Tag Defiance

Pay Attention to Inattention

boy head on handAn important study was recently published in April, 2015 edition of the Journal of the American Academy of Child and Adolescent Psychiatry. This study followed 11,640 kids in England from age 7 to age 16; the researchers focused on adolescent correlates of attention symptoms in childhood. These are some of their primary findings

Teaching Kids Anger Management

parents and young boy in intense conflictA frequent question I get from parents is what can be done to teach a kid how to control his or her anger. This entry reviews six of my favorite strategies.

#1: As is the case with so many issues in parenting, we do well to begin with a gut check. “How am I doing with managing my own anger?” While hypocrisy is an upgrade over disengagement, our credibility is enhanced when we walk our talk. Moreover, if I’m losing it with some regularity, I could be significantly contributing to my child’s problem with anger control.

#2: Also like so many issues in parenting, proactive strategies usually work better than reactive ones. We all lose IQ points when we’re angry (i.e., the more primitive parts of the brain take over), so if I wait until my kid has lost it to do my interventions, my odds of success are not great, and I may end up loosing it as well. I do better if I think ahead and imagine which situations could be challenging and prepare my child (and me) with a plan.

#3: Anxiety and anger are incompatible with a relaxed body. The first step to doing this is to belly breathe (instead of chest breathe), comfortably but deeply, both in and out. With anger and anxiety, the breath rises up and becomes shallow. With peace and relaxation, the breath drops and becomes deeper. The next thing is to relax all of the muscles. The metaphor I use is to try to turn each muscle into a cooked piece of pasta. I have a free 15-minute audio file that helps a kid build up this sort of muscle memory. You can download it here; strive to have your kid practice it three times a week until s/he is able to relax his or her entire body effectively and instantly.

#4: A useful cognitive approach is to try to move the focus of attention away from angry kidthe agitating agent or situation. Sometimes this can be accomplished by separating from the bother (e.g., having siblings separate). Other times this can be done by focusing on a coping or happy thought (i.e., true things that make a kid feel good). Or, it can be done by engaging in something fun or positively engaging.

#5: You can incentivize your child handling challenging situations well. Let’s say your guy is a little league pitcher who tends to lose his composure during games when things don’t go his way. You might tell him that he earns his technology (e.g., video games, cell phone) the next day by not showing negative emotions during the game. Of course, following up with proportionate positive commentary is a nice adjunct.

black mom with kids, white background#6: Try not to let advantages accrue to your child because of his or her temper outburst. If s/he is able to get out of undesirable responsibilities (e.g., chores, homework), gets more attention (e.g., one-on-one attention is most likely to occur during or after a fit) or gets his or her way because of the loss of control, then the frequency of such behaviors may rise, and not necessarily with intention. I would also be very cautious about trying to protect your child from any appropriate consequences that might come his or her way (e.g., a coach wants to bench your kid for a game for having thrown his bat in anger after striking out). It’s good for the anger control problem to not lead to good things (which includes the avoidance of important undesirable activities) and to be associated with developmentally appropriate consequences that sting.

If these strategies don’t work, please consider seeking out a child psychologist. S/he can help you to develop a more elaborate plan for resolving or improving this problem. For a referral, click here.

Defiance in a Young Child Needn’t Be Tolerated (usually)

defiant boyAn important study was published a couple of months ago in the Journal of the American Academy of Child and Adolescent Psychiatry titled “Psychosocial treatment efficacy for disruptive behavior problems in very young children: A Meta-analytic study.” The first author is Boston University professor Dr. Jonathan Comer. This study of studies examined 36 studies investigating 3,042 children. The high points from this study support the headline for this entry.

Backdrop for the study

The authors first reviewed some key findings in the research literature:

• About 10% of preschoolers meet criteria for a disruptive behavior disorder. These conditions exist across cultures and are associated with debilitating outcomes (e.g., profound family disruption, continued psychopathology).

• The rates of psychotropic medication treatments for preschoolers has experienced between a two and five fold increase despite the fact that “…controlled evaluations of the efficacy of antipsychotic treatment for early child disruptive behavior problems have not been conducted…(and) potential adverse effects of antipsychotic treatment in youth, including metabolic, endocrine, and cerebrovascular risks, have been well documented.”

• While only a minority of children with disruptive behavior problems have ever tantruming girlgotten evidence-based treatment, there is evidence of a decreasing trend of kids getting needed mental health care.

Results

When considering if interventions work, researchers calculate an effect size. A “0” score means no effect; .2 means a small benefit; .5 is a moderate benefit and .8 represents a large benefit (what one well known statistician described as “whopping”).

The average effect size was .8! Remember, this is across 36 studies and more than 3K kids.

• The largest effect sizes were found for treatments that took a behavioral approach (see the commentary section below).

bipolar child• There is evidence that many treatments offered to youth with disruptive behavior problems are not the ones with the most evidence supporting their use; moreover, when these treatments are compared to evidence-based behavioral treatments there is a large difference in favor of the behavioral treatments. As the authors note “…widely used approaches rarely show support.”

• “Treatment effects were consistent across samples of varying compositions of racial/ethnic minorities.”

• “These findings provide robust quantitative support for consensus guidelines suggesting that psychosocial treatments alone should constitute first line treatment for early disruptive behavior problems. Against a backdrop of reduced reliance on psychosocial treatments in this age range, and increased reliance on pharmacological treatments in the absence of controlled safety and efficacy evaluations, the present findings also underscore the urgency of improving dissemination efforts for supported psychosocial treatment options, and removing systematic barriers to psychosocial care for affected youth.”

• “Roughly 50% of U.S. counties have no psychologist, psychiatrist or social worker.”

Comment

Readers of this blog will note how much this study is consistent with a primary ball and chain runningpoint I’ve been trying to make (and quoting from my own previous entry):

“Psychological problems are akin to medical problems in so many ways: they are nearly universal by the time a kid reaches adulthood (about 90%), most of the time they are treatable in a short period of time, they are easier to treat the earlier they are caught and, if they are left unchecked, can cause very stressful and costly consequences. However, unlike medical problems, only about 20% of youth who need evidence-based mental health care get it.”

This is profound social injustice and it needs to stop!

character holding checkmark-bulletWhat can you do to help?

• Ask your pediatrician if s/he screens all children for mental health problems in her/his practice on well visits. If not, ask him or her to reconsider. If s/he says that s/he doesn’t screen because s/he would have no one to refer such children to, make a counterpoint and a suggestion. The counterpoint: parents deserve to know if their child could benefit from a mental health evaluation. So, even if no help can be found, the problem has been upgraded. The suggestion: contact your state’s psychological association and ask if they can help to identify a provider to whom your pediatrician may refer; it is highly likely that that they will be passionate in their efforts to assist. Should you convince your pediatrician to grow in this way, a quickly administered pediatric mental health screening tool is available in the public domain (i.e., it’s free): Pediatric Symptom Checklist.

• If your child’s defiant or disruptive behavior is causing anyone distress, get him or her help for it today. Besides tapping your state’s psychological association, you may also try here .

• Ask the mental health professional you interview at least two questions:

√ “In what types of problems do you specialize?” (This is a better question than question mark over brain“do you specialize in working with children?”) If you hear kids listed, that’s good. If not, ask if s/he knows of someone who does. Of course you may live in a community where this person is your only choice. So, you can ask if s/he has had success treating this problem.

√ Once you identify a viable clinician, ask “You obviously can’t know if my child has Oppositional Defiant Disorder at this point, but what is your treatment approach when you have diagnosed a child with Oppositional Defiant Disorder(ODD) and that’s the only problem?” There are synonymous terms for a good answer: “behavior modification,” “parent training,” (an unfortunate term in my view but it’s used), “behaviorally oriented family therapy,” and “behavioral treatment.” The clinician might also name some specific treatment manuals/approaches such as “Parent-Child Interaction Therapy,” “Incredible Years,” “Helping the Noncompliant Child,” “The Triple P-Positive Parenting Program,” and “The Defiant Child Program.” I would be very concerned if the first line of approach were a different one, including the use of medication treatment.

key in lockJust to give you an idea of what you might be in for, when I have a child who has ODD, and that’s the only problem, the treatment phase of the work (i.e., not including the evaluation phase), takes 8 sessions. In my own practice this cures the problem over 90% of the time. And, the two most common reasons I’ve found it doesn’t work are (1) the parent(s) don’t apply the techniques, usually because of personal pain and limitations or (2) there was another or different problem interacting with the ODD (e.g, the child really was suffering from an emerging case of bipolar disorder, the child was privately sniffing glue on a regular basis, a parent was substance dependent but tried to hide that). If a child truly has just ODD, and the parent does the techniques, it works.

The truth I/m reviewing here still seems to be too much of a secret, at least from most parents, teachers and pediatricians I’ve known. This leaves kids, parents and families suffering needlessly. As Jerry Garcia once noted: :Somebody has to do something, and it’s just incredibly pathetic that it has to be us.”

In closing let me share that you can also find multiple behavioral strategies in my parenting book as well as suggestions for identifying, and affording, quality mental health care.

Seven Tips for When Your Child Refuses to Do a Chore

What’s a parent to do when a child resists doing a chore? In this post I offer seven tips for dealing with such a situation. These tips are premised on three assumptions:

  1. The chore is age appropriate and skill appropriate for your child. Said another way, the task is within your child’s reach to complete.
  2. Your child is not suffering from an untreated psychiatric problem. If a child suffers from depression, anxiety, bipolar disorder, or another diagnosable mental health disorder he or she may need interventions that are more sophisticated than what’s indicated below.
  3. Your child’s resistance to the chore is not in response to someone else’s psychiatric problem (e.g., someone acting in an abusive fashion, someone abusing alcohol, etc.).

Tip #1: Make it clear what you expect. Your idea of a clean room and your child’s idea of a clean room may be very different. One way to avoid this problem is to write down on an index card what effective task completion looks like. For instance, a clean room = bed made, all clothes put in their place and all food particles/dishes out of the room and either in the trash or the dishwasher (for pre-readers this can be indicated with pictures). It’s also a good idea to put down how long you expect it to take for your child to complete the task.

Tip #2: Don’t make it sound like you’re asking for a favor. “Colin would you Puhleezzee take out the trash just once this week without a hassle?! Puhleezzee!” sounds like I’m asking for a favor, and we all get to say no to favors.

Tip #3: When giving a command make eye contact and use as few words as possible. If my child is watching TV, or I’m issuing a command from another room, the odds of compliance go down. Moreover I facilitate the escalation of anger and resistance if I start lecturing in these moments.

Tip #3: Establish a reward.  In the mildest cases of non-compliance your praise for a job well done may be sufficient. If that doesn’t work you can make your child’s access to a privilege contingent upon having done the chore properly. “Jaden from now on you earn the privilege of watching TV by doing kitchen duty.” After having done the chore multiple times in a row a bonus can be offered (e.g., a game rental, a trip to an ice cream shop, etc.).

Tip #4: Give your child the opportunity to control aspects of the task. “Peter which day of the week would you like to pick up the dog’s poop off the lawn?” “Brooke do you want to take your shower right after dinner or right before bed?” “Claire do you want to rub my shoulders before or after you rub my feet?” (Just kidding on that last one…or am I?)

Tip #5: Give a warning that the task is about to be due. “DJ I know you’re into your video game but in 15 minutes I’m going to need you to stop and pick up your toys and put them in their place.”

Tip #6: Use time out if the reward is not sufficient. If your child resists doing the chore after you’ve given three commands to do it (issue the threat of time out when giving the command the second time), have her sit in a hard chair for a minimum sentence of one minute for each year she has lived outside the womb (don’t let your child know what the minimum sentence is). After the minimum sentence has elapsed your child can get out if she is sitting there quietly and she agrees to do the chore. If either or both conditions haven’t been met, and without announcing that you are doing so, cylce through new periods of minimum sentences until your child is sitting there quietly and agrees to go do the chore.

Tip #7:, Seek out help if your child has a persistent patter of non-compliance, that is not responding to your best efforts. For a referral for a provider near you click here.

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