Download Learning Objectives What is normal opposition? Oppositionality

10/30/2012
Diagnosing the
Out of Control Pre-Schooler
Barbara J. Howard, MD
bhoward@chadis com
[email protected]
www.CHADIS.com
I & my spouse have the following financial
relationship with the manufacturer of any
commercial product and/or provider of commercial
services discussed in this CME activity: CHADIS
The Center for Promotion of Child Development through
Primary Care and its for-profit subsidiary, Total Child
Health, Inc. developed CHADIS, a web-based screening
and
dd
decision
i i supportt system.
t
D
Dr. H
Howard
d iis P
President
id t and
d
she and her spouse Dr. Sturner are members of the Board
of Directors of the for-profit subsidiary, Total Child Health.
Dr. Sturner is Director of the Center and both are members
of its Board of Directors. They are paid consultants to both
entities. The terms of the arrangement are being managed
by The Johns Hopkins University in accordance with its
conflict of interest policies.
I do not intend to discuss an unapproved/investigational use
of a commercial product/device in my presentation.
Learning Objectives
What is normal opposition?

Pediatricians will be able to develop a
differential diagnosis for the out of control
child
 Pediatricians will be able to carry out steps
to discover the “meaning” of children’s
behavior
Autonomy develops over time
 Directs/averts gaze at birth
 Initiate “dialogue” by 8 weeks
 Hatching at 8 months
 Resist object pull- 8 months
 Demand
D
d exclusive
l i care off mo
 Tantrums by 12 months
 Separate easily by 4 years
 “Identity” develops as teen


Assertion versus Aggression

Degree of dysfunction determines whether
behaviors are normal or abnormal
 Standing
Oppositionality
Common 2-16% of children
 Presents as:

 He
won’t listen
 Not minding
 Doing the opposite of what I say
 Have to tell her a hundred times
Typical compliance of preschoolers
60%; Noncompliant children often 30%
 Boys > Girls until puberty then =
 Onset usually < age 8

att 9 months
th
up for having their needs met
Definitions
V65.4 Aggressive/Oppositional Variationseveral x per wk, min impact
 V71.02
V71 02 Aggressive/Oppositional ProblemProblem
begins to effect, mod. impact
 313.81 Oppositional Defiant Disorder

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313.81 Oppositional Defiant Disorder– DSM V def. pending
A persistent pattern of angry and irritable mood along with defiant and
vindictive behavior as evidenced by >=4 of the following
symptoms being displayed with >=1 person other than siblings.
A. Angry/Irritable Mood
1. Loses temper
2. Is touchy or easily annoyed by others.
3 Is angry and resentful
3.
B. Defiant/Headstrong Behavior
4. Argues with adults
5. Actively defies or refuses to comply with adults’ request or
rules
6. Deliberately annoys people
7. Blames others for his or her mistakes or misbehavior
C. Vindictiveness
8. Has been spiteful or vindictive >=2x within 6 months
Anger
“A strong feeling of displeasure or hostility”
 Aggression – intrusive actions against
others or acts intended to hurt others
 “Frustration->Aggression” hypothesis
People respond with anger because
they feel helpless to fix how they feel.

A
B. Also under DSM 5 consideration
A. The persistence and frequency should be used to
distinguish normal from symptomatic to determine
disorder.
<5 years: most days for a period of at least six months
>5 years: at least once per week for at least six months
B Other factors to consider: developmental level
B.
level, gender
gender,
and culture.
C. Causes clinically significant impairment in social,
educational, or vocational activities.
D. The behaviors may be confined to only one setting or, in
more severe cases, present in multiple settings
Why is anger mgt important?

Those who have failed to master the early
regulatory tasks are more likely to
develop:
p
 Conduct
problems
 Peer-rejection
 Poor school performance
 Unhappy lives
universal emotion
Hard on everyone around them
(Strain, Kerr, Stagg & Lenkner, 1984).

Prevalence of Aggressive
Behavior in Young Children




15-30% of preschoolers have significant
behavior problems, usually incl. aggression
25-40% boys 2-5 yrs mod to high aggression
10 28% girls
10-28%
il 2
2-5
5 yrs mod
d tto hi
high
h aggression
i
Aggression typically peaks before age 3 years
Some Societal Trends Potentially
Increasing Aggression
64% of mothers work FT while child <1 yr
 Lower income families get poorer child care
 Television violence is modeled > 15
months
 Father presence modulates aggression
 Lack of sleep is rampant in children and
parents

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Environment of Anger: Parent factors
Caregivers themselves have:

Anger can be evoked by:
1))Environment of anger
g
2)Painful feelings
3) Thwarting of a perceived need








Painful feelings in Child -> anger
or hunger or fatigue or med effects
 Failure of mastery
Life stress beyond their coping ability
 Poverty, housing, immigration, legal problems,
discrimination
Lack of social support
Marital discord/divorce (45%)
Domestic or neighborhood violence
Depression (30-50% with kids <5), anxiety or other mental
health issues eg ADHD in 25% pa of kids with ADHD
Health problems with worry, pain, disability, exhaustion
Substances: prescribed, alcohol 6%, drugs, caffeine
Exhaustion, sleep debt
Frustration
Pain
 Pain

Low self-esteem
 Failure
socially
Loneliness
L
li
 Isolation

 Anxiety
about situations over which the child
has no control including sensory issues
 Failure of support

Dependency needs not met
 Sadness/depression-
“Better mad than sad”
Problems of Physical Punishment
Impulsive, poorly modulated, inconsistent
 Disrespectful to child, lowers self esteem
 Increases aggression, sibling rivalry
 Not educational
 Replaces other forms of management
 Not useful at older ages, long term
 Produces fear and anger, inhibits other
behavior
 Associated with later depression, alcoholism,
drug abuse, lower school/job achievement, less
stable marriages, spouse abuse, child abuse

Illness eg Sickle cell, arthritis, eczema,
IBD, constipation
 Injuries eg head injury and headache
 Abuse - Physical, emotional or sexual
 Corporal punishment

Rates of Corporal Punishment
in US
25% 1-6 months
50% 6-12 months
90% 3 years
60% 10-12
40% 14
25% 17
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Hunger in Children in the United States:
Potential Behavioral and Emotional
Correlates
Thwarting of perceived needs
Ronald E. Kleinman*, , J. Michael Murphy§, , Michelle Little§, Maria
Pagano§, Cheryl A. Wehler¶, Kenneth Regal#, and Michael S.
Jellinek§,
8% of US children <12 years classified as hungry
Pediatric Symptom Checklist showed that virtually all
behavioral, emotional, and academic problems were
more prevalent in hungry children, but that aggression
and anxiety had the strongest degree of association with
experiences of hunger.
Needs of Children
 Need
for state regulation
 Need for mastery
 Need for positive emotional tone
 Need for assistance regulating
negative affect
 Need to be taught prosocial behavior
and empathy
 Need for fair treatment
Patterns of Parenting Dysfunction
Over regulation
 Under regulation
 Inappropriate regulation
 Chaotic regulation
 Affective Mismatch

Perceptive caregivers recognize
needs of the child
Connected parents know their children
well, so they are less likely to create
situations that provoke anger.
 Confident parents know they don't have to
be harsh to be in control.
 The unconnected child feels something
important is missing in his “self” and is
angry about it. Well being is
threatened.

Under regulation - factors
Too
busy… ?cell phones
Guilty for absence
Vulnerable child syndrome
History of abuse/harsh parenting
Mood disorder in parent
Substance use by parent(s)
Marital discord
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Over regulation

Needs of Children
Intrusive management-
 Need
for state regulation
 Need for mastery
 Need for positive emotional tone
 Need for assistance regulating
negative affect
 Need to be taught prosocial behavior
and empathy
 Need for fair treatment
 May
be from parental anxiety, cultural,
“vulnerable child”

Excessively harsh punishment
1) Constantly
"being yelled at" for even minor
behavior (Nattering)
2) No attention/reinforcement for good behavior
3) Corporal punishment

Possible effects
 Anger,
opposition
back to their apparently “mean” parent.
 Low self esteem
 Pay
The Need for State Regulation
Attention/Impulsivity
Routines of eating, sleep
Consistent responsiveness
These stabilize mood, reduce resistance
 Avoid overstimulation- noise, awake time,
sex
 Especially important for temperamentally
irregular, unadaptable children
 Especially vulnerable- CNS damaged, lead
poisoned, prenatal substance exposed,
ADHD
 Likely missing in social chaos,
overextended


Attention/impulsivity problems commonly
associated with anger/aggression.
 Up
p to 60% of children with oppositional
pp
behavior have ADHD.
 Consider side effects of medications used

Preschool ADHD Diagnosis
Preschool ADHD Treatment Study (PATS)
DSM-5 requires onset < 12 years
Most had symptoms at 3-4 years (Eggar)
 Broad differential diagnosis
 Preschoolers more environmentally
sensitive
 DX: (1) symptoms >=9 months
(2) dysfunction in both home and other
settings such as preschool or child care,
(3) dysfunction that has not responded
adequately to behavior therapy.



303 preschoolers (3-5.5 years) with moderate
to severe ADHD
 8-phase, 70-week c two double-blind, controlled
phases, a crossover-titration trial followed by a
placebo-controlled parallel trial & 10 mo f/u
 69.6% c co-morbid disorders: ODD, anxiety,
communication disorders
 Those c communication disorders more anxious
and depressed.
 ADHD severity correlated c internalizing
disorders and lower functioning.
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Preschool ADHD

Harvard study of 4-6 year olds coming to
child psychiatry clinic
 86%
 68%
had ADHD
had 2 or more mental health disorders
40% resolve ADHD with age
 >50% persist: more if earlier onset, family
history of ADHD.
 More comorbidities, less responsive to
medications (MPH) than older kids c ADHD.

Needs of Children
Regulation Disorders of Sensory Processing
(DC: 0-3R; Zero to Three, 2005)
Three Features:
(1)
(2)
(3)
sensory processing difficulties,
motor difficulties, and
a specific behavioral pattern
Types
Hypersensitive Type A: Fearful/Cautious
Hypersensitive Type B: Negative/Defiant
Hyposensitive/Underresponsive
Sensory Stimulation-Seeking/Impulsive
The Need for Mastery
 Need
for state regulation
 Need for mastery
 Need for positive emotional tone
 Need for assistance regulating
negative affect
 Need to be taught prosocial behavior
and empathy
 Need for fair treatment
 Experiences
Developmental difference
Qualities of Good Child Care
Won’t do or Can’t do?
Use a standard developmental screen for:
 developmental delay
 low cognitive functioning
 learning disabilities
 speech/language delay
 social learning disability
 Sensory integration problem
 Autism Spectrum Disorder
of mastery should respect
need for autonomy but avoid
overwhelming child
 Stress of separation
p
for day
y care can
evoke anger (dependency need)
 Over protectiveness or over strictness
evoke anger (autonomy need)
 Inconsistency evokes anger (fairness)
 Inadequate limits evoke anger (anxiety)
 Adequate
caregiver:child ratios
 Attention to positive behavior
 Anticipation of problems and
redirection
 Adequately stimulating curriculum
 Space and toys for small group play
 Nonphysical discipline
Lower income child gets lower quality
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Needs of Children
 Need
for state regulation
 Need for mastery
 Need for positive emotional tone
 Need for assistance regulating
negative affect
 Need to be taught prosocial behavior
and empathy
 Need for fair treatment
Hostile Bias Attribution
Tendency to infer hostile intent in others
 May stem from:

 Past
adverse experiences
attachment
 Cognitive bias
 Mood disorder
 Insecure

Need for Positive Emotional Tone
 Positive
tone & stable attachment avoid
suspiciousness & enhance resilience
under stress which can evoke anger
 Hostility in the family:
raises
tension
aggression
includes pain/fear which evokes anger
models
 Depressed
child &/or adult need treatment
 Anxious children may over infer
aggressive intent & over react
Reaction to stressful
environment
Inconsistent/strenuous or irregular
schedules make children vulnerable to
aggressive
gg
behaviors due being
g tired,,
hungry, or stressed by irregular, unusual
demands.
Tend to act aggressively proactively
Traumatic Life Events
Feel badly about themselves
Children viewing violence may model it
 Children with a traumatic experience may
feel guilty and act up to elicit punishment
 Family members experiencing trauma may
change their parenting
 Include sexual traumas esp with older
child
 Trauma changes the brain/reactions


If told they are bad, will act the part
 Reassure: "You're not bad, you're just
young and young people sometimes do
young,
foolish things.
 Promise adult’s help: “I will help you stop
doing them so you will grow up feeling like
you are the nice person I know you are.”
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10/30/2012
Needs of Children
for state regulation
 Need for mastery
 Need for positive emotional tone
 Need for assistance regulating
negative affect
 Need to be taught prosocial behavior
and empathy
 Need for fair treatment
The Need for Assistance
Regulating Negative Affect
 Need
Environment reinforcing anger

Sometimes a child's anger prompts an
adult to set rules more clearly, explain
matters more thoroughly,
g y, or make changes
g
in the child's environment.
 Child
learns that anger is an all-purpose red
flag for help
 Especially if lesser signals don’t work

Mood Disorders





Remember that young children may not report
sadness.
Normal predominant child mood is cheerful
D
Depression
i may presentt as h
hyperactivity
ti it or
irritability.
Rapid mood swings may be bipolar
Family history of mood often suggestive
“Coercive Cycle” where child anger results
in parent backing off
Anxiety and Anger
Anxiety produces vigilance for threat
 High levels of arousal->readiness for
fight/flight
 May be combined with ADHD and
impulsivity or depression
 Proactive aggression is one coping
strategy
 May justify aggression with anger

Regulation occurs through: jollying,
distracting, modeling, acknowledging,
verbalizing,
g, compromising
p
g
 Depression/temperament can be source of
anger
 Excessive negative affect is encouraged by:
covert encouragement eg projection, passive
avoidance, punishment. These are likely
when parents can’t tolerate negative feelings.

Needs of Children
 Need
for state regulation
 Need for mastery
 Need for positive emotional tone
 Need for assistance regulating
negative affect
 Need to be taught prosocial behavior
and empathy
 Need for fair treatment
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The Need to Be Taught Prosocial
Behavior and Empathy
Skills include:
trading, taking turns, waiting, asking for
things, thanking, taking other’s point of
view seeing effects of own actions
view,
actions,
recognizing feelings of others
 Less taught/modeled if excess stress as in:
large family size
low income
single parenthood

Need for Fairness
 Children have an inherent sense of Justice
 Sibling rivalry related mostly to “perception
of differential treatment”
 Sibling
g may
y have special
p
needs
Needs of Children
 Need
for state regulation
 Need for mastery
 Need for positive emotional tone
 Need for assistance regulating
negative affect
 Need to be taught prosocial behavior
and empathy
 Need for fair treatment
Meaning of the Behavior
Child behavior has meaning to the child
and family and is initiated and/or
maintained by
y this meaning.
g
 Caregivers may be erratic or truly unfair
 Child may feel at unfair disadvantage:
Misunderstood
Outpaced in the group
Unable to perform to own standards
due to perfectionism
A,B,C of Behavior



Antecedent- setting events: what was going on
prior?
Behavior- what exactly did she do?
Consequence- what resulted for child and for
parent? (reinforcement, feelings)
Ask child: What do you think your parents should
do?
“Activities of Daily Living” Examples
Ask about:
meal times, bedtime (needs structure)
eating, toileting (needs autonomy)
separation,
ti
fears
f
(needs
(
d emotional
ti
l
development and security)
peers, school (needs competence)
OR
“Tell me about a typical day starting when he
gets up…”
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10/30/2012
Sleep debt
Average Sleep by Age
Age
18 mo
2-3 yr
4-6 yr
7-11yr
12-18yr
Destabilizes frontal lobe
Worsens all mood disorders
 Parent with sleep debt is more irritable
 Get sleep diary if necessary
 Consider Obstructive Sleep Apnea
 Work on sleep first or simultaneously


Example: Meal times-
Nighttime
Daytime
11.5
2.0
11.0-11.5
1.0-1.5
10.75-11.5
9.5-10.5
8.25-9.25
Components of Assessment
History from child and parents
 Physical exam- abuse, syndrome, neuro
 Vision and hearing
 Developmental
D
l
t l screen or assessmentt
 Checklists from daycare or teachers
 Relevant lab- eg lead, Hgb, sleep study
 Observation of parent-child interaction
 Hypotheses and trial of intervention




Won’t come, won’t sit, throws food,
hits sibs -> ADHD, attention getting
R f
Refuses
ttextures,
t
very picky,
i k chokesh k
> regulatory/sensory integration
Parent insists on eating/manners->
over control
Differential Diagnosis -ages 3-6
years
Most common
 Inappropriate expectations/mgt
 Difficult Temperament
 Sleep deprivation
 Stressful environment

ADHD
Differential Diagnosis - 3-6 yrs
Less common
 Hearing problem
 PTSD
 Mood Disorder incl. bipolar
 Mixed Expressive/Receptive Language
Disorder
 Low cognitive functioning
 Learning Disability/Difference
 Regulatory/Sensory Integration Problem
 Autism Spectrum Disorders: Autism, Pervasive
Developmental Disorder, Asperger’s
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Medical History- especially…
Risk factors for developmental disabilities
plus
 Pain
 Hunger
 Anemia/ iron deficiency
 Celiac disease
 ADHD
 Mood
 Sleep disorder

Family History




Any “health or emotional or learning
problems”
Include substance use
Educational/vocational attainments
Looking for: ADHD, mood, juvenile
delinquency, LD
History from Child


•
•

School, teacher, friends, bullies
Best friend, age, activities
Who lives at home? Nice/mean,
best/hardest parts from child
What do your parents do if you do
something bad?
Has anything bad or scary happened?
(trauma)
Social History from Parents





Hardest and best parts?
Do you agree on discipline?
Who can you count on?
How is the marriage?
“Who does he take after?” (projection)
Intervention for Diagnosis
Formulate a hypothesis
 Negotiate a plan
 Follow up

 Failure
Children who feel more loved, accepted and
competent are less angry!
is as telling as success
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10/30/2012
Tools to help in this process
Ages & Stages Questionnaires®– SocialEmotional (ASQ:SE) J Squires, D Bricker, & E Twombly
 Age range: 6–60 months
 General areas screened: Personal-social (self-regulation,
compliance, communication, adaptive functioning, autonomy, affect,
and interaction with people)
 Questionnaires for ages 6
6, 12
12, 18
18, 24
24, 30
30, 36
36, 48
48, and 60 months
months,
 Parents/caregivers complete questionnaires; 5-6 grade reading
 Takes 10–15 min to complete; 1-3 minutes to score
 Validity and reliability: n>3,000 across the age intervals and their
families. Reliability is 94%; validity is between 75% and 89%
 English and Spanish
ASEBA Child Behavior Checklist 1.5-5
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1.5-5 years
Caregiver and teacher forms; 15-20 min; multiple languages
99 items concerning issues, disabilities, descriptions of
problems about the child being rated, and the best things
about the child being rated.
Emotionally Reactive, Anxious/Depressed, Somatic
p
, Withdrawn,, Attention Problems,, Aggressive
gg
Complaints,
The three primary scales (Internalizing, Externalizing, Total
Problems) plus Sleep Problems syndrome.
DSM scales: Affective Problems; Pervasive Developmental
Problems; Anxiety Problems; Oppositional Defiant Problems;
Attention Deficit/Hyperactivity Problems
Includes Language Development Survey (LDS) indicating
whether a child's vocabulary and word combinations are
delayed relative to norms for ages 18-35 months.
Based on ratings of 1,728 children; normed on 700.
Automated scoring program available
CHADIS 0-3
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Brief Infant-Toddler Social & Emotional
Assessment (BITSEA)
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Symptom checklist for 1-2 year olds
12-36 months
60 items; 10 min
alphas=.83 for problem scale and .66 for
competence scale vs ITSEA
Tested on 1280 parents, fairly diverse both
ethnically and SES
Test-retest .72-.82; good sensitivity & specificity
(Albus, Sturner, Howard, Egger, Emde, Thomas, Wise, 2009)
Collects data on daily routines and functioning e.g eating, sleeping
Assesses all DC: 0-3R diagnostic criteria, incl: traumatic stress disorder;
anxiety disorders; grief; mixed disorder of emotional expressiveness;
adjustment disorder; regulatory disorders; sleep disorders; eating disorders;
and disorders of relating and communicating.
Translation of DC: 0-3R diagnostic descriptions into definable criteria by
concensus; where specific guidelines in DC: 0-3R, these were utilized.
Where no specific DC: 0-3R
0 3R guidelines but comparable disorders in the
DSM-IV or DSM-PC, effort to be consistent.
Modeled after DSM-PC categories of “variation,” “problem” and “disorder,”
based on degree of disruption of child and family life and/or # symptoms
endorsed, as appropriate.
Focus also on assets
Ages 2 months- 4 years
Takes 10-30 min depending on concerns endorsed
Test-retest reliability satisfactory
Validity vs BITSEA, ITQ, CBCL, PAPA underway n=450
Eyeberg Child Behavior Inventory
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Screens general behavior
2 to 11 y (best used to age 4)
36 items; 7 min
C score >16
Cut
16
Externalizing problems (eg, conduct, attention,
aggression)
Sensitivity 80%, specificity 86%
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10/30/2012
Behavior Assessment System
for Children (BASC)
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Comprehensive behavior rating scales
Ages: 2:6-18; self report 8-18
10-20 min;; 30-45 minutes ((SRP))
Parent, teacher, youth, devel. history, structured
observation versions
T scores, % by gender and age & a clinical
population
Strengths and Difficulties QuestionnaireGoodman
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Screen of burdensome behavior: conduct, attention,
anxiety-depression
Ages 4-16;33 items
As good as CBCL for conduct and emotional
problems,
bl
better
b tt for
f ADHD
Burden item highly related to use of mental health
services
Standardized in several countries,
Free; available in >40 languages
Computer scoring
Tools in CHADIS
INFANT & YOUNG CHILD




Questionnaires®,
Ages & Stages
Third Ed. (ASQ3™)
Modified Checklist for Autism in Toddlers (MCHAT) & Follow-up
CHADIS 0-3 (young child mental health)
ASQ-SE
SCHOOL AGE
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Pediatric Symptom Checklist (17 items)
Vanderbilt Parent Revised & Follow-up
CHADIS - DSM
Strengths & Difficulties Questionnaires & FA
SCARED: Parent and Child
Child Behavior Checklist (coming)
ADOLESCENT
GENERAL HEALTH

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CHADIS Visit Priorities
Early Periodic Screening Diagnosis and Treatment
(EPSDT)
Family Medical History
Family Cardiac History
Safety & Guidance Topics (Bright Futures)

Edinburgh Postnatal Depression Scale
Multidimensional Scale of Perceived Social
Support (MSPSS)
McMaster Family Assessment Device, General
Functioning Scale
CHADIS Stressors Checklist
Adverse Childhood Experiences (ACE)
Partner Violence Screen

2-PRIME adult depression

Safe Environment for Every Kid






CHAMPS (Adolescent Risk Behaviors)
QUALITY MONITORING


TEACHER DATA


Vanderbilt Teacher Revised & Follow Up
School Intervention Questionnaire
psychosocial screen
Ages 4-16
Child form >9
35 items,, 7 min
One page parent questionnaire
Free, English and Spanish
Cutoffs but no standard scores
Sensitivity (80% to 95%), but somewhat
scattered specificity (68% to 100%).
CHADIS decision support:

Parent and teen separately
take previsit online
questionnaires

Clinician reviews results,
can consult linked textbook

Clinician may exchange
findings with school or
mental health provider
online

Clinician finds relevant
resources, handouts from
links & prints for family

Education materials
automatically populate
MemoryBook/CarePortal
Diagnostic Classification 0-3R
FAMILY / ENVIRONMENT


General
(partial listing)
Pediatric Symptom Checklist - Youth
Patient Health Questionnaire 9 (PHQ-A)
CRAFFT
Kutcher Adolescent Depression Scale
CES-DC (depression)

Pediatric Symptom Checklist- Jellinek


Provider-level Promoting Healthy Development
Survey
Child-Adolescent Needs & Strengths (CANS)
13
10/30/2012
Hypersensitive Type A:
Fearful/Cautious

Hypersensitive Type B:
Negative/Defiant

Sensory Reactivity Patterns: overreactivity to sensory

stimuli, including light touch, loud noises, bright lights, unfamiliar smells
and tastes, rough textures, or movement in space.








Motor Patterns ((>=1)
1)
Difficulties with postural control and tone
Difficulty in fine motor coordination
Difficulty with motor planning
Less exploration than expected for age
Limited sensory-motor play
Behavioral Patterns: excessive cautiousness, inhibition, and
fearfulness
Hyposensitive/Underresponsive

Sensory Reactivity Patterns



Underreactivity to sounds, movement, smell, taste, touch, and proprioception
In infants, lack of responsivity to sensations and social overtures
Sensory Stimulation-Seeking/Impulsive
 Sensory Reactivity Patterns

Motor Patterns (>=2)

Limited exploration
Restricted play repertoire
 Search for sensory input, often repetitive
 Lethargy
 Poor motor planning and clumsiness



Behavioral Patterns (>=1)


Apparent lack of interest in exploring properties of objects, playing
challenging games, or engaging in social interactions
 Apathetic appearance
 Fatigability
 Withdrawal from stimuli
 Inattentiveness
May appear delayed or depressed.
Selected references
Barkley RA. Defiant Children: A clinician's manual
for assessment and parent training. NY, Guilford
Press, 1997
Barkley RA, Benton C, Your Defiant Child, The
Guilford Press,, NY,, 1998
Christophersen, E.R. & Mortweet, S.L. (2003).
Parenting that Works: Building Skills that Last a
Lifetime. Washington D.C.: APA Books
Christophersen, E.R. (2003). Part of the
Relationships APA Psychotherapy Video Series,
Washington, D.C.: American Psychological
Association. Parenting Young Children
Sensory reactivity patterns are identical to those of Type A
Motor Patterns are also identical to those described in Type
A: Fearful/Cautious
Behavioral patterns: avoid or be slow to engage & aggressive
only when provoked.
 Negativistic
N
ti i ti b
behavior...
h i
((one or more off the
th following)
f ll i )
 Controlling behaviors (For children older than 12 months:
 Defiance
 Preference for repetition, absence of change, and, if
change is necessary, change at a slow pace
 Difficulty adapting to changes in routines or plans (one or
both of the following)
 Compulsiveness and perfectionism
 Avoidance or slow engagement in new experiences or
sensations
Craving for high-intensity sensory stimuli. Such a craving may lead to destructive
or high-risk behaviors
Motor Patterns (>=1)

High need for motor discharge
Diffuse impulsivity
p
y
 Accident proneness without clumsiness


Behavioral Patterns (>=1)

High activity levels
Seeking constant contact with people and objects
 Seeking stimulation through deep pressure
 Recklessness
 Disorganized behavior as a consequence of sensory stimulation

Gordon T. Parent Effectiveness Training, NY, Peter H.
Wyden, Inc. 1970
Ghuman JK, et al. Comorbidity moderates response to
methylphenidate in the Preschoolers with AttentionDeficit/Hyperactivity Disorder Treatment Study (PATS).
J Child Adolesc Psychopharmacol. 2007 Oct;17(5):563-80.
Greene R, The Explosive Child, HarperCollins, 2nd editions,
NY, 2001
Greenhill L, et al. Efficacy and safety of immediate-release
methylphenidate treatment for preschoolers with ADHD.
J Am Acad Child Adolesc Psychiatry. 2006
Nov;45(11):1284-93.
Howard BJ, 2005, Aggression/Opposition, In Child Health
and Development interactive System, www.CHADIS.com
Howard, B. J., Discipline in Early Childhood, Ped. Cl. N.
Am. 38:1351, 1991.
Howard BJ Advising Parents on Discipline: What Works
14
10/30/2012
Landy S, Peters RD, 1990, Identifying and treating
aggressive preschoolers, Inf Young Child 3:24-38
Patterson GR: Living with Children, New Methods
for Parents and Teachers, Research Press, 2612
North Mattis Ave., Champaign Ill 61820, 1976
Patterson GR, Forgatch M: Family living series Part
1 (5 cassette
tt ttapes to
t be
b used
d with
ith Li
Living
i with
ith
Children), Champaign Ill: Research Press Co.,
1975
Patterson GR, Forgatch M: Family living series Part
2 (3 cassette tapes to be used with Living with
Children), Champaign Ill: Research Press Co.,
1976
Peter RD, McMahon RJ, Quinsey VL,(Eds), 1992,
Aggression and Violence Through the Life Span, Sage
Publications, Newbury Park, CA
Posner K, et. Al. Clinical presentation of attentiondeficit/hyperactivity disorder in preschool children: the
Preschoolers with Attention-Deficit/Hyperactivity
Disorder Treatment Study (PATS). J. Child Adolesc
Psychopharmacol. 2007 Oct;17(5):547-62.
S l
Solomons
HC
HC, El
Elardo
d R
R, 1991
1991, Biti
Biting iin d
day care centers:
t
Incidence, prevention and intervention. J Ped Health
5:191-6
Webster-Stratton, C, Kolpacoff M, Hollinsworth T, The
long-term effectiveness and clinical significance of three
cost-effective training programs for families with conduct
problem children. J Consulting and Clin Psychol.
1989;57:550-53
15