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Behavorial Difficulties – Treatment Outcome Studies

Diagnosing Behavior:  Is Johnny disturbed or disturbing?

As a powerful illustration of the subjective nature of defining behavioral “disorders,” consider that the first edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) in 1952 included homosexuality as a mental disorder.  The DSM is now in its fourth edition (DSM IV) and no longer considers homosexuality as a disorder.

DSM-IV does, though, include a diagnosis for older children called Oppositional Defiant Disorder (ODD).  According to the American Academy of Child and Adolescent Psychiatry, “In children with Oppositional Defiant Disorder (ODD), there is an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the youngster’s day-to-day functioning.  Symptoms of ODD may include: frequent temper tantrums, excessive arguing with adults, active defiance and refusal to comply with adult requests and rules, deliberate attempts to annoy or upset people, blaming others for his or her mistakes or misbehavior, and often being touchy or easily annoyed by others, frequent anger, and resentment, mean and hateful talking when upset, seeking revenge.”

Do you think this pattern of behavior “deserves” to be a formal “diagnosis” (ODD), or does this pattern of behavior just mean that the child “is a brat who needs a good swift talking to”?  Before answering, you should know that, according to DSM-IV, “In a significant proportion of cases, Oppositional Defiant Disorder is a developmental antecedent to Conduct Disorder,” and “Many individuals with Conduct Disorder…(have) a worse prognosis and increased risk in adult life for Antisocial Personality Disorder and Substance-Related Disorders.” Indeed, these questions that involve behavioral diagnoses are complex, and a parent’s responses to these questions are probably more greatly influenced by opinion, morality, and politics, than by “what the experts say.”

How many pre-schoolers have ‘behavior problems’?

About 15% of parents report their 3- or 4-year-old has a “mild behavior problem,” and about 7% of parents report their 3- or 4-year-old has a “moderate or severe behavior problem.”

During early childhood, when are behavior problems ‘the worst’?

Parents of 6-week to 5-year-old children report peak behavioral difficulty at 3- to 4 years of age. This is in contrast to the conventional wisdom of “the terrible two’s.”

Among children and families in need, how many receive mental health services?

Approximately 10 % of children who need mental health services actually receive such.

Do children “outgrow” behavior problems?

With behavioral problems, there is always the interesting question of whether this is simply “a phase”?  Parents ask themselves, “Should we ‘wait-and-see’ or seek help?”  About 50% of those with preschool externalizing behavior problems continue to have such problems in adolescence.

What does the research show about treatment for behavioral problems?

Michael Guralnick’s landmark 1997 book, “The Effectiveness of Early Intervention” examined 3 model programs of family-based intervention for young children with behavior problems (The Oregon Social Learning Center; Forehand and McMahon’s program, “Helping the Noncompliant Child”; and Webster-Stratton’s BASIC program).

These three programs all had similar therapeutic content, including parent training on precisely identifying and tracking problems
behavior, use of concrete and social reinforcement, the building of positive behavior (e.g., compliance training with young children, chores with older children), use of many different appropriate consequences (e.g., time-out, removal of privileges, response-cost), close supervision of children, problem-solving, negotiation, and monitoring/modifying strategies.   All three of the programs had similar results:

  • High parent satisfaction.
  • Short-term significant change in parent’s and children’s behavior as well as perceptions (e.g., 20 to 60% decrease in aggression).
  • Maintenance of treatment gains were observed in 1- and 4-year follow-up studies.
  • Generalization of positive results was observed (e.g., in school, at social gatherings, and at home).
  • The “earlier the better” as the younger the child, the more positive the outcomes (i.e., 2- to 6-year olds had the most improvement when compared to intervention with older children).

How much intervention seems necessary?

Ten or more hours yielded optimal results.  If more than one family member was involved, treatment had more positive effects. “Booster Shots” (periodic follow-up sessions) provided enhanced long-term treatment gains.