Munroe-Meyer Institute Department of Psychology

1. Munroe-Meyer Institute Department of Psychology Holly Roberts, Ph.D. Munroe-Meyer Institute University of Nebraska Medical Center

2. 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

3. Munroe-Meyer Institute Psychology • Services are provided • Hospitals • Schools • Community-based clinics throughout Nebraska

4. Munroe-Meyer Institute Psychology • Education • Training • Research • Clinical Services • MMI • Outreach clinics • Home and school visits

5. 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

6. Behavioral Health Clinics

7. Why Primary Care? • Physicians as gate keepers for mental health services

8. Why Primary Care? • Physicians as gate keepers for mental health services • Increased continuity of care

9. Why Primary Care? • Physicians as gate keepers for mental health services • Increased continuity of care • De-stigmatizes mental health treatment

10. 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.

11. 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.

12. Behavioral Approach • ABC’s • Functional Assessment informs treatment • Empirically supported treatments

13. 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?

14. Oppositional Behavior • Significant problems will not dissipate with age • 5% of 3-year olds. 68% @ 8 years

15. 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

16. Oppositional Behavior • Most parents rely on repeated: • Lecturing • Reasoning • Explaining • Warning • Threatening • Yelling

17. Oppositional Behavior • Children learn best from… Immediate feedback from their environment --i.e., “hands on” not by lecture by doing not from hearing

18. 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!

19. 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.

20. Oppositional Behavior • REPETITION X CONTRAST= BEHAVIOR CHANGE • High contrast= quick (often 1 trial) learning, requires less reps

21. 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

22. Oppositional Behavior • Time-Out: Discouraging Problem Behavior • Misconceptions: • Child must sit still • Child must be sorry • Child must understand

23. 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

24. 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

27. 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

28. 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

29. 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

30. Sleep/Bedtime Problems • Basic Intervention: • Improved sleep hygiene • Systematic ignoring---(EXTINCTION BURST) • Unmodified (“cold turkey”) • With parental presence • Quick check • Graduated (Ferber)

31. 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

32. Sleep/Bedtime Problems • Basic Intervention: • Improved sleep hygiene • Systematic ignoring • Faded bedtime procedure • Reward Program

33. 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

34. 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)

35. 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”

36. 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.

37. 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

38. Formal Diagnostic CriteriaDSM-IV, 1994 Criterion B: Some of the symptoms were present before the age of seven years.

39. 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).

40. Formal Diagnostic CriteriaDSM-IV, 1994 Criterion D: There is evidence of clinically significant impairment in social, academic, or occupational functioning.

41. Formal Diagnostic CriteriaDSM-IV, 1994 Criterion E: The identified symptoms are not better accounted for by another mental disorder.

42. ADHD: Assessment • Information gained by qualified clinician • Behavior ratings from family • Behavior ratings from the school • Observation (clinic or in vivo)

43. 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)

44. 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)

45. 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

46. 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

47. 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)

48. 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

49. Daily Home-School Note • Basic components • Specific behaviors are identified & defined • A school note is created • Divides day into shorter segments • Lists identified behaviors

50. 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