositional Behavior

  • Oppositional Defiant Disorder (DSM-IV)

    • 6 month pattern of negative, hostile, defiant behavior with 4 of the following:

      • Loses temper

      • Argues with adults

      • Blames others

      • Etc.

    • Causes Impairment

    • Not psychosis

    • Not Conduct Disorder—Part of Spectrum


Oppositional behavior3

Oppositional Behavior

  • Most parents rely on repeated:

    • Lecturing

    • Reasoning

    • Explaining

    • Warning

    • Threatening

    • Yelling


Oppositional behavior4

Oppositional Behavior

  • Children learn best from…

    Immediate feedback from their environment

    --i.e., “hands on” not by lecture

    by doing not from hearing


Oppositional behavior5

Oppositional Behavior

  • Talking with parents:

    • “teaching a behavioral skill”

      • Following instructions

      • Coping with anger

      • Persisting on a task

      • Self-quieting

  • Parent training only supported treatment!


Oppositional behavior6

Oppositional Behavior

  • Talking with parents:

    • “teaching a behavioral skill”

      • Following instructions

      • Coping with anger

      • Persisting on a task

      • Self-quieting

  • Must use two-part approach

    • Encourage skills you want to see more often.

    • Discourage behaviors you want to see less.


Oppositional behavior7

Oppositional Behavior

  • REPETITION X CONTRAST= BEHAVIOR CHANGE

    • High contrast= quick (often 1 trial) learning, requires less reps


Oppositional behavior8

Oppositional behavior

  • Time-In: Encouraging use of new skill

    • Frequent, intermittent “bursts” of attention for average behavior

      • Keep attention tank full

    • BIG reaction for demonstrating skill

      • Enthusiasm, Touch, Praise


Oppositional behavior9

Oppositional Behavior

  • Time-Out: Discouraging Problem Behavior

    • Misconceptions:

      • Child must sit still

      • Child must be sorry

      • Child must understand


Oppositional behavior10

Oppositional Behavior

  • Time-Out: Discouraging Problem Behavior

    • What it IS:

      • Brief, unpleasant consequence during which there is no access to attention or anything fun

      • Consistent use for every occurrence of target behavior

      • No reprimand on release


Oppositional behavior11

Oppositional Behavior

  • Time-Out: Discouraging Problem Behavior

    • Procedure

      • Adult-sized chair

      • Area easy to covertly monitor

      • 2-3 minutes

      • Parent ends the time-out

      • Child completes task after time-out is over


Sleep bedtime problems

Sleep/Bedtime Problems

  • 20-25% of 1-5 year olds

  • Parasomnias & Dyssomnias

  • Most common:

    • Difficulty settling and night time awakenings

      • Very persistent problem: 84% still have problems after 3 years


Behavioral formula for establishing pediatric sleep disturbance

Behavioral Formula for Establishing Pediatric Sleep Disturbance

  • Repeatedly attend to child’s continuous calling out, crying, and “curtain calls”

  • Allow child to fall asleep in living area, then transfer him/her to bed once asleep

  • When child awakens at night, stay with him/her or admit them to parents’ bed until they fall back to sleep


Sleep bedtime problems1

Sleep/Bedtime Problems

  • Basic Intervention:

    • Improved sleep hygiene

      • Routines

      • Consistent bed and wake times throughout the week

      • The Bedroom

      • Teach independent sleep onset skills (drowsy but awake)—i.e.,being alone, self-calming


Sleep bedtime problems2

Sleep/Bedtime Problems

  • Basic Intervention:

    • Improved sleep hygiene

    • Systematic ignoring---(EXTINCTION BURST)

      • Unmodified (“cold turkey”)

      • With parental presence

      • Quick check

      • Graduated (Ferber)


Sleep bedtime problems3

Sleep/Bedtime Problems

  • Basic Intervention:

    • Improved sleep hygiene

    • Systematic ignoring

    • Faded bedtime procedure

      • Establish time of sleep onset

      • Set “window” of sleep

      • Gradually increase time


Sleep bedtime problems4

Sleep/Bedtime Problems

  • Basic Intervention:

    • Improved sleep hygiene

    • Systematic ignoring

    • Faded bedtime procedure

    • Reward Program


Munroe meyer institute department of psychology

ADHD

  • “Attentional problems” greatest increase of all mental health problems in PC since 1979

  • ADHD diagnosis a 2.3-fold increase in the population-adjusted rate from 1990-1995

  • Children with ADHD use primary care more, cost more


Top 10 myths of adhd

Top 10 Myths of ADHD

10. ADHD and ADD are different disorders

9. Girls aren’t hyperactive

8. ADHD is outgrown in adolescence

7. ADHD is caused by poor parenting

6. ADHD is caused by diet (sugar, food additives)


Top 10 myths cont

Top 10 Myths cont.

5. There is a “cure” for ADHD

4. Taking medications for ADHD leads to drug abuse

3. Children who improve with stimulant medication (Ritalin) must have ADHD

2. If the child fails to display ADHD behaviors in the doctor’s office, then the child doesn’t have ADHD

1. It is a “medical diagnosis”


Formal diagnostic criteria dsm iv 1994

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion A:

Six or more symptoms from one or both of these lists:

  • Inattentive Type

  • Hyperactive/Impulsive Type

    …have been present for at least 6 months.


Symptom lists

Inattentive Type

fails to attend to details, makes careless mistakes

difficulty sustaining attention in play or work

does not listen when spoken to

does not follow through

difficulty organizing tasks

avoids task requiring sustained mental effort

loses things needed

distracted by extraneous stimuli

often forgetful

Hyper/Impulsive Type

often fidgets hands/feet or squirms

often leaves seat when sitting is expected

runs about or climbs excessively

difficulty playing or engaging in leisure activities quietly

often “on the go”/ “driven by motor”

talks excessively

blurts out answers before questions completed

difficulty awaiting turn

interrupts or intrudes on others

Symptom Lists


Formal diagnostic criteria dsm iv 19941

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion B:

Some of the symptoms were present before the age of seven years.


Formal diagnostic criteria dsm iv 19942

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion C:

Some impairment from the symptoms is present in two or more settings (e.g., home, and school or work).


Formal diagnostic criteria dsm iv 19943

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion D:

There is evidence of clinically significant impairment in social, academic, or occupational functioning.


Formal diagnostic criteria dsm iv 19944

Formal Diagnostic CriteriaDSM-IV, 1994

Criterion E:

The identified symptoms are not better accounted for by another mental disorder.


Adhd assessment

ADHD: Assessment

  • Information gained by qualified clinician

    • Behavior ratings from family

    • Behavior ratings from the school

    • Observation (clinic or in vivo)


Treatment unproven disproven

Treatment Unproven/Disproven

ADHD is a disorder of performance, not of skill

  • problem is not with “knowing what do”

  • problem is with “doing what you know”

    To be effective, treatments must be in place at the “point of performance”

     outpatient psychotherapy alone

     play therapy

     group classes (e.g., social skills training)


Adhd treatment

ADHD: Treatment

  • What we KNOW works:

    • Drug Therapy

      • Hundreds of studies (N > 5,000)

      • No Support for Antidepressants and Clonidine for young children

    • Behavior Therapy

      • 48 classroom studies (N > 900)

      • 80 parent/home studies (N > 5,000)

    • Combined Behavioral/Drug

      • 10 classroom studies (N > 800)


Adhd home programs

ADHD Home Programs

  • Parent training in behavior management

    • Positive attending

      • reinforcement, “time-in”

    • Anticipating and preventing problems

    • Compliance training

    • Discipline strategies

      • time-out

      • job card grounding

      • token systems


Job card grounding

Job Card Grounding

Primarily for older children (9 and up)

  • create 25 to 50 job cards (15 to 30 min each)

  • assign jobs for breaking rules

  • child/teen is grounded until jobs completed

    • no TV

    • no Telephone

    • no allowance

    • no going outside

    • no contact with friends

    • no playing with toys


School interventions

School Interventions

  • Token programs

  • Home School Notes

  • Classroom Accommodations

    • e.g., preferential seating, adjustments in testing and classwork (extra time, reading directions aloud to students)


Token systems

Token Systems

  • Program in which child (or group of children)….

  • Earn tokens for engaging in a variety of desired behaviors and,

  • Later exchange the tokens for things they want


Daily home school note

Daily Home-School Note

  • Basic components

    • Specific behaviors are identified & defined

    • A school note is created

    • Divides day into shorter segments

    • Lists identified behaviors


Daily home school note1

Daily Home-School Note

  • Basic components

    • Teacher marks note, gives feedback at end of each period

    • Rewards/consequences provided at home for performance at school

    • Student is responsible for getting note from place to place


10 management principles for children w adhd

10 Management Principles for Children w/ ADHD

  • Greater immediacy/frequency of consequences

  • Use of more salient (noticeable) consequences

  • More frequent change in rewards

  • “Act, don’t yack”

  • Use rewards before punishment

  • Anticipate problems; Have a plan

  • Keep a disability perspective

  • Prioritize

  • Don’t personalize the child’s problem

  • Practice forgiveness!


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