Presenter: Dr. Ewbank
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Dr. Ewbank presented that behavioral difficulties in children and adolescents can be best understood as skills deficits. He gave us strategies to making proactive response plans that reduce behavioral problems and that seek to build skills over time.
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Does CBT work with kids who have cognitive delays and Auditory Processing issues?
Have you seen success with the methods discussed tonight with children as young as preschoolers?
How does a parent deal with a school and child that seems to think the way to handle this child is to make him sit there in a Behavior Intervention Class after school until he complies and ultimately he is pushed into an outburst. Then when cursing begins police are called to issue citations, child is suspended from school, etc. The school recently forced my child into a Behavior Intervention Class and has had multiple explosive outbursts in a matter of 3 weeks causing police to be called, citation issued, CPS called and child to be suspended.
We have a third grade student who has outbursts on a daily basis. There is the chance of a possible bi-polar diagnosis. How do you know if the outbursts are the result of a medical condition or that of a spoiled child?
My daughter repeated calls me, her mother, a BITCH, especially when she is angry. She is 8 years old and has Tourettes. How do I address this with her? Do I ignore this behavior because it appears to be out of her control or do I punish the behavior?
“Lost at School” by Dr. Ross Greene is also a great book for parents and school personnel. The hardest part is changing the school’s feelings that the child is a behavior problem opposed to needing some skill development!
My 8 year old son has Tourette Syndrome, pretty severe OCD, and ADHD (medicated for all three) and tends to have outbursts and refusal behaviors more at school. What type of strategies could we recommend for the school to assist him?
Would you receommend CBT for a 7 yr old who was adopted band does not have Touretts?
How do you help a sibling understand that the child with TS is not doing it on purpose?
How do you handle the motivation therapy when several older and younger siblings (without TS) are watching and wondering why the TS child gets special treatment? Do I need to do it for all 5 of my children? My children are — 11, 9 ( my son with TS), 7, and 4 yr old twins. Trying to work with him, creates issues with the 11 and 7 year old. We try very hard to hold him accountable so there is no preferencial treatment.
What do you do when your child does is not concerned about his actions? Or outbursts. Then has remorse after the outburst is over?
I work with a child (7) who seems to have all the necessary skills in school. but at home is when he is having his explosive outbursts. How is this possible?
Is there a different approach when dealing with violent and aggressive outburts?
I know there is no definite anwser to how you treat outburst but it just seemed you told us a bunch of ways that dont totally work, which one do you think would be the best method to long term treatment of outburst/expolsive behavior. Thank you for talking today.
I teach preschool autistic children. How would you handle a child whose behaivor is definately maintained by attention. He screams, cries, will try to hit anything he can to get attention from my or my staff.
My son has ts and ocd and adhd. his he is 16 and appears very intellegent and normal and polite and has friends but loses it with us, his parents. He is caught with anything he does wrong due to lack of executive functioning and can be abusive via language and outbursts. he blames us for anything wrong in his life. I know he can’t handle being to blame but how do we help him understand it is his choices that cause him problems.
Hi, Everyone. It is Dr. Ewbank. Thank you for all of the thoughtful questions. I have been informed that posts occur in order received. I will log on in my spare moments throughout then day and answer as many questions I can in the order that they came.
CHILD FIXATED ON IDEAS OF DEATH/CATASTROPHY:
It sounds like this child may be suffering intrusive thoughts as a part of OCD. If so, the thoughts cause anxiety and they are difficult to stop thinking about. In this case, Cognitive Behavioral Therapy for OCD could be indicated. As a parent dealing with his upset, my recommendation would be to normalize the thoughts, letting him know that all children and even adults have thoughts like this. I would try not to spend too much time arguing why the thoughts do not make sense. Instead, I would reassure the child that it makes sense that the thoughts make him anxious, but that it is okay to be anxious. Often, I am recommending this to parents as a part of the therapy treatment.
CBT 4 KIDS W/ COGNITIVE/AUDITORY DELAYS
Yes. CBT can be successful for children with cognitive delays and auditory processing issues. Ideally, the CBT clinician would have some knowledge of learning disabilities. Most important is that the difficulties are taken into account and that treatment is tailored to the child with the deficits. In general, CBT should be tailored to a child’s developmental level and any learning issues should be considered.
REDUCING OUTBURSTS IN PRESCHOOLERS
I do not experience working with families on these methods with preschoolers, but feel that they could be helpful. I would say that for younger children, there should be lower expectations on their ability to communicate about solutions. In fact, the adult may need to help the child speak their concerns. I would put more focus in creating an environment that reduces outbursts even if that means, at times, conceding to the child’s demands. Still, I would look to select common problem areas to engage them in collaborative problem solving. The young child practicing problem solving skills will become a better problem solver when they are older. Better problem solver = less outbursts.
CHILD IN SCHOOL WITH EXTREME CONSEQUENCES THAT ESCALATE BEHAVIORS
This is a tough one because some schools are more open to suggestion than others. That said, it would be useful to find an advocate for the child in the school (e.g. a prinicipal or school counselor) who can begin to change the behavioral plan for your son. Also, the more expertise you can gain, the better. I recommend reading the book Lost at School by Ross Greene (as was mentioned above). The book will describe an alternative method to helping your son (especially because it sounds as if the current method is NOT working). Now if you can get someone at the school to read the book as well, you may be on the path toward not just helping your own son, but towards helping many struggling students at that school. Good luck!
THIRD GRADER – OUTBURSTS DUE TO MEDICAL DIAGNOSIS OR SPOILED CHILD:
I would recommend an evaluation by a qualified neurologist, psychiatrist, or psychologist to determine whether there is a medical diagnosis that contributes to the behaviors. With either cause, I still recommend that the school team complete the ALSUP (www.livesinthebalance.org/paperwork) to get a better picture of lagging skills and unsolved problems and that the team consider a problem solving approach to address identified areas. This can help lower ourtburst behaviors regardless of their cause.
8 YEAR OLD CURSING AT MOTHER:
I am guessing that punishing your daughter has not helped the problem. It might be time to try a different approach. Use the method described in my talk to understand why your daughter is cursing at you. This involves completing the ALSUP and using the Plan B flowchart (www.livesinthebalance.org/paperwork) to identify what leads your daughter to use profanity and initiating problem solving during a moment when she is calm. The method to use is in detail in The Explosive Child by Ross Greene.
SCHOOL RECOMMENDATIONS FOR CHILD WITH TS, ADHD, OCD WHO HAS OUTBURSTS, AND REFUSAL BEHAVIORS AT SCHOOL:
It sounds like things are pretty tough for your son. This complex array of challenges makes it a difficult situation to advise in this format. Since he is already receiving medication consultation, I would further recommend working with a psychologist to help prioritize problems, to offer suggestions to the school, and/or to work directly with your son to decrease symptoms. All of this work would need to follow a thorough evaluation. For example, if ther evaluation suggested that OCD symptoms were likely the greatest contributor to school difficulties, it could be useful to begin exposure therapy (a form of CBT) for OCD.
QUESTION IS: Would you receommend CBT for a 7 yr old who was adopted band does not have Touretts?
I am sorry. I am not sure I understand the question. If you could rephrase and repost, perhaps I could provide some helpful answer.
HELPING A SIBLING TO UNDERSTAND TS:
The answer to this question can vary based on the age of the sibling. I think as a parent, you are doing well with this difficult issue if you are regularly checking in with the non-TS sibling about their experiences and frustrations around having a sibling with TS. See if the sibling can become better at telling you about their siblings tics and other difficulties. Another thing that can be helpful would be to get them into contact with other siblings of children with TS. If you are a New Jersey resident, NJCTS offers a wonderful program in the late spring called Camp Bernie which you can read about on their website. Lastly, I know there are some good children’s books for siblings, but do not have any titles. Are there any parents on this chat with book recommendations?
TS, 4 SIBLINGS AND CONCERNS ABOUT PREFERENTIAL TREATMENT:
As a parent it can be difficult to manage sibling expectations that everyone is treated fairly. The reality is, however, that every child in a family requires their own form of specialized treatment, because every child is different. Instead of trying to create an environment that is fair, I encourage parents to meet each child’s individual needs. Further, it may be beneficial to promote a family culture where children realize that they are all different and have different needs. When addressing this with your children, do not only focus on the different needs of the child with TS. Instead, focus on the different needs of everyone. This can help to create a context of acceptance for the needs of your child with TS.
CHILD IS FIRST UNCONCERNED, THEN REMORSEFUL ABOUT OUTBURSTS:
This scenario is actually rather common. In the midst of an explosive outburst, the child is reacting emotionally in the present moment, and can lack perspective. After an outburst, as the child settles back into their normal state, they often feel terrible about the way they acted, and the things they said or did. It can be challenging for an adult to ride this rollarcoaster. My advise, identify with the child who is not in the rage. Encourage the child to see the rage as something that happens to them, but is not a core part of who they are. As far as what to do, use the methods described to understand the sources of outburst behaviors and to make proactive plans that can decrease explosive outbursts over time.
HOW IS IT POSSIBLE TO HAVE RAGES AT HOME, BUT NOT AT SCHOOL:
This is not only possible, it is often the case. A large percentage of children with explosive outbursts only have outbursts in the home or with family members. I do not know of any specific research to explain this. Still, consider the unfortunate tendency for children to have outbursts in the environments and with the people with whom they feel safest. This is often at home with parents and siblings.
IS THERE A DIFFERENT APPROACH FOR VIOLENT/AGGRESSIVE OUTBURSTS:
The approach is same. Violent/aggressive outbursts are a good place to use the collaborative process to learn the child’s concerns in the settings where violent outbursts are occuring When the child’s concern has been heard, state the adult concern. Then, engage the child in problem solving to find a solution that works for both adult and child. As in all outbursts, it is ideal that this discussion occurs outside of the situation that leads to the outburst. If the level of violence and aggression has created concerns for the safety of the child or for others, then parents or teachers should be prepared to enact a safety plan that might involve mental health professions, police, or a trip to the emergency room.
Question: My son has been diagnosed with ODD. I often get the response from him “I don’t care” or “whatever”. The reward system does not see to matter as I always get the responses above.
Any suggestions?
WHICH IS THE BEST METHOD FOR CONTROLLING OUTBURSTS:
Good question. I realize that I may not have been so clear on this point. Different methods can be more useful at different times. That said, there is still an order to things. I am going to rank order the methods:
Best Method: Collaborate with the child on the planned solution – this is the superior method because it serves to reduce outbursts and to teach lagging skills. Unfortunately, it is often not realistic to use this method in too many situations at once. It is better to pick a couple of outburst areas for collaboration. As problems are resolved in these areas, target additional areas. For other areas, consider the 2nd best method.
2nd Best Method: Modify environment so that the child is not faced with the problem – this method is intended to reduce outbursts, but it does not teach skills. If the child is having frequent outbursts, it can be difficult to teach skills. This method should be used to lower overall incidence of outburst so that skills can be taught.
3rd Best Method: Accept that explosive outbursts are likely to occur- Clearly, this method will neither lower outbursts, nor teach skills. If you are need guidance to use the above two methods in an outburst situation, it is likely that outbursts will continue as they are. Knowing this, it might be best to accept that there are going to be outbursts for now. Hopefully, you are also seeking appropriate support to implement the above two methods
HOW TO HANDLE AUTISTIC 3 YEAR OLD WHOSE PROBLEM BEHAVIORS ARE MOTIVATED BY ATTENTION:
This is an excellent situation to employ motivational strategies (as opposed to the problem solving methods that I advocated for in my talk). Autistic children respond well to functional analysis followed by classic motivational methods. If the child has been found to be motivated by attention, provide attention whenever the child is doing something desirable. If the child is doing something undesirable, structure the environment so that they do not receive attention.
16 YEAR OLD WITH TS, OCD, ADHD, AND EXECUTIVE FUNCTIONING CHALLENGES WHO DOES NOT TAKE RESPONSIBILITY FOR HIS DECISIONS:
I am not sure it would be helpful to try to convince your 16 year-old that his choices cause him problems. With everything he is struggling with, I am pretty convinced that he is faced with a lot of demands that are not reasonable. I imagine it is unlikely that he will be convinced to make better choices. Instead, he needs the help of the adults in his life. I recommend the adults, parents, teachers, mental health professional, etc come together to understand what causes his outbursts by filling out the ALSUP to identify his lagging skills and the unsolved problem areas. Next, I recommend that expectations are lowered in most outburst areas as a way to decrease outbursts. In a couple of selected outburst areas, I recommend collaborating with the adolescent to come up with solutions. If he is really struggling, the adults may want to read The Explosive Child, by Ross Greene to gain a more detailed description of this approach.
SON WITH ODD WHO SAYS “I DON’T CARE” IN RESPONSE TO REWARD SYSTEM:
Spending time and energy on a reward system that is not working is incredibly frustrating. Unfortunately, rewards systems often do not work with children who are having explosive outbursts. A weakness of the ODD label is that it predicts defiant behavior, but does not explain what brings it about. Consider that there are reasons for your son’s outbursts. I imagine that he is lacking skills in areas such as cognitive flexibility or frustration tolerance or something else. At the moment when the expectations on your son exceed his skill level, he is likely to have an outburst. When this happens, he has little control over his ability to not have an outburst. Thus, when it is needed most, the reward program becomes arbitrary. Since the reward program does not help your son control his outbursts, it is not surprising that he does not care. I suggest you transition out of the reward program and instead identify the areas of lagging skills (using the ALSUP). From here move into a problem solving approach as discussed in my talk and as is laid out in detail in Ross Greene’s The Explosive Child.
This discussion has been closed. Thank you to everyone who participated!
My child gets fixated with ideas about death and end of the universe or catastrophic thoughts. How can I handle this subjects that make him very worried. He has TS and is 7 years old.
Posted on February 24th, 2011 at 7:55am by KelleyT