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Assessment and Treatment of Childhood Problems

Assessment and Treatment of Childhood Problems

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Sections

  • TREATMENT OF MIXED ENURESIS
  • ASSESSMENT OF HABITS AND TICS
  • ASSESSMENT OF SLEEP PROBLEMS
  • TREATMENT OF SLEEP PROBLEMS
  • CASE EXAMPLE: NIGHT WAKING
  • NORMAL SEXUAL DEVELOPMENT
  • CASE EXAMPLE: SCHOOL REFUSAL
  • ASSESSMENT OF DEATH-RELATED ISSUES

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
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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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4 Vulnerability and Resilience. 94 Case Example: Obesity. 45 Planning the Assessment. Eating Problems Normal Development of Feeding Behavior. 50 Methods for Gathering Information. 99 Food Refusal Problems. 82 Eating Problems Related to Infant Feeding. 40 Estimates of Prevalence. 73 40 PART II. MANAGING COMMON PROBLEMS Chapter 3. 90 Treatment of Obesity. 30 Summary and Conclusions. 102 Assessment of Food Refusal Problems. Development of Psychopathology Normal Development. and Encopresis Toilet Training. 49 A Comprehensive Assessment-to-Intervention System. 106 Case Example: Food Refusal Problem. 103 Treatment of Food Refusal Problems. 115 Enuresis.Contents PART I. 120 xiii 115 . 89 Assessment of Obesity. 18 Prevention of Problems. 39 3 Chapter 2. Toileting: Training. THE FOUNDATION Chapter 1. 85 Obesity. Enuresis. Assessment to Intervention Issues of Diagnostic Classification. 109 81 Chapter 4. 56 Treatment Issues. 48 Assessment Case Example.

123 Treatment of Nocturnal Enuresis. 133 Case Example: Enuresis. 247 Format for Immediate Short-Term Treatment When Abuse Has Been Substantiated. Fears and Anxieties Definitions. 280 Treatment of Anxiety Disorders. Sexuality and Sexual Problems Normal Sexual Development. 159 Trichotillomania. 225 Child Sexual Abuse. 164 Tics. 137 Encopresis. 275 Assessment of Fears and Anxieties. 231 Assessment of Sexual Abuse. 287 Case Example: School Refusal. 165 Assessment of Habits and Tics. 147 Treatment Protocols for Encopresis. 127 Treatment of Mixed Enuresis. 163 Other Habits. 222 Sexual Problems. 199 Treatment of Sleep Problems. 182 159 Chapter 6. 171 Treatment of Habits and Tics in General. 257 Case Example: Substantiated Sexual Abuse. Sleep Normal Sleep States and Patterns. 236 Treatment of Sexual Abuse. 180 Case Example: From Tics to Tourette’s Disorder. 297 262 . 142 Treatment of Encopresis. 251 Treatment in Cases Involving Nonsubstantiated Abuse. 262 Development of Fears and Worries.xiv Assessment of Nocturnal Enuresis. 269 General Characteristics of Anxiety Disorders. 214 186 Chapter 7. Habits and Tics Oral Habits. 132 Treatment Protocol for Enuresis. 155 Contents Chapter 5. 149 Case Example: Encopresis. 204 Case Example: Night Waking. 217 Sexuality Education. 139 Assessment of Encopresis. 186 Sleep Disturbances. 264 Anxiety Disorders. 189 Assessment of Sleep Problems. 176 Treatment for Tourette’s Disorder. 258 217 Chapter 8. 211 Case Example: Nightmares.

336 Development of Disruptive Behavior. 477 Case Example: Death of a Parent. 350 Treatment. 378 General Characteristics of ADHD. Depression Definition and Classification. 470 Assessment of Death-Related Issues. 374 331 Chapter 11. 450 Treatment of Divorce-Related Problems. 489 Teacher Rating Scales. Siblings Adjustment to the Birth of a Sibling. 305 Assessment. 322 Case Example: Subclinical Depression. 326 302 Chapter 10. 493 487 . 345 Assessment of Disruptive Behavior. 482 466 Appendix A. Disruptive Behavior Classification and Diagnosis. 467 Children’s Adjustment to Death. 381 Assessment. 402 Case Example: ADHD-C. 424 Assessment of Sibling Conflict. 430 Case Example: Physical Conflict among Siblings.Contents xv Chapter 9. 413 377 PART III. 420 Sibling Conflict. Divorce Effects of Divorce on Children. Bereavement Children’s Understanding of Death. Attention-Deficit/Hyperactivity Disorder Diagnostic Criteria. 462 440 Chapter 14. 332 General Characteristics of Disruptive Behavior Problems. 474 Treatment of Death-Related Issues. 315 Treatment. 480 Case Example: Death of a Sibling. 468 The Terminally Ill Child. 427 Treatment of Sibling Rivalry. 303 General Characteristics of Depression. 440 Assessment of Divorce-Related Issues. 357 Case Example: Preschool Oppositional Behavior. MANAGING STRESSFUL LIFE EVENTS Chapter 12. Description of Assessment Instruments Parent Rating Scales. 455 Case Example: Recommendations for a Child’s Living Situation. 393 Treatment. 433 419 Chapter 13.

B. 530 Child Attention Problems (CAP). 498 Attention-Deficit/Hyperactivity Disorder Measures. Anxiety. 507 Daily Log.7. B. 499 Depression. B. B.2. Assessment Instruments B.11. 502 Appendix B. 497 Structured Interviews.12. B. 513 Teacher Questionnaire. 536 Therapy Attitude Inventory (TAI).9. B. 514 Fear Survey Schedule for Children—Revised (FSSC-R) . 526 Hopkins Motor and Vocal Tic Scale.5.4. 517 Screen for Child Anxiety Related Emotional Disorders (SCARED)— Child Version. 495 Behavioral Observation Systems. 500 Parent Characteristic Measures. 534 Academic Performance Rating Scale (APRS). B. B.1.10. 512 Specific Events Causing Concern. B.13.6.xvi Contents Child Self-Report Measures. B. 539 505 References Index 541 615 .8. B. General Parent Questionnaire. B. 523 Hopelessness Scale for Children. 521 Screen for Child Anxiety Related Emotional Disorders (SCARED)— Parent Version.3. and Fear Measures. 528 Children’s Eating Behavior Inventory (CEBI).

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

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a hospitalization. competence or problems in any area of development early in life are seen as setting the stage for later development. emphasizes the emergence of independence and psychosexual development. cognitive. 1995). 1990).CHAPTER 1 Development of Psychopathology ost children. Children and parents also must sometimes cope with negative life circumstances (e. 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.. the physical and social environment. For all of this pressure to cope. Psychoanalytic theory. it is heartening that epidemiological studies find that over the course of any one year. or the birth of a new baby). poverty or parental unemployment) and stressful events. developmental gains in each area (social. a death.. the importance given to changes in development depended to a great extent on one’s theoretical perspective. and society that influence the child either directly or indirectly (Campbell. a divorce. learning about sexuality. which attempts to account for factors within the child. family. but also to help the other 80% of children and their parents manage the stresses of normal growth and development. 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. However. Mash and Terdal (1997a) point out that the child clinician must recognize “the ebb and flow of this develop3 M . Previously.g. 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. whereas social learning theory focuses on the development of self-control and self-efficacy. and the cultural milieu into which he or she is born. in the process of growing up. (e. 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. Within this perspective.g. 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. children represent a unique population. etc.” and dealing with siblings and peers. Moreover.) are thought to be related to progress in other areas. Because of their rapid growth and development. for example. motor. language. being told “no. fears. The goals of the child clinician are not only to assist this group of children who have major mental health problems.

measured. and each stage of development presents unique challenges to children and parents. In considering normal development. this chapter first focuses on issues related to the normal development of children from birth to 10 years. 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. Differences in physical growth become dramatically apparent in the late elementary school and early adolescent years. and many childhood problems may change both qualitatively and quantitatively as a child develops. begin to speak before the age of 1. NORMAL DEVELOPMENT General Comments The developmental tasks of children obviously change with age. A child may be speaking in sentences at age 2 years. Some of these inter. . Some children. a child may be at the top of the class in reading. changed. for excellent discussions of theoretical issues concerning development and behavior problems). but may have difficulty participating in group play activities. academic standards typically reflect great differences among children. THE FOUNDATION mental dialogue. but may not begin hopping or skipping until much later than expected. and the social support system available to the family at that time. 1990. An individual child’s rate of development within various areas can vary as much as the rate of development among children. Behaviors common at one age may be considered significant problems at another age. the parent’s characteristics. At school age. and the factors that influence children’s later development (see Campbell. Treatment of the school-age child. 22). 1998. whereas use of concrete. Similarly. 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. The ways in which significant adults help children through these difficult periods can have implications for children’s later development. The clinician must also have knowledge of the normal sequence of skill acquisition. diagnosed.4 I. although each child may be developing along a normal continuum.and intraindividual differences are primarily the result of genetic/biological factors. In addition. whereas other “normal” children have not acquired extensive language by age 3. for example. A child who is having trouble with separation and individuation. others seem to be more the result of environmental influences. models for prevention and early intervention are discussed.and intraindividual differences in mind. Of course. situation-specific tasks and developmentally appropriate play activities will be more appropriate for the preschool child. the clinician should keep both inter. classified. Individual differences in the rate of development are clearly apparent during the preschool years. and evaluated” (p. Next. because it has critical implications for the manner in which child behaviors are conceptualized. will rely more heavily on cognitive and language skills. for example. An understanding of normal development is also important in choosing appropriate intervention techniques. the impact of stressful life events may vary with the child’s stage of development. Finally. In light of the importance of a developmental perspective for clinical work with children. in order to plan appropriate treatment for such problems as social skills deficits. 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. research related to the variables that contribute to the vulnerability or resilience of children is reviewed. for example. and these differences often persist into the school-age years.

and (5) to explore and learn about the external world (Davies. clinicians should be knowledgeable about two areas of research most related to the development of later mental health problems: attachment and temperament. & Baker. & Elliott. DiGirolamo et al. Thus issues of parenting are most critical during this early time of life. Both the quality of primary caregiver–infant attachment and the child’s temperamental characteristics can potentially influence the child’s future functioning. emotional. and this development makes all other functions (sensory. It is usually the general pattern of development. and which will atrophy (Davies. 1998). and Child Behavior: The Classic Childcare Manual from Gesell Institute of Human Development (Ilg. Garrison. and Walker (1998) for more detailed descriptions of developmental milestones. 1992). (2) to develop interpersonal attachments and strategies for maintaining them. it is common for children who are not developing normally to be identified at this time (particularly during the preschool years). pay attention.1. 1998). 1999). we recommend three books for parents that cover developmental issues: Your Child (Pruitt. rather than slower development in any specific area.1 provides an overview of normal development from infancy through school age. 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. and school age. do arithmetic. and deal with difficult social situations. Brain development is most rapid during the first year of life. 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. Development during infancy is also inseparable from the child’s relationship with his or her caregiver(s). . they will almost inevitably be identified as a child enters school. In addition. for example. that alerts adults to potential problems. Ames. Problems during infancy typically come to the attention of pediatricians rather than mental health professionals (Campbell. helpful family members. The reader is referred to Davies (1999) and DiGirolamo. process more complex language. 1999). 1993). when there are increased expectations to sit quietly. 1999). and his or her capabilities unfold in a regular progression. 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. simple maturation is not sufficient to ensure normal progress (Davies. for example. perceptual.. The types of experiences to which the infant is exposed influence which neural pathways will be strengthened. along with the associated parental tasks. Although the child is born with certain biological prerequisites. and constant supervision may be needed at a time when most children are becoming independent. toddlerhood. Infant Development (Birth–1 Year) Development during the first year of life is phenomenal. Table 1. (2) to regulate arousal and affect. regulatory. may be slower and more difficult. (3) to develop and gain control over motor skills. read. 1999. the child may be slower to learn to dress and eat independently. motor. If developmental problems are not noticed during the preschool years. and cognitive) possible (Davies. The main tasks of the first year can be summarized as follows: (1) to gain physiological stability. and by 12 months of age infants barely resemble the beings they were at birth. Toilet training. Development of Psychopathology 5 Because many types of learning take place rapidly and simultaneously during childhood. preschool. which will remain available. Geis. (4) to begin to communicate needs and desires. However. The infant is born with a capacity to organize his or her experiences. 1999). 1998). often because they fail to achieve an expected developmental milestone.

good recognition memory. increase in ability to use retrieval strategies) • Uses verbally mediated thinking • Understands real vs. 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. Issues of Normal Development and Associated Parental Tasks Infants (0–1 years) • Brain develops rapidly • Weight triples. spoons) • Ties shoes • Copies shapes • 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 Cognitive development • Memory capacity develops (processing and storage in place. visual and auditory acuity • Motor skills develop: rolling. standing. persistence. seriation. and retrieve new information • Improved memory skills. sitting. walking. hand to mouth. and jumps Imitates motor actions • Throws ball Goes up and down steps holding on • Dresses Stands on one foot • Undresses Uses implements (crayons.1. not real • Engages in pretend play • Understands consequences and rules • Views the world egocentrically • Uses magical thinking 6 • Attention. skips. height doubles • Develops capacity for selfregulation • Physiological regularity increases • Becomes oriented to external world: sensory integration. and goaldirectedness allow formal schooling • Increased capacity to store.TABLE 1. pincer grasp. sustained attention . time orientation. reach and grasp. crawling. eye–hand coordination Toddlers (1–2 years) • • • • • Preschoolers (2–4 years) 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 Physical/motor development Stands and walks alone • Hops. auditory processing • Increase in executive processes: Problem solving. retain.

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.500.to 2.) . race. norms. and rules • Can see conflicting viewpoints and tolerates ambivalence • Identifies with parents as role models • Increased identification with samesex peers 7 (cont. ethnicity and personal characteristics • Self-esteem based on sense of competence and status in peer group • Uses cognition to regulate internal arousal.000-word vocabulary. 1. 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.or three-word sentences • Rapid development of grammar. 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 • More consistent sense of self • Increased sense of identity based on gender. and to solve problems • 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 Social/emotional • Balances desires for closeness with caregiver and for independence. and to control behavior • Internalizes values. syntax. to delay action.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 • • • • • • • • Imitates single words • Uses single words to communicate needs • Combines words and gestures • Vocabulary of 10–100 words • Two. to plan for the future and remember the past. to attain goals.

) Infants (0–1 years) • 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) • • • • • Preschoolers (2–4 years) School-age children (5–12 years) I. and relationships Start setting limits • Provide consistent daily routines and expectations Use distraction to discipline • 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 8 .8 TABLE 1. expression Ensure child’s safety of feelings. THE FOUNDATION Parenting tasks • Be an authoritative parent Provide opportunities for exploration and motor activities • Be a good role model for Talk to and describe child’s actions appropriate behavior.1. (cont.

1998). 13) Infants who are securely attached to their caregivers have been shown to have more optimal development in a number of areas (Campbell. Early in this process. and increased self-esteem (Cassidy. As the child progresses through the first year. & Sroufe. Mothers who respond to their infants abruptly. Kaplan. 6-year-olds who were insecurely attached at 12 months had great difficulty discussing their feelings and had few strategies for dealing with separation. Arsenio. responsiveness to crying.. The infant gradually learns that his or her needs will (or will not) be met consistently.g. clinging. the infant begins to discriminate between and respond differently to familiar and unfamiliar people. Hess. 1978). and Cassidy (1985). . 1986). At first any adult will do. 1997. are also associated with early secure attachment to caregivers. 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. foster the development of a secure attachment relationship. 1989). and better problem-solving skills (Matas. Furthermore. but gradually. number of social contacts. who are unresponsive. 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.e. Development of Psychopathology 9 and problems in either area are seen as risk factors for the development of behavioral or emotional problems. crying). ability to offer support to others. found that children who were securely attached at 12 months were more emotionally secure and better able to express their feelings at age 6. the infant begins to engage in active attempts to maintain contact with familiar people (usually parents) and becomes upset when separated from them. and the provision of opportunities to explore. or who pace their behavior to their own needs and schedules foster the development of an anxious or ambivalent attachment characterized by excessive anger. they are more popular. DeWolff & van IJzendoorn. By the end of the first year. early face-to-face play. 1971) and higher school achievement (Estrada. influencing popularity. Patterns of cognitive functioning. The quality of early attachment relationships has likewise been found to be important in emotional development. 2000). 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. 1988. 1987). As Campbell (1998) states: Mothers who are sensitive to their infants’ cues and responsive across a range of situations including feeding. Arend. including more symbolic play. Attachment The formation of “attachment”—that is. 2000).. Thompson. Main. As development progresses (usually by 6 or 7 months).1. for example. Sroufe & Fleeson. (p. and are more helpful to others) than children with less secure attachments do (Hartup. an emotional bond between the infant and his or her primary caregiver(s)—occurs gradually over the course of the first year of life. & Holloway. the process begins as caregivers (usually parents) respond to the infant’s signals of hunger or other distress. and as a result develops expectations about adult behavior relative to his or her signals. children with secure attachments to their caregivers show more appropriate social adaptations over time (e. more internal control. as well as increased task mastery (Baumrind. make more social contact. and/or avoidance behavior of the part of the infant. 1999. As Campbell (1998) describes.

Buss.10 I. 1996). 1988). Sanson. environments that predispose children to insecure attachments also typically contain a wide range of other risk factors. & Moore. Likewise. 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. 1997. & Waldman. so it is not always possible to determine whether adverse effects are due to poor-quality attachment or to other factors (Rutter. Oberklaid. Nonetheless. alertness. however. & Frankel. Bates & Bales. “Individual differences in the frequency and duration of crying. found a negative relationship between in- . it is reasonable to consider a disordered attachment. 1995). and predominantly negative mood) called “difficult temperament. 1985). Moreover. Kagan. slow adaptation. 1990. Lengua. The association between temperament and attachment is complex. Susman-Stillman et al. Davies. especially at extreme levels. however. Thompson. (1996). reported that negative emotionality was associated with symptoms of depression. & Prior. as early as the first few weeks of life.. activity level. intense responses.g. Thus difficult infants with highly stressed. with caregiver behavior and infant characteristics having both direct and indirect effects on attachment security (Susman-Stillman. whereas impulsivity was related to conduct problems. onset of mental health problems. Thus securely attached infants may become insecure if their caregivers become less able to meet their needs because of divorce. Goldsmith et al. 1987. 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. As Campbell (1998) states. withdrawal from novel stimuli..g. Temperament The early work of Thomas and Chess (1977) demonstrated individual differences in “temperament. Plomin. Maslin. infant cuddliness and consolability. an association between specific aspects of temperament and psychological symptoms has been found for school-age children.. unresponsive caregivers are considered at higher risk for later problems than difficult infants with responsive. Attachment status probably fluctuates as a function of parental and environmental circumstances (Belsky. Bates. Campbell. birth of a new baby. or other life stresses. Chess. 1998. Moreover. easy infants born into dysfunctional. Thomas. 1996. highly stressed families may later develop problems. and Sandler (1998). and self-quieting can have profound effects on parental behavior and the quality of the developing parent–infant relationship” (p. Goodness of fit is an important aspect of understanding the development of the caregiver– infant attachment relationship.” which was thought to be clinically significant.” or the behavioral style of a child’s interaction with the environment. 1995). as a risk factor for the development of problems later in life (Carlson. Thomas et al. 1997. 1989). Cohn. 11). despite being easier to care for during infancy and early childhood. Kalkoske. (1968) introduced the concept of “goodness of fit” to account for this phenomenon. Pedlow. West. Since that time. and some easy children exhibit difficulties later in life. Likewise. calm caregivers are (Campbell. Not all difficult children develop adjustment problems. for example. Research in behavioral genetics suggests that many aspects of temperament may be inborn (Goldsmith. insecure infants may become more secure if their environments become more stable. Gardner. 1999). & Charnov. Moreover. Rutter. Thompson. 1991). attachment is found to be less stable in higher-risk than in lower-risk families (Lamb. & Lemery. and Birch (1968) derived a cluster of traits (irregularity of biological functions or rhythmicity. for example. THE FOUNDATION Attachment relationships are not necessarily stable over time. sensitive. 2000). 1985. Egeland.

conversely. social relations (Keogh & Burstein. 1987).g. (4) to gain the ability to control emotions. Development of Psychopathology 11 fant irritability and “maternal sensitivity” (used broadly to represent a number of maternal behaviors). Understanding Your Child’s Temperament (Carey & Jablow. Toddlers have limited internal control over their behavior and impulses. Nonetheless. They may interpret all toddler defiance as a threat to their authority. to the extent that negative reinforcement cycles may develop and persist (Patterson. although parents frequently discuss problems with their pediatricians. and behavior. resulting in excessive punishment.. toddlers are rarely referred for mental health services. Skarpness & Carson. 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. impulses. 1988). They argue that the influence of temperament on attachment may be particularly important when maternal sensitivity is low. Children at this age have an intense desire to explore the world and to master new and increasingly complex experiences. measurement. this . they may have trouble setting appropriate limits on the child’s behavior. may be helpful in preventing problems related to child temperament.) continue to be debated. at the same time that he or she still wants to be close to the primary attachment figure. 1990). definition.1. and as a mediator of children’s adjustment to a variety of stressful life events (e. whereas high maternal sensitivity may mediate the effects of infant irritability. Thus consideration of temperamental characteristics in young children is clearly important to understanding many aspects of their development. Although various aspects of the construct of temperament (stability. (2) to become increasingly independent. temperament is currently being examined as one aspect of the ability to regulate one’s emotions and impulses. and adjustment to preschool and kindergarten (Parker-Cohen & Bell. Unfortunately. 1990. (3) to begin to internalize parental standards. many parents have trouble making this distinction. Campbell & Ewing. many later adjustment problems have their origins during this early period. such as academic skills and IQ (Palisin. 1988. 1976a). parental divorce. etc. It is clear that inappropriate parental responses to children’s noncompliance or defiance can exacerbate problems. Like infants. 1998). but they are still almost completely dependent on their caregivers. some amount of defiance and noncompliance is to be expected during the second year of life. 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. 1997). for fear of stifling the child’s initiative. Questioning parents or other caregivers about a child’s early temperament may shed light on current problems with behavior and interpersonal relationships. considerable research has demonstrated the relationship between specific dimensions of temperament and other aspects of later development. Davies (1999) summarizes the primary tasks of the toddler period as these: (1) to balance the need for closeness with exploration of the environment. 1986). and (5) to begin to use mental representations in play and communication. 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. Furthermore. and for the first time behavior management becomes an important issue for parents. As an example. A recent book for parents. death of a loved one).

Difficulty with language. Children born into homes with fewer economic resources. Moreover. words are initially acquired one by one. In other words. these two areas—language and self-regulation—are discussed in the next sections. however. as well as the acquisition of thousands more words. THE FOUNDATION ability develops gradually during the preschool years. Although most of these problems are transient. children born into middle-class families. self-awareness. to organize their thoughts. Increased frequency of talking provided greater language diversity. for example. so do the problems and concerns of parents. preschool children begin to be able to use language to develop new cognitive skills. Hart and Risley (1995. vocabulary increases to hundreds of words. peer relationships. play. 1989). as many as 14. During the third year. or problems with self-control can affect self-esteem and social relationships. and motor skills. to aid their remembering. These utterances form the basis for grammar. as well as the increased complexity of cognitive. In the second year. Language Development The hallmark of development during the preschool years is the development of language. significant problems in any one developmental area can affect the development of other skills in other areas.000 new word meanings may be acquired as children encounter them in meaningful situations and conversations. social. sets the stage for new and often intense interactions between the child and the environment. Preschool Development (2–4 Years) Child psychologists consider the preschool years (ages 2–4) to be among the most important developmental periods. As a child’s capacity to interact with the environment increases. the period between 2 and 6 years of age represents a time of enormous growth in children’s language abilities. 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. this phenomenon is the foundation for later reading skills. to facilitate their understanding of the world. whereas syntactic knowledge moves from the production of two-word utterances to full sentences. children start to master written language. By school age. and children with professional parents all had the same kinds of language experiences. As a result. children start to produce two-word utterances. They found that children living in poverty. driven in part by the development of cognitive and language skills. Rapin (1996). a primary parental task is to provide external controls that ensure children’s safety while they are busy exploring their environment. had fewer of these experiences. a proportional increase in the amount . the amount of talking the parents engaged in with their children was a crucial factor in the children’s later language development. and the process continues throughout toddlerhood. Although language obviously begins to develop during infancy. 1999) have demonstrated the profound effect that parenting style has on a child’s acquisition of language. and to control their impulses (Rice. After they acquire a few dozen single words. because the foundation for later competence in many areas is laid during this time. Rice (1989) states that without explicit teaching. From then on. and then vocabulary grows rapidly. can influence cognitive development. lanugage acquisition involves the comprehension and production of ever more complex sentences. and autonomy/independence. which allows children to understand and produce meaningful sentences. The emergence of language. Because of their importance to the development of psychopathology.12 I.

. and paraphrasing of the child’s utterances.g. Schwartz. The importance of language development is demonstrated by studies indicating that language mediates cognitive and social development (e. 1995. This style of caregiver language was associated with better language skills among low-SES children who did not have otitis media. disorders of language (understanding the symbol system. Gravel. Saxon. & Rosner. or otitis media. however. 1988). & Lehrer. & Ruben. which involves immediate responses to the child’s utterances. Sanyal. Delays in expressive language in children as young as 1 year with chronic middle-ear infections have been reported (Wallace et al. (1996) found that the language of caregivers of children with and without otitis media did not differ. and fewer questions and informative utterances. These include (1) speaking “motherese. 1988. Larson. Among those children with otitis media. and disorders of communication or pragmatics (social uses of language as a communication system) (Vetter. and conversing about what the child is presently interested in. for example.. Several other factors have been shown to enhance language development. at least among children from low-socioeconomic-status (low-SES) environments (Wallace. Klein. a greater opportunity to learn symbols for names and relations. including disorders of speech (articulation. Simon et al. (4) asking or suggesting rather than demanding. which may in turn lead to externalizing or internalizing symptomatology. 1999. Middle-ear disease. and fluency). Disorders of language and communication (but not speech disorders) are significantly associated with psychiatric disorders in childhood (Toppelberg & Shapiro.. (2001). Cantwell and Baker (1991) have reported that as many as 50% of children with language disorders also have psychiatric diagnoses. is associated with delays in language development (Simon. 1988). 1989.1. Vallance. 1988. slow rate of speech with pauses at significant words. Any of the major categories of speech and language disorders can be seen in children as young as the preschool years. Furthermore. 1997).” which consists of such features as simple sentences focused on present events. those whose caregivers used more directives. characterized by many commands. Otitis media is a significant problem when one considers that as many as 40% of preschoolers’ visits to the pediatrician involve middleear disease (Teele. (2) semantic contingency or joint attention. argue that impaired communicative competence contributes to poor social skills. McCarton. directives. and production of words. which is often accompanied by fluctuating hearing loss in preschool children. although this association has recently been found to be mediated by the communication style of caregivers. Wallace et al. and Humphries (1998). Cummings. 2001). Thus delays or disorders of language will impede development in other areas as well. Henderson. Beitchman et al.. despite the fact that the language delays had resolved. 1984). Wallace. and frequent attempts to shift the child’s attention to whatever the parent is interested in. and Appelbaum (1987) indicated that middle-ear disease in the preschool years was related to attentional problems in elementary school. and grammar). questions. (3) reading to the child. meanings. Collier. Development of Psychopathology 13 of encouragement the children received. For example. and (5) following the child’s lead during play interactions (Hart & Risley. comprehension delays at age 3 have been found to predict behavior problems at ages . 2000). 1980). 2000) and adolescence (Beitchman et al. about equally divided among behavioral and emotional disorders. 1996). Toppelberg & Shapiro. and enhancement of verbal recall. One factor that may impede language development is a controlling style of interaction with the child. Rice. & Ruben. a longitudinal study by Feagans. had lower language skills. 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. Gravel. This association appears to be strongest for children who have problems with receptive language or comprehension. voice quality. for example.

including (1) tolerating frustration. 1987). et al. Moffitt. 1994. pragmatic.e.. worsening social competence.. 150). Similarly. maintaining. & Wesson. Clearly. Schroeder. 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. 1994). 1997. the ability to label emotions. concerns about language should be referred immediately to the appropriate professionals for assessment and possible intervention. Kopp. In contrast. 1996). appropriate regulation is associated with more competent social functioning. “Behavioral regulation” refers to the ability to control emotionally driven behavior (facial or bodily reactions. Williams.. Children face many challanges in learning to regulate their emotions and behavior. 1999). p. Guthrie. 1989). MD 20852. and modulating the occurrence. Controls for family SES did not change these long-term associations.). had trouble sitting still. A longitudinal study of over 1. 1977). Eisenberg et al. etc. 1994). Fabes. intensity. 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. and Silva (1996) exemplifies this work and highlights the importance of emotional and behavioral regulation in children’s development. Michel. Temper outbursts occur most often at about 2–3 years of age. Self-regulation (e. A national resource for parents of children with language problems is the American Speech–Language–Hearing Association. 1997. Guthrie. and lacking in persistence.g. Anger is usually expressed behaviorally in response to an immediate stimulus (such as wanting a toy) by biting. The inability to regulate one’s emotions is associated with behavior problems—externalizing problems for children who are underregulated. to talk about emotions. Eisenberg. 800-638-TALK.asha.000 children by Caspi. Rockville. 1997). or duration of internal feeling states and emotion-related physiological processes” (Eisenberg. et al. scratching. 10801 Rockville Pike. who were irritable. In a review of 10 years of research on language disorders. 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. Newman. and internalizing problems for those who are overregulated (Cole et al. (3) defending themselves and their property. or kicking. both concurrently and in the future (Eisenberg. Kagan. and then gradually diminish during the later preschool years (Mesibov. because the child is in the process of learning how to communicate emotions in socially acceptable ways. & Teti. as dysregulation is a common component of most forms of psychopathology. especially ease and intensity of arousal . aggression. children who were underregulated (i. (2) coping with fear and anxiety. & McGee.14 I. and psychiatric comorbidity. and hyperactivity over the years and they are often not suspected or detected” (p.org. overregulated or inhibited 3-year-olds were more likely to meet diagnostic criteria for depression at age 21. In this study.. but is typically short-lived (Davies. Toppelberg and Shapiro (2000) conclude: “The presence of receptive or comprehension language disorders has proven to be the single most important consideration. The development of emotional regulation begins at birth with the infant’s inborn temperamental characteristics (Calkins.. and (5) negotiating friendships (Cole. and to use language about emotions to guide behavior) increases during the preschool years (Davies. http://www. 1999. impulsive. Self-Regulation The expression of emotion during the preschool years is usually uninhibited. (4) tolerating being alone. Conversely. THE FOUNDATION 7–11 (Silva. as they are a highrisk indicator of more phonological. “Emotional regulation” is defined as “the process of initiating... 1994. et al. 295).

and 5-year-olds become quite distressed in the presence of adult emotional expression and show different styles of coping (Cummings. disciplining. . By 3–4 years of age. Parents provide control either by manipulating the child’s environment or by providing consequences for the child’s appropriate or inappropriate behaviors (Pope. 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. the accurate interpretation of others’ emotional expressions does not develop until middle childhood (Covell & Abramovitch. Toddlers can comply with simple requests in familiar. Moreover.1. McHale. they directly teach regulation by modeling. Self-control at this age is still largely external. parents or other caregivers promote regulation through their interactive styles. clothing. sensitive responding to the infant’s signals. interfering with the child’s ability to learn. These skills are critical to the ability to self-regulate. & Boylan. such as responsive and contingent versus insensitive. 1987. 1982). allowing them to attend to and process parental messages. supportive versus overprotective. Kochanska. 1994). Chronically stressful occurrences. 1994). can alter a child’s internal reactivity to emotion and subsequent coping behaviors (Kagan. Posner. power-oriented or anxiety-arousing techniques may produce overarousal in a child. 1994. Thus control is entirely external to the child at this age. however.. Although 4. physical comforting. These characteristics set the stage for how the infant will react to incoming stimuli. as children learn to communicate their needs and emotions more effectively. 1990). Denham. begin to understand social situations and the need to regulate their behavior. children are better able to generalize rules from situation to situation and can recognize when other people behave inappropriately. 1994. At about age 6. Strandberg. Development of Psychopathology 15 (Rothbart. Feeding. & Craighead. As an example. By 5–6 years. 1986). the child is developing better cognitive and language skills.g. true self-control begins to emerge. Environmental circumstances also play a role in how children learn to self-regulate. and accepting versus neglecting (Calkins. reasoning) elicits the optimal level of arousal in children. 1982). Strayer. the infant is almost completely dependent on his or her caregivers for regulation. with the child’s own conscience controlling behavior to avoid personal guilt rather than the condemnation of others.. 1994. or child abuse. By 24 months of age. reciprocal versus unilateral. Kopp. 1997). and reinforcing their children (Calkins. At first. 1988). Verbal mediation of behavior increases rapidly during the preschool years. and is tied to concrete and specific situations. 1994). Later. and prevention of excessive stimulation or frustration all help the infant maintain a steady state (Calkins. & Blair. They also begin to exercise more control by talking out loud about their own behavior. however. 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. The child then tends to control his or her own behavior by following the rules to get approval from others. such as parental divorce. 1987). predictable situations. the beginnings of moral behavior appear.e. provision of regular and predictable routines. Conversely. Experience (particularly the responses of parents or other caregivers). They note that in some cases (e. but do not understand the rationale for compliance and do not generalize to new situations. there simply may not be a healthy way to cope. also plays a major role in moderating the infant’s reactions (Kagan. Auerbach. Kochanska (1995) argues that an inductive style of discipline (i. Mitchell-Copeland. and gain the ability to apply regulation strategies intentionally (Calkins. At the same time that parents are assisting the child to regulate his or her emotions and behavior. 1995). ongoing parental conflict or abuse). death of a loved one. this verbal control begins to be internalized. cooperative versus intrusive or controlling. and a child has less need for external constraints (Kopp.

It is during this period that children develop new and more complex cognitive and language skills. to the extent that the child can use these to guide behavior in the absence of authority figures. By 7–8 years. 1994) estimates the general prevalence of learning disorders at 2–10% of school-age children. 1992). The Diagnostic and Statistical Manual of Mental Disorders. THE FOUNDATION 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. American Psychiatric Association. children are able to use representational or internalized cognitive strategies in a systematic fashion to organize. A fairly large number of chil- . Self-concept and the perceptions of others become increasingly abstract and consequently more accurate. Moreover. school problems have been shown to vary with family circumstances.) that is substantially below expectations based on their age. These advances in cognition allow for formal schooling and permit the child to master increasingly complex academic material. and various psychiatric disturbances (Durlak. order. Learning and behavior problems in school tend to coexist. Children with learning problems also tend to be rejected by their peers. and manipulate objects. they confront the challenges of dealing with increased numbers of adults and children in both structured and unstructured settings. a child is able to think of possibilities that do not exist in reality. increased cognitive skills allow a child better control over his or her impulses and behavior. to manipulate things mentally that are not actually present. 1998). flexible. Later. dropping out of school. and to see that reality is just a special case of what is possible. children no longer think egocentrically and develop increasingly mobile. leading to the development of social support networks outside the immediate family. etc. poor self-esteem. Socially and emotionally. The hallmarks of development during this period are increased cognitive skills. which are more commonly found among boys than girls. In general. social withdrawal. and the development of social relationships outside the home. Other associated behavior problems include aggression. and logical thought processes. more severe problems are associated with greater family dysfunction. Parental standards and rules become internalized. arithmetic. and events. depression. The transition from preschool to elementary school is often difficult. According to DSM-IV. and language and social skills deficits. children with learning disorders evidence achievement in one or several academic areas (reading. 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. and many children with learning and/or behavior problems are identified at this time. and refine their fine and gross motor and attending skills. schooling. writing. approximately 5% of students in public schools are identified as having learning disorders. a more consistent and internalized sense of self. numbers. and intellectual abilities. 1992). fourth edition (DSM-IV. reversible. It is not surprising that school/academic problems are the most common referral concerns at this age (Campbell. Attention-deficit/hyperactivity disorder is most commonly associated with a learning disability (Durlak. From the age of about 6 onward. and thus are vulnerable to the long-term consequences of social rejection.16 I. including delinquency.

Preschoolers also tend to think of themselves in either–or terms—for instance. developmental research has shown that children’s experiences in early caregiving relationships provide the basis for the development of social competence (Jacobson & Wille. “Self-concept” refers to one’s view of oneself. Campbell (1990) states that adults have many opportunities to influence children’s self-esteem. punish. on the other hand. During the elementary school years. demonstrated that the quality . such as physical characteristics and possessions. Park & Waters. however. for example.1. or ignore their children’s successful experiences. High self-esteem. children begin to think of themselves in more abstract terms. Low self-esteem is associated with a number of psychiatric diagnoses (American Psychiatric Association. successful coping with stressful events can also foster a sense of mastery and thus can enhance self-esteem (Brazelton & Yogman. “self-esteem” is defined as one’s self-evaluation. or the discrepancy between one’s actual self-concept and the ideal self (Harter. has been shown to buffer the effects of stress (O’Grady & Metz. 1987).. Social development is dependent on many other aspects of development. such as representational or symbolic thinking and social perspective taking (Howes. Conversely. Consistent with cognitive development. other adults and peers play an increasing role in the child’s socialization. Self-esteem plays a critical role in social and emotional development during the middle school years. such as sociability and extroversion. denying them the experience of mastery and consequent self-confidence. 1988). They can reward. or they can shield them from every adversity. Research in behavioral genetics suggests that some aspects of social competence. Self-Concept and Self-Esteem Self-concept and self-esteem obviously develop throughout childhood and adolescence (and probably throughout life). Jacobson and Wille (1986). Although parents remain important sources of support. provides the basis for reasoning about the social world. 1983a). with estimates as high as 30% of children in the United States. have a substantial genetic component (Plomin. 1986). problem solving. sharing. the association between self-esteem and other factors is somewhat circular. self-concept and self-esteem are largely tied to feedback from parents and other significant adults. Durlak (1992) estimates that about 10% of school children have adjustment problems severe enough to interfere with their progress in school. 1994). such as conflict resolution. and behavioral regulation. 1987). At this time. 1986. Therefore. 1989). as “nice” or “mean. as well as language comprehension and communication skills. are worked out in the context of the peer group. Moreover. Peer Relations The tasks of social development are complex for school-age children (Davies. Development of Psychopathology 17 dren are thought to be at risk for adjustment problems in school. and their sense of themselves becomes increasingly dependent on how they think others (especially peers) perceive them. 1999). preschool chldren tend to view themselves in terms of concrete attributes. Social competence is in part a function of the development of specific cognitive skills. for example. Reasoning about the physical world. but they become increasingly consistent and abstract during the school-age years. Many aspects of socialization. particularly cognitive and language development. and also with poor academic achievement and peer relationship problems.” “good” or “bad” (Pope et al. They can also expose their children to mildly stressful experiences and help them to cope. 1989).

because both the children and the relationships change as a result of the interactions. they are protected by laws against abuse. horizontal relationships allow children to elaborate skills with individuals more or less similar to themselves. in part because of the developmental process of continual change and adaptation that characterizes childhood. Parker & Asher. especially for boys (Berndt. They are based on common play interests and the attraction that emanates from similarities between self and others. THE FOUNDATION of the caregiver–child attachment bond was related to the quality of a child’s later peer relationships: Securely attached children had happier. It is within the context of these relationships that the complexities of cooperation and competitiveness are mastered. for example. neglect. and “intimacy” in social relationships is first achieved (Hartup. children are also seen as behaviorally and emotionally resilient. and social limitations. friendships provide optimal context for learning certain social skills. These relationships are seen as bidirectional. Gradually play becomes more cooperative and reciprocal between 3 and 5 years of age (Howes. as such. we might ask. As a child gets older.18 I. and less controlling peer relations than did insecurely attached children. 1989). In an excellent review of the development of social relationships. the form of parent–child interactions changes from primarily physical to the parents’ giving verbal instructions to the parents’ sharing information. Given their cognitive. Children’s friendships are primarily same-sex at all ages from the preschool years through adolescence. such as cooperation and intimacy. Because of their intensity and equality. attachments to individuals with greater knowledge and social power) and “horizontal” relationships (i.. At this point. Given the importance of parent–child relationships in the socialization process. as defined by reciprocity and commitment between individuals who are more or less equal. Children’s friendships. 1993. physical. success with peers is associated in general with better psychological adjustment and school achievement (Campbell.e. usually begin to develop during the preschool years with the onset of parallel play. and if a parent does not change along with a child. Hartup (1989) points out that although close relationships with other children may not be developmental necessities. On the other hand. relationships in which individuals have equal amounts of social power). 1981). Hartup (1989) describes the importance of having both “vertical” relationships (i. There is substantial evidence that having friends is a “developmental advantage” (Hartup. VULNERABILITY AND RESILIENCE Children are viewed as simultaneously extremely vulnerable and wonderfully resilient. 1989). the child’s original maladaptive behavioral repertoire will continue to be elicited in interactions with peers. because social rejection in childhood is consistently found to be related to later adjustment problems (Coie & Cillessen. Achenbach and Edelbrock (1981) report that 30–75% of children referred to guidance clinics are reported by their parents to have difficulties with peers. 1998). Whereas vertical relationships provide security and protection. and exploitation. 1987). She states that the parent–child interaction easily becomes cyclical. more harmonious. and by middle childhood competition becomes an important part of social relationships. children are known to be especially vulnerable to adverse environmental conditions. 1987).. Putallaz (1987) suggests that intervention efforts for children with peer relationship problems should be directed at parent behavior as well as child behavior. “What makes some children more vulnerable or at risk for devel- . being disliked by one’s companions is an important risk factor. and provided with early intervention programs such as Head Start.e.

1985). such as poor prenatal care. The clinician must also understand the complex interplay between and among these risk and protective factors. 1987). Similarly. Masten. and that when accumulated and present across time. 1983... low level of language stimulation. conversely. but rather an aggregated accumulation of stressful events. 1990). prematurity. cumulative. Kogos. 1999). “Risk factors” in persons or environments result in a heightened probability for the subsequent development of a disease or disorder (Garmezy & Masten. and (3) environmental risk. We know that children with similar histories will have different outcomes. 1997. One way of categorizing risk factors is to view them as (1) established risk. for example. and also are more adversely affected by these negative life events than are children from more affluent families (Ackerman. McBride-Murry & Brody. the association between risk and protective factors and adjustment appears to be stronger for boys than for girls (Garmezy & Rutter. 1997). may be most helpful (Gordon & Jens. Down’s syndrome). for example. 1986). Greenberg. Rolf. 1999. drug and/or alcohol abuse by the mother during pregnancy. p. Cicchetti. Rutter (1996) points out that what contributes to psychological vulnerability for an individual child is not an isolated life event or stressor. & the Conduct Problems Research Group. are the critical foci for assessment and treatment. 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. This section focuses primarily on environmental risk and protective factors. “protective factors” are “those attributes of persons.1.g. 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. but has little effect on children with greater numbers of protective factors (Cowen et al. Nuechterlein. Chronic life stress. 1988).2. Socially and economically disadvantaged children. environments. such as a frank genetic disorder (e. Coie. despite having experienced conditions and stresses that are known to have adverse effects on development?” The answers to these questions are difficult. Thus the accumulation and interaction of risk and protective factors. and dynamic approach to vulnerability and resilience. 1990). fragile-X syndrome. situations and events that appear to temper predictions of psychopathology based upon an individual’s ‘at risk’ status” (Garmezy.. in which various factors interact over time to exacerbate or moderate the effects of adversity at any given time. Development of Psychopathology 19 opmental and/or emotional/behavioral problems?” or. Lengua. and the identification of areas of strength and vulnerability at any specific point in time. conversely. The socioeconomic context of growing up plays an important role in determining the vulnerability or resilience of children. & Weintraub. O’Grady & Metz. anoxia. “Why do some children growup to be competent and productive adults. and low birthweight. Moreover. 73). Protective factors can be categorized in the same way. This suggests that a multivariate. and that children with similar outcomes may reach them by different developmental pathways (Sameroff. such as poor responsivity or lack of sensitivity by a caretaker to a child. These are summarized in Table 1. it is recognized that protective factors are also on a continuum. (2) biological risk. is associated with increased adjustment problems among children with few protective factors available to them. Pinderhughes. are exposed to many more negative life events. these factors can increase the probability of a positive outcome for children in high-risk situations (Goodyer. . or poverty (Odom & Kaiser. 1985.

2. Risk and Protective Factors in Child Development Risk factors 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 Protective factors Child characteristics 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 .20 I. THE FOUNDATION TABLE 1.

(2) characteristics of the child. 1984). Belsky (1984) describes three possible sources of influence on parenting: (1) characteristics of the parents. & Izard. 1998. McBride-Murry & Brody. Parents’ Developmental History. supportive contacts with adults outside the family. highly structured. summarizing the research on resilence in children. 1998. 1999).3. and a strong sense of parenting efficacy has also been shown to buffer the effects of risk (Cowen et al. 1989. 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- . and environmental chacteristics to predict the path of development for individual children. & Crnic. high expectations for behavior and academic achievement. temperament. Parenting Practices Determinants of Parenting Current work in the area of parenting practices has focused on the determinants of parenting styles and. But the influence of parenting history has also been demonstrated for “normal” parents (Rodriguez & Sutherland. Other factors include an easy-going. a number of child and parent characteristics help buffer the effects of stress. Kendziora and O’Leary (1993) and Martin (1975) have summarized the various determinants of parenting. including sources of stress or support (such as the marital or couple relationship and social networks). on parenting styles is demonstrated most clearly in studies of abusive parents. including their genetic and environmental origins and personal psychological resources. 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. and these are shown in Table 1. Garcia.. they can explain why parents behave toward their children in a particular manner. connections to an extended family support system. Shaw. 1989). The parent–child relationship is a critical factor in determining both vulnerability and resilience among children. especially their own parenting histories. 1999. The next section reviews the work in this area. conversely. which interact with parental. not surprisingly. can place children at increased risk for problems (Blount et al. that is. and (3) characteristics of the environmental context of the parent–child relationship. 1993) propose that it is also important to understand parents’ attitudes and beliefs about child rearing. Parenting that involves consistent. suggests that these determinants are numerous. and biological status). Development of Psychopathology 21 Youngstrom. 1999). Woodworth.. because these can be critical motivational factors. 1988. McLoyd.1. Kendziora & O’Leary. Schoff. this relationship is influenced by child characteristics (such as sex. McLoyd. Masten and Coatsworth (1998). These show that parents who were mistreated during childhood are more likely than nonmistreated parents to mistreat their own children (Belsky. On the other hand. He and his colleagues argue that parenting is determined by the interaction among these sources of influence (Belsky. and participation in socially acceptable extracurricular activities. 1997. 1996). 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. & Yaggi. Giovannelli. Others (Abidin. Research related to the most important of these is discussed next. 1999). even for those children who grow up in poverty. or. familial. especially his or her unique temperamental profile. Owens. The influence of the developmental histories of parents. sociable temperament. intelligence level. age-appropriate discipline combined with warmth and sensitivity. Viewed in a broad context. Clarke-Stewart.

86). lengthy. ing (we are determined not to do to our children what our parents did to us) (Muller. early negative experiences of parenting can be overcome by current supportive relationships. he states that “in general.3. 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. highly aversive contact with relatives and helping agencies) Low SES Components of dysfunctional 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. Conger. moderated by current levels of social support: Rejected mothers with good support were less punitive than those with low levels of support. depression) Marital relationship (esp. Maternal depression is relatively common among mothers of young children. McLennan. Simons. activity level. ongoing conflict) Social support (esp. [one] that is then capable of providing sensitive parental care which fosters optimal child development” (p. particularly maternal depression.to 2-year-olds and 17% of mothers of children between 2 and 3 years reported elevated depressive symptoms. supportive developmental experiences give rise to a mature. Research on the effects of parental psychopathology. Parents’ Psychological Resources. and developmental changes Parental mental health (esp. 1991). & Chyi-In. The relationship between early rejection and punitive parenting practices was. Hunter. Whitbeck. 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. & Stollak. Kotelchuck. Mothers who are depressed engage in a variety of negative parental behaviors: increased criticism.22 I. physical punishment. Crockenberg concluded that parenting history has an important but not necessarily a determining role in the way mothers care for their children. on parenting behavior and child adjustment illustrates the importance of parents’ mental health status in determining how parents interact with their children. In a nationally representative sample. 1995. or delayed in dealing with misbehavior Components of optimal parenting • 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. however. This work demonstrates that maternal depression is strongly associated with poor child adjustment. and aversive responses to chil- . Belsky (1984) argues that the influence of parenting history is more likely to be indirect. The data are from Kendziora and O’Leary (1993) and Martin (1975). and Cho (2001) found that 24% of mothers of 1. insularity—few friends and frequent. A study by Crockenberg (1987) illustrates how parenting history is important in determining current parent behavior. healthy personality. THE FOUNDATION TABLE 1.

and overinvolvement).1. & Graziano. 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. Of all such characteristics that might influence the parent–child relationship. In a study of high-risk black children. 1986. Brand. depressed mothers perceive their children more negatively. It is suggested that stress has a negative effect on parents’ mood. sadness. Not only are “difficult” infants more difficult to parent and “easy” infants easier to parent. depressed mothers may be less organized and provide less stimulation than nondepressed mothers. 1985). hostility. conversely. child temperament has engendered the most research. It may also be the case. however. Faust. Gottesman. poor communication. McBride-Murry and Brody (1999) found that parenting protective factors. the parent. (1990) provided evidence for this direct link. Tschann. Development of Psychopathology 23 dren (Panaccione & Wahler. That is. & Welsh. The symptoms of irritability. demonstrated that irritable infants with angry. emotional unavailability.g. 2001). that maternal depression and other forms of parental psychopathology often occur in a context of multiple risk factors. Child temperament alone. The process by which maternal depression influences children’s behavior and/or development is theorized to be indirect. Alkon. report more behavior problems in their infants and more parenting stress than mothers of full-term infants (Halpern. RadkeYarrow. which leads to increased criticism and punishment. buffered the effect of difficult child temperament on the children’s ability to self-regulate their behavior. Webster-Stratton & Hammond. Campbell (1996) points out. and perceptions of increased child behavior deviance (Schaugnency & Lahey. 1990). 1986). Egeland. 1988). some or all of which may account better for children’s adjustment than parental mental health alone. which leads to poor parenting and subsequent adverse child outcomes (Kendziora & O’Leary. Crockenberg (1987). for example. however. Forehand.g. Child Characteristics. avoidance of confrontation and lack of success in controlling child behavior (Kochanska. 1987).. Chesney. These authors have also cited a substantial research literature linking maternal depression with non-nurturing caretaking behavior (e. and the environment is the critical factor in developmental outcomes. The fact that children’s characteristics have an important impact on their relationships with their parents is well accepted. Specifically. such as high expectations for child behavior and academic performance and consistent household routines. hostility.. Life stress and daily hassles can also have a negative influence on child adjustment by depleting the resources of parents (Crnic & Greenberg. Egeland et al. Lautenschlager. Rather. the “fit” among the unique characteristics of the child. Kuczynski. and negativity found in depressed mothers are common among highly stressed parents who are not clinically depressed (Downey & Coyne. Mothers of infants born prematurely. 1990). Kaiser. Kalkoski. & Malone. for example. inconsistency. In a longitudinal study of preschool children with behavior problems. 1993). mothers whose depression increased had children who functioned more poorly. Consistent with this work. but children with different temperamental characteristics also respond differently to the same environment. resulting in child behavior problems (e. does not determine parent–child relationships. punitive mothers were more likely to be angry and noncompliant and to have lower self-confidence later than were easy infants with angry. and Boyce (1996) found that preschoolers . punitive mothers. however. and Erickson (1990) have suggested that maternal depression may indirectly affect children’s development through the home environment. They found that mothers whose levels of depressive symptomatology decreased over time had children whose functioning improved.

Crockenberg. Parenting practices that are appropriate for a 2-year-old. and the broader environment’s ability to support the child’s development within this family context. points out that the marital relationship may also have an impact on parents’ general psychological well-being. Other characteristics of children that have been shown to have an effect on parenting are (1) the presence of conduct problems. 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.. their own or someone else’s mother). For currently married parents. Robinson. Pillegrini.) that enhance parenting abilities. Belsky (1984). regardless of the level of family conflict. Social support (e.. Anderson. Lytton. 1993). Eisenberg. being loved by a spouse or partner) can have a beneficial effect on parents’ mental health and sense of well-being in general. Belsky (1984) argues that social support can have both direct and indirect effects on parenting behavior. regardless of with whom they were interacting (i. ongoing conflict between parents may provide a significant source of stress that interferes with their abilities to care for their children adequately. & Burke. Ragozin. Many studies have documented the relationship among marital conflict (in either divorced or intact families).g. Contact with friends and family members that is desired and is positively perceived functions to moderate the stresses of parenting (Crockenberg. child care. Heller & Swindle. Homosexual Parents. support from one’s spouse may be a critical factor influencing parenting behavior (Brody.e. Similarly. & Basham. parents must adapt to the developmental changes in their children (McNally. It is estimated that between 6 million and 14 million . 1996). both externalizing and internalizing. Greenberg. In separated or divorced families. & Harris.24 I. 1989). increased activity level (or underactivity in some circumstances) in children has been shown to result in increased parental harshness. are not necessarily appropriate for older children (Socolar & Stein. Crnic.g. and Romney (1986) demonstrated that children with conduct problems elicited more negative feedback and were more noncompliant. Other work has shown that in intact families. for example.. 1986. & Sigel. 1983). (2) activity level. Brody. it can also provide concrete resources (financial help. 1987). Stoneman. Easy children had fewer such problems. 1987). 1991). the interplay among the child’s unique temperamental characteristics. THE FOUNDATION with difficult temperamental characteristics who lived in families with high levels of conflict had the most adjustment problems. Finally. 1984. and child problems (e. Positive perceptions of social support are associated with parents’ physical and mental well-being. more precisely. Another factor of interest to child clinicians is the adjustment of children raised by gay or lesbian parents. and (3) developmental changes (Kendziora & O’Leary. 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. Shaw & Emery. which in turn affects parenting behavior (Cutrona. however. the parents’ capabilities and resources. 1987. Social Support Networks. etc. The extent of parents’ social support networks—or. Marital Relationship. This research highlights the most important issue for prevention and/or intervention—that is. the marital relationship can be considered a source of either support or stress. 1983. and as such may exert an indirect but important influence on parenting skills. negative parenting behaviors.

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

1994. 1982. for example. Parents who spank their children tend to spank them a lot. and many continue to spank as the children grow older. throw or knock down. or hand. 1996. Straus & KaufmanKantor. & Elordi.g. however. 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. 1992). & Dishion. Rohner. However. the use of physical punishment may exacerbate a child’s aggressive and antisocial behavior. Physical punishment was most prevalent among African American parents. forcing parents to punish more frequently and more harshly. 1997. In contrast. But research suggests that it is not effective over time. the association was strongest in the context of high parental support. at least when the punishment occurs in the context of a warm. head. 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. Turner and Finkelhor (1996) found a significant association between physical punishment and child distress and depression even at low levels of punishment. (2000) confirmed that the more parents of clinic-referred children perceived their children as being oppositional and antisocial. 1994). That is. Perhaps a more important question is whether corporal punishment accomplishes what parents want it to. and Maynard (2000). those living in the South. (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. who also found that parents of clinic-referred children were more likely to use corporal punishment (spank with bare hand. Straus & Yodanis. Despite the inconsistency among studies. Straus. and later spouse abuse (e. Furthermore. (1996). Moreover. 1991. Sugarman. slap arm. grab neck and choke. 1996). Mahoney et al. and initially it may stop inappropriate behavior. suggesting that children do not learn how to behave . Mahoney et al. others have found no negative effects. reported that corporal punishment had an adverse affect on children’s adjustment only when it was perceived as reflecting parental rejection. leg. Reviews of research have reported inconsistent results. 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. Turner & Finkelhor. Rohner et al. The debate about corporal punishment revolves around whether or not it has harmful effects on children’s development. shake.. pinch. 1996). although their use of corporal punishment declined with child age. As in the Straus and Stewart (1999) study. Some studies find an association between corporal punishment of children and a variety of adverse effects. the less effective it becomes—in part because children habituate quickly. it seems clear that many children experience corporal punishment as highly stressful. the more likely they were to use physical punishment. such as aggression. and parents of boys. 1996. does it teach children to behave in a more appropriate manner? Spanking certainly gets children’s attention. Patterson. supportive parental relationship (Baumrind. Lewis. Donnelly. the use of corporal punishment in general declined with the age of the child. depression. 1998). the prevalence of severe physical aggression in particular remained stable across development. These data were replicated by Mahoney. and that for some it results in poor adjustment and increased aggressive behavior (Turner & Finkelhor. & GilesSims. slap face. Moreover. this suggests that causation is probably bidirectional. 1996. The more it is used. THE FOUNDATION for 2-year-olds. hit on bottom with hard object. or ears) and two to three times more likely to use severe physical aggression (hit body with hard object. Straus. Reid. Bourque.26 I. hit with fist or kick hard. threaten with knife or gun) with their children than were parents of nonreferred children. beat up.

Monitoring a school-age child involves keeping track of school achievement. and firm) and positive child behavior. Baumrind (1967) first identified an association between “authoritative” parenting (warm. Parenting practices that have been shown to promote more optimal adjustment in children are discussed next. Moreover. Development of Psychopathology 27 as a result of physical punishment (Straus & Stewart. In the preschool years. and the major components of optimal parenting are summarized in Table 1. and attending extracurricular events in which the child is involved. stimulating. responsive. If the real issue is “How do we teach children appropriate behavior?”. Monitoring in infancy includes sensitive and responsive parenting. Optimal Parenting Practices Despite the knowledge that many other factors influence children’s behavior. . monitoring means knowing where and with whom the child is. with verbal descriptions of the child’s activities. high levels of nurturance and affection. activities. During adolescence. we know that parents remain a critical avenue through which child behavior and development are influenced. They found that in families where children were perceived as having behavior problems. 1998). consistent discipline. Conversely. although the specific methods of monitoring will necessarily change with development. and intellectual achievement. and activities. 61). and expressions of affection are positively related to self-esteem. 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. reasonable. cognitive and motivational competence and healthy socioemotional development are promoted by parents’ attentive.3. an important question for clinicians is “What can parents do to ensure more optimal development for their children?” Considerable research has addressed this question. prosocial orientation. Building on this work. as well as joint attention to play activities. 1999). “Monitoring” is defined as “a set of correlated parenting behaviors involving attention to and tracking of the child’s whereabouts. Dishion and McMahon (1998) propose monitoring as a critical skill that is relevant for parenting from infancy to adolescence. mothers exhibited less proactive behavior than mothers in families with nonproblem children did. Pettit and Bates (1989) suggest that proactive parent behavior—characterized by monitoring children’s activities. overcontrolling or authoritarian discipline and undercontrolling or permissive discipline were associated with negative child behavior. For preschoolers. These are discussed in detail in Chapter 10. and nonrestrictive caregiving. Belsky (1984) has described the kinds of parenting at different ages that are thought to promote optimal child functioning. dance recitals. tracking school achievement. and attending extracurricular activities. expressing affection toward the children. and adaptations” (p. In infancy. accompanied by firm control. It is possible that this is the case because spanking does not teach children acceptable alternative behaviors. internalized controls.1. inductive reasoning. and teaching—function to prevent children’s misbehavior and thus reduce the need for parents to react punitively when children behave inappropriately. it simply teaches them what not to do (American Academy of Pediatrics. and achievement motivation. 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. providing anticipatory guidance. By school age. resourcefulness. homework. foster the development of good social skills. nonpunitive. learning principles suggest a number of methods that are more effective than physical punishment. affectionate. knowing who the child’s friends are. With the interrelated factors described above in mind. and school plays. monitoring ensures a child’s safety and can also be seen in joint attention. such as sports events.

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. Cox. Lewis. 1989. and relatives) with children is increasing as more mothers join the work force.28 I. social. fathers are particularly important in influencing children’s socialization and academic success. 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. has role models for father involvement.3. 1998. Tamis-LeMonda and Cabrera (1999) have reviewed the research in this area and found that for young children. In this study. 1998. adult male friends. With regard to emotional adjustment. fathers’ involvement (attending school meetings and/or parent–teacher conferences) is related to children’s academic performance. & Bjornason. 1990). Other . and intellectual development. Dysfunctional parenting styles of both fathers and mothers. For older children. 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. Coley. Amato & Rivera. 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. 1999). Scarr. Haskins. & Henderson. Phillips. The characteristics of dysfunctional parenting have been described by Kendziora and O’Leary (1993) and are summarized in Table 1. 1990. Mulligan.. what areas of development are affected. Other reviews concur with this reasoning (Hoffman. however. Specifically. These concerns revolve around the question of whether day care should be considered a risk factor for children’s development. 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. Brown & Eisenberg. This work indicates that the involvement of fathers and father figures (stepfathers. & McCartney. fathers’ emotional investment. 1998. and provision of resources are all associated with the children’s well-being. have negative effects of day care on children’s development been documented—and if so. attachment to children. A father is more likely to be positively involved with a child if he perceives the birth of the child as a desired event. & Ripamonti. Moreover. as measured by the mother– child attachment relationship. and what factors mediate or moderate these effects? Research on the effects of day care has focused on children’s emotional. has participated in the birth process and early care of the infant. has a good relationship with the child’s mother. 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. are clearly associated with a variety of child adjustment problems.. 1995. has indicated that children are particularly vulnerable to attachment problems at certain ages if they enter day care during these times (Varin. Owen. Scarr et al. Crugnola. on the other hand. 1989). 1985. they may not perceive it as a very stressful situation and thus may not exhibit attachment behaviors. Belsky. Scarr. 1998). 1996). Molina. 1989. THE FOUNDATION Recent work has examined the role that fathers play in their children’s development (e. One recent study. and has employment that is flexible enough to allow him to spend time with the child (Aldous.g. That is. Tamis-LeMonda & Cabrera. 1999.

enough trucks are provided so that each child can play with one). That is. It operates through its effects on the family environment and the child care arrangements. & Bryant.. is consistent with that discussed above: No short. This stress in turn affects their relationships with their infants and places the children at risk for later adjustment problems. & Hwang. both of which are associated with caregiver training. Burchinal et al. and. Clark et al. Hoffman (1989) states that “maternal employment is not so robust a variable that it can be related to child outcomes. Moreover. educational. language. Nabors. which gives children the opportunity to form emotional attachments with their substitute caregivers. the day care experience may serve to prevent a decline in intellectual functioning that results from a lack of early intellectual stimulation (Ramey & Campbell. which are related to increased safety and better cognitive and language stimulation. The quality of day care is a critical factor. Quality of care is consistently related to various areas of child development (but see Scarr. suggest that these behaviors may be primarily a function of the curriculum content of the day care program or of specific activities or toys. Development of Psychopathology 29 studies. however. Among economically and socially disadvantaged children. and Klein (1997) demonstrated a relationship between length of maternity leave and the quality of mother–infant interactions. Hyde. for a different opinion). when the curriculum is modified (e. 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. shorter leave was associated with less sensitive parenting. may find early return to work very stressful. (1997) suggest that mothers who experience symptoms of depression. A third important aspect of quality is the stability of care or low staff turnover.1.. and her child-related behaviors. 1984). Burchinal and colleagues (Burchinal. and (2) smaller group size. 1982). child–adult ratio and teacher education) is positively related to children’s cognitive. which almost always involves placing children in out-of-home care. for example. which is related to less caregiver time spent in management tasks and more spent in social. and also have infants who are more difficult to care for. Lamb. However. Clarke-Stewart (1989) concludes that day care may give intellectually average children a “head start. however. 1996. High structural quality includes (1) age-appropriate caregiver–child ratios. most important. Essex.. family structure. and these are moderated by parental attitudes. and (2) provision of developmentally apropriate stimulating activities. High process quality consists of (1) sensitivity and responsiveness to the children’s needs. 1986). Factors unique to working mothers and day care that influence children’s development are mothers’ feelings about working and about their child care arrangements.or long-term adverse effects of maternal employment on child adjustment have been found (Harvey. the support she receives from her spouse/partner and/or her family. levels of aggression and noncompliance decrease (Finkelstein.” but that children reared at home catch up quickly when they enter school.g. With regard to cognitive development. Wessels. her general sense of well-being.g. beliefs. by teaching prosocial behaviors) or activities and toys are changed (e. the quality of the care provided (Peterson & Peterson. Research on the effects of maternal employment. This relationship was mediated by mothers’ symptoms of depression and infant temperament. Roberts. Clark. 1998. and perceptions of child rearing. her level of education. 1999). have found that quality of care (specifically. These include a mother’s attitudes. Quality of care can be evaluated on two levels: structural and process. the positive effects of high-quality care during the preschool years have been shown to last well into elementary school (Broberg. and com- . In summarizing research related to mothers’ working. and other variables” (p. 2000). and cognitive activities. 1988). 1997).

The literature contains descriptions of a wide variety of prevention programs for children.4. the difficulty of finding any child care— much less affordable. 1998). and many families are forced to rely on less than adequate arrangements. Most disturbing about these cases is the finding that parents often were extremely careless in choosing a caregiver (e. nonsocial play. Their suggestions are summarized in Table 1. rated by their mothers as socially fearful).9 years). and positive interactions with caregivers. left the child with someone they did not know. PREVENTION OF PROBLEMS Children are prime targets for prevention programs. the abuse was committed by a caregiver hired by parents. 1998). relatives of caregivers (16%). high-quality day care reduced the incidence of social problems for children who were temperamentally vulnerable (i. however. A study by Margolin (1991) described cases of sexual abuse by nonrelated caregivers in informal arrangements or working in unlicensed. 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. The effects of quality of care are thought to be most important for children who live in impoverished environments (Scarr. did not attend to the child’s discomfort with or dislike of a caregiver. programs to alleviate fears of medical and dental procedures. or parents of the children’s friends (6%). good-quality care—is often so great that parents may be tempted to overlook signs that a child is suffering. follow-up. or left the child with someone who was intoxicated). it is costly. Although high-quality care is available. they had reason to believe the caregiver had a history of molesting children. Provision of adequate and affordable day care for all families who need it is an enormous problem. 1992. Similarly. The perpetrators in these cases were more likely than expected to be female (36%) and adolescent (mean age was 16. 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. these authors concluded that in reality. Other perpetrators were adult friends of children or parents (18% of cases). Williams. Moreover. Finkelhor. 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. young children are at greater risk of sexual abuse in their own homes than in day care settings. often caring for a child in the parents’ own home. Volling and Feagans (1995) reported an association between quality of care and children’s social competence..g. THE FOUNDATION munication skills during the first 3 years of life. Furthermore. live-in caregivers (8%). and prevention of sexual abuse in day care settings.30 I. and thus it may have somewhat underestimated the risk of sexual abuse for children in day care. or did not change caregiving arrangements when the child told them about being molested. programs to prevent emotional/behavioral problems for children of divorce or chronically ill . including programs to prevent child abuse and accidents. unregistered facilities. ad hoc caregivers (8% of cases). because many have not yet experienced significant damage from threats to their mental and physical health. Finkelhor et al.e.. (1988) discuss the role that parents can play in the early detection. In 31% of the sample of 325 cases. This study did not include informal small-scale child care operations.

. Finally. 2. Price. and Ramos-McKay (1989) reviewed 300 prevention programs and summarized the components shared by programs with demonstrated effectiveness. What Parents Can Do to Prevent Sexual Abuse in Day Care Settings 31 1. & Aber. and rules about when parents can visit. We will always protect you. genital rashes. Be alert to signs of distress in your child. 5. McDonald-Dowdell. and educational programs for disadvantaged children (Lorion. (3) strengthened the support systems available in the family. Williams. The need for prevention programs for children is highlighted by the American Psychological Association Task Force on Prevention.g. & Dennis..4. 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. general fears. as well as the size of the gain or loss. Interview people who live in or visit regularly the home of the day care provider. itching. (1989) note that although some programs may never be completely costeffective..g. • Physical complaints (e. Myers. pick up the child early or drop off late). 6. Brown. Discuss the possibility of sexual abuse with your child. which cites the increasing discrepancy between . and (2) policy makers and taxpayers want to know who will gain or lose from the program. Day care staff have no power to harm families. 9. 7. they may have great value in promoting human dignity or relieving human suffering. • “Nothing that happens should be a secret. Bartel. toileting problems. and Burns (1988). despite the critical information these can provide for policy makers and taxpayers. Price et al. and school.. carefully designed research to document their success.” 8. Reprinted by permission.” • “Tell me immediately if anyone does anything mean. and eagerness to leave when picked up. Insist on free access to all areas of the day care center. are grounds for suspicion. programs to prevent school-based violence by promoting social competence have been developed (Henrich. Development of Psychopathology TABLE 1. and seek advice from your primary health care provider. but rather may increase over often lengthy periods of time. They note two factors to consider in doing such analyses: (1) Benefits may not be apparent in the short term. Cowen. • Unusual sexual behaviors. bruising). Price et al. and (2) its cost– benefit ratio. Reprinted from Gordon and Schroeder (1995). no matter what you are told.g. you are safe. Data from Finkelhor. 1994). 3. whininess) that resolve when the child is absent from day care for a period of time. Effective programs (1) targeted a specific group of people. Locked doors. Teach your child about the intimidation tactics often used to ensure children’s silence. • “If anyone threatens you in any way. Lorion. (1989) state that cost–benefit analyses are rarely done in evaluating prevention programs. Copyright 1995 by Plenum Press. parent education programs. they aimed for long-term rather than short-term effects). 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). Visit frequently and at irregular times (e. Participate in the program as much as possible. 4. Teach your child about appropriate and inappropriate behaviors in the bathroom.e. children.” Note. & Beardslee. 2001).” • “Once you are home. (2) were designed to alter the life course trajectory of the participants (i. tell me right away. and (4) provided extensive. 1999). Be equally suspicious about day care in “good” and “high-risk” neighborhoods. community.” • “Mom and Dad are more important and powerful than any day care teacher. nightmares. • Persistent not wanting to go. Most recently. • Significant changes in behavior (e.1.

1990).3. building parenting and communication skills. or national level for the needs of children. Schultz and Vaughn (1999). whereas parent training is viewed as “selective” or “indicated” prevention. has inhibited the development of prevention programs to the extent thought to be necessary. The parents are in fact the ones who must carry out a sleep program or a habit reversal program.32 I. Despite increasing interest in prevention among professionals. Most parents had questions about child rearing and indicated that parent handouts. For example. whereas parent training attempts to resolve serious child disturbances (Schaefer & Briesmeister. particularly funding and staff time. Teaching parents specific parenting practices that have been shown . Learning to use contingent reinforcement provides a child with opportunities to develop positive self-esteem and learn new skills in other areas. however. Taylor & Biglan. for example. teaching parents how to use reflective comments can foster a child’s language development and self-esteem. Child clinicians can play an important role in this process by advocating on a local. surveyed parents attending an urban pediatric primary care clinic about their need for information. Parent training programs can be viewed broadly as the primary focus in the treatment of young children’s maladaptive behavior. however? The content and theoretical views of parent education programs are extremely varied. Moreover. and videotapes shown in the clinic waiting room would all be desirable methods of disseminating information. 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. and developing problem-solving skills. We can. or who must change their behavior or the environment to support a child’s learning new skills or decreasing negative behavior. parent groups. A distinction is made between “parent education” and “parent training”: Parent education focuses on preventing the development of dysfunctional child behavior.. 1998). teaching behavioral and learning principles. professionals have focused on providing parents with information about child development and training in behavior management techniques. share such techniques as provision of information. THE FOUNDATION the number of children who need mental health services and the number of providers of those services (Price et al. Parent education or parent training programs have become increasingly popular. including specific parenting styles and practices as outlined in Table 1. share with parents our knowledge about factors that increase vulnerability or resilience in children. What should be the focus of programs employing these methods. 1989). 1989). As previously stated. and equally difficult to delineate the specific factors contributing to or mediating outcome (Campbell. however. 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. Parent Education Programs In an attempt to prevent the common problems of childhood from persisting and/or becoming increasingly severe. 1987). Thus parent education is seen as “universal” prevention. and many do not reflect current research and thinking in child development (Dangel & Polster. it is difficult to identify specific causal mechanisms in the development of childhood disorders. Both types of programs. state. Teaching parents how to use time out contributes to an authoritative parenting style (warmth with firm limits). Parent education has received increased attention from child clinicians. Rickel and Allen (1987) argue that competition between prevention and direct services for scarce resources. and child clinicians can play an important role by offering these programs to parents in their communities. 1984.

and exploratory behavior) place them at high-risk for injuries (Baker. To be effective.. it is important to consider child characteristics in planning for effective parent education. such as praise or time out. The Confident Child: A Practical. We know. Development of Psychopathology 33 to increase positive parent–child interactions. Christophersen notes . These two types of injury account for more childhood deaths than the next six most frequent causes of death combined. and marital discord are all associated with the development of behavior problems among children (Bush & Cockrell. Taylor and Biglan (1998) review the components of parent training programs that have empirical support for their effectiveness. 1999). The normal developmental chacteristics of children (e.” Whether a child’s injury is considered accidental or intentional is often difficult to determine. Parents with these problems are less likely to access parent education programs than are better-functioning parents. We also like the following books for parents: How to Talk So Kids Will Listen and Listen So Kids Will Talk (Faber & Mazlish. 1996) and The Incredible Years: A Trouble-Shooting Guide for Parents of Children Aged 3–8 (Webster-Stratton. some of these programs also strongly advise parents against using certain proven behavioral techniques. for example. as well as guidelines for when parents should seek professional help. In summary. These are discussed in detail in Chapter 10. Prevention of Accidental Injuries Another form of prevention that is receiving increasing interest is the prevention of children’s accidental injuries. Compassionate Guide (Apter. that maternal depression or anxiety. teaching methods. 1989). because children respond differently to different parenting techniques. & Li. such as Parent Effectiveness Training (Gordon. and assisting parents in setting limits and providing consistent consequences for inappropriate behavior. to examine the relative efficacy of different contents. O’Neill.g. 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) recommend several books for parents that offer empirically supported advice for parents. thus data on intentional and nonintentional injuries are often combined. and Hyper-Parenting: Are You Hurting Your Child by Trying Too Hard? (Rosenfeld & Wise. lack any evaluation of effectiveness. These include Parenting the Strong-Willed Child (Forehand & Long. parent education programs not only should focus on specific information about child development and management techniques. 1992). This is reflected in the very high incidence of injuries among children. Taylor and Biglan argue that many popular parenting programs. 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. Panaccione & Wahler.. high activity levels. Stoneman et al. 2000). 1987. 1986. however. but also should take into account the broader personal needs of the family members. In contrast to these programs. 1997). curiosity. 1976). this research indicates that the expertise is available to design and implement more effective parent education programs. would constitute a reasonable approach to parent education programs. Thus parent education programs should provide information on the relationship of these risk factors to child behavior. Ginsburg. Further research is needed.1. mouthing objects. 1992b). 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. Moreover. and instructors for different samples of parents and children. missed school and/or bed rest. a poor social support network. 1970) and Systematic Training for Effective Parenting (Dinkmeyer & McKay.

however. particularly a lack of appropriate supervision or monitoring of the child. 1987). Toddlers whose mothers were more emotionally stable. safety caps for medicine bottles). This suggests that other types of prevention programs for parents should begin prenatally. 1988). THE FOUNDATION that there has been a dramatic increase in the number of childhood deaths due to both accidents and violence over the last 50 years. Specifically. whose mothers had more education. DiLillio and Peterson (2001) outline various approaches to injury prevention.g. Early intervention programs have primarily targeted high-risk children. Ramey & Campbell. & Newberger. Matheny (1986). Beckwith. which include passage of laws requiring people to change their behavior (e. Ramey. Garbarino (1988) has classified childhood injuries on a continuum from random accidents to preventable accidents to negligence to assault. Roberts and Turner (1986). Ross. society. Early Intervention Programs Yet another form of prevention that interests child clinicians is the early intervention program. Hampton. Garbarino. 1984). Injuries that occur in the home are responsible for the majority of childhood deaths.. Still other approaches have taught parents to use standard behavior management techniques to decrease dangerous behavior in their children (Matthews.S.34 I. Campbell. & Christophersen. . they include educational programs such as Head Start. less cluttered homes were less vulnerable to accidental injury. 1988). Hoffmann. laws requiring use of seat belts) and passive control by redesign of products and the environment (e. for example. Friman. 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. model programs such as the Abecedarian Project (Horacek.. Of most concern to child clinicians is family-focused early intervention. 1998. Poor parenting. and who lived in better-organized. and boys are more vulnerable to these injuries than girls. 1987. Other successful approaches to prevention of accidental injuries have utilized principles of reinforcement. and reported significantly increased usage during a 2-week period.g. but now are considered preventable). found that characteristics of the mother and the environment were more closely related to injuries than child characteristics were. in part reflecting a general increase in violence in U.. & Fletcher. 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!).g. The relationship between physical abuse and childhood injuries is complex. 1989). active. whether or not an injured child is reported for physical abuse is related to socioeconomic and racial factors. presumably because of behavioral differences (Christophersen. at which time parents could be given information designed to prevent a variety of childhood problems. & Thompson. injuries resulting from automobile accidents would once have been considered random accidents. Furthermore. rewarded parents with lottery tokens redeemable for prizes for using child safety seats. plays a critical role in the occurrence of childhood injuries (Dishion & McMahon. and energetic. 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. although there is some overlap between these categories (e. and interventions in the family system (Heinicke. Barone. 1983).

1988). (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.” Intervention can be directed at developing positive child-rearing techniques.1. The studies reviewed included work with parents during pregnancy. and ongoing sessions from the age of 1 month to school entrance. In a review of 20 early intervention studies with high-risk families. (1988) found that 15 (75%) showed at least one significant positive effect. Family intervention targeted toward families with additional risk factors that did not change as a result of lower levels of intervention. 3. The goal is not only to forestall events that are harmful to children’s development. free transportation to the health care clinic. Media and promotional strategies. Ten 90-minute individual sessions with home visits for some high-risk individuals. 4. This type of intervention is typically “selective” or “indicated.000 contacts. Burns. Development of Psychopathology 35 Family-focused early intervention is directed at changing parental functioning so that permanent negative effects on children are minimized (Heinicke et al. a series of parenting “tip sheets. those that influenced children’s functioning in a greater number of areas—had 11 or more contacts with each family. Heinicke et al. Components of the program ranged from “universal” to “indicated” prevention and included the following: 1. Although this in no way means that the direct impact on the parent–child relationship is not significant. Those who received the most intense and longest intervention (home visits every 2 weeks during pregnancy. 15-year!) benefits of a prevention program targeted at highrisk pregnant women. and telephone-assisted and self-directed parent training for those who could not come to the clinic. newspaper columns dealing with common parenting issues. Those programs producing a more pervasive effect—that is. such as television and radio advertisments. and less drug use. 2. Heinicke et al. Edwards. better education. In another example. As an example of family-focused early intervention. and developmental screening at 1 and 2 years of age) demonstrated the most benefit from the program. and 13 episodes of a 30-minute “infotainment” television show.” and four brief videotape programs.e. and allowed parents to practice specific skills and selective use of parenting tip sheets. immediately after a child’s birth. 1988). and all are reported to be successful in meeting their individual goals. which began before or shortly after the birth of the child and continued for up to at least 3 months of age. eight group sessions with follow-up telephone contact for other high-risk parents. and/or promoting children’s adaptive behaviors. Four 20-minute sessions that presented information. it does indicate that intervention may be primarily leveraged through . Hoagwood. The number of sessions varied from 1 to over 1.. 5. but also to enhance the children’s ability to cope with difficulties that occur in the normal course of development (Wolfe. Each of the components of this program has been evaluated. continued home visits until a child was 24 months old. improving parents’ abilities to cope with stress.. & Koverola. A brief 20-minute consultation for parents with specific concerns about a child’s behavior or development. Benefits noted included less use of welfare. and Mrazek (1999) reported long-term (i. 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. Manion.

which no doubt accounts for some of these differences.36 I.. more hours. teen pregnancy. more weeks per year) are more effective. Direct provision of learning experiences. THE FOUNDATION the relationship between the intervenor(s) and the family.g. Developmental timing. 2. such as training parents in ways to enhance their children’s cognitive development. this effect declines for Head Start children in the first few years of public schooling. 6. Some children will show greater benefits than others. Program intensity. delinquency. More comprehensive programs that use multiple methods to affect child development are more effective than those with a narrower focus. Thus programs that involve parents. 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. Interventions that begin earlier in a child’s life and continue longer are more effective. Wolfe. 5. Ramey and Ramey (1998) have summarized the early intervention research focused on improving children’s cognitive skills. to the extent that environmental supports to maintain the child’s gains are lacking. In contrast.. Haskins (1989). in a review of the efficacy of preschool education programs. 3. 4. Children who receive direct intervention show larger and longer-lasting benefits than do children in programs that rely on intermediary intervention. more days per week. teachers. Moreover. there is no evidence linking Head Start attendance with any of these variables. the evidence for improvement on long-term measures of school performance (e. more visits. and other important adults are likely to be more beneficial. Repucci. Based on the results of many studies across four decades. and employment) is substantial for the model programs. special education placement) and “life success” measures (e. the goals of prevention programs targeted at this problem are necessarily complex. 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. they propose six principles that should guide development of successful early intervention programs: 1. Individual differences in program benefits.g. 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” . Programs that are more intensive (e. Among the outstanding features of the model programs is parent and teacher involvement.g. The success of early intervention programs that focus primarily on children has been directly linked to parental involvement. Ecological dominion and environmental maintenance of development. In some cases those at highest risk benefit most. use of welfare.. parents and children who participate more regularly and actively show greater positive results. Initial positive effects tend to diminish over time. rather than through direct work with the child. More recently. whereas in other cases the opposite is true. Program breadth and flexibility.

depending on the needs of families.. Programs for adolescent parents required more intensive home visits to demonstrate effectiveness.. as well as the overall adjustment of mothers. Wolfe et al. and better parent–child relations than a group of abused children who received community services. 6). preadolescent children understand that sexual abuse involves sexual touching. These authors reviewed research related to prevention programs for physical abuse. Kast. or someone close to their own age. Repucci & Haugaard. aggression. Programs that targeted at-risk parents were found to be effective (at least in the short term) in improving parents’ attitudes and behavior. the treatment group was significantly less prone to violence. The program’s goals were to decrease the long-term adverse effects of maltreatment and to reduce the likelihood of recidivism. and had fewer disciplinary actions in school. Moore. These programs should . Wurtele and Miller-Perrin (1992) have summarized the important components of sexual abuse prevention programs for very young children. 1995). Preschoolers. more positive home environments. and they may not be able to discriminate “good” from “bad” physical contact. No particular approach was found to be essential. preschool and early elementary school) must be sensitive to the developmental needs of the children in order to be effective. but view perpetrators as older “mentally ill” or “sexually deviant” people (Wurtele & Miller. Evaluation research indicates that prevention programs can be successful even for preschool children when they include such behavioral techniques as modeling. whereas others suggest that because older children may know something about sexual abuse prior to participation. for example. The 12-year follow-up data indicated that the children who received treatment had fewer behavioral and emotional problems. home visits) are most successful with higher-risk parents. Programs that targeted new and expectant parents (including high-risk low-SES groups) were beneficial even if they provided only brief home visits. 1988. Wurtele. Prevention of Sexual Abuse With the increase in reports of sexual abuse of children. Active involvement of children is one factor that has been strongly associated with success. Wolfe et al. high-risk participants did not benefit from less intense interventions.. guided practice. 1987). and anger. Parents and siblings of the targeted children also received services. except that fairly intensive group and home visit components were associated with effectiveness. Other work indicates that programs for very young children (i.” strangers.e. Furthermore. (1995) conclude that multilevel programs offering escalating services over time. Some studies have found that older children benefit more from prevention.e. 2000.1. teaching children personal safety skills has become important. Younger elementary-school-age children are often unsure about the nature of sexual abuse and tend to view perpetrators as “bad people. they show smaller gains in knowledge than do younger participants. Programs that continue for 1–3 years and are personalized (i. and reinforcement of appropriate responses (Wurtele. Armsden. and Gogerty (1998) describe an early intervention/prevention day care program for abused and high-risk children ages 1 month to 5 years. 1989). Miller-Perrin. 1989). are necessary with this diverse population of parents. 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. & Kondrick. if the participants were considered to be at lower risk of abuse. have difficulty understanding that someone they love could hurt them. 1990. Development of Psychopathology 37 (p. prevention programs must recognize differences in how children at various developmental levels conceptualize sexual abuse (Kolko. That is.

. changing sleeping arrangements. It is important to note. and impulse control skills were taught (Committee for Children. Actual abuse situations are very complex. and male–female relationships contribute to a social context that supports sexual abuse of children (Wurtele & Miller-Perrin. Involving parents. recognition of exploitive situations. empathy. Kast. providing better supervision. A review of the epidemiological characteristics of child sexual abuse by Wurtele and Miller-Perrin (1992) suggests several potential targets: 1. there is no ethical way to demonstrate that children actually use the skills they have learned in abusive situations. and Miyoshi (1987a.” as the latter concepts are beyond the capabilities of preschool children (Miller-Perrin & Wurtele.g. Potential perpetrators of sexual abuse. Currier.g. modeling. was designed to teach adolescents who were at risk of abusing children about the nature and causes of child sexual abuse. 1992.” and “confusing touch. “Booster” sessions may be essential for maintaining effectiveness over time (Garbarino. THE FOUNDATION focus on teaching simple rules such as protection of private parts. rather than “good touch. Finally. problem solving. although parents may be willing to participate in teaching abuse prevention skills to their children. and it is not possible to predict what children will do if and when they are confronted with such a situation. especially for preschool children (e.. Teaching the importance of disclosure (“Tell someone”) is also considered a critical component of programs for young children. and sexual knowledge are better able to protect themselves from sexually exploitive situations. parents need to know that children who have good self-esteem. 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. 1989). for example. 1991).. male socialization. etc. In addition. etc.. that most sexual abuse is perpetrated by someone known to the child (Wurtele et al. Societal attitudes about children. and oneon-one practice that are provided increase.g. 1987b) engaged 5. Wurtele. Consequently. 1988). as well as increase the children’s personal safety skills (Wurtele & Miller-Perrin.). 1992). because it is unlikely that all children will be able to get away or say “No” (Kolko. Gillispie. Providing parents with the information they need to educate their children can improve the parents’ ability to protect their children (e. One prevention program. use of role play. 1991). many parents do not know. 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. anger management. whereas only half of the controls refused. 1992). Moreover. in combination with teaching behavioral skills (e. 1988). problem-solving skills. All but four of the children who participated in the prevention program refused to go (88%).g.). reinforcement to teach personal protection. & Melzer. children from dysfunctional families. Retraining for all children plus the control group resulted in refusal by everyone but two of these four original participants. Wurtele. checking on day care centers. Furthermore.to 7-year-olds in an interesting abduction analogue situation following their participation in an abuse prevention program. Moreover. 1995). socially isolated youngsters) are least likely to participate in such programs. & Franklin. sexuality. Kraizer. 2. effort. that parents of children who are most at risk for sexual abuse (e.” “bad touch... For example. Fryer. the effectiveness of prevention programs for young children increases as the time.38 I. it is likely that they will need information about what to teach. however. has been demonstrated to be a good way to approach sexual abuse prevention. . it is important for professionals to begin targeting other aspects of the child sexual abuse phenomenon (Wolfe et al. or do not know how to tell their children. 1988). decision making. Sociocultural attitudes and beliefs.

given the complex interplay between risk and protective factors: Multiple risk factors may combine and potentiate each other. 1990). we have the methodology. Development of Psychopathology 39 3. This presents a great challenge. their life course trajectory can be significantly changed for the better. Mass media and pornography. as well as documentation of outcome relative to cost. These programs are based on the assumption that if children are reached early enough. child clinicians and researchers must begin to focus on prevention programs. 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. Child biological factors and other characteristics. provides guidelines for planning early intervention or prevention programs for families that can enhance children’s development. Taken together. the research on parenting styles. whereas certain protective factors may buffer the effects of risk and stress. and other media may contribute to an increased sexual interest in children and decreased inhibitions about sexual contacts with children. Access to children. the quality of the programs and qualifications of the intervenor(s). and parental characteristics all must be weighed in the assessment of risk and protective factors. however. 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. must be carefully considered. the social and environmental context. and experience to implement more and better parent education programs. advertising. . but also to enhance the children’s ability to cope with the difficulties that occur over the normal course of development. In doing this. These programs should attempt not only to forestall harmful effects on children’s development. 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. family-focused early interventions.1. however. it seems reasonable to assume that such films. and other prevention programs to enhance the development of children. Although a direct connection between erotic portrayals of children and child sexual abuse has not been consistently documented (Murrin & Laws. is necessarily through parents. knowledge. as well as that focused on other risk and protective factors.

1996). and the broader ecological factors (familial. we focus on the assessment-to-intervention process in general. we discuss issues of diagnostic classification. and review estimates of prevalence for childhood problems. and which are only annoying and/or transient. In order to accomplish this task. The second step. social. Assessment identifies the distinguishing features of an individual case. is necessarily dependent on the quality of the assessment. (2) translation of research into practice.40 I. the potential biological influences on the child’s functioning. whereas classification groups cases according to these features (Kamphaus & Frick. Moreover. we present a comprehensive assessment-to-intervention system that is adapted to specific problems as they are covered in later chapters. the assessment process must determine what factors contribute to the problem and what the target areas for intervention should be. Some of the benefits of classification systems include (1) promotion of communication among professionals. intervention. First. issues central to the treatment process are covered. as well as of ways to document treatment progress for individual cases. and cultural) that interact with children’s characteristics. Finally. Furthermore. Methods of assessment that we have found most useful in clinical practice are also discussed. In addition to determining whether particular behaviors are clinically significant. THE FOUNDATION CHAPTER 2 Assessment to Intervention 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. since each system of classification defines the rules for distinguishing a particular disorder from normal functioning and facilitates reporting of data. Next. the clinician must take into account the developmental level of the child. a careful assessment informs the clinician about which treatment methods are developmentally appropriate for each child and family. The assessment process helps the clinician determine which problems are clinically significant and might benefit from treatment. The first step in accomplishing this complex task is a careful assessment of the presenting problem. since classification allows 40 . T ISSUES OF DIAGNOSTIC CLASSIFICATION Assessment and diagnostic classification are parts of a single process. the clinician must have knowledge of empirically validated treatment approaches. In this chapter.

presently in its fourth edition (DSM-IV. what informants should be included. there are inherent problems in any classification system. APA. there is no clear way to determine when a behavior should be considered pathological. for staff in a particular setting. for example. 1992). valid in terms of the etiology and course of the problem. 1998). The labels “mental retardation” or “attention-deficit/hyperactivity disorder” (ADHD). Third. and how the rating for presence and severity of the criteria should be made (Cantwell. 1994). “an ADHD child”). 2000]. an individual either meets or does not meet criteria for a particular disorder. First. (The text of DSM-IV has recently been revised [DSM-IV-TR. the assessment process for determining the diagnostic criteria does not always specify what instruments should be used. it must be simple and have explicit rules so that it can be used reliably by different raters over time. World Health Organization. diagnostic categories and criteria for defining each disorder are chosen by committees of mental health experts. it is important that the clinician have a clear understanding of the limitations of different classification systems. A related concern is that there is no systematic method of determining the extent to which symptoms interfere with children’s functioning. and the various orientations of committee members all contribute to the categories that are finally selected for inclusion. for a classification system to be useful. the criteria for many of the diagnostic categories for childhood disorders have changed with each new edition of DSM. This is problematic because impairment of functioning is a key criterion for making a DSM diagnosis. there is a high degree of overlap between various forms of psychopathology. The DSM system illustrates many of the problems with the categorical approach to diagnosis. structured interviews designed to give yes–no answers about whether a child meets . associated features. Hence clinical experience. it has recently become standard practice to use classification labels to describe the psychological construct rather than the person (e.. children who met the criteria for a particular diagnosis in one edition often fail to qualify for the diagnosis in the next edition. a stigma is often associated with the “label” derived from classification.) Another example of the categorical approach is the similar International Classification of Diseases. and that classification be used only when there is a clear purpose for doing so (Kamphaus & Frick. It must also be meaningful—that is. Categorical Approach The most commonly used categorical classification system in the United States is the Diagnostic and Statistical Manual of Mental Disorders. 1996). In an attempt to deal with this problem.g. Second. but the evaluation of impairment is currently left to “clinical judgment” (Bird et al. As the criteria for diagnosis became more detailed in DSM-III (APA. but the basic criteria sets remain the same. inferences from the existing empirical literature.2. that the labels or classification categories be used cautiously. Second. and (3) documention of the need for such services as special education. making categorization of cases difficult.. American Psychiatric Association [APA]. 2000). 1996). or for reimbursement of services. Assessment to Intervention 41 one to determine how the features of an individudal case relate to other cases for which research has identified similiar features. “a child with ADHD” vs. currently in its 10th revision (ICD-10. 2000). First. In both these systems. Although the benefits of classification outweight the disadvantages. and vice versa (Achenbach. or treatment approaches. can cause people to treat children differently from their unlabeled peers. 1980) and later DSM editions. 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. Furthermore. In contrast to these advantages. As a result.

and refer a wide spectrum of children’s behavioral and developmental problems. familiality. published by the American Academy of Pediatrics. (3) how to deal with comorbidity (i. and anorexia nervosa (Cantwell. 1996). 1996). 1996) . In addition. Wolraich. Frances. and cultural trends. or is there something unique about the co-occurrence?). THE FOUNDATION each criterion for each specified category or disorder became increasingly popular (McClellan & Werry. Rett’s disorder.. gender. 2000). 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. Another recently published categorical diagnostic system is the Diagnostic and Statistical Manual for Primary Care (DSM-PC. which is divided into clinically meaningful graduations. & First. The use of the DSM classification system can be particularly problematic with children. (3) children’s expression of symptoms and responses to stressful environmental situations vary as a function of age and level of development. Although DSM-IV encourages the clinician to view individuals with a particular disorder as heterogeneous and to gather information that goes beyond the diagnosis. few childhood and adolescent disorders are fully validated. whose ever-changing development makes it difficult to determine which behaviors are transient developmental problems and which are clinically significant (Campbell. Widiger. & Drotar. Davis. 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). and (4) the system is based on objective data where possible and on professional consensus in cases . 1990). This latest revision also provides the user with basic scientific information supporting the various categories. the diversity of these problems and their importance to the diagnosis of children’s problems are not adequately taken into account (Volkmar & Schwab-Stone. The DSM-IV childhood disorders for which there is a satisfactory amount of external validation include ADHD. 1999). (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. Tourette’s disorder. 1996). (3) prevalence. Felice. and (5) familial patterns (APA. however (Cantwell. 1994) that provide information on the scientific bases for the disorders. 675).. Despite these difficulties. In addition. The academy’s goal was to develop a comprehensive and developmentally appropriate categorical diagnostic system in order to help primary care pediatricians recognize. and (4) how to determine whether disorders differ qualitatively or quantitatively from “normal” (Cantwell. 1996). 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. (2) how to discriminate one disorder clearly from another disorder. (4) course.e. are disorders distinct.42 I. 1994). although both parent–child and sibling relational problems can be coded as “other conditions that may be a focus of clinical attention” (APA. manage. biological correlates. autistic disorder. 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. Structured interviews do not take into account the importance of such factors as the natural history. as well as to take into account stressful family and environmental situations (Drotar. obsessive– compulsive disorder. p. including (1) the characteristics of associated features. conduct disorder. 1994. there are five DSM-IV sourcebooks (e.g. and response to treatment. psychosocial correlates. 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. 1996). (2) age.

medium. child) to determine how well they discriminate between children who are considered in need of help and those who are considered relatively normal (Achenbach. it considers deviant behavior as a matter of degree rather than as being present or absent. In addition. Achenbach (1998) . pools of items are selected for reporting behavioral and emotional problems that are felt to be important among children. such as depression. and much research must be done to validate it. It thus provides information about prevention and early intervention for emerging problems. 1994). Rowe. with cutoff scores used to determine the clinical significance of specific behaviors for different age groups as rated by different respondents. teacher. Achenbach. 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. or high compared to nonreferred peers and as reported by each of the different informant sources. 1994) and ICD-10 (World Health Organization. Although its reliability and validity have not yet been widely studied. Data from the normative samples provide a frame of reference for judging problems reported for individual children. 1998). Reynolds & Kamphaus. Factor analysis and principal-component analysis are used to identify sets of problems that co-occur. Cody. The use of a dimensional approach has some advantages. Moreover.e. These items are then scored for large normative and clinical samples as assessed by different informants (i. 1980) or DSM-III-R (APA.2. Assessment to Intervention 43 where data are not yet available. Petoskey. 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). 1992) and the Behavior Assessment System for Children (BASC. Chen. 1992). Although this system is not yet in wide clinical use. studies with the DSM-III (APA. 1994).. 1998. 1992). the system was developed to be fully compatible with DSM-IV (APA. the DC 0-3 shows potential for categorizing disorders in the early years. 1998. Standard scores or percentiles are used to determine whether a child’s scores on each syndrome are relatively low. & Tsuang. and bases classification on patterns of behavior covariation (Achenbach. & Huberty. including parent–child relational disturbances. 1991a. in that it takes into account a full range of child behavior versus just categories of disorders. and the inclusion of adaptive scales gives information about protective factors and optimal development (Kamphaus et al. In the dimensional approach. parent. Faraone. 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. Thus a dimensional system of classification allows one to describe multiple behavior patterns for an individual child. Kamphaus. 1999). 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. Biederman. these sets or patterns of problems are viewed as syndromes. it holds promise in describing children’s problem behavior and its significance within a particular developmental and environmental context. Examples of dimensional systems include the Child Behavior Checklist (CBCL. 1999). but no assumptions are made about why they covary. Dimensional Approach In contrast to the categorical approach..

Focusing on 510 children ages 2–5 selected from pediatric primary care settings.” “clumsy. 1987) diagnoses derived from semistructured parent interviews. Walsh.44 I. the length of time the behavior has occurred. THE FOUNDATION cautions. 1992). the past 6 months).e. play observation. Arend et al. in which use of the CBCL indicated a prevalence rate of 25% (Costello et al. developmental stability (McConaughy.g. who exhibit a significant number of problem behaviors that are age-appropriate and transient. The greatest convergence between the two approaches was found when there was clearly no problem. The prevalence of behavior problems on the CBCL was 8. as reported by different informants who see the child under different conditions. It is remarkable that 28 different DSM-III-R diagnoses were used for this sample of preschoolers (Arend et al. but it seems clear that clinical judgment regarding the presence of a signifi- . and good discrimination between referred and nonreferred children (Achenbach. 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. Stanger. Although Arend et al.. or having both the teacher and the parent complete the CBCL.” and “prefers being with younger children”). So the addition to the CBCL parent questionnaire of questions regarding the crosssituational nature of the child’s behavior. 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. particularly with preschool children. cross-informant agreement (Sawyer. should enhance the utility of the CBCL dimensional diagnostic system in identifying children with significant problems that otherwise might be missed. 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. or the behavior’s impairment of a child’s functioning. community samples) (Keenan. & Achenbach. age of onset. This syndrome appears to represent an important pattern of behavior.” “too dependent.3%. These two groups differed in the severity of their behavior and in the number of situations in which the behavior occurred. parent questionaires. Shaw. Delliquadri. and there is empirical evidence to support its high heritability (Edelbrock. The instruments are not designed to address important relational issues. Arend. This is an important cautionary note. Lavigne. clinic-referred vs. 1990).. & Thompson.1% “severe”) with the DSM-III-R. 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.” “gets teased a lot. they compared DSMIII-R (APA. and developmental testing to parent ratings on the CBCL. & Giovannelli.e.” “doesn’t get along with other kids. (1996) indicate that their data do not lead them to recommend either the categorical or the dimensional approach. (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. 1995). 1991b). The dimensional approach also is not designed to assess for extremely rare behaviors such as autism. 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. Rende. Binns. and Christoffell (1996) compared the DSM approach with a dimensional one based on the CBCL and its Profile (Achenbach. all of which are included in the DSM criteria for many disorders. 1992). Rosenbaum.4% “probable” diagnoses (9. 1988). 1997). These results differ from those for a sample of older children from pediatric primary care. 1996).. however. “acts too young for age. 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. 1991a. Plomin. 1991a.” “not liked by other kids. that the empirically based assessment instruments were designed to measure relatively common behavioral/emotional problems occurring during a particular period of time (i. as compared to 21..

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. fears.g. Bird (1996) estimated that between 12. Kamphaus & Frick. which is discussed later in this chapter. 1996). as well as the varying labels and definitions of problem behaviors. such as medical evaluation. are useful for planning services as well as for determining etiology and prognosis. For example.9% and 19. In reality. the appropriate areas to be considered for treatment. Moreover. 1998). This information leads to a judgment about the significance of a behavior problem and. It can also result in the diagnosis of a specific DSM-IV disorder. uses a variety of assessment methods to obtain an understanding of the child in comparison to other children the same age. and tantrums decrease with age in preschool and school-age children. estimates of prevalence drop to between 5. 1996). Prevalence rates for DSM diagnoses of preschool children are consistent with those for older children. if necessary. 1998). When only clinically significant or severe disorders are included. Table 2. In addition. in a recent review of epidemiological studies conducted in various countries after 1980. 1999. In the United States. worries.2. toileting problems. or adolescence. many behaviors that might be considered symptoms of psychiatric disorders are surprisingly common in nonclinical samples of children (Campbell. from several sources. although the types of disorders evidenced may vary. 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. For example. 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. 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. Assessment to Intervention 45 cant problem is enhanced when information is gathered through multiple methods. and across situations. 1998. is a very useful indicator within both the normal and abnormal ranges for planning specific educational and rehabilitation programs. the categorical distinctions between severe and moderate mental retardation. and between these and normality.6%–22% (Nottelmann & Jansen.. Disruptive behaviors decrease in the preschool years and increase again as children move toward adolescence. which should discourage exclusive reliance on one versus the other (Kamphaus & Frick. Bernet. prevalence of disorders among children and adolescents in the general population is estimated at approximately 17. Research indicates that both the categorical approach and the dimensional approach to classification have problems. The child’s family. The wide variation in these rates is thought to be due to cultural factors rather than to methodological differences among studies. parent and child interviews. The dimensional aspect of the intelligence level. 1995).3% of children 6–18 years of age have a diagnosable disorder. however. More generally. and direct assessment of the child behavior (e. As noted above.1 indicates prevalence rates for the DSM-IV disorders that have their onset during infancy. childhood. a combination of these approaches is probably most useful. nightmares. Specific behaviors increase and decrease with age (Campbell. cognitive assessment. physical assessment. Achenbach.4% of children.4% and 51. social and ecological factors. Arend . Our assessment system.

5% of pediatric hospital admissions 4–5 per 10. 0.000 4–5 per 10. THE FOUNDATION TABLE 2.000 4–5 per 10. DSM-IV Disorders Usually First Diagnosed in Infancy.46 I. 3% female Age 10: 3% male. more common in males 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.to 7-year olds.000 Uncommon. 0. only females Very rare Unknown.1.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 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% of 17-year-olds 1% of preadolescents.8% of adolescents 2–5 cases per 10. The data are from American Psychiatric Association (1994). . 2% female Age 18: 1% male 4% of children and adolescents Rare.to 11-year-olds 3–5% of school-age children 3% of school-age children 2–3% of 6.000 1% of 5-year-olds Age 5: 7% male. Childhood. <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 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. or Adolescence Disorders 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 Stuttering Pervasive developmental disorders Autistic disorder Rett’s disorder Childhood disintegrative disorder Asperger’s disorder Age of onset Birth 6–9 years 6–10 years 7–? years Preschool 3 years Before 4 years Preschool 2–7 years Prevalence 1% 4% 1% Unknown 6% of 5.5–2.

1. (2001) study. Cauce. 2000). and timidity (Lavigne et al. Rates are higher for boys than girls. Children’s problems are most often identified by parents. Prevalence rates for infants and toddlers have only recently received attention from the research community. Similarly. attention-deficit and disruptive behavior disorders are the most common childhood problems reported (Bird. 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. 1998).to 3-times-higher rates of disorders. depression. 1991). approximately 6% of parents of 1. Skuban. behavioral and emotional problems among 1. Recently. persistence. higher rates of psychiatric disorders have been associated with low intelligence and child temperamental characteristics of activity level. Persistence Another interesting epidemiological question is the extent to which problems early in childhood are likely to persist. In a sample of older children (5–9 years old) in pediatric primary care settings. Estimates of prevalence are also influenced by the perceptions of the referral persons (Campbell. 1996) reported that 21.8% of parents of 2-year-olds reported clinical or subclinical levels of problems as measured by the CBCL/2-3 (Briggs-Gowan.6% at all severity levels. and for children from single-parent versus two-parent families.. self-esteem. These conduct . yet parents’ perceptions of deviance are clearly influenced by their own characteristics (e. Parent–child relational problem—which. Lahey.1% most severe) and was most often diagnosed at age 2 years. and Mancl (1994) reported that 31% of their sample of 5. The most common disorder was oppositional defiant disorder (ODD. In the BriggsGowan et al.. 2001). for older than younger children.. marital conflict. which is consistent with other work indicating a decline in oppositional behavior between 4 and 9 years (Loeber.1% at the most severe level). 2000). 1997). & Thomas.2.g.). in contrast to 18% of the normative sample for this measure. Many factors other than SES are known to influence prevalence rates for childhood disturbances. 1996).9% had a subclinical disorder (at least half of the symptoms necessary for a diagnosis) (Keenan et al. while 9.4% of 5-year-olds had a DSM-III-R disorder and that an additional 29..to 11-year-old low-SES children had total problem scores above the 90th percentile on the CBCL. as noted earlier. & Horwitz. Carter. and expectations..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). but a condition that may merit clinical attention—was the second most common diagnosis (4.8% at all severity levels and 8. 1996. Across a range of studies. Horwitz. Further. Parental depression/anxiety and possible child abuse were associated independently with 2. A study of low-SES families indicated that 26. attitudes. A recent survey of a representative sample of healthy births indicated that about 11.1% had “severe” DSM disorders. 1996). & Leaf. for children living in urban than in rural settings. Schwab-Stone.8% (Briggs-Gowan. Raadal. 1996). ODD was most common among 3-year-olds. Leventhal. Assessment to Intervention 47 and colleagues (Arend et al. the prevalence rate for DSM disorders was 16.4% of preschool children from pediatric primary care settings had “probable” DSM-III-R diagnoses. most likely because few reliable and valid methods for assessment are available for this age group (DelCarmen-Wiggins & Carter. and boys were twice as likely as girls to have this diagnosis.. ODD decreased in frequency between the ages of 4 and 5 years.to 2-year-olds were strongly associated with economic disadvantage. Lavigne et al. Milgrom. 16. is not considered a DSM disorder per se.

it is also important to get a description of the problems that have led to the referral. 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. (2) delineate the individual’s strengths and deficits. Costello. for example.48 I. may also indicate the need for a referral to another clinician. We have found that a brief phone contact at the time of the referral helps determine whether an evaluation should proceed. 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. for example. 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. and these are often interrelated. (4) classify the problem. whether direct observation is necessary. especially for children who demonstrate more severe symptoms (Achenbach. and many complex cases involve all five purposes. If a parent is seeking an evaluation for possible sexual abuse of a child. the quality of the parent–child relationship. Enough preliminary information on the child’s functioning should be gathered to permit some initial hypotheses about what the problem is. Taken together. & Keeler. Similarly. and (5) provide guidelines for intervention. In clinical practice. We suggest that in general. & Stanger. the risk of adolescent problems was five times greater than for healthy children. In addition to having an understanding of the purpose(s) of an assessment referral. Problems in the early years are often transitory and associated with a specific developmental period. or at least the need for an unbiased interpreter. 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. This will determine whether a psychiatric diagnosis is needed. poverty. 1995. frequency. what tests (if any) should be administered. (3) predict future behavior or the course of the disorder. and the type of disorder all appear to contribute to the stability of these problems. but only when the disturbance was accompanied by significant impairment in functioning. such as language barriers.. such as a 4-year- . PLANNING THE ASSESSMENT The intended purpose(s) of an evaluation. as well as to make recommendations regarding the need for treatment. what intake information should be gathered prior to the initial appointment. whether it warrants an evaluation. (1999). The nature of the problem. Biological vulnerability. should be articulated before the assessment process begins. including clearly specified goals and objectives. then the case should be referred to someone else. the research on prevalence of childhood problems indicates that rates of serious disorders are relatively low. environmental instability. If the person requesting the assessment is not sure whether there is a problem. McConaughy. and who is the most appropriate person to do the evaluation. Cultural issues. For children with subclinical disturbances. THE FOUNDATION problems evidence considerable stability over time. and severity of problems. Likewise. to differentiate between normal and abnormal behavior). 1999). the number. and whether there is a need for collaboration with allied health professionals. the goals of assessment are to (1) determine whether there is a problem (i. Most clinical cases referred for assessment involve some combination of these purposes. Howell. then the goal should be to determine the nature and source of the child’s difficulty. and it emerges that the child has already been interviewed.e. and if so. assessment can have multiple purposes. Angold. it may not be appropriate to do another interview. who should be interviewed. Costello et al.

g. parenting strategies. for example. moody. Because children’s behavior is influenced by the psychosocial environment. hypothesis-testing procedure that takes into account developmental psychopathology. 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. A number of other issues should be considered before embarking on an evaluation. or confirmed as the information is gathered. (Self-reports. 1998. Time and cost are also important considerations. The parents sought not only an understanding of the problem. if the referral is for an 8-year-old’s poor reading and written language achievement. Assessment to Intervention 49 old’s sleep “problems” described as one episode of a sleep terror (see Chapter 6). knowledge of normal development and developmental psychopathology helps the clinician place the child’s emotional and behavioral functioning within a developmental context.. may indicate that a full evaluation is not appropriate. so one must determine the most economical means of obtaining the essential information without compromising the usefulnesss of the information. 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. As an example. for example. Similarly. Hence it is important to consider developmental issues in planning the assessment process. and impulsive. particularly in the social and cognitive areas (Kamphaus & Frick. The assessment process is an evolving one. In summary.. If the intake information indicates that the problem is occurring only at school. Given that environmental contexts vary from child to child. then the stepparent’s input should be considered. the influences of context. rating scales. evaluation of childhood problems should be viewed as a quasi-scientific. 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. what context of the child’s life has the greatest impact on his or her functioning.) Certain behaviors occur more frequently at one age than at others. Likewise. First. and the assessment method should be appropriate to the child’s developmental level. so that hypotheses are made. are considered unreliable prior to age 9. or family interview). and having difficuty in school. or sibling relationships) and how they should be assessed (e. Kamphaus & Frick. 1996). so it must be determined whether the referred behavior is an exaggeration of a normal developmental pattern or is a significant problem requiring treatment. 1996). changed. referred by her parents.g. was described as impulsive. This means that the evaluation must be comprehensive enough to consider the problems most likely to be associated with the referred behavior. disorganized. it is important to determine what aspects of the environment should be assessed (e. but specific . and what is the best way to structure the assessment of family influences. ASSESSMENT CASE EXAMPLE A 6-year-old girl. if a 7-year-old is referred for problems in school that center around being overactive. as discussed in Chapter 1.2. then a developmental language disorder should be considered. then learning problems should also be considered. direct observation. then gathering information from the teacher and a school observation may be indicated before the initial parent or child interview. peer influences. The tests used should have good normative data for the age group of the referred child. Another area that should be considered in planning the evaluation is the context of the problem. and the best interests of the child (Achenbach. if a child spends significant time with a stepparent.

family. she had many friends and engaged successfully in age-appropriate activities. but recognized that her impulsive behavior often created problems for herself and her family. 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. and brief individual work with the child to help her recognize her strengths and cope with her weaknesses. THE FOUNDATION guidance to help their daughter make a better adjustment in the home and school. psychoeducational testing). In the intake information. and environment that influence a child’s behavior. which indeed indicated that this was the case. Although it was predicted that the child would probably have some difficulties in the future. supportive work with the family in regard to the diagnoses. the child’s profile of behaviors was found to have many characteristics of the female fragile-X carrier. and for planning areas of intervention. her many strengths made it likely that she would adapt and continue to develop successfully. . One of these relatives had recently been diagnosed as having a fragile-X chromosomal disorder. for summarizing the assessment data. Socially. her strengths were delineated (a desire to please. and the child (interview. the clinician reviewed the research literature on this disorder and learned that females are carriers of the defective gene for fragile-X syndrome. the child was referred for a genetic evaluation. direct observation. Specific methods used in the assessment process are discussed later in the chapter. It focuses on the specifics of the behavior of concern. Prior to the initial interview. and a learning problem). and the assessment process gave specific information for intervention strategies. Intervention strategies derived from the assessment data included changes in class placement and resource support. daily behavioral logs. referral to a parent association for children with fragile-X syndrome. and provided a structured yet stimulating environment. it is summarized in Table 2. As the assessment progressed. and supportive environments at home and school). and that there is a phenotype for these females. It was also understood that further assessment and intervention might be needed as the child encountered new challenges. The assessment process also revealed a child who met the criteria for a diagnosis of ADHD. Thus the nature and cause of the child’s problems were determined and classified (fragile-X carrier status. We describe a behaviorally oriented system for assessment of children’s problems that is based on Rutter’s (1975) work. the parents said that several male relatives on the mother’s side of the family were mentally retarded. she felt loved. ADHD. rating scales. Emotionally. the teacher (rating scales. as well as taking into account other characteristics of the child. achievement and test scores). It was also hypothesized that she might have ADHD and a learning disability. and who was functioning cognitively in the average range with achievement scores significantly below grade expectations. observation of parent–child interaction during interviews). the clinician hypothesized that the child might be a fragile-X carrier.2. good social skills.50 I. After discussion with the parents. This system is referred to in this book as the Comprehensive Assessment-to-Intervention System (CAIS). as well as with her peers. The CAIS also provides a framework for choosing tests and other information-gathering methods. specific behavior management techniques for the parents. some method of systematically collecting and organizing information during the assessment process is critical. Given the description of the phenotype and the initial description of the child’s behavior. Information was gathered from the parents (interview. Her parents were warm and supportive.

Marital status 4. 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. Medications 4. Availability and use of social support 5. Subcultural norms and values D. Chronic illnesses (e. Developmental status 1. A. Assessing general areas. Environmental characteristics 1. Social 5. Cognitive 3. Psychopathology 3. Sibling relationships C. A. Frequency of behavior E. Interference with development (cont. Parent and family characteristics 1. Assessing specific areas.2. This does not mean that the child needs treatment or that the child’s behavior is the problem. Severity of behavior D.) . Situation specificity F. Personality characteristics 2. Prenatal history. Socioeconomic status 3. Who is suffering? B. After the parent has described the problem. nonchalant? III. the clinician should be certain that he or she and the parent are thinking about the same problem. “Payoff” for child 3. and early development IV. Clarifying the referral question.2. Determining the effects of the problem. Determining the social context. Personality/emotional 6. Past and present management strategies 2. birth history. depressed. Impact of behavior on child. Type of problem V. and environment 4. Comprehensive Assessment-to-Intervention System (CAIS) for Child Behavioral Problems 51 I. as well as the different ways you and your husband are handling the situation. Parenting styles and techniques 6. A.” II.. otitis media) 3. A child is referred because someone is concerned. Consequences of the behavior 1. Prognosis with and without treatment E. Changes in the behavior C.g. Family history of medical/genetic problems 2. Medical/health status 1. Assessment to Intervention TABLE 2. parents. Persistence of the behavior B. 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. Physical/motor 2. Psychosexual B. Recent stressful life events 2. Language 4.

THE FOUNDATION VI. unstructured activities). Helping child/family cope with life events D. The clinician should clarify. Treating the effect of the problem Clarifying the Referral Question Although the need to clarify the referral question seems obvious.2. (cont.” This gives the parent the opportunity to restate his or her concerns until a mutual understanding is reached. Environment 1.. Teaching new parenting techniques 2. the clinician should be certain that he or she and the parent are thinking about the same problem. After the parent has described the problem. Treating marital problems or parent psychopathology 4. Changing others’ responses to the behavior 3. or that the child needs treatment. “Who is concerned about this child? Why is this person concerned? And why is this person concerned now. Consequences of the behavior 1. that the child’s functioning is impaired. Changing the payoff for the child E. as . this does not necessarily mean that the behavior of concern is deviant.g. the clinician must then decide which questions he or she can adequately or appropriately address. Changing parental expectations. with one parent vs. home. Medical/health status 1. The referral source may be a teacher or an agency. Parents often have questions that are not well articulated or not initially stated. A. attitudes. Once the issues to be addressed are clarified. as well as the different ways you and your husband are handling the situation. Determining areas for intervention. Helping parents build support networks and deal with daily living problems 3. 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. and these must be agreed upon by the parent. therefore. 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. Changing the cues that set off or prevent the behavior from occurring 2.) I. Changing the behavior by increasing or decreasing it B. A child is referred because someone is concerned. Intervening in the cause of the problem 2. Parents 1. 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. but it is most often a parent. the referral source is described as “the parent” in this section. at school vs. Development 1. another. its importance cannot be overemphasized. Teaching new skills to the child 2. Providing appropriate stimulation 3. Changing parents’ responses to the behavior 2. Changing the emotional atmosphere 3. or beliefs C. however. in structured vs.52 TABLE 2.

Are they overwhelmed. the other mother is extremely upset. The parents’ affect in describing the problem is also significant. infants and children are expected to sleep with their parents. especially if the clinician’s recommendations are contrary to the parents’ expectations or confirm their worst fears. (4) the consequences of the behavior in both a narrow and a broad sense. describe their 3-year-old daughters as being anxious and fearful. These areas are summarized in section III of Table 2. or nonchalant? Two mothers. In contrast. and using good judgment in attempting to deal with the problem. depressed. and unable to view the problem objectively. Assessment to Intervention 53 opposed to some other time?” This information not only clarifies the parent’s perception of the problem. and (5) the child’s medical or health status. the clinician should keep in mind the general areas that influence the development of behavior problems: (1) the child’s developmental status. Assessing General Areas In assessing a child’s behavioral problems. yet cosleeping may be viewed as a major concern in another culture. and fears in coming to a mental health professional helps in gathering and interpreting the material. (2) characteristics of the child’s parents or extended families. One mother is calm. for example. If a child began having a problem when a new teacher was assigned to the class. and this is not seen as a problem. for example. 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. 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. in control of herself. then these contexts obviously should be assessed.2. This information can also help the clinician develop a culturally sensitive treatment program. (3) environmental characteristics and events. 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. anxious.2.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. Each of these parents presents a different focus for the assessment-to-intervention process. 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. for example. hopes. The family’s sociocultural characteristics can also play an important role in the planning and implementation of a treatment program. The clinician’s job is to . fearful. In some cultural contexts.

The child’s environment provides the setting conditions for the behavior. for example. that low parental tolerance. and equally difficult to delineate the specific factors contributing to or mediating outcome. repeated commands. Thus the time when this behavior first occurs in a child’s life is as important as the behavior itself. The referring person may lack information about child development in general. SES.g. teasing. the presence of psychopathology in parents and other family members. These are discussed in Chapter 1. marital stress. chronic illness. 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. Thus the perspective of the referring person must be taken into account. A 3-year-old child who wets the bed. for example. parental divorce. and the availability and use of social support. Although physical aggression may be considered a problem at any age. hunger). and family dysfunction influence parents’ perceptions of their children’s behavior. all of which can distort his or her perception of the child’s behavior. It should be obvious that knowledge of normal developmental processes is critical in the assessment of these children. SES and other relatively stable characteristics. and in some cases it may be a more appropriate focus for intervention than the behavior itself. the developmental and child clinical literature provides evidence for certain parental characteristics and parenting practices that facilitate development. Furthermore. marital status. techniques.54 I. and models. the techniques they have tried in the . 1980). The setting conditions can include very specific antecedents to the behavior (e.g. Areas that are especially important to assess include parenting styles. reaches a peak during the preschool years and then naturally declines. and subcultural norms and values provide important information about the problems the child is experiencing and the intervention strategies that may be helpful.. sibling relationships. Also. or an impending move). and some behaviors improve without any intervention. criticism. a death in the family. Physical aggression. as well as those that make a child more vulnerable. has a behavior that may be considered “normal” or “common” for that age. its clinical significance increases with age. or major events (e. the frequency of problem behaviors changes developmentally. It is generally accepted. these factors affect how parents view their children. Environment Recent stressful life events. THE FOUNDATION judge whether the behavior of concern is more or less than one would expect of any child at that age and in that environment. or may be experiencing stress. whereas a 10-year-old who wets the bed is viewed as having a significant problem. the preschool years are a critical time for the identification of and intervention with children with developmental problems. unrealistic expectations for child behavior. Moreover. may have emotional problems. Characteristics of the Parents and Extended Family Although it is difficult to identify causal mechanisms in the development of childhood disorders. for example. 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..

Methods for doing this are described in the next section of this chapter and for specific problems in subsequent chapters. the parents indicated that he had had recurrent bouts of otitis media since 13 months of age.2. without intervention. Determining the Effects of the Problem It is important to note who is suffering from the referral problem(s). or low-level but “annoying?”). A learning disability. or in a variety of settings?). In the interview. On the intake questionnaire. the parents felt incapable of caring for him appropriately. the impact of the behavior on the child. and the type of problem (is the problem a discrete behavior. Observation of the child indicated that his language skills were delayed. Information should include the persistence of the behavior (how long has it been going on?). a 2½-year-old boy was referred by his parents because of noncompliance. the parents decided to postpone a referral to a communication specialist regarding the language delay. The child’s emotional lability improved immediately. it may lead to a poor outcome for the child. or is a problem in school or with peers but not for the parents. .” Medical/Health Status Assessment of medical/health status should include gathering information on the family’s history of medical or genetic problems. however. Much of this information can be gathered in an intake interview or with a general parent questionnaire. situation specificity (does the behavior occur only at home. it is important to get a descriptive analysis of the problem(s). current health and medications. “Yes. Given the child’s dramatic behavioral improvement. chronic illness of the child. frequency (has the behavior occurred only once or twice. After the clinician and parents discussed the potential negative effects of otitis media on the child’s development. and a brief course of parent training resolved the remaining parent–child problems. and environment. and sleep problems. or many times?). severity (is the behavior very intense or dangerous. and specific areas of concern can be followed up in the interview. In other cases. As an example. although the behavior may be interfering with the child’s development. prenatal history. parents. and that he did not always attend to language directed toward himself or others. changes in behavior (is it getting worse?). the parents decided to seek a second medical opinion. Assessing Specific Areas Given that many behaviors cannot be directly observed by the clinician. Assessment to Intervention 55 past. which resulted in surgical insertion of tubes. it may not be seen as a problem by the parents or other adults. or a set of diffuse problems?). the parents stated that medication had not been effective in controlling the infections. for example. but we have tried that. family. and it doesn’t work. and that the family physician did not believe in “elective” surgery to place tubes in the ears. but the child is likely to suffer negative consequences in school and in future opportunities if it is left untreated. Lack of careful assessment of these factors usually leads to the parents’ responding to suggestions by saying. and the prognosis for the child with and without treatment. It may be that the child’s behavior is bothering one parent but not the other. may not be viewed as a problem by the parents. and early development. irritability.

most of the necessary information was gathered quickly by listening carefully and asking specific questions. Kanoy. THE FOUNDATION Determining Areas for Intervention After assessing each of the areas described above. The CAIS is useful for complex cases. intervention strategies follow naturally from the assessment process if the child’s development and behavior. A case example taken from a parent call-in service in a pediatric primary care setting demonstrates a brief (15. to generate and test hypotheses. but these too will change with the age of the child—from contingency management techniques in the preschool and school-age years. it also works well to assist the clinician in gathering and organizing essential information very quickly. According to these authors. the clinician should have a good idea of what the problem is and what additional information is needed to conceptualize it. As illustrated in Table 2. the parents. Subsequent chapters focus on specific problems. and social functioning. thoughts and feelings become targets for intervention. thoughts. the consequences of the behavior.2 describes intervention strategies relevant to the child. or some combination of these. there is no one battery of assessment methods or tests that can be used for every case. METHODS FOR GATHERING INFORMATION Given the complexity of children’s behavior and of the potential contributing factors to emotional and behavioral problems. have been examined systematically. As the child’s cognitive skills develop and he or she is better able to reflect on inner thoughts and feelings. The data can be obtained from a variety of sources and different methods. Environmental targets for change also vary from changing the daily routines of the child or family to changing the emotional atmosphere in the home. As Kamphaus and Frick (1996) state. psychological assessment is not seen as “test-driven” but as “construct-driven. feelings. to negotiation techniques and communication skills in adolescence.3. Section VI of Table 2. The . The CAIS framework should not be seen as rigid. It also should be possible at this time to formulate plans for further assessment and/or intervention strategies. targets for change can be the child’s behaviors. and the medical/health status of the child. with cognitive and emotional level of development guiding the choice of treatment method. Although it is not possible to answer every question and/or to intervene effectively in every situation. xii).56 I. the significant targets for change for those disorders. 1983). & Routh. Gordon. the environment. Rather. Parenting skills also may be the focus for change. Given the uniqueness of each child and family. For example.to 20minute) assessment-to-intervention process involving a 6-year-old girl who was disrupting her class in school (Schroeder. it is offered as a logical and systematic way to gather and organize information. “the most critical component in choosing a method of assessment and in interpreting assessment data is understanding what one is trying to measure” (p. The focus for treatment in the preschool years is usually the child’s behavior. it is important to use several methods for gathering information from different informants and across settings. and the physical and sociocultural context in which he or she lives.” Hence it is important to be familiar with research literature on the psychological constructs that describe children’s emotional. with a greater reliance on cognitive-behavioral treatments. with parent skills training the typical mode of treatment. and to plan intervention for children’s problems. and methods to intervene in those areas. behavioral.

” (cont. 3 years ago.2. Persistence of the behavior “Jane has been upset since the divorce. I also have told her not to act up in school because it gets me in trouble. You’re also wondering why she seems so genuinely distraught one or two times a week. but in the last 3 months it has gotten to the point where I have to force her to go.” C.) . I also should tell you that the department of social services investigated my ex-wife’s charges against me for sexual abuse.” C. Who was concerned? The teacher was concerned for both Jane and the other children. 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. Clarifying the referral question. Environmental characteristics Jane visited her mother every Wednesday and every other weekend. III. A father called at the request of his daughter’s first-grade teacher. and was afraid of some of her mother’s friends. who was concerned that the 6-year-old girl. walked in circles. Jane’s doctor called the department because Jane had a number of bruises when she came home from a visit with her mother.” B. We still fight a lot over Jane. She has friends in the neighborhood and generally likes going to school. Listening to affect “I had so hoped this wouldn’t happen again in Jane’s new school. which were not substantiated. “I have been worried about Jane for the last 2 years. Assessing general areas. Recently. she becomes very upset. once or twice a week. A. A. in the last 3 months she has been to the doctor because of her wetting.” D. The father indicated that he and his wife were separated and that Jane was living with him.” C.” IV. Severity of behavior “The night before she goes to visit her mother. The Assessment Process in a Brief Case Example 57 I. The father stated.” II. and cried inconsolably. Determining the social context.” E. Why now? Jane just started in a new school. I don’t know what I can do to help her. doesn’t listen to me. became distraught. reported being left alone. Developmental status “Jane is a very bright child who rarely gives any problem at home. She hated to go. Sometimes she has nightmares. The clinician stated. and has a very hard time getting to sleep. Assessing specific areas.3. that she should love her mother and have a good time. D. She has complained of stomachaches and has had nightmares.” B. “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. but generally her teachers and I have been able to calm her down. Medical/health status “Although Jane has generally been healthy. Assessment to Intervention TABLE 2. Frequency of behavior “These problems only seem to occur when she has to visit her mother. A. Changes in the behavior “She has never liked to visit her mother. Recently she started wetting herself during the day and having nightmares. Parent and family characteristics “Her mother and I have been divorced for 3 years and went through a terrible custody battle.” B.

direct observation of behavior. the nature of the behavior problem. VI. and other children in school. Methods can include interviews. the characteristics of the assessor. Furthermore. 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.58 TABLE 2. rating scales. Type of problem This child’s behavior was indicative of significant emotional distress. integrating information across informants. Who is suffering? The child. (cont. self-monitoring procedures. Interference with development The behavior was already interfering with Jane’s adjustment at school. Situation specificity “She used to be upset only at home. She was beginning to exhibit a variety of problematic behaviors both at home and at school. role playing. projective tests. the parents. such as drawing. It is beyond the scope of this book to review all of the various methods used in the assessment of children. and assessment methods for specific disorders. analogue methods. Knowledge gained from this contact should guide the type of information that is gathered prior to the initial interview. and personality. In the meantime. anxiety hierachies. tests of perceptual–motor functioning. Determining the effects of the problem.) I. the characteristics of the child and the family. Most importantly. she had few appropriate alternatives available to express her feelings. standardized tests. B. social competence measures.3. simulated problem situations. the assessment setting. Descriptions of assessment instruments we have found most useful are provided in Appendix A. developmental measures. as well as standardized tests of ability. assessment methods chosen will depend on the purpose of the assessment. This section outlines the order in which we gather the information described in the CAIS framework. sociometrics. the teacher. 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. but now it’s happening at school too. ”It’s OK for you to act upset if you’re feeling bad on those days. working with clay. I also think she looks sad a lot of the time. Determining areas for intervention.” F. A. THE FOUNDATION E. psychophysiological recordings. and the characteristics of the available methods (Mash & Terdal. 1998) and Kamphaus and Frick (1996) for in-depth discussions of interviewing techniques. behavioral checklists and questionnaires. as . The extent of her upset was likely to have serious consequences for her functioning and development unless immediate intervention took place. The interested reader is referred to Sattler (1992. V. 1997b). In choosing assessment methods. The severity of this child’s behavior and the complexity of the situation warranted further evaluation and treatment. and the feedback conference. the child clinician should be aware of a particular method’s empirical validity and developmental sensitivity. and ecological assessment.” The father and teacher were told to give her specific ways to express her feelings. the child’s emotional needs were not being met. achievement. with special emphasis on parent and child interviews. or simply talking to them.

” “Scraped the new kitchen wallpaper with a knife. depending on the presenting problem. We may ask the parents to provide daily records of the child’s behavior. Rating scales are not interchangeable.2. and (2) a norm-referenced behavior rating scale. the BASC (Reynolds & Kamphaus. the BASC takes a broad sampling of behavior at home and in the community for the preschool (4–5). The PSI assesses the child-rearing environment of children between 1 and 4 years of age. Although the information requested will vary. for example. 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). The CBCL. a mother called with a concern about her 3-yearold’s disruptive behavior. and the Parenting Stress Index (PSI. habit diary). 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). and what they have done about it thus far. and adolescent (12–18) age ranges. for example. 1991a. 1992). as well as parental tolerance for these behaviors. and weaknesses of individual scales. as well as direct observation. 1995). and the individual scales in general have limited reliability.g. child (6–11). but it combines the constructs of anxiety and depression. parents record the antecedents and consequences of behaviors identified as specific problems. and of hyperactivity and inattention. however. and the clinician should be aware of the purposes. day care history. Recordings on the Daily Log during the week prior to the initial interview included such behaviors as “Kicked his grandfather in the shin. Eyberg & Pincus. the Conners-93 form). parents. On the reverse side of the form. 1999).. feeding diary. We have found it essential to have the parents complete and return two items before the initial interview: (1) a general parent questionnaire. Abidin. as well as an adaptive behavior scale. into single scales. Other information may also be requested prior to the first session. The CBCL and the BASC parent rating scales are both part of larger assessment systems that include ratings from teachers. another well-known battery that has been primarily used for its Hyperactivity Index (10 items that are sensitive to drug effects). hyperactivity. On the other hand. 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. and school history. its causes. The Conners Rating Scales—Revised (Conners. 1997). is only norm-referenced for the short form (the Conners-48 form vs. and (3) the parents’ perception of the child’s problem.” and “Bit a child at day care!” . and allow assessment across settings in a time.and cost-efficient manner. (2) the child’s developmental milestones. As an example. and the child. sleep diary. Assessment to Intervention 59 well as who will be seen in that interview. and inattention. depending on the behaviors of interest (e. This measure is one of the few ways of assessing problems in infancy. depression. strengths. the Eyberg Child Behavior Inventory (ECBI. 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!”). The parent rating scales that we use most frequently are the CBCL (Achenbach. The Daily Log can also be used during treatment to help parents and the clinician monitor progress. 1992). it has single scales for anxiety. and normative data. The ECBI assesses the intensity and generality of conduct problem behaviors for ages 2–16 years. which she felt was “not really bad” but which her parents had told her was a significant problem. This Index. foster objectivity through the specificity of the individual items. validity. Rating scales provide a broad assessment of problems. This allows similar information to be gathered from multiple informants in a reliable and valid manner. The General Parent Questionnaire we use (see Appendix B) provides information on (1) the family’s SES. has norms for children ages 3–17.

” or “The PSI will help us understand how your son responds and interacts in his environment. and expensive process that is best left until after the initial interview. time-consuming. Although providing a more standardized format. (2) the tendency to collect information selectively when confirming a diagnosis and/or to ignore information that rules out a diagnosis. (2) context is not taken into account. 2001). Kuttler. According to McClellan and Werry (2000). This information. 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. but also facilitates rapport with the parents. but greater freedom decreases their reliability. & Stone. however. These interviews can vary in the degree of structure (e. structured interviews generally give global information about the existence of a DSM disorder. In this time of managed care. (3) the lack of a systematic approach to combining different types of information. 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 reader is referred to that issue for more information. structured interviews that guide the interviewer’s questions have become more popular not only for research. despite the fact that it is fraught with a number of problems. 20). as well as any stresses you are currently experiencing”). 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. these problems include “(1) the tendency to determine diagnoses before all relevant information is collected.g. (3) parents cannot give their perspective or description of the problem. 1996. . 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.60 I.. and (5) the tendency to see correlations that are spurious or nonexistent or to miss real correlations” (p.g. and the importance of this information in helping us to understand the problem is discussed (e. because we are able to focus more quickly and specifically on their concerns. and 5) they are time-consuming. The various questionnaires and forms are described. Structured interviews involve a prearranged set of questions to be asked in sequential order that usually gather information about a specific DSM disorder. THE FOUNDATION At the time of the initial contact. Step 2: Parent and Child Interviews The unstructured interview is the standard assessment tool for determining emotional and behavioral disorders of childhood. the interviewer can follow up on questions or not ask all of the questions). or peer group that are needed for planning an intervention program (Kamphaus & Frick. (4) these interviews do not encourage rapport building. however. Parents are always given the option of not completing the questionnaires at this point in the assessment process if they are uncomfortable doing so. The clinician then reviews them prior to the interview. this could lead to inappropriate diagnosis). 2000). but also in clinical assessment. family. helps the clinician plan for the initial interview by developing various hypotheses as to the nature of the problem. “The BASC will give us information regarding how your daughter’s behavior compares to other children her age. (4) the tendency to make diagnoses or judgments based on what is familiar to the clinician. that having this information prior to the interview not only decreases the time required for assessment. La Greca.. In recent years. rather than specific details about a particular child. but clinically they should be used as only one part of a more comprehensive battery of assessment methods. Structured interviews have a clear advantage for research purposes. many clinicians may feel that this is an unnecessary. We have found.

(7) communicating with the parents about procedures that are to be used. preparing for the interview. In addition. If parents are unable or unwilling to participate in a joint interview. and delay reaching final decisions until all of the needed information is gathered (Karg & Wiens. get concrete examples of behavior. the unstructured interview requires prior knowledge about the nature of the specific presenting problem. and environment that is outlined in the CAIS framework (see Table 2. concerns. If the child is referred for an evaluation by someone other than the parent (e. the reasons for doing this should be explained (see Chapter 13). The unstructured interview allows the clinician more freedom to explore the nature and context of the problem. an attempt should be made to interview them separately. it is critical that both parents be included in the initial interview. 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.. If a parent calls about an impending marital separation. Assessment to Intervention 61 In contrast to the structured interview. and goals. For the trained clinician. and resources for taking an active role in the change process. we prefer to conduct an unstructured interview. motivations for changing the situation. 1998). avoid expectations and biases. Mash & Terdal. 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. (5) assessing parental perceptions and feelings about the child’s problems. The initial contact helps determine who should attend this first interview. its prognosis. It is important to include both parents if they are both actively involved in the child’s life. consider alternatives to the initial impression. using the CAIS framework to direct the questions asked and the information collected. expectations. social service. if one parent objects. and that the assessment process will be tailored to the particular needs of their child and family. clarifying the purpose and parameters of the interview with the parents. identify antecedents and consequences of the problem behaviors. even if this is done by tele- . 1996. and (10) providing the parents with an adequate rationale for proposed interventions (Kamphaus & Frick.2. courts. (3) establishing a collaborative and supportive relationship. (8) educating the parents with respect to the nature of the child’s problem. The efficacy and efficiency of the interview are significantly improved by determining the purpose of the interview ahead of time. as well as other potential problem areas for the child or family. (9) assessing the parents’ affective state. Moreover. On the basis of this knowledge. empirically derived methods for the assessment of childhood problems. and what responses from the client need clarification. Parent Interview The parent interview has many purposes: (1) gathering the information about the child. (2) obtaining informed consent. for example. it is important to demonstrate good interviewing and listening skills. (4) gathering information about parental concerns. We use such an interview along with other. (6) setting realistic goals for assessment and intervention. and goals. such as stimuli that may elicit the problem behaviors. and its possible etiologies.2). as well as the opportunity to investigate potential contributing factors. 1997b). this type of interview allows the clinician to begin to delineate acceptable behavioral alternatives. Even with all of the potential pitfalls. which guides both the content and the process of the interview. use other assessment methods. the interviewer determines what questions and follow-up questions will be asked. family. school).g. and collaborating with the parents during the interview. its prevalence.

and a tendency to describe the child in unrealistically positive or negative terms (Kanfer et al. intervention is necessary). Parents of a school-age child are typically interviewed alone. current behavior. This gives parents some initial information about what is expected of them. purposeful fashion (Kanfer. When the referral involves a preschool child.g. empathy. The ability to listen is also an essential skill. with age-appropriate toys and activities provided to keep the child occupied. but the goal is to be selective in pursuing areas with particular relevance to the presenting problem. and reflecting and paraphrasing let the parents know they have been heard (Morganstern. Although some clinicians may find it difficult to include a young child in the parent interview. To promote collaboration.. Eyberg. so if a relevant area is missed initially. 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. and an ability to keep the interview moving along in a smooth. An explanation should be given for why any additional information is needed (e. Interviewing parents is an interactive process that sets the tone for future intervention efforts. THE FOUNDATION phone. Background information is important. 1992). & Krahn. a sensitive and nonjudgmental approach that respects others’ feelings and cultures. Whereas it is important to get a thorough understanding of the nature and context of the problematic behavior.g. Focusing on the current situation—that is. Furthermore. to discuss more sensitive information or to provide information to the parents without the distraction of a particularly disruptive child.g. It also should be remembered that working with children almost always involves an ongoing relationship with the parents.62 I. it is very likely to be discussed in future meetings. Moreover. Listening helps parents focus on the problem. and also will provide information about his or her willingness to support the child’s treatment. later interviews can be conducted with the parents alone. Each parent brings his or her own perspective on the problem. depending on the nature of the problem. conflicting perceptions of the child between parents. if any. 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. which are covered in the chapters on specific problems..g. parents of an adolescent are first seen with the adolescent present or absent. 1988).. discussion of divorce issues). These include warmth. Asking for examples also helps the parents describe the problem in more concrete behavioral terms. There obviously are exceptions to this (e. Time should be allowed at the end of the initial interview to summarize and integrate the information gathered. we find that the information being discussed is usually not new to the child. as well as what they can expect from the clinician. current child management techniques. it helps them to start talking about their concerns. Characteristics of a good interviewer can contribute to a positive tone. 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. before the child is seen. to get a better understanding of the parents’ concerns in order to help determine what. we routinely include the child in the initial parent interview.. Problems with the information collected during parent interviews include inaccurate recall. and obtaining informed consent (e. limits of confidentiality. explaining the purpose of the interview (e. If necessary.. details of any assessment procedures that will be used). it is not possible or advisable to assess everything in the child’s or family’s background at this time. the opportunity to observe the child and the parent–child interaction far outweighs the drawbacks. . and current family strengths and weaknesses—can help increase the reliability of parental reports.. 1992).

self-concept). we have found that interviewing a child older than age 7 provides useful information on the child’s perception of him. potential treatment strategies should be discussed. behavior rating scales. observations of parent–child interactions. 1996). school. is doing. and to informally assess his or her cognitive. home visit. to facilitate establishing a relationship with the child and gathering the needed information.2.g. social. and parent–child interactions. Costello. the assessment process is unique for most children. at the end of the interview. Kalas. and engaging them in the process of determining the next step in the assessment process and setting treatment goals. 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. “I see that you have a stack of baseball cards. encourage them to be part of this process and maximize the chance that they will support the child’s treatment.. Building rapport with a child can be difficult. Various things can be done. interests. Child Interview Although self-reports by children prior to the age of 9 (Edelbrock. Assessment to Intervention 63 school visit. Although it may not be possible to give all of this information without further assessment. and perceptual–motor skills. psychometric testing of the child. Although children typically do not refer themselves. and they usually assume that they are at fault. wishes. with a friendly and interested tone of voice. the environment (e. or has brought to the session (e. so they have no idea what to expect. Dulcan.. mood. Greeting the parents and child by name. It is often helpful at this point to comment on something the child is wearing. fears. 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. Carolyn Schroeder. and the presenting problem. it is important that the parents have some understanding of the clinician’s thoughts regarding the need for treatment. activity level. because children usually are not very motivated to cooperate in the interview process. Thus the interview must be tailored to the individual child’s developmental level and needs (Kamphaus & Frick. 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). as well as the estimated length of time and cost for treatment. If possible. A good time to clarify the reason for the interview is while the . “I am Dr. & Conover. Early in the interview. Often parents have not said anything to the child and look to the clinician to guide them on how to approach this issue. Furthermore..or herself to the child by title and full name (e. I hope that you will show them to me”). It is also important for the clinician to introduce him. a psychologist. Meeting the family in the waiting room gives the clinician the opportunity to observe the child’s physical appearance. beginning at the first contact with the child and continuing throughout the interview. conveys to the child that the clinician is interested in him or her and glad that the child is present.or herself (e. peers.. Asking the parents what they think (or feel) about what they have heard.g. 1985) are typically unreliable. and a sense of hope that something can be done to help them and their child. The clinician can develop a collaborative relationship with parents by sharing information with them and allowing them choices in how to proceed. medical evaluations) and how this information will be gathered. as well as on the child’s attempts to cope with and solve personal and interpersonal problems.g. and I will be talking with you and your parents today”). family). their expectations can be discussed in relation to the gathered information. the clinician should have asked about the parents’ expectations.g. they already know that the referral means there is some problem.

THE FOUNDATION parents are with the child—for instance. 1995). Letting the child know what will happen in future meetings is also important. I talk to many children who have had problems in school.” At this point the parents can be dismissed. intellectual and language development. crayons. “What do you like about school?”). “I am glad to talk with you today. and the degree of structure provided during the play observation should also be varied. The clinician should (1) use language at or just above the child’s cognitive/language level (shorter. TV shows. John. what the child likes to do). then the tests and their purposes should be briefly described for the child. concrete questions ( “Can you tell me one thing you like about school?” vs. letting the child know where they will be during the interview. (1992). Providing the child with age-appropriate. be responsible for keeping the conversation going. activities). That is great. For young children. (7) praise the child verbally or physically.. Eyberg. (4) introduce topics of interest to the child that are developmentally appropriate (e. (3) avoid using many direct questions (these can be seen as demanding). demeanor. what the clinician and child will be doing and talking about (e. or activity. (5) use descriptive statements about the child’s clothing. observation of independent and interactive play can provide information about their perceptions of their world. feelings. the clinician should summarize for the child what he or she understands about what the child has said. A variety of age-appropriate toys should be available. creativity. and therefore can provide information about these areas (Russ. friends.g.64 I. Querido et al. such as a sentence completion or Draw-a-Person task. It is important to orient the child about what to expect in the interview. Querido. thoughts. unstructured materials (e. less complex words and sentences). “Your mother and dad also told me that things have not been going well for you in school. In the following chapters. Legos or other building . At the end of the interview. (6) use reflective or summary statements to help convey genuine interest in the child. as well as to articles by La Greca et al. (2001).g. to help the child feel more comfortable. and I would like to help you and your parents find ways to make things better. for indepth discussions of interviewing children.. The reader is referred to books by Sattler (1998) and Barker (1990). When appropriate. and Kanfer et al. or blaming questions (e. Do you know why you are here today?” Children usually say no or decline to answer this question. including the length of the session. Play-Doh) to play with while talking helps a child feel more comfortable. Legos.. (2001). and current concerns and anxieties.. Your mother and dad have told me that you play on the soccer team and that you recently got a badge in Scouts. It is also important to let children know that it is OK if they do not know something the clinician asks them about. (2) given that most children interpret silences as disapproval. and adjustment. If testing is to be done. Kanfer.g. social relationships. Play Play has an important role in the development of cognitive skills. and they would like to help make things better for you. “why” questions). and parents must be asked what they have told the child. we have also given a child a choice of snacks or a drink at the beginning of an interview. and Krahn (2001) note a number of communication techniques that can facilitate rapport building. The clinician can then continue. We also often begin with a structured activity. leading questions. and (8) use structured. child interview questions focusing on specific problem areas are presented. games. and should ask the child whether he or she would like to tell the clinician anything else or has any questions. school. to determine the child’s response to demands and ease in changing activities. and issues of confidentiality.g.

perceptions of family interaction. A doll house allows the child to demonstrate organizational skills.g. Hops & Davis. 1994. distractibility. 1994) can be readily used by clinicians.. provide an opportunity to observe fine motor skills. the child’s responsiveness to the parent. 1986. 1995.. tics. sleep. Observations can be done either in the child’s natural environment (e. and coping skills. the ecological validity of observing in a natural setting cannot be overestimated. Mash. emotional expression. or an outside observer such as the clinician. or an analogue setting. sequences of behavior are coded: parental responses (e. Forehand & McMahon. because it provides an objective view of the nature. aggression only during puppet play vs. however. and qualitative aspects of their interaction in three 5-minute standardized situations: (1) ChildDirected Interaction. 1981. Although the DPICS-II is typically used to code the behavior of parents and preschool children. for example. creativity. a laboratory. antecedents. the recordings can be unreliable. The observational recordings can be made by the child. Several systems have been developed for structuring and recording these interactions (Eyberg. Even with these difficulties.g. Terdal. The clinic version of the Dyadic Parent–Child Interaction Coding System—II (DPICSII. Eyberg. a number of structured observational systems are discussed. ignores or responds) to . determining how the target behaviors will be coded (how). Newcomb. Foster & Cone. it is often difficult to get an adequate sample of some behaviors. on-task behavior). and deciding who will observe the target behaviors (who). & Robinson. in which the parent is instructed to allow the child to choose any activity and to play along with the child. et al. as well as monitor the progress of treatment. they are often excluded from the assessment process. Although the latter settings can be more controlled and reliable... we have also found it useful for the older children. direct observations are often necessary to help the clinician understand and delineate the problem.g. and consequences of the child’s behavior. After a brief description of what is involved in developing a plan for direct observation. a parent.. observation of parent–child interactions is extremely important. Step 3: Observation of Behavior The direct observation of behavior is an important part of the assessment process. Assessment to Intervention 65 materials. The DPICS-II is a highly structured coding system that provides an assessment of the current level of parenting skills. a teacher. & Anderson. compliance. aggression with all types of material). The way in which a behavior is recorded depends on the target behavior (e. school). Simple rule-governed games reveal cognitive skills. home. noting the length of time the behavior occurs (duration recording). in which the parent is instructed to select an activity and to keep the child playing according to parental rules.g. selecting the most appropriate setting in which to observe the behavior (where). Given the time and expense involved in doing direct observations. symbolic and pretend play. and indicating whether or not the behavior occurred during a preset time interval (time sampling). 1973). and (3) Cleanup. Bessmer. Methods include counting the number of times it occurs (event recording). persistence. Puppets allow observation of language skills. and the use of help. frustration level. and interactive play skills. (2) Parent-Directed Interaction. frustration tolerance. Bessmer. or in the clinic. In addition. and role play. Edwards. In addition to discrete behaviors.2. in which the parent instructs the child to clean up the toys. The overall patterns of behavior in play are more important than any specific behavior (e. Direct observations require explicitly defining the concrete target behaviors to be observed (what). and behavior can change when people are aware that they are being observed. Given the significance of the parent–child relationship.

THE FOUNDATION the child’s defiant behavior. and (3) at the end of the 10-minute period. so the CBCL system provides a multimodal method of assessing a child’s emotional and behavior functioning. & Eyberg. Other observational systems have been developed for peer interactions (Dodge. 1982). duration. The reliability and validity of the Internalizing scales is weaker. noncomplies. the child’s behavior is observed for 3 seconds. noting the occurrence. Both of these systems can be used in conjunction with other components of the BASC and the CBCL. and child self-report versions of the CBCL. or no opportunity) to parental commands. Achenbach. the child’s behavior is coded as being on or off task for 5 seconds. A momentary time-sampling recording procedure is used. Several observational systems developed for parents to record specific child behavior are given in subsequent chapters.66 I. The CBCL-DOF (Achenbach. Monaco. The target behaviors are grouped into 13 categories (4 categories of positive/adaptive behaviors and 9 categories of problem behaviors). & Landau. 1983). but the resulting data are well worth the effort. it is a simple and time-efficient method to gather information on many behaviors important to children’s functioning in school. 1988). complies. 1986) is designed to be interpreted in conjunction with the parent. and intensity of specific problems. Observers with minimal training have been shown to be reliable. Two other commerically available observational sytems for recording classroom behavior are the BASC—Student Observation System (BASC-SOS. & Gent. 1999). There is a high degree of item overlap between the CBCL-DOF and the CBCL parent and teacher rating forms. 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. talking out in class. such as aggression. 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. 1986). 1992) and the CBCL—Direct Observation Form (CBCL-DOF. Training is required to code the behaviors. Moreover. at the end of each 30-second interval. teacher. At the end of the observation period. and these ratings are then averaged. the observer rates the child on 96 behaviors that may have been observed during the observational period. and so forth (Mash & Terdal. room cleaning.g. 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. family interaction (Patterson. going to the bathroom.. 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). eating. Loney. Reynolds & Kamphaus. the observer provides narrative information on the interaction between the teacher and the child. and the other after it. One can also use an individualized observational system for a particular child or type of problem. The coding system is a continuous frequency count of all behaviors observed during the 5-minute interaction periods. Although there are no reliability or normative data for this system. 1997b). there is evidence that the Off-Task and the Externalizing scores are valid (McConaughy. A child can even be asked to engage in selfmonitoring of his or her behaviors. and there are no representative norms with which to compare scores. 1982). These observations provide a frame of reference for interpreting the identified child’s scores. in which the 15 minutes are divided into 30-second intervals. and behaviors associated with ADHD (Milich. (2) at the end of each minute. The observer uses a checklist to mark each category of behavior that occurred during the 3-second observation interval. Achenbach. Children . fighting with siblings. The BASCSOS is a 15-minute observational system that specifies 65 target classroom behaviors. and child responses (e. Scores are reliable for trained observers and are sensitive to treatment effects (Rayfield. however.

parent–child interaction (including a home observation). teacher interviews. 1991). achievement. Information from the school and further information about the child’s functioning are most often the foci at this stage in the assessment process. 1987). this conversation helps determine what information should be gathered. behavioral. in classroom behavior. but these problems are often best referred to mental health professionals who deal specifically with marital/couple or adult mental health problems. Reynolds & Kamphaus. and these demands change as children progress through school. Assessment to Intervention 67 can be trained to self-monitor their behavior accurately if they have a clear and simple observational system. as well as what school resources are available to the child. it is not uncommon for them to exhibit difficulties in academic performance. and direct observation in the classroom. For example. parent and child interviews. but problematic for reliability purposes. See La Greica et al. parent rating scales. the marital/couple relationship. 1992) and the CBCL—Teacher’s Report Form . emotional. school behavior (e. as well as indicate what other information is needed to delineate the problem further and/or aid in treatment planning.2.. 1985). activity level. 1986). Research has also shown. & Stouthamer-Loeber. The school environment places a variety of demands on children (e. academic progress. they are less helpful for internalizing problems (Loeber.. We have included descriptions of tests in Appendix A that assess for some common parental problems. and behavior problems. or disruptive behaviors. After the clinician has obtained permission to gather information from the school. Having a preschool or elementary school teacher complete a general school questionnaire (see Appendix B for an example) that provides information on demographics. Green. interacting with peers).g. and have another person to monitor their recordings (Keller.. Although teachers can provide valuable information on externalizing behaviors such as sustained attention. are reinforced for the accuracy of their recording. is a time-efficient way to gather a great deal of information. Lahey. parental psychopathology. that children change their behavior as they become more aware of it through self-monitoring (Shapiro. Since children spend most of their time at school. teacher rating scales. keeping focused. Step 4: Further Assessment The data from the parent questionnaire. school observation). School Children who have a problem in one area of functioning are likely to exhibit problems in other areas. Moreover. and sibling or peer relationships. and informal or formal observation of the child should give the clinician information on the nature of the problem. This could be beneficial in a treatment program. further assessment of the child’s behavior may be needed in the areas of intellectual. they are also less helpful when teachers do not observe the child across several class periods (Edelbrock et al. teacher interview. or in interactions with classmates. (2001) for more information on behavioral observations of children. following directions. The teacher rating scales that we have found most useful are the BASC—Teacher Rating Scale (BASC-TRS.g. and these are briefly discussed. a brief phone contact with a teacher can set the stage for establishing a collaborative relationship with this professional. plus a broad-band teacher rating scale. and adaptive levels of functioning. sitting quietly. however. The details of these difficulties can be obtained through teacher questionnaires and rating scales. Their adaptation to this environment can have a dramatic impact on their overall psychological adjustment.

The Social Skills Rating System (SSRS. it is particularly important to give them feedback on the findings and recommendations. 2000). The reader is referred to Sattler (1992) for further information on assessment in these areas. asser- . The BASC-TRS includes several areas of adaptive functioning (Adaptability. the focus of this measure is clearly on social skills.” or “often true” of the child. Anxious/Depressed). Child Further evaluation of the child may include a psychoeducational or neuropsychological evaluation to assess intellectual. Social Problems. The inclusion of adaptive scales in the BASC and CBCL provides information on a child’s skill deficits. with teacher. testing of children is on the increase. cost-effectiveness. Aggression. and has good normative data. internalizing. however. and student forms measuring a variety of social skills across settings from preschool to grade 6 (see Appendix A). teachers. emotional. and children) (Kamphaus & Frick. and use by multiple informants (caregivers. Attentional Difficulties. Conduct Problems. as parts of multi-informant systems. Externalizing subscales (Delinquent Behavior. (2000) for a selected but extensive list of tests for children and adolescents. Social Skills. broad coverage of problem behaviors. Finally.68 I. 1991b). elementary school (6–11 years). Aggressive Behavior). and behavioral levels. Gresham & Elliot. It assesses the domains of cooperation. Study Skills).” “somewhat or sometimes true. Furthermore. According to a recent review of testing practices (Kamphaus. Both of these scales assess the emotional and behavioral functioning of children in school. and behavioral functioning. and a four-item screening scale for adaptive behavior. and uses a 4-point scale for rating the frequency of occurrence of behavior. It includes some background questions (e. 1996). Somatic Complaints. as well as on strengths that can act as protective factors for emotional and behavioral functioning. The reader is referred to Kamphaus et al. which includes age ranges and administration time. Other teacher scales that we have found useful are the Sutter–Eyberg Student Behavior Inventory—Revised (SESBI-R. rating scales have many advantages. Depression and Withdrawal. Anxiety. The BASC-TRS has forms for preschool (4–5 years). Scales include Internalizing subscales (Withdrawn. The area of social skills often needs further assessment. Somatization. Leadership. & Rowe. with a more diverse array of instruments available (especially in the area of abbreviated intelligence testing). the use of rating scales has increased and has supplanted the use of projective tests. Petoskey. achievement. The CBCL-TRF is designed for children between the ages of 5 and 18 years. THE FOUNDATION (CBCL-TRF.. which makes elevated scales difficult to interpret.g. and.” “very true. Achenbach. The item content of most of the scales tends to be quite heterogeneous. they permit comparision of behavior across informants. Thought Problems. “How well do you know him/her?”). percentile ranks. and Attention Problems. The scored tests give standard scores. The large research base for the CBCL-TRF aids in interpretation. Although the SSRS measures externalizing. Eyberg & Pincus. The teacher ratings on the emotional and behavioral items are “not true. It also screens for learning problems that can accompany emotional and behavioral problems in children. when a clinician is gathering information from teachers. 1990) is a comprehensive measure of social skills. or organic functioning. Moreover. including brevity. the Thought Problems scale has questionable reliability and validity. and Atypicality. and high school (12–18 years) ages. minimization of response set. parent. As previously noted. It covers adaptive. 1999) and scales for ADHD that are discussed in Chapter 11. and has separate scales for Motor Hyperactivity. and the teacher form includes a rating of academic competence. a teacher’s rating of the child’s academic performance. and hyperactivity problem behaviors.

and Wechsler Abbreviated Scale of Intelligence (Psychological Corporation. and even better than. this easy-to-use instrument is unique in its thorough measurement of this important area of development. 1995) for ages 9–19 years. 1992). In a survey of mental health professionals using different informants to assess psychopathology.g. more complex schemes in which different sources of information are weighed more heavily than others (e. and self-control. and Lahey (1990) found that clinicians tended to weigh the information from adults more heavily for observable externalizing behaviors. Although there is poor reliability for some of the subscales (especially the student form). It is important to have some estimate of the child’s level of cognitive functioning in order to tailor treatment for that child. teachers’ reports of inattention are given more weight than parents’) (Offord et al. 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..” “sometimes. including the BASC—SelfReport of Personality (BASC-SRP. Kovacs. Garrison.e. which has forms for ages 8–11 (SRP-C) and 12–18 (SRP-A) . Green. 1993). school suspension. and the normative samples are not described.g.. Assessment to Intervention 69 tion. The Peabody Picture Vocabulary Test (Dunn & Dunn.. sleep problems) (Kamphaus & Frick. even when external criteria for child. Reynolds & Richmond.. 1990). frequency. Meta-analyses yield a mean correlation of only r = . 1997) for ages 8–19 years. Reynolds & Kamphaus. teacher. inattention) than behaviors that occur outside of school (e. the Kaufman Brief Intelligence Test (Kaufman & Kaufman. whereas more weight was given to children’s self-reports of emotional or internalizing problems. The importance ratings help in prioritizing behaviors for intervention. Integrating Information across Informants As might be predicted.” “important. This implies that one informant may have better knowledge of certain behaviors than another informant. Loeber. & McKeown.2. responsibility (parent form only). There is growing research support for this practice (Bird. 1989) for ages 8–12 years. We often use a number of self-report inventories for children. it is viewed as a problem) works as well as. 1996). Frequency of behavior is rated on a 3-point scale (“never.” and “critical”). the Personality Inventory for Youth (PIY. 1992) for ages 6–17 years. Piacentini.. however.. Others have found that this level of disagreement also holds true for parents and children (Andrews. 1992). the Reynolds Child Depression Scale (RCDS. teachers will know more about behaviors that occur in school (e. and the Multidimensional Anxiety Scale for Children (MASC. & Cohen. and parent reports of disruptive behavior (e. & Howell. 1996. Piacentini et al. the Children’s Depression Inventory (CDI. 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.” “very often”). and severity of individual children’s problems. empathy (student form only). Gould. and the parent and teacher forms also rate the importance of each item (“not important. especially when cognitive-behavioral or problem-solving therapy is being considered. 1997).27 between parent and teacher reports of children’s problems (Achenbach. and teacher data are not always in agreement on the type. (1992). police reports) are used to validate the informants differentially across behavioral domains (Loeber. These measures are described in more detail in Appendix A. Reynolds. 1999) are quick methods to gather this information. & Staghezza. child. 1985) for ages 6–19 years. 1992). McConaughy. Jackson. parent. Lachar & Gruber. 1987). for example.g. if any informant says there is a problem. Cohen.g. . March. Addy. the Revised Children’s Manifest Anxiety Scale (RCMAS.

g. THE FOUNDATION Green. or may behave differently with one parent versus the other. Achenbach (1998) indicates that discrepancies between different informants are understandable. The program prints separate item scores. language. 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. so the clinician can identify specific areas of agreement and disagreement among informants. experience. Frick. Parent reports not confirmed by children were systematically related to the parents’ own levels of anxiety. (2) as a child moves from a single teacher to multiple teachers. and expectations. another). and the conditions under which the report is completed (e. at home vs. whereas another parent may do something that provokes the behavior. for several reasons: (1) As a child grows older. Other factors affecting the validity of reports of various informants include parental adjustment. then a referral should be made to the appropriate allied health professional.. which can be helpful in comparing the scores of multiple informants. rushed or tired). CBCL-TRF.70 I. he or she is better able to describe emotions and thoughts. As an aid to cross-informant comparisons. In addition to the type of problem being assessed. parents have less knowledge of the child’s emotions and behaviors (Paikoff & BrooksGunn. Thus discrepancies appear to be an expected part of the assessment process. and (3) as the child develops cognitively. and Evans (1994) found that teachers’ reports of anxiety were not related to maternal reports.g. . This involves understanding and appreciating the particular areas of expertise of these professionals. and profiles from each informant. 1991). Furthermore. teachers are likely to have less knowledge of the child’s behavior. and a double cross beside each scale score that is in the clinical range. scale scores. et al. The motivation of the informant is also a factor (e. giving further support for the emphasis on children’s self-reports of internalizing problems. 1996). Kamphaus and Frick (1996) also give a comprehensive system for integrating and interpreting assessment information. Arnold and Jacobowitz (1993) developed a computer program in which the CBCL. given that children display different behavior in different demand situations (e. and CBCL—Youth Self-Report (CBCL-YSR) data are entered for a combination of up to five respondents. 1991). The clinician must develop relationships with a variety of professionals from different disciplines who deal with children. for example. and if analyzed can provide important information about the presenting problem(s). Achenbach (1998) describes a taxonomic decision tree for comparing data from multiple sources. Silverthorn. 1996). marital/couple conflict. using maternal history of anxiety as a way of validating informants’ reports of childhood anxiety for children ages 9–13.. although child reports of anxiety were always accompanied by parent reports. a cross is printed beside each score that is in the borderline clinical range. as well as differences in training.. as parent and teacher reports decrease in importance (Kamphaus & Frick. a parent is seeking custody or a child does not want to admit to a problem).. The program also displays the item and scale scores for each informant side by side. school or with one teacher vs. the age of the child affects the quality of the information gathered by different informants. or neurological problems. Timeliness of services. however. Thus the importance of children’s selfreports increases with age. In another study. Many rating scales include validity scales that help detect such invalidating response sets (Kamphaus & Frick.g. One parent may not be around the child as much or may have a different tolerance threshold for a behavior.

presenting assessment results clearly and succinctly. 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. “consultant” often describes the role that the child clinician plays with parents and children. Giving the teacher an assessment or treatment plan. Although the focus of this book is on the individual child. in fact. It is important that both oral and written communications be timely. In developing such a program. consulting with other agencies is often required if a child and family are to receive the most appropriate and effective treatment. Pediatricians have a fast-paced schedule and are used to “fitting” patients into these schedules. specific goals for change. It will take a consistent. formulating a shared explanation of the problem. goal-oriented plan to help the teacher make changes in the classroom setting. developing a plan for assessing the problem(s). Consultation Children’s problems are usually not limited to the home. practical. problem-focused. the child clinician has to take these expectations into account without compromising standards of care. 1996). Assessment to Intervention 71 for example. consultation may focus on a special education program or on system-level issues (student absenteeism.) (Mattison. or it may involve working with the teacher to implement a behavior program in the classroom. the consultant must be aware of the teacher’s biases. negotiating intervention goals. They are often dismayed to discover that a psychological consultation may not be scheduled for weeks and then may take several weeks to complete. training. giving a rationale for data collection. and action-oriented. negotiating data collection methods. and/or assistance to the consultee. discussing the assessment results. helping others to carry out the treatment. who in turn is responsible for carrying out the agreed-upon program/actions necessary to resolve the problem. concise. Schools are the agencies with which child clinicians must work most often. Thus the consultation process requires many of the same tasks and skills needed for working with parents. jargon-free. disciplinary referrals. The consultant is responsible for providing information. with limited time devoted to psychosocial problems. and providing constructive feedback (Sanders. monitoring and evaluating progress. Although the term “consultation” has many meanings. and programming for generalization and maintenance of therapeutic gains (Sanders. the consultant will have a different task than if the teacher is driven by a desire to change the child’s behavior. for example. the translation of vague or nonspecific concerns into concrete. skills. implementing the intervention plan. To collaborate effectively with pediatricians. Tasks of the consultant include creating a therapeutic alliance. without including him or her in the process of assessing the behavior and developing the plan is likely to fail. etc. and time limitations. Communication is obviously a key issue in collaborating with other health professionals. The skills needed to complete these tasks include effective interviewing skills. 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. Consultation with the school about an individual child may involve simply giving a teacher information about the child’s development or recommending special services. 2000). If the goal of the teacher is to have the child removed from the classroom. just as it does when one is working with the parents to implement behavioral and environmental changes in the home.2. either orally or in writing. . is a common barrier to effective collaboration with pediatricians. 1996). therefore. designing an intervention.

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. and what has been done to answer their concerns/questions (e. Either this communication of information can motivate parents. parent and teacher questionnaires. The initial interview(s) will help prepare the clinician for possible parental reactions to the findings. Whenever possible. and thus for ways to help them deal with their feelings during the feedback meeting. parent and child interviews. a relative or teacher). Finally. and allow the parents to ask questions and express their feelings/concerns about the findings or recommendations. Anything beyond that amount of time is usually overwhelming to parents and unproductive. and Kratochwill. Wickstrom. so that parents can understand how their child is functioning in relation to other children his or her age. Any additional questions or concerns can also be raised at this time. along with possible alternative courses of action. and Rotto (1995) for further information on consultation.. with a focus on both the strengths and the weaknesses of the child and family. it is important to have both parents attend this meeting. they increased their mean levels of effectiveness from 9–37% to 60–83%! The reader is referred to Bergan and Kratochwill (1990). Step 6: Communication of Findings and Treatment Recommendations Communicating the findings of the assessment process provides the critical link to the intervention process. teachers. THE FOUNDATION The importance of providing feedback to teachers was underscored in a study by Jones. Sattler (1998) provides an in-depth discussion of the interpretive process. When teachers were given systematic feedback on their performance in carrying out treatment programs. encouraging parents to ask questions and express feelings. The findings should then be presented. If the child is seen alone. the parents should be given an opportunity to express their understanding of and feelings about the findings and recommendations.72 I. school observations). and to encourage questions or discussions.. After the findings of the assessment are presented. then they are less likely to accept the clinician’s conceptualization of the problem and treatment recommendations. help parents understand the findings and recommendations. Possible etiologies for the problem should also be discussed. It is often best to use percentile ranks when reporting test data. it is important to review briefly what the parents have said about their primary concerns. 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. This can be done by sharing information in jargon-free language. and Friman (1997). The length of treatment and financial costs should also be discussed. present recommendations (including alternatives). It is important for the clinician to evaluate continually how the parents are understanding and receiving the findings. what they hoped to learn from the evaluation. If parents feel that their concerns and observations have not been taken seriously. Just as the clinician should have initiated a collaborative relationship with the parents early in the assessment process. the recommendations should be given. Kazdin (1994). At the beginning of the meeting.g. and allowing them to make choices on how to proceed.g. and to ask them whether they would like anyone else to be present (e. he or she should continue to foster this relationship during the meeting devoted to interpretation of the findings. or it can overwhelm and immobilize them. Briefly. and others to provide the treatment necessary for the child’s optimal functioning. achievement testing. he states that the purposes of the interpretative or postassessment meeting are to share findings from the assessment process. Elliot. It is important to schedule adequate time for the meeting. as well as how they . allowing up to 1½ hours. whereas less time may not allow sufficient coverage of the important issues.

http://www. Specific treatment methods that have at least some empirical basis for their effectiveness are covered in subsequent chapters that focus on particular problems. They should be presented with the options to take time to think about the findings and recommendations. but also to target children who are at risk for problems. 1996). This increase reflects our growing understanding that children exist within a family. what treatment should be given. DC 20013.nichcy. Assessment to Intervention 73 would like to proceed. and how that treatment should be delivered is an ongoing clinical task. attitudes and perceptions of the parents. Intervention has been increasingly directed to treating children within their environments rather than in more restrictive settings. or to call the clinician if they have further questions. Kazdin. sleep problems). 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. and others whose problems have multiple determinants and occur across multiple settings (e. Walsh. Jensen. Katz-Leavy. 1995).1 In this section. and a specific period of history (Howard. Box 1492. 1021 Prince Street.. a peer group. 1999). reimbursement for treatment. including the availability of services. Treatment Effectiveness Studies The types of services and treatment methods available to children and families have increased over the past several decades (Kazdin. 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. and to promote the mental health of all children based on a knowledge of normal child development and developmental psychopathology (Offord. Not the least important factor in making treatment decisions is matching the targeted problem(s) with the least intrusive.org.. the child clinician’s role should be not only to provide services for those children who are seriously distressed. Kraemner.e. . 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. thumb sucking. and that their behavior is influenced by all of these contexts and social situations. 1995). 800-695-0285. Barton. & Harrington.fcmh. 1996). Various factors affect this decision-making process. a school system. and most efficient treatment method(s). with 5–9% of these children experiencing extreme functional impairment (Friedman. & Lerner. We then discuss issues related to the pharmacological treatment of children. given that approximately 20% of children (i. a culture. and training of the therapist. Manderscheid. As emphasized in Chapter 1. to seek a second opinion. to schedule another meeting. most effective. http:// www.. 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. & Sondheimer. 2000).g. Determining who should receive treatment.g. ADHD). one out of every five) has a diagnosable emotional or behavioral disorder (Angold & Costello. Washington.2. Alexandria. and the Federation of Families for Children’s Mental Health. Satcher. the National Information Center for Children and Youth with Disabilities (NICHCY).org. 1998. anxiety. VA 22314-2971. It’s Nobody’s Fault: New Hope and Help for Difficult Children and Their Parents (Koplewicz. a community. 2000). 703-684-7710. TREATMENT ISSUES The need for effective treatment for children in the United States is urgent.

In a review of nine studies in which treatment was carried out by practicing clinicians in clinic settings. some studies found an advantage for behavioral and cognitivebehavioral approaches. In a comprehensive review of the literature on the effectiveness of treatment for mental health disorders in children and adolescents. 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. One method of transporting interventions from the research to the clinic setting is the use of the manuals developed for treatment efficacy studies. Harris.. is an important consideration.” which are directed at determining whether a particular intervention works under tightly controlled conditions (i.. group and family therapy for children and adolescents between 1985 and 1995. ethnically. clinic-referred children are racially. and there are fiscal restraints on the intensity and duration of treatment. inpatient and residential treatment centers. ADHD. the training of people who provide treatment in the community is diverse. Erkanli. Moreover. Moreover. which consume 75% of mental health dollars). THE FOUNDATION tial hazards of restrictive treatment (i. Overall. Results of a recent longitudinal community-based study indicated that improvement of symptoms was related to the number of sessions (eight or more).” which are aimed at determining how well a particular intervention works under the conditions in which treatment usually occurs. Weisz and Weiss (1989) found only medium to low treatment effects.e. 2000). including phobias and anxieties. conduct disorder.. it has caused a great deal of controversy. Weiss. who often use a treatment manual. 1998). nonbehavioral) did not differ consistently in effectiveness. Burns. In contrast.g. knowledge of the trajectories of development that can lead to poor outcome. studies of mental health interventions in “real-world” clinics are very limited. as well as how and who will deliver these services (Ollendick & Russ. and knowledge of the types of services that have failed to meet the needs of children and families. He found that changes with psychotherapy were greater than changes without treatment. Hoagwood. but a similiar impact was not observed on impaired functioning (Angold. many of the new community-based alternatives have little empirical evidence to support their effectiveness. Treatment outcome for externalizing and internalizing problems did not clearly differ. Burns. ODD. Translating studies of “efficacy. Although this appears to be a reasonable idea. Little is known about the actual treatment of children in nonresearch clinic settings. research must focus on determining which interventions are effective for specific problems and populations. into studies of “effectiveness. Catron.74 I. and usually have comorbid conditions. and socioeconomically diverse. and Phung (1999) found little support for the effectiveness of traditional child therapy in contrast to a controlled condition of academic tutoring. Moreover.e. Costello. Likewise. & Farmer. Furthermore. Questions have been raised about . functioning for the average treated child was at 76–79% of that for normally developing peers. 1999). Other research has identified effective treatments for specific childhood disorders. although the type of treatment (behavioral vs. clinical trials in research settings). and a variety of other behaviors (e. Kazdin (1996a) summarized nine meta-analytic studies covering individual. 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. toileting problems and thumb sucking) (Kazdin & Weisz. the treatment typically is carried out by specially trained therapists. but treatment has generally been found to be less effective in these settings than in research settings.

The first two barriers to treatment can be dealt with by improving service planning and providing more financial help to families. it is disturbing that the no-show rate for first appointments following the initial telephone request for services is 15–35% (Kourany.. In a review of studies of parental cognitions and attributions in engagement in treatment. unchangeable. Considerable research has documented that regardless of the objective severity of the child’s problem. (1990) found that the most common reasons parents do not keep the initial appointment are schedule conflicts. At the same time. perceptions about their ability to handle such problems. and it is likely that changes in professional training practices will have to be made if children’s needs are to be effectively met. and promote professional accountability. and outside their influence) tended to use a more authoritarian parenting style. Morrissey-Kane and Prinz (1999) found that parental beliefs about the causes of their children’s problems. and a perception shift (i. 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. 1990). Given that only a small percentage of families seek help for childhood psychological problems (Stouthamer-Loeber. the parents feel that the child’s behavior has improved or is no longer a problem). Kazdin. & Hatgis. 1999). Determinants of Attrition Another critical issue relevant to treatment effectiveness is to determine the factors that affect treatment initiation and completion. encourage innovation. the cost of the treatment. This involves training not only in specific techniques.e. and general counseling (Kazdin. facilitate training and supervision of therapists. increase dissemination to practitioners. 1998). that the techniques in use are eclectic and are combined with little attention to the quality and fidelity of the treatment. 2000. Wade. psychodynamic. Improvement in these areas demands an empirically based approach. 2001). Assessment to Intervention 75 the effects of using manuals on the therapeutic relationship and on therapists’ ability to meet their clients’ emotional needs. but also in the theoretical orientations that drive the development of effective treatments. and expectations about the ability of therapy to help them greatly influenced their engagement in treatment. researchers must find ways to test the effectiveness of their techniques in clinical settings (Kazdin. were more dissatisfied with treatment. Loeber. result in the replacement of doctoral-level professionals with less trained therapists. that the current manuals need to be made more therapist-friendly in providing more practical details about their use. 1992). and that there is little monitoring of progress (Kazdin. There are also concerns about the extent to which manual-based treatments can deal with patients with multiple problems. however. An important point in this discussion is that even when effective treatments are available. 2000. so that their range of application can be extended. restrict clinical innovation. do not exclude the treatment of comorbid problems.e. a belief that their children’s problems were stable. & Tornusciolo. & Bass. Garber.. & Thomas. and that 40–60% of families who begin treatment drop out prematurely (Kazdin. He also indicates. and require more frequent and regular sessions than is common in most clinical practices (Addis. Parents with an external locus of control (i. parents with an internal locus of control (i. and had poorer treatment outcomes. Kourany et al. the third is more difficult. Siegel.2. Currently it appears that in clinical practice there are unclear criteria for treatment selection. a belief . In response to these concerns. they are not necessarily used in clinical practice. perceived behavioral management strategies to be less relevant and acceptable. 1990). 1997).. 1996b).e.. Wilson (1998) argues that manual-based treatments encourage focused intervention. The predominant treatments for children and families continue to be eclectic. Conversely.

unlabeled praise). Rayfield. whereas satisfaction with treatment outcome was related to changes in observed child compliance (Brestan. strategies such as booster sessions or brief contacts by telephone after treatment has ended may be helpful. there is little empirical support for this assumption (Lambert. 1998). (3) the manipulation of antecedent conditions (e. 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. but to ensure treatment effectiveness (Henggeler. (8) regular feedback and reinforcement for accurate implementation should be provided.. 1994). found that satisfaction with the treatment process was related to changes in parent behavior ratings. Such a checklist should include the specific behaviors that the teacher or parent is expected to carry out in the program (e. another approach to treatment outcome evaluation that has become popular is consumer satisfaction. A number of studies indicate that parental attributions regarding treatment can be modified through such intervention strategies as letter writing (Lown & Britton. Eyberg. Consumer Satisfaction With the advent of managed care. for example. Jacobs.g. Although satisfaction and service effectiveness are often equated. 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. THE FOUNDATION that they could exert control over their children) were more likely to remain in treatment and had more positive treatment outcomes. Edwards. 1995). & Bickman. 1996). (4) programs should be initially implemented for one period or part of the day. and influencing the clients’ social networks (Pescosolido. & . and family therapy. 1994).g. rather than focusing on one student (e. A recent study using a brief consumer satisfaction measure of parent training. That is... 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. allowing choices. Boggs. such as completed homework or household chores. (7) available activities should be used as reinforcers. (5) behaviors that are already monitored. Salzer. parent– child treatments. or the parent reviewed the activities for the evening or used labeled vs. are the treatment procedures being implemented correctly and consistently? This is particularly important for children with disruptive behavior problems. and Foote (1998) suggest that to help maintain treatment effects. (2) the acceptibility of the intervention strategy should be assessed prior to treatment. a greater focus on parents’ expressed needs (Prinz & Miller. intensive telephone contact (Wenning & King.g. (6) the entire class should be involved. making work periods shorter. 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. the teacher recorded points. (9) the clinician should meet periodically with the teacher or parent to monitor progress and modify the program as needed. The bottom line is that the clinician must motivate parents to sustain their commitment to treatment. 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. should be targeted.76 I. 1991). peer tutoring). peer tutoring) versus consequences (giving tokens) should be emphasized.

Schoenwald. deficits. & Cunningham. the parent–child interaction. 2. Clinicians not only should be knowledgeable about the efficacy and safety of psychotropic medications. Furthermore. & Kuppinger.2. 1999). successful treatment of children and their families involves developing a relationship with the parents (and others. In this study. and maintenance of those effects must also be considered in this process. the TAI was demonstrated to be psychometrically reliable and valid. Only stimulant drugs have adequate data to inform their use with children. particularly multisystemic therapy with delinquent children and adolescents. 1999). the rate of progress is slow (Jensen et al. Treatments that provide training for foster parents to help them deal with children who have emotional and behavioral problems are effective. . 1996). Furthermore. The TAI is reprinted in Appendix B. Committee on Drugs. Multisystemic therapy is an intensive family-focused treatment that targets such risk factors as peer associations. This is of particular concern. There are few data to support their short. and psychoeducation) can be effective (Evans. 2000) on the sharp increase in the use of stimulants. 1999). and needs. Borduin. it emphasizes parental monitoring and coordination with schools and community. including them throughout the treatment process. 1996). 1999. and clonidine with preschoolers has caused even the White House to raise questions about this method of treatment (Rabasca. clinic-referred sample representative of typical clinical populations of young children with conduct-disordered behavior. 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. Weisz & Jensen. when necessary). 3. Three approaches to treatment in the “real world” that have been found to be effective are as follows: 1. and/or medical issues. there are indications that intensive case management (including behavior management. The treatment can focus on changing the child’s behavior. have clearly documented effectiveness (Henggeler. correlations between the Therapy Attitude Inventory (TAI.2 Although the number of efficacy and safety trials for psychotropic medications with children and adolescents is increasing.. Home-based services. the consequences of the behavior.and long-term efficacy and safety. antidepressants.. safety and efficacy concerns are not limited to psychotropic medications.. as are approaches involving structured therapeutic homes (Chamberlain & Reid. the parents’ behavior. It thus must be focused on multiple levels of interaction with ongoing monitoring of progress. To summarize. Rowland. but also should be aware of parents and children’s attitudes about such medications (Rappaport & Chubinsky. Some parents are apprehensive when it is recommended 2Unfortunately. 2000). service planning/coordination. such as teachers. Assessment to Intervention 77 Eyberg. 1998). 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. Armstrong. a recent report (Zito et al. 1974) and behavior problem severity after treatment were not significant. The success of treatment should be substantiated. and using effective treatment methods that target the child’s and family’s specific strengths. Although the evidence is small. Eyberg. 1998). however (Jensen et al. A major strength of the study was the use of a diverse. 2000). given the lack of information on the long-term effects of these medications on developing children. the environment.

and Jensen (1999) for reviews of pediatric psychopharmacology and Werry (2001) for a thoughtful commentary on psychopharmacological treatment. THE FOUNDATION 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. They may believe that it is proof that they are “defective. The use of psychotropic medications with specific disorders is discussed in later chapters. electrocardiograph).. children often have concerns about the effects or meaning of the use of psychotropic medications. psychotropic medication should be used cautiously with children. An important resource for parents who are considering medication for their children is Straight Talk about Psychiatric Medications for Kids (Wilens. they may also be frightened of the tests that monitor the medication (e. 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. . and the provision of appropriate information on how the body works and why medication is thought to be needed. and its use as the only treatment for children with psychiatric disorders is not warranted. is essential before any drugs are prescribed. To summarize.g. Bhatara. A recommendation for medication may even cause some parents to feel guilty that their child has inherited a biological basis for the problem. The interested reader is referred to Wiener (1996) and Vitiello.78 I. 1998). A careful assessment of these attitudes/concerns. Likewise.” or that they are responsible for their family problems.

PART II MANAGING COMMON PROBLEMS .

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

children’s weight gain slows and their appetites decrease substantially.82 II. and FTT. 1983). In a random survey of 140 parents in a private pediatric practice. NORMAL DEVELOPMENT OF FEEDING BEHAVIOR Understanding normal development of feeding patterns is critical in diagnosing and treating eating problems in young children. Children begin life eating only one food. feeling too fat and engaging in weight-control behavior) at age 8 years (Jacobi. Between 1 and 2 years of age. and food refusal problems (including finicky eating and food phobias). and Steiner (1998). This decrease in appetite. Kapphahn. & Seidel. however. and parents are often most worried about their children’s eating habits at this time. gaining about 12–18 pounds in this year (Hoekelman. and Rabalais (1998). Smith. Bryant-Waugh. This finding suggests that there might be precursors for adolescent eating disorders that are important in childhood.e. The assessment and treatment of cases in which children are or have been medically compromised are included in the section on food refusal problems. are then discussed in greater detail. & Hammer. Blatman. MANAGING COMMON PROBLEMS cal obstruction (e. Womble. . 1978. 2001). coupled with toddlers’ emerging drive for independence and autonomy. 2001). weight gain is only about 5 pounds per year.. during the next 3–4 years. sets the stage for a variety of feeding problems. In reality. Gordon. Sanders. Obesity. they are much more common during the toddler and preschool years. This chapter first reviews the normal development of feeding behavior. Infants double their weight during the first 5 months of life and triple it by the end of the first year.g. 1987). and Zucker (1998) for further discussion of these disorders. As can be seen in the table. Knibbs. The reader is referred to Garner and Barry (2000). Although feeding problems do occur during the first year (see “Eating Problems Related to Infant Feeding... requiring the child clinician to consult with other medical and nutritional professionals (Linscheid & Rasnake. the capacity of the stomach grows from about 10–20 ml at birth to 200 ml at 1 year of age. most feeding problems have multiple causes.1 outlines physical and behavioral development related to feeding during the first year. Williamson. and Williamson. pica. 60% of parents of 2-year-olds. that recent research has documented an association between mothers’ eating disorders and their children’s (especially girls’) self-reported eating disturbances (i. & Lask. as these are primarily problems of adolescence and beyond the scope of this book. It is important to note. 1977). failure to teach appropriate eating habits). Agras.g. and must gradually learn to accept a wide variety of foods. eating was not noted as a problem by any parents of newborns to 1-year-olds. By the end of the first year.” below). there are enormous changes in children’s diet and feeding behaviors during the first year of life. Kanoy. feeding tube). Table 3. milk. Friedman. almost all normally developing children are eating many different solid foods and are able to self-feed completely independently. It should be noted that although case reports of anorexia nervosa in children exist (Fosson. and (4) behavioral mismanagement (e. and 50% of parents of 4-year-olds indicated that mealtimes were a problem (Schroeder. Moreover. there is general agreement that this disorder is very rare in children under 10 years of age. for example. Bentz. In contrast. rumination. Brunell. & Routh. 30% of parents of 3-year-olds. Thus anorexia nervosa and bulimia nervosa are not covered here. It next briefly covers four eating problems that either occur primarily in infancy or represent dysfunctional forms of infant feeding patterns: colic.

Normal Feeding Development in the First Year Age Birth Physical development Physiological distress brought on by hunger Preference for sweet. 1998). and can intentionally bring things to their mouths. Eating Problems TABLE 3.1. Infants are also born with a predisposition to reject novel foods. In this way. as children at this age tend to put everything into their mouths anyway. early experience with a wide variety of tastes and textures leads to readier acceptance of new foods later in life (Birch & Fisher. Moreover. During the transition from milk to solids. fine motor skills are developing to the extent that children can reach and grasp. They recommend that parents expose their children to many different foods that are developmentally appropriate and varied in texture and taste. 1990. 1964). infants will eventually accept almost any new taste (Birch. In this regard. whereas bottle-fed babies experience only one flavor—that of commercially prepared formula. Menella and Beauchamp (1996) note that infants who are breast-fed may have an advantage over bottle-fed babies. 1998). 1998). Thus acceptance of new foods does not come naturally. bitter Sucking and rooting reflexes Extrusion reflex (tongue thrust) Stomach size = 10–20 ml Behavioral development Feeding on demand Colic is common Breast-fed babies experience many new flavors 83 2–3 months 3–5 months Sucking and rooting reflexes fade out New skills emerge: Reach and grasp Hand to mouth intentionally Munching Lateralization of tongue Sitting up propped Teeth appear Pincer grasp Lateral chewing movements Can lick food from bottom lip Sitting up unpropped Stomach size = 200 ml Weight gain decreases to 5 pounds per year Nighttime feedings end Colic resolves Begin solid foods Everything goes in the mouth 7–10 months Finger feeding Grabs for spoon Critical period for introducing solids Drink from spouted cup Spoon to mouth 9–10 months 12 months 15 months Can use spoon and other utensils Entirely self-feeding Linscheid and Rasnake (2001) stress the importance of preventing feeding difficulties. but it can easily be shaped by repeated exposure. salty Aversion for sour. acceptance of new foods is shaped by an inborn preference for sweet and salty. Between 4 and 6 months of age. Wren and Tarbell (1998) suggest that this may result from the lack of opportunity to develop adequate . This is an ideal time to introduce solid foods. 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. Wren & Tarbell. and children tend to like and eat what is familiar (Birch & Fisher. 1998). Breast-fed babies experience a variety of tastes as a result of variations in their mothers’ diets. Moreover.3. and an aversion to sour and bitter (Birch & Fisher. novel foods become familiar over time.

. A high degree of parental control is associated with eating problems (over. whereas it is the child’s responsibility to decide what and how much to eat. 5. 4. 1990). Remove food at the end of the meal. It is also important for parents to provide children with healthy meals and snacks on a consistent schedule. Use utensils when appropriate. 3. Thus it is important for parents not to revert to pureed food if a child gags on solid food as it is being introduced. as children begin to develop stronger food preferences and their appetites decrease. and by engaging in a variety of enjoyable physical activities to stimulate the appetite. when presented with a variety of healthy foods and left to their own devices. and preoccupation with food later in life (Birch. Use time out for breaking rules or engaging in other disruptive behaviors. they should continue presenting the child with various types of solid foods. 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. Allow between-meal snacks only if children have eaten a reasonable amount at mealtime. stress-free setting for family meals. increases the chances that a child will try these foods and eventually even learn to like them (Budd & Chugh. 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. Reward appropriate eating behavior with praise and attention. 7. Chew and swallow food with mouth closed. That is. parents do not need to worry excessively about whether or not their children are getting proper nutrition. allowing them plenty of opportunities to exercise their developing skills despite the inevitable mess. MANAGING COMMON PROBLEMS oral–motor skills.. children tend to eat what they need.or undereating).” Parents should remain flexible while feeding their children during these early years. weight fluctuations. Birch & Fisher. Research has shown that during the preschool years. especially “finger foods. parental control in the feeding context (e. can be good models for their children by eating a variety of healthy foods in reasonable quantities. by demonstrating appropriate eating behavior. however. for example. Christophersen and Hall (1978) suggest the following mealtime rules for parents and children: 1. 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. Bibliotherapy can be used to help parents in the prevention of eating problems. 1998). In order to ensure that a child’s internal regulatory system continues to operate efficiently. rather. Moreover. Rejection of various types of food is expected after the first year. urging children to clean their plates. Guidance in simple behavioral principles can help. Two of our favorite books are Coping with a Picky Eater: A Guide for the Perplexed Parent (Wilkoff. Include children in mealtime conversation. which will reduce their desire for low-nutrition foods. 2. Parents. In contrast. parents can limit the amount of television to which their children are exposed. and to arrange a pleasant. Remain seated until the meal is over.84 II. Repeated exposure to rejected foods. offering rewards for finishing everything) can override this regulatory system. Based on the early “cafeteria” studies. 8. 6. In contrast. 1998). 1990. Parents also must know how to teach appropriate feeding and mealtime behaviors. Moreover. Satter (1996) states that it is the parents’ responsibility to provide a healthy array of food and a supportive eating context.g.

among children versus adults. Medical problems must be ruled out before a diagnosis of colic is made. It does not appear to be caused by poor nutrition.. 1987).g.3. increased social and environmental stimulation. at about 6–9 months of age. The cause of colic is not known. Pica is considered a problem if it persists past the age of 18 months. It is characterized by inconsolable crying that may last 3 hours or more after feeding. children with pica are often brought to their pediatricians with bowel or intestinal obstructions or perforation (APA. 1994). rather than just tasting or chewing (Lyman & Hembree-Kigin.g. putting the baby on top of the clothes dryer when it is running). 1994. Indeed. Intervention for children with pica typically involves parental education regarding the hazards of eating nonfood substances. but it is associated with an impoverished environment and lack of stimulation. 1994). 1994. closer supervision. riding in the car. various medications (including alcohol) have been tried. Wren & Tarbell. as well as overcor- . 1999). 96). The etiology of pica is not well understood. but none have been found to work consistently. The latter involves differential reinforcement (e. Moreover. Prevalence of colic is estimated at between 10% and 20% of infants (Hewson. Eating Problems 85 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. Colic typically lasts about 13–16 weeks and then resolves on its own with no apparent long-term negative effects. Pica DSM-IV defines the essential feature of pica as “persistent eating of nonnutritive substances for a period of at least 1 month” (APA. Pica is more common in developing versus developed countries. 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. among the poor versus the affluent. and behavior therapy for persistent cases. EATING PROBLEMS RELATED TO INFANT FEEDING Colic Colic is the most common problem related to feeding in early infancy. and among those with severe versus mild mental retardation (Wren & Tarbell. 1998). and leg extension (Lyman & Hembree-Kigin. as well as with mental retardation. Pica is differentiated from mouthing in that it involves actual eating of nonfood substances. & Menahem.. Mouthing of nonfood substances is developmentally appropriate in infants and is motivated by their natural curiosity about the environment (Budd & Chugh. There is no one effective treatment for colic. and is seen frequently in some subcultures of the United States and other countries (Lyman & Himbree-Kigin. 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. and is accompanied by pain grimaces. abdominal distension. 1998). 1994). Oberklaid. although Hewson et al.g. 1986). food treats) for incompatible behaviors (e. playing with toys). p. although it has been suggested that at least some cases result from an allergic reaction to milk (Budd & Chugh. (1987) reported that some mothers indicated more feeding difficulties with their children even after colic had resolved. Ancedotal reports from parents indicate some success with noise and/or movement (e.. 1998). mouthing is a primary way of exploring the world. 1998).

1981). & Christophersen. as well as parent–child interaction. Current work.g. or mild electric shock for severe cases (e. It becomes a disorder only if it persists for 1 month or longer. as rumination can result in significant malnutrition. 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. 2001). Rumination occurs occasionally in almost all infants. but it is considered rare. 1998). usually at about the age of 6 months. despite ingesting adequate amounts of food (APA. Linscheid and Rasnake (2001) note. and parent training in the systematic use of social reinforcement for behaviors incompatible with rumination (Lavigne. and gender (Drotar. Worley. 2001). that it is important to consider cause and effect in observing parent–child interaction. 1986. In addition. two standard deviations below the mean for age or less than the 5th percentile. brushing the tongue and teeth with mouthwash contingent on eating nonfood substances) (Lyman & Himbree-Kigin.g. however.86 II. have anxious or depressed caregivers. 1998). 1993). Glasscock. & Cotter. in whom .. 1994). 1994). Infants who ruminate are reported to be generally irritable and hungry. O’Brien. in whom growth failure is due to deficiencies in the mother–child relationship. & Arthur. 1977.. Burns. 1995). Toister. and/ or come from very stressful environments (Budd & Chugh. although the ethics of this approach have been questioned (Wren & Tarbell. Linscheid and Rasnake (2001) describe two groups of children with NOFTT: (1) infants less than 8 months of age. Some clinicians have reported success using an aversive stimulus contingent on ruminating. and even death. 1994). however. The prevalence of rumination disorder in the general population is not known. dehydration. as the mother’s behavior can be considerably altered as a result of dealing with ongoing rumination. 1975). it is more common among children and adults with mental retardation (6–10% of the institutionalized population) (Wren & Tarbell. rumination is reported to occur more frequently in infants who lack sufficient stimulation. mortality rates are reported as high as 25% (APA. Treatment typically involves changes in the environment to ensure that the infant receives appropriate stimulation and attention. Linscheid & Cunningham. Colin. 1998). indicates that some infants who experience very postive relations with their caregivers and receive adequate stimulation are known to ruminate. parental growth patterns. such as a squirt of lemon juice or pepper sauce. boys with the disorder are estimated to outnumber girls 3:l (Johnston. when corrected for gestational age. 1994). Failure to Thrive FTT is diagnosed when a child’s weight falls significantly below normal—that is. Rumination Rumination involves intentional and repeated regurgitation and rechewing of food that is not associated with a medical problem (APA. suggesting that rumination is a form of oral self-stimulation that can rapidly become habitual through inherent reinforcement and parental attention (Linscheid & Rasnake. Moreover. Thus it appears that rumination is not a homogeneous disorder (Wren & Tarbell. Moreover. Friman. and (2) children over 1 year of age. and typically disappears spontaneously. MANAGING COMMON PROBLEMS rection (e. 1998). The term “nonorganic failure to thrive” (NOFTT) describes these characteristics in the absence of any known medical condition (Linscheid & Rasnake. Assessment of rumination disorder requires observation of rumination episodes to determine the setting conditions and consequences for the behavior. they appear to gain pleasure from the activity.

Moreover. Many factors have been implicated in the etiology of FTT. later academic and behavioral problems in school are documented in many TABLE 3.2. weaning. That is.3. and these are summarized in Table 3. Drotar (1995) suggests that instead of differentiating organically based FTT from NOFTT. in cases in which a child has no clear medical condition and the parent–infant interaction is problematic. and personal beliefs about feeding. Onset is typically in infancy. Drotar (1995) notes that it is not always easy to differentiate the cause of the disorder from the effects of malnutrition. Factors Implicated in the Etiology of FTT Area of risk Characteristics of the caregiver (usually mother) Risk factors • • • • • • • • • • • • • • 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 Characteristics of the infant 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 Characteristics of the environment • Low financial resources. the direction of causality is not always clear. reflecting the interplay of environmental and physical problems of varying severity. Thus “FTT” is used in this section to refer to either type. 1995. a parent’s dysfunctional behavior may result from having a child who will not eat sufficient food to maintain adequate growth and development. although older preschoolers are occasionally seen with these characteristics.5% to 35% of children (Drotar. psychological and developmental deficits. 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.2. 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 Note. 1999). Linscheid & Bennett-Murphy. Estimates of the prevalence of FTT suggest that it is not an uncommon disorder. ethnic. it is more appropriate to view FTT as occurring on a continuum. and social and environmental problems. which may limit food available • Cultural. . Eating Problems 87 growth failure is due to behavioral mismanagement and problems with achieving independent feeding skills. rates range from 3. Children with FTT present with a wide variety of medical conditions. The data are from Drotar (1995) and Lyman and Hembree-Kigin (1994). Moreover.

such as overeating. for an in-depth description of the roles of medical. Thus a diagnosis of PSS will almost always entail social services intervention (Wren & Tarbell. It is not possible. stealing or hoarding food. to distinguish the contribution of living in a poor environment from the contribution of early malnutrition to the persistence of these problems. It is interesting that up to 40% of these youngsters gain weight during hospitalization (Lyman & Hembree-Kigin. is a more severe and relatively rare variant of FTT. 1994). and most children relapse when returned home even after extended (up to 1-year) placement out of the home (Lyman & Hembree-Kigin. also known as psychosocial dwarfism. however. Assessment and treatment of FTT necessarily involve a multidisciplinary team of professionals (see Wren & Tarbell. . 1994). Chamberlin. intervention is typically multidimensional in focus. 1998). and treatment must focus on meeting these needs. Evaluation of treatment approaches to PSS is based entirely on case reports. focusing on gathering information about the various risk factors shown in Table 3. nutritional. drinking out of toilets. Typically. Rarely is it possible to allow a child to remain at home during treatment. 1989). environmental interventions to reduce parental stress. and roaming at night in search of food. eating garbage or feces. 1998). and providing the child with the opportunity to form appropriate attachment relationships (Wren & Tarbell. The etiology of PSS is thought to be a severely disturbed parent–child relationship. It typically begins between 2 and 4 years of age. and sleep and attentional problems (Lyman & Hembree-Kigin. Observation of parent–infant interaction at feeding times is crucial to determine specific contingencies or feeding practices that may be contributing to the problem. They also typically have mild mental retardation. and (3) documented endocrine disturbance that is environmentally induced (Wren & Tarbell. toileting problems. Medical professionals must first rule out any contributing physical problems. 1998. and other professionals). 1994). 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 assistance in accessing resources. and home visits after the babies are discharged from the hospital may be required (Drotar & Sturm. often involving physical. these families require a great deal of support. Treatment can involve changes in the parent–child interaction. 1986). MANAGING COMMON PROBLEMS of these children. & Tatelbaum. 1998). Psychosocial Short Stature Psychosocial short stature (PSS).88 II. vomiting. parent education about nutrition and infant development. psychological. emotional. placing him or her in a setting that promotes healthy growth and development. 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. 1998). 1988. modeling of appropriate child care and nurturing. and/or sexual abuse. The needs of each family must be prioritized.2 (Wren & Tarbell. Treatment typically focuses on removing the child from the “toxic” environment. disruptive behaviors. Children with FTT are often seen in an inpatient setting because of their compromised health status. Diagnosis is dependent on demonstrating the reversibility of the symptoms when the child is removed from the home environment. Sturm & Drotar. so there is no empirically validated approach. The psychologist must take a multidimensional approach to assessing these complex cases. Although there have been few controlled studies of treatment efficacy for FTT (Drotar. Children with PSS engage in very bizarre behaviors. 1995). Henderson.

The recent increase in childhood obesity is not due to increased caloric intake (Troiano & Flegal. and existing behavioral problems typically improve with weight loss (Myers et al. Television viewing contributes to obesity in a number of ways. never fell below 5% of the 17-year-olds. Gortmaker et al. Significant psychopathology is usually not associated with childhood obesity. 1994).114 children ages 9–14. 1960). 1998. Eating Problems 89 OBESITY Overeating to the point of obesity is an increasing problem among children in the United States. have lower incomes. & Epstein. however. Flegal. and when social support is lacking (Gerald. & Trimm. & Johnson. ethnic group. Thus it seems clear that overweight children are not likely to outgrow their excess weight. Kuczmanski. Abraham & Nordsieck. 1995). Hoff. 1998). for example. examined body mass index (BMI. a child has a 40–50% chance of becoming obese. whereas in 1995 the rate was about 22% (Troiano. rather. 1998). In surveys of national samples from 1963 to 1994. There is a belief that childhood obesity is in part genetically determined. are less likely to marry. They found that more boys than girls were overweight (26% vs. The proportion of girls who reported trying to lose weight and the incidence of binge eating among girls both increased with age. Field et al. (1996). as well as time spent with computers and computer games. & Pratt. 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.S. McBride.772 U. 1995. The incidence of childhood obesity also varies by age. Rosner. Obese adults complete fewer years of school. The percentage of children considered obese decreased with age but. Moreover. Risk of obesity in children is increased when they come from lower-socioeconomic-status environments. 19%).6 times as likely to be overweight as those who watched 0–2 hours per day. 1998). found that children who watched 5 or more hours of TV a day were 4. when their mothers are not married. Moreover. 1998). Anderson. but that girls were more likely than boys to perceive themselves as being overweight. If one parent is obese. Dietz. and high-sugar snacks and cereals. defined as weight in kilograms/height in meters squared) for a sample of 66. 1998) and tend to have lower self-esteem and more behavior problems than normalweight children (Kolody & Sallis. 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 chances . Chamblee. children ages 5–17. for example. and are more likely to live in poverty than adults of average weight (Wisniewski & Marcus. with the exception of Asian youth. Concerns about pediatric obesity stem from its strong association with adult obesity and the resulting serious health and psychosocial risks. 1976. Myers. if both parents are obese. children’s requests for specific foods are directly related to the frequency with which they are exposed to advertisements for these foods on TV. Lyon. and gender. Loggie. and Daniels (1998). high-fat.. Use of laxatives and purging to control weight was greater for girls aged 13–14 years than for younger girls. Johnson. Obese children are stigmatized by peers as early as the preschool years (Cramer & Steinwert. (1999) surveyed 16. Troiano and Flegal (1998) found that the heaviest children tended to become heavier over time. Between 1976 and 1980 the prevalence of obesity in children was estimated to be about 17%. Priness. Campbell. This belief is based on the fact that the risk of obesity increases if one’s parents are also obese. contributes to childhood obesity. 1998). Birch and Fisher (1998) note that 80% of food advertisements on television are for low-nutrition. the cause is an increase in sedentary lifestyles. the psychological and social consequences of obesity are significant for both children and adults (Wisniewski & Marcus. Raynor. Current research indicates that increased television viewing.3.

1992). misinformation about proper diet. 1992). the Behavior Assessment System for Children (BASC. Most clinicians. 1995) helps identify any stresses in the marital relationship or parent problems (e. 1991a. Eyberg & Pincus 1999) screen for behavior problems that might interfere with treatment. Reynolds & Kamphaus. and maladaptive family eating practices are implicated in causing this imbalance (Lyman & Hembree-Kigin. Kohl and Hobbs (1998) argue that learned physical activity behavior patterns in children are in part responsible for obesity. obesity is caused by an imbalance between the intake of food and the output of energy. The Children’s Eating Behavior Inventory (CEBI. is on those factors important in assessing and treating obesity. Treatment of children under the age of 5 years requires ongoing monitoring by a physician and/or nutritionist to ensure adequate nutrition for growth. Fundamentally. 1994). Rosenbaum. as well as their view of the child’s problem and what they have been told and/or done thus far. a child who looks fat is fat). (1998). Lack of parental concern with or supervision of children’s eating habits. ASSESSMENT OF OBESITY Obesity is defined as body weight above the 85th percentile for children of the same age. They note that environmental and social factors (e.90 II.g. which has been shown to correlate highly with tricep skinfold thickness (Rauh & Schumsky. In addition. Step 2: Parent and Child Interviews The parents and child should be seen together at the first session. see Chapter 2). Archer. The Child Behavior Checklist (CBCL. BMI can be used to diagnose obesity. lack of safe places to play outdoors. 1992). Abidin. the following discussion is based in part on their work. 1991) assesses behavior specific to eating problems. our own General Parent Questionnaire. Wisniewski and Marcus (1998) provide excellent guidelines for assessment of childhood obesity. see Appendix B) with demographic information.g. 1992). of course. Parents should be asked to complete a parent questionnaire (e. rely on visual assessment (i. computers. and genetic factors are estimated to account for only about 30% of the variance in weight. MANAGING COMMON PROBLEMS of a child’s becoming obese is over 70% (Linscheid. This suggests that obesity is caused more by family eating and activity patterns than by genetics (Linscheid. The assessment process described here follows the steps for gathering information in accordance with the Comprehensive Assessment-to-Intervention System (CAIS. tables of normal BMI by age and gender are shown in Rosner et al. Achenbach.g. 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. however. It is reprinted in Appendix B. & Steiner... The emphasis. however. and/or the Eyberg Child Behavior Inventory (ECBI..e. height. and gender. depression) that might make treatment more difficult or lead to premature termination of treatment. 1969). and other competing activities) have contributed to increased sedentary lifestyles among children. This allows the clinician to observe parent–child interaction. A similar association has been found for adopted children. and the attractiveness of television. The Parenting Stress Index (PSI.. and to assess both the child’s and the parents’ willingness to . reduced enrollment in physical education.

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. their attitudes. 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. and acceptance of the treatment approach must be carefully assessed before treatment begins. Because parents play such a critical role in the success or failure of a treatment program for childhood obesity. Sample food and activity records are shown in Figures 3. rather than at some other time. especially if the child is severely overweight.3. Often these attempts are made for brief periods of time and in an unsystematic fashion. but the clinician should be aware that overweight children and adults are known to be inaccurate in estimating their intake. nag- .g. beliefs. The following areas should be covered: 1. (Parents’ own eating problems may not be completely dealt with in a child-focused treatment approach. provides information about their attitudes toward the problem and potential compliance with treatment. (b) “What are the good things about being thinner?”. and what types of activities children engage in. The focus of this observation should be on behaviors that may interfere with treatment (e. Food and activity recording sheets should be given to the family and discussed at this session. as these can inform the clinician about the potential for more serious eating disorders (Wisniewski & Marcus. 5. Daily self-monitoring of food intake and activity is necessary for a baseline period of about 2 weeks. how food is prepared.) Successful treatment of childhood obesity necessitates changes in the parents’ eating and exercise habits. Finding out why parents are seeking help now. (e) “Can you see any problems with being thinner?”. (d) “What do you imagine might change if you lost weight?”. they also function as role models for eating and activity behavior. (c) “What difference would losing weight make for you?”. 3.2. as well as why these strategies might not have been successful. Eating Problems 91 participate in the treatment program. family conflict. 1998). the success of treatment is significantly diminished if the parents are not active participants along with the child. his or her eating habits and attitudes toward food should be assessed. Visiting the home during mealtime or videotaping several mealtimes can provide useful information.1 and 3. Furthermore. the clinician should follow up on the information obtained through the screening questionnaires and explore any behavioral or developmental problems reported. Consequently. In addition. and an appropriate referral may be necessary. 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?”. 4. 2.. The clinician should make sure that parents and child understand how to complete these records. It is important to give parents information about the usefulness of previously used weight loss strategies. and (f) “What might be the good things about being overweight?” 6. Moreover. Parents should be questioned in detail about their attempts to control their own and/ or the child’s weight. During the initial interview. The child’s feelings about his or her weight should also be assessed. his or her attitudes and beliefs about eating should be explored. respectively. They should be informed that regular completion of records is highly associated with successful weight loss and maintenance of the loss. If a parent is also significantly overweight. parents control what types of food are purchased.

Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details). juice Kitchen/Watching TV 92 Amount Where Eaten/Behavior 11:30 A. From Assessment and Treatment of Childhood Problems (2nd ed. A chart for recording daily food intake and behavior. 8oz. milk 3 slices. MANAGING COMMON PROBLEMS 92 FIGURE 3. milk School/With friends II.M. Schroeder and Betty N. orange juice 4 pancakes. Gordon. .M. Pizza.Food Diary Date Time Type of Food Sample Mon. Pancakes with syrup. 4/24/00 7:30 A.) by Carolyn S.1. Copyright 2002 by The Guilford Press. 8oz.

. Eating Problems 93 Daily Activity Record Date Time Activity Sample Mon.M. From Assessment and Treatment of Childhood Problems (2nd ed. Kickball Walked the dog around the block 20 minutes 15 minutes Picked last for team OK Amount Enjoyment FIGURE 3. 4:00 P.M. A chart for recording daily activity. 4/24/00 10:30 A. Schroeder and Betty N. Copyright 2002 by The Guilford Press.3. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).2. Gordon.) by Carolyn S.

there are treatments for childhood obesity that have been empirically demonstrated to be effective—not only in promoting weight loss. however. in order to rule out any problems that would contraindicate a moderate decrease in calories and increase in activity. and lifestyle changes). and contingency management. and (3) parent participation. Paluch. The nature and possible etiology of the obesity should be shared with the parents and child. Few successful treatment programs were found for children who were more than 100% overweight. This process often involves explanations of the value of previously attempted methods and the reasons why they did not work. (2) diet combined with increased lifestyle and/or aerobic activity. MANAGING COMMON PROBLEMS ging or teasing about the child’s eating) and on those that might indicate inaccuracy of food records (e. Gordy.. parents can be told the factors that have been shown to be associated with successful treatment (i.. TREATMENT OF OBESITY In contrast to treatments for many other childhood disturbances. 2000). to determine which of these components were critical to successful weight loss. and they should be given a rationale for the treatment recommendations. It was not possible.94 II. Parents may find that a consultation with a nutritionist is helpful as they progress in treatment. 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. Parents should be referred to an appropriate professional or agency if their own obesity is a significant problem. specific training in problem-solving skills was not found to add significantly to a family-based treatment program (Epstein. stimulus control strategies. such as self-monitoring. because the parents’ and child’s trust in the clinician and cooperation in the treatment process will depend on their understanding of the problem. family involvement. in a recent study. 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. Step 5: Referral to Allied Health Professionals A medical evaluation should be done before the initial interview with the family. Most of these programs involved some combination of behavior modification components. overly large portions. 1998). Furthermore. Step 4: Further Assessment Further psychological assessment is only necessary if other problems become evident during the assessment process. Step 6: Communication of Findings and Treatment Recommendations Following the assessment session. overuse of butter or salad dressing). careful self-monitoring. Jelalian and Saelens (1999) have reviewed studies of treatment programs targeting childhood obesity. but in helping children maintaining the loss over many years. This is particularly important. . Moreover. & Ernst. Saelens. 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. or who had comorbid psychopathology.e.g.

watching television or playing computer games—rather than on increasing exercise as the target for intervention (Epstein et al. A decrease of about 500 calories per day from a baseline of 1. & Valoski. 1995). Exercise for weight loss should be primarily aerobic.. 1990. As each goal is reached. to discuss and problem-solve difficulties. Myers. and iron. & Saelens. 1995). if a child is watching television. children have specific needs for protein. however. and treatment can be conducted either in groups or individually. Wing. as opposed to weight lifting or calisthenics. and increase his or her daily exercise by 200 calories a day. 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.. building or toning muscle) and can be used in combination with aerobic activities.e. the child should never consume fewer than 1. Parents and child can be seen separately as needed. Epstein. in part because attitudes toward exercise change as weight increases. walking or riding a bike to school. while leaving them with the . 1998). Lifestyle types of aerobic activities (e. 1998. it is recommended that fat intake should be at about 30% of calories. television viewing contributes to obesity in many ways: It promotes poor eating habits through commercials advocating unhealthy snack foods. he or she is not doing something more active. although the latter types have their own benefits (i. A reasonable goal is at least 20 minutes of aerobic exercise three to five times a week. Epstein. Research has shown that reinforcing children for reducing targeted sedentary behavior. It is difficult to motivate obese children to become more active. and to assign homework and set goals for the following week. Setting overall weight loss goals for children as they continue to grow is difficult. For some children. This enables the child to experience some success without feeling too overwhelmed with the overall task.500 calories. Targets for weight loss can be set in 5-pound increments. should be sufficient for a loss of 1 pound per week.g. which are sometimes prescribed for adults.3. Thus current work focuses on reducing sedentary activity— specifically.. using stairs instead of an elevator. Furthermore. Eating Problems 95 The treatment program described here is based on those reported by Epstein and his colleagues (e. The importance of increased exercise for weight loss cannot be overemphasized. 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. for example. as they will slim down as their height increases. in order to lose 1 pound a week. 1988) and Wisniewski and Marcus (1998). children also tend to eat while watching TV. the child must reduce the number of calories consumed by 300 a day. In order to ensure adequate calories for growth and development.800 calories. any combination of lower intake versus greater output will suffice. so the balance of intake and output must be adjusted accordingly. A pound equals about 3. 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. The child’s (and one or both parents’) weight should be measured and recorded at the start of each session. Raynor.. finally. simply maintaining their current weight will be sufficient.000 calories per day (Wisniewski & Marcus. to go over homework and goals for the previous week. McCurley. are not appropriate for children. a new 5-pound goal can be instituted. and children come to prefer more sedentary activities (Kolody & Sallis. so consultation with a nutritionist or dietitian may be needed. Very-low-fat diets. The parents and child are usually seen together to review the week’s progress. As an example.g. As noted earlier. Epstein & Squires. calcium.

1988) teaches children how to select appropriate foods.or herself every day and record the weight.” . contributes to a decreased preference for the specified sedentary activity (Epstein et al. how it was prepared (e. Dickson. exercise. Similarly. 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. parents. type of exercise. and when and where it is eaten. 1980).. environment. Furthermore. 1998). including the date. Wing.. The Clicker can be obtained for about $30 from Optimal Health Products. The child also must be taught to record (see Figure 3. and medical/health aspects.96 II. Other stimulus control techniques include (1) eating more slowly (e. fried or broiled). to ensure that the child understands it. Intervention with the Child The first step in treating childhood obesity is providing the child with accurate information about diet.g. a record should be kept (see Figure 3. Self-Monitoring Self-monitoring is a critical component of the weight loss program. Linscheid & Rasnake. chewing each bite a certain number of times). putting utensils down between each bite. The information outlined above can be given to the child in modified form. Providing this basic information to parents and children is usually not enough to promote weight loss (Epstein.” The Clicker records the number of steps taken. and whether or not the child enjoyed the activity. (2) eating only in one room (e. Another method of stimulus control (Epstein & Squires. 1998.2) of all exercise engaged in. the child should be engaged in setting weekly goals for calorie reduction and changes in activities.1) everything he or she eats. Specific intervention strategies are discussed in the context of the CAIS (see Chapter 2). 888-339-2067. and those that are high in calories and low in nutritional value are red or “stop. Steranchak.. and (4) serving individual portions versus family style. MANAGING COMMON PROBLEMS choice of what to do instead. the approximate amount and calories. (3) using smaller plates so that servings appear larger. 2001). In contrast.. A goal of 10. and weight loss.g. consequences of behavior. with emphasis on five areas: the child. Foods that are low in calories and high in nutritional value are categorized as green or “go”. not eating in front of the television). duration. 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. & Michelson. The child should weigh him.g. and place.000 steps or clicks per day is reasonable. time. children whose targeted sedentary activities are restricted by parents come to desire those activities more over time. and calories expended. Daily data on activity level. calories consumed. those that should be eaten in moderation are yellow or “caution”. Stimulus Control Examination of the child’s baseline data will help the clinician to identify situations that promote poor eating habits. We have found that a simple activity monitor called a Clicker is very effective in tracking daily activity and motivating children to “keep moving. miles traveled.. and weight can be graphed during the child’s weekly sessions with the clinician and will provide a visual demonstration of progress. 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.

I’m not hungry right now. all highcalorie snacks will be eliminated. thank you. or special family get-togethers. go outside. with low-calorie snacks substituted for the other one or two. the child can be helped to think of something else he or she could do (e. Eating Problems 97 Cognitive Restructuring Cognitive restructuring is a form of self-control that helps a child substitute helpful thoughts for less productive thoughts. Consequently.).. thanks. then every three days. Shaping Shaping involves taking gradual steps to meet a larger goal.” Cognitive restructuring requires the child to be aware of and record or verbalize his or her thoughts.” Relapse Prevention Children need to be taught that everyone experiences lapses in their efforts to lose weight. “No. A strategy for dealing with lapses might include cog- . the goal can be to reduce this to one a day. “I know I can lose 1 pound this week. Such a child may be engaged in thinking of alternative activities that would promote weight loss. play an active game with a brother or sister. it may be more useful with older children. a child who may be thinking. When calorie goals for the week are set. Similarly. the child can then eat otherwise forbidden foods without feeling guilty or getting discouraged. For instance. and so forth. Eventually. If the child’s baseline data indicate that he or she is eating two or three high-calorie snacks each day. Planning Ahead Learning to plan ahead is an important skill for children who want to lose weight. By reducing the amount of calories consumed in the days prior to the event.3. if television viewing or playing computer games is a predominant activity.” can be instructed to say instead. activities other than eating can be substituted at these times.g. The idea of setting smaller daily or weekly goals is an example of shaping. 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. children who are obese have often restricted their activities to sedentary ones. ride a bike. Developing Alternative Behaviors As noted above. I am trying not to eat so much. As an example. etc. The key is how these lapses are handled. so that he or she can participate without feeling left out or deprived. the child can be taught to anticipate such events as birthday parties. The next goal can be to eat one high-calorie snack every other day. Christmas. 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. when the times the child is most likely to snack are identified from the baseline data.” or “No. “I’ll never lose all this weight.

thus several sessions focused on basic principles of behavior modification may be needed. a baseball and glove.. for an older child) for something the child wants. it is important to engage the whole family in helping the target child with the program. etc. Moreover. as the child is. and weight. Moreover. Rather. The weight loss program can be described as a learning task for the child and parents. I am not a failure”) and a restart plan in which the child goes back to careful monitoring of calories.) or toys (e.98 II. that these are likely to be ongoing problems.). and gravy. Obviously reinforcers should not include food or increased television or computer time. “Everyone makes mistakes.. who may be asked to give up favorite desserts. For instance.g. the clinician can help the parents problem-solve difficult situations. Parents can be reassured that it never hurts anyone to change to a more healthful diet and that their other children will benefit. Reinforcers can be given by the child to the parents. Because parents (and other family members) also may need to change their eating behavior. Intervention in the Environment The clinician should help parents alter the home environment so that it facilitates the child’s weight loss.g. Basic knowledge will help the parents generalize behavioral techniques to the various situations they come across. . the clinician can help the family decide on things like special activities (e. Engaging the family in problem solving is an effective way to resolve these issues. One difficult task that many parents have is meeting the various needs of their children. just as they provide reinforcers for the child.g. Both parents must be in agreement with this idea. the family members can be engaged in contracting with each other so that each member is reinforced. purchasing appropriate foods. however. Changing the Consequences of the Behavior Parents must be involved in determining appropriate reinforcers to ensure that the child’s eating behavior changes. it will be difficult for the mother to prepare healthful low-calorie food for the child. taking dance lessons. a basketball goalpost. Intervention with the Parents Parents must be included in the discussions with the child of the information and strategies described above. Points can be assigned for daily recording. potatoes. playing a game with Mom or Dad. having a friend sleep over. especially when one child needs to lose weight and another does not. as such. roller skates. as they will be responsible for helping the child carry out his or her assignments at home. even if they do not need to lose weight. and providing regular and consistent mealtimes are all ways to accomplish this. and traded at the end of the day (or week. activity. the clinician cannot assume that parents will know how to implement the weight loss program at home. reinforcement for successful self-monitoring is often necessary to motivate children to do this routinely. Planning meals carefully. going bowling. The clinician should be aware. they will need to be revisited from time to time.. etc. If the father. insists on eating primarily meat. for example. MANAGING COMMON PROBLEMS nitive restructuring (e. and resets reasonable goals. at least while the target child is present. having healthy low-calorie snacks available. In these cases. This will involve sacrifices from other family members.

which she felt were due to her appearance. Ms. Step 2: Parent and Child Interviews Ms. as well as to complete 5-day food and activity records for Jamal. the PSI. Approximately 6 months ago. The Child Domain scores on the PSI were within the normal range. She was obviously self-confident. She said that Jamal had not shown a weight problem prior to the recent precipitious gain. children under the age of 5 must be followed by a physician to ensure adequate growth during a weight loss program. Early developmental history indicated an uncomplicated birth and no major health issues. despite all their efforts. who was clearly considerably overweight. Jamal. Jamal. Jones indicated that she herself had always been considerably overweight and had recently developed diabetes. and ate very fast. but that he had always eaten a considerable amount of food. Jones. She was worried that Jamal would experience similiar problems as he approached adolescence. she was having difficulty implementing the suggestions she had been given. Jones indicated that many of her concerns about Jamal stemmed from the fact that she had been overweight as a child. a secretary at a local university. who was doing average work in school. the ECBI. On the Parent Domain. Jones presented as a large but not obese woman. On the ECBI. At times he ate so much so quickly that he vomited. but she said that Jamal had decreased his participation in physical activities that he had previ- . Ms. called at the request of her pediatrician about her 9-year-old son. the mother had elevated scores on the Depression scale and noted physical health problems. and the CBCL. had the opposite problem—eating enough to maintain her weight. Jones was asked to complete and mail to the clinic the General Parent Questionnaire. Eating Problems 99 Intervention in Medical/Health Aspects As noted earlier. with the mother perceiving Jamal as a reinforcing child. In addition. CASE EXAMPLE: OBESITY Step 1: Initial Contact Ms. Ms. parents should have a consultation with a dietitian or nutritionist to obtain information about the specific dietary needs of children. and as a teenager had had difficulties with social relationships. he had gained 12 pounds over a 2-month period. whose members provided considerable support. Ms. which included eating and some toileting problems. who had mild cerebral palsy. The General Parent Questionnaire indicated a lower-middle-class family with a large extended family in the area. Jones wondered whether the problem was hereditary or just a result of poor eating habits. Jamal’s father was not involved with the family. who had experienced a significant weight gain in the past 6 months. Jamal’s recent weight gain was of concern because of Ms. Jones and Jamal came together for this interview. readily participated in the interview as he made interesting things with Legos. but very worried about her son.3. The only elevated score on the CBCL was in the area of Somatic Complaints. She stated that her 11-year-old daughter. Jones’s history of obesity. Ms. If necessary. Ms. Jamal was described by his mother as an active boy with many interests. Although the mother had taken him to a nutritionist. the mother scored Jamal well within normal limits on both frequency and intensity of disruptive behaviors. he was continuing to gain 2–3 pounds a month. Jones could not point to any major event or specific stress in the family that might have caused Jamal’s weight gain.

Other children were also beginning to make comments about his weight. Ms.100 II. She was asked to complete the Teacher’s Report Form of the CBCL and the Social Skills Rating Scale. who served delicious but high-calorie meals in large quantities. She was pleased that Ms. MANAGING COMMON PROBLEMS ously enjoyed. He described family relationships as mostly positive. in addition to the family issues. Although he could list a great many activities that he enjoyed. he indicated that he had a number of friends at school.” Step 3: Observation of Behavior The food and exercise records indicated that Jamal was eating a good variety of food (mostly healthy). She was referred to a psychiatrist for evaluation. In addition. Instead. with open communication. Exercise was limited to walking to the school bus each morning and an occasional game of basketball with his cousins. Part of the problem with trying to control Jamal’s weight was their frequent visits with the maternal grandmother. and that his sister had also begun calling him such names as “Fatty” and “Porky” and teasing him at mealtimes about his eating habits. She said that she was not sleeping well and had begun eating increasing amounts of food. She could give no medical explanation for his sudden weight gain. that his weight clearly bothered him. This. and the clinician agreed to provide regular feedback on Jamal’s progress. most social activities for the family revolved around food. and she reported that Jamal was healthy. She reported on the Social Skills Rating Scale that he had many excellent social skills. made meal planning and preparation overwhelming for Ms. . He was very interested in losing weight. but saw the only solution as “just stopping eating. Step 4: Further Assessment Given Jamal’s social problems in school. coupled with the need for her daughter to have a high-calorie diet and to gain weight. When the clinician followed up on the indications of depression on the PSI. his teacher was contacted by phone. She said that he was increasingly becoming the focus of teasing and jokes from his peers. and appeared to cause him to decrease his social interactions. he had developed an interest in playing computer games and building car models. but was clearly distressed about his sister’s teasing. The parent–child interaction was pleasant and supportive. Jones was seeking help with this problem. and encouraged everyone to eat. with ratings well within the expected range for children his age. but was consuming two to three times the expected amount for a child his size. this resulted in a prescription for an antidepressant. Jamal’s teacher said he was a pleasant child who presented no problems in the classroom. Jones said that she had been experiencing increasing stress at work over the past 2 years and was having difficulty coping with those stresses. Jones was receiving regular medical care for her diabetes. but not as many as he had had the previous year. Step 5: Referral to Allied Health Professionals Ms. In the interview with Jamal alone. His teacher felt. Jamal’s primary care physician was contacted. however. which he usually did while watching television. he said he often felt “too tired” to engage in them. Jones. Her previous consultation with the nutritionist provided a great deal of information that was used in planning a treatment program for Jamal. made him hesitant to engage in physical activities.

and Jamal in particular. which ultimately resulted in more appropriate weight for height. reporting that she was less distressed and sleeping better. his peers. Over the course of about 6 months. decided to terminate . and even by Jamal himself were also described as making it more difficult to get this problem under control.” “yellow” or “caution. Jamal and his mother were praised for their interest in participating in a healthy eating and exercise program. and weight loss was shared with the family. Rules for healthy eating habits were reviewed. thank you!” Ms. Jamal stated that he thought he could keep his own records. The negative focus on weight by his sister. The basic information outlined earlier in this chapter regarding diet. Eating Problems 101 Step 6: Communication of Findings and Treatment Recommendations Jamal’s sister was invited to participate in the feedback session with Ms. in agreement with the clinician. A self-monitoring system was developed. Ms. This gave Ms. At this point Ms. Course of Treatment On the basis of the food and activity records. Although there was no known medical cause for Jamal’s weight gain. were described as having many strengths. and weekly contact with the clinician to review food and exercise data. and learning to say “No. but that the whole family had to participate in the treatment program in order for him to be successful. primarily around eating. Jones the opportunity to reinforce his progress and to problem-solve any difficulties.” according to their relative caloric content. and to deal with any problems in following the plan. at any time. The family also was taught how to plan ahead for visits with the grandmother. and engaging in conversation with his mother and sister.” and red or “stop. Jones and Jamal. including the use of a Clicker. so that her food could be enjoyed but would not disrupt their long-range goals. Treatment recommendations included developing a family meal plan that took into account everyone’s needs. weekly goals for gradual calorie reduction and increases in activity level were agreed upon. Jones. to help Jamal develop more appropriate eating habits. they were faced with dealing with many potentially difficult health issues. Her weight also stabilized. One of these was for Jamal to eat a meal over a 20-minute period of time. Jones was encouraged to fix special drinks for her daughter. although these were not focused on specifically. to help her consume enough calories. Jones responded well to the antidepressant. Jamal slowly stabilized his weight and also began to grow taller.3. It was stressed that Jamal could not do this alone. such as smoothies or milk skakes. Foods were divided into categories of green or “go. exercise. He began to participate more in sports activities that he had previously enjoyed. however. but agreed to have his mother go over these with him every evening. and his lack of exercise were major contributing factors. it appeared that the quantity of food he was eating. His problems with constipation also decreased. eating smaller amounts. chewing food more times. including teasing or nagging. the pace at which he ate. 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. they were seen as no less important than Jamal’s and needed to be taken into consideration in planning treatment. A second rule was for all family members to avoid any negative comments about food. The family in general. this was to be accomplished by eating more slowly. and a list was prepared for the family to post on the refrigerator door. Suggestions included eating less the day before a visit. increasing Jamal’s physical exercise. Although the sister’s difficulties with weight were the opposite of Jamal’s.

The association between early food refusal problems and later eating disorders. complaining. noncompliance. children who have a history of early eating disturbance have more severe behavior problems than those whose eating difficulty had a later onset (Rydell. spitting out food. or a congenital cardiac condition). and (3) absence of developmentally appropriate early feeding experiences. bronchopulmonary dysplasia. and Shepherd (1993) documented a coercive cycle among families with food-refusing children. is not clear.e. gagging. 1998). which is reinforced by the children’s intermittent consumption of some foods. At the same time.g. “Food phobias. research has documented that children with food refusal problems have an assortment of externalizing and internalizing behavior problems. Moreover. oppositional behavior. 1995). These problems are typically seen in combination with other food-related habits. 1990). such as eating very slowly. playing with food) during mealtimes.g.g. Sanders et al. Dahl. and having a low level of interest in eating (Marchi & Cohen. and to call the clinician if needed. It is estimated that as many as 20–30% of children have significant food refusal problems (Bentovim. all of these problems are referred to in this section as “food refusal problems. Wren & Tarbell. & Sundelin. 1998). although some older children are reported to present with subclinical variations of full-blown eating disorders prior to adolescence (Garner & Barry. In support of the connection between childhood eating problems and later eating disorders. the parents of the children with food refusal were noted to be more negative in their feeding practices (i. compared with normally eating children. 1970. Medically compromised children or children with mental retardation may refuse all foods. fit within this category as well (Wren & Tarbell..” which are characterized by fear and/or anxiety symptoms in eating situations. 2000.. The family members were encouraged to continue to monitor their food intake and activity level. Marchi & Cohen. or escape behaviors when presented with all or most food. eating very small amounts of food. . crying. gastroesophageal reflux. (2) inadvertent positive or negative reinforcement by caregivers of food selectivity or refusal (e. All children reject certain foods at some time or another. unintentional vomiting while eating.. “Food selectivity” or “finicky eating” is characterized by these behaviors when a child is presented with specific foods.g..” Although there are probably multiple causes for these problems. Patel. choking. Wren and Tarbell (1998) list three major ones: (1) the association of feeding with an aversive experience (e. vomiting. MANAGING COMMON PROBLEMS treatment sessions. (1993) have described a typical sequence of parents’ coaxing and pressuring their children to eat. short-gut syndrome. and making more negative eating-related comments) than parents of typical children. 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. such as anorexia nervosa or bulimia nervosa. removing rejected food and substituting a preferred food). For the sake of simplicity. giving more aversive instructions and prompts to eat. LeGrice. Sanders. and/or engaging in temper tantrums.. FOOD REFUSAL PROBLEMS “General food refusal” is characterized by a child’s turning his or her head to avoid food. They found that the children engaged in high levels of negative behaviors (e.102 II. Maloney and Ruedisueli (1993) have reported that some adolescents and adults with eating disorders recall having food refusal problems as children. force-feeding for medical reasons). 1990). usually as a result of a medical condition (e.

as well as brief medical and developmental histories. 1999) determines the extent of problems in daily activities. the ECBI (Eyberg & Pincus. In addition. A father and mother are likely to manage feeding difficulties differently. Eating Problems 103 Most children with food refusal problems eat enough to ensure adequate growth. 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. We usually include the child in this interview. These children represent the bulk of those seen in an outpatient clinic. ASSESSMENT OF FOOD REFUSAL PROBLEMS Assessment of children who refuse most food or exhibit picky eating is complex. a comprehensive assessment is necessary to plan an appropriate treatment program. parental education and guidance in using behavioral principles may be all that is necessary. however. 1995) gives information on the child’s temperament. in order to observe the parent– . and the clinician will need to rely on parents for information and implementation of treatment recommendations.. The CEBI (Archer. 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. Step 2: Parent and Child Interviews Parent Interview It is important that both parents attend the initial interview. our General Parent Questionnaire. 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. the parents’ general levels of stress. parents should be asked to complete a Food Diary (see Figure 3. and/or emotional development is compromised. 1991) assesses specific eating behaviors (see Appendix B). For these children. and the quality of the marital/couple relationship. the CBCL (Achenbach. the emphasis here is on those factors particularly important in assessing and treating food refusal problems. 1991a. For most of these children. 1992) or the BASC (Reynolds & Kamphaus.1) for at least a week before the initial visit. Rosenbaum. do not receive adequate nutrition. 1992) screen for general behavioral or emotional problems. For a child over the age of 2 years. and the PSI (Abidin.3. Some of these children—specifically. and their problems typically resolve without treatment. social. and in some cases physical. as well as difficulties occurring around feeding. The assessment process described here again follows the steps for gathering information in accordance with the CAIS (see Chapter 2). and the clinician must be aware of their differing styles/ perceptions. Parents should be asked to complete a general questionnaire (e. see Appendix B) with demographic information. however. to gather specific information on the child’s eating patterns and the parents’ responses to them.g. growth and development continue on a normal course despite poor feeding habits and behavior. These two referrals are further discussed below (see “Step 5: Referral to Allied Health Professionals”). & Steiner. Some such children.

The Food Diary (Figure 3. How the parents have handled behavior problems in general provides helpful information on how to structure the feeding intervention. It should be remembered that poor nutrition can affect a child’s behavior. Behavior. may have influenced the development of poor eating habits. and (d) the nature of the problem (what foods does the child refuse. Given the distress that most parents experience related to feeding problems. and the parents’ level of stress related to the problem. seizures. Development. birth of a sibling)? Have there been changes in the family routines (e. Current feeding status. chronic ear infections. Some parents. a history of the food refusal problem. a session without the child should be scheduled for these parents. The focus of the parent interview should be on the child’s general development and behavior.104 II. 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. as well as its current status. 3. Has the child had an aversive experience with food? Have there been changes in the child’s daily routine (e. as this information may not be evident from the Food Diary. and arrangements to observe the child at another time should be made. for example. and the interview should follow up on any concerns. The screening instruments will give information in this area. especially noncompliance and oppositional behavior. at school. and/or sleep problems (Budd & Chugh. or whether treatment of the food refusal problem will aid in the resolution of the other problems. asthma. Many children referred for food refusal problems also have problems with general noncompliance or oppositional behavior.g.g. Other areas to assess include (a) the frequency of occurrence (has the problem increased or decreased over time?). however. toileting. though no longer active. What was the child’s birth history? Was the child premature.. 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. or both?). the environmental/ social context of the problem. 4. What illnesses has the child had (e. and the parents’ desire to get help with feeding. 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- . resulting in increased irritability. or does it depend on such factors as who feeds the child?). Daily routines. The clinician must determine whether these other behavior problems should be treated first. Medical history. starting preschool or a new school. Feeding history. it is usually best to focus initially on the food refusal problem unless the child is generally noncompliant. A careful history of the child’s feeding behavior should be obtained.. or were there perinatal problems? Were developmental milestones achieved normally? 2. are hesitant to discuss feeding issues with the child present. 1998). 6. and what does the child do when presented with various foods?). an illness or hospitalization.1) provides a good starting point for gathering information about a specific problem.g. chronic illness)? The child’s medical history can give clues as to past conditions that. (c) the place of occurrence (does the child have the problem at home. unusual absences of a parent)? 5. MANAGING COMMON PROBLEMS child interactions.. Specific areas to cover include the following: 1. Parents should be asked specifically about the child’s likes and dislikes. Family feeding history. (b) fluctuations in occurrence (is there a problem at every meal.

however. and family. Stein. Parental/social/environmental issues. and how they themselves view the problem). maternal depression. 8. Their attitudes and beliefs about eating should also be assessed. 1998. & Fairburn. The focus of this observation is on the behaviors that must be learned for selffeeding to occur. They suggest that the clinician present a variety of foods to the child and allow the child to eat whatever he or she likes. For example. what the children themselves have done to resolve the problem. school. parental behaviors that may reinforce inappropriate eating behavior. support networks. etc. The child’s response to each food is then recorded. vomiting. and that information obtained through food records may not be reliable. tantrums. leaving the table. and cultural or ethnic views about food and eating can shed light on what may be maintaining the problem. Information about the parents’ mental and physical health status. Eating Problems 105 lems than those whose mothers have no such history (Russell. The General Parent Questionnaire and the PSI should alert the clinician to potential contributing problems in these areas. marital/couple conflict. It can occur in the clinic or at the home. Observational assessment of the child’s food preferences is also important. and the child’s self-feeding skills.g. the latter method provides useful information about the setting conditions for food refusal problems. If the clinician cannot make a home visit. Parents’ response to the problem. it is not helpful to interview preschool children alone. School-age children with food refusal problems. The focus of observation should be on behaviors that interfere with eating (e. 1994). and/or the parents can be asked to videotape a feeding session at home. crying.. should be seen separately from their parents. the home environment. a separate interview with the child may be warranted. the family’s daily routine. & Eisler. . Treasure. 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. Step 3: Observation of Behavior Observation of parent–child interaction during feeding situations is the hallmark of assessment for food refusal problems. and for how long? What have they told the child? How is the problem affecting other family members? 9. Linscheid and Rasnake (2001) note that parents often do not really know what these are (although they think they do). its frequency. The focus should be on their general adjustment to friends. birth of a sibling. Cooper. and/or a hospitalization can exacerbate a feeding problem. 2001). If the problem involves the child’s ability to self-feed. Generally. observation of this process should be included. as well as their perception of the eating problem (including a description of the problem. Woolley. It is not possible to plan an appropriate intervention program without first completing this observation. as parents may present the child with only those foods they think he or she prefers.3.). the age of the child. and the presence of other problems. How do parents handle the problem? What advice have they been given? What have they tried. how their parents have viewed and handled the problem. The child will often eat foods that the parents report as disliked (Linscheid & Rasnake.

if the child is having trouble in school or has other emotional or behavioral problems. Consultation from a nutritionist should be obtained in all cases. or congenital abnormalities of the gastrointestinal system. or if the child is losing weight or not growing as expected. however. the clinician is primarily a consultant to the family members. Step 6: Communication of Findings and Treatment Recommendations The nature of the food refusal problem. that factors related to the parents can influence the course of treatment. that home-based treatment is likely to fail. vary according to the nature of the problem. growth. MANAGING COMMON PROBLEMS Step 4: Further Assessment Further assessment is indicated if the child or family presents with problems beyond those associated with the food refusal problem. inpatient treatment should be seriously considered. or the parents’ problems are so severe. low-fat or vegetarian diets. 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. In these cases. or (4) the intervention program .g. Linscheid and Rasnake (2001) recommend inpatient treatment if (1) the child’s medical/health status is poor. treatment for the food refusal problem is not likely to be effective. 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. For example. such as food allergies.. (3) the parent–child relationship is so impaired. independence. and potential treatment strategies should be shared with the parents. In these cases. TREATMENT OF FOOD REFUSAL PROBLEMS Treatment of children’s food refusal problems will. or if there is evidence of parental psychopathology. In the treatment of food refusal problems.. The first step in treatment for food refusal problems is to decide whether treatment should occur in an inpatient or outpatient setting. The clinician should also discuss the implications of the problem for the child’s development in other areas (e. the clinician’s view of the problem. It is best to support parents in getting help for themselves before addressing the child’s problem. it is important to evaluate these areas further. of course.106 II. these should be evaluated or referred for evaluation. excessive fears of obesity). mastery. and general health). In many cases. Step 5: Referral to Allied Health Professionals Medical conditions that can affect diet or reduce weight gain. This is particularly necessary if the parents lack knowledge about appropriate nutrition for children or have unusual attitudes or beliefs about food (e. It is important to note.g. who must carry out the actual intervention program. thyroid or endocrine problems. must be ruled out before treatment begins (Linscheid & Rasnake. (2) outpatient treatment has been attempted and has failed. Problems with the central nervous system that might result in oral–motor or fine motor delays must also be assessed. 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. ongoing monitoring with a physician is necessary. If there are marital/couple problems. 2001). If any of these are present.

including what the parents will do in response to the child’s expected behaviors. Murphy. a course of behavioral parent training may be necessary before the food refusal problem is treated. The clinician may also work directly with a child who exhibits symptoms of food phobia (fear and anxiety responses to food). 1995. 1993. In this case. & Wall.3. Turner. 2001). Outpatient treatment is appropriate when the child’s medical status is stable and the parents are supportive of the intervention plan. 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). not removing the spoon if the child refuses food. & Budd. Linscheid (1999) adds appetite manipulation to this list. Next. environment. development of fear hierarchies and systematic desensitization are likely to be components of the treatment (see Chapter 8 for a description of these methods). Eating Problems 107 will require medical monitoring. Tarnowski. These methods include positive reinforcement of appropriate feeding responses. The second step in treatment is to specify goals in clear behavioral and nutritional terms (Linscheid & Rasnake. & Brams. 1987. 1994. and medical/health interventions. in order to design an intervention program that is flexible enough to meet the specific needs of individual children and their families. Often this results from the baseline assessment of the child’s feeding behavior. Luiselli & Luiselli.g. Sanders. He also argues that the clinician must be well trained in behavioral principles. Werle. and teaching the child to swallow. 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. Intervention with the Parents If the assessment indicates that the child has significant noncompliance or oppositional behaviors outside the eating situation. Rasnake. Kerwin (1999) concluded that some specific behavioral strategies are most effective. Womble. ignoring or guiding inappropriate responses. Linscheid. Intervention in the Environment The clinician should help the parents alter the feeding routine so that it facilitates the child’s desire to eat. In a recent review of treatment programs for food refusal problems. with emphasis on five areas: child. Indeed. Someone should eat with the child and the atmosphere should be pleasant with- . behavioral strategies should be specified.. consequences of behavior. Finally. & Zucker. Specific behavioral techniques are discussed in the context of the CAIS (see Chapter 2). 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 feeding situation lends itself easily to direct intervention using behavioral techniques. and there are many reports of successful treatment using these strategies (e. parents. 1998). Williamson. a system for measuring progress must be determined. positive reinforcement for acceptance of food. This information should be shared with parents as the treatment program is explained.

The clinician can work with the parents to arrive at a reasonable compromise. It is likely.108 II. the parent should say nothing. which acts as a “double whammy” of both positive and negative reinforcement. 1998). Parents should be instructed to limit the child’s access to food between sessions. many parents habitually remove the refused food and substitute a preferred food. If the child refuses the food. and these are discussed below. Appetite Manipulation A very important component of any treatment program is to ensure that the child arrives hungry for the feeding sessions.. they should be presented at a consistent time and should be limited in quantity. and to stay seated for a snack or a meal for a set period of time. The reader is also referred to Linscheid and Rasnake (2001). food refusal). consumption of a previously refused food).e. Ignoring or extinction of inappropriate behavior is effective when used with positive reinforcement for alternative behaviors. . however. New foods should be introduced and presented on a regular basis (10 or more times) even if the child initially refuses them. If the child is to be given snacks. Moreover. but turn his or her head away from the child for a few seconds. The child’s medical condition and current weight are important considerations in determining the extent to which access to food is restricted (Linscheid & Rasnake. The child should be expected to eat at specified times every day.g. but many parents do not like this method because of the “extinction burst” (i. while at the same time ignoring or turning away from inappropriate responses (e. In other words. Various behavioral strategies have been used. 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. although some parents are not comfortable with this approach. 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. 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. when the parent removes the aversive food. In some instances. Preferably. that parents of children with food refusal problems will need to present nonpreferred food repeatedly over several feeding sessions before it will be accepted. MANAGING COMMON PROBLEMS out cajoling or nagging about eating. however.g. An average of 10 presentations is necessary for children without significant problems to accept previously refused food (Budd & Chugh. 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. 2001).. an increase in inappropriate behavior) that typically occurs when the parent begins to ignore the behavior. The parent should then re-present the food and follow the same procedure for a specified number of times. the probability that the child will refuse that food the next time it is presented is increased. Drinks such as milk or juice should usually be limited and presented only at the end of the meal. between-meal snacks should be eliminated and the child should be given only water. Removal of the refused food basically functions as negative reinforcement for the child. to eat in the dining room or the kitchen..

that for time out to be effective in this situation the child must be hungry. Maggie. however. and Mrs. The Percys were unhappy with this psychological consultation and were seeking a second opinion. Percy called about her 22-month-old daughter. Behavioral techniques as described above are used in these cases. Eating Problems 109 In addition to praise. In the feeding situation. ECBI. (2) providing pleasurable events. Percy was a computer programmer. and PSI). These include (1) presenting preferred foods contingent on eating nonpreferred foods. time out should be used as a consequence for temper tantrums or other disruptive behaviors that interfere with eating. they completed the General Parent Questionnaire and a 2-week Food Diary. Time Out A detailed description of the use of time out is included in Chapter 10. or grandparents. She said that although Maggie ate better with her babysitter than with either the mother. the assessment data may indicate that changes in the child’s nutritional intake may be necessary. but the treatment design and implementation will be different than for children without medical needs. Percy indicated that she was 5 months pregnant and quite concerned about dealing with both Maggie’s poor eating and a new baby. and (4) for older children. father. various reinforcers have been used to motivate children to eat appropriately. Percy was a dental hygienist who was currently working full-time at a dental practice that was a 45-minute drive from home. The reader is referred to Luiselli and Luiselli (1995) for a description of such a program. The General Parent Questionnaire indicated that the Percys were a middle-class family. Mr. 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. CASE EXAMPLE: FOOD REFUSAL PROBLEM Step 1: Initial Contact Mrs. it took her 45– 60 minutes to complete even a small meal. awarding points that can be traded for special activities. whom she described as healthy but eating a limited variety and only small amounts of food. Together. each parent was asked to complete checklists to rule out emotional and behavioral problems (the CBCL. and the eventual goal is to eliminate the tube. She had recently had a complete physical workup at a local hospital and was reported to be healthy. with both parents in their late 20s. . reading stories. Finally. This intervention should be coordinated with a nutritional specialist. such as short bursts of watching television.3. coloring. Mrs. they were being seen once a month for weight checks. It is important to note. (3) giving a desired toy for a short period of time. Maggie was reported to be in the 3rd percentile for weight and the 5th percentile for height. The attending physician had referred the family to a psychologist to deal with parent– child power struggles. Maggie was their first child and was described on the questionnaires as a child with many abilities who enjoyed a variety of activities. coordination of the treatment program with medical personnel is required. including playing with other children. She said that at their pediatrician’s request. Prior to the initial interview.

however. rather they allowed Maggie to get up and down from the table as she desired. and having trouble calming down. On the CBCL. indicating that they perceived Maggie as engaging in more noncompliant and disruptive behaviors than most children her age. On the Parent Domain. but the parents said they didn’t use one at home. canned fruit. Although she had been weaned from the bottle at 1 year of age.M.or perinatal complications. On the ECBI. length 19½ inches). she was extremely distracted during meals. yogurt. The parents appeared to be a pleasant young couple. grapes. and she could eat at the clinic as the parents and clinician were talking. and setting a regular schedule) with limited or no success. Percy had opted to use formula rather than breast milk because of her demanding work schedule. the mother and father had Intensity scores of 130 and 125. The parents’ responses to the rating scales were similar in most areas. she was described as never showing an interest in foods. Furthermore.” and rigidity. Mr. they did not think these techniques worked with their daughter. A review of Maggie’s developmental history indicated no pre. indicating that the parents did not see these behaviors as problematic. the parents put some cheese and pudding on a child-size table for her. peanut butter. The parents indicated that they experienced this as extremely stressful and did not see her as a child who gave them much pleasure. displaying emotional upset with changes in her routine. or French toast. Maggie was described as a relatively difficult baby. Pureed food and some finger foods were introduced at about 9 months of age. however. putting her in time out. The 2-week Food Diary indicated that the parents and babysitter were extraordinarily detailed record keepers. respectively. and 16–24 ounces of chocolate milk a day. The Problem scores were 4 and 6. she had begun to eat solid foods only recently. Other problems noted on the CBCL were resisting the toilet. such as hot dogs. . A high chair was provided. 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. Mrs. both parents’ scores were within the average range on all scales. MANAGING COMMON PROBLEMS and so forth. both parents rated Maggie above the 98th percentile on Somatic Complaints and within the normal range on all other scales. and they recognized that she liked to engage in power struggles. She was. On the PSI Child Domain. Although both parents indicated that they were aware of and had tried behavior management techniques. time for the initial interview because of their work schedules. Only occasional foods requiring chewing. who was easily upset and difficult to calm. Step 2: Parent and Child Interview The parents requested a 6 P. Their data indicated that there was no set time for meals or snacks. They had seen another psychologist for four sessions. Although Maggie said that she was not hungry. but felt they had tried all the suggested techniques (limiting milk.110 II. and although the parents continued to offer solid food. Percy saw their daughter as having a high activity level but did not think she was hyperactive. They said that they would bring Maggie’s supper. were noted. the parents described Maggie as very moody. and Mrs. “too neat. She had been a full-term baby (weight 7 pounds 5 ounces. The Somatic Complaints ratings were primarily focused on eating problems and painful bowel movements. juice. except for her formula or milk. and that foods consumed consisted of apple sauce. she returned to work 6 weeks after the birth. They felt that her eating problems resulted from her never having made the transition from the bottle to solid foods. unable to attend to eating. who were quick to say that they really had very few problems except Maggie’s refusal to eat. pudding.

in addition to encouraging her to eat at mealtimes. Step 3: Observation of Behavior Maggie was a physically small but very bright child. Her language skills were excellent. Percy returned home between 6 and 7 P. Although she usually went to sleep easily. Mr.3. At the babysitter’s. Eating Problems 111 Mrs. Maggie was usually very sleepy and out of sorts in the morning. Percy picked Maggie up at 5 P. Maggie was described as a generally happy child who liked to play with other children.M. They handled Maggie’s refusals or upsets by giving in to her demands or dropping their requests. Mr. At 12 months Maggie was weaned from the bottle. with a better routine for all of them than during the week. but did not use contingent reinforcement for appropriate behaviors. and if she didn’t eat it. but who had difficulty in making transitions from one activity to another (e. Mrs. . The parents described the weekends as much calmer than the week. demanding milk (which they gave her). Parent–child interaction was pleasant but characterized by frequent commands. wanting to be held. Percy’s work schedule. and crackers. so they could get her ready to go to the babysitter by 7 A.M).. Percy was also planning to decrease her work to 3 days a week at that time. A review of the family’s daily routine indicated that the parents woke Maggie at 6 A. They described Maggie as cranky and demanding in the evening.M. she asked her parents for milk. She had 4–8 ounces of chocolate milk before leaving for the sitter’s home. when both parents were working. and many questions. and said she often refused to eat. Maggie was put to bed at about 8 P. At lunchtime. soup.. prompting the referral for a full medical evaluation. Although the pediatrician had reassured Mrs. Percy said he would prefer to present Maggie with food. she would often sleep until 8 or 9 A. moving quickly from one activity to the next. Maggie showed no interest in the food available. she would wake three or four times during the night. Throughout the 1-hour interview. who eagerly explored the room. This issue had caused increasing conflict between the two of them. except for Maggie’s eating. Percy said they generally agreed on most things. but continued to lack interest in solid food. which they gave her. The parents demonstrated considerable interest in Maggie’s activities. Given Mrs. from playing outside to eating lunch to naptime). after going through a bedtime ritual of reading stories and saying “good night” to her dolls. the sitter sat with her for 30– 60 minutes. however. Several times during the interview.M. she lost 4 pounds.M. On days when she did not have to go to the sitter. The sitter reported that Maggie usually ate an adequate lunch and liked snacks of milk and cookies. Percy said Maggie was not interested in it and preferred her formula. and Mrs. Mr. she described her activities in complete sentences and asked many questions. The maternal grandparents were planning to move to the area shortly before the second baby’s birth.g. Maggie was reported to take a 1½-hour nap during the afternoon. encouraging her to eat such things as macaroni and cheese. On weekends they tried to eat earlier. Percy that Maggie was healthy. Between 12 and 18 months. she was concerned about ensuring Maggie’s growth and development.. and Mrs. but she refused. dinnertime was usually late (7:30–8:00 P. but she drank approximately 12 ounces of chocolate milk. 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. and they said they would care for both Maggie and the new baby in the parents’ home. Mrs.M. to give her nothing until the next meal. Several times the father encouraged Maggie to have some cheese and crackers. enjoy playing with dolls and reading books with them. low expections for compliance.M. She did.

and that although these behaviors were not uncommon among 2-year-olds.” The psychologist felt that the family wanted a “quick fix” and did not want to explore any family issues other than Maggie’s eating. The parents were told that Maggie was more demanding and less adaptable than many children her age. It was explained to them that most children begin to make the transition to solid food between 6 and 9 months of age. It was also pointed out that the parents seemed to be more tolerant of these behaviors than other parents. Mr. Her distractibility and activity level were seen as appropriate for a child of her age. it was also recommended that the parents learn some techniques to increase her compliance and decrease her disruptive behavior. she was essentially seen as a healthy youngster. as well as slowly introducing foods of differing consistencies. Maggie was described as a delightful youngster. the primary care pediatrician was contacted regarding possible treatment strategies. the child would eat a wider variety of foods. MANAGING COMMON PROBLEMS Step 4: Further Assessment Arrangements were made to obtain all the records from the previous hospital evaluation. The present task was to help Maggie move to more solid foods as the milk intake was gradually decreased. Percy seemed relieved that there was an explanation for why their daughter was having so much difficulty eating. The clinician expressed her belief that although transitions were likely to continue being difficult for Maggie. Course of Treatment The parents were seen for four sessions over a 2-month period of time. Medical records indicated that Maggie had received a diagnosis of NOFTT. and that with proper management of mealtime behavior. He viewed the eating difficulty as part of a general parent management problem. She also was described as a child with a very strong will. due to poor parental management of her behavior. Although there was concern about the child’s weight. who was well advanced for her age in many areas.112 II. she needed to learn more appropriate ways of interacting. Step 5: Referral to Allied Health Professionals Maggie was being followed closely by her pediatrician and had recently had a thorough physical evaluation. 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. and Mrs. Prior to the beginning of the intervention. This would involve setting up a regular eating schedule for a specified period of time. the goal of treatment was to get Maggie on a consistent eating schedule and to have her eat within a rea- . and they readily agreed to a short-term behaviorally oriented treatment program. and to contact the Percys’ pediatrician and the psychologist who had worked with them earlier. The psychologist described the family as very resistant to help. Mr. Given Maggie’s strong-willed temperament. and Mrs. She felt that Maggie did not need more than 16 ounces of milk per day. Step 6: Communication of Findings and Treatment Recommendations Information from the questionnaires and rating scales was shared with the parents. interests. Initially. she could be taught to handle them better. meeting every recommendation with “We’ve done that and it doesn’t work. and one who had learned how to get her parents to do what she wanted. and abilities. and that this might be inadvertently perpetuating them.

the clinician called the parents for a brief consultation (primarily to reinforce them for following the recommendations). it was clear that they were having trouble getting her back on a regular eating schedule. Eating Problems 113 sonable period of time. Not surprisingly. baked potatoes were substituted for mashed potatoes. 6:30 P. and the parents allowed her to have as much milk as she wanted and to eat at random times. Given the parents’ concern about Maggie’s eating. toys. 3:30 P. the possiblity of other relapses was discussed. Since they were already using time out. no milk between . At the second session. Between these six meals. it was determined that the goals for the next 2 weeks were to teach the parents how to implement time out consistently. The parents were told that the rules (regular meals. but they were not to cajole or be negative in any way. According to the food records. the parents and the babysitter were instructed to give Maggie six regularly scheduled (6:30 A. and to increase the size of the three main meals. 9:30 A. she quickly began to eat more at each meal. and Mrs. after 2 weeks of following this schedule.. and pancakes for French toast. Maggie was to sit in a high chair or on a booster seat at the table with no other distractions (TV. 12:30 P. She continued to be allowed to have as much water as she wanted between meals. however. Maggie was only permitted to have water. All food would be removed at the end of each meal.M. and the parents used time out if she had a temper tantrum when this was refused. see Chapter 10). Maggie became ill with an ear infection midway through this period.).M.M.. even if the child initially refused it.M. lasting no longer than 15 minutes per meal. etc. and to give milk or juice only at the end of each 15-minute meal.. Mr. The parents were also instructed to offer Maggie a greater variety of foods by introducing a new food about every 3 days. The parents kept food records during this time and mailed these to the clinic at the end of the week. Maggie was eating at regular times and actually asking for specific food items at mealtimes. they were asked to keep a record of when and how they used it. They were encouraged to comment about and praise her eating. They were to select foods that the child liked. to manage temper outbursts and refusals appropriately. initially no restriction was put on the amount of chocolate milk or juice Maggie was allowed to have at the end of each meal. and before bed) small meals per day. as well as to decrease the amount of milk to a maximum of 16 ounces per day. They were surprised at how much happier Maggie seemed.. 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. For example. When the ear infection resolved. At the third session.3. and reinforce Maggie’s appropriate behavior and to decrease their commands/demands (Part I of our parent training program. and (2) to substitute regular milk for chocolate milk. Percy quickly learned new parent–child interaction behaviors and began enjoying their daughter as her compliance increased. 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.g. Food records indicated that she was not only eating more during the mealtime. cookies). Food and time-out records continued to be kept. while decreasing the other three meals to snacks of an appropriate size and quality (e.. fruit vs. The parents were instructed to handle demands for food between meals by telling Maggie when the next meal was scheduled and offering her water. For the first 2 weeks. and the parents or babysitter were to sit and eat with her. and reported that she was able to make transitions much more easily. At the fourth session. Unfortunately.. but actually requesting seconds and beginning to experiment with some new foods. The parents continued to keep detailed food records. and to present this food on a regular basis. After reviewing the data. Maggie began to demand more food between meals.M. follow.

114 II. Maggie’s temper tantrums and moodiness had decreased. but that their expectations of Maggie could be lowered (not expecting her to eat as much or as varied a diet. Mrs. and regular visits to the doctor indicated that she was steadily gaining weight. 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. . Over the next 6 years. Furthermore. The parents elected to have no further sessions. MANAGING COMMON PROBLEMS meals) should not be changed. 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. her nighttime wakings had stopped without further intervention. Percy felt that time out was working effectively. allowing her to eat mostly preferred foods). Mr. and Mrs.

in Paris 7. and (3) the trend as of 1990 was in the direction of later completion of training. tantrums. avoidance through retention of urine and/or stools. this does 115 . Whether toilet-training children earlier will increase parent–child problems related to training is not clear. Fillozat. 1977. 1987). and Encopresis TOILET TRAINING Although all parents face the task of toilet-training their children.8 months. Klackenberg. Ball. In the United States. and in Stockholm 12. very little research supports one method of training over another. The developmental and scientific literatures. & Wesson.4 months (Hindley. the suggested age at which to start training has varied from 1 (!) to 24 months.13 years for the physicians).. do give us some general guidelines for toilet training. although limited. surveyed 1. and almost all children are trained by 48 months of age. In a review of 40 years of research on toilet training. 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.6 months. Lancioni. Even with the more permissive delayed approach. (2) training focused on independent. Schmitt. One early cross-cultural study found that the median age of starting regular toilet training in London was 4. many parents report problems with toilet training. strange behaviors (e. (1981). Luxem and Christophersen (1994) indicate that this trend toward delayed toilet training and permissiveness may have begun to reverse itself. Parents’ unrealistic expectations for when their children should achieve continence may also increase parent and child stress.CHAPTER 4 Toileting: Training. Shelov et al. Schroeder. emotional upsets (both parent and child). Largo & Stutzle. & Sand. Berk and Friman (1990) concluded that (1) most children are trained between 24 and 36 months of age. 1965). with current support for 18 months and preferably 24 months (Luxem & Christophersen. including refusal. & Oliva. age 5.75 years (vs. 1985. and found that parents felt a child should stay dry through the night by age 2. Nicolet-Meister. Enuresis. 1994). extreme interest in toilets and toilet waste).435 parents and 446 physicians. for example. and parent–child conflict (Mesibov. 1977).g. voluntary control is completed later than training focused on biological and behavioral indices of toileting readiness. 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. 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.

(2) physical readiness (the child picks up objects easily and walks without assistance). (4) attention to the component responses (undressing. etc. 1977.5 hours! These rapid and effective results were of interest not only to professionals but also to the public. for example. 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. 1992. (2) modeling (with a baby doll). Kimmel. sitting. They also include a Toilet Training Checklist. range 0. (3) a large number of trials for repeated practice (increased liquid intake). Several approaches have been widely disseminated in the popular press. and (3) instructional readiness (the child understands and complies with one. in follow-up. coordinate with other caregivers. Brazelton et al. 1976. These factors include (1) a stimulus-free environment (the bathroom). which include a Readiness Checklist based on Azrin and Foxx’s (1974) list of criteria for toilet training. 1974). All children were trained in an average of 3. decide .5–14 hours). but few of these have empirical support. children in both the supervised and unsupervised groups also showed emotional side effects.5 hours. whereas the Foxx and Azrin (1973) method has strong empirical support but is often difficult for parents to implement without professional help. (5) immediate reinforcement for correct responses with a variety of reinforcers. and medical influences affecting toilet training. The program provides an intensive learning experience that emphasizes the important factors in learning how to go to the bathroom independently. Matson & Ollendick.and two-step directions). Although research has supported the effectiveness of the Foxx and Azrin (1973) approach when it is used with clinical supervision (Matson & Ollendick. including tantrums and avoidance behaviors. and (8) stimulus control (a distended bladder is associated with the potty). which is still in print today. purchase a footstool. MANAGING COMMON PROBLEMS not constitute voluntary and independent toileting. It does. (7) mild punishment (cleaning up accidents). has popular appeal but no empirical support. 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). 1974).116 II. however. in terms of both time and effort. with accidents decreasing to near-zero and remaining so during 4 months of follow-up.9 hours (median time 3. Furthermore.g. and the dry pants procedures were published in a manual for parents called Toilet Training in Less Than a Day (Azrin & Foxx. we also know that if toilet training is begun when the child is older than 26 months. Children aged 20–25 months had a mean training time of about 5 hours. 1974). focused on what parents need to do to set the stage for training (e. “manual-only” children may actually increase their mean number of accidents above pretreatment levels (Butler. Nonetheless. 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.). Brazelton’s (1962) approach. 1981). (1999) give a detailed review of the instructions. Thus the Foxx and Azrin (1973) program is not recommended without professional supervision (Christophersen & Rapoff. On the other hand. whereas children aged 26–36 months were trained in about 2. indicate the power of consistently applied behavioral reinforcement methods and the lack of support for delaying training on the basis of maturation. several studies indicate that parents have trouble using the manual without supervision. In the Matson and Ollendick (1977) study. Pirnstill.. 1977). it is accomplished twice as fast as if it is started when the child is younger than 2 years (Azrin & Foxx. timeliness. Christophersen and Purvis (2001) outline the components for successful toilet training. (6) immediate detection of incorrect responses (accidents). The fact that most children are successfully toilet-trained during the preschool years testifies to the effectiveness of a variety of methods.

Step 2: No More Diapers The next step in the training process is to stop using diapers (except for naptime and at night). which will make the consequences of wetting or soiling immediate and very evident (“Yuck!”). Bowel movements may occur at regular intervals (e. If the child does not show a regular pattern or is wet every hour. they indicate that for children 24 months and older. For this reason. you’re dry.” or “Oh. Bowel movements may occur at intervals varying from once every other day to twice daily. When they are ready to be trained. The first step in toilet training is to determine the times when the child normally empties his or her bladder or bowel. or they may occur about 30 minutes after a meal. Schaefer and DiGeronimo (1997) provide a practical guide for parents on urine and bowel training. with occasional accidents up to several months following the initial training. After 3–5 days of checking. a child must be able to do three things: (1) voluntarily control the sphincter muscles. a regular pattern of wetting should be evident. 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 have given it strong endorsement. and Encopresis 117 on rewards) and to deal with difficult cases. W (wet). and (3) have the desire to control the impulse to urinate or defecate. . Parents should comment matter-of-factly to the child by saying “Oh. Urine training is often accomplished before bowel training.” This will take some effort on the parents’ part. “pull-up” diapers or heavy training pants should not be used.g. or S (soiled) on a chart such as that shown in Figure 4. In addition. given that the child has more opportunities to practice urinating in the toilet. and methods for training the mentally and physcially challenged children. This gives information on the child’s ability to control the sphincter muscles (increased time between wets). and at different times each day. but the importance of gathering this baseline information before starting training should be stressed.4. every 14–18 hours) as opposed to regular times of day. clothing that is easy to take off and put on will allow the parent to respond quickly to the child’s signals. and offers parents a choice of four effective approaches to toilet training. (2) communicate needs verbally or by other means. Thus even periodic use of diapers during the day can be confusing to the child. The child should wear regular underpants. Diapers serve as a cue to the old behaviors (urinating or defecating in a diaper). Although we do not have empirical data to support the efficacy of our approach. 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. Parents are instructed to check the child’s diaper every 30 minutes and record D (dry). you’re wet. bedwetting. training resistant children. It is based on physiological facts and learning principles. Step 1: Determining Readiness To be successful at toilet training. it may be best to postpone training for a month or two.. the average toilet training time is 2–4 weeks. Enuresis. yuck. Toileting: Training. good. as well as learning a complex set of new behaviors. most children show a fairly regular pattern of urinating four to nine times a day.1. making it more difficult to break old habits and learn new ones (urinating or defecating only in the toilet). 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. Toilet training involves helping the child unlearn certain behaviors that were acceptable in the past. This approach is summarized below.

the following directions: (1) Set a timer for 30 minutes. MANAGING COMMON PROBLEMS Dry Pants Chart Record data for any 5 consecutive days during usual waking hours. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details). Gordon. (4) Do not act upset.M. yuck.118 II. (2) If dry and clean.) From Assessment and Treatment of Childhood Problems (2nd ed.) by Carolyn S.” and mark a D on the chart. “Oh. Copyright 2002 by The Guilford Press. say.” and mark a W or S on the chart. Schroeder and Betty N. A chart for recording baseline data in toilet training. dry. check the child’s pants or diapers. say. wet [or stinky]. Take your child to the bathroom and change the soiled clothes. Child’s Name: ______________________________________________ Time 6:30 A. (3) If wet or soiled. (5) In 3–5 days you should see a regular pattern of times your child wets or soils. When it rings.1. good.M. . “Oh. 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 12:00 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. (Parents should be given NOON Sunday Monday Tuesday Wednesday Thursday Friday Saturday 12:30 P.

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. support for the child’s feet (e. can be used to help him or her sit happily. (This information should be evident from the daily Dry Pants Chart. a small step stool) should be provided.1. Depending on the age of the resistant child. Let’s change. 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). the parent should use the timer.” The parent should have the child help clean up and change clothes. there are bound to be accidents. to help the child associate toileting with the bathroom..2). This approach allows the child to participate actively in gaining control over urination and defecation.g. hard stools) or a frightening thought or experience (e. plenty of exercise. At first the child may wet his or her pants soon after getting off the potty chair or toilet. For most children who refuse to use the toilet to urinate and/or defecate. fear of falling into the toilet). It is our experience that if children successfully use the toilet a few times. You’ll make it to the toilet next time. see Figure 4.. resistance is best handled by systematically teaching good toileting habits. and the training process. A parent should handle accidents matter-of-factly by saying. or “do some” in the potty chair or toilet and then shortly afterward “do some” more in the pants.g. you’re wet [or dirty]. he or she goes back to the thin “regular” pants until the next successful toileting. it may be best to delay the training process until a later date or carefully review the parent–child interaction.. More praise and a special sticker should be given when the child urinates or defecates in the toilet. They may even ask to use a diaper or newspaper rather than use the toilet or mess their pants.) Use of a timer will help parents and child keep track of the time. Many parents reward their children by allowing them to wear fancy “grown-up” pants when they are using the toilet successfully.4. it is time to stop using diapers completely. In the absence of physical or significant emotional/behavioral problems or stress. “Oops. the toilet seems to be associated with some painful event (e.g. as well as by ensuring that the child has a proper diet. A special “potty toy. performing all of this in the bathroom. the environmental context. If a potty chair is used. The chart helps to record progress and reinforces successes. to decrease a child’s realistic fear of falling into the toilet. it can be used to reinforce the child for dry. without setting the expectations too high. these problems quickly go away. clean days. Gradually desensitizing them to sitting on the toilet by first having them sit with their clothes or underpants on for increasing . Toileting: Training.” which the child plays with only while sitting on the toilet. The child should then sit on the potty chair or toilet for 5 minutes to “finish up”. 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. If the child wets the grown-up pants. and a consistent daily routine. The parents should reward the child for sitting with praise and a star drawn on a Sitting Chart (Figure 4. and let the child know when it’s OK to get off the potty chair or toilet. and Encopresis 119 and will make it easier for the child to use the toilet independently. Step 4: Handling Accidents/Resistance Because toilet training is a learning process. When the child is dry during the day and begins to have occasional dry naps and nights. If the child sits on the regular toilet. it should be kept only in the bathroom. later. Enuresis.

nocturnal enuresis is the most common urological complaint of children (Norgaard & Djurhuus. Taubman. the children can get off when they are quiet for a count of 10. with a discussion of enuresis in the Ebers Papyrus of 550 B. 1951). 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. Copyright 2002 by The Guilford Press. in a section titled “Of Pyssying in the Bedde” (Glicklich. can often resolve the problem. A chart for recording sitting on the toilet. For bowel movements. Treatment remedies predate modern civilization. and then having them sit without clothes at times when they don’t have to void or defecate. However. Gradually increasing the count will help them learn there is nothing to fear.) by Carolyn S. “enuresis. ENURESIS Description and Prevalence Although no fatal case has ever been reported. Schroeder and Betty N. It is important to note that Blum. and then having the child sit on the toilet. From Assessment and Treatment of Childhood Problems (2nd ed.M. MANAGING COMMON PROBLEMS Sitting Chart Time to Sit Sits Quietly—5 Minutes Sample As soon as awake 10:00 A. (star) (star) (sticker) (sticker) Urination Defecation FIGURE 4.”—involuntary urination with no known organic cause—has been a nuisance for literally hundreds of years. mineral oil can be used.120 II. Gordon. The essential features of enuresis are repeated urination into clothes or bed. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details). occurring at least twice a week for a minimum of 3 consecutive months (or causing clinically significant .C. Even today. Christophersen and Purvis (2001) suggest using glycerin suppositories before a meal or before a bowel movement is likely to occur. or more fiber and water can be added to the diet to help stools become looser and more difficult to retain. Although enuresis is usually not medically significant.2. it does cause distress for many children and their parents. lengths of time (up to 5 minutes). 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 was also listed as a disease in the first book of pediatrics written in English. If the stools are hard. 1993).

lower intelligence. the wetting cannot be exclusively due to a medical condition or drug reaction (American Psychiatric Association [APA]. 1994. 1972). in a child at least 5 years of age or the developmental equivalent. (1995) reported that children with enuresis were at increased risk for learning disability. bedwetting is clearly a common childhood problem that improves significantly with age alone. but in the past it has been defined as lasting from 6 to 12 months. Etiology Because enuresis is a heterogeneous disorder. and marked structural or functional disorders (Jarvelin et al. Perlmutter. reports a much lower rate of 10% for 5-year-olds. 1997) with more urinary tract abnormalities such as incomplete bladder emptying. It also reports that 5–10% (vs. We also know. 1998).. fourth edition (DSM-IV) does not specify the length of time one must be incontinent. The most common explanations are presented here. the etiological explanations for it are varied (Mellon & Houts. however. that some children who are of superior intelligence have enuresis. 1998). & Moilanen. Older prevalence studies in the United States have consistently reported that 15–20% of 5-year-olds. DSM-IV (APA. & Rider. 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. as well as the amount of effort expended in the training process. There are three subtypes of enuresis: “nocturnal” (wetting only during sleep). when children are expected to be consistently dry both day and night (APA. “diurnal” (wetting only during waking hours).. 1990. 5% of 10-year-olds. Biederman. but both physi- . however. with approximately 80–90% of bedwetting in this category (Mellon & Houts. fractionated voiding curve. enuresis is not diagnosed until age 5. These two problems are uncommon for both boys and girls after 9 years of age (APA. 1968. compared with children who did not wet the bed. According to the DSM-IV definition. and poor school achievement. There appears to be a greater incidence of medical problems in daytime wetting (LoeningBaucke. Children who have never been dry are described as having “primary” (vs.to 14-year-olds experience nocturnal enuresis (Oppel. 1989). Enuresis. in large families.4. previous reports of 15%) of these children will spontaneously achieve control every year from 5 to 18 years. 1994). Some data indicate that it is more prevalent at lower socioeconomic levels. Huttenen. 1995). 1994). The Diagnostic and Statistical Manual of Mental Disorders. Jarvelin et al.5% and 2% for both boys and girls at ages 6–7 years (see Friman & Jones. 1985). Hjalmas. 1991). “secondary”) enuresis. Santangelo. 1994). Walker (1995) points out. The prevalence of enuresis varies from country to country and among ethnic and racial groups (deJonge. and in families where mothers have less education (Bakwin & Bakwin. 1992). Enuresis is also more prevalent among developmentally delayed youngsters and institutionalized children. Toileting: Training. 1994). with a prevalence rate of only 1% in adults. and “nocturnal–diurnal” or “mixed” enuresis (APA. however. Harper. but occasionally it is done on purpose. Seppanen. Estimates of daytime wetting and mixed enuresis are lower than for bedwetting. that these differences probably reflect cultural beliefs and attitudes about toilet training. et al. 1973). 1990). Walker (1995) suggests that enuresis is more similar to a specific learning disability than to a lack of intellectual capacity. and about 2% of 12. whether they are of normal or subnormal intelligence (Moffatt. Seppanen. Despite these discrepancies in the data. The wetting is usually unintentional. ranging between 0. and Encopresis 121 distress or impaired functioning).

1996). when neither parent has a history of enuresis. Furthermore. and Djurhuus (1989) conducted extensive investigations of enuresis and found that (1) children with the disorder had normal daytime bladder capacities. Although there currently is not enough evidence for allergies or organic brain pathology to be considered significant in the development of enuresis. & Wille. 1996. According to Bakwin. Hjalmas. These findings have led to the use of desmopressin acetate. 44% of children are enuretic. 1994). 1995). Organic causes that have been clearly identified include various acquired and congenital nervous system lesions.. Walker. when both parents have a history of enuresis. (3) enuresis did not occur during any specific sleep stage. although there is some support for an exceptionally small functional bladder capacity among such children (Bath. and (4) there were no specific sleep patterns before or during the enuretic episode. 77% of children have enuresis. which stimulates the kidneys to concentrate urine and therefore decreases the volume of urine during the night. a small “functional bladder capacity” (i..122 II. Genetic factors appear to be strong contributors to enuresis (Mikkelsen. developmental delay. Morris. and organic brain pathology (Biederman. Norgaard. Walker (1995) notes that children with enuresis tend to become dry at about the same age as older relatives who had the problem. and some chronic diseases. 1992). has not been established (Bath et al. Gellis (1994). as well as the response to desmopressin. or a combination of both (Readett. Other research suggests that many enuretic children have an excessive production of overnight urine. Morton. no specific mechanism has yet been identified to explain the inheritance of enuresis. 1995. Thus the link between levels of antidiuretic hormone and bedwetting. 1974). disorders in the neural enervation of the bladder. Rittig. & Sergeant. 1995). Evans & Meadow. estimates range from 1% to 3% of cases of enuresis (Forsythe & Redmond. MANAGING COMMON PROBLEMS cal and psychological/behavioral factors should be considered in determining the best course of treatment for an individual child. there is some support for a maturational lag. structural problems of the genitourinary system. Uing. 1990). Norgaard. The increased prevalence of enuresis in boys (who usually have a slower rate of develop- . seizure disorders. however. Furthermore. relapse rates when the drug is discontinued are nearly 100% (Djurhuus. or sickle cell disease (Walker. monozygotic twins have a greater concordance for enuresis than dizygotic twins do (APA.e. and the data on heritability do not take into account intergenerational transmission of toilet training practices. enuretic children were four to five times harder to awaken than nonenuretic children. a synthetic form of the hormone vasopressin. Biological Factors The actual incidence of organic urinary incontinence is low in children. only 15% of children have enuresis. but continence is maintained only while the drug is being used. For many children. Other biological factors that may contribute to enuresis are food allergies. Santangelo. (2) a full bladder was necessary for enuresis to occur. 1992).. 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. bladder or urinary tract infections. & Williams. No fewer than 75% of all children with enuresis have a first-degree biological relative who had the disorder (Bakwin. 2001). et al. when only one parent has a history of enuresis. such as diabetes. other studies do not support poor nocturnal concentration of urine for enuretic children under 12 years of age. the immediate response to treatment with desmopressin is good. 1973). a small volume of urine in the bladder triggers a response to urinate). Although these statistics are impressive.

4. Swearer. Learning Factors Learning problems appear to be primary factors in the etiology of enuresis. 1995. et al. with success rates of 70–90% (Mellon & McGrath. McGee. Feehan. & Houts. and if the child is an older female (Wagner. & Silva. late. most emotionally disturbed children are not enuretic. More recent work has documented that the majority of children with enuresis do not have emotional or behavioral problems (Friman. strict or lax toilet training relates to enuresis. immaturity.. 2000. or anxiety (Pierce. Stress that occurs during ages 2–4 years. McGinnis. Barclay. 1995). this conceptualization is consistent with our approach to assessment and treatment of nocturnal enuresis. 1992). Emotional Factors Psychodynamic theory had a major impact on the study and treatment of children with enuresis in the early 20th century. Scott. 1986). except for a brief mention of treatment for mixed enuresis (see below). Toileting: Training. Clearly. . family conflict. Handwerk. and attention-deficit/hyperactivity disorder (Biederman. Enuresis has not been associated with any particular disorder. but commonly noted problems include anxiety. & Brook. Houts (1991) conceptualizes enuresis as a “biobehavioral” problem. Valdez. in that children learn skills at different rates. but research does not support this view (Biederman. and Encopresis 123 ment than girls) and the high annual spontaneous remission rate indicates that there is a developmental delay in acquiring these skills. Walker (1995) points out that although there is no evidence that early. Enuresis. can often result in incomplete toilet training and thus lead to enuresis. 1988). There is some support for the role of learning factors in the etiology of enuresis. Santangelo. He speculates that conditioning or operant intervention may correct the underlying physiological mechanisms that cause and/or maintain the problem. In addition. or secondary to some specific psychosocial stressor (Rutter. 1995). we focus on this subtype from this point on. Santangelo. 1973. Smith. Nonetheless. these could be contributing factors.. although enuresis is more frequent in children who do have emotional disturbance. Learning theory suggests that habit deficiency. 1998). Enuresis was felt to be the result of an underlying emotional dysfunction. psychological conflict. ASSESSMENT OF NOCTURNAL ENURESIS Because nocturnal enuresis is the most common subtype of enuresis. Foxman. Stanton. At least one study has found that an emotional disturbance is more likely to be associated with enuresis if daytime wetting is present. 1971). & Norris. treatment based on learning principles has proven to be the most effective long-term intervention for nocturnal enuresis. more research is needed to understand this linkage between the physical and behavioral aspects of the disorder. Most importantly. at least in some cases (Friman & Jones. Furthermore. There is a common belief that emotional disturbance is more likely to be associated specifically with secondary enuresis. 1998). et al. in that it is a physical problem but responds best to learning-based treatment approaches. & Graham. and emotional and psychosocial factors can interfere with the learning process (Walker. inadequate learning experiences. & Warzak. and inappropriate reinforcement contingencies result in the failure to learn to control the complex urination reflex. 1990). Yule. when children are in the process of being toilettrained or have just completed training.

our General Parent Questionnaire. During this baseline period the child should be taken out of all protective clothing. if possible. however. A urinalysis and urine culture should be part of the evaluation.. 1992) or the Behavior Assessment System for Children (BASC.. changing sheets). do they wake up right before or after they urinate? Do they feel bladder pressure indicating the need to void? Butler.g. a referral should be made for such an evaluation. Treatment of enuresis involves a great deal of cooperation on the child’s part.124 II. see Chapter 2). Step 1: Initial Contact When a parent refers a child for enuresis.g. In addition. For example. and the Parenting Stress Index (PSI. with a focus on gathering information specifically pertinent to understanding and treating this disorder. Eyberg & Pincus. This can be done by mailing a general questionnaire (e. thick underwear. Developmentally. 1992). treatment was less successful with children who perceived bedwetting as having predominantly nonpsychological implications (e. The clinician should next rule out the presence of significant emotional or behavioral problems. in the initial interview with the parents. 1973). In contrast. and his or her level of interest in a treatment program must be determined. the Eyberg Child Behavior Inventory (ECBI. or rubber pants. 1995) to parents. and Forsythe (1990) have illustrated the importance of interviewing children about their perceptions of bedwetting. 1991a. and. if at all possible. (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. see Appendix B) and screening instruments such as the Child Behavior Checklist (CBCL. All of this information should be returned and reviewed by the clinician prior to the initial interview. Achenbach. the ability to take a psychological perspective increases with age. as well as the number of wet and dry nights. thus the older the child. bad smell.3) to parents on which to keep this information ensures that the appropriate data will be obtained. MANAGING COMMON PROBLEMS when the term “enuresis” is used alone. every 2–3 hours (!) throughout the night. Abidin. if not. should not be construed as meaning that treatment should not be offered to a 5. 1999). children often share information about the problem that is not known by the parents. Sending a form (Figure 4. We have found that a 7-day record is usually sufficient. nocturnal enuresis is meant. Although the incidence of organic or physiological difficulties or medications resulting in nighttime urinary incontinence is low. regardless of age. since 5% of males and 10% of females have urinary tract infections that require antibiotic treatment prior to bedwetting treatment (Stansfeld. The assessment process for nocturnal enuresis follows the Comprehensive Assessment-to-Intervention System (CAIS. Step 2: Parent and Child Interviews We recommend including the child. Redfern. Reynolds & Kamphaus. Parents should check to see whether the child is wet before they go to bed. the more likely it is that treatment will be effective. Resistance to change was also an important factor. In a study of 55 children ages 6–14 years. including diapers. the clinician should first determine whether there has been a recent medical evaluation of the problem. successful treatment was associated with children’s perception of bedwetting as having psychosocial implications. these must be ruled out before further assessment and treatment take place. These data.or 6-year-old .

and Encopresis 125 FIGURE 4.) by Carolyn S.M. Toileting: Training. Gordon. of wet(s) Size Small Medium Large What did you do? Comments 4. Enuresis. 125 . Copyright 2002 by The Guilford Press. From Assessment and Treatment of Childhood Problems (2nd ed. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details). A chart for recording enuresis baseline data. Schroeder and Betty N.Nighttime Wetting Chart Baseline Child’s Name: _____________________________________________________________________________ Age: _________________________________ Address: _________________________________________________________________________________________________________________________ Date/day Bedtime Time up Time i n A.3.

as well as why some techniques might not have been successful. and circumstances of the initial toilet training process. or ongoing stressful life events. if the child was previously dry.g. also should be explored. These include (a) the type. but it may affect the parents’ attitude toward treatment (e. the time and circumstances when wetting began). and time of daily fluid intake. the clinician should be particularly careful to gather the following information: 1. are they overindulgent or exasperated?) and the methods previously used to deal with the problem. given the increased frequency of enuresis among children when other family members have been enuretic. conflict over how it should be handled. Problems such as oppositional behavior and noncompliance can interfere with treatment of enuresis and should be treated first. then it is recommended that treatment of enuresis be postponed until these problems are further evaluated and possibly treated. If the child has never been dry. are very helpful in determining whether there is a potential bladder capacity problem. The usefulness of previously attempted techniques. or do you have to rush to the toilet?”) and daily frequency of voiding. 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. 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. Urinary tract infections can cause frequent urination. Parents are a critical factor in the success or failure of a treatment program for enuresis. The clinician should also be alert to fears of the dark or of the toilet. 4. can you hold it for 5–10 minutes. as well as quantity and type of liquids consumed on a daily basis. special attention should be given to whether the child has learned the prerequisite skills. and (d) age. The parents’ attitudes about the toileting process. 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. would like to stop bedwetting. (d) sleeping arrangements that make getting to the toilet difficult. and (g) what the child wears to bed.. time. 5. treatment has a good chance of being successful. amount. (e) proximity to the bathroom. How have the parents handled the problem? Information on the previous attempts at treatment should be gathered in great detail. (c) lack of or inconsistent bedtime rituals. so a query should be made about the history of such infections. which may be causing the child to avoid using the toilet at night. MANAGING COMMON PROBLEMS child. (f) temperature in the house. Information on the child’s ability to retain urine after he or she has the urge to void during the day (e. and has a supportive family. 3. (c) primary or secondary status (and. and consequences). and their willingness to follow through on a treatment program should be assessed at this time.g. methods. 6. A positive family history does not preclude treatment. unexpected. During the initial interview. If there is indication of psychopathology.126 II. their attitudes. 2. and amount of wets). . (b) intermittent or daily incontinence (frequency. Are there other behavioral or developmental problems? The presence of other difficulties can be determined from the screening instruments. and acceptance of a treatment approach must be carefully considered before beginning.. “When you have the urge to go to the bathroom. Is there a family history of incontinence? A family history of enuresis is important. (b) recent. beliefs. If the child is not resistant to change. antecedents.

These included (a) “What are the bad things about bedwetting?”. Step 4: Further Assessment Further psychological assessment is only necessary if other problems become evident during the assessment process.4. and Encopresis 127 7. (1990) used a series of questions to determine a child’s understanding of the benefits of stopping bedwetting. (c) “What difference would being dry make to you?”. 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. In helping the parents and child determine whether or not to proceed to treatment. Butler et al. “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. one child said. Enuresis. to rule out any organic problem or medication that could be causing nighttime urinary incontinence. our understanding and effective treatment of nocturnal enuresis have been slow to develop. Treatments have included everything from potions of berries and animal parts. Step 6: Communication of Findings and Treatment Recommendations Following the assessment session(s). How does the child feel about the problem? The child’s interest in resolving the problem must be assessed. . it is important for the child clinician to share information with the parents and the child about how enuresis fits into the developmental process. Step 5: Referral to Allied Health Professionals As noted earlier. The nature and possible etiology of the enuresis should be discussed. they also should be made aware of the spontaneous remission rates. TREATMENT OF NOCTURNAL ENURESIS Despite early recognition of the problem and a voluminous professional and lay literature. Toileting: Training. his or her cooperation is as crucial as the parents’ in successful treatment. In addition. and a rationale for the treatment recommendations should be given. because the parents’ and child’s trust in the clinician and cooperation in the treatment process will depend on their understanding of the problem. (b) “What are the good things about being dry?”. 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. a medical evaluation should be done before the initial interview with the family. to sleeping on spikes. again. This process often involves explanations of the value of previously attempted methods and why they did not work. This is particularly important. as well as the facts that some children do not succeed in staying dry and that relapses can occur.

or Palco Laboratories. Figure 4. The average success rate for the alarm system is 77. Morgan. by the time parents seek help from other health professionals. Lovibond (1964) has suggested that an avoidance learning paradigm better explains the learning process. resuming treatment for a shorter length of time results in successful reconditioning for over 60% of these cases (Doleys. and severe beating (Glicklich. 831-476-3151. com. because most children using this method learn to sleep through the night without wetting or awakening to use the bathroom. may also play an important role in treatment. Moreover. Although a recent survey indicates that physicians are increasingly prescribing learning-based treatments. MANAGING COMMON PROBLEMS electrical shock. The child learns to avoid the aversive alarm by retaining urine and sleeping through the night. however. a family and child have often experienced repeated failure and frustration with trying to stop the child’s bedwetting. This conceptualization. or by awakening and using the bathroom before the alarm sounds. The apparatus includes a urine-sensitive pad. 1996). www. 8030 Soquel Ave.9% (Mellon & McGrath. 2000).128 II. 801-973-4090. see below) over every other type of treatment (Mellon & McGrath. www. Turner. This section discusses various treatment approaches for nocturnal enuresis.4 illustrates this device. CA 95062. 1977). Eventually bladder distension becomes the cue for the child to wake up and go to the bathroom to urinate. Most parents initially seek help with enuresis from their pediatricians. Santa Cruz.. which is placed under the child’s buttocks and is connected to a loud bell or buzzer. Young. which can be obtained from Nytone Medical Products. 2000). Although the relapse rate within 6 months of treatment is reported to be as high as 41%.com. but became popular following the publication of an article by Mowrer and Mowrer (1938). & Premack. & Jones. . 2424 South 900 West. Urine. which contains salt and is an electrolyte. Urine Alarm The urine alarm or bell-and-pad method of treating enuresis was first described in the literature as early as 1904 (Pfaundler. For a complete review of treatment approaches. does not appear to be applicable. over 50% of physicians reported using medication to treat enuresis. with an emphasis on behavioral treatments. 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. Thus. Berman. Newer models use metal snaps that are attached to the crotch of the child’s underpants and connected to a small wristwatchtype apparatus. such as positive reinforcement from the parents. 1972).. 1904). Several studies have shown that the relapse rate can be significantly reduced by employing overlearning (increasing the liquid intake prior to bedtime (Young & Morgan. This can be worn on the child’s arm or attached to the shoulder of the pajamas.palcolabs. Inc. increasing the volume of the alarm appears to contribute to less wetting among children who are slow to respond to treatment (Finley & Wansley. activating an alarm that continues to sound until manually turned off. in which the sensation of bladder distension becomes associated with the sound of the alarm. Salt Lake City. 1978). Mowrer and Mowrer (1938) originally conceptualized the bell-and-pad method as a classical conditioning paradigm. 1977). Utah 84119. and by using the alarm on an intermittent schedule after dryness has been achieved (Jehu. and Abramson (1994). see Mellon and McGrath (2000) and Houts. Other factors.nytone. despite its limited efficacy (Vogel. completes an electrical circuit in the pad.

rather. van Londen-Barentsen. return to bed. To be rewarded. This decrease is usually followed by intermittent dry nights for the next 2 weeks and consistent dryness in 6–8 weeks. and its relatively low cost. Toileting: Training. the child must turn off the alarm within 3 minutes after it has rung.4. For example. 1989) uses the urine alarm. and reset the alarm. In a study of 113 children between the ages of 6 and 12 years. & Bonner. van Londen. Wrist urine alarm for treatment of enuresis. along with information gathered in the assessment process. Our experience and that of others (Walker. Parents are instructed to reward the child with two stickers if he or she follows the proper procedure when the alarm goes off. written material is included with the alarm when parents purchase it. van Son. and to take one sticker away if the child does not (response cost). urine retention or sphincter control exercises can be added for the child who exhibits excessive frequency or urgency. it reinforces the child for getting up and going to the bathroom. Given the empirically demonstrated effectiveness of the urine alarm system. we begin almost all treatment for enuresis with this method. Enuresis. There is no contact with a professional in this program. go to the bathroom to urinate. alert the clinician to potential problems and guide the treatment program. and Encopresis 129 FIGURE 4. Data from the first 2 weeks of treatment provide important information about the child’s progress. Arousal Training Arousal training (van Londen. its ease of implementation. 1988) indicates that the size of the wet spots and then the number of wets per night should decrease during this period of time. 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 . Milling. These data.4. but instead of focusing on dry nights.

Although it would be good to have more studies of this method. relax 5 seconds. A study using Kegel exercises. These data are impressive. later work has indicated that increasing functional bladder capacity alone is not sufficient or necessary to eliminate enuresis for most children (Bath et al. MANAGING COMMON PROBLEMS (control group 1). usually up to 30 minutes (Christophersen & Rapoff. Responding to the alarm and going to the bathroom can be rewarded or punished with response cost. 1996. 1996). & Surwitt. King. had 79 children with diurnal enuresis hold the contraction 5–10 seconds. however. which involve dry contractions of the pelvic muscles. the arousal training group was still doing significantly better (92% continent) than either of the control groups. Another technique that has been used to strengthen the sphincter muscles and thus increase bladder capacity is sphincter control training. 1972). it can easily be incorporated into a treatment program that reinforces dry nights. we have found them useful when the frequency of wets or urgency does not . had relapses during the 2½ years before follow-up. and (2) the urine alarm without using any rewards or response cost (control group 2). At a 2½-year follow-up. and Bonner (1988) suggest having the child do this three to five times during each voiding and providing rewards to encourage this practice.. 1992). whereas 45% and 50% in the respective control groups relapsed. Children in all groups. Walker. when the urge to urinate occurs. 1977).. Although a dry bed is the ultimate goal. They found that 20 weeks after the beginning of training. There was no contact with a professional for any of the conditions. the child is encouraged to refrain from urinating as long as possible. These authors found that these exercises eliminated diurnal enuresis for about 60% of children. To help the child increase the amount of urine in the bladder before getting the urge to urinate. however.130 II. he or she is given increased liquids during the day. whereas a dry night can be further reinforced and wet nights ignored. Milling. “functional bladder capacity” refers to the ability of the bladder to retain a given volume of urine without producing an urge to void. children can hold for several minutes to hours. & Kimmel.. and ultimately a better outcome.g. especially considering that parents did the training by themselves. 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. Although there is little empirical support for bladder retention training and sphincter control training. control group 2 = 72%). nocturnal enuresis was eliminated. 1978. a lower relapse rate. focusing on the prerequisite skill of getting up to go to the bathroom seems to lead to a higher success rate. 1973). 1994). Although the initial studies of these techniques were promising (e. the success rate was 98% for the arousal training group. which was significantly higher than that for either control group (control group 1 = 85%. Children who have a small functional bladder capacity tend to have increased frequency of daytime urination. 28% relapsed in the arousal training group. if the frequency of wets or awakenings during the night does not decrease as expected. Doleys. With practice. Kimmel. as well as a sense of urgency when they need to urinate. and that for 34% of the children with mixed enuresis. 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. Bladder retention training may be helpful. This involves the child’s practicing starting and stopping the stream of urine when voiding. Harris & Purohit. and repeat this exercise at least 10 times on three separate occasions during the day (Schneider. Paschalis. As previously stated. Bladder Retention Training and Sphincter Control Exercises Some children with enuresis have been found to have a small functional bladder capacity (Bath et al.

although a recent review reported a decrease in the use of imipramine and an increase in the use of demopressin (Mikkelsen. Mellon & Houts. but it essentially involves the use of operant conditioning principles to teach the child the responses necessary to stay dry. Milling. Thus. go to the toilet. (7) mild punishment (parent disapproval). The systematic use of these techniques. he or she starts by counting to 50. 1998). including recording the amount of fluid consumed and the length of time the urine is held after urgency is felt. the clinician should consider what parts of DBT might be added to a particular child’s treatment program. This intervention program has generated considerable research and has been described in a self-help book. Walker (1995) also reports finding them clinically useful and has developed a treatment protocol for using them (Walker. A Parent’s Guide to Bedwetting Control (Azrin & Besalel. Each time the child wets the bed during the night. The instructions for DBT. Medication Given that medication is frequently prescribed for enuresis. Full-spectrum home training uses the urine alarm. The caretaker then wakes the child every hour and asks him or her to go to the toilet. and Encopresis 131 decrease with other methods. with an emphasis on positive practice. and a graduated overlearning procedure (Houts & Liebert. (5) cleanliness training (cleaning the bed. 1984. Toileting: Training. Do this 20 times. Next six nights: If the child has wet the bed the night before. (Bath et al. These include (1) positive reinforcement for inhibiting urination. has been crucial to their successful use in our clinic. (6) negative reinforcement. (8) family encouragement. 1996. The effects of the other components were cumulative when added to the urine alarm. 20 times. and oxybutynin chloride (Ditropan) are the most frequently used drugs.4. on going to bed. Imipramine (Tofranil). self-monitoring of wet and dry nights.. for a period of up to 45 minutes). (2) urine retention control training. This 7-day programme can be re-used for relapse of enuresis. Sneed. as used successfully in the Bath et al. (4) nighttime waking. including the mattress. and (9) a urine alarm. he or she must count to 50 and go to the toilet 20 times. if the alarm alone is not working as expected. attempt to urinate. Count to 50 lying on the bed. then go to the toilet. . Success rates for this procedure are reported to be about 80% within 8–16 weeks. then going to the toilet. and Foxx’s (1974) dry bed training (DBT) approach to treatment of enuresis. DBT has undergone a number of changes. (3) positive practice (repeatedly getting out of bed to go to the bathroom). 2001). Dry Bed Training No discussion of enuresis would be complete without mentioning Azrin. retention control training with monetary rewards. then gives the child another drink. Bollard and Nettlebeck (1982) examined the various components of the program and concluded that only the urine alarm produced significant effects alone. (1996) study follow: First night: Have a drink. Over the years. a brief discussion of its effectiveness is warranted. he or she has to count to 50. cleanliness training. p. attempt to urinate. Enuresis. & Bonner. 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. If at any time the child wets and the alarm goes off. desmopressin acetate (DDAVP). 1979). and then return to bed 20 times. 1988). return to bed and count to 50 again.

which allows an increase in bladder volume before the reflex contractions induce voiding (Rushton. but studies with children report seizures after 3 weeks of use. In a review of treatment studies. have not found excessive production of urine at night in enuretic children (Bath et al. 1996. & Harris. Indeed. the clothes. 1992). Rushton. 1989). Evans & Meadow. the sparse research on oxybutynin indicates limited effectiveness (Walker. 1995. 1989). 1998. appears to relax the detrusor muscle. We suggest first dealing with the daytime wetting by establishing good toileting habits.. Belmaker (1986) reports it to be relatively safe for up to 6 months of use with adults. Thus it is not clear why desmopressin is effective. We argue. In the absence of a physical disorder or significant emotional/behavioral problems or stress. 1995). Furthermore. 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. Studies indicate some success in the first week of treatment with imipramine. & Hertzog. 1986). 1996). desmopressin is expensive (more than $100 per month). previously reviewed. It is. and that this drug should not be used unless there is medical evidence of spasms of the bladder. that a more conservative approach is warranted. but not in children with enuresis. the safety of this medication is problematic. Mol. daytime wetting is most often the result of poor toileting habits. 1992). It is important to note that relapse rates are very high when desmopressin is discontinued (Djurhuus et al. MANAGING COMMON PROBLEMS Imipramine. In combination with the urine alarm.132 II. commonly used for depression. (3) cleanliness training (including cleaning him. Latimer. indicates that increased bladder capacity alone is not enough to eliminate enuresis. and that treatment with desmopressin should be reserved for those children who do not respond to a behavioral approach. and some more minor side effects (Donoghue. however. In addition. Other literature. and the floor if wet) and having the child sit on the toilet for 5 minutes after each wet. 1989). however. The rationale for this intranasal medication is based on studies that found that vasopressin was increased in nonenuretic children at night. including (1) taking data on when the child wets. (4) positive practice.. particularly among children who present with severe wetting and those with behavioral problems (Bradbury & Meadow. Sukhai. 1973. desmopressin has been found to decrease the amount of wetting during treatment. 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%. often prescribed when a child needs to remain dry for relatively short periods of time. which stimulates the kidneys to concentrate urine and decreases the volume of urine during the night. Robson & Leung. Other studies. such as having the child go to the bathroom from different . Oxybutynin is used to reduce spasms of the bladder and increase functional bladder capacity. (2) encouraging the child to empty the bladder fully. but there is almost always a relapse when the medication is stopped (Blackwell & Currah. however. and having him or her sit on the toilet for 5 minutes at those times.. Desmopressin is a synthetic form of the hormone vasopressin.or herself. 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. water intoxication. such as overnight visits or camp. Pillsbury.

the muscles contract to discharge urine into the tube at the lower end of the bladder. (5) charting progress and providing rewards for dry days. and the reinforcement system is gradually faded by increasing the number of dry days necessary for rewards. The parents and child should be told that there may be some regression during the day. Once continence is established. 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. It involves a 1-hour initial interview and the provision of a urine alarm. 1995). 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. and we have also found this helpful for daytime wetting. however brief. and (6) supporting parents and child through regular therapist contact. When this is accomplished.4. Rushton. Our approach is based on information derived from the empirical literature. and Encopresis 133 parts of the house. 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. the internal sphincter muscle then opens. The use of a diagram of the bladder. Whelan. yard. Enuresis. and this is the signal that one has to go to the bathroom. as well as to strengthen the sphincter muscle. and they and their parents find it reassuring that they are not the “only ones” with this problem. 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. & Peterson. The cost is based on 2. it becomes distended. The clinician should begin by describing how urine from the kidney fills the bladder. When the bladder expands to a certain point. Walker. . which functions like a storage bag.5 hours of professional time. such the one in Figure 4. helps both children and parents understand the process. 1987. 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. Most children are not aware of the prevalence of enuresis. 1989. overlearning (increased fluids) is added. they are usually able to sleep for longer periods of time without needing to use the bathroom. called the urethra. if the child continues to wet the bed and wants a treatment program for the bedwetting. Depending on the age of the child. The point is to give the child a picture of what he or she is trying to learn to do—that is. TREATMENT PROTOCOL FOR ENURESIS The specific components of a behavioral treatment program used in our clinic are described in this section. The sphincter muscles close the entrance to the urethra. When the bladder is full. but that with continuation of good toilet habits daytime wets should decrease. and neighborhood. followed by biweekly phone contacts and letters to the child for a period of up to 3 months. 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.5. one can give as brief or as long a description of this process as necessary. Toileting: Training. the urine alarm system can be used.

the wire can be shortened by taping a length of it together with adhesive tape. The snaps can be put on the outer clothing. Urinary tract system. so there is no chance that the child will become caught up in the wire or the leads will be disconnected. change pajamas. without excessive praise or disappointment. going off when it should not or not going off when it should.6). MANAGING COMMON PROBLEMS FIGURE 4. The child’s goal is to “beat the buzzer”—that is. Parents should be instructed to do this in a calm. and the child is given two stickers for following this procedure (Figure 4. so it is important to keep backup alarms in the clinic. matter-of-fact way. The alarm can be unreliable at times.5. does not go to the bathroom. When the alarm rings but the child fails to get out of bed. into the sleeve of the shirt. The next step is to describe the typical stages of treatment. and down into the crotch of the pants. to get up before it goes off or to sleep dry through the night. Data are then recorded. or does not reset the alarm. with the first wet occurring later in the night. If possible. At night. The procedure for using the alarm is as follows. The child should initially expect to wet with the same frequency. the parents should have the child give back one sticker. and reconnect the alarm. Parents go to the child’s room when the alarm rings and prompt the child to go to the bathroom. the child . 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. This is an important step. but the wet spots should become smaller. Then the frequency of the wets will decrease. change the bed. The child is instructed to empty the bladder completely. the alarm should be demonstrated on the child or a parent during the first treatment session. 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.134 II. and a drop of water placed on the cloth near the snaps will set off the alarm. Next. put the soiled linen in the proper container.

Copyright 2002 by The Guilford Press.M.’s Wet Clothing 3-22-90/Thurs 135 9:00 7:00 11:30 P. Schroeder and Betty N. and Encopresis Date/Day Bedtime Time up i n A. Toileting: Training. 6:30 A.M.6.) by Carolyn S. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details). A chart for recording enuresis treatment data.M. From Assessment and Treatment of Childhood Problems (2nd ed. Enuresis.Nighttime Wetting Chart Treatment Child’s Name: _____________________________________________________________________________ Age: ______________________________________ Address: ______________________________________________________________________________________________________________________________ _ Time (Wet/Beat Buzzer) 4.M.J. Size of Wet Small Medium Large Sample Beat the Go to Change Change Dispose of Buzzer Bathroom Sheets P. 4:00 A. 135 . ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ FIGURE 4. Gordon.

Dr. they should use the alarm again until the child has 30 consecutive dry nights. to further strengthen the newly learned behavior of sleeping through the night dry. Have you noticed that you are also sleeping longer before you “beat the buzzer” or wet? That is just what we want to happen. in which the child drinks 6–8 ounces of his or her favorite liquid (drinks that are diuretic. Intermittent Use of the Alarm The next phase of treatment is to use the alarm on an intermittent schedule. at which time an overlearning procedure is instituted. Overlearning Procedure After 14 consecutive dry nights. 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. Wow! You must be very pleased with yourself! Four dry nights in one week. 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. We find that with the use of the overlearning procedure and the intermittent alarm schedule. Soon the child will be waking without the alarm with greater frequency and will no longer wet the bed.136 II. reinstituting the alarm quickly resolves the problem. relapses are rare. 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. and to get up if necessary to go to the bathroom. this will help him or her to learn to sleep through the night without the alarm. 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. and will eventually sleep through the night without needing to void until morning. Schroeder . The parents should be asked to disconnect the alarm two nights during the first week. The child should be told that on some nights the parents will disconnect the alarm after he or she has gone to sleep. such as cola and tea. Finally. when they do occur. Because the child will not know when the alarm is connected. They should be warned that there may be some accidents. Keep up the good work. but that this is to be expected at this stage of the training. an overlearning procedure is implemented. you are already having dry nights. should be avoided) before bed. Thank you for being so prompt in sending your chart to me. The alarm should be removed at this time. MANAGING COMMON PROBLEMS will start to “beat the buzzer” and awaken to void before actually wetting the bed. but if wetting occurs more than once a month for 2 months. and then to increase the number of nights after each completely dry week until the alarm is no longer connected. This phase of the treatment should continue until there are 14 more consecutive dry nights. The time it takes to go through this process can vary from 1 to 3 months. The goal is to get 14 consecutive dry nights. but remember to tell yourself to “beat the buzzer” before you fall asleep. and on the other nights the wet spots were small. the child can expect to sleep longer and longer between wakenings. The parents and child should be reminded that relapses are not unusual. Enjoy your dry nights! Sincerely. After three weeks of using the buzzer.

A referral to an occupational therapist resulted in a diagnosis of mild dyspraxia—that is. To rule out the presence of significant emotional or behavioral problems. The clinician should review the data. 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. Andrew reported that he still had occasional accidents during the day when he delayed going to the bathroom because he was playing.6) to the clinic every week. Andrew had been seen in our clinic at age 5 regarding readiness for school. Enuresis. An evaluation at that time indicated a verbally bright child with poor visual–motor organizational skills. observe the course of treatment. . and was currently doing quite well in second grade. reading. and playing computer games). help in setting up a reinforcement system. The request for treatment had come because Andrew wanted to have friends over.3) for 7 days prior to their appointment. Andrew was described as a well-adjusted child who had a number of close friends. the single mother of a 7-year-old boy. 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. and call the parents if necessary. O’Dell and Andrew came in together for the initial interview. They will need instructions on how to keep data. and Encopresis 137 Intervention with the Parents The parents’ motivation to implement the treatment program is critical for success.4. Andrew was initially bowel-trained and then bladder-trained. Step 2: Parent and Child Interviews Mrs. and the PSI. The child had recently had a physical examination. Andrew. the physician encouraged him to do this and to be sure the friends slept in the same bed with him. She was also asked to complete a nighttime wetting record (Figure 4. and preferred quiet activities (such as rock collecting. Bladder and bowel training during the day was started at 2½ years and completed at age 4. The physician had suggested that he be made to sleep in his soiled sheets for a minimum of 2 weeks before washing. and go to a week-long overnight camp in the summer. O’Dell. and regular feedback. A phone call at least every 2 weeks is important to support the parents and answer any questions. These accidents occurred approximately once a month. Toileting: Training. difficulty in motor planning skills. When the child indicated that he wanted to have some friends spend the night. O’Dell was a licensed practical nurse who worked the day shift at a local nursing home. Neither the mother or the child was pleased with this advice. was doing well in school. spend the night with friends. and the mother decided that they would seek help from a psychologist. called the clinic regarding treatment of her son’s bedwetting. They also should be given addressed envelopes to mail their data charts (see Figure 4. the CBCL. The child had a course of treatment with the occupational therapist. went on to kindergarten. CASE EXAMPLE: ENURESIS Step 1: Initial Contact Mrs. and the physician had indicated that there was no organic basis for the bedwetting. A review of the parent assessment instruments indicated that Mrs. the mother was asked to complete the General Parent Questionnaire. She had been divorced for 4 years. the ECBI. Mrs.

but the mother felt that Andrew was already waiting too long before going to the bathroom. Andrew was attentive during the interview. Mrs.138 II. They were told that wetting the bed seemed to be an isolated problem for Andrew. and the wrist alarm system was demonstrated. was already sleeping dry through the night. with regular daily routines. so he would have more opportunities to practice sphincter control. had his first wet at 11 to 11:30 P. had friends. The record also indicated that Andrew would often put a blanket over the wet spot. he would change his clothes and spend the rest of the night in his mother’s bed. Step 5: Referral to Allied Health Professionals The medical examination had been done prior to the initial contact.M. He was also instructed not to change his consumption of liquids before bedtime and to increase fluids during the day. had a variety of interests. The size of the wets varied from medium to large. information was shared on bladder functioning and enuresis.M. Course of Treatment In the first week. and got up at 7 A. wet again between 3 and 5:30 A.. no one in her or Andrew’s father’s families had a history of enuresis.M. Andrew beat the buzzer one night. and in fact had done nothing about it.M. O’Dell did not consider the bedwetting as a problem for her.. if the wet was too large. and the atmosphere in the home was described as calm. he was instructed to start and stop the flow of urine three to five times each time he urinated. A younger sister. and wet once on three nights. Next. all the information indicated that he was a well-adjusted child. and the rationale for the specific treatment recommendations was given. During the second . There had been no major changes for this family in the last year.. Nighttime wetting data forms and stamped envelopes were given to the mother and child to complete and return on a weekly basis. wet two times a night for three nights. Step 4: Further Assessment No further assessment was indicated at this time. He enjoyed the demonstration of the alarm and was enthusiastic about starting the program. Given that Andrew had periodic difficulty making it to the bathroom during the day. The purpose of this was to strengthen his sphincter muscle. The size of the wets was medium to large. and was doing well in school. Andrew was clearly interested in stopping the bedwetting for legitimate reasons. Although Mrs. he soon contributed information readily. Bladder retention training was considered. MANAGING COMMON PROBLEMS To the mother’s knowledge. Step 3: Observation of Behavior The nighttime wetting chart indicated that Andrew went to bed at about 8:30 P. she was supportive of Andrew and agreed to help with the program. He was well accepted by his family. Step 6: Communication of Findings and Treatment Recommendations The findings were summarized for Andrew and his mother. and although he was initially reticent. in short. O’Dell was respectful of his input and often deferred to him in answering questions. age 4.

which is used by the child to control the environment. Another useful distinction among types of encopresis is made by Walker (1978).5% to 7. with encopresis four to five times more common in boys than in girls (Doleys. 1994).) Encopresis is thus a heterogeneous problem. & Cineinero. and (3) “manipulative” encopresis. 2000). and soiling is intermittent. 1981). and had one small wet on each of the remaining four nights. and age ranges make it difficult to compare results. 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. Toileting: Training.4. DSM-IV lists two subtypes of encopresis. Estimates of occurrence range from 1. Andrew had 30 days dry. which is the result of constipation. and Encopresis 139 week. Although to date there are no well-established interventions. In the third week. he slept dry through one night. but it has received far less attention in the scientific literature than enuresis. settings. and had three nights with one wet. 1990). feces are normal in form and consistency.7% of all clinic referrals (Olatawura. & Murphy. and appropriate treatment will depend on a careful analysis of the problem for the individual child. He beat the buzzer on two nights. This problem has been around for a very long time. and within 8 weeks Andrew had 14 consecutive dry nights. beat the buzzer two nights. 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. The course of treatment was unremarkable.” there is no constipation. with most well-controlled research beginning in the 1990s. continuous leakage that occurs during the day or at night. which also includes poorly formed feces.” Constipation is the essential feature of this subtype. 52–64% of medically treated children evidenced persis- . Although there is evidence that the prevalence of encopresis declines to about 0. 1989) and 5. the size of the wets was small to medium. The incontinence is typically resolved with treatment of the constipation. Schwartz. This second type of encopresis is thought to be associated with oppositional defiant disorder (ODD) or conduct disorder. wet two times on two nights. 1973). The etiology and treatment of these cases may differ. 1960). and the differences among these studies in definitions. The first of these is “with constipation and overflow incontinence. although it is not in the DSM-IV criteria.5% of children ages 6–12. In encopresis “without constipation and overflow incontinence. Overlearning and later intermittent use of the alarm were then instituted. 4 months from the start of treatment. Mellon. (Our own treatment protocols for encopresis are based on this distinction.75% of children by age 12 (Houts & Abramson. which involves either poor toilet training or chronic diarrhea and irritable bowel syndrome (the apparent results of stress). Enuresis. After a period of slight regression. Encopresis and constipation account for 3% of all general pediatric visits and 25% of all pediatric gastroenterology visits (Sonnenberg & Koch. A distinction should also be made. more information is now available to help guide the clinical treatment of encopresis (McGrath. There are few epidemiological studies of encopresis. and only small amounts of feces passed during toileting. see below. and the time of wetting was later. who classifies these as follows: (1) “retentive” encopresis. (2) “nonretentive” encopresis.

. Basile.” 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. 1982). Children with encopresis are found at all socioeconomic and intellectual levels (Walker. & Bonner. 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. & Savage. 1993. structural anomalies or diseases of the bowel or sphincters (obstructing lesions or tumors). 35% of girls and 55% of boys reportedly have concomitant soiling (Staiano et al. 1992). 1987). In contrast. McKay. chronic abdominal pain. but there is little additional support for a genetic basis for this disorder. & Auricchio. 1979).140 II. and lethargy (Levine. Thus this problem will persist into adolescence and adulthood for many children. as well as of the nervous system (myelomeningocele. 1994). which results from an absence of both the ganglion cells and the normal peristaltic waves in one segment of the bowel. 1993). & Behrman. 50–60% of these cases had previously been successfully toilet-trained (see Christophersen & Rapoff. Abrahamian and Lloyd-Still (1984) reported that 50% of their chronically constipated patients had a positive family history for encopresis. Belanger. diet. and the clinician should distinguish these conditions from encopresis. 1994). Greco. 1988). Constipated children who had this abnormal anal pressure were significantly less likely to improve after conventional laxative. Etiology Organic Factors By definition. several organic problems can cause fecal incontinence. Andreotti. 1993). resulting in an enlarged colon or “megacolon. Parents rate these children as also having poorer self-esteem and more emotional and behavioral problems than other children (Bernard-Bonnin et al. For example. 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. Hirschsprung’s disease. It is not surprising that approximately 25% of encopretic children are also enuretic. Cruikshank. with children reporting pain as the worst consequence of constipation (Bernard-Bonnin et al. MANAGING COMMON PROBLEMS tent constipation 3½–5 years after the intervention (Bernard-Bonnin. Staiano. encopresis is functional in nature. spina bifida). Other organic problems can result from dietary factors. given the pressure that an impacted colon can put on the bladder (Levine. 1975). In this disorder. however. Common physical symptoms associated with encopresis include poor appetite. and infectious diseases of the large intestines. Milling. Haley. fecal material becomes impacted above this segment. & Nadeau. It is estimated that 80–95% of children treated for encopresis have chronic constipation (Levine... can cause fecal incontinence. and toilet training treatment than constipated children who did not have this problem. 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. among children with constipation. Some milder cases may not be discovered until much later. . 1975). allergic reactions to food. is common in children.

of course. changes in routine can also lead to toileting . the psychiatric literature has viewed encopresis as a symptom of severe emotional problems. the empirical literature does not indicate any association with a particular disorder (Young et al. Although encopretic children in general have more behavioral. sitting on a toilet). 1995). 1992. Shapiro & Henderson. Certain lifestyles can also promote constipation. with psychological conflict as the primary catalyst for the onset of the problem (Halpern. 1987. emotional. Stark et al. 1984. & Leibowitz. 1984. Young et al. a chaotic home environment with inconsistent daily routines can lead to a breakdown in toileting habits. 1997). 1977). Milling. aggressive training techniques. It is not clear. As noted above. Christophersen. Family problems. and Encopresis 141 Emotional Factors Traditionally. A sedentary lifestyle can also promote constipation. DSM-IV indicates that encopresis without constipation and overflow incontinence is usually associated with ODD and conduct disorder. Similarly.. (2) the physical condition of chronic constipation may result in a breakdown in the learned cognitive control of the bowels. Toileting: Training. Moreover. Learning Factors The empirical literature supports the view that learning principles play an important role in the etiology of encopresis (e. some children develop a fear of the toilet as the result of a painful bowel movement. important to understand the part that child and family problems can play in the successful treatment of this disorder. or (4) stress or anxiety may lead to impaired bowel control. with a consequent loss of successful performance of toileting behaviors. 1995). however. could set the stage for encopresis. whether these problems cause or are secondary to the severe constipation. 1988). 1976. and Bonner (1988) propose that (1) children may not have acquired the prerequisite skills for toileting (recognizing body cues. for example. Some children.. & Baker. which can cause constipation. (3) a child’s soiling may be reinforced through his or her manipulation of the environment. Mathews. or a hospitalization) related to the onset of soiling can be identified in some cases (Abrahamian & Lloyd-Still. exercise is an important element in keeping the gastrointestinal (GI) tract working properly. Others report that a specific stressful event (such as loss of a parent. Moreover. have diets that contain little fiber and/or a predominance of dairy products. and that some children with encopresis exhibit significant problems.. It is. and most emotionally/behaviorally disturbed children are not encopretic (Young. Baker. these problems are not usually clinically significant. 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.g. emotional factors alone cannot account for the etiology of encopresis. however. or fearful fantasies regarding the toilet. and social problems than children in the normal population. undressing. Walker (1995) makes the observation that family turmoil and conflict are common when children have encopresis. Friman. going to the bathroom on cue. These fears can disrupt the training process or the use of appropriate toilet habits. 1995).4. Walker.. In addition. Brennen. resulting in soiling accidents. Finney. birth of a sibling. 1975). Enuresis. Levine & Bakow. Levine. punitive consequences following a soiling accident. it is important to note that successful treatment typically results in improvement in various behavioral/emotional problems (Owens-Stively. however. Although it is not surprising that emotional and behavioral problems can play a part in encopresis.

in school) can result in constipation and/or soiling. 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. ASSESSMENT OF ENCOPRESIS The assessment process presented here follows the CAIS (see Chapter 2). On average. the clinician must have a basic understanding of normal defecation. The ability to control defecation depends on adequate enervation of the colon and anus. Schaefer (1979) and Walker. where water is reabsorbed and the waste material is formed into fecal material or “stools. about 1% of the normal population has a bowel movement fewer than three times per week or more than three times per day. First. .7. The peristaltic action resulting in the urge to defecate is usually strongest 15–30 minutes after breakfast. Finally.. Gastrointestinal (GI) system. The passage of feces through the intestinal tract is the result of a series of wave-like motions of the entire tract (“peristalsis”). three-quarters of food waste is excreted within 96 hours. The normal stool should be soft. and Bonner (1988) provide the following description of the GI system and of the process resulting in constipation.142 II. and should have a distinct shape. Distension of the rectum by the arrival of additional fecal material creates the urge to defecate. MANAGING COMMON PROBLEMS problems. should be moist on the outside surface. but some people experience a rush after each meal. but there are wide individual differences. as well as on the child’s ability to relax and contract the external sphincter purposively.” which are excreted through the anus.g. with a focus on information pertinent to the problem of encopresis. Although most people have a bowel movement every day. delaying toileting because a toilet is not readily accessible or because a child is embarrassed to go to the bathroom (e.7). which involves a coordination of physiological and behavioral responses (see Figure 4. The FIGURE 4. Milling.

it forms a pool above the impacted feces in the colon.8) and loses its muscle tone. and Encopresis 143 toilet training process teaches the child to recognize and respond to the stimulation of the rectum. Copyright 1982 by M. dry. Because the passage of this material is not accompanied by the usual sensation of the urge to defecate. In some cases. As fecal material continues to accumulate. one can readily see that chronic constipation is likely to inhibit learning of bowel control or to interfere with previously learned toileting skills. The intestinal wall becomes thin as a result of stretching caused by the impacted fecal material. and the stool becomes hard. see Figure 4. In the meantime. Megacolon: Patient training diagram. staining the child’s clothes with a paste-like material. . and then to relax the external anal sphincter voluntarily when he or she is seated on a toilet or potty chair (Walker. Children are reluctant to expel hard. consequently. This fluid material then seeps around the impacted mass and out through the anus. large stools. the urge to defecate passes. Enuresis.8. & Bonner. Used by permission. When this process is repeated many times. the child does not realize that it has happened until he or she feels wetness in the rectal area or on his clothing. and a chronic state of constipation results. the large intestine becomes so impacted with feces that the entire abdominal cavity is filled. which are painful. Given that neither the seepage nor the explosive bowel movements are under voluntary control. Toileting: Training. If for any reason the urge to defecate is not responded to. MD. Milling. D. At other times large amounts of the impacted material may be explosively expelled. 1988). the fecal mass is redeposited into the lower end of the colon by reverse peristalsis.4. the colon is constantly absorbing water from its contents. bowel function is compromised. the intestine becomes enlarged (“psychogenic megacolon”. as fluid from the small intestine makes its way to the large intestine. FIGURE 4. and constipation may result. Levine. and difficult to pass. causing major soiling of the clothes. Then. and normal peristaltic and mass movements are not able to evacuate feces fully from the bowel. With impaction. the normally empty rectum tends to become accustomed to the increased pressure caused by the presence of stool.

The CBCL (Achenbach. the clinician should investigate the possibility that the encopresis is the result of manipulation on the child’s part. paste-like stains. however. and the ECBI (Eyberg & Pincus.. The clinician should determine whether any of these events occurred close to the time the soiling started. 1992).144 II. 1995). Have there been recent stressful life events for the family or the child? A review of family history is important.. and nature of the stool (e. frequency of bowel movements (children can go several times a day in small amounts and still be constipated). responsiveness of the child. 3. etc. The parents should be asked to keep data on bowel and toilet activity for at least a week (Figure 4. 1991a. an illness or death. our General Parent Questionnaire. and data on food and liquid intake as well as physical activity for 3 days (Figure 4. 5. 1992) or the BASC (Reynolds & Kamphaus. Previous treatment attempts should also be described in detail. 2. as is the parent–child interaction in regard to this issue.g. What is the current status of toileting habits and bowel movements? A thorough review should be made of the bowel movement data. soft. 4. If there is significant psychopathology. small stools or occasional enormous amounts that are painful or difficult to pass. including the age at which it was begun. and the age at which both daytime and nighttime continence were achieved (if at all). How did toilet training proceed? Parents should be asked to describe the process of toilet-training their child. methods used. Current toileting habits (time of day. A . then continued collaboration with the physician is necessary to coordinate the use of cathartics.10). We have found that even if emotional and behavioral problems are present.g. 1999) are recommended for this purpose. or serious parent–child conflict. treating the encopresis generally helps to improve these problems. length of sits).. noncompliance. a new school. MANAGING COMMON PROBLEMS 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. and these issues should be treated before the encopresis.). with an emphasis on stressful life events (e. runny. 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. parent separation.9). If the child is chronically constipated. hard. a household move. A general questionnaire (e.g. see Appendix B) and checklists to rule out emotional or behavioral problems should be sent to the parents prior to the initial interview. the PSI (Abidin. a hospitalization. Step 2: Parent and Child Interviews The child and parents should be seen together for the initial interview. This information will help the clinician determine whether the child actually was taught and/or learned appropriate toileting skills. The interview should focus on the following questions: 1. or an unusual foul odor) should be noted. 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. the birth of a sibling. The child’s perceptions of the problem and willingness to engage in a treatment program are important to assess.

145 . 3:00 P. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details). etc. 6:00 P. Gordon. milk of magnesia.) by Carolyn S. Copyright 2002 by The Guilford Press.M.9. Chart for recording bowel movements during baseline and treatment.M. S ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Mother cleaned up " Painful BM 1Cathartics: Suppository (S). Enema (E).Bowel Movement Chart Baseline/Treatment Child’s Name: _____________________________________________________________________________ Age: ______________________________________ Address: ______________________________________________________________________________________________________________________________ _ In Toilet In Pants Consistency Size Runny/ Soft/ Small Medium Large Paste-like Hard Unformed Formed Sample 3-21 " " 145 Date Time Cathartics1 What Happened? 4. Schroeder and Betty N. FIGURE 4. From Assessment and Treatment of Childhood Problems (2nd ed. and Encopresis 10:00 A. Enuresis. Oral (O)—mineral oil. Toileting: Training.M.

How do the child and parents perceive the problem? The child’s beliefs. Does the child hide his or her underpants. . 1998)? The dietary and exercise data also should be reviewed at this time. treatment will fail. Diet/exercise record for baseline data. Thus it is important to assess their motivation for treatment. which might indicate the use of punishment (Friman & Jones. MANAGING COMMON PROBLEMS Diet/Exercise Record Child’s Name: _____________________________________________________________________ Day 1 Date/Day Breakfast Day 2 Day 3 Snack Lunch Snack Dinner Snack Exercise Comments FIGURE 4. Copyright 2002 by The Guilford Press. “Why are you seeking help now?” Treatment of encopresis requires considerable effort and vigilance on the part of both parents and child.) by Carolyn S. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details). and concerns about the problem should be assessed. without their full cooperation. It is always important to ask. to determine whether these might be factors contributing to the problem. feelings.10. From Assessment and Treatment of Childhood Problems (2nd ed. Gordon. 6. chaotic environment with irregular meals or a stressful time schedule can interfere with consistent toilet practices.146 II. Schroeder and Betty N.

including play therapy.4. medical treatment that involves the use of enemas to cleanse the bowel and laxatives for ensuring regular bowel movements is almost always the first . child psychotherapy. which can involve initial cleaning of the bowel. dietary recommendations of increased fiber and water. TREATMENT OF ENCOPRESIS A brief review of the treatment literature is given in this section. McGrath et al. parenting skills. Collaboration with the physician is often necessary for a child with encopresis. the clinician should engage in more systematic observation of parents and child. In communicating the recommendations to the child and family. Step 5: Referral to Allied Health Professionals A physician should see the child prior to the initial interview. (3) behavioral interventions. skills-building techniques. Step 6: Communication of Findings and Treatment Recommendations It is strongly recommended that the child be present to hear the findings and recommendations. including the importance of consistency in carrying out its component parts. parent support. especially if the child is impacted and/or cathartics are used in the treatment program. this cooperation is essential to resolving bowel problems. punishment via overcorrection and cleanliness training. see McGrath et al. including reinforcement. enhances the likelihood that the parents and child will cooperate with treatment. (2000) indicate that interventions have included (1) medical treatment. it is important for the clinician to give them information about the GI system and the rationale for the treatment program. classical conditioning. multidetermined problem for which there is no well-established “best” treatment. and (4) psychotherapeutic interventions. with the goal of identifying additional areas in need of attention or to change the treatment focus. and home practice of sphincter tightening and relaxation. The family’s clear understanding of the problem and the proposed treatment process. which can involve strengthening of the external anal sphincter’s contraction. with a focus on the most successful treatments to date. For example. and a sitting schedule. If the parents report significant management problems. (2000). ongoing use of laxatives. Again. Step 4: Further Assessment Further assessment is necessary only if other problems are suspected. and awareness training. For a more comprehensive review of the literature. and family therapy. Enuresis. Toileting: Training. The influence of encopresis on the child’s development in other areas should also be discussed. For children with retentive encopresis. it is very likely that a child presenting with manipulative encopresis will need further evaluation. and Encopresis 147 Step 3: Observation of Behavior Data on bowel habits and informal observation of parent–child interaction are usually all that are needed. as noted above. sensory discrimination training. (2) biofeedback interventions. Encopresis is a complex.

then the addition of biofeedback can serve to decrease the focus on behavioral interventions and decrease the overall effectiveness of treatment (Cox. A brief review of a few successful programs for children with constipation and fecal incontinence follows. then an enema is given. 1997. the parent inserts a glycerin suppository. plus a systematic way to collect data on these changes). 1998). caution that “more is not always better. and these are described in the following treatment protocol section. the addition of biofeedback enhances the medical interventions’ effectiveness. Stark.g. Whitehead. just as with other emotional and behavioral problems. for an in-depth description of this procedure). the child’s clothing is examined for soiling.g. if it is soiled. this program has resulted in cessation of soiling in 100% of cases. Thus these areas will require some interventions. the child is instructed to sit on the toilet again. (2000) also report that when a child has not evidenced a complete elimination of symptoms by 6 months after treatment. and the child is instructed to dress. an additional cathartic-free day is added until the child is defecating completely independently (see Walker.148 II. 1990) describe a promising 6-week group treatment protocol that does not include the . if this attempt is successful. Then. 1998). the individual needs of the child must be taken into consideration if a treatment program is to be effective. Ling. Wright (1975) has described a highly successful procedure for retentive encopresis. Stark and colleagues (Stark et al.” and warn that unneeded treatment strategies can result in decreasing the effectiveness of treatment. 1988. Failure to improve during the first 2 weeks of intervention has been found to predict nonresponse at 3 months (Cox et al. prepare for school.. and have breakfast. Some physicians and parents resist using enemas and suppositories repeatedly.. In addition. For example. sitting on a chair for 10 minutes) is administered. No reward is given if an enema is needed to produce defecation. Quillian. especially for children who have had severely impacted bowels. pp. Stour. & Bonner. he or she is praised and given a reward. At the end of the day. many children who have retentive encopresis have not developed good toileting habits.. however. if a child does not have abnormal defecation dynamics. Yet McGrath et al. a different or a more intensive intervention should be considered. MANAGING COMMON PROBLEMS step in the treatment protocol. After breakfast. 1985). Spirito. McGrath et al. We have also found this program to be the most effective method of treatment. Owens-Stively. in the morning immediately upon awakening. effective treatment is related to a shorter duration of symptoms (Lowery. the child is given another reward. so early intervention increases the chances of complete elimination of symptoms. Training proceeds in this manner until the child has 2 consecutive weeks with no soiling.. the child is told to sit on the toilet and attempt to have a bowel movement. Milling. Thus. Moreover. usually through the use of enemas administered by the parents under a physician’s direction. Furthermore. Then the cathartics are discontinued for 1 day of the week. Likewise. If the child produces ¼ to ½ cup of feces. for children with constipation and abnormal defecation dynamics. Sutphen. 388–391. The first step in the program is to ensure that all fecal material is removed from the colon. & Schuster. & Borowitz. 2000).. the child is given a reward. a mild punishment (e. Walker and colleagues report that when properly applied. The combination of behavioral approaches and medical intervention has been demonstrated to be more effective than medical treatment alone (McGrath et al. Lewis. If the second attempt is unsuccessful. or their environment does not support good toileting habits. but one smaller than the one for defecating independently. & Guevremont. dietary changes without systematic information on foods with fiber and the importance of water consumption. and as each week is soil-free. If the child produces less than that amount or nothing. which includes the systematic use of suppositories and enemas as well as behavioral techniques. If it is clean. recommendations that do not include a systematic way for the family to implement them may not be helpful (e.

A brief description of the digestive system and of where the problem may lie for the particular child should be given in simple language . Although it is not possible to determine the unique contributions of each treatment component in this study. lifestyle changes (e. increased dietary fiber. Stark et al. to help change their inappropriate beliefs or attitudes about the problem and to facilitate understanding and cooperation. and contracting). Each protocol should be modified to meet the needs of the individual child. especially given the costeffectiveness of group treatment and the absence of laxatives after the initial bowel cleanout. and stress reduction techniques. & Gabel. and training in synchronization of internal and external sphincter responses (Whitehead. Their protocol uses enema cleansing. 1986. exercise and diet). it would seem best reserved for those cases that do not respond to standard treatment or that have a clear organic basis (Walker. as well as the teaching of appropriate toilet habits. 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). dietary. it demonstrates the value of a combined approach with a systematic focus on a diet of increased fiber and water consumption. and because this form of treatment is invasive. Enuresis. 1990). and (5) consequences for appropriate and inappropriate behaviors are changed. (2) medical. contingency management. and increased water consumption (with specific instructions and data collection). 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. Chiponis. Toileting: Training. Chandra.g. (3) appropriate toileting behaviors are taught or increased. followed by protocols for nonretentive encopresis and manipulative encopresis. 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. and Encopresis 149 continuous use of laxatives. training in discrimination of rectal sensations. This approach was successful in 6 weeks for the majority of children (86%).. It includes the following components: (1) Information is provided to the parents and child. 1992).4. Retentive Encopresis Information Sharing The parents and child should be told that encopresis with constipation is not an uncommon problem. (1997) note that even children who “failed” treatment showed improvement over baseline. The particular components of a treatment protocol for retentive encopresis are described. and exercise interventions are used to correct the physical problems of chronic constipation or chronic diarrhea. These results are impressive. and a number of these children benefited from either brief individual behavior therapy or anal sphincter biofeedback. TREATMENT PROTOCOLS FOR ENCOPRESIS We have come to view encopresis as primarily a “plumbing problem” that most often requires medical intervention. and that early treatment can help to alleviate it. This form of treatment involves exercise of the external sphincter. and daily toilet sitting (with behavior management strategies—differential attention. (4) environmental conditions are changed to facilitate the acquisition of the correct responses. 1995). Loening-Baucke.

7) showing the GI tract. A star for each time the child complies with the routine. and sorbitol have each been used for this purpose. The use of a diagram or simple drawing (Figure 4. even if they have. Kugler. The dose should be sufficient to produce one or more daily bowel movements. The idea is to promote several loose bowel movements daily. The child should be shown how constipation can cause the colon to get out of shape (Figure 4. and fancy stickers for successful defecation.9). The type of enema used should be one that is safe for repeated administration. MANAGING COMMON PROBLEMS appropriate to the child’s level of understanding. and then gradually decrease the use of cathartics over a period of several weeks as bowel movements come under the child’s control. With chronic constipation. A timer can be used so the child can sit independently. then he or she does not have to sit after the next meal. with points exchanged for rewards at a later time. In addition. mineral oil. If the child is successful in defecating ½ cup or more of feces. so the child can learn to tune in to the cue. & Bauer. has proven very helpful with our parents and children. 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 also imperative that the child’s feet be firmly planted on the floor or a stool to aid in expelling feces. however. he or she can sit upon returning home). which then results in uncontrollable seepage (the paste-like stains) or very large bowel movements. the appearance of normal bowel movements (large. the dose should produce the urge to defecate. 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. the use of enemas may have to be repeated (Davidson.1) can be used. such as Children’s Fleet Enemas. Many encopretic children have not learned proper toileting habits. the onset of constipation usually disrupts these once-learned skills. Keeping a chart in the bathroom is a good way to record sitting on the toilet and successful defecation (see Figure 4. the bowel will have to be cleansed of impacted feces with one or more enemas. Once the impacted mass is removed from the colon. Intervention with the Child Physical Intervention. and that the toilet seat be comfortable.150 II. 1963). 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. Finally. well-formed) should be described. lactulose. It should be stressed that the colon has to be evacuated regularly in order for it to begin to function properly. none of these products should be used without consultation with the child’s physician. Depending on how severely impacted the child is. . a chart system (see Chapter 12. Development of Toileting Skills. and bowel movements are no longer painful. Suppositories. Needless to say. instead of a dose calculated by body weight or a fixed dose. It is important for the child to sit long enough to evacuate all the feces. The requirement of sitting should be handled in a matter-of-fact way. Figure 12. and enemas should always be given under the direction of a physician. are good reinforcers for young children. moist. Constipation can also make it difficult to feel the urge to defecate and to empty the colon completely of feces. For older children. with some discussion of where things can go wrong. As regularity increases. Thus finding the correct dose will take some attention. 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. and this should be practiced on a regular basis. the sitting times will naturally move to the times when the child gets the urge to defecate.8) and not work properly.

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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) All-Bran (cereal) Bran Buds (cereal) Bran Flakes (cereal) Fiber point rating 7 Food (normal serving) Carrots Celery Brussels sprouts Kidney beans Corn (canned or fresh) Peanut butter Cabbage Tossed salad (lettuce) Oatmeal pancakes 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 Apple (with skin) Turnips Pear (with skin) Popcorn Banana Squash Green beans More than 20 ounces of milk per day More than 2 cookies per day Cake Saltine crackers Ice cream Fiber point rating 3

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

6

2

Total (cereal) Fruit and Fiber (cereal) Baked beans Nutri-Grain (cereal) Peas Brown rice Shredded Wheat (cereal) Parsnips Sweet potatoes Broccoli Nuts (at least 10) Whole wheat spaghetti Water consumed at one sitting 8 ounces 12 ounces 16 ounces Miscellaneous notes

5

1

4

–1

Points 1 2 3

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.)

4. Toileting: Training, Enuresis, and Encopresis TABLE 4.1. (cont.) Food preparation ideas 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

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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

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.

I

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
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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 Simple motor Examples 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 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) Coughing, “hawwwwk” noises, squeaking, “aaaaa,” “tttttuh,” throat clearing, “uh, uh, uh,” blowing across upper lip, popping sounds, snorting, gnashing teeth, swishing “Uh huh,” “you bet,” “all right,” “yeah,” palilalia (repeating one’s own words, phrases, sentences), swearing, obscene language of noises, racial or colloquial insults

Complex motor

Simple vocal

Complex vocal

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

& Whitmore. Environmental etiologies include emotional tension (Bakwin & Bawkin. 1972) and serious home conflicts (Feldman & Werry. and 13 years. Habits and Tics 167 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. In addition. Unlike children with TD. Tizard. whereas the opposite is true for TD. Shapiro. 1966).500 children ages 9. with a peak frequency reached at 6–7 years of age. 1976).S. but the head or entire torso may also be involved. but Rutter et al. however. such tics are estimated to occur in 1–24% of children (Azrin & Nunn. it is difficult to determine its exact prevalence. and only a small percentage will show no change or worsening of tics. Moreover. Allen. 1992).. Graham. 1979). the typical onset is between 5 and 7 years (Berkow. with the overall prevalence rates at 3–18% for boys and 0–11% for girls (Zohar et al. & Feinberg. & Sullivan. A lower prevalence rate was found in the Isle of Wight Study (Rutter. Etiology of Transient and Chronic Tic Disorders There is little agreement on the etiology of transient and chronic tic disorders. 1977. Yule. Given that this disorder is transient by definition. and there are no prospective longitudinal studies of epidemiological samples of children with transient tics. Psychodynamic theorists argue that tics represent repressed feelings or conflicts expressed in a symbolic manner (Cavenar. MacFarlane. Some behavioral theorists assert that both chronic and transient tics are learned responses that are maintained by operant conditioning (Azrin & Peterson. Young. Chronic motor or vocal tic disorder is thought to be similar to but less severe than TD. with age of onset between 4 and 12 years. Chronic motor or vocal tics are estimated to occur in approximately 1. but not both. children with chronic motor or vocal tic disorder do not present simultaneously with both types of tics.. especially between the ages of 4 and 8 years. 1999). occurring throughout a period of more than 1 year. Teachers in this study reported that 5–6% of school-age boys and 1–2% of school-age girls had “twitches. 11. It is estimated that 24–61% of children presenting with tics will have complete remissions without treatment. Azrin and Nunn (1973) argue that tics may either start as normal reactions to physical or psychological trauma and continue . vocal tics occur less frequently than motor tics in chronic tic disorder. The most common form of transient tic is the eye blink or other facial tic. set a relatively strict criterion that a tic had to be significantly interfering with the child’s life.” Hence tics are not unusual in children. and Honzik (1954) reported that 4% of the children evidenced tics. In the Berkeley Growth Study. However. however. 1988). Spaulding. population (Shapiro et al. Shapiro. Chronic Motor or Vocal Tic Disorder DSM-IV characterizes chronic motor or vocal tic disorder as either single or multiple motor or vocal tics.5% for motor tics and <1% for vocal tics that lasted 3 or more months.6% of the U.5. In a sample of 4. there is a gender difference for chronic tics in children. The rates for children. occurring almost every day for at least 4 weeks and for no longer than 12 consecutive months. with no tic-free period of more than 3 consecutive months during this period. with less variablity in the frequency and type of tics. Most of the remainder will improve. 1988). Costello et al. are higher. Boys are affected two to three times more often than girls. (1996) found a prevalence rate of 3. 1988).

is one of the least effective of the behavioral approaches. It is distinctive from the other behavioral approaches in its use of competing responses to prevent the occurrence of tics (Carr. a recent longitudinal study found that childhood tics predicted symptoms of obsessive–compulsive disorder in adolescence (Peterson. 1994). or persistent. Given the frequency of transient tics in children.. intense. Pine. 1994). 2001). Moreover. Overall.168 II. See Watson and Sterling (1998) for a detailed review of the various behavioral techniques used with tics.. Most tics in children are not acccompanied by other disorders (Watson & Sterling. These movements can then result in strengthening particular skeletal muscle groups and weakening the antagonistic muscles. 1958). as a family history of tics is found in 10–30% of all cases (Matthews et al. It also appears that some tics can be precipitated by phenothiazines. . The duration of the tics (for more than one year). 1992). limited awareness of engaging in the behavior. 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. Treatment using habit reversal is comprehensive and includes 10 different components. 30 minutes) interspersed with brief rest periods (e. 2001). it seems probable that tics and their phenotypic expression or severity arise from various interactions of developmental issues. followed by the emergence of vocal tics and a subsequent diagnosis of TD (Cohen. which reduces tics by up to 90% in the home environment and 80% in the clinic setting (Peterson et al. and life experiences. Behavioral treatments have included contingency management (the use of positive reinforcement and punishment). It is estimated that approximately 5–24% of children with transient tic disorder will develop chronic motor tic disorder. 1998). and social tolerance of the tics.g. Habit reversal is based on the premise that tic behaviors are maintained by response chaining (linking a sequence of conditioned responses by reinforcement). however. and habit reversal instruction (the use of competing responses and other methods to prevent the occurrence of tics) (Peterson et al. Genetic factors may also play an important role in the development of tics. chronic motor or vocal tics are usually the focus of treatment. head trauma. 1994). 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. Like other habits. thus making it harder to inhibit the tics. the most rapid and long-lasting treatment for tics is habit reversal or some variation of this procedure. & Brook. The most frequently studied and used treatment approach for tics is massed negative practice (Yates. the progression to different tics. 1995). may initially be difficult to differentiate from TD. In general. Contigent negative practice in which the negative practice is engaged in only after the occurrence of the tic is somewhat more effective. will usually remitt without intervention. relaxation training. excessive practice. MANAGING COMMON PROBLEMS long after the initial event.. if the tics are frequent. Transient tics. and a family history of tics should make a clinician suspect TD. and central nervous system stimulants (APA. 1994). which can be both motor and vocal. & Leckman. however. 4 minutes of exercise. Cohen... Treatment of Transient and Chronic Tics Transient tics. Riddle. This approach. 1994). self-monitoring (daily recording of tics). massed negative practice (voluntary repetition of a tic for the purpose of extinguishing it). by definition. they can result in social difficulties. as well as problems with attention or somatic complaints..g. genetic vulnerabilities. these treatments. 2 minutes of rest). or originate from normal movements that over time gradually assume an unusual form and high frequency.. In children. with decreases in tic rates of only about 50% (Peterson et al.

15% to 3. however. rapid movements and noises are the hallmark of TD. with no tic-free period of more than 3 consecutive months during this period. TD is characterized by both multiple motor and one or more vocal tics present at some time (but not necessarily concurrently). but this is not always the case.g.3%. & Cohen. throat clearing. “I can say just what I want.g. and other noises. 1999). Habit reversal and contingent negative practice are described in greater detail later in this chapter. and the child remained tic-free after 1 year. Leckman. barking. Kadesjo & Gillberg. 1999). but diagnosis is often delayed due to the erratic symptoms and the fact that transient tics are at their peak near this age (King. and complexity of the tics change over time. There also appears to be a progression of symptoms from simple motor tics to vocal tics. The anatomical location. and the presence of throat clearing.5. but it can include other tics of the face or body and sniffing. 1998). and environmental factors (Sallee & Spratt. severity. genetic. grunts. 7 months. Himes.g. Eventually all cases have involuntary movements and some vocal tics (Leckman & Cohen. most cases fall in the mild range.. The tics occur many times a day (usually in bouts) nearly every day or intermittently for more than 1 year. In 10 weekly sessions lasting 1 hour each. Habits and Tics 169 Other techniques have been used to modify an emotional state (e. & Robertson. the morphology and timing of TD are probably the results of interactions among developmental.. Estimates of the prevalence rates for TD vary from about 0. 1990. Although TD can be quite severe. Tourette’s Disorder TD. the disorder starts with a single tic (most frequently eye blinking). 1999). Retrospective studies indicate that the median age of onset for TD is 8 years. Eapen. The one-to-one treatment with the child was supplemented by contact with the mother for general guidance and feedback. requesting to join a group. handling teasing) and given self-instruction training in the form of positive self-statements (e. Simple. the child was taught assertive responses to heretofore threatening situations (e. nonpurposeful. 1993). . and cognitive training to eliminate a series of facial tics in a 10-year-old boy. A study by Mansdorf (1986) is a good example of the use of self-control techniques. As with the transient and chronic tic disorders. 1998). Furthermore. it has received a great deal of attention because of its lifelong course and bizarre manifestations. & Comings.” “I’ll tell him just what I feel”). but typically begin at about 7–8 years. There is some evidence for a cephalocaudal (head-to-toe) progression of tics. frequency. was first described by Itard in 1825. anxiety) that is thought to be mediating the tic behavior. depending on the characteristics of the population studied (Comings. In about 50% of cases. or Gilles de la Tourette syndrome. Family genetic studies provide evidence for a single dominant autosomal gene (Eapen. with coprolalia (vocalizing curse words and/or racial slurs) beginning from 3½ to 7½ years after the onset of motor tics (Comings & Comings. Medication treatments are discussed in connection with the treatment of TD. the TD tics change in intensity and type. Zettin. 2000. Although it is one of the rarer tic disorders. assertiveness. & Robertson. biological.. psychological. Symptoms of TD can appear as early as 12 months of age. 1993). or noises accompanied by arm or leg tics should raise suspicion of TD. Banerjee. with onset in the majority of cases occurring before age 14 (Watson & Sterling. but these symptoms convey only a partial view of this complex disorder and its clinical expression. TD is five to six times more common in boys than girls (Witelson. Mason. Pauls. Unlike transient tics. The treatment was successful within eight sessions. 1988). She was instructed to avoid criticizing the child for his tics and to reinforce ticfree behavior with praise. According to DSM-IV.” “I’m just as good as Nate. Scahill.

Sprafkin. 28%. 1986). Given the common use of this drug for ADHD. Towbin & Cohen. chronic motor tic disorder. Brown. The percentages of these children having other elevated scores (T-score > 70) included 39%. Camfield. It is estimated that from 40% to 90% of all patients with tic disorders have characteristics of ADHD (Kadesjo & Gillberg. 30%. 1996). Grad. & Dooley. (1999) hypothesize that premonitory urges with their feelings of mounting tension and anxiety can cause more distress than the tic itself. & Grad. 38%. In a study using the Child Behavior Checklist (CBCL) with 186 children ages 6–11 years with TD. Sverd. and TD has been precipitated in an estimated 10% of children as a result of being given methylphenidate (Lipkin. 1996). and mood. children with TD have trouble modulating their anxiety. or has a family history of tics. 1999). with the ADHD symptoms preceding the onset of motor or vocal tics by 2–3 years (Walkup et al.. Schizoid Anxious. ADHD makes children with TD even more vulnerable to the stresses of development and societal expectations. Other risk factors for more severe symptoms of TD include pre. teachers’. and peers’ ratings. Others view ADHD as a comorbid condition that complicates the course and management of the tic disorders. 1994). Nolan... In contrast to parents’. Others have found that low doses of methylphenidate have improved the ADHD symptoms without significantly increasing the tics (Castellanos & Rapoport. since tics are exacerbated by stress. including anxiety. Pelcovitz. with variable expressivity as either TD.. while another 10–20% experienced a decrease in tics. & Cohen. but King et al. and 26%. 1986. children’s own self-reports reveal less psychopathology (Rosenberg et al. with periods of remission lasting for weeks or years. Social Withdrawal. In addition. Bawden. Family interview data support the hypothesis that tic disorders and some forms of OCD are linked etiologically (Pauls & Leckman. It is estimated that in one-third to one-half of cases. There are also data to support a sex-influenced autosomal dominant mode of inheritance. clinicians should be aware of this potential problem. withdrawal from neuroleptic drugs. exposure to bacterial antigens provoking an autoimmune system response. Backman. Matthews. Depressed.. Uncommunicative. as well as the treatment of ADHD (Pauls et al. 1999). 1999). It is not clear why these children have so many internalizing problems. anxiety. Goldstein. Olson. In any case. heat exposure. Walkup et al. Various other symptoms are associated with TD.170 II. Rosenberg. & Adesman. 1994. 1988). Somatic Complaints. The co-occurrence of OCD among children with TD is less than that among adults (Frankel et al. .. depression and other internalizing disorders. 1987). Although stimulant medication is a primary treatment for ADHD.. this is problematic.and perinatal insults. & Ezor. MANAGING COMMON PROBLEMS The course of TD is usually lifelong. Symptoms can be exacerbated during periods of high emotional stress and excitement. Symptoms seem to get worse through late adolescence or early adulthood. and Nolan (1992) found that stimulant medication exacerbated tics in 20–30% of children with TD. 1986). 2000.g. arousal. Some argue that ADHD is a component of tic disorders. Gadow. and Singer (1994) found that 45% had significantly elevated Total scores on the Internalizing scale. or when an individual is fatigued (Leckman. Other studies using both parent and teacher reports have found similar results (e. 1988). exhibits minor tics. It is difficult to determine which cases of TD will be linked with OCD. 1986). and the presence of a range of comorbid psychiatric disorders (Leckman et al. and pleasurable excitement. Gadow.. however. Classmates of children with TD rate them as less popular and more withdrawn than their peers (Stokes. King. the severity of the tics is exacerbated by the administration of a central nervous system stimulant. From 10% to 40% of patients with TD report obsessional thoughts and exhibit compulsive behaviors and rituals (Towbin. it can be problematic with comorbid TD. 1999). Sverd. when they become less frequent and severe (Leckman & Cohen. 1991). especially if a child is anxious. or OCD (Kurlan et al.

given the primary problems implicit in the disorder itself. Referral for clinical evaluation and treatment of a habit or tic usually indicates that the behavior has continued longer than is typical. Shame. The benefits and risks of using stimulant medications for children with TD and comorbid ADHD obviously have to be carefully weighed for each child. see Chapter 2). & Leckman. Walkup et al. however. argumentativeness. with math and written language skills the most likely areas of weakness. Other questionaires that should be completed by each parent include the Behavior Assessment System for Children (BASC: Reynolds & Kamphaus. (1999) estimated that 38% experienced school difficulties or special education placement. 1990). Step 1: Initial Contact Parents should be asked to complete a general questionnaire (e. or is engaged in so frequently that it interferes with ongoing physical. These are discussed later in this chapter. Treatment for TD reflects the complexity of the disorder in including a variety of approaches. 1992). with an emphasis on those factors particularly important in assessing habits and tics. 1999). the . Brown. 1999). & Newby. social. Hardin. Children with TD are at high risk for educational problems. 1998). Walkup et al. Fischer. Diminished frustration tolerance. see Appendix B). Sparrow. social discomfort. The potential indirect effects of impaired attention. Given all the problems associated with TD. and/or cognitive development. & Cohen. Cohen. the assessment process can be complex. & Singer. there is evidence that children with TD have significant problems in visual–motor integration and fine motor coordination (Schultz. 1996). severity was not associated with overall or individual behavior problems. & Leckman. 1991a) to screen for coexisting behavioral/emotional problems. & Cohen. another 22% were diagnosed with a specific learning disability (Abwender et al.5. Ort. and periods of extreme temper or aggressive behaviors are reported to occur more frequently in children with TD (Riddle. and self-consciousness also frequently occur as a result of the disorder (Sallee & Spratt. (1992) found that the severity of the tic symptoms was associated with disruption in global social functioning. In addition. Rosenberg. as various problems wax and wane. Scahill. Data from this and other studies indicate that learning disabilities and ADHD are strongly associated in children with TD. The assessment presented here follows the Comprehensive Assessment-to-Intervention System (CAIS. Carter. In addition.. ASSESSMENT OF HABITS AND TICS Habits or tics may present as isolated behaviors or may be part of a larger constellation of problems. assessment involves contact over time. which is not surprising. Konkol. our General Parent Questionnaire. both of which increase the isolation from their peers. Riddle. Leckman. behavioral problems. Habits and Tics 171 1993. especially in school and social interactions. Leckman.g. mood lability. has become severe or chronic enough to cause physical damage. and problems with adjustment and acceptance by peers all set the stage for learning problems. 1988). Bruun. Others have advocated a more conservative approach that focuses on changing the environment and specific behaviors (Towbin. Children with TD also have a greater incidence of behavioral problems than other populations (Walkup. Research indicates that 73–78% of these children experience teasing and 68% have trouble getting along with their classmates (Dykens.. 1992) or the CBCL (Achenbach. Scahill. 1988). For most children with this disorder. In a retrospective chart review of 138 children with TD.

The PITS is used in a semistructured interview and addresses the history and current status of hair-pulling behaviors (sites. 1989) are easy to use in a semistructured interview and allow for multiple informants. duration. intensity of the urge to bite nails. especially if the child is exhibiting complex tics or the behavior is affected by environmental changes.. & Rapoport. It can also be used to monitor the progress of treatment. the briefer Hopkins Scale provides valuable information in assessment of tics. but there should also be an opportunity to interview the child alone. 1992) and the Yale Global Tic Severity Scale (YGTSS. Leckman et al. A scale to aid in assessing TTM is the Psychiatric Institute Trichotillomania Scale (PITS. Abidin. tics.. and consequences of the behavior (e. Although the specific time and length of the observation period should be consistent each day. antecedents. Although not as detailed as the YGTSS. 1999) to determine the level of compliance to parent requests in daily activities. and the extent to which nail biting interferes with the child’s functioning. they give the clinician some information about the behavior and the parents’ response to it. It consists of five items: the amount of time spent each day biting nails.1) for at least 1 week prior to the initial interview. Leckman and Cohen (1999) give an outline for the clinical evaluation of tic disorders and closely related conditions. to gather specific information on the frequency. MANAGING COMMON PROBLEMS Eyberg Child Behavior Inventory (ECBI. Lenane. and the Parenting Stress Index (PSI. 1992). it should be set to fit the parents’ and child’s schedule. if possible) and the child on the first contact. These two measures focus on the tics themselves and the resulting impairment. In a review of the scales for tics.. severity. Step 2: Parent and Child Interviews It is important to have an opportunity to interview at least one parent (or both.. Developmental history. 1991) has been adapted from measures used to assess TTM. and distress). Rettew. Swedo.g. Winchel et al. even if the data are not entirely accurate. In addition. . Eyberg & Pincus. 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. Parent Interview The parent interview should focus on the following areas: 1. and aid in operationally defining the tics. amount of distress caused by nail biting. interference. resistance. resistance exerted against nail biting. Several rating scales have been developed to help evaluate habits and tics. topography. Walkup et al. The Nailbiting Severity Scale (Leonard. Yet. 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. and it is included in Appendix B. hair pulling. (1992) also demonstrated that both historical information and direct observation contribute significantly to the overall assessment of tic severity. as this will increase the likelihood of getting consistent data. A review of the General Parent Questionnaire will indicate questions in this area that should be followed up in the interview. 1995) for information on the child’s temperament and the parents’ general level of stress. thumb sucking). The child can be included in the parent interview.172 II. the parents should be asked to complete the Habit Diary (see Figure 5. Walkup et al. (1992) suggest that the Hopkins Motor and Vocal Tic Scale (Walkup et al. Gathering this information is a difficult task.

Copyright 2002 by The Guilford Press. . Gordon. From Assessment and Treatment of Childhood Problems (2nd ed.Habit Diary Child’s Name: ___________________________________________________________________________________ Date: _________________________ Behavior: _________________________________________________________________________________________________________________________ Day Observation Time Antecedents Behavior (What’s Happening) (Frequency or Duration) Sample Consequences Comments Monday 173 5–5:30 P. used to record the frequency with which habits and tics occur.M. Schroeder and Betty N. The Habit Diary. Permission to photocopy this figure is granted to purchasers of this book for personal use only (see copyright page for details).) by Carolyn S. 5.1. 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. Habits and Tics 173 FIGURE 5.

. Impact of behavior or the child and parents. For TD and tics in general. MANAGING COMMON PROBLEMS 2.g. the child’s lack of assertiveness in a stressful situation) may make it difficult to treat a habit or tic successfully. (1994) found that fetal exposure to relatively high levels of coffee. initially just thumb sucking and now thumb sucking and hair pulling). 6. frequency. intensity. and has it changed in topography (e.174 II. When was the behavior first noticed? What does it look like. 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. Whether environmental or genetic factors play a part is not always clear. rituals and obsessive or compulsive symptoms. Is the behavior interfering with the child’s academic performance.g. Were there any prenatal.g. a poor parent–child relationship. obsessive–compulsive behaviors are also more prevalent among family members. Other problems (e. and friends. irritability and mood lability. Is the child aware of when and where the . expressing anger or excitement. 4. their relationship with the child. parental coping skills. or self-esteem? In addition. Medical history. alcohol. or postnatal risk factors? For TD.or time-specific)? Are there times when it occurs more frequently (e. but it sets the stage for later more effective treatment of the habit or tic. Family history. it is important to gather information on inattention. and associated disruptions? When does it occur (e. Intervention in these areas does not mean that the habit or tic will decrease in intensity or stop.. Associated behaviors. is it situation.. and cigarettes. and social support available to the parents. Santangelo et al.g. and motoric hyperactivity. as well as on his or her perception of the presenting problem. Children with tics are more likely to have parents or extended family members with a history of tics than other children.. concentrating. the stability of family life. the child should be seen alone sometime during the initial contact. and learning problems (see Step 4 below). 5. but a family history of similar problems often dictates how the parents respond to the behavior. or neurologist to rule out possible organic causes for the habit or tic? 3. 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. impulsivity. social relationships/participation in social activities. Child Interview As noted above. as well as delivery complications (especially forceps delivery). dermatologist. when the child is under emotional stress. perinatal. for TD. The focus of the interview should be on the child’s general adjustment to family. school. Course of the behavior and current status. and other significant people in the child’s life are often the determining factors in seeking treatment for habits or tics. complexity. Moreover. A family history of similar behavior is important in the assessment of habit and tic disorders. increased the association of OCD with TD. how is the child’s behavior affecting the parents? The parents’ views of the problematic behavior and the impact it is having on them. 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.

so videotaping such a child in the room without the interviewer can be helpful. 1992. . The parents’ periodic use of the Hopkins Motor and Vocal Tic Scale (Walkup et al.5. Watson and Sterling (1998). with emphasis on the area(s) in which intervention is needed (child. measuring their length. environment. consequences of behavior. there is no need for an assessment to include standardized tests or costly in-home or school observations. Habits and Tics 175 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. oral habits that are causing physical damage should be referred to a dentist. Additional observational methods. the clinician should evaluate the child for visual–motor. Some habits. the child should be assessed for anxiety disorders (especially OCD). and recording the number of times the behavior occurs in the treatment session.. Similarly. such as TTM or bruxism. Appendix B) can be very helpful in the assessment process as well as in charting the course of treatment. It is important for the child clinician and the neurologist to work together in the treatment and monitoring of TD. parents. The clinician will have to be innovative in finding methods to gather these data. can be effective ways to measure progress. for example. or breath holding. and using a video camera to record a 2-year-old’s TTM that occurred only during sleep. an immediate referral to a pediatric neurologist should be made. teachers and parents should be asked to fill out the appropriate Conners Rating Scales (see Appendix A) to screen for ADHD. For TD. and learning problems. children with tics can often suppress or cover up the tics. such as taking pictures of the nails. and/or medical/health aspects). and an older child should be asked to complete the self-report form of the BASC. counting the number of hairs in bald spots. During clinical interviews. it is useful to have the parents continue to keep a record of the behavior in order to monitor progress in treatment. For oral habits. have described using a soundactivated tape recorder to record a child’s nocturnal bruxism. TTM. Step 5: Referral to Allied Health Professionals If there is any suspicion of TD. can be engaged in covertly or at times that make it difficult to monitor the behavior. fine motor. Step 4: Further Assessment For most isolated habits. Step 6: Communication of Findings and Treatment Recommendations Findings and treatment recommendations should be discussed in the context of the CAIS (see Chapter 2). the teacher should be asked to complete the BASC Teacher Rating Scale and the Sutter–Eyberg Student School Behavior Inventory (see Appendix A).

and the available treatment options.g. This can be done by reinforcing the child for completing the treatment procedures. early warning. Silber & Haynes. Hence it is very important for them to understand the rationale and steps for successful treatment and to be committed to the treatment program. money. the environmental variables influencing the behavior. a number of treatment approaches have been discussed. This section focuses on the techniques of habit reversal and contingent negative practice. Although the clinician can teach the child and parent intervention strategies. as well as reinforcing habit-free periods with a chart system and tangible rewards (e. in socially reinforcing compliant child behavior. 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. Miltenberger & Fuqua. the child and parent are responsible for carrying out the treatment program. not all of the components may be necessary in the treatment of a particular habit or tic. The components of habit reversal include awareness training (response description.. as one or another component may be more or less useful for a particular child or situation. social support. and in helping to devise charts and select rewards (Watson & Sterling. using a wrist counter or . MANAGING COMMON PROBLEMS The clinician plays an important role in sharing information about a particular habit or tic. public display). The number.g. contingency management (habit inconvenience review. Although the habit reversal procedure outlined by Azrin and Nunn (1973) has many components. length. the advisability of treatment. Habit Reversal Habit reversal has been demonstrated to be an effective treatment for a variety of habits and tics (Azrin & Peterson. 1991). The clinician should be aware of all the specific components of the procedure as used in the original studies. 1990. 1994. It may also be important for the clinician to model the parent’s role in monitoring and prompting the procedures. situation awareness). however. special activities). and generalized training (including symbolic rehearsal). relaxation training. There is also some evidence that it can decrease the number and severity of tics in TD (Azrin & Peterson. 1990).176 II. competing-response training. which have empirical support for their effectiveness. 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. 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. and thus it may be necessary to specifically reinforce compliance with the program. response detection. TREATMENT OF HABITS AND TICS IN GENERAL In the overview of the various habits and tics. An inconsistent approach to eliminating troublesome habits or tics is sure to fail. Treatment approaches for TD in particular are outlined in a separate section.. Habit reversal requires effort on the part of the parent and child.. 1985). Peterson et al. and several studies have attempted to simplify the procedure (e. 1998).

For example. Competing-Response Training Competing-response training typically requires the person to engage in a response that is incompatible with the habit or tic. with one training session devoted to working on each type of tic. Azrin & Peterson. before school. (3) socially inconspicious. Finally. during the morning.. 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. contingent on its occurrence (e. clenching of the fists has been shown to be an effective competing response.to 30-minute recording period at the same time each day is usually sufficient for most habits. For tic movements.g.g. A 10. or clenching the fist contingent on thumb sucking or nail picking). For thumb sucking or TTM.1) on which to record the behavior at different times during the day (e. or immediately after the actual occurrence of a tic or habit. The child can then be prepared to implement the appropriate procedures or even to practice them upon entering the situation (e. in which the child verbally and/or physically describes the details of the habit or tic to the therapist. and to produce a heightened awareness through tensing of the muscle. or can be given a simple chart (see Figure 5. opening the eyes wide contingent on eye blinking. the child should be helped to become more aware of the situations (situation awareness training) in which the habit or tic occurs most frequently. the environmental stimuli precipitating or aggravating the tics can be identified. For instance.e. the most frequent and disruptive type should be treated first. the isometric tensing of the muscles opposite to those involved in the tic is recommended. so that it is compatible with ongoing activities. A second part of awareness training is response description.. (2) capable of being maintained for several minutes. in which the therapist alerts the child to each occurrence of the habit. the child who sucks a thumb at bedtime can practice fist clenching upon going to bed). and to identify situations associated with making it better or worse.. and Miltenberger (1989) demonstrated that the contingent competing response did not have to be a response that was incompatible with the habit.g. A third component of awareness training is response detection. For tics. The child is also taught to recognize the earliest sign (early warning procedure) that the habit or tic is about to occur (e. The length of recording time depends on the frequency of the behavior (i. Sharenow. . but if the child is capable of recording the habit or tic throughout the day and listing the events occurring at the time. Azrin (Azrin & Nunn. rhythmic. Fuqua.. 1973. Habits and Tics 177 notebook.g. lunch). 1988) suggests that the competing response be (1) opposite to or incompatible with the habit response. higherfrequency behaviors can be recorded for a shorter period of time than lower-frequency behaviors). even when he or she is instructed to attempt to perform the movement intentionally. If continuous written recording is not possible. and (4) able to strengthen the muscles antagonistic to those used when engaging in the habit behavior. This makes the child more aware of the behavior and increases his or her motivation to stop it. the child can wear a wrist counter to record the tics. deep breathing through the nose while keeping the mouth closed. using a mirror or videotape if necessary. For tics.5. touching the lips in thumb sucking or feeling the urge to engage in a tic). A competing response for barking is slow. the child should be instructed to tense the muscles just tight enough so that the tic movement cannot occur. 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)..

Practicing selfstatements to “relax” or “be calm” during relaxation exercises help the child to relax at other times upon verbalizing the “calm” statement. it may be very helpful when the habit or tic occurs in particularly stressful settings or situations. Deep breathing is a form of relaxation that can be easily taught to children. and Frantz-Renshaw (1980) taught the use of a competing response (grasping and clenching the fist for 1–3 minutes). and self-statements of relaxation. including progressive muscle relaxation. as a cognitive strategy to increase the motivation to use the treatment procedures. This involves having family members observe the child’s ability to control the behavior in the presence of the therapist. 1984). Relaxation Training Relaxation training is taught to reduce tension and decrease the frequency and severity of the habit or tic. visual imagery. Their study suggests that the competing-response intervention is essentially a mild punishment procedure. 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. such as clenching the left fist contingent on a mouth twitch. A token or chart system can also be used to reward the young or unmotivated child more concretely. the reward system can be dependent upon not engaging in the behavior for a specified period of the day. If the habit or tic occurs at a high rate.178 II. the potential to use competing responses that are not as obvious as others is of clinical importance. The first step is to increase motivation by doing a habit inconvenience review. deep breathing. and the positive aspects and advantages of reducing or eliminating the behavior. in which the child and therapist discuss in detail the inconveniences. Although the small number of subjects (n = 3) should make one cautious. Azrin. As an example of habit reversal for thumb sucking. Nunn. 7 seconds) and when the child inhales and exhales slowly without pausing (Cappo & Holmes. and suffering that result from the tic or habit. embarrassment.to 2-hour session with telephone follow-up. they suggest that the parents and teacher praise the child for performing the exercises and for not engaging in the tic or habit. 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. as well as . MANAGING COMMON PROBLEMS a child could tighten a muscle not related to the habit. The imagery helps the child imagine that he or she is in the ideal situation for relaxation. Although relaxation has not always been found to be a necessary component of the habit reversal procedure. and stimulus identification) to 18 parents and children during one 1. A combination of methods is recommended. 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. Next. 89% of the children had stopped thumb sucking. It is most effective when exhalation is slightly longer than inhalation (5 vs. parental support for not sucking the thumb. Contingency Management Contingency management is used to ensure that the child is highly motivated to carry out the treatment procedures. The goal of the training is for the child to relax upon cue in stressful situations. and the time period can be gradually increased as the frequency of the behavior decreases. then a public display procedure can be used.

given that people are required to engage in the very response that they have worked so hard to inhibit. 1994). the child is given practice and instruction on how to control the habit or tics in everyday situations. Practicing the motor response involved in a tic increases the voluntary control over the involuntary response of a tic. and stuttering is one of the most often cited treatments for tics. 2. Voluntary repetition of an involuntary response contingent upon its occurrence punishes the involuntary response immediately. In some cases this method has stopped the tic behavior within a few days. 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. A rule of contingent negative practice is not to fight the tic but to go with it. but improvement was not always maintained over time. Thus it is analogous to a desensitization procedure in which anxiety-producing stimuli are presented and the child remains calm. The child is encouraged to engage in the contingent negative practice every day while at home. just as it is in the competing response of habit reversal. Unfortunately. According to Levine and Ramirez (1989). the therapist prompts him or her to engage in the appropriate procedure. Contingent negative practice may be a desensitization or habituation procedure when the involuntary response (tic) is required and there are no negative social consequences. Paradoxical intention may play a role. 4. during which time the tic is to be repeated as exactly as possible for 30 seconds immediately after every occurrence of the tic. with reported success rates (eliminated or reduced to normal limits) of approximately 50–80% (Peterson et al. Generalized Training In generalized training. One method for doing this is symbolic rehearsal. Also. relatives) that the behavior is under the child’s control. if the child fails to detect a tic or habit response during the treatment session. Levine and Ramirez (1989) state that contingent negative practice is a relatively simple. Punishment may be an active ingredient in contingent negative practice. in Yates’s work tics were reduced. Once the tic has occurred.or 2-minute rest periods every 4 minutes). some plausible explanations for the behavioral change produced by contingent negative practice include the following: 1. Contingent Negative Practice Contingent negative practice for involuntary motor responses. Habits and Tics 179 having them inform other significant people in the child’s life (teachers.. . siblings. 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. the child engages in contingent negative practice of the tic for a period of 30 seconds. 3. cost-effective treatment method. as opposed to 30 minutes with 1. tics. This was the basis for the massed negative practice procedure used by Yates (1958). and has been demonstrated to generalize to situations outside the treatment setting.5. This procedure involves having a child engage in the tic rather than fighting the urge to have it.

therapist. education. advocacy in the school. There is no “prototypical” child with TD. and the use of behavioral techniques. anxiety.. 1999).. and social components of the disorder. Furthermore. and on ways these strengths can be used to compensate for the problems and to increase a sense of competence.g. MANAGING COMMON PROBLEMS TREATMENT FOR TOURETTE’S DISORDER Treatment of TD must take into account the “whole” child. because the disorder is a lifelong problem. The Tourette Syndrome Association (see the contact information provided in “Intervention with the Parents”) has a wealth of information on this disorder. and medical/health interventions. Family members often have symptoms similar to the child’s. psychotherapy. tics). including those of educator. OCD.. As the symptoms of TD wax and wane. 1999. Support groups can be particularly helpful for children as they learn that they are not the only ones with TD. emotionally calm environment. and begin to understand the potential course of the disorder. Thus the individual child’s strengths and how they can be used to help the child cope should be a prime target for intervention. and local chapters often have both child and parent groups. a developmental perspective to treatment must be taken. optimistic attitude. these roles change over time as the needs of the child and family change. and pharmacotherapy (Leckman & Cohen. Treatment approaches should focus on the specific needs of the child and family at any particular age. which can make it difficult to maintain a structured. and to determine ways to decrease the symptoms.e. intelligence. Treatment for TD should follow the CAIS (Chapter 2) and focus on the child. as have cognitive-behavioral approaches (Leckman & Cohen. its course. hence they should be involved in the treatment planning as far as is appropriate to their developmental level. It is also important that children develop competence and a sense of control over their lives. to understand how such circumstances arise. these other areas may also be foci of treatment for a given child. as well as contingent negative practice) has been effective in treating TD. the parents.g.180 II. Given that TD is highly associated with other problems (e. with a focus on the interaction of the biological. Therapy approaches to TD generally focus on helping the child to recognize the circumstances associated with the exacerbation of the symptoms. hear about ways that others have coped. psychological. 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. learning disabilities). ability to enjoy life). Moreover. 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 select ways to diffuse or avoid them. and advocate. and guidance. including reassurance. . humor. ADHD. consultant. The focus of treatment should not simply be on “the problem. Intervention with the Parents Like the child. 1994). and potential treatment options.. as they encourage parents and other family members not only to understand and deal with the stresses of this disorder. Support groups can be very helpful. diagnostician. Behavioral treatment (including habit reversal or some of its components. but also to advocate for the child.” but also on the child’s strengths (e. the environment. physical attributes. rather than on any one specific behavioral manifestation (i. The clinician’s roles are varied. Peterson et al. the parents and other family members will need information on TD.

NY 11361. so that information is shared and a team approach is taken to treatment planning.edu/. however. http://www. The use of computers. and prevents them from being overwhelmed by the complexity of a task or length of assignment. tape recorders. some school personnel believe that children with TD can control their behavior. when appropriate. The Tourette Syndrome Association has a number of excellent films and publications that can be used for this purpose. 42-40 Bell Boulevard. and calculators can often help make the learning experience more successful.g. Although not all children with TD require intervention in the educational setting. 3. is ideal. 1999): 1. Fredine. Being in a classroom that permits freedom of physical movement when their symptoms require it. This team should always include the parents and. although 50% were motivated to learn specific behavioral and teaching strategies to help children with TD. Alternative learning methods. 1992). that even with the best information and explanations. When a child’s symptoms are especially severe. teachers.harvard. Educational setting. 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. and having directions repeated. 50% felt nothing could be done . Informing school personnel. The clinician should be aware. 800-237-0717. pediatrician).tsa. 70% had no knowledge of TD. Thus a moderate amount of structure is important. It is important to coordinate treatment with other involved health professionals (e. a resource room. 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. Most children with TD need help with directions. 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. Finally. Giving small segments of work seems to help children with TD set reasonable goals. as is allowing rest breaks during long examinations.g. but that also offers appropriate environmental cues to guide learning. In a recent survey of teachers. 4. Support. The best environment for children with TD is one that is calm and supportive. 2. many will need help in adjusting to that environment. neurologist..ngh. Bayside. the nurse’s office). and sequencing steps for a task can help with this problem. the child. Findley. with a gradual increase in the quality of work. underlining significant words. 6. An excellent book for parents is Children with Tourette Syndrome: A Parents’ Guide (Haerle. and peers about TD is extremely important and relieves a child of continually having to explain his or her behavior. Moreover. and their own special needs must be taken into consideration. Children with TD should be allowed to work at their own pace with the least amount of time pressure. a national resource for both children and parents is the Tourette Syndrome Association. A number of modifications in school can help the child with TD to learn and to adjust more effectively (Carter. Habits and Tics 181 Parents should be involved in both the planning and the carrying out of any treatment program. All of these modifications can help reduce a child’s stress level and allow him or her to perform well. many believe that it is the result of parents’ mishandling of a child. 5. et al. Directions. The focus at first should be on work completed. Reasonable goals.5.. Timing. 718-224-2999. The untimed administration of tests in private is especially important..

behavior changes) and potentially harmful. If a child is taking 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. 1996). dizziness. Schultz. Moreover. dermatological reactions. In addition. tremors. At Steve’s last physical examination. the risks and benefits of using neuroleptics should be very carefully weighed. social phobia. they include cognitive impairment. 1999). Side effects include sedation.. Persistence is needed in dealing with the school environment. drowsiness. CASE EXAMPLE: FROM TICS TO TOURETTE’S DISORDER Step 1: Initial Contact Mrs. hypertension. but has explosive rates of tics at home after school. Although stimulants have been used to counteract the side effects of neuroleptics (Towbin & Cohen. has received less study. clonidine is generally not as effective as the neuroleptic drugs. for an excellent review of the risks and benefits of using pharmacological interventions). rigidity. has also been widely used for tics.182 II. Steve. however. Another drug of the same type. Fox called for an appointment for her 7-year-old son. et al. extreme anxiety.. 1993). make this a questionable choice of treatment. insomnia. the potential problems of stimulants in exacerbating the symptoms of TD. 1996). however. who had exhibited a recent increase in eye blinking and head jerking. primozide. constipation. MANAGING COMMON PROBLEMS to improve the school situation for these children (Carter. Given the adverse side effects and the high percentage of patients who discontinue the drugs. see Towbin & Cohen. she had dis- .g. 1996). and sometimes a change in schools may be necessary. their use should be considered only for cases where the tics are significantly interfering with development or when bouts of tics are particularly severe. with as few as 38% of clonidine-treated patients having a reduction of 50% in severity of tics (Leckman & Cohen. lethargy. abruptly stopping this drug can be uncomfortable (e. and some instances of sudden death from cardiac arrest while taking it mandate repeated electrocardiograms (Towbin & Cohen. dry mouth. depression. abrupt stopping of the medication can result in increased symptoms that last for several months (Towbin & Cohen. 1996. a non-neuroleptic drug. and Parkinson-like effects (drooling. and loss of associated movements) (Towbin & Cohen. The negative side effects of neuroleptics are substantial. Finally. 1992. 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. 1991). tardive dyskinesia. it should be stopped gradually after a period of time to determine whether it is still needed. agitation. Clonidine. If medication is used. 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. 1996). Fredine. it is important to provide the school with information on the potential side effects of the medication. Of these. In general. haloperidol is the most commonly used neuroleptic (Erenberg. Neuroleptic medications result in 50% or more reduction in tic severity for approximately 70–80% of people with TD who take them. as well as the problems of using multiple medications. and hypotension.

Step 2: Parent and Child Interviews Parent Interview Mrs. Because he was in an “open” classroom. but this did not bother Mrs. Mrs. Moreover. . Fox later related to the separation and move. On the Parent Domain of the PSI. he was doing relatively well in school. They did. and 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. The recent move had been difficult for all of the family. Fox said he refused to follow a set visitation schedule. Steve had asked his mother whether there were something he could do to stop the tics. visit the maternal grandparents every weekend. Steve was involved in many after-school activities and had responsibility for age-appropriate chores. The children did not feel they got to see enough of their father. and Mrs. who assured her that they were typical for children Steve’s age. the only significant score was on the Depression scale. Mrs. however. The only problems noted on the CBCL were a high frequency of tics. She felt there was no reason not to include him in the interview. Fox said that Steve had no significant developmental or medical problems and had not taken any medication in the recent past.5. and a very high activity level.1) to complete and return prior to the initial interview. Visitation problems centered around the father’s complaints that he was not able to see the children often enough. the ECBI. his high activity level did not cause problems in school. and the children’s primary playmates had been cousins. Furthermore. Although he had trouble completing written assignments and attending to academic work for more than 10 minutes at a time. Fox. which he completed without problems. Mrs. The marital separation had resulted in a recent move away from the family home near her large extended family. although there had been no open parental conflict prior to the separation. The parents’ separation had occurred after many unhappy years of marriage. although her mother had told her that one of her brothers had had similar tics at about the same age as Steve. She had not noticed any vocal tics. as well as a significant decrease in income. Fox said that she and Steve had openly discussed his tics. Fox was at a loss as to how to increase their contact with their father. but that they might have gotten worse because of her recent marital separation and the resultant conflict over visitation. some worries about these. The clinician sent Mrs. Fox had separated 4 months previously and that Mrs. The mother’s current concern about the tics had begun with a phone call from the teacher to ask her about them. but Mrs. the PSI. and his 4-year-old sister was in a day care program. Mrs. which Mrs. Fox had returned to school for her teaching degree. Steve was described as physically active. because Mr. Fox the General Parent Questionnaire. and the Habit Diary (Figure 5. Fox stated that Steve had engaged in some eye blinking at about age 4. and that he was as eager to resolve them as she was. but that the frequency had decreased up until the present time. the CBCL. Fox had spent very little time at home. The teacher was also concerned that they might begin to interfere with Steve’s ability to sustain attention. Steve was in second grade at a local elementary school. The teacher felt that other children were beginning to notice the tics and tease Steve. because they enjoyed close relationships with the extended family. Habits and Tics 183 cussed these behaviors with the pediatrician. The General Parent Questionnaire indicated that Mr. Fox said that no one else in the immediate family exhibited tics.

they occurred across a variety of activities. and his tics were quite obvious to the clinician. Step 3: Observation of Behavior The Habit Diary. which was completed for the half hour after dinner each evening. he sometimes found it difficult to work “all day. were asked to complete the Conners Parent and Teacher Rating Scales to gather further information on possible ADHD.184 II. Fox also proudly described Steve’s many activities. and the mother did not respond to them. He readily described family activities and said that he already had made a lot of friends in school. During the interview Steve’s eye blinks increased when he was talking about the parental separation. however. and they decreased when he was involved in a game that required concentration. and that normally (but not consistently) she told Steve to stop. before picking it up to write). During the parent interview. In general. athletic skills. and he said he wished he could see his father more often. with peers. The mother–child interaction was positive. He also felt that the tics made it more difficult for him to complete his work in school. and good relationship with his 4-year-old sister. except that his mother had to study after she put them to bed at night. as well as provide him with ways to decrease the frequency of tics. Steve played with cars on the floor. Fox was asked to continue keeping track of Steve’s tics with the Habit Diary throughout treatment. The mother and teacher. There was no specific antecedent to these behaviors. Steve reported increased compulsive behaviors (e. 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. Fox later admitted that her nonresponse was the result of having made an appointment with the clinician. Steve appeared to be well adjusted in school. which have a high incidence at Steve’s age. putting his pencil to his mouth. Step 5: Referral to Allied Health Professionals Steve had had a recent physical examination. Step 6: Communication of Findings and Treatment Recommendations The following information was shared with Mrs. Mrs. It seemed important to decrease Steve’s stress with regard to visitation with his father. . Mrs. MANAGING COMMON PROBLEMS Child Interview Steve presented as a pleasant child who interacted freely with the clinician. who was described as “fun but firy.g. and at this time there was not sufficient evidence to suspect TD. He said that although school was not hard. It was felt that the recent move and parental separation might have precipitated tics. In addition to the tics. then laying it on the desk..” It was hard for him to talk about his parents’ separation. and at home. Mrs. indicated that Steve blinked 20–30 times on average and that this was often followed by head jerking. Steve said that the family’s daily routine had not changed much since the separation.” Step 4: Further Assessment There were no major concerns about other areas of development at this time. Fox.

Mr. and she agreed to ask Steve’s father to make an appointment with the clinician or at least to contact her by phone. Fox was to let them know on the Wednesday before the weekend whether he planned to see the children. Because of his high activity level. and provided teachers and the children’s classmates with films and handouts describing TD. Steve’s sister was also diagnosed with TD.5. Significantly. The clinician had the opportunity to work with Steve and his mother over the next 4 years. Mrs. She further agreed to transport the children to see their father one weekend a month. using relaxation. but that it was up to their father to carry it out. habit reversal. he was easily taught habit reversal for these new tics. 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. Mr. When Steve was seen by the clinician. Fox decided on a visitation schedule that included Mr. Fox also refused to set up a regular visitation schedule. however. The focus of treatment was on helping the family cope with this chronic disorder. The clinician also wrote a letter to Mr. Fox called to report that Steve was once again engaging in tics. Both the mother and teacher indicated that they rarely observed either tic over the next 2 months. This was successful in decreasing the eye blinks to an average of 1–2 times in the 30-minute home recording period. It was also noted during the treatment sessions that Steve was clearing his throat a great deal. she said that she would send it in writing to their father. Mrs. but this time they involved the jerking of his arm and leg as well as eye blinking. over the next 4 months. Fox told the children about this plan. who confirmed this diagnosis. During this time. Fox’s having the children every other weekend and at any other time with 1 day’s notice. Mrs. Fox was put in contact with the Tourette Syndrome Association. He said that Steve’s problems were all related to the mother’s desire to separate. . psychoeducational evaluations of both children (the sister also proved to have a learning disability). Two months after treatment ended. including consultation with the school. This tic also decreased within a 2-week period to a frequency of 0–1 during the 30-minute home observation period. and that if she would return to the marriage Steve would be fine. the rate of tics increased dramatically after he left the clinic. the mother reported that Steve would engage in the tics at a very high rate after periods of no tic behavior. and he off-handedly told the clinician that “he had a tickle in his throat” and probably just needed a cough drop. He was also taught habit reversal. With the clinician’s encouragement. though Steve engaged in very low levels of tics during two treatment sessions (apparently in order to please the clinician). Mr. Furthermore. Fox refused to do so. Unfortunately. Thus he was taught relaxation by deep breathing. Habits and Tics 185 Mrs. Mrs. however. Fox saw the children only 1 full day and several evenings. and teaching the children coping skills (defining stressful situations. Fox became a strong advocate for her children. Fox encouraging him to visit the children on a regular basis. Fox was open to the possibility of regular and frequent visitation. and both she and the children participated in local chapter meetings. Steve was not able to engage in muscle relaxation. and avoidance of stressful situations). The head jerk was also treated through habit reversal by having him tense his neck in response to each head jerk.” At this point the clinician began to suspect TD and referred Steve to a neurologist. Mrs. Mr.

The types of sleep disturbances seen in children change with age. but his or her sleeping state is a complex. teeth grinding. A mature nervous system is necessary to regulate the sleep cycle over many hours. one must first have a rudimentary understanding of the physiology and development of sleep. It is characterized by an irregular pulse and respiratory rate. as well as to be aware of the role sleep problems can play in other disorders of childhood. MANAGING COMMON PROBLEMS CHAPTER 6 Sleep S leep! Throughout our lifetimes this restorative activity is fought. This chapter first reviews age differences in normal sleep states and patterns. It is important for the child clinician to be able to help these parents and their children. although sleep disturbances such as bedtime struggles. The parents of infants have firsthand experience in dealing with interrupted sleep. As children get older. and thus children’s sleep cycles follow a developmental course. NORMAL SLEEP STATES AND PATTERNS To understand sleep disturbances. their repertoire of nighttime behaviors expands. and parental responses evolve and become more varied. When parents request help with sleep problems.186 II. night wakings. 1969). they do not always go away on their own. and finally accepted as a necessary part of our lives. head banging and rocking. Sleep States and Stages The sleeping person may appear inert. and nightmares) that are common among children. Thus. the situation has usually reached a crisis point.” because it has features of both deep sleep and light sleep. although sleep problems in children may be common. 1997). and the rather bizarre nocturnal occurrences (sleepwalking. Sleep is divided into two distinctly different states: rapideye-movement (REM) sleep and non-rapid-eye-movement (NREM) sleep (Kales. manipulated. embraced. sleeptalking. REM sleep is also called “paradoxical sleep. sleep terrors. and sleepwalking have been shown to persist over a number of years (Anders & Eiben. and the types of sleep disturbances seen in children. as well as rapid eye move186 . and many go on to learn about night wakings. highly organized neurophysiological process. early risings of energetic toddlers. bedtime struggles. Assessment and treatment of the most common sleep problems are then discussed.

by 3 months. the person will promptly awaken but may be in a confused state for a few minutes (Kales. a sick child crying). or face. There is a dramatic increase in blood flow to the brain. the time in the REM sleep state is reduced to 30%. In contrast to REM sleep. with the total amount of sleep gradually decreasing as the duration of each sleep period gradually increases. 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. confused. Although full-term infants have differentiated REM and NREM periods. 1981). although there may be small twitches of the hands. however. 1998). Children usually fall asleep in 10–15 minutes. sleep loss. with two separate daytime naps for a total of approximately 13.. but most people quickly return to sleep without any memory of the wakings. the body uses more oxgyen. 1994). the four stages of NREM sleep are differentiated. with an additional 1. and is very difficult to awaken. Sleep regulation changes with development. 1996). The longest and most intense REM activity occurs at the end of the sleep period. or chronic sleep disturbance.1. 1998). but these gradually decrease with age (Dahl. The normal adult sleep cycle is reached by about 8 years of age (Zuckerman & Blitzer. and 8 hours by age 18 years. 1976). Cul- . As can be seen in Table 6. During the latter two stages (stages 3 and 4). Arousal from the initial 1–3 hours of deep NREM sleep is very difficult for children. legs. Ware. and Bond (2001) describe the typical sleep pattern for children. Although dreams and nightmares occur during REM sleep. Muscles are very relaxed and nerve impulses are essentially blocked within the spinal cord. the sleep–wake cycle changes considerably with age (see Table 6. with later REM periods lasting 15–20 minutes. the average child gets 10. Confused partial arousals can occur during NREM sleep. Infants enter sleep through REM rather than NREM. the deepest NREM sleep occurs in the first 1–3 hours after falling asleep. NREM sleep is divided into four stages.5 hours of sleep a day. Short periods of waking from REM and stage 2 of NREM sleep occur about five to seven times a night. or cognitively slow (Mindell & Dahl. so the body is effectively paralyzed. most children in the United States sleep 11 hours each night without a daytime nap (Mindell & Dahl.g. often sweats profusely. If the stimulus is important enough (e. and brain waves resemble a mixture of waking and drowsy patterns (Parmeggiani. he or she can move.to 90-minute cycles. which are most frequent in the 60– 90 minutes after the child has fallen asleep. alertness returns relatively quickly. By 2–3 months of age. spend 50% of total sleep in REM sleep (compared to 20% in adults). little happens behaviorally. in 60. The average 1-year-old sleeps about 11 hours a night. 1969). Although there is considerable individual variability in sleep requirements. resulting in sleep terrors and sleepwalking. Children have large amounts of deep sleep. When a person is awakened from REM sleep. which peak between 3 and 6 years (when children are giving up naps). Sleep 187 ments. and have the first REM period (which lasts about 5 minutes) 1–2 hours after sleep onset. just prior to morning awakening. Although the person usually lies very quietly. Orr. The NREM-REM sleep cycle is then repeated. By age 3. and by 1 year.5 hours of sleep each night. reach NREM stage 4 (via stages 1–3) 5–20 minutes after falling asleep. breathing and heart rate become very stable. Mindell and Dahl (1998) point out that these deep stages of sleep are increased in proportion to the amount of awake time. the NREM period does not have different stages. and the muscles are very relaxed. the infants enter NREM sleep first. By age 4 or 5 years. A normal sleep cycle consists of alternating periods of NREM and REM sleep.1).6. which represent progressive levels of sleep from drowsiness to very deep sleep (Guilleminault & Anders. Thus dreaming and nightmares are more frequent in the early morning hours. who will appear disoriented.5-hour daytime nap. and have sleep cycles about 50–60 minutes long (compared to the 90–100 minutes for adults).

may not return to sleep after these wakings. to concentrate attention on one task. affect. He points out that emotional disturbances (both positive and negative) can cause at least transient disruption in sleep. and a clinician should take this into consideration when assessing sleep problems. perhaps sensing that something is wrong. in which the mind wakes up before allowing signals to be received by the body.M. 1973). Once sufficiently alert. check the environment. because we wake up after each episode of dreaming. Typical Amounts of Sleep at Different Ages Age Early infancy 3–4 months 6–8 months 12 months 24 months 3 years 5 years 10–12 years Total amount of sleep 16 hours 14–16 hours 12–16 hours 14 hours 13–14 hours 12–13 hours 11 hours 10 hours Sleep periods 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. and attention. whereas REM sleep would allow the animal’s brain to become more active without the accompanying body movements that could attract a predator. The link between emotional regulation and sleep regulation is amply demonstrated in mood disorders. 1981). where sleep disturbance often represents a major diagnostic symptom. In the waking state. Zuckerman & Blitzer. such as anxiety dis- . sudden waking from NREM sleep would leave an animal confused and unable to protect itself. No naps No naps ture can influence time spent in sleep. NREM sleep is thought to allow restoration of the body and to regain physical strength (Hartmann. though receiving signals. Thus we appear to live in three distinct states. however. 1987). and restoration occurs. 11–12 hours at night 2-hour nap in P. and the muscle “paralysis” of REM sleep would disappear. the body rests. It has been hypothesized that the function of REM sleep is to allow us to process daytime emotional experiences. the animal would wake up fully. and to integrate newly learned material (Ferber. Ferber (1985) suggests that REM sleep can be thought of as an intermediate state between NREM sleep and waking. We do not usually remember these wakings. they may need to be rocked or need to feel the closeness of a parent to go back to sleep.1.. In evolutionary terms. 1985. Among depressed children. In the REM sleep state. but the body. to transfer recent memories into long-term storage. Altered sleep has also been associated with a number of other clinical disorders. MANAGING COMMON PROBLEMS TABLE 6. In the NREM sleep state. does not carry them out. mental processes are minimal.188 II. Dahl (1996) provides strong empirical support linking the regulation of sleep. thoughts can be translated into action so we can maintain the necessary activity for survival. 75% complain of insomnia and 25% have symptoms of hypersomnia during episodes of depression (Ryan et al. for example. Some children. Ferber (1985) states that this checking for danger may still be relevant for humans. and (if all is well) go back to sleep.M. the mind is active again and dreams occur.

A person falls asleep when body temperature is falling toward a daily low. because of the many terms used to describe sleep problems and the varying definitions of what consti- . SLEEP DISTURBANCES It is often difficult to understand what constitutes a sleep disorder in children. Hartman. & Janovic.. Fjallberg. If the sleep–wake cycle gets out of rhythm. Although the cause–effect relationship between sleep and emotional/behavioral disorders is not known. with sleep tending to increase in the winter and decrease in the summer. 1985). 2000). 1995). and low self-esteem were significantly correlated with an objective sleep measure indicating poorer sleep quality (Sadel et al. in adults. & Torronen. If children’s schedules are irregular. studies and case examples indicate that treatment of sleep problems often results in a decrease of daytime behavioral problems (e. Dahl.6. For example.g. Sleep 189 orders (Mellman & Uhde.. going to bed. The children wore ambulatory activity monitors on belts for 72 consecutive hours. the amount of time after falling asleep to REM onset. 1998. The connection between sleep and behavior probems is further illustrated in a study of sleep and behavior in 49 physically healthy 7. and attention-deficit/hyperactivity disorder (Marcotte et al.. and fluctuations in body temperature and hormone release. eating. Faucon. the quantity of the child’s sleep was significantly associated with the Total symptom score on the CBCL Teacher’s Report Form. Teicher.g. 1998). Although the parents were not aware of a sleep problem and did not report behavior problems at home. getting them up earlier. activity and rest. it is hard to wake up when the body temperature is still low. it is possible that their circadian rhythms may be off. Jet lag is a good example of this.. 1983). 1994). “Circadian rhythms” are biological cycles that repeat themselves about every 25 hours. and awakes as it starts rising toward a peak. or having them sleep later in the morning) must take into account the children’s normal body rhythms. the children’s selfratings of depression. but the ability to fall asleep and to stay asleep is closely tied to the timing of these cycles. and both parents and teachers completed the Child Behavior Checklist (CBCL). they include patterns of sleeping and waking. hopelessness. and changes must occur gradually. getting children to bed earlier.to 12-year-olds without known sleep problems (Aronen. and so on. Changing sleep routines (e. self-rated alertness. hunger and eating. and the duration of the sleep period are all related to body temperature (Czeisler et al.. Glod. selection of bedtimes. It is thus important to give strong consideration to a child’s sleep patterns and behaviors during assessment and treatment of all childhood problems. & Falkner. These cycles are set each day by the daily routines of arising. and the person may have trouble falling asleep when the body temperature is high (Ferber. Minde. activity. Frost. Circadian Rhythms Some understanding of the circadian rhythms that are associated with the sleep–wake cycle is necessary to treat children’s sleep problems. a person begins to feel bad. 1997). and vice versa. In a study of children ages 7–14 on a psychiatric inpatient unit. Sleep–wake cycles can also be affected by such things as seasonal changes in the light–dark cycle. Paavonen. 1989. & Harakal. they may want to sleep when they should be awake. Tourette’s disorder (Glaze. 1981). Not only is it important for our sense of well-being that these cycles be in harmony during the day. Soininen.

and sleep terrors (7%) (Salzarulo & Chevalier. there are no sleep disorders listed in the childhood-onset section. Although there is compelling evolutionary and cross-cultural evidence supporting a cosleeping environment for the first few months of an infant’s life. and substanceinduced sleep disorder (American Psychiatric Association. 1990) in classifying its primary sleep disorders into two major categories: “dyssomnias” and “parasomnias. has been found to be more common in African American families. 1997). sleep rocking or head banging. for example. 1997. is widely viewed as a problem. & Lozoff. . Miyahara. waking at night (28%). nightmares (31%). sleep-related respiratory problems). and disorders of initiating and maintaining sleep (bedtime struggles. Wolf. for example. MANAGING COMMON PROBLEMS tutes a “problem. and sleeptalking). Common problems in a survey of 218 parents of children ages 2–15 years referred for a psychiatric or pediatric consultation included sleeptalking (31%). bruxism (10%). sleep terrors. fourth edition (DSM-IV) classifies sleep disorders into four broad categories: primary sleep disorders. & Anders. and night waking (6. In contrast to the 100% all-night cosleeping in Japan. Cosleeping. we first review dyssomnias. or sleep stage transitions. 1994). 84% of a sample of pediatricians felt that an infant should never sleep with his or her parents (Anders & Taylor. sleep disorder related to another mental disorder. sleep–wake schedule disorders. trouble falling asleep (23%). Mindell & Dahl. The ICSD categories fit well in understanding children’s sleep problems. Koplewicz. Nugent. but rather how it is perceived and then carried out. including disorders of excessive sleepiness (narcolepsy. & Brazelton. 1994). Sleep disturbances are very common in children. sleep rocking (7%). DSM-IV does follow The International Classification of Sleep Disorders (ICSD. Miyashita. Abikoff. 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. Keener. as a result of bedtime struggles and night wakings (Latz. We then review parasomnias. five common sleep-related complaints were reported: bedtime resistance (27%).5%) (Blader. moreover. Cortesi. with few sleep problems (Kawasaki. Ginsburg. Ottaviano. 1994). In European American families. 1983). Diagnostic Classification Steering Committee.000 parents of 5. where it is not associated with sleep problems. 1999). fatigue (17%). REM sleep behavior disorder. all but the first of these categories apply more to adults than children. In this section. 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. and partial arousals (sleepwalking. & Ottaviano. 1984). sleep paralysis. 1987).” “Cosleeping” (child and parent sleeping together in the same bed). getting up early). In Japan. cosleeping in the United States occurs in 15% of families and usually involves intermittent and partial-night cosleeping. Wolf.190 II. and are disorders of arousal. sleep-onset delays (11%). sleep bruxism. morning wakeup problems (17%). Thus cosleeping per se is not the problem.” Dyssomnias include difficulties in either initiating or maintaining sleep. 1996). however. sleep disorder due to a general medical condition. partial arousal. The Diagnostic and Statistical Manual of Mental Disorders. Unfortunately. or daytime excessive sleepiness. & Foley.to 12-year-olds. Bruni. & Davis. night wakings. most children consistently sleep with their parents for the first 3 years of life. Parasomnias include disorders that disrupt sleep after it has been initiated. cosleeping is associated with sleep problems (Lozoff. 1998. The significance of a problem can also vary with the population studied. including nightmares. Giannotti. In another survey of approximately 1.

. Narcolepsy. exercise. Inadequate sleep. If a child sleeps more than 2 hours longer than the average for his or her age. Mignot. fussiness. 2001). the child may be suffering from excessive sleepiness (Ferber. on waking. 1998). Although narcolepsy is usually first diagnosed in adults. rather than after the normal 90 minutes (Ware et al. narcolepsy... The REM state most often begins immediately or within 10–15 minutes after falling asleep. & Grumet. These findings give hope for the development of medication to treat this serious problem. the sleep system is uncontrolled. Sleep 191 Dyssomnias Excessive Sleepiness Excessive sleepiness can be the result of illness. Ware et al. other classic symptoms that occur in a significant majority of people with narcolepsy are cataplexy (sudden loss of muscle tone without loss of consciousness). or overactivity. poor nighttime sleep. It occurs at the rate of 3 per 10. Nighttime sleep is usually disturbed by many wakings. Viral infections and illnesses with a high fever leave a child feeling tired and sleepy. eating. Treatment will depend on the nature and cause of excessive sleepiness. Only 1 out of the 16 cases had all four symptoms of narcolepsy. Narcolepsy appears to be a neurological disorder with a strong genetic component (Mindell & Dahl. Teachers are usually the first to notice these problems. or inadequate deep sleep often result in daytime sleepiness. 2001). 1998). There are also episodes of partial activation of the REM system at bedtime.6. In addition to inappropriate sleepiness. In narcolepsy. hypnagogic hallucinations (dream-like imagery before falling asleep).. depression. Holtum. or requires daily naps beyond the preschool years. In a sample of 16 cases with the onset of narcolepsy before age 13. however. Such concerns warrant investigation of the child’s sleep patterns. Depression in children can also result in excessive sleepiness. 1994). sleep is distributed across 24 hours rather than occurring in a single block at night. poor-quality sleep. structuring the child’s daily routines of sleep. 1989). 1994). or sleep apnea syndrome (Ware et al. as well as obesity. one-third of persons with this disorder date the onset of their sleepiness to adolescence or earlier (Dahl. especially if the child is both overactive and continuing to take naps after the age of 5 years. and a child is often described as performing poorly because of inattention. and during the day. laziness. This suggests that the disorder often goes undiagnosed in children. with neurons located in the lateral and posterior hypothalamus.. and short periods of uncontrollable daytime sleep occur in unstimulating or physically inactive situations (very similar to the sleep patterns of newborns). having a first-degree relative with narcolepsy increases the probability by 18 times (Guilleminault. Some medications (such as antihistamines and drugs used to control seizures) can cause excessive sleepiness as a side effect. (1994) found significant associations with behavioral and emotional disturbance. 1985). 2001). (2001) report on the recently identified narcolepsy gene in canines and mice. Dahl et al.000 in European Americans (Hublin et al. forgetfulness. and general “laziness” (Ware et al. The behavioral signs of sleepiness usually include shorter attention span. In narcolepsy. medication. irritability. and sleep paralysis (inability to move after waking up) (Mindell & Dahl. & Trubnick. but these feelings subside as the child recovers from the illness. but this should be only one of a number of other behavioral symptoms. and social activities can be helpful in decreasing this problem. In the absence of medication or psychopathology. The gene controls the hypocretin–orexin neuropeptide system. reduced coordination.

See Ware et al. toss and turn. and documenting the appearance of REM sleep soon after sleep onset (Ware et al.192 II. 2001). and they are at risk for the development of hypertension. Obstructive Sleep Apnea. and imipramine or other trycyclic antidepressants for muscle weakness) can result in further sleep disturbances and should be used with caution. These repeated chronic disruptions in sleep can occur up to several hundred times per night. 2001). daytime fatigue. the babies simply stop breathing. Staats. and restlessness (Hansen & Vandenberg.. and can fall asleep during the day at inappropriate times (Hansen & Vandenberg. They may have morning headaches. plus a regular sleep schedule with short naps throughout the day (Ware et al. In most SIDS cases. determining the pattern of sleep. 1997). 1997).. with an average of 30–40 seconds (Anders & Eiben. Due to the frequent nocturnal arousals. MANAGING COMMON PROBLEMS Diagnosis of narcolepsy involves ruling out other possible problems that may cause sleepiness. These children arouse frequently during the night. Obstructive sleep apnea (OSA). This results in frequent arousals from sleep. The documentation of REM sleep is carried out by means of a multiple sleep latency test (MSLT). but many teachers refuse to acknowlege narcolepsy as a medical problem. the upper airway narrows or closes off so that the person cannot breathe. This usually involves an overnight sleep study in which recordings of oxygen saturation. resulting in excessive daytime sleepiness. and an electroencephalogram are taken. Unlike other sleep disturbances. limb muscle activity. Ferber. Children with OSA present with very restless sleep. Although OSA was once thought to be rare in children. the stopping of breathing does not involve airway obstruction. thoracic and abdominal respiratory movements. given . but it should be understood that it is not the same disorder as that which causes sudden infant death syndrome (SIDS). and hypoxia.. a child with OSA can suffer from inattention. and intervening silences. The obstruction usually occurs in the back of the throat behind the base of the tongue. and Belfer (1981) reported that 14% of the children seen in their sleep disorders clinic had a primary diagnosis of OSA. 1997). decreased academic performance. This interruption of breathing can last from 10 seconds to 3 minutes. 1998). the medications (methylphenidate hydrochloride for sleepiness. However. Complaints of lethargy. Although there is no cure for narcolepsy. Although OSA should not be diagnosed without PSG. sweat. can produce a sleep disturbance resulting in sleepiness during the day. which increase the muscle tone to the neck and pharyngeal muscles. A polysomnogram (PSG) should also be performed to rule out other sleep disorders. excessive daytime sleepiness. 1983). The average age for diagnosis of OSA is 7 years (Mauer. the results are often difficult to interpret. (2001) for an in-depth discussion of SIDS. snorting or gasping for breath. Educating the child and family as well as teachers is also important. 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. characterized by loud snoring. and extreme difficulty waking in the morning are also common (Ware et al. open the airway. rather. & Olson. Boyle. nasal and oral airflow. and many families refuse counseling (Guilleminault & Pelayo. or the absence of breathing during sleep. OSA in children must be taken seriously. 1998). because the OSA is a constant component of their sleep pattern. children with OSA cannot return to sleep following the resolution of the problem or even catch up on their sleep during the day. 2001). 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. Once a person is asleep. performed in a sleep laboratory. oppositionality. there is treatment in the form of medication for the various symptoms. and allow the child to resume breathing.

Treatment usually involves surgery to remove the airway obstruction (Croft. Some children have consistent schedules and still have problems with the disturbance of their total amount of sleep throughout the 24-hour period (e. Initiating and Maintaining Sleep Bedtime problems and/or frequent night wakings during sleep are very common problems among preschool children. for a good discussion of this problem and treatment methods). Resolving these problems involves determining the total length of time the child sleeps per day. Simmons. (1981) reported that 9% of the patients seen at their sleep disorders clinic had schedule problems. Other daily activities.. & Hart. Stevenson. napping. which has been effective for OSA in adults (Guilleminault. in which a tube is inserted into a hole made through the neck below the vocal cords (larynx) and into the windpipe (trachea). Sleep 193 the few normative studies in this age group. Prime clues that a schedule problem exists are that the child is not sleepy at bedtime. & Graham. not sleeping through the night. and gradually changing the schedule (see Ferber. Brockbank. A consistent daily schedule is needed to solve this circadian rhythm disturbance. & Nino-Murcia. Frequent night wakings occur in approximately 20% of 1. because they are in the wake phase of the sleep–wake cycle (Ferber. 1981. Down’s syndrome. 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. and cystic fibrosis (Ware et al. 1998). determining what factors may be interfering with establishment of a better pattern. & Swanston. going to sleep at a specific time at night. Powell. S. and most children respond fairly quickly. A daily rhythm of waking at a specific time in the morning. 1995). Phototherapy (administering bright light pulses at appropriate times of the day) can also be helpful in treating circadian rhythm disorders (S. or having a normal sleep– wake cycle that is out of phase with the rest of the household). 2001). 1980. Ferber et al. usually within a few weeks. this pattern can be disturbed by a number of factors. illness.to 2-yearolds. are also likely to be irregular. including the inconsistency of the daily schedule. 1985). environmental changes. 1990).. and sleeps at irregular times. An MSLT is also usually done (Mindell & Dahl. 1985). gets up too early. parental response to the waking child. 1985. waking very early in the morning.6. oc- . Riley. Other risk factors are obesity. may be performed (Ferber. Richman. In more severe cases a tracheostomy. having too many or too few naps. Infants who are premature or have had perinatal problems tend to take longer to settle into a regular sleep–wake pattern (Moore & Ucko. with tonsillectomy and/or adenoidectomy relieving symptoms in about 70% of all cases (Mindell & Dahl. 1957). 1998). eating at set times. 1985). Difficulties with getting to bed are also common. such as eating or playing. and 8% of 4-year-olds (Jenkins.g. The most common causes of OSA among children are enlarged tonsils and adenoids. 1975). 4% of 3-year-olds. Wright. Campbell et al. Once a child has settled into a pattern.. Richman. 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. oral or facial abnormalities (such as a markedly recessed chin or repaired cleft palate). 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. Other treatments may include weight loss or the possible use of nasal continuous positive airway pressure. Bax. 2001). and emotional trauma (Ware et al.

physical discomfort. found that difficult temperament and difficult birth histories were associated with sleep problems. Furthermore. 16% called to their parents or came out of their rooms after being put to bed. both bedtime problems and night wakings increased. In the oldest group (30–36 months). bedtime problems increased. Finally. Richman et al. parents are typically asked to keep records and change their . In the middle age group (24–29 months). 55% of 1. and that these may not be the same factors contributing to the maintenance of the problems (Anders & Eiben. so they cannot be readily observed.5% of 3-year-olds and 5% of 4-year-olds. Problems with initiating and maintaining sleep can be difficult to treat for a number of reasons.g. Similarly. (1987) concluded that the most prominent sleep problems—going to bed and going to sleep—mirror the developmental task of separation and independence. 1981. Richman. Kataria. In a sample of 8-year-olds who were waking during the night. these problems were associated with sleep problems at ages 6 months and 10 years. 30% of these children had generalized behavior problems. The youngest children (18–23 months) had the least difficulty with bedtime. Gaylor. Stevenson. as compared to 19% of non-sleep-disturbed children. and Graham (1982) found that 40% had had the problem since at least age 3. The behaviors that most concerned parents were cosleeping all or part of the night. Goodlin-Jones. and 31% took more than 30 minutes to fall asleep. These two problems are often found together.. and to have temper tantrums. but 21% of this group woke in the night. MANAGING COMMON PROBLEMS curring in 12. infant temperament. which in turn precede problems with going to bed (Anders. Developmentally. problems with night waking occur before problems with falling asleep.to 2-year-olds and 29% of 3-year-olds who wake in the night also have trouble going to bed (Richman. 20% fell asleep in their parents’ arms. 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. It is interesting that few parents saw these problems as significant enough to seek help. First.194 II. In a study of 100 children ages 18–36 months. Crowell et al. and Trevathan (1987) found that 84% of children with sleep problems at 15–48 months of age continued to have problems 3 years later. Atkinson. Second. to have eating and appetite problems. and a parent’s having to hold a child until he or she fell asleep. family illnesses. & Hua. Beckwith. but that these associations were not evident by age 3. Vetere. a child’s resisting being alone in such a way as to make bedtime difficult or unpleasant. and 24% expressed fear of the dark. 1997). and maternal psychopathology) contribute to the development of sleep behavior problems. Sigman. Swanson. 1975). 1983). for example. the clinician has to rely on the parents’ reports of the problem and of whether or not treatment is effective. milk allergy. nutrition. and Grayson (1995) found that although “difficult” temperament was significantly related to sleep problems in preschoolers. Sleep problems do not simply “go away” with time. Crowell et al. and Anders (2001) found that an infant’s ability to self-soothe at 12 months of age predicted night waking two years later. (1987) demonstrated a developmental progression of sleep problems in this 1½-year age span. Other work suggests that many factors (e. the parents were also a contributing factor. & Parmelee. in which 25% were reported by parents to have sleep problems. Richman (1981). consequently. Cohen. the children with night waking at age 5 were more likely to report recurrent headaches and stomachaches.. marital/couple conflict. In addition. Persistent sleep problems were associated with increased stress in the environment. Pollack (1994) also documented the continuity of night wakings in a national British cohort of 5-year-olds. and episodes of depressed maternal mood. including unusual maternal absences. they occur at home and at night. 1992). accidents and injuries of the child. Halpern.

and Poole (1989) demonstrated the effectiveness of providing parents with written information in a standardized night waking program. an extensive literature on the side effects of drugs in adults with insomnia. Hunt. but there is evidence to suggest that it is not a disturbance of sleep. deep sleep. and cueing (making a clear distinction between daytime and nighttime activities) (Ware et al. a few weeks). and it is not discussed here (see Chapter 4). and instructions for handling crying. Parasomnias are most common among children. Parasomnias Parasomnias are disturbances during sleep or at the transition from sleep to wakefulness. 1985). 2001). improvement was only moderate in the other subjects. Third.6. Douglas. Nocturnal enuresis has also been put in this category. & Kales. procedures for settling the child. 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. sleep rocking or head banging. 1997). are not associated . Both Ware’s group and Anders and Eiben (1997) advise against the use of drugs. perhaps 20% of all children experience at least one of these disturbances (Ware et al. Finally. Although parasomnias get a lot of attention. Sleep 195 behavior in the middle of the night. Medication is the most widely used treatment. Treatment of these problems is further discussed later in this chapter. Although there is no one solution for all sleep problems. and getting out of bed. positive reinforcement of appropriate bedtime and sleep behavior. 2001). have no clear etiology. they include nightmares. consistent bedtimes. Seymour. the therapist cannot model the desired behavior. Tan. This can include a variety of techniques: gradual or rapid withdrawal of parental attention (Mindell. and no child started to sleep through the night after its use. (2001) caution that hypnotic-like drugs used in any context may produce significant sleep and behavioral disturbances. 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. these include deterioration in the quality of sleep and drug withdrawal insomnia (Kales. there have been very few studies of their effectiveness. Brock.. REM sleep behavior disorder. which involved organized bedtime routines. and wakefulness. There is. when they are least alert. Ware et al. Landsdown. It is interesting that although the parents reported improved sleep. (2001) point out that sedatives or hypnotics will suppress REM sleep. tolerance develops as the use of a hypnotic continues. sleep terrors. although this is rarely necessary (Anders & Eiben. Furthermore. 25% of 59 first-born children had been given sedatives. and partial arousals from deep sleep (sleepwalking. sleep bruxism. A behavioral approach is the most effective treatment for problems with initiating and maintaining sleep. 1999). Richman (1985) found that one-third of 22 children with severe waking problems showed no improvement even on relatively high doses. In spite of this wide use of sedatives or hypnotics with children. Ware et al. During. if used. Ounsted and Hendrick (1977) reported that by 18 months of age. especially with young children (Richman. they generally occur infrequently in individual children. their sleep records did not support their oral reports. and sleeptalking). In a doubleblind trial of the hypnotic drug trimeprazine tartrate. however. 1974). Bixler. shaping (making a gradually earlier bedtime). sleep paralysis. & Levere. calling out. Richman concluded that strong hypnotics have little effectiveness for most wakeful children. it is hard to use positive reinforcement to encourage development of new sleep-related behavior.. at most. Scharf. and a higher dose is required for the same effect. The studies of drug effectiveness with children are no more encouraging.

g. with reports of 10–50% of all children between the ages of 3 and 6 years experiencing them (Mindell & Dahl. Merckelbach. a brief description of each disorder mentioned above is given. and Moulaert (2000) found that 67. However. and they are often associated with posttraumatic stress disorder. 95. 2000). which occur in the REM stage of sleep. Although more children report having scary dreams in the early elementary school years than at other ages (Muris. Muris. Children are also very likely to talk about nightmares in the morning.. Some medications (e. or harm to others and animals.7% of 7.to 12-year-olds said they had scary dreams. and the ability to recall in detail the dream content.to 9-year-olds. they can easily be distinguished by the lack of physical activity during the nightmares.. They usually occur in the last third of the sleep period. Gadet. 1990). Gadet. and withdrawal from other medications (e. 1985). alertness upon awakening. 1999).. which are seen in the NREM sleep.. as well as continuing to dream of imaginary creatures and personal harm or harm to others (Muris. and 10. 1987). 2000).196 II.. and Boarini (1988). and their content represents a developmental sequence of fears and concerns. According to these data. Although . report scary dreams about imaginary creatures.3% of 10. they can result in disturbed sleep and fear of going to bed (Dollinger et al. de Pablos.to 6-year-olds. beta-blockers and antidepressants) are associated with nightmares. This may underestimate the prevalence of nightmares. and 76. et al. Nightmares Nightmares. Nightmares appear to reflect stresses experienced during the day. Stressful times and traumatic events can also exacerbate nightmares. personal harm. Horn. who found nightmares to be more common among learning-disabled students who were concerned about their intellectual and academic adequacy. Support for the hypothesis that troubled sleep reflects emotional concerns is provided by case studies and in an empirical study by Dollinger. Merckelbach. Because parasomnias are so common in young children. Almost all children will have a nightmare at some time in their lives. Whereas nightmares per se are not seen as pathological. Caminero. Nightmares are very different from night terrors. for example.. 2001). REM Sleep Behavior Disorder REM sleep behavior disorder occurs as a result of an unusual lack of muscle paralysis during REM sleep. referrals for problems with nightmares are more common for preschoolers and adolescents (Ferber. Gadet. Using a child self-report method. Nightmares are very common. et al. 1988). benzodiazepines) can cause nightmares (Mindell & Dahl. Treatment approaches for nightmares are discussed in a later section of this chapter. barbiturates. are frightening dreams that wake a person and leave him or her with a feeling of profound fear and anxiety. MANAGING COMMON PROBLEMS with psychopathology. 1998).9% are reported to have them once a week or more (Fisher & Wilson. older children report dreaming about being kidnapped. and usually disappear with maturation (Pargja. Frequent or persistent nightmares may reflect inordinate stress during the day and should prompt an inquiry about other problems. however. which allows the physical acting out of nightmares (Ware et al. & Dobato.g. work with adults indicates no relationship between nightmares and anxiety (Wood & Bootzin. many children continue to have nightmares throughout childhood. Merckelbach. Preschool children. Millan.7% of 4. 1998).

Ware et al. Reding.g. 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. No treatment other than reassurance is usually necessary. 1998). No treatment is suggested for a young child. These behaviors tend to decrease with age. can be associated with narcolepsy. and recur repeatedly during the night. Ferber (1985) states that if the rhythmical patterns are strong. Blaw. if it is severe. occurring in 22% of children under 2 years but only about 5% of children after age 2. Bruxism can occur while an individual is awake or asleep (see Chapter 5 for a brief discussion of the waking variety). (2001) explain this phenomenon as related to REM sleep when the person actually awakens. with 60% of 9-month-olds engaging in these behaviors (Mindell & Dahl. Sheldon & Jacobsen. . but can continue as long as 1–4 hours.. to have the child wear a helmet. they usually disappear by age 4 (Mindell & Dahl. last longer than 15 minutes. 1968). In over half of these cases there is some identifiable neuropathology. Robinson. Zimmerman.. Sleep 197 it is rare in children. in an older child. Sleep paralysis. 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. especially if it is accompanied by hallucinations. or to have the child sleep on a mattress on the floor to decrease the noise of the rocking crib or bed. 2001). 1998). 1998). bruxism is generally benign and resolves with time (Ware et al. Persistent or severe cases resulting in headaches or jaw pain are treated with biofeedback and stress management (Mindell & Dahl. over 50% of normal infants and 15% of children between 3 and 17 years old engage in this behavior (Mindell & Dahl. so this association should be considered when one is evaluating either problem. 1998). Though temporary and not harmful. other behavioral or emotional problems) may need to be assessed. and autism should be distinguished from these behaviors in normally developing children. but the paralysis that accompanies REM sleep remains. 1989. Sleep Bruxism The repetitive grinding of teeth or clenching of jaws during sleep can occur at any age and is very common among children. but parents may be advised to pad the crib. & Smith. Sleep Rocking and Head Banging Rhythmical movements of a child’s body during sleep usually begin around 6 months of age. Episodes usually last from 5 to 15 minutes. It is a problem that often runs in families. The head banging. may necessitate the use of a tooth-protective device. and body rocking associated with blindness. Movement can usually be restored by rapid eye movements or the touch of another person. mental retardation. & Steinberg. clonazepam) is effective in 80% of the cases. additional problems (such as parental attention to the behavior or. Zepelin. it can be a frightening experience. Head banging and head rolling are seen at about 9 months.6. head rolling. who probably engage in these behaviors to soothe themselves to sleep. treatment with a benzodiazepine (e. it has been reported in children as young as 22 months old (Herman. 1998. Although there is some evidence that stress may play a part in this problem. however.

If stress or anxiety is present. 1981). and they should be given information and reassurance. but they can be precipitated by fever. Spirito. A sharp noise or standing the child on his or her feet can precipitate an episode (Broughton. During sleep terrors. calmly leading the child back to bed.5%. with the child becoming calm and continuing to sleep. Chamberlin. OSA) . If sleepwalking occurs in the early morning. the child often has strange fears and is inconsolable (Zuckerman & Blitzer. Mean age of onset is 5–6 years. and some medications (e. Klackenberg. Exacerbating factors such as sleep deprivation (which increases deep sleep). the use of stimulants such as caffeine (which can cause fragmented sleep). They are less frequent than sleepwalking. wake in a state of confusion. since there is often a family history of similar sleep problems (Mindell & Dahl. sleep deprivation. rapid pulse and respiration. There is no evidence that partial arousals result from psychological problems (Auchter. 1990). Most children. and he or she has no memory of the episode. or other sleep problems (e. which decreases the quality of sleep) may be present and contribute to the sleepwalking. with estimates of prevalence ranging from 1–6% of children (American Psychiatric Association. 1998). it can occur at other times (Fisher & Wilson. Since children are in deep sleep 1–3 hours after sleep onset. & Owens-Stively. There may be a genetic component in sleep arousals. and do not remember the event in the morning. Sleepwalking. 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. it could suggest a seizure disorder (Ware et al. 1979). it is important for a child to get sufficient sleep on a regular schedule. Most of these problems decrease with age. Stark. 1982). They are also known to occur during an illness with a high fever (Kales. 1982. 1968).g.. however.198 II. Fisher & Wilson. stress. Sleepwalking should be differentiated from a seizure disorder. Sleep Terrors. 1980. 1987). Sleep terrors usually occur within 15–90 minutes of sleep onset.. and a glassy stare. 1987).. a chaotic sleep schedule. a loud panic-stricken scream. Sleep terrors are characterized by intense sudden arousal. with rates as high as 18. 1994). Other sleep disturbances (such as OSA. Most children sit up in bed with a glassy stare and may walk for a few seconds to several minutes. Parents are usually very frightened when sleep terrors occur in their children. Although sleep terrors are not associated with psychiatric disturbance. Sleep terrors resolve with central nervous system maturation. they may be precipitated by stressful life events. 1997). a stressful environment. sleep terrors. Children are not easily awakened. Management of the sleepwalking episode should consist of preventing accidents. MANAGING COMMON PROBLEMS Partial Arousals Sleepwalking.g. and desipramine) (Klackenberg. & Martin. although they usually end quickly. 2001). Soldatos. these problems usually occur when a child is making the transition from these deep stages to a lighter stage of sleep or REM sleep. it is difficult to awaken the child. lithium. and are most common in preschool children. profuse perspiration. Since sleepwalking can be exacerbated by fatigue. first appear after 18 months of age. then treatment of these issues may be necessary. Sleep terrors can last up to 20 minutes. and prevalence is highest in children ages 9–12 years. prolixin. have infrequent episodes (Kales et al. and sleeptalking are all variations of partial arousals from deep sleep (NREM stages 3 and 4). and doing nothing until the child is calm (if he or she is agitated).. when stage 4 sleep is less concentrated. as the number of deep sleep stages drops off in adolescence. Although sleepwalking usually occurs in stage 4 of NREM sleep in the first third of the night. Kales.

. Sleeptalking appears to be associated with sleepwalking and nightmares (Fisher & Wilson. such as benzodiazepine (e. A sleep questionnaire such as the Albany Sleep Problem Scale (Durand. since these are the most common sleep problems in childhood. bedtimes. This should include napping. or it may become evident in the process of evaluating other behavioral or emotional problems.6. fatigue. It is also not wise to discuss the sleep terror episodes in any detail with the child. decreasing factors that increase partial arousals (e. 1995) gives information on the child’s temperament and the parents’ general levels of stress. Mapstone. When parents are tired or have had a particularly bad .g. 1987). Mindell. 1981. caffeine. diazepam) or a tricyclic antidepressant (e. as well as around bedtime. 1991a. our General Parent Questionnaire.1) prior to the initial visit. the emphasis here is on those factors particularly important in assessing and treating disturbances of initiating and maintaining sleep. parents should be encouraged simply to keep the child safe. stress. Step 1: Initial Contact The parents should be asked to complete a general questionaire (e. Fisher & Wilson. In addition.. as with sleepwalking (Durand & Mindell. imipramine) can temporarily improve night terrors. medications that decrease stage 4 sleep. as abrupt withdrawal can cause a rebound in partial arousals (Mindell & Dahl. During a sleep terror episode.g. The importance of a Sleep Diary for assessing the problem and determining the effectiveness of treatment cannot be overemphasized. and the Parenting Stress Index (PSI. etc. regardless of the presenting problem. ASSESSMENT OF SLEEP PROBLEMS A sleep disturbance may represent an isolated problem. 1999). Although it is rarely a major problem. is a very common behavior. with reports in the general population as high as 50–60% (Coates & Thoresen. as well as their view of the problem and what they have been told and/or done thus far.g. Abidin.) should improve this problem. & Gernert-Dott. 1999) should be carefully reviewed and investigated. parents should be asked to complete a Sleep Diary (Figure 6. The CBCL screens for general behavioral/emotional problems. Sleeptalking. The questions regarding sleep on screening questionaires such as the CBCL (Achenbach.” or spontaneous speech during REM or NREM sleep. Although they are not recommended. These medications should be stopped gradually. 1998). Sleep 199 should be assessed and treated. to gather specific information on the child’s sleep pattern and the parents’ response to it. “Somniloquy. see Appendix B) with demographic information. since consolation or trying to awaken him or her usually does not help. 1992) or Eyberg Child Behavior Inventory (ECBI. Eyberg & Pincus. the ECBI determines the extent of problems in daily activities.. 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. 1998) can also be very helpful.. since this might increase his or her fear of going to sleep. daytime sleepiness. 1987) and is not associated with pathology. and night awakenings over 24-hour periods for at least 1 week and preferably 2 weeks.g. 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.

. Schroeder and Betty N. Chart for recording periods of sleep. 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).) by Carolyn S.200 Sleep Diary Time Date Awake Mood Naptime Bedtime Time Asleep Parent Bedtime Sample 7/6/01 6:00 A. From Assessment and Treatment of Childhood Problems (2nd ed. MANAGING COMMON PROBLEMS Night Wakings What Did Time Asleep Comment 200 FIGURE 6. Gordon.1.M Happy 1:00–3:00 9:00 10:20 11:00 12:00 3:00 5:00 Rocked Milk Talked 12:20 3:30 5:10 II.

moving to a new bed or bedroom)? Have there been changes in the family routine (e. poor coordination. with a focus on both sleep and waking behavior. It is important that both parents attend the initial interview. the environmental/social context of the problem. feeding the child at wakings) than a father (Crowell et al. and the parents’ level of stress. seizures. a death. and complaints of laziness. What was the child’s birth history? Was the child premature. Given the impact that a sleep problem can have on the child and family. Is the child taking (or has he or she recently stopped taking) any medication. Press. especially an older child (who may have his or her own perceptions of the problem.g. unusual parental absence. Step 2: Parent and Child Interviews Parent Interview The parent interview should be developmentally appropriate and culturally sensitive. especially after 3 years of age (Crowell et al.. especially noncompliance. asthma. How the parents have handled behavior problems in general can provide helpful information on how to structure the intervention. overnight guests)? . inattentiveness. and autism (Tiara. with a mother tending to be more nurturant (taking a child into her own bed. a history of the sleep problem. 3.. & Sasaki. or whether treatment of the sleep problem will aid in the resolution of the other problems. 4. What illnesses has the child had (e.. Behavior. Richman. sedatives. that a disturbance such as OSA can profoundly affect the child’s daytime behavior. 1998). History of the sleep problem. Specific questions include the following: 1.. chronic ear infections. Sleep 201 night. or stimulants? Has the child ever had a head injury? Disturbed sleep has also been associated with fibromyalgia syndrome in children (Siegel. & Tarasiuk. 1998). Tal. The clinician must determine whether these other behaviors should be treated first. and daytime behavior is not highly correlated with nighttime behavior. such as antihistamines. a divorce.g. Development. the birth of a sibling. 1987). A father and mother are likely to handle sleep problems differently. and the parents’ desire to get help with this problem. juvenile rheumatoid arthritis (Zamir. an illness or hospitalization.. atopic eczema. 1981). however. The screening instruments will give information in this area. 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. their perception of the problem is not always an accurate reflection of the actual behavior (Ferber. It should be remembered. 1985. Takase. Janeway. 1998). Most sleep problems are circumscribed. About one-third of children presenting with sleep problems also have more generalized behavior problems (Richman. 1985). resulting in poor school performance. allergies. or were there perinatal risk factors? Were developmental milestones achieved normally? 2. The focus of the parent interview should be on the child’s general development and behavior. & Baum. starting preschool or a new school. 1987). it is usually best to focus initially on the sleep problem unless the child is generally noncompliant. other chronic illness)? A history of medication use is especially important to obtain. and may also be able to describe more accurately how he or she feels about the problem and handles the situation). and the interview should follow up on any concerns.6. fussiness. Medical history. It is usually best not to have the child accompany the parents to the initial interview.g. as well as its current status. seizure medication.

Parents’ response to the sleep problem. marital/couple conflict. or early morning rising? For events like sleep terrors. caffeinated beverages or chocolate and sweets vs. and if so. cuddling with a special toy. Does the child’s schedule include regular exercise. or the birth of a sibling can precipitate or exacerbate a sleep disturbance. the family’s daily routine. Child Interview Depending on the type of sleep problem.g. it is not helpful to inter- . 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 the presence of other problems. thus as a child moves from the 16-hour daily sleep requirement of the infant to the 10-hour requirement for the adolescent. is the child anxious or worried about the problem? 6. Just as there are predictable physiological patterns of sleep. Daytime activities. saying prayers. and how does he or she look.. sleeptalking. head banging. maternal depression. while asleep?). saying “good night” to stuffed animals. Current sleep status. and so on. in what way?) and the nature of the sleep behavior (what does the child do. Generally.. what was their course. most children develop presleep behavior patterns between the ages of 2 and 5 years. Family sleep history. and are they taken at regular times? There is a negative correlation between the length of daytime sleep and nighttime sleep. 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? 10.202 II. The clinician should also determine the frequency of occurrence (has the problem increased. These serve the purpose of calming the children and preventing sleep-related anxiety. Problems such as unaccustomed parental absences. Parental/social/environmental issues. 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. and if so. 8. the age of the child. Do other members of the family have similar sleep problems? If so. Information about the parents’ mental and physical health status. how long are they. MANAGING COMMON PROBLEMS 5. It is important to get descriptions of current family sleep practices. how were they treated. The Sleep Diary provides a good starting point for gathering information on a particular problem. Sleep habits and schedule. How have the parents handled the problem? What advice have they been given? What have they tried. enuresis. and the home environment can shed light on what may be maintaining the problem. it is important to determine the actual clock time of the events and their timing in relation to sleep onset. 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. or are there complaints about inattentiveness or laziness? Finally. 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. a separate interview with the child may be indicated. night wakings. The presence of other sleep problems should be assessed: (Does the child snore? Stop breathing? Are there other sleep-related behaviors (e. a light snack that improves sleep)? How many naps are taken during the day. 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. the naps should also decrease. hospitalization of a family member.g. although the child may still have a quiet time. sleepwalking. and how were they viewed? 9. they include such bedtime rituals as hearing a story. The General Parent Questionnaire and the PSI should alert the clinician to potential contributing problems in these areas. support networks.

in the parents’ perceptions and handling of the problem. or has other emotional/behavioral problems. Giving parents information on normal sleep states and patterns. If there are marital/couple problems or if there is evidence of parental psychopathology. for example. The clinician should also discuss the implications of the sleep problem for the child’s development in other areas (e. as well as his or her perceptions of the sleep problem. If there is any suspicion of narcolepsy or OSA. 1997). Step 4: Further Assessment Further assessment is indicated if the child or family presents with problems beyond those associated with the sleep problem. independence. infrared videosomnography (Anders & Eiben. these should be evaluated or referred for evaluation. should be interviewed alone. If a referral is made to a sleep disorders center. and portable. it would be important to further evaluate these areas. and how the child views it. If the child has been taking antibiotics. time-lapse. mastery). with an emphasis on how their child’s . or the child is or has been taking medication. or seizures. or the medium in which it is delivered. Step 3: Observation of Behavior The Sleep Diary serves as the source of observational data for sleep problems. the time of dose. then these should be discontinued before behavioral treatment begins. for which treatment often involves medication that can cause sleep problems. school. The focus should be on the child’s general adjustment to friends. electronic detectors in mattresses that track body movements and respiration. If the child has trouble in school. problems (and the focus of treatment) may have been identified in the child’s development. asthma. the dose.g. Step 5: Referral to Allied Health Professionals If there are medical problems. Coverage of the problem should include a description of what it is. the clinician is primarily a consultant to the family members who must carry out the actual treatment program. There are also new technologies that can be employed in the home. and/or in the consequences of the problem for the child and family. in medical issues. a school-age child who is having sleep problems. the sleep problems may be caused by additives in the medium in which the antibiotics are given. such as 24-hour ambulatory monitoring. and family. what the child has done to resolve it. The nature of the sleep disturbance. the clinician’s view of the problem. If the child is taking sedatives for the sleep problem. A referral to a sleep disorders center is also appropriate if a severe sleep problem is persistent and unresponsive to treatment. in the environment. the child should be referred to a sleep disorder center.6. it is important for the clinician to contact the child’s physician. then further observation will be done in that facility. and possible treatment strategies should be shared with the parents. In the treatment of a sleep disturbance. how the parents have viewed and handled it. it may be possible to make changes in the medication. how often it occurs. Sleep 203 view a preschool child alone. for example. Step 6: Communication of Findings and Treatment Recommendations In an assessment that has followed the CAIS. however. For such problems as allergies..

The parents should be given information on circadian rhythms. depending on the nature of the problem. Wolfson. used a group format to teach prospective first-time parents behavioral strategies to promote healthy. and Futterman (1992).204 II. Even though many sleep problems appear topographically similar. Sleep–Wake Schedule Problems Sleep–wake schedule problems can occur when daily routines are irregular. the etiology of the problem will vary for each child and family. when a child naps at inappropriate times or for too long a time. 1999). In the meantime. 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. . MANAGING COMMON PROBLEMS disturbance fits into this process. so that what happens one day may not be the same the next day. the parents in the training group reported less stress and a sense of greater parental competence. see Durand et al. 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. bedtime struggles and night waking. Factors related to the parents can also influence the course of treatment for any problem. the advantages and disadvantages of naps at various ages. These individual differences must be taken into account when one is planning a treatment program. In addition. for example. parents also should be encouraged to set regular and appropriate bedtime schedules with good prebed routines.2. selfsufficient sleep patterns in their infants. For a more in-depth discussion of treatment strategies. treatment for the sleep disturbance per se is not likely to be effective. 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. However. the infants of the trained parents had significantly better sleep patterns than a control group. environmental influences on disturbed sleep are cumulative. TREATMENT OF SLEEP PROBLEMS Treatment of children’s sleep disturbances will of course vary. In many cases. 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. Lacks. and the importance of establishing regular routines throughout the day and night. It is best to support such a parent in getting personal help or recovering from the illness before helping the child to sleep alone. but this is particularly true for sleep problems. This section focuses on treatment approaches that are appropriate for the more common sleep disturbances: sleep–wake schedule problems. the average amount of sleep expected for the age of their child. for example. or a parent who is recovering from a serious illness. it is better for the parent to handle the behavior in a consistent manner. In such a case. At the ages of 6–9 weeks. (1998). and bedtime fears and nightmares. or when the child’s normal sleep–wake schedule does not fit into the family’s routine. The information needed by parents for managing other sleep problems is shown in Table 6. Group treatment and written materials have been found useful for a number of sleep problems (Mindell. Furthermore. A mother who is depressed. can both relieve the parents’ fears about the problem and ensure their understanding of and cooperation in selecting and carrying out appropriate treatment strategies.

Bedtime routine Bedtime fading Daily routine Bedtime struggles. Sleep TABLE 6. Have parents check on the child after progressively longer periods of time. Give information on the disorder. Bedtimes and scheduled short naps should be consistent. This teaches them to go back to sleep on their own when aroused from deep sleep. appropriate sleep for age. tonsils. bath. after ruling out medical or psychological problems that could affect the quality of sleep (e. and social activity routines should be consistent.g. Give information on the disorder and its effects on the child. reasons for night waking. Establish consistent unstimulating bedtime routine beginning about 30 minutes prior to bedtime (e. night waking.g. and bedtime to conform to night and day. Surgery to remove airway obstruction (e. story) that always leads to bed. bath. narcolepsy. medicine. and explain dreams versus reality. Tracheostomy for severe cases.. then systematically make bedtime 15 minutes earlier until child is falling asleep at desired time.g. For early morning rising. exercise.. (cont. importance of routines appropriate to day and night. (REM-NREM cycles). Establish consistent routine regarding arising. Eating. wait to go to the child for progressively longer periods of time. Give information on appropriate sleep for age. unstimulating routine beginning about 30 minutes prior to bedtime (e. adenoids). until child falls asleep on own. and importance of bedtime routines and of learning to fall asleep independently. have parents wake them 60 minutes before usual awakening. its effects on the child. Establish a consistent. 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 Parasomnias: Problems that occur during sleep or at transition from sleep to wakefulness Nightmares Support for child Parents should have child describe nightmare. and be calm but firm that nothing will happen to harm the child. sleeping.. Find time child consistently falls asleep. Give information about appropriate sleep for age. and depression). story) that always leads to bed. Continuous positive nasal airway pressure to keep airway open.g. use a night light. Methods for Managing Children’s Sleep Problems Sleep Problem Sleep–wake schedule Treatment Information Description 205 Dyssomnias: Difficulties in initiating or maintaining sleep or day time excessive sleepiness Give information on the effect of the circadian rhythm on sleep–wake cycle.. exercise. activities.2.) . and lack of relationship to SIDS. For children with frequent night wakings. sleep apnea. eating.6.

Parents should calmly return child to bed. and providing cues for the child when it is time to sleep by establishing bedtime routines and rituals that are not stimulating. Discuss possible sources of stress.206 TABLE 6. Explain nature of problem and give reassurance. Mindell. arising. Parents should be helped to adjust the child’s schedule gradually to the family’s routine or. Adapted from Durand. and/or caffeine can increase it. and exercising. Explain the normal progression of the behavior and its probable causes. Build a fear hierarchy and gradually pair items with relaxation and pleasant imagery. stress. Treatment may also involve gradually establishing later or earlier bedtimes and/or waking the child earlier from naps and in the morning. Reward child for using coping skills and staying calm for progressively longer periods of time. Have parents awaken child 30 minutes before usual time of night terror. use a helmet. Explain that sleeptalking is innocuous but that fatigue. Copyright 1998 by Plenum Publishers. Have parents pad the crib. eating. Have parents awaken child 30 minutes before expected episode for 1 month. Sleep terrors Information Scheduled waking Sleeptalking Sleepwalking Information Information Scheduled waking Sleep paralysis Information Rocking and head banging Information Protective measures Sleep bruxism Information Tooth-protective device Biofeedback and stress management Note. This can be done by changing the current bedtime or waking time by 15 minutes every 2 days until the desired time is reached.2. (cont. Parents should encourage eye blinks or give light touch to restore movement. Depending on the basis of the problem. clearly separating day and night activities. stress the importance of keeping the child safe and not giving details of the episode to the child. and Gernert-Dott (1998). conversely. Explain how sleep terrors fit into the sleep cycle. or have the child sleep on a mattress on the floor. Adapted by permission. Give information about the problem and the need for accident prevention. Use in cases where headache or jaw pain persist.) Sleep Problem II. Establishing an appropriate sleep– . MANAGING COMMON PROBLEMS Treatment Progressive relaxation Systematic desensitization Coping skills Contingency management Description Teach relaxation skills and pair with pleasant imagery at bedtime and upon waking in the night. Have child wear device to reduce pressure and protect teeth. to reorganize the family’s routine in order to accommodate a routine for the child. Have child practice at bedtime. changing the child’s irregular sleep patterns may involve setting up regular daily schedules for going to bed. Mapstone. Have the child play out fear or nightmare and take an active role in vanquishing the fear.

the parent should follow the schedule for closing the door as shown in Table 6. and closing the door). bedtime struggles can be understood in terms of the normal but often difficult separation that going to sleep alone involves. If the child cries when the parent leaves the room. 1985). a story. The child should be put to bed just before he or she falls asleep. the parent should return to the child on the schedule recommended by Ferber (1985) as shown in Table 6. Each subsequent night the first period to wait was increased by 5 minutes. and likability actually improved after treatment! Despite this evidence. in 5-minute increments. 2. the first step should be to stop nursing before bed. France (1992). Treatment of bedtime struggles and night wakings involves techniques that focus on helping the child learn new and more independent bedtime behaviors. A review of empirically tested interventions for these problems indicated that although extinction is a well-established and effective treatment. are able to tolerate crying. This essentially involves helping the child learn the task of falling asleep on his or her own. that there is no psychological damage to the child with this technique. if the child is used to being nursed to sleep. 1999): 1. etc. either gradually or by extinction through totally withdrawing all attention (i. but replace it with holding the child and reading a book or singing. the parents should be given information on the usual distribution of sleep at various ages. with the longest period being 20 minutes (Durand & Mindell. As an example.6. or want a fast cure. Both clinical and research data indicate. Sleep 207 wake schedule. for example. appropriate snack. the parent should be instructed to hold the door closed until the child is quiet. not going back into the child’s room. Bedtime Struggles and Night Waking For the 6. most parents find a gradual approach more tolerable. however. emotional tension.) as ways to cue the child that it is time to sleep.e.to 3-week period. Likewise. 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. It should be explained how good bedtime routines and rituals help decrease the child’s anxiety about going to sleep. or changing an inappropriate one. before checking on the child. Mindell & Durand. It involves letting the child know that the parent will not return to the room after saying good night. but there is support for the efficacy of this approach. If necessary. The parents should establish good bedtime routines and rituals (including quiet activities.4 (Ferber. These children’s scores on security. The most successful approaches to these problems involve the following steps (Mindell. The extinction method is especially appropriate for parents who have tried many techniques without success. must occur gradually and should be accomplished over a 1. the reasons for the normal wakings every night (NREM-REM cycles). found no evidence of detrimental effects on 35 children (6–24 months of age) treated with extinction for sleep problems.. they cannot tolerate the child’s crying and worry about the psychological effects on the child (Mindell. The waiting times have varied in different studies. Two studies had parents wait for progressively longer periods of time. 1999). A chain lock that . not talking to the child. 1990. The child’s need for the parents should be eliminated by withdrawing parental attention after saying good night.to 24-month-old who is still waking several times a night. parents find it difficult to implement. and how parental responses can change the behavior without causing psychological problems for the child.3. 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. 1993). For an older child who is capable of leaving the room.

and Their Parents Can Get a Good Night’s Sleep (Mindell. By day 7 your child will most likely be sleeping very well. Each time you go in to your child.4 (though without closing the door). 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 5 10 15 20 25 30 35 Second wait 10 15 20 25 30 35 40 Third wait 15 20 25 30 35 40 45 Subsequent waits 15 20 25 30 35 40 45 Note. the parents should be clearly instructed to unchain the door when the child is quiet or has gone to sleep. 9. MANAGING COMMON PROBLEMS TABLE 6. Remember. or if he is awake again and crying vigorously after getting some sleep. or if he is still awake then after waking earlier.) you have previously decided to be reasonable to start the day. without being held. When you get to the maximum number of minutes to wait for that night. get him up and begin the morning routines. The child’s sleep disturbance should resolve in a few days with this approach to treatment. 3.3. In fact. Reprinted by permission. spend only 2 to 3 minutes. 5. In our experience. begin the waiting schedule at the minimum waiting time for that day and again work up to the maximum. or using a bottle or pacifier. Use the same schedule for naps. The parents should continue using the Sleep Diary to keep data. We use a story called “I’ll See You in the Morning. 1997) or The Sleep Book for Tired Parents: Help for Solving Children’s Sleep Problems (Huntley. but long-standing problems may take up to 3 weeks. simply putting the lock on the door is enough to remind the child that he or she must stay in the room. Parents may also benefit from reading Sleeping Through the Night: How Infants. MD. If the lock is used. 3. 8. Copyright 1985 by Richard Ferber. A sticker chart that is hung on the back of the child’s door provides extra motivation. 2. 1991). 4. rocked. 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. nursed. but if your child has not fallen asleep after one hour. just continue to add 5 minutes to each time on successive days. any schedule will work as long as the times increase progressively.” which is adapted from a story by Ann Spitznagel (1976) (see Table 6.5). Toddlers. allows the child to see outside the room but not get out is often helpful in extreme cases. use the times shown on the chart in Table 6. 6. The goal is for him to learn to fall asleep alone. and also helps the parents and other caregivers be consistent in carrying out the program. This chart shows the number of minutes to wait before going in if your child is crying at bedtime or after nighttime wakings. 7. not necessarily to help him stop crying and certainly not to help him fall asleep. 5. If he wakes during the night. end that naptime period. but if further work is necessary.208 II. you are going in briefly to reassure him and yourself. Our favorite bedtime book for young children is Goodnight Moon (Brown. If he wakes after that time. 1947/1991). continue leaving for that amount of time until your child finally falls asleep during one of the periods you are out of the room. Continue this routine after all wakings until reaching a time in the morning (usually 5:30 to 7:30 A. 4. For children 2 years or older. 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. . reading a story about a child who has experienced a similar problem and what was done about it helps them understand what will happen. The number of minutes listed to wait are ones that most families find workable. 1. Be sure to follow your schedule carefully and chart your child’s sleep patterns daily so you can monitor his progress accurately. From Ferber (1985). If they seem too long for you.M.

If he is still out of bed. . just continue to add 5 minutes to each time on successive days.) is associated with going to bed and nighttime. offer encouragement. etc. starting with short periods. parents need to know when dreaming occurs during the sleep cycle. However. Copyright 1985 by Richard Ferber. From Ferber (1985).M. 7. By day 7 your child will most likely be staying in bed.4. and leave. 10. 4. 6. switch to the progressive routine described in Table 6. end that naptime period. but if you are wrong. do not threaten or scream. the content of the nightmare (monsters. 9. put him back in bed (if it can be done easily). Continue this routine as necessary after all wakings until reaching a time in the morning (usually 5:30 to 7:30 A. you may talk to him through the door and tell him how much time remains. By progressively increasing the time of door closure. Sleep 209 TABLE 6. but if your child has not fallen asleep after one hour. 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. When you open the door. but you can still talk to him reassuringly from another room. 11. Remember that your goal is to help your child learn to sleep alone. So reassure him by talking through the door. begin the door-closing schedule at the minimum time for that day and again work up to the maximum.3. the clinician should determine whether this fear has been precipitated by nightmares. For other children. Bedtime Fears and Nightmares The nature of nightmares can make some children afraid to go to bed for fear that a nightmare will recur. or if he is awake again and out of bed after getting some sleep. MD. Therefore. your child does not have to be shut behind a closed door unsure of when it will be opened. If he lets you put him back easily and you are convinced he will stay there. if a child is afraid to go to sleep. When you get to the maximum number of minutes for that night. 2. Use the same routine at naptimes. 3. If the problem is one of nightmares. In this case you must be out of his view during the periods of gate closure. They can then understand the need to support the child and desensitize him or her to the feared stimuli. The number of minutes listed to close the door are ones that most families find workable. speak to him briefly if he is in bed. He will learn that having the door open is entirely under his control. If he wakes and calls or cries but does not get out of bed. Be sure to follow your schedule carefully and chart your child’s sleep patterns daily so you can monitor his progress accurately. and shut the door for the next amount of time listed. you may try leaving the door open.) previously decided to be reasonable to start the day. you may change the schedule as you think best as long as the times increase progressively. 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 1 2 3 5 7 10 15 Second closing 2 4 5 7 10 15 20 Third closing 3 6 7 10 15 20 25 Fourth closing 5 8 10 15 20 25 30 Subsequent closings 5 8 10 15 20 25 30 Note. 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. 5.6. 1. do not keep making the same mistake. continue closing the door for that amount of time until he finally stays in bed. rather than insisting that the child avoid all potentially frightening material on TV or in daily activities. restate the rules. Reprinted by permission. but if further work is necessary. even if your child goes back to bed sooner. If your child wakes during the night and won’t stay in bed. Keep the door closed for the number of minutes listed. not to scare or punish him. 13. 12. 8. However. You are using the door as a controlled way of enforcing this. 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.

If you come out of the room. at the same time he or she is exposed to many new and varied stimuli through social interactions. Hollifield. Referrals for treatment of nightmares are common for children 4–6 years old.. a night light). 1990). Mommy is not going to talk to me until the morning.5. “This is silly. & Terry. she said. One night her mommy said. “I can stay in my room without Mommy.” She gave Susie a pretty butterfly sticker for staying in her room all night. the treatment process must take into account what happens to the child during the day and help the child . Bradley. and I am very proud of you. hugs. although the clinician may tell a 4-year-old that his or her dream is not real. children typically have a full understanding of dreams as thought processes (Foulkes. become less frequent at 7–9 years. I’ll see you in the morning!” Then when Susie cried. 2000). “If you go to bed quietly. I am not going to come back to see you if you cry. Susie cried harder and harder. kissed her. and television.” When Susie woke in the middle of the night. I am a big girl. By 8 years. and said “Good night. and if you stay in your room all night. Susie would get out of bed and cry for her mommy to lie down with her. I am OK in my bed. Details of this story can be changed to fit a child’s individual circumstances. It will be good for everyone else. Her mommy took her right back to the room and closed the door. I will give you another pretty sticker in the morning. I will stay here until the morning. Thus treatment techniques for children who have frequent and recurrent nightmares must take into account the children’s developmental level and understanding of dreams. so she said. and that it is caused by one’s own thought processes follows a developmental progression. If Susie woke up in the middle of the night. books. 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.g. too. If you wake up at night I am going to take you back to your own room..” Next morning Susie’s mommy said. as in the preschool years). most children have some understanding of the difference between dreams and reality. Susie went to find her mommy.” So one night. MANAGING COMMON PROBLEMS TABLE 6. Although a parent and child must deal with a nightmare when it occurs. For older children. however. but her mommy did not come. then I will take you back and close the door until you stop crying. Merckelbach. She said that she could not go to sleep without her mommy beside her. Children are able to describe the content of a nightmare as soon as they can talk. I am not going to talk to you until the morning. Every night when her mother put her to bed. or take a bath. “This is silly to cry. Susie said to herself. and then tend to increase again during the adolescent years (mirroring the conflict and struggle of becoming more independent.” That night the mommy read Susie a story. “You are really a big girl. My little girl is growing up to be a big and helpful girl. Sullivan.’ and leave the room. that it is invisible to others. Note. that it comes from within and goes on inside a person. a discussion of the dream and its possible basis can facilitate the development of coping skills. and if you come out I will close the door. It will be good for her to know that she can go to bed any time without her mommy. her mommy did not go back to the room. A young child is expected to have greater control over his or her behavior and to express emotions appropriately. I will give you a sticker.210 II. Gadet. I’ll see you in the morning. I can get my housework done. By the age of 3–4 years. She can learn to sleep by herself. the understanding that a dream is not real. Susie’s mommy told her that things would be different that night.” Susie’s mother knew that this might be hard for her little girl. it is also important to give the child concrete reassurance (e. As an example. Her mommy said: “Tonight I am going to read you a story and then say ‘Good night. et al. and go to bed any time I want. she would either go to her mommy’s bed or her mommy would have to come to Susie’s bed. Adapted from Spitznagel (1976) by permission of Ann Spitznagel. Nightmares are understandable when one considers the fears children experience on a daily basis (Muris.

this indicated that any program would have to be a gradual one. and the continual night wakings had left her exhausted. when she slept for 8 hours during the night and took two 1½. Both parents indicated that their sexual relationship had been almost nonexistent since Amy’s birth. including teaching relaxation. Amy’s 8-year-old sister had not presented any sleep problems. The PSI. the child may have been exposed to situations that are too stressful or frightening to handle. Mrs. Her mother or father rocked her to sleep every night. he was more in need of an uninterrupted night’s sleep. but firmly making it clear that nothing will happen to the child. the parents of 3-year-old Amy. Knight worked as a carpenter. the parents felt that of the two of them. Knight helped in caring for Amy at night. with the child taking an active role in coping victoriously with the feared event or object in the replay. and held her until she fell asleep again. one of them slept in the room with her. Amy was waking two to four times throughout the night. using pleasant imagery. Treatment in these cases will involve removing the child from those situations (e. Knight did part-time work in a grocery store.to 2½-hour naps during the day. age-appropriate fashion. and because of her early developmental history. Knight explained that she was a very light sleeper. Knight made it clear that she would not be able to tolerate a lot of crying. CASE EXAMPLE: NIGHT WAKING Step 1: Initial Contact Mr. ECBI. Sleep 211 gain a sense of control over or competence in difficult situations. One should be careful not to decrease a child’s exposure to all frightening movies or events. and both parents reported marital problems and disagreement about handling the sleep problem.. and reinforcing the child for appropriate sleep behavior (Greening & Dollinger. and being supportive. called for help in getting her to sleep through the night. All of this took about 5 minutes from the time of awak- . Having the child replay the nightmare. Knight. 1989). is also a good way for the child to gain a sense of competence. 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. and Mrs. or dressing up as the feared monster. not allowing the child to watch monster movies. and they clearly wanted this to change. 1988). making statements about competence in regard to sleeping.6. Although Mr. after a complicated pregnancy that resulted in Mrs. at which times her mother or father changed her diaper. and CBCL scores indicated a well-adjusted child during the day and parents who were stressed. Amy’s sleep pattern was erratic until about age 16 months. The mother reported health problems. In some instances. he had a very strenuous job. Knight’s being confined to bed for 5 months. and Mrs. gave her a drink. Currently. Mr. having a night light that allows the child to see that nothing is in the room. Mrs. or stopping the physical and verbal battles to which the child is exposed in the home or the day care center). Step 2: Parent Interview Amy had been born prematurely.g. are always important. because part of learning to cope with fearful and stressful situations is being exposed to them in a gradual. Allowing the child to describe a nightmare. and she did not wake up when Amy cried in the night. The literature reports a number of successful treatment approaches. An excellent book that helps children cope with nightmares (and other common problems) through storytelling is Annie Stories: A Special Kind of Storytelling (Brett.

but they did not want to use medication. and that their parents are understandably more reluctant to allow the children to cry for any extended period of time. Knight were resistant to the idea of allowing Amy to cry herself to sleep. The clinician voiced concerns about their staying in the room with Amy. many children. gradually decreasing the pats to a 1-minute back rub before saying good night. quickly learn that they are able to go to sleep independently and therefore feel better about themselves. Step 6: Communication of Findings and Treatment Recommendations Mr. (5) having a parent lie down on a cot in Amy’s room without speaking to her until she fell asleep. however. Amy. Mr. In fact. and not talking to her during the middle of the night. Step 5: Referral to Allied Health Professionals Referral to other professionals was not necessary in this case. but returning to her room when they retired for the night. (3) patting Amy’s back for a count of 100 initially. and emphasized the need for consistency over a long period of time to make the program effective.212 II. (2) reading a story to Amy that described the planned treatment with another little girl. 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. In the past they had let her cry up to 45 minutes before going to her. Step 4: Further Assessment Further assessment was not needed in this case.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. 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. and Mrs. who recommended a sedative. Other advice had been to “let her cry it out. they had talked with her about the need for all of them to get a good night’s sleep.” They were not able to follow this advice and were concerned about the psychological effects on Amy. (4) not speaking to Amy after saying good night. MANAGING COMMON PROBLEMS ening. They stated that it was easier to give in to her than to tolerate her crying and have a totally sleepless night. by crying themselves to sleep. and . The parents insisted on a very gradual approach. Knight were told that many children who are born prematurely take a longer time to develop a regular sleep pattern. They had also talked with their pediatrician. and Mrs. The initial intervention program included (1) establishing a clear nighttime ritual with a story and songs. and they had even screamed at her in the middle of the night to stop crying. Step 3: Observation of Behavior The Sleep Diary served as the source of observational data for this case. (6) leaving Amy after she was asleep. but within 10 minutes they would do so. 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. including gradually decreasing the frequency with which a parent slept in Amy’s room. even though they were told that this would not result in any psychological harm to her.

and giving Amy a sticker for staying in her bed during each night. She was told that if she came out of the room after they said good night to her or during the night. but she was waking four to five times each night and coming to the parents’ room. it was agreed that a “cold turkey” approach was needed at this time. but if she woke she could call to her mother. At this point. Mrs. She was still going to bed on her own. but did not get out of bed or talk to Amy when she woke. with the parents sitting in the rocking chair for a few minutes. If Amy got out of bed. and follow-up a month later found that Amy was continuing to call to her parents one to two times per night. Within 2 weeks Amy was going to sleep on her own. but did not talk or interact with her in any way when she awoke. By the third night. Knight was once more sleeping in Amy’s room during the night. Knight slept in Amy’s room. or Mrs. During one of these nights. The chain lock was never fastened. but Amy repeatedly came into their room upon awakening. Knight went away for a weekend. the parents indicated that Amy was no longer clingy during the day and seemed comfortable being away from the mother. The parents agreed that they had to respond consistently to her if she were ever to learn to sleep on her own. Neither parent wanted to give up sitting in the rocking chair as Amy fell asleep. Amy did fine during her absence. Sleep 213 (7) putting a chart with the days of the week on Amy’s bedroom door. Knight also continued to sleep in Amy’s room. Amy was continuing to sleep through the night. Amy got a sticker for staying in her room during the night. Knight became so angry with Amy that he turned on the light. put on his coat. For their sakes and Amy’s. At a follow-up 1 year later. The parents put a chain lock on the door. Several months later Mrs. Mr. they reminded . but when she returned Amy was very clingy during the day and was described as “inconsolable” when she awoke at night. Amy only called out twice to her parents. but by the seventh day she was calling to the parents only once per night. The parents indicated that after illnesses that required their attending to her during the night. she was going to bed on her own and sleeping through the night without disturbing the parents. During the first and second nights. who would answer but would not go into her room. even to the point of letting Amy know when she was going to another room. The plan for the next 2 weeks included telling Amy that her mother would no longer sleep in Amy’s room. Mrs.6. Amy evidenced no separation anxiety during the day and was clearly capable of sleeping through the night without their assistance. Knight continued to sleep in Amy’s room. Knight allow Amy to stay close by her throughout the day. and Amy soon went back to sleep on her own after calling out to her mother. Knight was instructed to take her back to bed but not to talk to her or sleep in her room. and walked out the front door! The parents agreed with the clinician that the gradual approach they had helped design was not working. The parents were comfortable with this. on four out of seven nights. By the time the parents contacted the clinician. Course of Treatment Treatment occurred over a 6-month period with erratic progress. Mrs. so that Amy could not get out of her room but could see into the hall. she would be taken back to her room and the lock would be fastened until she was quiet and in bed. Within 3 weeks. Mrs. Amy spent the rest of the night in their bed or Mrs. They were satisfied with the procedure at that time. The first night she came out twice. Mrs. As noted above. reading the newspaper. while either Mr. it was recommended that Mrs. Given Amy’s increased insecurity. Knight sat in a rocking chair placed at the doorway of the room. Knight went back to sleeping in her own room.

Although he was described as a rather sensitive and serious child. the third of four children. Moon. Matthew went to sleep in his own bed. parents of 11-year-old Matthew. The parents indicated that the family situation was stable and that they were in good health. they saw him as quite happy. he had been taking longer to get to sleep at night. In the last 5 days. age 5. Mr. These had seemed to occur at about the time of the maternal grandfather’s death and after a particularly difficult bout with the flu. and Mrs. Moon was a security guard. He knew that the nightmares were not real. and that if she did come out of her room. including a very high fever. and a day later Matthew was seen. A Sleep Diary indicated that nightmares had occurred on 11 out of the last 14 nights. For example. The recent nightmares followed the theme of some tragic event occurring to a member of the family. but after talking with their pediatrician. but after having a nightmare he slept on the floor of his parents’ bedroom or with his older brother. but said that they were still very frightening. CASE EXAMPLE: NIGHTMARES Step 1: Initial Contact Mr. however. it was interesting that he estimated having nightmares only every other night. was involved in many activities. The night terrors had been especially frightening for the parents. they would return her and fasten the lock. and Mrs. 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.214 II. and had friends. there were several bullies on the school bus who were constantly teasing and pushing the younger . Screening instruments indicated that Matthew was doing well in school. He described fairly stimulating and enjoyable daily routines. There was a great deal of focus on things happening to his youngest brother. was described as a healthy youngster who had never been hospitalized and had received only occasional antibiotics. they had been reassured. requested help in dealing with Matthew’s recurrent nightmares. MANAGING COMMON PROBLEMS Amy that she was now well and could manage on her own. Matthew. Child Interview In the interview with Matthew. but Matthew saw it as immature behavior. Moon cleaned houses. The nightmares during the preschool years had involved monsters chasing him and weird flying birds. but he was currently at home and recovering. They never actually had to do this. with repeated calling to the parents or staying up to read. Matthew’s parents and his older brother did not mind his coming into their rooms. with Matthew feeling helpless to stop it. His parents described a sleep history of occasional night terrors from ages 4 to 6. Matthew complained of feeling tired during the day and becoming increasingly upset about the thought of going to sleep and having yet another nightmare. Step 2: Parent and Child Interviews Parent Interview The parents came alone for the initial interview. The only upsetting event that had occurred recently was that the paternal grandfather had had a heart attack 2 months previously. He also described a number of situations that caused him to be either very sad or very angry.

Sleep 215 children (including him and his younger brother). 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. At the same time. Matthew felt that his mother did not always treat him fairly when he got into a fight with his older brother. He and the clinician took a problem-solving approach to the issue of the bullies on the bus. with responses from Matthew that resulted in a victory over the scary events. as well as to learn more effective ways to deal with current and future stresses in his life. Step 5: Referral to Allied Health Professionals Referral to other professionals was not necessary in this case. friends. Treatment also focused on the areas that were creating stress for Matthew during the day. Step 4: Further Assessment Further assessment was not needed in this case. Moon after each session. he was to imagine one of two scenes that he particularly enjoyed. These were winning a basketball game. His nightmares seemed to be related to stresses that he was encountering at home from interactions with his older brother. however. and age-appropriate interests). and seeing himself get physically stronger and stronger as he rode his bike and engaged in other pleasurable activities. One of them was to take him back to his room. As he was relaxing. have him describe the nightmare to them. Step 6: Communication of Findings and Treatment Recommendations Mr. He expressed affection toward his parents. Matthew agreed to go to his parents’ room when he had a nightmare. Phone contact was made with Mrs. Given the frequency and upsetting nature of Matthew’s nightmares. and Mrs. he was having trouble completing the requirements for a particular Scout badge. particularly his mother. but one who was also sensitive to injustices and to people being hurt or bullied by others. who (he felt) was treated unfairly by his older brother. it was understandable that going to bed was unpleasant for him. . Moon and Matthew were told that Matthew was a chid with many strengths (good school performance. 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). and he described his older brother as being particularly irritable with the entire family.6. Matthew and the clinician went over his descriptions of the nightmares and role-played them. Course of Treatment Matthew came in for four weekly appointments with the clinician. and reassure him that all was well. It was recommended that Matthew be seen for four to six sessions to learn ways to cope with his nightmares when they occurred. Step 3: Observation of Behavior The Sleep Diary served as the source of observational data for this case.

which he handled by making the statement. . The principal’s investigation into this matter revealed real intimidation and physical aggression on the part of the bullies. and especially with the resolution of the problem with the bullies.216 II. They were suspended from riding the bus for a week. and he planned to tell them to pick on someone their own size. The older brother was also encouraged to spend more time with his own friends. “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. When they returned they made verbal threats to Matthew. 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. he decided that if they physically attacked him. it was time for him to look for and cope with stressors in his environment. Furthermore. both inside and outside the home. MANAGING COMMON PROBLEMS Matthew decided to ask his parents to inform the principal of his school about the bullies. he was capable of defending himself. The decrease in nightmares over the next month coincided with Matthew’s having greater control over daily events. but that when he had recurrent nightmares.

child sexual abuse and its assessment and treatment are reviewed in detail. give lower estimates of the frequency and nature of children’s sexual experiences than studies that include self-reports. societal. especially the Scandinavian countries. Finally. are then discussed. This chapter provides the child clinician with empirically based information about the complex area of childhood sexuality. particularly after the preschool years. that the child clinician can come to a complete understanding of a presenting problem involving sexuality. is undiscovered by adults.CHAPTER 7 Sexuality and Sexual Problems ew topics are more difficult to discuss or engender more controversy in our society than sex. 1994). First. where attitudes toward sexuality are more permissive than they are in the United States. Indeed. Childhood sexual problems. including precocious or delayed puberty. this narrow focus ignores other sexual problems that can arise during childhood and. research in this area has centered around issues related to child sexual abuse. methodological issues have led to inconsistencies across the results of various studies. Studies that rely on parental reports of children’s sexual behavior. what is known about normal sexual development is reviewed. Most recently. Moreover. Although understanding sexual abuse is undeniably important. This inconsistency simply reflects the fact that much of children’s sexual behavior. gender identity disorder (GID). for example. and sexually aggressive behavior. Much of the work in this area has come from Europe. 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. if left untreated. and about children and sexuality in particular (Rosenfeld & Wasserman. the participants involved in the studies are 217 . and ethical restrictions on our ability to gather empirical data on children’s sexual behavior and development. where there are significant political. as well as of where things can go wrong. Finally. 1993). It is only through a broad knowledge of normal sexual development. can have a negative impact on a child’s development. This is followed by a discussion of issues related to sexuality education. F NORMAL SEXUAL DEVELOPMENT The study of sexual development is clouded by cultural attitudes and values about sexuality in general. Thus the conclusions resulting from this work may not always apply to children in the United States. especially children and sex.

are present at the time of a child’s birth. the next sections examine what is known about physical sexual development. inserts objects in vagina/anus. as well as the development of sexual behaviors..218 II. Although there is a great deal of variation. in both sexes. In a survey of parents of nonabused children ages 2–12 years. These include growth of testes and penis in boys. that fetuses suck their fingers and toes. 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). We know. Masturbation is reported by some to increase among boys and girls in the years preceding puberty. A number of the childhood sexual problems covered in later sections of this chapter originate during these early stages of development. children discover that genital stimulation results in particularly pleasurable sensations. puts mouth on sex parts. 1981). Fetal sexual development involves a complex interaction between genetic and hormonal processes (Money. Friedrich. masturbation appears largely related to general curiosity about one’s body. Melas. and that newborn male babies have penile erections. & Skar. for example. Broughton. 2000.1. 1981). Masturbation Masturbation is one of the most common sexual behaviors seen in young children (Ryan. whereas female babies are capable of vaginal lubrication (Martinson. in groups of two or more. and the capacity for various sexual behaviors. Grambsch. It is generally recognized that the physiology for sexual arousal and orgasm. 1981). imitates intercourse. Routh & Schroeder. 1962). Kuiper. Child Sexual Behavior Despite the lack of physical changes prior to adolescence. 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. and emergence of pubic hair. Physical Aspects of Sexual Development Although a child’s genetic sex is determined at conception. masturbates with object). although the rates are .g. The types of sexual behaviors that are to be expected at different ages are summarized in Table 7. 1994). MANAGING COMMON PROBLEMS typically white and from higher-socioeconomic-status (higher-SES) backgrounds. 1981). Thus the results may not represent the full range or frequency of sexual behaviors exhibited by children from different ethnic or SES groups. breast development in girls. boys are generally observed to masturbate earlier and more frequently than girls. During the first 2 years of life. and masturbation begins to take on a decidedly erotic aspect. and no developmental milestones have been clearly identified (Tanner. however. for example. whereas girls tend to engage in this behavior alone. all of the 44 sexual behaviors listed on their questionnaire were shown by at least some children. and Beilke (1991) found that although some behaviors were reported relatively rarely (e. With these problems made clear. Boys also are more likely to masturbate socially. It is clear that children engage in a surprising variety of overt and covert sexual behaviors. There are few if any physical changes in sexual development during infancy and early childhood. differentiation as male or female does not begin until about the sixth or seventh week of pregnancy. and a growth spurt resulting in adult height. Gradually. It has been observed in infants as young as 7 months (Martinson. much important development in the psychosexual arena occurs during early childhood.

simulated intercourse. petting • Sexual fantasy and dreams • Sexual intercourse may occur in up to one-third Note. exploration of own and other’s genitals. 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. may experience orgasm • Sex play with peers and siblings: exhibits genitals. 1991) are more likely to find decreases in masturbation and other sexual behaviors with age than those that include self-reports. may insert objects in genitals • Enjoys nudity. embarrassment: hides sex games and masturbation from adults • Body changes begin: girls may begin menstruation. thought to be somewhat lower among girls (Rutter. 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.g. Thus studies that rely on parental reports (such as Friedrich et al. Copyright 1995 by Plenum Publishers. most boys are capable of ejaculation by age 14 • Dating begins • Sexual contacts are common: mutual masturbation.. . Normal Sexual Development Sexual Knowledge • • • • Origins of gender identity Origins of self-esteem Learns labels for body parts. 1970).7. From Gordon and Schroeder (1995). intercourse • Knowledge of physical aspects of puberty by age 10 • Sex games with peers and siblings: role plays and sex fantasy. 1991) report a decline in sexual behavior in general.. Reprinted by permission. takes clothes off in public • Uses “dirty” words.. 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. kissing. attempted intercourse. takes clothes off in public 219 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. Friedrich et al. mutual masturbation. and masturbation in particular. with age.1. Sexuality and Sexual Problems TABLE 7. including genitals Uses slang labels Sexual Behavior Birth to 2 years • • • • • Penile erections and vaginal lubrication Genital exploration Experiences genital pleasure Touches own and other’s sex parts Enjoys nudity. kissing. playing “doctor” • Masturbation in private • Shows modesty. others (e.

some involve coercion (persuasion. cultural attitudes and values greatly influence our understanding of this issue. Child–Adult Sexual Interaction Although the data on sexual play among children may not be surprising. but how much and where masturbation occurs. the motivations associated with the interactions. MANAGING COMMON PROBLEMS Despite the fact that masturbation is such a common sexual behavior in children. it is common knowledge that preschool children are very curious about their own and others’ bodies. these early experiences of touching and physical affection are essential for a child’s healthy development. Rather.220 II. Estimates of the prevalence of sibling sexual encounters range from 9% (Lamb & Coakley. Although most childhood sexual experiences with peers or siblings are viewed positively. and that given the opportunity. 1995). In contrast. manipulation. 1983). the ages at which they occur. or force) of some type. whether or not masturbation constitutes a “problem” is in large part a function of family. societal. Because it is inherently pleasurable. Lamb & Coakley. it has also been demonstrated that nonabusive sexual encounters between children and adults are quite common. sex play between siblings appears to occur much less frequently than between friends. 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. it is seen by many as a viable sexual activity throughout the life span. Nonetheless. Child–Child Sexual Interaction The age at which children first become aware of sexual behavior as an interpersonal phenomenon is unclear. 1991). Yet there is no evidence that masturbation is harmful. Obviously. Not surprisingly. beginning at birth and continuing throughout the early years. 1993) to 13% (Finkelhor. and . Parents who accept masturbation in their preschool children may become uncomfortable with this behavior as it assumes a more adult sexual quality (Klein & Gordon. such as genital fondling. Sexual play with peers is very common among preschool and school-age children and may involve relatively adult-like sexual activities. and by some as an important developmental step in becoming reliably orgasmic in adult partner sex (Haroian. 1991). and the perception of the experiences as relatively positive or normal. It is likely that the lower rate of sex between siblings reflects in part the age differences that typically exist between them. 1993). the key clinical question regarding masturbation among children is not why they masturbate. oral–genital contact. and cultural attitudes. Clearly. 1993). many parents still react negatively to it and may even punish their children if they are caught touching themselves (Calderone & Johnson. 1981. insertion of objects in genitals. 1981) of children. In other instances. the more coercion reported. or attempts at sexual intercourse (Lamb & Coakley. Sexual encounters between siblings appear to be similar to those between friends in the types of activities involved. they will engage in sexual exploration with other children. masturbation that interferes with other activities or causes physical harm should be considered abnormal. Many sensual and possibly erotic encounters between the infant and mother (and other caregivers) occur in the context of nurturant caregiving. Indeed. the less likely the experience is to be perceived positively (Finkelhor. Research also indicates that nonabusive sexual interaction occurs with surprising frequency between older children and their parents.

& Harrell. bribery. These include the following: 1. 60). 6. 7. Sexual behaviors engaged in by children who do not have an ongoing. Obviously. Sexual behaviors that persist in spite of frequent requests to stop or occur in public places. Gil (1993). or intrusiveness. Siegel.” inspecting others’ bodies. The next section addresses this issue. We approach this assessment very broadly so as to view the behavior in context. or anger. size. and presence or absence of coercion. force. 2. for example. Sexual behaviors that are associated with negative emotions. 4. coercion. Preschool children. can be expected to touch the genitals or breasts of familiar adults or children.” Professional help should be sought when a child forces another to “play doctor” or to take his or her clothes off. and relative status or authority. 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. the type and amount of sexuality education the child has re- . the child’s exposure to adult sexual material. This behavior becomes a matter of concern if the child touches the genitals or breasts of unfamiliar adults or children. Johnson and Friend (1995) provide criteria for child sexual behaviors that fall outside the norm. 1986. Symonds. Sexual behaviors that cause physical or emotional pain or discomfort to self or others. Mendoza. 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. frequency. when these behaviors are of concern. intense guilt or shame. Rosenfeld. Sexual behaviors that increase in intensity. anxiety. mutual play relationship. such as fear. manipulation. Similarly. Much of this contact is motivated by children’s curiosity about their bodies and those of others. or asks to be touched him. & Bailey. 3. consistency with developmental norms. Sexuality and Sexual Problems 221 that these experiences do not necessarily have a negative or damaging effect on the children or other family members involved (Nelson.or herself. Behaviors that are embarrassing or annoying and elicit complaints from other children or adults. 9. or threats. 8. Sexual behaviors that are associated with aggression. and when they indicate the need for professional help. Professional help should be sought when the child “sneakily touches adults. Sexual knowledge that is greater than expected for the child’s age. early-elementary-school-age children can be expected to “play doctor. p. Information gathered should include the specific behavior of concern. 1981. for example. Issues of relative power and freedom of choice appear to be important in determining how these experiences are preceived. 1995. Bailey. Sexual behaviors that interfere with other aspects of the child’s life. It is of concern when a child frequently engages in this behavior or gets caught after being told “no. makes others allow touching or demands touching of self” (Johnson & Friend. 1981). 5.7. The important clinical issue is to determine when children’s sexual interactions are developmentally appropriate and when they are inappropriate and/or abusive. provides a framework that focuses assessment of sexual behaviors on such factors as differences in age. only careful assessment of children’s sexual behavior can determine whether or not it is a problem.

SEXUALITY EDUCATION The importance of sexuality education cannot be overemphasized. The relationship between children’s sexual knowledge and their sexual behavior is complex. 15%).. In our (Gordon et al.g. Schroeder. whereas knowledge of genitalia among boys increased gradually with age. At least two studies (Gordon. The next section examines issues related to the topic of sexuality education (including sexual abuse prevention).. Schroeder. Research in this area is inevitably biased by the culture in which it is conducted. 1990b. the parents’ attitudes about sexuality. The discrepancy between knowledge and behavior indicates that we have much to learn about how to educate children effectively about sexuality. 1975. 1975). and abuse prevention than did middle.and upper-SES children. Moreover. whereas knowledge about other areas (e.g. and older children having a more accurate understanding of these topics (Bernstein & Cowan.. significantly more girls knew what “vagina” meant than did boys (58% vs. Children today are bombarded with sexual messages from films.. school. but boys and girls knew “penis” equally well. 1981) suggest that sexual experience does not always lead to increased sexual knowledge/understanding. for example.. as well as the child’s developmental. gender differences). & Abrams. advertising. television situation comedies and soap operas. with younger children having incomplete and inaccurate knowledge. We (Gordon et al. It is important to note that the research reviewed in this section was primarily conducted in the United States. and any history of possible sexual abuse. the sexual attitudes of the parents. for example. sexual intercourse. 1990a). Researchers have generally found a developmental progression in children’s understanding of gender and the birth process. Gordon et al. 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. these age differences may vary depending on the area of sexuality assessed. This work has been replicated by Lloyd and Stroyan (1994). pregnancy. 1990a) study. 1990a).. MANAGING COMMON PROBLEMS ceived. body parts and functions. Gundersen et al. 1979). 1989. suggest that children first understand that gender is permanent (e. & Abrams. and therefore reflects the prevailing attitudes (considered to be relatively restrictive) in this country. Other work indicates that even very young children can be quite knowledgeable about many aspects of sexuality (e. and the SES of the family (Bem. Slaby & Frey. for example. and birth) may be lacking even in older children (Gordon.g. Sexual knowledge that can be expected at different ages is summarized in Table 7. the Internet. found that lower-SES children had less knowledge about body parts and functions. Studies of the concept of gender. Bem (1989) reported that girls knew as much about genitalia at 3 years as they knew at 5 years. Moreover. 1990a. a girl always was and always will be a girl) and only later understand that gender is determined by one’s genitalia (McConaghy. although the reasons why this is the case are not clear.222 II. It is possible that the relationship between knowledge and experience are mediated by parental attitudes toward sexuality.1. pregnancy. 1986). Waterman. and social history and current status.. and even the nightly news report! Education about sexuality can help to . the sex of the child. children with less knowledge had parents who reported more restrictive attitudes toward sexuality and had engaged in less sexuality education with their children.

especially behaviors that appear deviant. By understanding normal sexual development. 1983).). parents talk with children about pregnancy and the birth process. 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. Many parents. For a variety of reasons. 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. sexuality education actually begins at birth and is most appropriately thought of as a process that continues throughout one’s lifetime.2. values. even if they do not actively provide information. Sexuality education in its broadest sense involves communication of attitudes. parents are the primary sexuality educators for their children. As an infant begins to exhibit exploratory sexual behaviors. however. require some adult response. one must keep in mind that it is not sufficient to teach the facts about sex. or sexual abuse—the very topics about which children. need information. .7. Most commonly. and feelings about being male or female. so parents must respond to behavioral cues that their children are “ready” for sexual information. sexually transmitted diseases. In reviewing the information in Table 7. assist children in making sense out of confusing messages. parental reactions to these behaviors send clear positive or negative messages to the child about these behaviors. and especially adolescents. children learn a great deal about sex from peers and the mass media. Thus children’s knowledge of and values about sexuality are clearly going to be related to the information provided by parents. and may even be damaging to the child’s self-perception. telling the children how those behaviors make others feel. Because many parents do not provide their children with sexual information. Suggestions for what to teach children at different ages are outlined in Table 7. many children do not initiate conversations about sex. 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. this information is often inaccurate and confusing. 1998). failure to respond to sexual behaviors can easily be interpreted by the children as acceptance or approval. are uncomfortable discussing sexual matters with their children. In the preschool years. Answering children’s questions and responding to their sexual behavior in a simple. (2) recognize and respond empathically to the needs of others. Children begin to learn about sexuality as parents communicate their feelings about different body parts through caregiving behaviors (breast feeding.2. and (3) take responsibility for their own behavior. Although most parents do not talk with their children about sex until preschool or early school age. etc. attitudes and values must also be taught. bathing. 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. Unfortunately. Ryan proposes that goals for sexuality education should include teaching children to (1) communicate openly about sex. and encouraging the children to control their behavior in the future. Ryan (1997b. This can be done by nonjudgmentally describing behaviors as the children engage in them. changing diapers. as well as teaching the anatomical parts and functions of the body. and increase the chances that they will behave responsibly with regard to their own sexuality. 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. Because children inevitably look to adults for guidance. and most do not discuss all aspects of sexuality. but do not discuss sexual intercourse. 2000) suggests that all sexual behaviors exhibited by children. Furthermore. birth control. Sexuality and Sexual Problems 223 put it into proper perspective.

Have the child make a list of who to tell. clothing. Gender identity Learning about gender begins at birth. Child should learn that masturbation is a “private” behavior. Gender identity Gender identity is fixed by this age. and elimination functions of body parts. Practice “what would you do if” role plays. Parents provide guidance about this topic by their choices of toys. including menstruation and wet dreams. Children should know not to go with a stranger under any circumstances. Sexual abuse prevention Children must first learn about body parts and functions before they can learn to protect themselves from exploitation. 3–5 years Body parts and functions Continue to use proper labels for body parts. Allow child to explore all his or her body parts. Practice saying no and telling.2.224 II. 6–12 years Body parts and functions Children should have complete understanding of sexual. Teach the child to tell someone if this happens and keep telling until someone who will help is found. Talk about what is special about being male or female.” Explain that insertion of objects into body openings may be harmful and is prohibited. Encourage both boys and girls to pursue individual interests and talents regardless of gender stereotypes. Teach child about functions of genitalia. but flexibility is healthy.” and to get away if someone tries to touch his or her private parts. Sexual abuse prevention Genitalia are private parts. Reinforce the idea that each child is special and has unique characteristics. Allow your child to say no in other situations that are uncomfortable. when baby boys are dressed in blue and girls in pink. The best prevention at this age is close supervision. (cont. when child is touching or parent is pointing to each part. Use it as a “teachable moment. Begin to teach the child what is special about being either a girl or boy. Sexual behavior Don’t overreact if child is caught in sex play with another child. including being a girl or a boy. including both elimination and reproduction. This is a good age to begin talking about sexual intercourse. Gender stereotypes are pervasive in our culture. my parents told me not to do that. “No. reproductive. Gender identity Talk about the physical differences between boys and girls. Information for Parents to Teach Children at Different Ages Birth to 2 years Body parts and functions Provide correct labels for body parts. Teach about appropriate and inappropriate words. including sexual intercourse.) . Teach the child to say. Provide simple information about basic body functions. and the behaviors of the child they choose to notice. It’s OK for boys to play with dolls and girls to play with trucks. including male and female genitalia. including male or female genitalia. MANAGING COMMON PROBLEMS TABLE 7. activities. and no one should touch them for purposes other than health or hygiene. Explain that these rules apply to friends and relatives as well as strangers. and make sure the child knows what a stranger is. Explain why. Children should not touch anyone else’s private parts. as children are naturally curious about pregnancy and often have a new brother or sister. Discuss changes that will come with puberty for both sexes.

Sexual behavior Talk about making good decisions in the context of potentially sexual relationships. in sexual abuse prevention programs for preschool children. Let your teenager know you are available for a ride home any time he or she is in a difficult or potentially dangerous situation. 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. SEXUAL PROBLEMS Many different sexual problems are seen among children. walking alone at night. role play.g. p. Kast. including sexual harassment by peers. and in particular date/acquaintance rape and its association with alcohol and drug use.g.. including physical/anatomical abnormalities that have an impact on later psychological and social development. friendliness) as sexual invitations. Provide information about birth control and sexually transmitted diseases (including AIDS). modeling. For example. 13–18 years Body parts and functions Discuss health and hygiene. Set clear rules about dating and curfews. Practice assertiveness and problem-solving skills in troublesome social situations. if necessary. Provide more information about contraceptives and sexually transmitted diseases. Sexual abuse prevention Teach teens to avoid dangerous situations (e. and correct misperceptions. 1991. it is important to teach behavioral skills using participatory methods (e. Wurtele. Enroll your child in a self-defense class. Copyright 1995 by Plenum Publishers. 432). Note.) 225 Sexual abuse prevention Discuss the child’s conceptualization of an abuser. and aggressive or abusive sex. 1991). clothing. Males tend to perceive social situations more sexually than girls and may interpret neutral cues (e. “public or semipublic behaviors that cause adults (usually the parents) embarrassment and concern because they are a departure from society’s expectations” (Haroian. (cont. Explain how abusers. Sexuality and Sexual Problems TABLE 7.2. Provide access to gynecological exam for girls if sexually active. may manipulate children. Currier. Sexuality education programs for groups of children must recognize differences in children’s cognitive development. guided practice. Gillispie.. 1992. Gender identity Although boys and girls are able to do many of the same things. Gordon and Schroeder (1995).7. Moreover. & Franklin. reinforce the idea that there are special aspects of being male or female. relatives.g. 2000).. avoiding certain parts of town). and strangers. Discussion of anatomical sex abnormalities is beyond the scope of this chapter. Accept your teenager’s need and desire for privacy. and positive reinforcement) (Wurtele. . & Melzer. Identify abusive situations. Talk about the differences between girls and boys in social perception. Provide access to contraceptives. especially AIDS. Reprinted by permission. Discuss dating relationships. including friends. Sexual behavior Share your attitudes and values regarding premarital sex.

(2) an identified syndrome. distinct advantages come with early maturation. 1991). 1995. 1986). although the problems experienced as a result of delayed or precocious puberty are different for boys and girls. such as congenital adrenal hyperplasia (Mazur & Cherpak. including sexual intercourse (MeyerBahlburg et al.. both internalizing and externalizing (Sonis et al. As a result. Regardless of its cause. or to precipitate the onset of puberty when it is quite delayed (Money. such as neurofibromatosis. 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. a brain tumor). 1970). and greater social maturity (Rekers. Precocious puberty is caused by increased levels of sex steroids. and more withdrawn. others have been shown to engage in a range of precocious sexual behaviors. Sonis et al.. and these effects may persist into adulthood (Rutter. Although some girls who mature early may withdraw and consequently become less popular among their peers (Rekers. MANAGING COMMON PROBLEMS The interested reader is referred to Gordon and Schroeder (2001). for example. Boys tend to suffer more from delayed puberty. For boys. Treatment of precocious or delayed puberty should include a thorough medical evaluation to determine the cause and rule out dangerous conditions (e.. Rekers (1991) suggests that group treatment for children with late or early sexual maturation can focus on empathy and social skills.. whereas the majority of cases (approximately 65%) among boys involve an organic disorder. Psychological intervention is likely to involve issues of selfesteem and social relations. 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. 1993). 1986). (3) genetic disorders. Most cases (up to 80%) of precocious puberty in girls are idiopathic or of unknown origin (and may be considered extreme variations of normal). Rutter & Rutter. and Mazur and Dobson (1995) for further information. 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. greater self-confidence. which can have a variety of etiologies: (1) central nervous system lesions. Money (1994). For girls. These advantages result in higher self-esteem. 1985). 1995). 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. 1991). Increases in height and weight. early-maturing boys often receive more positive feedback from adults and may be considered more attractive by their peers. less confident. 1970. Finally. the impact of the timing of puberty is quite different than it is for boys. Sonis et al. girls who mature very early are at risk for a number of behavior problems. boys who mature late tend to be less popular.g. sexuality education with an emphasis . enhance boys’ abilities to compete in athletics. In contrast. or (4) a premature signal from the hypothalmic–pituitary biological clock (Money. 1994).. In contrast. Puberty is considered to be precocious or delayed if it occurs outside this normal range (Mazur & Cherpak. whereas girls experience more problems associated with early or precocious puberty (Rutter. such as hydrocephalus. The age at which puberty is reached appears to have a significant impact on adjustment. 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. 1994.226 II. 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. 1986).

at least for boys. probably because of the social stigma associated with these behaviors (Zucker. Sexuality and Sexual Problems 227 on the bodily changes that are occurring and the potential for sexual exploitation is essential for these children. as manifested in aversion to one’s own genitalia or sex-typed behavior. there is some agreement that GID is a relatively rare disorder. and roles in fantasy or make-believe play. Cross-gender behavior and explicit statements about wishing to be the opposite sex. Same-sex preferences typically are reflected in children’s behavior (e. probably reflecting different societal attitudes toward sex-typed behaviors for boys and girls.. Hospital personnel. and are preoccupied with activities that are strongly associated with the opposite sex. as manifested in a desire to be or belief that one is the opposite sex. activities. choice of toys. Although instances of cross-gender behavior among preschool children are quite common. These children express a firm desire to be (or a belief that they are) of the opposite sex. however. it is not known how many of these children would fulfill all the criteria for a DSM-IV diagnosis of GID (Achenbach & Edelbrock. attitudes. and the value one places on being a member of one’s sex—begins very early in life. for example. depending on the child’s physical sex. activities.g. parents. and most children have developed at least a partial understanding of the concept of gender identity by 2–3 years (Gordon et al. Most children begin to engage in behaviors and hold preferences that are consistent with their physical gender by the preschool years. and preferences for stereotypical cross-gender clothing. Boys appear to develop a same-sex preference earlier and more consistently than do girls (Rutter.” and often receive a diagnosis of gender identity disorder (GID). 1995). there is a significant incongruity between their biological sex and their preferred gender. games. Epidemiology Although the definitive epidemiological study remains to be done. For some children. Diagnostic Issues In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV. clothing) by the age of 2 years.7. the diagnostic criteria for GID include two central features: (1) powerful and persisting cross-gender identification. especially those with precocious puberty. a sense of oneself as male or female. 1983). 1975). less is known about the course of the disorder in girls. or clothing. Gender Identity Disorder The development of “gender identity”—that is. Referral rates . 1994). A full understanding of gender roles (the behaviors. 1970). They are different from children who are simply “tomboys” or “sissies. decrease with age among boys. playmates. American Psychiatric Association. 1990a.. Symptoms of GID typically appear between 2 and 4 years of age (Zucker & Bradley. Rutter. and traits designated by society as male or female at any given time) typically develops between 3 and 7 years. and (2) persisting discomfort with one’s own sex. Many of these symptoms appear to be age-dependent. playmates. 1990a). and families typically begin to influence the development of gender identity at birth by providing blue or pink clothing and masculine or feminine names.

1992). First. 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. which subsequently mediates behavior. Aronica. 1991). external genitalia.g. Other research demonstrates higher rates of parental and family dysfunction for children with GID than for controls (see. 1972). MANAGING COMMON PROBLEMS for GID are much higher for boys than for girls (6–7:1) (Bradley & Zucker. no definitive studies have replicated this phenomenon in humans. 1997. and poor self-esteem) of engaging in cross-gender behavior. clinical reports indicate that parents of children with GID often respond neutrally or positively to their children’s early cross-gender behavior. Zucker & Green. however. Quattrin. This view suggests that the co-occurrence of other forms of psychopathology with GID may be the result of the social consequences (peer rejection. Molenaar. 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. 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. 1972). To date. 1995). 1995. increases or decreases in androgens) have been shown to influence later behavior (without altering external genital structures) of both animals and humans (Money & Ehrhardt. 1996). Fetal sex hormones influence brain development. Money and Russo (1979) suggest that GID results from an interaction between biological and environmental factors. . 1990. Marantz & Coates. & Hume. 1995. It may be that boys are more vulnerable to GID because masculine development is dependent on prenatal androgen secretion. Money & Norman. Zucker. rather than in biological factors. prenatal maternal stress during pregnancy has been linked with decreased androgen secretion and later demasculinized behavior in male offspring of rats (Ward. 1992) summarize the research related to various theories about the etiology of GID.e.or same-gender behavior and identification. and that this effect may increase over several pregnancies involving male fetuses (Blanchard et al. The social environment then functions to reinforce or discourage cross. 1998). Devore. Blanchard. Bradley. This process creates a predisposition to behave as a male or a female. thus potentially increasing this behavior through differential reinforcement (Zucker & Green. Variations in prenatal hormone exposure (i. boys with GID are more likely than boys without GID to be later-born and to have more brothers than sisters (Blanchard. Drop.. 1987. 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. Rekers and Kilgus (1995) argue that the lack of evidence for abnormal chromosome numbers. They present some evidence that biological factors. Zucker. may predispose children to problems with gender identity. whereas feminine development occurs in the absence of prenatal androgens (Money & Ehrhardt. particularly prenatal hormone secretion. & deMuinck-Keiser-Schrama.. & Bailey. Alternatively. 1995). 1986. & Norman.. 1984). social isolation. but see Slijper. Moreover. Second. The causes of variations in hormone secretion during pregnancy are not yet well understood. e. Gooren. & Mazur. Zucker & Bradley.228 II. 1997. Zucker & Bradley. but two possibilities have been proposed. Cohen-Kettenis.

1995). 1995. Kilgus. and therefore it is inappropriate to try to change a child’s discordant gender identity. 1990b). & Cohen-Kettenis. research indicates a somewhat different picture. This approach may speed up the natural developmental process of cross-gender behavior (i. Such males typically do not have gender problems as children or as adults (Blanchard.g. 1990). however. however: Many homosexual adults do not recall engaging in cross-gender behavior during childhood. The function of cross-dressing appears to distinguish potential transvestism from GID. a decrease with age) and prevent the development of other forms of psychopathology that typically result from peer rejection. 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). Zucker and Bradley (1995) suggest that the transition from childhood to adolescence may be a critical time for the development of transsexualism. 1990. 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. 1987).. Transvestism (cross-dressing by heterosexual males for purposes of sexual arousal) does not appear to be related to GID. The association between cross-gender behavior in childhood and later homosexuality is not absolute. It would be reasonable to expect a similar strong association between GID and transsexualism (i. and argue that the treatment may in effect cause more harm than good by focusing on the idea that homosexuality is undesirable (Green. see Bailey & Zucker. They note that those children who maintain a consistent cross-gender identification as they move through adolescence are most at risk for transsexualism. Although retrospective studies show that almost all adults with a transsexual orientation (both males and females) recall cross-gender behavior as children (e. 1979). and some children with gender disturbance do not adopt a homosexual orientation as adults. Clemmensen. Prospective work indicates that a substantial majority (60–80%) of boys with GID have a homosexual or bisexual orientation as adults (Bailey & Zucker. Treatment Treatment of GID in children has generated considerable controversy. 1992). and may also be effective in resolving the gender identity disturbance (Rekers.. Blanchard. as opposed to a soothing or erotic function (typically involving female underwear) for transvestism (Zucker & Green. Money & Russo.7. its significance as a clinical problem lies in the strong relationship between early cross-gender behavior and later homosexuality. Sexuality and Sexual Problems 229 Long-Term Prognosis Although GID is relatively rare. persistent gender identity problems in adulthood and a wish to undergo sex reassignment). 2001). prospective studies of children with GID indicate that very few develop transsexualism as adults (Green. This link has been shown in both prospective and retrospective studies for boys and in retrospective studies for girls (for a summary. 1987). & Rosen.. A third . van Goozen. Green. & Steiner.e. 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. 1990b). One view argues that treatment reinforces a sexist view of child rearing (Zucker. Cross-dressing among gender-disturbed boys is done for the purpose of enhancing identification with the opposite sex (typically employing outer clothing). Zucker.e. 1987. 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.

the behavior is unresponsive to parental limit setting. some appear to be focused on and preoccupied with sexual matters beyond what is expected for their age. Parents can contribute by ensuring that the program is implemented consistently across settings and people.g. You are getting to be just like your dad”). MANAGING COMMON PROBLEMS approach is to focus treatment on first acknowledging and affirming the child’s cross-gender preference. many children who have been abused do not exhibit sexualized behavior. many sexual behaviors (e. a history of sexual abuse has been found in almost all cases of sexu- .g. The behavior of these children may vary a great deal. “You are such a strong young man.. The possibility that the child may have been sexually abused should be explored (but. However. Self-esteem enhancement focused on gender-related issues is also an important component of treatment in most cases of GID (Pope.230 II. without raising unnecessary concern). 1974. 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. But not all children who exhibit these types of behavior have been sexually abused. for alternatives). Indeed. For instance. 1990b).and samegender behavior (Meyer-Bahlburg. and may indicate serious psychopathology.) have been shown to occur more frequently among children who have been sexually abused than among those who have not (Friedrich et al. For the most part.. 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). if possible. asking to engage in sex acts. 1990). A behavioral approach to treatment of GID in children is most common (but see Soutter. 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. The clinical picture for children who engage in such behaviors varies according to age and gender. Verbal feedback is given about gender-appropriate and gender-inappropriate behavior. For example. McHale. treatment of any accompanying parental or family psychopathology is essential to maximize the effectiveness of the treatment program. & Craighead. 1981). According to this view. 1992). putting mouth on sex parts. public masturbation to coercive or aggressive sexual interactions with other children. I really appreciate your carrying in the groceries. ranging from compulsive. Schaefer & Millman. Oversexualized and Sexually Aggressive Behavior Although all children display interest and curiosity about sexuality at various times during their development. however. 1985. Behavioral treatment provides opportunities and positive reinforcement for engaging in gender-appropriate behavior and choosing gender-appropriate games and toys. 1996. sexualized behavior that interferes with other age-appropriate activities is a warning signal that a child may have other problems. 1995. and cross-gender behavior is extinguished by ignoring (Rekers & Lovaas. and Sugar. Sexualized behavior is often thought to be an indication that a child has been sexually abused. masturbating with objects. Sexually aggressive behaviors among children are never normal and always warrant careful assessment and treatment. conversely. Zucker. Nonetheless. crossgender behaviors are only seen as problematic in reference to where and when they are expressed. and to enable them to assist with the treatment program. the clinician can instruct parents to describe positively the specific gender-related attributes of the child (e. This approach assumes that cross-gender behavior is learned and therefore can be changed by manipulation of the consequences for cross. etc. 1988).. interferes with other age-appropriate activities.

and a therapist’s unwillingness or inability to be goal-oriented and directive.7. including clinical case studies. Because of the co-occurrence of sexual aggression and conduct disorder. 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. although the majority come from dysfunctional families (Johnson. Definitional Issues Although there is not yet a commonly agreed-upon definition of child sexual abuse. have a close relationship to the perpetrators. Moreover. These can then be prioritized. 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.” and “nonsymptomatic” (Pithers. 1989). In contrast to girls. Treatment of children who engage in sexually aggressive behaviors is very complex and must necessarily be multifaceted. preadolescent boys who engage in sexually aggressive behavior may or may not have a history of sexual abuse. & Houchens.” “abuse-reactive. and comprehensive reviews and meta-analyses. diagnostic. A recent report differentiated five types of sexual problems on the basis of demographic. 1998). abuse-reactive. Different treatment approaches were shown to be effective with different types of problems.” “highly traumatized. and nonsymptomatic. Excellent detailed descriptions of other treatment approaches for sexually aggressive children are provided by Friedrich (1990) and by Gil and Johnson (1993). relapse prevention was more effective than expressive therapy with children who were classified as highly traumatized. group. in that they have been more severely and frequently abused. empirical research. observational studies. including a primary parental figure’s lack of support for or participation in treatment. historic. These girls can be distinguished from others who have been abused but do not engage in sexually aggressive behaviors. parental failure to protect a child from further victimization. Friedrich (1990) notes that many factors can interfere with individual therapy for sexually aggressive youngsters. controlling the child’s own abusive sexual behavior. 1988). Gray.” “rule-breaking. Sexuality and Sexual Problems 231 ally aggressive behavior in preadolescent girls (Johnson. Reid. whereas both types of treatment were equally beneficial for children classified as rule-breaking. and family intervention. and tend to come from very dysfunctional families that have not provided support following disclosure of the abuse (Johnson. and helping parents to manage the child’s behavior. Neither approach to treatment was very successful with children classified as sexually aggressive. Jones. It is suspected that those boys who do not have a history of sexual abuse have been exposed to deviant sexuality of some sort. the approach outlined by Patterson. CHILD SEXUAL ABUSE The professional literature on the topic of child sexual abuse is overwhelmingly large and diverse. and behavioral variables: “sexually aggressive. involving individual. and treatment can be planned to deal with each in turn. 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). For instance. definitional issues are important in determining when children’s sexual experiences are part of nor- . Busconi. Among the treatment issues likely to be important are dealing with the child’s experience of sexual abuse (when this exists). In this section. 1989).

Although there is agreement that sexual abuse in general tends to be underreported. These rates are fairly consistent with those reported in other work when sampling and definitional issues are taken into account (see Wolfe & Birt. 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. applying ointment to the genital area or taking showers together). many suspect that prevalence rates are underestimated for boys to a greater extent than for girls. 25. 25% were ages 0–5. Among children who were sexually abused. manipulation. their status in relation to each other. children who have been exposed to sexual abuse prevention programs may be overly sensitive to innocent.3% were ages 6–11 years. to experience anal penetration.e. to be physically as well as sexually abused. 1990). Similarly.e. and the use (or not) of coercion.3% were 6–10 years old. and vary tremendously. and to be forcefully abused (Watkins & Bentovim. contact as well as noncontact sexual behavior) reported a history of sexual abuse for 27% of women and 16% of men (Finkelhor. Other work suggests. 1997). 1997). Perhaps because of the attention that child sexual abuse has received in the mass media. Prevalence Estimates of the prevalence of sexual abuse reflect definitional problems as well as differences in the populations sampled (i. Walker. 1997).. clinical vs. community). and 40.2% were 11–17 years old when the abuse occurred. A large survey (completed in 1985) that was representative of the demographics of the U.S. From a practical perspective. . Higher rates are found in studies of clinical samples and studies with broader definitions of sexual abuse. Wolfe & Birt.5% were 2–5 years old. ranging from 6% to 62% of girls and from 3% to 31% of boys (Finkelhor. 1992.. This decrease probably reflects the increased size and strength of boys as they develop.. from 20. we argue that in determining whether or not sexual abuse has occurred. Bagley (1990) examined age cohorts of young adults and found that prevalence rates for retrospective reports of childhood sexual abuse increased with age.8% of 18-year-olds to 42. 34.0% of 24-year-olds. and may report this behavior as abusive. Many other characteristics of sexual abuse have been found to differ for boys and girls. 1990). and 17. 58. It is not clear whether the prevalence of sexual abuse is actually increasing or decreasing. however. incidental contact with others (such as others’ accidentally brushing against their breasts or genitalia during a game or a hug). that the incidence of abuse actually decreases with age for boys. Census and used a relatively broad definition of sexual abuse (i. to be abused by multiple perpetrators who are typically outside the family. in part because boys are less likely to report abuse (Wolfe & Birt.6% were ages 12–17. Hotaling.g. MANAGING COMMON PROBLEMS mal development and when they should be considered abusive. Bonner. Lewis. Boys are more likely than girls to be abused at a younger age.232 II. The relative developmental level of the participants. Faller (1989) has reported data indicating that in her sample of sexually abused boys. clinicians should focus on understanding the specific behavior that is reported. indicating a decrease in rates of sexual abuse over time. and Kaufman (1988) presented data from the American Association for Protecting Children indicating that the incidence of sexual abuse increases with children’s age. the context in which this behavior occurs. He speculates that younger women have increasingly been exposed to media presentations about sexual abuse. and the intent of the participants. 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. or force are also important factors in determining that any specific sexual behavior is abusive. & Smith.

In most cases. power and dominance) is satisfied by this relationship. Although there have been several attempts to classify perpetrators of child sexual abuse (see Wolfe & Birt. Thus it seems more productive to examine the conditions that increase the risk of sexual abuse’s occurring. It is estimated that adolescent males are responsible for up to 50% of child sexual abuse cases. More frequently. First. and found no changes in prevalence rates over 10 years. Many factors can contribute to this. Although abuse by fathers and stepfathers is most common among cases reported to child protective agencies.6% female) . Metzner. failure to prosecute or convict offenders and weak sentencing patterns). 1987). the average number of victims reported in a national survey was 7. 2. 1989). rates of repeated offenses among these teenagers are very high. 1986).g. divorce. In contrast. neighbors. national community samples indicate that these individuals commit no more than 7–8% of all cases of sexual abuse (Finkelhor. Sexuality and Sexual Problems 233 and that this increased exposure may be contributing to an actual decline in instances of abuse. unemployment. 1997a). the vast majority of adolescent sexual offenders are male (97.g. 1997).. appropriate sources of sexual gratification often may be unavailable. 1989). they are a very diverse group (Finkelhor. the perpetrator must be sexually aroused by children. etc. & Fryer. Wolf. and alternative. Miyoshi. Finkelhor (1984) summarizes some of these conditions. the perpetrator must be motivated to relate sexually with a child. as well as the child’s lack of knowledge of sexuality and personal safety skills. and few of these individuals evidence a diagnosable mental disorder. external inhibitors that would ordinarily prevent abuse from occurring must be overcome. the child’s resistance must be overcome. 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). Conte.). 16– 42% of cases) and nonrelatives (friends. Krugman. Ryan. emotional distress. Factors that can contribute to this include the perpetrator’s use of coercion or manipulation. etc. emotional/psychological dysfunction. Loeb. and a lack of strong community sanctions (i. and Carmona (1999) repeated a 1984 (Wyatt. internal inhibitions must be overcome.4% vs. including alcohol and drug use. Ryan. stressful life events (e. Hall (1990) reviewed research on multiple factors that might distinguish perpetrators from others. an important emotional need (e. and concluded that a history of sexual aggression was the most accurate predictor of future sexual aggression. Consistent with research on adult offenders. 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.7.e. with more offenses committed by older teens (Ryan. and it is suspected that this estimate may underrepresent the actual incidence because of a reluctance to report these young offenders (Kempton & Forehand. 1985) survey of women in Los Angeles County. child care workers... Solis.7. California. Third. Moreover. no single psychological profile distinguishes these perpetrators. Moreover. 1997c). and in a lack of involvement in the early day-to-day care of their children as infants (Parker & Parker. 1987). 1987).. Wyatt. 1996. or physical or intellectual handicaps (Budin & Johnson. perpetrators include other family members (typically uncles or brothers. Finally. A perpetrator must have access to a child and may gain this access through the physical or psychological absence of the mother. 1989. Current research on perpetrators of sexual abuse focuses on young offenders. Second. poor self-confidence. sexualized portrayal of children in the media. & Smith. 1992. 32–60% of cases) (Finkelhor.

Quinsey. & Gauthier. there are no data on rates of long-term recidivism among treated offenders. and as many as 80% report having been sexually abused (Shaw. Symptoms that are seen most commonly among abused children include fears. Of these. Williams.. 1993). 2000). and (4) hyperarousal (i. Effects of Sexual Abuse Short-Term Effects Although some children who have been sexually abused show no harmful effects of the abuse. Research consistently indicates that symptoms of PTSD are seen in many children who have been sexually abused.17% vs. treatment for adult sexual abuse perpetrators has not been very effective. 1996).8%). (2) reexperiencing the traumatic event (e. Steffy. there is little research examining its efficacy with this population.234 II. and a history of sexual offenses (Hanson et al. sexualized behavior. & Orvaschel. 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..e. but fewer than nonabused clinic-referred children (Kendall-Tackett. 1995. 17. 1999). 1993. a great number evidence clinically significant symptoms. startle responses. posttraumatic stress disorder (PTSD). Although use of relapse prevention with sexual abuse perpetrators makes intuitive sense. Worling & Curwen. (3) avoiding stimuli associated with the trauma (e. 1992).. Little is known about recidivism rates for perpetrators who are not convicted or who never enter the criminal justice system. Unfortunately. inattentiveness. Studies of recidivism rates for incarcerated perpetrators indicate that reoffending is a very common problem even for those who have received treatment. 1991. only PTSD and sexualized behavior differentiate sexually abused children from nonabused clinic-referred children (Wolfe & Birt. irritability or anger. 2000) describes a treatment program that significantly reduced recidivism rates among treated adolescents versus a nontreated control group (5.. McLeer. Rice. 1993). & Finkelhor.g. 1982). and are most prominent among preschool children (Kendall et al. Although many sexually abused children may show some symptoms of PTSD. & Harris. it is likely that a diagnosis of PTSD is appropriate only for the most severely abused children. 1997). Henry.g.. a treatment model first developed for substance use disorders (Marlatt. It seems likely that rates of reoffending for this population would be even higher than among those who have been imprisoned. and/or trouble sleeping). 1988). . is currently widely employed in the treatment of sexual offending (Pithers & Gray. Research has clearly documented the fact that sexually abused children as a group have more symptoms than nonabused nonreferred children. Child maltreatment is common in the histories of these youth. the more likely it is that he has been sexually abused (Johnson. 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. hypervigilance. helplessness. trauma-specific reenactment in play). nightmares. A recent report (Worling & Curwen. Deblinger. and responding with intense fear. and poor self-esteem.. There are few empirical studies of treatment for adolescent sexual offenders. MANAGING COMMON PROBLEMS (Ryan et al. affective numbing or lack of general responsiveness). sexual interest in children. Relapse prevention. Moreover. general behavior problems. or horror. 1996). The DSM-IV (American Psychiatric Association. Factors that may contribute to recidivism include choice of boys as victims. and that reconvictions often occur years after the first offense (Hanson. 1993. The younger a boy is when he commits his first sexual offense.

1994). Kendall-Tackett et al. This research typically assesses clinical symptoms in adults who recall being sexually abused as children. & Place.. smoking. 1995). with girls more likely to experience sexual anxiety and boys to be more eroticized (Feiring. Pollock. Women who have been sexually abused as children evidence a variety of significant problems as adults. Moreover. 1992). This should not be surprising. and a lower frequency of Pap smears) and medical/gynecological problems than women without a history of sexual abuse (Springs & Friedrich.g. 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. 1988. personal identity and relationships in adolescence. 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. Thus using sexualized behavior as an indicator of sexual abuse can result in very high rates of false positives and false negatives.) (Feiring et al. as well as through surveys of the general population. Long-Term Effects Studies on the long-term effects of sexual abuse have been conducted with clinical populations.. and many nonabused children do so.. As a result. although revictimization may be mediated by a higher level of sexual activity and more sexual partners (Krahe. suicidal ideation/behavior. and posttraumatic stress responses (Jumper. A child’s age at the time of the abuse has also been found to be related to adjustment. 1993). Luecke. 1991. & Lewis. (3) oral. depression. excessive alcohol consumption. The effects of sexual abuse are highly variable. 1998). Taska. 1999). Moreover. & . one cannot assume that children who are sexually abused as infants will not remember the abuse and thus will not evidence any symptoms. etc. maternal support. Sexuality and Sexual Problems 235 Sexualized behavior is consistently found to a greater extent in sexually abused children than in nonabused nonclinical or clinical samples (e. More symptoms are evidenced by children whose experience of abuse has included the following factors: (1) a close relationship with the perpetrator. earlier age at first intercourse. increased numbers of sexual partners. anal. especially at the time of disclosure. including increased rates of sexual dysfunction. or vaginal penetration. 1990. as older children are more likely to have experienced abuse over a longer period of time and more frequently than younger children. The clinical literature includes cases of children who begin to disclose abuse that occurred during infancy as they gain language and communication skills (Friedrich. Women who have been sexually abused also appear to be especially vulnerable to revictimization (Collins. 1996). however. Houskamp.. automony and control in toddlers. 1992. Scheinberger-Olwig. Inderbitzen-Pisaruk. many children who have been sexually abused do not evidence sexualized behavior. however. 1999). has consistently been found to be related to a child’s adjustment. Gale. 1993). Friedrich. with older children showing more symptoms than younger children.g. reflecting the interaction of characteristics of the abuse itself. & Hoier. and (4) use of force (Beitchman et al. (2) high frequency and long duration of sexual encounters. and no evidence exists for a “sexual abuse syndrome” (Berliner & Conte. & Briere. and community stress or support (Wolfe & Birt. Thompson. Beilke. 1992). Moran.g. As noted earlier. The impact of age at the onset of abuse is not known. the functioning of the individual child and family. Shawchuck. no one symptom or cluster of symptoms characterizes sexually abused children. Neumann. Hewitt.7. They may also experience higher rates of other health risk behaviors (e. This finding is confounded with the frequency and duration of abuse. & Sack. 1995.. anxiety and fears.. Waizenhofer. recent work suggests that boys and girls may differ in the nature of the sexual symptoms shown. Furthermore.

Edelsohn. Longitudinal studies are important to understanding sexual abuse. one recent study using meta-analysis found that men tended to react less negatively to childhood sexual experiences than women did (Rind et al. and relationship difficulties at higher rates than nonabused men do (Watkins & Bentovim. 1998). although some children clearly benefited from treatment. found that children who received cognitive-behavioral therapy improved significantly more over 6 and 12 months than did children who received nondirective supportive therapy. MANAGING COMMON PROBLEMS Koplin. abused men have been found to have depression. treatment must be targeted specifically to issues most pertinent for an individual child and family. Finally. Rather.236 II. Cohen and Mannarino (1998a). Everson. Tremblay. such as aggressive and sexualized behavior. 1992. found no relationship between therapy and adjustment outcome. the majority of child sexual abuse victims improve over time. family support for the child. 1994. In general.. largely because there tend to be fewer males included in these studies. Like abused women. One recent study that found a significant decrease in children’s functioning over a 2-year period indicated that treatment services were generally unavailable. Glasgow. . some children who are symptom-free at the time of assessment may begin to show problems at a later time (Kendall-Tackett et al. Oates et al. 1992). as well as of the factors contributing to recovery. No one approach to treatment was found to be more effective than another. 1999). and that this fact might have mediated adjustment (Calam. Oates et al. It is possible that the nature of the treatment received is a critical factor in mediating adjustment. & Cox. Runyon. Moreover. 1992. because they permit examination of the course of sequelae over time.. anxiety disorders. Hebert. Moreover. others did not. it is very difficult to change. suicidal feelings/behavior. Doll et al. 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. In a review of treatment studies. that many women who experience sexual contact in childhood do not have long-term negative effects (Rind. Furthermore. Factors that may mediate adjustment are family functioning. 1992). Tromovitch. & Coulter. the child’s coping skills. ASSESSMENT OF SEXUAL ABUSE Assessment of children who are alleged to have been sexually abused is challenging. 1994). Hunter.. sexual dysfunction. although a substantial minority may continue to evidence significant symptoms (Oates. Finkelhor and Berliner (1995) conclude that it is unreasonable to expect one abusespecific treatment approach to be effective for all victims of child abuse. once an opinion about what happened is established. and a variety of techniques will need to be used. 1993. 1988. 1998). and whether or not he or she appears in court (Cohen & Mannarino. O’Toole. 1998). although not all such perpetrators have been abused in childhood (Watkins & Bentovim. The relationship between treatment and later adjustment is not clear. in part because there is no way to determine with absolute certainty the truth about what happened. & Bauserman. & Cooney. Stern. Oates et al. Horne. 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.. 1994). 1998).. for example.. 1999). & Piche. 1992). (1994). were particularly resistant to change. 1998b. Moreover. Finkelhor and Berliner (1995) found that some symptoms. however. low self-esteem. It is important to note. Goodman et al. Lynch.. Abused males are thought to be more likely to experience gender identity confusion and homosexual preferences than are abused women (Watkins & Bentovim. however. The data on long-term effects for male victims are less clear than those for women.

Each type involves different issues. etc. whereby it is known for sure whether or not the child was actually abused” (p. and Ornstein (2001) for more extensive discussions of this topic. The essential features of these documents are summarized in this section. Baker-Ward. the assessment must include a structured protocol that takes into account recent em- . Although we believe that a “scientist–practitioner” perspective is appropriate for all clinical work. and Baker-Ward (1995).7. 113). 1990. 1993). with the addition of more specific information on assessment methods (e. including parents. it is most critical in evaluating sexual abuse cases. and be able to apply this knowledge to individual cases. physicians. the clinician must recognize “that mental health professionals have no special capacity to determine whether someone is being truthful” (p. a comprehensive review of this extensive literature is beyond the scope of this chapter. so that the clinician and the referring person are in agreement about the focus of the assessment. and others. police. 1997a. the clinician must have knowledge of child development (particularly sexual development). examining alternative hypotheses that might explain the information gathered. In these cases. The four types are as follows: 1. Step 1: Initial Contact The Referral Clarifying the Referral Question. assessing development.) and on interpreting the assessment data according to the Comprehensive Assessment-toIntervention System (CAIS. The clinician must then decide which questions can reasonably be answered according to the facts of each case. The clinician is asked to determine whether or not sexual abuse has occurred. and Gordon. Ornstein. It is imperative that the criteria used in making probability statements about abuse be made explicit. and therefore different assessment and treatment processes. In assessing these cases.” gathering information and making professional judgments about the meaning of those facts. Referral for assessment of sexual abuse can potentially involve four different types of cases. the judgment that a child has or has not been sexually abused is just that—a clinical judgment. We urge clinicians to adopt a “quasi-scientific” approach. As Berliner and Conte (1993) state.. 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. American Professional Society on the Abuse of Children. 1994). 121) and that “there is no mechanism for establishing the absolute truth. Gordon. see Chapter 2). protective services workers. 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. Schroeder. Various guidelines for evaluation of suspected sexual abuse in children and adolescents have been proposed (American Academy of Child and Adolescent Psychiatry. and can focus the assessment carefully on only those questions. it is most important to clarify the referral question(s). The reader is referred to Ceci and Bruck (1995). To do this adequately. Fundamentally.g. Sexual abuse cases can be referred by many different people. be familiar with recent research on memory and suggestibility. the clinician functions as a “fact finder. using questionnaires. including the support for and limitations of each criterion (Berliner & Conte. attorneys. Lamb. Although clincially relevant aspects of the research on children’s memory and suggestibility are included in this section. Sexuality and Sexual Problems 237 In the assessment of sexual abuse.

and to promote collaboration. Questionnaires Depending on the specific questions to be addressed and the availability of parents to complete them. In reviewing background information. but the parent has continuing concern regarding the child’s behavior(s) and may even express a belief that abuse may have occurred. It is imperative in these cases that the clinician maintain a neutral attitude toward the possibility of abuse. if possible. The clinician is asked to plan a treatment program for a child when abuse has not been substantiated. information about the child’s current living circumstances should be obtained. 1990). and begin to formulate alternative explanations for the allegations. to find out what information has already been gathered. In these cases. This step is particularly important if the case is likely to be prosecuted. and a plan should be made to gather information about the parents and family. if there is no disclosure. Bonner. type and. the focus of the assessment is on acknowledging the abuse and determining the treatment needs of the child and family. but the child has been interviewed regarding the alleged abuse on one or more previous occasions. Table 7.238 II. MANAGING COMMON PROBLEMS pirical work on children’s memory and suggestibility. It may be neither preferable nor necessary to reinterview the child (American Professional Society on the Abuse of Children. Gathering Background Information. Walker. as well as the potential involvement of the child in the legal system. because the child has been removed from the home and/or a parent is suspected of perpetrating the abuse. the nature of the child’s initial disclosure (or. verbatim transcripts) of all previous interviews. Often one or both parents are not available during an investigation. and a brief family and developmental history.3 presents many of the factors associated with poor outcome in families where sexual abuse has occurred. the reason why abuse is suspected). Before interviewing the child and/or family. and Kaufman (1988) suggest that risk assessment is helpful in organizing background data. the accumulation and interaction of risk factors determine outcome in most cases. 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 focus of assessment in this instance should be on the behaviors of concern. the clinician must be neutral as to whether abuse actually occurred or not.3. as well as on risk factors for sexual abuse (see Table 7. 3. or if the clinician is asked to plan treatment and abuse has not been substantiated. 4. 2. In this regard. Sexual abuse has been substantiated. transcripts or recordings of prior interviews. The clinician is asked to determine whether or not sexual abuse has occurred. questionnaires and checklists may be helpful in completing the task of gathering . if the clinician is being asked for a second opinion. The background information to be gathered at this stage in the assessment process includes the number. however. and the clinician is asked to plan a treatment program. below). This information should be interpreted in light of current research on children’s memory and suggestibility. behavioral changes evidenced by the child. In these cases. results of any medical examinations. without the assumption that abuse has occurred. This assessment must include careful review of all relevant background information including the records (ideally. Rather. the clinician should contact all persons involved in the case to determine their roles. the clinician’s opinion about the probability that the alleged abuse occurred may be based on this review of existing records. Rather. The presence of any one or two factors may not necessarily be of concern.

including sexualized behavior (Berliner & Conte. and the reader is referred to Wolfe and Birt (1997) for a comprehensive review. 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. These items are shown in Table 7. 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. 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.g. Wolfe and Birt (1997) have used the CBCL to document PTSD symptoms by selecting items that represent DSM-IV criteria. The CSBI— Revised (CSBI-R) is described in Appendix A.. Friedrich. 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. The questionnaires mentioned here are those we have found most useful in a general pediatric psychology clinic.3. 1993). Achenbach. It consists of questions about specific types and frequencies of sexual behavior exhibited by children. 1988). Friedrich. Thus it is critical to evaluate information about . Sexuality and Sexual Problems 239 TABLE 7. In using data from these questionnaires. & Urquiza. Beilke. PTSD. 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. 1992) has been used extensively in research with sexually abused children and provides information on sexual behavior. force. unemployment) background information. and other emotional or behavioral problems that can corroborate the allegations of sexual abuse (e.7. they suggest that this measure can serve as an adjunct to the regular scoring of the CBCL. 1991a. Our General Parent Questionnaire (see Appendix B) provides information about the family constellation and the parents’ perceptions of the problem.g.. the clinician must understand that there are no empirically validated behavioral indicators of sexual abuse. especially the CSBI-R. The Child Behavior Checklist (CBCL. 1997) is useful in documenting unusual sexual behaviors.4. Many questionnaires specific to child sexual abuse have been developed. The Child Sexual Behavior Inventory—Revised (CSBI-R.

The data are from Wolfe and Birt (1997). Obsessive thoughts Confused. or places Fears going to school Fears doing something bad Nervous. 56f. 30. 17. depending on the purpose of the assessment. Among children at these ages. Step 2: Parent and Child Interviews Parent Interview The nature of the parent interview will obviously vary. ages 3 and 5 years. 10. because this is often the most accurate account of the abuse. 111. MANAGING COMMON PROBLEMS TABLE 7. 8.4. and the way in which the abuse was initially disclosed. 41. the initial parent interview is usually brief and the child is not present. and what was said . situations. 112. 14. 86. The clinician should determine where and how the disclosure occurred. were referred for assessment of suspected abuse because their grandmother caught them behind the sofa touching each other’s penises. the Parenting Stress Index (PSI. 71. this behavior is typical and does not necessarily indicate sexual abuse. Details of the child’s initial disclosure are important. 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. 29. 87. 1995) provides preliminary information about the child’s temperamental characteristics and sources of stress for the child’s parent(s) apart from the abuse. 3. Child Behavior Checklist (CBCL) Posttraumatic Stress Disorder (PTSD) Items DSM-IV PTSD symptom domain Reexperiencing CBCL items 9. 50. 13. seems in a fog Cries a lot Daydreams Nightmares Self-conscious Worries Clings to adults Fears certain animals. Abidin. 11. as well as other factors pertinent to a specific case. what the child’s exact words were. The focus of this interview should be on the parent’s perceptions of the situation. 47. 31. high-strung Fearful. For instance. 69. If the assessment is being conducted for purposes of investigation of sexual abuse. the family’s reactions. sexual behavior in light of children’s normative sexual behavior and knowledge. 45. anxious Secretive Withdrawn Argues a lot Can’t concentrate Can’t sit still. 110. Finally. two brothers.240 II. restless Impulsive Stomachaches Irritable Moody Trouble sleeping Fears and avoidance Hyperarousal Note.

Child Interview Taping the Interview. The clinician must then evaluate the child’s “disclosure” in the context of the child’s history and the events that precipitated the disclosure. and thus can reduce the possibility of contamination of the child’s report. for example. the focus should be on the behaviors of concern. although this should be done in the absence of the child. First. and values.7. detailed information should be gathered about the behaviors or events that led to the suspicion of abuse. including how it was first disclosed. In cases in which the child has not verbally reported sexual abuse. If the referral question concerns a parent’s ability to care for and protect the child. but the child never verbally disclosed the abuse. a separate parent interview is likely to be necessary. the child should not be included in any discussion of sexual abuse and should not be questioned regarding suspected abuse. Second. 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. If the purpose of the assessment is to make a judgment of whether or not abuse has occurred. a child may disclose information about abuse when the clinician gives him or her information about sexuality. it should also be determined whether the parent was ever molested as a child. Although some argue against taping the interview (in part because of the possibility of its being dissected in court). while checking periodically with the child to verify the information. and the clinician should entertain hypotheses other than sexual abuse to explain these behaviors. 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. In these cases. The parent’s “parenting models. we ask the parent or caregiver to tell us the details of the abuse. the clinician can review the questions asked and the . it is important prior to the parent interview to determine if abuse has been substantiated. This is critical. Sexuality and Sexual Problems 241 and/or done in response. Questions should be asked about the parent’s sexuality education and age at first sexual experience. for example. 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. It is often relevant to briefly assess a parent’s sexual history. it can help to minimize the number of interviews to which the child is exposed. Rather. arrangements should be made prior to seeing the child and/or parents to audio. In order to decrease the pressure on the child. we think this record serves two very important purposes. even when asked directly.or videotape the child’s interview. 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 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. attitudes. In a recent case assessed in our clinic. it is important to consider the possibility that the clinician has influenced a false disclosure.” attitudes and values about parenting. In the course of treatment. because our approach to cases in which abuse has been substantiated is to interview the parent (or other primary caregiver) with the child present. When the purpose of assessment is to plan a treatment program. 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. This informs the child that it is OK to talk about sexual matters. after the interview is completed. with an emphasis on changes in the child’s behavior since the abuse occurred.

1992). Today I would like to get to know you better and ask you some questions about your school. or informally if the child appears to be developing normally. the details of which can be verified by parents. Yuille. . Areas to assess include language comprehension and expression. the interviewer may ask the child. It is important that the child be informed what the reason for the interview is. This allows the interviewer to model the form of the interview (e. Joffe. We can color for a while if you’d like to. memory skills. Arranging the Setting. and family. the clinician must establish rapport with a child before discussion of sensitive issues will be productive.. Hunter. and objectively evaluate the child’s reponses to these questions for indications of suggestibility. this assessment provides a framework for deciding how questions will be asked. MANAGING COMMON PROBLEMS manner in which they were asked. In cases involving investigation of sexual abuse. If the purpose of assessment is investigation of abuse. I talk with lots of children who are having the same problem(s). First. the clinician should be aware that for children under the age of 5 years.. doctors] are concerned that you have been having trouble with sleeping [touching yourself in public. asking to look at other kids’ private parts. & Bornstein. The child simply needs to be told how the session will be conducted and what is expected of him or her. Establishing Rapport. “You are here because ______ is worried that something bad [uncomfortable. and dolls (not necessarily anatomically detailed [AD] dolls.g. The setting in which the child will be interviewed for alleged sexual abuse should be arranged to facilitate the child’s recall. the interviewer may continue.242 II. If the purpose of the assessment is to plan treatment for a child for whom abuse has been substantiated. I talk with lots of children who have had bad things happen to them. Regardless of the referral question. see below) should be provided. so it’s OK for you to tell me anything you want to. a doll house. the child can be told. The interview should be conducted as soon after the referral as possible. and what is expected of the child. Then I’ll ask you some questions. the child has documented learning or language problems). Geiselman.” Development. and knowledge of sexuality.. and how the child’s responses will be evaluated. “Your parents [teachers. 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. not wanting to visit Daddy. Together we will try to understand what is troubling you and what we can do to make things better for you. A “child-friendly” environment with age-appropriate toys and props. since he or she was present in the parent interview. see Saywitz.g. free recall of details is more difficult than for older children. friends.g. If the assessment is to plan treatment for a child for whom the abuse has not been substantiated. yucky. but you should only tell me about things that really happened. however. intellectual level.] might have happened to you. etc. and Saparniuk (1993) suggest that the child be asked to describe two specific past experiences (e. emotional status. within a few days to a week at most. I think we should get to know each other better. the child’s developmental status should be assessed—formally if there appears to be some concern in this area (e. Regardless of the referral question. the child is already aware of the purpose of the session. asking lots of questions) and the child to practice giving complete descriptions. what props will be used. A speedy interview is particularly important for preschool children. a birthday or last Christmas). such as crayons and paper. or whatever behavior is of concern]. what will happen during the session(s). “Do you know why you are here today?” If no response is forthcoming (which is usually the case).

To assess the child’s understanding. Dorado and Saywitz (2001) describe an intervention. is important. “What are the private parts?”. and abuse prevention (e. multiple-syllable words. AD dolls can also be used for this purpose (but see below). for example. guilt. and poor self-esteem. called narrative improvement. For instance. (For suggestions on conducting a “cognitive interview. guilt. Additional information can be obtained by observing the child’s play and noting unusual themes (aggression. Sexuality and Sexual Problems 243 Specific questions. such as unusual fears. hostility.7. The clinician could say. anger. children’s knowledge of sexuality is an important area of development to assess. etc. so we use pictures of nude boys and girls and nude men and women as we ask questions in these areas.) to one or more specific family members is especially important to assess. 1987).) Regardless of the referral question. 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 . 1983) are useful for assessing self-esteem. gender differences and gender identity. & KlajnerDiamond.or underactivity. or have only a partial understanding. who have trouble with vocabulary. Saywitz. The Pictorial Scale of Perceived Competence and Social Acceptance for Young Children (Harter & Pike. The clinician can assess the child’s general perceptions of family members through a variety of methods. the clinician must make sure the child is aware of the transition.. “What should you do if someone tries to touch your private parts?”). the clinician should request definitions or explanations.).” 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. can provide corroborative evidence regarding the child’s report or the parent’s suspicion of abuse. Extreme or intense reactions (fear. sexual behavior (masturbation and sexual intercourse). The language used in the interview must be consistent with the language comprehension level of the child. Maladaptive responses and poor coping skills can be assessed in children ages 6–15 with the Roberts Apperception Test for Children (McArthur & Roberts.” are easier for younger children to answer than open-ended questions. and syntax. & Bornstein. Young children respond better to concrete stimuli. etc. such as “Tell me one thing you got for your last birthday. 1993. rather than accepting “Yes” reponses to “Do you understand?” When changing the topic. 1984) and the Self-Perception Profile for Children (Harter.g. or “Your mom said you got a doll” (when the child did not receive a doll). since children often think that they know the meaning of a word or a question when in fact they do not. fear. 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. anxiety. designed to improve the recall of preschool children (ages 3½ to 6 years). and this information can be particularly informative if a family member is suspected of the abuse. over. as well as status prior to the suspected abuse. “You didn’t really get a bicycle for your birthday. We assess knowledge in the following areas: body parts and functions (including sexual and nonsexual body parts). Research indicates that this method increases the details remembered without increasing errors or false statements. The existence of recent emotional problems.” see Geiselman. did you?”. This is particularly important for most preschool children. With preschool children. The clinician should check out what the child actually understands. in a case we recently assessed. 1982). and sometimes spontaneously precipitates discussion of the child’s sexual experience. and intense or unusual reactions to ordinary stimuli. such as “Tell me about your last birthday. pregnancy and birth. Assessment of current emotional status. Assessment of sexual knowledge often elicits emotional reactions from a child who has been sexually abused. but it is not known whether it is practical for use in clinical situations.

& Renick. it is essential that the child be questioned about a variety of people. “Tell me about your stepfather. 1994).” “What do you like/dislike about him?”). he or she must be asked directly about the possibility that sexual abuse has occurred. however. others as well) presents detailed descriptions of a father who molested a child. “Yes” responses require further clarification (e. in several cases referred to us (including the case of the 3-year-old described above). This particular book (and. the clinician should begin with a brief statement that he or she does not know what happened.” and he responded.. so it is important for the child to provide as much detail as possible. yet later. At the same time.g. as well as the interviewer’s (and others’) perceptions of the credibility of the child’s report. although sexualized play with AD dolls is un- . these responses must be interpreted cautiously. MANAGING COMMON PROBLEMS him. we are sure. “yes–no” questions are problematic for preschoolers. American Psychological Association.244 II. 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. “What did Dad do when he touched your bottom?”). described in the report of the Anatomical Doll Task Force. if the child has not volunteered information about the alleged abuse. For example. The question “Has anyone ever touched your [use the child’s own label for genitalia]?” is very ambiguous. 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 important because the types of questions asked are directly related to the accuracy and completeness of the child’s recall. a 3-year-old boy (with a history of encopresis. because children’s bottoms are often touched for a variety of nonabusive reasons.” The mother (who had recently separated from the father) interpreted this as possible sexual abuse. 1994). the boy would only demonstrate that his father had touched the side of his hip with his index finger. but their responses to these questions may be difficult to interpret.g. “Daddy poked my bottom. This is not appropriate. 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. when asked to elaborate. 1994) concluded that clinicians should not be discouraged from using AD dolls in interviews with children who may have been sexually abused. and we think it has the potential to elicit a false accusation. Francoeur. In particular. More general books on sexuality education or sexual abuse prevention can be used during assessment or treatment in most cases. Furthermore. In a case recently referred to us. When the interview involves questions specific to sexual abuse. the book I Can’t Talk about It (Sanford. At some point. and the validity of their responses to such questions must be viewed cautiously (Gordon & Follmer. Using Anatomically Detailed Dolls. she was very open and expressed positive feelings about other family members. Ceci. Furthermore. 1994). 1986) was read to the children during the assessment process. They must be particularly cautious in the use of these dolls with preschool children. The use of AD dolls is very controversal (Everson & Boat. and if none is forthcoming. which had been treated with enemas and suppositories) had complained to his mother of a sore bottom. because it introduces information that can influence the child’s report. The interview should begin with open-ended questions (e. Preschool children will require more direct and specific questions. She asked him whether anyone had ever “touched his bottom. Questioning about Sexual Abuse. the Anatomical Doll Task Force (American Psychological Association.

1994). or seductive behavior in the father–child interaction. this should be done before or soon after the first session. Step 3: Observation of Behavior Observation of the child’s behavior during the interview is a critical component of the assessment. The family should be referred to a physician who has specific expertise in this type of examination. Moreover. In this regard. Boat & Everson. the data from this evaluation can often corroborate the clinician’s hypothesis about what might have happened. 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. AD dolls are clearly not appropriately used as a diagnostic “test” of sexual abuse. and excessive clinging to the mother in the presence of the father. evidence of significant psychopathology (or any of the other risk factors presented in Table 7. We often make this referral at the start of the assessment process and then work with that agency to coordinate the assessments. whereas the father does not. Adams (1995) outlines the various types of possible physical evidence and provides guidelines for interpreting this evidence. it is useful to request (or conduct) a psychological evaluation of both parents. or are too embarrassed to describe the sexual details of an abuse experience. Certainly. For instance. 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. they may facilitate communication with children who have limited vocabulary with which to talk about sexual matters. whereas the absence of such findings may support an alternative hypothesis.3) in one or both parents may raise suspicions about the possibility of abuse. therefore. Although physical evidence of sexual abuse is not frequently found. Sexuality and Sexual Problems 245 common among nonabused children. Further observation of parent–child interaction is indicated in cases where this is to be a focus of treatment. their use is not standardized and has no demonstrated reliability or validity.. or where the referral question involves determining the adequacy of parents to care for and protect the child. but the mother evidences significant psychopathology. it is wise to observe the child interacting with the mother and father separately as well as together. In cases where the allegation of sexual abuse is made in the context of a custody dispute. . 1993. there is no evidence that the information gained with AD dolls is enhanced or diminished by the use of a structured protocol. Gordon et al. and has been covered to some extent above. Although there is no psychological profile that can identify perpetrators of sexual abuse.7. some children may exhibit such play even though they have not been abused (Everson & Boat. 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. Step 4: Further Assessment In cases where the person suspected of abuse is a parent. 1989. the family should be referred to an appropriate agency. Green (1986) suggests noting fearfulness. inhibition. it does happen. Step 5: Referral to Allied Health Professionals If the child has not had a complete medical examination. If the child clinician is not trained to do this evaluation. it can be critical in cases that are prosecuted. 1993). In sum.

miscommunication. MANAGING COMMON PROBLEMS 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. such as fantasy. custody. and visitation. 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. False allegations on the part of the child that are purposeful.” In these cases. the clinician must consider whether the child is intentionally distorting the truth. Finally. 1990). misinterpretation. the child’s developmental status. or fabricating a fantasy. This step is particularly important for cases in which there are also issues of divorce. In addition to evaluating the possibility of a false report of sexual abuse.. As an example. Thoennes & Tjaden. The clinician must also attend to the nature of the behavior (if any) described by the child. False allegations that involve identifying the wrong person. a single father with limited knowledge of appropriate parenting practices used a rectal thermometer to take the temperature of his 2-year-old daughter. Organizing the background information collected according to the risk factors shown in Table 7. and perhaps most importantly. was the response relatively spontaneous or heavily cued (e. 1993). the data gathered during the assessment must be evaluated. 1993). delusion. cases of intentional fabrication do occur. A clinician may be well intentioned in attempting to persuade a child to disclose abuse (motivated by a desire to protect the child). the child’s safety must be considered in relation to the needs of the family and the suspected perpetrator. 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. “Did Daddy touch your bottom?”). respectively) (Everson & Boat. a judgment about the credibility of the child’s responses should be made. because rates of false allegations of abuse are higher among these families than among intact families (33% vs. persisting in pressuring a child to disclose abuse in the face of denial greatly increases the risk of a false “disclosure. when the clinician is uncertain about the occurrence of abuse. Although most fictitious reports of sexual abuse are thought to be the result of misinterpretations on the part of parents and clinicians. 4. or confabulation (filling gaps in memory with whatever information makes sense at the time). For example. The child’s interview data must be reviewed in the context of the child’s and family’s history. lying because it seems to be the best way to handle a situation. or group contagion and is imposed on the child through suggestion or indoctrination. Finally. 2.246 II.3 is helpful in negotiating a reasonable plan with child protective . Children often describe touching (even genital touching) that is not necessarily sexually motivated on the part of the alleged perpetrator (Berliner & Conte. and the circumstances surrounding the allegation of abuse. however. The American Academy of Child and Adolescent Psychiatry (1997a) outlines several possible explanations for false allegations: 1. especially among teenagers (Berliner & Conte. including deliberately lying. A false allegation that arises in the mind of a parent or other adult through misinterpretation of a remark or behavior.g. A false allegation that originates in the child’s mind through unconscious or nonpurposeful means. the clinician must recognize that sometimes it is not possible to determine what (if anything) has happened. 1989. “Tell me about Uncle Joe” vs. 5–8%. 3.

for example. In a case where the family has many risk factors. whereas issues involving interpersonal and intimate relationships are more important for adolescents. The importance of a written report cannot be overemphasized. recommendations regarding treatment or monitoring by social services may be indicated. In an investigative assessment.7. Who Should Receive the Communication? Communication of assessment findings in sexual abuse cases is a very important part of the process. so that the reasons why specific conclusions were reached are clear. no single treatment protocol is appropriate for all of them. and information for the family on the potential effects of sexual abuse. 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. We have found three models to be particularly helpful in our work: the traumagenic factors model proposed . Developmental factors influence all aspects of treatment. This plan should include provisions for sexuality education and abuse prevention for the child. A developmental approach is essential in treating such children. TREATMENT OF SEXUAL ABUSE Because children who have been sexually abused are a heterogeneous group. however. as this document is likely to be used as evidence in legal proceedings. so that they will have some idea of what to expect. developmental issues interact with treatment issues. The report should contain considerable detail about the assessment process. If possible. is a critical developmental issue for preschoolers and is likely to be a focus of treatment for this age group. placement and protection decisions. 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. their understanding of sexual experiences is necessarily a function of their developmental level and will change as they gain new cognitive abilities. Furthermore. Thus a sexually abused child will probably “reprocess” his or her experience of sexual abuse as cognitive capacity increases. Trust. Table 7. We have found it helpful to specifically state alternative explanations regarding the allegations and provide data (if any) to support each one. should also be discussed. it is helpful for the clinician to have a framework within which to organize the data gathered on the child and family. such as sexual acting out or increased irritability or fears. treatment issues and approaches.5 provides a framework for organizing the information to be included in the written report. a protective services worker or district attorney may be the appropriate person to receive the results. 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. and expectations for a child as a witness in legal proceedings. including the effects of abuse and prognosis for treatment. Sexuality and Sexual Problems 247 services for protection of the child and family. but the advisability of this must be judged on a case-by-case basis. Because children understand the world differently at different ages. In some cases we provide parents/caregivers with a copy of the written report. Ways of handling inappropriate behaviors.

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? What is the child’s age or developmental level (language and cognitive skills. The four factors are betrayal.248 II. There is some empirical support for this model (Mannarino. 1994. or developmental problems? Does the child show symptoms of distress or sexualized behavior? What are the child’s life circumstances? 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? 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? Characteristics of the initial disclosure Subsequent interviews Characteristics of the child Characteristics of the alleged perpetrator Characteristics of the family by Finkelhor and Browne (1986). behavioral. and Kaufman (1988). 1996a. MANAGING COMMON PROBLEMS TABLE 7. 1996b). stigmatization. & Berman.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? 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). Bonner. and the coping model developed by Friedrich (1990). Cohen. and we have found it to be particularly . traumatic sexualization. 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. sexual knowledge)? Are there preexisting emotional. the risk factors model of Walker. and powerlessness. especially the mother? To what extent have parents questioned the child? What factors might have influenced the child’s report? How many times was the child interviewed and by whom? Were the interviews recorded? If so. Mannarino & Cohen.

1997. Factors that can increase a child’s ability to cope include the child’s disposition or temperament. mild. increasing self-esteem and decreasing fears)—is stressed (O’Donohue & Elliott. family. 1996. Friedrich’s (1990) model is based on the principles of “coping” (the way one actively adapts to a stressful event or series of events. 1998a. Deblinger & Heflin.. and Kaufman (1988) takes a broader view in considering the factors that can influence the child’s and family’s response to sexual abuse. and by increasing such skills as assertion. This model uses risk factors identified by research as associated with a child’s adjustment to sexual abuse. socialization. Deblinger. & Steer. are presented later in Table 7. and court to the discovery of the abuse. and an external social support system. The model outlined by Walker. Intervention with the Child Individual Approaches In general. in planning a child’s individual treatment. This model has been outlined previously in Table 7. The importance of including abuse prevention training as part of any treatment program for sexually abused children—not only to decrease revictimization. techniques such as stress inoculation training. and the social and situational context are assessed according to their degree of risk (none. 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. Sexuality and Sexual Problems 249 helpful in understanding the child’s perceptions of the abuse experience and the resulting symptoms. and environmental variables. For example. but also to provide secondary benefits in other areas (e. while Walker.7. may be helpful in guiding the treatment process. (2) the nature of the sexual abuse. We find Finkelhor and Browne’s (1986) model particularly helpful. 1992). and these data are used to identify and plan interventions in each area. problem solving. anxiety management.6. anger control. family cohesion and warmth. and identifies areas on which to focus treatment. The focus of these interventions is on alleviating specific abuserelated symptoms by monitoring and modifying deviant thought processes and/or behaviors. These factors. systematic desensitiza- . Any one of these models.” or delayed onset of behavioral and emotional symptoms. O’Donohue & Elliott. and factors that enhance the ability to cope) and “human ecology” (the way events are embedded in various social relationships). the nonabusing family member(s). social. the child. 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. Bonner.g. or a combination of them. and suggested treatment strategies for children at different ages. This model views coping as an active process that can be influenced positively or negatively by many personal. 1996. Consideration of these factors helps the clinician understand why some children are more or less affected by sexual abuse than others. and communication. Bonner.3. 1992). (3) the response of the child. It emphasizes four areas: (1) the functioning of the child and family prior to the abuse. and (4) the factors that could contribute to a “sleeper effect. The characteristics of the abuser. Each of these models can contribute to the clinician’s understanding of the different behavioral and emotional responses exhibited by sexually abused children. or severe) for a particular child. for example. 1996. including the risk and protective factors present at that time. and Kaufman’s (1988) and Friedrich’s (1990) models are more useful in determining where to intervene in the family and environment. moderate. school. Lippman. social services.

1993). Burke (1988. and art activities to deal with issues of sexual abuse.g.. cited in O’Donohue & Elliott.g. problem-solving skills. Components of treatment included relaxation exercises. structured group experiences using social learning principles can be beneficial for sexually abused children. In a case of incest.250 II. A group exercise or game ends each session. etc. the nonabusing parent (usually the mother) is often either overtly or covertly blamed for collusion with the perpetrator. (2) to enhance parental support . Berliner and Ernst (1984) describe a group treatment program for school-age children that uses a combination of discussion. self-portraits. & Shawchuck. 1992) reported significant reductions in depression. Cohen and Mannarino (1998a) specifically targeted parents in their sexual-abuse-specific cognitive-behavioral treatment program. Parent work in cases of incest is necessarily different from that in cases involving extrafamilial abuse. These authors used a group treatment program that encouraged honest expression of feelings. anxiety. what is sexual abuse. Hoier. Factors that have been found to help mothers cope with stress include social support. and a realistic. MANAGING COMMON PROBLEMS tion. socialization training. making name tags. support for court appearances. Next. InderbitzenPisaruk. offender pictures. and receiving weekly reports of day-to-day functioning from each member. feelings about abuse. Each of six sessions begins with a snack and a reminder of why the children are in the group (e. personal safety skills.. games.). 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. 6 months after a minimum of 6 months of group treatment. education. access to financial resources. nondistorted belief system. Rust and Troupe (1991) also reported significantly improved self-esteem and school achievement for 25 girls ages 9–18 years. Haizlip. 1990. The goals were (1) to decrease parental emotional distress by modifying distorted attributions and perceptions. and fears for both children and parents following a 6-week program that was based on social learning theory. family drawings. increasing positive reinforcement through fun activities.g. education. This view can set the stage for the clinician to take a negative attitude toward the mother. and education that helps children “normalize” their emotional and behavioral reactions are advocated for the treatment of anxiety (Saunders. or a group mural). Moreover. Group Treatment Studies of the efficacy of group treatment suggest that short-term. ventilation of anger. and role plays to teach preventive skills. in instances of incest. especially school-age children and adolescents (Corder. Thus a major focus of treatment of sexual abuse involves correcting failed adult–child relationships—and. “You are all here because someone has touched you in a way that was wrong”). and consequently to decrease her involvement in the therapeutic process. this is followed by an art activity (e. & DeBoer. Intervention with the Parents Sexual abuse is fundamentally a relationship problem. Friedrich (1990) clearly states the need for therapists to take a neutral attitude toward mothers. The leaders then conduct a discussion of a topic related to abuse (e. each child tells of a pleasant event that happened during the past week.. 1988). A therapist must be willing to understand the abuse from the mother’s perspective in order to help her cope with the situation. failed relationships that may span generations. and we give a brief overview of the important issues to consider in planning treatment for these two types of cases.

or that the parents were careless in making child care arrangements or neglectful in monitoring the child’s safety and well-being. Unfortunately. 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. and (3) to provide interventions for specific inappropriate behaviors and to teach problem-solving skills. Treatment strategies include providing sexuality education and teaching personal safety skills. Damon. FORMAT FOR IMMEDIATE SHORT-TERM TREATMENT WHEN ABUSE HAS BEEN SUBSTANTIATED Providing immediate help for a sexually abused child. In addition. In instances in which a child has ongoing contact with a perpetrator or the perpetrator acknowledges the abuse. Obviously. the clinician is still dealing with an adult–child relationship problem. the child should receive treatment for any sexually transmitted diseases he or she may have contracted. so that he or she can begin to understand and deal with the abuse. work with parents should include helping them understand what to expect as children begin to cope with the abusive experience. and to monitor the situation over an extended period of time. therefore. the child talks freely about sexual matters). and MacFarlane (1987) describe a structured and directive program for sexually abused preschool children and their parents. to provide ongoing support for the child. and talking openly about the abuse. Sexuality and Sexual Problems 251 for the children by helping parents set appropriate limits and manage the children’s symptoms in a supportive manner. It may be that the mother has also been abused. In a case of extrafamilial abuse. Intervention in Medical/Health Aspects The physical examination should indicate whether intervention is needed in this area. consistent. 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. for many . Psychopharmacological treatment for severe anxiety problems may also be considered (see Chapter 8). Todd. Parents will need help in dealing with their guilt regarding the child sexual abuse. helping parents provide a safe. telling a child what happened to a perpetrator. 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). 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. 1992) is an excellent resource..7. and predictable environment for their children is a difficult but important part of this work.g. however. In addition to focusing on these areas. even in cases not involving incest. The book Helping Your Child Recover from Sexual Abuse (Adams & Fay. a series of family meetings (including the perpetrator) should be held to set some ground rules for appropriate and inappropriate touching. that sexual abuse usually is not a random event. something sets the stage for the abuse to occur. is crucial to the child’s adjustment. Friedrich (1990) points out.

the number of treatment sessions can vary.” “You were very brave to tell. If the child is in foster care. the order in which they are included in treatment (with the exception of the first two components) is not fixed. while the child periodically is asked for confirmation. but it should be communicated to the child that he or she is the primary focus of the session. so that the parent and child can discuss it more freely with each other. If this is not possible. we have developed a protocol to provide immediate and potentially time-limited treatment for children and adolescents who have been sexually abused. The primary purpose of the initial contact with the child and family is to develop rapport with the child.). Having the parent describe the abuse in front of the child also takes the “secrecy” out of the abuse. in the rare case where the perpetrator has admitted to the abuse and is willing to be involved in treatment). Initial Interview A child and parent or other primary caregiver are usually seen together for the initial treatment interview. but in which there is ongoing concern about abuse (by parents or child protective agencies). but we have done it all in one marathon session when we had only one opportunity to see a child. so the clinician should take considerable time to talk about the child’s interests and . as well as make decisions about whom to see. Furthermore. it is important to arrange another time to talk specifically with the parent/caregiver to discuss the adult’s concerns. Setting the Stage Before any treatment is begun. the clinician can also briefly discuss the parent’s or caregiver’s concerns. a comprehensive assessment should be completed as described above. A brief discussion of treatment in cases in which abuse has not been substantiated. Making the child feel important and in control is a primary goal for the first treatment session. Although we have found all the components to be essential.6. The information gathered in this first step can help the clinician plan the first contact with the child and family. what questions to ask. It is important to note that this treatment format is only recommended for children whose sexual abuse has been substantiated. is presented in a later section. the majority of children never receive treatment or do not receive help for months after the abuse.. 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. This approach is summarized in Table 7.” “It’s OK to talk about it. The protocol covers many of the critical treatment issues and helps the clinician determine the need for long-term treatment. and things to expect from the child. depending on the needs of the individual child. ways to support the child. and how much case management is needed.252 II. This serves to acknowledge the abuse openly without placing demands on the child. or hold a stuffed animal as they listen). It usually takes six to eight sessions.” etc. what materials to have available. the perpetrator may also be involved in this interview (e. and describe what will happen in the session. When possible. In the hope of encouraging more clinicians to work with these children. At this time. 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. Depending on the circumstances of the abuse and the status of the case. MANAGING COMMON PROBLEMS reasons. a protective service worker also often accompanies the child and should be included in the interview. 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.g. The clinician should explain his or her understanding of why the child and family have come to the clinic. draw.

Treatment Issues and Intervention Strategies for Sexually Abused Children Age group 0–6 years Traumatic sexualization • Sexuality education • Limits on sexual acting out • Reinforcement of appropriate interaction • Role plays • Sexuality education • Cognitive-behavioral techniques for assertiveness training and gaining control • Reinforcement of age-appropriate sexual behavior • Social skills training • Sexuality education • Cognitive-behavioral techniques for assertiveness training and gaining control • Role plays of relationship skills • Social skills training • Relaxation training Stigmatization • Something Happened to Me (Sweet. 1981) • Reinforcement of positive characteristics • Group treatment • No More Secrets for Me (Wachter. Sexuality and Sexual Problems 7–11 years • Making a book—“Whom can I trust?” • Cognitive restructuring for depression • Teaching problem-solving skills regarding trust issues 253 12–18 years • 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 253 .6. 1983) • Liking Myself (Palmer.TABLE 7. 1977b) • Letter to abuser • Channeling aggression • Support success in school activities • • • • Prevention skills Assertiveness training Letter to abuser Role plays of relationship skills • Support success in school activities • Support independence 7. 1977a) • Group treatment • Age-appropriate activities Betrayal of trust • Setting and keeping routines • Reinforcing independence • Providing safe environment Powerlessness • Treatment of nightmares and sleep problems • Prevention skills • “What if” exercises • Role plays • Identifying feelings • Prevention skills • Assertiveness training • The Mouse and the Monster. and Me (Palmer.

We often begin by making a “feelings book” in which various feelings are described and illustrated. Before the child and parent/caregiver leave. the child is told that he or she can have a snack at the end of the session. and both should be given the clinician’s card in the event that either needs to call before the next session. as well as ways to cope with these feelings. the clinician will have to determine how and in what order to cover the material in the time available. and have fun. Any concerns that the adult may have about the child’s sexual behavior can be discussed at this time. One way of communicating to the child that he or she is an important. and plans can be made to handle any inappropriate sexual behavior. Ideally. 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. so that the clinician can clarify any concerns the adult may have about the material. instead of asking many questions. This confirms for the child that it is acceptable to talk about these things. private parts. Sharing the sexual information with a parent or other caregiver before the session is important. Reading a book about sexuality often elicits further questions and comments from the child.254 II. and so . It is good if the sexuality education materials or book used can be sent home with the child. however. MANAGING COMMON PROBLEMS activities. 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. or that next time the clinician will remember to bring drawing material. they are covered over a period of six to eight sessions. valued person is for the clinician to keep all contracts and appointments consistently and on time. sexual behaviors) and the terms he or she uses for sexual parts and functions. the clinician must be careful not to let the adult monopolize the session. with parent/caregiver work occurring parallel to the child’s treatment. We typically begin by assessing what a child already knows about normal sexuality (body parts and functions. is essential to making the child feel comfortable. Older children enjoy making lists of things that make them happy. Using reflective comments and praise. regardless of the nature of the abuse. angry. afraid. Although the parent or caregiver is invited to stay in the room if the child wishes. they should be told what to expect in the next session. They then can be taught what to do when they feel angry. Feelings and Coping Skills Children’s knowledge of feelings and their ability to cope with them are dependent on their developmental status. and so on. and allows a clinician to provide reassurance and information directly related to the child’s experience of sexual abuse. Younger children can cut out pictures depicting various feelings and paste them on each page. Issues for Treatment The following issues are those that we feel are most important to cover with every child who has been abused. sad. so assessment of what they currently understand is essential prior to attempting to deal with their feelings about the sexual abuse. For example. draw. when time is limited. play games. sad. We then provide the child with appropriate information. the clinician must be sure to keep these promises. Sexuality Education Giving children information about sexuality helps them to protect themselves and results in a sense of power.

and a list should be made of people the child should tell. to the extent that they are temporarily unable to meet the children’s needs. Children also should be told that it is not their fault if they cannot get away or make someone stop hurting them. especially if the case will be prosecuted. Then the clinician wrote a short story dealing with each issue to read to her the following week. especially if a child’s testimony is believed and a perpetrator is found guilty. what will happen and in what order. A youngster usually wants to know. The importance of telling someone should be recognized. Having the child assume a variety of roles (includ- . Good preparation helps children and parents/ caregivers handle the experience as well as possible. the child should be told who will be there. The important thing is to tell someone. Children should be provided with the opportunity to practice skills in role-play situations. where these people will sit. We provide adults with information about normal sexuality and abuse prevention skills. so that the person can be made to stop hurting them. Adolescents often like to draw pictures of themselves with different feelings represented by different colors. Finally. may need separate sessions in which they can express and work through their feelings about the abuse and receive support. Sexuality and Sexual Problems 255 forth. and then talk about situations that give them those feelings and ways to cope with the feelings. as needed. or at least help in appropriately managing the behavioral sequelae of the abuse. Various techniques are effective in helping a youngster deal with feelings about the perpetrator. Both adults and children need to know what to expect from a court appearance. The parent/caregiver is given basic instruction in parenting skills. Personal Safety Skills Teaching sexually abused children self-protection skills is essential to restoring a sense of personal control and power. most parents appreciate help with the many decisions that must be made. If one-way mirrors are available. but that the behavior of the perpetrator was wrong and not the child’s fault. Preparation for Court Although testifying in court can be a very stressful experience for children. the child can be prepared to testify by role-playing various situations that are likely to occur during the trial. A visit to the courtroom should be arranged some time shortly before the the start of a trial. In the weeks prior to the trial. An older child often finds it helpful to dictate or write a letter to the perpetrator (which can be sent or unsent.7. usually sending home material used in treatment with the children. allowing parents to observe their child’s sessions can help them come to terms with the abuse. the child has to be helped to understand that he or she can have both negative and positive feelings toward the perpetrator. and what is expected of the child. and should be told. what has happened to the perpetrator. many children with whom we have worked have found it actually beneficial. Parents/caregivers who are extremely upset. a 6-year-old girl who was not able to talk about her feelings demonstrated them each week in doll play. Parent/Caregiver Work Some time should be set aside after each session with the child to talk with a parent or other caregiver. The clinician should not appear surprised to hear concern or affection expressed for the perpetrator. depending on the circumstances). Especially in an incest case. As an example.

In the case of a “not guilty” verdict. We have found. behavioral. family friend. There are a few books available for children about being a witness at a trial (Anderson & Finne. The child should also be prepared for either a “guilty” or “not guilty” decision by the jury. the child needs to know that this does not mean the abuse did not happen. MANAGING COMMON PROBLEMS ing those of the judge. The clinician must assess the status of each child and family at the end of these sessions. The actual incident of abuse under examination should not be used as content for these role plays. Children who live in unstable environments. It is likely that the child will have ambivalent feelings about a “guilty” verdict. especially if the perpetrator is a family member. we have found that most children need “booster” sessions from time to time as they . neighbor. For example. 1986. or abuse that results in injury to the child. oral. Furthermore. lest the clinician be accused of biasing the child’s testimony. the prosecutor. some children will continue to need treatment beyond the six to eight sessions. and (4) ongoing emotional. however. Beaudry & Ketchum. or who minimize the potential negative effects. (2) parental denial of the abuse. abuse involving anal. 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. role plays of the child’s being a witness to a car accident or a shoplifting incident can be used. the more likely the child is to have suffered damage to self-esteem and personal identity—both key issues in adolescent development. Older children (especially adolescents) are likely to need longer treatment. make it difficult for the child to feel accepted and safe. or learning problems. 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). The parent/caregiver and child should be aware that the adult may not be allowed into the courtroom during the child’s testimony. and a witness) helps to develop a sense of control and relieve anxiety. etc. taking into account factors that have been identified in the empirical literature as contributing to the need for longer-term treatment (see Chapter 2). Children who have other problems that either predate or result from the abuse will need further treatment focused specifically on these problems. especially depression (which may have been present before the abuse was disclosed). the longer the abuse has gone on. If a parent also has significant psychopathology. and that the clinician still believes the child. is related to poorer adjustment. Parents who deny the possibility of abuse in spite of a child’s disclosure of abuse.256 II. because they are aware of the implications of the abuse for their own developing social and sexual relationships. 1987). 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. and these feelings should be explored. Similarly.) 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. Finally. Another person who is well known and liked by the child (a teacher. social worker. (3) environmental instability. or genital penetration. that “homemade” books with simple line drawings that are specific to an individual child’s experience are just as effective. then the child is likely to need ongoing help in learning to cope with a dysfunctional parent. The child also will need additional help in dealing with this lack of support and the poor parent–child relationship. 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.

and increase the risk of a false allegation.) 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. the clinician should assess the child’s knowledge of sexuality. If one parent is concerned that the other parent is abusing the child. interviews by other mental health professionals. and should provide sexuality education and personal safety information to both the child and parents.7. “red flags” suggesting that abuse could have occurred are present. Sexuality and Sexual Problems 257 progress through developmental stages. were interviewed 36 times over a 2-year period by 13 different individuals (!) and had repeatedly denied abuse by their father. and medical records—should be done prior to seeing the child. it is critical to include the suspected parent in the treatment process. We recently worked on a case that illustrates this clinical pitfall. ages 4 and 6. there are no valid “indicators” for sexual abuse (Berliner & Conte. 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. If the clinician is concerned about the possibility of abuse. In addition to treating specific child behaviors. Many clinicians unintentionally encourage a persistent concern about sexual abuse by telling parents that although abuse cannot be substantiated. (See Chapter 13 for discussion of the assessment process with referrals involving divorce issues. Two boys. the mother took . The referral can also result from parental conflict. It is important not to question the child repeatedly about sexual abuse. or the fact that no abuse has occurred. specific ground rules for appropriate and inappropriate touch should be set. 1993). 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. especially when heated divorce and custody proceedings are involved. 1991).) In providing treatment for a child for whom abuse has not been substantiated. These books often contain detailed information that is highly suggestible. When the child is treated as if he or she may or may not have been sexually abused. the child should be instructed to tell the therapist and/or parents about any situations that make him or her uncomfortable. children come to a different. especially to young children. In fact. and to focus instead on the specific behaviors of concern. With increasing cognitive skills. A thorough review of all pertinent background information—including previous investigations by the legal or social service systems. the clinician must be very careful to take a neutral position regarding the possibility of abuse. more complex understanding of their experience and often have new questions or concerns about the abuse. even though one or more previous investigations have not determined that abuse has occurred. 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. and the situation should be closely monitored for up to a year (Hewitt. TREATMENT IN CASES INVOLVING NONSUBSTANTIATED ABUSE A clinician is often asked to treat children for sexual abuse. or to use books that describe a child being abused or being afraid to tell about abuse. In the presence of both child and parent. Despite this evidence. relying solely on the information presented by the concerned parent. any disclosure that may occur during the treatment process can be viewed more objectively. or aligning themselves with one parent against the other. (This work should not be confused with a referral for a second opinion on whether or not the child has been abused.

Comfort. The purposes of the referral were to determine the emotional status of both children. but the damage done to these children and their relationship with their father was devastating. the 9-year-old. he remained in the home while John was placed in the custody of Mrs. who was found to have anal lacerations and venereal disease. Although he was not a lawyer. Mrs. Given the father’s position in the community and the lack of evidence for abuse of Jimmy. no one had asked him about the sexual abuse. the stepmother admitted that the father had indeed abused the children and had been doing so over a long period of time. including them in discussions with other children in group treatment about sexual abuse. and their stepmother. the children “disclosed” that their father had abused them! Fortunately. had told his maternal grandmother. Both children were then placed in the custody of Mrs.258 II. however. ages 9 and 5. who was a local magistrate. abuse charges were not brought against this father. Comfort. 1983). The department of social services asked that the 5-year-old be brought to the clinic. with significant fears and physical complaints. They were reported. The children’s teachers and Mrs. Her therapeutic work consisted of reading highly suggestive stories about children who had been abused. MANAGING COMMON PROBLEMS the children to a therapist who provided individual and group treatment for “sexual abuse. CASE EXAMPLE: SUBSTANTIATED SEXUAL ABUSE Step 1: Initial Contact The district attorney called to request treatment and possible court preparation for two brothers. The therapist aligned herself with the mother. 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). Comfort. He told his grandmother that he “got better” so he could come home to protect his little brother from his father. During the course of this evaluation. The stepmother brought Jimmy. the father planned to defend himself in court. During hospitalization.” Although she was aware that the parents were in the middle of a heated divorce. nor did he tell anyone. nor did she ask to meet with the father. and persistent encouragement to “tell what happened to them. The two boys had been living with their father. and to determine the probable effects on the children of going to court to testify against their father. and his grandmother if he told. and reported that his father had said he would kill John. phone calls were also made to each of the boys’ teachers to determine their academic and social functioning within the school setting. This child had recently returned home from a 6-month inpatient stay for severe depression. for medical and psychological evaluation. John. Comfort were asked to complete the version of the CBCL in use at that time (Achenbach & Edelbrock. and the father was charged with sexual abuse but released on bail. Two weeks prior to this contact.” It was not surprising that after 10 sessions. and an investigation substantiated the abuse. Prior to the initial interview. that his father had been sexually abusing him and his little brother. The boys’ mother had died 2 years previously. which was in a neighboring county. who would be cross-examining them. his brother. to . Mrs. to provide the children and the grandmother with short-term treatment. Jimmy. Both boys had significantly high scores on the Internalizing scales of the CBCL. Comfort took the child to the department of social services. John described oral and anal sex as well as mutual masturbation. who believed that the children were being sexually abused by their father.

appeared sad. loving. the social worker. Jimmy was active and easily distracted by any noise or sudden movement on the part of the clinician. Both boys expressed a great deal of anger at their father. She transported the children to and from school. alertness. Comfort. and outside of school they rarely left her side. he turned away and refused to continue his play. He obviously was relieved by having told about the abuse and was able to express his anger toward his father. Comfort’s request. He was reluctant to talk about his father. Sexuality and Sexual Problems 259 be well liked by their peers and “no problem” to their teachers. at Mrs. and he was not pressured to do so. Comfort assured them that the house was secure and that she was quite capable of protecting them. He found it difficult to discuss the specifics of the abuse. but they were also quite fearful that he would come to the grandmother’s house and kill all of them. Comfort presented as a warm. related what had been done and what was known about the abuse. they often added information to the social worker’s report. He . 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. but stated that he missed being at home and playing with his toys. she was included in this session. The boys were given some toys to play with during the interview. to keep contact with her grandchildren since the death of her daughter. Five-year-old Jimmy refused to separate from his grandmother.7. as a result. 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. John did not feel that his younger brother had been abused. despite his fear of him. 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. against the father’s wishes. she also allowed them to sleep with her. Child Interviews The boys were seen separately for their initial interviews. It was after her death that the father began to abuse him. He described with great sadness the death of his mother. When the clinician introduced the father doll. Mrs. he said he felt safe both at school and when he was with his grandmother. John felt she had protected him from his father. Step 2: Caregiver and Child Interviews Caregiver Interview Mrs. Because they were both having nightmares. In playing with the doll house. and willingness to participate in activities in the short time since they had begun living with their grandmother. Mrs. Until he was hospitalized. and both boys were present for the initial interview. Although John was afraid of what his father might do. who had been rushed to the hospital in a diabetic coma. Jimmy carefully avoided including the father doll in his play. Although he admitted it would be “scary. The social worker. They had noticed a dramatic improvement in the boys’ affect.” John stated that he wanted to testify in court so that his father would never be able to do this again. John was able to share difficult information easily. The teachers indicated that the boys often came to school very tired. supportive person who had struggled. and on many days did not want to join in on academic tasks or social activities. 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. As they were playing.

They also were engaged in a sexuality education program that taught them the correct names for body parts and functions. Comfort participated in the last 15 minutes of each 1-hour session. putting to bed. During this time. their private parts and who may touch them and when. on the other hand. Although the district attorney was told that the younger boy was not as well able to handle court as his brother. how they felt. and Jimmy was being treated for venereal disease. MANAGING COMMON PROBLEMS also did not have any knowedge of adult sexual behavior.260 II. or birth. They were told that John appeared to be resilient and was using a lot of good skills to cope with a very difficult situation. were affectionate with her. The children made “feelings books” to identify and talk about feelings and to learn appropriate ways to express their feelings. and what they would do in the future if anyone tried to abuse them. Step 5: Referral to Allied Health Professionals The boys had already had a medical evaluation. and Mrs. he was emotionally capable of dealing with the legal process. and responded well to her requests and discipline. the clinician met with Mrs. 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. Mrs.). She was given books on sexuality education . he needed a great deal of support from his grandmother. etc. Mrs. both boys were able to talk more openly about the abuse and to give details of what had happened to them. with few coping skills available with which to deal with the trauma. 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. Course of Treatment John and Jimmy were seen together for treatment. He felt well loved and protected by his grandmother. Comfort had a good support system in the community and was handling the situation well. Step 6: Communication of Findings and Treatment Recommendations Prior to beginning treatment. the district attorney was told that although John was frightened. he was willing to testify against his father. Step 3: Observation of Behavior Only observations during clinic sessions were done in this case. pregnancy. 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. was seen as emotionally vulnerable. In a phone call. She needed little help from the clinician. Unlike John. the clinician felt that with support and preparation. The course of six sessions followed the short-term treatment program outlined earlier in this chapter. Jimmy. he was eventually required to appear. and personal safety skills. Comfort and the social worker to summarize the assessment findings. and was clearly very attached to his brother.

as well as the children’s “feelings” exercises to take home so that she could talk with the boys about them throughout the week. Jimmy clung to the district attorney. Preparation in the clinic involved the use of role play to practice court procedures. Given the trauma these boys had experienced. and that they could look to them for reassurance. regardless of the outcome of the trial. Comfort had already engaged a lawyer to help her take permanent custody of the children. The clinician was very careful not to tell them what to say. but he still demonstrated significant fear about potential interactions with his father. Jimmy was able to talk about his father and the abuse. the father was found guilty and sentenced to two consecutive life terms. it was felt that only John would be able to do so. This was particularly significant in this case. The children knew that the therapist and their grandmother would be in the courtroom with them. and their unresolved issues regarding the death of their mother. although he was allowed to sit on the courtroom floor rather than in the witness box. described to them what would happen in court. They were told that this would not mean he had not been abusive. . With treatment. Sexuality and Sexual Problems 261 and abuse prevention. but rather that the court would not punish him for this. The children were also prepared for the possibility that their father might not be convicted. and a booklet was written for the boys to describe what would happen and what would be expected of them. Mrs. he was not able to talk. both children were referred for further treatment. The district attorney met with both children. because the father would be cross-examining the boys. Nonetheless. although he was visibly upset with his father’s cross-examination and the attempts to confuse him. With the support of the department of social services. and took them to visit the actual courtroom in which the trial would take place. She was also given information on sexual abuse and its effects on children. The clinician supported her good parenting skills. John was able to testify. Court Preparation Although both children were prepared to testify in court.7.

and worry. and a child who has had one episode of an anxiety disorder is at high risk for further episodes. The past 10 years have brought increased knowledge about anxiety disorders in children. but children who have anxiety disorders typically have multiple problems and often live with parents who themselves suffer from psychiatric symptoms. but the empirical literature continues to be sparse in regard to the etiology. In addition. and worry. 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. Furthermore. anxiety. anxiety disorders in children persist longer than previously thought. prevalence. and self-reports. physiological responses. and can also increase the motivation for learning adaptive skills. 262 . 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. Depression often occurs along with anxiety disorders. 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 serve to elicit behaviors essential to survival. and this further increases the risks for these children. a number of children who exhibit subclinical levels of anxiety symptoms may be experiencing such marked distress that treatment is warranted. The terms “anxiety. what is known about the assessment and treatment of these disorders is presented.” “fear. Children tend to have fewer anxiety disorders than adolescents and adults. there is no clear consensus on how to define or conceptualize them. Finally.” and “worry” are hypothetical constructs reflecting subjective events that must be inferred by behavioral signs. MANAGING COMMON PROBLEMS CHAPTER 8 Fears and Anxieties e all experience fear and anxiety as normal emotions at some times during our lives. and the three are often used interchangeably.262 II. anxiety. and treatment of children with these symptoms. have been studied for decades. Next. W DEFINITIONS Although fear. This chapter first briefly reviews the definitions and developmental aspects of fear. the classification. assessment. and nature of the most common anxiety disorders experienced by children are discussed.

attention is focused on either escaping the situation or fighting the potential threat (Barlow. more diffuse construct of “negative affect” (Albano. Given that fear and anxiety are hypothetical constructs inferred from self-reports.g. These responses fade with the disappearance of the perceived or real threat. physiological monitoring. 2002).g. fear of strangers at 7–8 months. discomfort. ghosts at 6 years. Cognitive development affects an individual’s perception and understanding of what is perceived as a threat. gastrointestinal distress. situation. 2001). Both fear and anxiety. Some people appear to be predisposed to experience anxiety in response to a wide range of stimuli. like other emotions. trembling. and worry that some future negative event. rapid breathing. The physiological symptoms that occur with anxiety include fidgeting. and pounding heart. feelings of apprehension. or misfortune will occur (Barlow. and in the nature of the physiological response as an alarm reaction versus an elevated level of tension and apprehension. the person may preceive a wide range of stimulus situations as dangerous or threatening.. are thought to have three distinct but highly interrelated components: (1) cognitive or subjective reactions that involve all the thoughts. & Carter. it has long been debated whether they are two distinct constructs or manifestations of the larger. (2) motoric or behavioral reactions. including tension and uneasiness. 1996). Anxiety In contrast to the immediate alarm reaction of fear. which are expressed as distress. 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. Fear versus Anxiety The distinction between fear and anxiety lies in the interpretation of threat as immediate versus sometime in the future. images. increased heart rate. for example. Causey.. Spielberger (1972) has described these two different conditions as “trait” and “state” anxiety. the dark at 3 years. and that they share many characteristics. and muscle tension. and attributions about the situation and its expected outcomes. Children. and minor injuries at 6–12 years). muscle tension. apprehension. beliefs. large approaching objects at 2 years. thus. and behavioral observations. Trait anxiety is defined as relatively stable chronic anxiety that a person may experience regardless of specific circumstances. or terror. motivating a child to study for an exam or enhancing performance in various situations).8. & Turovsky. loud noises at 6 months. and with experience. “anxiety” is an emotion or mood state characterized by negative affect. and activation of the autonomic nervous system. Chorpita. State anxiety refers to varying or fluctuating aspects of anxiety that may change relative to a given situation. The fear reaction is seen as adaptive. respond with an alarm reaction to different stimuli and situations as they develop (e. whereas others have less frequent and more transitory moments of anxiety that fluctuate in duration and intensity. Fears and Anxieties 263 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. such as avoid- . a person learns what is a real threat and what is an innocuous situation or stimulus. which responds with such physiological sensations as sweating. Anxiety is thought to assist in planning or managing future events (e.

La Greca. and motoric components. walking rituals. 1990). and poor concentration (Barrios & Hartmann. clenched jaw. DEVELOPMENT OF FEARS AND WORRIES Fears and worries are common phenomena for children and adolescents. An anxious child may respond to a social situation. for example. It involves thoughts or images that are related to possible negative or threatening outcomes. 1998. exhibiting trembling. Merckelbach. crying. Implicit in this three-component view of anxiety and fear are potential variations in the individual expression of the subjective. In addition. worry and anxiety are significantly related but independent constructs (Muris. adult retrospective reports. but if it is excessive it can actually interfere with the problem-solving process (Matthews. In contrast to anxiety. Recent studies provide empirical support for the hypothesis that in children. & Zwakhalen. and (3) physiological reactions. Although they have been measured by a number of different methods (e. 1994). for example. Just as fear is viewed as a special state of the biological alarm system. 1983). patterns of fears and worries clearly change over the course of development. A summary of common fears and worries exhibited at different ages is shown in Table 8. an anxious child’s response can vary across settings. muscle tension. Two children who are suffering from school refusal. profuse sweating.g. 1998. with 10 or more expressed at any given time in their development (Muris et al. given the varying task demands of different situations. may react very differently. and tearing of eyes (Barrios & Hartmann. fourth edition (DSM-IV) anxiety disorders found in children. One child may begin to exhibit somatic complaints and crying the night before school. which is thought to be a complex emotional response involving cognitive.264 II. escape or tentative approach. In contrast. & Wasserstein. physiological. Development of Fears Research on fears in the general population of children has lead to a detailed understanding of normal fear experiences. These thoughts or images are difficult to control and can be quite intrusive. 2002. 1997). by refusing to interact with anyone and having thoughts of going crazy. urgent pleas for help. 1997). Worry The construct of “worry” complicates our understanding of fear and anxiety. fear survey schedules). he or she may blank out when called on in school. such as heart palpitations. rapid breathing. 1995). worry is viewed as a cognitive component of anxiety (Barlow. MANAGING COMMON PROBLEMS ance. worry is seen as a special state of the cognitive alarm system that prepares the individual to anticipate possible future dangers. including the ways in which they change with maturation and demo- . child interviews. Silverman. Sermon.. Ollendick. This problem-solving function is seen as adaptive in preparing for and coping with future events. physiological. given that worry is a central component of several Diagnostic and Statistical Manual of Mental Disorders. This is of some importance. stuttering. uneasiness. sleep disturbance. Vasey & Daleiden. and immobility.. Meesters. and motoric responses. whereas the other child’s response may be to enter school reluctantly but refuse to participate in any activities. reflecting a maturation of cognitive processes.1. Worry involves rehearsing possible aversive events and at the same time searching for ways to avoid them.

angry voices. injury. fire engines. noises) Darkness Animals Parents leaving at night Imaginary creatures Burglars Visual stimuli Concrete stimuli (e. dogs) “Bad” people Separation from caretakers Imaginary creatures Animals Personal harm or harm to others Auditory stimuli (e. fire..g.g. floods) Animals Dying or death of others Imaginary creatures Staying alone Personal harm or harm to others Media exposure to extraordinary events (e.g.. bombings..g.1. bright light) Separation from caretakers Strangers Toilets Auditory stimuli (e. trains and thunder) Imaginary creatures Darkness Separation from caretakers Visual stimuli (e..g..g. noise. masks) Animals Darkness Being alone Separation from caretakers Auditory stimuli (e. sirens. kidnappings) Failure and criticism Medical and dental procedures Dying or death of others Frightening dreams or movies Animals (cont..8.) 265 6–9 months 1 year 2 years 3 years 4 years 5 years 6 years 7–8 years . thunder) Imaginary creatures Burglars Sleeping alone Personal harm or harm to others Natural disasters (e. Sources of Fears and Worries at Different Age Levels Age 0–6 months Sources of fear or worry Loud noises Loss of support Excessive sensory stimuli Strangers Novel stimuli (masks) Heights Sudden or unexpected stimuli (e.g. Fears and Anxieties TABLE 8.g. falling...

such as fear of animals. creepy houses. the unknown. burglars. and Muris. the content of the fears of low-SES children suggests a basis in immediacy and reality for these fears. perceive their environments as more hostile and dangerous. and report fears of ani- . they mostly indicate a decrease with age. Ollier. In a recent study in which children ages 11–18 years were asked to list their three greatest fears. 1999). or being alone. Gullone (1999) summarizes the developmental progression of fears and their demographic characteristics. The major types of fears have been fairly consistently clustered into five categories: failure and criticism. fears are quite concrete in nature and reflect present experiences.. 1999).. Socioeconomic status (SES) also affects the number and content of fears reported by children. et al. the increase in fears of strange persons. danger and death. however. getting lost in a strange place. 1999)! Sex differences in fears have been reported. which suggests that differences between boys and girls are influenced by gender role stereotyping (Gullone & King. fire. for example. earthquakes.) are consistently among the most commonly reported from early childhood through late adolescence (Gullone. By the early preschool years. graphic differences in their content (Gullone. (cont. especially those who are older. snakes. Children from low-SES environments tend to have more fears than children from middle. It is interesting that fears of death and danger (e. school evaluation) Rejection Peer bullying or teasing Kidnapping Dying or death of others Personal harm or harm to others Illness Social alienation Failure Embarrassment or humiliation Injury or serious illness Natural and human-made disasters (e. spiders.1. economic and political concerns) Death and danger 13–18 years Note.g. Adolescent fears reflect the increased maturation of cognitive processes. and psychic/stress/medical fears (Burnham & Gullone. mice. MANAGING COMMON PROBLEMS Sources of fear or worry Failure and criticism (e. girls report a greater number of fears than boys in all of the major fear categories.or high-SES settings.. younger children (8–10 years) have more fears than older children (11–13 years) or adolescents (14–16 years) (King. the item listed most frequently was spiders (Lane & Gullone. By the end of the first year. 1993). illness. etc. In a recent review. The data are from Gullone (1999). also consistently report a greater fear intensity than boys. with more global fears (including economic and political concerns) predominating. Gadet. The items that most strongly discriminate boys from girls include rats. 1997). strange objects. Moreover. minor injury and small animals. and anticipatory in nature.. Children from low-SES environments. An increase in fears that are more abstract. such as fears of evaluative or social situations.266 TABLE 8. Miller (1983). and having bad dreams. being alone. is seen in the elementary school years. Merckelbach.) Age 9–12 years II. being hit by a car. bodily injury. and Moulaert (2000).g.g. imaginary. 1989). Girls. and heights reflects a cognitive maturation in both the capacity to remember and the ability to distinguish the familiar from the unfamiliar. the dark. and school. When age differences in the frequency and intensity of fears are found.

rates of fears remained high across all ages and all fear levels among Nigerian children. 1999). non-clinicreferred children also worry intensely about low-frequency events even though they realize that they are not likely to occur. & Carter.to 6-year-olds. ghosts in China. In an entire elementary school sample from second through sixth grades. excluding. In a study of children ages 7–11 years from four cultures. guns in Australia. reported fears of burglars breaking into their homes or of getting lost in strange places. as well as its relationship with anxiety. Other fears were specific to each country (e. & Moulaert. 70% of primary school children report 10 or more things about which they worry (Orton. exposure to specific fear-producing stimuli in the environment also affects the content of the fears evidenced by youth in different countries. Vasey and Daleiden note that children’s worries become increasingly complex after the age of 8. emotional restraint. who worry more about threats to their physical well-being. Not surprisingly. This worry decreases for 5. and personal harm. and the content of the worries shows a developmental progression (Muris. social evaluation. and Akande (1996) reported that children and adolescents from Nigeria and China (countries that tend to stress greater self-control. 1982). 2000. Interestingly. 1994). American and Australian youth expressed decreasing numbers of fears with age. just as anxious children tend to worry about events that rarely or never occur (American Psychiatric Association [APA] 1994). Culture also has been found to affect the number. the greatest number of fears occurred between 11 and 13 years (the period when decisions are made regarding higher education). due to their increased ability to reason about future possibilities. and to elaborate potential negative consequences. health. Preschoolers worry about imaginary and supernatural threats. Other frequent worries reported were social in nature.. and psychological well-being take the forefront (Vasey & Daleiden. or ignoring them. but this work is quite informative about the nature. Fears and Anxieties 267 mals. In contrast. A large percentage of American and Australian youth. frequency. Over 8 years of age. Thus. 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. Silverman et al. These included worries about classmates’ rejecting. (1995) found that the three most common types of worries in children ages 7–12 involved school.. In contrast. to consider multiple threatening outcomes. and compliance with social rules) reported higher levels of social-evaluative and safety fears than youth from America or Australia.. The increased opportunity to experience aversive experiences also plays a role in the worries expressed by children as they develop. they also report a considerable number of worries. violence. and intensity level of fears. 1995). 1994). and intensity of worry. although the specific content of the worries is closely linked to level of development. King. death. pattern. Among Chinese youth. the children rated these events as low in occurrence. Merckelbach. being abandoned by parents. for example. friends’ betraying . worries about behavioral competence. Ollendick. looking foolish in America. Just as children express many fears.g. Worrisome thoughts become prominent after age 7 years.8. and deep water or the ocean in Africa). bears in China and snakes in Nigeria). whereas an equally high percentage of Nigerian and Chinese youth expressed fears of electricity and potentially dangerous animals (e.and upperSES children. and police officers (Gullone. Dong. content. Threats to their well-being constitute a predominant worry across age (Silverman et al. Yang. heights and ill health are more characteristic fears of middle.g. Development of Worries There have been only a few studies on worry in the general population of children. Gadet. strange people. Crnic. Vasey.

g.to 6-years-olds and the 11. Worries were also described as persistent and difficult to control. and worries in children ages 4–12 years. and Moulaert (2000) examined the developmental pattern of scary dreams. in number as a function of age and gender. fears. Another study on children’s worries done in the Netherlands (Muris et al. kidnapping were more prominant in the 4. given DSM-IV’s assumption that worry is integral to the clinical picture of anxiety. with almost 70% of the children reporting that they had scary dreams about something they had seen on television. worries. Silverman et al. and being kidnapped (dreams about animals vs.to 6-year-olds).3%). and anxiety are quite common among children of all ages. 1998) found that children ages 8–13 years. Negative information (55%) was also found to be involved in the etiology of the children’s main fears. gender. and negative information contributed to the etiology of these behaviors. and in foci as a function of age. Girls of European and Hispanic descent had more worries than boys. worries increased systematically with age. and the extent to which conditioning. the mass media. fears. whereas worry about test performance increased with age). A recent study by Muris. Scary dreams followed a pattern of development similiar to fears: they were common in the 4. Only about 30% of the children could relate their worries to a specific threatening or aversive event. and discussing the worry with someone else (8. An important finding of this study was a significant difference in the content and origins of the children’s fears. worries. This is important. thinking about more pleasant things (37. the most intense fears. There were few age-related differences in reported worries. Scary dreams focused on imaginary creatures. Distressing fears and anxiety can also have a significant impact on children’s personal and social functioning. Ollendick and King (1994) found that 60% reported that their fears or anxieties caused high levels of daily inter- .g. and scary dreams remained relatively stable across age levels. and scary dreams. and cultural differences. MANAGING COMMON PROBLEMS them. ethnic. By contrast. but were most prominent at 7–9 years. Gadet. (1995) also found that highly anxious children could be discriminated from less anxious children on various worry parameters (number. For worries. with conditioning experiences reported for 33% and modeling for 25% of the children. modeling. In a study of 648 youth ages 12–17 years. Source of Fears.to 12-year-olds. and Scary Dreams Like fears and worries. and ratings of event frequency). Worries. who overall had a greater number and higher intensity of worries than the other children. and that worrying was accompained by modest levels of anxiety and interference with functioning.. scary dreams are common in children and are thought to be another expression of anxiety. intensity. the frequency of fears and scary dreams about imaginary creatures decreased with age. and SES. and conflicts between parents or among family members. suggesting that they may reflect separate phenomena. Although the prevalence of some specific types of fears. the most common pathways were a conditioning experience (58%) and negative information (33%). In summary. worries. Merckelbach.268 II. Information (e.8% of the children reported negative information as being the source of the fear.6%). people) was found to be the most commonly reported pathway for scary dreams. books. This is different from a study by Ollendick and King (1991).. no differences were found for African American boys and girls. reported worrying 2–3 days a week. which indicated that 88.6%). They tend to vary in their expression as a function of age. A strong positive relationship was found between trait anxiety and the frequency of worry. for example. Strategies used to control the worries included using some activity to distract themselves (55. and dreams changed across age groups (e.. personal harm or harm to others. worries.

When children with SAD are separated from parents. The expression of SAD can vary with age (Francis. parents or other primary caretakers). by phone). Children ages 5– 8 years most commonly report unrealistic worry about harm to attachment figures and engage in school refusal. DSM-III-R’s avoidant disorder of childhood is now considered to be a form of social phobia.3. and phobias. Young children with SAD have more symptoms than older children with this disorder. is significant enough to interfere with a child’s functioning or well-being. Separation anxiety disorder (SAD) is now the only anxiety disorder first evidenced in infancy. and lasts for a period of at least 4 weeks (APA. separation is typical. panic disorder. because its age of onset is prior to 18 years. The DSM-IV (APA. the child often needs to know the parents’ whereabouts and to stay in touch with them (e. Among the youngest children. Homesickness to the point of misery and panic often occurs when away from home. adolescents. Below. Fears and Anxieties 269 ference with their participation in desired or required activities. and specific phobia are typically far more prevalent among children than the other disorders. 1994) indicates that the symptoms associated with anxiety are consistent across children. whereas others examine the characteristics of only one specific type. 1987).. and the yearning to return home interferes with participation in activities.e. social phobia. 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. 1994). shadowing behavior (i. Separation Anxiety Disorder SAD has retained its status as a DSM disorder of childhood. from one’s home or from one’s attachment figures (i. in part.g. Last. when away from the home or parents.. to the increased specificity of the DSM classification system. agoraphobia. and an additional 20% reported moderate levels of daily interference. and adolescence in DSM-IV. although the specific manifestations of these disorders may reflect developmental differences. Moreover. including SAD. obsessive–compulsive disorder [OCD]. or that something will happen to themselves to cause a separation. GAD. or at the time of. posttraumatic stress disorder [PTSD]. childhood. and adults. Crying or other excessive distress in anticipation of.e.2. A number of changes in the classification of children’s anxiety disorders have been made in DSM-IV. ANXIETY DISORDERS Our understanding of anxiety disorders has evolved over the past 15–20 years. and anxiety disorder not otherwise specified) can be diagnosed regardless of age. SAD. and DSM-III-R’s overanxious disorder of childhood (OAD) is subsumed under generalized anxiety disorder (GAD). The DSM-IV symptoms of the anxiety disorders that have been examined in children are presented in Table 8. Research in this area is confusing because many studies combine the various types of anxiety disorders. GAD. The other anxiety disorders listed in DSM-IV (specific phobia. we describe the types of anxiety disorders most common in children. due. such as being kidnapped or lost. closely following a parent throughout the day or frequently checking on a parent’s whereabouts) may be the major . All the features associated with SAD can be attributed to recurring and excessive anxiety about being separated. either permanently or temporarily.8. & Strauss. they are often preoccupied with morbid worries that something terrible will happen to their parents.. Epidemiological data for these disorders are summarized in Table 8. The characteristics of anxiety disorders in general are presented in a later section.

specific phobia. impulses. separation anxiety disorder.2. generalized anxiety disorder/overanxious disorder. . PH1. PH3. SAD. selective mutism. obsessive– compulsive disorder. animals.270 II. Copyright 1998 by Plenum Publishers. GAD. flying. heights.. OCD. PD. 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. Symptoms Associated with DSM-IV Anxiety Disorders Symptoms 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 × × × × × GAD SAD OCD PD PH PTSD Recurring experiences • Recurrent and persistent thoughts. lightheaded. blood) • Persistent avoidance of stimuli associated with trauma 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. Adapted by permission. despite speaking in other situations × × × × ×3 • • • • • × × × × ×1 ×2 × Note. PH2. MANAGING COMMON PROBLEMS TABLE 8. images. social phobia. Adapted from Laurent and Potter (1998). 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. or behaviors • Persistent reexperiencing of traumatic event Actual or perceived physical symptoms • • • • • • • • • • • • • • • • • • • • • Restlessness Being easily fatigued Difficulty concentrating Irritability Muscle tension Sleep disturbance—insomnia. panic disorder.g. too much sleep.

and school refusal is common.5 yrs Girls > boys Girls = boys Girls = boys Girls = boys Girls < boys Girls > boys Girls > boys Girls > boys Note. and Strauss (1987). school refusal is exhibited by three-fourths of children with SAD. 1999). Fears and Anxieties TABLE 8. Young children with SAD also often have associated fears. and poor concentration when separated from their parents. X| = 7.8–13. It can also correspond to developmental transitions. 1992). McGee. Kashani and Orvaschel (1990). and children may leave school during the day to return home. School refusal may be seen in complaints of illness or tantrums when it is time to depart for school. it is considered “early-onset” (APA. Hersen. about 8 years of age) (Kashani & Orvaschel. apathy.5% at 11 yrs. or that it involves a regression to a prior level of functioning in the face of stressors (Fischer. 2000). Epidemiological Data for Anxiety Disorders Prevalence Disorder SAD GAD Social phobia Specific phobia All anxiety disorders Clinic 4% 14–58% 15% 39–42% Community 4–13% 3–7% 1–9% 2–13% 6–18% (7. Albano et al. including going to camp.7% at 15 yrs) Age of onset 8. feature. & Thyer. Prepubertal children (9–12 years) evidence withdrawal. overnight stays with friends. it is most often diagnosed in prepubertal children (i. such as nightmares involving separation.. Although SAD can be seen at any age up to young adulthood. including familial transmission (Abelson & Alessi. Last.3. When it begins before age 6. They may also refuse to participate in activities that involve extended separation from parents. Hersen. A child can have periods of exacerbation and remission of the symptoms over several years. Overall. or periods of increased demands and stress (Albano et al. and Kazdin (1992). or day excursions with peers. Williams. and Francis (1987).8. or a change of school. in which the anxiety-provoking stimuli are clearly related to social situations involving exposure to unfamiliar people or embarrassing situations. Last. sadness. Strauss.4 yrs Boys/girls Clinic 271 Community >6 yrs. Finkelstein. Kazdin. such as entering school for the first time. and Silva (1987). it is possible that SAD represents a child’s failure to make a successful transition from this developmental phase.e. The data are from Anderson. such as a death. Reccurrence appears to be tied to such events as prolonged illness. a move. or beginning middle or junior high school (Albano. or insist on sleeping with parents or siblings. The onset of SAD is often acute and precipitated by a stressful life event. & Barlow. There is some evidence that SAD may be a precurser to the subsequent development of panic disorder or agoraphobia in adulthood (Silove et al. Strauss and Last (1993). Others have suggested that SAD is a childhood version of panic disorder or agoraphobia and thus shares etiological pathways with these disorders. . Given that separation anxiety is normal from about 9 to 18 months of age. Adolescents (13–16 years) with SAD evidence more somatic complaints on days involving separation. 1994).4 yrs X| = 11. Himle. school holidays. 10... 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. 1990). (1996) also found that children with SAD are at considerable risk for developing social phobia. Perrin. Last. 1995).3 yrs X| = 8. Chorpita. These children may demand that someone stay with them until they fall asleep. 1991). 1996).

headaches. stomachaches... Hersen. Tracey. can give them the appearance of being “mature. 1991. Children with GAD also often have a preoccupation with an adult figure who seems “mean” or critical to them (Albano et al. It is interesting that in a clinical sample.” Thus parents and teachers do not always recognize when these behaviors are excessive for a young child (Kendall. as well as more frequent comorbidity with major depressive disorder or specific phobia (McGee et al. they are quite common in children with GAD.and upper-SES families than among African American and low-SES children (Last. In addition to these desirable behaviors. 1990). For a DSM-IV diagnosis of GAD. & Strauss. children with GAD do not often present with disruptive behaviors. so it appears that past research on OAD can be generalized to current and future research on GAD in children. Perrin.g. OAD was more prominent in European American children from middle. The various symptoms must cause significant distress or impairment in important areas of functioning. Although other somatic complaints (e.. and sleep disturbance. muscle tension. In addition. even when their performance is not being evaluated. Kazdin. as well as their inquiries about the dangers of situations. 1987).to 4-year follow-up . 1999). irritibility. because their anxieties about meeting deadlines and adhering to rules. 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. & Kazdin. 1996. The core feature of GAD is excessive. Beidel. research indicates no significant difference between the two diagnoses (Kendall & Warman. and catastrophic events such as earthquakes or nuclear war are common. academic. Finkelstein. children with GAD may be excessively self-conscious. Hersen. so they tend to avoid age-appropriate activities such as social or sport events. Chorpita. 2001). 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). as exhibited in their not being able to complete a project or homework without continuous feedback that they are doing a good job. the symptoms of OAD are reported to remit over time (Last. such as being embarrassed in public (social phobia) or being away from home or close relatives (SAD). Last et al. Children with GAD are often overlooked.272 II. Krain. tiring easily. (1996) found that 80% of children originally diagnosed with OAD did not meet the criteria at a 3. problems with concentrating or mind going blank. Worries about the past. Furthermore. the worry and anxiety are not limited to a feature of one of the other anxiety disorders. The onset of GAD may be sudden or gradual. this is similar to the findings on the development of worry in the normal population. 1996. sweating) are not required for a diagnosis. there must also be evidence of at least one of the following physiological symptoms: restlessness. & Treadwell.. the future. Kazdin. or athletic events. and older children (12–19 years) have higher levels of anxiety and depression in general. Last. & Strauss. Finkelstein. unrealistic worry and anxiety about a number of areas of life. 1997). 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. MANAGING COMMON PROBLEMS Generalized Anxiety Disorder Although the diagnostic criteria for GAD are slightly different from those for DSM-III-R OAD. There also can be an excessive need for reassurance. and often symptoms are exacerbated by stress. 1987). They are often perfectionistic and redo a task numerous times before believing it is acceptable. Douban. For many children. Hersen. Children with GAD usually worry excessively about the quality of their work or about their performance in social. & Barlow. The excessive worry/anxiety must be difficult to control and must be present for more days than not for at least 6 months. 1996).

In one study. or it may be more specific (i. 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. The age of onset for social phobia is relatively early. etc. These children also had poor social skills. 1994). not being able to talk while speaking in public. for a comprehensive review). a sizable number of children continue to suffer from it or other. Although adolescents and adults usually recognize that their fear is excessive or unreasonable.. the symptoms must persist for at least 6 months. & Kessler. and there is some evidence that it may be increasing (Heimberg. Perrin. & Kazdin. choking on food in public.8. such as parties or club meetings). were not ones that would readily lead teachers or parents to seek help for them. there must be evidence that the child has the capacity for social relationships with familiar people. Thus. however. 2001. 1995). 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. Turner. see Kashdan & Herbert. The key feature of social phobia is a strong. however. school refusal and selective mutism were present. more specific anxiety disorders.. For a child to be diagnosed with social phobia. 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. Hersen. fear in a particular situation. although GAD appears to remit for many children. 3 months to 12 years. Stein. and a substantial number of moderately distressing specific fears. They had high levels of anxiety in general. Cohen. Stein. show a relatively high likelihood (35%) of developing a new psychiatric disorder at follow-up. The behaviors they exhibited.. Somatic complaints of headaches and stomachaches were common.. Social phobia can be of a “generalized” type (i. Beidel.6% of children and 3. 2000). Hiripi.. including public and interpersonal). have high anxiety in the situation. most adults with social phobia cannot recall a time when social anxiety was not present in their lives (Heimberg. Hiripi. The average age of onset for clinic-referred children with social phobia ranges from 11 years. 3 months (Last. and the social anxiety must occur in peer settings. vomiting in front of others. 1994). In a study comparing 50 children with social phobia (7–13 years. 1992). 2000. & Brook.1 years) to 22 normal control children.). & Kessler. 1993). children may not view it as such (APA.e. 7.7% of adolescents met DSM-III-R criteria for social phobia (Shaffer et al. fear that occurs across most social situations. It affects as many as 13% of individuals at some time during their lifetimes (Kessler et al. They tended to have few friends. Phobias Social Phobia Social phobia (also called social anxiety disorder) is currently among the most common anxiety disorders. Children with social phobia exhibit marked anticipatory anxiety when they must enter the social situation of concern. with some children being diagnosed as young as 8 years (Beidel & Turner. Fears and Anxieties 273 assessment. academic. and avoid the situation if at all possible. These children did. and family functioning. as might be expected from their avoidance of childhood activities involving peers. Early social isolation may actually pre- . 1996). and avoided extracurricular activities.g. were extremely lonely. In contrast. Moreover. and Morris (1999) found that the children with social phobia suffered substantial emotional distress and impairment in their daily social. mean age 10. in extreme cases. 1998). not just in interactions with adults.e.

3% for dizygotic twins have been reported (Kendler. and avoidance) in infancy and early childhood may be a precursor to social phobia (Schwartz. Zvolensky.. Common phobias in childhood involve animals. 1999). Nelson. Fears may also involve concerns about panicking or losing control when exposed to the feared object or situation (e. 2001). social inhibition. & March. 1991) and increase their negative/avoidant coping style. Beidel. but children may not view their fear as excessive or unreasonable. 2001. particularly skills and/or performance deficits are implicated in the maintenance of social phobia (Hopko. LaGreca & Lopez. & Sigman. a diagnosis of specific phobia requires that the phobia must have lasted for at least 6 months. 2001). Turner. Heath. & Roth. 1994). particularly for children ages 8–12 years. Snidman. A cycle of negative thoughts. & Eifert. with adolescents reporting more social phobia than SAD symptoms (Compton.4% for monozygotic versus 15. feelings. Phobias can occur at an early age. 1998. darkness. GAD. Pinto. 1999. peer rejection and victimization. or specific phobia). needles. School Refusal Although it is not listed in DSM-IV. 2001. 2000). Specifically. 1999). Whaley. Moreover. (1999) also found that children with social phobia were at high risk for developing other disorders (60%). Beidel. a circumscribed object or event. and are not necessarily tied to traumatic precipitating events (Muris. Kessler. Environmental events that may contribute to the development of social phobia include high levels of parental criticism and control. and are perceived as uncontrollable by a child (Silverman & Carmichael. & Jacob. Stemberger. storms. & Moulaert. Neale. McNeil. MANAGING COMMON PROBLEMS vent such children from acquiring social skills (Turner. Stanley. The fears expressed are persistent and maladaptive. Specific Phobia The core feature of specific phobia (formerly DSM-III-R simple phobia) is excessive fear in the presence of. and behaviors. or anticipation of. be non-age-specific. Borden. Ehlers. & Eaves. Kashdan & Herbert. concordance rates of 24. The fear is out of proportion to reality. & Calhoun. the fear may be ageappropriate but so excessive that it interferes with their functioning and thus warrants treatment.g. Merckelbach. 1993). fear of dogs because of concerns about being bitten).. Beidel et al. Gadet.274 II. For some children. 2000). and significantly interfere with the child’s functioning. For a child. one of the most common symptoms exhibited by anxious and fearful children is refusal to go to school (see King & Bernstein. and operant conditioning following a bad experience in a social situation (Hofmann. are evident in both children and adolescents. the temperamental style of behavioral inhibition (shyness.g. blood and injury may cause the person to worry about fainting) (APA. 1995. & Kagan. 1995). The focus of the fear may be anticipated harm from some aspect of the specific object or situation (e. 1992). Social phobia and SAD seem to co-occur in both clinical and community groups. lead to the avoidance of the feared object. also found that European American children endorsed more symptoms of social phobia than African American children. Social phobia is thought to result from a combination of biological and psychological vulnerabilities and life stresses or traumatic events (Kashdan & Herbert. Compton et al. who had more SAD symptoms. and high places (Silverman & Rabian. The level of fear usually varies with the proximity of the feared object or situation and the degree to which escape is limited. for a comprehen- . with 36% of this sample having another anxiety disorder (typically SAD.

as well as always missing school. and the economic consequences of dropping out of school (N.8. King. anxiety. School refusal is viewed as constituting a spectrum that includes rarely missing school but attending under duress. but neither of these terms fully captures the range of behavors leading to or maintaining refusal to go to school. 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. 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- . & Grubb. 2000). (3) attention seeking (e. 1987a... delinquency. Children refusing for the first or second reason are motivated by a negative reinforcement paradigm. J. academic problems. N. Hersen. School refusal is of some significance because school attendance is mandated by law (King & Bernstein. reduced social interaction. Anxiety about attending school appears to stem primarily from separation problems or from excessive fear about some aspect of the school (i. depression). social anxiety due to peer evaluation). tests. working. 1987b). Last and colleagues found that children with school phobia were more likely than those with SAD to present with school avoidance (100% vs. 1997): Children presenting with phobic school-avoidant behavior are likely to have parents with specific and/or social phobia.g.g. fear. secondary gains of separation anxiety). hanging out with friends. 2001. following behavior problems such as tantrums in the morning. (2) escape from aversive social and evaluative situations (e. Kearney and Silverman (1993. & Ollendick. (2) initially attend. 1–10% of school-age children and it is equally common among boys and girls (King & Bernstein. Ollendick. and treatment of school refusal. the problem peaks at times of transitions to new schools (Kearney & Albano. Prevalence rates for school refusal are estimated at 5% of all clinic referrals. 2000. Fears and Anxieties 275 sive review). Mietz. see Table 8.g. Kearney & Albano. 1996) identify the characteristic behaviors related to school refusal through the use of empirically derived criteria. (3) go to school.. Kearney and Silverman (1993. Finney. including family conflict and disruption. Kazdin. 73%). 1995).4). It is possible for a child’s school refusal to be maintained by two or more of these factors. oral reports. whereas children who are school-avoidant due to SAD are more likely to have parents with panic disorder and/or agoraphobia. 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. school refusal refers to the behavior of youth ages 5–17 years who (1) are completely absent from school. King. a genuine school phobia) (Last. 1996). and (4) possible tangible reinforcement (e. Although children at any age may exhibit school refusal. then leave school during the school day. assessment. anxiety/depression. sleeping late). Francis. 2001) and refusal to attend school affects the child and his or her family in a variety of ways.. 1995). 1996) have proposed a functional-analytic model to explain the behavior. Such terms as “truancy” and “school phobia” were previously used to describe this behavior.e. and/or (4) display unusual distress during school days that leads to regular pleas for future nonattendance (Kearney & Silverman. J. 1999. Specifically. whereas refusal for the third or fourth reason is maintained by a positive reinforcement paradigm.g.. To help in the classification.. Other evidence indicates that specific anxiety disorders in parents predict an increased prevalence of specific anxiety disorders in school-avoidant children (Bernstein et al. “School refusal” is now the term most commonly used to describe these children. 1990. & Tonge.

given the changes in cognition. illicit drug dependence. Studies of OCD also indicate that this condition is quite persistent. and consequences for compliance and noncompliance Family contingency contracting to increase rewards for attending school and decrease rewards for missing school For positive tangible reinforcement Note. Crockett. these data indicate that one episode of an anxiety disorder represents a risk for further episodes of the same general type of disorder (Cohen. Werthamer-Larsson. This persistence is remarkable. Cohen. Kovacs. Leonard et al.to 4-year prospective study of children from an anxiety disorders clinic.. & Brook. . 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.8% had a recurrence. In first-grade children. Thus the persistence of anxiety disorders is thought to be linked to something intrinsic to the individual. which is an aspect of temperament and quite stable over time (Fox. and so forth that take place during the transition from childhood to adolescence to young adulthood. 1996). regular evening and morning routines. (2) the prevalence of anxiety disorders seems to increase with age. except for SAD. recurrent. as adults.4. depression. which decreases with age. and Brook (1993) found that the probability of OAD’s recurring at a 2½-year follow-up assessment was 23%. In addition. 1989.to 18-year-olds. 19% continued to experience their previous primary anxiety disorder. 1996). Cohen. and 15. 1994). & Kellam. A Functional Model for Prescriptive Treatment of School Refusal Reason for school refusal To avoid stimuli that provoke negative affect (crying. It is interesting that age of onset was inversely related to the length of time to remission. 7. 1993. the symptoms of children with OAD took longer to remit.276 II.. at increased risk of anxiety disorders.5% had new anxiety disorders.. Edelsohn. and (3) more girls than boys have anxiety disorders in nonclinical samples. stomachaches. or new) was present at follow-up in 35–42% of the 84 patients who initially had such a disorder (Last et al. social and interpersonal roles. extrafamilial contacts. distress) To escape aversive social and evaluative situations To get attention Prescriptive treatment Somatic control exercises and gradual reexposure to the school setting to reduce physical symptoms and anticipatory anxiety Role play and cognitive therapy to build social skills and reduce social anxiety Parent training in contingency management to establish clear parental commands. In a community sample of 9. In a 3. Approximately two-thirds of the children who recovered did so within the first year of follow-up. with 43–50% continuing to exhibit OCD over 2–7 years (Berg et al. 1993). Symptoms of anxiety appear to be persistent among both community and clinic-referred children. MANAGING COMMON PROBLEMS TABLE 8. for example. 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. Woodward and Fergusson (2001) found that youngsters who have anxiety disorders are. Taken together. and education underachievement. Specifically. an anxiety disorder (persistent. Cohen. Persistence of specific anxiety disorders has also been documented. such as negative affect. 1995).

Frick. Last et al. which have an onset before depression (Kovacs & Devlin. This was two to three times more likely than their association with depression (22–44%) or disruptive behavior disorders (8–27%). high negative affect (i. Thus anxiety and depression are neither totally unitary nor separate constructs. and low positive affect . The cooccurrence of more than one anxiety disorder is especially high. Lahey. Furthermore. 1989). Laurent. In an 8-year prospective study. in the outcome of children with anxiety disorders is highlighted in a study by Last.. 1998). These children exhibit impaired peer relations. higher levels of depression. and teacher-reported deficits in academic performance. 1988). whether anxiety actually causes depression or whether the psychosocial sequelae of the anxiety disorder place a child at risk for depression (Seligman & Ollendick. High physiological arousal is specific to anxiety. Given that the DSM-III-R symptoms associated with anxiety (other than worry) did not differentiate children with anxiety from those with depression. & Hund. This could explain. There is considerable overlap in the symptoms of anxiety and depression. the anxiety disorder precedes the depressive disorder about two-thirds of the time. & Richards. (1992) reported that the lifetime rate of a specific anxiety disorder’s occurring with any other anxiety disorder was between 65% and 95%. poorer self-concepts. particularly depression.8. They found that individuals who did not have comorbid depression in childhood were functioning relatively similarly to normal controls once they reached aduthood. Fears and Anxieties 277 The impact of anxiety on children’s functioning is considerable. Comorbidity The comorbidity of anxiety disorders with other psychiatric disorders is significant. 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. but are also differentiated by two distinct factors. Gatsonis. follow-up data were collected on 101 adults with a history of diagnosed childhood anxiety disorders. attention problems. whereas those with previous comorbid depression continued to experience considerable adjustment difficulties. It is also important to note that children with anxiety disorders are as disliked by their peers as are children with conduct disorders. and Franco (1997). Strauss. 1994. Depression The importance of comorbidity. Paulauskas. 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. and they also tend to be socially neglected by their classmates (Ollendick & King. Factor-analytic research does indicate that anxiety and depression share a common component. Reviews of the literature indicate that anxiety disorders typically have an onset prior to disruptive behavior disorders. symptoms of general distress). They found that symptoms describing worries. 1998). the high comorbidity rate of anxiety with other childhood disorders. in part. These factors place them at increased risk for further interpersonal problems. especially worries about future events and academic competence. 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. and much effort has gone into differentiating the two types of disorders (see Chapter 9). served as the most efficient inclusion criteria for anxiety disorders. Hansen. Landau. Frame. It is not clear. however.e.

were also combined with direct conditioning experiences. although the former remain more impulsive than normal children. & Tellegen. Jolly & Dykman. for a review). Etiology The etiology of anxiety disorders in general is not clearly understood. MANAGING COMMON PROBLEMS (anhedonia) is specific to depression (Joiner. self-concept. 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. Murphy. 1994. This might help explain the low incidence of mood disorders in preschool children and the fact that anxiety disorders precede mood disorders. learning factors. Attention-Deficit/Hyperactivity Disorder ADHD is also frequently comorbid with anxiety disorders. Gadet. and cognitive processes (Calkins. & Laurent. Learning Theories The learning-based theory that best explains the etiology of phobias is that of Rachman (1977). and Moulaert (2000) found that information was the most commonly reported pathway for scary dreams. 1988). & Cantwell. and reduced responsiveness to stimulant medication (see Jensen. Martin. This reflects the theory that mood structure is best described by two personality dispositions: negative and positive affect (Watson & Tellegen. Newcorn. the relative influence of these factors varies for the individual child. 1985). Muris. Thompson.to 14-year-olds. compared to children with ADHD and without anxiety. 1994. In a study of child and adolescent twins. Marelich. 1997. for example. Clark. however. Eley and Stevenson (1998) found that experiencing situations involving threat or . conditioning experiences. Primary fears were influenced by negative information. The comorbidity of anxiety and mood disorders with ADHD is often associated with a history of greater family and personal stress. 2000). Merckelbach. and transmission through information and instructions. and may be further modified in later years (Fox. Given that emotional regulation skills (including arousability) are a function not only of biological mechansims but also of behavioral. 1994).278 II. These indirect sources. The ability or skills to modulate or control emotional or affective arousal are acquired gradually throughout infancy and childhood. The co-occurrence of anxiety and ADHD seems to reduce the level of impulsiveness in these children significantly. 1991). Catanzaro. 1994). & Hoffman. A combination of genetic and familial factors with environmental events. social. The fact that stressful life events are associated with anxiety is also consistent with learning theory. greater parental symptoms of mood and anxiety disturbance. Negative affect has pervasive influences on mood. their acquisition and maintenance are constrained by developmental age. Rachman proposed three prime pathways for fear acquisition: conditioning. for example. Similarly. vicarious exposure. Previously cited studies on the development of fears and worries are consistent with these pathways for children. Ollendick and King (1991). 1996. found that vicarious learning and instructional factors were the most influential pathways for 10 highly prevalent fears reported by 9. and world view. and cognitions appears to contribute to the development of anxiety. of course. Positive affect reflects an individual’s level of pleasurable engagement with the environment (Watson. & Sprich. and modeling. The primary theories of etiology are summarized here.

e. causal attribution (e. attentional bias (i. “This is overwhelming”). Albano. Several cognitive factors that could influence the thinking of fearful and anxious children have been studied (e. & Perrin. The emotional intensity related to a behavioral event can also influence the associated cognitions.. 1999). and neuroticism. Eley (1999) found evidence for a genetic influence on anxiety in childhood. Dadds. (1996) found an association between a marker in the promoter of the serotonin transport gene and the emotional triad of anxiety.g. this explanation has some heuristic value. involving negative or unrealistic expectations for future events. There is also some research to support it. 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. in a review of behavioral genetic studies. but less threat than children diagnosed with oppositional defiant disorder..8. and Ryan (1996) found that children with specific and social phobias perceived more threat in ambigious situations than non-clinic-referred children. N. Chorpita. Furthermore. They indicate that repetitions of behavioral events and the related cognitive processes result in some degree of consistency in these events and processes. Thus learning experiences appear to play a significant role in the development of fears. Fears and Anxieties 279 danger occurred more often for anxious children than for either their nonanxious cotwins or other nonanxious children. If children have early anxiety-provoking experiences. King. Rapee. a child begins to have anticipatory cognitions (expectancies). Kazdin.. With the accumulation of a history of behavioral events.. Lesch et al. et al. the rate of anxiety disorders has been found to be higher in children of adults with anxiety disorders (Last. Kendall et al. 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. & Barlow. with high emotional intensity exerting a greater influence. including cognitive interpretative style (i. Familial/Biological/Genetic Factors There is considerable evidence for a genetic component in the etiology of anxiety. children with specific phobia gave more avoidant solutions to physical situations than children with any other type of disorder. Orvaschel. J.g. Thus cognitive distortions clearly play a significant role in fear and anxiety disorders and have implications for treatment. Barrett. (1999) explain the interrelationship between cognitions and behavior. Indeed. In a study of cognitive interpretive style. Hersen. 1991. and that the development of fears has been shown to be related to cognitive maturation (Gullone. First. Cognitive Factors Maladaptive cognitions are thought to play a significant role in the etiology and maintenance of fears and anxieties. 1995). accounting for approximately one-third of the variance in most cases. However. cognitive distortions characterized by misperceptions. depression. 1996). 1991). indicating that a specific .. The genetic contribution appears to increase with age. how a situation is perceived). exaggerations. whereas children with social phobia tended to be more avoidant in social situations. what aspect of the situation is focused on). Given that cognitive processes develop over time. Mietz.e. for example. and problem solving. or overattending to environmental threat are more prevalent in fearful and anxious children than in other youngsters (Kendall & Chansky. they may develop distorted cognitive schemas. with girls evidencing greater heritability than boys. When asked to problem-solve what they would do in specific physical and social situations.

and those who have comorbid anxiety and depressive disorders. Work by Kagan. The intensity of the child’s reaction is out of proportion to the actual threat or demands of the situation. The child’s withdrawal. although biological factors set the stage for this progression. 2000). Clinically significant anxiety disorders have some characteristics in these areas that make them distinguishable from more age-related. 1993b). but may serve to increase a child’s vulnerability to anxiety as well as to specific types of fears (Bohlin. developmental fear or anxiety from a clinically significant phobia or other anxiety disorder? Although DSM-IV (APA. ASSESSMENT OF FEARS AND ANXIETIES Given the frequency of fears and anxieties in children. there appears to be a greater contribution of genetic factors in the etiology of specific phobia than for the more general social phobia (Kendler. & Oakman. Further research on children with “pure” cases of anxiety or depressive disorders.g. including the intensity and frequency of the behavioral and physiological reactions. it is also important to systematically evaluate the nature of the specific fear.. than uninhibited children (see Turner. and Snidman (1988) suggests that certain individuals have a biological trait called “behavioral inhibition” (BI) that predisposes them to the development of pathological conditions.. & Eaves. Manassis and Bradley (1994) describe a transactional model for the development of anxiety that attempts to integrate various causal mechanisms. its developmental timing. Neale. the content of the fear or anxiety. For example. This pattern of insecure–anxious attachment then leads the child to react in ways that causes difficulties in other relationships. BI appears to be most closely associated with phobias that are social or social-evaluative in nature. 1998). especially phobias. 1996. its persistence. Reznick. Heath. BI refers to the temperamental propensity to react with inhibition to both social and nonsocial novel situations (Van Ameringen. Biederman et al. 1994) provides criteria for each of the anxiety disorders experienced by children. 1992). however. which then leads to an insecure attachment between the mother and child due to the child’s highly reactive and difficult-to-soothe qualities.280 II. 1994): 1. Children with high BI have higher rates of all types of anxiety disorders. Using the example of social phobia. & Andersson. It is estimated that approximately 10–20% of European American infants are born with this temperamental predisposition (e. in turn. transient fears and anxieties (APA. Thus. Beidel. parent–child interactions. MANAGING COMMON PROBLEMS genetic marker is associated with both anxiety and depression. 1993a). for a review). with the result that the child ultimately withdraws from peer interaction. will give more information on the behavioral phenotypes of this gene. the presence of behavioral inhibition is neither necessary nor sufficient for developing an anxiety disorder. and the familial and environmental circumstances that could have precipitated and/or are maintaining it. and experience are also important. Mancini. how does one distinguish a normal.. a child who cries uncontrollably the entire time he . Intensity. For example. Bengstgard. Despite these associations. & Wolff. decreases the opportunities to develop the social skills needed to form supportive relationships. they suggest that the development of social phobia in children is the result of a sequential process that begins with an inborn temperamental inhibition. particularly when they are exposed to certain experiences and environmental stimuli (Biederman et al. Other work has found genetic contributions for particular anxiety disorders.or anxiety-based symptoms. Furthermore. 1993a. the mediating roles of attachment. Kessler.

For example. Interference.. or a child shadowing a parent all day so as not to be separated or refusing to go to school. 1996). The child’s fear or worry is usually focused on a nonthreatening situation or stimulus that is not likely to cause harm. 5. No amount of reassurance seems to help. 1998). children with high BI have higher rates of anxiety disorders (Biederman et al. 1999). Further. The fear or worry is not specific to a child’s age or stage of development. The fear reaction leads to the avoidance of or escape from the feared stimuli. divorced. Content. an adolescent may refuse to spend the night away from home. The reaction of the child is not adaptive and is persistent. Spontaneity.. In addition to overly permissive or restrictive parenting. or starts vomiting every morning before school. The fear reaction or anxious symptoms occur with increased frequency and cannot be explained or reasoned away. Fears and Anxieties 281 or she is in school. reconstituted. academic performance. especially in combination with restrictive parental control (Messer & Beidel. 8. Anxious parenting appears to promote anxious cognitions and avoidance behavior in children. 2. et al. a child becomes distraught at the news that a thunderstorm might occur that day. 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. or unusually large family (regardless of SES) may be difficult to manage for some anxious children. children with social phobia are more severely affected than those with DSM-III-R OAD (Beidel et al. . Rapee. Poor social adaptation during the preschool years also has been shown to be a robust predictor of anxiety (and depressive) disorders in kindergarten children. A child who refuses to leave the house if there is a chance of rain. and the presence of psychosocial adversity related to family composition and size (Manassis & Hood. Certain types of anxiety disorders also appear to increase the level of impairment. Impaired functioning in an anxious child is significantly correlated with maternal reports of conduct problems. Frequency. 1994).. The reaction appears spontaneous and beyond the voluntary control of the child. or thunder.. Nonadaptive and persistent nature. and family functioning. are examples. The last factor suggests that the stress of living in a single-parent. thus the child does not learn more effective ways to deal with the situation or feared stimuli. Others have found that panic disorder and social phobia are more impairing than other anxiety disorders (Last et al. and these must be taken into consideration when one is determining the effect of the anxiety on the child’s functioning (see Table 8. a history of developmental difficulties in the child. A number of risk factors are associated with childhood anxiety. Clinical levels of anxiety or fear reactions can interfere with social relationships and activities. 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. 1993a). and reassurance often actually makes the situation worse. 6. Barrett and colleagues also found that parental rejection played a significant role in the development of anxiety symptoms.8. should be assessed for a phobia or other anxiety disorder. 4. dogs. 3.5). For example. or a school-age child may refuse to use public toilets. an anxious parenting style is a strong predictor of anxiety symptoms in children (Barrett. Avoidance. and worries about vomiting or being separated from parents. 1992). For example. Stage of development. maternal phobic anxiety. 7. This could include such things as the toilet.

Several factors have been shown to mediate this association. Social Phobia. Sorting this out is part of the assessment process for all disorders. 1999. It is important to note. the Screen for Child Anxiety Related Emotional Disorders (SCARED. this can be helpful to the clinician in understanding the wide variation of symptoms. as well as among the specific anxiety disorders. list of children’s motoric. & Streit. or with other disorders that may be secondary to the anxiety but have a major impact on treatment. Borchardt. Birmaher et al. 2000). divorced. Merckelbach. MANAGING COMMON PROBLEMS TABLE 8. Greenburg. and childhood bereavement (Goodyer & Altham. Various rating scales give specific information about the presence and content of anxieties/fears. 1991). and School Phobia. Barrios and Hartmann (1997) give a partial. hand wringing) to overwhelming. which assess five factors: Panic/Somatic. For example. as well as to Appendix B for copies of the rating scales we have found most useful. & Mitchell. see Appendix B) is particularly helpful in sorting out the DSM categories of anxiety disorders. The reader is referred to Barrios and Hartmann (1997) and Bernstein. Schumacher. Symptomatology of anxiety can range from mild distress (crying. 2001). & Meesters. McCauley. since anxiety is associated with many of the other childhood disorders (Manassis & Monga.5.282 II. Furthermore. incapacitating fear or anxiety. and parental psychopathology itself. tantrums. that these mediating factors. but extensive. and Perwien (1996) for lists of rating scales for anxiety disorders. If oppositional defiant behavior is present. physiological. Separation Anxiety. and subjective responses to fears. Korver. The SCARED differentiates between children with and without anxiety disorders. but it is particularly important for anxiety disorders. . children often present with more than one anxiety disorder. Burke. These include insecure attachment (Armsden. Schumaker. have also been shown to influence the development of a range of disorders in children. 1997. inconsistent and restrictive parenting styles (Kohlmann. 1990). 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. Generalized Anxiety. Risk Factors Associated with Anxiety Disorders in Children Child risk factors Developmental problems Conduct problems Poor social adaptation Parent risk factors History of anxiety disorders Permissive parenting (younger children) Restrictive parenting (older children) Parental rejection Anxious parenting High behavioral inhibition (BI) Insecure attachment Bereavement Environmental risk factors Family composition (single. it may interfere with the treatment of the anxiety disorder and therefore will have to be the initial focus of treatment.. however. 1988). thus they are not specific to anxiety. 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. It has child self-report and parent report forms with 41 items each. for example. Several of these scales also measure somatic symptoms and/or are helpful in monitoring the individual child’s progress in treatment.

Abidin. Behavior. 1985. see Appendix B). 2001). Reynolds & Richmond. plus a broad band behavior questionnaire such as the Behavior Assessment System for Children (BASC. Step 1: Initial Contact The parents should be asked to complete and return prior to the initial interview a general questionnaire (e. the parents’ general level of stress. 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. This chart can be very helpful in guiding the interview and also in measuring the effects of treatment. Reynolds & Kamphaus. Stark & Laurent. with its separate scales for Anxiety and Depression. The focus should be on the specific manifes- . which can show whether fear or anxiety is interfering with the child’s functioning. The BASC. The Parenting Stress Index (PSI. The Daily Log and the Mood Diary should be kept for a week prior to the initial appointment.8. and thus it is best used as a symptom inventory and a global measures of distress (Last. (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. records the antecedents. 1983. and types of fears that a child experiences. and consequences of specific instances of observed fear and anxiety. with particular focus on issues relevant to anxiety problems. see Appendix B) and the Revised Children’s Manifest Anxiety Scale (RCMAS. 1983) provides information on the number. 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.. severity. 1993. behavior. 1991a. is recommended over the Child Behavior Checklist (CBCL. and gives a rating of the child’s fears in relation to other children the same age. Depending on the age of the child. The reverse side of the Daily Log. 1992) which has a combined Anxious/Depressed scale. The FSSC-R (Ollendick. 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. 1995) provides information about the child’s temperament. it also provides an opportunity for observation of the parent–child interaction. then the child should be seen at a later time. regardless of age. and their attachment to the child—all important areas for the assessment of anxiety. Fears and Anxieties 283 Two other widely used scales are the Fear Survey Schedule for Children—Revised (FSSC-R. has the advantage of clarifying discrepant views of the problem. see Appendix A). Achenbach.g. The parent and child should be asked their perceptions of the problems as well as to define the specific problem behavior. Ollendick. our General Parent Questionnaire. The assessment process outlined below follows the Comprehensive Assessment-to-Intervention System (CAIS) framework presented in Chapter 2. 1997b). either the child or the parents can be asked to complete the Mood Diary (see Chapter 9). The RCMAS does not have good discriminative validity in distinguishing anxiety from depression. If the parent feels that a joint interview would be unsatisfactory for either the parent or the child. the Specific Events Causing Concern chart (see Appendix B). Step 2: Parent and Child Interviews Parent Interview Including a child in the initial interview with a parent.

social. as well as efforts that may have inadvertently strengthened the . Fear of going to bed. including (a) reactions to caffeine. as well as potential comorbid conditions. 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.or fear-related behavior. avoidance. and academic work should be noted. psychostimulants. Problems with family members (e. escape.. duration. neglect. and situation specificity. immature or dependent behaviors). arrhythmias. peers. Family and environment. recent changes in the family situation or changes at the time of symptom onset should be explored. (b) central nervous system problems. 2. A child may not show fear of the dark when he or she is with a sibling or parent. Efforts to help the child. The fear may also be maintained by the child’s coping strategies (e. A medical history should include information about visits to the physician for anxiety symptoms. such as bullies on the school bus) can also precipitate anxiety symptoms. or criticism is not effective with children who are fearful or anxious. the use of punishment. Changes in the environment or the child’s attachment figures (e. and child care can give further information about the child’s response to everyday events. for example. including hypoglycemia. 3. The clinician should also determine whether there are conditions under which the fear is not exhibited. persistence. including frequency. such as mitral valve prolapse.. as well as the child’s coping strategies and support networks. hyperthyroidism. for example. and the antecedents and consequences of the anxiety. and whether the parents’ expectations for the child are too high are especially important in the assessment of anxiety disorders. A number of physical conditions may produce anxiety symptoms. specific worries.284 II. and exposure to danger or violence (including apparently innocuous events. agitated behavior. The impact of the symptoms on the daily life of the child and family. Questions regarding who is concerned about the behavior. inhalants. force. toileting. The child’s academic. and behavioral functioning should be explored. should be reviewed as well. sedatives/hypnotics. whereas intrusive and restrictive practices tend to increase anxiety in older children. A review of the child’s general pattern of coping with sleep. or fear that the parents may leave the child. (c) metabolic and endocrine disorders.). athletic. intensity.g. stranger and separation responses. and neuroleptics. The child’s history of temperamental problems. 4. 5. medications. the onset and development of the symptoms. whether the child wants help. may be associated with fear of ghosts. Social and familial reinforcers of the symptoms should be particularly noted. MANAGING COMMON PROBLEMS tation of the fear or anxiety (avoidant behavior. and early fears should be considered. What are the parenting styles and the family coping styles? Permissive childrearing practices are often associated with anxiety in younger children. Environmental stressors such as a disorganized home. lesions of the limbic system and frontal lobes. etc. and medical conditions. Developmental and medical history. as well as the extent to which the problem interferes with the child’s and/or family’s activities. and (d) cardiac problems. Child functioning. 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. intense sibling conflict).g. Have the parents been rejecting or overly anxious in their rearing practices? Furthermore. and postconcussion syndrome. death of a grandparent) can precipitate problems with anxiety. and valvular diseases causing palpitations. including partial seizures.g. and hypocalcemia.. eating. It is important to assess events or meanings associated with the fear or anxiety responses and the child’s coping strategies. carcinoid tumor. fear of a recurrent nightmare.

The latter has child. This is particularly important for school refusal. Structured interviews are not always feasible in clinical practice. Kendall. Family and community resources.g. The scale(s) chosen will depend on the specific symptoms of the child. 1996). an interview with the child is imperative. verbal skills.. avoidance. 1994) and the Coping Questionnaire (Kendall.g. The child interview also gives the clinician an opportunity to observe the child’s emotional reactions. and father versions. mood disorders. not allowing the child to watch any TV shows or movies with imaginary figures. they can also be used to assess the other domains through general and specific questions (e. and physiological responses (“how . and compliance should generally be assessed.. and ADHD. and we use a semistructured interview based on the CAIS (see Chapter 2). or repeatedly insisting that the child participate in anxiety-arousing or fearful situations with little or no support). Family history. 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. It is important to ask the child about the nature of the distressing behavioral. What is the medical and psychiatric history of the parents and family members? Emphasis should be placed on anxiety disorders. tic disorders. 1988). suicidal behavior. Although interviews are used primarily to assess the subjective/cognitive domain. the RCMAS. the SCARED). Depending on the specific fear or anxiety. Fears and Anxieties 285 fear or anxiety (e. increased heart rate. The use of one or more self-report measures can be helpful in determining this information in a structured and systematic manner (e.. and most children will not want to do this. maladaptive thoughts and images) will have a direct impact on the treatment strategy selected. The child should be asked to rate cognitions or thoughts (“what you are thinking”). 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. behaviors (“what you do”). Determining the response (e. as well as to get the child’s subjective description of the fear or anxiety. the clinician should also determine what support can be offered by neighbors. diffuse muscle tension. in addition to how well the family will be able to carry out a particular procedure. The clinician should remember that anxious children tend to respond better to specific questions than to open-ended questions (Ollendick & Francis. The child’s cognitive-developmental level. representing extreme fear or anxiety).g. 6. & Rowe. physiological. school personnel. 7. 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. “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?”). substance use disorders. 10. or other community resources. 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. and/or cognitive responses that result from the actual or anticipated exposure to the feared stimulus or situation. The clinician should try to determine who in the family is best suited to help the child through the treatment process. 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. Parents are often ambivalent about having a child confront a feared stimulus.g.8. mother..

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 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.. Although they have their shortcomings. MANAGING COMMON PROBLEMS your body feels”) separately on the thermometer. Step 3: Observation of Behavior In an extensive review of performance-based measures (e. and community) and record the targeted behavior. Behavioral avoidance tests have been used to assess children’s motor reactions to medical procedures. Furthermore. and then performs a series of graduated tasks that call for approaching and interacting with the feared object (Barrios & Hartmann. . strangers.. 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. Observation of the child’s behavior in analogue situations. the child is placed in a setting that contains the feared stimulus. 1990) can be completed by parent. Kendall. can be very helpful. Given the varying stimuli or circumstances that can provoke the specific fear or anxiety and the differences in the behavioral responses to these situations. For example. and water. Assessment of social skills may be indicated. 1994).g. 1999). 1984) may also be useful if there is a question about the child’s overall level of adaptive functioning. 1997. 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. and the Social Skills Rating System (Gresham & Elliot. and child. analogue observations are straightforward and allow assessment of multiple motor responses. school-related events. In this procedure. “It feels a lot or just a little like bees or butterflies”). the clinician also can observe the child’s behavior in natural settings (home. parent. A measure such as the Vineland Adaptive Behavior Scales (Sparrow. measures of attachment. Using such a sheet. For example. Other analogue observations may involve setting up anxiety-provoking situations in the clinic and observing the child’s behavioral response. as well as subjective responses.g. it is generally best for the clinician to develop an observation sheet on which the individual child. or teacher can monitor the behavior of interest (e. a behavioral avoidance test has been used with specific phobias. teacher. among other things. however. Parent–child interactions can also be observed systematically in clinic analogue situations.. avoided or delayed behaviors). Systematically observing the parent–child interaction (see Chapters 2 and 10) is always an important part of the assessment process. BI. if the parents or siblings are also exhibiting significant fears or symptoms of anxiety. & Cicchetti. Vasey and Lonigan (2000) concluded that none of the current measures possess sufficient documented clinical utility. since the parents will play a significant role in the treatment process. Balla. and their behavior may be a target for intervention.286 II. number of minutes to fall asleep. and behavioral avoidance tests) and their utility for measuring childhood anxiety. with the parents’ consent. these should be addressed by the clinician or referred for further evaluation.. school.g. the time between when the parent brings the child to school and departs.

the characteristics of the child and parent. physical harm. 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. modeling. a highly anxious child or parent . Klein. or a combination of two or more of these treatments. 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. contingency management. Step 6: Communication of Findings and Treatment Recommendations As with all childhood problems. Although all of the aforementioned treatments have been used with a wide range of fears and anxieties. 2001). nighttime. and separation issues. and test taking. and ethical considerations. & Corda. Fears and Anxieties 287 Step 5: Referral to Allied Health Professionals The child should have had a physical exam within the last year. prolonged exposure. systematic desensitization has been used most frequently for fears and anxieties related to small animals. Generally. CBT combines a number of treatment procedures and has been used to treat a range of anxieties that focus on school. social situations. cost-effectiveness. and the clinician should consult with the physician regarding the child’s health and the behaviors of concern. cognitive-behavioral therapy (CBT). certain procedures have been used predominantly for particular types of fears or anxieties. 1998). effective ways of treating the problem. Unless there is some unusual circumstance. as well as fears/anxieties related to school. For example. and. As with the selection of any clinical intervention. There is also some evidence that school-based interventions may be more successful than clinic-based treatment for social anxiety (Masia. a follow-up discussion should occur with the child and parents together. Stroch. the child should be included in this initial discussion. the goal of treatment is to help the child learn to cope with the feared stimulus or anxiety-provoking situation. thought stopping. These techniques include systematic desensitization. If the child is not included. if indicated. or contamination.8. The parents and child should be included in the choice of treatment. whereas prolonged exposure is used to treat obsessions and compulsions. with a discussion of their advantages and disadvantages. or learn that he or she is no longer fearful in the presence of the stimulus or situation. 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. Modeling treatments have been used to help children deal with small animals and stressful medical or dental procedures. Methods with the greatest empirical support are behavioral and cognitive-behavioral interventions (Ollendick & King. thus the various treatment options should be presented. A referral to a child psychiatrist for psychotropic medication is indicated only in extreme cases. The parents’ and child’s trust in the clinician is very important in the treatment of fears and anxieties. For example. including the nature of the fear/anxiety and its stimulus. the clinician must take several factors into consideration when selecting a treatment approach for the anxious or fearful child. and their cooperation and collaboration in the treatment process will depend on their understanding of the problem and the various treatment options.

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. may be the focus of treatment. being relaxed). 1994. Silverman. Amaya-Jackson.g. (2) having the child rank-order. 1998. however. Although the number of treatment sessions for the most common anxiety disorders ranges from 4 to 18 (Kendall. from least to most distressing. with interventions that focus primarily on the child. however.. and medical/health areas.. Silverman et al. a series of scenes depicting the feared stimulus (fear hierarchy). a cooperative dentist. the child can move up the hierarchy. In some cases. a friendly but slow dog). then imagine the least feared scene for 10–15 seconds. and paranoia) and family dysfunction (Berman. particularly in periods of stress or transition. When no anxiety is evoked. Pictures or slides can be used to help with the imagery. consequences of the behavior.. Intervention with the Child Systematic Desensitization Wolpe (1958) developed systematic desensitization. and also had less effect when the parents and children were treated in groups versus an individual format (Berman et al. not the child. 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. 1988). eating a favorite food. Hamilton. this may be the method of choice. depression. Crawford & Manassis. King et al. 1988). Systematic desensitiza- . but laughter (e. the clinician must be sure to have control over the feared stimuli (e.. (2000) suggest that both the anxiety symptoms and the depressive symptoms be treated simultaneously. 2001).. if time is of the essence (e.g. Vicarious desensitization (in which the child observes another child receiving desensitization). the child may need periodic booster sessions. & Schulte. 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. MANAGING COMMON PROBLEMS is not likely to accept a prolonged exposure treatment method. or interacting with a special person can also be used with children. 2000. & Kurtines. hostility. the environment. the parents. If real-life exposure is not feasible.. playing with toys or games. group desensitization. Ollendick. These researchers also found that children who had a depressive disorder and high trait anxiety had poorer treatment outcomes. for example. imagery should proceed by having the child relax (specific muscle relaxation training procedures have been developed for use with children—e. with progression through the series contingent upon imagining a scene without significant discomfort (King. 2000)..288 II. 1979. Research has indicated. Berman et al. The treatment procedures presented here follow the CAIS framework (see Chapter 2). March. The incompatible response used most often is muscle relaxation.g. however. having the child imagine the feared monster dressed in red flannel underwear!)... the child must undergo surgery). Weems. & Ollendick. had less effect on adolescents’ than on younger children’s treatment. which is based on the view that fears and phobias are classically conditioned responses and that they can be unlearned through specific counterconditioning procedures. King et al. and (3) gradually having the child imagine the feared scenes while engaged in the incompatible response (e. Murray.g. muscle relaxation).g. the parents. 1999). 1998. though in vivo training is the most effective treatment (Ollendick & King. 1998). In these cases. The parents’ pathology.. that poor treatment outcome is associated with parental psychopathology (e. and real-life or in vivo desensitization (desensitization carried out with the actual feared stimulus or situation) are all effective.g. In setting up the real-life situation..g.

Cranstoun. 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. pride. Thus one should not immediately remove the fear-producing stimulus. Although experimental evidence is not extensive at this time (Ollen