Transcript Document

Working with young children and
their families
Wednesday 4th December, 2013
2.30-4.00pm AEDT
PRESENTERS:
Dr Katie Wood
Clinical Psychologist/Senior Lecturer
Swinburne University of Technology
Dr Kate Reid
Clinical Psychologist
Goulburn Valley Medicare Local
Facilitator: Bella Saunders, Senior Psychologist APS
Working with young children
and their families
Dr Katie Wood
Clinical Psychologist/Senior Lecturer,
Swinburne University.
Overview of Presentation…
Overview of
anxiety
during
childhood
Benefits of
early
intervention
Overview of
CBT:
Theoretical
perspective
Overview of Presentation…
CBT:
Assessment
CBT
In Practice
Therapeutic
Relationship
Common presentations during childhood
• Anxiety, including separation anxiety, OCD,
social anxiety, generalised anxiety.
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Low self-esteem.
Disruptive behaviour.
Affect dysregulation.
Attachment difficulties.
Learning difficulties.
Peer difficulties.
Family difficulties (e.g., marital discord, social isolation,
financial hardship).
Anxiety Disorders during childhood
• One of the most common mental health conditions in children.
• Can be comorbid with other difficulties (e.g., academic impairment).
•
Developmental differences in the manifestation of anxiety disorders
across childhood.
• Evidence that the overall prevalence of anxiety disorders is similar in
preschoolers (aged 2-5 years) and children/adolescents (aged 5-17
years) (Egger & Angold, 2004).
• Diagnosis in preschoolers is complicated by limited verbal skills. Rely
more on parent report.
(Hirshfeld-Becker et al.,2010; Minde et al., 2010)
Benefits of early intervention
• Children and parents learn tools to manage anxiety
before has significant impact on self esteem and other
areas of functioning.
•
Provides the opportunity to intervene with other factors
that might serve to maintain / reinforce the anxiety.
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Can prevent chronicity of anxiety.
(Hirshfeld-Becker et al.,2010)
Treatment Approaches
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Cognitive-behavioural therapy
Solution-focused therapy
Play therapy
Individual therapy
Child-parent psychotherapy
Parent-Child Interaction Therapy
Acceptance and Commitment Therapy
Parent training
Group therapy.
(see Njoroge & Yang, 2012 for a review)
What is CBT ?
An approach to assessment & treatment that
assumes that the way an individual behaves is
determined by immediate situations & the
individual’s interpretations of these situations
(Hawton et al., 1992, p. 13)
Thoughts
Feelings
Behaviour
Key concepts
model
of
the
CBT
•
Relationship exists between thoughts, feelings, &
behaviour.
•
Content-specificity hypothesis – specific emotional
states are associated with distinct cognitions (e.g.,
depression is associated with the negative cognitive triad
– negative view of self, current experience, & future (see
Beck).
•
Our thoughts about a situation & how we interpret it are
influenced by our belief system (i.e., beliefs about self & world).
•
Cognitive schemata – structures that hold a child’s core
beliefs; represent the child’s world view.
Usually
develop early & are reinforced by past & present
experiences.
(Friedberg & McClure, 2002; Friedberg et al., 2009; Hawton et al., 1992;
Nelson, 2001; Zarb, 1992)
(Refs Friedberg & McClure, 2002; Nelson, 2001)
Key concepts
model
of
the
CBT
Cognitive schemata
Beliefs
Situation
Thought/
interpretation
(Model adapted from Nelson, 2001, p.2)
Feeling
Key concepts
model cont.
of
the
CBT
• Our thoughts & interpretations influence behaviour.
• Thoughts also affect physical states (e.g., sweating may be
interpreted as a sign of fainting).
• Emotions, behaviours, negative physical states, thought
chains can all be considered symptoms. These symptoms
can influence other thoughts, which can serve to
maintain a negative emotional state.
• Two-way relationship between thoughts & symptoms (i.e.,
thoughts influence initial symptoms; symptoms then
influence ongoing negative thinking). This can serve to
maintain the symptoms.
(Nelson, 2001)
Key concepts
model cont.
of
the
CBT
•Automatic thoughts -can be positive, neutral or negative. In
CBT, we mostly refer to Negative Automatic Thoughts
(NATs).
• Automatic thoughts:
Cognitive products–like the “stream of consciousness”;
Constant;
Not under conscious control;
Spontaneous;
Not purposeful;
Can be verbal & preverbal;
Can be rational & irrational;
Can reflect an underlying belief system about self,
others & world – but not always;
Can elicit strong emotional reactions without these
necessarily coming to conscious awareness;
Examples “he hates me”, “I can’t do this”.
(Refs Friedberg & McClure, 2002; Nelson, 2001; Zarb, 1992)
Key concepts of the CBT model cont.
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Beliefs & belief systems –usually have a combination of
functional & dysfunctional beliefs.
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Depending on the situation, context, & stage of life, a
belief may be functional or dysfunctional. A belief could
also be functional & dysfunctional in the same
context – beliefs can vary & fluctuate.
•
Where do beliefs come from?
internal (e.g., thoughts, feelings, imagination) & external
experiences
(e.g., childhood experiences),
what we learn from others, books,
films etc.,
cultural experiences, religion,
biological
predisposition.
(Nelson, 2001)
Key concepts of the CBT model cont.
• How are beliefs maintained?
Biased interpretations – people interpret situations so
as to reinforce an existing belief;
Selective attention – people tune into evidence that is
consistent with a belief; attend to confirmatory evidence.
(Nelson, 2001)
(Model adapted from
Nelson,
2001, p. 15)
Putting it all together..
Cognitive schemata
= influence
Beliefs
3
Selective attention
Situation
Thoughts /
interpretations
Thinking errors
2
Symptoms
1
feeling states
behaviours
physical states
thought chain
CBT with children: Some points to remember
Typical versus atypical development
cognitive development expectations
Choice of CBT interventions
need to be adapted to suit the child
Therapist as educator
the therapeutic learning experience should generalise to the outside
world; transference of skills.
(Kendall, 2002; Zarb, 1992)
CBT with preschoolers
•
Limited research on the treatment of anxiety disorders in young children (Minde et al.,
2010).
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Efficacy for CBT in children aged 8 years and over is strong (Kendall et al., 2004).
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CBT for preschoolers typically includes a parent component. More likely to have
treatment success when there is consistent support and involvement of the family
(Minde et al., 2010).
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Need to present abstract concepts in a concrete manner (Minde et al., 2010).
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Rely more heavily on graded exposure to reduce anxiety symptoms (Hirshfeld et al.,
2010; Minde et al., 2010).
Assessment using a CBT approach
By the end of an assessment, the clinician should have:
1. Developed a formulation of the target
problem that the client agrees with.
2. Detailed information regarding the factors
that trigger, underlie, & maintain the problem.
3. Begun to educate the client about the CBT model
in child sensitive language.
(France & Robson, 1997; Hawton et al.)
Goals of a CBT assessment
• Develop an initial hypothesis & treatment plan.
• Test out hypothesis during treatment sessions & homework- revise if
needed.
• Assessment usually continues throughout treatment.
Areas to assess..
• Functional analysis of behaviour
• presenting problem; aim is to identify the factors that
maintain the problem, how the problem interferes with
life, & whether the problem serves a useful function.
• Target problem/behaviour is examined in terms of its
antecedents & consequences (A-B-C model)
• Cognitive factors – look for thinking errors
• Family factors
• Peer relationship factors
• School performance factors (if attending school)
• Coping style.
( Friedberg & McClure, 2002, p. 14)
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Case formulation: Components
Beh
Antecedents &
consequences
CBT Approach
Culture
Presenting Problems
Physiological sxs
Interpersonal
Mood
Cognitive
structures
Cognition
Behaviour
Hxs &
development
7/16/2015
(Adapted from Friedberg & McClure, 2002, p. 14)
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(see Friedberg & McClure, 2002)
Case Formulation ….example..
Presenting problem = anxiety associated with germs
7-year-old female
Behavioural:
avoidance of certain objects and people, increase
clinginess, seeking reassurance.
Emotional:
anxiety.
Interpersonal:
social withdrawal.
Physiological:
stomach aches.
Cognitive:
“I am going to get sick”; “I don’t feel safe”.
Nature of CBT with clients
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Collaborative relationship between client & therapist.
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Guided discovery - therapist works to guide the
client’s thinking rather than giving direct information.
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Flexible session structure with a clear agenda.
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Feedback obtained about process of therapy.
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Focus on working towards & achieving goals
articulated by client – problem focused & active.
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Socratic questioning.
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Therapist uses reframes, recaps & summaries.
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Importance of rapport & trust.
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Homework tasks.
(Freidberg & McClure, 2002; Nelson, 2001)
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Aim of CBT Interventions …..
1.Recognise and correct unhelpful
thoughts
(Zarb, 1992)
What to target during therapy
• The thoughts/interpretation & symptom cycle – with
aim to break any part of the cycle & develop a more
positive one.
• Behavioural interventions - target specific behaviours
that are maintaining the cycle.
• Physiological interventions (e.g., relaxation training) –
target negative emotional states such as anxiety.
• Cognitive interventions - target specific thought chains
& thinking errors.
• Targeting underlying beliefs – usually the last
treatment option because beliefs are usually resistant
to change & can therefore take some time to
modify.
(Nelson, 2001)
Setting the agenda…

Therapist with client identifies topics to be addressed during
session.
 Prioritise items.
“Tell me what you would like to add to our list of things to
discuss today?”
What has been a “good” and “not so good” experience
during the week?

Be mindful of children who test limits – keep structure
& be consistent.
(Friedberg & McClure, 2002;Minde et al., 2010)
Content of sessions

Discuss what is going to happen in each session. Keep
sessions structured.
Be mindful of child’s language ability & motivation
level.
Use creative techniques – stories, comics, role
plays, games. Avoid over reliance on talking and work
sheets.
Use child friendly language –e.g., “boss back the
worries/scary thoughts”.
(Friedberg & McClure, 2002; March & Mulle, 1998)
.
Homework tasks
• Should follow from what was discussed in the session
– focusing on practice outside the session and skill
generalisation.
• Make a clinical judgement regarding whether or not
homework should be given.
• Keep simple for younger children.
(Friedberg & McClure, 2002)
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Feedback
• Ask for some feedback from the child regarding the
session content – helps to maintain engagement &
rapport
• What was helpful and what was not?
• At beginning of session, might also ask if the child
had any thoughts about the last session
• Feedback also provided by clinician.
• Feedback with parents & school – keep the system
in mind.
(Friedberg & McClure, 2002)
PSYCHOEDUCATION
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Role of psychoeducation
• Educate child about CBT assumptions and proposed treatment
strategies – clinician is more directive than for adult clients. Take into
account cognitive ability and developmental stage. Use stories /
pictures to educate young children about the CBT model.
• Provide information about the presenting problem (e.g., nature & impact
of anxiety, flight-fight response, related physical sensations,
when anxiety is helpful and when it is not, symptoms of anxiety- in child
sensitive language).
• Role and importance of homework (if appropriate for child)
• Also important to educate the parents about the CBT model, and
relationship between thoughts, feelings, & behaviour. Parents will
often be your co-therapist.
BEHAVIOURAL INTERVENTIONS
Behavioural Interventions
Increase positive behaviour and decrease unhelpful
behaviour
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Positive and negative reinforcement
Prompts or cues (e.g., verbal prompts to cope with situation)
Modelling. Role plays, videos, films
Stimulus discrimination training – response reinforced
in the presence of one stimulus but not in the presence
of another stimulus. Includes:
Shaping. Differential reinforcement of target behaviour in small
steps
Fading. Stimulus controlling a response is gradually changed – towards new
stimulus controlling response
Chaining. Stimulus-response links involved in chain of behaviour are
increasingly reinforced.
(Friedberg & McClure, 2002; Vitulano & Kraemer Tebes, 2002)
Behavioural Interventions 2
What techniques decrease or eliminate behaviour?
Punishment (e.g., hitting, removing privileges)
Extinction
Response cost – removal of reinforcer contingent on
occurrence of misbehaviour
Time-out
Differential Reinforcement of other behaviour.
(Friedberg & McClure, 2002; Vitulano & Kraemer Tebes, 2002)
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Contingency Management
Reinforcers/Rewards = contingent on a specific
behavioural response
Fixed intermittent schedules of reinforcement
Variable schedules of reinforcement
Reinforcement should be consistent, meaningful,
appropriate, frequent, specific, & without criticism.
Reward Charts
(Friedberg & McClure, 2002; Vitulano & Kraemer Tebes, 2002)
Relaxation Training
Why important?
Releases built up tension and allows child to gain control
over negative feelings
Breathing techniques
Progressive Muscle Relaxation
Guided Imagery
Quick relaxation exercises
(e.g., screw up face, squeeze eyes tight & push lips together)
Importance of script, voice of clinician, length of session.
(Friedberg & McClure, 2002; Stallard, 2002; Zarb, 1992)
(Stallard, 2002)
In addition to Relaxation..

Physical exercise

Controlled breathing – quick method when not enough time to do
relaxation in full. The child needs to stop, concentrate and gain
control of his/her breathing.
“draw in a deep breath & hold it for 5 seconds, then slowly let it out.
As you breath, say relax. If you do this a few times, you will feel more
control & calmer”
see also Peaceful Piggy
Moody Cow Meditates
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Calming pictures
Yoga for children
Relaxing activities
in
Thought stopping

A useful way to stop negative thoughts.

Child can wear an elastic band on his/her wrist.

Tell child – when he/she notices that he/she is
listening to the same unhelpful thoughts, he/she
can pull the elastic band.
(Stallard, 2002)
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Pleasant Event / Activity Scheduling

Similar to a daily planner with the aim to increase positive
reinforcement in child’s daily routine. More for older children.

Child is first asked to provide a baseline of current activities.

Discuss association between pleasant activities & positive mood.

Ask client to schedule activities at specific times each day for one week
and tick when activity done. Each activity is done for a specified time.
Clients rate degree of pleasure or mastery related to performance.
Also record mood ratings & cognitions. Need to be suitable to child’s
age and developmental stage.
(Friedberg & McClure, 2002; Zarb, 1992)
(Friedberg & McClure, 2002; Zarb, 1992)
Pleasant Event / Activity Scheduling
Monday
9 am
11 am
3pm
Tuesday
Wed
Thurs
Friday
Walk
Mood /10
Listen to
relaxing
music
Mood /10
Play with
dog
Mood /10
7 pm
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Play a
game
with
mum
Mood
/10
Problem Solving
Steps
1.
2.
1.
(Stallard, 2002)
Red Light – stop before you do anything.
Amber Light – plan and think about what you
want to do or say.
Identify different solutions
Think through the positive and negative
consequences.
Choose best solution on balance.
Ask someone successful what they do, watch
him/her, then talk self through it.
Green Light – go with the plan.
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IDENTIFYING FEELINGS AND
THOUGHTS
(Friedberg & McClure, 2002; Friedberg et al., 2009; Stallard,2002)
Feeling identification
• How to help child to identify his/her feelings.
• Age & developmental level
• Limited feeling vocabularly
• Techniques
• self-report questionnaires
- CDI, RCMAS, YSR, Y-BOCS
• Story, song, poetry writing - (e.g., David and the
Worry Beast, The Kissing Hand)
• Poster, art work, draw a face (children)
• Feeling charades
• Feeling Finder
• Watch, Warning, Storm – teaches children to track
feelings at different intensities
• Feeling Compass.
Thought identification
Thought Bubbles with cartoons
Thought Flower Garden
Feelings
Thoughts
Situation
(Friedberg & McClure, 2002)
Coping Cat program = Kendall
HOW TO ASK QUESTIONS
Questioning techniques
• Socratic questioning
systematic
inductive reasoning – finding the evidence and
evaluate it – assist the child to discover things about
his/her thinking
universal definitions are developed
• Types of socratic questions
What’s the evidence for what is being said?
What is an alternative explanation?
What are the advantages and disadvantages of
holding the belief?
How can I solve this problem?
Decatastrophizing.
(Friedberg & McClure, 2002)
Questioning techniques 2
• Be mindful of how the child responds to questions.
•
•
•
•
Be mindful of cultural issues
Tune into client’s level of distress
How well does the child handle uncertainty
May need to keep questions fairly simple and concrete
(e.g., “would you like the kids to only call you names, stop
teasing you or pick on someone else?)
rather than abstract (what would have to happen for
things to be different at school?)
(Friedberg & McClure, 2002)
Questioning techniques 3
• Five steps to socratic process (see F & M, p. 107-110)
1. What is the automatic thought?
2. Link the thought to the feeling and behaviour
3. Make this link using an empathic response
4. Ensure that child is following you and agrees
continue
5. Test the belief….
(Friedberg & McClure, 2002)
to
Cognitive Restructuring –
“talking back to the brain”
The child is first asked to monitor the thoughts
going through his/her mind right now. Once the child
gets better at identifying negative thoughts, he/she is
encouraged to consider the impact of these thoughts on
mood, functioning etc.
Then identify cognitive distortions, testing the evidence
for and against the thoughts. Would not do this for pre
schoolers – need to use more concrete strategies that don’t
require metacognition.
(Drewes, 2009; Friedberg & McClure, 2002; Friedberg et al., 2009;
Minde et al.,2010)
Cognitive Restructuring –
“talking back to the brain”
• Clean up your Thinking Diary
• Swat the Bug
• Trash Talk
• Hot Shots, Cool Thoughts
• Mad et 'em Balm Diary
• Taming the Impulse Monster
• Boss back the worries
• “String Test”- good for preschoolers
All serve to illustrate “mind power” that can be used to
“boss back” worries or talk to the brain when have a
worry.
(Drewes, 2009; Friedberg & McClure, 2002; Friedberg et al., 2009; March &
Mulle,1998)
INTERVENTIONS FOR
BUILDING COPING SKILLS:
A CBT FRAMEWORK
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Self-instructional Training
Challenging internal dialogue – as per Meichenbaum
Aim is to replace unhelpful thoughts with more helpful ones when
doing exposure task.

Prepare for the stressor
(e.g., “I can do this, I know how to manage my worries”)

Confront the stressor
(e.g., “Stay calm, breath deeply, I can manage this”)

Dealing with the feelings at the key point
(e.g., “I will stay relaxed, it’s just my worry, I am not going to
give in to this”)- use bossing it back technique.

Self-reward
(e.g., “I am proud of myself, I did my best, I will try again next
time”)
(Friedberg & McClure, 2002)
Systematic Desensitisation
Use to develop a fear hierarchy
for a feared stimulus. Need to:
Identify specific fear
Imagined and/or in vivo
Bottom steps need to be
achievable
Social Skills Training


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Teach skills using direct instruction. Can use
psychoeducation materials and therapist modelling.
Practice – graduated – role plays, regular feedback
In vivo practice with positive reinforcement
Anger management – coping with anger
Assertiveness
Empathy training
Conversation-skill training.
(Friedberg & McClure, 2002; Zarb, 1992)
Assertiveness Training




( Zarb, 1992)
Educate child about the three ways of communicating
Passive, Aggressive, Assertive
Role plays to illustrate
Examine underlying cognitions
Scripts- what situations would child like
to be more assertive in? – plan scripts that
allow practice of assertive behaviour.
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(Friedberg & McClure, 2002, p. 139-142)
Reattribution

Techniques for considering alternative explanations.
 Responsibility Pie – pie is sliced into
pieces, which correspond to the degree to
which each explanation causes a specific
event/experience to happen.
 What are the possible reasons for the
distressing event? = these reasons are then
allocated to the pie and account for a
specified percentage. The self as
explanation is allocated last.
Role of the parents/caregivers




Co therapist
Provided with information about anxiety disorders and
their impact.
Provide psychoeducation regarding the CBT model.
Review with parents each session and explain
session content & goal for the coming week.
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For the mental health practitioner
• Remember developmental and cultural factors.
• Goal setting and reviewing of goals.
• Resources available.
• Monitoring progress and change.
• We do not have all the answers.
• Role of supervision.
• Relapse prevention.
(Herbert & Harper-Dorton, 2002; Prout & Brown, 2007)
• LUV: Listen, Understand, & Validate as the foundation of the
therapeutic relationship.

•
•
•
•
•
•
•
•
•
•
•
Therapeutic relationships also provide:
Connection
Compassion
Contingency
Cohesion
Continuity
Clarity
Co-construction
Complexity
Consciousness
Creativity
Community
Support the interconnection
between mind, body, human
relationships and developmental
processes. A key aim is for the
mind to self-organise
(Seigel, 2003)
References/suggested readings
•
Drewes, A.A. (2009). Blending play therapy with cognitive behavioral therapy. New Jersey: John Wiley & Sons.
•
Hirshfeld-Becker, D., et al.(2010). Cognitive behavioural therapy for 4-to 7-year-old children with anxiety disorders:
A randomized clinical trial. Journal of Consulting and Clinical Psychology,78 (4), 498-510.
•
Heubner, D. (2005). What to do when you worry too much. United States of America: Magination Press.
•
France, R., & Robson, M. (1997). Cognitive behavioural therapy in primary care: A practical guide. United Kingdom:
Jessica Kingsley Publishers.
•
Friedberg, R.D., & McClure, J.M. (2002). Clinical practice of cognitive therapy with children and adolescents: the
nuts and bolts. New York: Guilford Press.
•
Friedberg, R.D., & McClure, J.M., Garcia, J.H. (2009). Cognitive therapy techniques for children and adolescents.
New York: Guilford Press.
•
Hawton, K., Salkovskis, P.M., Kirk, J., & Clark, D.M. (1989). Cognitive-behaviour therapy for psychiatric problems: A
practical guide (eds). Oxford: Oxford University Press.
•
Herbert, M., & Harper-Dorton, K.V. (2002). Working with children, adolescents, and their families (3rd Ed). Great
Britain: BPS Blackwell.
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References/suggested readings
•
March, J., & Mulle, (1998). OCD in Children and Adolescents: A cognitive-behavioural treatment manual. New York:
The Guildford Press.
•
Minde, K.,Roy, J., Bezonsky, R., & Hashemi, A. (2010). The effectiveness of CBT in 3-7 year old anxious children:
Preliminary data. J Can Acad Child Adolesc Psychiatry, 19 (2), 109-115.
•
Nelson, H. (2001). Cognitive Behavioral Therapy with Schizop. United Kingdom: Nelson Thorns Ltd.
•
Njoroge, W.F.M., & Yang, D.(2012). Evidence-based psychotherapies for preschool children with psychiatric
disorders. Curr Psychiatry Rep, 14, 121-128.
•
Prout, T., H., & Brown, D.T. (2007). Counseling and psychotherapy with children and adolescents: Theory and
practice for school and clinical settings. New jersey: John Wiley & Sons.
•
Seigel, D, (2003). An interpersonal neurobiology of psychotherapy: The developing mind and the resolution of
trauma. In Marion. F. Soloman & D J. Siegel (Eds) (pp. 1-56). Healing trauma: Attachment, mind, body, and brain.
United States of America: W.W Norton & Company.
•
Stallard, P. (2005). A clinicians’s guide to think good-feel good: Using CBT with young people. England: John Wiley
& Sons.
•
Zarb, J. (1992). Cognitive behavioral assessment and therapy with adolescents. New York: Bruner/Mazel.
Working with young children
(3-8 year olds)
through ATAPS CMHS.
Dr Kate Reid
Clinical Psychologist
Goulburn Valley
Medicare Local
Which also means. . . Working with young
children and their families
• When working with children of this age group,
we often work with:
–
–
–
–
–
Individual parent (usually Mum)
Sometimes both parents as a team
Sometimes grandparents and other carers
Siblings
Kinder/ School.
Work might comprise:
– Individual work with the child
– Parenting interventions
– Parent-child interaction work
– Intervention/support at Kinder/School
– Group interventions e.g. the Exploring Together
Preschool Program
– Combination of any of the above.
Assessment
• Developmental history
• Parent and family history
• Kinder/School report
• Behaviour rating scales
• Individual assessment.
Exploring Together Preschool Program
• A multi-faceted, short-term group therapy
program for young children, their parents and
teachers.
• Focussing on:
– reducing children’s problematic behaviour
– developing social skills with peers
– enhancing children’s self-esteem
– enhancing parenting practices
– improving parent-child interactions
– assisting with parents’ personal issues
– strengthening family relationships.
Structure of Exploring Together
Preschool Program
• Ten week, two hour intensive program
• First parent-child interactive group (40 mins)
• Separate concurrent groups for children and
parents (1 hour)
• Second parent-child interactive group (20
mins)
• Evenings for partners/support persons (90
mins)
• Meetings for preschool teachers (90 mins).
Structure of
Exploring Together Preschool Program
First interactive group
40 mins, 4 leaders
Parents’ group
Children’s group
1 hr, 2 leaders
1 hr, 2 leaders
Second interactive group
20 mins, 4 leaders
Who is the Exploring Together Preschool
Program for?
• Families with children aged 3 - 8 years with emotional and
behavioural problems including:
–
–
–
–
–
–
–
–
–
–
–
aggression
oppositional behaviour
hyperactivity/impulsivity
distractible/inattentive behaviour
sibling rivalry
difficult parent-child relationships
problematic peer relationships
depression
separation anxiety
social withdrawal
anxiety/phobias.
Rationale for the Program
 Young children (3 - 8 years olds) are frequently
brought to the attention of services because they
exhibit emotional and behavioural problems
• It is important to intervene when these problems
are noticed at the preschool level to prevent them
becoming more severe, difficult and costly to treat.
• The problems relate to multiple systems in the
child’s life (e.g. home and preschool), so
interventions need to target all of these areas.
Theoretical basis for the ETPP
• Comprised of most effective components from
empirically derived, well-researched programs including
Exploring Together Primary School Program.
– parent behaviour management training (eg.
Patterson, Webster-Stratton)
– parent-child interaction therapy (eg. Eyberg)
– children’s social skills training
– children’s emotion regulation training
– children’s problem-solving skills training (eg. Spivack
& Shure).
Program outline
First parent-child interactive group
Uses direct dyad work
Aims to help parents and children:
• develop age appropriate expectations of children's
behaviour
• enhance communication
• develop emotion regulation skills
• manage separation issues
• develop strategies to deal with difficult behaviour
• facilitate cooperative relationships
• improve problem solving
• experience play and mutual enjoyment
• work on relationship issues as they arise.
Program Outline
Children’s Group
Aims to:
• reduce antisocial behaviour
• develop emotion regulation skills
• improve peer interactions.
Teaches:
prosocial skills
how to negotiate friendships
sharing and turn taking
affect recognition
how to cope with frustration
management of strong emotions (e.g. anger and
anxiety)
• the basics of problem solving and decision making.
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Program outline
Parents’ group
Uses discussion and modelling to:
• develop parents’ understanding of factors underlying
their children's behaviour
• challenge parents' unhelpful beliefs about their
children's behaviour and about parenting
• teach behaviour management principles and
techniques, and put these into practice
• teach emotion regulation principles and techniques,
and put these into practice
• deal with parenting issues and relationship issues.
Program outline
Second parent-child interactive group
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Focuses around morning/afternoon tea
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Aims to help parents and children:
handle reunion after separation
manage a major issue for this age group – eating
deal with sharing and other behaviour problems
share nutritious and enjoyable snacks
observe other families and the way others resolve issues
around eating
– normalise their own problems.
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What else do we do in ATAPS?
• Individual work
– Play, drawing, painting
• commentary on relevant topics around play
• interpretation of play and drawings
– Games
– Emotion recognition and discussion
– Practice skills with puppets, dolls, toys.
Parent work with young children
– Psychoeducation
• normal development, interruptions to development, how
to adapt to these
• defining appropriate behaviour
• rules and limit setting
• parental roles and responsibilities.
– Individualised behaviour plans
• ABC of behaviour management; focus on antecedents
and prevention of problems
• preparing a procedure to manage meltdowns
• natural and logical consequences
• rewarding appropriate behaviour
• star charts for behaviour management.
Parent work with young children
• Emotion validating parenting
• How to validate your child’s emotions
• How to work with your child to help her manage her
emotions
• How to give positive instructions
• Managing your own emotions
• Helping your child to express herself.
• Try to also help parents with:
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social support
special time for themselves
assertiveness; self-esteem
recognising strengths and resources
relapse prevention.
Parent-child interaction work
– Model positive interactions
– Practice positive interactions, e.g. parents
provide some positive feedback
– Teach parents to manage their own emotions
– Teach parents to help their child with emotion
recognition and regulation skills
– Teach parents non-judgemental commentary
– Play skills through positive games, such as:
“Catch my child being good”; negotiate a trip to
the shop, with rewards built in for desired
behaviour.
Interventions at Kinder/School
– Behaviour management suggestions for staff.
– Again focusing on preventative and positive
interventions.
– Psychoeducation re effects of trauma and
attachment disturbance on a child’s development
and presentation at school.
Case Study 1: Rosemary, 4 year old girl
Summary
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Parents separated; living with Mum
Concerns about having witnessed violence
Some anxiety symptoms
Enuresis (wetting)
Tantrums
Sibling on Autism spectrum.
Assessment
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Clinical assessment interview
Family session
Individual session
Interview with preschool teacher
Questionnaires – Mum and Preschool teacher.
Intervention
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Individual
– Play
– Drawing
– Felt stories; puppets
– Games around emotion recognition and expression.
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Parenting
– Normal development
– Psychoeducation re trauma
– Behaviour management re wetting and tantrums
– Parenting both children – positive and fostering attachment
– Education re parenting child on autism spectrum.
Intervention (cont.)
• Parent-child interaction work and family work
– Modelling positive interactions and
attachment-building responses, for instance:
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giving clear instructions
validating emotions
time in
doing daily tasks together
using language to resolve problems.
Recommendations
• Further assessment.
Case Study 2: Matt, 5 year old boy
Summary
• Parents separated
• Mum had a history of trauma
• Concerns regarding “out of control” behaviours at
home and school; major aggressive outbursts;
defiance; oppositionality.
Assessment
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Clinical assessment interview
Family session
Individual session
Interview with teacher and welfare coordinator
Classroom observation
Questionnaires – Mum and teachers.
Intervention
• Individual
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Play–liked trucks, construction, trains. Chatted as we played.
Drawing on whiteboard – feelings, thoughts, comic strips.
Talking “through” animals.
Working on core beliefs, eg. “I’m bad”.
• Parenting
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Interruptions to normal development.
Psychoed re trauma – parental separation.
Attachment/developmental focused re-parenting.
Behaviour management – positive and fostering attachment.
Intervention (cont.)
• Parent-child interaction work and family work
– Education re how to respond to challenging behaviours.
– Informing Mum of Matt’s core beliefs and helping her to help
him challenge these and see himself in more positive light.
– Modelling positive interactions and attachment-building
responses, for instance:
• validating emotions
• time in
• re-parenting through rocking, cuddling, soothing as you would a
much younger child.
• School
– Implementing good positive behavioural strategies.
– Some education re effects of trauma and attachment on kids
in the classroom (and playground).
Recommendations
• Ongoing parenting/family support.
QUESTIONS &
ANSWERS
REMINDERS
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Contact The ATAPS CMHS Clinical Support Service. Phone on
1800 031 185 or email [email protected]
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A series of CMH webinars will be available in 2014-advertised via
ATAPS clinical support service web portal.
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A recording of this webinar will be available on the APS website
shortly. See
http://www.psychology.org.au/ATAPS/networking_CMHS/
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