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Children & Cochlear Implants
  Issues in Behavior Management




           James H. Johnson, Ph.D.
  Department of Clinical and Health Psychology
             University of Florida
Overview and Objectives
 The  focus of this presentation is on the role of
  behavior management and other intervention
  approaches in the cochlear implant process.
 We will begin by briefly reviewing issues addressed
  in the pre-implant psychological evaluation.
 Examples of issues raised in this evaluation, that
  may suggest the need for intervention, will be
  highlighted.
 Finally, we will consider the nature of approaches to
  intervention that may be of value in addressing pre
  and post implant issues.
The Pre-Implant Psychological
              Evaluation
   Knowledge Assessment
   Motivation for Implant
   Family Agreement/Disagreement
   Appropriateness of Expectations
   Challenges to Compliance
   Parent-Child Communication
   Family/Psychological/Behavioral
    Issues
   Issues of Stress and Coping
   Questions/Concerns Regarding the
    Implant Process
Knowledge Assessment
 Do the parents (and child, if older) have reasonable
  knowledge of what the implant process involves?
  – What surgery will involve and the time necessary for
    healing.
  – The nature of post-implant activities (e.g., initial
    fitting/activation and mapping, auditory training,
    speech/language therapy, scheduled follow-ups).
  – The need for parental involvement in the child’s therapy?
  – What this will require in parental time and effort.
 Have parents gone beyond “passive learning” in an
  attempt to obtain information (e.g., internet
  searches, making contacts with others who have been
  implanted)?
 Any needed information?
Assessing Motivation for
            Implantation
 Do  the parents (and child, if older) indicate a
  desire for the implant?
 Have they been active in seeking information
  regarding the implant?
 Have they been active in moving the implant
  process along?
 Do they show a willingness to do “whatever
  is necessary” to make the implant a success?
Family Agreement and
   Disagreements
     Do parent and child agree on the
      desirability of the implant?
     Do both parents agree on the
      desirability of an implant?
     Are both willing to be active
      participants in the implant
      process?
     Do other close family members
      support the idea of an implant?
Assessing Expectations
 Do  parents and child (if old enough) convey an
  understanding that children vary in response to
  implants?
 Is there understanding that degree of success depends
  on parent and child being active participants in the
  process (e.g., auditory training, speech/language
  therapy, etc)?
 Do they understand that the child may not “hear” the
  same way as a non-hearing impaired individual?
 Is there implied acceptance of outcomes that may not
  involve;
  – the development of functional speech
  – a full understanding of speech without speechreading?
Challenges to Compliance
 Do parents/child convey a willingness to be an active
  participant in the implant process?
 Do they have a plan to deal with practical issues
  associated with implantation;
   – arrangements for surgery,
   – travel to doctor appointments,
   – auditory training, speech therapy, etc.?
 Is there a history of keeping appointments, active
  participation in prescribed communication
  programs, complying with the use of assistive
  devices, and dealing with other required medical
  treatments?
Assessing Stress and Coping
 Isthere evidence of significant family stress?
 What are the nature of existing stressors?
 Do family members have adequate social
  supports to assist them in coping with
  ongoing stressors?
 Do family members appear to have adequate
  skills to cope with existing stressors?
 Considering both the level of stress and
  coping styles, is stress likely to compromise a
  successful outcome?
Assessing Other Psychosocial
              Factors
 Do parents appear to show evidence of deficits
  that could compromise successful outcome or
  require special assistance?
 Does the child show evidence of delays in
  development severe enough to compromise
  success?
 Do either parents or child show evidence of
  psychological/behavioral problems that could
  compromise success?
Psychological and Behavioral Issues:
     Implications for Intervention
 While not meant to be inclusive, listed below are
 selected examples of psychological and family issues,
 sometimes highlighted in the pre-implant evaluation,
 that may warrant family or behavioral intervention.
  – Family Disagreement Regarding Implantation
      Parent-child differences
      Parent-parent differences

  – Externalizing Disorders of Childhood
      Oppositional Defiant Disorder

      Attention Deficit Hyperactivity Disorder (ADHD)

  – Issues of Selective Noncompliance
Issues of Family Disagreement
 Sometimes   parents have markedly different views
  regarding the desirability of an implant.
 In the case of older children or adolescents, parent
  and child may have different views regarding the
  implant decision making process.
 Such conflicts can potentially represent a significant
  challenge to a successful outcome and may, in some
  instances, represent a significant contraindication for
  implantation.
 In other instances, family based interventions may be
  recommended in an attempt to resolve issues prior to
  implantation.
                     Case Examples
“Externalizing” Disorders
         of Childhood
 Externalizing  disorders of childhood are conditions that
  are characterized by a constellation of behaviors that
  bring the child into conflict with his/her environment.
 Here, we will focus on two such conditions,
   – Oppositional Defiant Disorder (ODD)
   – Attention Deficit Hyperactive Disorder (ADHD).
 Special attention will be given to these conditions, as
  both can pose significant challenges for the child being
  considered for a cochlear implant.
 Discussing these conditions also provide a way to
  highlight behavior management approaches that can be
  useful in dealing with a range of implant related issues.
Oppositional Defiant Disorder
   Diagnostic Criteria - A pattern of
    negativistic, hostile, and defiant
    behavior lasting > 6 months, with four
    (or more) of the following present:
     – Often loses temper
     – Often argues with adults
     – Actively defies or refuses to comply
       with adults’ requests or rules
     – Often deliberately annoys people
     – Often blames others for his/her
       mistakes or misbehavior
     – Is often touchy or easily annoyed by
       others
     – Is often angry and resentful
     – Is often spiteful and vindictive
Attention Deficit Hyperactivity
           Disorder (ADHD)
   ADHD is a frequently occurring and
    chronic, neurodevelopmental disorder
    of childhood.
   Symptoms include developmentally
    inappropriate levels of activity,
    distractibility, and impulsivity.
   Children with ADHD have functional
    impairment across multiple settings
    including home, school, and peer
    relationships.
   ADHD has been shown to have long-
    term effects on school performance,
    vocational success, and social-emotional
    development
Treatments of Externalizing
          Disorders
 Treatment  typically involves
  interventions derived from an operant
  behavioral model.
 Interventions may involve more general
  approaches to teaching parents principles
  of behavior modification or more
  structured approaches to parent training.
 Behavior management is often combined
  with other forms of intervention, with
  childhood ADHD being a case in point.
The Behavioral Model: Basic
    Assumptions and Features
 Abnormal     behavior is learned!
 It is learned according the same principles that
  govern the acquisition of normal behavior.
 The focus is on one’s social learning history and
  on overt observable behavior rather than on
  putative internal or “intrapsychic” determinants
  of behavior.
 Emphasis is on those factors in the environment
  that elicit and maintain problem behavior.
 Much of abnormal behavior can be unlearned.
Basic Principles of
  Behavior Management
 Approaches   for Increasing Behavior
  – Modeling/Observational Learning
  – Reinforcement
     Positive Reinforcement
     Negative Reinforcement

 Approaches   for Decreasing Behavior
  – Extinction
  – Punishment
Modeling/Observational
         Learning
 Involves  providing the child with models
  where he/she can learn new skills by
  observing the behavior of others.
 Most useful in teaching new behaviors to
  reduce skills deficits - can also be used to
  facilitate performance of previously
  learned behaviors and to decrease fear
  reactions.
 Is usually combined with reinforcement
  procedures.
Reinforcement: Increasing
Behavior for Better or Worse
 The  principle of Positive
  Reinforcement states that
  behaviors followed by a
  reinforcing state of affairs
  (rewards) are increased.
 The principle of Negative
  Reinforcement states that
  behaviors that result in the
  reduction of an aversive state of
  affairs will be increased.
 Example: At The Grocery
Using Rewards to Change
  Behavior: Some Basics
 Rewards   need to be individualized to the child.
   – Some Children don’t like M&M’s and they do melt
     in your hand!
 Use  a variety of rewards to avoid satiation.
 Rewards should be administered in small units.
 Rewards should usually be administered
  immediately after the desired behavior has
  occurred.
 If this is not possible, use points or tokens to
  bridge the gap between behavior and back-up
  reinforcement.
Still More Principles of
              Reward
 Reinforcers  should be exclusively under the
  parent’s control.
 Rewards should be practical!
 They should be easily given, not too costly, and easy
  to obtain.
 Consistency is everything!
 Rewards should usually be given on a continuous
  reinforcement schedule (at least at the beginning).
 After a behavior is well learned you might switch to
  a partial reinforcement schedule.
Extinction
 Extinction: A decrease in
  behavior associated with the
  withdrawal of reinforcement.
 May result in the failure of some
  desired behaviors to be
  maintained.
 Can result in strong emotional
  reactions or response “Bursts”.
 Can be used to reduce problem
  behavior – Case Example.
Punishment
   Punishment: A decrease in behavior
    resulting from behavior being
    followed by an aversive state of
    affairs.
   Punishment can be of the physical
    variety, as in example to the right.
   It can involve the loss of rewards as in
    a loss of points for inappropriate
    behavior in token programs or when
    a child is put in “Time-Out”.
   Punishment procedures, when used,
    are generally combined with
    reinforcement for desired behavior.
Using Punishment: Some
      Negative Effects
 Used  consistently with young children, punishment
  results in strong negative emotional responses that
  can lead to both avoidant behavior and decreased
  levels of attachment.
 Punishment is one way of modeling aggression and
  is associated with increased aggressive behavior in
  the child.
 Punishment often results in only a short term
  reduction in problem behavior.
Punishment: Additional
        Issues
 Punishment   does not teach the child how
  to behave – what he or she is supposed to
  do.
 Punishment is often not needed, as
  alternative approaches, such as
  rewarding desirable behaviors that are
  incompatible with problem behavior can
  often bring about desired results.
Child Behavior Management:
      Two Approaches
 There  are two primary treatment approaches for
  working with children displaying oppositional
  defiant behavior.
 One can be described as the “Patterson – Living
  with Children” Model.
 The second is Parent-Child Interaction Therapy,
  developed by Dr. Sheila Eyberg of the
  University of Florida.
 Both are “Empirically-Supported Treatments” as
  research has consistently documented their
  effectiveness.
Living with Children Model
         Based on the work of Dr. Gerald
          Patterson.
         Involves a therapist working with
          parents, teaching basic principles of
          behavior modification so they can
          effectively modify their child’s
          behavior.
         The program focuses on:
           – Targeting Problem Behavior
           – Increasing desirable behavior
           – Decreasing undesirable behavior
           – Documenting effectiveness.
           – Helping parents become effective
             behavioral trouble-shooters in
             managing their children.
More About the “Living With
     Children” Model

 The  “Living with Children” Model is less
  structured that the Parent Child
  Interaction Training Model, to be
  described next.
 It can be used with parents of children of
  all ages, rather than only those below the
  ages of 6 or 7, as is the case with Parent
  Child Interaction Training.
Parent Child Interaction Therapy
   PCIT is a treatment for children with disruptive behavior
    disorders that emphasizes improving the parent-child
    relationship and changing parent-child interaction
    patterns.
   Parents are taught specific skills to establish a nurturing
    and secure relationship with their child while increasing
    positive behavior and decreasing negative behavior.
   Treatment is usually carried out in a playroom equipped
    with a one-way mirror so the therapist can guide the
    parent as he/she interacts with the child.
   Communication between therapist and parent is via a
    bug-in-the-ear device where the therapist can actively
    coach the parent in how to respond to the child’s behavior
    and reinforce the parents in-therapy behavior.
PCIT: Stages of Treatment
   In addition to the therapist providing parents with overviews
    of different stages of therapy and principles of behavior
    management, PCIT involves two stages:
   The first stage is Child Directed Interaction (CDI) where the
    focus is on parents engaging their child in nondirective play
    with the goal of enhancing the parent-child relationship.
   Here the child is allowed to take the lead with parents
    focusing on communication with the child by:
     – Praising the child’s behavior,
     – Reflecting the child’s statements,
     – Imitating and Describing the child’s play,
     – Being Enthusiastic,
     – Ignoring any negative behavior, and
     – avoiding any attempt to lead the play, give commands, ask
       questions or give criticism.
PCIT: Stages of Treatment II
   Parent Directed Interaction (PDI), where the parent takes a
    more active role, is designed to teach parents specific behavior
    management techniques for dealing with problem behavior.
   Here, the primary goals are increasing compliance and
    deceasing inappropriate behaviors.
   In PDI the parent learns to give clear and direct commands, to
    reward compliance, and to use time-out as a consequence for
    non-complaint or other disruptive behavior (while continuing
    to use elements of CDI between commands).
   Time-out initially involves setting on a chair (3 minutes), with
    a Time-out room used as backup, for refusals to stay in the
    chair.
   A major focus of therapy is on helping parents learn to use the
    skills developed in PCIT sessions in the home environment.
PCIT: Final Comments
 PCIT    is generally used with children between the
  ages of 3 and 6.
 The length of treatment is determined by the length
  of time it takes parents to reach criterion in terms of
  skills development (usually 12 to 16 session).
 Many controlled research studies have provided
  strong support for the effectiveness of this approach.
 Another strength of this treatment is the “hands on
  approach” to teaching basic behavior management
  skills (reinforcement, extinction, punishment) that
  are easily transportable the home situation.
Treatment of ADHD
       As children with ADHD often display
        disruptive behavior, approaches like
        those just described may also be useful
        with these children as well.
       However, it is often the case that other
        approaches will also be necessary. These
        may include:
         – The use of medication to treat ADHD
           core symptoms.
         – Other treatments for comorbid
           conditions.
         – Educational accommodations to
           minimize problems with inattention
           and distractibility and problems with
           academic achievement.
Behavior Management: Other
   Areas of Applicability
          The use of behavioral principles discussed
           here is not restricted to children with serious
           behavior disorders.
          They are also applicable to other situations
           where it is desirable to either increase or
           decrease specific behaviors.
          One example might include a home-based
           reinforcement programs for children who
           are non-compliant in wearing hearing aids.
          Clinic based reward programs might also be
           useful with children who are poorly
           motivated to participate in auditory
           habilitation programs, speech therapy, and
           other training necessary for implant success.
That’s All Folks!   Questions?

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Cochlear

  • 1. Children & Cochlear Implants Issues in Behavior Management James H. Johnson, Ph.D. Department of Clinical and Health Psychology University of Florida
  • 2. Overview and Objectives  The focus of this presentation is on the role of behavior management and other intervention approaches in the cochlear implant process.  We will begin by briefly reviewing issues addressed in the pre-implant psychological evaluation.  Examples of issues raised in this evaluation, that may suggest the need for intervention, will be highlighted.  Finally, we will consider the nature of approaches to intervention that may be of value in addressing pre and post implant issues.
  • 3. The Pre-Implant Psychological Evaluation  Knowledge Assessment  Motivation for Implant  Family Agreement/Disagreement  Appropriateness of Expectations  Challenges to Compliance  Parent-Child Communication  Family/Psychological/Behavioral Issues  Issues of Stress and Coping  Questions/Concerns Regarding the Implant Process
  • 4. Knowledge Assessment  Do the parents (and child, if older) have reasonable knowledge of what the implant process involves? – What surgery will involve and the time necessary for healing. – The nature of post-implant activities (e.g., initial fitting/activation and mapping, auditory training, speech/language therapy, scheduled follow-ups). – The need for parental involvement in the child’s therapy? – What this will require in parental time and effort.  Have parents gone beyond “passive learning” in an attempt to obtain information (e.g., internet searches, making contacts with others who have been implanted)?  Any needed information?
  • 5. Assessing Motivation for Implantation  Do the parents (and child, if older) indicate a desire for the implant?  Have they been active in seeking information regarding the implant?  Have they been active in moving the implant process along?  Do they show a willingness to do “whatever is necessary” to make the implant a success?
  • 6. Family Agreement and Disagreements  Do parent and child agree on the desirability of the implant?  Do both parents agree on the desirability of an implant?  Are both willing to be active participants in the implant process?  Do other close family members support the idea of an implant?
  • 7. Assessing Expectations  Do parents and child (if old enough) convey an understanding that children vary in response to implants?  Is there understanding that degree of success depends on parent and child being active participants in the process (e.g., auditory training, speech/language therapy, etc)?  Do they understand that the child may not “hear” the same way as a non-hearing impaired individual?  Is there implied acceptance of outcomes that may not involve; – the development of functional speech – a full understanding of speech without speechreading?
  • 8. Challenges to Compliance  Do parents/child convey a willingness to be an active participant in the implant process?  Do they have a plan to deal with practical issues associated with implantation; – arrangements for surgery, – travel to doctor appointments, – auditory training, speech therapy, etc.?  Is there a history of keeping appointments, active participation in prescribed communication programs, complying with the use of assistive devices, and dealing with other required medical treatments?
  • 9. Assessing Stress and Coping  Isthere evidence of significant family stress?  What are the nature of existing stressors?  Do family members have adequate social supports to assist them in coping with ongoing stressors?  Do family members appear to have adequate skills to cope with existing stressors?  Considering both the level of stress and coping styles, is stress likely to compromise a successful outcome?
  • 10. Assessing Other Psychosocial Factors  Do parents appear to show evidence of deficits that could compromise successful outcome or require special assistance?  Does the child show evidence of delays in development severe enough to compromise success?  Do either parents or child show evidence of psychological/behavioral problems that could compromise success?
  • 11. Psychological and Behavioral Issues: Implications for Intervention  While not meant to be inclusive, listed below are selected examples of psychological and family issues, sometimes highlighted in the pre-implant evaluation, that may warrant family or behavioral intervention. – Family Disagreement Regarding Implantation  Parent-child differences  Parent-parent differences – Externalizing Disorders of Childhood  Oppositional Defiant Disorder  Attention Deficit Hyperactivity Disorder (ADHD) – Issues of Selective Noncompliance
  • 12. Issues of Family Disagreement  Sometimes parents have markedly different views regarding the desirability of an implant.  In the case of older children or adolescents, parent and child may have different views regarding the implant decision making process.  Such conflicts can potentially represent a significant challenge to a successful outcome and may, in some instances, represent a significant contraindication for implantation.  In other instances, family based interventions may be recommended in an attempt to resolve issues prior to implantation. Case Examples
  • 13. “Externalizing” Disorders of Childhood  Externalizing disorders of childhood are conditions that are characterized by a constellation of behaviors that bring the child into conflict with his/her environment.  Here, we will focus on two such conditions, – Oppositional Defiant Disorder (ODD) – Attention Deficit Hyperactive Disorder (ADHD).  Special attention will be given to these conditions, as both can pose significant challenges for the child being considered for a cochlear implant.  Discussing these conditions also provide a way to highlight behavior management approaches that can be useful in dealing with a range of implant related issues.
  • 14. Oppositional Defiant Disorder  Diagnostic Criteria - A pattern of negativistic, hostile, and defiant behavior lasting > 6 months, with four (or more) of the following present: – Often loses temper – Often argues with adults – Actively defies or refuses to comply with adults’ requests or rules – Often deliberately annoys people – Often blames others for his/her mistakes or misbehavior – Is often touchy or easily annoyed by others – Is often angry and resentful – Is often spiteful and vindictive
  • 15. Attention Deficit Hyperactivity Disorder (ADHD)  ADHD is a frequently occurring and chronic, neurodevelopmental disorder of childhood.  Symptoms include developmentally inappropriate levels of activity, distractibility, and impulsivity.  Children with ADHD have functional impairment across multiple settings including home, school, and peer relationships.  ADHD has been shown to have long- term effects on school performance, vocational success, and social-emotional development
  • 16. Treatments of Externalizing Disorders  Treatment typically involves interventions derived from an operant behavioral model.  Interventions may involve more general approaches to teaching parents principles of behavior modification or more structured approaches to parent training.  Behavior management is often combined with other forms of intervention, with childhood ADHD being a case in point.
  • 17. The Behavioral Model: Basic Assumptions and Features  Abnormal behavior is learned!  It is learned according the same principles that govern the acquisition of normal behavior.  The focus is on one’s social learning history and on overt observable behavior rather than on putative internal or “intrapsychic” determinants of behavior.  Emphasis is on those factors in the environment that elicit and maintain problem behavior.  Much of abnormal behavior can be unlearned.
  • 18. Basic Principles of Behavior Management  Approaches for Increasing Behavior – Modeling/Observational Learning – Reinforcement  Positive Reinforcement  Negative Reinforcement  Approaches for Decreasing Behavior – Extinction – Punishment
  • 19. Modeling/Observational Learning  Involves providing the child with models where he/she can learn new skills by observing the behavior of others.  Most useful in teaching new behaviors to reduce skills deficits - can also be used to facilitate performance of previously learned behaviors and to decrease fear reactions.  Is usually combined with reinforcement procedures.
  • 20. Reinforcement: Increasing Behavior for Better or Worse  The principle of Positive Reinforcement states that behaviors followed by a reinforcing state of affairs (rewards) are increased.  The principle of Negative Reinforcement states that behaviors that result in the reduction of an aversive state of affairs will be increased.  Example: At The Grocery
  • 21. Using Rewards to Change Behavior: Some Basics  Rewards need to be individualized to the child. – Some Children don’t like M&M’s and they do melt in your hand!  Use a variety of rewards to avoid satiation.  Rewards should be administered in small units.  Rewards should usually be administered immediately after the desired behavior has occurred.  If this is not possible, use points or tokens to bridge the gap between behavior and back-up reinforcement.
  • 22. Still More Principles of Reward  Reinforcers should be exclusively under the parent’s control.  Rewards should be practical!  They should be easily given, not too costly, and easy to obtain.  Consistency is everything!  Rewards should usually be given on a continuous reinforcement schedule (at least at the beginning).  After a behavior is well learned you might switch to a partial reinforcement schedule.
  • 23. Extinction  Extinction: A decrease in behavior associated with the withdrawal of reinforcement.  May result in the failure of some desired behaviors to be maintained.  Can result in strong emotional reactions or response “Bursts”.  Can be used to reduce problem behavior – Case Example.
  • 24. Punishment  Punishment: A decrease in behavior resulting from behavior being followed by an aversive state of affairs.  Punishment can be of the physical variety, as in example to the right.  It can involve the loss of rewards as in a loss of points for inappropriate behavior in token programs or when a child is put in “Time-Out”.  Punishment procedures, when used, are generally combined with reinforcement for desired behavior.
  • 25. Using Punishment: Some Negative Effects  Used consistently with young children, punishment results in strong negative emotional responses that can lead to both avoidant behavior and decreased levels of attachment.  Punishment is one way of modeling aggression and is associated with increased aggressive behavior in the child.  Punishment often results in only a short term reduction in problem behavior.
  • 26. Punishment: Additional Issues  Punishment does not teach the child how to behave – what he or she is supposed to do.  Punishment is often not needed, as alternative approaches, such as rewarding desirable behaviors that are incompatible with problem behavior can often bring about desired results.
  • 27. Child Behavior Management: Two Approaches  There are two primary treatment approaches for working with children displaying oppositional defiant behavior.  One can be described as the “Patterson – Living with Children” Model.  The second is Parent-Child Interaction Therapy, developed by Dr. Sheila Eyberg of the University of Florida.  Both are “Empirically-Supported Treatments” as research has consistently documented their effectiveness.
  • 28. Living with Children Model  Based on the work of Dr. Gerald Patterson.  Involves a therapist working with parents, teaching basic principles of behavior modification so they can effectively modify their child’s behavior.  The program focuses on: – Targeting Problem Behavior – Increasing desirable behavior – Decreasing undesirable behavior – Documenting effectiveness. – Helping parents become effective behavioral trouble-shooters in managing their children.
  • 29. More About the “Living With Children” Model  The “Living with Children” Model is less structured that the Parent Child Interaction Training Model, to be described next.  It can be used with parents of children of all ages, rather than only those below the ages of 6 or 7, as is the case with Parent Child Interaction Training.
  • 30. Parent Child Interaction Therapy  PCIT is a treatment for children with disruptive behavior disorders that emphasizes improving the parent-child relationship and changing parent-child interaction patterns.  Parents are taught specific skills to establish a nurturing and secure relationship with their child while increasing positive behavior and decreasing negative behavior.  Treatment is usually carried out in a playroom equipped with a one-way mirror so the therapist can guide the parent as he/she interacts with the child.  Communication between therapist and parent is via a bug-in-the-ear device where the therapist can actively coach the parent in how to respond to the child’s behavior and reinforce the parents in-therapy behavior.
  • 31. PCIT: Stages of Treatment  In addition to the therapist providing parents with overviews of different stages of therapy and principles of behavior management, PCIT involves two stages:  The first stage is Child Directed Interaction (CDI) where the focus is on parents engaging their child in nondirective play with the goal of enhancing the parent-child relationship.  Here the child is allowed to take the lead with parents focusing on communication with the child by: – Praising the child’s behavior, – Reflecting the child’s statements, – Imitating and Describing the child’s play, – Being Enthusiastic, – Ignoring any negative behavior, and – avoiding any attempt to lead the play, give commands, ask questions or give criticism.
  • 32. PCIT: Stages of Treatment II  Parent Directed Interaction (PDI), where the parent takes a more active role, is designed to teach parents specific behavior management techniques for dealing with problem behavior.  Here, the primary goals are increasing compliance and deceasing inappropriate behaviors.  In PDI the parent learns to give clear and direct commands, to reward compliance, and to use time-out as a consequence for non-complaint or other disruptive behavior (while continuing to use elements of CDI between commands).  Time-out initially involves setting on a chair (3 minutes), with a Time-out room used as backup, for refusals to stay in the chair.  A major focus of therapy is on helping parents learn to use the skills developed in PCIT sessions in the home environment.
  • 33. PCIT: Final Comments  PCIT is generally used with children between the ages of 3 and 6.  The length of treatment is determined by the length of time it takes parents to reach criterion in terms of skills development (usually 12 to 16 session).  Many controlled research studies have provided strong support for the effectiveness of this approach.  Another strength of this treatment is the “hands on approach” to teaching basic behavior management skills (reinforcement, extinction, punishment) that are easily transportable the home situation.
  • 34. Treatment of ADHD  As children with ADHD often display disruptive behavior, approaches like those just described may also be useful with these children as well.  However, it is often the case that other approaches will also be necessary. These may include: – The use of medication to treat ADHD core symptoms. – Other treatments for comorbid conditions. – Educational accommodations to minimize problems with inattention and distractibility and problems with academic achievement.
  • 35. Behavior Management: Other Areas of Applicability  The use of behavioral principles discussed here is not restricted to children with serious behavior disorders.  They are also applicable to other situations where it is desirable to either increase or decrease specific behaviors.  One example might include a home-based reinforcement programs for children who are non-compliant in wearing hearing aids.  Clinic based reward programs might also be useful with children who are poorly motivated to participate in auditory habilitation programs, speech therapy, and other training necessary for implant success.
  • 36. That’s All Folks! Questions?