Treating Childhood Psychopathology and Developmental Disabilities

Treating Childhood Psychopathology and Developmental Disabilities Treating Childhood Psychopathology and Developmenta...

Author: Johnny L. Matson | Frank Andrasik | Michael L. Matson

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Treating Childhood Psychopathology and Developmental Disabilities

Treating Childhood Psychopathology and Developmental Disabilities Edited by

Johnny L. Matson Louisiana State University, Baton Rouge, LA

Frank Andrasik University of West Florida, Pensacola, FL

Michael L. Matson Louisiana State University, Baton Rouge, LA

Editors Johnny L. Matson Department of Psychology Louisiana State University Baton Rouge, LA 70803 225-752-5924 [email protected]

Frank Andrasik Department of Psychology University of West Florida Pensacola, FL 32514-5751 [email protected]

Michael L.Matson Department of Psychology Louisiana State University Baton Rouge, LA 70803

ISBN: 978-0-387-09529-5 e-ISBN: 978-0-387-09530-1 DOI: 10.1007/978-0-387-09530-1 Library of Congress Control Number: 2008931350 © Springer Science + Business Media, LLC 2009 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. Printed on acid-free paper springer.com

Contents PART I: INTRODUCTION Chapter 1. History of Treatment in Children with Developmental Disabilities and Psychopathology ..................... Jonathan Wilkins and Johnny L. Matson

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Chapter 2. Applied Behavior Analysis and the Treatment of Childhood Psychopathology and Developmental Disabilities ........ Joel E. Ringdahl and Terry S. Falcomata

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Chapter 3. Cognitive Behavior Therapy .......................................... Ellen Flannery-Schroeder and Alexis N. Lamb

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Chapter 4. Parent-training Interventions ........................................ Nicholas Long, Mark C. Edwards, and Jayne Bellando

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PART II. CHILDHOOD PSYCHOPATHOLOGY AND DEVELOPMENTAL DISABILITIES Chapter 5. Conduct Disorders ....................................................... Christopher T. Barry, Lisa L. Ansel, Jessica D. Pickard, and Heather L. Harrison Chapter 6. Treatment of Attention-Deficit/ Hyperactivity Disorder (ADHD) ........................................................ Ditza Zachor, Bart Hodgens, and Cryshelle Patterson

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Chapter 7. PTSD, Anxiety, and Phobia ............................................ Thompson E. Davis III

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Chapter 8. Treatment Strategies for Depression in Youth................ Martha C. Tompson and Kathryn Dingman Boger

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CONTENTS

Chapter 9. Medication Treatment of Bipolar Disorder in Developmentally Disabled Children and Adolescents.............................................................................. Zinoviy A. Gutkovich and Gabrielle A. Carlson Chapter 10. Treatment of Autism Spectrum Disorders ................... Mary Jane Weiss, Kate Fiske, and Suzannah Ferraioli

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Chapter 11. Treatment of Self-Injurious Behaviour in Children with Intellectual Disabilities.......................................... Frederick Furniss and Asit B. Biswas

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Chapter 12. Communication, Language, and Literacy Learning in Children with Developmental Disabilities...................... Erna Alant, Kitty Uys, and Kerstin Tönsing

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PART III: BEHAVIORAL MEDICINE Chapter 13. Eating Disorders ......................................................... David H. Gleaves, Janet D. Latner, and Suman Ambwani

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Chapter 14. Treatment of Pediatric Feeding Disorders ................... Cathleen C. Piazza, Henry S. Roane, and Heather J. Kadey

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Index ..............................................................................................

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List of Contributors Erna Alant Center for Augmentative and Alternative Communication, University of Pretoria, Pretoria 0002 South Africa, [email protected] Suman Ambwani Department of Psychology, Dickinson College, P.O. Box 1773, Carlisle, PA 17013, [email protected] Lisa L. Ansel Department of Psychology, The University of Southern Mississippi, 118 College Dr., Box 5025, Hattiesburg, MS 39406, [email protected] Christopher T. Barry Department of Psychology, University of Southern Mississippi, Hattiesburg, MS 39406, [email protected] Jayne Bellando Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR 72202 Asit B. Biswas Leicestershire Partnership NHS Trust and University of Leicester, Leicester Frith Hospital, Leicester LE3 9QF, UK, [email protected] Kathryn Dingman Boger Department of Psychology, Boston University, Boston, MA 02215, [email protected] Gabrielle A. Carlson Stony Brook University School of Medicine, Stony Brook, NY 11794, [email protected] Thompson E. Davis III Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, [email protected]

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LIST OF CONTRIBUTORS

Mark C. Edwards Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR 72202 Terry S. Falcomata Center for Disabilities and Development, Division of Pediatric Psychology, Department of Pediatrics, Children’s Hospital of Iowa, Iowa City, IA 52242 Suzannah Ferraioli Douglass Developmental Disabilities Center, 151 Ryders Lane, New Brunswick, NJ 08901, [email protected] Kate Fiske Douglass Developmental Disabilities Center, 151 Ryders Lane, New Brunswick, NJ 08901, [email protected] Ellen Flannery-Schroeder Department of Psychology, University of Rhode Island, Kingston, RI 02881, [email protected] Frederick Furniss The Hesley Group, School of Psychology, University of Leicester, Doncaster DN4 5NU, UK, [email protected] David H. Gleaves Department of Psychology, University of Canterbury, Christchurch, New Zealand, [email protected] Zinoviy A. Gutkovich Division of Child and Adolescent Psychiatry, Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY 11004, [email protected] Heather L. Harrison Department of Psychology, The University of Southern Mississippi, 118 College Dr., Box 5025, Hattiesburg, MS 39406, [email protected] Bart Hodgens Civitan International Research Center, University of Alabama at Birmingham Alexis N. Lamb Psychology Department, University of Rhode Island, 10 Chafee Rd., Kingston, RI 0288, [email protected] Janet D. Latner Department of Psychology, University of Hawaii at Manoa, 2430 Campus Road, Honolulu, HI 96822, [email protected]


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Nicholas Long UAMS Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72202, [email protected] Heather J. Kadey Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha 68198, NE Johnny L. Matson Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, [email protected] Cryshelle Patterson Sparks Clinics, University of Alabama at Birmingham Cathleen C. Piazza Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha 68198, NE Jessica D. Pickard Department of Psychology, The University of Southern Mississippi, 118 College Dr., Box 5025, Hattiesburg, MS 39406, [email protected] Joel E. Ringdahl Center for Disabilities and Development, Division of Pediatric Psychology, Department of Pediatrics, Children’s Hospital of Iowa, Iowa City, IA 52242, [email protected] Henry S. Roane Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha 68198, NE Martha C. Tompson Department of Psychology, Boston University, Boston, MA 02215, [email protected] Kerstin Tönsing Center for Augmentative and Alternative Communication, University of Pretoria, Pretoria 0002, South Africa, [email protected] Kitty Uys Center for Augmentative and Alternative Communication, University of Pretoria, Pretoria 0002, South Africa, [email protected] Mary Jane Weiss Douglas Developmental Disabilities Center Rutgers, The State University of New Jersey, New Brunswick, NJ 08901, [email protected]

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Jonathan Wilkins Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, [email protected] Ditza Zachor Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, [email protected]

1 History of Treatment In Children With Developmental Disabilities And Psychopathology JONATHAN WILKINS and JOHNNY L. MATSON

INTRODUCTION The history of modern child psychopathology and developmental disabilities is of fairly recent origins. However, of the two topics, intellectual disability (ID) is the area which has received the most attention as a modern science and profession for the longest period of time. In December of 1896 in an address to the American Psychological Association, Lightner Witmer outlined what he descried as a scheme for practical work in psychology. The plan had four components: 1) the investigation of mental and moral development; 2) a psychological clinic supplemented by a training school/hospital to treat retardation or physical defects interfering with school progress; 3) practical work in the observation and training of normal and retarded children; and 4) training of students for a new profession, the psychological expert, who would examine and treat mentally and morally retarded children, or in connection with the practice of medicine (Witmer, 1907). Witmer discusses pedagogical treatment for stammering and other speech defects, bad spelling, slow mental development, and motor defects. As such, these early efforts were primarily geared toward remediation of what we would now call developmental or learning disabilities.

JONATHAN WILKINS and JOHNNY L. MATSON • Louisiana State University

J.L. Matson et al. (eds.), Treating Childhood Psychopathology and Developmental Disabilities, DOI: 10.1007/978-0-387-09530-1, © Springer Science + Business Media, LLC 2009

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JONATHAN WILKINS and JOHNNY L. MATSON

This topic is followed by autism and more recently the autism spectrum disorders (ASD), followed by child psychopathology such as depression, hyperactivity, and anxiety. The area that has the briefest history is behavioral medicine with children. There are of course various reasons for the time when various areas of study began to emerge with children. The purpose of this chapter is to provide an overview of these areas and major developments that have led to the establishment of each topic as an evidence-based area of research and practice.

INTELLECTUAL DISABILITY Intelligence testing is one of the first and best established areas of study with children. These developments initially grew from pragmatic considerations about how to differentiate slow learners and high achievers in the school system. Alfred Binet of the Sorbonne pioneered a series of tests to identify “at risk” school children. With his assistant Theodore Simon, they published their new IQ test in 1905, the Binet–Simon scale. In 1908, they revised the scale, dropping, modifying, and adding tests by age level for ages 3–13. The test was later renormed in the United States at Stanford University and became the Stanford-Binet Intelligence Test which is in wide use today. Herbert H. Goddard translated Binet’s writings from French to English. He was an early proponent of IQ testing and served as Director of Research at the Vineland Training School for Feeble-Minded Girls and Boys. Goddard also developed the notion of subcategories of ID and used the terms moron and imbecile for those with lower IQ, and idiot for those with the lowest scores (Goddard, 1920). Although the terminology has changed from these labels to mild, moderate, severe, and profound, the recognition that marked performance differences exist in ID and that subcategories are advisable has persisted. Lewis H. Terman, a professor at Stanford University, went beyond Goddard in that he actually revised the test itself. Most important in his changes were more standardized responses. He also revised the test so that it could be used to identify gifted children as well as those with ID. Published in 1916, the Stanford Revision of the Binet-Simon Scale of Intelligence became the standard in the United States for assessing IQ. One of the unforeseen developments from the widespread acceptance of IQ testing was the creation of a multimillion dollar testing industry with hundreds of millions of standardized tests being given to children yearly. A second development was the recognition that objective standardized measures could be developed using the IQ test model for a range of developmental disabilities and forms of child psychopathology. There was a rather long germination period relative to this later trend with most of the innovations coming in the latter half of the 20th century. A third related development involved treatment. Once disorders and disabilities had been defined and identified, there was an obvious need for training and treatment strategies.

HISTORY OF TREATMENT IN CHILDREN

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CHILD PSYCHOPATHOLOGY The establishment of the first juvenile court in the United States in 1899 is often considered the beginning of the child mental health movement (Schowalter, 2000). The thrust was the treatment of juvenile delinquency and was spearheaded by women civic leaders who established the Juvenile Psychopathic Institute. A neurologist named William Healy headed the institute. One of his primary accomplishments was the development of a triad of professionals including a psychiatrist, psychologist, and social worker. The psychiatrist typically provided treatment, the psychologist did testing, and the social worker coordinated services and assisted parents. As reported in many books and articles, this approach became the service model for treating children. Typically these services were provided via community mental health clinics. Great momentum occurred in 1963 when President John F. Kennedy signed the Community Mental Health Centers Act mandating the construction of community outpatient facilities. The dominant treatment paradigm during this time was psychodynamic. In many ways this approach retarded the growth of treatments for child psychopathology and developmental disabilities. For example, children and people with ID were described as lacking sufficient “ego strength” to develop many forms of psychopathology. As recently as 1978, researchers were debating if children could evince depression (Lefkowitz & Burton, 1978). Similarly, major diagnostic systems such as DSM have only recently begun to present and refine various forms of psychopathology in children (Matson, 1989).

MODERN TREATMENT METHODS The primary means of intervention for children have involved learningbased models. More recently medications for some problems have also begun to be used, typically in combination with learning-based treatments. For example, Tofranil was approved to treat depression in 1951, and Thorazine was used to treat psychotic behaviors in Paris in 1952 and was approved for use in America in 1954. Although psychodynamic formulations have not been supported by the research, evidence-based practice does go back to the very founding of the area. Witmer (1907) described his work as clinical psychology, a term he says he “borrowed” from medicine. He suggested the term “clinical” implied a method and noted that the clinical psychologist was primarily interested in the individual child. He stressed the relationship between science and practice as well as the notion that the clinical psychologist was a contributor to science who must discover the relationship between cause and effect in his applications of treatment. There have been a number of general movements from a historical point of view. These include classical conditioning, operant conditioning/

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applied behavior analysis, behavior therapy/cognitive behavior therapy, medication, and combined therapies. The evaluation of each of these methods follows.

Classical Conditioning John Broadus Watson is credited with applying the principles of classical conditioning (first demonstrated by Pavlov) to human beings. His research and charismatic personality led to the establishment of behaviorism (Maultsby & Wirga, 1998). Watson championed Pavlovian conditioning as the basis for behavioral psychology, and he maintained an inflexible adherence to its tenets in his work. Behaviorism was a response to structuralism, a movement spearheaded by E. B. Titchenor in America and based on the ideas of Wilhelm Wundt, which focused on the passive introspection of one’s mind. Watson completely rejected the notion of consciousness and introspection, and publicly attacked them in 1913 at Columbia University with his famous lecture, which was published under the title, “Psychology as the Behaviorist Views It” and later became known as the “behaviorist manifesto”. However, behaviorism as a movement did not become popular in the United States until the 1920s. It was during this time, and as a result of the involvement of American psychologists in World War I and the publishing of Watson’s Psychology from the Standpoint of a Behaviorist in 1919, that behaviorism began to spread throughout American psychology. Watson’s text was the first to analyze human psychological functioning in terms of behavior (Wozniak, 1997). In the book, he conceptualized psychopathology as a failure to adjust to change; it develops when a person holds onto old habits and associated emotions that no longer work in the context of new situations. Watson also pointed out that proof for his ideas was evident in the possibility of retraining as a cure. Watson first applied classical conditioning to a human subject in 1920 with the case study of Little Albert. In this classic study, Watson and one of his students, Rosalie Rayner, conditioned the 11-month-old child to have an irrational fear of a white rat by pairing the presentation of the animal with an unexpected loud noise. Watson and Rayner (1920) also demonstrated the generalization of the conditioned fear response as Albert had spontaneously become afraid of other furry objects. Although they made some suggestions as to how the fear might be unlearned, no attempt was made to then reduce Albert’s fear of the furry objects. It wasn’t until Mary Cover Jones, another one of Watson’s students, that the elimination of irrational fears by induced extinction was demonstrated. In her research, children who were already overly fearful were treated with a combination of social imitation and counterconditioning. The feared objects were gradually presented while the children enjoyed a preferred food. Her research was notably documented in with the case of Peter (Jones, 1924). In this study, Jones eliminated the boy’s fear of a white rabbit using counterconditioning (i.e., preferred food was presented


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simultaneously with the rabbit). During treatment, the rabbit was gradually brought closer to Peter and he became more tolerant of its presence, eventually touching the animal without fear. As a result of her work with conditioning and fears, Jones is often cited as pioneering behavior therapy (Goodwin, 2005). However, Watson’s ideas and the doctrine of behaviorism did not make a large impact in the realm of psychotherapy until after World War II (Pichot, 1989). This was largely due to the dominant forms of therapy at the time, hypnosis and suggestion initially and later psychoanalysis; in addition, the practitioners and proponents of behaviorism were experimental psychologists and outside the field of medicine, which handled the treatment of neuroses at the time. The basic principles of classical conditioning have had a far-reaching influence on treatment strategies for children. Most of the treatments described below are based on these principles or contain elements of classical conditioning. Classical conditioning has also been used to treat fear and phobias of children with developmental disabilities and other learning disorders but these studies have been sporadic (Labrador, 2004). Usually elements of classical conditioning are paired with other closely related techniques such as exposure. A further discussion of these studies is presented in the section on behavior therapy.

Operant Conditioning/Applied Behavior Analysis B. F. Skinner’s research and theories have had a profound effect on the development of behavioral and learning-based therapies. His concept of reinforcement schedules and how controlling the delivery of reinforcement can influence the speed of learning new habits and their resistance to extinction was especially important to the development of behavior therapy (Maultsby & Wirga, 1998). Behavior modification represented an alternative to psychotherapy, which was lengthy, costly, and ultimately ineffective, and it was in Science and Human Behavior that Skinner (1953) outlined his alternative to current theories of psychopathology and psychotherapy (Labrador, 2004). The goal of therapy in Skinner’s mind was not to eliminate the impulse that caused the occurrence of a problem behavior but to introduce a replacement behavior that could overcome the circumstances that had produced the problematic behavior. The way to correct these circumstances, then, is to first systematically analyze them (i.e., perform a functional analysis). Skinner’s goal was to use the experimental analysis of behavior to modify and reduce abnormal behavior. He believed that abnormal behavior, as any behavior, has been learned in an attempt to adapt to some environment. However, when a learned behavior is disapproved by society, it becomes abnormal or maladaptive, and the goal of treatment, then, is to modify the behavior by replacing it with a more appropriate one. The effectiveness of treatments for maladaptive behaviors is evaluated by comparing end results to baseline data. These ideas formed the basis for applied behavior analysis (ABA) and behavior therapy.

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Skinner’s research and ideas have even become an international movement, spreading to places such as Latin America in the 1960s (McCrea, 1976). Fuller (1949) was the first to demonstrate that operant principles could be applied in a clinical setting. The sole participant in this study was an 18-year-old male described as a “vegetative idiot”. Using sweetened milk as a reinforcer, a significant increase of the target behavior (raising his right arm to a vertical position) was demonstrated in four sessions. Fuller was also able to show that the behavior could be extinguished by removing the reinforcing stimulus. A few years later in 1953, Skinner and Lindsley began applying the principles of operant conditioning to psychiatric inpatients at a state hospital. They created what was essentially a Skinner box for humans, a room that allowed tangible reinforcers to be dispensed depending on the behavior performed by the inhabitant of the room (Skinner, 1954). The psychiatric patients, who were described as “catatonics, mental defectives with delusions, paranoids, and in one case, a manic,” were left alone in the room for one hour each day. The experimenters studied the effects of different reinforcement schedules and noted that response patterns were similar to those of animals that had been studied previously in a similar setting. Skinner believed that applying operant techniques in such a way would have great motivational value and ultimately lead to positive behavior change. From this early research with adults, Bjou and colleagues (Bjou, 1959, 1963; Bjou, Birnbrauer, Kidder, & Tague, 1966) and Barrett and Lindsley (1962) applied operant conditioning to children with ID. Ferster and DeMyer (1961) did the same with autistic children by employing a similar apparatus to the one used by Skinner that dispensed tangible objects when a key was pressed. Children with developmental disabilities (especially severe ID and autism) represent one population that has benefited greatly from the development of operant-based treatment techniques. The efficacy of behavioral treatments has been well documented in the literature with this group, especially with regard to reducing the frequency and severity of symptoms and challenging behaviors and facilitating the acquisition of adaptive skills (Rogers, 1998). Such children are likely to evince challenging behaviors, such as aggression or self-injury, that are severe in intensity and pose a threat to self and others, and it is currently recognized that the most effective method for treating these high-intensity behaviors is based on the principles of operant conditioning: either via reinforcement, punishment, or a combination of the two (Pelios, Morren, Tesch, & Axelrod, 1999). Challenging behavior is a term that is used interchangeably with maladaptive or problem behavior and was introduced to American psychology in the 1980s to describe problematic behaviors commonly evinced by individuals with ID (Xeniditis, Russell, & Murphy, 2001). Over the years these behaviors have been treated with aversive stimuli such as electric shock (Lovaas & Simmons, 1969), water misting, exposure to aromatic ammonia, or physical restraint. One problem, however, is that the treatment must be able to be applied consistently across settings.


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Although these procedures were usually highly successful at eliminating the behaviors, there are obvious ethical implications. However, in some cases the behavior is so severe that there is no other alternative. This is usually the case when no consistent maintaining functions for the behavior can be identified. Azrin and Holz (1966) noted that the reason that punishment-based procedures are so effective at eliminating self-injury, for example, is that the aversive nature of the treatment is able to overcome whatever source of reinforcement is sustaining the behavior. Less aversive punishment techniques are still frequently employed (e.g., extinction, time-out, response cost). Because behaviors such as self-injury or aggression can have different functions across individuals and settings and may even vary across situations for the same individual, selecting a potentially effective treatment can only be accomplished once the maintaining events or factors for that behavior are understood (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982). Therefore, an important development in the use of operant techniques in modifying maladaptive behavior in children with ID was the increasingly pronounced role of functional assessment. Functional assessment or analysis involves a thorough assessment of the events preceding (antecedents) and following (consequences) the behavior. Understanding the antecedents and consequences of a behavior provides essential information about the reasons why a problem behavior is occurring or why a desired behavior is not occurring. Therefore, treatments that are constructed on the basis of a careful consideration of a target behavior’s maintaining factors are more likely to be effective in reducing or eliminating the behavior and can be just as effective as punishment (Iwata et al., 1994). A comprehensive approach for conducting a functional analysis was first delineated by Iwata and colleagues in 1982. In this study, the authors described four experimental conditions related to different maintaining factors: social disapproval, academic demand, unstructured play, and alone. For example, the self-injurious behavior (SIB) of many children is maintained by social reinforcement; children exhibiting this behavior have not learned a socially appropriate way of gaining attention from adults and have discovered that the behavior gets them the attention they desire (e.g., parent telling them to stop). In this case, after the function of the behavior has been identified (i.e., attention), the intervention or treatment will focus on replacing the maladaptive behavior with another, more appropriate behavior that serves the same function (e.g., saying “Come play with me.”; Iwata et al., 1994). This procedure is known as functional communication training (FCT). The desired response is then reinforced by providing social attention whenever the child asks appropriately and ignoring instances where the child is engaging in the problem behavior. In general, this procedure is referred to as differential reinforcement of alternate behavior (DRA). Alternately, the child could be provided with social attention anytime he or she is not engaging in the behavior, which is known as differential reinforcement of other behavior (DRO). More specifically, functional communication training teaches the child to emit some type of communicative behavior that results in the same

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outcome as the challenging behavior and ultimately reduces the frequency of that behavior. This procedure is especially appropriate for children with severe ID and/or ASD, who are often limited in their abilities to communicate. This procedure was first described by Carr and Durand (1985), and in that paper, the authors stated that the goal of FCT is replacing challenging behaviors with socially appropriate behaviors, one of which is functional communication. In order for the communicative replacement behavior to effectively reduce or replace the maladaptive behavior, it needs to be functionally related to the controlling stimuli (Carr & Durand, 1985). This is because the socially inappropriate behavior was previously serving as a form of nonverbal communication for the child. Common replacement behaviors include asking for help or for a break for escape-motivated behaviors or an appropriate way to request attention for socially motivated behaviors. Appropriate responses can be spoken, or in the case of nonverbal individuals, involve gestures as in pointing to a picture board. When FCT does not produce a significant reduction in the problem behavior, adding a punishment component can increase its effectiveness (Fisher et al., 1993). An early emphasis on functional assessment was evident in the work of Wolpe (1969). However, the technique fell to subsequent neglect in the 1980s as punishment-based procedures began to gain popularity. During this time it was believed that punishment alone was sufficient to control behavior, and the number of these studies increased greatly throughout the 1970s and mid-80s (Matson & Taras, 1989). It was believed that punishment could not only reduce challenging behavior but oftentimes eliminate the behavior completely (Iwata et al., 1982). However, after reviews by Carr (1977) and Johnson and Baumeister (1978), functional analysis began to regain favor with clinicians. In these reviews, it was suggested that some of the failings in the treatment of SIB reported in the literature were likely due to a lack of information regarding setting and maintaining factors. It was recognized that failing to conduct an adequate functional assessment prior to treatment would mean that the treatment chosen would be implemented without an understanding of the underlying causes of the behavior and would therefore be less effective. And, when a clinician conducts a functional assessment before selecting a treatment, he or she is more likely to choose a reinforcementbased procedure, which is a trend that has become increasingly evident since the late 1980s/early 1990s (Pelios et al., 1999). Such reinforcementbased treatment programs would be tailored toward targeting the motivating factors behind the behavior and should be able to effectively reduce the problem behavior without the use of punishment. However, behaviors that have nonsocial functions can be very difficult to treat with reinforcementbased procedures alone (Iwata et al., 1994). Treatment based on functional analysis, therefore is most effective when the behavior is maintained by positive (e.g., attention or tangible function) or negative reinforcement (e.g., escape function; Fisher et al., 1993). ABA has been the treatment of choice not only for severe problem behaviors such as aggression and SIB but also in treating sleep problems (Didden, Curfs, Sikkema, & de Moor, 1998), and star charts and rewards have been found to be effective in the treatment of enuresis (Järvelin,


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2000). Sleep problems in particular are prevalent and usually persist into later childhood for developmentally disabled children; additionally such difficulties can contribute to the manifestation of other challenging behaviors during the day (Didden et al., 1998). In many cases, sleep problems have been determined by functional assessment to be maintained and shaped by parental attention and have thus been successfully treated with extinction (Didden et al., 1998).

Behavior Therapy From these operant-based techniques, behavior therapy diversified and progressed in a rapid manner. In 1952 with his article, “The Effects of Psychotherapy: An Evaluation,” Hans Eyesnick convincingly brought the ineffectiveness of psychoanalysis to light. It was at this time that psychoanalysis began to lose its grip as a dominate therapy in the United States and new treatments based on the principles of classical and operant conditioning began to gain popularity. One of the most influential of the new therapies that emerged was created by Joseph Wolpe and called systematic desensitization or reciprocal inhibition.

Systematic Desensitization In the early 1950s, Wolpe was dissatisfied with the poor outcome he was getting treating patients with psychoanalysis. He combined his medical training with learning theory to create a medically credible, non-Freudian hypothesis with regard to the origin of neurotic fears and how to effectively treat those fears in a behaviorally informed manner (Maultsby & Wirga, 1998). The result was a combination of deep muscle relaxation and emotive imagery that Wolpe termed systematic desensitization. He described his theories in a landmark text published in 1958 entitled Psychotherapy by Reciprocal Inhibition. Wolpe (1958) conceptualized fears or phobias as responses that have been learned through classical conditioning and can therefore be eliminated by applying specific counterconditioning. In a typical session, which usually lasts one hour, the client first selfinduces a state of deep muscle relaxation. This is followed by the therapist verbally leading him or her through a predetermined list of feared objects or events that the client imagines starting with the least fear-inducing and gradually moving up to the most feared object or situation. If the client becomes noticeably anxious, he or she is told to stop imagining the object or situation and return to establishing the state of relaxation. Exposure to the actual feared objects is often incorporated as well. The rapid effectiveness of systematic desensitization and the large number of successful cases surprised the field. Some of the earliest studies were conducted by Lang and colleagues and involved using the technique to reduce fear of snakes in college students (Lang & Lazovik, 1963; Lang, Lazovik, & Reynolds, 1965; Lazovik & Lang, 1960). Although the effectiveness of systematic desensitization for treating phobias and anxiety was well documented throughout the 1960s, interest

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began to wane as the number of published studies dropped dramatically starting in the early 1970s (McGlynn, Smitherman, & Gothard, 2004). This decline was evident both in research and clinical practice. The reason for the decline has been attributed to the emergence of other therapies that competed directly (e.g., flooding, participant modeling) and indirectly (cognitive behavior therapy; McGlynn et al., 2004). There are two main variants of systematic desensitization that have been used to treat fears and anxiety in children: in vivo desensitization (i.e., exposure), which has confrontation with the actual feared stimuli as the principal feature, and in vitro, also known as standard or vicarious, desensitization, which uses symbolic representations (e.g., imagination or modeling) in place of the actual feared stimuli (Ultee, Griffioen, & Schellekens, 1982). Early applications of these techniques with children yielded positive results in reducing fear of animals with the former technique (Kuroda, 1969; Murphy & Bootzin, 1973; Ritter, 1968) but mixed results with the latter (Lazarus & Abramowitz, 1962; Miller, Barrett, Hampe, & Noble, 1972). Ultee et al. (1982) compared the two procedures directly in a sample of children with water phobia; in vivo was found to be more effective than in vitro desensitization, and the response to the latter treatment was not significantly different from a wait-list control condition. It was also determined that the combination of the two was no more effective than in vivo desensitization alone. Similar results were found in a later study by Menzies and Clarke (1993), who not only demonstrated that in vivo exposure was significantly more effective in reducing fear of water in children, but that those treatment gains generalized to other situations involving water and were maintained after three months. Based on the results of these studies and others, real-life exposure to the feared object appears to be the most important component of systematic desensitization (Ollendick & King, 1998). Anxiety and phobia frequently co-occur with ASD and are present in higher rates than in normally developing children (Love, Matson, & West, 1990; Luscre & Center, 1996; Reaven & Hepburn, 2006; Woodard, Groden, Goodwin, Shanower & Bianco, 2005), and children with ID have more fears than children of normal intelligence with and without learning disability (Deverensky, 1979). In addition, individuals with Williams syndrome evince higher levels of anxiety and phobias than normally developing children as well as children with ID (Dykens, 2003). Common phobias reported in the literature for children and adolescents with developmental disabilities include animals (particularly dogs; Obler & Terwilliger, 1970), the toilet (Jackson & King, 1982; Luiselli, 1977), medical and dental procedures (Freeman, Roy, & Hemmick, 1976; Kohlenberg, Greenberg, Reymore, & Hass, 1972; Luscre & Center, 1996), riding the bus (Luiselli, 1978; Obler & Terwilliger, 1970), strangers (Matson, 1981), loud noises (e.g., thunder; Guarnaccia & Weiss, 1974), and water (Guarnaccia & Weiss, 1974). Systematic desensitization can be difficult to apply with children because relaxation training can be fairly demanding and tedious for the average child, as can the controlled recall of feared images (King, Cranstoun, & Josephs, 1989). Given the difficulty of applying the procedure to normally


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developing children, this renders the application of traditional systematic desensitization even more problematic for developmentally disabled children. As a result, treatment of phobias and anxiety in children with ASD and ID has focused on related techniques such as emotive imagery, graduated exposure, counterconditioning, and modeling, and usually includes operant components such as providing tangible rewards for tolerating the feared object. Counterconditioning in such treatment with developmentally disabled children usually includes the presence of a comforting person (e.g., child’s mother) whose involvement is gradually faded as the child becomes more comfortable around the fear-inducing stimulus (Sovner & Hurley, 1982) Emotive imagery involves the therapist evoking positive emotions in the child, usually by including characters from television or fiction that the child enjoys, and then gradually introducing the feared stimuli in the context of a fun or exciting narrative involving the child and the characters (Lazarus & Abramovitz, 1962). These authors used the technique to successfully treat fear of dogs, darkness, and school. More recently, Cornwall, Spence, and Schotte (1997) demonstrated that the procedure was superior on a variety of outcome measures in treating fear of darkness in 24 children when compared to wait-list control. The active mechanism of the procedure is believed to be reciprocal inhibition, in that instead of the child inducing a state of ease or relaxation himself or herself, this positive state is induced by engaging in an activity the child enjoys (e.g., pretending to be a superhero; King et al., 1989). In a study by Freeman et al. (1976), a hierarchal series of real-life exposures was created to treat an intellectually disabled boy’s fear of physical examinations with a preferred nurse from the ward being used as the counterconditioning agent. In another similar study, an autistic child’s fear of the sound of toilet flushing was successfully treated using laughter to reduce anxiety (Jackson & King, 1982). Laughter was induced by tickling and this was gradually introduced while the child used and then flushed the toilet. However, these were uncontrolled case studies so the results should be interpreted with some degree of caution. On this note, Obler and Terwilliger (1970) employed a modified version of systematic desensitization with 15 “neurologically impaired” children who presented with excessive fear of dogs or riding the bus. Significant reduction in phobic symptoms was reported for the treatment group but not for a group of matched controls. The treatment procedure in this study involved first presenting a picture of the feared stimulus and then once this was tolerated, presenting the actual object and rewarding the child for moving closer and closer to it. Rewards were chosen by the participants prior to treatment and included toys, books, and candy. Modeling involves a peer or adult demonstrating nonfearful behavior in the fear-producing situation and can be either live or filmed. Bandura and colleagues conducted some of the earliest research with this technique and demonstrated that modeling, both live and filmed, was able to effectively reduce fear of dogs (Bandura, Grusec, & Menlove, 1967; Bandura & Menlove, 1968). In addition, Lewis (1974) found a combination of modeling

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(video of peers) and participation to be more effective than either modeling or participation alone in reducing water phobia. However, each condition alone also significantly reduced avoidance behavior when compared to a control condition. Modeling has also been used to treat phobias in developmentally disabled children. This usually consists of the therapist demonstrating an appropriate nonfearful response to the presence of the fear-inducing object or situation (King, Ollendick, Gullone, Cummins, & Josephs, 1990). For example, Matson (1981) used modeling in a multiple baseline study across subjects to treat three children with moderate ID who refused to interact with or be around people other than a few close family members. Modeling was performed by a parent in the clinic and then generalized to home with treatment gains being maintained after six months. In contrast to emotive imagery and modeling, operant-based treatment of anxiety and phobias does not assume that the anxiety must first be reduced or eliminated before exposure to the feared object or situation will be tolerated (King et al., 1990). Such techniques are typically used in combination with the procedures described above. Luiselli (1977, 1978) demonstrated successful implementation of operant-based treatments with an intellectually disabled adolescent who was afraid of the toilet and an autistic child who was afraid of riding the bus. In the latter study, the autistic boy’s mother initially sat on the bus with him and provided tangible reinforcement. Eventually, she moved farther away from him until he was able to ride the bus to school by himself, which was achieved in seven days. In addition, Kohlenberg et al. (1972) successfully treated fear of dental procedures in a sample of children and adolescents with ID ages 8–20 using shaping with social and tangible reinforcement. The outcome measure for this study was the number of physical restraints required for the procedure, of which, after treatment, the experimental group received significantly less than a control group.

Cognitive Behavior Therapy Around the same time as Wolpe’s formulations regarding his ideas for systematic desensitization and for principally the same reason (i.e., a lack of success treating patients with psychoanalysis), Albert Ellis developed his brand of highly effective, therapist-led psychotherapy that he termed rational emotive therapy (Maultsby & Wirga, 1998). This treatment model later became known as rational emotive behavior therapy or cognitive behavior therapy (CBT). From this viewpoint, maladaptive behavior is the result of maladaptive cognitions, and therefore cognitive changes can produce a change in behavior. The therapy focuses on the ABC model of human emotions: Activating event, Beliefs about the event, and Consequence of or emotional response to the event. Its goal is to get people to recognize and then eliminate their irrational beliefs. CBT encourages therapists to be active, objective, and firmly directive while combining talk therapy with elements of classical conditioning. Variants of Ellis’s original therapy have been applied to children with fear and anxiety. In an early study of this type, Kanfer, Karoly, and Newman (1975) found that having children repeat verbal self-instructions related to


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competence in dealing with their fear of the dark (e.g., “I am a brave boy/ girl. I can take care of myself in the dark.”) while in a dark room was more effective than stimulus control (e.g., repeating “The dark is a fun place to be.”) and control (repeating nursery rhymes) conditions. Kane and Kendall (1989) treated four children diagnosed with Overanxious Disorder with a cognitive-behavioral based treatment. The cognitive component included teaching the children to recognize their anxious feelings and bodily reactions to those emotions, clarifying their cognitions in anxiety-provoking situations, developing strategies to cope with those situations, and evaluating the success of those strategies. The behavioral portion of the treatment included elements of modeling, in vivo exposure, relaxation training, role play, and contingent reinforcement. Homework was also included. The treatment was effective at reducing anxiety to within normal limits and was maintained at three- to six-month follow-up. Meichenbaum and Goodman (1971) were among the first to advocate the application of cognitive-behavioral techniques in the treatment of ADHD. Since that time, a great deal of research has been directed toward this topic (Pelham, Wheeler, & Chronis, 1998). CBT for ADHD typically consists of weekly sessions in which the therapist works with the child on developing cognitive techniques to help control inattention and impulsive behavior that the child will hopefully generalize to other situations (Pelham et al., 1998). However, the results of multiple controlled studies have not supported the effectiveness of this approach (Abikoff & Gittelman, 1985; Bloomquist, August, & Ostrander, 1991; Brown, Borden, Wynne, Spunt, & Clingerman, 1987). Cognitive-behavioral approaches have also been utilized for children and adolescents with depression and are commonly done in group settings (Kaslow & Thompson, 1998). Because of the initial debate on the existence of childhood depression and the fact that depression is an internalizing disorder and thus may go unnoticed, controlled studies evaluating the effectiveness of CBT and related therapies are scarce. For the most part, interventions for children have been modified from those available for adults and lack a developmental framework (Kaslow & Thompson, 1998). Stark and colleagues (Stark, Reynolds, & Kaslow, 1987; Stark, Rouse, & Livingston, 1991) conducted some of the first controlled studies of psychosocial treatment of childhood depression. In the first study, Stark et al. (1987) compared 12 sessions of group therapy with a wait-list control condition in a sample of fourth- through sixth-graders. Group therapy consisted of either a self-control intervention that taught self-management skills or a behavior-problem solving intervention that included education and group problem solving. Compared to the control condition, the children in the two experimental conditions reported fewer symptoms of depression with the majority no longer meeting criteria for depression at eight-week follow-up. However, caretaker ratings of depression, anxiety, and self-esteem did not significantly differ among the three conditions. Stark et al. (1991) then expanded this procedure to 24 to 26 sessions and included monthly family meetings that added a parent training component to help their children generalize the skills to the home. This method

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was found to be superior to a traditional counseling approach at reducing depressive symptomatology. The efficacy of manualized approaches to CBT with young persons suffering from depression has also been demonstrated (Lewinsohn, Clarke, Hops, & Andrews, 1990; Lewinsohn, Clarke, Rhode, Hops, & Seeley, 1996). Dykens (2003) suggests that specific cognitive-behavioral interventions for phobia and anxiety may be applicable for people with Williams syndrome given the circumscribed goals and relatively short duration of such treatments as well as the well-developed expressive language and interpersonal skills in many individuals with the condition. However, the application of cognitive-behavioral interventions for children with developmental disabilities awaits further investigation. Reaven and Hepburn (2006) suggest that cognitive-behavioral treatment strategies for children with high-functioning ASD and anxiety should include a high level of parental involvement.

Medication The prescription of psychotropic medication for adolescents increased by 2.5% from 1994-2001 (Thomas, Conrad, Casler, & Goodman, 2006). In 1997, the Food and Drug Administration passed the Modernization Act, which made it easier for off-label medications to be promoted to physicians (Buck, 2000). This, taken with the increased presence of managed care incentives limiting the number of therapy visits, has contributed significantly to increased reliance on psychotropic medication in treating childhood psychopathology (Thomas et al., 2006). However, there remains a paucity of empirical research concerning the utility of using psychotropic medication to treat developmentally disabled children with comorbid mental health conditions. This puts the clinician in the position of having to extrapolate from the existing data regarding adults with ID and children of normal development (Aman, Collier-Crespin, & Lindsay, 2000). As mentioned above, because response to psychotropic medication may depend on the child’s developmental level, extrapolating from research on adults can be problematic (Aman, Collier-Crespin, et al., 2000). There is no medication for intellectual disability or ASD and medical professionals should proceed with caution before prescribing psychotropics for children with these conditions. When such a child is being prescribed medication for the suppression of challenging behaviors and not for an underlying comorbid condition, the treatment may serve primarily as chemical restraint. A summary of research on the major classes of psychotropic medication used in the treatment of childhood psychopathology follows.

Psychostimulants For some mental health conditions, pharmacological interventions have been the most widely used and recommended. Since the 1970s this has been the case with stimulant medication and ADHD (Pelham et al.,


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2000). However, stimulant medication does not work for everyone with ADHD (70–80% of cases respond) and the long-term efficacy is questionable (Pelham et al., 2000). From 1980 to 2000, there were at least ten group studies examining the effects of stimulant medication (methylphenidate and dextroamphetamine) in intellectually disabled children and adults with ADHD (Aman, Collier-Crespin, et al., 2000). The cumulative results of this research indicate that psychostimulant medication is effective in treating symptoms of ADHD in individuals with ID. With the exception of one instance, all of the studies yielded statistically significant, positive results with improvements noted in the areas of managing motor overflow, attention span, and impulsiveness along with cognitive performance, social behavior, and independent play (Aman, Collier-Crespin, et al., 2000). However, the overall response rate in children and adolescents with ID at 54% is less than that for those of typical development (Aman, 1996). Later research with methylphenidate in intellectually disabled children has yielded similar results (Pearson, Lane, et al., 2004; Pearson, Santos, et al., 2004). Although current DSM-IV-TR diagnostic criteria preclude a comorbid diagnosis of ADHD in children with ASD, core symptoms of ADHD such as impulsivity, hyperactivity, and inattention are common in children with ASD (American Psychological Association [APA], 2000; Lecavalier, 2006). The effects of stimulant medication on symptoms of ADHD in ASD children are mixed. For example, Stigler, Desmond, Posey, Wiegand, and McDougle (2004) found a low rate of treatment success with a high rate of side-effects in a retrospective review of 195 ASD children. On the other hand, Posey et al. (2007) demonstrated that methylphenidate was superior to placebo in 66 children with ASD in alleviating primary symptoms of ADHD.

Antidepressants Since the early 1990s, antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs), have increasingly become the treatment of choice in treating childhood depression (Jureidini et al., 2004). Prescription of SSRIs increased dramatically from 1998–2002 among adolescents aged 15–18 (Delate, Gelenberg, Simmons, & Motheral, 2004). One major concern with this trend is the efficacy and safety of these drugs with children. Of particular concern is the risk of suicide among adolescents taking SSRIs (Jureidini et al., 2004; Whittington et al., 2004). Treatment with tricyclics in children has largely been abandoned due to the high frequency of adverse side-effects and a lack of efficacy (Whittington et al., 2004). In a review of six clinical trials comprising 477 children treated with paroxetine, fluoxetine, sertraline, or venlafaxine, and 464 children treated with placebo, Jureidini and colleagues (2004) found the children treated with antidepressant medication only significantly improved on 14 of 42 reported outcome measures. In addition, a larger number of children treated with antidepressant medication experienced adverse side-effects (paroxetine) and some had to withdraw from one of the studies as a result (sertraline). Whittington et al. (2004) also reviewed the risk–benefit profiles of these drugs by examining published and unpublished studies. Fluoxetine

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was cited as having a favorable risk–benefit profile in children with noted efficacy in reducing depressive symptoms with no increased risk of sideeffects. The risk–benefit profiles of sertraline and paroxetine were mixed, whereas both citalopam and venlafaxine were found to have unfavorable risk–benefit profiles. In addition, Emslie and colleagues (1997) conducted a double-blind, randomized, placebo-controlled study of fluoxetine in 96 children and adolescents and reported a 60% response rate. Pary (2004) notes that, as with children of normal development, the first-line treatment for major depression in Down syndrome is SSRI treatment (with the exception of paroxetine). In one study, however, paroxetine was found to be effective in reducing symptoms of depression in seven mildly intellectually disabled adolescents (Masi, Marchesci, & Pfanner, 1997). However, SSRIs (i.e., fluoxetine, paroxetine, and sertraline) may be less effective in children with ASD. In an open label study, Awad (1996) treated a small sample of children with ASD with these medications and found a reduction in symptoms of obsessional, repetitive, and anxiety symptoms in half the children but that treatment had to be discontinued for the other half because of side-effects and worsening of symptoms. SSRIs may also have some benefit in reducing self-injury in developmentally disabled children (Aman, Arnold, & Armstrong, 1999). However, at this point, this data are preliminary, based on case reports, and more research is needed. When medication fails to alleviate symptoms of depression, alternative treatments such as electroconvulsive therapy (ECT) may be effective. One case report documents successful remediation of depressive symptoms in a 15-year-old adolescent with Down syndrome and treatment-refractory major depressive disorder (Gensheimer, Meighen, & McDougle, 2002). For this individual, ECT was found to be safe and effective after four administrations.

Mood Stabilizers Adolescents diagnosed with bipolar disorder are treated with the same medications as adults with the condition; however, mixed or rapid cycling, which adolescents tend to experience more than adults, has been associated with a poor response to lithium (Cogan, 1996). Although the expression of bipolar disorder in preadolescent children is rare and even rarer in children with ID, a few case studies have found positive results for treatment with valproic acid (Kastner, Friedman, & Plummer, 1990; Whittier, West, Galli, & Raute, 1995) and lithium in young people with ID (Dostal & Zvolsky, 1970; Goetzl, Grunberg, & Berkowitz, 1977; Linter, 1987). However, lithium has also been associated with limited clinical efficacy and adverse side-effects in this population (Kastner et al., 1990). In addition, Komoto and Usui (1984) reported a case study in which a 13-year-old autistic female with moderate ID and depression was effectively treated with valproic acid.

Antipsychotics Because the symptoms of schizophrenia do not usually manifest themselves until late adolescence, there is very little research concerning


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treatment of young persons with antipsychotic medication specifically for schizophrenia. Based on a review of this small body of literature, Campbell and Gonzalez (1996) summarize research indicating that thiothixene was superior to thioridazine in adolescents with chronic schizophrenia, whereas haloperidol and clozapine may also be effective for young people with schizophrenia, However, much more research is warranted. An early study by Cunningham, Pillai, and Blanchford-Rogers (1968) found that haloperidol was effective in treating children with aggressive and destructive behaviors. Although, Conduct Disorder can be difficult to diagnose in children with ID because of determining the intent of the behavior, risperidone significantly reduced clinician and parent ratings on conduct problems in 118 intellectually disabled children with comorbid Conduct Disorder or Oppositional Defiant Disorder compared to placebo (Aman, Findling, Derivan, & Merriman, 2000). There has been a notable increase in recent years of using atypical antipsychotic medication to treat self-injurious behavior in developmentally disabled children with risperidone and olanzapine being the most common (Aman, Collier-Crespin, et al., 2000). However, these studies were not controlled and more research is needed.

Anxiolytics Little is known about the effects of treating childhood anxiety with benzodiazepines with only a few controlled studies available (Simeon, 1993). The paucity of such research is likely due to SSRIs being commonly prescribed to treat anxiety conditions among young persons (Reinblatt & Riddle, 2007). Among those with ID, this class of drugs has been commonly used to manage challenging behaviors and treat generalized anxiety disorders (Aman, Collier-Crespin, et al., 2000). A handful of studies has examined the effects of benzodiazepines in treating children with ID to mixed results (LaVeck & Buckley, 1961; Krakowski, 1963; Bond, Mandos, & Kurtz, 1989). The children in these studies were not only small in numbers but were being treated more for behavioral problems than any underlying anxiety disorder. As mentioned above, anxiety conditions seem to be more prevalent in children with ASD and have been successfully treated with behavioral approaches. One study did find that buspirone was effective at reducing symptoms of anxiety and irritability in children and adolescents with ASD (Buitelaar, van der Gaag, & van der Hoeven, 1998). Side-effects were reported to be minimal except for one child who developed abnormal involuntary movements. Werry (1999) suggests that the anxiety associated with ASD may respond better to antipsychotic drugs than to anxiolytics.

Other Drugs There is currently only one recommended medication for enuresis, which is desmopressin (Jarvelin, 2000). Desmopressin is typically administered as a nasal spray. In the past, imipramine has also been used, but research

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indicates that children with ID have responded unfavorably (Aman et al., 2000). Studies of imipramine with children of normal development have also been mixed with response rates of 10–60%; however relapse was high (90%; Schmitt, 1997).

Combined Therapies ADHD For ADHD, limitations of both pharmacological and behavioral interventions have led to the development of combination therapies consisting of behavior modification and stimulant medication (Pelham et al., 2000). Such treatment packages are most successful when the behavioral component includes outpatient parent training and school training or occurs in the context of a summer treatment program (Pelham et al., 2000). In the case of parent and school training, this helps to increase the generalizability of the treatment across settings and people.

ASD Comprehensive early intervention treatment packages with the aims of reducing level of impairment and improving outcome are available for children with ASD (Rogers, 1998). Better outcomes have been reported for children enrolling in such programs before the age of five years (Fenske, Zalenski, Krantz, & McClannahan, 1985). Other than behavioral interventions aimed at remediation of specific deficit areas, this is the only other empirically supported treatment available for children with ASD (Rogers, 1998). However, these comprehensive programs are expensive and timeconsuming, involving a team of professionals across different settings (home, classroom, and clinic), and in some cases, thousands of hours of treatment over many years. According to Kabot, Masi, and Segal (2003), for an early intervention program to be appropriate and effective it should: begin at the earliest possible age, be intensive, include parent training, focus on social and communication domains, contain individualized goals and objectives, and emphasize generalization. One example of this type of approach is the Treatment and Education of Autistic and related Communication handicapped CHildren (TEACCH) program established in 1966 at the University of North Carolina in Chapel Hill. At a time when the prevailing psychodynamic model of the time was spreading the notion that autism was the result of a lack of parental emotional support or “refrigerator mothers”, TEACCH recognized parental involvement as a critical factor and incorporated parent training into the program so that treatment strategies could be implemented in the home. The program was demonstrated to be effective early after its inception (Schopler, Brehm, Kinsbourne, & Reichler, 1971). Ozonoff and Cathcart (1998) demonstrated that a TEACCH-based home program resulted in three to four times greater improvement than a control group on tests of imitation, fine and gross motor, and nonverbal conceptual skills in autistic preschoolers.


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Another notable comprehensive treatment package for autism was developed by Lovaas and colleagues (1981). This manualized protocol utilizes reinforcement-based operant techniques along with some punishment-based procedures to increase a variety of social, language, cognitive, and self-care skills while reducing maladaptive behaviors in children with autism. The effectiveness of Lovaas’s program was documented in two published studies (Lovaas, 1987; McEachlin, Smith, & Lovaas, 1993). The research was conducted over a two-year span and involved a group receiving the treatment compared with two control groups: one group who received a few elements of the program delivered by the same staff in the treatment group in limited duration and intensity and a second group matched on chronological and mental age that was obtained through chart review. They found a large and statistically significant difference in IQ scores and educational placement, with the treatment group scoring 25–30 points higher in IQ and a larger percentage of placements in typical classrooms for this group (47% to 2% for the control groups). However, one critique of this research is that group assignment was nonrandom (Rogers, 1998). Regardless of this methodological flaw, the effectiveness of this treatment package has been replicated by two other sets of independent researchers, albeit at a lower rate of success (Birnbrauer & Leach, 1993; Sheinkopf & Siegel, 1998).

CONCLUSIONS Psychopathology is a common problem for children and adolescents, with one prevalence study finding a rate of 36.7% of 9- to 13-year-olds meeting criteria for at least one psychiatric disorder (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). Because the way child psychopathology is conceptualized and classified has changed from various editions of the DSM and is still changing (Ollendick & Vasey, 1999), it is important that future trends in treatment strive to empirically validate various treatments and not simply assume that therapies for adult disorders will apply to children. Treatments utilizing operant principles and elements of systematic desensitization for reducing phobias are among the best studied and have proven thus far to be the most effective. On the other hand, the efficacy and effectiveness of cognitive behavioral and pharmacological treatments warrants further study. However, the trend toward establishing empirically supported treatments for children is encouraging (Lonigan, Elbert, & Johnson, 1998). These issues become even more critical with developmentally and intellectually disabled populations. Taken with the finding that children with ID are at a greater risk for developing psychopathology than the general population (Menolascino & Swanson, 1982) and present with higher rates of depression (Matson, Barrett, & Helsel, 1988), it is of great importance that the treatments outlined in this chapter be validated and proven efficacious for this group. Further complicating the issue is that major mental health problems are often undiagnosed and untreated in individuals with developmental disabilities (Deb & Weston, 2000).

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Recognizing these disorders in such individuals is difficult because of cognitive and communication difficulties. In addition, the role of early intervention has been increasingly emphasized in treatment programs for ASD children, and this represents the best chance these children have at functioning independently as adults. Along the same lines, because these treatment packages are so intensive and costly, parents of children with ASD have become increasingly susceptible to buying into new treatments or “miracle cures” offering little to no empirical support (e.g., glutein-free diet, chelation therapy). These issues represent some of the major challenges currently facing the treatment of childhood psychopathology and developmental disabilities.

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2 Applied Behavior Analysis And The Treatment of Childhood Psychopathology And Developmental Disabilities JOEL E. RINGDAHL and TERRY S. FALCOMATA

INTRODUCTION This chapter provides a description and examples of the use of applied behavior analysis (ABA) in the treatment of childhood psychopathology and developmental disabilities. This task is a daunting one given that many of the single topics that are discussed in the following pages can, and have, served as topics for entire chapters and texts. This limitation means we are not able to delve into each topic in a comprehensive manner. However, we do provide an overview of the important topics related to ABA and its use in the treatment of childhood psychopathology and developmental disabilities. In addition, we provide a discussion of literature-based examples for these ABA-based treatments, brief examples of generalization of treatment effects, and discussion of effectiveness. It is important to note that ABA is not a single treatment. It is more accurate to say that ABA represents an approach to treatment as opposed to a specific type of treatment. This approach includes a number of treatment strategies that can be used to address the behavioral symptoms associated with childhood psychopathology and the behavioral challenges

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associated with developmental disabilities. As an approach to treatment, ABA relies on arranging response–consequence relationships (including positive and negative reinforcement and punishment), schedule of reinforcement effects, and antecedent manipulations (including stimulus-control procedures and altering establishing operations) to reduce problem behavior and increase appropriate behavior. In the paragraphs that follow, we provide an overview of ABA, including how it is defined, a description of ABA-based treatment strategies, including both consequence and antecedent-based interventions, and a brief summary of recent effectiveness research related to ABA-based treatments and behavior problems common to individuals with childhood psychopathology and/or developmental disabilities.

APPLIED BEHAVIOR ANALYSIS DEFINED Baer, Wolf, and Risley (1968) outlined seven dimensions of applied behavior analysis. It is upon these dimensions that the clinical applications are based. According to Baer et al., ABA is applied, behavioral, and analytic. In addition, ABA should be technological, conceptually systematic, effective, and generalizable. The term applied indicates that the target behavior is of social significance. It is the emphasis on social significance that sets ABA apart from laboratory analysis. Examples of applied are wideranging and can include any behavior that society deems important. The term behavioral indicates the focus of ABA should be on actions exhibited by the individual as opposed to what the individual says about those actions. Pragmatically, the implication is that what should be measured are observable actions exhibited by an individual. The term analytic indicates that a “believable demonstration of events … responsible for the occurrence or non-occurrence of that behavior” (p. 93–94). Thus, ABA approaches to treatment are often implemented and demonstrated within a single-subject research design (e.g., reversal, multielement, or multiple baseline designs). Along with establishing what constituted applied, behavior, and analytic, Baer et al. delineated four other dimensions for ABA. Applied behavior analysis should be technological, meaning that the “techniques making up a particular behavior application are completely identified” (p. 95). Thus, it is incumbent upon the behavior analyst implementing an ABA-based treatment to provide a complete description of its components. Baer et al. also asserted that ABA be conceptually relevant explanation. Additionally, Baer et al. stressed practical significance, as opposed to theoretical significance, as a hallmark of ABA. In essence, if a behavioral technique does not produce effects that are of practical value, that application has failed. Finally, behavior change produced by ABA should be durable over time (i.e., effects should be generalizable). Since the publication of Bear et al.’s dimensions of applied behavior analysis, other behavior analysts have described additional characteristics of ABA. Heward (2005) described ABA as accountable, public, doable, empowering, and optimistic. Cooper, Heron, and Heward (2007) described these characteristics in the following manner.

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Accountable: “The commitment of applied behavior analysis to effectiveness, their focus on accessible environmental variables that reliably influence behavior, and their reliance on direct and frequent measurement to detect changes in behavior yield an inescapable and socially valuable form or accountability” (p. 18). Public: “… ABA is visible and public, explicit and straightforward” (p.18) Applied behavior analysis is transparent and there are no hidden or unexplained treatments. Doable: the interventions found to be effective in ABA studies are able to be implemented by “teachers, caregivers, coaches, supervisors, and sometimes even the individuals themselves” (p.19). Cooper et al. suggest that the procedures are not “prohibitively complicated or arduous” (p. 19). Empowering: “ABA gives practitioners real tools that work” (p. 19) thus improving their confidence. Optimistic: the result of practitioners having effective strategies and the ability to detect improvements, along with literature-based examples of success gives cause for optimism regarding the future success of behavior change programs. Collectively, Cooper et al. (2007) summarized these dimensions and characteristics of applied behavior analysis as “… the science in which tactics derived from the principles of behavior are applied systematically to improve socially significant behavior and experimentation is used to identify the variables responsible for behavior change” (p. 20). This reliance on systematic evaluation of the variables responsible for behavior change results in an approach to the assessment and treatment of behavior problems that is functional, as opposed to structural. Thus, the selected treatment, or treatment package, is based on the relationship demonstrated between the presenting behavior of interest (i.e., out of seat behavior) and the environment. This approach can be contrasted to an approach that prescribes or selects treatment based on the diagnosis (e.g., ADHD) that is of concern. Using this functional approach, it is conceivable that the same treatment(s) could be used to address different presenting concerns and different treatment(s) might be used to address similar presenting concerns.

DESCRIPTION OF ABA TREATMENT APPROACHES In this section, an overview of many of the frequently used ABA-based treatments is provided. The section has been subdivided into consequence-based treatments (reinforcement and punishment based), antecedent-based treatments (noncontingent reinforcement and prompting strategies), and treatments in combination (i.e., including two or more consequence or antecedent components or at least one antecedent and one consequence-based component). Also included in this section are examples in application of each of the treatment strategies described. At least two examples from the literature are

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provided for each treatment. When possible, an example is provided for both childhood psychopathology (or disorders not associated with developmental disabilities) and developmental disabilities. Given that the ABA approach has been most widely used to treat the psychopathologies of children in two broad categories (early childhood disorders such as conduct disorder, disruptive behavior disorder, and attention-deficit/hyperactivity disorder and anxiety and phobias), childhood psychopathology examples will likely fit into one of these two categories. The developmental disabilities examples focus on the treatment of behavioral challenges presented by individuals with developmental disabilities and autism. These challenges include, but are not limited to (1) problems of behavioral excess such as stereotypic movement disorder, self-injurious behavior, aggression, destruction, tantrums, and so on, and (2) problems of behavioral deficit such as delays in language development, difficulty with skill acquisition, and problems with academic performance.

Consequence-Based Procedures: Punishment Punishment is a response-dependent (i.e., contingent) operation resulting in the decreased likelihood of a particular response. Two types of punishment have been described in the behavior analysis literature: positive and negative. Positive punishment involves the response-dependent delivery of a stimulus that results in a subsequent decrease in responding. Alternatively, negative punishment involves the response-dependent removal of a stimulus that results in a subsequent decrease in responding. The effect on behavior is the same; the difference stems from the action given to the stimulus (i.e., presented or removed).

Positive Punishment As indicated, positive punishment involves the contingent presentation of an aversive stimulus following the target response. In application, this approach to treatment has included any number of aversive stimuli including, but not limited to, aversive outcomes such as electric shock (Linscheid, Iwata, Ricketts, Williams, & Griffin, 1990), water mist (Singh, Watson, & Winton, 1986), facial screen (Rush, Crockett, & Hagopian, 2001), aversive activities such as exercise (Kahng, Abt, Wilder, 2001), and overcorrection (Foxx & Azrin, 1973). Linscheid et al. (1990) described the treatment of self-injurious behavior (SIB) exhibited by five individuals, including three individuals under the age of 18, with developmental disabilities. It is important to note that each of the five cases had a long-standing history of SIB that had proven unmanageable and was severe in nature (i.e., caused significant tissue damage or put the individual at risk of tissue damage or death). As well, the authors address issues related to generalization, maintenance, and potential for abuse for this particular treatment. Treatment included the contingent application of electric shock following occurrences of severe SIB. Immediate and pronounced effects were observed for each of the five participants. Anecdotal follow-up data suggested that no habituation had occurred for four of the five participants months after treatment was initiated.


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Kahng et al. (2001) described the implementation of a positive punishment procedure to reduce the SIB exhibited by a 16-year-old girl. One topography of SIB was reduced by the implementation of a noncontingent reinforcement procedure. However, other topographies of SIB continued to be exhibited when this treatment procedure was in place. As a second treatment component, an aversive activity (i.e., exercise; touching toes) was made contingent on each occurrence of all topographies of SIB. This procedure was added to the ongoing noncontingent reinforcement program as well as a restraint fading program. Immediate reductions in SIB were observed when this punisher was in place.

Negative Punishment Negative punishment involves the contingent removal of a reinforcer following occurrences of the target response. Applied examples of the procedure include response cost and timeout from reinforcement. Response cost is the loss of a specific amount of a reinforcer following each occurrence of the target response, resulting in a decreased probability of the response (Cooper et al., 2007). Conyers et al. (2004) used a response cost procedure to reduce the disruptive behavior exhibited by 25 children in a classroom setting. Specifically, the authors compared a reinforcement-based procedure (differential reinforcement of other behavior; DRO) with response cost. During RC, each child’s name was displayed on a board and 15 stars (tokens) were placed next to each name. Disruptive behavior resulted in the loss of a token. The remaining tokens could be traded for preferred items at the conclusion of each session. Results of the study suggested that, although both RC and DRO behavior were effective in reducing disruptive behavior, the classroomwide RC procedure was more effective. Long, Miltenberger, and Rapp (1999) incorporated response cost into a treatment package to reduce the thumb sucking and hair pulling exhibited by a typically developing six-year-old girl. Reinforcement-based procedures were ineffective in reducing the behavior to sufficiently low levels. Thus, a response cost contingency was added to the reinforcement package. Specifically, the participant was able to earn an M&M at specific time intervals for engaging in behavior other than thumb sucking or hair pulling. When the RC component was added, the participant was told she would lose one M&M for engaging in either thumb sucking or hair pulling. Immediate reductions of both these target responses were observed. According to the authors, the participant only lost access to one M&M during the first session of treatment with the RC contingency in place. Treatment gains were maintained for 23 weeks. Corresponding decreases in problem behavior were reported by the participant’s parents in the home setting. Time out from reinforcement (TO) includes the “withdrawal of the opportunity to earn positive reinforcers or the loss of access to positive reinforcers for a specified time, contingent on the occurrence of a behavior” (p. 357). Again, the effect on behavior is decreased probability of future occurrence (Cooper et al., 2007).

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Kodak, Grow, and Northup (2004) used time out from reinforcement as a component of treatment to reduce the elopement exhibited by a young child diagnosed with ADHD. A functional analysis of the child’s elopement behavior indicated it was maintained by adult attention. During treatment, this consequence (adult attention) was provided on a scheduled basis (every 15 s). However, if the child engaged in the target response (elopement), she was removed from the activity for 30 s and adult attention was withheld. This combination of components resulted in a decrease in elopement to near-zero levels. Falcomata, Roane, Hovanetz, Kettering, and Keeney (2004) implemented a time out from reinforcement procedure to reduce the inappropriate vocalizations exhibited by an 18-year-old individual with developmental disabilities. The researchers were able to identify a highly preferred activity (i.e., a positive reinforcer, listening to the radio), and access to this activity was interrupted for a specified time following occurrences of the target behavior. The timeout contingency resulted in almost immediate reductions in problem behavior. Any number of studies could have been included here to illustrate the effects of timeout from reinforcement in application. The Falcomata et al. study was included because it illustrates the close relationship between RC and time out from reinforcement. Many researchers in applied behavior analysis do not draw a distinction between the two treatments (in fact, the title of the Falcomata et al. article is “Response cost in the treatment of …”). The take-home point is that both RC and TO involve contingent removal of positive reinforcers. There are several concerns that go along with the use of punishment. Vollmer (2002) discussed four potential concerns regarding the use of punishment that are often raised. First, punishment procedures can sometimes produce negative emotional side-effects. Second, the effects of punishment are often short-lived. Third, punishment procedures have the potential to be abused. This risk of abuse, to some, outweighs the benefits of some procedures. Finally, the treatment does not teach the individual an appropriate behavior that can be used to recruit reinforcers from their environment. Additional concerns regarding the use of punishment include the development of escape and avoidance behavior, behavioral contrast (i.e., an increase in the behavior targeted for punishment in the absence of the punisher), and undesirable modeling (Cooper et al., 2007). It is important to note that neither Vollmer (2002) nor Cooper et al. (2007) advocate against the use of punishment procedures. Instead, they provide discussions of some of the considerations that need to be taken into consideration before developing and implementing a punishment-based procedure. However, for the above stated reasons, and, often because of administrative and legal reasons, reinforcement-based strategies are typically implemented as a first step in the treatment of behavior problems.

Consequence-Based Intervention Strategies: Reinforcement Reinforcement involves the response-dependent delivery (positive reinforcement) or removal (negative reinforcement) of a stimulus, resulting in an increased future likelihood of the target response. Reinforcement-based


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procedures often serve as the cornerstone for both simple and complex behavior-change programs. In application, reinforcement-based procedures include such strategies as token economies, contingency contracting, and differential reinforcement. In each approach, a consequence is identified using some sort of selection process including preference assessments, reinforcer assestsments, or functional analyses of target behavior. The stimulus or stimuli identified via these procedures are then scheduled for delivery contingent on the behavior targeted for increase. Delivery can take place after each occurrence of the behavior, after a specified number of occurrences, following the first response after a specified time interval (i.e., the stimuli are delivered on ratio or interval schedules), or in a deferred manner once some behavioral criteria are met (i.e., the stimuli are delivered as part of a token economy). In addition, a single response can be targeted for increase, or a sequence of responses can be targeted.

Positive Reinforcement Positive reinforcement procedures involve the contingent delivery of a known preferred item or reinforcer contingent on a behavior targeted for increase. When delivered on a ratio or interval schedule, the individual must meet a particular response requirement (e.g., two responses or one response after 10 s has elapsed) to gain access to the positive reinforcer. This strategy is most often used when the clinical goal is the establishment of an appropriate behavior, such as communication or task completion, or a repertoire of appropriate behavior such as social skills or toileting. Graff, Gibson, and Galiatsatos (2006) used a positive-reinforcement procedure to increase the vocational and academic work completed by four adolescents with developmental disabilities. In this study, high and low preferred stimuli were identified via a series of preference assessments. High preferred and low preferred stimuli were then made contingent on completion of various vocational tasks. The results of the study demonstrated that the contingent presentation of both high and low preferred stimuli increased the rate of vocational responses. However, contingent presentation of the high preferred stimuli was correlated with higher, sustained response rates for each participant. Luiselli (1991) described the use of a positive reinforcement procedure to increase the independent feeding behavior of a boy with Lowe’s syndrome. Specifically, praise and access to sensory-based reinforcers (i.e., light and music stimulation) was provided contingent on independently completing components of the self-feeding response. As each component was mastered, the reinforcer was provided for the next response in the task analysis. Results indicated that the participant exhibited acquisition of each of the steps of the task analysis, eventually exhibiting independent self-feeding.

Negative Reinforcement Negative reinforcement procedures involve the contingent removal (escape) of an aversive event, or allow the individual to postpone an aversive event (avoidance). When delivered on a ratio or interval schedule,

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the individual must meet a particular response requirement (e.g., two responses or one response after 10 s has elapsed) before the negative reinforcer is removed or postponed. This strategy is most often used when an individual exhibits problem behavior maintained by escape or avoidance of instructional, self-care, or other aversive situations. Kelley, Piazza, Fisher, and Oberdorff (2003) increased the number of cup sips exhibited by a child with a feeding disorder through the application of a negative reinforcement procedure. Prior to treatment, nonpreferred foods were identified via a stimulus preference assessment. During treatment, spoonfuls of the nonpreferred food were presented along with prompts to take sips from a cup. Sips from the cup allowed the child to escape the bite of nonpreferred food that was otherwise presented if inappropriate behavior or sip refusal was exhibited. Increases in sips were observed as a function of this negative-reinforcement procedure. Rolider and Van Houten (1985) applied negative reinforcement to the treatment of encopresis associated with constipation exhibited by a 12year-old with no other stated diagnoses. During the negative reinforcement-based treatment, the participant was required to sit on the toilet for 20 min or until a bowel movement occurred. If the child had a bowel movement, she was not required to sit on the toilet again that day. If no bowel movement occurred, she was required to sit on the toilet for 40 min or until a bowel movement occurred at the next scheduled toilet sitting. Defecation resulted in no more sitting that day. If no bowel movement occurred, she was required to sit for 90 min or until a bowel movement occurred at the next scheduled toilet sitting. Any bowel movement outside of scheduled toilet sittings also resulted in the child being able to avoid the remaining toilet sittings for the remainder of that day. The treatment resulted in increased levels of successful bowel movements on the toilet.

Token Economy A token economy involves the delivery of a conditioned reinforcer (e.g., a token, point, or other stimulus) that can later be exchanged for another reinforcer. According to Cooper et al. (2007), token economies consist of three components including a list of target behavior or responses, tokens or points that will be earned for exhibiting the target response(s), and a menu of items or activities for which the points or tokens can be exchanged. When implementing a token economy, considerations need to be made regarding the conditioning of the tokens, the menu of backup or primary reinforcers, and the schedule with which the backup reinforcers are accessed. Breakdowns in any of these areas can reduce the effectiveness of the procedure. For example, if the tokens are not explicitly tied to the backup reinforcer(s), they will not affect the individual’s behavior. Similarly, if the menu or backup reinforcers include nonpreferred stimuli, are arbitrarily selected (e.g., without the use of a stimulus preference assessment), or the stimuli are only available on a very lean schedule, the effect of the program could be limited. Token economies are often used in large group settings such as classrooms, residential treatment centers, and group-living environments.


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Field, Nash, Handwerk, and Friman (2004) implemented a token economy to decrease the inappropriate behavior (or, conversely, to increase the appropriate behavior) displayed by three children living in a residential treatment center. Each child had been diagnosed with various psychiatric disorders including conduct problems, ADHD, and PTSD. The existing, centerwide token economy was in place for each participant; however, the children’s behavior continued to be unacceptable. The experimenters increased the schedule of token exchanges from a single exchange each day to two exchanges per day. This change in scheduled exchanges resulted in both a decrease in problem behavior and an increase in the percentage of exchange opportunities during which the participants earned the backup reinforcer. Mangus, Henderson, and French (1986) described the use of a token economy system to improve the on-task physical activity time exhibited by children with autism in an educational setting. In their study, a peer tutor was trained to deliver a token on a predetermined schedule (the schedule differed for each of the five participants, based on the participants’ performance during the last three days of baseline data collection) contingent on engagement in a physical education activity (i.e., walking on a balance beam). Tokens could be exchanged for edible reinforcers from a reinforcement menu once five tokens had been earned. Results of the study indicated that the on-task, physical activity of four of the five participants varied as a function of the token economy intervention. Specifically, when the token economy was in place, higher levels of on-task physical activity were observed. When the token economy was not in place, lower levels of on-task physical activity were observed.

Consequence-Based Intervention Strategies: Extinction Extinction is a procedure that consists of the discontinuation of reinforcement for a behavior with a previous history of reinforcement for the purpose of reducing that behavior. In contrast to the variations of differential reinforcement (described later in this chapter), extinction-only procedures do not include reinforcement for alternative responses or decreases in the rate of the target response. Typically, the reinforcer that is withheld during any extinction procedure is one that has been identified as maintaining a target behavior (i.e., is a functional reinforcer). Iwata, Pace, Kalsher, Cowdery, and Cataldo (1990) treated the escapemaintained SIB exhibited by six children with developmental disabilities. Treatment consisted of extinction and guiding the child through tasks contingent on occurrences of problem behavior (a response-blocking component was added for one participant), thus interrupting the aberrant response-reinforcement relationship identified during a functional analysis of the consequences maintaining problem behavior. Reductions in SIB were observed for each of the six participants. Compliance increased for five of the six participants (compliance data were not presented for the remaining participant), although compliance was not explicitly targeted for change (i.e., no consequences had been programmed for this response). Magee and Ellis (2000) described the sequential application of extinction to the problem behavior exhibited by two children with attention-deficit/

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hyperactivity disorder. One child’s problem behavior (out of seat) was maintained by escape from task. This behavior decreased following the implementation of extinction. However, an increase in other behavior problems (yelling, inappropriate gestures, and destruction) was observed. Using a multiple baseline design, extinction was sequentially applied to each topography. A decrease in each topography was observed following the application of the extinction procedure. The second child’s problem behavior was maintained by social positive reinforcement (attention). When the extinction procedure was first applied to object mouthing, that behavior decreased. However, increases were noted for two other responses, destruction and aggression. When extinction was implemented for each response, responding again decreased to near-zero levels. Although these examples suggest that extinction can be an effective approach to treatment, its use has some limitations that preclude it from being used as the sole treatment component. First, implementing extinction can result in temporary increases in problem behavior at the outset of treatment (i.e., extinction burst), an outcome that can be especially problematic when treatment targets behavior that has the potential to cause injury. Second, extinction can lead to variations in response topography, including aggressive behavior. To further evaluate these two drawbacks, Lerman, Iwata, and Wallace (1999) reviewed 41 data records for individuals whose treatments included an extinction component and for whom aggression was neither a target response nor programmed for reinforcement at any point during assessment. Their review identified extinction-induced response bursts for 39% of the 41 reviewed cases. Similarly, Lerman et al. noted extinction-induced aggression in 22% of the data records included in their sample. A third drawback with extinction-only procedures is that they do not teach the individual alternative methods to obtain the reinforcer. Each of these three limitations can be addressed by including a differential reinforcement component to treatment. Differential reinforcement programs include contingent reinforcement of an alternative response, or the absence of the target response, is targeted for reinforcement, thus increasing the likelihood of an appropriate alternative behavior. This additional component can improve the effectiveness and limit the drawbacks associated with extinction-only procedures. Again, looking at the data provided by Lerman et al., when the extinction-based procedure included a differential reinforcement, noncontingent reinforcement, of some antecedent manipulation as a component of treatment, extinction bursts were evident in only 15% of cases. Similarly, extinction-induced aggression was also only evident in 15% of cases when extinction was accompanied by other treatment components.

Consequence-Based Intervention Strategies: Differential Reinforcement Differential reinforcement is a consequence-based procedure that consists of the reinforcement of one response class (i.e., a set of responses maintained by the same reinforcer or reinforcers) and withholding


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reinforcement for another response class (Cooper et al., 2007). Behavior analysts have developed several variations of differential reinforcementbased treatments. These treatment strategies are typically implemented to reduce a target problem behavior, whereas some include a component designed to increase a target appropriate behavior (e.g., compliance). When used for the purpose of reducing a target behavior, differential reinforcement involves two components: reinforcement of behavior(s) other than the target behavior or the reinforcement of decreasing rates of the target behavior, and withholding of reinforcement following the occurrence of the targeted problem behavior (Cooper, et al.). Although behavior analysts often use differential reinforcement procedures for the purpose of reducing problem behaviors, it should be noted that differential reinforcement is also often used for the purpose of shaping new appropriate behaviors. As with all reinforcement-based procedures, differential reinforcement procedures can include positive or negative reinforcement.

Differential Reinforcement of Alternative Behavior (Including Functional Communication Training) Differential reinforcement of alternative behavior (DRA) is a procedure that consists of the reinforcement of a specified behavior that is different from the behavior that has been targeted for reduction (but not necessarily incompatible with that target response). In a typical application, all occurrences of the behavior targeted for reduction are placed on extinction, and reinforcement is available for each appropriate response. One example of DRA treatment is functional communication training (FCT). This treatment consists of identifying the functional reinforcer responsible for the maintenance of problem behavior, and then delivering that reinforcer contingent on an appropriate communicative response (Carr & Durand, 1985). When this procedure is implemented in such a manner that the reinforcer responsible for problem behavior is withheld (i.e., extinction is in place) contingent on that response or set of responses, it fits within the parameters of a DRA treatment. It should be noted that researchers have compared the effectiveness of FCT with and without this extinction component. In one notable study, Hagopian, Fisher, Sullivan, Acquisto, and LeBlanc (1998) found that FCT without extinction was minimally effective for 11 participants. Some participants displayed a reduction in problem behavior, but none achieved a 90% reduction. Three of the 11 participants exhibited an increase in problem behavior of atleast 50% when FCT was conducted without extinction. By contrast, FCT with extinction was effective in achieving a 90% reduction in 44% of applications (11 of 25). No increases in problem behavior were reported when FCT was implemented with an extinction component. There have been several articles published regarding the utility of FCT in the behavior analytic literature. Derby et al. (1997) described the longterm effects of FCT as treatment for the problem behavior exhibited by four young children with developmental disabilities. Each of the children displayed reductions in target problem behavior and exhibited increases

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in or acquisition of appropriate communication following FCT implementation. This study demonstrated the robust effectiveness of FCT because the children’s problem behavior was maintained by different functions (both positive and negative reinforcement), including one child whose problem behavior was maintained by multiple functions, and the treatment effects were observed across a longer than two-year time period. Other DRA procedures focus on increasing appropriate behavior such as compliance with instructions. Reed, Ringdahl, Wacker, Barretto, and Andelman (2005) implemented differential reinforcement of alternative behavior to increase the compliance and decrease the problem behavior exhibited by two children with developmental disabilities. Each child’s problem behavior was maintained by escape from tasks. During treatment, compliance with the tasks resulted in a 30 s break from instruction (i.e., negative reinforcement). Problem behavior resulted in immediate guidance through the task (i.e., extinction). For each child, compliance increased and problem behavior was reduced relative to baseline when the DRA treatment was in place.

Differential Reinforcement of Incompatible Behaviors Differential reinforcement of incompatible behaviors (DRI) is a procedure that is very similar to DRA except that the designated alternative behavior targeted for reinforcement is incompatible with the behavior that has been targeted for reduction. Friman and Altman (1990) implemented a DRI schedule to address the disruptive behavior exhibited by a 4-year-old boy with developmental disabilities. The target response for the child was out-of-seat behavior. During the treatment procedure, parents delivered reinforcers (praise and edibles) contingent on the child exhibiting an incompatible behavior (i.e., staying in his seat) for specified intervals (initially, 10 s). If the child left his seat, he was reseated and the reinforcer was not delivered at the end of the interval. The treatment resulted in a decrease in out-of-seat behavior and a corresponding decrease in other inappropriate behavior (e.g., mouthing and throwing objects), whereas appropriate behavior (toy play) increased slightly. Buzas, Ayllon, and Collins (1981) described the use of a DRI procedure to reduce the SIB (biting lip and tongue, picking at lips and mouth, biting inside of cheek, gouging tongue frenulum, and falling out of wheelchair) exhibited by a young boy with Lesch–Nyhan Syndrome. The participant’s SIB was so severe that he spent the majority of his day in mechanical restraints. On the occasions when restraint was removed (for hygiene activities, dressing, etc.), almost immediate attempts at SIB were observed (e.g., tearing his lip with fingernail). In this case study, an array of responses incompatible with SIB (drawing, throwing plastic darts, playing games, doing puzzles, eating candy, playing catch, reading while holding a book, adding and subtracting numbers on a die, typing, wheeling his wheelchair, and learning sign language) resulted in access to attention from various therapists and caregivers. When this DRI procedure was in place, the participant was able to interact out of restraint for up to three-and-a-half hours without


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attempting to engage in SIB. When the procedure was not in place and restraints were removed, attempts at SIB were observed within 5 to 15 minutes. Although this study is descriptive and lacks systematic experimental control, it is included here because of the clinically significant outcomes achieved. The behavioral problems associated with Lesch–Nyhan syndrome are notoriously resistant to treatment, both pharmacologic and behavioral in nature. One potential reason for this difficulty in treatment is that the reinforcers relevant to the behavior are unidentifiable or change too often to allow for systematic evaluation. The described study demonstrates the potential utility of arranging a differential reinforcement-based treatment when a reinforcing consequence can be identified and manipulated.

Differential Reinforcement of Low Rates of Behavior Differential reinforcement of low rates of behavior (DRL) is a procedure that consists of the reinforcement of a behavior targeted for reduction but on a schedule of reinforcement that is leaner than what was in place prior to the implementation of the DRL procedure (i.e., the schedule of reinforcement in place in the natural environment). With the DRL procedure, the behavior targeted for reduction is reinforced only following a specified length of time in the absence of the behavior. In addition, as the reductions of the target behavior are observed over time, the length of the interval can be systematically increased in order to bring about lower and lower rates of the target behavior (often referred to as differential reinforcement of diminishing rates; DRD). Wright and Vollmer (2002) reported the use of a DRL procedure to reduce the rapid eating exhibited by a teenage girl with developmental and physical disabilities. The procedure consisted of reinforcing bites (i.e., allowing access to the bite) only if bite attempts occurred on a predetermined interval. If the participant attempted to take a bite of food before the predetermined interval elapsed, that bite was blocked. If the participant attempted to take a bite of food after the predetermined interval elapsed, the bite was allowed (i.e., reinforced). The authors noted that the DRL procedure was more effective if the time interval was adjustable and based on the mean interresponse time (IRT) from the preceding five sessions than if it was fixed (i.e., 15 s for every session). The DRL procedure resulted in longer time between bite attempts relative to baseline which translated to a decrease in the participant’s bite rate. Deitz and Repp (1973) reported a series of three experiments in which DRL schedules were used to reduce the disruptive behavior exhibited by a student diagnosed with a developmental disability, a classroom of students diagnosed with developmental disabilities, and a group of high school students enrolled in regular education. In each experiment, there was a decrease in disruptive behavior exhibited by either the target individual or the class as an aggregate when the DRL schedule was implemented. The treatment effects were maintained when the DRL schedule was withdrawn during Experiment I (single student). However, treatment effects were lost when the DRL schedules were withdrawn during Experiments II and III.

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Differential Reinforcement of Other Behavior Although DRA, DRI, and DRL-based treatments target increasing a specific appropriate response along with reducing the target problem behavior, differential reinforcement of other behavior (DRO) consists of the delivery of reinforcers contingent on the absence of identified problem behavior for a specified time period. Whereas reinforcement involves the presentation of a stimulus contingent on a target behavior, DRO entails the contingent application of a reinforcing consequence (either positive or negative) for the nonoccurrence of a target behavior. Other terms that are sometimes used for DRO include differential reinforcement of the omission of behavior and differential reinforcement of zero rates of behavior. Ringdahl et al. (2002) described the use of a DRO-based treatment to reduce the stereotypic hand movements exhibited by an adolescent boy with developmental disabilities. The stereotypic hand movements exhibited by the participant were serious in nature because they could trigger photosensitive grand mal seizures. The researchers were unable to identify any social reinforcers maintaining the problem behavior and noted that the behavior only occurred when adult supervision was not provided. A reinforcer assessment indicated that video games could potentially function as a reinforcer for appropriate behavior. Following assessment, access to video game time was allowed contingent on time intervals during which the participant did not engage in the target response. Initially, the DRO interval was set at 10 s (based on the average time between hand-flapping episodes during baseline) and gradually increased to 600 s (10 min) by the end of treatment. Decreases in repetitive hand movements were observed when the DRO procedure was in place. Watson and Sterling (1998) used a DRO procedure to reduce vocal tics exhibited by a 4-year-old girl. A functional analysis of this behavior indicated the vocal tics were maintained by social consequences in the form of adult attention. During treatment, adult attention was withheld or removed when vocal tics occurred. Alternatively, adult attention was provided following brief intervals (15 s) with no vocal tics. The interval was increased by 10 s following three consecutive deliveries of the reinforcer until the DRO interval reached the terminal length of 300 s (5 min). A decrease in the rate of the vocal tic was observed when the DRO was implemented. This decrease was still apparent at one-, three-, and sixmonth follow-up visits.

Thinning Differential Reinforcement Schedules One limitation of DR approaches to treatment, particularly DRA/FCT and DRI programs, is that the target individual can access reinforcers at any time contingent on appropriate behavior. If delivery of the reinforcer requires the presence of a caregiver, such programs can be labor intensive. As well, the individual may spend all of his time accessing the reinforcer, which can compete with academic or vocational goals. Thus, one goal of treatment is to reduce the availability of the reinforcer by increasing the response requirement or implementing a delay to reinforcement.


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Lalli et al. (1999) provided access to differential positive reinforcement contingent on compliance in the treatment of the escape-maintained problem behavior displayed by five individuals 21 years old or younger. The programmed positive reinforcement schedule resulted in increases in compliance and decreases in problem behavior exhibited by each participant. The response requirement to obtain the positive reinforcer was then increased for three of the five participants. At the outset of treatment, compliance resulted in positive reinforcement on a fixed-ratio (FR) 1 schedule. That schedule was increased to at least FR 10 for each of these three participants. This change in schedule did not result in degradation of treatment effects. Hagopian, Contrucci Kuhn, Long, and Ruch (2005) implemented FCT for three boys diagnosed with PDD spectrum disorders admitted to an inpatient hospital setting for the assessment and treatment of severe behavior problems including aggression and disruption. Functional communication training resulted in decreases in problem behavior for each child. The authors thinned the schedule by implementing a delay between occurrences of appropriate requests and delivery of the reinforcer (attention or preferred tangible items). The delays were progressively increased if the participant exhibited less than 0.2 responses per minute (RPM) of problem behavior for two consecutive sessions at a given delay. If two sessions of greater than 0.2 RPM of problem behavior was observed, the delay was reduced to the previously longest successful delay. This progression continued until a terminal goal was met for each participant. For each of the three participants, delays of at least 4 min were achieved. One interesting finding from this study was that allowing the participants access to competing reinforcers during the delay interval allowed for quicker attainment of the terminal delay length and fewer occurrences of problem behavior.

Antecedent Approaches to Treatment The majority of ABA treatments focus on manipulating consequences to change behavior, however, there are some treatments that focus on manipulating antecedents relevant to the target behavior. For the purposes of this chapter, four antecedent-based interventions are highlighted. These interventions include: procedures that manipulate establishing operations, stimulus control procedures, prompt procedures, and procedures that provide choice-making opportunities.

Establishing Operations The relationship between environment and behavior is often described as a 3-term contingency. The three components of this contingency are what happens prior to the response (the antecedent, or A), the behavior the individual exhibits (B), and what happens immediately following the behavior (the consequence, or C). Often, this 3-term contingency is denoted as A-B-C. A complete understanding of the antecedent requires that behavior analysts take into account variables that alter the effectiveness of a stimulus as a reinforcer. The term that has historically been used to describe this relationship between the environment and reinforcer

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effectiveness or value is “establishing operation” (EO; Michael, 1982). More recently, the term “establishing operation” has been replaced with the term “motivating operation” (MO) when the effect is an increase in the value of the reinforcer and the term “abolishing operation” (AO) when the effect is a decrease in the value of the reinforcer (Laraway, Snycerski, Michael, & Poling, 2003). These operations (motivating or abolishing) affect behavior by either increasing (via an MO) or decreasing (via an AO) responding. The most salient example of MOs and AOs are deprivation and satiation. Deprivation consists of withholding the stimulus that functions as a reinforcer from the individual. Deprivation has at least two effects. First, it results in an increase in the value of the stimulus as a reinforcer. Second, it results in an increase in responding that occurs as a function of that reinforcer. Conversely, satiation consists of presenting a sufficient amount of the stimulus that functions as a reinforcer and has two opposite effects: a decrease in the value of the reinforcer and a related decrease in responding that occurs as a function of that reinforcer. In application, EOs can be manipulated in a number of ways. When attempting to decrease a target response, the identified reinforcer for that response can be provided on a noncontingent basis during treatment (i.e., reinforecers are delivered on a relatively dense fixed-time schedule; Ringdahl, Vollmer, Borrero, & Connell, 2001). Alternatively, the functional reinforcer could be provided to the individual prior to exposing her to the context(s) in which the target response has historically been likely to occur (e.g., Vollmer & Iwata, 1991; Berg et al., 2000). When attempting to increase a target response, the reinforcer can be withheld prior to training (e.g., Vollmer & Iwata, 1991). Lalli, Casey, and Kates (1997) used a fixed-time (FT) reinforcement schedule to reduce aberrant behavior exhibited by two children with mental retardation and one child with a developmental disability. The FT schedule specified when reinforcers were to be delivered. Delivery occurred independent of the child’s behavior. The specific FT schedules used during treatment reflected the mean latency to problem behavior during baseline for each child. Decreased rates of problem behavior were observed with all three children when the FT schedule was implemented. One possible explanation for the decrease in aberrant behavior was that the FT schedule of reinforcement resulted in satiation indicating AO effects. Taylor et al. (2005) manipulated the EO associated with preferred snacks to increase peer-directed mands (i.e., requests) exhibited by three children with autism. MOs were altered through the restriction of the preferred snacks and access to the snacks was made contingent on mands that were peer-directed. When the MO was in place, rates of peer-directed mands were observed at high rates. Conversely, when the MO was not in place, mands decreased to near-zero rates for each of the children. The results demonstrated that targeted appropriate behaviors can be increased through the direct manipulation of MOs.

Stimulus Control Stimulus control is demonstrated when a particular behavior is reliably occasioned by specific antecedent stimuli (Sulzer-Azaroff & Mayer,


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1991). In terms of the 3-term contingency, stimulus control describes a relationship between environment and behavior that consists of A (the antecedent) reliably occasioning B (the behavior), which results in C (the consequence or reinforcement). One way stimulus control can be established is by pairing specific responses with reinforcement only when they occur in the presence of specific antecedent stimuli, and withholding reinforcement when those specific responses are exhibited in the absence of the specific antecedent stimuli. This process is often programmed in laboratory research. However, it can also occur naturally as individuals are exposed to different stimulus contexts and their specific reinforcement schedules. For example, behavior may come under stimulus control due to the different ways a child’s parents respond to his or her behavior. In the presence of the father, problem behavior might always result in attention. Conversely, in the presence of the mother, problem behavior might have no differential consequence. If attention from care providers is a reinforcer, the child might begin engaging in problem behavior only in the presence of the father. In a similar fashion, punishment of a behavior in the presence of a specific stimulus might result in that behavior being inhibited in the presence of the stimulus. Using the same example, if the child’s mother always delivered an aversive consequence (e.g., timeout or spanking) following problem behavior, but the father provided no differential consequence, the child might stop engaging in problem behavior in the presence of the mother only. When stimulus control is apparent as exhibited by differential responding correlated with specific stimuli, treatment might focus on transferring stimulus control to improve behavior across stimulus contexts. Ray, Skinner, and Watson (1999) used stimulus control procedures to increase compliance exhibited by a five-year-old boy diagnosed with autism. During baseline, the investigators evaluated compliance when demands were delivered by the child’s teacher as compared to when demands were delivered by the child’s mother. The likelihood that the child would comply with demands was increased when his mother delivered demands as opposed to when his teacher delivered demands. This finding suggested that stimulus control had been established. Using that information, the investigators next implemented a series of procedures in which the teacher was paired with the mother during demand situations. Initially, the child’s mother delivered three demands and the teacher delivered one demand and compliance was observed at high rates with both adults. Over time, a fading procedure was used in which the teacher delivered an increasing number of the demands and the child’s mother delivered fewer of the demands while compliance continued at high rates. Eventually, the child’s mother was faded completely out of the demand situation, the teacher delivered all of the demands, and compliance continued at high rates. The results of Ray et al. (1999) suggested the fading procedure resulted in a transfer of stimulus control from the child’s mother to the teacher. In a similar study, Knoff (1984) used stimulus control procedures to treat problem behavior exhibited by two boys, 9 and 10 years of age, who engaged in aggression, disruption, and oppositional behavior. With each of the children, problem behavior was occurring at high rates in the presence

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of a paraprofessional during morning and noon recesses. Likewise, with each of the children, appropriate behavior was reliably occurring at high rates in the presence of their classroom teacher. The goal of the stimulus control procedures was to generalize the apparent stimulus control that the presence of the teacher was exerting over appropriate behavior to the paraprofessional during recess times. The procedure consisted of the teacher attending each recess period during the first week. High levels of appropriate behavior were immediately observed with each of the children during the first week. During subsequent weeks, the teacher spent fewer and fewer days attending recess periods until she was completely faded out. After the teacher was completely faded out of the recess, high levels of appropriate behavior continued to be observed with each of the children suggesting that stimulus control had been generalized or to the paraprofessional.

Prompt Procedures Cooper et al. (2007) defined prompts as supplementary antecedent stimuli intended to occasion specific responses. Whereas response prompts (i.e., graduated guidance) target behavior, stimulus prompts target the antecedent conditions that exist prior to the occurrence of specific behavior (i.e., antecedents). Behavior analysts use stimulus prompts as auxiliaries to be removed over time as the intended behavior occurs more reliably in the presence of natural stimuli (discriminative stimuli). Prompts are often used during initial phases of treatment programs to facilitate the acquisition of specific responses. Following acquisition, the prompts can then be systematically faded so that naturally occurring stimuli will come to reliably occasion the acquired behavior. Taylor and Levin (1998) and Shabani, Katz, Wilder, Beauchamp, Taylor, and Fischer (2002) each used a prompting procedure to promote social initiations with children with diagnoses of autism. The investigators used a tactile prompting device located in the children’s pockets. Specifically, the device was programmed to vibrate for 3 to 5 s whenever the investigators activated it using a remote control. The investigators initially paired a vocal model with the tactile prompt to bring about social initiations, and then gradually faded the vocal model as the children independently exhibited social initiations following tactile prompts. The use of the vocal modeling and tactile prompts resulted in high rates of social initiations exhibited by the children across both studies. In addition, Shabani et al. (2002) also attempted to fade the tactile prompt with two of the three participants by systematically reducing the frequency of the prompts over time. The results suggested that fading the tactile prompt was partially successful for each of the particiapants as social interactions continued, but at lower and more variable rates. Rivera, Koorland, and Fueyo (2002) used picture prompts to promote sight word reading with a nine-year-old boy diagnosed with a learning disability. The picture prompts, which were generated by the child himself, were illustrated representatives of the targeted sight words. Initially, the experimenters reviewed with the child the meaning of each of the targeted sight words and had him generate illustrations for each of the words on


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large index cards. As the child’s sight-word reading accuracy increased, the index cards on which he drew the illustrations were reduced and the colors that he was allowed to use were systematically lightened until the illustrations were successfully faded from the program. Even as the picture prompts were faded, the child continued to exhibit a high level of accurate sight-word reading.

Choice Another antecedent-based intervention that has been demonstrated to be effective involves providing choice-making opportunities. Numerous studies have shown that providing choice can serve to decrease problem behavior and increase appropriate behavior including academic and vocational task engagement. Furthermore, choice has been conceptualized as a functional variable (i.e., a reinforcer for appropriate behavior) in and of itself rather than simply a means to identify highly preferred stimuli (Dunlap et al., 1994). Dibley and Lim (1999) provided choice-making opportunities during treatment with a 15-year-old girl diagnosed with a severe intellectual disability. Choice-making opportunities were incorporated into various activities including meal-time routine, toileting routine, and leisure time activities for the purpose of increasing compliance and decreasing problem behaviors. During baseline, the adolescent was prompted to engage in each step that made up the respective activities and no choices were incorporated. During treatment, the adolescent was prompted to engage in each step that made up the respective activities with various opportunities for choice embedded throughout each of the activities. For example, during the toileting routine, the adolescent was provided with a choice between initiating the activity immediately or following a 10-min delay, basin or sink for hand washing, and hand-towel or hand dryer. When choices were provided, compliance was observed at higher levels and problem behavior was observed at lower levels when compared to baseline. These results were consistent across each of the three targeted activities. Dunlap et al. (1994) incorporated choice-making opportunities into treatment programs for three young boys aged 11, 11, and 5 for the purpose of decreasing noncompliance and aggressive behavior. Two of the children received opportunities to make choices during instructional times in the form of menus containing several academic tasks. Choice-making opportunities for the third child were incorporated into reading time. Specifically, the child was allowed to pick a book from an array prior to storytime. When choices were provided, each child exhibited lower levels of noncompliance and problem behavior and task engagement was observed at higher levels than those observed during baseline.

Combining Antecedent and Consequence-Based Treatments Often, more than one treatment is selected for implementation. Such treatment packages might be constructed of both antecedent and consequencebased components. Ringdahl et al. (2002) provided one such example.

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Treatment evaluated in that study combined DRA with instructional fading in the treatment escape-related problem behavior exhibited by a girl diagnosed with autism. The consequence portion of the treatment was a differential reinforcement schedule that specified the delivery of brief breaks contingent on appropriate compliance (i.e., completion without exhibiting problem behavior) with academic tasks. The antecedent component of the treatment was systematically increasing the number of instructions that were delivered during a 5-min work session, as long as problem behavior remained low, until a terminal goal of one instruction per min was achieved. Results of this study suggested that this combination of treatment components resulted in successful treatment with fewer occurrences of problem behavior than a consequence-based treatment (DRA) alone. Marcus and Vollmer (1996) combined antecedent and consequencebased treatments in the treatment of SIB and aggression displayed by a young girl with developmental disabilities. Their investigation evaluated a treatment comprised of two components: NCR (antecedent) and differential reinforcement of compliance (consequence). Results of the study indicated that the treatment package was effective in reducing problem behavior. In addition, the treatment was effective in teaching the young girl how to use an alternative, appropriate communicative response to obtain the reinforcer that maintained problem behavior. The use of the package allowed for effective treatment while limiting some of the side effects (e.g., response bursts) sometimes observed during behavioral treatments with an extinction component.

Generalization Generalization is one of the stated characteristics of applied behavior analysis (Baer et al., 1968). According to Cooper et al. (2007), generalization is a broad term that refers to a number of behavior change outcomes. During clinical application of ABA-based treatments, there is often an attempt to expand the effects of treatment from the clinical setting to the naturalistic environment (i.e., stimulus/setting generalization). Stimulus/setting generalization refers to the occurrence of a behavior under different conditions than which the behavior was acquired. Cooper et al. point out that this behavior change can occur without being directly taught. However, some behavior analysts attempt to facilitate this outcome through programming. Literature-based examples of generalization can be broken into two broad categories. Some studies describe the naturally occurring spread of effects across setting, time, and stimuli, whereas others describe systematic processes to achieve generalization. Bonfiglio, Daly, Martens, Lin, and Corsaut (2004) described the effects of various reading interventions on the reading accuracy of a third-grade girl. The participant was exposed to performance-based, skills-based, and combined performance-based and skills-based reading interventions. Each treatment was demonstrated to improve reading behavior. The effects of treatment were noted across time and reading passages. These effects were achieved without specific programming. The authors hypothesized that generalization, particularly across passages, was a function (or, partially a function) of a fluency threshold.


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Eikeseth and Nesset (2003) described a treatment designed to improve vocal articulation exhibited by children with phonological disorder. As part of their treatment, the goal was to bring about mastery of a variety of target sounds (i.e., vocally produce the sounds without articulation errors). Toward this end, the two participants were exposed to a treatment that included sufficient response-exemplars. Specifically, a set of ten words was programmed to be used to teach the child the sound. During treatment, participants received tokens that could be exchanged for individually determined back-up reinforcers contingent on correct articulation or close approximations of the therapist’s vocal model. Results suggested that both participants mastered each sound without needing to be exposed to all ten target words. The necessary number of words needed varied from one to eight. Thus, according to Eikeseth and Nesset, “after acquiring correct articulation of some words containing a particular target sound, other words containing the same target sound were subsequently echoed correctly without training” (p. 33–334). That is, generalized behavior change took place.

EFFECTIVENESS RESEARCH Another s tated characteristic of applied behavior analysis is effectiveness (Baer et al., 1968). Although metaanalyses regarding the effectiveness of ABA-based treatments are difficult to identify, there are a number of studies that review the effectiveness of ABA-based strategies in the treatment of severe behavior problems exhibited by individuals with and without developmental disabilities. These reviews and summary papers can be placed into one of three broad categories: summaries of treatments for behavior associated with particular disorders (e.g., autism, ADHD), summaries of treatments for specific behavior problems (e.g., SIB, aberrant behavior, and stereotypy), and summaries of the effects of a specific treatment approach (e.g., NCR and FCT).

Treatment of Behavior Challenges Associated with Particular Diagnoses Matson et al. (1996) provided a review of behavioral treatment strategies designed to address the challenging behavior exhibited by individuals with autism. Results of their review suggested that behavior analysts have used methods derived from the principles of operant conditioning to address a wide range of target behaviors exhibited by children diagnosed with autism including aberrant behavior, language, and social, daily living, and academic skills. These authors also found the percentage of interventions reported that used positive procedures outnumbered significantly the number of interventions that used aversive procedures. Olson and Houlihan (2000) reviewed behavioral treatments for challenging behaviors associated with Lesch–Nyhan disorder. The review suggested that in most cases, the use of behavioral treatments (i.e., DRO, DRI, extinction) were effective in treating self-injury exhibited by children with Lesch–Nyhan and that in many cases the results generalized to other settings and care providers.

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Treatment of Specific Problem Behavior A number of other review papers have summarized ABA-based procedures as they pertain to the treatment of specific behavior problems. Iwata et al. (1994) reported the use function-based behavior analytic treatment to reduce self-injurious behavior (SIB) exhibited by adults and children with developmental disabilities. Effective treatment was defined as a treatment procedure that resulted in a decrease in problem behavior to below 10% of the baseline level for a given individual. Iwata et al. reported that, when interventions were based on identified functions of SIB, antecedent-based interventions were effective in 84.2% of reported cases, extinction was effective in 86.8% of reported cases, differential reinforcement was effective in 82.5% of reported cases, and punishment was effective in 88.2% of reported cases. Similarly, Asmus et al. (2004) reported the treatment effects of function-based behavior analytic treatments in the reduction of aberrant behavior (SIB, aggression, stereotypy, destruction, and disruption) exhibited by adults and children with and without developmental disabilities. They reported an 80% decrease in aberrant behavior following the implementation of ABA-based treatments for 76% of the treated individuals. Rapp and Vollmer (2005) provided a summary of the literature concerning the treatment approaches to reducing stereotypy (i.e., repetitive behavior that serves no apparent social function). These authors concluded that there is ample support in the literature for the effectiveness of ABA-based treatments (both antecedent and consequence) in reducing stereotypy.

Effectiveness of Specific Treatment Strategies Finally, several summaries have been published on the effectiveness of specific ABA-based approaches to treatment. Miltenberger, Fuqua, and Woods (1998) reported on the effectiveness of habit reversal methods for the treatment of target behaviors including tics, nervous habits, and stuttering. The authors suggested that habit reversal methods have been consistently demonstrated as effective even in the absence of identification of functions of the treated tics, habits, and stuttering. Carr et al. (2000) conducted a review of studies that evaluated the use of NCR in the treatment of aberrant behavior. The authors reported that NCR has been an effective treatment strategy for a variety of problem behaviors exhibited by individuals with developmental disabilities but included the caveat that more clinical research needs to be conducted in the area. Taken as a group, summaries provide a persuasive demonstration of the effectiveness of ABA-based treatments for a number of childhood behavior challenges exhibited by children with psychiatric and developmental disabilities.

SUMMARY We have attempted to provide an overview of the conceptual basis for ABA-based treatments, a description of several of the more common of these treatments, and a brief discussion of their effectiveness. Applied behavior


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analysis-based treatment approaches have an established and effective history in the treatment of problem behavior and the establishment of appropriate behavior across a wide range of disabilities. The approach is not designed to treat the underlying disorder, per se. Instead, ABA-based treatments target specific behavioral symptoms indicative of an individual’s diagnosis. Related strategies can be used to either establish new behavior or decrease existing problem behavior through an analytic process requiring an understanding of the antecedent and consequent variables affecting the target behavior. Although several approaches to behavior change exist, ABA-based treatments offer an evidence-based methodology with strong roots in basic and applied research. In our opinion, ABA represents a state-of-the-art approach to the development of behavior-change programs.

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Eikeseth, S. & Nesset, R. (2003). Behavioral treatment of children with phonological disorder: The efficacy of vocal imitation and sufficient-response-exemplar training. Journal of Applied Behavior Analysis, 36, 325–337. Falcomata, T. S., Roane, H. S., Hovanetz, A., N., Kettering, T. L., & Keeney, K., M. (2004). An evaluation of response cost in the treatment of inappropriate vocalizations maintained by automatic reinforcement. Journal of Applied Behavior Analysis, 37, 83–87. Field, C. E., Nash, H. M., Handwerk, M. L., & Friman, P. C. (2004). A modification of the token economy for nonresponsive youth in family-style residential care. Behavior Modificaiton, 28, 438–457. Foxx, R. M., & Azrin, N. H. (1973). The elimination of autistic self-stimulatory behavior by overcorrection. Journal of Applied Behavior Analysis, 6, 1–14. Friman, P. C. & Altman, K. (1990). Parent use of DRI on high rate disruptive behavior: Direct and collateral benefits. Research in Developmental Disabilities, 2, 249–254. Graff, R. B., Gibson, L., & Galiatsatos, G. T., (2006). The impact of high- and low-preference stimuli on vocational and academic performances of youths with severe disabilities. Journal of Applied Behavior Analysis, 39, 131–135. Hagopian, L. P., Contrucci Kuhn, S. A., Long, E. S., & Rush, K. S. (2005). Schedule thinning following communication training: Using competing stimuli to enhance tolerance to decrements in reinforcer density. Journal of Applied Behavior Analysis, 38, 177–193. Hagopian, L. P., Fisher, W. W., Sullivan, M. T., Acquisto, J., & LeBlanc, L. A. (1998). Effectiveness of functional communication training with and without extinction and punishment: A summary of 21 inpatient cases. Journal of Applied Behavior Analysis, 31, 211–235. Heward, W. L. (2005). Reasons applied behavior analysis is good for education and why those reasons have been insufficient. In W. L. Heward, T. E. Heron, N. A. Neef, S. M. Peterson, D. M. Sainato, G. Cartledge, R. Gardner, III, L. D. Peterson, S. B. Hersh, & J. C. Dardig (Eds.), Focus on behavior analysis in education: Achievements, challenges, and opportunities (pp.316–348). Upper Saddle River, NJ: Merrill/Prentice Hall. Iwata, B. A., Pace, G. M., Dorsey, M. F., Zarcone, J. R., Vollmer, T. R., Smith, R. G., Rodgers, T. A., Lerman, D. C., Shore, B. A., Mazaleski, J. L., Goh, H. L., Cowdery, G. E., Kalsher, M. J., McCosh, K. C., & Willis, K. D. (1994)The functions of selfinjurious behavior: An experimental-epidemiological analysis. Journal of Applied Behavior Analysis, 27, 215–240. Iwata, B. A., Pace, G. M., Kalsher, M. J., Cowdery, G. E., & Cataldo, M. F. (1990). Experimental analysis and extinction of self-injurious escape behavior. Journal of Applied Behavior Analysis, 23, 11–27. Kahng, S. W., Abt, K. A., & Wilder, D. A. (2001). Treatment of self-injury correlated with mechanical restraints. Behavioral Interventions, 15, 105–110. Kelley, M. E., Piazza, C. C., Fisher, W. W., & Oberdorff, A. J. (2003). Acquisition of cup drinking using previously refused foods as positive and negative reinforcement. Journal of Applied Behavior Analysis, 36, 89–93. Knoff, H. M. (1984). Stimulus control, paraprofessionals, and appropriate playground behavior. School Psychology Review, 13, 249–253. Kodak, T., Grow, L., & Northup, J. (2004). Functional analysis and treatment of elopement for a child with attention deficit hyperactivity disorder. Journal of Applied Behavior Analysis, 37, 229–232. Lalli, J. S., Casey, S. D., & Kates, K. (1997). Noncontingent reinforcement as treatment for severe problem behavior: Some procedural variations. Journal of Applied Behavior Analysis, 30, 127–137. Lalli, J. S., Vollmer, T. R., Progar, P. R., Wright, C., Borrero, J., Daniel, D., Barthold, C. H., Tocco, K., & May, W. (1999) Competition between positive and negative reinforcement in the treatment of escape behavior. Journal of Applied Behavior Analysis, 32, 285–296. Laraway, S., Snycerski, S., Michael, J., & Poling, A. (2003). Motivating operations and terms to describe them: Some further refinements. Journal of Applied Behavior Analysis, 36, 407–414.


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Lerman, D.C., Iwata, B.A., & Wallace, M.D. (1999). Side effects of extinction: Prevalence of bursting and aggression during the treatment of self-injurious behavior. Journal of Applied Behavior Analysis, 32, 1–8. Linscheid, T. R., Iwata, B. A., Ricketts, R. W., Williams, D. E., & Griffin, J. C. (1990). Clinical evaluation of the self-injurious behavior inhibiting system (SIBIS). Journal of Applied Behavior Analysis, 23, 53–78. Long, T. S., Miltenberger, R. G., & Rapp, J. T. (1999) Simplified habit reversal plus adjunct contingencies in the treatment of thumb sucking and hair pulling in a young child. Child & Family Behavior Therapy, 21, 45–58. Luiselli, J. K. (1991) Acquisition of self-feeding in a child with Lowe’s syndrome. Journal of Developmental and Physical Disabilities, 3, 181–189. Magee, S. K., & Ellis, J. (2000). Extinction effects during the assessment of multiple problem behaviors. Journal of Applied Behavior Analysis, 33, 313–316. Mangus, B., Henderson, H., & French, R. (1986). Implementation of a token economy by peer tutors to increase on-task physical activity time of autistic children. Perceptual and Motor Skills, 1, 97–98. Marcus, B. A., & Vollmer, T. R. (1996). Combining noncontingent reinforcement and differential reinforcement schedules as treatment for aberrant behavior. Journal of Applied Behavior Analysis, 29, 43–51. Matson, J. L., Benavidez, D. A., Stabinsky Compton, L., Paclawskyi, T., & Baglio, C. (1996). Behavioral treatment of autistic persons: A review of research from 1980 to the present. Research in Developmental Disabilities, 17, 433–465. Michael, J. (1982). Distinguishing between discriminative and motivational functions of stimuli. Journal of the Experimental Analysis of Behavior, 1, 149–155. Miltenberger, R. G., Fuqua, R. W., & Woods, D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. Journal of Applied Behavior Analysis, 31, 447–469. Olson, L. & Houlihan, D. (2000). A review of behavioral treatments used for LeschNyhan Syndrome. Behavior Modification, 24, 202–222. Rapp, J. T., & Vollmer, T. R. (2005). Stereotypy I: A review of behavioral assessment and treatment. Research in Developmental Disabilities, 26, 527–547. Ray, K. P., Skinner, C. H., & Watson, T. S. (1999). Transferring stimulus control via momentum to increase compliance in a student with autism: A demonstration of collaborative consultation. School Psychology Review, 28, 622–628. Reed, G. K., Ringdahl, J. E., Wacker, D. P., Barretto, A., & Andelman, M. S. (2005). The effects of fixed-time and contingent schedules of negative reinforcement on compliance and aberrant behavior. Research in Developmental Disabilities, 3, 281– 295. Ringdahl, J. E., Andelman, M. S., Kitsukawa, K., Winborn, L. C., Barretto, A., & Wacker, D. P. (2002). Evaluation and treatment of covert stereotypy. Behavioral Interventions, 17, 43–49. Ringdahl, J. E. Kitsukawa, K. Andelman, M. S. Call, N. Winborn, L. Barretto, A., & Reed, G. K. (2002). Differential reinforcement with and without instructional fading. Journal of Applied Behavior Analysis, 35, 291–294. Ringdahl, J. E., Vollmer, T. R., Borrero, J. C., & Connell, J. E. (2001). Fixed-time schedule effects as a function of baseline reinforcement rate. Journal of Applied Behavior Analysis, 34, 1–15. Rivera, M. O., Koorland, M. A., & Fueyo, V. (2002). Teaching sight words to a student with learning disabilities. Education and Treatment of Children, 25, 197–207. Rolider, A., & Van Houten, R. (1985). Treatment of constipation-caused encopresis by a negative reinforcement procedure. Journal of Behavior Therapy and Experimental Psychiatry, 16, 67–70. Rush, K. S., Crocket, J. L., & Hagopian, L. P. (2001). An analysis of the selective effects of NCR with punishment targeting problem behavior associated with positive affect. Behavioral Interventions, 16, 127–135. Shabani, D. B., Katz, R. C., Wilder, D. A., Beauchamp, K., Taylor, C. R., & Fischer, K. J. (2002). Increasing social initiations in children with autism: Effects of a tactile prompt. Journal of Applied Behavior Analysis, 35, 79–83.

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Singh, N. N., Watson, J. E., & Winton, A. S. W. (1986). Treating self-injury: Water mist spray versus facial screening or forced arm exercise. Journal of Applied Behavior Analysis, 19, 403–410. Sulzer-Azaroff, B., & Mayer, G. R. (1991). Behavior analysis for lasting change. New York: Harcourt Brace College. Taylor, B. A., Hoch, H., Potter, B., Rodriguez, A., Spinnato, D., & Kalaigan, M. (2005). Manipulating establishing operations to promote initiations toward peers in children with autism. Research in Developmental Disabilities, 26, 385–392. Taylor, B. A., & Levin, L. (1998). Teaching a student with autism to make verbal initiations: Effects of a tactile prompt. Journal of Applied Behavior Analysis, 31, 651– 654. Vollmer, T. R. (2002). Punishment happens: Some comments on Lerman and Vorndran’s review. Journal of Applied Behavior Analysis, 35, 469–473. Watson, T. S., & Sterling, H. E. (1998). Brief functional analysis and treatment of a vocal tic. Journal of Applied Behavior Analysis, 31, 471–474. Wright, C. S., & Vollmer, T. R. (2002). Evaluation of a treatment package to reduce rapid eating. Journal of Applied Behavior Analysis, 35, 89–93.

3 Cognitive Behavior Therapy ELLEN FLANNERY-SCHROEDER and ALEXIS N. LAMB

INTRODUCTION Increasingly, attention is turning to the significance of children’s mental health. This attention results from a confluence of information sources collectively emphasizing the prevalence of childhood problems. Epidemiological estimates for the prevalence rates of childhood emotional and behavioral disorders range between 15 and 22% (e.g., McCracken, 1992; Roberts, Attkisson, & Rosenblatt, 1998; Rutter, 1989; Kazdin & Weisz, 2003a; WHO, 2001). These rates may be underestimates as epidemiological studies often do not include children exhibiting subclinical distress despite the fact that these subclinical conditions have been found to be associated with significant functional impairments (e.g., Angold, Costello, Farmer, Burns, & Erkanli, 1999). Childhood difficulties have been associated with problems in adolescent and adult adjustment (e.g., Colman, Wadsworth, Croudace, & Jones, 2007). Evidence exists suggesting that childhood psychopathology has long-term social consequences including truncated educational attainment, teen parenthood, early marriage, and marital instability (e.g., Kessler, Berglund, Foster, Saunders, Stang, & Walters, 1997; Kessler, Molnar, Feurer & Appelbaum, 2001; Kessler, Foster, Saunders, & Stang, 1995; Kessler, Walters, & Forthofer, 1998; Forthofer, Kessler, Story, & Gotlib, 1996). Despite the evidence that a large number of children are diagnosed or at risk for disorder, research has suggested that as few as 40% of children experiencing mental health problems receive help and only about 20% receive specialty mental health services (Burns et al., 1995). Hence, there is a real need for easily accessed, client-acceptable, and effective interventions for childhood mental health issues. In recent years, the child therapy literature has grown with a profusion of empirical investigations of

ELLEN FLANNERY-SCHROEDER and ALEXIS N. LAMB

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University of Rhode Island.


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Table 3.1. General Characteristics of Cognitive Behavioral Approaches Fairly structured Time-limited (5–20 sessions; 45–50 minutes) Session agenda setting Goal setting Homework Experimental orientation to human behavior Problem-oriented focus Collaborative empiricism Behavioral experiments Measurable outcomes Performance-based assessments/procedures Skill- and knowledge-building Psychoeducation (e.g., directed reading, rating scales, handouts) Behavioral methods (e.g., behavioral rehearsal) Cognitive methods (e.g., cognitive restructuring)

efficacy. Many of these investigative efforts have involved cognitive-behavioral treatments. Cognitive-behavioral treatments (CBTs) with youth have garnered a good deal of clinical and research attention of late (e.g., Christner, Stewart, & Freeman, 2007; Friedberg & McClure, 2002; Graham, 2005; Kazdin & Weisz, 2003b; Kendall, 2006; Mennuti, Freeman, & Christner, 2006; Reinecke, Dattilio, & Freeman, 2006a). Cognitive-behavioral approaches have been used for a broad array of childhood problems including, but not limited to, anxiety, depression, anger, aggression, eating disorders, autism, and learning difficulties. Numerous treatments (e.g., self-instructional training, problem-solving therapy, stress inoculation therapy, social skills training) have fallen under the heading of cognitive-behavioral. These varied treatments, however, share some common features (see Table 3.1). Early child treatment models have been downward extensions of treatments designed for adults. Many researchers have sounded a call for intervention and prevention programs that are based on theory and research emerging from the field of developmental and child clinical psychology (Greenberg, Domitrovich, & Bumbarger, 2001; Holmbeck, O’Mahar, Abad, Colder, & Updegrove, 2006; Kazdin, 2001; Weisz & Weersing, 1999). All CBTs with children are based on an explanatory model of behavior that emphasizes cognitive processing, behavior, and affective responding. CBT finds its roots in classical and operant conditioning and social learning theory.

UNDERLYING THEORY OF CBT In its most basic form, the cognitive-behavioral model posits that one’s response to events is dependent upon one’s perception or interpretation of that event. In other words, children respond to a cognitive representation

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of the event, not the event itself. If one’s interpretation of the situation is not supported by the facts or reality, then the thinking is deemed distorted, irrational, or dysfunctional. One of the goals of CBT is to identify and restructure the dysfunctional thoughts and beliefs related to one’s self, world, and future (Beck, 1970). The manner in which children think about situations or events will determine not only their affective response but also their behavior. These cognitive representations and resulting affect and behavior are reciprocally determined. That is, changes in one result in changes in the other. CBT therapists aim to educate children about this reciprocal relationship and to heighten awareness of their cognitive processes (i.e., self-statements). Cognition is thought of as an information-processing system with different levels, structures, and processes. Automatic thoughts, intermediate beliefs, and schemas comprise three components of the system. Automatic thoughts are those situation-specific self-statements that we make without deliberation or reasoning. They are closest to our conscious level of thinking and therefore are easily accessed. Beck and colleagues (1979; Clark, Beck, & Alford, 1999) have described characteristic errors in logic in automatic thoughts. Sample categories of cognitive errors include magnification or minimization, overgeneralization, all-or-nothing thinking, and personalization. Much research evidence has demonstrated that adults and children with psychological disorders (e.g., depression, anxiety) have a high frequency of distortions in their automatic thoughts (e.g., Bogels & Zigterman, 2000; Haaga, Dyck, & Ernst, 1991; Hollon, Kendall, & Limry, 1986; Kazdin, 1990; Kendall, Stark, & Adam, 1990; Schniering & Rapee, 2002, 2004; Wright, Beck, & Thase, 2003). Intermediate beliefs comprise those attitudes, rules, and assumptions that one holds (e.g., “If I don’t get an A on my math test, I am a failure.”). These beliefs may be out of conscious awareness, unspoken, and often reflect conditional “if-then” thinking. Core beliefs (or schemas) represent thinking which is absolute (e.g., “I am unlovable.”). These beliefs may be characterized as “global, rigid, and overgeneralized” rules for interpreting one’s environment (Beck, 1995, p. 16). According to Beck’s (1976) content-specificity hypothesis, thought content is specific to psychological disorder or affective state. As an example, Beck’s model posits that cognitive processes in depression center on loss, hopelessness, and failure whereas cognitive processes in anxiety focus on perceived threat, danger, and uncontrollability. Two relatively recent studies using both community and clinic-referred samples of children and adolescents have demonstrated support for the content-specificity hypothesis (e.g., Epkins, 2000; Schneiring & Rapee, 2004) whereas others (e.g., Epkins, 1996; Treadwell & Kendall, 1996; Ronan & Kendall, 1997) have found mixed support. Once children become adept at metacognition (i.e., thinking about their own thinking), children are taught strategies to modify their thinking. The modification of irrational or distorted thinking occurs through cognitive (e.g., collection of “evidence” against which to evaluate the veracity of the irrational thought, Socratic questioning, problem-solving)

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or behavioral (e.g., behavioral experiments designed to “test” the validity of beliefs or to build skills) means. It is important to note, however, that the reliance on cognitive versus behavioral techniques is often determined both by the nature of the disorder as well as the age of the child. As an example, behavioral techniques may have greater utility in work with younger children. Contingent reinforcement is often used to enhance a child’s motivation and involvement in therapy. The process of CBT has often been described as collaborative empiricism: therapist and child work together to form and experimentally “test” hypotheses through the collection of behavioral evidence. Together, therapist and child monitor the progress of therapy, making necessary revisions and refinements across time. To best fulfill the goals of cognitive behavioral therapy, one must consider the child’s functioning (e.g., cognitions, affect, and behavior) within a context. Therapists must consider biological, cultural, social, environmental factors to best understand the contextual influences impinging upon the child. The field of developmental psychopathology has come to recognize that change involves a dynamic interplay among the individual characteristics and contextual systems (Cairns, Cairns, Rodkin, & Xie, 1998). Recognition of these contextual systems is especially important given the fact that children have little control over choosing and altering their environments (Erickson & Achilles, 2004).

ASSESSMENT METHODS Numerous assessment techniques have been researched and cited in the child assessment literature. Therapists select certain measures and assessment tools depending on the nature of the information they seek. For cognitive behavioral therapists, particular assessments are more widely used than others. These include functional assessment, behavioral observations, interviews, self-report/parent-report measures, and outcome assessment techniques. The collection of information from multiple sources known to the child provides the most accurate picture of the child, his or her difficulties, and the surrounding systems that contribute to these difficulties. Similarly, using multiple methods to gather information from the child and family will result in a more thorough understanding of the target problem (Krain & Kendall, 1999; Pellegrini, Galinski, Hart, & Kendall, 1993). Assessment tools that differ in the means of information access will tap into different processes. For example, behavioral observations carried out by the therapist will provide fundamentally different information than self-report measures completed by the child and/or the child’s parents. Each of the aforementioned assessment techniques will be discussed below.

Functional Assessment The main goal of a functional assessment is to systematically examine the problem behaviors exhibited by the child in order to plan the most effective way of addressing those behaviors. Information regarding the child


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or adolescent’s overt behaviors, emotional behaviors, and cognitive/verbal behaviors is used to ascertain the target problem(s) that need treatment. After identification of the target problem, a variety of assessments are used to determine what promotes and reinforces this behavior for the child. These are commonly referred to as antecedents and consequences of the target problem. According to Zarb (1992), four different types of assessments are generally used to conduct functional analyses: repeated self-report measures, behavioral observations of the child and family, interviews with the child and family, and school report forms. Combining information from both the child’s school and the child’s family provides the therapist with a more complex understanding of why and when the target problem occurs, thus allowing the therapist to develop the most effective treatment.

Behavioral Observations Many of the difficulties addressed by CBTs are observable. The anxious child shows obvious signs of fear in certain situations (e.g., sweating, shaking), the depressed child appears withdrawn and “flat,” and aggressive children demonstrate antagonistic behavior towards others. These are just a few examples of overt signs characteristic of internalizing as well as externalizing disorders. Behavioral observation relies upon close scrutiny of these overt signs to assess how well the child or adolescent is functioning given the target problem. Observing the child or adolescent in session allows the therapist to witness first-hand the child’s behavior and interpersonal functioning. Observing the interactions between the child and her family can also provide information about how significant others in the child’s life may be contributing to the development and/or maintenance of the target problem. Even brief parent–child interactions in the therapy setting can be very informative as parents may be unaware of the impact of their behavior on the child. Consequently, behavioral observation will provide information that interviews and self-report measures may not. Additionally, behavioral observation can provide valuable information when it is implemented in a more natural setting, such as a child’s home or school. Therapists can develop a greater understanding of the impact of the targeted problem when they observe the manner in which it interferes in every-day situations.

Interviews Whereas observations have the unique advantage of allowing the therapist to witness first-hand certain interpersonal and/or family dynamics that may be involved in the maintenance of the target problem, interviews provide the therapist with historical information about the problem. During interviews, therapists have an opportunity to gain knowledge about relationships within the family as well as child- and parent-reported strategies for modifying behavior (Pellegrini et al., 1993). Semi-structured interviews are recognized as being reliable and valid for making diagnoses, and they are commonly used in CBT assessments (Clark, 2005). The CBT therapist will not only pay attention to the child’s behavior during the interview but also to any cognitions that the child may share during the

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interview that may be contributing to the target problem. For children and adolescents, interviews are generally conducted with both the child and the parents, either separately or together. Interviews with both parent and child together allow for observation of the interactions, whereas separate interviews offer greater freedom for both parties to speak openly about the presenting problem and surrounding issues.

Self-Report Measures Questionnaires completed by the child or adolescent and his parents provide yet another source of information for the therapist. For younger children, more valuable information may be garnered from parent-report of the child’s behavior. However, when working with adolescents, there are many self-report measures that address internal states and cognitions. For example, certain self-report measures assess attributions regarding the world around them (Pellegrini et al., 1993). This type of information is generally more difficult to gather during an observation or interview and may be quite hard for parents to report on accurately. For some children and adolescents, self-report measures may represent a less intimidating way to share thoughts and feelings that are otherwise too uncomfortable to express. Parent-report forms and teacher-report forms have significant utility as they provide information about what occurs outside the therapy setting. Teachers and parents spend the most time with children and, as a consequence, are invaluable sources of information about child functioning. Although behavioral observations in the school or home certainly provide useful information to the therapist, questionnaires are significantly more cost- and time-effective. Use of these forms during the initial assessment and throughout treatment is essential in the monitoring of treatment progress (Pellegrini et al., 1993).

Outcome Assessments As with most types of psychotherapy, cognitive-behavioral therapy monitors symptomatology throughout treatment to assess progress. If the child is showing little or no progress, this may be an indication to the therapist that either the initial conceptualization of the target problem and corresponding contributing factors is incorrect or that the treatment formulation may need alteration. Outcome assessments provide an objective way to evaluate the impact of treatment. Many of the aforementioned assessments may be implemented as outcome assessments, yet certain types may be considered more objective than others. For example, selfreport measures and other questionnaires are less likely to be biased by the therapist’s expectations for treatment gains although they may be influenced by the child’s expectations. Re-administration of structured interviews by an independent diagnostician at the end of treatment also provides a relatively objective indication of changes in the child’s functioning as a result of receiving services. Behavioral observations, although somewhat less objective than


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questionnaires and structured interviews and certainly more difficult to code, can also provide useful information about treatment outcome. For example, observations of a socially anxious child interacting comfortably with a stranger at the end of treatment can be an excellent index of outcome if that child was unable to make or sustain eye contact with others at the beginning of treatment. Such obvious and clinically meaningful treatment gains can easily be captured by behavioral observations.

Cultural Considerations When providing assessment or treatment services for children of different cultures, it is important to take into account both the appropriateness of the assessment measures as well as norms and expectations inherent to the child’s cultural background. Many measures that are used commonly in CBT have not been normed on non-European-American cultures. Consequently, evaluating a child’s score relative to existing norms may be very misleading. Moreover, research has shown significant differences across cultures in the prevalence and intensity of different emotions (Okazaki & Tanaka-Matsumi, 2006). For example, Latin American individuals report high levels of positive affect, whereas individuals from Asian cultures generally do not report high levels of positive affect (Okazaki & Tanaka-Matsumi, 2006). As a result, an Asian American woman who shows low positive affect may “present” as depressed or dysthymic when actually she is within the normative range given her cultural background. Alternatively, a Latino American man who might be exhibiting reduced affect relative to his cultural norms may not be identified as such if he is evaluated against existing norms. In addition, more research needs to be conducted on the reliability, validity, and utility of behavioral assessments in other cultures (Okazaki & Tanaka-Matsumi, 2006). Cultures vary in their conceptualizations of what is considered “appropriate” or “acceptable” behavior. Thus, therapists are urged to be cautious when assessing children from other cultures or ethnicities. It is critical to ascertain relevant information regarding the child’s cultural background before arriving at conclusions about target problems and contributing systems.

THERAPEUTIC TECHNIQUES Common cognitive behavioral therapeutic techniques include affective education, cognitive restructuring, contingency management, behavioral rehearsal, problem-solving, and self-monitoring, self-evaluation, and selfreinforcement. CBTs often use a few, many, or all of these techniques in the conduct of therapy.

Affective Education An important first step towards identifying and changing faulty cognitions is recognizing the emotions associated with these thoughts. Children and adolescents often lack the insight or maturity to realize that their body

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produces physiological reactions to emotional states. For example, an anxious child might feel “butterflies in her stomach” when she finds herself in an anxiety-producing situation. Instead of recognizing, for example, that she is nervous, this child might conclude that she is sick with a stomachache. Affective education addresses this disconnect between the physical and psychological experiences of emotional states. Children and adolescents are often asked to reflect upon ways in which people demonstrate their feelings. This may be done via role-playing or charades, by drawing pictures of faces or people experiencing different feelings, or simply jotting down a few signs that someone is angry, sad, happy, or confused. This focus on the physical signs of emotions is applied to the child so that the child is asked to think about what happens to his or her body when a certain emotion is experienced. For some children, it is helpful to either provide a drawing of a human body or have them draw a person on which they can circle or otherwise mark the part of their body in which they experience a somatic symptom (e.g., drawing a hammer hitting the head to indicate the experience of headaches). Children and adolescents are encouraged to view these feelings as “clues” to their emotional experience. In such a way, coping mechanisms can be put into place at the first physiological signs of emotional distress in an effort to prevent a worsening of the emotional and/or physical response.

Cognitive Restructuring A key element of CBT is recognizing and altering the faulty cognitions that underlie the emotional distress. For a depressed adolescent, for example, the maladaptive automatic thoughts might include, “I’m not good at anything,” and “No one is ever going to like me.” There are many creative ways to help children and adolescents identify their automatic thoughts. One way to illustrate the concept in a more concrete way for younger children is to use cartoons and to talk about the character’s “thought bubble” (see Kendall & Hedtke, 2006). This is a very visual way for children to gain insight into cognitive processes. Use of cartoon characters can help to illustrate, for example, that two people in the same situation may have different thoughts, and, as a result, will experience different emotions and/or behaviors. Once children have mastered the skill of identifying their self-talk, they are taught to undergo a rational analysis of that selftalk. Is there evidence to support their thinking? Is there another way of looking at the situation? Through this process, children are able to modify their dysfunctional thinking from irrational to rational, and the cognitivebehavioral model then predicts a corresponding decrease in emotional and behavioral distress.

Contingency Management Cognitive-behavioral therapy places strong emphasis on the consequences of behavior. In line with the fundamental principles of behavior therapy, positive consequences will increase the frequency of behavior whereas negative consequences will reduce the frequency. As such, contingency management


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is an effective means to create and sustain behavioral modifications. Contingency management procedures often include the praising of desired behaviors and/or planned ignoring of undesired behaviors. Often rewards are used to heighten engagement in therapy tasks; however, rewards are only effective to the extent that they are desirable to the child. The rewards may be material (e.g., small trinkets or toys) or social in nature (e.g., selecting the dinner menu at home, attending a movie, or staying up a half hour later at night). Often treatment begins with the provision of material rewards then shifts into the provision of social rewards later in treatment in order to enhance the likelihood of sustaining the provision of rewards by parents after treatment. Consistency in contingency management is essential to promote effective maintenance of treatment gains.

Behavioral Rehearsal Behavioral rehearsal is a crucial part of both cognitive and behavioral change. Behavioral rehearsal involves the simulation of situations inside the therapy room for the purpose of skill development and practice. Thus, behavioral rehearsal can help children to utilize new ways of responding to life situations that cause them difficulty. Once new response patterns are trained in therapy, they are then tested out in “real world” settings. Some children find it difficult to role-play; others relish the opportunities. Clearly, the success of behavioral rehearsal is dependent upon a child’s openness to engagement in the activity. Behavioral rehearsal typically proceeds in a steplike fashion with easier to manage situations practiced prior to more difficult ones. Corrective feedback is provided by the therapist; however, the child is encouraged to self-monitor and evaluate her own performance as well. Often modeling of the skill is necessary when the child’s skill deficit is profound or corrective feedback is proving ineffective. Once the child demonstrates mastery of the skill being practiced, therapist and child move to the next more difficult situation. Homework assignments are critical to ensure that the skill receives practice in vivo.

Problem-Solving Bedell and Lennox (1997) have proposed a problem-solving model that includes seven steps in the problem-solving process. The seven steps include: (1) recognize the existence of a problem, (2) define the problem in a goal-directed manner in which your own and other’s unmet wants are identified, (3) brainstorm problem solutions without evaluation of their possible efficacy, (4) evaluate the potential effectiveness of the alternatives generated, (5) select the best alternative or combination of alternatives, (6) implement the chosen solution, and (7) verify the effectiveness of the chosen solution. Thus, the problem-solving process acknowledges that there is a conflict to be addressed, and it provides a structured way for approaching the problem.

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The cognitive-behavioral approach requires that the therapist lead the child through the steps under the guiding principle of collaborative empiricism. Together, therapist and child brainstorm numerous potential solutions (some likely ineffective, some silly, some first-rate) without regard to their potential usefulness until the possibilities are exhausted. Next, the therapist and child evaluate each item on the list both in terms of its effect on the child’s thoughts and feelings and in light of the probable consequences of the choice: “If you did this, how would you feel? Would it help you in this situation to do that?” Once the child has identified those alternatives likely to be helpful in the resolution of the problem, he has developed an admirable problem-solving strategy. As with all CBT techniques, the goal is to teach the child how to independently use problem-solving so that it becomes a tool that may be frequently referred to by the child. Problem-solving is applicable to a wide-range of difficulties and can be used in the treatment of depression, anxiety, anger management, attentional problems and myriad other challenges.

Self-Monitoring, Self-Evaluation, Self-Reinforcement In order for children to be able to effectively use many of the abovementioned CBT techniques independently, they must have the ability to reflect on their thoughts, feelings and actions and use that information to regulate their behavior. Developmental level must be considered when honing these skills with children and adolescents as younger children may lack the insight necessary for this process, thus requiring more external reinforcement at first. For all child clients, self-monitoring, self-evaluation, and self-reinforcement techniques will need to be modeled by the therapist so that the child develops an awareness of how to self-monitor. Depending on the target issue of the child, self-monitoring can be structured or even scheduled. For example, a child with attention-deficit problems can be asked at the end of every class at school to write down how well she did at trying to concentrate during class. In the beginning, it is helpful to have the child or adolescent record the data when selfmonitoring so that later the therapist and child can evaluate the data together in the spirit of collaborative empiricism. This allows opportunities for therapist modeling of self-evaluation and self-reinforcement. For younger children, a scale or wheel depicting different levels of satisfaction may make the self-evaluation process more concrete and thus more effective. When training a child to self-reinforce, it is important to illustrate that decisions about whether a self-reward is deserved is made in light of effort as well as outcome. Children must be taught to see the nuances of success in order to reward themselves appropriately. For example, if a socially anxious child works up the nerve to say hello to another child on the playground, the anxious child is worthy of self-reward regardless of the other child’s response. Initially, the self-monitoring, self-evaluation, and self-reinforcement processes will be externalized as the therapist models for the child. Homework assignments may include keeping a log that serves as a record of self-monitoring, self-evaluation,


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and self-reinforcement practice. Last, the therapist tapers his or her guidance as the child develops mastery over the process and begins to implement the skills independently.

EMPIRICAL SUPPORT ACROSS DISORDERS The past few decades have seen a remarkable increase in the number of studies demonstrating empirical support for the effectiveness of various forms of psychotherapy. Many of these studies have looked at the overall effectiveness of therapy. That is, in general, does therapy result in positive gains? Initial studies focused on outcomes for adults receiving therapy, and results indicated positive effects (e.g., Shapiro & Shapiro, 1982; Smith, Glass & Miller, 1980). However, when various orientations and types of therapy were compared, no significant differences were found. This phenomenon was deemed the “Dodo bird verdict” in reference to Lewis Carroll’s Alice in Wonderland in which the dodo bird said, “Everyone has won, and all must have prizes” (Rosenzweig, 1936). In other words, any form of psychotherapy results in positive gains, and all these gains are roughly comparable. The “Dodo bird verdict” implies that the specific technique used is not as important as some underlying commonality shared by all forms of psychotherapy. However, in an attempt to replicate Smith et al.’s 1980 meta-analysis, Shapiro and Shapiro (1982) found slightly discrepant results. Although factors such as target problem appeared to have a greater impact on treatment outcome than type of treatment, there was evidence suggesting that cognitive and behavioral treatments demonstrated greater treatment gains than other forms of psychotherapy (e.g., dynamic therapy). Several meta-analyses were conducted to evaluate whether the “Dodo bird verdict” also applied to child therapy outcomes. Results were mixed. Each meta-analysis found positive effects for psychotherapy with children and adolescents, however, results varied in terms of whether all types of treatment were equally effective. Casey and Berman (1985) found little support for the superiority of behavioral treatments over nonbehavioral treatments in their meta-analysis of 75 studies of children 13 or younger at the time of treatment. Although, in general, behavioral treatments had better outcomes, Casey and Berman concluded that there were too many potentially confounding factors (e.g., different target problems) to be able to attribute differences in outcomes to type of treatment. Weisz, Weiss, Alicke and Klotz (1987), in a meta-analysis of psychotherapy studies including both children and adolescents, found the mean effect size for behavioral treatments to be significantly greater than nonbehavioral treatments. This difference remained significant even when analyses were conducted to control for the child’s age, target problem, and therapist level of training. Later, a subset of the studies included in the Weisz et al. (1987) meta-analysis were subjected to further analysis by Weiss and Weisz (1995) to evaluate whether the apparent superiority of behavioral treatments was due to higher methodological quality of behavioral interventions, resulting in larger effect sizes for those treatments.

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Results suggested that the difference in effect sizes for behavioral and nonbehavioral treatments was not an artifact of methodological quality. A subsequent meta-analysis by Weisz, Weiss, Han, Granger, and Morton (1995). also failed to support the “Dodo bird verdict” for psychotherapy with children and adolescents. Behavioral treatments again exhibited higher effect sizes than nonbehavioral treatments, although effect sizes in this study were somewhat more conservative than those found previously. Weisz, Weiss, et al. (1995) asserted that, because the studies used in their meta-analysis had not been included in previous meta-analyses, “the present findings must be seen as rather strong independent evidence of the replicability of this ‘non-Dodo verdict’” (p. 461). They note, however, that of the 150 studies involved in this meta-analysis, only 10% included nonbehavioral treatments. Similarly, there were relatively few nonbehavioral studies in Weisz et al.’s (1987) meta-analysis, thus limiting the potential generalizability of this sample to all nonbehavioral interventions. In addition to broader meta-analyses studying the effectiveness of behavioral versus nonbehavioral treatments, there have been numerous studies focusing specifically on the efficacy of CBTs with children and adolescents. As Ollendick, King, and Chorpita (2006) have argued, any form of psychotherapy used in treatment should have first been shown to be effective in randomized clinical trials (RCTs). These trials allow for comparisons of CBT to either other forms of treatment or to control groups, and these comparisons may provide scientific evidence supporting the effectiveness of CBTs. CBT has been one of the most researched forms of treatment, and over 300 RCTs have shown it to be an effective way of addressing a range of Axis I disorders (Wright, Basco & Thase, 2006). Over the past two decades, structured treatments, such as CBT, have been shown empirically to be one of the more effective forms of psychotherapy (Erickson & Achilles, 2004). During the 1990s, the use of CBT with children and adolescents was supported by the treatment outcome literature (Braswell & Kendall, 2001). CBT has been shown to be effective with children and adolescents with depression, anxiety, attention-deficit difficulties, oppositionality, aggression, autism, mental retardation, low self-esteem, poor academic skills, learning disorders, eating disorders, and other difficulties (Braswell & Kendall, 2001; Clark, 2005; Craighead, Craighead, Friedburg & McClure, 2002; Kazdin & Mahoney, 1994; Kendall, 1991, 2006; Reinecke et al., 2006b). In fact, CBT is considered a “probably efficacious” treatment for the treatment of childhood anxiety disorders (Kazdin & Weisz, 1998; Ollendick & King, 1998), ADHD and depression (Ollendick et al., 2006) as well as aggression, anger, and conduct disorders (Kazdin, 2003, 2005; Larson & Lochman, 2002; Lochman, Barry, & Pardini 2003). Although the treatment outcome literature has shown consistent support for CBT, many clinicians claim that this research is of questionable utility in nonlaboratory-based treatment clinics (Weisz, Donenberg, Han & Weiss, 1995). This is due to the possibility of limited transportability of treatment outcome results. There are many factors that may affect treatment outcome that vary between research settings and clinical practice. First, study samples in clinical trials may not be representative of the general


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population of clinical patients. Whereas clinical clients are often seeking services, study participants are more actively recruited. In addition, researchers aim to recruit a somewhat homogenous sample so that treatment can focus on one or two target problems, whereas clinicians may find themselves treating a wide variety of diagnoses and difficulties. Second, the research experimenters are not comparable to therapists in clinical practice. They may differ in amount and type of training and supervision. Research therapists will have undergone intensive pretherapy training on the intervention being used in the study. Practicing clinicians, however, rarely receive such training. Third, the manner in which treatment is administered is unique to research settings. Study participants are not permitted to obtain simultaneous services elsewhere, and experimenters must strictly follow treatment protocols. In general practice, however, clinicians may use several techniques depending upon the child or adolescent’s responsiveness to therapy (Ollendick et al., 2006; Weisz, Donenberg, et al., 1995). Weisz, Donenberg, et al. (1995) assert that the meta-analyses showing overall positive effects for psychotherapy must be considered in light of these limitations. Only nine studies included in the broad meta-analyses included what they call “clinic therapy” which involves clients, therapists, and settings that approximate actual clinical practice. All other studies included in the meta-analyses involved strictly “research therapy.” Weisz, Donenberg, et al. (1995) calculated the effect sizes for the nine studies involving “clinic therapy” and found that the mean effect size for these studies was much lower than that of the “research therapy” studies. In evaluating this difference, Weisz and colleagues identified two possible explanations. First, behavioral methods, which generally have higher effect sizes, are more common in “research therapy” than in clinical practice. Consequently, the higher effect sizes might actually be due to a greater percentage of behavioral treatments included in the “research therapy” studies. If “clinic therapy” studies included more behaviorally based treatments, the difference in effect sizes might be reduced. Second, clients who actively seek out treatment in clinical settings may be fundamentally different than those therapy clients who are recruited for study participation. Recruited clients may have less complex problems, rendering them more likely to be successful in treatment.

THERAPEUTIC RELATIONSHIP CBT is sometimes mistakenly viewed as having little emphasis on the quality of the therapeutic relationship. However, many CBT therapists assert that the therapeutic relationship is one of the most essential components of treatment (e.g., Beck et al., 1979; Kendall, 1991). Most schools of therapy view the therapeutic alliance as an important variable in treatment outcome. Most conceptualizations of alliance use Bordin’s (1979) definition in which alliance is comprised of three facets: an agreement on goals, an assignment of task(s), and the development of a bond. Cognitive-behavioral therapy clearly emphasizes each of the three facets. It has

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been proposed that the therapeutic relationship may be more important in child versus adult therapy. As children rarely self-refer and therefore may be unwilling or unable to acknowledge difficulties and adolescents are in the process of becoming more autonomous, the formation of a strong therapeutic alliance can be particularly challenging (DiGiuseppe, Linscott, & Jilton, 1996; Shirk & Karver, 2003; Shirk & Russell, 1998). A multitude of studies have examined the relationship between therapeutic alliance and treatment outcome in adult treatment samples (e.g., Barber et al., 1999; Gaston, Thompson, Gallagher, Cournoyer, & Gagnon, 1998; Horvath & Luborsky, 1993; Horvath & Symunds, 1991; Martin, Garske, & Davis, 2000; Stiles, Agnew-Davies, Hardy, Barkham, & Shapiro, 1998), and there is a confluence of evidence that efforts to build strong therapist–client relationships has a positive impact on the results of treatment. The research on therapy alliance and outcomes in child therapy, however, is strikingly less well developed. In a meta-analysis of 23 studies examining relationship variables in child and adolescent therapy, Shirk and Karver (2003) found the association between therapeutic relationship and outcome to approximate the results found in studies of alliance–outcome relations in adults. The correlations were modest (weighted r = .22) but consistent across developmental levels and types of treatment. Similar findings were reported by Green (2006) and Kazdin, Marciano, and Whiley (2005). In contrast, Hogue, Dauber, Stambaugh, Cecero, and Liddle (2006) found no effect on outcome for alliance measured early in treatment in a sample of 100 adolescents randomized to CBT or family therapy for substance abuse.

Therapist Characteristics Not all therapists are created equal. As Kendall and Choudhury (2003) note, treatments are often described as though they are equally effective across therapists. This may be especially true of manualized treatments. However, we know that therapists differ on a wide variety of dimensions (e.g., energy, animation, self-disclosure, warmth, flexibility, sociability, adherence to protocol). Therefore, it is unlikely that they impart little effect on outcome. Research on the importance of the therapist’s contributions to therapeutic alliance and outcome has been sparse (Garfield, 1997). It stands to reason that there may be particular therapist characteristics which hasten (or detract from) alliance and/or treatment outcomes. The importance of investigating the role of the therapist is heightened by the difficulty in disentangling the effects of the treatment from the effects of the therapist. That is, true treatment effects may be obscured by therapist competency (or incompetency) or other therapist characteristics (e.g., therapist efficacy, therapist training and supervision; Elkin, 1999). Ackerman and Hilsenroth (2003) examined therapist characteristics and techniques that have a positive impact on the therapeutic alliance in therapist–adult client relationships. Therapist characteristics including being flexible, honest, respectful, trustworthy, confident, warm, interested, and open were found to be positively correlated with therapeutic alliance.


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Little is known, however, about the personal attributes of the therapist that have a positive impact on the child–therapist alliance. Although one may assume that the therapist characteristics approximate those found in the adult literature, more research is needed to draw firm conclusions. One study investigating therapist flexibility in the administration of a manualized CBT for childhood anxiety disorders failed to find an association between therapist-rated flexibility and treatment outcome (Kendall & Chu, 2000).

Child Characteristics Child therapy outcome studies must concern themselves with those child characteristics that may mediate or moderate outcomes. Age, gender, ethnicity, familial or cultural background, socioeconomic status, and other child characteristics have received relatively little research attention. Are there preferred ages or developmental stages for the effective implementation of cognitive-behavioral interventions? Durlak, Fuhrman, and Lampman (1991) conducted a meta-analysis on the effectiveness of CBT for children with a variety of mental health problems. The authors looked at developmental stage as a moderator of outcome and found a larger effect size (.92) for children at the formal operational level (age 11–13) than for children at less advanced levels (age 7–11, effect size = .55; and age 5–7, effect size = .57). Thus, the authors conclude that children who are more cognitively mature may be more capable of abstract thinking and deductive reasoning, making them more likely to benefit from CBT. Conversely, in a study examining the predictors of remission from major depressive disorder in children and adolescents treated with CBT, Jayson, Wood, Kroll, Fraser, and Harrington (1998) found older age to be associated with the poorest outcomes. Similarly, in the field of anxiety disorders, there is some evidence to suggest that younger children might benefit more from CBT than older children, especially when the family is involved in treatment (Barrett, Dadds, & Rapee, 1996; Hudson, Kendall, Coles, Robin & Webb, 2002). For example, Southam-Gerow, Kendall, and Weersing (2001) found that those children who were identified as poor responders (retained an anxiety diagnosis posttreatment) were more likely to be older than children in the good treatment response group (no posttreatment anxiety disorder). Several hypotheses have been suggested to explain why younger children may do better. Older children’s disorders may be more chronic and resistant to change or they may be more “nonnormative” in the course of development, making them less well able to navigate the tasks of adolescence. Younger children may benefit more due to an increased involvement from parents. Last, it might be the case that treatment materials commonly used in anxiety treatment packages for youth (e.g., Coping Cat; Kendall & Hedtke, 2006) may be more age-appropriate for younger children. If the latter is true, it may be that interventions designed for middle childhood may need substantial modifications prior to use with adolescents. Gender has received limited attention as a factor in treatment outcomes of CBT. Although gender has been identified as a significant variable in the

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research on depressive disorders, the role of gender in treatment efficacy remains unclear. Some evidence suggests that adolescent girls show better outcomes in psychotherapy outcome research; yet this finding is not specific to CBTs (Weisz, Weiss, Han, Granger, & Morton, 1995). Research on CBT outcomes for childhood anxiety disorders yields conflicting findings regarding the effects of gender. Some studies fail to find gender effects on outcome (e.g., Southam-Gerow et al., 2001); other studies have found significant effects with female children faring better (e.g., Mendlowitz, Manassis, Bradley, Scapillato, Miezitis, & Shaw, 1999). Moreover, there exists some evidence that child gender may influence the effectiveness of parental involvement in treatment. Barrett et al. (1996) found that females who participated in a CBT plus family management condition had more positive outcomes than those in conditions without parental involvement. Similarly, Cobham, Dadds and Spence (1998) found that girls with an anxious parent were more likely to be diagnosis free if they had participated in the CBT plus parent anxiety management condition. Cognitive-behavioral models for the treatment of youth have received criticism for a lack of developmental sensitivity (e.g., Reinecke et al., 2006b; Weisz & Weersing, 1999). It is essential to evaluate a child from a developmental systems framework. As mentioned previously, most CBTs for children have been adaptations of treatments formulated for adults. As such, many CBTs for children may be anchored in the “developmental uniformity myth” (Kendall, Lerner, & Craighead, 1984). This myth holds that childhood disorders present akin to and are responsive to the same treatment procedures as adult disorders. Thus, assessments and treatments may fail to consider age, developmental level, timing of intervention, and other developmental issues. In the course of development, important changes in reasoning, emotional understanding, judgment, and language among other cognitive capacities, undergo significant changes in content, organization, and structure (Toth & Cicchetti, 1999). Given these significant changes during this developmental period, it may be that childhood and adolescence are critical periods during which skill building and alteration of one’s developmental trajectory is possible (Reinecke et al., 2006b). Moreover, it may be the case that treatments vary in effectiveness across ages or that treatments need to be implemented differently at different ages. For example, younger children may require greater in-session flexibility, especially with the use of manualized interventions. Additionally, younger children may require the use of more behavioral (versus cognitive) interventions (O’Connor & Creswell, 2005). Thus, developmentally informed CBT models are a must. Holmbeck and colleagues conducted two reviews of the empirical research examining developmental factors in the design and evaluation of cognitive-behavioral interventions for adolescents. Although the first review (1990–1998; Holmbeck, Colder, Shapera, Westhoven, Kenealy, & Updegrove, 2000) found only 26% of the articles directing attention to developmental issues, a more recent review (Holmbeck et al., 2006) found that 70% of the articles considered developmental issues in the design and evaluation of outcome. It appears that developmental issues are receiving increased


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attention in recent years, however, Holmbeck and colleagues note that, in the 2006 study, at least half of the studies failed to interpret results in light of developmental issues and very few (22%) evaluated age as a moderator of outcome. Attention to moderator variables such as resiliency, aptitudes, and protective factors is critical in the development of prevention efforts.

CONTEXTS As briefly discussed earlier in this chapter, a cognitive-behavioral framework must provide explicit attention to the child in various contexts (e.g., family, school, peer group, ethnicity, culture, religion). Numerous researchers have proposed that the inclusion of family members (namely, parents) in the therapeutic process is an effective means to enhance treatment success (e.g., Ginsburg, Silverman, & Kurtines, 1995; Kazdin, 1993; Kendall, 1994; Silverman, Ginsburg, & Kurtines, 1995). Ginsburg and colleagues (1995) have described a transfer of control model in which an expert therapist passes along knowledge, skills, and methods to the child, either directly or from therapist to parent to child. However, they note some “blocks” that may occur in this transfer process. The “blocks” often involve maladaptive family processes (e.g., parental psychopathology, dysfunctional family relationships). In order to clear the pathway to facilitate transfer of control, parental inclusion in therapy is a necessity. Although many therapists support the inclusion of parents, especially with young children, there remain questions regarding the degree to which and in what capacity parents should be involved in child treatment. Are parents informants, consultants, or co-clients? The degree of parental participation is likely to be determined in part by child age and type of presenting problem. Hays (2006) has noted the widespread omission of ethnic and cultural information in clinical research. Research on CBT, for example, has almost exclusively relied on individuals with European American identities (Hays, 1995; Iwamasa & Smith, 1996; Suinn, 2003). Thus, the success and limitations of CBT with minority populations have not been evaluated. Due to CBT’s experimental orientation to human behavior, there may exist an implicit assumption that CBT is value-neutral. Hays (2006) notes that “CBT is as value laden as any other psychotherapy” (p. 7). In fact, CBT’s emphasis on rationality and definitions of adaptive versus maladaptive behaviors may conflict with values and ideals prominent in other cultures (e.g., spirituality). Training in working with diverse populations, sensitivity workshops, and consultations with experts in cultural diversity are all necessary to ensure sensitivity.

FUTURE DIRECTIONS Despite the apparent efficacy of CBT with children, there remain substantial numbers of children who do not progress in treatment. Little research has been conducted on how to address these treatment-resistant

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cases. In the case of a less than successful outcome, are there particular treatment techniques that may be employed? Is medication warranted? Should frequency or length of treatment sessions be increased? Is work with parent(s) needed? These questions will linger until treatment research addresses how to facilitate improvement in all cases. The answers lie in understanding the mechanisms of therapeutic action in CBT, and despite much treatment outcome research, research on knowing how and why CBT works remains sparse (Kazdin & Nock, 2003; Shirk & Karver, 2006). While research on the efficacy of cognitive-behavioral interventions is amassing, the majority of randomized clinical trials evaluating CBT have used waitlist control conditions. Much work remains to evaluate the relative efficacy of CBT and active control conditions. Also, much of the research has employed CBT treatment “packages.” That is, most CBT treatments are comprised of several cognitive-behavioral elements (e.g., cognitive-restructuring, homework, problem-solving training); yet little is known about the influence of individual elements on treatment outcomes. Other methodological considerations include evaluation of CBT efficacy with youth via an examination of clinical as well as statistical significance (e.g., Kendall, 1999; Kendall & Grove, 1988, Kendall, Marrs-Garcia, Nath & Sheldrick, 1999). Whereas statistical significance determines the likelihood that a mean difference may have resulted by chance, clinical significance can determine the meaningfulness of the magnitude of change. In treatment outcome research, clinical significance may be helpful in evaluating whether deviant scores have been returned to within normal limits on a particular assessment measure. There is a clear call for more developmentally oriented research designs. For example, longitudinal designs would better evaluate CBT’s impact on developmental processes and trajectories. However, longitudinal designs bring additional considerations. Issues such as measurement equivalence remain to be resolved (Kendall & Choudhury, 2003). In the measurement of a particular construct across time, it is likely that several measures will be warranted in order to ensure that the measures are developmentally appropriate. However, the comparability of these measures is at issue. For example, do the Children’s Depression Inventory (Kovacs, 1981) and the Beck Depression Inventory (Beck,Ward, Mendelson, Mock, & Erbaugh,1961; Beck, Steer, & Garbin, 1988) measure depression in a similar manner? How can one evaluate depression across the span of early childhood and into young adulthood? Longitudinal designs also afford an opportunity to consider the indirect effects of treatment (Kendall & Kessler, 2002). Given the long-term social and economic consequences of childhood psychopathology, researchers should examine for treatment impacts on the sequelae of targeted disorders (e.g., impact of childhood anxiety treatment on adolescent or early adulthood substance use). In addition, there is a great need to generate treatment samples from ethnically and socioeconomically diverse populations in order to enhance treatment generalizability and transportability. Regarding the latter, there is little reason to believe that all CBTs found efficacious in the research lab will show a corresponding efficacy in clinical settings. However, the extent to which the results of randomized clinical trials can be applied in the “real world” remains to be determined by research (Kendall & Southam-Gerow, 1995; Persons & Silberschatz, 1998; Silverman, Kurtines, & Hoagwood, 2004; Southam-Gerow, Weisz, & Kendall, 2003).


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Stiles, W. B., Agnew-Davies, R., Hardy, G. E., Barkham, M., & Shapiro, D. A. (1998). Relations of the alliance with psychotherapy outcome: Findings in the second Sheffield Psychotherapy Project. Journal of Consulting and Clinical Psychology, 66, 791–802. Suinn, R. M. (2003). Answering questions regarding the future directions in behavior therapy. The Behavior Therapist, 26, 282–284. Toth, S. L., & Cicchetti, D. (1999). Developmental psychopathology and child psychotherapy. In S. W. Russ & T. H. Ollendick (Eds.), Handbook of psychotherapies with children and families (pp. 15–44). New York: Kluwer. Treadwell, K. R. H., & Kendall, P. C. (1996). Self-talk in youth with anxiety disorders: States of mind, content specificity, and treatment outcome. Journal of Consulting and Clinical Psychology, 64, 941–950. Weiss, B., & Weisz, J. R. (1995). Relative effectiveness of behavioral versus nonbehavioral child psychotherapy. Journal of Consulting and Clinical Psychology, 63, 317–320. Weisz, J. R., Donenberg, G. R., Han, S. S. & Weiss, B. (1995). Bridging the gap between laboratory and clinic in child and adolescent psychotherapy. Journal of Consulting and Clinical Psychology, 63, 688–701. Weisz, J. R., & Weersing, V. R. (1999). Developmental outcome research. In W. K. Silverman & T. H. Ollendick (Eds.), Developmental issues in the clinical treatment of children (pp. 457–469). Boston: Allyn & Bacon. Weisz, J. R., Weiss, B., Alicke, M. D., & Klotz, M. L. (1987). Effectiveness of psychotherapy with children and adolescents: A meta-analysis for clinicians. Journal of Consulting and Clinical Psychology, 55, 542–549. Weisz, J. R., Weiss, B., Han, S. S., Granger, D. A., & Morton, T. (1995). Effects of psychotherapy with children and adolescents revisited: A meta-analysis of treatment outcome studies. Psychological Bulletin, 117, 450–468. Wright, J. H., Basco, M., & Thase, M. E. (2006). Learning cognitive behavior therapy: An illustrated guide. Washington, DC: American Psychiatric. Wright, J. H., Beck, A. T., & Thase, M. E. (2003). Cognitive therapy. In R. E. Hales & S. C. Yudofsky (Eds.), The American psychiatric publishing textbook of clinical psychiatry (4th ed., pp.1245–1284). Washington, DC: American Psychiatric. World Health Organization. (2001). The world health report: 2001: Mental health: New understanding, new hope. Geneva, Switzerland: Author. Zarb, J. (1992). Cognitive behavioral assessment and treatment with adolescents. New York: Brunner/Mazel.

4 Parent-training Interventions NICHOLAS LONG, MARK C. EDWARDS, and JAYNE BELLANDO

Prior to the 1960s, therapy for children typically involved traditional one-on-one sessions with a therapist addressing intrapsychic issues rather than specific behaviors (Kotchick, Shaffer, Dorsey, & Forehand, 2004). However, in the early 1960s a paradigm shift started in regard to psychosocial treatment for children’s behavior problems. This paradigm shift was the function of several factors (Kotchick et al., 2004) including a growing concern that traditional psychodynamic approaches were not very effective in addressing immediate issues related to children’s behavior problems nor in changing children’s behavior in the home. Around the same time period, behavior modification techniques were beginning to be successfully utilized to change children’s behavior (Williams, 1959). The confluence of such factors created momentum for the concept of therapists training parents to utilize specific behavior management techniques to change their children’s’ behavior. By the mid- to late-1960s the use of parents as formal behavior change agents for their children’s behavior started to take hold and the roots of “parent training” were established (Hawkins, Peterson, Schweid, & Bijou, 1966; Wahler, Winkel, Peterson, & Morrison, 1965). Although most of the early research in parent training was conducted by those coming from a behavioral orientation, it should be noted that the use of parents as change agents was also advocated by professionals from various orientations including those coming from a psychodynamic perspective (e.g., Zacker, 1978).

NICHOLAS LONG, MARK C. EDWARDS, and JAYNE BELLANDO for Medical Sciences and Arkansas Children’s Hospital

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Gerald Patterson’s (1982) research on coercive parent–child interactions offered a major contribution to the early development of parent training. His model on reciprocal influences provided an explanation as to how the behavior of both parents and children contribute to the escalation of child aggression and behavior problems. The model explained how children use high rates of aversive behaviors to stimulate parental attention, and in turn, this parental attention reinforces the children’s aversive behavior. Such parental attention can involve either giving in to the aversive behavior or using coercive tactics (e.g., nagging, yelling) in an attempt to stop the aversive behavior. Patterson’s model also helped explain how children’s behavior simultaneously reinforces and escalates parental use of coercive tactics through negative reinforcement. Thus his model of reciprocal influences helped explain how children’s disruptive behavior can escalate while parent management tactics become more punitive and coercive. Such coercive exchanges within the home were believed to be “basic training” for the development of aggression and disruptive behavior that generalizes to other settings. The entry into this coercive cycle was considered to be ineffective parenting, especially in regard to child compliance to parental directions during the preschool years (McMahon & Wells, 1998). Since its development in the 1960s, behavioral parent training has gone through three distinct stages of development (McMahon & Forehand, 2003). The first stage, during the 1960s and early 1970s, focused on the initial development of a “parent training” intervention model. The parent training model, based on Tharp and Wetzel’s (1969) triadic model, utilized a therapist (consultant) who taught the parent (mediator) to reduce the child’s (target) disruptive behavior (McMahon & Forehand, 2003). The research conducted during this first stage was largely limited to case studies or singlecase designs. However, during this first stage, evidence was obtained that demonstrated that, at least in the short-term, parent training interventions could produce changes in both parent and child behaviors. At about the same time, researchers also started to examine different strategies (e.g., written instructions, videotaped instruction, modeling, etc.) for teaching parents how to use specific behavior management strategies (e.g., Flanagan, Adams, & Forehand, 1979; Nay, 1975; O’Dell, Mahoney, Horton, & Turner, 1979; O’Dell, Krug, O’Quinn, & Kasnetz, 1980). Parents could learn to effectively use specific techniques through a variety of instructional modes. However, there was also the realization that although parents could be taught basic behavior modification techniques through various instructional modes, to effectively address significant child behavior problems interventions for parents needed to be more multifaceted and take into account the complexities of parent–child interactions in the home (Kazdin, 1985). The second stage of parent training research, from the mid-1970s to the mid-1980s, focused on social validity and the generalization of treatment effects. Issues examined included whether behavior changes observed in the clinic generalized to the home, whether improvements were seen in behaviors other than the target behaviors (behavioral gen-

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eralization), and whether behavior changes were maintained over time (temporal generalization). The third stage in the development of parent training, from the mid1980s to present, has focused primarily on ways to enhance the effectiveness of parent training. The primary focus of parenting training research since its beginnings has been in the area of children’s disruptive behavior. This focus has been the result largely due the belief that disruptive behavior in the home is often inadvertently developed, exacerbated, or sustained by maladaptive parent–child interactions (Kazdin, 2003; Patterson, 1982). These maladaptive interaction patterns include reinforcing disruptive behavior, the use of ineffective parental directions, and the failure to adequately reinforce appropriate behavior. Today parent training is considered one of only a handful of empirically supported treatments for children’s externalizing behavior problems (Kazdin, 2005). The following section summarizes this research base.

AN OVERVIEW OF THE EMPIRICAL SUPPORT FOR PARENT TRAINING There have been hundreds of studies that have evaluated programs designed to train parents to intervene with their children’s problems. The volume of studies examining the effects of parent training is reflected in the number of reviews that have been published. From 1972 to 2006, there have been no less than 17 narrative reviews (Atkeson & Forehand, 1978; Berkowitz & Graziano, 1972; Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004; Dembo, Sweitzer, & Lauritzen, 1985; Graziano & Diament, 1992; Johnson & Katz, 1973; Kohut & Andrews, 2004; Mooney, 1995; McAuley, 1982; Moreland, Schwebel, Beck, & Well, 1982; O’Dell, 1974; Sanders & James, 1983; Todres & Bunston, 1993; Travormina, 1974; Wiese, 1992; Wiese & Kramer, 1988) and at least four quantitative reviews (Cedar & Levant, 1990; Lundahl, Nimer, & Parsons, 2006; Lundahl, Risser, & Lovejoy, 2006; Serketich & Dumas, 1996) that have specifically focused on parent training outcomes. In addition to the above reviews, other papers have examined parent training interventions as part of a broader review of psychosocial treatments for children and adolescents in general (Weisz, Weiss, Han, Granger, & Morton, 1995) and specific child and family problems, such as conduct problems (Brestan & Eyberg, 1998; Bryant, Vissard, Willoughby, & Kupersmidt, 1999; Dumas, 1989; Kazdin, 1987; Miller & Prinz, 1990; Webster-Stratton, 1991) and ADHD (Chronis, Jones, & Raggi, 2006; Pelham, Wheeler, & Chronis, 1998). As indicated by the number of reviews, parent training interventions are among the most frequently and rigorously studied of the psychosocial interventions for children. To illustrate the scope of studies, a recent quantitative analysis of parent training outcomes with disruptive behaviors identified 430 studies published in peer-reviewed journals between 1974 and 2003 (Lundahl, Risser, & Lovejoy, 2006). The literature on the effi-

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cacy of parent training interventions varies considerably in terms of study methodology, program features, and participant characteristics. In this section, we examine the immediate, generalization, and moderator effects of training parents to intervene with their children.

IMMEDIATE EFFECTS OF PARENT TRAINING There is substantial evidence that supports the short-term effectiveness of parent training as a general treatment approach. Lundahl, Risser, and Lovejoy (2006) conducted a meta-analysis of experimental and quasiexperimental studies that evaluated the effects of parent training programs on child behavior, parent behavior, and parent perceptions. This study examined 63 studies from 1974 to 2003 that included 83 treatment groups. Overall, this study reported immediate effect sizes of .42, .47, and .53 for child behavior, parent behavior, and parent perceptions outcomes, respectively. The magnitude of these effect sizes can be considered moderate.1 These effect sizes compare favorably to the average effects of other behavioral (d = .54) and nonbehavioral (d = .30) psychotherapy treatments (Weisz et al., 1995). Many of the early reviews focused almost exclusively on behavioral parent training programs as they represent the majority of studies. Nonbehavioral parent training programs tend to lag behind behavioral programs not only in number, but also in methodology. For example, of the 63 experimental studies review by Lundahl, Risser, and Lovejoy (2006), only 14 parent training programs had a nonbehavioral focus. In their study, the behavioral programs were found to have significantly higher methodological rigor than the nonbehavioral programs. There are also other differences between behavioral and nonbehavioral parent training studies that make comparisons difficult. The majority of behavioral studies used clinical samples, whereas the majority of nonbehavioral studies used nonclinical samples. Furthermore, parent training programs with different theoretical orientations tend to target different outcomes, making direct comparisons impossible. Nonetheless, several narrative reviews have examined the methodology and efficacy of parent training programs from different theoretical orientations (i.e., reflective, Adlerian, & behavioral; Dembo et al., 1985; Mooney, 1995; Todres & Bunston, 1993). All three reviews noted that few studies met the criteria for well-designed investigations, and the diverse methodologies precluded direct comparisons of efficacy. All three reviews reported mixed results, with positive findings following what would be expected from the specific theoretical orientation. For example, the Adlerian programs showed a greater percentage of positive findings in the outcome domain of parental attitudes and perceptions, and behavioral programs showed a greater percentage of positive findings on child behavior.

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Cohen (1988) defined effect sizes as small, d = .2, medium, d = .5, and large, d = .8.


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The largest subgroup of parent training outcome studies are those that evaluated programs which train parents in behavioral child management strategies to address deviant behaviors, such as aggressiveness, temper tantrums, and noncompliance. Behavioral parent training (BPT) typically included strategies such as differential reinforcement of other behavior, extinction, and time-out. An early narrative review was supportive of the efficacy of BPT with deviant behavior. Atkeson and Forehand (1978) reviewed 24 studies which included three outcome measures (observations, parent collected data, and parent completed measures) and reported positive results in all three outcome domains. Serketich and Dumas (1996) conducted a meta-analysis of studies evaluating the effects of behavioral parent training program on child antisocial behavior and parental adjustment. They analyzed 27 studies from 1969 to 1992 that included 36 comparisons between experimental and control groups. In these studies, 22 received some form of individually administered BPT and 13 received BPT in a group format. The average numbers of sessions was 9.53 (SD = 4.17). This study reported a mean effect size for overall child outcome of .86, which is considered large (Cohen, 1988). The mean effect sizes for child outcome based on parent, observer, and teacher were .84, .85, and .73, respectively. The mean effect size for outcomes of parental adjustment was moderate at .44. As a result of the favorable outcome evidence, behavioral parent training for oppositional children has been designated by the American Psychological Association Task Force as an empirically validated intervention (Chambless et al., 1996). Several studies have evaluated the efficacy of BPT programs with parents of children with ADHD. Seven of eight studies which compared BPT with no treatment reported positive findings (Anastopoulos et al., 1993; Duby, O’Leary, & Kaufman, 1983; O’Leary, Pelham, Rosenberg, & Price, 1976; Pisterman et al., 1989; Pisterman et al., 1992; Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001; Thurston, 1979). However, the effects of BPT were not found to be superior to a cognitive-behavioral self-control therapy (Horn, Ialongo, Popovich, & Peradotto, 1987; Horn, Ialongo, Greenbert, Packar, & Smith-Winberry, 1990) or stimulant medications (Firestone, Kelly, Goodman, & Davey, 1981; Horn et al., 1991; Klein & Abikoff, 1997; Pollard, Ward, & Barkley, 1983; Thurston, 1979). BPT has not been shown to enhance treatment response when combined with medications (Firestone et al., 1981; Horn et al., 1991; Klein & Abikoff, 1997; Pollard et al., 1983). However, there is some evidence that suggests that combining BPT with medications may allow for lower doses of medications (Horn et al., 1991) or lead to enhanced outcomes in functioning (social skills; improved parent–child relationships; parenting) and consumer satisfaction (Hinshaw et al., 2000; Multimodal Treatment Study of Children with ADHD Cooperative Group, 1999). Reviews of parent training interventions with ADHD populations have concluded that more systematic study is needed but that existing studies provide sufficient evidence to consider parent training an effective treatment for ADHD (Chronis et al., 2004; Kohut & Andrew, 2004; Pelham, Wheeler, & Chronis, 1998).

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BPT has been evaluated with other specific childhood problems. Graziano and Diament (1992) reviewed 186 empirical studies that evaluated the efficacy of BPT with childhood problems. In addition to problems with conduct and hyperactivity, studies have examined BPT with children with mental retardation, physical disabilities, autism, overweight, enuresis, fears, and other specific behavioral problems. They concluded that the BPT showed clear positive results for conduct problems and discrete child behavior problems (e.g., enuresis, fears, weight reduction), some success with hyperactivity, and mixed results with autism and mental retardation. For the latter two conditions, they suggested that BPT may be more effective in improving parent outcomes than child behavior. A recent randomized controlled trial of parent education and skills training interventions supports this notion (Tonge et al., 2006). This study showed significant improvements in the functioning of parents of young autistic children following treatment relative to the control group. There have also been some mixed results evaluating BPT with children with anxiety disorders. A recent study tested Parent Child Interaction Therapy (PCIT; a manualized BPT program) with three families of children with separation anxiety using a multiple-baseline design (Choate, Pincus, Eyberg, & Barlow, 2005). This study found clinically significant changes in both separation anxiety and disruptive behaviors. Another study raised the question of what specific treatment components were active in producing change in children with separation anxiety (Silverman et al., 1999). This randomized clinical trial compared interventions that included an exposure-based behavioral parent training component with a control group offered parent therapeutic support and information. The results showed improvement in measures of both child and parent functioning across all groups. These results suggested that generic parent support and education is as effective as parent training with an “active” therapeutic component for children with separation anxiety. Lundahl, Nimer, and Parsons (2006) conducted a meta-analysis of studies evaluating the effects of parent training programs on parent risk factors related to child abuse and documented abuse. They identified 23 studies from 1970 to 2004 that included 25 parent training treatment groups. Of the 23 studies, 17 used pre–post only designs. The parent training interventions used in these studies varied on a number of characteristics, including theoretical orientation (behavioral, nonbehavioral, mixed), location of intervention (home, office, mixed), delivery mode (group, individual, mixed), and number of sessions. Immediately following parent training, parents showed moderate improvement in outcome variables. The average effects sizes were .60 for attitudes linked to abuse, .53 for emotional adjustment, .51 for child-rearing skills, and .45 for documented abuse. There was a significant difference between the effect sizes of studies with a control group (d = .30) and those without (d = .62) for the emotional adjustment outcome variable, suggesting (at least for this variable) that the effects are more in the small to moderate range. In a recent randomized trial of an enhanced Parent Child Interaction Therapy program (PCIT; a manualized BPT program) with physically abusive parents (Chaffin et al, 2004), parents receiving PCIT showed significant


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reductions in negative parent behaviors in a structured parent–child interaction observation compared to the control group. Other measures of child and parent behavior and parent functioning showed improvements across both experimental and control groups. Cedar and Levant (1990) conducted a meta-analysis of studies that evaluated the efficacy of the Parent Effectiveness Training program (PET; Gordon, 1970) on the behavior and cognitive adjustment of both children and parents. Most of the studies were doctoral dissertations rather than peer reviewed journals. PET is based on a reflective/Rogerian approach rather than a behavioral orientation and consists of training parents in the use of active listening, “I” messages, and conflict resolution. Cedar and Levant examined 26 studies from 1975 to 1990. Their analyses found no to small effects on outcomes related to child attitudes and behaviors (ds = .12 & .03, respectively), small to moderate effects for child self-esteem (d = .38), small to moderate effects on parent attitudes and behavior (ds =.41 & .37, respectively), and large effects on outcomes related to parental knowledge of course content (d =1.10).

Generalization Effects It is reasonable to assume that changing parents’ behavior would result in some generalization of treatment effects across time and settings and to untreated siblings. Although there is some supporting evidence for such generalization, confidence in the generalizability of treatment effects would be increased with additional studies with improved methodology, such as larger sample sizes, multiple outcome measures, and control groups. Three of the four meta-analytic studies reviewed above evaluated the follow-up effects of parent training. The long-term effect (interval not reported) of the PET program showed an attenuation of overall effect over time, from small to moderate (d = .35) to small (d = .24; Cedar & Levant, 1990). Of the 23 studies that evaluated the efficacy of parent training programs on child abuse risk factors reviewed by Lundahl, Nimer, and Parsons (2006), five studies reported follow-up effects for child-rearing behaviors and six studies reported follow-up effects on parental attitudes and emotional adjustment. The effects were moderate for child-rearing attitudes (d =.65) and small for emotional adjustment and child-rearing behaviors (ds =.28, .32, respectively). Both of these reviews did not report separate follow-up effects for studies that employed control groups at follow-up and those that did not. Lundahl, Risser, and Lovejoy (2006) reported on the follow-up effects (1 to 12 months post treatment) of behavioral parent training programs. They reported the effects of those studies that employed a control group at follow-up and those that did not. Studies that include a control group at follow-up can provide a more accurate picture of the long-term impact. The follow-up impact of the programs that used a control group at followup was shown to maintain in the moderate range for parent perceptions (d =.45) and to attenuate from moderate in magnitude at post-test to small at follow-up for child behavior (d =.21) and parenting skills (d = .25). A couple of recent studies reported follow-up effects of BPT with physically abusive parents and parents of children with Oppositional Defiant

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Disorder. Chaffin and his colleagues (2004) reported follow-up data (median interval of 2.3 years) in their randomized controlled trial of a BPT program with physically abusive parents. Forty-nine percent (49%) of parents in the control group (standard community group intervention) had a re-report for physical abuse at follow-up compared to 19% of parents assigned to the BPT group. Reid, Webster-Stratton, and Hammond (2003) reported on a two-year follow-up of 159 four- to eight-year-old children diagnosed with Oppositional Defiant Disorder and treated with a behavioral parent training program (Incredible Years). At posttreatment, 46.2% of participants who received parent training alone and from 55% to 59.1% who received parent training in combination with teacher or child training, showed clinically significant changes (defined as a 20% reduction in ratings of behavior) at posttreatment compared to 20% of controls. At the two-year follow-up, the percentage of participants who received the parent training alone or in combination with teacher or child training who showed clinically significant improvements was 50%, 81.8%, and 60%, respectively. No control group was used at this two-year follow-up. There is some support for the generalization of behavioral parent training treatment effects to untreated siblings. Four studies showed significant improvements in the untreated siblings observed compliance (Humphreys, Forehand, McMahon, & Roberts, 1978; Eyberg & Robinson, 1982) and deviant behavior (Arnold, Levin, & Patterson, 1975; Wells, Forehand, & Griest, 1980) at posttreatment. In one study, the improvements were maintained at a six-month follow-up (Arnold et al., 1975). Eyberg and Robinson (1982) reported significant improvements in observed parent behavior with untreated siblings and no significant reductions in the number or intensity of negative sibling behaviors. Two early studies failed to show generalization of treatment effects from clinic to school settings (Breiner & Forehand, 1981; Forehand et al., 1979). However, McNeil, Eyberg, Eisenstadt, Newcomb, and Funderburk (1991) reported significant improvements in teacher-rated deviant behavior and observations of appropriate and compliant behaviors at school in ten children treated with a BPT program relative to controls. In this study, they selected subjects who showed high levels of behavior problems across home and school settings at pretreatment and who all showed clinically significant improvements in home behavior after treatment.

Moderator Effects A number of child, parent, and program characteristics have been associated with parent training outcomes, such as child age, child IQ, family’s socioeconomic status, parental social support, parental education level, parental functioning, family stress, and ethnicity (see Graziano & Diament, 1992 for review); however, relatively little research has been done where these characteristics have been studied as independent variables. Lundahl, Risser, and Lovejoy (2006) assessed moderator effects of parent training in their meta-analysis. They found financial disadvantage to be the most salient moderator of outcomes. Children and parents from non-disadvantaged families benefited more across the child behavior, parent


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behavior, and parental perception outcome constructs compared to disadvantaged families. They also found that marital status was a moderator of child behavior outcomes. Studies with a higher percentage of single parents (Number of studies (k) = 29) did not show as much change as studies with a lower percentage of single parents (k = 16). There have been some mixed results related to child’s age and parent training outcomes in three quantitative reviews. The Lundahl, Risser, and Lovejoy (2006) and the Cedar and Levant (1990) meta-analyses found no relationship between age and positive outcomes, whereas Serketich and Dumas (1996) reported a positive relationship between age and positive outcomes. There have been some program characteristics associated with parent training outcomes, including the format of training and number of sessions. In their meta-analysis, Serketich and Dumas (1996) found a nonsignificant correlation between the effect size for the overall child outcome and the format of the treatment (individual vs. group). Studies have found individual, group, and self-administered BPT to be equally effective and superior to a no-treatment control group (Webster-Stratton, 1984; Webster-Stratton, Kolpacoff, & Hollinsworth, 1988). Lundahl, Risser, and Lovejoy (2006) also found no differences in effect sizes between face-to-face and self-directed interventions. However, they reported that among the 20 studies that treated financially disadvantaged families, individual parent training resulted in significantly greater improvements in child and parent behavior than group parent training. There were no differences between individual and group treatment in the parental perceptions outcome domain. Lundahl, Nimer, and Parsons (2006) found that studies whose programs were more than 12 sessions had greater improvements in parental attitudes linked to abuse compared to programs with fewer than 12 sessions. No differences in child-rearing behavior were found between programs with low and high number of sessions.

SUMMARY OF THE EMPIRICAL EVIDENCE OF PARENT TRAINING There have been a substantial number of studies evaluating parent training programs from different theoretical orientations and across different child problems. As a whole, the research is supportive of the immediate effectiveness of parent training across many parent and child outcome domains. Parent training can be considered at least moderately effective which compares very favorably to the effects found for other psychotherapy treatments. More specifically, there is sufficient evidence to consider behaviorally oriented parent training programs efficacious in treating children with oppositional and ADHD problems. Although results are mixed and more studies needed, there is evidence to support the generalization of parent training effects across time, and some evidence to suggest generalization across settings and to untreated siblings in some families. Of course there are limitations in examining the effectiveness of parent training programs in general by relying on the results of meta-analytic reviews. As stated previously, parent training programs vary significantly

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across a number of factors (e.g., theoretical basis, format and content of the intervention, target behaviors, length of the intervention, etc.) and some programs are more effective than others.

OVERVIEW OF SELECTED PARENT TRAINING PROGRAMS As is clear from the review of the empirical support for parent training, programs vary significantly. In order to provide a better understanding of some of these differences, as well as more details regarding specific programs, the next section highlights several selected parent training programs. In order to impart the greatest understanding of parent training programs, within the confines of this chapter, some programs are described in detail and others are briefly summarized.

Parent Programs That Target Externalizing Behavior Problems Helping the Noncompliant Child (HNC) Helping the Noncompliant Child is a behavioral parent training program that targets young children (two to eight years old) who exhibit high levels of noncompliance to parental directions (McMahon & Forehand, 2003). The extensive research base and evaluation studies supporting this program are thoroughly summarized in McMahon and Forehand (2003) and in Forehand and McMahon (1981). It is included on several “best practices” lists for evidence-based treatment programs for conduct problems (Brestan & Eyberg, 1998), child abuse (Saunders, Berliner, & Hanson, 2004), and the prevention of substance abuse and delinquency (Alvarado, Kendall, Beesley, & Lee-Cavaness, 2000; Webster-Stratton & Taylor, 2001). This clinic-based program involves a therapist working with individual families. The child attends all sessions with her parent(s). The primary goals of the program are to improve child compliance to directions and to decrease disruptive behavior through teaching parents more appropriate ways of interacting with their child. The intervention consists of two major phases. During Phase 1, differential attention skills are taught that are designed to improve the parent–child relationship as well as increase desirable behaviors. Phase 2 involves compliance training skills that assist parents in dealing with noncompliance and other problematic behavior. A detailed training manual is available for therapists (McMahon & Forehand, 2003). The instructional format for each session follows a standard process that includes didactic instruction and discussion of a specific skill, the therapist demonstrating the skill through modeling and role-playing, the parent practicing the skill with the therapist, the skill is then introduced to the child, the parent then practices the skill with the child while the therapist provides cues/feedback, and finally a homework assignment is given to allow the parent to practice/utilize the skill at home. Skills addressed in the program include attending, rewarding, ignoring, directions, and time-out. Phase 1 of the program involves teaching


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parents the effective use of the skills of attending, rewarding, and ignoring. Phase 2 involves teaching parents to give effective directions and how to use time-out appropriately. The clinical program typically takes 8–12 sessions to complete. The number of sessions varies from family to family because HNC uses a competency-based approach which requires parents to achieve a certain level of competence with a skill before the next skill is introduced. Details regarding the specific skills are provided below.

Phase 1 (Differential Attention Skills) Attending. Attending is a skill that parents can use to help increase their child’s desirable behaviors. It also helps lay the groundwork for a more positive parent–child relationship. After discussing, modeling, and role-playing the skill with the parent(s) the therapist helps the parent master the skill through practicing it in what is called the “child’s game.” This is a time where the child selects the play activity (e.g., playing with blocks) and the parent is nondirective. The parent is taught to simply describe a child’s activity while eliminating directions and questions addressed to the child. This practice allows the parent to master the skill of attending that will later be used to increase desirable behavior. This skill is the focus of the intervention until the parent demonstrates competence. This competence is assessed using specific behavioral criteria recorded during a structured observation. Rewarding. The second skill involves teaching the parent to praise or reward the child’s positive behavior. This skill is taught using the same instructional procedures and is practiced using the “child’s game.” The types of rewards that are taught consist of labeled verbal (e.g., “I really like it when you pick up your toys!”) and physical (e.g., hug, pat) rewards. Parents are taught to focus on and reward prosocial behaviors rather than negative behaviors. The parent has to demonstrate competence before the next skill is introduced. Ignoring. The third component of the initial phase of the program involves teaching a parent to ignore minor unacceptable behavior, such as whining and fussing. Again, the standardized instructional procedures are used. The parent is taught an ignoring procedure that involves no eye, physical, or verbal contact when minor unacceptable behaviors occur. Differential Attention Plans. After the parent has mastered the skills of attending, rewarding, and ignoring, the therapist assists the parent in targeting specific child behaviors to increase using differential attention. Parents use the skills taught in Phase 1 to implement differential attention plans with guidance provided by the therapist.

Phase 2 (Compliance Training Skills) The second phase of the program consists of teaching parents two primary components of disciplinary skills: how to give effective instructions to the child and how to use a time-out procedure appropriately. Giving effective instructions. Parents are taught the elements of giving effective instructions/commands to their child. The parent practices giving

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instructions to their child within the “parent’s game.” Unlike the “child’s game” which is used to teach Phase 1 skills and involves the parent being nondirective, the “parent’s game” involves the parent taking direction of the activities (e.g., the parent issues frequent instructions/commands while directing the activity). The therapist provides feedback to the parent regarding the directions being issued (e.g., how they could be improved). The parent is also taught to attend to or praise their child’s compliance to their directions. Time-out. Parents are taught a specific time-out procedure to use with their child. The child is also informed about the time-out protocol within the session. The therapist provides guidance to the parent in terms of issues related to time-out. The therapist then helps the parent utilize a clear instruction sequence that guides the parent in how to manage compliance and noncompliance to parental directions. Standing rules. Once the parent is effectively implementing the clear instruction sequence at home, the use of standing rules is introduced. Standing rules are typically “If … then … ” statements (i.e., rules that specify the consequences for specific behavior). The therapist assists the parents in developing appropriate standing rules. Extending the skills. The therapist discusses with the parents how they can use the skills they have been taught to manage their child’s behavior outside the home.

SELF-ADMINISTERED AND PARENTING CLASS ADAPTATIONS OF HNC Given early evidence that parents could be effectively taught child management skills through written instructions (O’Dell, Krug, Patterson, & Faustman, 1980; O’Dell et al., 1982) a booklet was written for parents that provided them with information on the core skills taught in the HNC program. An initial evaluation of this booklet in a randomized study found that the booklet appeared to be effective in helping parents learn the basic skills and utilize them to improve their children’s behavior (Long, Rickert, & Ashcraft, 1993). This led to a book, Parenting the Strong-Willed Child, being written for parents that contains a self-guided approach to learning the core skills of HNC (Forehand & Long, 2002). A six-week parenting class program (total of 12 hours) has also been developed based on the HNC program and the Parenting the Strong-Willed Child book. During each weekly 2-hour class, one of the core skills is taught to parents as well as an additional topic. Additional topics discussed in the class include creating a more positive home, improving communication, developing more patience, building positive self-esteem, and problem solving. A recent evaluation of this parenting class suggested that the class can lead to improved parenting, reduced child behavior problems, and reduced parenting stress (Conners, Edwards, & Grant, 2007). It should be noted that both the self-guided and parenting class formats are intended for parents whose children have relatively mild problems


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whereas the clinical HNC program is intended for parents whose children have more significant behavior problems.

Other Parent Programs That Primarily Target Externalizing Behavior Problems There are numerous other evidence-based parent-training programs that have been found to be effective in reducing children’s externalizing behavior problems. Three of these programs will be briefly discussed.

Parent-Child Interaction Therapy (PCIT) PCIT (Brinkmeyer & Eyberg, 2003) is similar in many ways to the Helping the Noncompliant Child (HNC) program. This similarity is a function of the fact that both programs were developed from the early work of Constance Hanf (1969). Both programs focus on young children with disruptive behavior, have two phases, and are delivered to individual families by a therapist. The two phases in PCIT are: child-directed interaction, and parent-directed interaction. Training is provided through didactic instruction, modeling, role-playing, and coaching. In PCIT, children attend most but not all of the sessions with their parents. Only the parents attend a single teaching session at the beginning of each phase. During these teaching sessions the parents are taught all of the skills for that phase (whereas in HNC the skills are taught sequentially within each phase). PCIT also emphasizes the role of traditional play therapy as part of their child directed interaction phase. There is extensive evidence supporting the effectiveness of PCIT (see Brinkmeyer & Eyberg, 2003).

The Incredible Years (TIY) TIY training series (Webster-Stratton & Reid, 2003) is a comprehensive program that has intervention components for parents, teachers, and young children (two to eight years old). TIY is an extremely well-evaluated program (see Webster-Stratton & Reid, 2003). The goals of the parenttraining component are to promote parent competencies and strengthen families. This is a videotape modeling/group discussion program. The BASIC parenting training program takes 26 hours to complete (13 weekly 2-hour group sessions). The videotapes used in the program contain 250 short vignettes (one to two minutes each) of modeled parenting skills. The vignettes are show to groups of 8 to12 parents with a therapist leading group discussion. The program focuses on teaching parents how to enhance the parent–child relationship through the use of child-directed interactive play, to use praise, and to use incentives. The program also teaches parenting techniques such as monitoring, ignoring, use of effective directions, time-out, and natural and logical consequences. Webster-Stratton has also developed an ADVANCE parent training program (Webster-Stratton & Reid, 2003). This is a 14-session videotapebased program that can be used following completion of the BASIC program. The ADVANCE program has four primary components: personal

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self-control, communication skills, problem-solving skills, and strengthening social support and self-care.

Triple P Triple P (Positive Parenting Program) developed by Sanders (Sanders & Ralph, 2004) is a unique parent-training program. Developed in Australia and currently being used around the world, Triple P is a multilevel parenttraining program that targets children 2–12 years old. The program has five levels. Level 1 is a universal parent information strategy that makes general parenting information available to all parents through the use of various strategies including tip-sheets and promotional media campaigns. Level 2 consists of a brief one- or two-session primary healthcare-based parenting intervention targeting children with mild behavior problems. Level 3 is a four-session more intensive parenting intervention that targets children with mild to moderate behavior problems. Level 4 is an eight- to ten-session individual or group parent-training program targeting children with more significant behavior problems. Level 5 is an enhanced behavioral family intervention program that is utilized for significant behavior problems that are complicated by other factors (e.g., marital conflict, high stress).

Parent Programs That Target Internalizing Behavior Problems As discussed previously, the vast majority of parenting programs have been developed to address children’s externalizing behavior problems. However, a limited number of parenting programs have been developed to specifically address internalizing behavior problems. These parent programs, unlike the programs for externalizing problems, are often used in an adjunctive manner to interventions that involve working with the child directly. This reflects the belief that: (1) although parenting may be a contributing factor to children’s internalizing problems it typically plays a less central role than it does with externalizing problems; and, (2) other intervention approaches working directly with children (e.g., cognitive-behavior therapy) have been found to be effective. In several studies researchers have found that the risk for the development of internalizing disorders in children is associated with parent–child interactions that involve parental overcontrol, less granting of autonomy, and low maternal warmth (Hudson & Rapee, 2001; Rapee, 1997; Siqueland, Kendall, & Steinberg, 1996). Child anxiety may also result in parental distress and changes in parenting practices including changes in terms of parental expectations and demands that may maintain or exacerbate children’s anxious and avoidant behaviors through negative reinforcement (Kendall & Ollendick, 2004). Therefore, although cognitive-behavioral therapy has been found to be an effective treatment for childhood anxiety disorders, researchers have recommended the involvement of parents in the treatment process as a way to improve outcomes (Barrett & Farrell, 2007). Barmish and Kendall (2005) reported several common components of parent-focused interventions for childhood anxiety:


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Removing the reinforcement of children’s anxious behavior. This included teaching parents contingency management strategies to extinguish avoidant behavior and expressions of fear and to reward courageous behavior. Specific strategies included planned ignoring, verbal praise, privileges and tangible rewards. Modeling appropriate behavior. This included teaching parents how to gain greater awareness of their own anxious behaviors and how to become better models for the children. Parents were also taught problem-solving skills, how to restructure their cognitions, and to engage in appropriate responses to anxiety-provoking situations. Reducing family conflict. This included teaching parents specific strategies to improve communication, parent–child relationships, and reduce conflict. Other. Other techniques used by some programs included teaching parents about the etiology of anxiety (and the role of the family), relaxation training, and how to build a support network with other parents of anxious children. Barmish and Kendall (2005) conducted a review and meta-analysis of nine controlled studies that have involved parents in the treatment of child anxiety. Unfortunately, there was large variability across the studies including such factors as the content of parent sessions, number and format of sessions, and who attend the parent sessions. This variability precluded any definitive conclusions to be drawn. The reported effect sizes for CBT treatment without parental involvement ranged from small to medium for self-reported data to large for parent-reported measures. When the treatment programs involved parents, the effect sizes ranged from small to large for self-reported measures to large for diagnostician and parent-reported measures.

FRIENDS for Life Program One program that targets internalizing behavior problems is The FRIENDS For Life Program (Barrett & Farrell, 2007; Barrett & Shortt, 2003), which targets childhood anxiety, and includes a parent component. This treatment program, which was initially designed to be a group-based intervention (it has also been adapted for individual clinical use), has a primary child-focused cognitive-behavioral component. That is, the primary focus is working with children directly to address their dysfunctional cognitions. The parent and family skills component is designed to be run in a group format for approximately 6 hours (typically four 1.5 hour sessions). The major focus of the parent/family skills component (Barrett & Farrell, 2007; Barrett & Shortt, 2003) is to:

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Encourage parenting strategies including attending to and reinforcing their children’s coping, approaching behaviors, and parental modeling of appropriate coping behavior to their children Teach parents self-awareness and appropriate management of their own stress and anxiety.

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Increase parents’ awareness of at-risk time for their children, how they can coach their children to cope, and reinforcing their children’s appropriate attempts to cope.

The parent component follows along with the FRIENDS components for the children. Barrett and Farrell (2007) have outlined the specific strategies of the parent component for each component as indicated by the FRIENDS acronym as summarized below. Feelings. Parents are encouraged to focus on their own responses to fear and anxiety and on learning the skills of anxiety awareness. The importance of accepting individual differences, particularly in response to feelings, is discussed. Remember to relax. Have a quiet time. Parents are taught relaxation skills and are encouraged to practice and coach other family members. Parents are also encouraged to ensure that the family has regular periods of quiet time. Parents are also encouraged to reinforce relaxation practice in children. Parents are supported and encouraged to spend quality time with their children. I can do it! I can try my best! Parents are encouraged to become aware of their own cognitive style and how their responses to stress model optimism or pessimism to their children. Parents are encouraged to use positive thoughts and to notice and reward their children for positive thoughts. Parents are also asked to use positive prompts (e.g., “You can do it, you’ve done it before”) with their children. Explore solutions and coping step plans. Parents are taught how to help their child develop coping step plans (based on a fear hierarchy). They are given examples of coping step plans and rules to help ensure the success of coping step plans. Now reward yourself! You’ve done your best! Parents are encouraged to notice brave/confident behaviors and reward approach behaviors. Parents are also taught to ignore complaining and avoidance behaviors. Don’t forget to practice. Parents are taught to encourage their child to use their FRIENDS plan. They are also encouraged to role-play with their children how to utilize the skills to handle upcoming challenges. Smile! Stay calm for life. Parents are encouraged to help their children recognize they have effective strategies for overcoming challenges they will face.

Parent Programs That Target Developmental Disorders The role of parents in the treatment of children with developmental disorders has significantly changed over the past several decades. Parents have moved from being minimally, if at all, involved in their children’s treatment to being integrally involved. This transition has been especially significant for some disorders such as autism. In the not too distant past, parenting style (cold and rejecting) was considered to be the cause of autism (Bettleheim, 1967). Fortunately, autism is no longer considered an emotional problem related to parenting but rather a neurodevelopmental disorder for which parents can play an important role in helping interventions succeed.


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The literature on parent training for children with developmental disorders and specifically autism has, for the most part, developed separately from the parent training literature for areas such as disruptive behavior disorders (Brookman-Frazee, Stahmer, Baker-Ericzen & Tsai, 2006). In reviewing the literature on parent training and autism spectrum disorders (ASD) Brookman-Frazee and colleagues (2006) identified some general differences when compared to more traditional parent training studies for disruptive behavior disorders. They report that parent groups for ASD tend to be smaller and that studies often include single case examples, single case design, and more descriptive reports. Programs for ASD tend to include more modeling of behaviors for parents. They also tend to include more home treatment components and fewer strictly didactic components for parents. The degree of parental participation varies significantly across treatment programs for ASD and other developmental disabilities. The level of parental involvement is discussed below for some of the most popular treatment programs for ASD.

Planned Activities Training (PAT) Planned Activities Training (Lutzker & Steed, 1998) is a parent-training approach that focuses on antecedent prevention of challenging behaviors. Unlike many other parent-training approaches that rely primarily on contingency management techniques, PAT teaches parents to plan and to structure activities in order to prevent challenging child behaviors. PAT has been used successfully to reduce inappropriate behaviors with various groups including children with developmental disabilities (see Lutzker & Steed, 1998). PAT involves teaching parents time-management skills, how to choose activities, how to explain activity rules, incidental teaching, feedback, and reinforcement. This training of parents is provided by a therapist across five structured sessions with an individual family. Training initially involves teaching parents to use the techniques for activities that are not problematic. As parents master the techniques more problematic activities and settings are targeted. Training involves extensive modeling, parent practice, and performance feedback. Training sessions are typically conducted in family homes and in settings where challenging behaviors occur.

Parent Involvement in Lovaas’s Treatment Program for Autism The early applied behavior analysis (ABA) interventions focused on the child and did not involve the parents. However, in an early study by Lovaas and his colleagues (Lovaas, Koegel, Simmons, & Long, 1973) it was noted that children who were discharged back to families who were eager to participate in treatment did much better in maintaining skills (or improving skills) learned during the one-year treatment program (Lovaas, 2003). This anecdotal evidence was seminal in Lovaas’ understanding of the need for parental involvement with the children diagnosed with autism. However, the extensive demands of parental implementation of an ABA intervention

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(for at least 40 hours a week) requires a lifestyle change that is impossible for many parents. It should be noted that the effectiveness of using parents for the delivery of an ABA program is not clear. A recent study compared the outcomes of ABA intervention provided by parents with that provided by students (Smith, Groen, & Wynn, 2000). At four-year follow-up the children enrolled in the student therapist group made more gains than the children in the parent therapist groups on IQ tests, visual spatial skills, and in specific aspects of language. There is some evidence to suggest that parents who participate in parent training for their children with autism continue to use some of the behavioral techniques they were taught, but many tend to stop using the complete set of operant learning procedures including ongoing formal data collection (Harris, 1986).

Pivotal Response Training (PRT) Pivotal Response Training (PRT) was developed as a modified behavioral intervention for children with autism (Koegel, O’Dell, & Koegel, 1987). PRT focuses on addressing pivotal areas of functioning that can lead to widespread collateral changes in other behaviors (Koegel, Koegel, & Brookman, 2003). Although specific target behaviors are determined based on individual needs, much of the focus is on communication skills and social communication interactions. PRT differs from traditional operant training in several ways including: (1) that it allows the child to take the lead in what toys/stimulus items are used in a session, (2) it rewards goaldirected attempts at correct responses, and (3) it uses more direct/natural reinforcers in training. PRT has been found to change not only the target behaviors but also improve the affective relationship between parent and child, resulting in lower stress during family interactions, and improve positive communication (Koegel, Bimbela & Schreibman, 1996). The addition of a parent support group to the standard parent-training program has been found to improve the performance of parents in the use of the PRT techniques (Stahmer & Gist, 2001). In Koegel’s PRT, parents serve as key coordinators and interventions for the program. Initially, the individually tailored parent-training program focuses on introducing basic behavioral interventions (e.g., antecedents, behavior, and consequences), characteristics of the pivotal area of motivation, and identifying learning opportunities in the natural environment (Koegel, Koegel, & Brookman, 2003). The training program involves extensive parent practice with clinician provided feedback on parent implementation of each procedure. Specific skills taught to parents (Koegel, Koegel, & Brookman, 2003) include:

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How to present clear instructions and questions, use child-selected stimulus materials, and use direct natural reinforcers How to intersperse previously learned tasks with new acquisitions tasks (interspersing maintenance trials)


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- How to reinforce a child’s attempts to respond to instructional materials or natural learning opportunities Koegel’s research indicates that most parents reach criterion (80% correct use of the motivational procedures within the natural environment) within 25 hours of training.

TEACCH Program (Treatment and Education of Autistic and related Communication-handicapped Children) The TEACCH program, developed by Eric Schopler and his colleagues at the University of North Carolina at Chapel Hill, can be conceptualized as a network for the state of North Carolina that provides services for children with autism, education and support for families, research and training for professionals, as well as a base for international education, research, and training. It is not a single intervention. Working with the families of individuals with autism is a major component of this program (Marcus, Kunce, & Schopler, 2005). The initial work of Eric Schopler was a direct response to the psychoanalytic theories of the 1960s that parents were the cause of a child’s autism. Some of his earliest research looked at parents of children with autism and found that these parents did not have thought disorders as originally reported in the literature (Schopler & Loftin, 1969a, 1969b). His early research also found that parents of children with autism were able to accurately evaluate the variations their children’s developmental progress and that these evaluations were consistent with standardized testing results (Schopler & Reichler, 1972). These studies were seminal in incorporating parent involvement and parent report as part of the evaluation and treatment of the child with autism. Education, training, and parent support are included in the core mission statement of the TEACCH model. The key values of the TEACCH model include: (1) respecting the parent’s knowledge of their child, (2) respecting the individuality of each family, (3) respecting the love parents have for their child, (4) respecting the resilience of parents in finding solutions in the face of intense stress, (5) respecting the contributions parents make in advocating and developing new services, and (6) respecting the needs of parents for accurate information, emotional support, comprehensive services, and professional guidance for their child with autism (Mesibov, Shea, & Schopler, 2006). The TEACCH program involves parents at various levels (Marcus, Kunce, & Schopler, 2005). Parents are educated about autism, trained to work directly with their child, and to participate in advocacy efforts. Specific training efforts, in working with their child, include helping them establish positive routines through structured teaching. The TEACCH program utilizes a collaborative model in working with parents. The exact content of parent training efforts varies based on the child’s stage of development and individual family needs.

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Stepping Stones Triple P (SSTP) The Triple P (Positive Parenting Program; Sanders, 1999), which utilizes behavioral family interventions and parent management training, has been modified for use with children with autism (Roberts, Mazzucchelli, Studman & Sanders, 2006). Stepping Stones Triple P (SSTP) modifies the original program by including material sensitive to families of children with disabilities. It also covers issues relevant to this population and additional factors that could contribute to behavioral issues (i.e., problems with communication skills). A randomized control trial of SSTP (Roberts, Mazzucchelli, Studman & Sanders, 2006) with parents of children with autism found that the SSTP program resulted in a decrease in child behavior problems. Parenting changes included mothers becoming less overreactive and fathers becoming more effective in their discipline strategies. Raters found parents to be more positive in their praising of children’s behavior. These results were maintained at a six-month follow-up. The modification of existing parent training for uses with different populations, as described above, is a trend that will most likely increase in the future.

CONCLUSION From its early development in the 1960s, parent training has made great strides. It has grown from an intervention focused on helping parents to address specific child behaviors to a method of intervention used for a variety of child problems and disorders. No other psychological therapy for children has been as extensively studied (Kazdin, 2005). Meta-analytic reviews of the parent-training literature suggest that parent training is at least moderately effective. These results are very favorable when compared to the effects found for other psychotherapy approaches. Such research findings have resulted in parent training being considered one of the relatively few empirically supported treatments for children’s externalizing behavior problems. The use of parent training in other areas of childhood psychopathology and developmental disorders is less well established but is rapidly gaining support. Unfortunately, parent training is not a panacea nor is it consistently effective. Much work remains to be conducted to fully understand factors that impact the effectiveness of parent training interventions. A greater understanding is needed of how contextual factors such as ethnicity/culture, socioeconomic status, parental psychopathology, and various family stressors relate to parent training interventions. Parent-training interventions certainly need to better address issues related to ethnicity and culture, which are known to affect parenting, if treatment outcomes are to be maintained in our increasingly diverse society. At this stage of the development of parent-training interventions, more effectiveness trials are needed (the primary focus to this point in time has been on efficacy trials) (Weisz & Kazdin, 2003). That is, there is a


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growing need to move beyond assessing treatment outcomes in controlled research settings to assessing outcomes when parent-training interventions are used in “real world” clinical settings. Related to this issue is the need to study how to most effectively train clinicians in parent-training approaches. Most research studies to date (efficacy trials) have utilized therapists who are extensively trained over long periods (e.g., graduate students who are trained over years in a particular parent-training program). How can therapists at the community-level be trained to a level of proficiency that will maintain the effectiveness of the intervention? It is questionable whether traditional continuing education methods (e.g., written manuals, one- to two-day training workshops with no ongoing training support or supervision) are adequate. Perhaps newer technologies (e.g., Web-based tutorials and/or booster training sessions, Web-based group supervision) will be used to assist in training efforts. Finally, there is a need for research involving direct comparisons of different parent-training interventions to determine which approaches are most effective under which conditions. At the present time, there are many parent-training interventions that have been demonstrated to be effective; however, it is often difficult for clinicians to know which approach is best for a specific family with whom they are working. In conclusion, parent training has come a long way but still faces many challenges as this approach to intervention continues to evolve. The future of parent training looks bright as researchers and clinicians will continue to use, improve, and study this very promising intervention for treating and preventing child problems.

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5 Conduct Disorders CHRISTOPHER T. BARRY, LISA L. ANSEL, JESSICA D. PICKARD, and HEATHER L. HARRISON

INTRODUCTION Disruptive behaviors—defined here as behaviors that are associated with diagnoses of Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD)—are the most common reason for referral to mental health services for children and adolescents (Kazdin, 2003). The behaviors that comprise these diagnoses include argumentativeness, temper tantrums, often being angry or resentful, lying, stealing, hurting or threatening to hurt others, cruelty to animals, setting fires, and destruction of property (American Psychiatric Association, 2000). Kazdin (2003) estimates “conservatively” that between 1.4 million to 4.2 million children in the United States meet criteria for CD alone. Conduct problems or other externalizing behavioral difficulties constitute the most common referral issues for children and adolescents for mental health services (Brinkmeyer & Eyberg, 2003). The presence of these symptoms can be detected early in childhood (Webster-Stratton & Reid, 2003), making them amenable to treatment as long as candidates for intervention are identified and followed through with the prescribed treatment recommendations. ODD and CD encompass a broad array of acts, and young person need not exhibit all, or even most, of the symptoms of ODD and CD to warrant a diagnosis or be a candidate for intervention. Noncompliant behavior is frequently demonstrated in children with ODD or CD; however, many parents whose children do not meet diagnostic criteria for these disorders commonly report seeking outpatient mental health services for noncompliance in their children (McMahon & Forehand, 2003). One of the initial symptoms of conduct problems to emerge in children is lying (Christophersen & Mortweet, 2001). Specific behaviors

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that are associated with ODD and CD may in and of themselves be reason referring a young person for treatment, including bullying, rigidity/stubbornness, and temper tantrums (Christophersen & Mortweet, 2001; McMahon & Forehand, 2003). Researchers also suggest that oppositional behaviors, including argumentativeness and temper outbursts, typically predate the onset of the more severe behaviors that comprise CD (Greene, Biederman et al., 2002; Loeber, Green, Lahey, Christ, & Frick, 1992). To wit, current and well-supported interventions are geared toward early identification and treatment of oppositional and noncompliant behaviors more so than severe conduct problems which have a low base rate among young children (e.g., McMahon & Forehand, 2003). It should be noted that we use the terms “conduct problems, conduct disorders, and behavioral problems” essentially interchangeably and in reference to behaviors that comprise, or are similar to, the symptoms of ODD and CD. The reason behind the above consideration is that individual symptoms of either diagnosis may warrant intervention, CD often encompasses symptoms of ODD, a diagnosis of CD supersedes a diagnosis of ODD, and it may be difficult to clearly distinguish among CD, ODD, and an exaggeration of typical developmental processes, particularly in preschool-aged children and adolescents (American Psychiatric Association, 2000). The designs of treatments for conduct disorders have not only been an artifact of the theoretical perspectives that predominate at a given time but more specifically reflect the presumed causal factors (e.g., environmental, cognitive) at play in the onset and persistence of these behaviors. For example, researchers point to infrequent use of positive parenting and inconsistent or harsh parenting as factors in development and maintenance of child conduct problems (Gardner, Sonuga-Barke, & Sayal, 1999; Gardner, Ward, Burton, & Wilson, 2003). Therefore, as described below, many treatments for conduct disorders focus on these very parent factors through discussion and modeling of positive parental strategies (e.g., labeled praise, positive reinforcement based on clear contingencies) as well as effective, consistent punishment strategies (e.g., time out). Hart, Nelson, and Finch (2006) caution that these theoretical perspectives are just that, and care must be taken to not be unduly biased or exclusive in our assessment, conceptualization, and treatment of child conduct problems. They describe the importance of the therapeutic relationship, the importance of family relationships and parents, the influence of peers, and the consideration of an individual’s risk and protective factors as factors that generally cut across various interventions for these problems. Regardless of the presumed etiology of conduct disorders, the need for effective treatment is evident in the numerous domains in which conduct problems are related to impaired functioning and the fact that many conduct problem behaviors have a victim. Our discussion of treatment for conduct disorders focuses on psychosocial, as opposed to pharmacological treatments, given (a) the lack of pharmacological treatments geared specifically to ODD and CD symptoms; (b) the fact that the medicinal treatments that are implemented with children with conduct problems typically target comorbid conditions of these problems (e.g., mood

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disorders, Attention-Deficit/Hyperactivity Disorder [ADHD]) and (c) the evidence supporting psychosocial interventions in the reduction of these symptoms. The improvements in conduct problems that have been found for psychopharmalogical interventions have typically been short in duration (Farmer, Compton, Burns, & Robertson, 2002). Thus, although more research and treatment innovation are certainly needed, the evidence base for psychological/behavioral treatments of youth conduct disorders is relatively strong. With the recent and still-emerging emphasis on evidence-based practice using empirically supported treatment strategies, there exists great potential for both the expansion and synthesis of ideas on how to intervene regarding specific problem behaviors at various developmental periods. The treatments that are considered empirically supported target both the symptoms of ODD and CD, including a particular emphasis on parenting strategies to reduce noncompliance as well as work on individual coping strategies for anger-provoking events (see Brestan & Eyberg, 1998). However, the empirically supported psychosocial treatments for ADHD also may be effective for reducing conduct problems insofar as they also include strategies for reducing noncompliance and target the poor impulse control that may be at the root of many child externalizing behaviors. From the review of interventions that follows, it is apparent that many of the empirically supported treatments for conduct disorders share a view on some of the main causal pathways for problem behaviors among youth and on the techniques that will abate conduct problem symptoms. Nevertheless, key questions remain as to the most essential aspects of common strategies such as parent training (Anastopolous & Fairley, 2003), as well as the extent to which therapist fidelity to these interventions occurs and the extent to which it is necessary (Brinkmeyer & Eyberg, 2003). The relevance of these questions for evidence-based practice and the further advancement and innovation of such practice is discussed below. What remains an ever-pressing issue is that of the influence of developmental issues in determining the need for intervention and in the selection of intervention strategies for conduct disorders. That is, there is much research indicating that an onset of conduct problems prior to adolescence is associated with more persistent and severe problems than is a later onset (Loeber et al., 1993; Moffitt, 2006). Therefore, the need for early intervention is clear. Specific treatment programs such as those reviewed in these chapters are typically most useful for specific developmental periods rather than one-sizefits-all across childhood and adolescence. Treatments for conduct disorders are only as effective as their appropriateness for the developmental level of the child, thus making the consideration of development in the research on which the interventions are based critical. The goal of this chapter is to provide a description of the unique and common elements of empirically supported interventions for conduct disorders, as well as our view—in light of current research and theory—as to the future directions that this work will likely take. Researchers have indicated that a variety of approaches can be effective in reducing child conduct problems (e.g., Nock, 2003). For example, the evidence supporting cognitive-behavioral or behavioral parenting interventions for preventing or

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treating child conduct problems is extensive. Therefore, we cannot provide an exhaustive review of each treatment approach, its specific features, and its empirical support in this chapter. Indeed, we seek to give an overview of the issues inherent in treating child conduct disorders and of the current strategies that are evidence-based. We begin with a discussion of parentbased interventions given their utility for treating a variety of behavioral problems in children beginning at a very young age.

PARENT-BASED TREATMENTS Common Elements That parent-based strategies are, or are part of, many of the empirically supported treatments for conduct problems speaks to the potential influence of the youth’s immediate home environment in the development of conduct problems and in the usefulness of environmental interventions in the reduction of these problems. It is important,to note that regardless of the specific hypothesized developmental pathway toward conduct problems for a given young person, parent-based interventions are developmentally necessary for young children who generally lack the capacity to directly participate in treatment in lieu of their parents. Indeed, considering the potential etiological effects of contextual factors, it has been argued that intervention for children with an early onset of conduct problems should have parent-based treatment as its central component (Beauchaine, Webster-Stratton, & Reid, 2005). Empirically supported parenting interventions generally target child noncompliance and have some theoretical foundation based on Patterson’s (1982) model of coercive parent–child interactions. Specifically, parenting practices that are thought to negatively reinforce child noncompliance (e.g., withdrawing a request/command after repeated refusals by the child) are replaced by clear commands and immediate negative consequences for noncompliance. Furthermore, Patterson’s model suggests that increasingly harsh parenting strategies are used as child noncompliance increases, and such strategies are positively reinforced by the child’s eventual compliance in the face of harsh parenting or threat thereof. Parent-based interventions seek to emphasize positive reinforcement for compliance in the form of praise, privileges, or larger, more long-term rewards as well as to diminish the likelihood of increasingly aversive parenting practices by promoting the use of immediate and consistent punishment strategies such as time-out. Response cost (i.e., removing tokens, privileges, or points when inappropriate behavior occurs) can provide an alternative to time-out (Forehand & McMahon, 2003). However, the improvement of parent–child interactions through the use of positive parenting strategies (i.e., parental attention, positive reinforcement) is emphasized before the implementation of punishment strategies for misbehavior (cf., Webster-Stratton & Reid, 2003). Such models seem warranted in light of evidence demonstrating that increases in positive parenting

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practices are a mediating factor in improved child behavior (Gardner, Burton, & Klimes, 2006) and that changes in parenting skills are a better predictor of child outcome from parent-based treatment than change in parental mood or parental confidence (Gardner et al., 2006; Hutchings, Lane, & Gardner, 2004). Specifically, parent training or family-based treatments for conduct disorders routinely progress through the normal initial discussions and modeling of positive attention and praise, to skills such as appropriate commands, making attention and reinforcement contingent upon child behavior, and use of a time-out for negative behaviors (see McMahon & Wells, 1998). Additional treatment methods emphasize the use of ignoring minor misbehaviors, the need for parents to be more proactive as opposed to reactive in their plans to deal with problematic behaviors, and the use of natural consequences for certain misbehavior (WebsterStratton & Reid, 2003). Initial sessions of parent-based programs often begin with a psychoeducational component so that parents can better understand their children’s difficulties and the rationale for the planned treatment. This understanding may aid parents in being less emotionally reactive to the child’s behaviors. Thus, parental anger management is often a component of treatment, promoting a model of effective coping skills resulting in parents being less likely to interact angrily—and thus problematically—with his or her child. Specific parenting techniques may be discussed didactically (e.g., Barkley, 1997), practiced and modeled in vivo (see Brinkmeyer & Eyberg, 2003), modeled using videotape (see Webster-Stratton & Reid, 2003), or often, some combination of these approaches. Naturally, in-session modeling and practicing of parenting skills will not be a component of treatment once the child reaches a certain age. For example, Parent–Child Interaction Therapy (PCIT; see below) is based on such in vivo practice but is geared toward children ages three to six (Brinkmeyer & Eyberg, 2003). It should be noted that these interventions are not synonymous with family therapy approaches that emphasize problematic family boundaries as factors that exacerbate a child’s problems such as in structural family therapy (Minuchin, Montalvo, Guerney, Rosman, & Schumer, 1967) or that emphasize family interactions across multiple generations and ways for the child/adolescent to individuate adaptively as in a Bowenian approach (see Hart et al., 2006). To date, these specific approaches have not demonstrated empirical support for child conduct disorders, although a study by Santisteban and colleagues (2003) found positive results particularly in the reduction of adolescent substance use as well as peer-based delinquency and conduct problems for Hispanic adolescents who were treated with a brief model of strategic family therapy. Furthermore, as discussed below, family therapy that takes a multifaceted approach has shown some benefits in terms of reducing adolescent problem behavior as well as in addressing some of the risk factors for such behavior. Finally, not all programs targeted at parents of children with conduct problems focus exclusively on parenting practices in relation to the child’s behavioral difficulties. Broader family-based approaches (see Kazdin, 1987)

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have also targeted parental stress, parental problem-solving, and marital discord insofar as they exacerbate the child’s misbehavior (Lochman, 1990). Such factors can be addressed within the context of individual parent treatment, couples therapy, during the course of a child’s treatment for conduct problems, or in parenting groups designed for parents of children with conduct problems. Such issues could be addressed generally in parenting groups, as many of the empirically supported parenting interventions are group-based and may include discussion of family issues that are often associated with child problem behaviors. In fact, given their effectiveness, group therapy for parents of children with externalizing problems have been touted as more cost effective than individual parent-based treatment (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004) provided that the approach to parent training is amenable to group work.

Examples of Empirically Supported Treatments An important and influential approach to parent-based treatments for conduct problems is the Living with Children program that was originally developed by Patterson and Guillion in 1968 (Patterson & Guillion, 1968; see Brestan & Eyberg, 1998). This program is conducted primarily with the parents in an individual training format typically targeted at children ages two to eight. This manualized treatment teaches skills such as attending and rewards, ignoring, helping the parent with the effective use of differential attention regarding the child’s behavior, finding ways to eliminate coercive cycles of parent–child interactions, establishing clear and consistent rules, and behavioral generalization to other settings. That is, it follows a sequence now generally adopted across parenting programs. Such skills are taught using psychoeducation, homework assignments, role-plays, and modeling. Living with Children and subsequent adaptations have demonstrated positive outcomes in a variety of controlled studies (Brestan & Eyberg, 1998), but recent studies on this specific program have not been conducted (Farmer et al., 2002). Nevertheless, the innovativeness of the theoretical foundation of this program and its approach has clearly influenced more recently developed parent-based treatment programs. A unique approach falling under the rubric of parent management training is Carolyn Webster-Stratton’s “Incredible Years: Early Childhood BASIC Parent Training” (see Webster-Stratton & Reid, 2003) which is particularly oriented toward parents of children ages 6 to 12. However, a similar program also developed by Webster-Stratton is geared toward children who are younger (Webster-Stratton & Reid, 2003). This treatment approach is unique in that it makes use of videotape modeling. It occurs in a group setting rather in an individual format. It consists of ten videos that demonstrate appropriate and inappropriate interactions to the parents and can be used for parents of children of all ages. The videos facilitate a group discussion with the parents. In addition to the traditional parent management techniques that are taught, BASIC incorporates the skills of logical consequences and response cost (Webster-Stratton & Reid, 2003). Furthermore, a key tenet of this treatment is that parents can reduce their children’s oppositional behaviors and even more significant conduct

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problems by abandoning harsh or overly critical parenting and employing consistent use of the kinds of strategies that are common to parent-based programs (e.g., positive reinforcement, response cost, time-out, etc.). This approach and variations of it have been shown to have positive effects on child conduct up to one year later (Webster-Stratton & Hammond, 1997). The intervention is particularly effective when combined with parent discussion groups or a child-focused component (see Farmer et al., 2002) which is discussed below. The program developed by Russell Barkley (1997) for parents of elementary school-aged children generally follows the above approach and is based on the coercive cycle of parent–child interactions. Many of the specific strategies of this program (e.g., clear, short parental commands) are geared toward accommodating the specific difficulties that children with Attention-Deficit/Hyperactivity Disorder (ADHD) might have. In addition, this program provides a good model for beginning treatment with psychoeducation on noncompliance and other conduct problems with a discussion of both the child and familial factors that may lead to or help sustain such behaviors. The program progresses through discussion of attending to a child’s positive play behavior using a set-aside parent–child play time during which the parent provides attention to the child’s behavior with very limited questioning and no commands. In a subsequent session, parents are encouraged to frequently praise and reinforce child compliance with commands—and to give more opportunities for compliance—so that the child understands the contingency between compliant behavior and the positive consequences that follow. The sessions that follow are consistent with the sequence of steps described above in which positive parenting skills are first introduced, followed by punishment strategies, with specific homework and handouts concerning each skill being provided to parents (Barkley, 1997). This intervention program is typically conducted in groups but can be easily adapted to individual families. Relatively unique aspects of this program include detailed discussions of the importance of praising/attending to a child’s independent play behaviors, managing behavior in public places, and establishing effective home–school notes such that school behaviors are subject to contingencies at home. As with other approaches, much emphasis in this program is placed on clear consistent expectations and immediate praise for compliance and punishment (i.e., response cost, time-out) for noncompliance. The importance of attending to positive behaviors and ignoring/withholding attention from negative behaviors is also a focus. This program has been extended to adolescents in a separate treatment format (Barkley, Edwards, & Robin, 1999), combining elements of the parenting approach implemented for younger children just described and family therapy centered on effective family communication and problem-solving skills. Each of the parenting skills discussed and practiced in the program for younger children is presented first in the adolescent program, with modifications made so that the strategies are developmentally appropriate (e.g., grounding instead of time out). Behavioral contracts are used as a version of a reward point system, but the adolescent is

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involved in the planning of the contract. The rationale for the adolescent’s increased involvement includes a more sophisticated understanding of the approaches used to improve his or her behavior and family relationships, the benefits of having the adolescent as part of the intervention process, making the parent accountable for providing appropriate consequences contingent upon the adolescent’s behavior, and making the adolescent responsible for meeting the behavioral expectations set forth by the contract (see Barkley et al., 1999). The second phase of this program is family-focused and deals with the importance of improving family communication habits in reducing the teen’s problematic behaviors. In addition, unreasonable beliefs (e.g., expectations of perfect compliance, expectations of negative outcomes if the adolescent is granted some autonomy) are discussed as a precipitant of many hostile adolescent–parent interactions. Finally, the family members practice their communication and problem-solving skills in sessions with direction and guidance from the therapist. Of course, a wealth of evidence supports the effectiveness of the parenting strategies introduced in the first part of this program, although less is known about developmental adaptations for adolescents. Recent evidence has also specifically supported the benefits of family-based intervention such as that provided in the second part of this program for symptoms associated with ADHD and ODD (Anastopolous, Shelton, & Barkley, 2005). An example of a parent-focused intervention with clear empirical support for reducing child oppositional and noncompliant behavior is PCIT developed by Sheila Eyberg and colleagues (see Brinkmeyer & Eyberg, 2003). This program is oriented toward a variety of child acting-out behaviors ranging from talking back to authority figures to aggression and is based on both attachment and social learning theories. More specifically, maladaptive parent–child attachment (e.g., low tolerance for child emotional expressiveness) and patterns of escalating and aversive parent–child interactions are thought to contribute to the child’s aggression, poor coping skills, and noncompliance (Eyberg & Brinkmeyer, 2003). In this approach, however, the parent is the agent of change in the child’s behavior. In other words, PCIT does not focus on enhancing the child’s coping skills per se. As with many other parenting programs, PCIT begins with a focus on child-directed interactions, a difference being that parenting skills surrounding such interactions are modeled and practiced in vivo with regular practice assigned between sessions as opposed to only being discussed and assigned as subsequent homework. Indeed, therapists in PCIT serve as “coaches” in that they discuss and model parenting skills and then observe the parents’ use of these skills in session (Brinkmeyer & Eyberg, 2003). During child-directed interactions, the parent is charged with “praising the child’s behavior, reflecting the child’s statements, imitating and describing the child’s play, and using enthusiasm (i.e., PRIDE skills; Brinkmeyer & Eyberg, 2003; p. 207). In other words, the parent is cautioned not to make commands during this time or to control the activities in which he or she engages with the child. Instead, the parent ignores minor misbehavior during these interactions and discontinues the

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interaction should the child’s behavior become difficult to manage. These interactions are thought to target the attachment-related influences on the child’s disruptive behaviors. The focus of sessions—when the parent has mastered the skills necessary during child-directed interactions—shifts to parent-directed interactions. These interactions are based on social learning processes whereby the parent’s skills for issuing effective commands, ignoring minor disruptive behaviors, and implementing consequences for continued or more severe disruptive behaviors are discussed, modeled, and practiced in session. Parents are taught the importance of clear concise commands, and as with other empirically supported parenting interventions, PCIT emphasizes consistency in the consequences provided for both compliant and noncompliant behaviors. PCIT is most effective and useful for children ages three to six (see Brinkmeyer & Eyberg, 2003). Systematic progress monitoring is a feature of this program that is essential given that PCIT is performance-based, not time-limited. That is, new parenting techniques are not discussed, modeled, and practiced until previous skills have been mastered. Progress is monitored through direct observations of parenting behaviors and child disruptive behaviors in session. Research points to the effectiveness of this approach in terms of both child behavior and reports of parental satisfaction (see Brinkmeyer & Eyberg, 2003). In addition to the parenting skills emphasis described briefly above, PCIT, as do other programs for parents of children with conduct problems includes a parent relaxation component with the perspective that parental stress will likely exacerbate problematic parent–child interactions and child misbehavior. A relatively recently developed program designed by Ross Greene and colleagues (Greene, Ablon, & Goring, 2002)—also geared primarily toward parents of school-aged children and known as collaborative problem-solving—has a somewhat different approach and rationale from traditional parent-based programs. Indeed, although the targets of this intervention (e.g., temper outbursts) are within the purview of traditional parenting programs, the presumed cause of these behaviors is different, thus leading to different considerations as to the families who would benefit from this approach. In short, rather than an emphasis on contingencies to motivate increased child compliance and decreased conduct problems as in traditional parent training, collaborative problem-solving emphasizes on enhancing the abilities of both parents and children to resolve disagreements or issues that typically result in child outbursts (Greene et al., 2004). The psychoeducational component of this program focuses on the cognitive and intrapersonal factors that may be associated with children’s aggressive outbursts such as poor frustration tolerance, poor adaptability to change, and emotional dysregulation. A key skill for parents to develop in this approach is to distinguish between situations in which they must implement consequences for child misbehavior, situations that call for collaboration between parent and child in resolving an issue, and situations in which the parent’s expectations are unrealistic (Greene et al., 2004).

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Therefore, although traditional parent management strategies are a facet of collaborative problem-solving, particularly for clear problem behaviors (e.g., aggression toward others), the parent is called upon to be flexible in which an expectation or rule is less clear or important but that may make the difficult-to-adapt child quite frustrated. Collaborative problem-solving has been shown to be at least as effective as parent training for reducing oppositional behaviors and may be a more appropriate intervention strategy for parents of children who meet criteria for ODD in addition to subclinical levels of mood symptoms (Greene et al., 2004). This approach has recently been applied in inpatient settings, with the use of collaborative problem-solving approaches on the part of direct care staff being associated with reductions in the use of seclusion and restraint for the youth in the facilities (Greene, Ablon, & Martin, 2006). The existence of a program such as this and the evidence supporting it underscore a need to tailor interventions geared toward conduct problems or conduct problemlike symptoms as closely as possible to the presumed etiology of those problems.

INDIVIDUAL-BASED TREATMENTS Common Elements The development of individual-based treatments (i.e., those that involve direct work with the child or adolescent) for conduct disorders speaks to the role of the youth’s individual tendencies in the development and maintenance of many problem behaviors. In addition to various familial risk factors for conduct problems, youth with such problems may also have poor interpersonal skills as well as cognitive distortions or deficiencies (Kazdin, 2003). Many treatment programs geared directly toward youth with conduct disorders are born out of presumed interpersonal and intrapersonal etiological factors. For example, the individual’s (perceived) reinforcement and punishment history for a set of behaviors as well as his cognitive appraisal of a situation and of the available consequences for a set of behaviors may serve to shape some conduct problem behaviors such as aggression. Thus, individual-based treatments tend to emphasize cognitive and behavioral strategies to reduce the frequency of problem behaviors and to improve the youth’s positive coping responses to anger-provoking situations. The programs may be geared toward increasing cognitive activity (i.e., impulse control) or altering maladaptive cognitive strategies (i.e., hostile attributional biases) that may contribute to conduct problem, including aggressive, behaviors (see Crick & Dodge, 1996; Lochman & Wells, 1996) These programs also typically include social skills training given the social skills deficits that are often part of the clinical picture for children with conduct problems (Kazdin, 2003) as well as social problem-solving skills so that an individual can employ effective and prosocial behaviors in difficult peer contexts.

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Even authors who have discussed those individual factors recognize the interaction of individual and environmental factors in explaining a person’s clinical presentation (Barkley, 1997). The most influential of these factors are most likely to be related to parent–child interactions and parenting practices. Therefore, it is usual practice to include a parent or family component with any child/adolescent individual treatment for conduct disorders. There exists a strong empirical basis for combining parent and youth treatment components when developmentally and clinically appropriate, as the combination of these components often outperforms either component alone in the reduction of conduct problems (e.g., Kazdin, 2003; Webster-Stratton & Hammond, 1997). Benefits have also been demonstrated for embedding individual-based treatments within universal prevention programs (e.g., teacher in-service; general parent meetings) compared to individual-based programs without universal prevention components (Lochman & Wells, 2002). As noted above, parenting programs that have a group design could be considered more cost effective than interventions administered to individual parents or sets of parents. However, some significant practical problems have been noted with group therapy with individual youth or with parents. Those barriers include differential acquisition and understanding of new skills across group members, differential practice of skills outside sessions, and inconsistent attention at settings (Kazdin, 2003). The individual-based programs discussed differ in terms of their initial format being group or individual; however, the key elements of these programs and the rationale behind the skills thought to reduce conduct problem behavior are very likely amenable to presentation in either format.

Examples of Empirically Supported Treatments The Coping Power Program (Lochman & Wells, 1996) has an extensive child component, although a formal parent component designed similarly to those reviewed above is also part of the program. This program has demonstrated positive outcomes particularly in terms of child aggression and substance use (see Lochman, Barry, & Pardini, 2003). In short, the individual-based program in Coping Power is an intervention that focuses on anger management and social problem-solving skills and is conducted in groups of late elementary school- to middle school-aged children identified at-risk based on teacher ratings of aggression. The program has both cognitive and behavioral components, the latter exemplified by the reward system that is based on the child’s weekly progress on targeted behavioral goals. The emphasis on coping skills and social problem-solving skills and the techniques for developing those skills (e.g., positive self-statements) exemplifies the cognitive aspect of the program. The program includes an initial psychoeducational component centered on identifying physiological cues to anger, differing levels of anger and other emotions, and relaxation skills. The role of cognitions in facilitating or impeding effective anger coping is also introduced, and the program proceeds with a substantial cognitive focus. Social problem-solving

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skills are then introduced to emphasize the accurate identification of problems, considering all possible courses of action, and then consideration of the positive and negative consequences of each behavioral choice. This problem-solving model is repeated throughout the remainder of the sessions. The program also has a significant modeling component whereby not only do the individuals in the group learn coping skills from others as well as model them in the group, but they also create a video illustrating the coping skills developed in the program as a sort of public service announcement. The final six to ten sessions focus on applying problem-solving skills geared toward particular peer contexts, reviewing the progress of each group member, and planning for the generalization of these skills to individuals’ various contexts. The group format allows for role-playing activities that involve identifying problematic social cognitions (e.g., hostile attributional biases) and that allow practice of effective social problem-solving skills (e.g., resistance to peer pressure; see Lochman & Wells, 1996). A similar program to the Coping Power Program is an anger control training program entitled the Chill Out Program (Feindler & Guttman, 1994) which has enjoyed considerable empirical support. However, this program has been more specifically geared toward adolescents, whereas the Coping Power Program is specifically geared toward aiding at-risk youth in making the transition to middle school. The Chill Out Program subscribes to the idea that adolescents lose control of their anger due to deficits in both cognitive and behavioral skills (Feindler, Ecton, Kingsley, & Dubey, 1986; Feindler, Marriott, & Iwata, 1984), and as such, it seeks to rectify such deficits by focusing on the underlying cognitions (e.g., hostile attributional bias) involved in the expression of anger and impulsivity that is typically associated with these cognitive distortions (Feindler et al., 1986). The Chill Out Program is designed for use with adolescents aged 13 to 18 who have already demonstrated aggressive behavior in their environment. It is a highly structured program conducted in a group setting with typically eight individuals per group. There are ten sessions, each of which focuses on a specific skills being taught, then modeled, rehearsed through role-play, and then applied to the natural environment. The skills taught at the ten sessions are rules and reinforcers, relaxation, self-monitoring, triggers, refuting aggressive beliefs, assertion techniques, self-instruction training, problem-solving training, thinking ahead, and program review (see Feindler & Guttman, 1994). Feindler and others (Feindler, 1990; Lochman & Lampron, 1988) have noted that the anger control training may only be useful for a limited period of time immediately following treatment and not as effective longterm. In addition, it has been noted that anger control training tends to be more effective when it is used in conjunction with other behavioral strategies (e.g., consistent consequences for problem behaviors; Lochman & Lampron, 1988). Another investigation demonstrated empirical support for the Chill Out Program has also been indicated on self-report measures,

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but reduction in aggression or other conduct problem behaviors has not been clearly documented through direct behavioral observations. That is, individuals’ own cognitive processes or self-efficacy may clearly change, but the generalization to their actual behavior is not clear (Feindler & Guttman, 1994). Another individual-based approach with a similar theoretical foundation is Problem-Solving Skills Training (PSST) developed by Alan Kazdin (see Kazdin, 2003). PSST is a cognitive-behavioral therapy that has empirically demonstrated effectiveness for the treatment of conduct disorders and is based on the theory that many youth conduct problems are related to cognitive distortions (see Kazdin, 2003). The goal for PSST is to change the ways in which adolescents perceive, code, and experience the world based on research that has demonstrated that aggressive and antisocial adolescents tend to make hostile and inaccurate attributions towards other people’s behavior which creates problems in their social environments (Crick & Dodge, 1994). PSST is conducted in an individual format and is targeted at children ages 7 to 13. The treatment emphasizes teaching children how to cope effectively in interpersonal situations that are frequently encountered but ones in which the child experiences difficulty. It is a very structured approach that teaches children five problem-solving steps to use in their interpersonal relationships. These steps include identifying and defining the problem, developing solutions to the problem, evaluating the solutions from the set of solutions that the child generated, making a decision, and evaluated the decision (Kazdin, 1996). More specifically, youth are taught to work through common social problems or upsetting situations that they face in their own environments, break the situation down into objective identifiable elements, and then develop response options that include prosocial behaviors. The therapist facilitates the development of problem-solving skills through modeling each set of skills during sessions. Through PSST the cognitive work moves from being practiced out loud to becoming more covert and automatic (Kazdin, 2003). PSST has demonstrated many positive outcomes across multiple measures and multiple settings up to one year later (Kazdin & Wassell, 2000), with favorable comparisons to a variety of control conditions and other interventions (Kazdin, 2003). As noted above, PSST has also been used in combination with parent management training techniques and has shown to be effective when used in this manner as well (Christophersen & Mortweet, 2001). It is important to note that PSST has been associated not only with a decrease in aggression and other symptoms of conduct disorders, but also with an increase in prosocial behaviors (Kazdin, 2003). The moderators of treatment outcomes discussed more fully below also seem to attenuate the outcomes associated with PSST, although the addition of some attempt to address parental stress has demonstrated benefits (Kazdin, 2003). Therefore, some of the evidence base points to the need to intervene simultaneously in different ways with different systems in order to best target the factors contributing to the maintenance of conduct problems.

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MULTIFACETED PROGRAMS Overview Existing treatment approaches for child conduct disorders also include multifaceted approaches that take either a broad multisystemic approach (e.g., Henggeler & Lee, 2003) or have multiple related components that target multiple recipients in multiple settings (e.g., Conduct Problems Prevention Research Group, 1992). These programs have been influential in how treatments for conduct problems are viewed. Specifically, they have provided evidence that youth with conduct disorders can be effectively treated in home-based interventions (e.g., Henggeler, Schoenwald, Bordvin, Rowland, & Cunningham, 1998) and through in-school strategies (Lochman, Lampron, Gemmer, & Harris, 1987), rather than automatically equating conduct disorders with a need for treatment in more restrictive environments. For example, Multisystemic Therapy (MST; Henggeler & Lee, 2003) has enjoyed considerable empirical support and approaches conduct problems from a broad perspective, taking into account the influence of the youth’s various contexts on her behavior problems. MST is particularly oriented toward adolescents and comprises multiple levels of treatment that include the individual, family, school, peers, and neighborhood. Treatment is actually conducted in each of these contexts as appropriate and feasible (see below). The parent component of the Incredible Years Program was described above, yet this program is an example of one with well-defined child and teacher components. Therefore, it can function as a multifaceted program or any combination of the three elements could be used in treatment depending on the needs of the child and adults in his home or school contexts. As does the parent component, the child component uses social learning principles in developing basic coping skills as well as has an emphasis on helping the youth set appropriate behavioral goals. According to Webster-Stratton and Reid (2003), this program as a whole promotes parent–teacher communication and encourages parents to become involved in monitoring the child’s performance and behavior in school. The school component is particularly geared toward classroomwide interventions for the prevention of disruptive behaviors as opposed to targeting one specific child or a small group of children for in-school intervention. Researchers have demonstrated that the addition of parent, teacher, and/or child components to the treatment package using The Incredible Years Program enhances outcomes regarding the target child’s conduct problem symptoms (Webster-Stratton & Reid, 2003). In most multifaceted programs, parents are still exposed to traditional parent-training techniques, and although the presumed cause of the youth’s problems is thought to be reciprocal between the youth and his or her contexts, the parent may still be seen as the primary agent of change. Such as discussed below, family-based work within these models seeks to directly target family communication and conflict, and such an emphasis is thought to be associated with decrease

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in adolescent problem behaviors such as substance use (Borduin et al., 1995; Henggeler, Borduin, & Melton, 1991; Schmidt, Liddle, & Dakof, 1996). The degree to which schools and other contexts are formally involved in treatment varies with the particular treatment approach that is implemented.

Examples of Empirically Supported Treatments As mentioned above, MST (Henggeler et al., 1998) is targeted at at-risk adolescents who have previously engaged in severe misconduct and are at risk for being removed from their homes. This approach believes the child cannot be viewed outside the many systems of which they are a part (i.e., schools, families, neighborhood, culture, community). It stresses the need to include all these symptoms in treating the individual child. The primary goal of this approach is to decrease misconduct and to help the child function in his environment. It is an intensive program that makes use of many clinicians and caregivers as well as careful monitoring of those involved in the treatment of the child. This treatment is unique from others in that quality assurance checks are embedded in the treatment protocol (see Henggeler & Lee, 2003). MST is conceptually based on five key assumptions, namely that behavior problems are multidetermined, that caregivers are the key to positive long-term outcomes, that effective treatment must be comprised of treatment that has strong empirical support, that barriers to service access and delivery must be addressed in regard to treatment, and that treatment fidelity is maintained by quality assurance checks. Treatment is targeted at all environments and systems in which the child is involved, and as such, this treatment seeks to promote strong cooperation from all (Henggeler & Lee, 2003). MST includes intervention in the home which has increased participation and decreased attrition (Henngeler, Pickrel, Brondino, & Crouch, 1996). There are nine core treatment principles that guide treatment. These include finding the fit between problems and the child’s broader system, being positive and strength-focused, increasing responsibility, present focused/action-oriented and well-defined interventions, fits child’s developmental level, continuous effort, evaluation, and generalization (see Henggeler & Lee, 2003). Although each aspect of MST (i.e., therapy, supervision, consultation) is manualized and fidelity takes on particular importance, the extent to which various contexts are involved varies by case (Henggeler & Lee, 2003). However, for MST to progress, family engagement is crucial, and strategies for forming meaningful partnerships among the treatment team and additional systems are also needed. The treatment team is accountable for monitoring progress and managing any factors that appear to be impeding progress. Goals for treatment are established and monitored week by week, with all relevant systems for attaining those goals being engaged in treatment (Henggeler & Lee, 2003). MST has been found to decrease criminal behavior, substance abuse, and internalizing problems (Kazdin & Weisz, 1998; Stanton & Shadish, 1997; Farrington & Welsh, 1999). In a sample of youth presenting in psychiatric

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emergencies, MST resulted in a 75% reduction in days hospitalized and a 50% reduction in days that the child spent in an out-of-home placement (Schoenwald, Henggeler, Brondino, & Rowland, 2000). MST has also led to improved family relations and parent–child interactions (Brunk, Henggeler, & Whelan, 1987) as well as improving peer relations (Henggeler, Melton, & Smith, 1992). Because of the intensive nature of MST, including having an interventionist available for support at all times, treatment team members keep low caseloads, and treatment is limited to three to five months (Henggeler & Lee, 2003). The FAST (Families and Schools Together) Track Program (Conduct Problems Prevention Research Group, 1992) is an example of a program that involves targeting risk factors for conduct problems such as parenting practices, academic and social difficulties, and community factors. This program is geared toward young elementary school-aged children and includes strategies such as home visits to target parenting practices and other familial factors relevant to child problem behaviors, social problemsolving training for children, academic tutoring particularly in reading, and classroom management strategies for teachers. The FAST Track Program also includes a traditional parent management program that includes an emphasis on fostering positive parent–school communications. This program is designed from the standpoint that early intervention in multiple domains that influence the child’s social and behavioral development is optimal and that fostering consistency and communication across the contexts will improve the child’s behavioral, social, and academic outcomes (Conduct Problems Prevention Research Group, 1992). Each of the components of the FAST Track Program has demonstrated positive shortterm effects; however, the long-term effectiveness, particularly of the program as a whole, needs further investigation (Frick, 1998). Similar to the approach for adolescents developed by Barkley and colleagues (1999) and described above, a recent investigation by Hogue, Dauber, Samuolis, and Liddle (2006) found that a family-based intervention that included work with both parents and adolescents simultaneously (i.e., Multidimensional Family Therapy; Liddle, 2002) demonstrated positive outcomes on adolescent substance use. It should be noted, however, that the adolescent-focused strategies within this intervention (e.g., drug refusal skills, anger management, impulse control) seemed to be particularly useful in reducing family conflict and increasing family cohesion (Hogue et al., 2006). Multidimensional Family Therapy (MDFT) has also demonstrated usefulness for more varied adolescent behavior problems (e.g., Dennis et al., 2004; Liddle, Rowe, Dakof, Ungaro, & Henderson, 2004). Therefore, for adolescents with externalizing problems, it may be that approaches which incorporate both individual and family-based work, rather than an exclusive focus on either will be most likely to yield positive results. MDFT fits that bill insofar as it includes individual, parent, and family interactional domains (Liddle, Rodriguez, Dakof, Kanzki, & Marvel, 2005). However, MDFT is truly multifaceted in that an extrafamilial domain is included whereby direct attempts are made to address school failure and lack of positive community connections as risk factors for a teen’s conduct problems. More specifically, MDFT interventionists

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work directly with school officials regarding academic planning for the adolescent and work with the family on ways to engage the adolescent in positive extracurricular activities. The influence of peer affiliations is also addressed in this intervention through discussions of friendship choice and the influence of decisions in that domain on the youth’s outcomes (see Hogue et al., 2006). A formal focus on community-based factors is unique, even though tight control over how such extramilial factors are implemented and the behavioral contingencies in place in such contexts cannot be fully addressed. MDFT also seeks to address parental risk factors for youth problems both within the intervention (e.g., parenting skills; family communication) but also through additional resources (e.g., parental drug treatment; increasing social support; Hogue et al., 2006). An initial clinical trial of MDFT found it to be as effective as a traditional cognitive-behavioral intervention but more effective for the long-term maintenance of positive outcomes in the form of reduced substance use (Liddle, 2002).

RESIDENTIAL TREATMENT Overview The term “residential treatment” has been used to describe a number of varied approaches to intervention beyond outpatient care. We have thus far focused our discussion on treatments that are applied in outpatient settings, although elements of these treatments (e.g., Coping Power) could be applied within a residential setting. Although obviously less intensive in surroundings, outpatient treatments are not necessarily shorter in duration than residential treatments, particularly inpatient hospitalizations (see Lyman & Barry, 2006). More restrictive than most outpatient treatment models are day treatment models—also referred to as partial hospitalization programs—which provide a therapeutic environment during the day including academic instruction such that the child is not removed from the home environment. The range of services available in these settings are broader than those often employed in outpatient settings and include individual therapy, group therapy, psychopharmacological interventions, and classroom accommodations. Several additional treatment models involve removal of the youth from the home environment at least for some period of time and in that sense, are considered residential. These placements include short term respite care, group-home care, residential treatment centers, inpatient hospitalization, and institutionalization (Lyman & Barry, 2006). The specific treatment strategies within each of these models are diverse ranging from virtually nonexistent in some respite care or group-home settings to quite intensive in any of these settings. For instance, and depending often on local resources, group-home care may or may not include a formal treatment regimen conducted by trained professional. Each of these treatment models also varies in size and scope. It should also be kept in mind that children may be placed in residential settings

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primarily because of significant problems and/or safety concerns in their home environments and not necessarily because they themselves are exhibiting significant emotional or behavioral problems. Although theoretically the more similar the residential treatment setting is to the youth’s home setting (i.e., the more the setting mimics a home), the more generalization of behavioral gains from the treatment setting to the home environment. However, there are no data to indicate whether this is the case. Perhaps because of the numerous forms of residential or inpatient treatments that are typically geared toward youth with the most severe, persistent, or complex conduct problems, the research literature on these programs is relatively limited. The large number of treatment models that vary in structure, clientele, length, restrictiveness, and scope make welldesigned controlled studies very difficult to conduct (see Lyman & Barry, 2006). The limited evidence in support of these interventions may be a consequence of the lack of close empirical examination. However, it has also been argued that residential treatments are less likely than community-based interventions to reduce child conduct problems because the treatment focuses largely on the child and occurs in a separate context than the one in which the problems developed (Hart et al., 2006). That is, in light of the evidence supporting parent-based treatments for child conduct problems, it would make sense to provide such interventions first before resorting to a more restrictive placement for the child. Indeed, although residential treatments offer immediate respite for both the child and caretakers, the benefits may very well not be sustained both within the program and upon discharge. An argument can be made, on the other hand, that removal of the child from a problematic environment can be beneficial, even necessary, for the treatment of conduct disorders. Residential interventions provide a controlled environment often with expansive behavioral contingencies, as well as the opportunity for the youth to receive individual, group, and pharmacological interventions. However, research does not support significant improvements in symptoms for many youth, particularly if they return to their previous environment (Hart et al., 2006; Lyman & Barry, 2006). The adjustment for both the child and family after residential care has ended can be quite difficult, although the availability of wraparound services that include the parents as part of the services provided by the residential facility, particularly at the end of services, can aid in this transition (Lyman & Barry, 2006). In addition, because of the external controls on the youth’s behavior inherent in such settings, it is not clear to what extent the youth develops effective self-control or coping skills that she will then be able to utilize once out of the residential setting (Barker, 1993). Similarly, although residential treatments often demonstrate a decrease in conduct problems within the milieu, it is unclear if such gains are above and beyond what the youth would achieve through intensive behavioral interventions outside of the residential setting (Lyman & Barry, 2006). Still, some children’s behavior problems can be so severe or have cause for safety concerns that residential treatment may be viewed as a suitable short-term option.

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Children served by the various residential treatment models present with issues such as severe impulsivity, erratic or disorganized behavior, severe internalizing problems, and/or threats to harm themselves or others (Lyman & Barry, 2006). The available information on youth who attend residential treatment facilities suggests that they often do not live with both biological parents which includes coming from foster care or other similar placements, have parents with a history of psychopathology and/ or substance abuse problems, have experienced and/or witnessed abuse or violence, have families with little social support or cohesion, and have a history of being involved in or around criminal activity (Lyman & Barry, 2006). Assuming that family instability is the root cause of the youth’s conduct problems, it has been argued that alternative home placements— particularly given the relatively low cost of such solutions—may make the most sense (Hussey & Guo, 2002). Given the concerns regarding the effectiveness, cost, and restrictiveness of residential treatment on the one hand, and the need for intensive interventions in some instances on the other, Lyman and Barry (2006) discuss four considerations based on those initially proposed by Wilson and Lyman (1982). First, youth should be treated in the least restrictive setting possible in light of the youth’s diagnosis, severity of conduct problems, and level of behavioral and emotional stability. Therefore, in some instances (e.g., threat to harm self or others) intensive placements—even if short term—are warranted. Second, the treatment components should be related to the antecedents of the child’s problems, such that if coercive parent–child interactions appear to be a main factor in the child’s behavior problems, then home- or parent-based treatments are indicated. Third, the treatment should be cost-effective based on considering the effectiveness of the selected intervention, the monetary cost, the expected duration, and the social cost of treatment failure. Finally, the treatment structure, focus, and resources should match the youth’s problems and developmental level. In short, although some residential programs may be quite beneficial for some children, particularly those with particularly severe conduct problems and/or severely adverse environmental conditions, there is limited evidence supporting their long-term effectiveness. Moreover, in light of the monetary expense involved with such interventions, their costeffectiveness relative to other community-based interventions is not favorable. A general overview of residential treatment centers and inpatient hospitalization is given below. In the past 15 to 20 years, a number of more specified residential models have been developed (e.g., wilderness therapy, boot camps). See Lyman and Barry (2006) for a more complete discussion of these and other residential models, including their potential benefits and drawbacks.

Examples of Residential Treatments Again, because of the myriad philosophies, structures, and models of residential treatments, it is not possible to discuss in detail a particular, easily replicated program. Nevertheless, because of the use of such

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programs in the treatment of youth conduct disorders, it makes sense to discuss some features of such programs and how they target behavioral problems. As the term implies, residential treatment centers are typically located in facilities that do not mimic a typical single-family home setting. However, many models include locating client living quarters and activity areas in smaller units consisting of approximately 15 to 20 youth (Lyman & Barry, 2006). Peers also take on importance in residential centers through their involvement in group therapy, the need for youth to practice appropriate self-control and coping strategies with others who may engage in behaviors that are upsetting to the youth, and the ability of peers to model and reinforce adaptive behaviors. Residential programs typically provide an academic component, and formal therapeutic services administered by trained staff (e.g., psychologists, psychiatrists, social workers) are also a core component of these interventions. Residential treatment centers also often incorporate contingency management systems such that, for example, youth are provided different levels of privileges for meeting certain behavioral goals. Therefore, direct care staff training in residential programs is of utmost importance, as staff members are called upon to administer both positive and negative consequences for behaviors throughout the day and throughout activities. Furthermore, low resident-to-staff ratio appears to be important in therapeutic effectiveness including settings in which the youth’s presenting problems are rather severe (Friman, Toner, Soper, Sinclair, & Shanahan, 1996). Close contact between staff and residents likely serves both therapeutic and safety functions. Because of the relative severity of youth served in such centers and their close proximity to each other and to staff, behavioral disruptions can occur often. However, residential treatment centers typically have clear staff procedures for dealing with such incidents to prevent them from escalating. These procedures include time-out, restraint, and seclusion with the least restrictive strategy that will still maintain safety being implemented first (Lyman & Barry, 2006). Many programs also incorporate a psychoeducational model such as originated by Hobbs (1966) wherein youth learn and practice coping skills as well as more prosocial behavioral choices rather than an exclusive focus on managing behaviors as they occur in the milieu. In such a model, the child still has contact with his family, and the family is informed of treatment plans throughout the residential stay with the hopes of treatment gains being more readily generalized to the home setting after discharge. Much less similar to a youth’s home environment is an inpatient hospital setting. Daily activities in these settings tend to be much more structured and monitored, with limited opportunity for recreational activities or time outside the unit. Medical professionals necessarily staff these settings, whereas psychologists, social workers, and teachers may also be involved in service provision in inpatient settings. Inpatient placements have moved more toward an emphasis on psychopharmacological than psychological treatments (see Lyman & Barry, 2006), perhaps as a function of the emergent cases served and managed care necessitating shorter-term stays in inpatient units. Therefore, they

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are often effective and necessary for youth whose emotional and/or behavioral state is dangerous to themselves or others and whose psychological difficulties seem to have some organic component. Inpatient hospitalization is primarily focused on crisis stabilization as opposed to long-term treatment. The usefulness and cost-effectiveness of hospitalization for conduct disorders is quite limited, although such an approach may be warranted and effective for substance abuse problems in particular (see Lyman & Barry, 2006).

EVIDENCE-BASED PRACTICE The interventions discussed above, particularly the outpatient interventions with parent, child, and/or teacher components have enjoyed a great deal of empirical support. The APA Task Force for identifying empirically supported treatments presents summaries of the treatments that have met the criteria to be considered well established and those meeting the criteria of being probably efficacious. These empirically supported treatments, some of which are summarized above, are discussed on the website: www.effectivechildtherapy.com. It is expected that the attention to, and debate concerning, evidence-based practice will only further the efforts of professionals and the public at large to consider what works in designing, seeking, or implementing the treatments most likely to ameliorate child conduct problem symptoms. This evidence base also serves as the foundation for further research and innovation in the design of interventions that might demonstrate even more effectiveness, for longer periods of time, and/or for a broader range of youth. With well-developed supported interventions in existence, it becomes the charge of practitioners and training programs to make evidencebased practice the centerpiece of their work and training of treatments for conduct disorders. For example, as noted above, empirically supported parenting interventions generally include an emphasis on positive reinforcement and increasing positive behaviors first before an emphasis on strategies to punish noncompliance. In part, the theoretical rationale for such a strategy is to provide guidance to children on “what to do” instead of only what behaviors not to engage in, as well as to improve the quality of parent–child interactions (e.g., Barkley, 1997). Therefore, to emphasize punitive strategies in parent training first would be doing so against the preponderance of empirical evidence. In addition to the mediating effects of positive parenting practices resulting from parenting programs, these approaches to intervention are also thought to be most effective through the reduction of coercive parent–child interactions and when management strategies are more clearly and consistently associated with the child’s behavior (Reyno & McGrath, 2006). Furthermore, parenting programs can be effective in not only reducing the target child’s conduct problem symptoms, but also in improving parent–child interactions, parental consistency, and even sibling behavior (see Gardner et al., 2006). More important, it appears that the effects of evidence-based treatments for conduct problems maintain some level of

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positive outcomes over time (Gardner et al., 2006). The length of treatment varies with the approach and severity of the child’s problems, but for parenting interventions in particular, having a greater number of sessions is associated with poorer outcomes, often because of poor parental adherence or performance while moving through the sequence of parent training steps implemented in most programs (see Hogue et al., 2006). Although fairly well-developed theoretical rationales exist for the treatment of conduct disorders through psychoanalytical perspectives (e.g., self-psychology; see Liberman, 2006), the evidence supporting these interventions is lacking. Unlike the approaches outlined in this chapter, selfpsychology takes a nondirective approach whereby the therapist seeks to understand the youth’s subjective world view. Such an approach is likely quite limited for young children and/or youth who have difficulty with verbal expression. It should also be noted that verbal reasoning deficits are often associated with child conduct disorders (Lynam & Henry, 2001; Speltz, DeKlyen, Calderon, Greenberg, & Fisher, 1999), further calling into question the utility of this treatment for a sizable segment of the population who exhibit conduct problems. The presumed cause of child conduct problems from this perspective is that of unrealistic, or immature, narcissism that develops—at least in part— from inappropriate or absent parental response to child distress (Liberman, 2006). Although narcissism has been found to be related to child and adolescent problem behaviors (Barry, Frick, & Killian, 2003; Barry, Grafeman, Adler, & Pickard, in press), it is unclear how the self-psychology approach to assessing child narcissism would fit with current approaches to common approaches for assessing the construct in youth and adults. The intervention itself seeks to alter the youth’s unrealistic self-perceptions and to foster resilience in the face of adversity. Such goals could certainly reduce the likelihood of acting-out behaviors, but the evidence of the presumed causal model and the intervention itself are quite limited. More recent efforts have sought to understand the intervening variables that indicate for whom and under what circumstances treatments for conduct disorders are most effective. For example, Beauchaine and colleagues (2005) examined the short-term treatment outcomes for children with an early onset of conduct problems. They found that parental risk factors (i.e., drug abuse, marital discord, maternal depression) and child risk factors (e.g., comorbid internalizing problems) influenced treatment outcomes. For example, although children with comorbid internalizing problems presented with higher externalizing problems than children without internalizing problems, the rate of improvement of the former group was greater. That is, children and families who present with multiple risk factors—thus complicating the clinical picture—can still, and often do, benefit greatly from intervention targeting parenting skills and child conduct problems. Kazdin and Whitley (2006) similarly demonstrated that children with comorbid presentations exhibited the most change in response to intervention and outcome symptom levels equivalent to children with a single primary clinical problem. Of course, clients presenting for treatment of child conduct disorders—or any other clinical issue for that matter—vary in the degree to which they

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present with other factors that might complicate treatment planning and call into question the applicability of evidence-based treatments. With the influence of such risk factors (e.g., comorbidity) on the severity of the child’s presentation and response to intervention having been demonstrated (see Beauchaine, Gartner, & Hagen, 2000; Kazdin & Whitley, 2006), it is clearly indicated that interventions are not one-size-fits-all. Recent efforts to address issues surrounding the influences of comorbidity and other indices of case complexity (e.g., low SES) only serve to inform practitioners of the potential benefits of many evidence-based interventions as well as instances in which further examination and innovation are needed. The design of interventions in terms of their target recipients and settings does seem to influence the specific conduct problem behaviors that are affected. In particular, for families of children with conduct problems, a parent-based component is essential for reducing the child’s symptoms, whereas teacher-based interventions appear to be particularly useful for reducing disruptive classroom behaviors (see Beauchaine et al., 2005). Based on the performance of standalone in relation to combined interventions, it has been argued that for young children in particular, parenting interventions should be the front-line intervention for younger children with supplemental teacher- or child-based interventions as indicated (Beauchaine et al., 2005). However, research cited above has demonstrated the benefits of adding components of treatment compared to a single intervention approach. In addition, for older children and adolescents, it may be necessary to include a direct intervention with the young person, considering parent and teacher interventions as supplemental. Even with the most comprehensive approach to intervention involving all important systems or contexts, conduct problems remain difficult to treat. As noted by Beauchaine and colleagues (2005), treatment nonresponders are of concern for practitioners and researchers, but they also are the basis of all advancements in treatment design. That is, moderators of treatment outcome for youth with conduct disorders are variables that are present at the outset of treatment. Therefore, awareness of the variables that appear to predict treatment response allows for the selection of the most appropriate treatment for the presenting child. The age of the child is one such variable in regard to treatment for conduct problems, not only in terms of with whom treatment is performed but also with the general expectation that earlier intervention increases the likelihood of meaningful reduction in conduct problems (see Webster-Stratton & Reid, 2003). The youth’s developmental level and developmental trajectory of problem behaviors is a similarly important consideration. For example, a preschool- or early school-aged child would likely not comprehend the cognitive coping strategies that are the bedrock of treatment approaches such as Coping Power or PSST. Likewise, older but developmentally delayed youth would likely benefit less from such cognitive strategies than those that emphasize clear behavior-consequence contingencies. Another such variable may be the level of perceived social support experienced by families going through treatment (Dadds & McHugh, 1992).

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Similarly, family isolation, single parent status, and social disadvantage have been found to interfere with progress in family therapy approaches for treating child conduct problems (e.g., Brestan & Eyberg, 1998; Dumas, 1986; Miller & Prinz, 1990; Webster-Stratton, 1985). Conversely, parents have reported qualitatively that increasing social support and being able to discuss problems with other parents can be effective in enhancing parenting skills and ameliorating child behavior problems (Stewart-Brown et al., 2004). However, Dadds and McHugh (1992) have noted how difficult it is to make meaningful changes in a family’s social support system or resources within typical treatment approaches. The wider examination and dissemination of treatment approaches such as MST may help advance the field in this direction from its focus on capitalizing on the strengths in each of the child’s contexts and engaging more of those contexts to allow treatment to most effectively work through systemic barriers to the improvement of the youth’s behavior. Because many of the empirically supported treatments for conduct disorders appear to be most effective the earlier they are initiated, and because researchers suggest that an early onset of conduct problems is a predictor of persistence of such problems (e.g., Moffitt, 2006), comprehensive evidence-based assessment of conduct problems becomes essential (see McMahon & Frick, 2005 for a review). A lack of appropriate assessment and intervention may result in problematic behavioral patterns becoming less malleable and in the emergence of additional risk factors (e.g., delinquent peer affiliations) that would make treatment more complex (Beauchaine et al., 2005). Not surprisingly given the vital role of parents in the treatment of conduct disorders, parental psychopathology has been shown to be not only a risk factor for the development and maintenance of conduct problems, but also a factor in treatment response (see Chronis et al., 2004; Reyno & McGrath, 2006). Kazdin and Whitley (2006) found that greater familial barriers to treatment participation were associated with worse outcomes in a study of parent management training and problem-solving skills training for children with ODD or CD. A recent study also demonstrated that assessment of specific aspects of parental functioning better informed intervention and improved outcomes for families receiving an empirically supported treatment for conduct problems than did more global assessments of family needs (Bierman, Nix, Maples, & Murphy, 2006). It is not uncommon for parents to simultaneously seek parenting interventions while also seeking individual treatment for their own difficulties. As described above, many parenting interventions have included components that focus on parental stress and strategies to manage that stress apart from an exclusive focus on the child’s behavior problems in an attempt to target some of the parental/familial factors that might negatively influence treatment response. Moreover, direct efforts at addressing some of these factors (e.g., poor father involvement in treatment, the intervening role of parental psychopathology) have been described (Chronis et al., 2004), contributing further to the evidence base. Additional research brings to light the need for comprehensive assessment of the child, parent(s), and contexts so that optimal treatment plans

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are implemented. A child factor that has been associated with poorer treatment outcomes is the presence of psychopathy-linked characteristics, or callous-unemotional (CU) traits (Hawes & Dadds, 2005). More specifically, Hawes and Dadds (2005) found that CU traits were associated with poorer outcomes among children with ODD following parent training, even when controlling for parental education, child age, and parental adherence to treatment. CU traits include a relative lack of empathy and guilt as well as flat affect (see Frick, Bodin, & Barry, 2000). Researchers have found that CU traits moderate the relation between parenting practices and conduct problems (Wootton, Frick, Shelton, & Silverthorn, 1997; Oxford, Cavell, & Hughes, 2003), thus perhaps predicting the attenuated effects of parenting interventions for the conduct problems of children with these traits. CU traits are particularly important to understand in light of intervention planning and design given the association of these features with particularly severe, varied, and persistent child conduct problems (Barry et al., 2000; Christian et al., 1997). Researchers in this area suggest that children with this interpersonal style tend to be insensitive to punishment cues in laboratory situations (O’Brien & Frick, 1996) and to respond more to rewards than to punishments such as time-out (Hawes & Dadds, 2005). Thus, it is imperative that pretreatment assessments consider the presence of CU traits and that interventions be developed that effectively address the unique presentation of conduct problem symptoms for this subset of youth.

CONCLUSIONS Limited, although emerging, research has examined the effectiveness of adaptations of existing interventions for conduct problems. Bierman and colleagues (2006) have noted that individualized interventions are quite appealing but that the evidence regarding these adaptations is limited. Greene and colleagues (2004) have referred to such adaptations as “indispensable” (p. 1163), and some treatment approaches (e.g., collaborative problem-solving) do not prescribe a particular topic or coverage of a specific skill to a particular sequence of sessions. Given the advocacy of evidence-based practice in psychology, not just for treating child conduct disorders, and the evidence in support of these interventions relative to usual clinical practice (Weisz, Jensen-Doss, & Hawley, 2006), understanding if and how adapted treatment plans may be useful is an essential question. A primary question in this regard is that of therapist fidelity to a treatment program or protocol. The degree to which therapists adhered to the guidelines of a particular program is unclear in much of the research showing positive effects of treatment for conduct disorders. On the other hand, it is unclear to what extent therapist fidelity is necessary to achieve positive behavioral outcomes. To further advance the knowledge, use, and effectiveness of evidencebased interventions, successful adaptations must be disseminated, and judgments regarding the need for making adaptations must follow guidelines that can be easily documented and followed by other professionals.

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It has been shown that the more specific the areas of functioning on which such judgments are based, the greater likelihood of positive outcomes for adapted interventions (Bierman et al., 2006). Therefore, a call for evidence-based practice is not to limit the flexibility of clinicians or the applicability of interventions to specific clients with conduct problems, but to ultimately allow our field to widen the evidence base and to enhance the services provided to the youth and families who we serve. A similar area of inquiry is the degree to which efficacious treatments show effectiveness for a broader range of settings, trained professionals, and clients. The generalizability of evidence-based treatments has been called into question based largely on the relative homogeneity of clients participating in clinical trials and heterogeneity of clients presenting in clinical practice settings (Dulcan, 2005; Westen, Novotny, & Thompson-Brenner, 2004). Chorpita (2003) has clearly described a number of important practice considerations (e.g., supervision, addressing attrition, demographics, payment options, client’s prior experience with treatment, etc.) that must be made for efficacious treatments to most readily demonstrate effectiveness. Furthermore, an expanding body of literature has examined the adaptability of existing interventions to clients from diverse backgrounds (e.g., Forehand & Kotchick, 1996; Santisteban et al., 2003) or the effectiveness of interventions developed for clients from nondominant cultures (e.g., Non-English-speaking background; Sonderegger & Barrett, 2004). Of course, direct investigations of the outcomes for interventions with diverse clientele are preferable to assumptions that existing treatments for conduct problems will translate directly to diverse clientele. A complete consideration of the strides made in these areas as well as the numerous unanswered questions for treatment and treatment outcome research would be too extensive for the present discussion. Because of the level of similarity among empirically supported treatments for child conduct problems, it remains unclear as to which elements of these interventions are more or less dispensable. To address this question, dismantling studies that incorporate multiple intervention conditions and that include frequent assessment of processes and outcomes are necessary (Kazdin & Nock, 2003). Such an undertaking would be daunting but could be useful in further streamlining interventions and informing practitioners as to the key aspects of treatment on which to focus. Without extensive research on this issue, we still remain optimistic about the current state of treatment for youth conduct problems in that the treatment packages that exist—if imparted to the practicing public—have demonstrated that they can improve the functioning and lives of youth and their families. Perhaps the clearest conclusion from the literature on developmental trajectories of children with conduct disorders and the treatment of these problems is the need for early prevention/intervention. Webster Stratton and Reid (2003) noted that “the primary developmental pathway for serious conduct problems in adolescence and adulthood appears to be established during the preschool period” (p. 224). It is has been concluded that such efforts—particularly for the youngest children—should include a parent-based or family-based perspective with attention devoted to ways

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in which services can be most accessible to families (Centers for Disease Control, 2004). In light of the existing evidence-based interventions, sound efforts in this regard can reduce the likelihood of the poor outcomes for which children with an early onset of conduct problems are at risk. Early treatment also has broader societal implications given the cost of juvenile delinquency and adult antisocial behavior in the form of intensive residential treatments, incarceration, and the impact on victims.

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6 Treatment of Attention-Deficit/ Hyperactivity Disorder (ADHD) DITZA ZACHOR, BART HODGENS, and CRYSHELLE PATTERSON

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common neurobehavioral disorder affecting school-age children. Studies suggest that approximately 8–12% of children (9.2 in males and 3.0 in girls) meet diagnostic criteria for the clinical disorder of ADHD (Faraone, Sergeant, Gillberg, & Biederman, 2003). Approximately 40–70% of those diagnosed with ADHD will have persistent symptoms into adolescence and adulthood with substantial risk of job instability, mood and anxiety disorder, motor vehicle accidents and substance abuse. ADHD is characterized by various symptoms of inattention, and/or impulsivity and is conceptualized as a spectrum, with a range of severity from mild variation of normal behavior to a chronic and severe condition. ADHD affects the individual, the family, and society and can have negative impact on multiple areas of functioning (Wolraich, Hannah, Baumgaertel & Feurer, 1998, American Academy of Pediatrics, 2000). Children with the disorder often suffer from impaired interpersonal relationships with family and peers, academic underachievement and poor self-esteem (Goldman, Genel, & Bezman, & Slanetz, 1998). In addition, children with ADHD commonly exhibit other comorbid developmental and psychiatric disorders that may complicate the intervention plan (Table 6.1; Pliszka, 1998; Spencer, Biederman & Wilens, 1999). DITZA ZACHOR • Tel Aviv University, Tel Aviv, Israel. BART HODGENS • Civitan International Research Center, University of Alabama at Birmingham. CRYSHELLE PATTERSON • Sparks Clinics, University of Alabama at Birmingham.


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Table 6.1. ADHD Comorbid Disorders ADHD: Common Comorbid Disorders Developmental Dimension Poor academic performance Learning Disability Mental Retardation Autism Spectrum Disorders Tic Disorders (e.g., Tourette Syndrome) Behavioral Disorders Oppositional Defiant Disorder Conduct disorder Anxiety Depression / Dysthymia Obsessive Compulsive Disorder

Clinicians who diagnose and treat children with ADHD should develop a comprehensive treatment plan that recognizes the complexity and chronic nature of the disorder. First, a diagnosis of ADHD requires that the child meet criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM–IV) in terms of core symptoms, onset, duration, and functional impairment in more than one setting (American Academy of Pediatrics, 2001). During the initial assessment, clinicians should first obtain information regarding the nature of the child’s symptoms (mostly inattention, behavioral difficulties, etc.) and then determine the severity of the core ADHD symptoms, existence of comorbidities, and the extent of the impairment seen across the different environments. Because the diagnosis of ADHD and the possible need for chronic medical treatment may cause concerns and even anxiety for the family and the child, it is important to provide counseling prior to initiation of therapy. In addition, clinicians should be aware of the family expectations from the treatment and their treatment preferences, thereby optimizing compliance and clinical outcome. Next, it is important to set individualized treatment goals. The American Academy of Pediatrics (AAP) guidelines suggest several outcome measures based on the most disabling core ADHD symptoms (e.g., decrease disruptive behaviors, improve academic performance, improve relationship with family, teachers, and peers and improve self-esteem). It is advisable to choose measurable goals that can assess progress from a baseline state (American Academy of Pediatrics, 2001). Treatment of ADHD consists of two general categories, medication management and behavioral treatment strategies. The following sections describe these treatment strategies in detail, as well as the benefits of a multimodal strategy. The multimodal approach combines the careful medication management of ADHD with proven psychosocial interventions such as parent education, educational intervention, and behavioral therapy in a comprehensive approach. Throughout this chapter, frequent reference is made to the Multimodal Treatment Study of children with ADHD (MTA), the largest randomized clinical trial for the treatment of ADHD ever conducted (MTA Cooperative Group, 1999a). Therefore, it merits particular attention before discussing treatment approaches in detail.

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NIMH MULTIMODAL TREATMENT STUDY OF ADHD (MTA) In 1992, the National Institute of Mental Health (NIMH) and six teams of investigators began a multisite clinical trial to systematically investigate the effectiveness of medication and behavioral treatments for ADHD. The MTA remains the largest ADHD clinical trial to date and its findings continue to be reported and debated (e.g., Arnold, et al., 2004). The design of the treatment protocols, study methodology, and research design were all carefully considered by a steering committee composed of representatives from the six clinical sites and reflected state-of-the-art procedures at the time (Arnold, Abikoff, & Cantwell, 1997). Utilizing a parallel group design, 576 children (96 from each site) ages 7–9 years were randomly assigned to one of four treatment conditions: (1) a medication management-only strategy, (2) a behavioral treatment-only strategy, (3) a combination strategy, and (4) a community-care comparison group. This large sample size nearly doubled the total number of children with ADHD that had ever participated in a rigorously controlled clinical trial for treatment of ADHD prior to that time (Jensen, Hinshaw, Swanson, et al., 2001). The participating children were selected to reflect a broad range of comorbid conditions (e.g., ODD, anxiety), a diversity of referral settings (e.g., school, mental health clinic), and a range of socioeconomic levels. The treatment period was 14 months. The MTA Medication strategy involved an initial titration period, testing placebo versus three different doses of methylphenidate (5 mg, 10 mg, and 15/20 mg, depending on child’s weight). Other medications could be introduced after the first month if a desirable response wasn’t achieved. Ongoing treatment involved monthly meetings with the family and monthly contact with the child’s teacher. The medication treatment was maintained throughout the 14-month period. The MTA Behavioral treatment strategy was initially intense and then faded to monthly meetings over the last 4–6 months of the treatment period. Parents received behavioral parent training over 35 sessions (8 individual, 27 group sessions) to teach them behavior management techniques and coordinating the child’s care in school. Children also participated in an 8-week summer treatment program, an intensive manualized program that is discussed in detail in another section of this chapter. During the first 12 weeks of the school year, each child was assigned a behavior aide who was directly supervised by the same therapist who was responsible for the behavioral parent training and supervised the counselors in the summer treatment program. This same therapist met with each child’s teacher in the fall and spring on a consultative basis. An effort was made to teach parents and teachers to “carry on” as the behavioral treatment components were faded except for monthly follow-up visits. The MTA Combined treatment strategy was a combination of these two strategies with an emphasis on making their implementation as efficient for the family as possible. The Community-care comparison group was given a list of referral sources within the community and treatment consisted of whatever was agreed to by the parents and the care provider. Overall, the community care group had much less frequent contact (i.e., 2.3/year) with care providers and took less medication on average (18.7 mg total daily dose).

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When considering treatment effects for the core symptoms of ADHD (i.e., inattention, impulsivity, and hyperactivity), careful medication management was the most effective single treatment; that is, the Medication and Combined strategies were clearly superior to the Behavioral strategy and Community-care groups. The Medication and Combined groups did not differ on any of the measures of ADHD symptom outcomes. However, when other areas of functioning (e.g., social skills, academic functioning, and parent–child interactions) were evaluated, the Combined treatment appeared to offer some advantages although these were often not statistically significant based on the strict criteria initially established by the MTA workgroup. Using a composite score based on all outcome measures (Conners, et al., 2001), as well as when measures were combined across settings (Hinshaw, 2007), the Combined treatment strategy was found to have significantly better treatment effects than all other treatments. Parents and teachers also provided much higher consumer satisfaction ratings for both behavioral treatment strategies (i.e., Combined and Behavioral). Subsequent analyses indicated that for children with a comorbid anxiety disorder, the addition of a behavioral treatment strategy either alone or in combination with medication was clearly more effective. This finding also held true for families receiving public assistance. No other analyses of potential moderator effects were found to be significant in the initial analysis. The initial findings of the MTA were widely disseminated with some news agencies reporting that behavioral interventions “didn’t work” in treating ADHD (Arnold, et al., 2004). The principal investigators for the MTA have clearly stated in subsequent articles that this is not the case (Jensen, 2001). The MTA study did not include a “no treatment” control group for comparison and all four treatment groups showed a substantial reduction of symptoms over the treatment period. The results for the behavioral treatment strategies are actually quite robust when considered in the context of the strong effects consistently achieved with stimulant medications on ADHD symptoms (Arnold, Chuang, Davies, Abikoff, Conners, & Elliot, 2004). For example, children in the Behavioral group did at least as well as children in the Community-care group, most of whom were being treated with stimulant medications. Also, three-fourths of the Behavioral group were satisfactorily managed for the 14-month treatment period without taking any medication. Another criticism of the initial MTA findings is that they report on treatment effects after the behavioral intervention was faded and medical treatment was still active (Pelham, 1999). This aspect of the research design was based on the view that attempting to promote the generalization of behavioral treatment effects as the intensive program components were withdrawn was desirable and more closely reflected “realworld” practice (Jensen, 1999). The impact of this aspect of the research design in evaluating the true contribution of behavioral interventions to the treatment of ADHD remains a subject of ongoing discussion (Arnold et al., 2004). A primary goal of future research efforts is determining what “dose” of behavioral intervention is sufficient to provide benefits; that is, how intensive does the treatment have to be?


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Regardless of the issues surrounding the evaluation of behavioral intervention effects, the MTA study clearly demonstrated the very strong effects of carefully managed medical treatment on symptoms of ADHD. This finding is consistent with the results from previous studies (Schachar, Tannock, Cunningham, & Corkum, 1997) demonstrating the short-term robust efficacy of medication management out to a period of 14 months. A follow-up of these treatment groups after 24 months revealed that the two most beneficial groups who used medication show deterioration of effectiveness because these groups had a larger number of cases that stopped medication. This deterioration may reflect the lack of maintenance of an effective intervention. The effects of the behavioral therapy although smaller than that of medication, were maintained, suggesting that generalization occurred (MTA Cooperative Group, 2004a).

MEDICATION The neurobiological basis of pharmacotherapy in ADHD has been based on the catecholamine mechanism of action in the central nervous system (CNS). The frontal subcortical-cerebellar circuits are rich in dopaminergic synapses and control a set of executive functions (inhibition, working memory, set shifting, planning and sustained attention, regulation of reward systems and arousal states; Castellanos & Tannock, 2002). The pattern of neuropsychological deficits in ADHD might originate from deregulation of these CNS circuits. The underlying causes of ADHD are not well understood, but there is considerable evidence indicating that dopaminergic and noradrenergic neurotransmission are dysregulated in ADHD. Support for this concept comes from different studies: The action of drugs that increase the synaptic availability of dopamine and norepinephrine on ADHD symptoms. Animal models of ADHD (created via lesions in dopamine pathways). Structural and functional neuroimaging studies showing that brain regions rich in dopaminergic innervations are associated with ADHD. Various genes coding for proteins involved in dopaminergic neurotransmission were associated with ADHD (Cheon et al., 2003; Castellano, & Tannock, 2002; Krause, Dresel, Krause, Kung & Tatsch, 2000; Solanto, 2002). The main pharmacotherapy for ADHD has for decades been the stimulant drugs methylphenidate and amphetamine, which are believed to enhance neurotransmission of dopamine and epinephrine. Methylphenidate is thought to act primarily by blocking reuptake of dopamine transporters, whereas amphetamines are thought to exert their effect by blocking noradrenergic transporters and by facilitating neurotransmitter release. Because ADHD symptoms of inattention and hyperactivity/impulsivity reflect possible dysregulation of the monoamines system, stimulants are thought to normalize the function of the relevant brain regions by enhancing the neurotransmission of dopamine and norepinephrine in therapeutic doses.

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The AAP guidelines recommend that stimulant agents that have been Food and Drug Administration (FDA)-approved as ADHD treatments should be used to achieve the desired treatment goals in children with ADHD. A large body of evidence supports the effectiveness of stimulants in treating ADHD symptoms and endorses their use as first-line treatment (reviewed in Biederman, & Faraone, 2005; Lopez, 2006). Randomized, controlled trials have consistently demonstrated the efficacy of stimulants for reducing the core symptoms of hyperactivity, impulsivity, and inattention. Studies also documented improvement in classroom behavior, academic achievements, conduct, and self-esteem of children and adolescents with ADHD. The majority of children with ADHD (70%) are effectively treated with stimulant medications. With appropriate dose titration and selection of the most effective stimulant, up to 90% of children with ADHD would respond favorably (Hechtman et al., 2004; Mannuzza & Klein, 2000). The most common stimulants in use are methylphenidate and amphetamine (Dexedrine and Adderall, a mixture of four neutral amphetamine salts). Both drug groups are classified as Schedule II controlled substances and are available in short-acting (4 hours), intermediate (8 hours), and long acting (12 hours; Table 6.2). The immediate-release stimulants have a relatively short duration of action, which is a challenging limitation during the school day. Children treated with the short-acting stimulants will often need multiple doses throughout the day to provide coverage of ADHD symptoms both at school and during after school activities. The need for an “in school” second dose, or a third dose for leisure time activities, may cause embarrassment, stigma, and peer ridicule for the school-aged children. This may result in lack of compliance, loss of effectiveness in the afternoon, and more problems with symptoms control. Stimulant medications have a rapid onset of action, a flexible dosing schedule, and many choices of medications that facilitate the development of an individual treatment plan. The decision with which type of medication to start therapy should take into account age, desired duration of action, response type, side effects, and availability.

Table 6.2. Immediate Release Stimulant Medications Active Ingredients

Drug Name

Methylphenidate (MPH) Maximal dose: 60 mg

Ritalin Methylin

Duration (Hours) 3–4

2–3 times a day 2–3 times a day Chewable tablets 2–3 times a day d-MPH isomer

4–5

× 2 daily

4–6

2–3 times a day depending on dose Scored tablets

Focalin Amphetamine: Dextroamphetamine Maximal dose: 40 mg Mixed salts of amphetamines Maximal dose: 40 mg

DextroStat Dexedrine Adderall

Special Consideration


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New Advanced System Delivery Stimulants New developments in stimulant treatment have led to better quality of care. One of the major advances in stimulant treatment has been the development of long-acting formulations with range of action between 8– 12 hours (Table 6.3). These regimens provide coverage for most of the day, prevent humiliation in front of peers, and enable the child to complete his homework and participate in extracurricular activities. Recently, the pharmaceutical companies have developed more technologically advanced formulations of MPH, combining the advantages of both immediate release (IR) and extended release (ER) MPH by using innovative delivery systems. These advances permitted the production of long-acting medications that provide rapid onset of effect with prolonged duration of action in a single dose intended for once-daily administration. Ritalin LA is an example of an intermediate release regimen, which was designed to mimic a twice-daily regimen, releasing 50% of the dose immediately and the other 50% approximately 4 hours later. Ritalin LA™ uses SODAS technology (IR beads contain MPH within sugar spheres and delayed release beads that are coated with a polymer controlling the rate at which the drug diffuses out of the pellet) to achieve bimodal release profile. This drug offers a level of clinical efficacy similar to the effect of immediate release MPH (Biederman et al., 2003).

Table 6.3. Sustained Release Stimulant Medications Duration (Hours)

Active Ingredients

Drug Name

Methylphenidate (MPH)

Ritalin SR

4–8

Ritalin LA

4–8

Metadate ER Metadate CD

4–8 4–8

Methylin ER Focalin XR

4–8 4–8

Concerta

12

Daytrana

9 wear time

Dexedrine Spansules Adderall XR

6–8 10–12

Vyvance

10–12

Amphetamine: Dextroamphetamine Mixed salts of amphetamines Amphetamine prodrug: Lisdexamfetamine dimesylate

Special Consideration Tablets must be swallowed whole Maximal dose: 60 mg Bimodal release system Capsules must be swallowed whole or sprinkled on applesauce Maximal dose: 60 mg Tablets must be swallowed whole Capsules must be taken whole, available in dose packs Maximal dose: 60 mg Tablets must be swallowed whole d-MPH isomer Maximal dose: 20 mg OROS delivery system Maximal dose: 72 mg Transdermal patch

Maximal recommended daily dose: 45 mg Maximal recommended daily dose: 40 mg Maximal recommended daily dose: 70 mg

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An example of an extended release drug is the osmotic release oral system (OROS) that was designed to mimic three doses of MPH (12 hours) duration of action (Concerta™). About 22% of the dose is contained in the tablet overcoat and is released immediately, and the remainder of the dose is released from a trilayer core through a controlled ascending osmotic process (Wolraich, Greenhill & Pelham, 2001). Another example is the controlled-delivery methylphenidate extended release capsule (Metadate CD™), which utilizes Diffucaps technology, a multiparticulate bead delivery system. Contained within each capsule is a combination of IR MPH and ER MPH coated beads proportioned in 30:70 ratio yielding a biphasic, ascending dose-proportional pharmacokinetic profile preventing tolerance development (Hirshey-Drisken, D’Imperio, Birdsall & Hatch, 2002). Another method of delivery is the MPH transdermal system (MTS) patch, which permits sustained absorption of the drug through the skin and into the bloodstream using DOT matrix technology that combines adhesive properties and effective drug release vehicle (Anderson & Scott, 2006). MTS delivery results in a uniform systemic drug delivery while avoiding firstpass metabolism by the liver. The transdermal patch (Daytrana™) is the only nonoral medication available for the treatment of ADHD and is FDAapproved. MTS use allows physicians to control the daily dose and the duration of effect by using different patch sizes and changing wear time. The ability to remove the patch permits greater flexibility in dosing for those children who need to stop and start treatment at different times of the day. It may be a suitable solution for those who have difficulty swallowing pills, have rapid metabolism of the drug, or suffer from late-day side effects. The most widely prescribed medication for ADHD is the racemic mixture of both the d-threo and l-threo enantiomers of MPH (National Institute of Health, 1998). However, the clinical efficacy of d,l-MPH is thought to be mediated by the d-enantiomer (Weiss, Wasdell & Patin, 2004). Focalin™ (d-MPH), a new formulation of the active d-isomer, was as effective as d,l,-MPH for the treatment of ADHD even in half dose, thus providing use of the lowest effective dose and possibly limiting the occurrence of serious side effects. In the amphetamine group, Adderall XR™ is a two-component extended release capsule (50:50% beads), designed to produce pulsedrelease amphetamine salts mixture yielding a therapeutic effect that lasts throughout the day and evening in one morning dose (Biederman, Lopez, Boellner, & Chandler, 2002). Lisdexamfetamine dimesylate (Vyvance™) is a prodrug of d-amphetamine, which was recently approved by the FDA for use in ADHD. This compound is a conditionally bioreversible derivative of amphetamine, meaning that it is conjugated to a specific amino acid. The compound is activated only when the amino acid is cleaved from the amphetamine molecule during metabolism. Following ingestion, the pharmacologically active s-amphetamine molecule is gradually released by rate-limiting hydrolysis. This medicine provides an extended duration of effect that is consistent throughout the day, with reduced potential for abuse, overdose toxicity, and drug tampering. Clinical studies documented significant


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improvements in the children’s behavior throughout the day on ADHD rating scales for three examined doses (30, 50, 70 mg) compared with placebo (Biederman, Krishnan, Zhang, McGough, & Findling, 2007). Modafinil™ is a new stimulant that is structurally and pharmacologically different from other stimulant medications for ADHD and has low potential for abuse. Modafinil has been used to promote wakefulness for narcolepsy. The mechanism of action is not entirely known, but it appears that Modafinil alters the balance of gamma-aminobutyric acid and glutamate, which results in activation of the hypothalamus, and increases the metabolic rate in the thalamus, amygdala, and hippocampus (Rugino & Copley, 2001; Rugino & Samsock, 2003). In a double-blind placebo-controlled study in children with ADHD, one 300 mg dose of Modafinil per day greatly improved symptoms that were rated by teachers, clinicians, and parents. A larger dose of 400 mg did not add greater effect than the lower dose. All the doses were well tolerated and the most common adverse effects were insomnia, headache, decreased appetite, abdominal pains, cough, fever, and rhinitis (Turner, Clark, Dawson, Robbins, & Sahakian, 2004).

Adverse Effects of Stimulant Medications Adverse effects of stimulants are usually mild and can be managed by changing the dose, the timing, or the type of stimulant. The most common side effects are decreased appetite, transient headache and stomachache, sleep problems, and behavioral rebound. Somatic complaints described on the first days of use, typically resolve within one to two weeks of treatment. Rarely appetite suppression will lead to weight loss and growth suppression. Published reports on the effect of longterm stimulant therapy on growth are controversial. Some early reports suggested stimulants may induce growth suppression (Poulton & Powel, 2003). The MTA study found mild growth suppression in height after ten months of consistent use of stimulant medication (MTA Cooperative Group, 2004b). More recent reports using standardized tools such as body mass index (BMI) charts and Z-scores, have not reported significant effects on height or weight growth over time. In addition, several longterm studies suggested that deficits in weight and height are reversible and not of clinical significance even with continued treatment for two to three years (Faraone, Biederman, Moonuteau, & Spence, 2005; Zachor, Roberts, Hodgens, Isaacs, & Merrick, 2006). Infrequently, children can become socially withdrawn, extremely unresponsive, dizzy, and extremely focused on trivial information as a side effect of stimulant medication. These side effects are more common in young children with mental retardation or with other developmental problems. Most of the side effects abate with long-term treatment. In very rare cases, side effects that are more serious can occur, such as hallucinations, exacerbation of tics, and adverse cardiovascular events. About 20% of children with ADHD are affected by chronic tic disorder, whereas about half of the cases with chronic tics or Tourette syndrome also meet criteria for ADHD. Usually, ADHD is diagnosed two to three years

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before first tic onset. Some concerns exist that stimulants may increase the risk of first-onset tics or worsening of pre-existing tics. Early reports showed stimulants might raise the risk for tics in patients with a personal or family history of tics (Lowe, Cohen, Deltor, Kremenitzer, & Shaywitz, 1982). These authors claimed that Tourette syndrome or tics in a child are a contraindication to the use of stimulants. However, recent reports challenge this view and a metaanalysis of studies with high methodological quality (double-blind placebo-controlled) revealed that there seems to be no elevated risk of first-onset tics during stimulant treatment (Roessner, Robatzek, Knapp, Banaschewski, & Rothenberger, 2006) In addition, stimulants are believed to lower the threshold for seizures but a diagnosis of epilepsy is not an absolute contraindication to the use of stimulants. Although several studies have revealed that stimulants do not exacerbate well-controlled epilepsy, children should be monitored closely for exacerbation of seizures while on the medication. A recent study reported 2% seizures in a stimulant-treated group of children diagnosed with ADHD. This rate is not exceptionally high given that an estimated 1% of unselected children will have at least one afebrile seizure by 14 years of age. This study found that epileptiform EEGs identified a subgroup of children with ADHD with seizure risk of up to 20%, whereas normal EEGs indicated minimal risk ( W-L

*

TX > W-L

ns

CBT > TX

*

CBT > TX

*

=

*

CBT > TX

ns

TXs > W-L

*

TXs > W-L

*

*

TX > Placebo

NR

TX > Placebo ns

*

TXs > W-L

*

TX > W-L

*

TX > W-L

*

=

NR

*

* NR

NR NR

NR NR

* =

*

ns

*

ns

NR

TXs > W-L

ns

TXs > W-L

*

ns

*

TX > W-L

*

CBT > TX

*

ns

NR

TX > W-L

TX > W-L

NR

TXs > W-L

TX > W-L *

ICBT+Med vs. ICBT vs. Med vs. Pill Placebo ICBT vs. GCBT vs. W-L

POTS (2004) Barrett et al. (2004)

Posttraumatic Stress Disorder ICBT vs. ParCBT vs. ICBT+ParCBT vs. Com Deblinger et al. (1996) ICBT vs. ICBT+ParCBT King et al. vs. W-L (2000) GCBT vs. W-L Stein et al. (2003) ICBT+ParCBT vs. Child- Cohen et al. centered (2004) Childhood Anxieties (combined) ICBT vs. W-L Kendall (1994) ICBT vs. ICBT+ParBT Barrett et al. vs. W-L (1996)

ns (continued)

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THOMPSON E. DAVIS III

Table 7.2. (continued ) Evidence for Efficacy at Treating Response Component Symptoms ICBT vs. W-L GCBT vs. GCBT+ParBT vs. W-L ICBT+ParBT vs. W-L GCBT vs. W-L ICBT vs. GCBT vs. W-L

GCBT+ParCBT vs. W-L GCBT vs. Psychological Placebo GCBT vs. Psychological Placebo ICBT vs. ICBT+ParCBT vs. W-L GCBT vs. GCBT+Internet vs. W-L

Kendall et al. (1997) Barrett (1998) King et al. (1998) Silverman et al. (1999) FlannerySchroeder et al. (2000) NR Shortt et al. (2001) Ginsburg et al. (2002) Muris et al. (2002) Nauta et al. (2003) Spence et al. (2006)

NR

TX > W-L

TX > W-L

TX > W-L

*

TXs > W-L

*

ns

NR

TX > W-L

TX > W-L

TX > W-L

NR

TX > W-L

*

TX > W-L

TX > W-L

TX > W-L

TX > W-L

NR

TX > W-L

*

TX > W-L

*

*

*

TX > Placebo

*

*

*

TX > Placebo

*

TXs > W-L

*

TXs > W-L

NR

TXs > W-L

*

TXs > W-L

Key: “*” = not measured, “=” = groups were equivalent, Com = Community Care/Treatment as usual, E/ RP = exposure with response prevention, G = group, I = individual, Med = medication, NR = component was measured but not reported (e.g., a total score was reported but not a subscale containing the needed information), ns = no significant differences, Par = parents involved with treatment, TX(s) = treatment or treatments, SD = systematic desensitization, W-L = wait-list control.

disorder, or generalized anxiety disorder as separate diagnostic entities (i.e., in RCTs specifically designed to determine the effects of treatment on that disorder). However, several studies have examined various anxiety disorders in combination (e.g., the well-known CBT RCT by Kendall, 1994). Given this, the review focuses on the empirical support for treatments of specific phobia, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and a final category deemed “childhood anxieties.” This combined group is composed of studies that meet the Task Force’s (1995) guidelines, even for specificity of the sample; however, the studies did not focus on a single anxiety diagnosis (e.g., GAD, SoP, and SAD in a single sample).

Specific Phobia (SP) Utilizing the review criteria specified, four RCTs were identified that lend empirical support to the behavioral treatment (BT) and cognitive-behavioral treatment of clinically significant specific phobias. For BT, Cornwall, Spence, and Schotte (1996) examined the effects of SD (specifically emotive

PTSD, ANXIETY, AND PHOBIA

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Table 7.3. Empirically Supported Treatments for Anxiety Disorders Affecting Children and Their Effects on the Components of an Emotional Response Level of Empirical Support DSM–IV–TR Disorder and Treatments

Overall Status

Physiology

Behavior

Cognition

Experimental Probably Efficacious

Exper Exper

Exper Prob

Exper Exper

Exper Prob

Probably Efficacious Probably Efficacious

Exper

Prob

Exper

Prob

Exper

Exper

Exper

Prob

Obsessive-Compulsive Disorder CBT Well Established

Exper

Exper

Exper

Exper

Posttraumatic Stress Disorder CBT Well Established

Exper

Prob

Exper

Prob

Childhood Anxieties (combined) CBT Well Established

Exper

Prob

Prob

Well Est

Specific Phobia SD CBT Social Phobia BT CBT

Subjective

Key: BT = behavior therapy, CBT = cognitive-behavioral therapy, Exper = experimental empirical status, Prob = probably efficacious empirical status, Well Est = well established empirical status, SD = systematic desensitization.

imagery: a technique involving hierarchical exposure with an imagined “superhero.”) on children with phobias of the dark. Results indicated significantly better outcomes in behavior and on self-reports with SD compared to a wait-list group, warranting experimental status (i.e., needs replication or comparison to a more rigorous intervention/placebo). Three studies examined the effects of CBT on specific phobias (Muris, Merkelbach, Holdrinet, & Sijsenaar, 1998; Muris, Merkelbach, Van Haaften, & Mayer, 1997; and Öst et al., 2001). Although the studies by Muris and colleagues were crossover studies, information regarding comparisons from pretreatment to posttreatment prior to the crossover does produce results consistent with an RCT design. Overall, results from these RCTs indicate CBT for childhood-specific phobia merits probably efficacious status as it has been found superior to another treatment in two studies and to a wait-list control on a third. Specifically, CBT was superior to eye movement desensitization and reprocessing (EMDR) in the studies by Muris and colleagues and superior to wait-list on a variety of measures (Öst et al., 2001). An analysis of the effects of SD on the components of the emotional response indicates experimental status for all three responses (i.e., physiology, behavior, and cognition) as well as the subjective experience of anxiety. Cornwall et al. (1996) included measures of behavior and rating scales of subjective fear that indicated treatment was superior to wait-list; however, these findings require replication in clinical child populations.

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Moreover, a measure of psychophysiology was obtained (i.e., physiological anxiety: Revised Children’s Manifest Anxiety Scale, RCMAS; Reynolds & Richmond, 1978) but not examined. Componential analysis for CBT indicates experimental status for both the physiological and cognitive components (i.e., no significant differences in groups in two studies). CBT for the behavioral component can be considered probably efficacious given its demonstrated superiority to two other treatment conditions but only in one group of researchers (see Tables 7.2 and 7.3), whereas probably efficacious status is warranted for the subjective experience of fear and anxiety. Of note, these conclusions regarding EST status and the studies included for review differ from those of Davis and Ollendick (2005) and from Ollendick and King (1998). Difference can be directly attributed to the more stringent criteria being applied in the current review and the emphasis on examining studies using children with actual specific phobias and not analogue fears.

Social Phobia (SoP) RCTs supporting the treatment of SoP in children include two using CBT conducted in a group format (Gallagher, Rabian, & McCloskey, 2004; Spence, Donovan, & Brechman-Toussaint, 2000) and one utilizing BT in a mixed individual and group format (Beidel, Turner, & Morris, 2000). The CBTs incorporated a variety of techniques including exposure, cognitive challenges/therapy, social skills, modeling or participant modeling, and psychoeducation (Spence et al., 2000 also included relaxation). Results of both CBT trials indicated treatment gr oups were superior to wait-list conditions on numerous measures, including diagnostic outcomes. As a result, group CBT for SoP merits probably efficacious status. The BT trial included a variety of techniques similar to the other trials including psychoeducation, social skills training, modeling, and exposure, but did not reportedly include an explicitly cognitive component. BT trial results were also significant and superior to a study skills psychological placebo. As a result, BT also merits probably efficacious status by having met a more rigorous standard. Specifically, according to EST criteria, Beidel et al. (2000) met all the criteria for a well-established treatment with the exception of independent replication. Componential analysis of the three studies indicates that none contained a measure that could be considered cognitive. Spence et al. (2000) included a measure of physiology but did not report on those data (physiological anxiety, RCMAS). All three RCTs did, however, include measures of the behavioral component and of the subjective emotional experience. In addition to rating scale data, Beidel et al. (2000) included a behavioral observation. Results from these data indicate that BT is probably efficacious at treating the behavioral response given BT was superior to a psychological placebo on these measures and observations. Furthermore, BT was superior to psychological placebo on several self-reported measures of the subjective experience of anxiety, thereby meriting probably efficacious status. Turning to CBT, Spence et al. (2000) assessed phobic behavior using both parent-report questionnaires and direct observation;


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however, they found no significant differences between CBT and wait-list conditions. On a parent-report measure Gallagher et al. (2004), however, did find CBT superior to wait-list. Taken together and given the level of evidence (i.e., one significant comparison to a wait-list), CBT for SoP still warrants experimental status for the behavioral response. In contrast, CBT’s effects on the subjective experience of anxiety merits probably efficacious status as both studies found a wait-list inferior to CBT on numerous selfreport measures.

Obsessive-Compulsive Disorder (OCD) Three RCTs meeting the review criteria were identified and used to determine the overall and componential EST status for this disorder (Barrett, Healy-Farrell, & March, 2004; de Haan, Hoogduin, Buitelaar, & Keijsers, 1998; POTS, 2004). All three of these studies used forms of manualized CBT that included psychoeducation, cognitive interventions, and exposure and response prevention (E/RP). Overall, results from these studies indicate individual CBT is more effective than clomipramine (de Haan et al., 1998), pill placebo (POTS, 2004), and a four- to six-week wait-list condition (Barrett et al., 2004). These effects were also obtained across two different groups of researchers and all three used participants diagnosed with OCD. Group CBT was provided by Barrett et al. (2004) and was found to be equivalent to individual CBT and superior to the wait-list condition. Given this level of evidence, CBT for OCD meets the criteria for a well-established intervention. Of note, these conclusions are made tentatively and are in need of replication. Even though CBT is considered the treatment of choice for OCD based on the results of this review and numerous other studies (e.g., open trials; for a review see Turner, 2006) further RCTs are necessary. The results of POTS (2004) are intriguing as a combined approach to OCD (i.e., both medication and CBT) was found to be superior to both CBT and sertraline administered separately, which did not differ from each other (although site differences were apparent). As a result, it may be that the actual best practice is a combination approach, especially for serious cases. Finally, parents were involved to varying degrees in all three trials which may have contributed to treatment success. Componential analysis of EST status led to conclusions that CBT provided either in individual or group format merited only experimental status for addressing the components of the emotional response. This finding was especially disappointing given all three studies included the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Goodman et al., 1989; Scahill et al., 1997) and one study included a measure having a physiological symptoms scale (Multidimensional Anxiety Scale for Children, MASC; March, 1997). Specifically, studies consistently reported and analyzed only the total score instead of also examining the obsessions severity and compulsions severity scores which might have added to empirical support for the cognitive and behavioral components. Barrett et al. (2004) did include a measure of subjective anxiety; however, no differences between groups over time were observed.

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Posttraumatic Stress Disorder (PTSD) Cohen, Deblinger, Mannarino, and Steer (2004), Deblinger, Lippman, and Steer (1996), King et al. (2000), and Stein et al. (2003) all reported on trials of CBT for PTSD or clinically significant PTSD symptoms. As with the previous reviews, all four included manualized CBT and included techniques such as cognitive coping skills, psychoeducation, graduated exposure, cognitive therapy, and other techniques. Outcomes from these studies indicate CBT for PTSD in children meets well-established status. Parent and child CBT was found superior to child-centered therapy (Cohen et al., 2004) and the combination of child CBT and child and parent CBT (i.e., two separate groups collapsed) was superior to a combination of parent-only CBT and care as usual in the community (Deblinger et al., 1996). In addition, two trials found CBT superior to wait-list conditions (King et al., 2000; Stein et al., 2003). As a result, CBT for PTSD has been found superior to another treatment or placebo in at least two trials by two different research groups. The effects of CBT on the components of the emotional response indicate it meets experimental criteria for physiology and cognition; however, probably efficacious status is warranted for the behavioral component and the subjective experience of anxiety. King et al. (2000) was the only study to measure cognition (i.e., coping self-efficacy; no significant differences among groups) and physiology (i.e., RCMAS; physiological anxiety scale not examined). The effects of PTSD on behavior were measured in all four trials, but only two found differences: King et al. (2000) found significant differences with CBT superior to a wait-list and Cohen et al. (2004) found CBT superior to another treatment. Finally, all four trials measured subjective anxiety with only King et al. (2000) and Stein et al. (2003) finding CBT superior to wait-list conditions leading to probably efficacious status.

Childhood Anxieties Frequently, studies in this category compared CBT to CBT with an alteration (i.e., group vs. individual format, child and parent or family treatment vs. child treatment) and/or to wait-lists. CBT to CBT comparisons were often difficult to separate and appeared to suffer from insufficient power to obtain differences (cf. Kazdin & Bass, 1989). As a result, general impressions of outcomes are conservatively reported in an attempt to summarize frequently inconsistent (e.g., mother vs. father vs. child vs. clinician reports) or vacillating results (e.g., changes in the superiority of a group from post to follow-up to later follow-up). Moreover, preference in interpreting outcomes was given to the results of diagnostic depictions and widely used measures (e.g., CBCL, RCMAS, FSSC-R). Excluding some studies where results generally appeared to be equivalent (e.g., Manassis et al., 2002), 12 RCTs were identified and examined. As a whole, well-established status for CBT with children is warranted as Ginsburg and Drake (2002) and Muris, Meesters, and van Melick (2002) all found CBT superior to a psychological placebo intervention. Moreover, the 10 additional studies included for review found CBT superior to varying wait-list conditions in every instance (see Tables 7.2 and 7.3; Barrett,


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1998; Barrett et al., 1996; Flannery-Schroeder & Kendall, 2000; Kendall, 1994; Kendall et al., 1997; King et al., 1998; Nauta, Scholing, Emmelkamp, & Minderaa, 2003; Shortt, Barrett, & Fox, 2001; Silverman et al., 1999; Spence, Holmes, March, & Lipp, 2006). Conservatively, however, it may be more appropriate to assert that group CBT merits well-established status and that individual CBT or CBT with a family or parent component merit probably efficacious status (see Table 7.2). Componential analysis of CBT for these combinations of childhood anxiety indicates experimental status is warranted for the physiological response. None of the 12 studies reviewed reported on or examined physiological results, even though 8 included measures that could have been tapped. Behavior was measured in some form in 10 of the 12 studies with all 10 finding CBT superior to a wait-list condition, resulting in probably efficacious status. Only four studies included a measure of cognition; however, results all supported the superiority of CBT to a wait-list and probably efficacious status. Finally, all 12 studies included a measure of the subjective experience of anxiety with eight RCTs finding CBT superior to wait-list and two RCTs finding CBT superior to a psychological placebo. Given this level of evidence, CBT’s effects on the subjective experience of anxiety are well established. Notably, the use, influence, or adaptation of the CBT by Kendall was clearly observable to varying degrees in almost all of the 12 studies (i.e., Coping Cat Workbook; Kendall, 1990; Kendall & Hedtke, 2006). Briefly, this CBT focuses on “recognizing anxious feelings and somatic reactions to anxiety, clarifying cognition in anxiety provoking situations, developing a plan to cope with the situation, and evaluating performance and administering self-reinforcement as appropriate” (Kendall, 1994, p. 103). With the Coping Cat program, children are taught to use the acronym FEAR to guide their coping and exposure in session and through weekly homework assignments: “F”eeling frightened, “E”xpecting bad things to happen, “A”ttitudes and actions that can help, and “R”esults and rewards (Kendall, 1990). Approximately one-half of the 16 or more sessions are devoted to psychoeducation, coping, relaxation training, and so on with the remaining sessions focusing on exposure.

CONCLUSIONS AND FUTURE DIRECTIONS The preceding review of empirically supported treatments for childhood anxiety disorders attests to the benefits of the growth in treatment research over the last decade. Of the four specific anxiety disorders for which RCTs have been conducted using clinical child samples, probably efficacious or well-established treatment options exist for each disorder. Moreover, for the combined childhood anxiety disorder studies, probably efficacious support or better exists for a variety of treatment options including formulations with the individual child, the child and the family or parent, or variations with a group format. Overall, although these studies have excelled in including measures of the behavioral component and the subjective anxiety experience, more

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focus needs to be placed on the physiological and cognitive components. In particular, only 2 of the 26 RCTs examined measures that could be considered physiological. Even more disappointing, 12 of the remaining 24 RCTs included measures that address psychophysiology only to neglect or not report their examination in treatment outcomes (e.g., RCMAS physiological anxiety). Similarly, 5 of the 26 RCTs included measures of cognition, with 3 others not reporting treatment outcomes (i.e., CY-BOCS obsessions). Summarizing, it would seem Davis and Ollendick’s (2005) conclusion of a disconnect existing between treatment theory and RCT practice applies broadly to all disorders of childhood anxiety included in this review. In addition to including cognitive and physiological assessments in CBT RCTs, more effort also needs to focus on the use of alternate treatments or placebos over wait-list controls and CBT to CBT comparisons. An examination of Table 7.3 reveals that even with 24 RCTs examining the behavioral component (included and reported in 22 of the 26 RCTs), studies made such frequent use of wait-list conditions, CBT to CBT comparisons, or suffered from inadequate power (cf. Kazdin & Bass, 1989) such that well-established status was achieved for no intervention. Of note, a potentially rich focus for future RCT examination would be the comparison of CBT to the behavioral techniques of past decades. These techniques (e.g., PM, RP, and SD) showed considerable empirical promise in mostly analogue fear samples in previous reviews (cf. Davis & Ollendick, 2005; Ollendick & King, 1998) and are frequently incorporated into CBT protocols. It would be beneficial and timely to examine their merit singly against CBT in demonstrably clinical child samples. Similarly, it is also disappointing that the studies reviewed generally did not include examinations of the mechanisms of change and potential ESPs. Such examinations would be easy to accomplish with the existing datasets and have been fruitful (Treadwell & Kendall, 1996, and the impact of treatment on negative self-talk). Moreover, such mediational testing (cf. Baron & Kenny, 1986; Holmbeck, 1997; Kraemer, Wilson, Fairburn, & Agras, 2002) would assist in the study and empirical support of ESPs as well as the ESTs being examined. Such analyses and refinements are crucial for further treatment development and refinement, especially for the children with anxiety receiving therapy. Specifically, in examining the 12 studies of combined childhood anxieties for which arguably the most widely studied and disseminated CBT or an adaptation/variant was used (i.e., The Coping Cat), on average across the studies roughly 43% of children receiving CBT still met criteria for their primary anxiety disorder at posttreatment assessment (range 11.8% to 50.0%). This very rough estimate (e.g., differences in samples, time of assessment, measures), however, indicates a great deal more needs to be done for even wellestablished interventions. The criteria implemented in the current study were necessarily strict in adherence to the important function of ESTs: to identify those treatments deserving emphasis for training, dissemination, and practice. An effort to avoid questing for the “prize” of EST status was embodied in the conservative approach taken (e.g., adherence to the Task Force criteria, preponderance of evidence suggesting clinical disorders or symptoms for


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inclusion). Although this approach led to results that are generally more conservative than those of previous EST reports and reviews, it is believed these more accurately reflect the state of the science in treating psychopathology. For example, as previously mentioned, Menzies and Clarke (1993) was used to suggest probably efficacious status for “exposure” (cf. Chambless et al., 1998) for “water phobia” (Menzies & Clarke, 1993), but also did so using arguably analogue participants who on average at pretreatment could at least proceed down to about neck depth in a pool, if not farther with hesitation. A developmental approach to childhood anxiety disorders and their treatment is also needed. Future researchers should aspire to move RCTs toward a more developmentally sensitive and informed model, compared to the continuing downward extension of adult treatments (Barrett, 2000). Such work can be advanced by examining moderators and mediators of treatment, and has begun by examining various treatment techniques designed to target potential etiological and maintenance factors of anxiety particular to children (e.g., family treatment in Barrett et al., 1996) and by examining the effects of CBT for anxiety on those with severe intellectual, emotional, and developmental delays (e.g., Davis, Kurtz, Gardner, & Carman, 2007). However, the study of the effects of childhood anxiety on development and of the ability of treatments to remediate psychopathological developmental insults is also necessary. A developmentally appropriate approach involves moving beyond a mere diagnostic assessment to incorporate outcome measures of the entire emotional response and indicators of a child’s developmental functioning and trajectory. This observation points to a gap in the current treatment literature: the need to consider factors beyond psychopathology including a child’s emotion regulation, progression through developmental milestones and developmental capabilities, and overall environment (Southam-Gerow & Kendall, 2000, 2002). In sum, research into the treatment of childhood anxiety disorders has blossomed over recent years with cognitive-behavioral EBTs at the forefront. Although this renaissance has led to the development and study of elegant therapies, controversy still surrounds their evaluation and study. Future research should focus on the mechanisms of change and moderators of outcome (i.e., for what individuals does treatment work or is treatment most effective?). The various refinements and formats of CBT for childhood anxiety will likely prove beneficial considering the equifinality and multifinality of psychopathology. Given the heterogeneity of pathways to childhood anxiety, it is likely that specialized treatments addressing these moderating and mediating variables will be ideal (e.g., cognitive-behavioral family interventions for families in which anxious functional behavior is reinforced or individual CBT for children from chaotic families for whom little familial support of treatment procedures exists). These more complex questions of applicability of ESTs (i.e., treatment effectiveness) are likely to be ones of greater interest to practitioners and critics of EBP. In closing, a framework for future EBP progress is offered using the following circular process: (1) planners of RCTs should actively attempt to address weaknesses pointed out in the literature, (2) active treatment

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or placebo comparison conditions should be incorporated into RCTs in addition to wait-lists for more rigorous comparisons, (3) measures of the various components of anxiety and development should be purposefully included and examined, (4) mediational and moderational analyses should be undertaken to elucidate ESPs and mechanisms of change and to examine developmental variables, (5) future evaluations of these treatment studies should adhere strictly to Task Force criteria, and (6) efforts should be made to disseminate EST findings to academic, research, and practice communities.

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8 Treatment Strategies for Depression in Youth MARTHA C. TOMPSON and KATHRYN DINGMAN BOGER

There is a well-developed literature on depression in adults, including risk factors, phenomenology, correlates, course, and biological substrates (Kessler et al., 2003). Examination of both psychopharmacologic and psychosocial treatments is extensive (de Maat, Dekker, Schoevers & de Jonghe, 2007), and treatment guidelines have been developed to direct clinicians’ interventions (American Psychiatric Association, 2006). However, examination of depression in youth has commenced much more recently, and the research literature to guide treatment is less well-developed. The last 25 years have seen a surge in our understanding of the phenomenology, course, correlates and etiology of youth depression. Despite the many questions that remain, the field has moved forward in the development of efficacious treatment strategies. Recent data support the use of selective serotonin reuptake inhibitors (SSRIs) in the treatment of youth depression (Emslie, et al. 1997; 2002; Keller et al., 2001; Wagner et al., 2003, 2004) but do not suggest efficacy for tricyclic antidepressants (Keller et al., 2001). Given the rates of adverse events in clinical trials with youth (Cheung, Emslie & Mayes, 2005), their limited efficacy (Hamrin & Scahill, 2005), and recent concerns about the potential for increased risk of self-harm associated with SSRIs in youth (United States Food and Drug Administration, 2004), there is a strong need for the development of effective psychosocial treatments as treatment alternatives and supplements to medication in the comprehensive treatment of depressed youth. MARTHA C. TOMPSON and KATHRYN DINGMAN BOGER

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Boston University.


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MARTHA C. TOMPSON and KATHRYN DINGMAN BOGER

Although depression appears to be relatively rare prior to adolescence, representing only 3% of school-aged youth (Costello et al., 1996), its incidence increases significantly post-puberty (Costello et al., 1996; Lewinsohn, Hops, Roberts, Seeley & Andrews, 1993; Kessler & Walters, 1998), with 20% of youth expected to experience a depressive episode by age 20 (Lewinsohn et al., 1993). Literature to date suggests important differences in adolescent-onset and preadolescent-onset depression. First, earlier onset depression may be associated with a more pernicious course than later onset depression (Kovacs, Feinberg, Crouse-Novak, Paulauskas, & Finkelstein, 1984). Second, early-onset depression frequently disrupts important developmental processes during the elementary school years and is likely to result in reduced psychosocial competence (Puig-Antich et al., 1985a; 1985b). Thus, compared to nondepressed school-aged youth, depressed schoolaged youth are more likely to enter adolescence with fewer skills to cope with an increasingly demanding environment. Third, although research generally supports the role of negative attributional processes in adolescent depression (Garber & Flynn, 2001), the data on the role of cognitions in preadolescent depression is less clear (Nolen-Hoeksema & Girgus, 1995). During the elementary school years children are still developing schemas for understanding and making sense of events. Fourth, although the data suggest strong continuity between adolescent and adult depression (Bardone, Moffitt, Caspi, & Dickson, 1996; Fleming, Boyle, & Offord, 1993; Lewinsohn, Rohde, Klein, & Seeley, 1999; Pine, Cohen, Gurley, Brook, & Ma, 1998; Weissman et al., 1999), studies of preadolescent-onset depression suggest high rates of ongoing maladjustment and psychiatric disorders but less specificity for later depression. In sum, there is evidence that adolescent-onset and preadolescent-onset depression differ in important ways. For these reasons we have chosen to examine treatments for adolescent and preadolescent depression separately. In this chapter we describe the primary psychosocial treatments approaches that have been investigated for depression in youth. First, we outline some of the critical issues to consider in treatment for youth depression. Second, we review the literature on treatment efficacy. Third, we outline directions for future research.

CRITICAL ISSUES IN TREATMENT OF DEPRESSED YOUTH Discovering and deciding upon the important issues that contribute to a child’s depression is not only one of the first steps in determining the course of treatment but it is also one of the most difficult tasks to undertake. Although children might acknowledge some symptoms or issues, they often may be dismissive or unaware of issues that feed the depression. However, understanding the context within which the child develops, including developmental phase effects, comorbidity, familial processes, stress, and cultural background is essential to conducting an assessment that adequately informs treatment. As evidenced by the paucity of preadolescent treatment studies outlined in the treatment outcome tables in this chapter, the majority of the treatment

TREATMENT STRATEGIES FOR DEPRESSION IN YOUTH

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outcome literature on youth depression has focused on adolescents. Although a few treatment development studies have been conducted with diagnosed school-aged youth (Flory, 2004; Kaslow, Baskin, Wyckoff, & Kaslow, 2002; Kovacs et al., 2006; Tompson et al., 2007), there has not been a single randomized control trial that exclusively targeted preadolescents with diagnosed depression. The few existing trials conducted with preadolescents have focused on those with high levels of depressive symptoms rather than diagnosable disorders. In addition, research findings on the relationship between the child’s age and treatment outcome have been mixed. Weisz and colleagues (Weisz, Thurber, Sweeney, Proffitt, & LeGagnoux, 1997) found that therapy was more effective for children (ages 4–12) than for adolescents (ages 13–18). However, in their review of 150 different studies of the effects of psychotherapy with children and adolescents, Weisz and colleagues (Weisz, Weiss, Han, Granger, & Morton, 1995) found that treatment outcomes were superior for adolescents compared to children. More specifically, they reported a mean effect size of 0.48 for children under the age of 12 and a mean effect size of 0.65 for children over 12. A recent meta-analysis (Weisz, McCarty & Valeri, 2006) specifically examining treatment for depressed youth found that, excluding trials with mixed child and adolescent samples, the effect size for studies of youth under age 13 was not significantly different from the effect size for treatment of adolescents (0.41 versus 0.33). However, the effect size for the younger children (vs. adolescents) was based on a very small number of trials (n = 7) all of which were selected based on depressive symptoms versus diagnoses, which likely led to less severe depression in the child samples. Clearly, there is a need for a better understanding of the relationship between age and treatment outcome, particularly in relation to youth depression. Such research should be informed by the developmental tasks and changes associated with preadolescence and adolescence and the ways in which they interact with various treatment approaches. Each developmental phase brings with it tasks to be completed in order for the youth to successfully move toward the next developmental stage. These particular tasks interact differently with the youth’s vulnerability and symptom expression at various stages of development. For example, specific developmental considerations that differ between youth’s preadolescent years and adolescent years include their changing cognitive capacity and social influences. The preadolescent’s cognitive development may contribute to an expression of depressive symptoms that differs from that of adolescents or adults (Harter, 1999). It has been suggested that preadolescents have not yet gained capacity for formal operational thinking and abstract reasoning necessary for the formation of internal, global, and stable explanation cognitive styles that are associated with depression (Turner & Cole, 1994). For example, preadolescents endorse hopelessness less frequently than adolescents, likely due to the fact that they have not yet gained the level of generalization necessary for an understanding of the concept (Carlson & Kashani, 1988; Stark, Sander, & Hauser, 2006). In addition, although preadolescents tend to rely heavily on their parents for guidance, feedback,

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and support in negotiating the outside world, adolescents are shifting their focus from family to peers as the primary unit of socialization. During adolescence, youths begin to increasingly attend to environmental information from their peers, leading to higher levels of peer-related stress (Rudolph & Hammen, 1999; Wagner & Compas, 1990). Adolescents’ advanced cognitive perspective-taking abilities also cause social comparisons to become a central means of evaluating their self-worth (Stark, Sander, & Hauser, 2006). Effective treatment strategies should therefore be tailored to the specific socialization needs and cognitive capacities of youth at different developmental stages. Adolescent depression frequently presents with comorbid conditions. Indeed, research suggests that upwards of half of the youth with diagnosable depression also meet criteria for another Axis I disorder (Lewinsohn, Rohde & Seeley, 1998). Comorbidity may be even higher in younger children (Kovacs, 1996). Common comorbidities include anxiety disorders and attention deficit disorders in both preadolescent and adolescent youth, as well as substance abuse during adolescence (Kovacs, 1996). Risk for depression may be particularly heightened in individuals with Asperger’s syndrome, Autism and associated development disabilities (Ghaziuddin, Ghaziuddin, & Greden, 2002; Matson & Nebel-Schwalm, 2007; Saulnier & Volkmar, 2007), and there is a strong need to enhance strategies for assessing depression in these individuals (Matson & Nebel-Schwalm, 2007). Knowledge of the disorders that both parallel and likely contribute to and interact with youth depression is crucial to understanding children’s ongoing depression and psychosocial difficulties. Familial processes are also key factors associated with youths’ risk and vulnerability to depression. Parental psychopathology has often been associated with youth depression (Beardslee, Versage, & Gladstone, 1998). Research suggests that children of depressed parents are three times more likely to develop depression than children of nondepressed parents (Downey & Coyne, 1990). Findings from multiple studies also show that children of depressed parents have higher rates of depression diagnosis, recurrence, and chronicity than those of nondepressed parents (Hammen, Burge, Burney, & Adrian, 1990; Wickramaratne & Weissman, 1998; Beardslee, Keller, Lavori, Staley, & Sacks, 1993; Billings & Moos, 1986; Lee & Gotlib, 1991). In addition to the genetic and biological risk factors that may account for these associations, psychosocial factors in families may also contribute (Goodman & Gotlib, 2002). First, parental depression may affect the parents’ ability to effectively care for the child (Downey & Coyne, 1990). Observational data show that mothers who are depressed exhibit more sad and irritable affect than nondepressed mothers during interactions with their children (Cohn, Campbell, Matias, & Hopkins, 1990; Hops et al., 1987; Radke-Yarrow & Nottelmann, 1989). Second, parental depression may increase stress within the family, thereby affecting the child’s stress level. For example, children of depressed mothers report more episodic and chronic stressors than those of nondepressed mothers (Adrian & Hammen, 1993). Taken together, these studies underscore the need to understand the complex role of the family in the etiology and maintenance


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of youth depression. Such understanding should inform treatment planning in terms of determining the target of treatment (child, parents, both) and the most appropriate treatment strategies (medication, family-focused treatment, or individual treatment). Researchers have indicated that stress is one of the predominant pathways to the development of and manifestation of youth depression (Stark, Sander, & Hauser. 2006, Stark et al., 2005). Knowledge of the role that stress plays in the youth’s environment is therefore crucial in designing and implementing effective treatments. In terms of the etiology of youth depression, the diathesis-stress model posits that stress activates underlying vulnerabilities to produce the disorder (Monroe & Simons, 1991). There has been some research to suggest that youths’ maladaptive cognitions are the diathesis in this model. For example, research by Rudolph and colleagues (Rudolph, Kurlakowsky, & Conley, 2001) shows youth stress to be a precursor to control-related beliefs that are then associated with higher levels of depressive symptoms. In addition to its causal role, stress may also contribute to the maintenance of depression. Depressed youth report more negative life events and chronic stress on both questionnaires (Compas, 1987) and on objective ratings of stress based on life stress interviews (Garber & Robinson, 1997; Hammen, 2002). Families of depressed youths even report high levels of stress and negative life events (Hammen, 2002). Childhood depression is particularly associated with negative interpersonal events (such as conflicts with peers) (Monroe, Rohde, & Seeley, 1999) and events that are caused by the depressed youth himself or herself (such as failure in a class; Rudolph et al., 2000). Comparisons between depressed children and those with externalizing disorders show that depressed children report more dependent, interpersonal stress than children with externalizing disorders. However, no differences emerge between the groups on independent life stress (Rudolph et al., 2000). Other research has shown that some stressors that are independent of the child’s control are associated with depressive symptoms in children. For example, researchers indicate that children in families with less money are relatively more likely to experience depressive symptoms (as indicated by teacher reports) than those with more money (Aber, Brown, & Jones, 2003). In addition to experiencing heightened stress, depressed children and adolescents are also more likely to use avoidant coping strategies to manage stress (Chan, 1995). Conversely, children’s use of more adaptive coping strategies for managing stressors is associated with fewer depressive symptoms (Jeney-Gammon, Daugherty, & Finch, 1993). In response to the powerful role of stress and coping in youth depression, key components of certain evidence-based treatments, such as Interpersonal Psychotherapy for Depressed Adolescents (IPT-A; Mufson et al., 1999, 2004), include careful assessment of negative situations and problems as well as the implementation of coping strategies and skills for managing them. Cultural background is another key factor that relates to the manifestation of youth depression and its treatment. Existing research on ethnicity and depression indicates that various racial groups experience differing

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levels of depression severity, varied symptom expression, and different likelihoods of receiving treatment (Stark, Sander, & Hauser, 2006). For example, Iwata, Turner, and Lloyd (2002) found that African American, U.S.-born Hispanic, non-U.S.-born Hispanic, and non-Hispanic white adolescents and young adults provided different responses to symptoms as reflected on the Center for Epidemiologic Studies Depression Scale (CESD). More specifically, they found that the African American respondents scored low on depressed affect symptoms and high on somatic symptoms, whereas the U.S.-born Hispanic respondents scored low on the interpersonal symptoms but had higher levels of low positive affect. In addition, researchers have found differences in the level of mental health service utilization across racial groups. For instance, Cuffe and colleagues (Cuffe, Waller, Cuccaro, Pumariega, & Garrison, 1995) found that although African American adolescents had higher scores on a measure of depression, they were less likely than European American adolescents to receive outpatient treatment for any disorder and were more likely to drop out of treatment early. Taken together, these findings indicate that response to treatment might differ according to the client’s ethnic background. In fact, some of the authorities on ethnicity and culture have argued that findings from the majority of the current clinical trials may not generalize to minorities (Bernal, Bonilla, & Bellido, 1995; Bernal & Scharron-Del-Rio, 2001; Hall, 2001; Sue, 1998). Clearly, depressed youths (and likely their treatment providers) hold beliefs and values about psychopathology and treatment that are influenced by their various cultural backgrounds (Weisz, Jensen Doss, & Hawley, 2005). Therefore, a sensitive understanding of these differences is essential to accurate assessment and effective planning of treatment and treatment research.

EFFICACY OF TREATMENTS FOR YOUTH DEPRESSION Adolescent Depression As reviewed briefly above, research on correlates of depression in youth emphasizes its association with negative cognitions (review, Garber & Flynn, 2001), disturbed interpersonal relationships (review, Kaslow, Jones, Palin, Pinsof, & Lebow, 2005), and stress (Rudolph et al., 2000). Accordingly, treatments for adolescents have focused broadly on changing maladaptive cognitions or on improving interpersonal functioning. Studies vary in their inclusion of subjects with diagnosed depressive disorders versus subjects with high levels of depressive symptoms. It is not clear the degree to which findings from studies of youth with high depressive symptoms generalize to youth with a diagnosable depressive disorder. Table 8.1 includes studies conducted with youth with diagnosed depressive disorders. The 17 studies include 12 with a cognitive behavioral intervention condition, 3 with an interpersonal therapy condition, 2 with social skills conditions, and 2 with family therapy conditions. Four studies include comparison with medication conditions. Table 8.2 includes interventions conducted with youth


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experiencing high levels of depressive symptoms and reviews six interventions all of which are cognitive behavioral in their approach.

Maladaptive Cognitions As illustrated in Tables 8.1 and 8.2 cognitive behavioral interventions have been more thoroughly investigated than any other intervention approach for adolescent depression. The specific cognitive interventions used have varied across treatment studies. These studies have compared cognitive behavioral treatment with different conditions, examined its delivery in different formats (group vs. individual), looked at longer-term follow-ups, and examined the role of parallel parent groups in enhancing treatment efficacy. Of the 12 studies of diagnosed depressed youth that included a cognitive behavioral treatment condition, nine support the superiority of CBT in comparison to control conditions. The efficacy of cognitive-behavioral interventions has been demonstrated when compared to wait-list or nointervention conditions in three studies. CBT showed superiority in all studies comparing it to wait-list control (Clarke, Rohde, Lewinsohn, Hops, & Seeley 1999; Lewinsohn, Clarke, Hops, & Andrews, 1990; Rosello & Bernal, 1999), but in only one of the three studies comparing it to usual care (Asarnow et al., 2005). In one of the studies in which CBT did not show an advantage (Clarke et al., 2005) the usual care consisted primarily of medication (SSRI) intervention. Both studies (Clarke et al., 2002; 2005) underscore the importance of understanding what participants are receiving in “usual care” conditions. Five studies have compared CBT to other psychosocial treatments, and it has been shown to be superior to systemic family therapy, supportive therapy (Brent et al., 1997), relaxation training (Wood, Harrington, & Moore, 1996), and life skills training (Rohde, Clarke, Mace, Jorgensen, & Seeley, 2004). However, in one study comparing it to Interpersonal Therapy (IPT), IPT had a larger effect size and greater enhancements in social functioning and self-esteem (Rosello & Bernal, 1999). In the three studies that included medication arms, one was not designed to compare the two interventions (Asarnow et al., 2005), one found medication alone to be superior to CBT (TADS team, 2004), and one found CBT to be superior to medication intervention (Melvin et al., 2006). In the study by Asarnow and colleagues (2005) 418 adolescents in primary care settings (ages 13–21) were randomly assigned to a six-month “quality improvement” intervention or usual care. Those in the quality improvement intervention had access to a care manager, who educated them about depression and treatment options, and participants could select medication or CBT treatments. Although the study was not designed to evaluate the relative efficacy of CBT and medication, the quality improvement intervention overall was associated with significantly lower depressive symptoms, and adolescents were somewhat more likely to prefer CBT. In the study conducted by Melvin and colleagues (2006) 73 adolescents (ages 12–18) were randomly assigned to the CBT alone, medication

Subjects

Ages 13-21 (n=418)

Ages 13-18 (n=107)

Ages 14-18 (n-=123)

Ages 13-18 (n=88)

Reference

Asarnow, Jaycox, Duan, LaBorde, Rea, Murray, et al., 2005

Brent, Holder, Kolko, Birmaher, Baugher, Roth, et al., 1997

Clarke, Rohde, Lewinson, Hops, & Seeley, 1999

Clarke, Hornbrook, Lynch, Polen, Gale, O’Conner, et al., 2002

Diagnosis of DSM–III–R MDD and/or DD based on the K-SADS interview

Diagnosis of MDD or DD based on the K-SADS interview

Either: (1) Endorsed “stem items” for MDD or DD from the CIDI-12, 1 week or more of past-month depressive symptoms, and a total CES-D score≥16, or (2) CES-D score≥24 Diagnosis of MDD based on K-SADS Interview and BDI ≥ 13

Diagnostic/ Risk Assessment

Group

Group

Family Individual

Individual

Treatment Format(s)

(1) Usual care plus group CBT program (CWD-A) (2) Usual care

(1) Adolescent Coping with Depression Course (CWD-A) (2) CWD-A with nine-session parent group (3) Wait list control

(1) Systematic Behavior Family Therapy (2) CBT (3) Supportive therapy

(1) 6-month quality improvement intervention (2) Usual care

Intervention Type(s)

Immediate; 12 months; 24 months


Immediate

Immediate

Post-treatment Assessment

Intervention patients, compared with usual care patients, reported significantly higher mental health care utilization, fewer depressive symptoms, higher mental health-related quality of life, and greater satisfaction with mental health care. The CBT group had faster response, fewer cases of diagnosable MDD at the end of the treatment, a lower number of depressive symptoms, and were more likely to be remitted than other groups. No difference between family and supportive therapies. CBT was associated with higher depression recovery rates (66.7% vs. 48.1% in wait list condition) and greater reduction in depressive symptoms. Addition of parent group had no significant effect. Booster sessions accelerated recovery among youth still depressed at the end of acute treatment but did not reduce recurrence. No significant differences between CBT and usual care, either for depression diagnoses, continuous depression measures, nonaffective mental health measures, or functioning outcomes.

Impact of Treatment

Table 8.1. Randomized Clinical Interventions Trials for Adolescents with Diagnosed Depression

Ages 12-18 (n=152)

Ages 13-17 (n=32)

Ages 13-17 (n = 66) 83% female

Ages 14-18 (n = 59)

Clarke, Debar, Lynch, Powell, Gale, O’Conner, et al., 2005

Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002

Fine, Forth, Gilbert & Haley, 1991

Lewinsohn., Clarke, Hops & Andrews, 1990

Diagnosis of major, minor, or intermittent depression based on K-SADS interview with mother and adolescent

Diagnosis of MDD or DD based on K-SADS Interview

Diagnoses of DSM–III–R MDD based on the K-SADS

Diagnoses of DSM–IV MDD based on the K-SADS-PL interview

Group; Family

Group

Family

Individual

(1) Adolescent only CBT training group (2) Adolescentparent CBT training groups (3) Wait list control

(1) Therapeutic Support Group (TSG) vs. (2) Social Skills Group (SSG)

(1) AttachmentBased Family Therapy (ABFT) (2) Minimal-contact, waitlist control group

(1) Brief CBT plus treatment as usual (primarily SSRI) (2) Treatment as usual

Immediate; 1 month; 6 months; 12 months; 24 months

Immediate; 9 Months

Immediate; 6 months

Immediate; 26 weeks; 52 weeks

(continued)

CBT program showed advantages on the Short-Form-12 Mental Component Scale and reductions in treatment as usual outpatient visits and days’ supply of all medications. No effects were detected for MDD episodes; a nonsignificant trend favoring CBT was detected on the CES-D. At post-treatment, 81% treated no longer met criteria for MDD vs. 47% of patients in the waitlist group. The ABFT patients showed greater reduction in depressive and anxiety symptoms and family conflict. At follow-up, 87% of the ABFT patients continued to not meet criteria for MDD. At posttest both groups improved; TSG significantly more effective than SSG in reducing depression on K-SADS with more subjects in non-clinical range. Group differences disappeared at follow up. Significantly fewer youths in the treatment groups met criteria for depressive disorders after treatment and at follow up. Significantly improved on selfreported depression, anxiety, number of pleasant activities, and depressogenic thoughts. Trend for adolescent-parent condition to out-perform adolescent only group.

Subjects

Ages 12-18 (n=73)

Ages 12-18 (n=48)

Ages 12-18 (n=63)

Ages 14-19 (n = 18)

Reference

Melvin, Tonge, King, Heyne, Gordon & Klimkeit, 2006

Mufson, Weissman, Moreau, & Garfinkel, 1999

Mufson, Dorta, Wickramaratne, Nomura, Olfson, & Weissman, 2004

Reed, 1994

Clinician diagnosis of MDD or DD

DSM–IV diagnosis of MDD, DD, adjustment disorder with depressed mood, or DDNOS and HAMD≥10 and a C-GAS score≤65

Clinician diagnosis of MDD based on the HRSD

Diagnosis of DSM–IV MDD, DD, or DDNOS based on the K-SADS

Diagnostic/ Risk Assessment

Group

Individual

Individual

Individual

Treatment Format(s)

(1) Social skills training (2) Attention placebo control

(1) IPT-A (2) Treatment as usual

(1) Interpersonal psychotherapy for depressed adolescents (IPT-A) (2) Clinician monitoring

(1) CBT (2) Antidepressant medication (Sertraline) (3) Combined CBT and medication


Table 8.1. (continued)

Immediate; 6-8 weeks

Immediate

Immediate

Immediate; 6 months

Post-treatment Assessment

All groups showed significant improvement on outcome measures and this was maintained at follow-up. Combined group was not superior to monotherapy. CBT alone was superior to medication alone. IPT-A patients reported greater decrease in depressive symptoms, improved social functioning, and improved problem-solving skills compared to controls. In the IPT-A condition 74% recovered compared to 46% in the control condition. IPT-A associated with fewer clinicianreported depression symptoms on the HAMD, better functioning on the C-GAS, better overall social functioning on the Social Adjustment Scale-Self-Report, greater clinical improvement, and greater decreases in clinical severity on the Clinical Global Impressions scale. Skills group participants scored significantly higher on clinicians’ rating of improvement. Male subjects improved, but female subjects deteriorated.

Impact of Treatment

Ages 13-18 (n=71)

Ages 12-17 (n=439)

Ages 8-17 (n=56)

Rosello & Bernal, 1999

TADS Team, 2004

Vostanis, Feehan, Grattan, & Bickerton, 1996 Wood, Harrington, & Moore, 1996

Diagnosis of MDD, DD, or minor depression based on K-SADS Diagnosis of MDD or RDC minor depression based on K-SADS interview with both parent and child

DSM–IV diagnosis of MDD based on the KSADS-PL

Diagnosis of MDD, DD, or both

DSM–IV diagnoses of MDD and Conduct Disorder based on the K-SADS-E-5

Individual

Individual

Individual

Individual

Group

Twelve weeks of: (1) Fluoxetine alone (2) CBT alone (3) CBT with fluoxetine (4) placebo (1) Depression treatment program (2) Attention placebo (1) CBT (2) relaxation training

(1) CBT (2) IPT (3) Wait list control

(1) CWD-A (2) Life skills tutoring/control

Immediate; 6 months

Immediate; 9 months

Immediate

Immediate; 3 months


Post-treatment MDD recovery rates better in CWD-A group (36%), compared to ife skills/tutoring (19%). CWD-A participants reported reductions in BDI-II and HDRS scores and improved social functioning posttreatment. Group differences in MDD recovery rates at follow-up were nonsignificant. Both active treatments were associated with significant reductions in depression when compared to wait list. IPT was superior to CBT in enhancing social functioning and self-esteem. There were significant differences between combination treatment and placebo on the CDRS-R. Combined treatment was superior when compared with fluoxetine alone and CBT alone. Fluoxetine alone was superior to CBT alone. No difference in remission rates; remission rates were high in both groups. Post-test revealed greater reductions in depressive symptoms and an advantage in overall outcome in the CBT group. At follow-up, group differences were attenuated.

Note: MDD = Major Depressive Disorder; DD = Dysthymic Disorder; DDNOS = Depressive Disorder Not Otherwise Specified; K-SADS = Schedule for Affective Disorders and Schizophrenia for School-Aged Children; BDI = Beck Depression Inventory; CDI = Children’s Depression Inventory; GAF = Global Assessment of Functioning Scale; CES-D = Center for Epidemiologic Studies - Depression Scale; CDRS-R = Revised Children’s Depression Rating Scale; RADS = Reynolds Adolescent Depression Scale; BID = Bellevue Index of Depression.

Ages 9-17 (n = 48)

Ages 13-17 (n=91)

Rohde, Clarke, Mace, Jorgensen & Seeley, 2004

Symptomatic adolescent offspring (CESD>24) of recently depressed parents, assessed using the F-SADS Contact with social services within the previous 2 years; Mood and Feelings depression questionnaire≥23

9th and 10th graders (n=150)

Ages 13-19 (n=94)

Clarke, Hawkins, Murphy, Scheeber, Lewinsohn, & Seeley, 1995 Clarke, Hornbrook, Lynch, Polen, Gale, Beardslee, et al., 2001

Kerfoot, Harrington, Harrington, Rogers, & Verduyn, 2004

CES-D >23 but does not meet criteria for MDD or DD (K-SADS)

Ages 14-18 (n=22)

Ackerson, Scogin, McKendree-Smith, & Lyman, 1998

CDI≥10 and HRSD≥10

Subjects

Reference

Diagnostic/Risk Assessment

Individual

Group

Group

Selfadministered

Treatment Format(s)

(1) Brief CBT (2) Routine care

(1) Usual HMO care plus group cognitive therapy (2) Usual HMO care

(1) Cognitive Bibliotherapy (reading “Feeling Good”) and weekly monitoring phone calls (2) Delayedtreatment control (1) CWD-A (2) No intervention


17 weeks after initial assessment; 33 weeks after initial assessment



Immediate; 1 month

Post- intervention Assessment

No significant differences between groups in depression or global adjustment. At post-treatment, 77% of the CBT group and 80% of the routine care group had residual depressive symptoms or disorder.

Significantly fewer CWD-A adolescents diagnosed MDD or DD. Higher GAF and lower CESD for CWD-A group at posttest but no differences at follow-up. Group intervention decreased depression symptoms and episode rates to the communitynormal range and decreases in the incidence of MDD at followup.

Treatment produced statistically and clinically significant improvements in depressive symptoms that were maintained at follow-up, and a significant decrease in dysfunctional, but not in negative automatic, thoughts.

Impact of Treatment

Table 8.2. Randomized Clinical Interventions Trials for Adolescents with Depression Symptoms or Risk Factors for Depression

Ages 14-17 (n=25)

9th-12th graders (n=30)

Marcotte & Baron, 1993

Reynolds & Coats, 1986

CDI≥15 on two administrations and elevated score on semistructured interview focusing on depressive symptoms (1) BDI score > 11; (2) RADS > 71; (3) BID > 20; (4) no other current treatment Group

Group

(1) CBT (2) Relaxation Training (3) Wait-list control

(1) Rational-emotive (2) No treatment

Immediate; 5 weeks

Immediate; 8 weeks

Both active treatments showed significant decreases in depressive symptoms and improved academic self-concept compared to wait list. Relaxation associated with reductions in anxiety as well.

No difference between the two treatments: Depressive symptoms reduced at post-treatment in both groups.

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alone (sertraline), or a combined CBT and medication intervention. CBT alone was superior to medication alone and the combined treatment was not superior to either treatment alone. The authors have noted that the poor showing for medication in this study may be a function of inadequate dosing. Finally, the Treatment of Adolescent Depression Study (2004) compared CBT alone, fluoxetine alone, CBT combined with fluoxetine and placebo. Although the combination treatment was superior to all other conditions, fluoxetine was superior to CBT alone, and CBT alone was not significantly better than pill placebo. It has been noted that the effect size for the CBT intervention in the TADS study was significantly smaller than in other studies of CBT, and the version used may have been “low potency” (Weisz, McCarty, & Valeri, 2006). In fact, other investigators have questioned the implementation of the specific CBT intervention in the TADS study, suggesting it may have been overly structured and not have allowed the flexibility necessary for maximally effective implementation (Hollon, Garber, & Shelton, 2005). At this time, given the conflicting findings, the role of medication–psychotherapy combination treatments for adolescent depression remains unresolved. Six studies have examined group cognitive behavioral interventions in adolescents with high levels of depressive symptoms rather than diagnosed depressive disorders. In the studies where treatments have been applied to participants who are not diagnosed, samples were frequently heterogeneous. Using cutoffs on continuous measures of depressive symptoms, some researchers may include many youth with diagnosable depression (Kerfoot, Harrington, Harrington, Rogers, & Verduyn, 2004; Reynolds & Coats, 1986; Marcotte & Baron, 1993) but for practical reasons are unable to provide specific diagnoses. Others, in an effort to focus on the prevention of morbidity in at risk-samples—secondary prevention studies—have purposely excluded diagnosed youth and focused on subsyndromal depression (Clarke et al., 1995, 2001). Due to this heterogeneity, it is difficult to determine whether findings from these studies can be generalized to youth with diagnosable depressive disorders. In four of the studies cognitive behavioral treatment was superior to a no-treatment comparison group. Clarke and colleagues (1995, 2001) examined the 15-session Coping with Depression Course (CWD) in two studies. In the first study 9th- and 10th-graders, who had high CES-D scores but did not meet criteria for a depressive disorder, were randomly assigned to CWD or a no-intervention group and followed up at 6- and 12-month intervals after treatment completion. In the second study, youth ages 13 to 19, whose parents had recently been depressed and were themselves currently symptomatic (but did not meet criteria for Major Depressive or Dysthymic Disorders) were assigned to usual care or usual care plus CWD and followed at 12 and 24 months after treatment was completed. In both studies the rates of depressive disorders at follow-up were significantly lower in the CWD-treated groups and comparable to community rates of depression. In a small study of youth with mild to moderate depressive symptoms, Ackerson and colleagues (Ackerson, Scogin, McKendree-Smith, & Lyman, 1998) found a significant advantage of implementing cognitive


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bibliotherapy over no treatment, suggesting the possible utility of brief, inexpensive, cognitively-focused interventions for milder depressive symptoms. Finally Reynolds and Coats (1986) compared cognitive behavioral therapy to relaxation training and to no intervention. Although the cognitive behavioral intervention was superior to the no-treatment condition, it showed no advantage over relaxation training. Overall, these studies of cognitive behavioral interventions in youth with depressive symptoms provide support for these treatments; however, they are unable to address whether psychosocial treatments generally or cognitive behavioral treatments specifically are superior to no-treatment conditions. Two studies found no advantage for cognitive treatments. Kerfoot and colleagues (Kerfoot, Harrington, R., Harrington, V., Rogers, & Verduyn, 2004) found no differences between brief cognitive behavioral therapy and routine care in a sample of youth seen through social service agencies. However, chronicity, comorbidity, and residential instability led to high levels of treatment noncompletion in this challenging sample. Indeed, fewer than one half of participants in the study completed four sessions of cognitive behavioral therapy. Marcotte and Baron (1993) compared Rational Emotive Therapy to no treatment in a small sample of teens with high depressive symptoms. Symptoms reduced in both groups posttreatment; however, the extremely small sample and limited statistical power make it difficult to draw meaningful conclusions. Cognitive interventions have been implemented in different formats, including individual and group. Of those studies conducted with diagnosed depressed adolescents, eight were conducted in an individual format and four in a group format, and all were associated with significant improvements in depressive symptoms. Of those studies of adolescents with high depressive symptoms, four used a group format and three found significant advantage to CBT over a no-intervention control (Clarke, Rohde, Lewinsohn, Hops, & Seeley, 1999; Clarke et al., 2001; Reynolds & Coats, 1986). Indeed, meta-analysis supports the observation that both formats may be useful in the treatment of adolescent depression (Weisz, McCarty, & Valeri, 2006). Although the immediate effects of cognitive behavioral interventions for youth depression have been evaluated, fewer studies have examined longer-term impact. Indeed, as revealed in Tables 8.1 and 8.2, a limited number of studies have provided follow-up evaluations. Clarke and colleagues have included the longest follow-up intervals, ranging from 12 months (Rohde et al., 2004) to 24 months (Clarke et al. 1999, 2002, 2005; Lewinsohn et al., 1990). Results are mixed. In two studies in which there were initial group differences, treatment effects were maintained throughout a 24 month follow-up in one (Lewinsohn et al., 1990) but attenuated by 12 months in another (Rohde et al., 2004). Two studies showed no difference between CBT and usual care conditions either immediately or at 24-month follow-up (Clarke, 2002, 2005). One study examined the use of booster sessions to promote recovery in youth who remained depressed following the 8-week group CBT intervention and to prevent recurrence in recovered youth (Clarke et al., 1995). Booster sessions significantly

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reduced time to recovery in symptomatic youth but failed to prevent recurrence. Alternatively, in a small pilot study, Kroll, Harrington, Jayson, Fraser, and Gowers (1996) found much lower rates of relapse among youth receiving continuation CBT compared to an historical control group. Overall, the degree to which CBT interventions are sustained over time is not clear, and future studies need to include substantial follow-up periods. Finally, two studies have examined the role of parent involvement in cognitive behavioral therapy. Both studies compared the Adolescent Coping with Depression (CWD) course alone both to a waitlist control group and to CWD supplemented with cognitive behavioral training for parents. In both studies treated groups had higher rates of recovery from depression and greater reductions in depressive symptoms. However, there was not strong support for the addition of parental involvement. One of these studies found no difference between CWD alone and CWD with the supplemental parent group (Clarke et al., 1999), and the other revealed only a slight trend for the adolescent-parent condition to outperform the adolescent-only condition (Lewinsohn et al., 1990). Thus, while it is generally agreed that parent involvement in youth treatments is important, extensive parent involvement in the delivery of cognitive behavioral interventions is not supported.

Interpersonal Functioning Therapies focused on enhancing interpersonal functioning vary widely and include group-based social skills training, individually based Interpersonal Psychotherapy, and family-based interventions. Although they share common goals of improving interpersonal relationships, decreasing social isolation, and enhancing interpersonal skills, these interventions vary greatly in their formats, techniques, and foci. Two studies examining the efficacy of social skills training for depressed adolescents have yielded mixed results. First, Fine, Forth, Gilbert, and Haley (1991) compared a 12-session social skills training group to a therapeutic support group. Although both groups had improved significantly posttreatment, contrary to expectation, the therapeutic support group was superior in reducing depressive symptoms to the nonclinical range. Second, Reed (1994) compared social skills training to an attention placebo control condition. Although participants in the overall skills group showed a greater improvement in clinicians’ ratings, there were significant gender effects with boys showing some improvements and girls deteriorating. The small sample size in this study (18 participants) makes it is difficult to draw firm conclusions. Overall, the limited available data do not suggest that social skills training alone is an efficacious treatment for adolescent depression. Three studies have examined Interpersonal Psychotherapy (IPT) for the treatment of adolescent depression and all show strong support for this intervention. In IPT clinicians focus on reducing depressive symptoms and enhancing interpersonal functioning using an active collaborative approach and focusing on one or two primary interpersonal problem areas. In an initial study, Mufson and colleagues (Mufson, Weissman,


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Moreau & Garfinkel, 1999) compared IPT to clinician monitoring in 48 depressed adolescents. Those patients in IPT showed greater improvements in depressive symptoms, social functioning, and problem-solving compared to those in the clinical monitoring condition. Significantly more patients in IPT showed recovery from depression as well. Second, Rosselló and Bernal (1999) adapted the IPT model specifically for Puerto Rican adolescents. They compared IPT to CBT and wait-list control conditions. Both CBT and IPT were superior to the wait-list in reducing depression, and IPT was associated with greater gains in social functioning and selfesteem compared to the wait-list condition and exhibited a larger overall effect size (.73) than did CBT (.43). Third, Mufson and colleagues (2004) replicated their original findings by comparing IPT to treatment as usual in a school-based health clinic. Those receiving IPT showed greater reductions in symptoms of depression and improvements on social and global functioning. Overall, IPT appears to be a powerful treatment for depression in youth that is flexible in its adaptation to other cultural settings. Given its focus on interpersonal functioning, IPT necessarily emphasizes family relationships and often includes parents in some sessions (Mufson et al., 2004). However, the long-term effects of IPT have yet to be established, as followups either occurred only immediately (Mufson et al., 1999; 2004) or up to three months following treatment completion. The importance of family support and involvement in treatment of youth is often considered a clinical given, but few studies have examined the role of family treatments in adolescent depression. Brent and colleagues (1993) demonstrated that a two-hour psychoeducational session for parents was associated with their greater knowledge and fewer dysfunctional beliefs about depression and its treatment. Most parents (97%) found such psychoeducation to be worthwhile. Indeed, in their large adolescent depression treatment study, Brent and colleagues (1997) included brief family psychoeducation in all treatment conditions with the goal of minimizing dropout and supporting treatment. However, the outcomes of more extended interventions aimed at altering family relationships have been more mixed. First, Brent and colleagues (1997) compared systemic-behavioral family therapy to individual CBT and individual nondirective supportive therapy for the treatment of adolescents with major depressive disorder. The systemic-behavioral family therapy focused on altering family interaction patterns through the use of reframing and communication and problemsolving skills interventions. However, this family therapy was significantly less effective than CBT and comparable to nondirective supportive therapy. Second, Diamond and colleagues developed and examined Attachment-Based Family Therapy (ABFT; Diamond, Reis, Diamond, Siqueland, & Isaacs, 2002), a family treatment model for depressed adolescents that is derived from attachment theory. This treatment focuses on building alliances between the therapist and both the parent and the adolescent, repairing the parent–child bond, and (with parental support) building the adolescent’s competencies. An initial evaluation of this model, comparing it to a wait-list control group, found substantially greater rates of recovery

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(81% vs. 47%) from depression; these recovery rates were maintained at six-month follow-up. Overall, interventions that focus on interpersonal functioning appear promising in the treatment of adolescent depression. However, the appropriate role of family involvement has yet to be clarified in treating depression during this developmental period, and clinicians tread a difficult path in balancing the need to enhance family support and functioning while supporting the adolescent’s burgeoning autonomy.

Preadolescent Depression Although an increasingly well-developed literature exists on treatment of adolescents with depression, far less exists to guide the treatment of preadolescents with depression. In fact, we found only one study in the literature that included any children younger than 8 years of age. Furthermore, as illustrated in Table 8.3, the few published studies of preadolescents focused on those with high levels of depressive symptoms, and not one study has exclusively targeted preadolescents with diagnosed clinical depression. Two studies included some children 12 years of age and younger with depressive diagnoses in their samples (Wood, Harrington, & Moore, 1996; Vostanis, Feehan, Grattan, & Bickerton, 1996), but neither included separate analyses of these groups, precluding an examination of treatment effects in younger children. One study included only eight prepubertal subjects (Wood, Harrington & Moore, 1996), and the other, although they did not administer a measure of pubertal status, included six 12-year-old participants and 13 participants under the age of 12 years (Vostanis, Feehan, Grattan, & Bickerton, 1996; Vostanis, personal communication, February 2007). Although a few treatment development studies have been conducted with diagnosed school-aged youth (Flory, 2004; Kaslow et al., 2002; Tompson et al., 2007) much work remains to be done in this area. Unlike the studies examining treatments with adolescents, those conducted with preadolescents frequently include cognitive behavioral interventions that are also strongly focused on improving interpersonal functioning. Most of the studies have focused on cognitive-behavioral and skills-building interventions and have been delivered in a group format. As illustrated in Table 8.3, in all examined treatments, group formats allow practice of skills and interventions are designed to be active and interactive. Indeed, most often the cognitive-behavioral components are part of a larger skills-building package. Skills targeted include problemsolving, self-monitoring, and social abilities. For example, Asarnow and colleagues (Asarnow, Scott, & Mintz, 2002) include a segment on building friendships that specifically targets the developmental social challenges of late-elementary and middle-school youth. Thus, these cognitive-behavioral interventions are frequently heterogeneous and broad-based. In terms of efficacy, in eight of nine intervention studies, treated groups showed significant improvements over untreated groups in reduction of depressive symptoms (Asarnow et al., 2002; Butler, Meizitis, Friedman, & Cole, 1980; DeCuyper, Timbremont, Braest, Backer, & Wullaert, 2004;

Teacher referral; high scores on CDI



Ages 10-12 (n=20)

Ages 10-13 (n=143)

Asarnow, Scott, & Mintz, 2002

Butler, Miezitis, Friedman, & Cole, 1980

De Cuyper, Timbremont, Braet, De Backer, & Wullaert, 2004

Jaycox, Reivich, Gillham, & Seligman, 1994; Gillham, Reivich, Jaycox, & Seligman, 1995

CDI score≥11 and/or T score≥23 on CBCL Internalizing and Anxious/ Depressed subscale; at least one MDD criterion but without other apparent Axis-I Z-scores on CDI + Child Perception Questionnaire > 0.50

School screening; CDI

Subjects

Reference


Group

Group

Group

Group

Treatment Format(s)

(1) Cognitive (2) Social ProblemSolving (3) Combined (both above treatments) (4) Wait-list control (5) No participation control

(1) Role Play Problem Solving (2) Cognitive restructuring (3) Attention control (1) CBT program (‘Taking Action’) (2) Wait-list Control group

(1) CBT and family education (2) Wait-list control


Immediate; 6 months; 12 months; 18 months; 24 months


Immediate

Immediate

Post-intervention Assessment

(continued)

Children in the intervention group were more likely to show reductions in depressive symptoms, negative cognitions, and internalizing coping. Role play group showed significant reduction on CDI and improved classroom functioning. One of two groups in cognitive restructuring showed significant reductions on CDI. Four-month follow-up comparisons with baseline measures, showed significant improvement on the CDI and the Self-Perception Profile only for CBT group. At the 12-month follow-up, CBT group showed further improvement and significant decreases on the CDI, STAI, and CBCL. No differences between treated groups who had fewer depressive symptoms at post-test and at follow up and improved classroom behavior (teacher report) than untreated groups. Effects more pronounced among children from high conflict homes. Follow-up revealed even greater group differences in depressive symptoms over time.

Impact of Treatment

Table 8.3. Randomized Clinical Interventions Trials for Preadolescents with Depression

Subjects

Ages 10-14 (n=68)

Grades KG- 4 (n=135)

Ages 7-11 (n=31)

Reference

Kahn, Kehle, Jensen, & Clark, 1990

King & Kirschenbaum, 1990

Liddle & Spence, 1990

CDI ≥ 19 CDRS-R ≥ 40

Multistage Gating: Stage 1: CDI>14; RADS>71. Stage 2: Reassessment 1 month later with CDI and RADS. Stage 3: Interview, BDI>19. No other depression treatment Children who scored above a cutoff on the Activity Mood screening questionnaire


Group

Group

Group

Treatment Format(s)

(1) Social skills training plus consultation with parents and teachers (2) Consultation only (1) Social competence training (2) Attention placebo (3) Waitlist control

(1) Cognitivebehavioral (2) Relaxation Training 3) Selfmodeling 4) Wait list control



Immediate; 3 months

Immediate

Immediate; 1 month

Post-intervention Assessment

No group differences at pretest, post-test, or follow-up. All groups declined on CDI scores and increased on teacher’s reports of problem behavior.

Combined program showed reduced depressionas compared to consultation only. Multidimensional ratings of behavior and skills improved across both groups.

All active treatment groups showed significant improvement in depression compared to control. Most children in CBT and relaxation groups went from dysfunctional to functional range on depressive symptoms; self-modeling group less improved than other groups.

Impact of Treatment

3rd-6th graders (n=48)

Weisz, Thurber, Sweeney, Proffitt, & LeGagnouz, 1997

CDI≥10 and/or identified by teachers/counselor as depressed; and CDRS-R interview score≥ 34

CDI scores>12 on 2 administrations

(1) Behavioral problem solving (2) Self-control (3) Wait-list control

(1) Primary and secondary control enhancement training (2) No treatment control

Group

Group

Immediate; 9 months

Immediate; 8 weeks

Both active treatment groups showed significant reductions in depressive symptoms; however, in Behavioral Problem Solving both mothers and children reported differences, whereas in self-control only children reported differences. At post-test and follow-up, treated group showed significantly greater reductions on both CDI and CDRS-R.

Note: MDD = Major Depressive Disorder; DD = Dysthymic Disorder; DDNOS = Depressive Disorder Not Otherwise Specified ; K-SADS = Schedule for Affective Disorders and Schizophrenia for School-Aged Children; BDI = Beck Depression Inventory; CDI = Children’s Depression Inventory; GAF = Global Assessment of Functioning Scale; CES-D = Center for Epidemiologic Studies - Depression Scale; CDRS-R = Revised Children’s Depression Rating Scale; RADS = Reynolds Adolescent Depression Scale; BID = Bellevue Index of Depression.


Stark, Reynolds, & Kaslow, 1987

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Jaycox, Reivich, Gillham, & Seligman, 1994; Kahn, Kehle, Jenen, & Clark, 1990; King & Kirschenbaum, 1990; Stark, Reynolds, & Kaslow, 1987; Weisz et al., 1997). One study found no difference between children treated with social competence therapy, attention control, and no treatment, as all groups showed improvement over time (Liddle & Spence, 1990). In contrast, of the five studies comparing different treatments, only two showed group differences. Both Butler and colleagues (1980) and Stark and colleagues (1987) showed an advantage of problem-solving interventions over both self-control and cognitive restructuring interventions, potentially suggesting superiority of problem-solving. However, another investigation (Jaycox et al., 1994; Gillham et al., 1995) failed to support the superiority of social problem-solving over more cognitive-focused interventions. Thus, although at this time studies support the overall efficacy of psychosocial interventions for depression in preadolescent youth, they do not currently support differences between depression-specific and more general interventions. Although most of the studies are limited in their follow-up, focusing only on immediate treatment effects, three studies completed evaluations over a longer period. First, Jaycox, Gillham, and colleagues (Jaycox et al., 1994; Gillham et al., 1995) compared five groups: a cognitive intervention, social problem-solving, a combined group, a wait-list control, and a no-participation control. At immediate posttest, all treated groups showed superiority to untreated groups and at two years posttreatment the differences were even more striking. Second, after comparing an 18-session CBT protocol to wait-list, DeCuyper and colleagues (2004) followed the school-aged participants for one year and found continued increases in positive self-perception and decreases in both child and parent reports of symptoms. Third, Weisz and colleagues (1997) followed school-aged youth for nine months following a trial of Primary and Secondary Control Enhancement Therapy, which focuses on the development of both problem-solving and cognitive restructuring skills. Group differences continued to be evident at the nine-month follow-up point. The goal of skills-building interventions is to increase coping and competence, and we would anticipate that such interventions may have increasing effects over time. Indeed, these limited follow-up data suggest, at minimum, maintenance of treatment gains and possibly enhancement of these gains over time. Longer-term follow-up evaluations need to be included in all studies to understand durability of intervention effects. The role of the family in the treatment of depression in school-aged youth remains to be clarified. Although the interventions examined at this point have focused on group formats, several have included family involvement (Asarnow et al., 2002; Stark, 1990). Given the embeddedness of school-aged youth within their families, there are strong reasons to believe that family-based approaches may be particularly potent during this developmental period. Indeed, in a study of family intervention for childhood anxiety disorders comparing individual CBT, CBT plus family treatment, and a wait-list control group, Barrett, Dadds, and Rapee (1996) found a significant age effect; younger children showed better outcomes in CBT plus family treatment whereas older children did equally well in both


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active treatments. These findings highlight the importance of examining family-based treatments in school-aged youth. Three treatment development studies have been published describing family-based treatments for depressed preadolescents. First, Schwartz, Kaslow, Racusin, and Carton, (1998) have described a sophisticated family therapy model that integrates theory and techniques from family systems perspectives, cognitive-behavioral approaches, attachment theory, interpersonal therapy, and elemental psychopathology. Interpersonal Family Therapy seems to decrease depressive symptoms, change maladaptive cognitions, and improve family affect and communication. To our knowledge, it has not yet been tested. Second, Kovacs and colleagues (2006) developed Contextual Emotion Regulation Therapy (CERT) specifically for school-age children with chronic depression. CERT is individually tailored using “contextual mapping” of dysphoric emotional responses and emphasizes the development of skills to enhance the down-regulation of dysphoric emotional responses. In an open trial of 20 chronically depressed youth, CERT was associated with significant remission of depression, decreases in symptoms of both depression and anxiety, and reduction in maternal symptoms of depression and anxiety. Third, Flory (2004) described Emotionally Attuned Parenting, an intervention aimed at improving the parent–child relationship in youth with internalizing psychopathology. The intervention, with its focus on enhancing parental empathy, included parents only. In a small open trial, a mixed sample of children with depressive and anxiety symptoms displayed significant symptom improvement and their parents reported reductions in parenting stress, with gains maintained six months posttreatment. Fourth, and finally, Tompson and colleagues (2007) have developed Family-Focused Treatment (FFT) for depressed children. The treatment integrates family systems and cognitive-behavioral models and provides expanded family psychoeducation and skills building within a family context. Interventions are focused on understanding the family’s unique interactional processes and increasing positive and decreasing negative interactional sequences. The treatment includes modules that are focused on: (1) educating family members about depression, focusing on its interpersonal nature; (2) enhancing positive interactions; (3) practicing communication skills; and (4) teaching problem-solving skills. Initial open trial data suggest that FFT was associated with remissions in depression and associated syndromes, reductions in self- and parent-reported depressive symptoms, and improvements in family functioning. In sum, pilot interventions suggest the promise of the family-based approaches in the treatment of depressed school-aged youth.

DIRECTIONS FOR FUTURE RESEARCH Treatment research to date supports the value of psychosocial approaches for the treatment of youth depression. However, many issues remain and further research is necessary to determine optimal strategies

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for the comprehensive treatment of depression. Areas of concern include limited treatment efficacy, insufficient examination of continuation treatment strategies, narrowly defined treatment outcomes, lack of research examining treatments for younger children with depression, lack of treatments for special populations, and limited data examining treatments in “real-world” clinical settings. First, treatments to date have demonstrated limited efficacy. Although earlier meta-analytic studies of psychosocial treatments for youth depression optimistically suggested very large effect sizes (Lewinsohn & Clarke, 1999; Reinecke, Ryan, & DuBois, 1998), a more recent metanalysis with more comprehensive inclusion of treatment studies indicates effect sizes in the small to medium range (Weisz, McCarty, & Valeri, 2006). Current data with clinically depressed youth suggest that approximately 40 to 50% fail to show significant recovery or remission in trials of either psychosocial or pharmacologic treatments. These findings highlight the critical need to develop new efficacious treatment strategies and enhance the impact of current treatments. Second, most treatment studies with depressed samples have focused on acute treatment impact and few studies have followed youth for any substantial time following treatment completion. Data on the high risk of relapse following both psychosocial (Vostanis et al., 1996; Wood et al., 1996) and pharmacologic intervention trials (Emslie et al., 1997) suggest a need to examine continuation treatment strategies. Very few studies have included significant follow-up periods, and even fewer have examined continuation treatment strategies for maintaining and enhancing treatment gains over time. Third, most studies examining psychosocial treatments for youth depression have focused primarily on symptom outcomes. It is not clear the degree to which symptomatic improvement is accompanied by improvements in functional outcomes. Recent evidence of enhanced social functioning following IPT (Mufson et al., 1999; Roselló & Bernal, 1999) are encouraging and, it is hoped, will spur additional evaluation of such outcomes. Future studies need to assess multiple outcome domains, including associated syndromes and social and academic functioning. Fourth, as has been emphasized throughout this review, most of the clinical trials examining treatments of youth depression have focused on adolescents. There is a strong need for additional studies examining optimal treatment strategies for younger children with depression. Developmental considerations during middle to late childhood, including greater dependence on parents and rapidly changing cognitive capacity, make it unlikely that adult treatments can simply be extended downward, pointing to a need for developmentally-informed treatment specifically for children. Treatment development work to this point has generated promising, developmentally targeted intervention strategies for preadolescent youth, and there is a strong need for clinical trials in this area. Fifth, there is currently a paucity of research on depression in individuals with developmental disabilities and mental retardation (Lowry, 1998). Although limited studies suggest that individuals with developmental disabilities and/or mental retardation can experience high levels of


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depressive symptoms, and those with Asperger’s syndrome may be at particular risk (Ghaziuddin, Ghaziuddin, & Greden, 2002; Matson & NebelSchwalm, 2007; Saulnier & Volkmar, 2007), there are no clinical trials examining depression treatments for these special populations. Some case studies suggest the utility of behaviorally-based approaches for individuals with mental retardation (Frame et al., 1982; Matson, 1982) and autism spectrum disorders (Matson & Nebel-Schwalm, 2007). There is a strong need to develop and test treatments for these populations. Finally, although randomized clinical trials indicate efficacy for CBT interventions for depressed youth, effectiveness trials have documented weak effects of CBT in community settings (Clarke et al., 2002, 2005; TADS, 2004; Weisz et al., 1995). On the other hand, recent work comparing youth receiving care in community mental-health centers to youth receiving CBT in depression clinical trials does suggest greater benefits for the CBT-treated youth (Weersing & Weisz, 2002). Overall, findings highlight the need to both examine and enhance depression treatment in real-world settings.

CONCLUSIONS Our understanding of depression in youth has advanced significantly in the past 20 years, treatments have demonstrated efficacy, and guidelines for clinical practice have been developed. In addition to medication strategies, interpersonal interventions and both individually based and group-based cognitive behavioral interventions are treatment options for depressed youth. More limited data suggest the utility of brief family psychoeducation, and further studies are examining the utility of more extended family interventions. However, additional research is required to enhance and develop treatment approaches, to examine combined treatments, to delineate algorithms for making treatment decisions, and to develop longer-term interventions aimed at preventing relapse and promoting recovery. Finally, there is a strong need to ensure that treatments developed for the laboratory setting are available and effective for youth in the wide range of real-world clinical settings where youth receive care. REFERENCES Aber, L. J., Brown, J. L., & Jones, S. M. (2003). Developmental trajectories toward violence in middle childhood: Course, demographic differences, and response to school-based intervention. Developmental Psychology, 39, 324–348. Ackerson, J., Scogin, F., McKendree-Smith, N., & Lyman, R. D. (1998). Cognitive bibliotherapy for mild and moderate adolescent depressive symptomatology. Journal of Consulting and Clinical Psychology, 66, 685–690. Adrian, C. & Hammen, C. (1993). Stress exposure and stress generation in children of depressed mothers. Journal of Consulting and Clinical Psychology, 61, 354–359. American Psychiatric Association. (2006). American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. Asarnow, J. R., Jaycox, L. H., Duan, N., LaBorde, A. P., Rea, M. M., Murray, P., Anderson, M., Landon, C., Tang, L., & Wells, K.B. (2005). Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics. Journal of the American Medical Association, 293, 311–319.

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9 Medication Treatment Of Bipolar Disorder In Developmentally Disabled Children and Adolescents ZINOVIY A. GUTKOVICH and GABRIELLE A. CARLSON INTRODUCTION If systematic data on the treatment of bipolar disorder in children and adolescents is meager, information on treatment of bipolar disorder in developmentally disabled children is virtually nonexistent. Not only are many of the challenges to diagnosing young children relevant to persons with autism and intellectual disability of any age, but also, accumulating a sample size large enough to randomize to treatment alternatives would require financial resources that are not likely to be forthcoming any time soon. This chapter, then, begins with a review of the treatment of bipolar disorder (BD) in normally developing youth, summarizes current treatment of BD in adults with developmental disabilities (DD), and then moves to the review of available literature on the treatment of developmentally disabled children and adolescents with BD. We conclude with our thoughts about treatment in this vulnerable population.

ZINOVIY A. GUTKOVICH • Assistant Professor of Clinical Psychiatry, Attending Child Psychiatrist, St. Luke’s Roosevelt Hospital, 1090 Amsterdam Avenue, 17th Floor, New York, NY 10025. GABRIELLE A. CARLSON • Stony Brook University School of Medicine, Stony Brook, NY, USA.


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Our understanding of BD as a recurrent disorder in which mood and activity level are either significantly increased (hypomania and mania) or decreased (depression) with return to premorbid levels of functioning in between emerged largely from the vast clinical experience of psychiatrists such as Kraepelin in the early 20th century recognizing syndromal similarities of hundreds of his patients. Our initial understanding of BD in youth, however, emerged from attempts to find pediatric equivalents of what adult psychiatrists appeared to be describing (see Glovinsky, 2002; Carlson, 2005). This form of manic depressive illness did indeed exist in youths, occurred mostly in adolescents, was depressive, and familial. In the early 1950s, a volume of a journal called The Nervous Child raised the issue of an “alternative form” of manic depression, children whose behavior fluctuated and might be construed as cycling. Anthony and Scott (1960) explored the question of strictly defined, classical “manic depressive psychosis” in preadolescents in a literature review, and they found it to be uncommon, generally beginning to emerge at around age 11. In the past 30 years, with the adoption of DSM–III–IV–TR, diagnosis has been made cross-sectionally, using a checklist of symptoms rather than pattern recognition. With this approach, more adults and more children have been given the diagnosis of BD, and a spectrum of severity and intensity of symptoms as well as co-occurrence with many other conditions has been found. The degree to which this redefined population is the same as earlier descriptions of manic-depressive illness is the source of some dispute (Carlson and Meyer, 2006; Andreasen, 2007). In adolescents, the diagnosis of acute mania or severe depression used to be missed because of confusion with schizophrenia (e.g. Carlson and Strober, 1978). In preadolescents, the diagnostic conundrum has been separating mania from a variety of behavioral disorders in children in which activation, short attention span, and irritability cooccur chronically. The essential question then becomes whether the frequent and brief episodes of intense mood volatility and irritability that is being called “prepubertal mania” or “juvenile bipolar disorder” is the same illness as bipolar disorder in adults (Leibenluft, Charney, Towbin, Bhangoo, & Pine, 2003; McClellan, 2005). The further one diverges from the description of BD as it has been conceptualized for the past century, the more difficult it becomes to extrapolate those findings to children. Diagnostic issues become even more challenging in the developmentally disabled. Interestingly, as shown, classic manicdepression/BD is readily identifiable in the case histories of older children and adolescents regardless of their developmental age, something observed in adults with BD and DD as well (Carlson, 1979).

CLINICAL MANAGEMENT OF NORMALLY DEVELOPING CHILDREN AND ADOLESCENTS The first step in treatment of BD, regardless of the chronological or developmental age of the patient is a good assessment. It is necessary to

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clarify if treatment is addressing mania or depression, if the target symptoms are acute or chronic, or are characterized mainly by aggression, mood instability, depression, insomnia, or other symptoms. The frequency, intensity, number, and duration of periods of significant symptoms must be captured at baseline and followed with intervention in order to determine whether intervention is having an impact. Finally, an understanding of the environmental context of the condition is imperative: how do symptoms/behaviors change at home, in school, in residential treatments, time of day, with and without structure, and with some people and not others. Although people like to talk about “mood swings” as if they are imposed by divine interference, they almost invariably have triggers that increase their frequency and intensity, and moderators that decrease it.

Evaluating the Evidence Base Compared to what is known about the risks and benefits of medication for mania, hypomania, and depression in adults, what is known for normally developing children and adolescents is still meager, although growing, as is briefly summarized below. The “gold standard” of evidence for treatment safety and efficacy has been the randomized, double-blind, placebo-controlled study. The prototype of this study has a number of standardized components including: (1) A clinical history to screen the patient for bipolar disorder and exclude other conditions, such as schizophrenia, substance abuse, eating disorder, and medical and neurological conditions felt to compromise the integrity of the study. Relevant to this chapter, intellectual disability (IQ below 70) and pervasive developmental disorder are invariably exclusionary criteria. (2) Structured/semistructured interviews are often used to ensure the presence of mania or depression (depending on what phase of the condition is being addressed). (3) Finally, a number of standardized rating scales are administered to gauge the severity of the condition(s). In the case of mania, the Young Mania Rating Scale (Y-MRS, Young et al., 1978) has been most frequently used, and a cutoff score of 20 is needed to enter the mania study to ensure the patient is sick enough for treatment. This is an interview scale where answers are determined by the interviewer either observing or speaking to the patient, caregiver, or both. For depression in youth, the Children’s Depression Rating Scale-revised (CDRS-R) (Poznanski et al., 1984) is most often used with a score of ≥40 for depression as the entry criterion. In adults, a variety of scales are used. Mania trials are usually three to eight weeks depending on the drug’s pharmacologic properties (i.e., what dose and how long it takes to work). Trials are kept as short as possible to minimize the untreated time for the placebo-treated patients but if they are not long enough, a fair appraisal of drug efficacy is not possible. Although remission of symptoms is highly desired (for the Y-MRS scores it should be 1200 mg/day. Treatment with lithium was successful in cases with both depressive and manic states as well as in cases with manic states only, but not for other conditions, or for rapid cycling. Duration of treatment and follow-up allows for the tentative conclusion that lithium was overall effective for maintenance. As with normally developing youth, accompanying psychosis required addition of antipsychotic drug during the most acute phase. Lithium was used safely, with manageable side-effects. As with normally developing children (e.g., Campbell et al., 1984; Malone, Delaney, Luebbert, Cater, & Campbell, 2000) there is some evidence that lithium reduces aggression, impulsivity, and severe excitement in some youth with intellectual disability. Dostal and Zvolsky (1970) reported a 65% reduction in acute outbursts for the group and statistically significant reduction in affectivity, aggression, psychomotor activity and undisciplined behavior with lithium at .92 meq/L. Nine patients developed reversible polydipsia and polyuria. Sovner and Hurley (1981) conducted an extensive review of the literature and reported two cases of their own,,a total of five cases on the use of lithium carbonate for “chronic behavior disorders” in people with ID. In their two cases they used ABA design with return of symptoms with discontinuation of lithium carbonate and stabilization after reintroduction of lithium treatment. The authors conclude lithium carbonate may be safe and somewhat effective for symptoms such as long-standing hyperactivity, aggression, and/or self-mutilation. Polydipsia and polyuria proved to be the most difficult side-effect to manage. In summary lithium has been used with positive results in classically appearing bipolar disorder in developmentally disabled youth and adults. Effects are more modest in those with broader affect dysregulation.

Valproate: Monotherapy and Combined Treatment When anticonvulsant treatment entered the medication armamentarium for bipolar disorder, its use in DD youth has also increased. Kastner et al. (1993) conducted an open prospective trial of VPA for affective symptoms in children, adolescents, and adults. Hollander et al. (2001) conducted an open trial in ten autistic patients with mood instability, impulsivity, and aggression, four of whom were diagnosed with Mood or Bipolar Disorders. Two of four of these latter patients improved including a 15 year-old adolescent with autism, mild ID, and co-morbid Bipolar Disorder. Eight of the ten patients overall were rated as having a sustained response to valproate with doses ranging from 250 to 1000 mg/day and levels between 50 to 85 µg/ml). Two patients were discontinued because of behavioral activation but VPA was otherwise well tolerated. Open trials on VPA are summarized in Table 9.5 and case reports are presented in Table 9.6. Interestingly, data suggest that the effect of valproate may be limited to a specific effect on symptoms of bipolar disorder in developmentally disabled youth. Hellings et al. (2005) studied VPA efficacy and safety for aggression in children and adolescents with PDD. In this prospective


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Table 9.5. Two Open Trials of Valproate (VPA) in People with MR/Autism with Affective Illness Author Kastner et al. (1993)

Sample Size and Age

Psychopathology

Methodology

Results

Comments

Total N = 18 Inclusion Open 2 Children:1 8 patients with mild to criteria: year trial; very much needed profound MR 3 of the Assessment improved; additional Children N 4 sympwith semi1 no medications = 2 (both F) toms: structured improvement. (CBZ, Li, Adolescents irritabilinterview of Adolesverapamil, N = 10, age ity, sleep caregiver; cents: 8/10 buspirone, 13–18 disturMain improved or or thiori(F = 3; M = 7) bance, outcome very much dazine); VPA Adults N = 6 aggressive measure improved; associated or selfCGI-Improve2/10 - little with lower injurious ment scale improvement. doses. behavior, VPA therapy Adults: 4/6 A history of behavioral with levels much or epilepsy or cycling of 50 to very much a suspicion 125 µg/ml improved 2/6of sei(dose not no change zures was reported) or worse; No strongly difference in associserum VPA ated with a favorable response to VPA Hollander PDD with Impulsivity/ RetrospecChild: 10 Adolescent et al. comorbid aggrestive review y.o.boy also took (2001) Mood Disorsion, of DVP in autism, mood fluoxetine der (1 child), mood autism; disorder NOS, 20 mg/d 3 with BP lability main OCD, impulse and ( 1 teen, 2 and 3 core outcome control disoralprazolam adults) autistic measure der; IQ = 87 1 mg prnv dimenCGI-I – minimally sions worse (social, Adolescomcent: 15 y.o. municaautism, tion and IQ = 55; BP; repetitive agitation, behaviors) insomnia, impulsivity, hyperactivity, very much improved VPA level 66 µg/ ml), Adults: N = 2 with BP and BPNOS; 1 very much improved; 1 – no change

Whittier et al. (1995)

Kastner and Friedman (1992)

Kastner et al. (1990)

Author

Psychopathology Addressed

Medication Used

Response and Comments

N = 1 13-yearold mentally retarded girl

Onset age 12 MDD ; treated VPA 1250 mg/d with sertraline 50 mg/d. (level 109.2 µg/ml). Then developed mania with Perphenazine and pressured speech, flight of benztropine ideas, grandiosity, marked (duration of treatincrease in energy, insomnia, ment not reported) hyperactivity lasting 4 days. Stopped treatment; .

Rapid (starting within 24 hours) and dramatic response with decrease in total scores on Young Mania Rating Scale from 29 to 11; on Hamilton Rating scale for Depression from 27 to 9, and improvement in GAF from 25 to 55. Antipsychotic medication introduced after patient had significant reduction in her symptoms

N = 3 (1)16 y.o. (1) Irritability, aggressiveness, (1) VPA 2750 mg/d; level (1) No further symptoms of mania. 4 episodes of adolescent with decreased sleep, severe fre109 µg/ml; stable for head banging due to environmental stress (2) moderate MR quent head banging more than 10 months Excellent clinical response, face gouging and blindness (2) (2) History of 7 years of (2) VPA 3,000 mg/day eliminated. Improved family relationship 13 y.o. girl with hyperactivity, irritability, -level 75 µg/m-Follow(3) Became very calm, in good control, profound MR, mildly aggressive up 7 months (3)VPA elimination of self-injury Was able to return to visual and hearbehavior, self-injurious 1,500 mg/day-level foster family All 3 had failed Li trial; 2 became ing impairment, behavior (face gouging); 111 µg/ml-Follow-up “manic” on CBZ spastic quadraworsened on Nortriptyline 8 months paresis (3) Severe self-injurious (3) 8 y.o. girl with behavior, hyperactivity, profound MR and irritability, distractibility, Down syndrome unmanageable, Placed into RTF N = 1 18 y.o. boy Onset severe sleep disturbance VPA 2,750 mg/d- level Patient failed adequate trials of Li and CBZ. Initial with severe MR age 4; severe self injuri111 µg/ml; verapamil response to VPA, not sustained with and blindness ous behavior- age 8; age 18 320 mg/d monotherapy. Augmentation with Verapamil increased activity level, mood provided long-lasting effect. It is important to lability with inappropriate note that the patient had nonparoxismal EEG bouts of crying changes (general slowing) and laughung, irritability, hyposomnia, and severe self-injurious behavior

Number of Patients and Age

Table 9.6. Case Reports/Series on Use of Valproate in Developmentally Disabled Children and Adolescents with Bipolar Disorder

272 ZINOVIY A. GUTKOVICH and GABRIELLE A. CARLSON

Damore et al. (1998)

N = 3 Children with fluoxetineinduced manic symptoms (1) 10 y.o. boy with Asperger Disorder, ADHD (2) 9 y.o. boy with Asperger Disorder, ADHD and OCD (3) 9 y.o. boy with Asperger Disorder, meeting DSM–IV criteria for Bipolar II Disorder

3 months later presented with extreme irritability, suicidal ideation, pressured speech, flight of ideas, grandiosity, marked increase in energy, and insomnia, auditory and visual hallucinations (1) Hypomanic episode after 5 weeks on fluoxetine 20 mg/ d with marked impulsivity, aggressive behavior, mood lability and irritability (2) After 2.5 months on fluoxetine 20 mg/day florid hypomania with pressured speech, marked circumstantiality, sexual inappropriateness, and irritability (3) Patient had severe depressive episodes. After 1 month on fluoxetine 10 mg/ day he became increasingly hyperactive, irritable impulsive and unmanageable, with silly and inappropriate behavior in school, removed from classroom (1) VPA 250 mg/day (level not reported) (2) VPA 500 mg/day (level not reported) Methylphenidate 20 mg/day VPA 250 mg BID (level not reported)

Marked improvement within 3 weeks with disappearance of impulsivity, aggressive behavior, and irritability; significant family history of affective illness (2) Manic symptomatology ceased after 2 weeks; marked improvement in social relatedness, isolative behavior and significant decrease in anxiety (3) Within 3 weeks noticeable improvement in his behavior, was able to return to his class Patient had significant family history of affective illness

MEDICATION TREATMENT OF BIPOLAR DISORDER 273

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Table 9.7. Double-Blind Trial on Use of VPA in Aggressive Youth with PDD Author Hellings et al. (2005)

Sample Size and Age

Psychopathology

Total N = 30 Significant children aggresand adosion to self, lescent others, or outpaproperty at tients with least three ASD, 6–20 times per years of week age (M = 20, F = 10) average IQ = 54.

Methodology

Results

Randomized, con- No statistrolled trial of 8 tically weeks duration. significant Baseline improvemeasures: ment on DSM–IV-based any of the interview; measures Autism Diagnostic Inventory— Revised, Autism Diagnostic Observation Schedule Primary outcome measure - parent and teacher rated Aberrant Behavior Checklist— Community scale (ABC-C) weekly Secondary outcome measures: the description of each aggressive outburst by parents and teachers as it occurred on the Overt Aggression Scale (OAS) and CGI— Improvement Subscale

Comment Large placebo response, subject heterogeneity, and small group size were problems in this study

double-blind, placebo-controlled study, 30 participants (20 boys, 10 girls) 6–20 years of age with PDD and significant aggression were randomized and received treatment with VPA or placebo (PBO) for eight weeks as outpatients. No treatment difference was observed statistically between VPA and PBO groups (Tables 9.6 and 9.7).

Carbamazepine, Monotherapy and Combined Treatment Data in the child literature are extremely limited. Komoto et al. (1984) reported dramatic improvement of mood symptoms in two children with autism treated with carbamazepine. It is of note that in their report patients suffered primarily from depression although one of them had mild manic episodes as well (Table 9.8).


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Table 9.8. Case Reports on Use of Carbamazepine (CBZ) in Developmentally Disabled Adolescents with Bipolar Disorder Author Komoto and Usui (1984)

Number of Patients and Age

Psychopathology Addressed

Medication Used

N = 2 (1) !3-year- Onset: Since age 9 mild CBZ 400 mg/ old adolescent day CBZ depressive episodes autistic male 300 mg/ for 2–3 days following with MR, day mild manic episodes untestable on lasting 1–2 weeks once WISC (2) 13 a month periodically ½ -year-old Depressive episodes: autistic female sad appearance, long with modercrying spells, would ate MR, IQ on not eat or talk, motor WISC = 49 activity remarkably diminished, would not get up from bed Manic episodes: inappropriately cheerful and silly, would often laugh and parrot TV commercials, ate voraciously, extremely hyperactive and sleepless Onset: Since 10 years 9 months had mild depressive episodes lasting a week once a month periodically. Depressive episodes: Typical course starting from sobbing, crying, “Yuki (her name) scared,” keeping her face down; then not talking and not getting out of bed, not eating, disturbed sleep

Response and Comments Episodes stopped Prior trial of Li at dose 600 mg/ day produced no response Depressive episodes stopped except for a single episode at 12 years 2 months of age when she had menarche Patient had first time convulsion during her fifth depressive episode and second convulsion episode at age 13 years 5 months. EEG was abnormal. Diphenylhydantoin 60 mg/day was added Family history negative in both cases

Atypical Antipsychotics Atypical or second-generation antipsychotic medications have not been studied even on a small scale in developmentally disabled youth with bipolar disorder. Two case reports (Frazier & Jackson, 2008; Gutkovich, Carlson, Carlson, Coffey, & Wieland, 2007) describe risperidone’s efficacy in autism spectrum youth with bipolar disorder. On the other hand, and very relevant for treatment of behaviors characteristic of mania, risperidone has been studied extensively in children and adolescents with irritable and agitated behavior in autism (e.g., McCracken et al., 2002) and has recently received FDA approval for treatment of irritability and self-injurious behavior in autism. In particular, an eight-week, double-blind, placebo-controlled study found risperidone to be superior to placebo for treating aggression, tantrums, and self-injury in children

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with autistic disorder (McCracken et al., Research Units on Pediatric Psychopharmacology Autism Network, RUPP, 2002). The study included 101 youths ages 5 to 17 (82 boys and 19 girls). Treatment with risperidone (dose range 0.5 to 3.5 mg/day) resulted in a 56.9 percent reduction in irritability score in the Aberrant Behavior Checklist (Aman, Singh, Stewart, & Field, 1985) as compared to 14.1 percent decrease in the placebo group. Hellings et al. (2006) conducted a 46-week placebo-crossover investigation of risperidone of safety and efficacy for aggressive and destructive behaviors in a mixed sample of children (N = 13), adolescents (N = 8), and adults (N = 19) with all levels of ID and PDD. This longer-term study which utilized the same primary outcome measure as the study by RUPP yielded very similar results. During the acute 22-week phase out of 40 subjects 23 (57.5%) responded fully (50% decrease in Aberrant Behavior Checklist-Community Irritability subscale score), whereas 35 subjects (87.5%) showed a 25% decrease. Pattern of response in children and adolescents was similar to the whole group. It is important to note that the presence of comorbid mood disorder did not alter the results. Children had overall poorer response during the 24-week maintenance phase compared to adolescents and adults (adolescents and adults did not differ). Low dose risperidone (mean optimal dose for children and adolescents 1.67 mg/day) was effective for aggressive behaviors and irritability. Increased appetite and weight gain (7.9 kg for children and 8.3 kg for adolescents) were the most problematic side-effect especially in children and adolescents. The authors comment that weight gain is an especially serious problem in the DD population because individuals with ID have less autonomy and ability to take control of the weight gain side-effect. However, a recent study by Klein and collegues (2006), which included some children with ID and PDD, demonstrated the utility of metformin for controlling weight gain. Risperidone has also been studied extensively (randomized, doubleblind, placebo-controlled trials) in lower IQ youth with conduct disorder (i.e. irritable aggression). Aman et al. (2002) conducted a placebo-controlled trial in children with severely disruptive behaviors and subaverage intelligence. Risperidone at doses up to 0.06 mg/kg per day was associated with significantly greater improvement than placebo on measures of irritability and aggression. Risperidone was safe and well tolerated. Turgay et al. (2002) conducted a long-term extension open trial of risperidone (dose range 0.02–0.06 mg/kg/d) in a similar sample. Risperidone was well tolerated, safe, and showed maintenance of effect in the treatment of disruptive behavior disorders in children aged 5 to 12 years with subaverage IQs. Other atypical medications have been/are being studied including a registry trial for aripiprazole (www.clinicaltrials.gov). Two retrospective chart reviews (Corson, Barkenbus, Posey, Stigler, & McDougle, 2004; Hardan, Jou, & Handen, 2005) addressed efficacy and safety of quetiapine in the DD population. Doses ranged from 25 to 600 mg/day. Target symptoms of irritability, self-injury, aggression and hyperactivity diminished in


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8 out of 20 patients in the former and 6 out of 10 in the latter. Weight gain and tardive dyskinesia were the main adverse events. In general, it appears that, in the absence of specific studies on efficacy of medication for mania in DD youth, the positive responses in cognitively normal adults and teens with mania, and positive results in autistic youth with irritability would make it likely that manic symptoms in DD youth would also be responsive.

Electroconvulsive Treatment Thuppal and Fink (1999) described five inpatients with mild to moderate intellectual disability with catatonia and affective and psychotic disorders who were treated with bilateral ECT after they failed to respond to medication trials. Affective and aggressive symptoms improved. One 18-year-old male with moderate ID and Bipolar Disorder received 17 ECT treatments, was discharged markedly improved. He then received four continuation ECT treatments and then remained stable on clozapine 300 mg/day. This is the only publication reporting treatment of an adolescent patient with intellectual disability and Bipolar Disorder that we were able to identify in the literature. Guze et al. (1987) reported use of ECT in treatment of 21-year-old man with bipolar depression, mild intellectual disability, and cerebral palsy. Depressive symptoms resolved but the patient switched to mania, which was stabilized on lithium.

CURRENT STATUS OF PSYCHIATRIC ADVERSE EVENTS IN CHILDREN AND ADOLESCENTS Medication-induced behavioral toxicity, e.g. activation/disinhibition/ manic symptoms and suicidal behavior, is not uncommon in youths. Rates of activation vary, but appear to be more common in children (around 10%, Carlson & Mick, 2003) than adolescents (around 3%), at least in clinical trials of antidepressants (Safer & Zito, 2006). Rates of occurrence in adults with bipolar depression are higher, about 20%, although rates vary widely (Goldberg, 2003). Studies in adults appear to suggest that rapid cycling bipolar patients are especially vulnerable to destabilization (Ghaemi, Hsu, Soldani, & Goodwin, 2003). This is relevant to pediatric bipolar patients, among whom the percentage with a rapid cycling course ranges from from 19% (Faraone, Biederman, Wozniak, Mundy, Mennin, & O’Donnell, 1997) to 83% (Tillman, Geller, Bolhofner, Craney, Williams, & Zimerman, 2003) depending on the study. In the DD population, carbamazepine was most associated with behavioral toxicity. Friedman et al. (1992) found that 6 of 65 DD patients (9.2%) experienced medication side-effects, ranging from irritability to mania, occurring predominantly in patients being treated for psychiatric disorders (4 of 20 psychiatric patients (20%) vs. none of the 21 patients treated seizure disorders). The incidence of behavioral side-effects of medication was not associated with age, sex, or serum carbamazepine level. The authors

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suggest that the chemical structure of carbamazepine which is similar to tricyclic antidepressants contributed to behavioral side-effects. It is also worth remembering, however, that in patients with pre-existing emotional lability, it is difficult to separate medication effect from course of illness. The question of antidepressant-induced “suicidal behavior” has been a contentious and confused topic. Although medication-associated suicidality has not been examined at all in the DD population, in 24 pediatric trials of antidepressants, the FDA (2004) found an increased risk for suicidal behavior of about 2% in placebo and about 4% in SSRI-treated subjects. (There were no suicides; Hammad, Laughren, & Racoosin, 2006). This small but significant elevated rate is apparent through young adulthood according to a recent FDA warning (February, 2007).

RELEVANT MEDICAL ADVERSE EVENTS IN THE USE OF BIPOLAR MEDICATIONS IN CHILDREN AND ADOLESCENTS An extensive discussion of medication side-effects is beyond the scope of this chapter. Several observations are relevant to young people and people with DD. For instance, although lithium may be tolerated as well in this population as any other (Pary, 1991), lithium toxicity, a potentially lethal risk, is greater in this population because of difficulties with self-monitoring and poor ability to report symptoms of all sorts. In addition, possible worsening of seizures already common in this population, disabling tremor, polydipsia, polyruria, and incontinence need close attention (Elliot, 1986; Hellings, 2006; Maruta, 2003). Tremor or incontinence are more likely to occur in children with severe or profound intellectual disability because they may have cerebral palsy, movement disorder, or difficulties with bladder control (Kastner, Friedman, Plummer, Ruiz, & Henning, 1990). We suggest however that decisions on lithium use in children with the most severe ID should be made on a case-by-case basis because, as reported earlier in this chapter, some of them have positive response to lithium with manageable side-effects. As with normally developing people, renal disease and thyroid suppression may occur, although the latter is quite treatable with thyroid supplementation. Combining lithium with valproate worsens some of these symptoms. Initial concerns about valproate-associated polycystic ovary syndrome (PCOS; chronic anovulation and hyperandrogenism, with or without actual polycystic ovaries, is associated with oligomenorrhea, hirsutism, and acne) were raised in people with seizures, some of whom had DD (Isojarvi, Timo, Laatikainen, Pakarinen, Juntunen, & Myllyla, 1993). Given that menstrual irregularities are common in adolescents, it is important to obtain a baseline menstrual history when evaluating the impact of valproate. The Stevens-Johnson syndrome, a life-threatening skin condition, although rare in young people, has been associated with lamotrigine (Messinheimer, 2002). With low dosing and gradual increase, the risk is reduced but treatment still warrants close observation.


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Significant weight gain, especially in young people, is associated with atypical antipsychotics, lithium, and divalproex. The occurrence of the metabolic syndrome in young people predicts early atherosclerosis and vascular disease as adults, and obesity during adolescence predicts later coronary artery disease and colorectal cancer even more strongly than obesity as an adult. Data from adults (ADA Consensus Development Conference 2004; Allison et al. 1999 Casey, Haupt, Newcomer, Henderson, Sernyak, & Davidson, 2004) and from an ongoing, large scale naturalistic study in children and adolescents (Correll et al., 2005) suggest the following rank order in terms of ability to promote weight gain and development of the metabolic syndrome: Clozapine = Olanzapine >> Risperidone >/= Quetiapine > Ziprasidone >/= Aripiprazole. Undoubtedly caution and close monitoring should be exercised when one deals with developmentally disabled patients especially the most severely retarded individuals who are not able to verbally report their complaints, those with known organic brain injury, and especially when lithium is used in combination with neuroleptics or anticonvulsants.

CONCLUSION Aman et al. (2000) concluded that in lieu of “woeful lack of empirical data … clinicians will often be forced to extrapolate from data on adults having intellectual disability and from typically developing children. The best policy is probably to treat such patients cautiously, while gathering data on the effects of such therapy.” The largely anecdotal reports we found showed effectiveness of moodstabilizing agents in people with all degrees of intellectual disability including profound ID. Nor did etiology of the developmental disorder appear to matter (Adams, Kivowitz, & Ziskind, 1970, Kastner et al., 1990; Reid et al., 1981; Sovner, 1991). Patients with more clearly delineated mood states with normal interepisodic functioning (i.e., more classic bipolar disorder) had a better response. As in normally developing adolescents, initial manifestation of the disorder often includes frank psychotic symptoms that can be easily misdiagnosed as schizophrenia. History of depressive episode preceding mania is also common as it is documented for nondevelopmentally disabled population. We cannot, of course, address frequency of response to various bipolar regimens because these case reports were published precisely because patients responded, often dramatically, to treatment. With regard to safety of treatments, affective illnesses themselves often cause regression (e.g., incontinence), confusion, and disorientation making it difficult to separate the toxicity of illness from the potential toxicity of treatment. We have reviewed somatic treatment of 191 patients with developmental disabilities and Bipolar Disorder, among them 12 children and 27 adolescents, including three double-blind trials, one single-blind trial, two open trials, five retrospective chart reviews and the rest single case reports or small case series.

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We offer the following tentative observations. 1. Lithium appears to be effective medication for treatment of maniclike symptoms, more so than nonspecific hyperactivity and aggression in the developmentally disabled population. Caution and close monitoring should be exercised in all cases, but especially in those with known organic brain injury, or with medication combinations, because this vulnerable group is often not able to verbally report their symptoms. Tremor or incontinence can have a profoundly negative effect on the ability of these children to function. Data are suggestive for usefulness of lithium in maintenance. 2. Valproate appears to be an effective and safe agent and is preferable to Lithium in cases with seizure disorder or nonparoxismal EEG activity 3. Carbamazepine may be useful in some cases alone although more likely to be helpful as adjunctive treatment. It may be more useful in patients with depressive symptomatology. Behavioral toxicity may be a problem. 4. Anticonvulsants alone or in combination may be more effective in patients with rapid cycling although nothing is truly effective in this form of illness. 5. Gabapentin might be considered as adjunctive treatment in combination with valproate, especially if lithium is not tolerated. 6. Some of the atypical antipsychotics will be systematically tested for people with pervasive developmental disorders and irritable difficult behavior, which can certainly describe bipolar disorder even if not specifically identifying it. So far risperidone has the most data. 7. Clozapine may be considered in treatment-resistant cases. 8. More data are needed on ECT treatment, which appears to be promising in adults. As with normally developing children and adolescents comorbidities must be addressed and appropriate psychosocial and educational interventions provided. REFERENCES Adams, G. L., Kivowitz, J., & Ziskind, E. (1970). Manic depressive psychosis, mental retardation, and chromosomal rearrangement. Archives of General Psychiatry, 23, 305–309. Allison,D. B., Mentore, J. L., Heo, M., Chandler,L. P., Cappelleri, J. C., Infante, M. C. & Weiden, P. J. (1999). Antipsychotic-induced weight gain: A comprehensive research synthesis. American Journal of Psychiatry, 156, 1686–1696. Altshuler, L. L., Keck, P. E. Jr., McElroy, S. L., Suppes, T., Brown, E. S., Denicoff, K., Frye, M., Gitlin, M., Hwang, S., Goodman, R., Leverich, G., Nolen, W., Kupka, R., & Post, R. (1999). Gabapentin in the acute treatment of refractory bipolar disorder. Bipolar Disorder, 1, 61–65. Aman, M. G., Collier-Crespin, A., & Lindsay, R.L. (2000). Pharmacotherapy of disorders in mental retardation. European Child & Adolescent Psychiatry, 9, I98–107. Aman, M. G., De Smedt, G., Derivan, A., Lyons, B., & Findling, R.L. (2002). Risperidone disruptive behavior study group. Double-blind, placebo-controlled study of risperidone for the treatment of disruptive behaviors in children with subaverage intelligence. American Journal of Psychiatry, 159, 1337–1346.


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10 Treatment of Autism Spectrum Disorders MARY JANE WEISS, KATE FISKE, and SUZANNAH FERRAIOLI

INTRODUCTION This chapter provides an overview of the treatment of autism spectrum disorders. This is both an exciting and confusing time within treatment for autism; early identification continues to allow for more intensive and effective early intervention, prevalence estimates of autism are suggesting increased incidence, and claims for effective treatment abound. Consumers are faced with myriad choices for treatment, and have difficulty navigating the claims and opinions of professionals from multiple perspectives and disciplines. In this chapter, we review the evidence for the effectiveness of behavior analytic interventions for autism. We also review the evidence for nonbehavior analytic interventions. In addition, we describe interventions that have been targeted to individuals with Asperger’s syndrome, and we discuss the relevance and use of functional assessment procedures for developing effective behavior intervention plans for individuals with ASDs. We also highlight new directions within treatment, including some social skill interventions and information on early identification.

AUTISM SPECTRUM DISORDERS: AN OVERVIEW The most widely accepted criteria for autism are contained in the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition Text Revision (DSM–IV–TR; American Psychiatric Association, 2000). According to this resource, autism has three central defining characteristics: Qualitative impairment in reciprocal social interaction MARY JANE WEISS, KATE FISKE, and SUZANNAH FERRAIOLI

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Qualitative impairment in verbal and nonverbal communication and in imaginative ability Markedly restricted and repetitive repertoire of behavior, activities, and interests The ways in which these characteristics are manifested, however, are extremely divergent. Whereas some individuals with autism are aloof and socially disinterested, others are affectionate, attached to others, and desirous of interaction. Whereas some individuals with autism lack vocal language ability, others may engage in simple echoing or may use vocal speech communicatively. When speech is used communicatively, however, there are often still idiosyncratic uses of the speech, or the speech may fail to represent the full range of communication potential. For example, a child may only request wanted items and not be able to hold conversations, or may converse only about topics of special interest. Restricted behaviors and interests may manifest themselves as classically autistic rocking or flapping. Alternately, it may present as lining up toys, adhering to a routine, or becoming fixated on a single object or topic. It is estimated that about 75% of children with autism have developmental delays (APA, 2000). There is also a tendency for the development to be uneven, with clear strengths and weaknesses evident. Behavioral difficulties occur in about 90% of individuals with autism, and at least 10 to 20% exhibit severe behaviors such as aggression and self-injury (Lovaas, 1987; Smith, McAdam, & Napolitano, 2007). DSM–IV–TR (APA, 2000) also classifies other Pervasive Developmental Disorders (PDDs) along with autism: Rett’s Disorder, Childhood Disintegrative Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder–Not Otherwise Specified (PDD-NOS). Rett’s Disorder is a degenerative disorder that occurs in girls, and is characterized by a different course and prognosis than autism (Kerr & Ravine, 2003). Childhood Disintegrative Disorder is not well defined and is rare (Mouridsen, 2003). The current diagnostic criteria for Asperger’s Disorder highlight impairments in nonverbal communication and in social interaction with an absence of delays in cognitive or language skills (APA, 2000). Individuals with Asperger’s Disorder do experience a variety of problems in communication and interaction, such as poor reciprocal conversational abilities, difficulties in comprehending figurative and abstract language, and perseveration on topics of special interest that impede the development of true reciprocal exchanges with others. Individuals classified as PDD-NOS generally exhibit features of autism, but fail to meet the full diagnostic criteria for Autistic Disorder. In recent years, many clinicians and researchers have begun to discuss autism, PDD-NOS, and Asperger’s Disorder as a spectrum. We do not yet have reliable criteria for distinguishing among these groups, and it may be that the same disorder essentially varies in presentation and severity along the continuum (Wing, 1988). We refer to ASDs in the remainder of this chapter.

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BEHAVIORAL TREATMENT OF AUTISM SPECTRUM DISORDERS Behavior analytic treatment of children with autism began in the 1960s. Ferster and DeMyer (1962) first demonstrated that behavioral principles could be used to increase appropriate behavior in children with autism. At the time, this was a radical notion, as autism was perceived as essentially unchangeable. In the years that followed, behavioral intervention was demonstrated to be effective in increasing skills (e.g., Wolf, Risley, & Mees, 1964) and in reducing challenging behaviors (e.g., Lovaas, Freitag, Gold, & Kassorla, 1965). Applied Behavior Analysis (ABA) appeared to be very effective in increasing skills and in remediating deficits. It became clear that children with autism were capable of learning and of altering their behavior, and that certain procedures worked better in helping children with autism learn than did others (e.g., Lovaas, Schreibman, Koegel, & Rehm, 1971). In particular, it became clear that individuals with autism learned well in a form of teaching in which there were clear instructions, repetition and practice, and immediate reinforcement for correct responses.

Discrete Trial Training Discrete trial training (DTT) uses repetition and sequenced instruction to build a variety of skills in students with autism (Lovaas, 1981; Lovaas, Koegel, Simmons, & Long, 1973; Smith, 1993). It has been effective in teaching a wide variety of core skills in a structured formalized context. Elements of its effective use include errorless learning procedures (e.g., Etzel & LeBlanc, 1979; Lancioni & Smeets, 1986; Terrace, 1963; Touchette & Howard, 1984) and task variation and interspersal (e.g., Dunlap, 1984; Mace et al., 1988; Winterling, Dunlap, & O’Neill, 1987; Zarcone, Iwata, Hughes, & Vollmer, 1993). These strategies diverge from some historical applications of DTT, which often utilized blocks of identical target trials and procedures that allowed for repeated errors. State-of-the-art clinical application of DTT procedures generally involves the mixing of new and mastered material, as well as the prevention and interruption of errors. Discrete trial training remains very useful for teaching a wide variety of skills to children with autism spectrum disorders, and its utility should not be obscured by the recent emphasis on more naturalistic approaches. DTT is well matched to teaching skills requiring repetition, to teaching skills that are not intrinsically motivating, and to building solid repertoires of tacting, imitation, and receptive skills (e.g., Sundberg & Partington, 1998; 1999). In addition, discrete trial teaching is much more effective if utilized with strategies for effective generalization to the natural environment (Smith, McAdam, & Napolitano, 2007; Stokes & Baer, 1977). Teaching proceeds more effectively if instruction is conducted across environments, if parents and peers are involved in training, and if discrete trial teaching is used in combination with other, more naturalistic approaches.

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Naturalistic Teaching Methods Over the past 25 years within ABA, there has been a strong focus on the development and use of naturalistic teaching methodologies to meet the needs of learners with autism. The best researched and oldest of these approaches is incidental teaching. Incidental teaching emphasizes receiving an elaborated response from the individual, after they have initiated interest in an item or a topic (Hart & Risley, 1982). Incidental teaching has been shown to be a successful teaching methodology for building initiation skills and a wide variety of language and conversation skills (e.g., Farmer-Dougan, 1994; McGee, Krantz, & McClannahan, 1985, 1986). Perhaps most important, incidental teaching procedures have been shown to have substantial generalization benefits, compared to discrete trial teaching (McGee et al., 1985). This is a substantial advantage, as the strength of DTT is in building responsivity. DTT is relatively weak in increasing initiations and in generalizing skills without additional training. In incidental teaching, the teacher arranges the environment to create learner interest. The learner then initiates a request or a conversation about a particular item or topic. The teacher prompts an elaboration of that initiation, and the learner’s more elaborate communication results in immediate access to the desired item (Fenske, Krantz, & McClannahan, 2001). One of the most substantial advantages of an incidental approach over a DTT approach is that the learner is leading the teaching interaction. The learner’s interests create the opportunity for the instruction (Fenske et al., 2001). Incidental teaching is an excellent way to increase initiation and spontaneity and to augment the complexity of communication. Other naturalistic methodologies within ABA have emphasized learner interests. Pivotal Response Training (PRT) and Natural Language Paradigm (NLP) emphasize using high-interest and motivating materials, teaching in natural situations, and capitalizing on the child’s interests to target deficits in language (Koegel & Koegel, 2005; Koegel, Koegel, & Surrat, 1992; Koegel, O’Dell, & Koegel, 1987; Laski, Charlop, & Schreibman, 1988). Natural Environment Training (NET; Sundberg & Partington, 1998), as do NLP and PRT, focuses on the use of intrinsically motivating materials and on following the child’s lead in language instruction. NET also, however, uses Skinner’s Verbal Behavior language classification system to guide language instruction (Skinner, 1957). The use of this classification system increases the comprehensiveness of the attention given to the functions of language. Sundberg and Partington’s emphasis on building manding (requesting) skills targets this very important response class of initiations. Other behavior-analytic approaches to building communication skills have also used Skinner’s classification system, with good results. One example of this is the Picture Exchange Communication System (Frost & Bondy, 2002), which teaches individuals with autism to interact with a listener in order to communicate through the exchange of pictorial representations. PECS has been shown to increase functional communication and reduce behavior problems (Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet, 2002; Bondy, Tincani & Frost, 2004).


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DTT and naturalistic methods such as incidental teaching target different deficits within autism spectrum disorders. Each methodology has distinct advantages and unique applications. Although DTT is efficient and effective in teaching a wide variety of skills, there is almost always a need for additional generalization training procedures. Responsivity improves dramatically within DTT, however, it is likely that initiation skills, requesting, and conversation may be best taught within more naturalistic methodologies.

Outcome Data To date, a number of reports of long-term outcome with behavioranalytic intervention have been published. In the best-known study of this type, Lovaas (1987) compared a group of children under age four who received 40 hours of intervention per week for two or more years with groups of children who received either fewer hours of such intervention or no intervention. Almost half of the children in the intensive intervention group were able to be placed unassisted in regular education classes and achieved IQs in the average range. Other researchers have documented that early intensive behavioral intervention results in significant gains for some children (e.g., Green, Brennan, & Fein, 2002; Smith, 1999). More research is still needed to completely understand the effective elements and intensity levels of intervention, and how such variables affect outcome. It is also true that outcome remains highly variable, and that reliable predictors of outcome have not been confidently identified.

Other Directions In recent years, behavior analytic treatment of autism has begun to incorporate elements of rate-building to achieve fluency. Fluency has been defined as responding accurately, quickly, and without hesitation (Binder, 1996; Dougherty and Johnston, 1996). Although fluency has been a goal of Precision Teaching, a field within the discipline of ABA instruction that has existed for many years and served many populations (e.g. Lindsley, 1992), it has only recently been focused on as a goal for learners with autism (Fabrizio & Moors, 2003). Rate-building procedures are used to build fluency in the demonstration and availability of skills. Rate-building addresses the specific deficits and needs of learners with autism. Many learners on the autism spectrum exhibit motor dysfluencies. Although they may be able to achieve mastery when accuracy is used to gauge success, they may still perform the task laboriously, inefficiently, or slowly. Furthermore, many individuals with ASD demonstrate a long latency to respond to instructions or to social initiations and bids. Slow response times can lead to missed opportunities, especially in social contexts (Weiss, 2001, 2005). Rate-building procedures focus on rate of response, and utilize coaching to build performance. Practice sessions begin as very short sprints

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(e.g., ten seconds), and increase as performance increases. A performance aim is used to guide daily progress (Fabrizio & Moors, 2003), and may be determined by a celeration line on a Standard Celeration Chart (or may be more individually determined by a learner’s own rate.) Progress is tracked on a daily basis, and the learner is actively engaged in tracking progress. The attainment of fluency has been associated with a number of outcomes of learning, which represent true mastery (Binder, 1996; Fabrizio & Moors, 2003; Haughton, 1980; Johnson & Layng, 1992). Johnson & Layng (1992) emphasized the outcomes of stability (capacity to engage in behavior in face of distraction), endurance (capacity to engage in behavior for extended periods), application (broadly, ability to generalize and combine skills), and retention (ability to maintain skills). Research shows that rate-building is essential to achieving fluency, yet nearly all instructional models for children with autism attend only to accuracy (and not to rate) to evaluate mastery (Fabrizio & Moors, 2003). Fabrizio and Moors (2003) have suggested the use of frequency aims in teaching students with autism, and have provided suggested aim ranges for core skills in this population of learners. Advantages to rate-building, and to achieving fluency, include the outcomes of fluency instruction (stability, endurance, application, retention), the addition of rate data, and the capacity to track and target errors separately from correct responses. There is some debate within the field about whether fluency is achieved as a function of rate-building or is an artifact of another element of instruction (Doughty, Chase, & O’Shields, 2004). In fact, several potential confounds and explanatory variables may be responsible for the effects. These include the experience of practice itself, as well as rate of reinforcement. Practice itself has been shown to facilitate learning (Samuels, 2002). The type and amount of practice opportunities offered to learners does affect mastery (Ericsson, Krampe, & Tesch-Romer, 1993). Learners given specific immediate feedback and multiple trials improve both their accuracy and speed. Furthermore, the high rates of reinforcement used in rate-building may be responsible for the positive effects and outcomes. Finally, some of the benefits of rate-building may be achieved simply by sensitizing staff to fluency building procedures (Binder, 1996) or tracking latency as an important qualitative aspect of response. Another related instructional approach that has been discussed as potentially relevant for learners on the autism spectrum is Direct Instruction. Direct Instruction’s focus on specific behavioral targets, scripted teaching formats, and data-based decision making fits well with other ABA approaches to teach skills to this population of learners. In addition, several commercially available curricula that utilize elements of this approach may improve how learners with autism are taught basic skills. Direct instruction has been applied to a variety of curricular areas, including language, reading, mathematics, and writing. Although the intervention and research done in these areas exists outside the realm of ASDs, there may be utility for these procedures with learners on the autism spectrum. Many of the curricula that exist for children with autism do not


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adequately or completely emphasize academic skills. Direct Instruction approaches may meet the needs of learners with ASDs in effective ways, but scripted available curricula may need to provide methodical manuals for teachers of learners with autism spectrum disorders to follow to effectively meet the needs of these learners. It is also very likely, however, that several elements of the DI curricula approaches would need to be modified for this population of learners.

Summary The treatment of autism spectrum disorders continues to receive a great deal of attention in the professional and lay communities. Applied Behavior Analysis has substantial documentation of its effectiveness in remediating the deficits associated with autism. There is no other treatment approach that even approaches ABA in terms of empirical validation, scientific support, or confidence of findings. Within ABA, Discrete Trial Training has been used to build core skills, with increased emphases in recent years on using task interspersal procedures, errorless learning procedures, embedded generalization strategies, and high rates of instruction (Weiss, 2001, 2005). DTT continues to be effective in building responsivity and in establishing a wide variety of core skills, and is best used in combination with other ABA procedures that target different deficits. Naturalistic ABA teaching procedures such as Incidental Teaching facilitate generalization and increase initiation. Ratebuilding procedures may help to address problems in speed of response and/or in latency to respond, which are critically important to ensure the functional availability of responses in the natural environment. Furthermore, Direct Instruction’s foci on effective instructional design, individual assessment of progress, and scripted curricula may also benefit this population. The use of all of these procedures provides a comprehensive approach to addressing the diverse profiles and characteristics encountered among learners with ASDs.

NONBEHAVIORAL APPROACHES Applied behavior analysis’ foundations in evidence-based principles may be its most compelling quality to parents and practitioners. However, the widespread implementation of interventions lacking empirical support has been well documented (Levy, Mandell, Merhar, Ittenbach, & PintoMartin, 2003). Smith and Wick (2008) suggest that the popular media’s focus on such treatments as opposed to those that are data-driven may contribute to this phenomenon. Their investigation of reports on alternative treatments in the media since 1990 yielded frequencies in the high hundreds, most of which presented a positive or neutral perspective of these therapies. Although these numbers have declined in the past few years, parent utilization of alternative treatments that lack empirical evidence of effectiveness for children with autism has been estimated at 74% (Hanson et al., 2006).

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Sally Rogers (1998) differentiates two types of treatment for children with autism. Behavioral treatments target certain autism-related skill deficits (e.g., social skills, imitation, play, communication, etc.) as well the reduction of positive symptoms (e.g., inappropriate behaviors). The second type aims to address the global severity of autism and its associated symptoms. The latter is of interest in this review; we present information on a variety of biomedical, sensory-motor, and quasi-behavioral treatments.

Biomedical Interventions The Gluten-Free Casein-Free (GFCF) Diet The rationale behind the GFCF diet stems from a variety of studies and anecdotal reports of gastrointestinal abnormalities in children with autism. Panksepp (1979) linked excesses of opiates in animals to the types of social deficits and aberrant behavior observed in the autistic population. The theory further posits that inadequate digestion of gluten and casein in individuals with autism can lead to opiatelike peptides in the gut that are likely to seep back into the system to limit social relatedness and cause maladaptive behaviors (the “leaky gut” theory). Indeed, findings of urinary peptide abnormalities in this population (Knivsberg, Reichelt, Hoien, & Nodland, 2003; Reichelt et al., 1981; Shattock et al,. 1990) as well as amino acid deficiencies (Arnold, Hyman, Mooney, & Kirby, 2003) have been documented. As the name implies, the GFCF diet removes all gluten (a mixture of proteins found in wheat products) and casein (a milk protein) from the diet. Individuals on the diet must also avoid touching products containing gluten and casein (e.g., Play-Doh®) that may transfer the compounds through the skin. This is an important consideration for children in a school setting who may encounter exposure to gluten or casein from classroom items (e.g., Play-Doh, glue) or from another student. Data on the GFCF diet have been mixed. Evaluations of the efficacy of this intervention are based on parent- and teacher-report (Cade et al., 2000; Whiteley, Rodgers, Savery, & Shattock, 1999), urinary analysis of peptides (Elder et al., 2006; Knivsberg, Reichelt, Nodland, & Hoien, 1995; Knivsberg, Wiig, Lind, Nodland, & Reichelt, 1990), or a variety of behavioral observation scales (Elder et al., 2006; Kinvsberg et al., 1990; Lucarelli et al., 1995). Knivsberg and colleagues’ randomized control trial of dietary intervention yielded significant improvements in behavior, nonverbal cognition, and motor difficulties. In their 2006 review, Christianson and Ivany detail six studies that reported significant improvements of children with autism on the GF CF diet based on parent- and teacher-reports, urine peptide analyses, and assessments of autistic behavior and cognitive skills. These analyses, however, do raise some methodological concerns. Four of the studies did not include a control group; one performed an unblinded comparison and then based improvements on teacher and parent ratings (Whiteley et al., 1999). Other studies have found no differences in symptom severity or urine peptides between diet and control groups (Elder et al., 2006)


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or reported mixed results (Whiteley et al., 1999). The literature also documents frequent discrepancies between parent- and teacher-reports or between parent-/teacher-reports and scores on standardized measures. Other types of dietary interventions are also occasionally implemented. The ketogenic diet (Wilder, 1921), more commonly used for individuals with seizure disorder, is high in fat and low in carbohydrates. There is limited preliminary evidence that the ketogenic diet may be useful in children with autism (Evangeliou et al., 2002). More general elimination diets also exist in which children are tested for sensitivity to a variety of foods, which are then eliminated from their diet. Frequently tested foods include soy, milk, nuts, corn, eggs, and chocolate; these diets may elicit behavior improvements in children with autism (Torisky, Torisky, Kaplan, & Speicher, 1993). Without more extensive controlled analyses these results are considered very preliminary; currently the use of these types of interventions is not empirically supported.

Vitamin Therapy It has been proposed that individuals with autism require more nutrients than their typical peers, and that nutritional deficiency may impede normal processing of sensory information (Rimland & Larson, 1981). Vitamin therapy involves the administration of specific compounds, most commonly vitamin B-6 (pyridoxine) and magnesium. The benefits of this intervention have been suggested over the past 25 years for decreasing symptomatic behavior (Barthelemy et al., 1981; Lelord, Muh, Barthelemy, Martineau, & Garreau, 1981; Martineau et al., 1989; Rimland, Callaway, & Dreyfus, 1978) and normalizing antibody deficits (Menage, Thibault, Barthelemy, Lelord, & Bardos, 1992). Ascorbic acid supplements have also resulted in decreases on abnormal sensory motor scores on a commonly used behavior measure (Dolske et al., 1993). Opponents of vitamin therapy argue that existing literature does not standardize dosage or units of measurements and criticize the methodology (e.g., unblinded, absence of control, lack of random assignment; Pfeiffer, Norton, Nelson, & Shott, 1995). More recent studies have shown no benefits of vitamin therapy in double-blind, placebo-controlled clinical trials (Findling et al., 1997; Tolbert, Haigler, Waits, & Dennis, 1993).

Medication Children with autism may receive medication as a supplement to other treatments. Commonly administered medications include atypical antipsychotics (e.g., risperidone, aripiprazole), psychotropics (e.g., methylphenidate), and SSRIs (e.g., fluoxetine). These drugs are typically prescribed to target specific behaviors such as aggression, rituals and compulsions, and attention deficits.

Atypical Antipsychotics Risperidone is one of the most well-studied medications currently approved by the FDA. It is tolerated well by children as young as

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preschool age with minimal side-effects, the most common being weight gain, excessive appetite, and hypersalivation (Aman et al., 2005; Luby et al., 2006; Williams et al., 2006). Several studies have suggested the efficacy of risperidone in reducing hyperactivity and repetitive behaviors (Barnard, Young, Pearson, Geddes, & Brien, 2002), aggression (Bernard et al., 2002; AJP, 2005), autism severity (Luby et al., 2006) and self-injurious behaviors (Research Units on Pediatric Psychopharmocology Autism Network, 2005), and promoting increases in communication, daily living skills, and socialization (Williams, et al., 2006). There is also evidence that risperidone may be more effective than alternative atypical antipsychotics (Barnard et al., 2002). Because of the lack of control in these studies, there is a need for randomized control trials to further evaluate the efficacy of this medication.

Selective Serotonin Reuptake Inhibitors SSRIs are frequently used to treat obsessive and compulsive behaviors in children with autism. The literature presents mixed findings regarding the efficacy of a variety of these medications. In recent randomized trials, Hollander and colleagues found that children who were administered fluoxetine showed a reduction in repetitive behaviors on the Yale-Brown Obsessive-Compulsive Scale (2005), and the Autism Diagnostic Observation Schedule (2006) but no significant reductions on global measures. Similar decreases in repetitive behaviors were observed with fluvoxamine (McDougle, 1996), although not all individuals may respond to treatment (Martin, Koenig, Anderson, & Scahill, 2003). Other drugs, such as paroxetine (Posey, Litwiller, Koburn, & McDougle, 1999) and sertraline (Steingard, Zimnitzky, DeMaso, Bauman, & Bucci, 1997), have been related to decreases in aggression and self-injurious behaviors. As with atypical antipsychotics, the effects of SSRIs should be further examined in placebo-controlled studies.

Secretin Therapy Secretin is a hormone that regulates the pH balance of the stomach and the pancreas; it was originally administered to children with autism to alleviate gastrointestinal difficulties. Parent reports of salutary effects on the core features of autism led to the use of secretin to directly target these symptoms. In 1998, Hovarth and colleagues reported gains in language and socialization in three children with autism who received one dose of secretin therapy. Randomized controlled trials of the effects of secretin generally suggest that there is no causal relationship between secretin and changes in autism symptomology. Although some have reported positive results (Kern, Miller, Evans, & Trivedi, 2002), in most cases no changes in behavior were reported (Dunn-Geier et al., 2000; Sandler et al., 1999) or concurrent benefits were observed in both treatment and placebo groups (Handen & Hofkosh, 2005; Unis et al., 2002). In some instances, treatment groups suffered deterioration of skills (Carey, Ratliff-Schaub, Funk, Weinle, Myers, & Jenks, 2002) and increased autism severity when paired


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with other medications (Ratcliff-Schaub, Carey, Reeves, & Rogers, 2005). Esch and Carr (2004) and Sturmey (2004) offer comprehensive reviews of the literature on secretin. Regardless of the data, there is continuing support for the use of secretin therapy with individuals with autism. Although Handen and Hofkosh (2005) found inconsistent performance and, in some cases, worsening scores on the Gilliam Autism Rating Scale, improvements in communication and social relatedness were anecdotally reported in seven out of eight participants. Sandler and colleagues (1999) note that 69% of parents whose children participated in their study sustained interest in secretin therapy, despite the lack of significant improvements in behavior.

Chelation Chelation is a detoxification process created to remove heavy metals from the body, in circumstances such as lead poisoning. Proponents of its use with children with autism attribute its alleged efficacy to the link between heavy metals (principally mercury) and autism symptoms (e.g., language deficits, motor difficulties, sensory abnormalities, repetitive behaviors; Bernard, Enayati, Redwood, Roger, & Binstock, 2001). It is purported that the inclusion of the preservative thimerosol in the MMR and other childhood vaccines facilitates this mercury leak into the body. Currently, there are no published clinical trials on the efficacy of chelation or any other evidence to suggest that chelation may be an appropriate treatment for individuals with autism (Sinha, Silove, & Williams, 2006). Further arguments suggest that the underlying theory is flawed, that the symptoms of mercury poisoning do not mimic specific autism symptoms (Nelson & Bauman, 2003), and that chelation has not been shown in any instance to reverse neurological damage (Shannon, Levy, & Sandler, 2001). Shannon and colleagues also highlight the dangers of this treatment, citing possible kidney and liver damage, and severe allergic reaction. The recent death of a five-year-old boy during chelation therapy also cautions against the blanket administration of this procedure (DeNoon, 2005).

Sensory-Motor Treatments Sensory and auditory integration are posited to alleviate symptoms that arise from abnormal processing of sensory input in individuals with autism. There is evidence to suggest that the autistic population experiences hypo- and hyperarousal to usual sensory stimuli (Frith, 1989; Ke, Wang, & Chen, 2004; Ornitz, 1974); these atypical processes may affect development and account for attentional difficulties, social deficits, and maladaptive behaviors (Ornitz, 1974).

Sensory Integration Implementation of sensory integration therapy can vary; it may be proprioceptive (e.g., deep pressure massage), tactile (light touching, brushing), or vestibular (swinging, rolling, jumping). There is mixed evidence of the

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effects of sensory integration on attentional and behavioral outcomes in children with autism. Case-Smith and Bryan (1999) reported gains on measures of engagement, play behavior, and adult and peer interactions, as well as decreases in nonengagement following an intervention of swinging, brushing, and deep pressure massage. Linderman and Stewart (1999) documented overall gains in social interaction, approach, and response. However, the use of an AB design without reversal may caution our interpretation of their results. In a brief report on touch therapy, 22 children with autism showed decreased aversion and off-task behavior as well as collateral gains in joint attention, behavior regulation, social behavior, and imitation (Field et al., 1997). Watling (2004) reported more mixed findings: increases in engagement but no effect on maladaptive behavior following thirty-three 40-minute sessions of sensory therapy. Others have found no positive effects on behavior (Gillberg, Johansson, Steffenburg, & Berlin, 1997; Kane, Luiselli, Dearborn, & Young, 2004) and have even noted increases in stereotypy as a result of the weighted vest intervention (Kane et al., 2004). Until more consistent evidence is presented under controlled conditions, the outcomes of sensory integration training should be considered uncertain and the treatment possibly contraindicated.

Auditory Integration Training (AIT) Auditory Integration Training provides the child with a device that filters out certain frequencies to which he or she is supposedly hypersensitive. Randomized high and low frequencies then “exercise” the inner ear and brain to decrease atypical sensitivity to frequencies above or below the sensitivity threshold across twenty sessions of 30 minutes listening time (Berard, 1993). Again, mixed results typify the literature. Positive outcomes in cognitive scores (Bettison, 1996), observational measures (Rimland & Edelson, 1995, 1994), and decreases in problem behavior (Rimland & Edelson, 1994; Zollweg, Palm, & Vance, 1997) were observed in response to AIT, under the conditions of random assignment. Subsequent findings suggest that there are no clinically significant benefits to AIT (Gillberg et al., 1997; Link, 1997; Mudford et al., 2000), and it is therefore not recommended.

Facilitated Communication (FC) This intervention stems from Rosemary Crossley’s work with individuals with physical disabilities and was later adapted to aid individuals with autism who cannot verbally communicate (Biklen, 1993a). In facilitated communication a person with autism types words on a keyboard with the physical guidance of an assistant positioned behind him. It is hypothesized that individuals can use FC to convey previously unexpressed needs and wants, as well as reveal formerly unexposed intelligence (Biklen & Schubert, 1991; Bilken, 1992d). A small number of studies have reported some limited success of FC with individuals with autism (Biklen, Saha, & Kliewer, 1995; Cardinal, Hanson, & Wakeham, 1996; Janzen-Wilde, Duchan, & Higginbotham, 1995; Simon,


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Toll, & Whitehair, 1994; Simpson & Myles, 1995b). Many more investigations have indicated that performance with FC is largely due to facilitator influence (Kezuka, 1997; Oswald, 1994; Shane & Kearns, 1994; Perry, Bryson, & Bebko, 1998) and that collateral improvements are unlikely (Beck & Pirovano, 1996; Myles, Simpson, & Smith, 1996a). Indeed, other methods of encouraging communication, such as the Picture Exchange Communication System, are evidenced to be preferable (Simon, Whitehair, & Toll, 1996). FC is considered not only ineffective, but possibly harmful, and is not recommended.

Psychoeducational / Psychosocial Treatments TEACCH The TEACCH strategy, developed by Mesibov, Schopler, and colleagues at the University of North Carolina, focuses on providing services to individuals with autism throughout the lifespan. The fundamentals of TEACCH include highly structured environments and routines, an abundance of visual cues, parent collaboration, and individualized assessment (Schopler, 1998). However, this structure also provokes the main critique that TEACCH does not specifically target the reduction of problem behavior. To date there are few extensive assessments of this approach in the published literature. Some examinations have yielded gains in play skills (Francke & Geist, 2003), task mastery (Hungelmann, 2001), independent functioning and interpersonal behavior (Persson, 2000), academic and cognitive functioning (Ozonoff & Cathcart;, 1998; Schopler & Hennike, 1990), and decreases in self-injurious behavior (Norgate, 1998). However, Smith (1999) suggests that these data are limited as a result of quasi-experimental design, potential confounds, or pretest group differences. Other efforts to validate TEACCH yielded mixed results; Van Bourgondien and colleagues (2003) found no increases in skill acquisition in the experimental group, but decreases in abnormal behavior (albeit, author proclaimed “exploratory findings”). It has also been suggested that skills acquired in these programs do not generalize reliably (Tutt, Powell, & Thornton, 2006). There are fairly strong findings supporting parental satisfaction in the TEACCH model (Van Bourgondien, Reichler, & Schopler, 2003), perhaps because parents are so integrated into this approach. Furthermore, TEACCH programs may provide good long-term support for adults with autism. An investigation of the supported employment program under Division TEACCH found an 89% retention rate among adults with autism (Keel, Mesibov, & Woods, 1997). This program has been crucial in employing individuals with autism and other related disorders, roughly a third of whom had no prior placement.

Developmental Individual Difference, Relationship-Based Model (DIR) Also called “floor time,” this play-based approach targets social interactions between children with autism and their parents and therapists to increase communication and social relatedness (Greenspan, 1992). DIR is a

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child-directed treatment; parents and therapists play with the target child on the floor with preferred materials to promote manding, eye contact, conversation, and other social interfaces. Greenspan and Wieder (1997) conducted a chart review of 200 children with autism who received DIR treatment and compared outcomes with those of children who received traditional (unspecified) services. After two years, they found that 58% of children were categorized as “good to outstanding” compared to 2% in traditional services. Their recent 10- to15-year follow-up of the 16 most high-functioning participants revealed long-term positive outcomes in social and school competence, low rates of comorbid depression and anxiety, and variable outcomes on sensory motor profiles (Wieder & Greenspan, 2005). Limitations of these studies include a nonexperimental design and a lack of information on concurrent treatments, making it very difficult to confidently attribute gains to the approach.

Relationship Development Intervention (RDI) RDI is a family-centered treatment that proposes to enrich an individual’s life with empathy and emotion sharing, suggested prerequisites to typical social interaction. Rather than targeting individual skills, RDI utilizes a broader approach. A comparison of 17 children with autism in an RDI program to 14 children receiving alternative early intensive interventions yielded positive outcomes on the Autism Diagnostic Observation Schedule (ADOS) for 12 participants in the experimental group (Gutstein, 2005). No other empirical analyses of RDI have been published to date.

Conclusion The widespread use of alternative nonbehavioral treatments warrants our attention. Because these interventions are so prevalent, and because rigorous scientific data are largely absent, additional empirical analyses are necessary. Until more data are collected, service providers, teachers, physicians, and parents should be aware of these treatments and of their potential benefits, risk of harm, and possible shortcomings.

ASPERGER SYNDROME Asperger syndrome (AS) is characterized by deficits in social behavior, insistence on sameness, poor nonverbal language development, inappropriate affect, and stereotyped behavior (Asperger, 1944; Wing, 1981). According to the American Psychological Association (APA), differential diagnosis of AS and autism lies in the diagnostic criterion that individuals with AS— unlike those with autism—generally do not demonstrate communication, language, imagination, cognitive, or self-help deficits (APA, 1997). Regardless, researchers and clinicians point out that the differentiation between individuals with autism and AS is often unclear, and requires additional research before a firm conclusion can be made regarding the differential diagnosis (Barnhill, Hagiwara, Myles, & Simpson, 2000).


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In parental report of selected groups of children with AS and autism diagnoses, children with AS seem to engage in more prosocial behavior, make more eye contact, and demonstrate more willingness to engage in friendships and play than do children with autism. Although fewer children with AS demonstrate delayed onset of language as compared to children with autism, both groups demonstrate significant disturbances in communication skills, as reported by parents. Such communication deficits are evident in the children’s use of repetition, poor prosody, literal translation of peers’ language, and an inability to sustain conversation. Overall, although both groups appear to exhibit deficits in social skills and communication, children with AS typically exhibit greater social interest and less delayed communication than would be expected of a child with autism (Eisenmajer et al., 1996).

Social Deficits As indicated by Myles and Simpson (2002), “AS is foremost a social disorder” (p. 132). The authors report that one of the primary differentiating characteristics of children with AS, when compared to children with autism, is that individuals with AS desire and seek social interactions. Difficulties in initiating and sustaining relationships, however, are evident at an early age. Church, Alisank, and Amanullah (2000) conducted an analysis of individuals with autism from preschool to teenage years. The authors reported that, even in preschool, parents indicated that although the children interacted well with adults, they had difficulty interacting with children their age and seemed more comfortable on the periphery of social groups. This difficulty in initiating and maintaining relationships seemed exacerbated by difficulty reading social cues and situations and regulating behavior. Through middle school, individuals with AS exhibit inappropriate affect, resulting in inappropriately loud, aggressive, and often silly behavior. Much of the difficulty experienced by children with AS stems from their inability to learn and understand what Myles and Simpson (2001) term the “hidden curriculum.” Rules of social interaction and behavior are learned rigidly by children with AS and are inflexibly applied to all situations regardless of setting and audience. The ability to flexibly apply these rules of interaction—which is demonstrated effortlessly by typical children—is a skill that is never directly taught but is expected of all individuals. As a result, children with AS appear socially awkward and often inappropriate (Myles & Simpson, 2001). One approach for improving social skills in this population is the development of social skills groups for children and adolescents that target appropriate behavior, recognition of verbal and nonverbal social cues (Barnhill, Cook, Tebbenkamp, & Myles, 2002), and understanding the “hidden curriculum” (Myles & Simpson, 2001). For example, Myles and Simpson (2001) suggest that the hidden curriculum can be taught to children with AS using a variety of methods, including direct instruction— comprised of methods such as providing a rationale for behavior, presentation of skills, modeling, evaluation, and assessment of generalization—and

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social stories written to describe information about specific situations, appropriate behavior in those situations, and the thoughts and beliefs of others in the situation (Gray, 1995). Other skill-building activities may include acting lessons, in which they learn to openly express emotions and receive consistent feedback on performance from peers and instructors; cartooning, to help a child identify different perspectives; “social autopsies” (Bieber, 1994, as cited in Myles & Simpson, 2001, p. 283) in which the child and an adult meet to analyze recent social mistakes and develop steps to ensure that the mistake does not occur again; and problem-solving behavior. Many of these methods are widely used in social skills groups, but the outcomes of such social skills groups remain mixed. Although the children in some groups evidence an improvement in social skills within the group, measures of improvement such as performance on psychometric tests may not capture the improvement (Barnhill et al., 2002). Additionally, many children show limited generalization of skills learned in social skills groups to new settings and situations (Barnhill et al., 2002). Church et al. (1999) point out, however, that in a sample of elementary-aged children with AS, only 23% were receiving a social skills curriculum when the deficit is arguably one of the most profound in the disorder. In contrast, 76% of children in the middle-school sample received the social skills curriculum. Social skills and the utilization of social skills groups may need to be introduced during the child’s early development to attain optimal acquisition and generalization of these difficult but crucial skills. Aside from reliance on social skills groups, teachers may be able to improve social interactions by increasing the sensitivity of other children to the child with AS. For example, the teacher may educate other children on the difficulties experienced by an individual with AS. By developing cooperative learning groups in which children must work together toward a common goal, or creating a “buddy system” in which children must work together during the course of the day, children with AS can be paired with appropriate models. Furthermore, these contexts provide an opportunity for children with AS to demonstrate their academic strengths in social environments. This approach may increase the social acceptance of these children and increase their self esteem (Barnhill & Myles, 2001; Tsatsanis, Foley, & Donehower, 2004; Williams, 1995).

Behavioral Difficulties Young children with AS often exhibit rigid behavioral routines and rituals, becoming preoccupied with stereotypical body movements and inappropriate object use. Interruptions of and transitions from these routines often result in maladaptive behavior such as tantrums (Church et al., 1999). Many of these behaviors appear to dissipate as the children grow older, however, they are often still evident in times of high frustration; elementary-aged children frequently engage in behaviors such as self-talk, humming, and pacing. These children remain extremely literal and rulebased in their interactions with others (Church et al., 1999). Managing these restricted interests can be difficult, but promoting a predictable


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environment for the child with AS by creating a consistent routine and avoiding unexpected changes may minimize maladaptive responses in response to changes in routine. When change is inevitable, one should expose individuals with AS to the change gradually so as to shape appropriate behavior in the new setting or situation (Williams, 1995). In addition, many children develop an intense preoccupation with specific topics that dominate a child’s interest (Myles & Simpson, 2001). Frequently, parents and teachers find difficulty in motivating a child without the use of these interests (Williams, 1995). Several hypotheses have been developed regarding the emergence of these restricted interests: children may develop these interests to facilitate conversation, to provide the individual with an enjoyable activity, for relaxation, and for order and consistency (Barnhill, 2001b). Regardless, the development of these interests will often last into adulthood. To manage this behavior, parents and teachers may implement rules to limit the child’s perseveration on a given topic. For example, a parent may allow the child to talk about the perseverative interest only at specific times of the day, reinforcing appropriate alternative behavior in the absence of perseveration. In addition, a teacher may also be able to use the restricted interests to motivate a child to complete a task by tailoring the task to the child’s interests or linking other skills to the restricted interest. For example, writing a history report for a child who perseverates on trains may be more tolerable if he is allowed to write a report on the history of the railroad, and writing this report may be linked to learning about the development of the western United States following the expansion of the railroad. Ultimately, the teacher will have to set rules regarding work that must be performed outside the child’s interests, and reinforce the child for completing such work independently (Williams, 1995). Many children with AS have difficulty regulating their emotional behavior, and as a result are prone to emotional outbursts and tantrums. Because these children have difficulty reporting their own internal states (Barnhill, Hagiwara, Myles, Simpson, Brick, & Griswold, 2000) and often do not indicate increasing stress through either voice or body language, emotional situations may escalate quickly without warning (Myles & Southwick, 1999 as cited in Myles & Simpson, 2002). Family and teachers may be able to prevent such outbursts by maintaining a predictable structured environment for children with AS. In addition, children with AS should also be taught how to self-manage their own behavior using coping strategies such as problem-solving skills and de-escalation techniques (Tsatsanis, Foley, & Donehower, 2004; Williams, 1995). The assessment and treatment of problem behavior will be discussed more extensively later in this chapter.

Language and Cognitive Skills The APA diagnostic manual indicates that children with AS are not significantly delayed in either language development or cognitive development, but in fact a range of deficits do occur. Church et al. (1999) report normal or early language emergence in 88% of children with AS, but also report that 90% of children with AS exhibit language pragmatic problems in preschool years.

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In elementary school and middle school, 96% and 76% of children, respectively, receive speech and language services to address difficulty with conversational skills, vocal regulation and modulation, and language expression. Although these children often perform above average in academics, the individual performance of students with AS varies widely. Griswold, Barnhill, Myles, Hagiwara, and Simpson (2002) conducted an assessment of children ages 6 to 17 years old with AS using the Wechsler Individual Achievement Test and found that, whereas the aggregate score for the children fell within the average range, individual scores ranged from significantly below to significantly above average. Children with AS demonstrated specific weaknesses in language and reading comprehension (Church et al., 1999; Barnhill et al., 2000; Griswold et al., 2002) and mathematical concepts and principles (Barnhill et al., 2000; Griswold et al., 2002). Such deficits may arise from difficulties with social and communication related tasks, literal thought and interpretation, and poor problem-solving skills (Frith, 1991; Siegel, Minshew, & Goldstein, 1996). These children appear to demonstrate above-average performance in tests of nonverbal reasoning and factual recollection (Barnhill et al., 2000), as well as reading. Teachers should note, however, that reading proficiency is not an indicator of strong comprehension; these children often demonstrate weakness in this area (Griswold et al., 2002). In addition, they are often unable to differentiate between general knowledge and personal thought, responding both verbally and in writing with responses that may be incomprehensible by a teacher due to their reliance on personal thought (Williams, 1995). Researchers caution that knowledge of the AS diagnosis will not provide information about specific strengths and weaknesses; rather, comprehensive assessment must be conducted for all students (Griswold et al., 2002). Many children with AS, because of their myriad strengths and deficits in unpredictable areas, will require individualized programs to ensure success in an academic setting. These children may require additional explanation and instruction, especially of abstract concepts. Care should be taken to assess a child’s comprehension of spoken and written material (Williams, 1995). Additional supports can be implemented in the general classroom area to increase skills in concentration, an area of difficulty for the child with AS. A structured predictable classroom setting may increase a child’s attention, as might seating arrangements that facilitate concentration (e.g., seating near the teacher, seating with a classroom “buddy”). Visual prompts for these children may be especially helpful in facilitating adherence to instruction and smooth transitions to new activities (Williams, 1995). Visual prompts may also be useful in improving performance in auditory tasks, as many children with AS may have difficulty processing auditory instructions and descriptions. A lecture format may be especially difficult for a child with AS to attend to, and additional visual strategies such as the use of role-play and videos may make information more salient to the child (Griswold et al., 2002).

Emotional Characteristics Of great importance in the discussion of AS is the profound impact that the disorder has on the emotional adjustment of the individuals. As has


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been mentioned previously, unlike their peers with autism, children with AS have a desire to develop social relationships but often fail at doing so. These children also have the insight to understand that they are different from others and do not “fit in” (Myles & Simpson, 2002). Such realizations have effects on the individuals’ self-esteem and self-concept and put children, adolescents, and adults with AS at increased risk for a number of comorbid disorders, including depression and anxiety (Barnhill et al., 2000; Kim, Szatmari, Bryson, Streiner, & Wilson, 2000). Up to 20% of adults with AS have experienced a period of depression at some point in their lives (Kim et al., 2000; Tantam, 2001), but research indicates that often these children are poor reporters of such internal states. Barnhill et al. (2000) conducted an analysis of internalizing and externalizing problem behavior among adolescents with AS and revealed that, although parents and teachers indicated that children were at risk for internalizing problems, the adolescents did not report any internalizing difficulties. Such poor insight may make it difficult to diagnose these problems in AS individuals, but the identification of these diagnoses is critical to ascertain treatment. Much research has focused on the underlying cause of depression in children and adolescents with AS. Recently researchers have indicated that adolescents with comorbid AS and depression indicate a greater propensity to view situations in a way that indicates both helplessness and hopelessness. They perceive many events as beyond their control and take personal responsibility for the negative events in their lives (Barnhill & Myles, 2001). Additionally, authors have found that IQ is negatively related to this finding, in that adolescents with high IQ are less likely to make these attributions and to instead realize the impact external situations have on one’s social success (Barnhill, 2001a). As a result of these findings, researchers have begun to examine the use of cognitive behavior therapy (CBT)—a problem-oriented therapy in which focus is placed on psychological and environmental contributors to emotional distress—for treatment of AS individuals with comorbid disorders. CBT places focus on the alteration of thoughts and behavior to improve symptoms such as anxiety and depression. For example, Sofronoff, Attwood, and Hinton (2005) found that the use of a CBT package, which included teaching children with AS to identify emotions, thought patterns, and behavior and instructing them in ways of controlling anxiety using a variety of coping skills and social stories, was effective in decreasing anxiety symptoms in children with AS. The treatment was most effective when paired with parental involvement in therapy. Research in the use of CBT with individuals with AS, however, is still emerging. In an investigation of the use of CBT in individuals with AS, Anderson and Morris (2006) reported that only five published studies— four of which were case studies—have examined the use of CBT in individuals with AS. More research is required in this area to fully understand the intricacies of utilizing the therapy within this population. Researchers speculate that the highly structured format of the therapy and the focus on the development of affect recognition and thought evaluation may be beneficial to AS individuals suffering from comorbid disorders, especially when enhanced by visual materials, emphasis on rules rather than on

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abstract concepts, a directive approach, and family involvement (Anderson & Morris, 2006). Although further research is required to gain a better understanding of diagnosis and treatment of AS, researchers agree that treatment for AS should begin early in development. Because of the high academic functioning of many children with AS, diagnosis can occur later than it does in children with autism (Eisenmajer et al., 1996). Early detection and intervention in areas of social understanding and social skills is essential in the treatment of AS. Again, one should recognize the importance of a detailed assessment of the strengths and deficits of each child to develop the most appropriate individualized education plan. Family members should be involved at all stages of treatment to facilitate generalization of learned skills, and to increase family understanding and management of challenging behavior (Tsatsanis, Foley, & Donehower, 2004). Comprehensive treatment in the areas of social, behavioral, cognitive, and emotional development may vastly improve the quality of life for the child with AS.

Functional Assessment and Treatment Children on the autism spectrum exhibit a wide range of challenging behavior, including aggressive, self-injurious, and disruptive behavior. Some behavior may be severe and intrusive enough to warrant a behavior intervention plan informed by a functional behavioral assessment (FBA). An FBA is defined as “a process which searches for an explanation of the purpose behind a problem behavior” (OSEP Questions and Answers, 1999) and is mandated by the Individuals with Disabilities Education Act (IDEA) Amendments of 1997 in cases in which a child’s behavior has resulted in negative educational outcomes. Specifically, FBAs are mandated when the behavior has resulted in the child’s suspension or placement in an alternative setting either for 10 consecutive days or because a due process hearing officer has determined the behavior is dangerous to the student or others, or when a student is placed in an alternative setting for 45 days when he or she has been involved in a weapons or drug offense. Although children with autism may infrequently meet these extreme requirements, IDEA also stipulates that if an individual’s behavior interferes with his or her learning or the learning of others, or poses a danger to the individual or others, then the student’s individual educational plan (IEP) team should implement a behavior intervention plan informed by a functional behavior assessment to address the behavior. These stipulations apply to many children with autism. Unfortunately, IDEA does not specify what elements constitute either an FBA or an effective intervention. We summarize here the components of a functional behavioral assessment and also discuss the importance of using the results of an FBA to inform and develop a function-based intervention for challenging behavior.

Functional Assessment Iovannone, Dunlap, Huber, and Kinkaid (2003) conducted a review of comprehensive treatments for children with autism and found that one of the


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components common to all effective treatments was a functional approach to challenging behavior. Although a child’s behavior may often appear unpredictable and random, most professionals in the field agree that all adaptive and maladaptive behavior is functionally and lawfully related to events in the environment and serves a purpose for the individual (Northup et al., 1991). An FBA is used to identify this function of a behavior so that an appropriate, function-based treatment can be implemented. In the context of functional assessment, behavior is maintained by either positive reinforcement or negative reinforcement, that is, by environmental stimuli that are either added to (i.e., positive reinforcement) or removed from (i.e., negative reinforcement) the environment following the occurrence of a behavior that subsequently increases the likelihood of that behavior occurring again in the future. Examples of positive reinforcement may include the presentation of attention, desired items, or pleasurable sensory input, and examples of negative reinforcement include the removal of demands or other aversive environmental stimuli or physical sensations. A behavior may function to gain access to any of these forms of reinforcement and, additionally, the behavior may function to gain access to several forms of reinforcement simultaneously (Northup et al., 1991). The purpose of a functional assessment is to determine which of these myriad functions currently maintains a maladaptive behavior so that an effective intervention can be developed. Prior to either the functional assessment or development of a behavior intervention plan, one must develop an operational definition for the challenging behavior. An operational definition defines the behavior as a measurable observable event, thus reducing biased reporting of the behavior and increasing the reliability of measurement of the behavior (Cooper, Heron, & Heward, 2007). Accurate assessment and treatment of the behavior will rely heavily on accurate data collection and measurement of the behavior. Without data and measurement, one cannot determine conclusively that a behavior has been reduced.

Indirect Assessment Functional assessments can be conducted using three types of assessment: indirect assessment, descriptive assessment, and functional analysis (O’Neill, Horner, Albin, Sprague, Storey, & Newton, 1997). Indirect methods include assessment techniques such as rating scales and interviews which require an individual who is familiar with the child to provide information about environmental antecedents and consequences. Antecedents, or events that frequently occur before the onset of the behavior, may include the time of day, the presence of a specific person or activity, or inclusion in a particular setting. Consequences, or events that frequently occur following the behavior, might include examples of positive or negative reinforcement as discussed above (e.g., access to attention, removal of attention, etc.). The informant should also be asked to provide information about the child’s current skill level and ability to communicate. All of these responses will be helpful in informing a function-based intervention (O’Neill et al., 1997).

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Although rating forms and interviews are frequently easy and efficient to conduct, they should not be the sole form of assessment on which treatment is based. Both rating scales and interviews are subject to bias or error on the part of the informant and may provide unreliable results (LaRue & Handleman, 2006; Sturmey, 1994; Zarcone, Rodgers, Iwata, Rourke, & Dorsey, 1991). As a result, such methods of indirect assessment should be used as a preliminary step to inform subsequent assessment and, with very few exceptions (e.g., suicidal behavior), an intervention should not be based solely on an indirect method of assessment.

Descriptive Assessment In contrast to indirect methods of assessment, descriptive assessment involves the direct observation and recording of the target behavior in the natural environment. A frequent method of descriptive analysis is Antecedent-Behavior-Consequence (ABC) recording, in which the observer watches the child in vivo in the natural setting and records the antecedents, behavior, and consequences, all of which must be operationally defined to ensure accurate recording (LaRue & Handleman, 2006; Sasso et al., 1992). The observer is then able to calculate the conditional probability of each antecedent and consequence by calculating the percentage of behavior episodes that were preceded by a specific antecedent and followed by a specific consequence. The most frequent antecedent and consequence for the behavior, or those with the greatest conditional probability, indicate a function (e.g., escape from demand, gain access to tangible, gain access to attention) of the behavior (LaRue & Handleman, 2006; Sasso et al., 1992). If the data indicate a clear functional relationship between environmental events and behavior, the descriptive analysis may be the terminal step of the functional assessment (LaRue & Handleman, 2006). Descriptive analysis provides more objective information about the behavior as compared to indirect methods of assessment. By observing the behavior in the natural environment, the observer decreases the likelihood that identification of the function of behavior is biased. Criticisms of descriptive analyses, however, include the fact that they offer little control over the behavior and thus one cannot assume functional relationships between events and behavior (Sasso et al., 1992). The temporal contiguity of two events does not indicate a relationship, as the two events may be completely unrelated and occur temporally proximate to each other by coincidence only. In addition, many events may occur simultaneously prior to or following the occurrence of the behavior, making observational recording and analysis of antecedents and consequences difficult (LaRue & Handleman, 2006).

Functional Analysis A functional analysis evinces significantly more control over environmental events through the systematic manipulation of environmental antecedents and consequences (Carr & Durand, 1985; Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994). These manipulations, referred to as


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conditions, are representative of reinforcement contingencies that may occur in the natural environment. Behavior is recorded during various conditions, and conditions in which the highest rate of behavior occurs indicate a function for the target behavior. Conditions commonly implemented in a functional analysis include social attention, demand, tangible, alone/ignore, and toy play control (LaRue & Handleman, 2006). In the social attention condition, the child is antecedently allowed to play with neutral items, but receives no attention from the therapist/teacher. Upon the occurrence of the target behavior, the therapist/teacher provides the child with attention. High rates of behavior in this condition imply that the behavior is maintained by social attention. In the demand condition, the child is antecedently engaged in a demand activity, and as a consequence for the target behavior the therapist removes all demands from the child and provides her with a break. High rates of behavior in this condition imply that the behavior is maintained by escape from demands. In the tangible condition, the child is antecedently deprived of preferred tangible items, and the consequence for the behavior is delivery of the items. High rates of the behavior in this condition imply that the behavior is maintained by access to preferred items. In the alone/ignore condition, the child is allowed to play with neutral items and no consequences are provided upon the occurrence of the behavior. High rates of behavior in this condition imply that the behavior is automatically reinforced, that is, the student receives sensory input that acts as positive reinforcement (e.g., pleasurable sensation) or negative reinforcement (e.g., alleviates bodily discomfort, such as eye pressing might alleviate sinus pressure). All conditions are compared to the toy play condition, in which the child receives constant access to preferred tangible items, social attention, and is not presented with demands. No consequence is provided for the behavior. This condition serves as the control condition, as the behavior should occur at a low rate in this condition. In a review of published functional analysis outcomes through the year 2000, Hanley et al. (2003) reported that functional analysis was shown to be overwhelmingly successful in identifying functions of problem behavior; 95% of outcomes were interpreted by the authors as “differentiated outcomes,” meaning a maintaining variable had been identified for the target behavior. Despite the success of the assessment method, common criticisms include the suggestion that the method is too complex and that the procedure takes too long to complete (Axelrod, 1987). In response to this, several studies have revealed that the use of brief forms of functional analyses have vastly reduced the amount of time required for assessment and have also reliably identified maintaining contingencies for behavior (Derby et al., 1992; Northup et al., 1991). Another concern regarding the functional analysis is that the sterilized procedure may not utilize contingencies that maintain the behavior in the natural environment (Mace & Lalli, 1991). Results indicate, however, that functional analyses run by teachers in the classroom environment produce differentiated results that match those of analogue functional analyses and ABC data. In addition, the teachers reported that this technique

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allowed the assessment in the natural environment with control over the environmental events controlling the behavior (Sasso et al., 1992).

Function-Based Behavior Intervention IDEA specifies that behavior intervention plans intended to decrease challenging behavior should be based on a functional behavior assessment. Although IDEA does not specify the components of a successful behavior intervention plan (Drasgow & Yell, 2001), many effective behavior intervention plans include antecedent-based components, such as noncontingent reinforcement and functional communication training, and consequencebased components, such as extinction. Each component can be implemented in a variety of ways depending on the function of behavior, and thus require that one understands and is able to translate the principles of behavior change based on different functions of behavior (Iwata, Pace, Cowdery, & Miltenberger, 1994).

Noncontingent Reinforcement Noncontingent reinforcement is the time-based, response-independent delivery of an activity or item that is known to be a reinforcer for the individual (Vollmer, Marcus, & Ringdahl, 1995; Vollmer, Iwata, Zarcone, Smith, & Mazaleski, 1993). The frequent delivery of this reinforcement is intended to decrease an individual’s motivation to engage in the challenging behavior; if he receives the reinforcing activity at a rate that is the same or higher than that achieved by using the maladaptive behavior, his motivation for engaging in the behavior may subsequently decrease, and lower rates of the behavior may occur (Vollmer et al., 1993). For noncontingent reinforcement to be effective, it is paramount that the child receives reinforcement that is matched to the function of her behavior. For example, if a child’s noncompliance is maintained by access to attention, a teacher might provide the child with noncontingent attention every ten minutes. Alternatively, if the noncompliance functions to help the child escape from work tasks, the teacher may provide the child with a noncontingent break from work every ten minutes. Researchers have also found that the delivery of stimuli that may provide the same sensory input as an automatically reinforced challenging behavior may also decrease the target behavior. Again, a comprehensive assessment of the reinforcement received from engagement in the behavior is required to identify a form of noncontingent sensory reinforcement that may reduce the behavior (Piazza, Adelinis, Hanley, Goh, & Delia, 2000)

Functional Communication Training To further reduce a child’s motivation to engage in challenging behavior, he should be taught to secure his own reinforcement using an alternative behavior. The behavior should be matched to the maladaptive behavior so that it is effective in soliciting the same form of reinforcement acquired using the maladaptive behavior. Functional communication training is a


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method frequently used to teach a child replacement skills. Through functional communication training, a child learns to solicit his own reinforcement using communication, be it through sign language, picture exchange, or a verbal response (Carr & Durand, 1985). In teaching this skill, the alternative behavior must be as efficient—if not more efficient—than the maladaptive behavior. That is, the alternative behavior must result in more consistent, reliable reinforcement delivery than the maladaptive behavior to result in a decrease of challenging behavior (Carr & Durand, 1985). The advantage of functional communication training is that it puts the child in the active role of securing reinforcement. By instructing the child in the use of a functional communication skill, she is able to gain access to reinforcement independently and perhaps at a more frequent rate than might be determined by a noncontingent reinforcement schedule (Carr & Durand, 1985). Functional communication training can be effective when used as the sole element in a behavior reduction plan (Carr & Durand, 1985), but many researchers recommend the use of FCT in addition to other procedures (e.g., extinction) to decrease maladaptive behavior (Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998).

Reinforcement Procedures In addition to delivering reinforcement noncontingently or in response to an alternative behavior, positive or negative reinforcement can also be delivered contingently on the absence of a student’s behavior (Lalli et al., 1999). Function-based reinforcement may be delivered when the child has not engaged in the behavior for a specified period of time (Vollmer et al., 1993) or when the child has engaged in a behavior incompatible with the maladaptive behavior (e.g., placing hands in pockets instead of engaging in repetitive motor movements) (Cooper, Heron, & Heward, 2007) to further increase motivation for engagement in appropriate behavior.

Extinction One of the most critical components of behavior intervention plans is that of extinction. Extinction refers to the elimination of reinforcement for the maladaptive behavior, and takes place when reinforcement that previously maintained a behavior is withheld following the occurrence of a behavior (Iwata et al., 1994). Extinction is especially potent when combined with other intervention components, such as functional communication training and reinforcement procedures, because it eliminates the contingency maintaining the behavior while the child’s motivation to engage in appropriate behavior increases (Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998; Mazaleski, Iwata, Vollmer, Zarcone, & Smith, 1993). Extinction takes on many forms, and each is specific to a different function of behavior. For instance, in the case of behavior that is main tained by attention, extinction would take place when attention was withheld (i.e., “planned ignoring”) following the occurrence of the behavior. For a behavior maintained by escape from demands, “escape extinction” would be implemented by prompting a student through the current task

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following the occurrence of behavior (e.g., Iwata, Pace, Kalsher, Cowdery, & Cataldo, 1990). Automatically reinforced behavior would be placed on extinction by implementing a procedure that would block or eliminate the automatically reinforcing properties of a behavior, for example, by placing a helmet on a student who engaged in automatically reinforced head-hitting. The importance of identifying the function of a behavior prior to implementing an extinction procedure must be stressed, as arbitrarily implemented procedures may be ineffective or contraindicated. For example, planned ignoring following the occurrence of a behavior that functions to escape from demands will perpetuate the reinforcement of that behavior (Iwata et al., 1994).

Summary of Functional Assessment and Analysis Although individuals with autism frequently exhibit maladaptive behavior, extensive research supports the use of functional assessment and function-based behavior intervention plans. Initial indirect assessments greatly inform further descriptive assessment and functional analysis, allowing parents, teachers, and other service providers a method by which they can identify the underlying motivation for an individual’s maladaptive behavior. With this valuable information, effective treatments may be developed that are solidly function-based. The inclusion of noncontingent reinforcement, functional communication training, reinforcement, and extinction in behavior intervention plans—if matched to the function of the behavior—have been demonstrated as highly effective in decreasing maladaptive behavior. Further research will continue to assess the most effective methods of conducting assessments and implementing treatments in various settings, including the classroom and the home. Although the utility of function-based assessment and treatment cannot be questioned, and the mandates set forth by IDEA ensure that the use of functional assessment and treatment cannot be dismissed, researchers and professionals should continue to develop methods that increase the ease of use of this science. This future work will ensure that individuals with autism receive access to the most informed and appropriate assessment and treatment possible.

FUTURE RESEARCH IN THEORY OF MIND AND JOINT ATTENTION AND EARLY INTERVENTION There are several areas that are very exciting in the identification and treatment of autism spectrum disorders. Social skills remain the most difficult deficits to have an impact upon, however, there has been some progress in how such deficits are conceptualized and treated. In particular, there has been great interest in how skills in both perspective taking and joint attention might be increased. In addition, there has been great


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progress in the early identification of autism spectrum disorders in toddlers, making it possible for treatment to begin at younger ages.

THEORY OF MIND Theory of mind (ToM) refers to both the ability to understand the presence of others’ mental states (e.g., beliefs, desires, intentions) and the capacity to reasonably predict these mental states in various situations. Impairments in ToM are evident in individuals with autism, and some argue that in these impairments lies a core deficit of autism. Recent studies have brought into light new possible mechanisms, constructs, and implications of ToM, thus creating an exciting new realm for future research.

Biological Mechanisms The prefrontal cortex (PFC) has been connected to certain core deficits of autism, as it is implicated in the development of social, emotional, and memory skills. Currently, researchers aim to substantiate hypotheses of domain specificity in areas of the brain as they relate to ToM. Sabbagh (2004) examined event-related potentials (ERP) in individuals with autism during an emotional mental state judgment task. His results specifically implicate the inferior frontal and anterior temporal regions of the right hemisphere in mental state decoding. In contrast, the left PFC is associated with executive function, inhibitory control, and the development of emotional quality in social interactions. The PFC is also related to other constructs related to ToM, including joint-attention and visual perspective shifting. Sabbagh’s findings suggest that the cognitive processes of ToM may not be a result of deficits in general neural systems, but domain-specific. Future research may focus on the need for a developmental trajectory of cortical brain activity in individuals with autism. Sabbagh’s final comments target mental state decoding as a core deficit in autism. In typical development, decoding emerges prior to reasoning; the similarities between the cortical localizations in decoding and other ToM and social skills processes (e.g., mental state reasoning, facial emotion recognition) justify additional attention to this area of research. Other investigations have targeted neural functioning to explain ToM. A recent study of Von Economo neurons (VENs) suggests that ToM deficits may be explicated at this level (Allman, Watson, Tetreault, & Hakeem, 2005). VENs transmit output of the fronto-insular and anterior cingulate cortex to the frontal and temporal cortex; they are believed to be related to intuition, or the ability to make quick judgments in complex social situations. Allman and colleagues suggest that VENs are especially vulnerable to dysfunction due to their late emergence in the evolutionary development of humans. VENs may be responsible for integrating the balance between rewards and punishments derived from a variety of inputs in social situations, a kind of rapid cost-benefit analysis based on expectancy and experience. Analyses of VEN location and distribution in

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the brains of individuals with autism will extend this line of investigation and may further link specific brain abnormalities to ToM difficulties.

Cognitive Processes of Theory of Mind There are varied theories as to the specific process deficits in ToM, although they may not all be mutually exclusive. Weak Central Coherence (WCC) has been proposed as a cognitive style underlying the social difficulties in autism (Frith, 1989). This theory posits that individuals cannot integrate unique details into a more global context. Research by Burnette and colleagues (2005) highlights the mixed evidence of WCC as a sound construct. In their analysis, verbal aspects of WCC (e.g., ability to correctly interpret and pronounce homographs) were directly correlated with performance on ToM tasks; however, this was not true of visual spatial aspects (block design, pattern recognition, identification of embedded figures). Furthermore, WCC was not correlated with symptom presentation, as has been hypothesized. The authors predicted that comorbid anxiety may have acted as a moderating variable, but the results refuted this theory. This study added to mixed findings on the relationship between WCC and ToM (Brian & Bryson, 1996; Ozonoff, Pennington, & Rogers, 1991a). WCC may be measuring similar deficits as ToM, such as the need for inhibition. If this is true, more research is needed to determine whether this common paradigm may lead to fallacious correlations, or whether the integrative processing difficulty is in fact the key construct. The “three-element schema” is a more fundamental model that focuses on the specific factors that influence behavior at each level of a ToM task (Bowler, Briskman, Gurvidi, & Fornells-Ambrojo, 2005). The theory stemmed from results the authors obtained from the performance on two types of false-belief games by children with autism. One of the games was “agentless,” in that it involved deciding the location of a train based on color. The other was the Sally-Anne task; Sally puts her marble in one of two boxes and then leaves the room. Anne comes in and moves the marble to the other box. A child is then asked, “Where will Sally look for her marble?” A child who answers “in the first box” has demonstrated ToM. Children with autism performed significantly better on the agentless task than on the Sally-Anne task. The correspondant theory breaks down this task into three main components: the goal (marble), the signal (Sally’s belief), and the agent (Sally’s behavior). According to Bowler and colleagues, the agent adds a third dimension to the train task; in this case the response should change contingent upon a change in the goal based on information provided by the signal. The authors assert that an understanding of this relationship does not lie within a capacity to understand mental states (social deficits), but in integrating changing information from two sources (processing deficits). The ability to pass an agentless task was seen as a prerequisite on a ToM hierarchy of situation complexity. A longitudinal examination of this phenomenon may explicate the validity of the degrees of ToM. Are ToM deficits social in nature or indicative of more general representational difficulties? This is one of the central questions in ToM research. Impairments have been reported on both social (e.g., face


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processing, identifying emotions) and nonsocial domains (e.g., ambiguous figure perception, pattern recognition), suggesting that ToM is specific to neither. To address the representational deficit theory, Sobel, Capps, and Gopnik (2005) presented an ambiguous figure task to children with and without autism to measure their capacity for perceptual shifts. In typically developing children, successful perception of ambiguous figures has been linked to ToM performance (Gopnik & Rosati, 2001). The 2005 study found no differences across diagnosis in the perception of a single image or in the informed perception of multiple images. However, children with autism were significantly less likely to spontaneously identify multiple images (reversal) than their typical peers. On a variety of ToM tasks, results were mixed; in individuals with autism there was no relationship between reversals and a false-belief task, but a correlation was present between image reversals and discrimination between literal and nonliteral stories. Although, the results support a link between ToM and executive functioning as opposed to specific social or representational deficits, the mixed results warrant further study.

Theory of Mind and Other Social Constructs The relationship between ToM and other social qualities has also been a recent focus of the literature. For example, interesting links between ToM and cooperation and fairness have been posited. In individuals with autism, successful performance on second-order ToM tasks were significantly correlated with cooperation (Sally & Hill, 2006). One theory of cooperation suggests that cooperation happens when a person can anticipate that another person will also cooperate, to both their benefits (an understanding of intentions). It is therefore surprising that performance on firstorder ToM tasks was negatively correlated with cooperation. An additional bargaining task was presented, in which a player had the opportunity to offer a certain number of his points to another player. ToM correlated with mutually beneficial offers, even at the expense of short-term gain. Children with autism were bimodal in their offers, being more likely to offer either half their points (fairness) or none at all. They were also more likely to decline “fair” offers and to accept “unfair” offers. Differences between groups may lie in the ability to understand the offerer’s intentions. A strong link between ToM and language abilities has been supported (Tager-Flusberg & Sullivan, 1994), suggesting that language may be a reliable precursor to perspective-taking skills. Recent findings indicate there may be a reciprocal relationship between ToM and discourse in children with autism (Hale & Tager-Flusberg, 2005). The authors found concurrent reciprocal relationships between performances on a variety of ToM tasks and contingent discourse, but these predictors were not reliable across time. There is existing evidence that language predicts contingent discourse over time, so further analyses may want to examine longitudinal relationships of both ToM and discourse as a function of language development. The authors also found that the quality of the conversing partner effected differences in contingent discourse. These results may have implications for parent-training interventions. Because children

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make longitudinal developmental gains in language, parents are the most obvious choice to implement consistent interventions. However, it may be necessary to teach the components of a strong discourse so that these children can maximally benefit from conversations with their parents.

Sibling Research To further the argument that ToM difficulty is a core feature of autism, researchers have turned to typically developing siblings to examine parallel deficits in this construct. Shaked, Gamliel, and Yirmiya (2006) presented false-belief and strange story tasks to siblings of children with autism and typically developing children. They found that the relationship between receptive verbal language and performance on ToM tasks was upheld in both sibling groups, but no significant differences in performance were found between groups. These results were both consistent with and contradictory to previous evidence. Longitudinal research is needed to identify group differences across the developmental span and across other populations with developmental disabilities, learning disorders, and cognitive impairments. A deficit in theory of mind is undoubtedly a fascinating feature in individuals with autism. The ample current literature delineates many future research directions to further examine its mechanisms, related constructs, and the implications for individualized treatment. Because theory of mind represents a core deficit in children with autism, remediation of these skills may have important implications for more developmentally advanced social skills (e.g., emotion recognition and interpretation, reciprocal discourse) and possibly for academic skills as well (e.g., reading comprehension, number sequencing). The nature of theory of mind as a critical prerequisite skill underlines the need for future research into the mechanisms of this phenomenon, so we can better identify the critical components of effective interventions.

Joint Attention Joint attention is generally defined as one’s ability to use gestures or eye contact to share an interest in or desire for an object or event with another person. Children with autism historically have difficulties interpreting others’ eye gaze and alternating their own between a person and an object, to indicate interest. This deficit in joint attention has been the focus of numerous studies, and there is much yet to be explained. Furthermore, joint attention is seen as a critically important social behavior that aids the development of reciprocity and social interactions. As with ToM, the underlying processes of joint attention are subject to much debate. At the most fundamental level, amygdala dysfunction may be implicated in joint attention difficulties. The amygdala primarily regulates emotion processing and memory, as it relates to emotion. Researchers have also suggested that dysfunction in this area may inhibit certain rewarding qualities of social interaction, making the individual less likely


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to seek out or sustain social interactions (Berger, 2006). A relationship between joint attention and face processing, specifically attending to a person’s eyes, has also been proposed. Eye gaze development may be delayed in children with autism, which would explain concurrent deficits in joint attention. Facial processing is also regulated by the amygdala, suggesting a shared biological mechanism. Future research may examine this relationship across time to see if gains in eye gaze would have collateral effects on joint attention. Biological abnormalities also have implications for early diagnosis (Dawson, 2008). Berger proposes that electrophysiological measures of facial processing in infants may contribute to earlier identification of autism, if such a reliable relationship can be established. These findings have exciting implications for early intervention; if these social deficits can be identified in infants, we could potentially initiate interventions much earlier than is currently possible. Is joint attention indicative of a general processing deficit or is it resultant of specific social or attentional impairments? There is evidence to suggest that children with autism have an impaired ability to switch their attention between two stimuli (Siller & Sigman, 2002); this suggests that joint attention difficulties may stem from trouble shifting attention between an object or event and another person. However, this theory does not eliminate the possibility that social skills are also a factor. It has been proposed that joint attention should be considered less as an outcome and more as an indicator of the grander social development process (Mundy & Crowson, 1997). Such a model explains the relationships observed between joint attention and other social skills, such as imitation, pretend play, affect, theory of mind, and communication. The evidence supporting these links still requires replication. Whalen and colleagues (2006) detected collateral gains in imitation, affect, and language after implementing joint attention training with children with autism; Ingersoll and Schreibman (2006) found joint attention benefits as a result of imitation training. Future directions of this research should examine the reciprocity of these associations within datasets. The contingent relationship between certain social domains may have a significant influence on how social skills interventions are planned and sequenced. A significant body of research is also concentrating on improving treatment techniques to target joint attention. Generalization is of paramount importance in any treatment for autism, and current joint attention interventions have shown limitations in this area. There are several factors to consider in promoting generalization. Longitudinal research should focus on current joint attention skills and joint attention teaching in the natural environment (at home, in the classroom, etc.) to see in what settings and with whom are the greatest gains observed (Tsao & Odom, 2006). This line of research also has implications for parent, peer, and sibling training. Typically developing siblings have been shown to effectively teach social skills to children with autism (Celiberti & Harris, 1993; Pierce & Schreibman, 1995; Tsao & Odom, 2006), and children with autism may be more likely to respond to initiations made by siblings (El-Ghoroury & Romanczyk, 1999). Joint attention training may therefore be more likely

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to generalize when taught by siblings or peers in their naturally occurring environments. Upcoming research may also investigate what types of interventions yield robust gains; currently many methods are used to teach joint attention (e.g., pivotal response training, discrete trial training, video modeling, reciprocal imitation). Lastly, there is a need for component analyses of both joint attention interventions and joint attention as an outcome. To maximize intervention benefits, it is crucial to know where these gains are occurring and where they are not. Future studies should break down joint attention into its bipolar components (bids vs. responses, mands vs. shared attention, dyadic vs. triadic interactions) and see where progress is observed. These individual components may also be interesting as they may relate to ancillary gains in social skills and generalization. It may be that certain interventions target specific aspects of joint attention, and that gains in those areas may have particular concurrent benefits for other skills. Furthermore, certain domains of joint attention may be more longitudinally robust than others. These questions are all relevant to future research in joint attention.

Summary on Theory of Mind and Joint Attention The field has made innumerable gains in process-specific and treatment-oriented research on social skills in children with autism. Ongoing evidence continues to explicate the functions and mechanisms of theory of mind and joint attention. These two skill areas are of central importance in understanding the social deficits of autism. Theory of mind describes the perspective-taking deficit that nearly universally characterizes the population of individuals with autism, whereas joint attention describes the lack of shared social interest so often seem among members of this population. It is likely that our difficulties in effecting social change are due, at least in part, to our difficulties in effecting change in these core skill areas. Thus, research into the mechanisms that explain these deficits, and into interventions that remediate these deficits is of critical importance for clinical interventions. It is likely that continued research will yield interesting findings that may fuel innovative clinical approaches to building skills in the focal areas of social skills training.

Early Intervention One of the more exciting developments in recent years in ASDs has been the ability for clinicians to diagnose ASDs at earlier ages. The earlier identification of ASDs leads to earlier, effective treatment, and may increase positive outcomes of intervention. It is generally thought that autism can be diagnosed as young as 20 months (Cox et al., 1999). Early signs include limitations in eye contact, poor reciprocity in smiling, and impaired joint attention (Robins, Fein, Barton, & Green, 2001). Poor imitation and play skills are also associated with ASDs (Rogers et al., 2003). In general, early diagnosis has been shown to be stable over time (Eaves & Ho, 2004; Moore & Goodson, 2003). Intensive


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early intervention produces the best treatment results (McEachin, Smith, & Lovaas, 1993; Sallows & Graupner, 2005). Treatment includes a high number of hours, lots of structure and consistency, and a focus on the development of functional language, imitation, and social skills (Dawson & Osterling, 1997; Rogers, 2001). The Baby Siblings Research Consortium is a network of researchers who study infant siblings of children with autism and other very young children who are at risk for developing ASDs (Yirmaya & Ozonoff, 2007). One clear indicator of emerging ASD is an impairment in social communicative development, which co-exists with atypical sensory and/or motor behaviors (Bryson et al., 2007; Loh et al., 2007). Another indicator of emerging ASDs is a low level of responsiveness to joint attention at 14 and 24 months, and a lack of improvement in response to joint attention between 14 and 24 months of age (Sullivan et al., 2007). In particular, these authors suggest that children who are not responsive to pointing cues for responding to joint attention by 24 months of age should be considered at-risk for developmental delay and should receive intervention to address deficits in joint attention. Although there is great excitement about identifying early markers, there is also some need for caution. It is certainly the case that broadbased screenings will yield some false positives (Watson, Baranek, Crais, Reznick, Dykstra, & Perryman, 2007). Clinicians are urged to be honest and cautious with parents about the limits of available screening tools.

SUMMARY The treatment of Autism Spectrum Disorders has grown immensely over the last 20 years. ABA is clearly the treatment of choice for ASDs, with substantial and significant evidence of its effectiveness for this population. Within ABA, there is good evidence for the positive impact of discrete trial teaching and for naturalistic approaches such as incidental teaching. Recently, there has also been interest in the potential relevance of rate-building to achieve fluency and of direct instruction approaches for building core academic skills. ASDs have also received a great deal of attention from nonbehavioral treatment providers. Treatments commonly used include biomedical interventions, sensory-motor interventions and psychoeducational/psychosocial treatments. The majority of parents of children with autism will use several of these approaches, despite the fact that most lack empirical support or verification. In recent years, there has been progress in identifying the specific needs of and effective intervention for individuals with Asperger’s Disorder. Furthermore, the technology of Functional Behavioral Assessment has greatly improved the precise assessment of challenging behaviors, the functions of challenging behaviors, and the link between the assessment and the treatment of challenging behaviors. Areas of future growth include more explication of how joint attention and perspective-taking deficits help to explain the clinical profiles of individuals with ASDs. It is likely that our understanding of social deficits,

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and of how to have an impact upon or remediate such deficits, will improve over time. Finally, as detection of ASDs occurs earlier and earlier, our understanding of how to best serve the youngest group of individuals with ASDs will likely change substantially.

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11 Treatment of Self-injurious Behaviour in Children with Intellectual Disabilities FREDERICK FURNISS and ASIT B. BISWAS

INTRODUCTION Definitions of self-injurious behaviour (SIB) generally describe such behaviour as comprising nonaccidental self-inflicted acts causing damage to or destruction of body tissue and carried out without suicidal ideation or intent (Yates, 2004). For the clinician working with children with severe intellectual disabilities, such behaviours are likely to be a frequent cause for concern. Between 4% and 12% of such children exhibit SIB (Oliver, Murphy, & Corbett, 1987), which may present as repetitive head banging or face slapping, self-biting to the hands or other parts of the body, removing scabs from old wounds, self-pinching or scratching, hair-pulling and eye-poking, often presented in multiple forms in the same child. Selfinjury may emerge as early as 11–13 months of age (Berkson, Tupa, & Sherman, 2001; Hall, Oliver, & Murphy, 2001a), increases in prevalence and severity throughout the school-age years and young adulthood (Oliver et al. 1987), and once established in adulthood is likely to be chronic in nature (Emerson et al., 2001). Presentation of SIB is associated with FREDERICK FURNISS ● The Hesley Group, Doncaster, UK and School of Psychology, University of Leicester. Mallard House, Sidings Court, Doncaster DN4 5NU, United Kingdom. ASIT B. BISWAS ● Leicestershire Partnership NHS Trust and University of Leicester, Leicester Frith Hospital, Groby Road Leicester LE3 9QF, United Kingdom.


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a range of negative physical and social consequences (Emerson, 1992). Timely, comprehensive, and, where necessary, persistent intervention is therefore indicated when a child with intellectual disabilities presents with SIB. After discussing the range of treatment options currently available to the professional, this chapter briefly reviews recent research on the aetiology and developmental course of SIB and resulting implications for treatment. Self-injury is seen in a wide variety of disorders (Bodfish & Lewis, 2002), and may be categorised as major, stereotypic, compulsive, or impulsive (Yates, 2004), distinctions which may be helpful in considering the general direction of strategies for assessment and treatment. Any attempt to treat SIB should be preceded by a prior comprehensive assessment (Vollmer, XXXX) covering social and medical contextual factors, history, phenomenology including comorbidity with other emotional and behavioural difficulties, and detailed assessment of functional relationships among SIB and antecedent and consequent environmental events. Detailed assessment is necessary in designing effective behavioural treatment and in considering possible psychopharmacological interventions. It may, however, often be useful to have an overview of possible underlying mechanisms or causes of SIB in a particular individual and a working hypothesis regarding causation, as preliminary treatment may need to be initiated quickly to prevent further injury.

SCREENING FOR AND TREATING CONTRIBUTING MEDICAL AND SOCIAL CONDITIONS A variety of physical and social contexts has been demonstrated or suggested to be implicated in some cases of SIB in children and adults. Medical conditions which may have an impact on SIB include otitis media (O’Reilly, 1997) and pain related to a variety of other conditions (Symons, 2002). Examination for and treatment of possible related physical complaints is therefore indicated as part of the assessment of SIB. Sleep deprivation and disturbance are also associated with SIB (O’Reilly & Lancioni, 2000; Symons, Davis & Thompson, 2000), and in at least some cases behavioural intervention to stabilise sleep patterns may have a beneficial effect on SIB (DeLeon, Fisher & Marhefka, 2004). Attention to other physical conditions such as menstrual discomfort may be useful in designing multicomponent interventions (Carr, Smith, Giacin, Whelan & Pancari, 2003). Where SIB occurs episodically, assessment may reveal relationships with social factors whose mechanism of effect remains obscure but which can be modified to reduce SIB. O’Reilly (1996), for example, identified a relationship between the episodic SIB of a young man with moderate intellectual disabilities and use of a respite care facility the previous evening. Arrangement of alternative, family-based respite eliminated SIB. Consideration of a broad range of physical and social factors may therefore contribute to effective treatment.

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PSYCHOPHARMACOLOGICAL TREATMENT A variety of neurotransmitter systems, alone and in interaction, has been implicated in self-injurious behaviour. These include the dopamine, serotonin, opioid, and noradrenaline systems, and basic research on dysregulation of these systems in clinical disorders and in animal models has suggested a number of approaches to psychopharmacological treatment of SIB.

Rationale for the Use of Dopaminergic and Serotonergic Drugs in Treatment of SIB In a number of specific syndromes often associated with intellectual disability, prevalence of SIB, sometimes at least initially of rather specific topographies, is elevated well beyond overall rates typical in total population surveys of people with intellectual disabilities. Recent interest in animal models of SIB has been stimulated by findings in the neuropathology of Lesch-Nyhan disease, an X-linked genetic disorder involving drastically reduced levels of hypoxanthine-guanine phosphoribosyl transferase. Among the characteristic features of the disorder are dystonia, dysarthria, intellectual disability, and behavioural disturbance including aggression, disturbing interpersonal behaviours, and SIB (Schretlen et al., 2005). Development of SIB in children with Lesch-Nyhan disease usually begins at a young age with biting of lips and fingers, but a wide variety of other topographies including head-banging and head-hitting is also frequently seen (Hall, Oliver, & Murphy, 2001b; Robey, Reck, Giacomini, Barabas, & Eddey, 2003). A combination of post-mortem (Lloyd et al., 1981; Saito, Ito, Hanaoka, Ohama, Akaboshi, & Takashima, 1999) and in vivo (positron emission tomography; Ernst et al., 1996; Wong et al., 1996) studies has demonstrated reduced levels of dopamine in the striatum. These findings renewed interest in the earlier findings of Breese and his colleagues (see Breese, Knapp, Criswell, Moy, Papadeas, & Blake, 2005, for an overview) who had demonstrated that rats in whom dopaminergic neurons had been destroyed in the neonatal period using 6-hydroxydopamine showed severe self-biting when given L-DOPA in maturity. Further studies examining the effects of agonists and antagonists with differential effects on D1 and D2 receptor subtypes suggested that the selfinjury produced by L-DOPA is mainly produced by activation of the D1 subtype, although activation of the D2 subtype, although not leading to SIB in isolation, might facilitate expression of SIB produced by D1 activation. In addition to depletion of dopamine levels, the neonatal lesioning of dopaminergic neurons results in increases in striatal serotonin, and a variety of evidence suggests that both serotonin modulation of D1 receptor activity and changes in GABAA receptor function in the substantia nigra reticulata may be involved in the increased susceptibility to SIB in neonatally 6-hydroxydopamine-lesioned rats (Breese et al., 2005). Although both antipsychotics and serotonergic drugs have long been used in attempts to treat a variety of behavioural disorders in individuals with intellectual disabilities, the specific implication of the D1 dopamine

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receptor subtype in the self-injury observed, and the increases in striatal serotonin, in neonatally 6-hydroxydopamine lesioned rats has led to particular interest in the possible utility of the “atypical antipsychotics” and serotonergic agents in treating SIB.

Atypical Antipsychotics Clozapine, olanzapine, and quetiapine all block both D1 and D2 dopamine receptor subtypes, together with several types of 5-HT receptor and a variety of other receptors including adrenergic receptors, whereas risperidone blocks D2, 5-HT, and adrenergic receptors (Aman & Madrid, 1999). In a systematic review of studies using atypical antipsychotics to treat persons with intellectual disabilities and/or autism published up to and including 1999, Aman and Madrid (1999) identified nine studies on children and adolescents or on mixed child/adult samples, seven on risperidone, and one each on olanzapine and clozapine. Several of these studies reported improvement in SIB in some participants. The majority of these studies, however, had multiple methodological problems. All but one were case series reports or open label studies, and in most cases participants were taking other medications throughout the trial. Sedation and weight gain were frequently observed and dyspepsia and hyperprolactaemia were also reported. Since Aman & Madrid’s review, however, a number of bettercontrolled studies of the use of atypical antipsychotics with children with developmental disabilities, especially of risperidone, have appeared.

Risperidone Table 11.1 summarises the results of two recent placebo-controlled double-blind evaluations of risperidone with children aged 5–12, with I.Q.s between 36 and 84, and presenting severely disruptive behaviours, and the subsequent open-label follow-ups. A post hoc analysis (LeBlanc et al., 2005) of data from 163 participants in the Aman et al. (2002) and Snyder et al. (2002) studies confirmed that risperidone-treated participants showed significantly greater decreases than placebo-treated participants on an “aggression score” derived from six core aggression items on the NCBRF, but no analysis was presented on change in a similarly derived “self-harm score”. These studies reported convincing evidence for a beneficial effect of risperidone on behavioural difficulties in young children with moderate, mild, or borderline levels of intellectual disability. Measures of stereotyped behaviour and SIB have, however, frequently shown either no significant change or changes of less significance than those shown for externally directed aggression. Aman, Buitelaar, De Smedt, Wapenaar, & Binder (2005), examining pooled data from these studies, showed that only one item from the NCBRF self-injury/stereotypic subscale showed improvement with risperidone. The above studies also excluded children with a diagnosis of pervasive developmental disorder. An eight-week, double-blind, placebo-controlled study by Scahill et al. (2002), however, examined the effect of risperidone (in doses between 0.5

110 (85) children, ages 5–12, I.Q. 36–84, with severely disruptive behaviours

Snyder et al. (2002)

6-week double blind parallel placebo-controlled (0.02–.06 mg/kg/day)

6-week double blind parallel placebo-controlled (0.02–.06 mg/kg/ day)

115 (87) children, ages 5–12, I.Q. 36–84, with severely disruptive behaviours

Aman et al. (2002)

Study

Design (in parentheses: dose range in doubleblind phase if any)

Participants (in parentheses: number completing study)

NCBRF conduct problem and most other subscales, all ABC subscales, BPI aggressive/destructive behaviour subscale: greater improvement with risperidone vs. placebo.

NCBRF conduct problem and all other subscales, ABC irritability, lethargy & hyperactivity subscales, BPI aggressive/destructive behaviour subscale: greater improvement with risperidone vs. placebo.

General Outcome Measures

(1) BPI self-injurious behaviour subscale: no difference in change between groups. (2) NCBRF self-injury/ stereotypic subscale: greater improvement with risperidone vs. placebo

(1) BPI self-injurious behaviour subscale: no difference in change between groups. (2) NCBRF self-injury/ stereotypic subscale: greater improvement with risperidone vs. placebo

Specific Sib Measures

(continued)

Weight and (boys only) prolactin levels increased with risperidone vs. placebo; transient heart rate increase also noted. Somnolence, headaches, vomiting, dyspepsia in 15% or more with risperidone. No between group difference in extrapyramidal symptoms Weight and prolactin levels increased with risperidone vs. placebo. Somnolence, headaches, dyspepsia in 15% or more with risperidone. No between group difference in extrapyramidal symptoms

Selected Side Effects Reported

Table 11.1. Recent Evaluations of Risperidone for Behavioural Difficulties in Young Children with Moderate-Borderline Intellectual Disabilities

77 children from Snyder et al. (2002) study.

Turgay, Binder, Snyder & Fisman (2002)

48-week open-label follow-up to Snyder et al. (2002)

48-week open label follow-up to Aman et al. (2002)

Design (in parentheses: dose range in doubleblind phase if any)

Children receiving risperidone in double-blind phase: all subscales of NCBRF improved by comparison with double-blind baseline. Children receiving placebo in double-blind phase: all subscales of NCBRF except selfinjury/stereotyped and self-isolated ritualistic subscales improved from follow-up baseline to endpoint.

All NCBRF subscales improved by comparison with baseline of double-blind phase.

General Outcome Measures

NCBRF self-injury/ stereotypic subscale: improved for children receiving risperidone during double-blind from double-blind baseline to endpoint; not improved for children receiving placebo in doubleblind from open-label baseline to endpoint

NCBRF self-injury/ stereotypic subscale: greater improvement with risperidone vs. placebo (smallest subscale change)

Specific Sib Measures

91% reported adverse events including somnolence (33%), headache (33%), rhinitis (28%) and weight increase (21%). Eleven withdrew from trial after adverse events including weight gain (N = 4), depression (N = 3), suicide attempt (N =2). Prolactin increased but within normal limits by end. Somnolence (over 50%), headache (over 35%). Prolactin levels increased, but levels at endpoint within or just above normal range. Mean weight increase 8.5 kg from baseline of 30.7 kg, half attributed to normal growth. Mild-moderate extrapyramidal symptoms in 26%.

Selected Side Effects Reported

NCBRF: Nisonger Child Behavior rating form (Aman, Tassé, Rojahn, & Hammer, 1996); ABC: Aberrant Behavior Checklist (Aman, Singh, Stewart, & Field, 1985); BPI: Behavior Problems Inventory (Rojahn, Matson, Lott, Esbensen, & Smalls, 2001).

107 participants from Aman et al. (2002) study

Findling, Aman, Eerdekens, Derivan & Lyons, (2004)

Study

Participants (in parentheses: number completing study)



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and 3.5 mg/day at the end of the study) on the behaviour of 49 children with autism (76% of whom had mild–severe intellectual disabilities) compared with 52 children receiving placebo. Participants were aged between 5 and 17 years and engaged in tantrums, aggression, SIB, or multiple behaviour problems. Repeated assessment on the ABC irritability subscale showed a significant group by time interaction, with a mean 57% decrease in irritability score in the risperidone-treated group compared with a 14% decrease in the placebo group. The ABC stereotypy and hyperactivity subscales also showed significantly greater reductions for the risperidone than the placebo group. Reporting of increased appetite, fatigue, and drowsiness were all significantly associated with risperidone treatment, and weight gain was significantly greater in the risperidone group. Clinical assessment using structured scales showed no extrapyramidal symptoms in either group. Parental reports of tremor and tachycardia were significantly associated (p = 0.06) with risperidone useage. A 16-week open label follow-up (Research Units on Pediatric Psychopharmacology Autism Network, 2005) of 63 children previously treated with risperidone in the double-blind trial or given eight weeks of open-label treatment following placebo showed small but significant increases in ABC irritability subscale score, although the mean score remained well below the baseline level of the double-blind phase. Participants showed a mean six-month weight increase of 5.1 kg. A subsequent eight-week double-blind placebo-substitution phase showed relapse rates of 13% with ongoing risperidone and 63% with placebo substitution. Anderson et al. (2007) confirmed that although the initial increase in prolactin levels decreased over the course of treatment, approximately one-third of participants had values above the normal range at 22 months of treatment. Further analyses also showed greater improvements with risperidone than placebo on measures intended to capture some of the “core” symptoms of autism, including a modified form of the Children’s Yale-Brown Obsessive-Compulsive Scale (McDougle et al., 2005). Shea et al. (2004) reported results from an eight-week, double-blind, placebo-controlled trial involving 79 children, aged between 5 and 12, all with PDD, 69% having diagnoses of autistic disorder. Forty participants (30 of whom had mild–severe intellectual disabilities) received risperidone and 39 (29 with intellectual disabilities) received placebo. At study endpoint all scales of the ABC showed significantly greater decreases for the risperidone group than for the placebo group, as did the conduct problem, hyperactive, insecure/anxious, and overly sensitive subscales of the NCBRF. There were no significant differences between groups in change on the self-isolated/ritualistic or self-injurious/stereotypic subscales of the NCBRF. Somnolence was reported for over 70% of the risperidone group, but was reported to resolve in most cases (usually following dose rescheduling or reduction). Increases in weight, pulse rate, and systolic blood pressure were all significantly greater at study endpoint for the risperidone versus the placebo group. Although therefore the above studies have produced evidence suggestive of a beneficial effect of risperidone on the behaviour of children with

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intellectual disabilities and behaviour problems, they provide little evidence specifically relevant to the impact of risperidone on SIB. Although several of the above studies, in addition to using standardised rating scales, have demonstrated improvements with risperidone on carer visual analogue ratings of severity of “most troublesome symptom”, none has presented outcomes by type of symptom, and for children with PDD “aggression” and “tantrums/negative mood” were the problems most frequently identified (Shea et al. 2004). Two recent sets of studies have in different ways attempted to focus more precisely on the effects of risperidone on specific problem behaviours. Zarcone et al. (2001) reported the results of a 22-week double-blind crossover design involving 11 children and 9 adults, all with some degree of intellectual disability. The study involved baseline, variable length initial placebo, randomly ordered high and low dose, and final placebo phases, followed by a six-month open follow-up. Total scores on the ABC were higher in the first placebo phase than during risperidone for both dosage orders, and placebo 2 scores were higher only for the low-high dose sequence. For five participants, direct observation of problem behaviour in their everyday environment was undertaken for 30 minutes approximately three times a week during the acute phase of the study. The behaviours observed included aggression towards persons and property, SIB, and disruption. Two participants showed higher frequencies of problem behaviour during drug than in placebo phases, two showed inconclusive results, and one showed higher frequency behaviour with risperidone than in both placebo phases. Zarcone et al. (2004) further reported on direct observation of problem behaviour (aggression, SIB, disruption, and elopement) during approximately weekly experimental functional analyses (based on the methods of Iwata, Dorsey, Slifer, Bauman, & Richman, 1982) conducted with eight children and five adults with autism and other developmental disabilities who participated in the Zarcone et al. (2001) study. Zarcone et al. (2004) presented data on mean rates per minute of all “destructive responses” combined for each acute study phase, concluding that for ten individuals, rates of destructive behaviour were reduced with at least one dose level of risperidone when compared with the first placebo phase. Their data also show, however, that for two of these “responders”, rates of problem behaviour were lower during the second placebo phase than under either risperidone dose, and in two further cases there was little difference between rates of behaviour in the second placebo phase and in the drug phase with the lowest rate of behaviour (no second placebo phase data were available for one participant). Arnold et al. (2003) pursued an alternative approach to assessing change in specific behaviours. Parents of 87 children participating in the Scahill et al. (2002) study were asked at baseline to describe and quantify their two greatest concerns regarding their child’s behaviour. After four and eight weeks, descriptions of the child’s current status with respect to these problems were rated for degree of change by a panel of blinded clinical judges. SIB was selected as a primary concern by parents of


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11 children receiving placebo and 8 receiving risperidone. The mean improvement rating for SIB was significantly higher for the children receiving risperidone, showing the greatest effect size of all target symptoms. A large-scale one-year open-label study of 504 children aged between 4 and 14 with moderate–borderline intellectual disabilities (Croonenberghs, Fegert, Findling, De Smedt, & Van Dongen, 2005) has confirmed and extended many of the findings from the above studies. The 367 children completing the trial (73%) showed significant improvement on all scales of the NCBRF and on ABC total score, with the smallest subscale change on the NCBRF for the self-injury/stereotypic subscale. Adverse events were reported by 92% of participants, with somnolence (30%), rhinitis (27%), headache (22%), and weight increase (17%) the most common. Adverse events led 43 children (8.5%) to withdraw from the study, with weight gain (N = 9), increased appetite (N = 4), gynaecomastia (N = 3), somnolence (N = 3), and headache (N = 3) the most common reasons. There was no increase in mean level of extrapyramidal symptoms over the course of the study, although five children (1%) required antiparkinsonian medications in the course of the study, and for 6 (1%) extrapyramidal symptoms resulted in discontinuation. Two children developed tardive dyskinesia which resolved rapidly after study medication was withdrawn. Mean serum prolactin increased early in treatment but for both boys and girls was within the normal range by study endpoint. A total of 205 boys had prolactin levels above the normal range. Mean body weight increase was 7 kg, of which 50% could be attributed to normal growth. Despite a considerable amount of well-controlled research indicating a beneficial effect of risperidone on behavioural difficulties of children and adolescents with intellectual disabilities and/or autism, it therefore remains difficult to evaluate the specific effectiveness of risperidone for treatment of SIB. The one study which has used reported clinician ratings of change in specifically described behaviour problems (Arnold et al., 2003) reported a larger effect size for risperidone treatment related to SIB than for any other behaviour problem considered, but this figure relates to only 8 children treated with risperidone and 11 given placebo. Studies of children with intellectual disabilities both with and without autism have, however, found mixed results on standardised ratings specifically related to SIB, with some finding significant advantage for risperidone over placebo on the self-injury/stereotypic scale of the NCBRF but not the self-injurious behaviour or stereotypic behaviour subscales of the BPI (Aman et al., 2002; Snyder et al., 2002), and some finding no advantage for risperidone on the self-injury/stereotypic subscale of the NCBRF (Shea et al., 2004; Turgay et al., 2002, for the group starting risperidone in the open-label phase). Where an advantage has been found for risperidone on the self-injury/stereotypic subscale of the NCBRF, the change observed in this subscale is typically small relative to change on other subscales (Aman et al., 2002; Croonenberghs et al., 2005; Snyder et al., 2002). In the studies on nonautistic children (Aman et al., 2002; Snyder et al., 2002), this pattern of results may be explicable by relatively low baseline scores on the NCBRF self-injury/stereotypic and BPI self-injurious behaviour subscales leaving limited scope for improvement, but this

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explanation seems unlikely to hold for the studies involving children with autistic spectrum disorders. Studies employing direct observation (Zarcone et al., 2001, 2004) have unfortunately contributed little to our knowledge of the specific effect of risperidone on SIB owing to small numbers of participants and reporting which collapses together differing forms of challenging behaviour. When SIB has been a specific focus, direct observation during blinded trials of medication for individual cases has suggested both a specific beneficial effect of risperidone on SIB greater than that on aggression (Crosland et al., 2003) and a negative effect (Zarcone et al., 2004). Further research on this question is clearly warranted, both because of the mixed results to date and because the specific role for the D1 dopamine receptor in selfinjury suggested by the 6-hydroxydopamine lesioned rat would suggest that if this animal model has validity as a general model for SIB, then owing to its lack of affinity for the D1 type receptor, risperidone may be a less effective treatment for this specific behaviour than other drugs with D1 affinity. The most efficient way forward on this issue would appear to be for double-blind trials to employ ratings of change on specific behaviour problems as demonstrated by Arnold et al. (2003).

Other Atypical Antipsychotics There is considerably less evidence regarding the effectiveness of the other atypical antipsychotics for behavioural difficulties in children with intellectual disabilities. Use of clozapine in children and adolescents is associated with risks of agranulocytosis and seizures (McDougle, Stigler, Erickson & Posey, 2006) and the need for frequent blood samples for white cell counts is particularly undesirable in children with intellectual disabilities and/or autism. Olanzapine has a high affinity for dopamine D1, D2, and D4 receptors as well as various 5-HT, alpha-1 adrenergic, H1 histaminic, and multiple muscarinic receptor subtypes (McDougle et al., 2006). In view of its ability to block the dopamine D1 receptor, McDonough, Hillery and Kennedy (2000) suggested that olanzapine might be an effective treatment for chronic, stereotyped SIB. An open, 15-week add-on trial of olanzapine with seven adults with severe to profound intellectual disability and long-term repetitive SIB produced overall improvement in a standardised measure of number and severity of lesions related to SIB, but not carer estimates of the frequency of the behaviours. Short-term open-label studies of 8 children and adults with PDD, most with intellectual disabilities (Potenza, Holmes, Kanes & McDougle, 1999) and 16 adolescents, 12 of whom had intellectual disabilities (Handen & Hardan, 2006) reported improvements on standardised measures of problem behaviour such as the ABC irritability and hyperactivity subscales. Malone, Cater, Sheikh, Choudhury, and Delaney (2001) randomised 12 children with PDD/autism, 11 of whom had intellectual disabilities, to 6 weeks of open treatment with olanzapine or haloperidol. The Children’s Psychiatric Rating Scale (National Institute of Mental Health, 1985) showed improvement for the olanzapine, but not the haloperidol group, on anger/uncooperativeness and hyperactivity factors.


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A small double-blind placebo-controlled trial with six children with PDD, four of whom had intellectual disabilities, receiving olanzapine, found no evidence for an effect of olanzapine on standardised measures of irritability or aggression, but had low power (Hollander et al., 2006). All the above studies noted problems with weight gain and sedation, and Handen and Hardan (2006) also noted a significant increase in prolactin levels. There have to date been no published controlled studies of the atypical antipsychotics quetiapine, ziprasidone, and aripiprazole with young people with developmental disabilities; McDougle et al. (2006) have reviewed retrospective and open-label studies with young people with PDD. In summary, despite the specific rationale for use of dopamine D1 receptor blockers in treatment of self-injury, there is no stronger evidence for the effectiveness of olanzapine than for risperidone in the treatment of SIB, and side effects of weight gain, sedation, and increases in prolactin levels are of equal concern. Evidence for the potential utility of the other atypical antipsychotics in behaviour disorders in children with PDD and/or intellectual disabilities is currently very limited.

Serotonin Reuptake Inhibitors The rationale for the use of serotonin reuptake inhibitors (SRIs) in treating SIB is much less specific than that for use of the atypical antipsychotics. Interest in the possible utility of the SRIs is based on (1) general evidence for abnormalities of serotonin function in persons with autism and intellectual disabilities (Aman, Arnold, & Armstrong, 1999; Posey, Erickson, Stigler & McDougle, 2006), (2) the suggestion that in some cases SIB in persons with severe intellectual disabilities might be an indicator of depression (Marston, Perry & Roy, 1997), and (3) the suggestion that in some cases SIB may have similarities to obsessional behaviours (King, 1993). Aman et al. (1999) reviewed studies to that date on use of clomipramine and the selective serotonin reuptake inhibitors (SSRIs) with people with developmental disabilities, noting the preponderance of case reports or uncontrolled trials and suggesting the need among others for further study of possible age differences in responsivity. The potential serious side effects of clomipramine (Aman et al., 1999) have led to more recent interest being focussed on the SSRIs, with most evidence available regarding fluvoxamine and fluoxetine. Recent reviews by McDougle et al. (2006) and Posey et al. (2006) suggest that although there may be some evidence for the effectiveness of SSRIs in treating repetitive behaviours in adults with developmental disabilities there are still few well-controlled studies, whereas for children the results of both open-label and double-blind placebo-controlled studies of fluvoxamine suggest limited effectiveness and frequent adverse reactions including insomnia, behavioural activation, and aggression. The few well-controlled studies which report beneficial effects of SSRIs (Hollander et al., 2005; Sugie et al., 2005) do not suggest any specific utility in treating SIB, and recent reports of positive effects of SSRIs on

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SIB (e.g., Carminati, Deriaz, & Bertschy, 2006) are uncontrolled studies of the addition of SSRIs to other treatments relying on limited outcome measures. For children with developmental disabilities the lack of evidence of effectiveness, frequent occurrence of adverse reactions, and uncertainties about appropriate dosage (Posey et al., 2006) do not support the utility of currently available SSRIs in treatment of SIB.

Naltrexone hydrochloride A variety of evidence has suggested dysregulation of the hypothalamicpituitary-adrenal stress system in persons with autism and others with developmental disabilities who engage in SIB (Sandman & Touchette, 2002), with recent interest in the pro-opiomelanocortin (POMC) system. Enzyme cleavage converts the POMC molecule into a number of biologically active products including the opioid β-endorphin and adrenocorticotrophin (ACTH), and in adults plasma levels of these products of the POMC molecule are normally highly correlated. Recent studies have suggested, however, that this normal “coupling” of β-endorphin and ACTH is reduced following episodes of SIB in adults with developmental disabilities (Sandman, Touchette, Lenjavi, Marion, & Chicz-DeMet, 2003), with levels of β-endorphin elevated with respect to levels of ACTH, and that the extent of this uncoupling is related to the extent to which occurrence of SIB is predicted by previous SIB events rather than by other behaviours or social environmental events (Sandman & Touchette, 2002). It has been argued that this phenomenon may indicate that persons showing SIB experience enhanced opioid-mediated analgesia and/or that SIB produces an opioid-induced state of euphoria. Administration of the opiate antagonist naltrexone hydrochloride would be expected to reduce both of the above effects. Although naltrexone may cause a number of side effects (Matson et al., 2000), research involving both nondisabled people and those with developmental disabilities suggests that the major possible serious side effect of naltrexone use is liver toxicity; however, signs of possible toxicity have been observed in people without disabilities treated for addictions and using substantially larger doses than those used to treat SIB in people with intellectual disabilities (Symons, Thompson & Rodriguez, 2004). Reports on the effectiveness of naltrexone in treatment of SIB have been extremely mixed (Symons et al., 2004). In contrast to much other work on psychopharmacology of SIB, the technical quality of research into naltrexone has been rather high; Symons et al. (2004) reviewed 27 studies from which information on individual participants could be extracted and reported that 85% of the total of 86 children and adults treated with naltrexone had received the drug in a double-blind study. Comparison of quantitative measures of SIB during baseline and during naltrexone administration showed that 47% of participants showed improvement of 50% or greater, and a further 33% showed smaller decreases, during naltrexone treatment. In addition, there is some evidence that for some people limited-term administration of naltrexone can produce reductions in SIB which persist after the medication is withdrawn (Crews, Bonaventura, Rowe & Bonsie, 1993; Sandman et al., 2000).


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Despite this promising overall picture, however, in addition to many reports of cases in which naltrexone has not improved SIB (e.g., Bodfish et al., 1997), there are also reports of paradoxical worsening of frequency and/or severity of SIB during naltrexone treatment (e.g. Benjamin, Seek, Tresise, Price & Gagnon, 1995). The specific mechanism of action of naltrexone is not well understood. Dose–response relationships appear to be complex (Symons et al., 2004), and people showing long-term improvement in SIB following time-limited naltrexone treatment may show worsening of SIB if treated again with naltrexone (Sandman et al., 2000). Topography of SIB does not appear to predict response to naltrexone (Symons et al., 2004). Sandman and his colleagues (Sandman et al., 2000; Sandman, Touchette, Marion, Lenjavi & Chicz-DeMet, 2002; Sandman et al., 2003) have suggested that baseline levels of β-endorphin relative to ACTH may be associated with patterns of SIB suggesting relative insensitivity to social/ environmental events and may predict response to naltrexone. However, the relationship between the direct opiate blocking effect, possible adjustments in receptor sensitivity, and operant learning mechanisms in the effect of naltrexone remains to be elucidated. Benjamin et al. (1995), reporting a case in which naltrexone appeared to markedly worsen severity of SIB in a young adult, suggested that his deterioration in behaviour might be an operant extinction-induced process caused by the failure of SIB to produce β-endorphin-related effects. Although therefore there is good evidence that naltrexone can be helpful in some cases of SIB, response to treatment and most effective dosage are difficult to predict, little is known regarding optimal duration of treatment, and paradoxical effects are possible. In addition, there is evidence that in some cases naltrexone may both reduce level of SIB and increase the strength of the relationship between carer behaviours and SIB, and it has been suggested that this effect may specifically compromise the utility of carer reports of the effectiveness of naltrexone (Symons et al., 2001). Particular attention to objective evaluation of treatment effect and dose parameters, as well as consideration of sensitivity to liver toxicity, are therefore needed with any trial of naltrexone in treatment of SIB.

Psychopharmacological Treatment of SIB in Children with Intellectual Disabilities: Cautions and Conclusions The most direct rationales for the use of psychopharmacological treatments of SIB relate to the dopaminergic and opioidergic sytems, and to date the strongest available evidence of treatment effectiveness relates to drugs targeting these systems. Of the atypical antipsychotics, by far the most extensive evidence base concerns risperidone. Despite a substantial number of well-controlled studies, the evidence regarding the utility of risperidone specifically for treatment of SIB both in children with autism/ PDD and in other children with intellectual disabilities remains inconclusive, mainly owing to the reliance of most studies on global ratings of improvement and generalised behaviour rating scales which do not focus on specific topographies of behaviour.

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Increases in weight and appetite, raised prolactin levels, and somnolence/sedation are frequently reported adverse events associated with risperidone treatment, although post hoc analyses suggest that the positive effects reported for risperidone are independent of the presence/absence of somnolence (Snyder et al., 2002; Turgay et al., 2002). Other side effects including effects on heart rate have also been reported. In considering the use of risperidone with children, the possible long-term health consequences of these effects warrant serious consideration. The possible negative consequences of weight increase are obvious, and although evaluations of risperidone (e.g., Croonenberghs et al., 2005) commonly advise clinicians to provide counselling on diet and exercise, in their open-label study of olanzapine Handen and Hardan (2006) noted that weight gain was observed despite provision of such counselling. The possible long-term effects of the increases in prolactin levels associated with risperidone treatment require further study. Extrapyramidal symptoms have been reported in up to 26% of participants in one-year follow-ups of children using risperidone (Turgay et al., 2002), and longerterm research will be needed on the question of whether long-term use of risperidone may be associated with development of tardive dyskinesia. Monitoring for other less frequent adverse events such as neuroleptic malignant syndrome remains important with the atypical antipsychotics. Careful consideration of the likely long-term benefits and risks of risperidone use is particularly warranted given that withdrawal of risperidone after periods of up to six months from children with autistic spectrum disorders who have been judged to respond positively to initial treatment has been reported to be associated with deterioration in behaviour in approximately two-thirds of cases (Research Units on Pediatric Psychopharmacology Autism Network, 2005; Troost et al., 2005). Observational studies suggest that the effects of risperidone treatment may be partially mediated by changes in carer–child interaction related to the reduction in irritability associated with risperidone (Zarcone et al., 2001). Together with the observation that in one-third of cases it appears that risperidone treatment can be successfully withdrawn, these observations suggest that if risperidone is used in treatment of SIB its effects should be carefully monitored, there should be frequent review to determine whether medication can be withdrawn without negative effects on behaviour, and prescription of risperidone should be accompanied by behavioural interventions. The evidence for the effect of naltrexone hydrochloride on SIB suggests that in cases where SIB is chronic and assesssment does not identify functional relationships with social/environmental events, consideration of naltrexone treatment may be warranted. The effects of naltrexone, however, vary dramatically across individuals, are clinically difficult to predict for the individual case, and include the potential for adverse as well as beneficial effects on SIB. Again therefore careful monitoring of effectiveness and frequent review are appropriate where naltrexone is used in treatment of SIB. The evidence regarding adverse events with naltrexone is largely drawn from its use with nondisabled adults and close monitoring for possible such events is appropriate where the drug is considered for use with children with developmental disabilities. The rationale for use


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of naltrexone suggests that its use may increase SIB-related pain and/or decrease SIB-related euphoria, and its use has been reported to increase signs of negative affect during SIB (Benjamin et al., 1995). Given that some level of SIB will usually continue to occur in most cases even of successful treatment with naltrexone, and that social/environmental factors may be implicated in the maintenance of the behaviour (Symons et al., 2001), it is therefore both practically and ethically important that consideration of naltrexone use in cases of SIB is accompanied by behavioural intervention.

BEHAVIOURAL TREATMENT Rationale for Behavioural Intervention Behavioural interventions for SIB were originally developed on the basis of demonstrations that rates of SIB in children with developmental disabilities could be increased by contingent social attention and reduced when such attention was witheld contingent on SIB but available at other times (Iwata, Roscoe, Zarcone, & Richman, 2002). Subsequent studies have demonstrated that SIB may also be maintained by socially mediated negative reinforcement (e.g., escape from task demands). Automatic reinforcement, that is, reinforcement produced directly by the SIB without social mediation, has also been implicated in maintenance of SIB, and again both positive reinforcement (e.g., sensory stimulation) and negative reinforcement (e.g., pain blocking or attenuation) have been suggested to be involved in individual cases (Iwata et al., 2002). Current approaches to the behavioural treatment of SIB have been profoundly influenced, firstly by a seminal review by Carr (1977), who reviewed evidence suggesting that SIB could be maintained by a variety of consequences in different individuals and argued that treatment should therefore be individualised with respect to the function of the behaviour for the specific individual; and secondly by a landmark article in which Iwata, Dorsey, Slifer, Bauman, & Richman (1982) described a method for assessing behavioural function prior to treatment planning. Iwata et al.’s (1982) method (see Vollmer, XXXX, for a detailed discussion), variously described as experimental functional analysis (EFA) or “analogue assessment”, involved briefly placing clients into a variety of highly structured social situations, each of which was designed to evoke high rates of problem behaviour maintained by specific functions. For example, one condition involved the presence of carers who interacted with the client only consequent upon SIB; this condition was predicted to lead to high rates of any behaviour typically reinforced by contingent carer attention. The advent of the methodology of experimental functional analysis led to a major shift in perspective in the treatment methods employed in clinical research. Instead of relying on use of reinforcers and punishers empirically demonstrated to be effective but possibly unrelated to the consequences maintaining SIB, treatment shifted to interventions based on identification of the reinforcer maintaining SIB in the client’s

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natural environment. Key elements in such interventions have frequently included (a) modification of antecedent motivating operations (Michael, 2000) in order to reduce the reinforcing value of the events which have previously reinforced SIB, (b) teaching and/or increasing the density of reinforcement for prosocial behaviours which compete with SIB for the reinforcer(s) which have maintained the SIB, and (c) increasing the effort involved in SIB and reducing or eliminating reinforcement of the behaviour (Iwata et al., 2002). Recent research has concentrated on identifying more precisely the behavioural mechanisms underlying the effectiveness of established treatment procedures with a view to improving the effectiveness, durability, and generalization of treatment effects. The remainder of this section illustrates how these principles have been applied in treatment of SIB maintained by socially mediated positive and negative reinforcement, and automatic reinforcement. Examples are largely drawn from treatment of SIB. Although operant theorists acknowledge the involvement of specific neurobiological processes in the aetiology and maintenance of SIB, the functional perspective assumes that the processes involved in the establishment and maintenance of SIB are essentially identical to those involved in the development of other problem and prosocial behaviours, and research into other behaviour problems will therefore generally be relevant to treatment of SIB. Similarly, because the functional approach considers that common processes control the behaviour of children and adults (although the development of language is associated with additional processes), treatment studies involving both children and adults are discussed.

Treating SIB Maintained by Socially Mediated Reinforcement Two types of socially mediated positive reinforcement have frequently been reported to be involved in maintenance of SIB in children with severe intellectual disabilities; attention from/interaction with carers and delivery of tangible items (e.g., food, toys), access to which is controlled or mediated by caregivers. The negative reinforcement process which has received most attention is escape from or avoidance of task demands, although escape from or avoidance of a variety of other aversive events and from people or situations which have been associated with such events is also frequently implicated in maintenance of SIB (Reese, Richman, Belmont & Morse, 2005).

Modification of Antecedent Motivating Operations Vollmer, Iwata, Zarcone, Smith and Mazaleski (1993) treated the longestablished SIB (head banging and hitting, body hitting, or hand-mouthing) of three women with severe/profound intellectual disabilities. After EFA had shown in each case that SIB was reinforced by contingent carer attention, Vollmer et al. (1993) provided attention on a fixed-time (FT) schedule; that is, attention was provided at fixed intervals irrespective of the womens’ behaviour. Attention was initially provided continuously and gradually reduced to 10 s of attention each five minutes, with reduction


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dependent on low rates of SIB in the previous session. For all three participants, rates of SIB were substantially reduced during the fixed-time treatment sessions. Van Camp, Lerman, Kelley, Contrucci, and Vorndran (2000) demonstrated that variable-time schedules in which interreinforcement intervals varied randomly around a mean value were as effective as the corresponding fixed-time schedules in reducing aggression and SIB which were maintained by access to leisure materials in two people with severe intellectual disabilities, increasing the utility of this approach for applied settings in which rigorous fixed-time schedules might be difficult to sustain. Kahng, Iwata, DeLeon, and Wallace (2000) further demonstrated that the reduction in frequency with which reinforcers were delivered could be achieved more rapidly than using the fixed-step approach of Vollmer et al. (1993), and without compromising intervention effectiveness, by a procedure in which the interval between reinforcer delivery was adjusted based on the mean interval between participants’ self-injurious behaviors. Time-based schedules have also been used to reduce SIB maintained by socially mediated negative reinforcement. Vollmer, Marcus, and Ringdahl (1995) treated the SIB of two young males with developmental disabilities for whom EFA had suggested that SIB was maintained by contingent escape from instructional activities. Provision of brief breaks from required activities on fixed-time schedules with the interval between breaks progressively increased, dependent on rates of SIB in previous sessions, to 10 minutes for one participant and 2.5 minutes for the second, produced substantial reductions in rates of SIB for both. Although discussed here in terms of modifying motivational processes, the procedures employed in the above studies may reduce problem behaviour through extinction (removing the contingency between the behaviour and the reinforcer) and by increasing tolerance of delay to reinforcement through the schedule thinning process (Vollmer et al., 1998). To the extent to which these additional processes are involved, use of fixed-time schedules may produce reductions in the level of problem behaviour extending beyond the period in which the motivating operation is modified. Where SIB occurs extensively, however, use of fixed-time schedules may risk maintaining the behaviour though adventitious reinforcement when SIB is occurring immediately before a scheduled reinforcer delivery, but in such situations briefly postponing reinforcement when a scheduled delivery is immediately preceded by SIB should avoid this possibility (see Carr & LeBlanc, 2006, for a thorough discussion of issues in use of FT schedules). Where SIB is maintained by escape from or avoidance of scheduled tasks or activities, modification of instructional activities may produce substantial reductions in the behaviour. Pace, Iwata, Cowdery, Andree, and McIntyre (1993) produced rapid and substantial reductions in levels of SIB for three young people with intellectual disabilities by initially completely withdrawing demands and then gradually increasing these over sessions to baseline levels while preventing escape from activities contingent on SIB. Zarcone, Iwata, Smith, Mazaleski, and Lerman (1994), working with three adults with developmental disabilities and instructional escape-maintained SIB, demonstrated that withdrawal and progressive reintroduction of demands

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without preventing escape for SIB was initially successful in reducing levels of SIB, but that levels of SIB increased as the intervention progressed and that periods of escape prevention were necessary to achieve desired levels of control of SIB. Problem behaviours including SIB may also be reduced by identifying specific tasks which elicit SIB and interspersing requests to complete these among tasks less likely to elicit SIB (Horner, Day, Sprague, O’Brien, & Heathfield, 1991). Other instructional procedures which may be helpful in reducing levels of demand-escape maintained SIB include increasing levels of reinforcement for task engagement (Hoch, McComas, Thompson, & Paone, 2002; Lalli et al., 1999), preceding demands which elicit SIB by a sequence of demands with which the child typically cooperates (although preventing escape from the demand contingent on SIB may again be important to the effectiveness of this approach; see Zarcone, Iwata, Mazaleski, & Smith, 1994), increasing levels of assistance with tasks, embedding task demands in reinforcing activities, increasing the predictability of demands, and increasing choice of activity (Miltenberger, 2006). Systematic evaluation of rates of SIB across activity or instructional conditions may also enable such activities to be scheduled so as to reduce levels of SIB. O’Reilly, Sigafoos, Lancioni, Edrisinha, and Andrews (2005) found that the SIB of a 12-year-old boy with autism and intellectual disabilities, normally elevated in the task demand condition of an EFA in comparison to other conditions, did not occur when the task demand condition was preceded successively by no interaction and play conditions. Introduction of a similar structure (a repeating schedule of five minutes each of no interaction, play, and task demand) into the classroom situation produced substantial reductions of SIB in the classroom which were maintained at five-month follow-up. Where motivating operations cannot be directly modified, it may be possible to increase tolerance of them or neutralise their effects. McCord, Iwata, Galensky, Ellingson, and Thomson (2001) reduced problem behaviours (including SIB) maintained by escape from noise by programmes involving progressive exposure to increasing noise levels accompanied by extinction (problem behaviour did not lead to noise termination) and, in one case, differential reinforcement for absence of problem behaviour in the presence of noise. Horner, Day & Day (1997) found that the escapemaintained aggression and SIB of two of the three children with severe intellectual disabilities who participated in their study occurred in response to error correction only following earlier delay or postponement of planned preferred activities. Implementation of individually developed calming routines (e.g., formally rescheduling the activity and reviewing pictures from the past) following such events reduced levels of problem behaviour in later instructional sessions. Even when the specific motivating operations which increase the reinforcing value of escape from demands cannot be isolated, their relevance may be inferred by systematically rating the mood of the person presenting problem behaviour and preceding task demands by moodenhancing activities where relevant (Carr, McLaughlin, Giacobbe-Greco, & Smith, 2003).


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Teaching and Reinforcing Competing Prosocial Responses In one of the first studies to focus on teaching competing prosocial responses, Carr and Durand (1985) reduced the behaviour problems (including aggression, tantrums, and self-injury) of four children with developmental disabilities whose problem behaviours were maintained by either positive or negative (escape from difficult tasks) social reinforcement by teaching them to verbally solicit attention and/or assistance from adults. Carr and Durand (1985) showed that the effect of such functional communication training (FCT) depended on teaching the child to verbally solicit the reinforcer maintaining the problem behaviour and also demonstrated that the positive effects of training on the children’s behaviour problems occurred with carers naïve as to the purpose of the study. Carr and Durand argued that the potential of functional communication training to improve behaviour in the presence of naïve carers offered an important potential advantage by comparison with approaches which required systematic changes in carer behaviour. Especially with individuals with limited behavioural repertoires, a single topography of problem behaviour may be maintained by several distinct reinforcers. Day, Horner, and O’Neill (1994) demonstrated that the SIB (or aggression) of three individuals with autism or severe intellectual disabilities was in each case maintained both by escape from tasks and by access to preferred items, and showed that establishing a communicative response appropriate to each function was necessary to reduce problem behaviour across both contexts in which problem behaviour was displayed. It should, however, be noted that there is no reason to expect that acquisition of a prosocial functional equivalent to SIB, even if that response is consistently reinforced, will necessarily reduce the level of SIB. If both behaviours elicit qualitatively similar responses from carers, the proportion of responses which are prosocial and self-injurious will be determined by the effort (and other costs) associated with each response (Richman, Wacker, & Winborn, 2001), the magnitude of the reinforcer, and the latency and schedule (reliability) with which reinforcement is delivered (Symons, Hoch, Dahl & McComas, 2003). A number of studies of FCT have found that FCT reduced problem behaviour only when extinction or time-out contingencies were in effect for problem behaviour in addition to positive reinforcement of the communicative response (Shirley, Iwata, Kahng, Mazaleski, & Lerman, 1997; Wacker et al., 1990). Even if the alternative response is well established simultaneously with SIB being placed on extinction, levels of SIB may increase to pretreatment levels if it is again reinforced (Shirley et al., 1997). Worsdell, Iwata, Hanley, Thompson, and Kahng (2000), treating the SIB of five adults with profound intellectual disabilities, showed that for one participant FCT (with every prosocial communication reinforced) reduced rates of SIB even when SIB continued to be continuously reinforced, but for four others substantial reductions in SIB were achieved only when the appropriate communication was continuously reinforced and rate of reinforcement of SIB was reduced, in two cases to one reinforcement per

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20 responses. These are important considerations in planning behavioural treatment programmes in many settings, where even given a high level of training and support for families and other carers, SIB may be at least intermittently reinforced. Additional complexity and importance is given to this issue by the fact that the unit of behaviour strengthened by reinforcement is the operant, defined as the class of all responses with the same functional relationship to the reinforcing event. Both appropriate and problem behaviours may belong to the same functional class, and if a member of that class is selected as the prosocial behaviour to be reinforced in FCT, the entire functional class including SIB may be strengthened in terms of rate of occurrence and resistance to extinction (Derby, Fisher, Piazza, Wilke, & Johnson, 1998). For optimal effect, FCT should therefore preferably teach a novel communicative response which has no history of membership of the same functional class as SIB (cf. Winborn, Wacker, Richman, Asmus, & Geier, 2002). Furthermore, to avoid or minimise the possibility of the communicative response joining the same functional class as SIB, reinforcement of SIB should be eliminated or minimised and attention may need to be given to the possibility that SIB may be maintained by reinforcement of other, apparently unproblematic, members of the preexisting functional class (Derby et al., 1998). A further possible difficulty with FCT is that the alternative communicative response may occur sufficiently frequently that to reinforce every occurrence is impracticable in the long term. Hanley, Iwata, and Thompson (2001) compared several methods for addressing this problem following FCT treatment of the SIB and aggression of three adults with profound intellectual disabilities. The most effective method proved to be establishing the communicative response using continuous reinforcement and then introducing and progressively lengthening periods of (signalled) extinction in which a coloured card indicated that the communicative response would not be reinforced. Hanley et al. showed that low rates of problem behaviour could be maintained under this arrangement with up to four minutes of signalled nonreinforcement of the communicative response alternating with one-minute periods of reinforcement.

Reducing or Eliminating Reinforcement of SIB Although eliminating or reducing the reinforcement maintaining SIB is likely to be essential to successful treatment using FCT, any attempt to treat SIB using extinction alone faces major ethical and practical problems. The transition from reinforcement to extinction of operant behaviour is frequently accompanied by an extinction burst, a temporary increase in the rate and intensity of the behaviour, and by aggression (Lerman, Iwata, & Wallace, 1999). Examining 41 datasets for children and adults with moderate to profound intellectual disabilities whose SIB was treated by behavioural interventions in a specialist day programme, Lerman et al. found evidence for extinction bursts in 62% of cases treated by extinction alone versus 15% of cases in which antecedent change and/or reinforcement procedures were used in combination


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with extinction. Aggression was also more commonly observed when extinction was used alone than when it was used in combination with other procedures. Behavioural accounts of the development of severe SIB (e.g., Oliver & Head, 1990) propose that it evolves through a process of operant shaping in which carers initially respond to SIB and then progessively reinforce increasingly severe forms of the behaviour by ceasing to respond to milder forms but reinstating their response to the more severe and/or frequent behaviour which occurs in the ensuing extinction burst. There are therefore both ethical and practical problems in any attempt to use extinction in isolation, and even when it is used together with reinforcement-based procedures such as FCT, care is needed to ensure that an extinction burst does not lead carers to reinstate reinforcement of SIB and inadvertently increase the severity of the behaviour.

Treating SIB Maintained by Automatic Reinforcement Experimental-epidemiological studies implicate automatic (nonsocially mediated) reinforcement as the major process maintaining SIB and other problem behaviour in approximately one-quarter to one-third of cases (Derby et al., 1992; Iwata et al., 1994). Assessment and treatment of automatically reinforced behaviour is challenging because it is typically difficult to identify precisely the nature of the reinforcement maintaining the behaviour (Vollmer, 1994). Nevertheless, some success has been reported with behavioural interventions analogous to those used with socially reinforced behaviour.

Modification of Antecedent Motivating Operations Where EFAs use the conditions originally described by Iwata et al. (1982), automatic reinforcement of SIB may be inferred if rates of SIB are highest when the client is left alone without activities or if SIB occurs at a high rate in all conditions. Such an analysis provides no information regarding the nature of the reinforcer. In the absence of this information, the most frequently investigated behavioural intervention has been providing noncontingent access to sensory and other stimuli. The items used are typically selected using structured preference assessments in which the child’s preferences from a range of sources of stimulation are assessed by systematically observing either choices when items are presented simultaneously (e.g., in pairs; Fisher et al., 1992) or the length of time for which the child interacts with items presented individually (DeLeon, Iwata, Conners, & Wallace, 1999) or simultaneously (Roane, Vollmer, Ringdahl, & Marcus, 1998). Vollmer, Marcus, and LeBlanc (1994) showed that noncontingent access to preferred items reduced levels of SIB in three young children with developmental disabilities, although additional procedures, including brief (5 s) restraint of one child’s hands, were necessary to achieve acceptable reductions in SIB for two of the children. Vollmer et al. (1994) reported positive results after training family members to implement the

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resulting treatment packages during particularly problematic periods of the day, but noted that treatment effectiveness might reduce owing to satiation if such treatments were used over extended time periods. Subsequent studies have, however, reported that where necessary, providing access to a variety of sources of stimulation and/or rotating the objects provided can produce long-term reductions in extent of SIB (DeLeon, Anders, Rodriguez-Catter, & Neidert, 2000; Lindberg, Iwata, Roscoe, Worsdell, & Hanley, 2003). Others (e.g., Goh et al., 1995; Patel, Carr, Kim, Robles, & Eastridge, 2000) have conducted additional assessments to identify aspects of the stimulation produced by the problem behaviour. Goh et al. (1995) for example, searching for sources of stimulation to reduce hand-mouthing, provided objects to manipulate to four adults with profound intellectual disabilities and showed that for all four hand–object contact was more extensive than mouth–object contact, suggesting that hand stimulation was the reinforcer maintaining hand-mouthing. Such assessments may suggest items likely to compete as sources of reinforcement with SIB to be further evaluated through stimulus preference assessment Although a variety of evidence suggests that pain may be a factor in some cases of SIB, with one possibility being that SIB attenuates pain (Symons, 2002), treatment of negatively automatically reinforced behaviour has received little attention. Fisher et al. (1998) showed that application of transcutaneous electrical nerve stimulation to a frequently injured area produced a transient reduction in the long-term, severe, apparently automatically reinforced SIB of a young man with Down’s syndrome. Although the effect reduced over sessions, pain was not identified as a factor in this report, and alternative mechanisms of action including positive automatic reinforcement were suggested, the results suggest a possible role for a treatment commonly used for chronic or untreatable pain in some cases of SIB.

Teaching and Reinforcing Competing Prosocial Responses In treatment of automatically reinforced SIB, noncontingent presentation of competing stimulation has been studied more extensively than differential reinforcement of alternative behaviour (DRA) using such stimulation, probably because early studies suggested that even where competing stimuli could be identified, attempts to use them in differential reinforcement programmes were ineffective (Shore, Iwata, DeLeon, Kahng, & Smith, 1997). Shore et al. suggested that the increased response effort involved in DRA was responsible for this effect. This analysis suggests that reducing the response effort required to produce the alternative stimulation, for example, by use of microswitches, may be effective. Steege, Wacker, Berg, Cigrand, and Cooper (1989) reduced the damaging hand-mouthing of a child with severe multiple disabilities by teaching him to use a microswitch to activate reinforcing stimuli (a radio or a fan). For a recent review on use of microswitch-activated stimulation to enhance wellbeing more generally, see Lancioni, Singh, O’Reilly, Oliva, and Basili, (2005).


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Reducing or Eliminating Reinforcement of SIB A number of studies in which apparently automatically reinforced SIB was reduced by blocking self-injurious behaviours, or application of protective clothing, have interpreted consequent reductions in SIB in terms of reduction of automatic reinforcement produced by the behaviour (e.g., Mazaleski, Iwata, Rodgers, Vollmer, & Zarcone, 1994; Moore, Fisher, & Pennington, 2004; Van Houten, 1993), but the mechanisms involved in such effects are often obscure, possibly including punishment.

Fading of Mechanical Restraints In cases of severe SIB, even in children, carers may have resorted to use of protective equipment such as helmets or mechanical restraints such as arm splints to reduce tissue damage. Such equipment is generally socially stigmatising and may limit engagement in constructive activities. Fisher, Piazza, Bowman, Hanley, and Adelinis (1997) with three clients including two children, and Oliver, Hall, Hales, Murphy, and Watts (1998) with three adults, all of whom showed SIB including head-hitting, replaced previous mechanical restraints with arm splints which initially prevented arm flexion but could be progressively modified to allow greater degrees of flexion. The results of both studies were mixed. Oliver et al. (1998) increased the flexion allowed by the splint to 100% while maintaining SIB at zero levels for two participants, although self-restraining behaviours were seen in both cases. For the third participant, levels of SIB were initially reduced but increased as restraint fading progressed. Fisher et al. (1997) reported that complete restraint fading was successfully achieved for one participant, but a second required other treatment to reduce SIB as restraints were faded, and a third responded to the introduction of the novel restraints by developing another topographical form not prevented by the restraint, a problem also noted by Kahng, Abt, and Wilder (2001). In a different approach O’Reilly, Murray, Lancioni, Sigafoos, and Lacey (2003) demonstrated that providing sensory stimulation demonstrated to reduce attempts at SIB with protective equipment in place reduced SIB when the protection was removed for brief periods. In at least some cases therefore where mechanical restraints have been used these can be successfully reduced while maintaining low rates of SIB.

Treatment of Self-Restraint Many individuals with intellectual disabilities who engage in selfinjurious behaviour (SIB) also engage in behaviours which may appear to observers to represent attempts by the person to prevent themselves engaging in SIB; such behaviours are generally referred to as self-restraint (SR). Topographies of SR, including entangling limbs in clothes, holding one body part with another, and seeking external mechanical restraints may be seen in as many as 75% of those who self-injure (Oliver, Murphy, Hall, Arron, & Leggett, 2003). Self-restraint may occur very extensively, severely limit

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involvement in constructive activities, and warrant intervention together with the SIB which may be observed if restraint is physically interrupted. A number of hypotheses concerning the relationship between SIB and SR have been suggested (Fisher & Iwata, 1996; Isley, Kartsonis, McCurley, Weisz, & Roberts, 1991). Firstly, SR may be reinforced by termination of, or avoidance of, SIB. Fisher and Iwata (1996) have speculated that in many cases SIB may be controlled by both positive and aversive consequences and that SR may emerge when the effects of reinforcement of SIB are outweighed by its aversive consequences. Secondly, access to self-restraint may reinforce SIB (Fisher & Iwata, 1996). Thirdly, SIB and SR may be functionally equivalent members of response classes maintained by positive or negative social reinforcement (Fisher & Iwata, 1996), or alternatively may be functionally independent (Rapp & Miltenberger, 2000). In these cases, if maintaining consequences can be identified, SR may be successfully treated by methods similar to those used for SIB, such as fixed-time schedules of reinforcement (Derby, Fisher & Piazza, 1996). In other cases, it may be possible to gradually shape the form of self-restraint into one which is less restrictive and socially stigmatizing. Pace, Iwata, Edwards, and McCosh (1986) progessively modified self-restraint involving wearing rigid tubes on the arms to wearing of tennis wrist bands while maintaining low levels of SIB. However, additional intervention including shaping and reinforcement of behaviours involving removal of hands from restraint may also be necessary (Lerman, Iwata, Smith, & Vollmer, 1994).

Behavioural Treatment of SIB in Children with Intellectual Disabilities: Cautions and Conclusions Reviewing research on behavioural treatment of SIB published between 1964 and 2000, Kahng, Iwata, & Lewin (2002) noted that most interventions produced reductions in SIB of at least 80% from baseline to the end of treatment, with a mean reduction of 83.7%. Clearly, behavioural treatments can be highly effective in reducing SIB. A number of issues arise, however, in considering these impressive results. Firstly, most evaluations of behavioural interventions use single-subject experimental designs, and these may be particularly susceptible to bias in publication of studies with positive rather than negative outcomes (Kahng et al., 2002). Secondly, although complex interventions can be successfully implemented by service staff such as teachers (e.g., Sigafoos & Meikle, 1996), some of the evidence for treatment effectiveness comes from data collected during defined time periods with interventions implemented by highly skilled staff, and only a minority of studies report data on generalization of treatment effects (DeLeon, Rodriguez-Catter, & Cataldo, 2002; Kahng et al., 2002). The extent to which generalization of treatment effects requires systematic re-implementation of treatment across carers, settings, and tasks varies substantially across individuals (Shore, Iwata, Lerman & Shirley, 1994). Thirdly, although behavioural interventions are less associated with adverse events than most psychopharmacological treatments, a variety


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of problems including inadvertent reinforcement of functional classes including SIB, extinction bursts, emergence of new topographies of SIB, and difficult-to-manage levels of alternative responses taught to replace SIB, may occur in the course of behavioural treatments, which therefore require supervision by professional staff with sufficient expertise to predict, recognise, and appropriately manage such events. Finally, only in a minority of cases do behavioural interventions completely eliminate SIB (DeLeon et al., 2002), and the overall effectiveness of behavioural interventions has not increased since the 1960s (Kahng et al., 2002).

RELATING TREATMENT TO FORMULATION AND DIAGNOSTIC SUBTYPING Assessment and treatment with SIB should generally first involve screening for possible contributing physical illness and a thorough functional assessment which will indicate directions for behavioural treatment. Where initial treatment fails, this should be regarded first of all as indicating the need for more detailed and individualised functional assessment to identify possible idiosyncratic functional relationships (Harding, Wacker, Berg, Barretto, & Ringdahl, 2005) rather than as requiring “default therapies” (Mace & Mauk, 1995). In general, current psychopharmacological approaches should be preferred only where detailed functional assessment suggests insensitivity of the SIB to environmental contingencies, (although sensitivity to one condition combined with a high rate of SIB across other conditions may suggest a need for combined behavioural and psychopharmacological interventions; Mace & Mauk, 1995), or where individualised behavioural interventions repeatedly fail to reduce levels of SIB. Where psychopharmacological intervention is considered, little evidence-based guidance is available to the clinician regarding initial choice of treatment for the individual client. Mace and Mauk (1995) suggested four subtypes of “possibly biologic” SIB selectively related to impairments in the opioid, dopamine, serotonin, or noradrenaline systems alone or in combination and corresponding preferred initial approaches to psychopharmacology. For subtype 1, involving extreme self-inflicted tissue damage (e.g., a history of severe self-injury involving biting off chunks of tissue, self-inflicted amputation of digits, extensive and multiple wounds, scarring, broken bones, “cauliflower ears,” etc.), disturbance of the opioid system may be implicated and treatment with naltrexone considered. For subtype 2, repetitive or stereotypic SIB, dysfunction in dopaminergic pathways may be suspected and a trial of low-dose atypical antipsychotics considered. Mace and Mauk (1995) suggested two further “biologic” subtypes of SIB, “high rate with agitation when interrupted,” and “SIB co-occurring with agitation,” for which they proposed use of SSRIs, and propanalol or mood stabilisers, respectively. However, the current evidence base regarding the utility of adrenergic drugs or mood stabilisers in treatment of SIB is very limited (King, 2000; McDougle et al., 2006). Furthermore, despite the

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face validity of Mace and Mauk’s subtyping of “biologic” SIB, there are no well-controlled studies demonstrating selective impact of specific agents on specific subtypes of SIB. Improvement of our ability to analyse the dynamics of individual patterns of SIB and relate these to possible rational pharmacotherapies remains an important goal for research (Thompson & Symons, 1999). Meanwhile, the fact that neither current behavioural nor psychopharmacological treatments typically eliminate established SIB, thus requiring extended treatment, and the fact that both may produce adverse effects, implies that both require expert management and careful monitoring.

AETIOLOGY, DEVELOPMENT, AND PHENOMENOLOGY OF SIB. Whereas the current evidence base supports the effectiveness of behavioural interventions, the lack of systematic improvement in outcomes attained clearly implies a need for better understanding of the fundamental processes involved in development and maintenance of SIB. The final section of this chapter briefly reviews selected recent research on the development and phenomenology of SIB and discuss implications for further development of effective behavioural interventions.

Age of Onset and Early Development Repetitive behaviours such as body rocking and self-injurious or potentially self-injurious behaviours such as head banging have long been known to be relatively common in both typical developing young infants and those at risk for developmental delay (Kravitz & Boehm, 1971). These observations, together with the association between stereotyped behaviours and SIB in adults with severe intellectual disabilities, have provided the foundations for theories suggesting that SIB may develop from early repetitive behaviours through a process in which repetitive behaviours first develop homeostatic functions in regulating overall degree of stimulation and are then shaped into SIB through socially mediated operant reinforcement (Guess & Carr, 1991; Kennedy, 2002). Four groups of researchers have recently reported data from longitudinal studies of groups of infants with intellectual disabilities at risk for developing self-injurious behaviours. Berkson and colleagues (Berkson, 2002; Berkson et al., 2001) followed up 39 children selected from a total of 457 children with developmental disabilities enrolled in early intervention (birth to 36 months) programmes as showing, or being at risk of developing, stereotyped and/or self-injurious behaviours. The children were followed up at weekly (or less frequent owing to practicalities) intervals and multiple sources of data (weekly reports on the child’s behaviour from parents and programme staff, direct observation, clinical records, and parental retrospective reports) were used to document trends in prevalence of various behaviours with age. Berkson et al. distinguished three categories of behaviour relevant to SIB: transient SIB (producing actual tissue damage), long-term SIB


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(producing actual tissue damage), and proto-SIB (behaviours with the same topographical form, e.g., head-hitting, as SIB, but not producing actual tissue damage). The proportion of the sample showing bodyrocking declined slowly between the ages of 9 and 36 months. The two forms of SIB or proto-SIB most commonly observed were head banging or hitting and eye pressing or poking. The proportion of the sample displaying eye- oriented SIB declined between the ages of 12 and 36 months, whereas the prevalence of head-directed SIB increased. The mean age of onset of long-term SIB (13 months) was lower than that for transient SIB (20 months) and proto-SIB (23 months). Mean age of onset of different topographies of SIB (Symons, Sperry, Dropik, & Bodfish, 2005) was 14 months for eye poking/pressing, 18 months for head banging, and 23 months for head-hitting. Murphy and colleagues (Hall, Oliver, & Murphy, 2001a; Murphy, Hall, Oliver, & Kissi-Debra, 1999; Oliver, Hall, & Murphy, 2005) studied a group of 17 children with a mean age of 67 months selected from a pool of 614 potential participants attending schools for children with severe intellectual disabilities and/or autism as having started to display SIB or “potential SIB” (equivalent to Berkson’s proto-SIB) within the three months prior to the beginning of the study. Murphy et al. also studied a comparison group of ten children identified by teachers as similar in age, ability, and degree of ambulation to the SIB group, but not displaying SIB or protoSIB. The children’s stereotyped behaviours and SIB, and teacher attention and demands, together with other categories, were observed for three to four hours every 3–6 months over an 18-month period for the SIB group and on a single occasion for the comparison group. Comparisons of characteristics of children in the SIB and comparison groups were confounded by the fact that direct observation showed that nine of the ten comparison children also showed SIB topographies, albeit at a lower rate than the children in the SIB group. Twelve of the SIB group showed increases in the amount of time spent in SIB over the course of the study, four showing significant increasing trends on regression analysis. When data from all 26 children in both groups actually observed to show SIB were combined, the percentage duration of SIB at school correlated negatively with developmental age and extent of ambulation. Hall et al. (2001a) showed by further analysis of the longitudinal data for the 16 children in the SIB group that the children whose SIB increased over time showed elevated probabilities of SIB under conditions of reduced social contact. Finally, Oliver et al. (2005) demonstrated that the degree of increase in SIB over time was greatest for the children showing patterns of conditional probability of social contact before, during, and after SIB which were most consistent with those to be expected if SIB was evoked by decreasing probability of social interaction and reinforced by subsequent increase in the probability of such contact. Richman and Lindauer (2005) focussed further on the functional properties of early stereotypy, proto-SIB, and SIB in following up 12 children aged 12 to 34 months who displayed such behaviours over a period of 2–23 months and examining functions of these behaviours using brief experimental analyses (Iwata et al., 1982). Five participants developed proto-SIB

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in the form of head-hitting and/or banging in the course of the study, with at least four of the total of seven topographies emerging apparently related to a pre-existing stereotyped behaviour (e.g., head-hitting developing in a child previously showing stereotyped arm-waving). Four children engaged throughout the study in behaviour initially observed as proto-SIB but eventually resulting in tissue damage, and one developed proto-SIB which eventually produced tissue damage. Most functional analyses showed undifferentiated patterns across conditions, and some degree of responding was observed in the “alone” (i.e., no social contingencies presented) condition for most behaviours evaluated, suggesting that the behaviours studied were at least partly maintained by nonsocial variables. One participant did show a pattern of responding consistent with positive social reinforcement of proto-SIB and SIB; this child, however, had presented SIB on entry to the study. Kurtz et al. (2003) reported the results of individualised experimental functional analyses conducted on the SIB (and other problem behaviours) of 30 children aged 10 months to 4 years 11 months (M = 2 years 9 months). Caregivers reported the mean age of SIB onset as 17 months (range, 1–36 months), with head banging the first topography of SIB observed for 70% of participants. Experimental functional analysis produced results consistent with socially mediated reinforcement in 14 cases (of 29 completed analyses) and automatic reinforcement in 4 cases. Undifferentiated patterns of response were observed in the remaining 11 cases. Detailed comparison of the results of these studies is difficult because of differences in methodology and groups studied (e.g., in ability, numbers of participants with specific diagnoses associated with presence of SIB, population-based samples vs. clinical samples). Taken together, however, the results of these studies suggest that, as would be expected on the basis of studies of older children (e.g., Iwata et al., 1994), the SIB of young children may be maintained by operant processes, with positive socially mediated reinforcement (in contrast to negative reinforcement processes frequently observed with older children) most often seen as the maintaining process. Although it seems likely, however, that cases occur where social reinforcement processes have shaped SIB from stereotyped or “proto-SIB” responses, it seems rather less likely that such shaping processes are initially involved in the development of SIB (although they may be involved in subsequently increasing its severity). It seems that many young children with intellectual disabilities display “proto-SIB” (Hall et al., 2001a). Furthermore, the reported age of onset of SIB appears to be similar (or perhaps even earlier) than that of motor stereotypies and “proto-SIB.” Finally, substantial numbers of young children show undifferentiated patterns of responding in experimental functional analyses (Kurtz et al., 2003; Richman & Lindauer, 2005). The implication for the treatment of SIB is that although SIB clearly frequently acquires operant functions, it may initially develop through other processes which may continue to be important even after operant functions are acquired. Further insight into the nature of these processes may be gained from studies of the phenomenology of SIB.


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Phenomenology of SIB and Comorbidity with Other Conditions Severe/profound intellectual disabilities, severity of autistic features, and severity of communication difficulties all appear to be risk factors for presence of SIB (McClintock, Hall, & Oliver, 2003). An association between presence of SIB and stereotyped behaviours has long been noted (Berkson & Davenport, 1962; Rojahn, 1986). Bodfish and colleagues (see Bodfish & Lewis, 2002, for an overview), using rating scales which operationally distinguish (on the basis of topography) different forms of repetitive behaviour, have shown that in adults with intellectual disabilities, by comparison with those who do not engage in SIB, people with SIB show increased prevalence not only of stereotyped behaviours (Bodfish et al., 1995), but also other repetitive behaviour patterns including “compulsive” behaviours (Powell et al., 1996). Powell et al. (1996) further showed that people who showed self-restraining behaviours in addition to SIB showed higher levels of compulsive behaviour than those showing SIB but no self-restraint, and in a national survey of people with Cornelia de Lange syndrome in the United Kingdom, Hyman et al. (2002) found that for 12 participants showing no compulsive behaviours presence of SR was not associated with presence of SIB, although such an association was found for the 77 who did show compulsive behaviours. The fact that SIB often co-occurs with other forms of behavioural disturbance has often been reported in population-based studies of adults with severe intellectual disabilities (see, e.g., Collacott, Cooper, Branford, & McGrother, 1998). A recent study of behaviour rating scales (the Behavior Problems Inventory (BPI); Rojahn et al. 2001; and the DASHII; Matson, 1995) completed on 180 adults with severe and profound intellectual disabilities living in a residential centre (Rojahn, Matson, Naglieri, & Mayville, 2004) found that SIB as measured by the BPI was strongly associated with aggression and property destruction, but the SIB/aggression factor was substantially independent of a stereotypy factor. Having any item on the BPI SIB scale rated as serious raised the risk of having any sign of depression, mania, signs of organic syndomes, or impulse control difficulties (as assessed by the DASH-2) by a ratio of two or more. Interpretation of the results of studies such as the above is complicated by the number of different conditions associated with SIB and the fact that individual studies considering the relationship between SIB and some other factor do not always control adequately for the effect of third factors which may be associated with both. For example, a diagnosis of autism is associated with increased prevalence and/or severity of both stereotyped behaviours and SIB by comparison with adults with severe intellectual disability without autism (Bodfish, Symons, Parker, & Lewis, 2000), but severity of autism has not always been controlled for in examinations of the association between stereotypy and SIB. Nevertheless, studies of phenomenology and comorbidity suggest that close attention to these aspects of SIB may be important in treatment selection. Specifically, there is evidence associating SIB both with compulsivity and impulsivity. The distinction between “impulsive” and “compulsive”

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types of SIB has been suggested to be important in understanding selfharm in adults without intellectual disabilities, and the distinction has been supported by factor analytic studies (Bodfish & Lewis, 2002). Treatment of choice in both behavioural and pharmacological interventions might be expected to depend on the context of comorbidity within which SIB is presented. Aman et al. (2005) have, for example, suggested that risperidone may be useful primarily in treatment of “impulsive” rather than “compulsive” forms of SIB.

Implications for Treatment of Recent Research on Aetiology, Development, and Phenomenology Recent developmental research has supported the relevance of the operant shaping hypothesis (Kennedy, 2002) for some cases of the development of SIB. In other cases, however, SIB (of severity sufficient to occasion tissue damage) seems to emerge at a similar or even younger age than “proto-SIB.” Anecdotal reports from parents suggested that the initial emergence of these behaviours (especially head-banging) was associated with tantrums “following frustration of a desire and/or rapid situational transitions” (Berkson, 2002, p. 476). Recent evidence from phenomenogical studies suggests that SIB may be associated with aggression and difficulties with impulse control (Rojahn et al., 2004). It has long been known that elicited (nonoperant) aggression is seen in response to extinction of (Azrin, Hutchinson, & Hake, 1966), or shifts in reinforcement schedules for (Hutchinson, Azrin, & Hunt, 1968), other behaviours. Aversive stimulation (Azrin, Rubin, & Hutchinson, 1968), also elicits nonoperant aggression. These effects (where they can be ethically demonstrated) are seen in humans as well as nonhuman animals (Kelly & Hake, 1970), and such aggression may come to be elicited by previously neutral stimuli through Pavlovian conditioning (Lyon & Ozolins, 1970) and may be directed to a variety of targets (Macurik, Kohn, & Kavanaugh, 1978). Physical disability, and specifically difficulties with ambulation, appear to be a specific risk factor for development of SIB (Emerson, 1992; Murphy et al., 1999). Recent data on development and phenomenology of SIB are consistent with the rather old suggestion that one dynamic in the development of the disorder may be Pavlovian conditioning of aggression which is originally elicited by aversive stimulation or denial of expected reinforcement but which may become conditioned to a variety of stimuli associated with such situations (Romanczyk & Matthews, 1998; Schroeder, Reese, Hellings, Loupe, & Tessel, 1999). The aggression may be self-directed simply because the child with ambulation difficulties cannot access any other target. The data supporting the operant shaping account of the development of SIB (Kennedy, 2002) are mainly provided by the success of behavioural treatments including noncontingent presentation (or avoidance) of presumed motivating variables and FCT which teaches the child to request availability of (or withdrawal of) such variables. These interventions should be as effective with elicited as with operant behaviour. The suggestion that Pavlovian conditioning of elicited behaviour may be one mechanism


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underpinning SIB is not inconsistent with the operant hypothesis, inasmuch as establishment of aggression elicited by aversive stimulation is particularly rapid where the aggression is also reinforced by escape from the aversive stimulus (Azrin, Hutchinson, & Hake, 1967). The presence of a process of elicitation underlying SIB would, however, be consistent with the clinical observation that even where bursts of SIB are clearly provoked by an aversive environmental event, immediate withdrawal of that event may not end the behaviour (Thompson & Caruso, 2002). The implication of Pavlovian conditioning of responses to aversive stimulation or changes in reinforcement schedules in development and maintenance of SIB would suggest that in addition to interventions based on operant conceptualisations, behavioural interventions well-established as treatments for other problems, such as graduated exposure (with or without counterconditioning) to aversive stimuli (e.g., McCord et al., 2001) and/or delay to reinforcement may in some cases usefully be added to operant-based interventions. Integration of interventions based on Pavlovian principles with the established operant technology may further enhance the effectiveness of behavioural interventions.

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12 Communication, Language, and Literacy Learning in Children with Developmental Disabilities ERNA ALANT, KITTY UYS, and KERSTIN TÖNSING

INTRODUCTION This chapter deals with communication, language, and literacy learning in children with developmental disabilities by integrating two perspectives, firstly that of information processing and the impact of specific impairments on information processing and interpretation of symbols used in interaction and, secondly, the role of sociocultural factors in facilitating learning and literacy learning. The use of augmentative and alternative communication (AAC) strategies is discussed by means of a case study to illustrate the interaction between individual and sociocultural factors in intervention. A differentiation is made between engagement and interactive behavior to enhance understanding of children’s participation, and intervention strategies based on these concepts are explored. Finally the importance of emergent literacy is discussed with reference to the importance of the sociocultural context within which families live. The term neurodevelopmental or developmental disabilities refers to a heterogeneous group of disabilities that include the long-term effects of delay and deviance as a result of some damage to the neurological processes responsible for developmental functioning (Yeargin-Allsop & Boyle, 2002). Conditions that generally are included in this group are cerebral ERNA ALANT, KITTY UYS, and KERSTIN TÖNSING Center for Augmentative and Alternative Communication University of Pretoria


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palsy, communication disorders, mental retardation, autism, auditory and visual impairments, emotion disorders, disorders of attention and hyperactivity, learning disabilities, chronic orthopedic conditions, and epilepsy (Capute & Accardo, 1996). This indicates a broad range of conditions, and the costs associated with these are tremendous as families endeavor to find the appropriate professional services and support for their children. In addition, indirect costs such as emotional costs to families cannot be measured. The importance of early intervention in limiting the impact of the neurological impairment on long-term development of the child is thus evident. Intervention strategies, however, not only need to take into account the neurological processes on the development of the young child, but also the cultural and social relevance of these intervention strategies within the ecological context in which the family lives.

COMMUNICATION AND LEARNING Communication is often described as the essence of life as it is the way in which individuals can break their isolation to develop relationships with others, experience love, and ensure their own development and independence. Apart from being able to communicate interpersonally, the ability to communicate through print also provides access to the broader outside world of public participation and employment. As an initial point of departure, the acquisition of language, the ability to express oneself (in one way or another) is vitally important to facilitate understanding and participation in activities of daily living. Within the past decades, increasing attention has been paid in the literature of learning difficulties to the importance of language and communication skills as a basis for learning. This realization grew from the notion that children’s ability to receive and interpret information as well as the ability to express themselves form a pivotal part of their learning experiences as they are able to co-construct with others the world in which they live. Making sense of what happens around one is a most important part of being able to understand, problem-solve, and adapt to circumstances of daily living. Basic to the process of sharing and expressing oneself is the ability to understand specific codes used for social interaction. This means that young children need to learn a specific language, its conventions, and rules in order to use these in a way that is understandable to others, allowing them to become part of a family and social group. Communication can be described as an intentional process through which individuals use symbols to interpret and express ideas in order to develop meaning. To participate in this process requires that the child has moved from the use of nonsymbolic to symbolic communication. The ability to interpret and use symbols will have an impact on the level of meaning that will be derived from the interactions. Various authors have described the different levels of communication behaviors by referring to the continuum of intentional communication. For example, Romski and Sevcik (2003) use the differentiation between perlocutionary (unintentional communication, e.g., gazing, crying, laughing, movement), illocutionally (becoming intentional through physical manipulation, pointing, vocalization with inflection), and locutionary (intentional

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through using words, signs, gestures, thus conventional communication) to describe the progression of behavior from least intentional to intentional. Typically a child would move through the perlocution and illocutionary stages approximately between the ages of 18–21 months of age. Rowland, Schweigert, and Stremel (1992) adapted these categories in working with children with multisensory impairments and describe the following behaviors: Primitive behaviors: Earliest behaviors that children may use to communicate. These are behaviors that most children use before they start to communicate. Children with multi-sensory impairments might use these beyond infancy. They include gross vocalizations, simple body movements, simple actions on people and simple actions on objects. Conventional behaviors: These are gestures agreed upon by society. Most adults use these to supplement oral communication, such as pointing, raise hand/wave, extend hands (receive an object). and nod/head shake and other conventional gestures. Symbolic behaviors: These are symbols that are used purposely for communication. The child thus understands the relationship between the symbol and the referent even though the referent is not present. Symbols stand for objects, people, activities, and concepts and allow us to communicate about things not present in the context. Symbolic behaviors include: Object symbols, three-dimensional objects that are used to represent people, concepts, activities, or other objects Picture symbols, for example, photos, line-drawings, or abstract graphics used to represent other referents Manual signs, any formation of one or both hands that represents words or letters Spoken words Printed letters or words Braille letters or words Prior to the child having 50 words (about 21 months) the focus of the communication development would typically be on the pragmatic aspects of language (i.e., the interactional aspects) as well as on language content (i.e., vocabulary and semantic relationships) rather than on grammatical aspects (Romski, Sevcik, Cheslock, & Hyatt, 2002). However, with children with developmental delays, individual profiles will vary largely due to the influence of biological status and environmental influences. Before school-going age much attention is directed at facilitating communication and language learning in preparation for academic learning. At the time of more formal learning in school, these language and communication skills become the medium for advanced learning through information exchanges and increasing levels of abstraction required as part of this process. The basic concept is thus that before school-going age, children generally learn to communicate, whilst during school they use communication skills to learn. Clearly this is not a linear process, particularly not for children with developmental disabilities who not only might have a developmental delay, but could also show patterns of atypical development which persist

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throughout a lifetime. Coping with the transition from the use of language for communication to the use of language for learning can therefore pose significant challenges to young children who, for the first time, have, to develop the awareness of language to enable them to identify words, play around with sounds, and make the connection between what is spoken and how the spoken word is represented in written form. This metalinguistic ability or awareness of language not only requires that the child has sufficient understanding of language as a means and object of learning, but also requires that the child is able to think analytically about symbols used in communication. The child needs to be able to interpret different types of information transferred via different modes of transmission. For example, the child not only needs to listen or hear the spoken word, but also needs to interpret the nonverbal or graphic symbols that accompany the spoken word. When any of the sensory channels of the child are thus impaired, the information process is modified which can affect the young child’s interpretation and experience of reality.

DEVELOPMENTAL DISABILITIES, COMMUNICATION, AND INFORMATION PROCESSING The neurological processing problems of children with developmental disabilities can have an impact on information processing in various ways, which in turn would have an impact on the way in which the young child perceives and relates to the world. The child’s ability to decode, receive, monitor, and interpret different codes used (e.g., auditory and visual signs) as well as the ability to encode and formulate messages using different codes with intra- and interpersonal feedback loops significantly influence the level of meaning derived from the interaction. However, even for the child with developmental disabilities whose processing abilities are relatively intact, the strategies used to enhance interaction and learning might have an impact on this process. The way in which information processing occurs and the different factors that could affect this are represented in Figure 12.1, which shows how the sender sends a message using different communication modes, for example, speech, writing, signing, and facial expressions. These different communication modes get transmitted through the transmission environment by, for example, using auditory waves (speech), light waves (writing, signing, facial expressions), or as a physical entity (passing an object or a Braille ‘letter’). Through the internal feedback loop, the individual is able to monitor his or her own production of messages to ensure that what is expressed is indeed what was intended. These signs are then received and interpreted by the communication partner by means of the different sensory systems (mainly auditory, visual, and tactile) and interpreted to develop meaning. This new information received is integrated into the existing experiences and frameworks of the individual and stimulates a response, such as the construction of another message to send back to the sender. This process is, however, not linear as simultaneous feedback (external feedback) between the two participants takes place all the

• • • • • • •

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Figure 12.1. The communication process.

Message received by ears eyes touch

Sender / Receiver

Via the transmission environment

Speech Writing/typing Signing Gesturing Pointing Facial expressions Posture and movement • • • • • • •

Message received by ears eyes touch

Receiver / Sender

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Speech Writing/typing Signing Gesturing Pointing Facial expressions Posture and movement

Via the transmission environment

External feedback loop

Socio-cultural environment

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time. The mere fact that the one individual communicates a specific message does not mean that the other can’t give some feedback via facial expression or other nonverbal and verbal means. This process of external feedback is important to enable the communicator to adjust the messages sent to prevent communication breakdown and facilitate effective communication. For the typically developing child, symbolic representation begins with speech developing from vocalization and eventually expands to include orthography. A significant number of children with developmental disabilities, however, are exposed to the use of manual signs, graphic symbols, or speech-generating devices as early forms of receptive and/or expressive communication. This modified interaction process can have an impact on the information processing demands placed on the child and thus influence the experience and meaning derived from interactions. McNaughton and Lindsay (1995) described the impact of the use of graphic communication symbols, for example, Bliss symbols on the symbolic representation process of the child who has little or no speech and uses graphic symbols to supplement existing vocalizations or speech. Unlike the child who uses speech to communicate, this child will be using graphic symbols to facilitate expression. Whereas the typically developing speaking child will, for example, verbalise “more” and get the auditory and proprioceptive feedback related to the speech act, the child using graphic symbols will be pointing to a graphic symbol of “more” on a communication board to indicate to people what is required. The feedback that the child using a communication board receives from this communication act is thus much different, as pointing at a line drawing provides mostly visual feedback with some proprioceptive feedback from the pointing. Similarly the child who makes a manual sign for “more” would get visual and proprioceptive feedback from the manual sign used to transmit the message. The question is thus how these different modes of communication affect information processing, language learning, and literacy learning of the child. Similarly, Von Tetzchner and Grove (2003) describe the asymmetry that exists between the communication modes used for receptive language input and expressive language output in children who can hear, but have little or no speech and use alternative modes to supplement speech. Receiving and understanding oral language whilst not being able to use speech to communicate can once again have an impact on language learning. In addition to the impact that the modes of communication have on information processing and interpretation, the sociocultural environment of the child also plays a most significant role.

SOCIOCULTURAL ASPECTS OF COMMUNICATION, LEARNING, AND LITERACY Use of Symbols in Context Just as specific impairments have an impact on the communication and language learning of young children with developmental disabilities, so also do the environment and rehabilitation strategies used.


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The ability to intentionally manipulate symbols for communication and learning implies that young children are able to participate in a constructive way in the world around them. For learning to take place the individual’s participation in the environment is required by using symbols in interaction as well as being engaged in activities. Dunst (2001) emphasised that children are exposed to experiences that can be described as either development-enhancing or developmentimpeding in their consequences. These experiences all occur within the sociocultural context within which the individual lives and they provide the opportunities for interactions and learning. He describes activity settings as the context within which a child can express interests, engagement, and develop competence as well as a sense of mastery. These activity settings provide the context for communication and learning, and also for literacy development of the young child. These activity settings are important not only in relation to the type of activities that the child is exposed to, but also in relation to the opportunities they present and the level of engagement of the child during these activities. The extent to which the child is acknowledged and encouraged to participate during an activity could make a significant impact on the learning outcomes for the child. However, interaction in activities is often determined by sociocultural factors as well as personality-related variables. Wachs (2000) refers to the concept of “niches” as the way in which the individual relates to specific situations, people, and settings around him or her. These unique ways in which a child relates to the environment significantly affect the way in which learning and experiences develop in interaction with the environment. The assumption that children of a same age or ability will relate to a specific learning context in the same way is thus questioned. These unique ways in which a child relates to the environment significantly affect the way in which learning takes place. For example, Dada, Granlund, and Alant (2007) describe how the response of four children exposed to the same treatment resulted in different outcomes and hypothesised that the way in which the children related to the context, thus their niches, might have differed based on their unique experiences. This focus on the individualised experiences of children is important in facilitating understanding of varied outcomes of intervention of children who seemingly have a similar profile of diagnoses and environmental contexts.

Literacy Learning as a Social Process When talking about literacy skills as a sociocultural process, the focus is on the process of learning to read and write as part of a complex set of social and cultural interactional patterns. These include not only the ability to read and write, but also the ability to respond appropriately to specific social situations as well as to know how much information to provide within a specific context and how to relate to printed matter. Heath (1984) gave an account of the different ways in which families from two different social groups related to the process of reading and writing within their own communities. It emphasised how the groups differed in relation to the type of literacy activities to which children were exposed.

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In addition, Hall (1976) also elaborated on the difference between a context-dependent and context-independent interactional style. Contextdependent refers to those types of interactions that require the presence of a communication partner to understand the meaning of the interaction, for example, “You have to go from here to there.” Context- independent refers to a more detailed description to ensure people who are not in the context can understand the message, for example, “You have to go from Pretorius Street to Church Street.” Written communication clearly calls for a much more context-independent style in order for a message to be conveyed successfully. Children who have been exposed to a context-independent style thus have an advantage as they approach the task of becoming literate. This research highlights the need for researchers and interventionists to also be cognizant of the impact of sociocultural factors on the language and literacy learning of children with developmental disabilities. The acknowledgement of the link between sociocultural orientation and the acquisition of reading and writing skills revolutionised the understanding of factors having an impact on children’s literacy achievements at school. The emphasis moved away from viewing reading and writing as essentially being located within the individual to understanding that the social context within which the individual lives largely affects the individual’s attitude and orientation towards the literacy learning process. This is particularly relevant for children with disabilities, as the label “developmentally disabled” often means that exposure to formal literacy instruction is minimal. The expectation of these children to achieve any meaningful literacy levels is thus often very low. It is therefore not always the child’s ability that is the primary barrier in acquiring literacy skills. In a similar vein, Hunter and Harman (1979, p. 9) stated that poverty and the power structures of society are more responsible for low levels of literacy than the reverse and that the elimination of illiteracy among many would not necessarily have an appreciable effect on the other factors that perpetuate poverty in their lives. The realization that the ability to acquire reading and writing skills is necessary but not sufficient to secure improved access to employment or other social contexts emphasised the need to understand the sociocultural issues involved in the process of literate environments. Issues of social power, exclusion, and disempowerment became quite prominent in understanding individuals’ failure in learning literacy skills. In recent years, there was a shift away from “readiness for reading and writing” (thus whether the child had acquired the visual and auditory perception and processing skills as well as motor coordination skills to cope with the process of reading and writing) to “emergent literacy” (whether the social environment was congenial to literacy development) in an effort to facilitate early literacy education for children. Focus was therefore not so much on whether the child had acquired the necessary underlying information-processing skills for reading, but whether the child was exposed to sufficient literacy experiences in the home and preschool contexts as a basis for learning how to read and write. The challenge of communication and literacy learning in children with developmental disabilities, however, also often relates to an inability, resistance, or lack of interest to participate in activities related to reading and


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writing due to difficulties in deriving meaning from the symbols or activities. In these scenarios, the use of augmentative and alternative communication strategies can be useful; not just to assist individuals to expand their communication, but also to give them easier access to the literacy process by introducing line-drawings and other symbol systems.

AUGMENTATIVE AND ALTERNATIVE COMMUNICATION AND ITS ROLE IN FACILITATING COMMUNICATION AND LITERACY DEVELOPMENT What is Augmentative and Alternative Communication? A significant proportion of people with disabilities are unable to use speech and/or writing to fully meet their communicative needs. They thus have a need to use augmentative and alternative communication (AAC), defined by Lloyd, Fuller, and Arvidson (1997) as the supplementation or substitution of natural speech and/or writing by symbols, strategies, and techniques which are not used or at least not relied on to the same extent by speaking individuals. As communication and literacy learning implies the use of specific symbolic codes to transmit and interpret meaning, the use of alternative signs and symbols in this process needs to be monitored and understood. The success with which AAC systems and strategies are used largely depends on their relevance and appropriateness for the child and family and the way in which child and family are able to accommodate these strategies in their own world. The introduction of strategies to augment existing communication not only affects the content of what is communicated and how communication takes place, but also on the way people in the environment relate to the individual. It is for this reason that the social and cultural factors of family and community life need to be reflected in the communication boards or strategies introduced so that the individual and family can optimally integrate them into everyday life. The following case illustration aims at demonstrating the process of AAC implementation within a particular sociocultural context.

Case Study Kagiso is a 4-year-old girl with a diagnosis of spastic quadriplegia. She presents with very low tone in her trunk, and increased tone in all four limbs. Kagiso lives with her mother, grandmother, and younger sister in an urban township in South Africa. Her mother is unemployed. The family income consists of the grandmother’s pension, a care dependency grant received for Kagiso, and a childcare grant received by unemployed parents. Kagiso has been attending a mainstream crèche for about 1 year now. Together with her mother, Kagiso (continued)

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Case Study (continued) has been attending group sessions at a weekly outreach clinic since the age of 2. The clinic is held in the community and run by an occupational and speech therapist from a nongovernmental organisation. During the group sessions at the clinic, it became obvious that Kagiso’s cognitive functioning and understanding of language were strengths in her skills profile. Her motor involvement was severe, and this also affected her speech. She initially used only undifferentiated vowel sounds and very slowly added some bilabial and lingual-alveolar consonants to these. Currently she is able to utter bisyllabic wordapproximations given much time and effort. Although her mother can understand these in context and after some guessing, most others cannot. Kagiso also uses eye gaze and yes/no signals to communicate. AAC intervention commenced with an exposure to key word signs in the context of songs. Kagiso was attentive to the signs. However, her motor limitations made production slow, and she struggled with the fine motor aspects. Within the group, the children were also prompted to use the gestures for MORE, MINE/MY TURN/ME, and OPEN. Kagiso learnt to use approximations of the signs and would consistently use the signs when the opportunity was created. Her mother was asked to create opportunities for Kagiso to use the sign for MORE at home, by withholding, for example, food until she made the sign to ask for it. However, her mother clearly found this concept strange. Rather, her mother took this exposure as a cue and taught Kagiso to wave goodbye as well as to clap hands as a way of requesting (saying please). The latter is commonly observed in African cultures as a way of polite requesting, and the former is also culturally applicable. It became clear quite quickly that Kagiso needed more strategies than key word signing to expand her expressive communication. With the knowledge that Kagiso could identify magazine pictures, her mother was shown how to make choice boards for food as well as choices for routine activities (brushing hair, brushing teeth, bathing, etc.) using pictures from magazines. These choice boards were, however, not found useful by her mother, other than being used for ‘show me’ activities. Within the daily routine, choices were not really offered, and when requesting food, Kagiso successfully used a combination of vocalisations and eye gaze to direct her mother to the desired item. Together with her mother, ‘Telling mum about school activities’ was identified as a communicative situation where breakdown occurred and where intervention was necessary. In order to achieve this, Kagiso was first given exposure to a commercially available set of line-drawings, Picture Communication Symbols (PCS), to allow access to more concepts. These PCS depicted mainly nouns and verbs that were related to language themes (clothing, animals, etc.) as well as therapy activities (singing, ball play, exercises, book reading). The aim was receptive exposure (i.e., Kagiso could observe therapists pointing to or showing pictures to convey a message), as well


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as matching (e.g., plastic horse to PCS picture: children had to point out the picture on their own board). Following this, and in interaction with Kagiso’s teacher and mother, a communication board was made for Kagiso, which she used successfully to communicate about school activities with her mother. This was followed by other boards being developed around activities Kagiso engaged in and enjoyed, such as ‘shopping’ and ‘visiting’. The ‘shopping’ communication board is shown in Figure 12.2. Kagiso started using these communication boards with the therapists at the clinic, to tell, for example, about her shopping of the past week. However, therapists and her mother were the only communication partners with whom she would use the boards. Her grandmother, for example, still found the boards too foreign. According to Kagiso’s mother, her grandmother was not literate, and found it hard to understand the PCS pictures. In school, it was also difficult for Kagiso to use her boards. They were not always available, and Kagiso’s teacher was often distracted by Kagiso’s talking peers, who were much better at demanding attention. The teacher also did not give many opportunities to individual children to talk or answer questions. A lot of unison chanting and repetition was the norm. A digital speech-generating device, which had been sponsored by a private sponsor, was introduced. The specific device was chosen because it was robust, and very easy to program, while still having relatively many message recordings (eight messages could be recorded onto each of eight levels, thus allowing for a total of 64 messages). Kagiso was able to access eight messages (prerecorded by an adult) at a time. Kagiso’s mother was taught to program and charge the device. Her teacher would not try, for fear of breaking it. Song time was chosen as the first activity during which the speaker was to be used, and the parts of a song were simply recorded in sequence on the eight buttons. Kagiso could now experience herself as a ‘speaker’ and could join with the other children in the particular song. Snack time was then identified as a time when there was potential for interaction. Kagiso became quite skilled at pressing 2–3 buttons in sequence to formulate sentences. Peer interaction drastically increased, as all her classmates were fascinated by the ‘talking machine’, and would seek opportunities to initiate interaction with Kagiso to see her use her speaker.

From this case illustration, certain factors which need consideration for appropriate AAC intervention can be highlighted. Firstly, Kagiso’s background and context need to be considered. She has a supportive and involved mother, who has time to spend with her, and who is able to bring her for regular intervention. Her mother gives input on vocabulary selection and feedback on the appropriateness of the systems and strategies. Kagiso’s main communication partners include her mother, grandmother, teacher, and classmates, and her communicative contexts are mainly home and school. Alant (2005a), in her description of AAC intervention as a support-based process, further elaborates on the importance of taking cognizance of partners and contexts.

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Secondly, her skills profile gives an indication as to the purpose of AAC, this being mainly to increase her ability to express herself, as receptive language seems age-appropriate. Kagiso thus falls into the so-called ‘expressive group’ (von Tetzchner & Martinsen, 2000), where a significant gap exists between receptive and expressive language (further explained in the following). The case study illustrates the need for multimodal communication, and for continuous ‘fine tuning’ and expansion of AAC symbols and systems as more and more contexts and partners are involved. As various benefits and drawbacks of the different systems become evident, interventionists need to introduce enough variety in order provide a robust and versatile system. This principle of working toward sustainability of the communication strategies is discussed in Alant (2005b) and focuses on the difference between effectiveness, sustainability, and versatility, the latter of which refers to the impact of skills acquired over time. In this case study, key word signing was first introduced, as this strategy is more ‘natural’ and easier for caregivers to implement than picturebased systems. However, due to motor problems this strategy was soon found to be too limited. Magazine pictures of food and daily activities were also too limiting, as Kagiso was able to convey those concepts using eye gaze, vocalizations, and pointing. Line drawings on paper-based communication boards gave Kagiso access to a much broader range of vocabulary, but these boards were again found difficult to implement with certain partners (e.g., her grandmother) and in certain contexts, such as school. Fuller and Lloyd (1997) give a detailed description of characteristics of various symbols, and issues in symbol selection, and Alant (2005c) describes the importance of cultural appropriateness of graphic symbols use in specific settings. Please see Figure 12.2 as an example of a communication boards developed for this case. Strategies for generalizing the use of AAC to other contexts need to take culture and preferences of partners into consideration. It is clear that interventionists need to gain knowledge not only of routine activities, but also about the way in which interaction happens within these activities. Whereas in Kagiso’s case eating and feeding was a routine activity, Kagiso’s mother did not see this as an opportunity for Kagiso to ask for ‘more’, and felt uncomfortable about withholding food to this purpose. Her mother did, however, see the potential of using signs/gestures, and took initiative to teach Kagiso those which she found culturally appropriate. Using hand clapping to politely request made Kagiso more socially appropriate within her community, and was thus seen by her mother as a gain for Kagiso. Similarly, ‘food choices’ was not an appropriate activity to introduce as a picture system, as Kagiso was already communicating successfully in this activity. The introduction of technology needs to take into account the resources to support and sustain the process of implementation; in this case, charging and programming of a device. Although a more sophisticated device might be beneficial to Kagiso, her family and community might not be able to support implementation. Also, although the device is accepted by peers,


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Figure 12.2. A communication board for the topic ‘shopping’, devised for a young child with cerebral palsy living in South Africa (gloss in Northern Sotho and English).

it is not accepted by Kagiso’s grandmother. Similarly, it is not practical to use it in community settings. Alant (2005d) gives a detailed description of factors that need consideration for introducing technology particularly into a low-income context.

Who Can Benefit from AAC Strategies? As children with motor impairments, developmental language disorders, learning disabilities, autism, and Rett syndrome often experience communication problems, issues surrounding communication intervention remain pertinent. In an attempt to understand the spectrum of communication problems that children with developmental disabilities might present with, this aspect is dealt with in more detail. Von Tetzchner and Martinsen (2000) identified three functional groups of children with disabilities in need of communication intervention and in particular in need of augmentative and alternative communication. Their description is slightly modified and used as a basis for the present discussion. The first group is called the expressive language group. This group of students displays a significant gap between receptive and expressive language. It could include children with motor impairments, Down syndrome,

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learning disability who have different cognitive abilities, but have a definite gap between their expressive and receptive language ability. These children could be severely physically impaired and thus use AAC as a permanent means of communication or could be using AAC as a temporary means of communication until speech has sufficiently developed. The second group is referred to as the developmental group. This group of children displays a general delay in language development on both a receptive and expressive level without any significant gap between the two. Typically this would include children with cognitive disabilities whose development is generally delayed. Intervention strategies should thus be used to enhance receptive and expressive language skills. The third group is referred to as the alternative language group. This group of students has difficulty in acquiring language and communication and is often not able to speak. They have limited ability to use symbolic language in spite of having normal hearing abilities. This group will typically rely on AAC strategies to communicate and could include children with severe and multiple disabilities as well as children with autism. Although it is possible to further differentiate smaller groups in some of the categories, differentiating the three main groupings is useful in facilitating understanding of the different roles that AAC can fulfil in intervention with this heterogeneous group of children with developmental disabilities.

AAC INTERVENTION: THE ASSOCIATION BETWEEN ENGAGEMENT AND INTERACTION As mere exchanges of messages do not necessarily reflect significant levels of engagement from the individual, the differentiation between engagement and interaction behavior could be important to facilitate intervention outcomes. This point can be illustrated with a study recently conducted by Sigafoos, Ganz, O’Reilly, Lancioni, and Schlosser (2006) where two students with developmental disabilities were taught to request snack items. Whilst both students learned to request using an exchange-based communication system, only one showed a high level of correspondence between the request and the outcome. They concluded that the one student still required explicit correspondence training. Although there could be various explanations for why these outcomes differ, a difference in the level of engagement between the two children during the process of intervention could provide one of the explanations. Even though both children behaved similarly in that they utilised the exchange-based system, a difference in the way in which they related to the process is evident. Some assessment of the level of engagement of both children in the above study might have rendered some explanations of how their participation during the intervention might have affected the outcomes. The one child might have participated in the exchanges as an empty ritual, thus with minimal levels of engagement, whilst the other might have been more engaged in developing meaning within the context. Raspa, McWilliam, and Ridley (2001) identified various levels of engagement in observing children in different contexts. These included


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sophisticated, differentiated, focused, and unsophisticated engagement. Taking cognizance of the concept of engagement in addition to the frequency of exchanges seems to be most important in enhancing understanding of the participation process. Two components of participation can be identified: these being engagement and the interactive behavior observed as part of the process. Engagement, although important, largely focuses on the relational component of participation. As this relational component could manifest in different ways during the process of participation, a second component of participation (i.e., interactive behavior) is important. Understanding the level of participation seems to be dependent on a dynamic interaction between engagement and interactive behavior. In an attempt to develop this argument further, Figure 12.3 represents participation with engagement on the one axis and interactive behavior on the other to describe the association between these two components of participation. According to this matrix, meaningful levels of participation will require high levels of engagement and differing levels of interactive behavior depending on the individual’s expressiveness and cultural context. Interactive behavior can manifest through verbal and nonverbal means and can vary from low (few observable interactive behaviors) to high (high frequency of interactive behaviors). Although the frequency of observed communication behavior can be high, this level of activity does not necessarily provide an adequate impression of the individual’s level of engagement in the process (as per the above example in Sigafoos et al., 2005). A high frequency of interactive behavior thus does not necessarily reflect a high level of engagement, just as a low level of interactive behavior does not necessarily infer a low level of engagement. This is particularly important in view of varied interaction styles prevalent in different social and cultural contexts (Alant, 2005b).

High

Active-engaged

Active-disengaged Interactive

High

Engagement behavior

Passive-engaged

Passive-disengaged

Low

Figure 12.3. Components of participation.

Low

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From Figure 12.3, four combinations of the association between engagement and interaction behavior can be identified in describing participation: - Active-engaged implies a high frequency of interactive behavior with a high level of engagement. This pattern would be characteristic of individuals who demonstrate a high number of exchanges with the interventionist, whilst at the same time indicating a high level of engagement. According to Seligman (2002), a high level of engagement could be evident from the level of gain and application of what was learned. - Passive-engaged implies a low frequency of interactive behavior with a high level of engagement. This pattern would be characteristic of individuals who are less demonstrative in their exchanges during intervention, but at the same time maintain high levels of engagement by reflecting understanding and application of what is gained as part of the process. - Active-disengaged implies a high frequency of interactive behavior, whilst being relationally distant. This pattern would manifest as individuals who demonstrate a high number of exchanges in interaction, but demonstrate low levels of meaning development. Whilst rituals might be taught, application will be limited. - Passive-disengaged implies low frequency of interactive behavior, whilst also remaining relationally distant. This pattern would typically manifest as individuals who have a low motivation and/or commitment to the process. Although the four identified combinations represent ideal types, they provide some guidelines for the recognition of similar trends within the intervention process to enable interventionists to develop some hypotheses in relation to the level of participation (i.e., engagement and interactive behavior) during intervention. As with the application of any model, the practical manifestation of ideal types needs to be flexible to account not only for contextual variables but also for individual differences. The personality, interests, past experiences, and cultural background of the person will all add to the way in which the individual relates to the process (Super & Harkness, 1986; Wachs, 2000).

Intervention: Observing and Understanding Engagement Patterns of the Child Engagement and interaction form the two basic constructs on which participation is built. McWilliam et al. (2001, p. 1) described engagement as the “amount of time children spend interacting with adults, other children, or materials in an appropriate manner.” Although time spent can be an important indicator of engagement, the quality of the involvement is also important. The reference to “appropriate manner” can be seen as an attempt to capture some aspect of the relational component in describing engagement. To understand the engagement patterns of a child, we have to observe him interacting with people and activities in ways that not only


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give information on time spent, but also the level of gains or enjoyment derived from the experiences. The use of purposeful activities such as play activities for young children to observe participation is not a novel concept. Play is the occupation of a child and has motivational value. A child experiences satisfaction when engaged in a purposeful activity, which leads to sustained performance, self-reward, and intrinsic motivation. This positive cyclical process of enjoyment through engagement contributes towards the development of new skills, mastery of skills, and the experience of a sense of control over the environment (Uys, Alant, & Lloyd, 2005). Enjoyment is an abstract concept and therefore difficult to measure, but an analysis of the construct reveals measurable behaviors, that is, attention to a task and performance on the developmental domains (social, emotional, sensory, motor, cognitive, and communication). For enjoyment to occur there should be a match between the child’s abilities and the environmental or activity demands and the activity should be culturally valued. Csikszentmihalyi (1990) explained in his epic research on optimal experiences that a person would be maximally engaged in an activity when there is a “just right challenge” between the abilities and the demands. However, the demands should always be a little higher than the skills to press for development of mastery of skills. Mastery motivation is defined as a “psychological force that stimulates an individual to attempt independently, in a focused and persistent manner, to solve a problem or master a skill or task which is at least moderately challenging for him or her” (Morgan, Harmon, & Maslin-Cole, 1990, p. 319). The question arises when observing children: what elements should be observed during play, the end product or the process of activity participation? McWilliam et al. (2001) indicated in a research study on teaching styles and engagement, that teachers who were product-focused inhibit learning opportunities for children and their students scored lower on developmental scales than those children exposed to teachers who are process-oriented. McWilliam et al. (2001) also found in their research that preschool children (3–6 years) presented with more sophisticated engagement than toddlers who were performing on an unsophisticated level. They suggest nine levels of engagement but only focused on five levels in their most recent research: sophisticated, differentiated, focused attention, undifferentiated, and nonengaged (McWilliam, et al., 2001). Table 12.1 presents the characteristics of each level. Two essential features in promoting child engagement seem to be the interventionist’s interactive behavior and the quality of the environment.

Facilitating Interaction Three key elements are intertwined in the learning process of young children, these being firstly the demands presented in the environment, secondly the child’s abilities and motivational level, and thirdly, the interventionist who has to integrate these elements to facilitate participation. Each element has the potential to be adapted or modified to suit the context. Adaptation is viewed as an external agent necessary for changing the

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Table 12.1. Levels of Engagement Sophisticated behavior

Differentiated behavior

Focused attention

Unsophisticated behavior Nonengaged behavior

Involves problem-solving and the child either uses changing strategies or the same strategies to solve the problem or reach the goal. The child uses language, pretend play, sign language, drawings, etc. that allows him or her to reflect on the past, present, and future and construct new forms of expression through combining symbols or signs. The child can communicate about something or someone not physically present. The child has a set of behaviors that permits adaptation to environmental demands and expectations. This includes active interaction with the environment (materials, tools, and people). At this stage the child is becoming more outcomes-focused. Includes watching or listening for features in the environment. Paying attention to the features is a requisite. Serious facial expression and quieting of motor activity characterise this level. Implies selectivity and intensity of attention. There is no clear differentiation in the child’s behavior. Behavior is repetitive and exploratory in nature. Attention is poorly focused and action is not aimed at a specific outcome. The child is seemingly uninvolved in any activity and tends to be destructive and aimless. Focus of attention seems fleeting.

Based on McWilliam et al. (2001).

environment to fit the person as well as an internal change that occurs when a person learns new behaviors. It is therefore the adjustments that are made between an individual and the environment that boost personal survival. To encourage interaction requires a close relationship between the challenges inherent in the activity and the child’s skills. The environment should therefore be structured to meet the abilities of the child to experience success. If the challenges are too high, the child can withdraw as anxiety is experienced, but if the challenges are too low, the child will be bored with the activity which could also lead to withdrawal (Csikszentmihalyi, 1990). Structuring of activities includes making items such as toys physically accessible (Uys, 1998), as well as presenting the activity in an accessible way to the child, especially to the child with developmental disabilities. Table 12.2 summarises some of the principles for adaptation used in intervention. From this table it is evident that adaptations can be made to play materials and presentation methods. Both these forms of adaptation need to be considered to ensure meaningful participation in an activity. Just as stabilisation of a toy for a child with coordination problems could facilitate access to toy manipulation, so can time delay or animation facilitate joint interaction. When successfully engaged in activities, the feedback from the activity would encourage the child to repeat the activity and practice new skills to enhance skill mastery. The function of internal systems influences a person’s desire for mastery and consequently the level of engagement. Personal capabilities include the skills of different developmental domains: sensory, motor, cognitive, socioemotional, and communication. A child has to integrate


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Table 12.2. Adaptation of Play Adaptation of Play Materials Stabilisation Enlargement Providing a prosthesis Reducing required response Making it more concrete Making it more familiar Removing distracting stimuli Adding cues Increasing safety and durability

Adaptation of Presentation Methods Requesting Commenting on objects Commenting on actions Protesting/denying Describing objects/actions Presentating an obstable Making a general statement Introducing time delay Using incidental teaching Giving more time to respond Initiating joint activity Using animation Using imitation

information from all the domains to perform effectively in a social context. A deficit in one domain has a direct influence on the other domains with subsequent impact on the general functioning. Because play is the child’s occupation, intervention’s main goal needs to include enjoyment through participation to enhance mastery. Children have an internal desire to become a master of the environment. To elicit this internal desire, meaningful activities need to be selected to accommodate each child’s interest. Children with developmental delays experience distress in relation to environmental challenges, which in turn interferes with all aspects of the learning process. These children are often unable to use learning situations optimally due to their inability to access the environment. They can be unable to initiate new responses to environmental demands, thus negating the process of differentiation and integration. It is against this background that interventionists need to remain cognisant not only of ways in which to facilitate interaction with a child, but also of the level of engagement of the child during interaction. Interaction between the child and the environment implies press for mastery. Ideally the interventionist should aim to create a match between the desire for mastery (child) and the demand for mastery (environment). Interaction (active participation in the environment) is the pivotal point for learning to occur. Interaction challenges the child’s abilities and presses for the improvement of behaviors indicative of development. When the children respond to stimuli from the external environment (e.g., a play activity), they have to use their internal abilities (systems) to interpret, integrate, and organise the stimuli, to give meaning to it and to respond accordingly. When these responses are effective, learning occurs and positive feedback is received from the external environment either through the activity itself or through interaction with the adult. This internal experience creates satisfaction, which increases self-esteem and engagement (Csikszentmihalyi, 1990).

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EMERGENT LITERACY: THE IMPORTANCE OF HOME-BASED LITERACY EXPERIENCES Just as communication and learning takes place as part of the daily interaction between family members and the young child, so also do these interactions provide opportunities for the development of the basic orientation to literacy development. Teale and Sulzby (1986) adopted the term ‘emergent literacy’ to signal a break from the approach of reading readiness where the focus was on the acquisition of specific skills associated with reading and writing to focus more on the informal learning in holistic activities at home, preschool, and kindergarten. The approach of emergent literacy is thus primarily concerned with the link between language and communication development and written language. It includes early skills relating to book orientation, early print awareness, and knowledge of print prior to the acquisition of formal literacy skills (Teale, 2003). During this time the child acquires knowledge on the functions, uses, and significance of text, which form the foundation for later conventional literacy learning (Whitehurst & Lonigan, 1998). Early reading and writing activities are considered as equal components of this complex process involving both production and reception of written language. Koppenhaver, Coleman, Kalman, and Yoder (1991) described reading and writing as cognitive activities embedded in social and linguistic contexts that involve communication, listening, speaking, reading, and writing within everyday life irrespective of the communication mode used by the young child. That the young child is able to participate in these activities is much more important than how (which mode of communication) the child is going to access the activities. The initial part of the 21st century has emerged as a period offering unprecedented attention to emergent literacy largely due to the realization of the importance of these activities for later literacy development and the impact that lack of early exposure to literacy activities has on the development of literacy skills of children with developmental disabilities. Light and Kelford-Smith (1993) for example, compared the home literacy experiences of physically disabled preschoolers who use AAC systems to the experiences of their typically developing peers. They found that the experiences of preschoolers using AAC differed significantly from the experiences of their typical peers. These children do not have the same access to communication and thus find it more difficult to respond during these activities. Story-book reading, which in the case of typically developing children can be highly interactive and enjoyable, often becomes more parent-dominated and directive in nature when parents interact with their child who has little or no functional speech. The engagement of the young child within this context also becomes more difficult as the child does not necessarily relate to the symbols or pictures used in the same way as the parent. Various authors have also conducted research on the early literacy experience of deaf children. The studies of Ewoldt (1985), Andrews and Taylor (1987), Akamatu and Andrews (1993), and Williams and McLean (1997) acknowledged the importance of storybook reading as part of emergent


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literacy development in children who are deaf. Gioia (2001), however, found that although literacy practices were established in the homes, shared reading rituals between parents and their deaf children were not always established. Although parents enjoyed reading with their children who are deaf they experience obstacles in the reading process (HeinemannGosschalk & Webster, 2003). Mirenda and Erickson (2000) also explored the use of AAC in facilitating literacy in children with autism. They emphasised the importance of a sociocultural model of literacy learning and acknowledged that the attitudes and expectations of those in the individual’s immediate environment, the availability of reading and writing materials, and the nature of interactions between the individual and his literacy partners are important. These partners do not only include parents or teachers, but also siblings. Lenhart and Roskos (2003) documented the literacy learning and interaction between two siblings in literacy activities and found that the older sibling was significant in demonstrating literacy skills to the younger child and that to a large extent the older sibling shaped the young child’s perception towards print and books. The role of siblings as part of the emergent literacy process is thus acknowledged as important in the process of literacy learning in the young child with developmental disabilities. Perhaps the most important strategy for enhancing the home literacy exposure of children with developmental disabilities is an understanding of the context within which families live and their perceptions of the importance of literacy learning of the young child. One of the first steps in this process is to make parents aware of their own literacy routines in the home to guide them in how to use these as a basis for further expansion.

Awareness of Literacy Exposure at Home Light and Kelford-Smith (1993) identified four contexts that form a part of early literacy experiences at home. Literacy learning is seen as embedded in multiple contexts which affect both child and literacy event. These contexts can be described as follows. - The physical and functional context: Although the physical aspect refers to the elements of the physical environment and the nature of the activities and material in the home, the functional aspect refers to the interpersonal interaction with the family around these activities. - The language context refers to the interaction patterns between the adult and child during the literacy activities at home. - The affective context refers to the parents’ values and beliefs about literacy and their expectations of literacy development. - The educational context refers to the collaboration between the parent and the teacher in facilitating literacy experiences of the child. It also includes the identification of strengths and challenges of interaction surrounding literacy activities as a basis for further guidance of parents.

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Based on these four contexts, Stobbart (2005) developed a questionnaire for parents that can be used as a basis to facilitate parents’ reflection on literacy exposure of their deaf child at home. Table 12.3 outlines some questions (based on Stobbart, 2005) that can be asked to assist parents in reflecting on home literacy exposure of children with developmental disabilities.

Table 12.3. Increasing Parents’ Awareness of Home-Based Literacy Experiences of Young Children with Developmental Disabilities Emergent Literacy Contexts The physical and functional context: reading

Physical and functional context: writing

Language Context

Affective context

Educational context

Based on Stobbart (2005).

Examples of Questions What are your child’s favorite reading activities? How interested are you and your family in reading? How often do you or others in your home read in the presence of your child with developmental disabilities? What printed materials are available in your home? How often does your child with developmental disabilities make use of the above-mentioned printed material? Is your child interested in reading activities? Does your child own any books? How many? Is writing or drawing something you or other members of your family enjoy? How often do you or others in your family write or draw at home? Which writing or drawing materials are readily available in your home? How often does your child use any of the above materials? Is your child interested in writing and drawing activities? When your child is involved in reading and writing activities, does anyone else participate? Who? Who usually initiates the reading and writing activities? How do siblings participate in reading and writing activities with your child with developmental disabilities? When you or other family members read to your child, what types of books do you usually read? When you read with your child, what does your child usually do? When you read, how does your child communicate with you? How is your child usually positioned during story reading activities? When you read to your child, what do you usually do? How important do you rate the following aspects of your child’s development at present? Ability to communicate Ability to speak Understanding Use of alternative ways of communicating Learning to read Learning to write, etc. Do you have any difficulties in finding suitable books to read to your child? Do you have any difficulty in communicating with your child? Do you have any difficulty in determining whether your child understands the stories you read?


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Based on information gained from dialoguing around these questions, some strategies can be developed – in collaboration with the parents – aimed at increasing emergent literacy exposure of the young child. The key to successful intervention, also in this context, is for professionals to take the lead from the parents. Rogoff (1990) coined the term “guided participation” which refers to the process through which children, their caregivers, and other companions learn and extend their knowledge, skills, and values in a community. Rogoff, Mistry, Göncü, and Mosier (1993) provided empirical evidence showing that there are both similarities and variations in guided participation across communities. Whilst the similarities include the structuring of joint engagement, the variations are more prominent in relation to the assignment of whether adults or children are responsible for a child’s learning, goals of development, and the means of communication. They emphasised that the term ‘guided participation’ is not intended as a classification scheme by which one can evaluate whether guided participation is effective, but rather a perspective through which to study change within the family or community. It thus promotes not just dyadic communication, but a system of relationships.

Using Graphic Symbols to Increase Early Literacy Experiences as a Meaning-Based Process Parents often regard reading and writing activities in relation to traditional orthography and learning of the ‘alphabet’. Whilst this is important in later stages of the process, emergent literacy requires a complex set of underlying orientations and skills that can be acquired through the use of different graphic symbols to facilitate the experience of reading as a meaningful event. Abbott, Detheridge, and Detheridge (2006) described the use of symbols in literacy and social justice contexts. They were particularly concerned with the use of graphic symbols to support the inclusion of children and adults with a range of disabilities by providing them with access to literacy. They regarded access to literacy, thus to reading and writing, as vital as the ability to communicate face to face. Access to the information in public spaces such as shopping malls could also include browsing the Web for information or reading books and magazines for pleasure. They emphasised that these are issues relating to social justice and that parents need to be involved in facilitating their children’s access into communities by becoming more familiar with the ways in which different graphic systems can be used to facilitate this process. There are varied ways in which children can gain access to literacy as part of a meaning-based process. These strategies can include: Picture or symbol reading Container or product discrimination by means of identification of labels Reading to make choices, for example, reading the menu in a restaurant, or reading the TV program Reading for mobility by recognizing familiar street signs, or indicators for elevators and bathrooms Gaining access to writing their name or develop a distinctive mark to sign their names

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Figure 12.4. Examples of symbol sets that can be used to facilitate reading through symbols.

Figure 12.4 provides some examples of different graphic symbol sets that can be used to facilitate reading through symbols. With an increase of software focused on providing young children with developmental disabilities with access to literacy through graphic symbols, the role of computer-based intervention strategies cannot be overemphasised. More detail on software programs that can be used to facilitate reading and writing development of children with developmental disabilities can be obtained in Smith (2005).

CONCLUSION This chapter focused on the importance of providing young children with developmental disabilities with access to communication and literacy development by firstly understanding the impact of their impairments on their use and interpretation of symbols as well as taking heed of the sociocultural factors that might have an impact on performance. It also discussed communication and participation from two perspectives, these being engagement and interaction. The mere fact that messages are exchanged does not guarantee that meaning is derived from the context. The ability to observe the level of engagement within the activity or situation is thus critical in understanding the participation of young children with developmental disabilities. This approach is explored further in terms of its application to play and emergent literacy intervention.


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REFERENCES Abbott, C., Detheridge, C., & Detheridge, T. (2006). Symbols. Literacy and social justice. Cambridge: Widgit Software. Akamatu, C. T., & Andrews, J. F. (1993). It takes two to be literate: Literacy interactions between parent and child. Sign Language Studies, 87, 333–360. Alant, E. (2005a). Support-based intervention. In E. Alant, & L. L. Lloyd. (Eds.), Augmenatative and alternative communication and severe disabilities. Beyond poverty (pp. 155–191). London: Whurr. Alant, E. (2005b). Intervention issues. In E. Alant, & L. L. Lloyd. (Eds.), Augmentative and alternative communication and severe disabilities. Beyond poverty (pp. 9–29). London: Whurr. Alant, E. (2005c). Issues in graphic symbol communication. In E. Alant, & L. L. Lloyd (Eds.), Augmentative and alternative communication and severe disabilities (pp. 108–130). London: Whurr. Alant, E. (2005d). AAC technology for development. In E. Alant, & L. L. Lloyd. (Eds.), Augmentative and alternative communication and severe disabilities. Beyond poverty (pp. 192–220). London: Whurr. Andrews, J. F., & Taylor, N. E. (1987). From sign to print: A case study of picture book “reading” between mother and child. Sign Language Studies, 56, 261–274. Capute, A. J., & Accardo, P. (1996). Developmental disabilities in infancy and childhood. Volume 1: Neurodevelopmental diagnosis and treatment. Baltimore, MD: Paul H. Brookes. Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York: Harper & Row. Dada, S., Granlund, M., & Alant, E. (2007). A discussion of individual variability, in activity-based interventions, using the niché concept. Child: Care, Health and Development. 33(4), 424–431. Dunst, C. J. (2001). Parent and community assets as sources of young children’s learning opportunities. Asheville: Winterberry Press. Ewoldt, C. (1985). A descriptive study of the developing litearcy of young hearing impaired children. Volta Review, 87(5), 109–126. Fuller, D. R., & Lloyd, L.L. (1997). Symbol selection. In L. L. Lloyd, D. R. Fuller, & H. H. Arvidson. (Eds.), Augmentative and alternative communication. A handbook of principles and practices (pp. 214–225). Needham Heights, MA: Allyn and Bacon. Gioia, B. (2001). The emergent language and literacy experiences of three deaf preschoolers. International Journal of Disability, Development and Education, 48(4), 411–428. Hall, E. T. (1976). Beyond culture. Garden City, NY: Doubleday Anchor Books. Heath, S. B. (1984). Ways with words. New York: Cambridge University Press. Heinemann-Gosschalk, R., & Webster, A. (2003). Literacy and the role of parents of deaf children. Deafness and Education International, 5(1), 20–38. Hunter, C. S. J., & Harman, D. (1979). Adult illiteracy in the United States: A report to the Ford Foundation. New York: McGraw-Hill. Koppenhaver, D. A., Coleman, P. P., Kalman, S. L., & Yoder, D. E. (1991). The implications of emergent literacy research for children with developmental disabilities. American Journal of Speech-Language Pathology, 1, 38–44. Lenhart, L., & Roskos, K. (2003). What Hannah taught Emma and why it matters. In D. M. Barone, & L. M. Morrow. (Eds.), Literacy and young children. Research-based practices (pp. 45–60). New York: Guilford Press. Light, J. C., & Kelford-Smith, A. (1993). Home literacy experiences of preschoolers who use AAC systems and of their nondisabled peers. Augmentative and Alternative Communication, 9(1), 10–25. Lloyd, L. L., Fuller, D. R., & Arvidson, H. H. (1997). Introduction and overview. In D. R. Fuller, L. L. Lloyd, & H. H. Arvidson (Eds.), Augmentative and alternative communication: A handbook of principles and practices (pp. 1–17). Needham Heights, MA: Allyn and Bacon. McNaughton, S., & Lindsay, P. (1995). Approaching literacy with AAC graphics. Augmentative & Alternative Communication, 11(4), 212–228.

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13 Eating Disorders DAVID H. GLEAVES, JANET D. LATNER, and SUMAN AMBWANI

INTRODUCTION Eating problems or irregularities are common among children and adolescents. When the problems reach the point of being gross disturbances in eating behavior and when accompanied by some form of body image disturbance, we enter the realm of the Eating Disorders (EDs). The current Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR; APA, 2000) distinguishes between three primary ED types: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Specified (EDNOS). The latter refers to cases that meet some but not all the criteria required for the diagnosis of either AN or BN. Binge-Eating Disorder (BED) is a more recently recognized disorder that is technically a variant of the EDNOS category (although research criteria have been developed). There are, however, numerous possible manifestations of EDNOS other than BED. In earlier versions of the DSM, up to and including the Third Edition–Revised (American Psychiatric Association, 1987), the EDs were listed within the Disorders Usually First Evident in Infancy, Childhood, or Adolescence section. Given their prominence among adults as well, their own section was created in the most recent edition. However, their origins in childhood or adolescence should not be forgotten and they are, in many ways, disorders of adolescence. In this chapter, we cover these above-mentioned disorders. There are also numerous other eating-related disorders that frequently occur in

DAVID H. GLEAVES • University of Canterbury JANET D. LATNER • University of Hawaii SUMAN AMBWANI • Texas A&M University


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childhood. These include pica, rumination disorder, or feeding disorder of infancy or early childhood (sometimes referred to as failure to thrive). See Piazza (in press) for a discussion of treatment of these problems. Another common eating related problem among children is obesity. See Henderson and Schwartz (2007) for a review of the literature on treatment of childhood obesity.

ANOREXIA NERVOSA (AN) The central feature of AN is a “refusal to maintain a minimally normal body weight” (APA, 2000, p. 583). The full DSM–IV–TR diagnostic criteria are listed in Table 13.1. Typically the minimum weight threshold is set at 85% of the person’s expected weight for his or her age and height. However, the weight criterion may also be expressed in terms of body mass index (BMI; weight in kilograms/height in meters2). A BMI of 17.5 or lower is considered to meet the body weight criterion for AN. However, BMIs are often difficult to interpret with children and adolescents, and there is often a need for some flexibility regarding an absolute cutoff. A percentage of expected weight may be more appropriate for this age group (Fisher et al., 1995). A person may be at a minimal body size through having lost weight or through never having gained the weight that would be expected with normal development. The latter may be more common among children and young adolescents although it would not be uncommon for older adolescents to lose a significant amount of weight. Persons diagnosed as having AN may use a variety of weight control mechanisms including intentional starvation, excessive exercising, or purgative behaviors (self-induced vomiting, and misuse of laxatives, diuretics or enemas). Table 13.1. DSM–IV–TR Diagnostic Criteria for Anorexia Nervosa A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. D. In postmenarchal females, amenorrhea, that is, the absence of at least three consecutive cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen administration.) Specify type: Restricting Type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Binge-Eating/Purging Type: During the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Note: From APA (2000, p. 589). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourt Edition, Text Revision, (Copyright 2000). American Psychiatric Association.

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In addition to the refusal to maintain a normal weight, individuals with AN also experience an intense fear of becoming fat or sometimes of gaining any weight (APA, 2000). This fear does not seem to diminish, and may even worsen, as the individual loses weight (Walsh & Garner, 1997). Individuals with AN may experience their bodies in a distorted way, feeling “fat” or extremely dissatisfied with their body shape and they may base their total self-worth on their body size. Such individuals may monitor their body weight and shape and experience strong negative emotional reactions if they gain weight. Another criterion of AN is the presence of amenorrhea (in postmenarchal girls). In young anorexic adolescents, the onset of menstruation may be delayed. Two subtypes of AN are described in the current DSM–IV–TR, and the typology is based on the presence or absence of binge eating as well as on the principal method of weight control. Restricting anorexics restrict only whereas Binge-Eating/Purging anorexics engage in purging which is usually associated with binge eating. However, excessive dieting and exercising may occur with either type of anorexia (APA, 2000). The distinction between subtypes appears to be quite valid (DaCosta & Halmi, 1992; Gleaves, Lowe, Green, Cororve, & Williams, 2000). Recognizing AN in children and adolescents presents many challenges. First, in a prepubescent female (or a male) the amenorrhea criterion is not applicable. Second, there may not be a noticeable weight loss but rather, a failure to achieve normal weight or to gain weight at a normal rate. As noted above, normal weight is also sometimes a challenge to determine and quantify. A related concern is that severe anorexia may inhibit normal skeletal development; thus height may be affected.

BULIMIA NERVOSA (BN) According to the current DSM, BN is characterized by repeated (at least twice a week for three months) episodes of binge eating followed by some sort of inappropriate compensatory response to prevent weight gain (APA, 2000). Full criteria are listed in Table 13.2. As with AN, there is some sort of body image disturbance. Although the DSM–IV defines a binge as “eating in a discrete period of time an amount of food that is definitely larger than most individuals would eat under similar circumstances” (p. 589), the requirement that binges be necessarily large has been questioned by some researchers (Rossiter & Agras, 1990). A perceived loss of control during the binge episodes must also be present and may be the more important factor (rather than size; Latner, Hildebrandt, Rosewall, Chisholm, & Hayashi, 2007). Binges are triggered by a variety of factors including hunger, stress, negative mood, feelings and thoughts associated with body image, and food cravings (Schlundt & Johnson, 1990; Walsh & Garner, 1997). As with the bingeing criterion, the compensatory behaviors need to occur on average at least twice a week for three months to meet the threshold for diagnosis. As with AN, persons with BN may be classified as

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Table 13.2. DSM–IV–TR Diagnostic Criteria for Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. (2) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify type: Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Nonpurging type: During the current episode of bulimia nervosa, the person has used inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Note: From APA (2000, p. 594). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourt Edition, Text Revision, (Copyright 2000). American Psychiatric Association.

having one of two types; in this instance, it is based on the type of compensatory behavior. If the person engages in self-induced vomiting or the use of laxatives, he or she is considered to have the purging subtype. If the person only uses excessive exercise or starvation (or similar methods), the nonpurging type of BN would be diagnosed. There is less support for the validity of this distinction (Gleaves et al., 2000) than there is for the subtypes of AN described above. However, the purging type, in general, appears to be associated with more pathology than the nonpurging type (e.g., Willmuth, Leitenberg, Rosen, & Cado, 1988). The DSM body image criterion for BN is less specific than for AN, and worded only as “Self-evaluation is unduly influenced by body shape and weight” (APA, 2000; p. 594). There is, however, evidence that, when controlling for actual body size, persons with BN seem very similar to those with AN in terms of body image (Williamson, Cubic, & Gleaves, 1993). Women with BN overestimate their current size and desire to be excessively thin, relative to same-sized women without BN (Williamson, Davis, Goreczny, & Blouin, 1989). However, it is no doubt also true that their self-evaluation is overly influenced by their body image, as stated in the criterion. In earlier versions of the DSM, it was possible for a person to be diagnosed with both AN and BN. With the current system, BN cannot be diagnosed if it occurs only in the context of AN. Such an individual would be diagnosed as having the binge-eating/purging subtype of AN. There is evidence that BN occurs on a continuum with the binge-eating/purging subtype of AN whereas the restricting subtype is qualitatively different from both other disorders (Gleaves et al., 2000).

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BINGE EATING DISORDER (BED) As noted above, BED is not currently accepted as a formal diagnosis in the DSM–IV but rather would be a subtype of EDNOS. However, it is also listed in the “Criteria Sets and Axes Provided for Further Study” (p. 759) section; thus a set of research criteria has been developed (see Table 13.3). These generally refer to the presence of recurrent binge eating (as seen with BN) but in the absence of the compensatory behaviors that occur with BN. Persons with BED may not be as restrictive in their eating as persons with BN, and a large percentage of individuals are consequently obese. Persons with BED are very often dissatisfied with their bodies. The body image disturbance in BED may seem more commensurate with patients’ actual size rather than exaggerated as in instances of AN or BN. However, the shape and weight concerns of obese individuals with BED, as well as their eating-related and general psychopathology, quality of life, and even physical health, are significantly more impaired than those of obese individuals without BED (Wilfley, Wilson, & Agras, 2003). Some researchers (e.g., Hay & Fairburn, 1998) may consider BED to be less severe than BN. However, the range and frequency of comorbid psychopathology for BED is similar to that for BN. Furthermore, the mortality rates for BED may actually be higher than with BN because the former is associated with obesity (Agras, 2001).

EATING DISORDER NOT OTHERWISE SPECIFIED (EDNOS) Although EDNOS is a residual category in the DSM, it warrants its own section here because it appears to be the most common ED encountered in clinical practice (Fairburn & Bohn, 2005). It may also be more Table 13.3. DSM–IV–TR Research Criteria for Binge-Eating Disorder A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following. (1) Eating in a discrete period of time (e.g., within any two-hour period) an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances. (2) A sense of lack of control over eating during the episodes (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. The binge eating episodes are associated with three (or more) of the following. (1) (2) (3) (4) (5)

Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not feeling physically hungry Eating alone because of being embarrassed by how much one is eating Feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present D. The binge eating occurs, on average, at least two days a week for six months. E. The binge eating not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa of Bulimia Nervosa. Note: From APA (2000, p. 787). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourt Edition, Text Revision, (Copyright 2000). American Psychiatric Association.

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common among adolescents than among adults (Fisher, Schneider, Burns, Symons, & Mandel, 2001). There are no positive criteria for EDNOS, and the DSM–IV–TR defines these only as “disorders of eating that do not meet the criteria for any specific eating disorder” (APA, 2000, p. 594). There are six examples (see Table 13.4) in the DSM of possible EDNOS presentations (with one being BED). Fairburn and Bohn described two subtypes as being particularly common. The first are instances where the individual’s presentation closely resembles AN or BN nervosa but (s)he fails to meet their diagnostic thresholds (body weight or frequency of bingeing). However, these cases are severe enough to warrant clinical attention and should not be thought of as subthreshold eating disorders in general. The second subtype are cases that might be instances of mixed AN and BN in which the clinical features of AN and BN are combined in ways other than in the two recognized syndromes. Williamson, Gleaves, and Savin (1992) provided empirical support for the existence of such clusters, in addition to BED. Specifically in the adolescent literature, Binford and le Grange (2005) recently describe another subtype, that of individuals who purge but do not binge (similar to #4 in Table 13.4).

EPIDEMIOLOGY Prevalence Although Hoek and van Hoeken’s (2003) review of the ED literature reported average prevalence rates of 0.3% (AN) and 1% (BN) for young women, and 0.1% (BN) for young men, among at-risk women, prevalence estimates typically range from 3% to 10% (i.e., ages 15–29 years; Polivy & Herman, 2002). The averages reported by Hoek and van Hoeken (2003) were not specific to eating disorders among adolescents, but most of the Table 13.4. DSM–IV–TR Eating Disorder Not Otherwise Specified The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the criteria for any specific eating disorder. Examples include: 1. For females, all of the criteria for anorexia nervosa are met except that the individual has regular menses. 2. All of the criteria for anorexia nervosa are met except that despite significant weight loss the individual’s current weight is in the normal range. 3. All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for duration of less than three months. 4. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies). 5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food. 6. Binge-eating disorder: recurrent episodes of binge eating in the absence if the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa. Note: From APA (2000, pp. 594–595). Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourt Edition, Text Revision, (Copyright 2000). American Psychiatric Association.

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literature reviewed included adolescent samples. Research exclusively conducted with children and adolescents suggests varying prevalence rates. For instance, a study with community adolescents reported that 3% met criteria for an eating disorder (not including EDNOS), of which 33.3% were male and 66.7% were female (Zaider, Johnson, & Cockell, 2000). In contrast, in a study of 1,960 adolescents aged 14–15 years in Norway, Kjelsås, Bjørnstrøm, and Götestam (2004) reported the overall lifetime prevalence of EDs to be 12.5%–12.9%, depending on whether DSM–IV or DSM–III–R criteria were used. Whereas the overall lifetime prevalence for girls ranged from 17.9%–18.6%, for boys, the prevalence rate was estimated at 6.5%. The authors reported the prevalence of AN among girls and boys to be 0.7% and 0.2%, respectively, whereas the prevalence of BN among girls and boys was 1.2%–3.6% and 0.4%–0.6%, respectively. As expected, relatively larger prevalence rates were detected for EDNOS, with estimates ranging from 12.9%–14.6% for girls, and 4.8%–5% for boys. Finally, BED prevalence rates were estimated at 1.5% for girls, in comparison to 0.9% for boys. An earlier study in Norway estimated somewhat lower prevalence rates: 1% BED, 0.7% BN, 0.3% AN-BP subtype, and 0% AN-R subtype (Rosenvinge, Borgen, & Börresen, 1999). Notably, in this latter study, none of the male students met criteria for an eating disorder, although 0.9% of the boys were categorized as “at-risk.” More recent studies of female adolescents in Italy (Cotrufo, Gnisci, & Caputo, 2005) and Spain (Ruiz-Lázaro, Alonso, Comet, Lobo, & Velilla, 2005) have estimated the following prevalence rates for eating disorders: 0.55%–0.77% (BN), 3.47% (partial BN), .38% (partial BED), 0.14% (AN), 5.79% (subclinical AN), and 3.83% (EDNOS). Similar lifetime prevalence rates have also been reported among adolescent girls in Iran, including, 0.9% (AN), 3.2% (BN), 1.84% (partial AN), and 4.79% (partial BN; Nobakt & Dezhkam, 2000) and female adolescents in Greece and Germany, including, 1.26%–1.18% (AN), 3.15%–3.54% (BN), and 13.84%–19.45% (EDNOS; Fichter, Quadflieg, Georgopoulou, Xepapadakos, & Fthenakis, 2005). In addition to studies of the prevalence of ED diagnoses, several researchers have examined the prevalence of eating disordered behaviors among adolescents. For instance, Croll, Neumark-Sztainer, Story, and Ireland’s (2002) research on disordered eating behaviors (i.e., bingeeating, or, using any of the following to control or lose weight: fasting/skipping meals, using diet pills or amphetamines, laxatives, vomiting, and/or smoking cigarettes) among 9th- and 12th-grade students in Minnesota (N = 81,247) revealed a high prevalence of such behaviors. For instance, among 9th-graders, 56% of the girls and 28% of the boys reported engaging in disordered eating behaviors. The estimates were slightly higher among 12th-graders, as 57% of the girls and 31% of the boys reported disordered eating. One limitation of this research is that it included a fairly broad definition of disordered eating. However, as the authors noted, engaging in any of the above behaviors would constitute risk-factors for the subsequent development of eating disorders. One limitation of such research is that in practice, recognizing and detecting EDs may often be restricted by the secrecy associated with binge

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eating and purging behaviors. Moreover, some have suggested that the prevalence of some EDs (particularly BN) may be lower among children and adolescents than adults for practical reasons, such as not having access to money or privacy required for binge eating (Netemeyer & Williamson, 2001). Similarly, although AN may be more obviously detectable because of patients’ extreme low weight, such detection may be more difficult when the low weight is a manifestation of a failure to gain weight. Overall, we view proper assessment as critical for diagnosis and treatment, and there are many issues specific to assessment of children and adolescents with eating problems. See Netemeyer and Williamson (2001) or Zucker et al. (2008 and with a 2009, publication data) for a more in-depth discussion of assessment of eating disorders among children and adolescents.

Incidence and Time Trends Lewinsohn, Striegel-Moore, and Seeley (2000) reported the incidence of EDs to be less than 2.8% by age 18, and 1.3% for individuals aged 19–23 years. In contrast, Rastam et al. (1989) screened the entire population of school children in an urban region of Sweden (N = 4,291), and reported 3 cases of BN, 17 cases of AN, and 3 cases of a partial AN syndrome. In their review of the research, Hoek and van Hoeken (2003) reported the incidence of AN to be 8 cases per 100,000 population per year, and noted that the incidence rates for AN are the highest for females in the 15–19 age group. They estimated the incidence of BN to be 12 cases per 100,000 population per year. With regard to time trends, van Son, van Hoeken, Bartelds, van Furth, and Hoek (2006) assessed the incidence of EDs in the Netherlands during two time periods, 1985–1989, and 1995–1999. The authors reported that although the incidence of AN was fairly stable for the general population (i.e., 7.4 to 7.7 per 100,000), the incidence for the 15–19-year-old female age group significantly increased, from 56.4 to 109.2 per 100,000. Of the individuals diagnosed with AN between 1995–1999, only one (2%) was male. In contrast, they reported that the incidence of BN decreased somewhat (nonsignificantly) from 8.6 to 6.1 per 100,000, a finding that has been corroborated by other recent research (Keel, Heatherton, Dorer, Joiner, & Zalta, 2006). Regarding trends in ED-related symptomatology, Fichter, Quadflieg, Georgopoulou, Xepapadakos, and Fthenakis (2005) reported significant increases in weight phobia and bulimic behaviors from approximately 1979 to 1998 among Greek girls in Germany, but interestingly, observed the reverse for the male adolescents, whose weight phobia scores decreased from the first to second assessment.

Gender Differences As reflected by the incidence and prevalence rates, EDs typically occur less frequently among males than among females. One possibility is that the prevalence of AN is higher among boys than it appears to be, but is not readily recognized due to its reputation as a stereotypically female

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disorder. Thus, research examining eating disorders among men and boys may have been limited by the tendency towards misdiagnosis, although greater attention has been devoted to this problem in recent years. In general, data suggest that boys with EDs typically strive for a more muscular body ideal, rather than the thin ideal typically pursued by girls (McCreary & Sasse, 2000; see Labre, 2002, for a review on adolescent boys and the muscular ideal). Although EDs have been diagnosed among individuals of all sexual orientations, bisexual and homosexual orientation may be particular risk factors for developing EDs (Austin et al., 2004). The prevalence of homosexuality and bisexuality is higher among men with BN than in the general population (43% versus 10%; Carlat, Camargo, & Herzog, 1997), however, it is not clear whether this applies to adolescents. Furthermore, athletes and other individuals for whom physical appearance and body shape are especially important (e.g., body builders) are at a higher risk of developing BN because they need to maintain their weight at or below specific thresholds (Carlat et al., 1997). For boys, the following estimates are available for lifetime prevalence rates: 6.5% (any ED), 0.2% (AN), 0.4% (BN), and 0.9% (BED) (Kjelsås, Bjørnstrøm, & Götestam, 2004). Among children and adolescents, consistently higher proportions of female than male patients present to eating disorder treatment programs (e.g., Geist, Heinmaa, Katzman, & Stephens, 1999; Peebles, Wilson, & Lock, 2006), but there may be some gender differences in the presentation of these disorders. For instance, Geist et al. (1999) reported that male adolescents presented with significantly lower drive for thinness and body dissatisfaction than their female counterparts. However, the authors noted that in the absence of adolescent male norms on the instrument used, their results may be difficult to interpret. In comparing a large sample (N = 959) of children and adolescents ages 8–19 years in an eating disorder treatment program, Peebles et al. (2006) reported that, compared with older adolescents (mean age = 15.6 years, SD = 1.4), younger patients (mean age = 11.6 years, SD = 1.2) were more often male, presented at a lower percentage of ideal body weight, and lost weight more rapidly. Specifically, in the younger sample, 16.5% was male, whereas 7.8% of the older sample was male. In the entire sample, most of the patients were female (91.1%), and presented with EDNOS (51.3%), although there were also large proportions presenting with AN (35.8%) and BN (12.9%).

Ethnicity, Culture, and Eating Disorders Overall, research on children and adolescents suggests that Hispanic and Asian American females are more likely than White/Caucasian females to report disordered eating, and that Black/African American students are least likely to report such behaviors (Croll et al., 2002; Robinson, et al., 1996). For instance, in one study, more Latina students reported bingeeating and/or vomiting in the past 28 days in comparison to the Caucasian and African American students, and Latina and Caucasian students exhibited higher levels of eating concerns, weight concerns, shape concerns, and global eating pathology in comparison to their African American counterparts

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(Pernick, et al., 2006). Similarly, Granillo, Jones-Rodriguez, and Carvajal (2005) evaluated data from 1,866 adolescent Latina adolescents, ages 11–20 years (median = 16), and reported fairly high prevalence rates for various behaviors placing them at risk for the development of eating disorders, including, dietary restraint (53.3%), low BMI (

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