BEHAVIORAL THERAPY

IN CHILDREN
DR.SU.POORNIMA
 INTRODUCTION

 In 1952 Eysenck coined the term “behavior therapy” to capture the application of behavioral
principles to treatment of patients, and Wolpe began developing treatments based on classic
conditioning theory.

 In the 1970s, many treatments were developed for children and adolescents. These covered all
the main disorder groupings, with, for example, exposure treatments with relaxation for fears
and anxiety, contingency management through parent training for disruptive disorders and
functional analysis for challenging behaviors in children with intellectual disability.
 In recent years, a “third generation” of behaviorally based cognitive therapies has emerged
following traditional behavior therapy and CBT. Examples
 Acceptance and Commitment therapy,
 Dialectical Behavior Therapy and
 Mindfulness-Based Cognitive Therapy
 BASIC TENETS

CLASSIC CONDITIONING:
 Pavlov described classic conditioning, whereby unconditioned stimuli (e.g., food) that led to
unconditioned responses (salivation) could be presented at the same time with other (conditioned)
stimuli (e.g., a bell), which then led to similar, but not identical, conditioned responses.
 For example, dogs given food as they smell explosives learn to associate the smell of explosives
with a reward, and can be trained to sniff airline luggage.

 This mechanism continues to underpin many current treatments for anxiety, phobias and PTSD.
 In phobias the unconditioned response of overwhelming fear to a stimulus could be replaced by a competing
conditioned response of relaxation through sufficient exposure, so that habituation occurred - systematic
desensitization.
OPERANT CONDITIONING:
 Skinner termed behaviors that led to rewards or punishments
operants because they operated to change the environment for
the individual.
 Thus, children starting school soon learn that speaking to their
friends in class may be punished by disapproval and a
consequence such as detention, but that putting their hands up to
answer a teacher’s question is likely to be rewarded by approval.
 BEHAVIORAL ASSESSMENT

INTERVIEW:
 In the interview, a thorough and detailed description of the behavior in question is elicited
including its frequency, duration and severity.
DIARY:
 Where the picture is unclear, parents can be asked to keep a diary and note each day what
happens over, say, a 2-week period. This may reveal exceptions, when the problem behavior
is not shown; then the clinician will work closely with the parents to elucidate what else
differed on those days.
 RATING SCALES

 A standardized rating scale is helpful in ensuring that a systematic approach is taken to measuring the extent and
severity of the problem domain.

 It can provide a useful talking point when an item has been checked, and can act as a baseline measurement of
severity, to be given at different points of treatment to monitor progress.
Some useful examples

 the Conner’s rating scales for ADHD symptoms,

 the Eyberg Inventory for conduct problems,
 the Mood and Feelings Questionnaire for depression,
 the Child Impact of Traumatic Events Scale Revised for PTSD, and
 the Yale–Brown Obsessive-Compulsive Scale for OCD
DIRECT OBSERVATION:
 Direct observation, preferably “live” in the context where the behavior occurs, is often revealing.
 For example, the same complaint “hits other children in school” might in one child be observed only to
occur when other children speak to him while he is engrossed in schoolwork, and in another when she is
taunted about her weight and told by her peers to go away.
FUNCTIONAL ANALYSIS:
 Functional analysis goes a step further so that after generating hypotheses, they are tested
experimentally.
 Thus, in the first example above, children might be asked to approach the boy and see
whether indeed he then lashes out; it might emerge that he does so when boys approach
and not girls
 INTERVENTION TECHNIQUES TO
INCREASE BEHAVIOR
POSITIVE REINFORCEMENT:

 This should be used when a new behavior is to be incorporated into

the child’s repertoire, or when an existing behavior is desired more
frequently or across more situations.
 SOCIAL REWARDS:

 In the social domain, attention is most powerful with younger children, but it
is often also very effective for adolescents. It is often enough to say a few
words showing that the behavior has been appreciated (e.g., describing what
they did). To add power, it may be combined with words of praise or physical
expressions of affection such as a hug.
TANGIBLE REWARDS:
 These include items such as food (from single sweets to a trip to a
restaurant), leisure activities (time on the computer or the
telephone, going swimming) and privileges (staying up late, having a
friend over).
APPLICATION OF REWARDS:

 In practice, rules for rewards must be clear and simple;

the therapist must check with the child that they
understand them, and check that the parent implements
them fairly and consistently. Rewards need to be changed
every week or so to avoid satiation.
 Non-contingent general praise will not improve specific
behaviors and can lead the child to be “spoiled”
(i.e.,believe they are approved of whatever they do).
 SCHEDULES OF REWARDS:

 These may be continuous (i.e., after each behavior ) or variable, either by

time or after a certain number of behaviors.

 Differential attention is where appropriate behavior is attended to, whereas

inappropriate behavior is ignored (e.g., minor irritations, whining; hitting and destruction
cannot be ignored).
 (e.g., “He’s only doing it for attention, I shan’t give in!”).
 NEGATIVE REINFORCEMENT :

 This refers to the removal of something unpleasant, with the consequence

that the procedure is reinforcing (the term is sometimes mistakenly used to
refer to receiving reinforcement for negative behavior; e.g., through
attention).

 Negative reinforcement can be used to increase wanted behavior through

removing a mildly aversive situation after the child behaves as desired (e.g., a
parent may threaten to turn off the TV unless the child takes his feet off the
table, and remove the threat after he does)
 Positive and negative reinforcement can be further divided into:
 1 Reward training: “If you make the response, you will get the reward”;
 2 Privation training: “If you don’t make the response, I will withdraw a reward”;
 3 Escape training: “If you make the response I will withdraw a punishment”;
 4 Avoidance training: “If you don’t make the response you will be punished.”
 TOKEN SYSTEM:

 These allow instant rewards to be given, and so maintain performance over a time when
reward cannot be without delay. Later, they can be exchanged for substantive rewards such as
a special meal, going to the park or having a friend round. Useful applications apply in
classrooms and in foster homes.
 For example ,groups of children in a classroom earn points for good behavior, and the winning
group gets rewarded; children monitor and control their peer group’s behavior to ensure their
group wins.
 Shaping

 Here one reinforces small steps in the right direction of a behavior the individual has not done
before.

 It is a popular technique with animal trainers, who can train two naïve pigeons to play ping-pong
in half an hour!

 Shaping is especially helpful for children if they cannot imagine what is required, the behavior
cannot be modeled for them or they will not understand it.

 Shaping is especially useful with children with intellectual disability.

 Modeling

 This technique is useful for learning new complex behaviors or for learning more
appropriate responses (e.g., a fearless response to a dog).
 It assumes the child can observe the model and internalize it, and that externally (or
through internal motivation) one can reward it.
 If the model has characteristics the child respects or desires, this will aid effectiveness. One
can use filmed modeling for children (e.g., of other children being brave when confronted
by feared situations) or to show parents other ways of responding to their children.
 Prompting

 A prompt is a stimulus that may help a behavior pattern be initiated, and is especially useful
at the beginning of a program.
 When giving a command it may help to hold up the reward (say, a token) to the child to
prompt him
 For prompting to work, it is crucial to have rewarding consequences in place
 – parents and teachers often use multiple prompts ineffectively (nagging) without setting up
the consequences likely to ensure that the desired behavior occurs.
 Written prompts are prevalent in everyday life (“Drive slowly!” “Now wash your hands”).
 INTERVENTION TECHNIQUES TO
DECREASE BEHAVIOR
EXTINCTION :

 This refers to the withholding of reinforcements for behavior so that it is

eliminated from the child’s repertoire.
 It requires careful analysis of all possible reinforcers (e.g., attention from
parents, siblings and peers) and then ensuring no source of reinforcement is
available – in this example, asking all parties not to respond to the behavior
in question.
 As ever, to succeed one has to be very clear and specific about the behavior
to target, and rehearse with parents and teachers how to avoid responding.
 STIMULUS CONTROL:

 Here the aim is to remove a stimulus that leads to a difficult behavior, rather than
changing the consequences. Turning off the TV may help a child get to bed by removing
the competing stimulus of the program
 PUNISHMENT:

 This can be the withdrawal of something reinforcing (i.e., extinction), or the contingent
application of something aversive; at times one may shade into the other. Hitting and hurting
are types of punishment that have been associated with more traditional cultures and
families. Apart from the inhumanity and potential for abuse of such methods.

TIMEOUT:
 The full term is time out from positive reinforcement. To be effective, before the punishment
is given, the child has to be in a context that is positively reinforcing.
 RESPONSE COST:

 This refers to the withdrawal of specified amounts of reinforcement

(e.g., points, tokens, money, privileges) immediately following a
previously defined unwanted behavior. Thus, for responding in a way
that violates rules, the child promptly loses out.

 Response cost tends to be used with tangible, rather than social

rewards, and consequently is especially helpful when social rewards are
not likely to work.
 OVERCORRECTION:

 Here the child is subjected not only to a response cost, but also to an
additional penalty to “overcorrect” for their misbehavior; the idea being to
make the child especially aware of the punishment that will follow the
unwanted behavior.

 Thus, a child who throws down litter may be made not only to tidy up his or
her own rubbish, but to clear up a whole field.
 SYSTEMATIC DESENSITIZATION:

 This procedure is typically used where there is avoidance (e.g.,because of phobias or

anxiety states, or events experienced as traumatic).

 When the child is comfortable,he is exposed to the stimuli, for long enough to overcome
an anxious or fearful response so that this is replaced with a relaxed one.

 Over a number of sessions, the stimulus strength is increased by ascending the hierarchy,
and supports are withdrawn. Encouraging active participation by the child enhances the
procedure.
 FLOODING:

 This is an extreme form of exposure, whereby the child is

brought into contact with the most feared item on the inventory
and kept in contact with it until the fear is extinguished.
 Modeling

 Here a model is exposed to the feared stimuli while the child watches – thus it is a form of exposure whereby the child can
identify and learn from the model that the stimuli are in fact safe and can be coped with.

 For example, a child can be shown a film of medical procedures, or a teddy bear can be given a blood test.

 Such procedures have been shown to reduce fear and anxiety

 Live modeling is generally more effective than symbolic modeling.

 If anxiety is severe, it can be combined with relaxation, and repeated several times in a graded way.
 Role Playing

 By enacting behaviors rather than just talking about them, the child gets to practice the new responses in a
favorable environment with fewer distracting stimuli than in real life.

 This is particularly helpful when emotional reactions may supervene (e.g., when a child with anger
management problems is trying to stay calm while being provoked).

 For parents who cannot imagine the impact of their harsh practices on a child, it can be helpful to set up a role
play with the parent playing the child, and another person behaving the way the parent usually does.
 FADING AND GENERALIZATION:

 Fading procedures gradually change the environmental stimuli so they

approximate, as far as possible, the natural conditions that will prevail following
treatment.
 Methods include reducing reinforcement to an intermittent schedule, arranging for
the artificial rewards such as tokens to be replaced by social ones such as praise
from close adults – in real life these rewards are likely to be given only
intermittently.
 Another approach is to widen the rewards and the people giving them, thus
increasing generalization.
APPLICATIONS OF BEHAVIORAL
THERAPY

EMOTIONAL DISORDERS:
 Anxiety disorder
 Obsessive Compulsive disorder.
 Post traumatic stress disorder
 PTSD and child sexual abuse.
DISRUPTIVE DISORDER:
 Conduct disorders
 Attention deficit/ hyperactivity disorder.
 DEVELOPMENTAL DISORDER:
 Nocturnal enuresis
 Pervasive developmental disorders
 Intellectual disability.
 Anxiety disorders

 Anxiety disorders respond well to behavioral approaches

 The underlying principle is to expose the child to the feared stimulus and teach an alternative conditioned
response characterized by calm and relaxation.

 Graded exposure and systematic desensitization are used

 Obsessive-Compulsive Disorder

 In childhood OCD, anxiety is a major feature, and the behavioral treatment is based on similar graded exposure to the feared object or context
(say, dirt).

 During exposure (E) to the phobic stimulus, it is important to prevent the child from carrying out the obsessive response, which acts as a
negative reinforcer for the child by reducing anxiety.

 Response prevention (RP) involves stopping the child carrying out rituals;

 for example, they must touch “germy things” but refrain from washing until their anxiety is reduced.

 A third element in additionto E and RP is stopping parental reassurance, to ensure full exposure effects

 Cognitive components may be added if there are substantial obsessive thoughts,

 Post-Traumatic Stress Disorder

 the core of behavioral treatment for PTSD is exposure, in this case to vivid recollection of the traumatic event.
 Disruptive Disorders
Conduct Disorders

 Behavioral methods and the social learning approach revolutionized the treatment of conduct problems.

 Anger management programs working directly with children and adolescents are also based on behavioral
theory, to which a self-control cognitive element has been added

 parent training alone. child social skills training alone, and both combined.
 Attention Deficit/Hyperactivity Disorder

 children with ADHD respond better to immediate rewards – delays beyond a few seconds lead to diminished responses;
 Modifications to standard behavioral programs should include giving rewards more rapidly and frequently, changing
them more often to avoid boredom, and givin directions mor e clearly.

 Generally speaking, core symptoms of ADHD change less in behavioral programs than do conduct symptoms.
 Pervasive Developmental Disorders

 Behavior therapy needs to be adapted to this client group in a number of ways.

 First, changes need to be introduced gradually, within a framework that is predictable and structured in terms of daily
routines – otherwise anxiety, social isolation and rigidities may emerge rapidly.
 Second, instructions need to be concrete, specific and calmly delivered, because metaphorical expressions and using tone
of voice to convey meanings may lead to misunderstandings.
 Third the intensity of social stimulation will need to be titrated to the level that can be handled, which may be quite low in
some cases.
 Fourth, training and interventions should be performed as much as possible in daily-life situations, to overcome the
problems in the transfer of skills mastered in one setting to another.
 Intensive early interventions for children with ASD are more likely to be successful
 Applied behavioral analysis

 Most widely used behavioral intervention

 It focuses on improving specific behaviors using discrete trials to teach simple skills, then progressing to more complex
skills and complex behaviors
 Useful in social skills,communication,reading, academics as well as adaptive learning skills such as, fine motor dexterity,
hygeine,grooming,domestic capablities,punctuality,and job competence
 Ideally more than 20 hr per week is recommended for under 4 years age.
 Helps in minimising negative behaviours
 in autistic adults helps with memory, relationships and cognitive strength
 Intellectual Disability (Mental Retardation)

 Behavioral methods are a major part of treatment regimes in children with intellectual disability.
 While children with Iqs above 60 or so may be able to participate to some extent in using cognitive techniques
 Stimulus control and manipulation of antecedent variables are often especially helpful
 Teaching alternative responses can also be very effective.
 Functional communication training is a form of functional displacement, whereby a child is taught a more appropriate
alternative.
 General Issues

 behavioral therapies have offered mainstream interventions for many conditions. However, they may not be especially
helpful where the primary problem is an inner mood or belief state without pressing behavioral manifestations.

 behavioral approaches offer unique strengths for conditions where the child’s problems cannot easily be changed effectively
by a cognitive approach, for example in babies and young infants (e.g., feeding and sleeping problems), in children with
severe learning disabilities (e.g., challenging behavior) and more generally where the behavior is not very amenable to
conscious control (e.g., hyperactivity and aggression).

 behavioral techniques are helpful for any condition where changes in the external environment can make a difference,
Thank you