Child Psychopathology Treatment

Treating Childhood
Psychopathology
and Developmental
Disabilities
Treating Childhood
Psychopathology
and Developmental
Disabilities
Edited by
Johnny L. Matson
Louisiana State University, Baton Rouge, LA
Frank Andrasik
University of West Florida, Pensacola, FL
Michael L. Matson
Louisiana State University, Baton Rouge, LA
Editors
Johnny L. Matson Frank Andrasik
Department of Psychology Department of Psychology
Louisiana State University University of West Florida
Baton Rouge, LA 70803 Pensacola, FL 32514-5751
225-752-5924 fandrasik@uwf.edu
johnmatson@aol.com
Michael L.Matson
Department of Psychology
Louisiana State University
Baton Rouge, LA 70803
ISBN: 978-0-387-09529-5 e-ISBN: 978-0-387-09530-1

DOI: 10.1007/978-0-387-09530-1
Library of Congress Control Number: 2008931350
© Springer Science + Business Media, LLC 2009

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Contents
PART I: INTRODUCTION
Chapter 1. History of Treatment in Children

with Developmental Disabilities and Psychopathology ..................... 3
Jonathan Wilkins and Johnny L. Matson
Chapter 2. Applied Behavior Analysis and the Treatment

of Childhood Psychopathology and Developmental Disabilities ........ 29
Joel E. Ringdahl and Terry S. Falcomata
Chapter 3. Cognitive Behavior Therapy .......................................... 55

Ellen Flannery-Schroeder and Alexis N. Lamb
Chapter 4. Parent-training Interventions ........................................ 79

Nicholas Long, Mark C. Edwards, and Jayne Bellando
PART II. CHILDHOOD PSYCHOPATHOLOGY

AND DEVELOPMENTAL DISABILITIES
Chapter 5. Conduct Disorders ....................................................... 107

Christopher T. Barry, Lisa L. Ansel, Jessica D. Pickard,
and Heather L. Harrison
Chapter 6. Treatment of Attention-Deficit/

Hyperactivity Disorder (ADHD) ........................................................ 139
Ditza Zachor, Bart Hodgens, and Cryshelle Patterson
Chapter 7. PTSD, Anxiety, and Phobia ............................................ 183

Thompson E. Davis III
Chapter 8. Treatment Strategies for Depression in Youth................ 221

Martha C. Tompson and Kathryn Dingman Boger
v
vi CONTENTS
Chapter 9. Medication Treatment of Bipolar

Disorder in Developmentally Disabled Children
and Adolescents.............................................................................. 253
Zinoviy A. Gutkovich and Gabrielle A. Carlson
Chapter 10. Treatment of Autism Spectrum Disorders ................... 287

Mary Jane Weiss, Kate Fiske, and Suzannah Ferraioli
Chapter 11. Treatment of Self-Injurious Behaviour

in Children with Intellectual Disabilities.......................................... 333
Frederick Furniss and Asit B. Biswas
Chapter 12. Communication, Language, and Literacy

Learning in Children with Developmental Disabilities...................... 373
Erna Alant, Kitty Uys, and Kerstin Tönsing
PART III: BEHAVIORAL MEDICINE
Chapter 13. Eating Disorders ......................................................... 403

David H. Gleaves, Janet D. Latner, and Suman Ambwani
Chapter 14. Treatment of Pediatric Feeding Disorders ................... 435

Cathleen C. Piazza, Henry S. Roane, and Heather J. Kadey
Index .............................................................................................. 445

List of Contributors
Erna Alant
Center for Augmentative and Alternative Communication,
University of Pretoria, Pretoria 0002 South Africa, erna.alant@up.ac.za
Suman Ambwani
Department of Psychology, Dickinson College, P.O. Box 1773, Carlisle,
PA 17013, ambwanis@dickinson.edu
Lisa L. Ansel
Department of Psychology, The University of Southern Mississippi,
118 College Dr., Box 5025, Hattiesburg, MS 39406, lisaansel@gmail.com
Christopher T. Barry
Department of Psychology, University of Southern Mississippi,
Hattiesburg, MS 39406, Christopher.Barry@usm.edu
Jayne Bellando
Department of Pediatrics, University of Arkansas for Medical Sciences,
Arkansas Children’s Hospital, Little Rock, AR 72202
Asit B. Biswas
Leicestershire Partnership NHS Trust and University of Leicester,
Leicester Frith Hospital, Leicester LE3 9QF, UK, asitbiswas@yahoo.co.uk
Kathryn Dingman Boger

Department of Psychology, Boston University, Boston, MA 02215,
dingman@bu.edu
Gabrielle A. Carlson
Stony Brook University School of Medicine, Stony Brook, NY 11794,
Gabrielle.Carlson@StonyBrook.edu
Thompson E. Davis III

Department of Psychology, Louisiana State University, Baton Rouge,
LA 70803, ted@lsu.edu
vii
viii LIST OF CONTRIBUTORS
Mark C. Edwards
Department of Pediatrics, University of Arkansas for Medical Sciences,
Arkansas Children’s Hospital, Little Rock, AR 72202
Terry S. Falcomata
Center for Disabilities and Development, Division of Pediatric
Psychology, Department of Pediatrics, Children’s Hospital of Iowa,
Iowa City, IA 52242
Suzannah Ferraioli
Douglass Developmental Disabilities Center, 151 Ryders Lane,
New Brunswick, NJ 08901, sferraioloi@gmail.com
Kate Fiske
Douglass Developmental Disabilities Center, 151 Ryders Lane,
New Brunswick, NJ 08901, katefiske@gmail.com
Ellen Flannery-Schroeder
Department of Psychology, University of Rhode Island, Kingston,
RI 02881, efschroeder@mail.uri.edu
Frederick Furniss
The Hesley Group, School of Psychology, University of Leicester,
Doncaster DN4 5NU, UK, fred.furniss@hesleygroup.co.uk
David H. Gleaves
Department of Psychology, University of Canterbury, Christchurch,
New Zealand, david.gleaves@canterbury.ac.nz
Zinoviy A. Gutkovich
Division of Child and Adolescent Psychiatry, Department of Psychiatry,
The Zucker Hillside Hospital, Glen Oaks, NY 11004, ZGutkovi@lij.edu
Heather L. Harrison
118 College Dr., Box 5025, Hattiesburg, MS 39406,
Heather.harrison@usm.edu
Bart Hodgens
Civitan International Research Center, University of Alabama
at Birmingham
Alexis N. Lamb
Psychology Department, University of Rhode Island, 10 Chafee Rd.,
Kingston, RI 0288, anlamb@mail.uri.edu
Janet D. Latner
Department of Psychology, University of Hawaii at Manoa,
2430 Campus Road, Honolulu, HI 96822, jlatner@hawaii.edu
LIST OF CONTRIBUTORS ix
Nicholas Long
UAMS Department of Pediatrics, College of Medicine,
University of Arkansas for Medical Sciences, Little Rock,
AR 72202, longnicholas@uams.edu
Heather J. Kadey
Munroe-Meyer Institute for Genetics and Rehabilitation,
University of Nebraska Medical Center, Omaha 68198, NE
Johnny L. Matson
Department of Psychology, Louisiana State University,
Baton Rouge, LA 70803, johnmatson@aol.com
Cryshelle Patterson
Sparks Clinics, University of Alabama at Birmingham
Cathleen C. Piazza
Munroe-Meyer Institute for Genetics and Rehabilitation,
University of Nebraska Medical Center, Omaha 68198, NE
Jessica D. Pickard
118 College Dr., Box 5025, Hattiesburg, MS 39406, pickard_jd@yahoo.com
Joel E. Ringdahl
Center for Disabilities and Development, Division of Pediatric
Psychology, Department of Pediatrics, Children’s Hospital of Iowa,
Iowa City, IA 52242, joel-ringdahl@uiowa.edu
Henry S. Roane
Munroe-Meyer Institute for Genetics and Rehabilitation, University
of Nebraska Medical Center, Omaha 68198, NE
Martha C. Tompson
Department of Psychology, Boston University, Boston, MA 02215,
mtompson@bu.edu
Kerstin Tönsing
University of Pretoria, Pretoria 0002, South Africa, kerstin.tonsing@up.ac.za
Kitty Uys
University of Pretoria, Pretoria 0002, South Africa, kitty.uys@up.ac.za
Mary Jane Weiss

Douglas Developmental Disabilities Center Rutgers, The State University
of New Jersey, New Brunswick, NJ 08901, weissnj@rci.rutgers.edu
x LIST OF CONTRIBUTORS
Jonathan Wilkins
Department of Psychology, Louisiana State University, Baton Rouge,
LA 70803, Johnmatson@aol.com
Ditza Zachor
Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
dzachor@asaf.health.gov.il
1
History of Treatment
In Children With
Developmental Disabilities
And Psychopathology
JONATHAN WILKINS and JOHNNY L. MATSON
INTRODUCTION
The history of modern child psychopathology and developmental dis-

abilities is of fairly recent origins. However, of the two topics, intellectual
disability (ID) is the area which has received the most attention as a mod-
ern science and profession for the longest period of time.
In December of 1896 in an address to the American Psychological
Association, Lightner Witmer outlined what he descried as a scheme
for practical work in psychology. The plan had four components: 1) the
investigation of mental and moral development; 2) a psychological clinic
supplemented by a training school/hospital to treat retardation or physical
defects interfering with school progress; 3) practical work in the observation
and training of normal and retarded children; and 4) training of students for
a new profession, the psychological expert, who would examine and treat
mentally and morally retarded children, or in connection with the practice
of medicine (Witmer, 1907). Witmer discusses pedagogical treatment for
stammering and other speech defects, bad spelling, slow mental develop-
ment, and motor defects. As such, these early efforts were primarily geared
toward remediation of what we would now call developmental or learning
disabilities.
JONATHAN WILKINS and JOHNNY L. MATSON • Louisiana State University
J.L. Matson et al. (eds.), Treating Childhood Psychopathology 3

and Developmental Disabilities, DOI: 10.1007/978-0-387-09530-1,
4 JONATHAN WILKINS and JOHNNY L. MATSON
This topic is followed by autism and more recently the autism spec-
trum disorders (ASD), followed by child psychopathology such as depres-
sion, hyperactivity, and anxiety. The area that has the briefest history is
behavioral medicine with children. There are of course various reasons for
the time when various areas of study began to emerge with children. The
purpose of this chapter is to provide an overview of these areas and major
developments that have led to the establishment of each topic as an evi-
dence-based area of research and practice.
INTELLECTUAL DISABILITY
Intelligence testing is one of the first and best established areas of

study with children. These developments initially grew from pragmatic
considerations about how to differentiate slow learners and high achievers in
the school system. Alfred Binet of the Sorbonne pioneered a series of tests
to identify “at risk” school children. With his assistant Theodore Simon,
they published their new IQ test in 1905, the Binet–Simon scale. In 1908,
they revised the scale, dropping, modifying, and adding tests by age level
for ages 3–13. The test was later renormed in the United States at Stanford
University and became the Stanford-Binet Intelligence Test which is in
wide use today.
Herbert H. Goddard translated Binet’s writings from French to Eng-
lish. He was an early proponent of IQ testing and served as Director of
Research at the Vineland Training School for Feeble-Minded Girls and
Boys. Goddard also developed the notion of subcategories of ID and used
the terms moron and imbecile for those with lower IQ, and idiot for those
with the lowest scores (Goddard, 1920). Although the terminology has
changed from these labels to mild, moderate, severe, and profound, the
recognition that marked performance differences exist in ID and that sub-
categories are advisable has persisted.
Lewis H. Terman, a professor at Stanford University, went beyond
Goddard in that he actually revised the test itself. Most important in
his changes were more standardized responses. He also revised the test
so that it could be used to identify gifted children as well as those with
ID. Published in 1916, the Stanford Revision of the Binet-Simon Scale
of Intelligence became the standard in the United States for assessing
IQ.
One of the unforeseen developments from the widespread acceptance
of IQ testing was the creation of a multimillion dollar testing industry
with hundreds of millions of standardized tests being given to children
yearly. A second development was the recognition that objective stand-
ardized measures could be developed using the IQ test model for a range
of developmental disabilities and forms of child psychopathology. There
was a rather long germination period relative to this later trend with most
of the innovations coming in the latter half of the 20th century. A third
related development involved treatment. Once disorders and disabilities
had been defined and identified, there was an obvious need for training
and treatment strategies.
HISTORY OF TREATMENT IN CHILDREN 5
CHILD PSYCHOPATHOLOGY
The establishment of the first juvenile court in the United States in

1899 is often considered the beginning of the child mental health movement
(Schowalter, 2000). The thrust was the treatment of juvenile delinquency
and was spearheaded by women civic leaders who established the Juvenile
Psychopathic Institute. A neurologist named William Healy headed the
institute. One of his primary accomplishments was the development of
a triad of professionals including a psychiatrist, psychologist, and social
worker. The psychiatrist typically provided treatment, the psychologist did
testing, and the social worker coordinated services and assisted parents.
As reported in many books and articles, this approach became the serv-
ice model for treating children. Typically these services were provided via
community mental health clinics.
Great momentum occurred in 1963 when President John F. Kennedy
signed the Community Mental Health Centers Act mandating the con-
struction of community outpatient facilities. The dominant treatment
paradigm during this time was psychodynamic. In many ways this
approach retarded the growth of treatments for child psychopathol-
ogy and developmental disabilities. For example, children and people
with ID were described as lacking sufficient “ego strength” to develop
many forms of psychopathology. As recently as 1978, researchers were
debating if children could evince depression (Lefkowitz & Burton, 1978).
Similarly, major diagnostic systems such as DSM have only recently
begun to present and refine various forms of psychopathology in chil-
dren (Matson, 1989).
MODERN TREATMENT METHODS
The primary means of intervention for children have involved learning-

based models. More recently medications for some problems have also
begun to be used, typically in combination with learning-based treatments.
For example, Tofranil was approved to treat depression in 1951, and
Thorazine was used to treat psychotic behaviors in Paris in 1952 and was
approved for use in America in 1954.
Although psychodynamic formulations have not been supported by
the research, evidence-based practice does go back to the very found-
ing of the area. Witmer (1907) described his work as clinical psychol-
ogy, a term he says he “borrowed” from medicine. He suggested the
term “clinical” implied a method and noted that the clinical psycholo-
gist was primarily interested in the individual child. He stressed the
relationship between science and practice as well as the notion that
the clinical psychologist was a contributor to science who must dis-
cover the relationship between cause and effect in his applications of
treatment.
There have been a number of general movements from a historical
point of view. These include classical conditioning, operant conditioning/
applied behavior analysis, behavior therapy/cognitive behavior therapy,

medication, and combined therapies. The evaluation of each of these
methods follows.
Classical Conditioning
John Broadus Watson is credited with applying the principles of clas-
sical conditioning (first demonstrated by Pavlov) to human beings. His
research and charismatic personality led to the establishment of behavior-
ism (Maultsby & Wirga, 1998). Watson championed Pavlovian conditioning
as the basis for behavioral psychology, and he maintained an inflexible
adherence to its tenets in his work. Behaviorism was a response to struc-
turalism, a movement spearheaded by E. B. Titchenor in America and
based on the ideas of Wilhelm Wundt, which focused on the passive intro-
spection of one’s mind.
Watson completely rejected the notion of consciousness and intro-
spection, and publicly attacked them in 1913 at Columbia University
with his famous lecture, which was published under the title, “Psychol-
ogy as the Behaviorist Views It” and later became known as the “behav-
iorist manifesto”. However, behaviorism as a movement did not become
popular in the United States until the 1920s. It was during this time,
and as a result of the involvement of American psychologists in World
War I and the publishing of Watson’s Psychology from the Standpoint
of a Behaviorist in 1919, that behaviorism began to spread throughout
American psychology. Watson’s text was the first to analyze human
psychological functioning in terms of behavior (Wozniak, 1997). In
the book, he conceptualized psychopathology as a failure to adjust to
change; it develops when a person holds onto old habits and associated
emotions that no longer work in the context of new situations. Watson
also pointed out that proof for his ideas was evident in the possibility of
retraining as a cure.
Watson first applied classical conditioning to a human subject in
1920 with the case study of Little Albert. In this classic study, Watson
and one of his students, Rosalie Rayner, conditioned the 11-month-old
child to have an irrational fear of a white rat by pairing the presenta-
tion of the animal with an unexpected loud noise. Watson and Rayner
(1920) also demonstrated the generalization of the conditioned fear
response as Albert had spontaneously become afraid of other furry
objects. Although they made some suggestions as to how the fear might
be unlearned, no attempt was made to then reduce Albert’s fear of the
furry objects.
It wasn’t until Mary Cover Jones, another one of Watson’s stu-
dents, that the elimination of irrational fears by induced extinction was
demonstrated. In her research, children who were already overly fearful
were treated with a combination of social imitation and countercondition-
ing. The feared objects were gradually presented while the children enjoyed
a preferred food. Her research was notably documented in with the case
of Peter (Jones, 1924). In this study, Jones eliminated the boy’s fear of a
white rabbit using counterconditioning (i.e., preferred food was presented
simultaneously with the rabbit). During treatment, the rabbit was gradu-
ally brought closer to Peter and he became more tolerant of its presence,
eventually touching the animal without fear. As a result of her work with
conditioning and fears, Jones is often cited as pioneering behavior therapy
(Goodwin, 2005).
However, Watson’s ideas and the doctrine of behaviorism did not
make a large impact in the realm of psychotherapy until after World War
II (Pichot, 1989). This was largely due to the dominant forms of therapy
at the time, hypnosis and suggestion initially and later psychoanalysis;
in addition, the practitioners and proponents of behaviorism were experi-
mental psychologists and outside the field of medicine, which handled the
treatment of neuroses at the time.
The basic principles of classical conditioning have had a far-reaching
influence on treatment strategies for children. Most of the treatments
described below are based on these principles or contain elements of clas-
sical conditioning. Classical conditioning has also been used to treat fear
and phobias of children with developmental disabilities and other learning
disorders but these studies have been sporadic (Labrador, 2004). Usu-
ally elements of classical conditioning are paired with other closely related
techniques such as exposure. A further discussion of these studies is pre-
sented in the section on behavior therapy.
Operant Conditioning/Applied Behavior Analysis

B. F. Skinner’s research and theories have had a profound effect on
the development of behavioral and learning-based therapies. His concept
of reinforcement schedules and how controlling the delivery of reinforce-
ment can influence the speed of learning new habits and their resistance
to extinction was especially important to the development of behavior
therapy (Maultsby & Wirga, 1998). Behavior modification represented an
alternative to psychotherapy, which was lengthy, costly, and ultimately
ineffective, and it was in Science and Human Behavior that Skinner (1953)
outlined his alternative to current theories of psychopathology and psy-
chotherapy (Labrador, 2004).
The goal of therapy in Skinner’s mind was not to eliminate the
impulse that caused the occurrence of a problem behavior but to intro-
duce a replacement behavior that could overcome the circumstances that
had produced the problematic behavior. The way to correct these cir-
cumstances, then, is to first systematically analyze them (i.e., perform a
functional analysis).
Skinner’s goal was to use the experimental analysis of behavior to
modify and reduce abnormal behavior. He believed that abnormal behav-
ior, as any behavior, has been learned in an attempt to adapt to some
environment. However, when a learned behavior is disapproved by society,
it becomes abnormal or maladaptive, and the goal of treatment, then,
is to modify the behavior by replacing it with a more appropriate one.
The effectiveness of treatments for maladaptive behaviors is evaluated by
comparing end results to baseline data. These ideas formed the basis for
applied behavior analysis (ABA) and behavior therapy.
Skinner’s research and ideas have even become an international move-

ment, spreading to places such as Latin America in the 1960s (McCrea,
1976). Fuller (1949) was the first to demonstrate that operant principles
could be applied in a clinical setting. The sole participant in this study
was an 18-year-old male described as a “vegetative idiot”. Using sweetened
milk as a reinforcer, a significant increase of the target behavior (raising
his right arm to a vertical position) was demonstrated in four sessions.
Fuller was also able to show that the behavior could be extinguished by
removing the reinforcing stimulus.
A few years later in 1953, Skinner and Lindsley began applying the
principles of operant conditioning to psychiatric inpatients at a state hos-
pital. They created what was essentially a Skinner box for humans, a
room that allowed tangible reinforcers to be dispensed depending on the
behavior performed by the inhabitant of the room (Skinner, 1954). The
psychiatric patients, who were described as “catatonics, mental defectives
with delusions, paranoids, and in one case, a manic,” were left alone in
the room for one hour each day. The experimenters studied the effects of
different reinforcement schedules and noted that response patterns were
similar to those of animals that had been studied previously in a similar
setting. Skinner believed that applying operant techniques in such a way
would have great motivational value and ultimately lead to positive behav-
ior change.
From this early research with adults, Bjou and colleagues (Bjou, 1959,
1963; Bjou, Birnbrauer, Kidder, & Tague, 1966) and Barrett and Linds-
ley (1962) applied operant conditioning to children with ID. Ferster and
DeMyer (1961) did the same with autistic children by employing a simi-
lar apparatus to the one used by Skinner that dispensed tangible objects
when a key was pressed.
Children with developmental disabilities (especially severe ID and
autism) represent one population that has benefited greatly from the
development of operant-based treatment techniques. The efficacy of
behavioral treatments has been well documented in the literature with
this group, especially with regard to reducing the frequency and severity
of symptoms and challenging behaviors and facilitating the acquisition of
adaptive skills (Rogers, 1998). Such children are likely to evince challeng-
ing behaviors, such as aggression or self-injury, that are severe in inten-
sity and pose a threat to self and others, and it is currently recognized
that the most effective method for treating these high-intensity behaviors
is based on the principles of operant conditioning: either via reinforce-
ment, punishment, or a combination of the two (Pelios, Morren, Tesch, &
Axelrod, 1999).
Challenging behavior is a term that is used interchangeably with mala-
daptive or problem behavior and was introduced to American psychology
in the 1980s to describe problematic behaviors commonly evinced by
individuals with ID (Xeniditis, Russell, & Murphy, 2001). Over the years
these behaviors have been treated with aversive stimuli such as electric
shock (Lovaas & Simmons, 1969), water misting, exposure to aromatic
ammonia, or physical restraint. One problem, however, is that the treat-
ment must be able to be applied consistently across settings.
Although these procedures were usually highly successful at eliminat-

ing the behaviors, there are obvious ethical implications. However, in some
cases the behavior is so severe that there is no other alternative. This is
usually the case when no consistent maintaining functions for the behav-
ior can be identified. Azrin and Holz (1966) noted that the reason that pun-
ishment-based procedures are so effective at eliminating self-injury, for
example, is that the aversive nature of the treatment is able to overcome
whatever source of reinforcement is sustaining the behavior. Less aver-
sive punishment techniques are still frequently employed (e.g., extinction,
time-out, response cost).
Because behaviors such as self-injury or aggression can have differ-
ent functions across individuals and settings and may even vary across
situations for the same individual, selecting a potentially effective treat-
ment can only be accomplished once the maintaining events or factors
for that behavior are understood (Iwata, Dorsey, Slifer, Bauman, & Rich-
man, 1982). Therefore, an important development in the use of operant
techniques in modifying maladaptive behavior in children with ID was the
increasingly pronounced role of functional assessment.
Functional assessment or analysis involves a thorough assessment
of the events preceding (antecedents) and following (consequences) the
behavior. Understanding the antecedents and consequences of a behavior
provides essential information about the reasons why a problem behav-
ior is occurring or why a desired behavior is not occurring. Therefore,
treatments that are constructed on the basis of a careful consideration
of a target behavior’s maintaining factors are more likely to be effective in
reducing or eliminating the behavior and can be just as effective as pun-
ishment (Iwata et al., 1994). A comprehensive approach for conducting a
functional analysis was first delineated by Iwata and colleagues in 1982.
In this study, the authors described four experimental conditions related
to different maintaining factors: social disapproval, academic demand,
unstructured play, and alone.
For example, the self-injurious behavior (SIB) of many children is
maintained by social reinforcement; children exhibiting this behavior have
not learned a socially appropriate way of gaining attention from adults
and have discovered that the behavior gets them the attention they desire
(e.g., parent telling them to stop). In this case, after the function of the
behavior has been identified (i.e., attention), the intervention or treat-
ment will focus on replacing the maladaptive behavior with another, more
appropriate behavior that serves the same function (e.g., saying “Come
play with me.”; Iwata et al., 1994). This procedure is known as functional
communication training (FCT). The desired response is then reinforced
by providing social attention whenever the child asks appropriately and
ignoring instances where the child is engaging in the problem behavior.
In general, this procedure is referred to as differential reinforcement of
alternate behavior (DRA). Alternately, the child could be provided with
social attention anytime he or she is not engaging in the behavior, which is
known as differential reinforcement of other behavior (DRO).
More specifically, functional communication training teaches the child
to emit some type of communicative behavior that results in the same
outcome as the challenging behavior and ultimately reduces the frequency

of that behavior. This procedure is especially appropriate for children with
severe ID and/or ASD, who are often limited in their abilities to communi-
cate. This procedure was first described by Carr and Durand (1985), and in
that paper, the authors stated that the goal of FCT is replacing challenging
behaviors with socially appropriate behaviors, one of which is functional
communication. In order for the communicative replacement behavior to
effectively reduce or replace the maladaptive behavior, it needs to be func-
tionally related to the controlling stimuli (Carr & Durand, 1985). This is
because the socially inappropriate behavior was previously serving as a form
of nonverbal communication for the child. Common replacement behaviors
include asking for help or for a break for escape-motivated behaviors or
an appropriate way to request attention for socially motivated behaviors.
Appropriate responses can be spoken, or in the case of nonverbal individu-
als, involve gestures as in pointing to a picture board. When FCT does not
produce a significant reduction in the problem behavior, adding a punish-
ment component can increase its effectiveness (Fisher et al., 1993).
An early emphasis on functional assessment was evident in the work
of Wolpe (1969). However, the technique fell to subsequent neglect in the
1980s as punishment-based procedures began to gain popularity. During
this time it was believed that punishment alone was sufficient to control
behavior, and the number of these studies increased greatly throughout
the 1970s and mid-80s (Matson & Taras, 1989).
It was believed that punishment could not only reduce challenging
behavior but oftentimes eliminate the behavior completely (Iwata et al.,
1982). However, after reviews by Carr (1977) and Johnson and Baumeister
(1978), functional analysis began to regain favor with clinicians. In these
reviews, it was suggested that some of the failings in the treatment of SIB
reported in the literature were likely due to a lack of information regard-
ing setting and maintaining factors. It was recognized that failing to con-
duct an adequate functional assessment prior to treatment would mean
that the treatment chosen would be implemented without an understand-
ing of the underlying causes of the behavior and would therefore be less
effective. And, when a clinician conducts a functional assessment before
selecting a treatment, he or she is more likely to choose a reinforcement-
based procedure, which is a trend that has become increasingly evident
since the late 1980s/early 1990s (Pelios et al., 1999). Such reinforcement-
based treatment programs would be tailored toward targeting the motivat-
ing factors behind the behavior and should be able to effectively reduce the
problem behavior without the use of punishment. However, behaviors that
have nonsocial functions can be very difficult to treat with reinforcement-
based procedures alone (Iwata et al., 1994). Treatment based on func-
tional analysis, therefore is most effective when the behavior is maintained
by positive (e.g., attention or tangible function) or negative reinforcement
(e.g., escape function; Fisher et al., 1993).
ABA has been the treatment of choice not only for severe problem
behaviors such as aggression and SIB but also in treating sleep problems
(Didden, Curfs, Sikkema, & de Moor, 1998), and star charts and rewards
have been found to be effective in the treatment of enuresis (Järvelin,
2000). Sleep problems in particular are prevalent and usually persist into
later childhood for developmentally disabled children; additionally such
difficulties can contribute to the manifestation of other challenging behav-
iors during the day (Didden et al., 1998). In many cases, sleep problems
have been determined by functional assessment to be maintained and
shaped by parental attention and have thus been successfully treated with
extinction (Didden et al., 1998).
Behavior Therapy
From these operant-based techniques, behavior therapy diversified
and progressed in a rapid manner. In 1952 with his article, “The Effects of
Psychotherapy: An Evaluation,” Hans Eyesnick convincingly brought the
ineffectiveness of psychoanalysis to light. It was at this time that psychoa-
nalysis began to lose its grip as a dominate therapy in the United States
and new treatments based on the principles of classical and operant con-
ditioning began to gain popularity. One of the most influential of the new
therapies that emerged was created by Joseph Wolpe and called systematic
desensitization or reciprocal inhibition.
Systematic Desensitization
In the early 1950s, Wolpe was dissatisfied with the poor outcome
he was getting treating patients with psychoanalysis. He combined his
medical training with learning theory to create a medically credible,
non-Freudian hypothesis with regard to the origin of neurotic fears and
how to effectively treat those fears in a behaviorally informed manner
(Maultsby & Wirga, 1998). The result was a combination of deep muscle
relaxation and emotive imagery that Wolpe termed systematic desensiti-
zation. He described his theories in a landmark text published in 1958
entitled Psychotherapy by Reciprocal Inhibition. Wolpe (1958) conceptual-
ized fears or phobias as responses that have been learned through classical
conditioning and can therefore be eliminated by applying specific coun-
terconditioning.
In a typical session, which usually lasts one hour, the client first self-
induces a state of deep muscle relaxation. This is followed by the therapist
verbally leading him or her through a predetermined list of feared objects
or events that the client imagines starting with the least fear-inducing and
gradually moving up to the most feared object or situation. If the client
becomes noticeably anxious, he or she is told to stop imagining the object
or situation and return to establishing the state of relaxation. Exposure
to the actual feared objects is often incorporated as well. The rapid effec-
tiveness of systematic desensitization and the large number of successful
cases surprised the field. Some of the earliest studies were conducted by
Lang and colleagues and involved using the technique to reduce fear of
snakes in college students (Lang & Lazovik, 1963; Lang, Lazovik, & Rey-
nolds, 1965; Lazovik & Lang, 1960).
Although the effectiveness of systematic desensitization for treating
phobias and anxiety was well documented throughout the 1960s, interest
began to wane as the number of published studies dropped dramatically

starting in the early 1970s (McGlynn, Smitherman, & Gothard, 2004).
This decline was evident both in research and clinical practice. The reason
for the decline has been attributed to the emergence of other therapies
that competed directly (e.g., flooding, participant modeling) and indirectly
(cognitive behavior therapy; McGlynn et al., 2004).
There are two main variants of systematic desensitization that have
been used to treat fears and anxiety in children: in vivo desensitization
(i.e., exposure), which has confrontation with the actual feared stimuli as
the principal feature, and in vitro, also known as standard or vicarious,
desensitization, which uses symbolic representations (e.g., imagination or
modeling) in place of the actual feared stimuli (Ultee, Griffioen, & Schelle-
kens, 1982). Early applications of these techniques with children yielded
positive results in reducing fear of animals with the former technique
(Kuroda, 1969; Murphy & Bootzin, 1973; Ritter, 1968) but mixed results
with the latter (Lazarus & Abramowitz, 1962; Miller, Barrett, Hampe, &
Noble, 1972). Ultee et al. (1982) compared the two procedures directly in a
sample of children with water phobia; in vivo was found to be more effec-
tive than in vitro desensitization, and the response to the latter treatment
was not significantly different from a wait-list control condition. It was also
determined that the combination of the two was no more effective than in
vivo desensitization alone.
Similar results were found in a later study by Menzies and Clarke
(1993), who not only demonstrated that in vivo exposure was significantly
more effective in reducing fear of water in children, but that those treat-
ment gains generalized to other situations involving water and were main-
tained after three months. Based on the results of these studies and others,
real-life exposure to the feared object appears to be the most important
component of systematic desensitization (Ollendick & King, 1998).
Anxiety and phobia frequently co-occur with ASD and are present
in higher rates than in normally developing children (Love, Matson, &
West, 1990; Luscre & Center, 1996; Reaven & Hepburn, 2006; Woodard,
Groden, Goodwin, Shanower & Bianco, 2005), and children with ID have
more fears than children of normal intelligence with and without learning
disability (Deverensky, 1979). In addition, individuals with Williams syn-
drome evince higher levels of anxiety and phobias than normally develop-
ing children as well as children with ID (Dykens, 2003). Common phobias
reported in the literature for children and adolescents with developmental
disabilities include animals (particularly dogs; Obler & Terwilliger, 1970),
the toilet (Jackson & King, 1982; Luiselli, 1977), medical and dental pro-
cedures (Freeman, Roy, & Hemmick, 1976; Kohlenberg, Greenberg, Rey-
more, & Hass, 1972; Luscre & Center, 1996), riding the bus (Luiselli,
1978; Obler & Terwilliger, 1970), strangers (Matson, 1981), loud noises
(e.g., thunder; Guarnaccia & Weiss, 1974), and water (Guarnaccia &
Weiss, 1974).
Systematic desensitization can be difficult to apply with children
because relaxation training can be fairly demanding and tedious for the aver-
age child, as can the controlled recall of feared images (King, Cranstoun, &
Josephs, 1989). Given the difficulty of applying the procedure to normally
developing children, this renders the application of traditional systematic

desensitization even more problematic for developmentally disabled chil-
dren. As a result, treatment of phobias and anxiety in children with ASD
and ID has focused on related techniques such as emotive imagery, gradu-
ated exposure, counterconditioning, and modeling, and usually includes
operant components such as providing tangible rewards for tolerating the
feared object. Counterconditioning in such treatment with developmen-
tally disabled children usually includes the presence of a comforting per-
son (e.g., child’s mother) whose involvement is gradually faded as the child
becomes more comfortable around the fear-inducing stimulus (Sovner &
Hurley, 1982)
Emotive imagery involves the therapist evoking positive emotions in
the child, usually by including characters from television or fiction that
the child enjoys, and then gradually introducing the feared stimuli in the
context of a fun or exciting narrative involving the child and the charac-
ters (Lazarus & Abramovitz, 1962). These authors used the technique to
successfully treat fear of dogs, darkness, and school. More recently, Corn-
wall, Spence, and Schotte (1997) demonstrated that the procedure was
superior on a variety of outcome measures in treating fear of darkness in
24 children when compared to wait-list control. The active mechanism of
the procedure is believed to be reciprocal inhibition, in that instead of the
child inducing a state of ease or relaxation himself or herself, this positive
state is induced by engaging in an activity the child enjoys (e.g., pretend-
ing to be a superhero; King et al., 1989).
In a study by Freeman et al. (1976), a hierarchal series of real-life
exposures was created to treat an intellectually disabled boy’s fear of
physical examinations with a preferred nurse from the ward being used
as the counterconditioning agent. In another similar study, an autis-
tic child’s fear of the sound of toilet flushing was successfully treated
using laughter to reduce anxiety (Jackson & King, 1982). Laughter was
induced by tickling and this was gradually introduced while the child
used and then flushed the toilet. However, these were uncontrolled
case studies so the results should be interpreted with some degree of
caution.
On this note, Obler and Terwilliger (1970) employed a modified version
of systematic desensitization with 15 “neurologically impaired” children
who presented with excessive fear of dogs or riding the bus. Significant
reduction in phobic symptoms was reported for the treatment group but
not for a group of matched controls. The treatment procedure in this study
involved first presenting a picture of the feared stimulus and then once
this was tolerated, presenting the actual object and rewarding the child for
moving closer and closer to it. Rewards were chosen by the participants
prior to treatment and included toys, books, and candy.
Modeling involves a peer or adult demonstrating nonfearful behavior
in the fear-producing situation and can be either live or filmed. Bandura
and colleagues conducted some of the earliest research with this technique
and demonstrated that modeling, both live and filmed, was able to effec-
tively reduce fear of dogs (Bandura, Grusec, & Menlove, 1967; Bandura &
Menlove, 1968). In addition, Lewis (1974) found a combination of modeling
(video of peers) and participation to be more effective than either modeling

or participation alone in reducing water phobia. However, each condition
alone also significantly reduced avoidance behavior when compared to a
control condition.
Modeling has also been used to treat phobias in developmentally
disabled children. This usually consists of the therapist demonstrating
an appropriate nonfearful response to the presence of the fear-inducing
object or situation (King, Ollendick, Gullone, Cummins, & Josephs, 1990).
For example, Matson (1981) used modeling in a multiple baseline study
across subjects to treat three children with moderate ID who refused to
interact with or be around people other than a few close family members.
Modeling was performed by a parent in the clinic and then generalized to
home with treatment gains being maintained after six months.
In contrast to emotive imagery and modeling, operant-based treatment of
anxiety and phobias does not assume that the anxiety must first be reduced
or eliminated before exposure to the feared object or situation will be toler-
ated (King et al., 1990). Such techniques are typically used in combination
with the procedures described above. Luiselli (1977, 1978) demonstrated
successful implementation of operant-based treatments with an intellectu-
ally disabled adolescent who was afraid of the toilet and an autistic child who
was afraid of riding the bus. In the latter study, the autistic boy’s mother
initially sat on the bus with him and provided tangible reinforcement. Even-
tually, she moved farther away from him until he was able to ride the bus to
school by himself, which was achieved in seven days. In addition, Kohlen-
berg et al. (1972) successfully treated fear of dental procedures in a sample
of children and adolescents with ID ages 8–20 using shaping with social and
tangible reinforcement. The outcome measure for this study was the number
of physical restraints required for the procedure, of which, after treatment,
the experimental group received significantly less than a control group.
Cognitive Behavior Therapy

Around the same time as Wolpe’s formulations regarding his ideas
for systematic desensitization and for principally the same reason (i.e., a
lack of success treating patients with psychoanalysis), Albert Ellis devel-
oped his brand of highly effective, therapist-led psychotherapy that he
termed rational emotive therapy (Maultsby & Wirga, 1998). This treatment
model later became known as rational emotive behavior therapy or cogni-
tive behavior therapy (CBT). From this viewpoint, maladaptive behavior
is the result of maladaptive cognitions, and therefore cognitive changes
can produce a change in behavior. The therapy focuses on the ABC model
of human emotions: Activating event, Beliefs about the event, and Con-
sequence of or emotional response to the event. Its goal is to get people
to recognize and then eliminate their irrational beliefs. CBT encourages
therapists to be active, objective, and firmly directive while combining talk
therapy with elements of classical conditioning.
Variants of Ellis’s original therapy have been applied to children with
fear and anxiety. In an early study of this type, Kanfer, Karoly, and Newman
(1975) found that having children repeat verbal self-instructions related to
competence in dealing with their fear of the dark (e.g., “I am a brave boy/
girl. I can take care of myself in the dark.”) while in a dark room was more
effective than stimulus control (e.g., repeating “The dark is a fun place to
be.”) and control (repeating nursery rhymes) conditions. Kane and Kendall
(1989) treated four children diagnosed with Overanxious Disorder with a
cognitive-behavioral based treatment. The cognitive component included
teaching the children to recognize their anxious feelings and bodily reac-
tions to those emotions, clarifying their cognitions in anxiety-provoking
situations, developing strategies to cope with those situations, and evalu-
ating the success of those strategies. The behavioral portion of the treat-
ment included elements of modeling, in vivo exposure, relaxation training,
role play, and contingent reinforcement. Homework was also included.
The treatment was effective at reducing anxiety to within normal limits
and was maintained at three- to six-month follow-up.
Meichenbaum and Goodman (1971) were among the first to advo-
cate the application of cognitive-behavioral techniques in the treatment of
ADHD. Since that time, a great deal of research has been directed toward
this topic (Pelham, Wheeler, & Chronis, 1998). CBT for ADHD typically
consists of weekly sessions in which the therapist works with the child on
developing cognitive techniques to help control inattention and impulsive
behavior that the child will hopefully generalize to other situations (Pelham
et al., 1998). However, the results of multiple controlled studies have not
supported the effectiveness of this approach (Abikoff & Gittelman, 1985;
Bloomquist, August, & Ostrander, 1991; Brown, Borden, Wynne, Spunt,
& Clingerman, 1987).
Cognitive-behavioral approaches have also been utilized for children
and adolescents with depression and are commonly done in group settings
(Kaslow & Thompson, 1998). Because of the initial debate on the exist-
ence of childhood depression and the fact that depression is an internal-
izing disorder and thus may go unnoticed, controlled studies evaluating
the effectiveness of CBT and related therapies are scarce. For the most
part, interventions for children have been modified from those available for
adults and lack a developmental framework (Kaslow & Thompson, 1998).
Stark and colleagues (Stark, Reynolds, & Kaslow, 1987; Stark, Rouse, &
Livingston, 1991) conducted some of the first controlled studies of psycho-
social treatment of childhood depression.
In the first study, Stark et al. (1987) compared 12 sessions of group
therapy with a wait-list control condition in a sample of fourth- through
sixth-graders. Group therapy consisted of either a self-control intervention
that taught self-management skills or a behavior-problem solving inter-
vention that included education and group problem solving. Compared
to the control condition, the children in the two experimental conditions
reported fewer symptoms of depression with the majority no longer meeting
criteria for depression at eight-week follow-up. However, caretaker ratings
of depression, anxiety, and self-esteem did not significantly differ among
the three conditions.
Stark et al. (1991) then expanded this procedure to 24 to 26 sessions
and included monthly family meetings that added a parent training com-
ponent to help their children generalize the skills to the home. This method
was found to be superior to a traditional counseling approach at reduc-

ing depressive symptomatology. The efficacy of manualized approaches to
CBT with young persons suffering from depression has also been demon-
strated (Lewinsohn, Clarke, Hops, & Andrews, 1990; Lewinsohn, Clarke,
Rhode, Hops, & Seeley, 1996).
Dykens (2003) suggests that specific cognitive-behavioral interven-
tions for phobia and anxiety may be applicable for people with Williams
syndrome given the circumscribed goals and relatively short duration of
such treatments as well as the well-developed expressive language and
interpersonal skills in many individuals with the condition. However, the
application of cognitive-behavioral interventions for children with devel-
opmental disabilities awaits further investigation. Reaven and Hepburn
(2006) suggest that cognitive-behavioral treatment strategies for children
with high-functioning ASD and anxiety should include a high level of
parental involvement.
Medication
The prescription of psychotropic medication for adolescents increased
by 2.5% from 1994-2001 (Thomas, Conrad, Casler, & Goodman, 2006). In
1997, the Food and Drug Administration passed the Modernization Act,
which made it easier for off-label medications to be promoted to physi-
cians (Buck, 2000). This, taken with the increased presence of managed
care incentives limiting the number of therapy visits, has contributed
significantly to increased reliance on psychotropic medication in treating
childhood psychopathology (Thomas et al., 2006). However, there remains
a paucity of empirical research concerning the utility of using psycho-
tropic medication to treat developmentally disabled children with comorbid
mental health conditions.
This puts the clinician in the position of having to extrapolate
from the existing data regarding adults with ID and children of normal
development (Aman, Collier-Crespin, & Lindsay, 2000). As mentioned
above, because response to psychotropic medication may depend on
the child’s developmental level, extrapolating from research on adults
can be problematic (Aman, Collier-Crespin, et al., 2000). There is no
medication for intellectual disability or ASD and medical profession-
als should proceed with caution before prescribing psychotropics for
children with these conditions. When such a child is being prescribed
medication for the suppression of challenging behaviors and not for
an underlying comorbid condition, the treatment may serve primarily
as chemical restraint. A summary of research on the major classes of
psychotropic medication used in the treatment of childhood psychopa-
thology follows.
Psychostimulants
For some mental health conditions, pharmacological interventions
have been the most widely used and recommended. Since the 1970s this
has been the case with stimulant medication and ADHD (Pelham et al.,
2000). However, stimulant medication does not work for everyone with
ADHD (70–80% of cases respond) and the long-term efficacy is questionable
(Pelham et al., 2000).
From 1980 to 2000, there were at least ten group studies examining
the effects of stimulant medication (methylphenidate and dextroampheta-
mine) in intellectually disabled children and adults with ADHD (Aman,
Collier-Crespin, et al., 2000). The cumulative results of this research indi-
cate that psychostimulant medication is effective in treating symptoms
of ADHD in individuals with ID. With the exception of one instance, all of
the studies yielded statistically significant, positive results with improve-
ments noted in the areas of managing motor overflow, attention span,
and impulsiveness along with cognitive performance, social behavior, and
independent play (Aman, Collier-Crespin, et al., 2000). However, the over-
all response rate in children and adolescents with ID at 54% is less than
that for those of typical development (Aman, 1996). Later research with
methylphenidate in intellectually disabled children has yielded similar
results (Pearson, Lane, et al., 2004; Pearson, Santos, et al., 2004).
Although current DSM-IV-TR diagnostic criteria preclude a comorbid
diagnosis of ADHD in children with ASD, core symptoms of ADHD such
as impulsivity, hyperactivity, and inattention are common in children with
ASD (American Psychological Association [APA], 2000; Lecavalier, 2006).
The effects of stimulant medication on symptoms of ADHD in ASD children
are mixed. For example, Stigler, Desmond, Posey, Wiegand, and McDougle
(2004) found a low rate of treatment success with a high rate of side-effects
in a retrospective review of 195 ASD children. On the other hand, Posey et
al. (2007) demonstrated that methylphenidate was superior to placebo in
66 children with ASD in alleviating primary symptoms of ADHD.
Antidepressants
Since the early 1990s, antidepressants, especially the selective serotonin
reuptake inhibitors (SSRIs), have increasingly become the treatment of
choice in treating childhood depression (Jureidini et al., 2004). Prescription
of SSRIs increased dramatically from 1998–2002 among adolescents aged
15–18 (Delate, Gelenberg, Simmons, & Motheral, 2004). One major concern
with this trend is the efficacy and safety of these drugs with children. Of
particular concern is the risk of suicide among adolescents taking SSRIs
(Jureidini et al., 2004; Whittington et al., 2004). Treatment with tricyclics in
children has largely been abandoned due to the high frequency of adverse
side-effects and a lack of efficacy (Whittington et al., 2004). In a review of six
clinical trials comprising 477 children treated with paroxetine, fluoxetine,
sertraline, or venlafaxine, and 464 children treated with placebo, Jureidini
and colleagues (2004) found the children treated with antidepressant medi-
cation only significantly improved on 14 of 42 reported outcome measures.
In addition, a larger number of children treated with antidepressant medi-
cation experienced adverse side-effects (paroxetine) and some had to withdraw
from one of the studies as a result (sertraline).
Whittington et al. (2004) also reviewed the risk–benefit profiles of
these drugs by examining published and unpublished studies. Fluoxetine
was cited as having a favorable risk–benefit profile in children with noted

efficacy in reducing depressive symptoms with no increased risk of side-
effects. The risk–benefit profiles of sertraline and paroxetine were mixed,
whereas both citalopam and venlafaxine were found to have unfavorable
risk–benefit profiles. In addition, Emslie and colleagues (1997) conducted
a double-blind, randomized, placebo-controlled study of fluoxetine in 96 chil-
dren and adolescents and reported a 60% response rate.
Pary (2004) notes that, as with children of normal development, the
first-line treatment for major depression in Down syndrome is SSRI treat-
ment (with the exception of paroxetine). In one study, however, paroxetine
was found to be effective in reducing symptoms of depression in seven
mildly intellectually disabled adolescents (Masi, Marchesci, & Pfanner,
1997). However, SSRIs (i.e., fluoxetine, paroxetine, and sertraline) may be
less effective in children with ASD. In an open label study, Awad (1996)
treated a small sample of children with ASD with these medications and
found a reduction in symptoms of obsessional, repetitive, and anxiety symp-
toms in half the children but that treatment had to be discontinued for the
other half because of side-effects and worsening of symptoms. SSRIs may
also have some benefit in reducing self-injury in developmentally disabled
children (Aman, Arnold, & Armstrong, 1999). However, at this point, this
data are preliminary, based on case reports, and more research is needed.
When medication fails to alleviate symptoms of depression, alternative
treatments such as electroconvulsive therapy (ECT) may be effective. One
case report documents successful remediation of depressive symptoms in a
15-year-old adolescent with Down syndrome and treatment-refractory major
depressive disorder (Gensheimer, Meighen, & McDougle, 2002). For this indi-
vidual, ECT was found to be safe and effective after four administrations.
Mood Stabilizers
Adolescents diagnosed with bipolar disorder are treated with the same
medications as adults with the condition; however, mixed or rapid cycling,
which adolescents tend to experience more than adults, has been associ-
ated with a poor response to lithium (Cogan, 1996). Although the expres-
sion of bipolar disorder in preadolescent children is rare and even rarer in
children with ID, a few case studies have found positive results for treat-
ment with valproic acid (Kastner, Friedman, & Plummer, 1990; Whittier,
West, Galli, & Raute, 1995) and lithium in young people with ID (Dostal &
Zvolsky, 1970; Goetzl, Grunberg, & Berkowitz, 1977; Linter, 1987). How-
ever, lithium has also been associated with limited clinical efficacy and
adverse side-effects in this population (Kastner et al., 1990). In addition,
Komoto and Usui (1984) reported a case study in which a 13-year-old
autistic female with moderate ID and depression was effectively treated
with valproic acid.
Antipsychotics
Because the symptoms of schizophrenia do not usually manifest
themselves until late adolescence, there is very little research concerning
treatment of young persons with antipsychotic medication specifically

for schizophrenia. Based on a review of this small body of literature,
Campbell and Gonzalez (1996) summarize research indicating that
thiothixene was superior to thioridazine in adolescents with chronic
schizophrenia, whereas haloperidol and clozapine may also be effective
for young people with schizophrenia, However, much more research is
warranted.
An early study by Cunningham, Pillai, and Blanchford-Rogers (1968)
found that haloperidol was effective in treating children with aggressive
and destructive behaviors. Although, Conduct Disorder can be difficult
to diagnose in children with ID because of determining the intent of the
behavior, risperidone significantly reduced clinician and parent ratings on
conduct problems in 118 intellectually disabled children with comorbid
Conduct Disorder or Oppositional Defiant Disorder compared to placebo
(Aman, Findling, Derivan, & Merriman, 2000). There has been a notable
increase in recent years of using atypical antipsychotic medication to treat
self-injurious behavior in developmentally disabled children with risperi-
done and olanzapine being the most common (Aman, Collier-Crespin, et
al., 2000). However, these studies were not controlled and more research
is needed.
Anxiolytics
Little is known about the effects of treating childhood anxiety with
benzodiazepines with only a few controlled studies available (Simeon,
1993). The paucity of such research is likely due to SSRIs being commonly
prescribed to treat anxiety conditions among young persons (Reinblatt &
Riddle, 2007). Among those with ID, this class of drugs has been com-
monly used to manage challenging behaviors and treat generalized anxiety
disorders (Aman, Collier-Crespin, et al., 2000). A handful of studies has
examined the effects of benzodiazepines in treating children with ID to
mixed results (LaVeck & Buckley, 1961; Krakowski, 1963; Bond, Man-
dos, & Kurtz, 1989). The children in these studies were not only small in
numbers but were being treated more for behavioral problems than any
underlying anxiety disorder.
As mentioned above, anxiety conditions seem to be more prevalent
in children with ASD and have been successfully treated with behavioral
approaches. One study did find that buspirone was effective at reduc-
ing symptoms of anxiety and irritability in children and adolescents with
ASD (Buitelaar, van der Gaag, & van der Hoeven, 1998). Side-effects were
reported to be minimal except for one child who developed abnormal
involuntary movements. Werry (1999) suggests that the anxiety associated
with ASD may respond better to antipsychotic drugs than to anxiolytics.
Other Drugs
There is currently only one recommended medication for enuresis,
which is desmopressin (Jarvelin, 2000). Desmopressin is typically administered
as a nasal spray. In the past, imipramine has also been used, but research
indicates that children with ID have responded unfavorably (Aman et al.,

2000). Studies of imipramine with children of normal development have
also been mixed with response rates of 10–60%; however relapse was high
(90%; Schmitt, 1997).
Combined Therapies
ADHD
For ADHD, limitations of both pharmacological and behavioral inter-
ventions have led to the development of combination therapies consisting
of behavior modification and stimulant medication (Pelham et al., 2000).
Such treatment packages are most successful when the behavioral com-
ponent includes outpatient parent training and school training or occurs
in the context of a summer treatment program (Pelham et al., 2000). In
the case of parent and school training, this helps to increase the generaliz-
ability of the treatment across settings and people.
ASD
Comprehensive early intervention treatment packages with the aims
of reducing level of impairment and improving outcome are available for chil-
dren with ASD (Rogers, 1998). Better outcomes have been reported for
children enrolling in such programs before the age of five years (Fenske,
Zalenski, Krantz, & McClannahan, 1985). Other than behavioral interven-
tions aimed at remediation of specific deficit areas, this is the only other
empirically supported treatment available for children with ASD (Rogers,
1998). However, these comprehensive programs are expensive and time-
consuming, involving a team of professionals across different settings
(home, classroom, and clinic), and in some cases, thousands of hours of
treatment over many years. According to Kabot, Masi, and Segal (2003),
for an early intervention program to be appropriate and effective it should:
begin at the earliest possible age, be intensive, include parent training,
focus on social and communication domains, contain individualized goals
and objectives, and emphasize generalization.
One example of this type of approach is the Treatment and Education
of Autistic and related Communication handicapped CHildren (TEACCH)
program established in 1966 at the University of North Carolina in Chapel
Hill. At a time when the prevailing psychodynamic model of the time was
spreading the notion that autism was the result of a lack of parental
emotional support or “refrigerator mothers”, TEACCH recognized paren-
tal involvement as a critical factor and incorporated parent training into
the program so that treatment strategies could be implemented in the
home. The program was demonstrated to be effective early after its incep-
tion (Schopler, Brehm, Kinsbourne, & Reichler, 1971). Ozonoff and Cath-
cart (1998) demonstrated that a TEACCH-based home program resulted in
three to four times greater improvement than a control group on tests of
imitation, fine and gross motor, and nonverbal conceptual skills in autistic
preschoolers.
Another notable comprehensive treatment package for autism was

developed by Lovaas and colleagues (1981). This manualized protocol
utilizes reinforcement-based operant techniques along with some pun-
ishment-based procedures to increase a variety of social, language, cogni-
tive, and self-care skills while reducing maladaptive behaviors in children
with autism. The effectiveness of Lovaas’s program was documented in
two published studies (Lovaas, 1987; McEachlin, Smith, & Lovaas, 1993).
The research was conducted over a two-year span and involved a group
receiving the treatment compared with two control groups: one group who
received a few elements of the program delivered by the same staff in the
treatment group in limited duration and intensity and a second group
matched on chronological and mental age that was obtained through
chart review. They found a large and statistically significant difference in
IQ scores and educational placement, with the treatment group scoring
25–30 points higher in IQ and a larger percentage of placements in typical
classrooms for this group (47% to 2% for the control groups). However, one
critique of this research is that group assignment was nonrandom (Rog-
ers, 1998). Regardless of this methodological flaw, the effectiveness of this
treatment package has been replicated by two other sets of independent
researchers, albeit at a lower rate of success (Birnbrauer & Leach, 1993;
Sheinkopf & Siegel, 1998).
CONCLUSIONS
Psychopathology is a common problem for children and adolescents,

with one prevalence study finding a rate of 36.7% of 9- to 13-year-olds meet-
ing criteria for at least one psychiatric disorder (Costello, Mustillo, Erkanli,
Keeler, & Angold, 2003). Because the way child psychopathology is concep-
tualized and classified has changed from various editions of the DSM and is
still changing (Ollendick & Vasey, 1999), it is important that future trends
in treatment strive to empirically validate various treatments and not simply
assume that therapies for adult disorders will apply to children. Treatments
utilizing operant principles and elements of systematic desensitization for
reducing phobias are among the best studied and have proven thus far to be
the most effective. On the other hand, the efficacy and effectiveness of cog-
nitive behavioral and pharmacological treatments warrants further study.
However, the trend toward establishing empirically supported treatments
for children is encouraging (Lonigan, Elbert, & Johnson, 1998).
These issues become even more critical with developmentally and
intellectually disabled populations. Taken with the finding that chil-
dren with ID are at a greater risk for developing psychopathology than
the general population (Menolascino & Swanson, 1982) and present
with higher rates of depression (Matson, Barrett, & Helsel, 1988), it
is of great importance that the treatments outlined in this chapter be
validated and proven efficacious for this group. Further complicating
the issue is that major mental health problems are often undiagnosed
and untreated in individuals with developmental disabilities (Deb &
Weston, 2000).
Recognizing these disorders in such individuals is difficult because

of cognitive and communication difficulties. In addition, the role of early
intervention has been increasingly emphasized in treatment programs
for ASD children, and this represents the best chance these children
have at functioning independently as adults. Along the same lines,
because these treatment packages are so intensive and costly, parents
of children with ASD have become increasingly susceptible to buying
into new treatments or “miracle cures” offering little to no empirical
support (e.g., glutein-free diet, chelation therapy). These issues rep-
resent some of the major challenges currently facing the treatment of
childhood psychopathology and developmental disabilities.
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2
Applied Behavior Analysis
And The Treatment of
Childhood Psychopathology
And Developmental
Disabilities
JOEL E. RINGDAHL and TERRY S. FALCOMATA
INTRODUCTION
This chapter provides a description and examples of the use of applied

behavior analysis (ABA) in the treatment of childhood psychopathology and
developmental disabilities. This task is a daunting one given that many of
the single topics that are discussed in the following pages can, and have,
served as topics for entire chapters and texts. This limitation means we
are not able to delve into each topic in a comprehensive manner. However,
we do provide an overview of the important topics related to ABA and its
use in the treatment of childhood psychopathology and developmental dis-
abilities. In addition, we provide a discussion of literature-based examples
for these ABA-based treatments, brief examples of generalization of treat-
ment effects, and discussion of effectiveness.
It is important to note that ABA is not a single treatment. It is more
accurate to say that ABA represents an approach to treatment as opposed
to a specific type of treatment. This approach includes a number of treat-
ment strategies that can be used to address the behavioral symptoms
associated with childhood psychopathology and the behavioral challenges
JOEL E. RINGDAHL and TERRY S. FALCOMATA ● The University of lowa.

30 JOEL E. RINGDAHL and TERRY S. FALCOMATA
associated with developmental disabilities. As an approach to treatment,

ABA relies on arranging response–consequence relationships (including
positive and negative reinforcement and punishment), schedule of rein-
forcement effects, and antecedent manipulations (including stimulus-con-
trol procedures and altering establishing operations) to reduce problem
behavior and increase appropriate behavior.
In the paragraphs that follow, we provide an overview of ABA, includ-
ing how it is defined, a description of ABA-based treatment strategies,
including both consequence and antecedent-based interventions, and
a brief summary of recent effectiveness research related to ABA-based
treatments and behavior problems common to individuals with childhood
psychopathology and/or developmental disabilities.
APPLIED BEHAVIOR ANALYSIS DEFINED
Baer, Wolf, and Risley (1968) outlined seven dimensions of applied

behavior analysis. It is upon these dimensions that the clinical applica-
tions are based. According to Baer et al., ABA is applied, behavioral, and
analytic. In addition, ABA should be technological, conceptually system-
atic, effective, and generalizable. The term applied indicates that the target
behavior is of social significance. It is the emphasis on social significance
that sets ABA apart from laboratory analysis. Examples of applied are wide-
ranging and can include any behavior that society deems important. The
term behavioral indicates the focus of ABA should be on actions exhib-
ited by the individual as opposed to what the individual says about those
actions. Pragmatically, the implication is that what should be measured are
observable actions exhibited by an individual. The term analytic indicates
that a “believable demonstration of events … responsible for the occurrence
or non-occurrence of that behavior” (p. 93–94). Thus, ABA approaches to
treatment are often implemented and demonstrated within a single-subject
research design (e.g., reversal, multielement, or multiple baseline designs).
Along with establishing what constituted applied, behavior, and ana-
lytic, Baer et al. delineated four other dimensions for ABA. Applied behavior
analysis should be technological, meaning that the “techniques making up
a particular behavior application are completely identified” (p. 95). Thus,
it is incumbent upon the behavior analyst implementing an ABA-based
treatment to provide a complete description of its components. Baer et al.
also asserted that ABA be conceptually relevant explanation. Additionally,
Baer et al. stressed practical significance, as opposed to theoretical sig-
nificance, as a hallmark of ABA. In essence, if a behavioral technique does
not produce effects that are of practical value, that application has failed.
Finally, behavior change produced by ABA should be durable over time
(i.e., effects should be generalizable).
Since the publication of Bear et al.’s dimensions of applied behavior
analysis, other behavior analysts have described additional characteristics
of ABA. Heward (2005) described ABA as accountable, public, doable,
empowering, and optimistic. Cooper, Heron, and Heward (2007) described
these characteristics in the following manner.
APPLIED BEHAVIOR ANALYSIS AND THE TREATMENT OF CHILDHOOD 31
Accountable: “The commitment of applied behavior analysis to effec-

tiveness, their focus on accessible environmental variables that reliably
influence behavior, and their reliance on direct and frequent measurement
to detect changes in behavior yield an inescapable and socially valuable
form or accountability” (p. 18).
Public: “… ABA is visible and public, explicit and straightforward”
(p.18) Applied behavior analysis is transparent and there are no hidden or
unexplained treatments.
Doable: the interventions found to be effective in ABA studies are
able to be implemented by “teachers, caregivers, coaches, supervisors, and
sometimes even the individuals themselves” (p.19). Cooper et al. suggest
that the procedures are not “prohibitively complicated or arduous” (p. 19).
Empowering: “ABA gives practitioners real tools that work” (p. 19)
thus improving their confidence.
Optimistic: the result of practitioners having effective strategies and
the ability to detect improvements, along with literature-based examples
of success gives cause for optimism regarding the future success of behav-
ior change programs.
Collectively, Cooper et al. (2007) summarized these dimensions and
characteristics of applied behavior analysis as “… the science in which
tactics derived from the principles of behavior are applied systematically
to improve socially significant behavior and experimentation is used to
identify the variables responsible for behavior change” (p. 20). This reli-
ance on systematic evaluation of the variables responsible for behav-
ior change results in an approach to the assessment and treatment of
behavior problems that is functional, as opposed to structural. Thus, the
selected treatment, or treatment package, is based on the relationship
demonstrated between the presenting behavior of interest (i.e., out of seat
behavior) and the environment. This approach can be contrasted to an
approach that prescribes or selects treatment based on the diagnosis (e.g.,
ADHD) that is of concern. Using this functional approach, it is conceiva-
ble that the same treatment(s) could be used to address different present-
ing concerns and different treatment(s) might be used to address similar
presenting concerns.
DESCRIPTION OF ABA TREATMENT APPROACHES
In this section, an overview of many of the frequently used ABA-based

treatments is provided. The section has been subdivided into conse-
quence-based treatments (reinforcement and punishment based), ante-
cedent-based treatments (noncontingent reinforcement and prompting
strategies), and treatments in combination (i.e., including two or more
consequence or antecedent components or at least one antecedent and
one consequence-based component).
Also included in this section are examples in application of each of the
treatment strategies described. At least two examples from the literature are
provided for each treatment. When possible, an example is provided for both
childhood psychopathology (or disorders not associated with developmental
disabilities) and developmental disabilities. Given that the ABA approach
has been most widely used to treat the psychopathologies of children in two
broad categories (early childhood disorders such as conduct disorder, disrup-
tive behavior disorder, and attention-deficit/hyperactivity disorder and anxi-
ety and phobias), childhood psychopathology examples will likely fit into one
of these two categories. The developmental disabilities examples focus on the
treatment of behavioral challenges presented by individuals with develop-
mental disabilities and autism. These challenges include, but are not limited
to (1) problems of behavioral excess such as stereotypic movement disorder,
self-injurious behavior, aggression, destruction, tantrums, and so on, and
(2) problems of behavioral deficit such as delays in language development,
difficulty with skill acquisition, and problems with academic performance.
Consequence-Based Procedures: Punishment

Punishment is a response-dependent (i.e., contingent) operation
resulting in the decreased likelihood of a particular response. Two types of
punishment have been described in the behavior analysis literature: posi-
tive and negative. Positive punishment involves the response-dependent
delivery of a stimulus that results in a subsequent decrease in respond-
ing. Alternatively, negative punishment involves the response-dependent
removal of a stimulus that results in a subsequent decrease in respond-
ing. The effect on behavior is the same; the difference stems from the
action given to the stimulus (i.e., presented or removed).
Positive Punishment
As indicated, positive punishment involves the contingent presenta-
tion of an aversive stimulus following the target response. In application,
this approach to treatment has included any number of aversive stimuli
including, but not limited to, aversive outcomes such as electric shock
(Linscheid, Iwata, Ricketts, Williams, & Griffin, 1990), water mist (Singh,
Watson, & Winton, 1986), facial screen (Rush, Crockett, & Hagopian,
2001), aversive activities such as exercise (Kahng, Abt, Wilder, 2001), and
overcorrection (Foxx & Azrin, 1973).
Linscheid et al. (1990) described the treatment of self-injurious behavior
(SIB) exhibited by five individuals, including three individuals under the age
of 18, with developmental disabilities. It is important to note that each of the
five cases had a long-standing history of SIB that had proven unmanageable
and was severe in nature (i.e., caused significant tissue damage or put the
individual at risk of tissue damage or death). As well, the authors address
issues related to generalization, maintenance, and potential for abuse for this
particular treatment. Treatment included the contingent application of elec-
tric shock following occurrences of severe SIB. Immediate and pronounced
effects were observed for each of the five participants. Anecdotal follow-up
data suggested that no habituation had occurred for four of the five partici-
pants months after treatment was initiated.
Kahng et al. (2001) described the implementation of a positive pun-

ishment procedure to reduce the SIB exhibited by a 16-year-old girl. One
topography of SIB was reduced by the implementation of a noncontingent
reinforcement procedure. However, other topographies of SIB continued
to be exhibited when this treatment procedure was in place. As a second
treatment component, an aversive activity (i.e., exercise; touching toes)
was made contingent on each occurrence of all topographies of SIB. This
procedure was added to the ongoing noncontingent reinforcement pro-
gram as well as a restraint fading program. Immediate reductions in SIB
were observed when this punisher was in place.
Negative Punishment
Negative punishment involves the contingent removal of a reinforcer
following occurrences of the target response. Applied examples of the pro-
cedure include response cost and timeout from reinforcement. Response
cost is the loss of a specific amount of a reinforcer following each occur-
rence of the target response, resulting in a decreased probability of the
response (Cooper et al., 2007).
Conyers et al. (2004) used a response cost procedure to reduce the
disruptive behavior exhibited by 25 children in a classroom setting. Spe-
cifically, the authors compared a reinforcement-based procedure (differ-
ential reinforcement of other behavior; DRO) with response cost. During
RC, each child’s name was displayed on a board and 15 stars (tokens)
were placed next to each name. Disruptive behavior resulted in the loss of
a token. The remaining tokens could be traded for preferred items at the
conclusion of each session. Results of the study suggested that, although
both RC and DRO behavior were effective in reducing disruptive behavior,
the classroomwide RC procedure was more effective.
Long, Miltenberger, and Rapp (1999) incorporated response cost
into a treatment package to reduce the thumb sucking and hair pull-
ing exhibited by a typically developing six-year-old girl. Reinforce-
ment-based procedures were ineffective in reducing the behavior to
sufficiently low levels. Thus, a response cost contingency was added to
the reinforcement package. Specifically, the participant was able to earn
an M&M at specific time intervals for engaging in behavior other than
thumb sucking or hair pulling. When the RC component was added,
the participant was told she would lose one M&M for engaging in either
thumb sucking or hair pulling. Immediate reductions of both these tar-
get responses were observed. According to the authors, the participant
only lost access to one M&M during the first session of treatment with
the RC contingency in place. Treatment gains were maintained for 23
weeks. Corresponding decreases in problem behavior were reported by
the participant’s parents in the home setting.
Time out from reinforcement (TO) includes the “withdrawal of the
opportunity to earn positive reinforcers or the loss of access to positive
reinforcers for a specified time, contingent on the occurrence of a behav-
ior” (p. 357). Again, the effect on behavior is decreased probability of future
occurrence (Cooper et al., 2007).
Kodak, Grow, and Northup (2004) used time out from reinforcement
as a component of treatment to reduce the elopement exhibited by a young
child diagnosed with ADHD. A functional analysis of the child’s elope-
ment behavior indicated it was maintained by adult attention. During
treatment, this consequence (adult attention) was provided on a sched-
uled basis (every 15 s). However, if the child engaged in the target response
(elopement), she was removed from the activity for 30 s and adult attention
was withheld. This combination of components resulted in a decrease in
elopement to near-zero levels.
Falcomata, Roane, Hovanetz, Kettering, and Keeney (2004) imple-
mented a time out from reinforcement procedure to reduce the inappropri-
ate vocalizations exhibited by an 18-year-old individual with developmental
disabilities. The researchers were able to identify a highly preferred activ-
ity (i.e., a positive reinforcer, listening to the radio), and access to this
activity was interrupted for a specified time following occurrences of the
target behavior. The timeout contingency resulted in almost immediate
reductions in problem behavior. Any number of studies could have been
included here to illustrate the effects of timeout from reinforcement in
application. The Falcomata et al. study was included because it illus-
trates the close relationship between RC and time out from reinforcement.
Many researchers in applied behavior analysis do not draw a distinction
between the two treatments (in fact, the title of the Falcomata et al. article
is “Response cost in the treatment of …”). The take-home point is that both
RC and TO involve contingent removal of positive reinforcers.
There are several concerns that go along with the use of punish-
ment. Vollmer (2002) discussed four potential concerns regarding the use
of punishment that are often raised. First, punishment procedures can
sometimes produce negative emotional side-effects. Second, the effects of
punishment are often short-lived. Third, punishment procedures have the
potential to be abused. This risk of abuse, to some, outweighs the benefits
of some procedures. Finally, the treatment does not teach the individual
an appropriate behavior that can be used to recruit reinforcers from their
environment. Additional concerns regarding the use of punishment include
the development of escape and avoidance behavior, behavioral contrast
(i.e., an increase in the behavior targeted for punishment in the absence of
the punisher), and undesirable modeling (Cooper et al., 2007).
It is important to note that neither Vollmer (2002) nor Cooper et al.
(2007) advocate against the use of punishment procedures. Instead,
they provide discussions of some of the considerations that need to be
taken into consideration before developing and implementing a punish-
ment-based procedure. However, for the above stated reasons, and, often
because of administrative and legal reasons, reinforcement-based strate-
gies are typically implemented as a first step in the treatment of behavior
problems.
Consequence-Based Intervention Strategies: Reinforcement

Reinforcement involves the response-dependent delivery (positive rein-
forcement) or removal (negative reinforcement) of a stimulus, resulting in
an increased future likelihood of the target response. Reinforcement-based
procedures often serve as the cornerstone for both simple and complex
behavior-change programs. In application, reinforcement-based proce-
dures include such strategies as token economies, contingency contract-
ing, and differential reinforcement. In each approach, a consequence is
identified using some sort of selection process including preference assess-
ments, reinforcer assestsments, or functional analyses of target behavior.
The stimulus or stimuli identified via these procedures are then scheduled
for delivery contingent on the behavior targeted for increase. Delivery can
take place after each occurrence of the behavior, after a specified number of
occurrences, following the first response after a specified time interval (i.e.,
the stimuli are delivered on ratio or interval schedules), or in a deferred
manner once some behavioral criteria are met (i.e., the stimuli are delivered
as part of a token economy). In addition, a single response can be targeted
for increase, or a sequence of responses can be targeted.
Positive Reinforcement
Positive reinforcement procedures involve the contingent delivery of a
known preferred item or reinforcer contingent on a behavior targeted for
increase. When delivered on a ratio or interval schedule, the individual
must meet a particular response requirement (e.g., two responses or one
response after 10 s has elapsed) to gain access to the positive reinforcer.
This strategy is most often used when the clinical goal is the establishment
of an appropriate behavior, such as communication or task completion, or
a repertoire of appropriate behavior such as social skills or toileting.
Graff, Gibson, and Galiatsatos (2006) used a positive-reinforcement
procedure to increase the vocational and academic work completed by
four adolescents with developmental disabilities. In this study, high and
low preferred stimuli were identified via a series of preference assessments.
High preferred and low preferred stimuli were then made contingent on
completion of various vocational tasks. The results of the study demon-
strated that the contingent presentation of both high and low preferred
stimuli increased the rate of vocational responses. However, contingent
presentation of the high preferred stimuli was correlated with higher, sus-
tained response rates for each participant.
Luiselli (1991) described the use of a positive reinforcement procedure
to increase the independent feeding behavior of a boy with Lowe’s syn-
drome. Specifically, praise and access to sensory-based reinforcers (i.e.,
light and music stimulation) was provided contingent on independently
completing components of the self-feeding response. As each component
was mastered, the reinforcer was provided for the next response in the
task analysis. Results indicated that the participant exhibited acquisition
of each of the steps of the task analysis, eventually exhibiting independent
self-feeding.
Negative Reinforcement
Negative reinforcement procedures involve the contingent removal
(escape) of an aversive event, or allow the individual to postpone an aver-
sive event (avoidance). When delivered on a ratio or interval schedule,
the individual must meet a particular response requirement (e.g., two

responses or one response after 10 s has elapsed) before the negative rein-
forcer is removed or postponed. This strategy is most often used when an
individual exhibits problem behavior maintained by escape or avoidance of
instructional, self-care, or other aversive situations.
Kelley, Piazza, Fisher, and Oberdorff (2003) increased the number of
cup sips exhibited by a child with a feeding disorder through the applica-
tion of a negative reinforcement procedure. Prior to treatment, nonpre-
ferred foods were identified via a stimulus preference assessment. During
treatment, spoonfuls of the nonpreferred food were presented along with
prompts to take sips from a cup. Sips from the cup allowed the child to
escape the bite of nonpreferred food that was otherwise presented if inap-
propriate behavior or sip refusal was exhibited. Increases in sips were
observed as a function of this negative-reinforcement procedure.
Rolider and Van Houten (1985) applied negative reinforcement to the
treatment of encopresis associated with constipation exhibited by a 12-
year-old with no other stated diagnoses. During the negative reinforce-
ment-based treatment, the participant was required to sit on the toilet for
20 min or until a bowel movement occurred. If the child had a bowel move-
ment, she was not required to sit on the toilet again that day. If no bowel
movement occurred, she was required to sit on the toilet for 40 min or until
a bowel movement occurred at the next scheduled toilet sitting. Defecation
resulted in no more sitting that day. If no bowel movement occurred, she
was required to sit for 90 min or until a bowel movement occurred at the
next scheduled toilet sitting. Any bowel movement outside of scheduled
toilet sittings also resulted in the child being able to avoid the remain-
ing toilet sittings for the remainder of that day. The treatment resulted in
increased levels of successful bowel movements on the toilet.
Token Economy
A token economy involves the delivery of a conditioned reinforcer (e.g.,
a token, point, or other stimulus) that can later be exchanged for another
reinforcer. According to Cooper et al. (2007), token economies consist
of three components including a list of target behavior or responses,
tokens or points that will be earned for exhibiting the target response(s),
and a menu of items or activities for which the points or tokens can be
exchanged. When implementing a token economy, considerations need to
be made regarding the conditioning of the tokens, the menu of backup or
primary reinforcers, and the schedule with which the backup reinforcers
are accessed. Breakdowns in any of these areas can reduce the effective-
ness of the procedure. For example, if the tokens are not explicitly tied
to the backup reinforcer(s), they will not affect the individual’s behavior.
Similarly, if the menu or backup reinforcers include nonpreferred stim-
uli, are arbitrarily selected (e.g., without the use of a stimulus preference
assessment), or the stimuli are only available on a very lean schedule, the
effect of the program could be limited. Token economies are often used in
large group settings such as classrooms, residential treatment centers,
and group-living environments.
Field, Nash, Handwerk, and Friman (2004) implemented a token economy

to decrease the inappropriate behavior (or, conversely, to increase the appro-
priate behavior) displayed by three children living in a residential treatment
center. Each child had been diagnosed with various psychiatric disorders
including conduct problems, ADHD, and PTSD. The existing, centerwide token
economy was in place for each participant; however, the children’s behavior
continued to be unacceptable. The experimenters increased the schedule of
token exchanges from a single exchange each day to two exchanges per day.
This change in scheduled exchanges resulted in both a decrease in problem
behavior and an increase in the percentage of exchange opportunities during
which the participants earned the backup reinforcer.
Mangus, Henderson, and French (1986) described the use of a token
economy system to improve the on-task physical activity time exhibited by
children with autism in an educational setting. In their study, a peer tutor
was trained to deliver a token on a predetermined schedule (the schedule
differed for each of the five participants, based on the participants’ per-
formance during the last three days of baseline data collection) contingent
on engagement in a physical education activity (i.e., walking on a balance
beam). Tokens could be exchanged for edible reinforcers from a reinforce-
ment menu once five tokens had been earned. Results of the study indi-
cated that the on-task, physical activity of four of the five participants
varied as a function of the token economy intervention. Specifically, when
the token economy was in place, higher levels of on-task physical activity
were observed. When the token economy was not in place, lower levels of
on-task physical activity were observed.
Consequence-Based Intervention Strategies: Extinction

Extinction is a procedure that consists of the discontinuation of rein-
forcement for a behavior with a previous history of reinforcement for the
purpose of reducing that behavior. In contrast to the variations of differential
reinforcement (described later in this chapter), extinction-only procedures
do not include reinforcement for alternative responses or decreases in the
rate of the target response. Typically, the reinforcer that is withheld during
any extinction procedure is one that has been identified as maintaining a
target behavior (i.e., is a functional reinforcer).
Iwata, Pace, Kalsher, Cowdery, and Cataldo (1990) treated the escape-
maintained SIB exhibited by six children with developmental disabilities.
Treatment consisted of extinction and guiding the child through tasks
contingent on occurrences of problem behavior (a response-blocking com-
ponent was added for one participant), thus interrupting the aberrant
response-reinforcement relationship identified during a functional analy-
sis of the consequences maintaining problem behavior. Reductions in SIB
were observed for each of the six participants. Compliance increased for
five of the six participants (compliance data were not presented for the
remaining participant), although compliance was not explicitly targeted for
change (i.e., no consequences had been programmed for this response).
Magee and Ellis (2000) described the sequential application of extinction
to the problem behavior exhibited by two children with attention-deficit/
hyperactivity disorder. One child’s problem behavior (out of seat) was main-
tained by escape from task. This behavior decreased following the imple-
mentation of extinction. However, an increase in other behavior problems
(yelling, inappropriate gestures, and destruction) was observed. Using a
multiple baseline design, extinction was sequentially applied to each topog-
raphy. A decrease in each topography was observed following the applica-
tion of the extinction procedure. The second child’s problem behavior was
maintained by social positive reinforcement (attention). When the extinction
procedure was first applied to object mouthing, that behavior decreased.
However, increases were noted for two other responses, destruction and
aggression. When extinction was implemented for each response, respond-
ing again decreased to near-zero levels.
Although these examples suggest that extinction can be an effective
approach to treatment, its use has some limitations that preclude it from
being used as the sole treatment component. First, implementing extinc-
tion can result in temporary increases in problem behavior at the outset of
treatment (i.e., extinction burst), an outcome that can be especially prob-
lematic when treatment targets behavior that has the potential to cause
injury. Second, extinction can lead to variations in response topography,
including aggressive behavior.
To further evaluate these two drawbacks, Lerman, Iwata, and Wallace
(1999) reviewed 41 data records for individuals whose treatments included
an extinction component and for whom aggression was neither a target
response nor programmed for reinforcement at any point during assess-
ment. Their review identified extinction-induced response bursts for 39%
of the 41 reviewed cases. Similarly, Lerman et al. noted extinction-induced
aggression in 22% of the data records included in their sample. A third
drawback with extinction-only procedures is that they do not teach the
individual alternative methods to obtain the reinforcer. Each of these three
limitations can be addressed by including a differential reinforcement
component to treatment. Differential reinforcement programs include con-
tingent reinforcement of an alternative response, or the absence of the
target response, is targeted for reinforcement, thus increasing the likeli-
hood of an appropriate alternative behavior. This additional component
can improve the effectiveness and limit the drawbacks associated with
extinction-only procedures.
Again, looking at the data provided by Lerman et al., when the extinc-
tion-based procedure included a differential reinforcement, noncontin-
gent reinforcement, of some antecedent manipulation as a component of
treatment, extinction bursts were evident in only 15% of cases. Similarly,
extinction-induced aggression was also only evident in 15% of cases when
extinction was accompanied by other treatment components.
Consequence-Based Intervention Strategies:

Differential Reinforcement
Differential reinforcement is a consequence-based procedure that
consists of the reinforcement of one response class (i.e., a set of responses
maintained by the same reinforcer or reinforcers) and withholding
reinforcement for another response class (Cooper et al., 2007). Behavior

analysts have developed several variations of differential reinforcement-
based treatments. These treatment strategies are typically implemented
to reduce a target problem behavior, whereas some include a component
designed to increase a target appropriate behavior (e.g., compliance). When
used for the purpose of reducing a target behavior, differential reinforce-
ment involves two components: reinforcement of behavior(s) other than
the target behavior or the reinforcement of decreasing rates of the target
behavior, and withholding of reinforcement following the occurrence of the
targeted problem behavior (Cooper, et al.).
Although behavior analysts often use differential reinforcement pro-
cedures for the purpose of reducing problem behaviors, it should be
noted that differential reinforcement is also often used for the purpose
of shaping new appropriate behaviors. As with all reinforcement-based
procedures, differential reinforcement procedures can include positive or
negative reinforcement.
Differential Reinforcement of Alternative Behavior

(Including Functional Communication Training)
Differential reinforcement of alternative behavior (DRA) is a procedure
that consists of the reinforcement of a specified behavior that is different
from the behavior that has been targeted for reduction (but not necessarily
incompatible with that target response). In a typical application, all occur-
rences of the behavior targeted for reduction are placed on extinction,
and reinforcement is available for each appropriate response. One exam-
ple of DRA treatment is functional communication training (FCT). This
treatment consists of identifying the functional reinforcer responsible for
the maintenance of problem behavior, and then delivering that reinforcer
contingent on an appropriate communicative response (Carr & Durand,
1985). When this procedure is implemented in such a manner that the
reinforcer responsible for problem behavior is withheld (i.e., extinction is
in place) contingent on that response or set of responses, it fits within the
parameters of a DRA treatment.
It should be noted that researchers have compared the effectiveness
of FCT with and without this extinction component. In one notable study,
Hagopian, Fisher, Sullivan, Acquisto, and LeBlanc (1998) found that FCT
without extinction was minimally effective for 11 participants. Some par-
ticipants displayed a reduction in problem behavior, but none achieved a
90% reduction. Three of the 11 participants exhibited an increase in prob-
lem behavior of atleast 50% when FCT was conducted without extinction.
By contrast, FCT with extinction was effective in achieving a 90% reduc-
tion in 44% of applications (11 of 25). No increases in problem behavior
were reported when FCT was implemented with an extinction component.
There have been several articles published regarding the utility of FCT
in the behavior analytic literature. Derby et al. (1997) described the long-
term effects of FCT as treatment for the problem behavior exhibited by
four young children with developmental disabilities. Each of the children
displayed reductions in target problem behavior and exhibited increases
in or acquisition of appropriate communication following FCT implementa-

tion. This study demonstrated the robust effectiveness of FCT because the
children’s problem behavior was maintained by different functions (both
positive and negative reinforcement), including one child whose problem
behavior was maintained by multiple functions, and the treatment effects
were observed across a longer than two-year time period.
Other DRA procedures focus on increasing appropriate behavior such
as compliance with instructions. Reed, Ringdahl, Wacker, Barretto, and
Andelman (2005) implemented differential reinforcement of alternative
behavior to increase the compliance and decrease the problem behavior
exhibited by two children with developmental disabilities. Each child’s
problem behavior was maintained by escape from tasks. During treat-
ment, compliance with the tasks resulted in a 30 s break from instruc-
tion (i.e., negative reinforcement). Problem behavior resulted in immediate
guidance through the task (i.e., extinction). For each child, compliance
increased and problem behavior was reduced relative to baseline when the
DRA treatment was in place.
Differential Reinforcement of Incompatible Behaviors

Differential reinforcement of incompatible behaviors (DRI) is a pro-
cedure that is very similar to DRA except that the designated alternative
behavior targeted for reinforcement is incompatible with the behavior that
has been targeted for reduction.
Friman and Altman (1990) implemented a DRI schedule to address the
disruptive behavior exhibited by a 4-year-old boy with developmental dis-
abilities. The target response for the child was out-of-seat behavior. During
the treatment procedure, parents delivered reinforcers (praise and edibles)
contingent on the child exhibiting an incompatible behavior (i.e., staying in
his seat) for specified intervals (initially, 10 s). If the child left his seat, he was
reseated and the reinforcer was not delivered at the end of the interval. The
treatment resulted in a decrease in out-of-seat behavior and a correspond-
ing decrease in other inappropriate behavior (e.g., mouthing and throwing
objects), whereas appropriate behavior (toy play) increased slightly.
Buzas, Ayllon, and Collins (1981) described the use of a DRI proce-
dure to reduce the SIB (biting lip and tongue, picking at lips and mouth,
biting inside of cheek, gouging tongue frenulum, and falling out of wheel-
chair) exhibited by a young boy with Lesch–Nyhan Syndrome. The par-
ticipant’s SIB was so severe that he spent the majority of his day in
mechanical restraints. On the occasions when restraint was removed (for
hygiene activities, dressing, etc.), almost immediate attempts at SIB were
observed (e.g., tearing his lip with fingernail). In this case study, an array
of responses incompatible with SIB (drawing, throwing plastic darts, play-
ing games, doing puzzles, eating candy, playing catch, reading while hold-
ing a book, adding and subtracting numbers on a die, typing, wheeling
his wheelchair, and learning sign language) resulted in access to attention
from various therapists and caregivers.
When this DRI procedure was in place, the participant was able
to interact out of restraint for up to three-and-a-half hours without
attempting to engage in SIB. When the procedure was not in place and
restraints were removed, attempts at SIB were observed within 5 to 15
minutes. Although this study is descriptive and lacks systematic experi-
mental control, it is included here because of the clinically significant out-
comes achieved. The behavioral problems associated with Lesch–Nyhan
syndrome are notoriously resistant to treatment, both pharmacologic
and behavioral in nature. One potential reason for this difficulty in treat-
ment is that the reinforcers relevant to the behavior are unidentifiable or
change too often to allow for systematic evaluation. The described study
demonstrates the potential utility of arranging a differential reinforce-
ment-based treatment when a reinforcing consequence can be identified
and manipulated.
Differential Reinforcement of Low Rates of Behavior

Differential reinforcement of low rates of behavior (DRL) is a procedure
that consists of the reinforcement of a behavior targeted for reduction but
on a schedule of reinforcement that is leaner than what was in place prior
to the implementation of the DRL procedure (i.e., the schedule of rein-
forcement in place in the natural environment). With the DRL procedure,
the behavior targeted for reduction is reinforced only following a specified
length of time in the absence of the behavior. In addition, as the reductions
of the target behavior are observed over time, the length of the interval
can be systematically increased in order to bring about lower and lower
rates of the target behavior (often referred to as differential reinforcement
of diminishing rates; DRD).
Wright and Vollmer (2002) reported the use of a DRL procedure to
reduce the rapid eating exhibited by a teenage girl with developmental
and physical disabilities. The procedure consisted of reinforcing bites (i.e.,
allowing access to the bite) only if bite attempts occurred on a predeter-
mined interval. If the participant attempted to take a bite of food before the
predetermined interval elapsed, that bite was blocked. If the participant
attempted to take a bite of food after the predetermined interval elapsed,
the bite was allowed (i.e., reinforced). The authors noted that the DRL pro-
cedure was more effective if the time interval was adjustable and based on
the mean interresponse time (IRT) from the preceding five sessions than
if it was fixed (i.e., 15 s for every session). The DRL procedure resulted in
longer time between bite attempts relative to baseline which translated to
a decrease in the participant’s bite rate.
Deitz and Repp (1973) reported a series of three experiments in which
DRL schedules were used to reduce the disruptive behavior exhibited by
a student diagnosed with a developmental disability, a classroom of stu-
dents diagnosed with developmental disabilities, and a group of high school
students enrolled in regular education. In each experiment, there was a
decrease in disruptive behavior exhibited by either the target individual or
the class as an aggregate when the DRL schedule was implemented. The
treatment effects were maintained when the DRL schedule was withdrawn
during Experiment I (single student). However, treatment effects were lost
when the DRL schedules were withdrawn during Experiments II and III.
Differential Reinforcement of Other Behavior

Although DRA, DRI, and DRL-based treatments target increasing
a specific appropriate response along with reducing the target problem
behavior, differential reinforcement of other behavior (DRO) consists of
the delivery of reinforcers contingent on the absence of identified problem
behavior for a specified time period. Whereas reinforcement involves the
presentation of a stimulus contingent on a target behavior, DRO entails
the contingent application of a reinforcing consequence (either positive or
negative) for the nonoccurrence of a target behavior. Other terms that are
sometimes used for DRO include differential reinforcement of the omission
of behavior and differential reinforcement of zero rates of behavior.
Ringdahl et al. (2002) described the use of a DRO-based treatment to
reduce the stereotypic hand movements exhibited by an adolescent boy
with developmental disabilities. The stereotypic hand movements exhib-
ited by the participant were serious in nature because they could trigger
photosensitive grand mal seizures. The researchers were unable to identify
any social reinforcers maintaining the problem behavior and noted that
the behavior only occurred when adult supervision was not provided. A
reinforcer assessment indicated that video games could potentially func-
tion as a reinforcer for appropriate behavior. Following assessment, access
to video game time was allowed contingent on time intervals during which
the participant did not engage in the target response. Initially, the DRO
interval was set at 10 s (based on the average time between hand-flapping
episodes during baseline) and gradually increased to 600 s (10 min) by the
end of treatment. Decreases in repetitive hand movements were observed
when the DRO procedure was in place.
Watson and Sterling (1998) used a DRO procedure to reduce vocal
tics exhibited by a 4-year-old girl. A functional analysis of this behav-
ior indicated the vocal tics were maintained by social consequences in
the form of adult attention. During treatment, adult attention was with-
held or removed when vocal tics occurred. Alternatively, adult attention
was provided following brief intervals (15 s) with no vocal tics. The interval
was increased by 10 s following three consecutive deliveries of the rein-
forcer until the DRO interval reached the terminal length of 300 s (5 min).
A decrease in the rate of the vocal tic was observed when the DRO was
implemented. This decrease was still apparent at one-, three-, and six-
month follow-up visits.
Thinning Differential Reinforcement Schedules

One limitation of DR approaches to treatment, particularly DRA/FCT
and DRI programs, is that the target individual can access reinforcers at
any time contingent on appropriate behavior. If delivery of the reinforcer
requires the presence of a caregiver, such programs can be labor intensive.
As well, the individual may spend all of his time accessing the reinforcer,
which can compete with academic or vocational goals. Thus, one goal of
treatment is to reduce the availability of the reinforcer by increasing the
response requirement or implementing a delay to reinforcement.
Lalli et al. (1999) provided access to differential positive reinforcement

contingent on compliance in the treatment of the escape-maintained prob-
lem behavior displayed by five individuals 21 years old or younger. The pro-
grammed positive reinforcement schedule resulted in increases in compliance
and decreases in problem behavior exhibited by each participant. The
response requirement to obtain the positive reinforcer was then increased for
three of the five participants. At the outset of treatment, compliance resulted
in positive reinforcement on a fixed-ratio (FR) 1 schedule. That schedule was
increased to at least FR 10 for each of these three participants. This change
in schedule did not result in degradation of treatment effects.
Hagopian, Contrucci Kuhn, Long, and Ruch (2005) implemented FCT
for three boys diagnosed with PDD spectrum disorders admitted to an inpa-
tient hospital setting for the assessment and treatment of severe behavior
problems including aggression and disruption. Functional communica-
tion training resulted in decreases in problem behavior for each child. The
authors thinned the schedule by implementing a delay between occur-
rences of appropriate requests and delivery of the reinforcer (attention or
preferred tangible items). The delays were progressively increased if the
participant exhibited less than 0.2 responses per minute (RPM) of problem
behavior for two consecutive sessions at a given delay. If two sessions of
greater than 0.2 RPM of problem behavior was observed, the delay was
reduced to the previously longest successful delay. This progression con-
tinued until a terminal goal was met for each participant. For each of the
three participants, delays of at least 4 min were achieved. One interesting
finding from this study was that allowing the participants access to com-
peting reinforcers during the delay interval allowed for quicker attainment
of the terminal delay length and fewer occurrences of problem behavior.
Antecedent Approaches to Treatment

The majority of ABA treatments focus on manipulating consequences
to change behavior, however, there are some treatments that focus on
manipulating antecedents relevant to the target behavior. For the pur-
poses of this chapter, four antecedent-based interventions are highlighted.
These interventions include: procedures that manipulate establishing
operations, stimulus control procedures, prompt procedures, and proce-
dures that provide choice-making opportunities.
Establishing Operations
The relationship between environment and behavior is often described
as a 3-term contingency. The three components of this contingency are
what happens prior to the response (the antecedent, or A), the behav-
ior the individual exhibits (B), and what happens immediately following
the behavior (the consequence, or C). Often, this 3-term contingency is
denoted as A-B-C. A complete understanding of the antecedent requires
that behavior analysts take into account variables that alter the effective-
ness of a stimulus as a reinforcer. The term that has historically been
used to describe this relationship between the environment and reinforcer
effectiveness or value is “establishing operation” (EO; Michael, 1982). More

recently, the term “establishing operation” has been replaced with the term
“motivating operation” (MO) when the effect is an increase in the value of
the reinforcer and the term “abolishing operation” (AO) when the effect is
a decrease in the value of the reinforcer (Laraway, Snycerski, Michael, &
Poling, 2003). These operations (motivating or abolishing) affect behavior
by either increasing (via an MO) or decreasing (via an AO) responding.
The most salient example of MOs and AOs are deprivation and satia-
tion. Deprivation consists of withholding the stimulus that functions as
a reinforcer from the individual. Deprivation has at least two effects.
First, it results in an increase in the value of the stimulus as a reinforcer.
Second, it results in an increase in responding that occurs as a function
of that reinforcer. Conversely, satiation consists of presenting a suffi-
cient amount of the stimulus that functions as a reinforcer and has two
opposite effects: a decrease in the value of the reinforcer and a related
decrease in responding that occurs as a function of that reinforcer.
In application, EOs can be manipulated in a number of ways. When
attempting to decrease a target response, the identified reinforcer for that
response can be provided on a noncontingent basis during treatment (i.e.,
reinforecers are delivered on a relatively dense fixed-time schedule; Ringdahl,
Vollmer, Borrero, & Connell, 2001). Alternatively, the functional reinforcer
could be provided to the individual prior to exposing her to the context(s) in
which the target response has historically been likely to occur (e.g., Vollmer &
Iwata, 1991; Berg et al., 2000). When attempting to increase a target response,
the reinforcer can be withheld prior to training (e.g., Vollmer & Iwata, 1991).
Lalli, Casey, and Kates (1997) used a fixed-time (FT) reinforcement
schedule to reduce aberrant behavior exhibited by two children with
mental retardation and one child with a developmental disability. The FT
schedule specified when reinforcers were to be delivered. Delivery occurred
independent of the child’s behavior. The specific FT schedules used during
treatment reflected the mean latency to problem behavior during baseline
for each child. Decreased rates of problem behavior were observed with
all three children when the FT schedule was implemented. One possible
explanation for the decrease in aberrant behavior was that the FT sched-
ule of reinforcement resulted in satiation indicating AO effects.
Taylor et al. (2005) manipulated the EO associated with preferred
snacks to increase peer-directed mands (i.e., requests) exhibited by three
children with autism. MOs were altered through the restriction of the pre-
ferred snacks and access to the snacks was made contingent on mands
that were peer-directed. When the MO was in place, rates of peer-directed
mands were observed at high rates. Conversely, when the MO was not in
place, mands decreased to near-zero rates for each of the children. The
results demonstrated that targeted appropriate behaviors can be increased
through the direct manipulation of MOs.
Stimulus Control
Stimulus control is demonstrated when a particular behavior is reli-
ably occasioned by specific antecedent stimuli (Sulzer-Azaroff & Mayer,
1991). In terms of the 3-term contingency, stimulus control describes a

relationship between environment and behavior that consists of A (the
antecedent) reliably occasioning B (the behavior), which results in C (the
consequence or reinforcement). One way stimulus control can be estab-
lished is by pairing specific responses with reinforcement only when they
occur in the presence of specific antecedent stimuli, and withholding rein-
forcement when those specific responses are exhibited in the absence of
the specific antecedent stimuli. This process is often programmed in labo-
ratory research. However, it can also occur naturally as individuals are
exposed to different stimulus contexts and their specific reinforcement
schedules. For example, behavior may come under stimulus control due to
the different ways a child’s parents respond to his or her behavior.
In the presence of the father, problem behavior might always result
in attention. Conversely, in the presence of the mother, problem behavior
might have no differential consequence. If attention from care providers is
a reinforcer, the child might begin engaging in problem behavior only in
the presence of the father. In a similar fashion, punishment of a behavior
in the presence of a specific stimulus might result in that behavior being
inhibited in the presence of the stimulus. Using the same example, if the
child’s mother always delivered an aversive consequence (e.g., timeout or
spanking) following problem behavior, but the father provided no differen-
tial consequence, the child might stop engaging in problem behavior in the
presence of the mother only.
When stimulus control is apparent as exhibited by differential respond-
ing correlated with specific stimuli, treatment might focus on transfer-
ring stimulus control to improve behavior across stimulus contexts. Ray,
Skinner, and Watson (1999) used stimulus control procedures to increase
compliance exhibited by a five-year-old boy diagnosed with autism. Dur-
ing baseline, the investigators evaluated compliance when demands were
delivered by the child’s teacher as compared to when demands were deliv-
ered by the child’s mother. The likelihood that the child would comply with
demands was increased when his mother delivered demands as opposed
to when his teacher delivered demands. This finding suggested that stimu-
lus control had been established.
Using that information, the investigators next implemented a series of
procedures in which the teacher was paired with the mother during demand
situations. Initially, the child’s mother delivered three demands and the
teacher delivered one demand and compliance was observed at high rates
with both adults. Over time, a fading procedure was used in which the teacher
delivered an increasing number of the demands and the child’s mother deliv-
ered fewer of the demands while compliance continued at high rates. Eventu-
ally, the child’s mother was faded completely out of the demand situation, the
teacher delivered all of the demands, and compliance continued at high rates.
The results of Ray et al. (1999) suggested the fading procedure resulted in a
transfer of stimulus control from the child’s mother to the teacher.
In a similar study, Knoff (1984) used stimulus control procedures to
treat problem behavior exhibited by two boys, 9 and 10 years of age, who
engaged in aggression, disruption, and oppositional behavior. With each of
the children, problem behavior was occurring at high rates in the presence
of a paraprofessional during morning and noon recesses. Likewise, with

each of the children, appropriate behavior was reliably occurring at high
rates in the presence of their classroom teacher. The goal of the stimulus
control procedures was to generalize the apparent stimulus control that the
presence of the teacher was exerting over appropriate behavior to the para-
professional during recess times. The procedure consisted of the teacher
attending each recess period during the first week. High levels of appropri-
ate behavior were immediately observed with each of the children during
the first week. During subsequent weeks, the teacher spent fewer and fewer
days attending recess periods until she was completely faded out. After the
teacher was completely faded out of the recess, high levels of appropriate
behavior continued to be observed with each of the children suggesting that
stimulus control had been generalized or to the paraprofessional.
Prompt Procedures
Cooper et al. (2007) defined prompts as supplementary anteced-
ent stimuli intended to occasion specific responses. Whereas response
prompts (i.e., graduated guidance) target behavior, stimulus prompts tar-
get the antecedent conditions that exist prior to the occurrence of specific
behavior (i.e., antecedents). Behavior analysts use stimulus prompts as
auxiliaries to be removed over time as the intended behavior occurs more
reliably in the presence of natural stimuli (discriminative stimuli). Prompts
are often used during initial phases of treatment programs to facilitate the
acquisition of specific responses. Following acquisition, the prompts can
then be systematically faded so that naturally occurring stimuli will come
to reliably occasion the acquired behavior.
Taylor and Levin (1998) and Shabani, Katz, Wilder, Beauchamp, Tay-
lor, and Fischer (2002) each used a prompting procedure to promote social
initiations with children with diagnoses of autism. The investigators used
a tactile prompting device located in the children’s pockets. Specifically,
the device was programmed to vibrate for 3 to 5 s whenever the investiga-
tors activated it using a remote control. The investigators initially paired
a vocal model with the tactile prompt to bring about social initiations,
and then gradually faded the vocal model as the children independently
exhibited social initiations following tactile prompts. The use of the vocal
modeling and tactile prompts resulted in high rates of social initiations
exhibited by the children across both studies.
In addition, Shabani et al. (2002) also attempted to fade the tactile
prompt with two of the three participants by systematically reducing the
frequency of the prompts over time. The results suggested that fading the
tactile prompt was partially successful for each of the particiapants as
social interactions continued, but at lower and more variable rates.
Rivera, Koorland, and Fueyo (2002) used picture prompts to promote
sight word reading with a nine-year-old boy diagnosed with a learning dis-
ability. The picture prompts, which were generated by the child himself,
were illustrated representatives of the targeted sight words. Initially, the
experimenters reviewed with the child the meaning of each of the targeted
sight words and had him generate illustrations for each of the words on
large index cards. As the child’s sight-word reading accuracy increased,

the index cards on which he drew the illustrations were reduced and the
colors that he was allowed to use were systematically lightened until the
illustrations were successfully faded from the program. Even as the picture
prompts were faded, the child continued to exhibit a high level of accurate
sight-word reading.
Choice
Another antecedent-based intervention that has been demonstrated
to be effective involves providing choice-making opportunities. Numerous
studies have shown that providing choice can serve to decrease problem
behavior and increase appropriate behavior including academic and voca-
tional task engagement. Furthermore, choice has been conceptualized as
a functional variable (i.e., a reinforcer for appropriate behavior) in and of
itself rather than simply a means to identify highly preferred stimuli (Dun-
lap et al., 1994).
Dibley and Lim (1999) provided choice-making opportunities dur-
ing treatment with a 15-year-old girl diagnosed with a severe intellectual
disability. Choice-making opportunities were incorporated into various
activities including meal-time routine, toileting routine, and leisure time
activities for the purpose of increasing compliance and decreasing prob-
lem behaviors. During baseline, the adolescent was prompted to engage
in each step that made up the respective activities and no choices were
incorporated. During treatment, the adolescent was prompted to engage in
each step that made up the respective activities with various opportunities
for choice embedded throughout each of the activities. For example, during
the toileting routine, the adolescent was provided with a choice between
initiating the activity immediately or following a 10-min delay, basin or
sink for hand washing, and hand-towel or hand dryer. When choices were
provided, compliance was observed at higher levels and problem behavior
was observed at lower levels when compared to baseline. These results
were consistent across each of the three targeted activities.
Dunlap et al. (1994) incorporated choice-making opportunities into
treatment programs for three young boys aged 11, 11, and 5 for the pur-
pose of decreasing noncompliance and aggressive behavior. Two of the
children received opportunities to make choices during instructional times
in the form of menus containing several academic tasks. Choice-making
opportunities for the third child were incorporated into reading time. Spe-
cifically, the child was allowed to pick a book from an array prior to story-
time. When choices were provided, each child exhibited lower levels of
noncompliance and problem behavior and task engagement was observed
at higher levels than those observed during baseline.
Combining Antecedent and Consequence-Based Treatments

Often, more than one treatment is selected for implementation. Such
treatment packages might be constructed of both antecedent and consequence-
based components. Ringdahl et al. (2002) provided one such example.
Treatment evaluated in that study combined DRA with instructional fading

in the treatment escape-related problem behavior exhibited by a girl diag-
nosed with autism. The consequence portion of the treatment was a dif-
ferential reinforcement schedule that specified the delivery of brief breaks
contingent on appropriate compliance (i.e., completion without exhibiting
problem behavior) with academic tasks. The antecedent component of the
treatment was systematically increasing the number of instructions that
were delivered during a 5-min work session, as long as problem behav-
ior remained low, until a terminal goal of one instruction per min was
achieved. Results of this study suggested that this combination of treat-
ment components resulted in successful treatment with fewer occurrences
of problem behavior than a consequence-based treatment (DRA) alone.
Marcus and Vollmer (1996) combined antecedent and consequence-
based treatments in the treatment of SIB and aggression displayed by a
young girl with developmental disabilities. Their investigation evaluated a
treatment comprised of two components: NCR (antecedent) and differential
reinforcement of compliance (consequence). Results of the study indicated
that the treatment package was effective in reducing problem behavior. In
addition, the treatment was effective in teaching the young girl how to use an
alternative, appropriate communicative response to obtain the reinforcer that
maintained problem behavior. The use of the package allowed for effective
treatment while limiting some of the side effects (e.g., response bursts) some-
times observed during behavioral treatments with an extinction component.
Generalization
Generalization is one of the stated characteristics of applied behavior
analysis (Baer et al., 1968). According to Cooper et al. (2007), generalization
is a broad term that refers to a number of behavior change outcomes. During
clinical application of ABA-based treatments, there is often an attempt
to expand the effects of treatment from the clinical setting to the natu-
ralistic environment (i.e., stimulus/setting generalization). Stimulus/set-
ting generalization refers to the occurrence of a behavior under different
conditions than which the behavior was acquired. Cooper et al. point out
that this behavior change can occur without being directly taught. How-
ever, some behavior analysts attempt to facilitate this outcome through
programming. Literature-based examples of generalization can be broken
into two broad categories. Some studies describe the naturally occurring
spread of effects across setting, time, and stimuli, whereas others describe
systematic processes to achieve generalization.
Bonfiglio, Daly, Martens, Lin, and Corsaut (2004) described the effects
of various reading interventions on the reading accuracy of a third-grade
girl. The participant was exposed to performance-based, skills-based,
and combined performance-based and skills-based reading interventions.
Each treatment was demonstrated to improve reading behavior. The effects
of treatment were noted across time and reading passages. These effects
were achieved without specific programming. The authors hypothesized
that generalization, particularly across passages, was a function (or, par-
tially a function) of a fluency threshold.
Eikeseth and Nesset (2003) described a treatment designed to improve

vocal articulation exhibited by children with phonological disorder. As part
of their treatment, the goal was to bring about mastery of a variety of tar-
get sounds (i.e., vocally produce the sounds without articulation errors).
Toward this end, the two participants were exposed to a treatment that
included sufficient response-exemplars. Specifically, a set of ten words
was programmed to be used to teach the child the sound. During treat-
ment, participants received tokens that could be exchanged for individually
determined back-up reinforcers contingent on correct articulation or close
approximations of the therapist’s vocal model. Results suggested that both
participants mastered each sound without needing to be exposed to all ten
target words. The necessary number of words needed varied from one to
eight. Thus, according to Eikeseth and Nesset, “after acquiring correct artic-
ulation of some words containing a particular target sound, other words
containing the same target sound were subsequently echoed correctly with-
out training” (p. 33–334). That is, generalized behavior change took place.
EFFECTIVENESS RESEARCH
Another s tated characteristic of applied behavior analysis is effective-

ness (Baer et al., 1968). Although metaanalyses regarding the effectiveness
of ABA-based treatments are difficult to identify, there are a number of
studies that review the effectiveness of ABA-based strategies in the treat-
ment of severe behavior problems exhibited by individuals with and with-
out developmental disabilities. These reviews and summary papers can
be placed into one of three broad categories: summaries of treatments for
behavior associated with particular disorders (e.g., autism, ADHD), sum-
maries of treatments for specific behavior problems (e.g., SIB, aberrant
behavior, and stereotypy), and summaries of the effects of a specific treat-
ment approach (e.g., NCR and FCT).
Treatment of Behavior Challenges Associated

with Particular Diagnoses
Matson et al. (1996) provided a review of behavioral treatment strate-
gies designed to address the challenging behavior exhibited by individu-
als with autism. Results of their review suggested that behavior analysts
have used methods derived from the principles of operant conditioning to
address a wide range of target behaviors exhibited by children diagnosed
with autism including aberrant behavior, language, and social, daily living,
and academic skills. These authors also found the percentage of interven-
tions reported that used positive procedures outnumbered significantly the
number of interventions that used aversive procedures. Olson and Houli-
han (2000) reviewed behavioral treatments for challenging behaviors asso-
ciated with Lesch–Nyhan disorder. The review suggested that in most cases,
the use of behavioral treatments (i.e., DRO, DRI, extinction) were effective
in treating self-injury exhibited by children with Lesch–Nyhan and that in
many cases the results generalized to other settings and care providers.
Treatment of Specific Problem Behavior

A number of other review papers have summarized ABA-based proce-
dures as they pertain to the treatment of specific behavior problems. Iwata
et al. (1994) reported the use function-based behavior analytic treatment
to reduce self-injurious behavior (SIB) exhibited by adults and children
with developmental disabilities. Effective treatment was defined as a treat-
ment procedure that resulted in a decrease in problem behavior to below
10% of the baseline level for a given individual. Iwata et al. reported that,
when interventions were based on identified functions of SIB, anteced-
ent-based interventions were effective in 84.2% of reported cases, extinc-
tion was effective in 86.8% of reported cases, differential reinforcement
was effective in 82.5% of reported cases, and punishment was effective in
88.2% of reported cases.
Similarly, Asmus et al. (2004) reported the treatment effects of func-
tion-based behavior analytic treatments in the reduction of aberrant
behavior (SIB, aggression, stereotypy, destruction, and disruption) exhib-
ited by adults and children with and without developmental disabilities.
They reported an 80% decrease in aberrant behavior following the imple-
mentation of ABA-based treatments for 76% of the treated individuals.
Rapp and Vollmer (2005) provided a summary of the literature concerning
the treatment approaches to reducing stereotypy (i.e., repetitive behavior
that serves no apparent social function). These authors concluded that
there is ample support in the literature for the effectiveness of ABA-based
treatments (both antecedent and consequence) in reducing stereotypy.
Effectiveness of Specific Treatment Strategies

Finally, several summaries have been published on the effectiveness
of specific ABA-based approaches to treatment. Miltenberger, Fuqua, and
Woods (1998) reported on the effectiveness of habit reversal methods for
the treatment of target behaviors including tics, nervous habits, and stut-
tering. The authors suggested that habit reversal methods have been con-
sistently demonstrated as effective even in the absence of identification
of functions of the treated tics, habits, and stuttering. Carr et al. (2000)
conducted a review of studies that evaluated the use of NCR in the treat-
ment of aberrant behavior. The authors reported that NCR has been an
effective treatment strategy for a variety of problem behaviors exhibited
by individuals with developmental disabilities but included the caveat
that more clinical research needs to be conducted in the area. Taken as a
group, summaries provide a persuasive demonstration of the effectiveness
of ABA-based treatments for a number of childhood behavior challenges
exhibited by children with psychiatric and developmental disabilities.
SUMMARY
We have attempted to provide an overview of the conceptual basis for

ABA-based treatments, a description of several of the more common of these
treatments, and a brief discussion of their effectiveness. Applied behavior
analysis-based treatment approaches have an established and effective

history in the treatment of problem behavior and the establishment of
appropriate behavior across a wide range of disabilities. The approach is
not designed to treat the underlying disorder, per se. Instead, ABA-based
treatments target specific behavioral symptoms indicative of an individual’s
diagnosis. Related strategies can be used to either establish new behavior
or decrease existing problem behavior through an analytic process requir-
ing an understanding of the antecedent and consequent variables affect-
ing the target behavior. Although several approaches to behavior change
exist, ABA-based treatments offer an evidence-based methodology with
strong roots in basic and applied research. In our opinion, ABA represents
a state-of-the-art approach to the development of behavior-change programs.
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3
Cognitive Behavior Therapy
ELLEN FLANNERY-SCHROEDER
and ALEXIS N. LAMB
INTRODUCTION
Increasingly, attention is turning to the significance of children’s mental

health. This attention results from a confluence of information sources col-
lectively emphasizing the prevalence of childhood problems. Epidemiologi-
cal estimates for the prevalence rates of childhood emotional and behavioral
disorders range between 15 and 22% (e.g., McCracken, 1992; Roberts, Att-
kisson, & Rosenblatt, 1998; Rutter, 1989; Kazdin & Weisz, 2003a; WHO,
2001). These rates may be underestimates as epidemiological studies often
do not include children exhibiting subclinical distress despite the fact that
these subclinical conditions have been found to be associated with sig-
nificant functional impairments (e.g., Angold, Costello, Farmer, Burns, &
Erkanli, 1999). Childhood difficulties have been associated with problems
in adolescent and adult adjustment (e.g., Colman, Wadsworth, Croudace, &
Jones, 2007). Evidence exists suggesting that childhood psychopathology
has long-term social consequences including truncated educational attain-
ment, teen parenthood, early marriage, and marital instability (e.g., Kes-
sler, Berglund, Foster, Saunders, Stang, & Walters, 1997; Kessler, Molnar,
Feurer & Appelbaum, 2001; Kessler, Foster, Saunders, & Stang, 1995; Kes-
sler, Walters, & Forthofer, 1998; Forthofer, Kessler, Story, & Gotlib, 1996).
Despite the evidence that a large number of children are diagnosed
or at risk for disorder, research has suggested that as few as 40% of chil-
dren experiencing mental health problems receive help and only about
20% receive specialty mental health services (Burns et al., 1995). Hence,
there is a real need for easily accessed, client-acceptable, and effective
interventions for childhood mental health issues. In recent years, the child
therapy literature has grown with a profusion of empirical investigations of
ELLEN FLANNERY-SCHROEDER and ALEXIS N. LAMB ● University of Rhode Island.

56 ELLEN FLANNERY-SCHROEDER and ALEXIS N. LAMB
Table 3.1. General Characteristics of Cognitive Behavioral

Approaches
Fairly structured
Time-limited (5–20 sessions; 45–50 minutes)
Session agenda setting
Goal setting
Homework
Experimental orientation to human behavior
Problem-oriented focus
Collaborative empiricism
Behavioral experiments
Measurable outcomes
Performance-based assessments/procedures
Skill- and knowledge-building
Psychoeducation (e.g., directed reading, rating scales, handouts)
Behavioral methods (e.g., behavioral rehearsal)
Cognitive methods (e.g., cognitive restructuring)
efficacy. Many of these investigative efforts have involved cognitive-behav-

ioral treatments.
Cognitive-behavioral treatments (CBTs) with youth have garnered
a good deal of clinical and research attention of late (e.g., Christner,
Stewart, & Freeman, 2007; Friedberg & McClure, 2002; Graham, 2005;
Kazdin & Weisz, 2003b; Kendall, 2006; Mennuti, Freeman, & Christ-
ner, 2006; Reinecke, Dattilio, & Freeman, 2006a). Cognitive-behavio-
ral approaches have been used for a broad array of childhood problems
including, but not limited to, anxiety, depression, anger, aggression, eat-
ing disorders, autism, and learning difficulties. Numerous treatments
(e.g., self-instructional training, problem-solving therapy, stress inocu-
lation therapy, social skills training) have fallen under the heading of
cognitive-behavioral. These varied treatments, however, share some com-
mon features (see Table 3.1).
Early child treatment models have been downward extensions of
treatments designed for adults. Many researchers have sounded a call
for intervention and prevention programs that are based on theory and
research emerging from the field of developmental and child clinical
psychology (Greenberg, Domitrovich, & Bumbarger, 2001; Holmbeck,
O’Mahar, Abad, Colder, & Updegrove, 2006; Kazdin, 2001; Weisz & Weers-
ing, 1999). All CBTs with children are based on an explanatory model of
behavior that emphasizes cognitive processing, behavior, and affective
responding. CBT finds its roots in classical and operant conditioning and
social learning theory.
UNDERLYING THEORY OF CBT
In its most basic form, the cognitive-behavioral model posits that one’s
response to events is dependent upon one’s perception or interpretation of
that event. In other words, children respond to a cognitive representation
COGNITIVE BEHAVIOR THERAPY 57
of the event, not the event itself. If one’s interpretation of the situation
is not supported by the facts or reality, then the thinking is deemed dis-
torted, irrational, or dysfunctional. One of the goals of CBT is to identify
and restructure the dysfunctional thoughts and beliefs related to one’s self,
world, and future (Beck, 1970). The manner in which children think about
situations or events will determine not only their affective response but
also their behavior. These cognitive representations and resulting affect
and behavior are reciprocally determined. That is, changes in one result
in changes in the other. CBT therapists aim to educate children about this
reciprocal relationship and to heighten awareness of their cognitive proc-
esses (i.e., self-statements).
Cognition is thought of as an information-processing system with dif-
ferent levels, structures, and processes. Automatic thoughts, intermediate
beliefs, and schemas comprise three components of the system. Automatic
thoughts are those situation-specific self-statements that we make with-
out deliberation or reasoning. They are closest to our conscious level of
thinking and therefore are easily accessed. Beck and colleagues (1979;
Clark, Beck, & Alford, 1999) have described characteristic errors in logic
in automatic thoughts. Sample categories of cognitive errors include mag-
nification or minimization, overgeneralization, all-or-nothing thinking,
and personalization.
Much research evidence has demonstrated that adults and children
with psychological disorders (e.g., depression, anxiety) have a high fre-
quency of distortions in their automatic thoughts (e.g., Bogels & Zig-
terman, 2000; Haaga, Dyck, & Ernst, 1991; Hollon, Kendall, & Limry,
1986; Kazdin, 1990; Kendall, Stark, & Adam, 1990; Schniering &
Rapee, 2002, 2004; Wright, Beck, & Thase, 2003). Intermediate beliefs
comprise those attitudes, rules, and assumptions that one holds (e.g.,
“If I don’t get an A on my math test, I am a failure.”). These beliefs may
be out of conscious awareness, unspoken, and often reflect conditional
“if-then” thinking. Core beliefs (or schemas) represent thinking which is
absolute (e.g., “I am unlovable.”). These beliefs may be characterized as
“global, rigid, and overgeneralized” rules for interpreting one’s environ-
ment (Beck, 1995, p. 16).
According to Beck’s (1976) content-specificity hypothesis, thought con-
tent is specific to psychological disorder or affective state. As an example,
Beck’s model posits that cognitive processes in depression center on loss,
hopelessness, and failure whereas cognitive processes in anxiety focus
on perceived threat, danger, and uncontrollability. Two relatively recent
studies using both community and clinic-referred samples of children and
adolescents have demonstrated support for the content-specificity hypoth-
esis (e.g., Epkins, 2000; Schneiring & Rapee, 2004) whereas others (e.g.,
Epkins, 1996; Treadwell & Kendall, 1996; Ronan & Kendall, 1997) have
found mixed support.
Once children become adept at metacognition (i.e., thinking about
their own thinking), children are taught strategies to modify their think-
ing. The modification of irrational or distorted thinking occurs through
cognitive (e.g., collection of “evidence” against which to evaluate the
veracity of the irrational thought, Socratic questioning, problem-solving)
or behavioral (e.g., behavioral experiments designed to “test” the valid-

ity of beliefs or to build skills) means. It is important to note, however,
that the reliance on cognitive versus behavioral techniques is often deter-
mined both by the nature of the disorder as well as the age of the child. As
an example, behavioral techniques may have greater utility in work with
younger children.
Contingent reinforcement is often used to enhance a child’s motivation
and involvement in therapy. The process of CBT has often been described
as collaborative empiricism: therapist and child work together to form
and experimentally “test” hypotheses through the collection of behavioral
evidence. Together, therapist and child monitor the progress of therapy,
making necessary revisions and refinements across time.
To best fulfill the goals of cognitive behavioral therapy, one must con-
sider the child’s functioning (e.g., cognitions, affect, and behavior) within a
context. Therapists must consider biological, cultural, social, environmen-
tal factors to best understand the contextual influences impinging upon
the child. The field of developmental psychopathology has come to recog-
nize that change involves a dynamic interplay among the individual char-
acteristics and contextual systems (Cairns, Cairns, Rodkin, & Xie, 1998).
Recognition of these contextual systems is especially important given the
fact that children have little control over choosing and altering their envi-
ronments (Erickson & Achilles, 2004).
ASSESSMENT METHODS
Numerous assessment techniques have been researched and cited

in the child assessment literature. Therapists select certain measures
and assessment tools depending on the nature of the information they
seek. For cognitive behavioral therapists, particular assessments are more
widely used than others. These include functional assessment, behavio-
ral observations, interviews, self-report/parent-report measures, and out-
come assessment techniques. The collection of information from multiple
sources known to the child provides the most accurate picture of the child,
his or her difficulties, and the surrounding systems that contribute to
these difficulties. Similarly, using multiple methods to gather information
from the child and family will result in a more thorough understanding of
the target problem (Krain & Kendall, 1999; Pellegrini, Galinski, Hart, &
Kendall, 1993). Assessment tools that differ in the means of information
access will tap into different processes. For example, behavioral obser-
vations carried out by the therapist will provide fundamentally different
information than self-report measures completed by the child and/or the
child’s parents. Each of the aforementioned assessment techniques will be
discussed below.
Functional Assessment
The main goal of a functional assessment is to systematically examine
the problem behaviors exhibited by the child in order to plan the most
effective way of addressing those behaviors. Information regarding the child
or adolescent’s overt behaviors, emotional behaviors, and cognitive/verbal

behaviors is used to ascertain the target problem(s) that need treatment.
After identification of the target problem, a variety of assessments are used
to determine what promotes and reinforces this behavior for the child. These
are commonly referred to as antecedents and consequences of the target
problem. According to Zarb (1992), four different types of assessments are
generally used to conduct functional analyses: repeated self-report meas-
ures, behavioral observations of the child and family, interviews with the
child and family, and school report forms. Combining information from
both the child’s school and the child’s family provides the therapist with a
more complex understanding of why and when the target problem occurs,
thus allowing the therapist to develop the most effective treatment.
Behavioral Observations
Many of the difficulties addressed by CBTs are observable. The anx-
ious child shows obvious signs of fear in certain situations (e.g., sweating,
shaking), the depressed child appears withdrawn and “flat,” and aggres-
sive children demonstrate antagonistic behavior towards others. These
are just a few examples of overt signs characteristic of internalizing as
well as externalizing disorders. Behavioral observation relies upon close
scrutiny of these overt signs to assess how well the child or adolescent is
functioning given the target problem. Observing the child or adolescent in
session allows the therapist to witness first-hand the child’s behavior and
interpersonal functioning. Observing the interactions between the child
and her family can also provide information about how significant others
in the child’s life may be contributing to the development and/or main-
tenance of the target problem. Even brief parent–child interactions in the
therapy setting can be very informative as parents may be unaware of the
impact of their behavior on the child. Consequently, behavioral observa-
tion will provide information that interviews and self-report measures may
not. Additionally, behavioral observation can provide valuable information
when it is implemented in a more natural setting, such as a child’s home
or school. Therapists can develop a greater understanding of the impact of
the targeted problem when they observe the manner in which it interferes
in every-day situations.
Interviews
Whereas observations have the unique advantage of allowing the ther-
apist to witness first-hand certain interpersonal and/or family dynamics
that may be involved in the maintenance of the target problem, interviews
provide the therapist with historical information about the problem. Dur-
ing interviews, therapists have an opportunity to gain knowledge about
relationships within the family as well as child- and parent-reported
strategies for modifying behavior (Pellegrini et al., 1993). Semi-structured
interviews are recognized as being reliable and valid for making diagnoses,
and they are commonly used in CBT assessments (Clark, 2005). The CBT
therapist will not only pay attention to the child’s behavior during the
interview but also to any cognitions that the child may share during the
interview that may be contributing to the target problem. For children and
adolescents, interviews are generally conducted with both the child and
the parents, either separately or together. Interviews with both parent and
child together allow for observation of the interactions, whereas separate
interviews offer greater freedom for both parties to speak openly about the
presenting problem and surrounding issues.
Self-Report Measures
Questionnaires completed by the child or adolescent and his parents
provide yet another source of information for the therapist. For younger
children, more valuable information may be garnered from parent-report
of the child’s behavior. However, when working with adolescents, there are
many self-report measures that address internal states and cognitions.
For example, certain self-report measures assess attributions regarding
the world around them (Pellegrini et al., 1993). This type of information is
generally more difficult to gather during an observation or interview and
may be quite hard for parents to report on accurately. For some children
and adolescents, self-report measures may represent a less intimidating
way to share thoughts and feelings that are otherwise too uncomfortable
to express.
Parent-report forms and teacher-report forms have significant utility
as they provide information about what occurs outside the therapy set-
ting. Teachers and parents spend the most time with children and, as a
consequence, are invaluable sources of information about child function-
ing. Although behavioral observations in the school or home certainly pro-
vide useful information to the therapist, questionnaires are significantly
more cost- and time-effective. Use of these forms during the initial assess-
ment and throughout treatment is essential in the monitoring of treatment
progress (Pellegrini et al., 1993).
Outcome Assessments
As with most types of psychotherapy, cognitive-behavioral therapy
monitors symptomatology throughout treatment to assess progress. If the
child is showing little or no progress, this may be an indication to the
therapist that either the initial conceptualization of the target problem
and corresponding contributing factors is incorrect or that the treatment
formulation may need alteration. Outcome assessments provide an objec-
tive way to evaluate the impact of treatment. Many of the aforementioned
assessments may be implemented as outcome assessments, yet certain
types may be considered more objective than others. For example, self-
report measures and other questionnaires are less likely to be biased by
the therapist’s expectations for treatment gains although they may be
influenced by the child’s expectations.
Re-administration of structured interviews by an independent
diagnostician at the end of treatment also provides a relatively objective
indication of changes in the child’s functioning as a result of receiving
services. Behavioral observations, although somewhat less objective than
questionnaires and structured interviews and certainly more difficult to

code, can also provide useful information about treatment outcome. For
example, observations of a socially anxious child interacting comfortably
with a stranger at the end of treatment can be an excellent index of out-
come if that child was unable to make or sustain eye contact with others at
the beginning of treatment. Such obvious and clinically meaningful treat-
ment gains can easily be captured by behavioral observations.
Cultural Considerations
When providing assessment or treatment services for children of dif-
ferent cultures, it is important to take into account both the appropri-
ateness of the assessment measures as well as norms and expectations
inherent to the child’s cultural background. Many measures that are used
commonly in CBT have not been normed on non-European-American cul-
tures. Consequently, evaluating a child’s score relative to existing norms
may be very misleading. Moreover, research has shown significant differ-
ences across cultures in the prevalence and intensity of different emotions
(Okazaki & Tanaka-Matsumi, 2006).
For example, Latin American individuals report high levels of positive
affect, whereas individuals from Asian cultures generally do not report high lev-
els of positive affect (Okazaki & Tanaka-Matsumi, 2006). As a result, an Asian
American woman who shows low positive affect may “present” as depressed or
dysthymic when actually she is within the normative range given her cultural
background. Alternatively, a Latino American man who might be exhibiting
reduced affect relative to his cultural norms may not be identified as such
if he is evaluated against existing norms. In addition, more research needs
to be conducted on the reliability, validity, and utility of behavioral assess-
ments in other cultures (Okazaki & Tanaka-Matsumi, 2006). Cultures vary
in their conceptualizations of what is considered “appropriate” or “acceptable”
behavior. Thus, therapists are urged to be cautious when assessing children
from other cultures or ethnicities. It is critical to ascertain relevant informa-
tion regarding the child’s cultural background before arriving at conclusions
about target problems and contributing systems.
THERAPEUTIC TECHNIQUES
Common cognitive behavioral therapeutic techniques include affective

education, cognitive restructuring, contingency management, behavioral
rehearsal, problem-solving, and self-monitoring, self-evaluation, and self-
reinforcement. CBTs often use a few, many, or all of these techniques in
the conduct of therapy.
Affective Education
An important first step towards identifying and changing faulty cogni-
tions is recognizing the emotions associated with these thoughts. Children
and adolescents often lack the insight or maturity to realize that their body
produces physiological reactions to emotional states. For example, an anx-

ious child might feel “butterflies in her stomach” when she finds herself in
an anxiety-producing situation. Instead of recognizing, for example, that
she is nervous, this child might conclude that she is sick with a stomach-
ache. Affective education addresses this disconnect between the physical
and psychological experiences of emotional states.
Children and adolescents are often asked to reflect upon ways in
which people demonstrate their feelings. This may be done via role-playing
or charades, by drawing pictures of faces or people experiencing different
feelings, or simply jotting down a few signs that someone is angry, sad,
happy, or confused. This focus on the physical signs of emotions is applied
to the child so that the child is asked to think about what happens to his
or her body when a certain emotion is experienced. For some children, it is
helpful to either provide a drawing of a human body or have them draw a
person on which they can circle or otherwise mark the part of their body in
which they experience a somatic symptom (e.g., drawing a hammer hitting
the head to indicate the experience of headaches). Children and adoles-
cents are encouraged to view these feelings as “clues” to their emotional
experience. In such a way, coping mechanisms can be put into place at
the first physiological signs of emotional distress in an effort to prevent a
worsening of the emotional and/or physical response.
Cognitive Restructuring
A key element of CBT is recognizing and altering the faulty cogni-
tions that underlie the emotional distress. For a depressed adolescent, for
example, the maladaptive automatic thoughts might include, “I’m not good
at anything,” and “No one is ever going to like me.” There are many creative
ways to help children and adolescents identify their automatic thoughts.
One way to illustrate the concept in a more concrete way for younger chil-
dren is to use cartoons and to talk about the character’s “thought bubble”
(see Kendall & Hedtke, 2006). This is a very visual way for children to
gain insight into cognitive processes. Use of cartoon characters can help
to illustrate, for example, that two people in the same situation may have
different thoughts, and, as a result, will experience different emotions
and/or behaviors. Once children have mastered the skill of identifying
their self-talk, they are taught to undergo a rational analysis of that self-
talk. Is there evidence to support their thinking? Is there another way of
looking at the situation? Through this process, children are able to modify
their dysfunctional thinking from irrational to rational, and the cognitive-
behavioral model then predicts a corresponding decrease in emotional and
behavioral distress.
Contingency Management
Cognitive-behavioral therapy places strong emphasis on the consequences
of behavior. In line with the fundamental principles of behavior therapy,
positive consequences will increase the frequency of behavior whereas negative
consequences will reduce the frequency. As such, contingency management
is an effective means to create and sustain behavioral modifications.

Contingency management procedures often include the praising of desired
behaviors and/or planned ignoring of undesired behaviors. Often rewards
are used to heighten engagement in therapy tasks; however, rewards are
only effective to the extent that they are desirable to the child. The rewards
may be material (e.g., small trinkets or toys) or social in nature (e.g., selecting
the dinner menu at home, attending a movie, or staying up a half hour
later at night). Often treatment begins with the provision of material rewards
then shifts into the provision of social rewards later in treatment in order to
enhance the likelihood of sustaining the provision of rewards by parents after
treatment. Consistency in contingency management is essential to promote
effective maintenance of treatment gains.
Behavioral Rehearsal
Behavioral rehearsal is a crucial part of both cognitive and behav-
ioral change. Behavioral rehearsal involves the simulation of situations
inside the therapy room for the purpose of skill development and prac-
tice. Thus, behavioral rehearsal can help children to utilize new ways
of responding to life situations that cause them difficulty. Once new
response patterns are trained in therapy, they are then tested out in “real
world” settings. Some children find it difficult to role-play; others relish
the opportunities. Clearly, the success of behavioral rehearsal is depend-
ent upon a child’s openness to engagement in the activity. Behavioral
rehearsal typically proceeds in a steplike fashion with easier to manage
situations practiced prior to more difficult ones. Corrective feedback is
provided by the therapist; however, the child is encouraged to self-moni-
tor and evaluate her own performance as well. Often modeling of the
skill is necessary when the child’s skill deficit is profound or corrective
feedback is proving ineffective. Once the child demonstrates mastery of
the skill being practiced, therapist and child move to the next more dif-
ficult situation. Homework assignments are critical to ensure that the
skill receives practice in vivo.
Problem-Solving
Bedell and Lennox (1997) have proposed a problem-solving model
that includes seven steps in the problem-solving process. The seven steps
include: (1) recognize the existence of a problem, (2) define the problem in
a goal-directed manner in which your own and other’s unmet wants are
identified, (3) brainstorm problem solutions without evaluation of their
possible efficacy, (4) evaluate the potential effectiveness of the alterna-
tives generated, (5) select the best alternative or combination of alterna-
tives, (6) implement the chosen solution, and (7) verify the effectiveness
of the chosen solution. Thus, the problem-solving process acknowledges
that there is a conflict to be addressed, and it provides a structured way
for approaching the problem.
The cognitive-behavioral approach requires that the therapist lead

the child through the steps under the guiding principle of collaborative
empiricism. Together, therapist and child brainstorm numerous poten-
tial solutions (some likely ineffective, some silly, some first-rate) without
regard to their potential usefulness until the possibilities are exhausted.
Next, the therapist and child evaluate each item on the list both in terms
of its effect on the child’s thoughts and feelings and in light of the prob-
able consequences of the choice: “If you did this, how would you feel?
Would it help you in this situation to do that?” Once the child has identi-
fied those alternatives likely to be helpful in the resolution of the problem,
he has developed an admirable problem-solving strategy. As with all CBT
techniques, the goal is to teach the child how to independently use prob-
lem-solving so that it becomes a tool that may be frequently referred to by
the child. Problem-solving is applicable to a wide-range of difficulties and
can be used in the treatment of depression, anxiety, anger management,
attentional problems and myriad other challenges.
Self-Monitoring, Self-Evaluation, Self-Reinforcement

In order for children to be able to effectively use many of the above-
mentioned CBT techniques independently, they must have the ability to
reflect on their thoughts, feelings and actions and use that information
to regulate their behavior. Developmental level must be considered when
honing these skills with children and adolescents as younger children may
lack the insight necessary for this process, thus requiring more external
reinforcement at first. For all child clients, self-monitoring, self-evaluation,
and self-reinforcement techniques will need to be modeled by the therapist
so that the child develops an awareness of how to self-monitor.
Depending on the target issue of the child, self-monitoring can be
structured or even scheduled. For example, a child with attention-deficit
problems can be asked at the end of every class at school to write down
how well she did at trying to concentrate during class. In the beginning,
it is helpful to have the child or adolescent record the data when self-
monitoring so that later the therapist and child can evaluate the data
together in the spirit of collaborative empiricism. This allows opportuni-
ties for therapist modeling of self-evaluation and self-reinforcement. For
younger children, a scale or wheel depicting different levels of satisfac-
tion may make the self-evaluation process more concrete and thus more
effective.
When training a child to self-reinforce, it is important to illustrate
that decisions about whether a self-reward is deserved is made in light
of effort as well as outcome. Children must be taught to see the nuances
of success in order to reward themselves appropriately. For example,
if a socially anxious child works up the nerve to say hello to another
child on the playground, the anxious child is worthy of self-reward
regardless of the other child’s response. Initially, the self-monitoring,
self-evaluation, and self-reinforcement processes will be externalized as
the therapist models for the child. Homework assignments may include
keeping a log that serves as a record of self-monitoring, self-evaluation,
and self-reinforcement practice. Last, the therapist tapers his or her

guidance as the child develops mastery over the process and begins to
implement the skills independently.
EMPIRICAL SUPPORT ACROSS DISORDERS
The past few decades have seen a remarkable increase in the number
of studies demonstrating empirical support for the effectiveness of various
forms of psychotherapy. Many of these studies have looked at the overall
effectiveness of therapy. That is, in general, does therapy result in positive
gains? Initial studies focused on outcomes for adults receiving therapy,
and results indicated positive effects (e.g., Shapiro & Shapiro, 1982; Smith,
Glass & Miller, 1980). However, when various orientations and types of
therapy were compared, no significant differences were found. This phe-
nomenon was deemed the “Dodo bird verdict” in reference to Lewis Car-
roll’s Alice in Wonderland in which the dodo bird said, “Everyone has won,
and all must have prizes” (Rosenzweig, 1936). In other words, any form of
psychotherapy results in positive gains, and all these gains are roughly
comparable. The “Dodo bird verdict” implies that the specific technique
used is not as important as some underlying commonality shared by all
forms of psychotherapy.
However, in an attempt to replicate Smith et al.’s 1980 meta-analysis,
Shapiro and Shapiro (1982) found slightly discrepant results. Although
factors such as target problem appeared to have a greater impact on treat-
ment outcome than type of treatment, there was evidence suggesting that
cognitive and behavioral treatments demonstrated greater treatment gains
than other forms of psychotherapy (e.g., dynamic therapy).
Several meta-analyses were conducted to evaluate whether the “Dodo
bird verdict” also applied to child therapy outcomes. Results were mixed.
Each meta-analysis found positive effects for psychotherapy with children
and adolescents, however, results varied in terms of whether all types of
treatment were equally effective. Casey and Berman (1985) found little
support for the superiority of behavioral treatments over nonbehavioral
treatments in their meta-analysis of 75 studies of children 13 or younger
at the time of treatment. Although, in general, behavioral treatments had
better outcomes, Casey and Berman concluded that there were too many
potentially confounding factors (e.g., different target problems) to be able
to attribute differences in outcomes to type of treatment.
Weisz, Weiss, Alicke and Klotz (1987), in a meta-analysis of psycho-
therapy studies including both children and adolescents, found the mean
effect size for behavioral treatments to be significantly greater than non-
behavioral treatments. This difference remained significant even when
analyses were conducted to control for the child’s age, target problem,
and therapist level of training. Later, a subset of the studies included in
the Weisz et al. (1987) meta-analysis were subjected to further analysis
by Weiss and Weisz (1995) to evaluate whether the apparent superiority of
behavioral treatments was due to higher methodological quality of behav-
ioral interventions, resulting in larger effect sizes for those treatments.
Results suggested that the difference in effect sizes for behavioral and
nonbehavioral treatments was not an artifact of methodological quality.
A subsequent meta-analysis by Weisz, Weiss, Han, Granger, and Mor-
ton (1995). also failed to support the “Dodo bird verdict” for psychother-
apy with children and adolescents. Behavioral treatments again exhibited
higher effect sizes than nonbehavioral treatments, although effect sizes
in this study were somewhat more conservative than those found previ-
ously. Weisz, Weiss, et al. (1995) asserted that, because the studies used
in their meta-analysis had not been included in previous meta-analyses,
“the present findings must be seen as rather strong independent evidence
of the replicability of this ‘non-Dodo verdict’” (p. 461). They note, however,
that of the 150 studies involved in this meta-analysis, only 10% included
nonbehavioral treatments. Similarly, there were relatively few nonbehavio-
ral studies in Weisz et al.’s (1987) meta-analysis, thus limiting the poten-
tial generalizability of this sample to all nonbehavioral interventions.
In addition to broader meta-analyses studying the effectiveness of
behavioral versus nonbehavioral treatments, there have been numerous
studies focusing specifically on the efficacy of CBTs with children and ado-
lescents. As Ollendick, King, and Chorpita (2006) have argued, any form of
psychotherapy used in treatment should have first been shown to be effec-
tive in randomized clinical trials (RCTs). These trials allow for comparisons
of CBT to either other forms of treatment or to control groups, and these
comparisons may provide scientific evidence supporting the effectiveness
of CBTs. CBT has been one of the most researched forms of treatment, and
over 300 RCTs have shown it to be an effective way of addressing a range
of Axis I disorders (Wright, Basco & Thase, 2006).
Over the past two decades, structured treatments, such as CBT, have
been shown empirically to be one of the more effective forms of psycho-
therapy (Erickson & Achilles, 2004). During the 1990s, the use of CBT
with children and adolescents was supported by the treatment outcome
literature (Braswell & Kendall, 2001). CBT has been shown to be effective
with children and adolescents with depression, anxiety, attention-deficit
difficulties, oppositionality, aggression, autism, mental retardation, low
self-esteem, poor academic skills, learning disorders, eating disorders,
and other difficulties (Braswell & Kendall, 2001; Clark, 2005; Craighead,
Craighead, Friedburg & McClure, 2002; Kazdin & Mahoney, 1994; Ken-
dall, 1991, 2006; Reinecke et al., 2006b). In fact, CBT is considered a
“probably efficacious” treatment for the treatment of childhood anxiety
disorders (Kazdin & Weisz, 1998; Ollendick & King, 1998), ADHD and
depression (Ollendick et al., 2006) as well as aggression, anger, and con-
duct disorders (Kazdin, 2003, 2005; Larson & Lochman, 2002; Lochman,
Barry, & Pardini 2003).
Although the treatment outcome literature has shown consistent sup-
port for CBT, many clinicians claim that this research is of questionable
utility in nonlaboratory-based treatment clinics (Weisz, Donenberg, Han
& Weiss, 1995). This is due to the possibility of limited transportability of
treatment outcome results. There are many factors that may affect treat-
ment outcome that vary between research settings and clinical practice.
First, study samples in clinical trials may not be representative of the general
population of clinical patients. Whereas clinical clients are often seek-

ing services, study participants are more actively recruited. In addition,
researchers aim to recruit a somewhat homogenous sample so that treat-
ment can focus on one or two target problems, whereas clinicians may find
themselves treating a wide variety of diagnoses and difficulties. Second,
the research experimenters are not comparable to therapists in clinical
practice. They may differ in amount and type of training and supervision.
Research therapists will have undergone intensive pretherapy training on
the intervention being used in the study. Practicing clinicians, however,
rarely receive such training. Third, the manner in which treatment is
administered is unique to research settings. Study participants are not
permitted to obtain simultaneous services elsewhere, and experimenters
must strictly follow treatment protocols. In general practice, however, cli-
nicians may use several techniques depending upon the child or adoles-
cent’s responsiveness to therapy (Ollendick et al., 2006; Weisz, Donenberg,
et al., 1995).
Weisz, Donenberg, et al. (1995) assert that the meta-analyses showing
overall positive effects for psychotherapy must be considered in light of
these limitations. Only nine studies included in the broad meta-analyses
included what they call “clinic therapy” which involves clients, therapists,
and settings that approximate actual clinical practice. All other studies
included in the meta-analyses involved strictly “research therapy.” Weisz,
Donenberg, et al. (1995) calculated the effect sizes for the nine studies
involving “clinic therapy” and found that the mean effect size for these
studies was much lower than that of the “research therapy” studies.
In evaluating this difference, Weisz and colleagues identified two pos-
sible explanations. First, behavioral methods, which generally have higher
effect sizes, are more common in “research therapy” than in clinical prac-
tice. Consequently, the higher effect sizes might actually be due to a greater
percentage of behavioral treatments included in the “research therapy”
studies. If “clinic therapy” studies included more behaviorally based treat-
ments, the difference in effect sizes might be reduced. Second, clients who
actively seek out treatment in clinical settings may be fundamentally dif-
ferent than those therapy clients who are recruited for study participation.
Recruited clients may have less complex problems, rendering them more
likely to be successful in treatment.
THERAPEUTIC RELATIONSHIP
CBT is sometimes mistakenly viewed as having little emphasis on the

quality of the therapeutic relationship. However, many CBT therapists
assert that the therapeutic relationship is one of the most essential com-
ponents of treatment (e.g., Beck et al., 1979; Kendall, 1991). Most schools
of therapy view the therapeutic alliance as an important variable in treat-
ment outcome. Most conceptualizations of alliance use Bordin’s (1979)
definition in which alliance is comprised of three facets: an agreement on
goals, an assignment of task(s), and the development of a bond. Cogni-
tive-behavioral therapy clearly emphasizes each of the three facets. It has
been proposed that the therapeutic relationship may be more important in

child versus adult therapy. As children rarely self-refer and therefore may
be unwilling or unable to acknowledge difficulties and adolescents are
in the process of becoming more autonomous, the formation of a strong
therapeutic alliance can be particularly challenging (DiGiuseppe, Linscott,
& Jilton, 1996; Shirk & Karver, 2003; Shirk & Russell, 1998).
A multitude of studies have examined the relationship between thera-
peutic alliance and treatment outcome in adult treatment samples (e.g., Bar-
ber et al., 1999; Gaston, Thompson, Gallagher, Cournoyer, & Gagnon, 1998;
Horvath & Luborsky, 1993; Horvath & Symunds, 1991; Martin, Garske, &
Davis, 2000; Stiles, Agnew-Davies, Hardy, Barkham, & Shapiro, 1998), and
there is a confluence of evidence that efforts to build strong therapist–client
relationships has a positive impact on the results of treatment.
The research on therapy alliance and outcomes in child therapy, how-
ever, is strikingly less well developed. In a meta-analysis of 23 studies
examining relationship variables in child and adolescent therapy, Shirk
and Karver (2003) found the association between therapeutic relationship
and outcome to approximate the results found in studies of alliance–out-
come relations in adults. The correlations were modest (weighted r = .22)
but consistent across developmental levels and types of treatment. Similar
findings were reported by Green (2006) and Kazdin, Marciano, and Whiley
(2005). In contrast, Hogue, Dauber, Stambaugh, Cecero, and Liddle (2006)
found no effect on outcome for alliance measured early in treatment in a
sample of 100 adolescents randomized to CBT or family therapy for sub-
stance abuse.
Therapist Characteristics
Not all therapists are created equal. As Kendall and Choudhury (2003)
note, treatments are often described as though they are equally effective
across therapists. This may be especially true of manualized treatments.
However, we know that therapists differ on a wide variety of dimensions
(e.g., energy, animation, self-disclosure, warmth, flexibility, sociability,
adherence to protocol). Therefore, it is unlikely that they impart little effect
on outcome.
Research on the importance of the therapist’s contributions to thera-
peutic alliance and outcome has been sparse (Garfield, 1997). It stands to
reason that there may be particular therapist characteristics which hasten
(or detract from) alliance and/or treatment outcomes. The importance of
investigating the role of the therapist is heightened by the difficulty in
disentangling the effects of the treatment from the effects of the therapist.
That is, true treatment effects may be obscured by therapist competency
(or incompetency) or other therapist characteristics (e.g., therapist effi-
cacy, therapist training and supervision; Elkin, 1999).
Ackerman and Hilsenroth (2003) examined therapist characteristics
and techniques that have a positive impact on the therapeutic alliance
in therapist–adult client relationships. Therapist characteristics including
being flexible, honest, respectful, trustworthy, confident, warm, interested,
and open were found to be positively correlated with therapeutic alliance.
Little is known, however, about the personal attributes of the therapist

that have a positive impact on the child–therapist alliance. Although one
may assume that the therapist characteristics approximate those found
in the adult literature, more research is needed to draw firm conclusions.
One study investigating therapist flexibility in the administration of a
manualized CBT for childhood anxiety disorders failed to find an association
between therapist-rated flexibility and treatment outcome (Kendall & Chu,
2000).
Child Characteristics
Child therapy outcome studies must concern themselves with those
child characteristics that may mediate or moderate outcomes. Age, gen-
der, ethnicity, familial or cultural background, socioeconomic status, and
other child characteristics have received relatively little research attention.
Are there preferred ages or developmental stages for the effective imple-
mentation of cognitive-behavioral interventions? Durlak, Fuhrman, and
Lampman (1991) conducted a meta-analysis on the effectiveness of CBT
for children with a variety of mental health problems. The authors looked
at developmental stage as a moderator of outcome and found a larger
effect size (.92) for children at the formal operational level (age 11–13)
than for children at less advanced levels (age 7–11, effect size = .55; and
age 5–7, effect size = .57). Thus, the authors conclude that children who
are more cognitively mature may be more capable of abstract thinking and
deductive reasoning, making them more likely to benefit from CBT.
Conversely, in a study examining the predictors of remission from
major depressive disorder in children and adolescents treated with CBT,
Jayson, Wood, Kroll, Fraser, and Harrington (1998) found older age to be
associated with the poorest outcomes. Similarly, in the field of anxiety
disorders, there is some evidence to suggest that younger children might
benefit more from CBT than older children, especially when the family is
involved in treatment (Barrett, Dadds, & Rapee, 1996; Hudson, Kendall,
Coles, Robin & Webb, 2002). For example, Southam-Gerow, Kendall, and
Weersing (2001) found that those children who were identified as poor
responders (retained an anxiety diagnosis posttreatment) were more likely
to be older than children in the good treatment response group (no post-
treatment anxiety disorder).
Several hypotheses have been suggested to explain why younger chil-
dren may do better. Older children’s disorders may be more chronic and
resistant to change or they may be more “nonnormative” in the course of
development, making them less well able to navigate the tasks of adoles-
cence. Younger children may benefit more due to an increased involvement
from parents. Last, it might be the case that treatment materials commonly
used in anxiety treatment packages for youth (e.g., Coping Cat; Kendall &
Hedtke, 2006) may be more age-appropriate for younger children. If the
latter is true, it may be that interventions designed for middle childhood
may need substantial modifications prior to use with adolescents.
Gender has received limited attention as a factor in treatment outcomes
of CBT. Although gender has been identified as a significant variable in the
research on depressive disorders, the role of gender in treatment efficacy

remains unclear. Some evidence suggests that adolescent girls show bet-
ter outcomes in psychotherapy outcome research; yet this finding is not
specific to CBTs (Weisz, Weiss, Han, Granger, & Morton, 1995). Research
on CBT outcomes for childhood anxiety disorders yields conflicting find-
ings regarding the effects of gender. Some studies fail to find gender effects
on outcome (e.g., Southam-Gerow et al., 2001); other studies have found
significant effects with female children faring better (e.g., Mendlowitz,
Manassis, Bradley, Scapillato, Miezitis, & Shaw, 1999). Moreover, there
exists some evidence that child gender may influence the effectiveness of
parental involvement in treatment. Barrett et al. (1996) found that females
who participated in a CBT plus family management condition had more
positive outcomes than those in conditions without parental involvement.
Similarly, Cobham, Dadds and Spence (1998) found that girls with an anx-
ious parent were more likely to be diagnosis free if they had participated in
the CBT plus parent anxiety management condition.
Cognitive-behavioral models for the treatment of youth have received
criticism for a lack of developmental sensitivity (e.g., Reinecke et al.,
2006b; Weisz & Weersing, 1999). It is essential to evaluate a child from a
developmental systems framework. As mentioned previously, most CBTs
for children have been adaptations of treatments formulated for adults.
As such, many CBTs for children may be anchored in the “developmental
uniformity myth” (Kendall, Lerner, & Craighead, 1984). This myth holds
that childhood disorders present akin to and are responsive to the same
treatment procedures as adult disorders. Thus, assessments and treat-
ments may fail to consider age, developmental level, timing of intervention,
and other developmental issues.
In the course of development, important changes in reasoning, emo-
tional understanding, judgment, and language among other cognitive
capacities, undergo significant changes in content, organization, and
structure (Toth & Cicchetti, 1999). Given these significant changes during
this developmental period, it may be that childhood and adolescence are
critical periods during which skill building and alteration of one’s devel-
opmental trajectory is possible (Reinecke et al., 2006b). Moreover, it may
be the case that treatments vary in effectiveness across ages or that treat-
ments need to be implemented differently at different ages. For exam-
ple, younger children may require greater in-session flexibility, especially
with the use of manualized interventions. Additionally, younger children
may require the use of more behavioral (versus cognitive) interventions
(O’Connor & Creswell, 2005). Thus, developmentally informed CBT models
are a must.
Holmbeck and colleagues conducted two reviews of the empirical
research examining developmental factors in the design and evaluation of
cognitive-behavioral interventions for adolescents. Although the first review
(1990–1998; Holmbeck, Colder, Shapera, Westhoven, Kenealy, & Updegrove,
2000) found only 26% of the articles directing attention to developmental
issues, a more recent review (Holmbeck et al., 2006) found that 70% of
the articles considered developmental issues in the design and evaluation
of outcome. It appears that developmental issues are receiving increased
attention in recent years, however, Holmbeck and colleagues note that, in

the 2006 study, at least half of the studies failed to interpret results in light
of developmental issues and very few (22%) evaluated age as a moderator
of outcome. Attention to moderator variables such as resiliency, aptitudes,
and protective factors is critical in the development of prevention efforts.
CONTEXTS
As briefly discussed earlier in this chapter, a cognitive-behavioral

framework must provide explicit attention to the child in various contexts
(e.g., family, school, peer group, ethnicity, culture, religion). Numerous
researchers have proposed that the inclusion of family members (namely,
parents) in the therapeutic process is an effective means to enhance treat-
ment success (e.g., Ginsburg, Silverman, & Kurtines, 1995; Kazdin, 1993;
Kendall, 1994; Silverman, Ginsburg, & Kurtines, 1995). Ginsburg and col-
leagues (1995) have described a transfer of control model in which an
expert therapist passes along knowledge, skills, and methods to the child,
either directly or from therapist to parent to child. However, they note
some “blocks” that may occur in this transfer process. The “blocks” often
involve maladaptive family processes (e.g., parental psychopathology, dys-
functional family relationships).
In order to clear the pathway to facilitate transfer of control, parental
inclusion in therapy is a necessity. Although many therapists support the
inclusion of parents, especially with young children, there remain ques-
tions regarding the degree to which and in what capacity parents should
be involved in child treatment. Are parents informants, consultants, or
co-clients? The degree of parental participation is likely to be determined
in part by child age and type of presenting problem.
Hays (2006) has noted the widespread omission of ethnic and cul-
tural information in clinical research. Research on CBT, for example, has
almost exclusively relied on individuals with European American identities
(Hays, 1995; Iwamasa & Smith, 1996; Suinn, 2003). Thus, the success
and limitations of CBT with minority populations have not been evaluated.
Due to CBT’s experimental orientation to human behavior, there may exist
an implicit assumption that CBT is value-neutral. Hays (2006) notes that
“CBT is as value laden as any other psychotherapy” (p. 7). In fact, CBT’s
emphasis on rationality and definitions of adaptive versus maladaptive
behaviors may conflict with values and ideals prominent in other cultures
(e.g., spirituality). Training in working with diverse populations, sensitiv-
ity workshops, and consultations with experts in cultural diversity are all
necessary to ensure sensitivity.
FUTURE DIRECTIONS
Despite the apparent efficacy of CBT with children, there remain

substantial numbers of children who do not progress in treatment. Little
research has been conducted on how to address these treatment-resistant
cases. In the case of a less than successful outcome, are there particular
treatment techniques that may be employed? Is medication warranted?
Should frequency or length of treatment sessions be increased? Is work
with parent(s) needed? These questions will linger until treatment research
addresses how to facilitate improvement in all cases. The answers lie in
understanding the mechanisms of therapeutic action in CBT, and despite
much treatment outcome research, research on knowing how and why
CBT works remains sparse (Kazdin & Nock, 2003; Shirk & Karver, 2006).
While research on the efficacy of cognitive-behavioral interventions is
amassing, the majority of randomized clinical trials evaluating CBT have
used waitlist control conditions. Much work remains to evaluate the relative
efficacy of CBT and active control conditions. Also, much of the research has
employed CBT treatment “packages.” That is, most CBT treatments are com-
prised of several cognitive-behavioral elements (e.g., cognitive-restructuring,
homework, problem-solving training); yet little is known about the influence
of individual elements on treatment outcomes. Other methodological consid-
erations include evaluation of CBT efficacy with youth via an examination
of clinical as well as statistical significance (e.g., Kendall, 1999; Kendall &
Grove, 1988, Kendall, Marrs-Garcia, Nath & Sheldrick, 1999). Whereas sta-
tistical significance determines the likelihood that a mean difference may
have resulted by chance, clinical significance can determine the meaningful-
ness of the magnitude of change. In treatment outcome research, clinical
significance may be helpful in evaluating whether deviant scores have been
returned to within normal limits on a particular assessment measure.
There is a clear call for more developmentally oriented research designs.
For example, longitudinal designs would better evaluate CBT’s impact on
developmental processes and trajectories. However, longitudinal designs
bring additional considerations. Issues such as measurement equivalence
remain to be resolved (Kendall & Choudhury, 2003). In the measurement of
a particular construct across time, it is likely that several measures will be
warranted in order to ensure that the measures are developmentally appro-
priate. However, the comparability of these measures is at issue. For exam-
ple, do the Children’s Depression Inventory (Kovacs, 1981) and the Beck
Depression Inventory (Beck,Ward, Mendelson, Mock, & Erbaugh,1961;
Beck, Steer, & Garbin, 1988) measure depression in a similar manner?
How can one evaluate depression across the span of early childhood and
into young adulthood? Longitudinal designs also afford an opportunity to
consider the indirect effects of treatment (Kendall & Kessler, 2002).
Given the long-term social and economic consequences of childhood
psychopathology, researchers should examine for treatment impacts on the
sequelae of targeted disorders (e.g., impact of childhood anxiety treatment on
adolescent or early adulthood substance use). In addition, there is a great
need to generate treatment samples from ethnically and socioeconomically
diverse populations in order to enhance treatment generalizability and trans-
portability. Regarding the latter, there is little reason to believe that all CBTs
found efficacious in the research lab will show a corresponding efficacy in clin-
ical settings. However, the extent to which the results of randomized clinical
trials can be applied in the “real world” remains to be determined by research
(Kendall & Southam-Gerow, 1995; Persons & Silberschatz, 1998; Silverman,
Kurtines, & Hoagwood, 2004; Southam-Gerow, Weisz, & Kendall, 2003).
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4
Parent-training
Interventions
NICHOLAS LONG, MARK C. EDWARDS,
and JAYNE BELLANDO
Prior to the 1960s, therapy for children typically involved traditional

one-on-one sessions with a therapist addressing intrapsychic issues
rather than specific behaviors (Kotchick, Shaffer, Dorsey, & Forehand,
2004). However, in the early 1960s a paradigm shift started in regard to
psychosocial treatment for children’s behavior problems. This paradigm
shift was the function of several factors (Kotchick et al., 2004) includ-
ing a growing concern that traditional psychodynamic approaches were
not very effective in addressing immediate issues related to children’s
behavior problems nor in changing children’s behavior in the home.
Around the same time period, behavior modification techniques were
beginning to be successfully utilized to change children’s behavior (Wil-
liams, 1959).
The confluence of such factors created momentum for the concept of
therapists training parents to utilize specific behavior management tech-
niques to change their children’s’ behavior. By the mid- to late-1960s the
use of parents as formal behavior change agents for their children’s behavior
started to take hold and the roots of “parent training” were established
(Hawkins, Peterson, Schweid, & Bijou, 1966; Wahler, Winkel, Peterson,
& Morrison, 1965). Although most of the early research in parent training
was conducted by those coming from a behavioral orientation, it should
be noted that the use of parents as change agents was also advocated
by professionals from various orientations including those coming from a
psychodynamic perspective (e.g., Zacker, 1978).
NICHOLAS LONG, MARK C. EDWARDS, and JAYNE BELLANDO • University of Arkansas

for Medical Sciences and Arkansas Children’s Hospital

80 NICHOLAS LONG et al.
Gerald Patterson’s (1982) research on coercive parent–child inter-

actions offered a major contribution to the early development of parent
training. His model on reciprocal influences provided an explanation as to
how the behavior of both parents and children contribute to the escala-
tion of child aggression and behavior problems. The model explained how
children use high rates of aversive behaviors to stimulate parental atten-
tion, and in turn, this parental attention reinforces the children’s aversive
behavior. Such parental attention can involve either giving in to the aver-
sive behavior or using coercive tactics (e.g., nagging, yelling) in an attempt
to stop the aversive behavior.
Patterson’s model also helped explain how children’s behavior simul-
taneously reinforces and escalates parental use of coercive tactics through
negative reinforcement. Thus his model of reciprocal influences helped
explain how children’s disruptive behavior can escalate while parent
management tactics become more punitive and coercive. Such coercive
exchanges within the home were believed to be “basic training” for the
development of aggression and disruptive behavior that generalizes to other
settings. The entry into this coercive cycle was considered to be ineffective
parenting, especially in regard to child compliance to parental directions
during the preschool years (McMahon & Wells, 1998).
Since its development in the 1960s, behavioral parent training has
gone through three distinct stages of development (McMahon & Forehand,
2003). The first stage, during the 1960s and early 1970s, focused on the
initial development of a “parent training” intervention model. The parent
training model, based on Tharp and Wetzel’s (1969) triadic model, utilized a
therapist (consultant) who taught the parent (mediator) to reduce the child’s
(target) disruptive behavior (McMahon & Forehand, 2003). The research
conducted during this first stage was largely limited to case studies or single-
case designs. However, during this first stage, evidence was obtained that
demonstrated that, at least in the short-term, parent training interventions
could produce changes in both parent and child behaviors.
At about the same time, researchers also started to examine different
strategies (e.g., written instructions, videotaped instruction, modeling, etc.)
for teaching parents how to use specific behavior management strategies
(e.g., Flanagan, Adams, & Forehand, 1979; Nay, 1975; O’Dell, Mahoney,
Horton, & Turner, 1979; O’Dell, Krug, O’Quinn, & Kasnetz, 1980). Par-
ents could learn to effectively use specific techniques through a variety of
instructional modes. However, there was also the realization that although
parents could be taught basic behavior modification techniques through
various instructional modes, to effectively address significant child behav-
ior problems interventions for parents needed to be more multifaceted
and take into account the complexities of parent–child interactions in the
home (Kazdin, 1985).
The second stage of parent training research, from the mid-1970s
to the mid-1980s, focused on social validity and the generalization of
treatment effects. Issues examined included whether behavior changes
observed in the clinic generalized to the home, whether improvements
were seen in behaviors other than the target behaviors (behavioral gen-
PARENT-TRAINING INTERVENTIONS 81
eralization), and whether behavior changes were maintained over time

(temporal generalization).
The third stage in the development of parent training, from the mid-
1980s to present, has focused primarily on ways to enhance the effective-
ness of parent training. The primary focus of parenting training research
since its beginnings has been in the area of children’s disruptive behav-
ior. This focus has been the result largely due the belief that disruptive
behavior in the home is often inadvertently developed, exacerbated, or
sustained by maladaptive parent–child interactions (Kazdin, 2003; Pat-
terson, 1982). These maladaptive interaction patterns include reinforcing
disruptive behavior, the use of ineffective parental directions, and the fail-
ure to adequately reinforce appropriate behavior. Today parent training is
considered one of only a handful of empirically supported treatments for
children’s externalizing behavior problems (Kazdin, 2005). The following
section summarizes this research base.
AN OVERVIEW OF THE EMPIRICAL SUPPORT

FOR PARENT TRAINING
There have been hundreds of studies that have evaluated programs

designed to train parents to intervene with their children’s problems. The
volume of studies examining the effects of parent training is reflected in
the number of reviews that have been published. From 1972 to 2006,
there have been no less than 17 narrative reviews (Atkeson & Forehand,
1978; Berkowitz & Graziano, 1972; Chronis, Chacko, Fabiano, Wymbs, &
Pelham, 2004; Dembo, Sweitzer, & Lauritzen, 1985; Graziano & Diament,
1992; Johnson & Katz, 1973; Kohut & Andrews, 2004; Mooney, 1995;
McAuley, 1982; Moreland, Schwebel, Beck, & Well, 1982; O’Dell, 1974;
Sanders & James, 1983; Todres & Bunston, 1993; Travormina, 1974; Wiese,
1992; Wiese & Kramer, 1988) and at least four quantitative reviews (Cedar
& Levant, 1990; Lundahl, Nimer, & Parsons, 2006; Lundahl, Risser, &
Lovejoy, 2006; Serketich & Dumas, 1996) that have specifically focused on
parent training outcomes.
In addition to the above reviews, other papers have examined par-
ent training interventions as part of a broader review of psychosocial
treatments for children and adolescents in general (Weisz, Weiss, Han,
Granger, & Morton, 1995) and specific child and family problems, such as
conduct problems (Brestan & Eyberg, 1998; Bryant, Vissard, Willoughby,
& Kupersmidt, 1999; Dumas, 1989; Kazdin, 1987; Miller & Prinz, 1990;
Webster-Stratton, 1991) and ADHD (Chronis, Jones, & Raggi, 2006; Pelham,
Wheeler, & Chronis, 1998).
As indicated by the number of reviews, parent training interventions
are among the most frequently and rigorously studied of the psychosocial
interventions for children. To illustrate the scope of studies, a recent quan-
titative analysis of parent training outcomes with disruptive behaviors
identified 430 studies published in peer-reviewed journals between 1974
and 2003 (Lundahl, Risser, & Lovejoy, 2006). The literature on the effi-
cacy of parent training interventions varies considerably in terms of study

methodology, program features, and participant characteristics. In this
section, we examine the immediate, generalization, and moderator effects
of training parents to intervene with their children.
IMMEDIATE EFFECTS OF PARENT TRAINING
There is substantial evidence that supports the short-term effectiveness

of parent training as a general treatment approach. Lundahl, Risser, and
Lovejoy (2006) conducted a meta-analysis of experimental and quasi-
experimental studies that evaluated the effects of parent training pro-
grams on child behavior, parent behavior, and parent perceptions. This
study examined 63 studies from 1974 to 2003 that included 83 treatment
groups. Overall, this study reported immediate effect sizes of .42, .47, and
.53 for child behavior, parent behavior, and parent perceptions outcomes,
respectively. The magnitude of these effect sizes can be considered
moderate.1 These effect sizes compare favorably to the average effects
of other behavioral (d = .54) and nonbehavioral (d = .30) psychotherapy
treatments (Weisz et al., 1995).
Many of the early reviews focused almost exclusively on behavioral
parent training programs as they represent the majority of studies. Non-
behavioral parent training programs tend to lag behind behavioral pro-
grams not only in number, but also in methodology. For example, of the 63
experimental studies review by Lundahl, Risser, and Lovejoy (2006), only
14 parent training programs had a nonbehavioral focus. In their study,
the behavioral programs were found to have significantly higher meth-
odological rigor than the nonbehavioral programs. There are also other
differences between behavioral and nonbehavioral parent training studies
that make comparisons difficult. The majority of behavioral studies used
clinical samples, whereas the majority of nonbehavioral studies used non-
clinical samples.
Furthermore, parent training programs with different theoretical ori-
entations tend to target different outcomes, making direct comparisons
impossible. Nonetheless, several narrative reviews have examined the
methodology and efficacy of parent training programs from different theo-
retical orientations (i.e., reflective, Adlerian, & behavioral; Dembo et al.,
1985; Mooney, 1995; Todres & Bunston, 1993). All three reviews noted
that few studies met the criteria for well-designed investigations, and the
diverse methodologies precluded direct comparisons of efficacy. All three
reviews reported mixed results, with positive findings following what would
be expected from the specific theoretical orientation. For example, the
Adlerian programs showed a greater percentage of positive findings in the
outcome domain of parental attitudes and perceptions, and behavioral pro-
grams showed a greater percentage of positive findings on child behavior.
1
Cohen (1988) defined effect sizes as small, d = .2, medium, d = .5, and large, d = .8.
The largest subgroup of parent training outcome studies are those that
evaluated programs which train parents in behavioral child management
strategies to address deviant behaviors, such as aggressiveness, temper
tantrums, and noncompliance. Behavioral parent training (BPT) typically
included strategies such as differential reinforcement of other behavior,
extinction, and time-out. An early narrative review was supportive of
the efficacy of BPT with deviant behavior. Atkeson and Forehand (1978)
reviewed 24 studies which included three outcome measures (observa-
tions, parent collected data, and parent completed measures) and reported
positive results in all three outcome domains.
Serketich and Dumas (1996) conducted a meta-analysis of stud-
ies evaluating the effects of behavioral parent training program on child
antisocial behavior and parental adjustment. They analyzed 27 studies
from 1969 to 1992 that included 36 comparisons between experimental
and control groups. In these studies, 22 received some form of indi-
vidually administered BPT and 13 received BPT in a group format. The
average numbers of sessions was 9.53 (SD = 4.17). This study reported
a mean effect size for overall child outcome of .86, which is considered
large (Cohen, 1988). The mean effect sizes for child outcome based on
parent, observer, and teacher were .84, .85, and .73, respectively. The
mean effect size for outcomes of parental adjustment was moderate at
.44. As a result of the favorable outcome evidence, behavioral parent
training for oppositional children has been designated by the American
Psychological Association Task Force as an empirically validated inter-
vention (Chambless et al., 1996).
Several studies have evaluated the efficacy of BPT programs with par-
ents of children with ADHD. Seven of eight studies which compared BPT
with no treatment reported positive findings (Anastopoulos et al., 1993;
Duby, O’Leary, & Kaufman, 1983; O’Leary, Pelham, Rosenberg, & Price,
1976; Pisterman et al., 1989; Pisterman et al., 1992; Sonuga-Barke, Daley,
Thompson, Laver-Bradbury, & Weeks, 2001; Thurston, 1979). However,
the effects of BPT were not found to be superior to a cognitive-behavioral
self-control therapy (Horn, Ialongo, Popovich, & Peradotto, 1987; Horn,
Ialongo, Greenbert, Packar, & Smith-Winberry, 1990) or stimulant medi-
cations (Firestone, Kelly, Goodman, & Davey, 1981; Horn et al., 1991;
Klein & Abikoff, 1997; Pollard, Ward, & Barkley, 1983; Thurston, 1979).
BPT has not been shown to enhance treatment response when com-
bined with medications (Firestone et al., 1981; Horn et al., 1991; Klein &
Abikoff, 1997; Pollard et al., 1983). However, there is some evidence that
suggests that combining BPT with medications may allow for lower doses of
medications (Horn et al., 1991) or lead to enhanced outcomes in functioning
(social skills; improved parent–child relationships; parenting) and consumer
satisfaction (Hinshaw et al., 2000; Multimodal Treatment Study of Children
with ADHD Cooperative Group, 1999). Reviews of parent training interven-
tions with ADHD populations have concluded that more systematic study is
needed but that existing studies provide sufficient evidence to consider par-
ent training an effective treatment for ADHD (Chronis et al., 2004; Kohut &
Andrew, 2004; Pelham, Wheeler, & Chronis, 1998).
BPT has been evaluated with other specific childhood problems.

Graziano and Diament (1992) reviewed 186 empirical studies that evalu-
ated the efficacy of BPT with childhood problems. In addition to problems
with conduct and hyperactivity, studies have examined BPT with children
with mental retardation, physical disabilities, autism, overweight, enu-
resis, fears, and other specific behavioral problems. They concluded that
the BPT showed clear positive results for conduct problems and discrete
child behavior problems (e.g., enuresis, fears, weight reduction), some
success with hyperactivity, and mixed results with autism and mental
retardation. For the latter two conditions, they suggested that BPT may
be more effective in improving parent outcomes than child behavior. A
recent randomized controlled trial of parent education and skills training
interventions supports this notion (Tonge et al., 2006). This study showed
significant improvements in the functioning of parents of young autistic
children following treatment relative to the control group.
There have also been some mixed results evaluating BPT with chil-
dren with anxiety disorders. A recent study tested Parent Child Interaction
Therapy (PCIT; a manualized BPT program) with three families of children
with separation anxiety using a multiple-baseline design (Choate, Pincus,
Eyberg, & Barlow, 2005). This study found clinically significant changes in
both separation anxiety and disruptive behaviors. Another study raised the
question of what specific treatment components were active in producing
change in children with separation anxiety (Silverman et al., 1999). This
randomized clinical trial compared interventions that included an expo-
sure-based behavioral parent training component with a control group
offered parent therapeutic support and information. The results showed
improvement in measures of both child and parent functioning across all
groups. These results suggested that generic parent support and educa-
tion is as effective as parent training with an “active” therapeutic compo-
nent for children with separation anxiety.
Lundahl, Nimer, and Parsons (2006) conducted a meta-analysis of
studies evaluating the effects of parent training programs on parent risk
factors related to child abuse and documented abuse. They identified 23
studies from 1970 to 2004 that included 25 parent training treatment
groups. Of the 23 studies, 17 used pre–post only designs. The parent
training interventions used in these studies varied on a number of char-
acteristics, including theoretical orientation (behavioral, nonbehavio-
ral, mixed), location of intervention (home, office, mixed), delivery mode
(group, individual, mixed), and number of sessions. Immediately following
parent training, parents showed moderate improvement in outcome vari-
ables. The average effects sizes were .60 for attitudes linked to abuse, .53
for emotional adjustment, .51 for child-rearing skills, and .45 for docu-
mented abuse. There was a significant difference between the effect sizes
of studies with a control group (d = .30) and those without (d = .62) for the
emotional adjustment outcome variable, suggesting (at least for this vari-
able) that the effects are more in the small to moderate range.
In a recent randomized trial of an enhanced Parent Child Interaction
Therapy program (PCIT; a manualized BPT program) with physically abu-
sive parents (Chaffin et al, 2004), parents receiving PCIT showed significant
reductions in negative parent behaviors in a structured parent–child inter-

action observation compared to the control group. Other measures of child
and parent behavior and parent functioning showed improvements across
both experimental and control groups.
Cedar and Levant (1990) conducted a meta-analysis of studies that
evaluated the efficacy of the Parent Effectiveness Training program (PET;
Gordon, 1970) on the behavior and cognitive adjustment of both children
and parents. Most of the studies were doctoral dissertations rather than
peer reviewed journals. PET is based on a reflective/Rogerian approach
rather than a behavioral orientation and consists of training parents in
the use of active listening, “I” messages, and conflict resolution. Cedar and
Levant examined 26 studies from 1975 to 1990. Their analyses found no to
small effects on outcomes related to child attitudes and behaviors (ds = .12
& .03, respectively), small to moderate effects for child self-esteem (d = .38),
small to moderate effects on parent attitudes and behavior (ds =.41 & .37,
respectively), and large effects on outcomes related to parental knowledge
of course content (d =1.10).
Generalization Effects
It is reasonable to assume that changing parents’ behavior would result
in some generalization of treatment effects across time and settings and to
untreated siblings. Although there is some supporting evidence for such
generalization, confidence in the generalizability of treatment effects would
be increased with additional studies with improved methodology, such as
larger sample sizes, multiple outcome measures, and control groups.
Three of the four meta-analytic studies reviewed above evaluated the fol-
low-up effects of parent training. The long-term effect (interval not reported)
of the PET program showed an attenuation of overall effect over time, from
small to moderate (d = .35) to small (d = .24; Cedar & Levant, 1990). Of the
23 studies that evaluated the efficacy of parent training programs on child
abuse risk factors reviewed by Lundahl, Nimer, and Parsons (2006), five
studies reported follow-up effects for child-rearing behaviors and six stud-
ies reported follow-up effects on parental attitudes and emotional adjust-
ment. The effects were moderate for child-rearing attitudes (d =.65) and
small for emotional adjustment and child-rearing behaviors (ds =.28, .32,
respectively). Both of these reviews did not report separate follow-up effects
for studies that employed control groups at follow-up and those that did
not. Lundahl, Risser, and Lovejoy (2006) reported on the follow-up effects
(1 to 12 months post treatment) of behavioral parent training programs.
They reported the effects of those studies that employed a control group
at follow-up and those that did not. Studies that include a control group
at follow-up can provide a more accurate picture of the long-term impact.
The follow-up impact of the programs that used a control group at follow-
up was shown to maintain in the moderate range for parent perceptions
(d =.45) and to attenuate from moderate in magnitude at post-test to small
at follow-up for child behavior (d =.21) and parenting skills (d = .25).
A couple of recent studies reported follow-up effects of BPT with physi-
cally abusive parents and parents of children with Oppositional Defiant
Disorder. Chaffin and his colleagues (2004) reported follow-up data (median
interval of 2.3 years) in their randomized controlled trial of a BPT program
with physically abusive parents. Forty-nine percent (49%) of parents in the
control group (standard community group intervention) had a re-report for
physical abuse at follow-up compared to 19% of parents assigned to the
BPT group. Reid, Webster-Stratton, and Hammond (2003) reported on a
two-year follow-up of 159 four- to eight-year-old children diagnosed with
Oppositional Defiant Disorder and treated with a behavioral parent train-
ing program (Incredible Years). At posttreatment, 46.2% of participants
who received parent training alone and from 55% to 59.1% who received
parent training in combination with teacher or child training, showed
clinically significant changes (defined as a 20% reduction in ratings of
behavior) at posttreatment compared to 20% of controls. At the two-year
follow-up, the percentage of participants who received the parent training
alone or in combination with teacher or child training who showed clini-
cally significant improvements was 50%, 81.8%, and 60%, respectively. No
control group was used at this two-year follow-up.
There is some support for the generalization of behavioral parent
training treatment effects to untreated siblings. Four studies showed
significant improvements in the untreated siblings observed compliance
(Humphreys, Forehand, McMahon, & Roberts, 1978; Eyberg & Robinson,
1982) and deviant behavior (Arnold, Levin, & Patterson, 1975; Wells, Fore-
hand, & Griest, 1980) at posttreatment. In one study, the improvements
were maintained at a six-month follow-up (Arnold et al., 1975). Eyberg
and Robinson (1982) reported significant improvements in observed par-
ent behavior with untreated siblings and no significant reductions in the
number or intensity of negative sibling behaviors.
Two early studies failed to show generalization of treatment effects
from clinic to school settings (Breiner & Forehand, 1981; Forehand et al.,
1979). However, McNeil, Eyberg, Eisenstadt, Newcomb, and Funderburk
(1991) reported significant improvements in teacher-rated deviant behav-
ior and observations of appropriate and compliant behaviors at school in
ten children treated with a BPT program relative to controls. In this study,
they selected subjects who showed high levels of behavior problems across
home and school settings at pretreatment and who all showed clinically
significant improvements in home behavior after treatment.
Moderator Effects
A number of child, parent, and program characteristics have been
associated with parent training outcomes, such as child age, child IQ,
family’s socioeconomic status, parental social support, parental educa-
tion level, parental functioning, family stress, and ethnicity (see Graziano
& Diament, 1992 for review); however, relatively little research has been
done where these characteristics have been studied as independent vari-
ables. Lundahl, Risser, and Lovejoy (2006) assessed moderator effects of
parent training in their meta-analysis. They found financial disadvantage
to be the most salient moderator of outcomes. Children and parents from
non-disadvantaged families benefited more across the child behavior, parent
behavior, and parental perception outcome constructs compared to dis-

advantaged families. They also found that marital status was a moderator
of child behavior outcomes. Studies with a higher percentage of single
parents (Number of studies (k) = 29) did not show as much change as
studies with a lower percentage of single parents (k = 16). There have been
some mixed results related to child’s age and parent training outcomes in
three quantitative reviews. The Lundahl, Risser, and Lovejoy (2006) and
the Cedar and Levant (1990) meta-analyses found no relationship between
age and positive outcomes, whereas Serketich and Dumas (1996) reported
a positive relationship between age and positive outcomes.
There have been some program characteristics associated with parent
training outcomes, including the format of training and number of ses-
sions. In their meta-analysis, Serketich and Dumas (1996) found a non-
significant correlation between the effect size for the overall child outcome
and the format of the treatment (individual vs. group). Studies have found
individual, group, and self-administered BPT to be equally effective and
superior to a no-treatment control group (Webster-Stratton, 1984; Web-
ster-Stratton, Kolpacoff, & Hollinsworth, 1988).
Lundahl, Risser, and Lovejoy (2006) also found no differences in effect
sizes between face-to-face and self-directed interventions. However, they
reported that among the 20 studies that treated financially disadvantaged
families, individual parent training resulted in significantly greater improve-
ments in child and parent behavior than group parent training. There were
no differences between individual and group treatment in the parental per-
ceptions outcome domain. Lundahl, Nimer, and Parsons (2006) found that
studies whose programs were more than 12 sessions had greater improve-
ments in parental attitudes linked to abuse compared to programs with fewer
than 12 sessions. No differences in child-rearing behavior were found between
programs with low and high number of sessions.
SUMMARY OF THE EMPIRICAL EVIDENCE

OF PARENT TRAINING
There have been a substantial number of studies evaluating parent

training programs from different theoretical orientations and across differ-
ent child problems. As a whole, the research is supportive of the immedi-
ate effectiveness of parent training across many parent and child outcome
domains. Parent training can be considered at least moderately effective
which compares very favorably to the effects found for other psychotherapy
treatments. More specifically, there is sufficient evidence to consider behav-
iorally oriented parent training programs efficacious in treating children
with oppositional and ADHD problems. Although results are mixed and
more studies needed, there is evidence to support the generalization of parent
training effects across time, and some evidence to suggest generalization
across settings and to untreated siblings in some families.
Of course there are limitations in examining the effectiveness of par-
ent training programs in general by relying on the results of meta-analytic
reviews. As stated previously, parent training programs vary significantly
across a number of factors (e.g., theoretical basis, format and content

of the intervention, target behaviors, length of the intervention, etc.) and
some programs are more effective than others.
OVERVIEW OF SELECTED PARENT TRAINING PROGRAMS
As is clear from the review of the empirical support for parent train-
ing, programs vary significantly. In order to provide a better understanding
of some of these differences, as well as more details regarding specific
programs, the next section highlights several selected parent training pro-
grams. In order to impart the greatest understanding of parent training
programs, within the confines of this chapter, some programs are described
in detail and others are briefly summarized.
Parent Programs That Target Externalizing Behavior Problems

Helping the Noncompliant Child (HNC)
Helping the Noncompliant Child is a behavioral parent training program
that targets young children (two to eight years old) who exhibit high levels
of noncompliance to parental directions (McMahon & Forehand, 2003).
The extensive research base and evaluation studies supporting this pro-
gram are thoroughly summarized in McMahon and Forehand (2003) and
in Forehand and McMahon (1981). It is included on several “best practices”
lists for evidence-based treatment programs for conduct problems (Brestan
& Eyberg, 1998), child abuse (Saunders, Berliner, & Hanson, 2004), and
the prevention of substance abuse and delinquency (Alvarado, Kendall,
Beesley, & Lee-Cavaness, 2000; Webster-Stratton & Taylor, 2001). This
clinic-based program involves a therapist working with individual families.
The child attends all sessions with her parent(s). The primary goals of the
program are to improve child compliance to directions and to decrease
disruptive behavior through teaching parents more appropriate ways of
interacting with their child.
The intervention consists of two major phases. During Phase 1, dif-
ferential attention skills are taught that are designed to improve the par-
ent–child relationship as well as increase desirable behaviors. Phase 2
involves compliance training skills that assist parents in dealing with non-
compliance and other problematic behavior. A detailed training manual is
available for therapists (McMahon & Forehand, 2003).
The instructional format for each session follows a standard process
that includes didactic instruction and discussion of a specific skill, the
therapist demonstrating the skill through modeling and role-playing, the
parent practicing the skill with the therapist, the skill is then introduced
to the child, the parent then practices the skill with the child while the
therapist provides cues/feedback, and finally a homework assignment is
given to allow the parent to practice/utilize the skill at home.
Skills addressed in the program include attending, rewarding, ignor-
ing, directions, and time-out. Phase 1 of the program involves teaching
parents the effective use of the skills of attending, rewarding, and ignoring.
Phase 2 involves teaching parents to give effective directions and how to
use time-out appropriately. The clinical program typically takes 8–12 ses-
sions to complete. The number of sessions varies from family to family
because HNC uses a competency-based approach which requires parents
to achieve a certain level of competence with a skill before the next skill is
introduced. Details regarding the specific skills are provided below.
Phase 1 (Differential Attention Skills)

Attending. Attending is a skill that parents can use to help increase their
child’s desirable behaviors. It also helps lay the groundwork for a more posi-
tive parent–child relationship. After discussing, modeling, and role-playing
the skill with the parent(s) the therapist helps the parent master the skill
through practicing it in what is called the “child’s game.” This is a time where
the child selects the play activity (e.g., playing with blocks) and the parent is
nondirective. The parent is taught to simply describe a child’s activity while
eliminating directions and questions addressed to the child. This practice
allows the parent to master the skill of attending that will later be used to
increase desirable behavior. This skill is the focus of the intervention until the
parent demonstrates competence. This competence is assessed using specific
behavioral criteria recorded during a structured observation.
Rewarding. The second skill involves teaching the parent to praise or
reward the child’s positive behavior. This skill is taught using the same
instructional procedures and is practiced using the “child’s game.” The
types of rewards that are taught consist of labeled verbal (e.g., “I really
like it when you pick up your toys!”) and physical (e.g., hug, pat) rewards.
Parents are taught to focus on and reward prosocial behaviors rather than
negative behaviors. The parent has to demonstrate competence before the
next skill is introduced.
Ignoring. The third component of the initial phase of the program
involves teaching a parent to ignore minor unacceptable behavior, such
as whining and fussing. Again, the standardized instructional procedures
are used. The parent is taught an ignoring procedure that involves no eye,
physical, or verbal contact when minor unacceptable behaviors occur.
Differential Attention Plans. After the parent has mastered the skills
of attending, rewarding, and ignoring, the therapist assists the parent in
targeting specific child behaviors to increase using differential attention.
Parents use the skills taught in Phase 1 to implement differential attention
plans with guidance provided by the therapist.
Phase 2 (Compliance Training Skills)

The second phase of the program consists of teaching parents two
primary components of disciplinary skills: how to give effective instructions
to the child and how to use a time-out procedure appropriately.
Giving effective instructions. Parents are taught the elements of giving
effective instructions/commands to their child. The parent practices giving
instructions to their child within the “parent’s game.” Unlike the “child’s
game” which is used to teach Phase 1 skills and involves the parent being
nondirective, the “parent’s game” involves the parent taking direction of
the activities (e.g., the parent issues frequent instructions/commands
while directing the activity). The therapist provides feedback to the parent
regarding the directions being issued (e.g., how they could be improved).
The parent is also taught to attend to or praise their child’s compliance to
their directions.
Time-out. Parents are taught a specific time-out procedure to use
with their child. The child is also informed about the time-out protocol
within the session. The therapist provides guidance to the parent in terms
of issues related to time-out. The therapist then helps the parent utilize a
clear instruction sequence that guides the parent in how to manage com-
pliance and noncompliance to parental directions.
Standing rules. Once the parent is effectively implementing the clear
instruction sequence at home, the use of standing rules is introduced.
Standing rules are typically “If … then … ” statements (i.e., rules that
specify the consequences for specific behavior). The therapist assists the
parents in developing appropriate standing rules.
Extending the skills. The therapist discusses with the parents how
they can use the skills they have been taught to manage their child’s
behavior outside the home.
SELF-ADMINISTERED AND PARENTING CLASS

ADAPTATIONS OF HNC
Given early evidence that parents could be effectively taught child

management skills through written instructions (O’Dell, Krug, Patterson,
& Faustman, 1980; O’Dell et al., 1982) a booklet was written for parents
that provided them with information on the core skills taught in the HNC
program. An initial evaluation of this booklet in a randomized study found
that the booklet appeared to be effective in helping parents learn the basic
skills and utilize them to improve their children’s behavior (Long, Rickert,
& Ashcraft, 1993). This led to a book, Parenting the Strong-Willed Child,
being written for parents that contains a self-guided approach to learning
the core skills of HNC (Forehand & Long, 2002).
A six-week parenting class program (total of 12 hours) has also been
developed based on the HNC program and the Parenting the Strong-Willed
Child book. During each weekly 2-hour class, one of the core skills is taught
to parents as well as an additional topic. Additional topics discussed in the
class include creating a more positive home, improving communication,
developing more patience, building positive self-esteem, and problem solving.
A recent evaluation of this parenting class suggested that the class can
lead to improved parenting, reduced child behavior problems, and reduced
parenting stress (Conners, Edwards, & Grant, 2007).
It should be noted that both the self-guided and parenting class for-
mats are intended for parents whose children have relatively mild problems
whereas the clinical HNC program is intended for parents whose children
have more significant behavior problems.
Other Parent Programs That Primarily Target Externalizing

Behavior Problems
There are numerous other evidence-based parent-training programs
that have been found to be effective in reducing children’s externalizing
behavior problems. Three of these programs will be briefly discussed.
Parent-Child Interaction Therapy (PCIT)

PCIT (Brinkmeyer & Eyberg, 2003) is similar in many ways to the
Helping the Noncompliant Child (HNC) program. This similarity is a func-
tion of the fact that both programs were developed from the early work of
Constance Hanf (1969). Both programs focus on young children with dis-
ruptive behavior, have two phases, and are delivered to individual families
by a therapist. The two phases in PCIT are: child-directed interaction, and
parent-directed interaction. Training is provided through didactic instruc-
tion, modeling, role-playing, and coaching. In PCIT, children attend most
but not all of the sessions with their parents. Only the parents attend
a single teaching session at the beginning of each phase. During these
teaching sessions the parents are taught all of the skills for that phase
(whereas in HNC the skills are taught sequentially within each phase).
PCIT also emphasizes the role of traditional play therapy as part of their
child directed interaction phase. There is extensive evidence supporting
the effectiveness of PCIT (see Brinkmeyer & Eyberg, 2003).
The Incredible Years (TIY)

TIY training series (Webster-Stratton & Reid, 2003) is a comprehen-
sive program that has intervention components for parents, teachers, and
young children (two to eight years old). TIY is an extremely well-evaluated
program (see Webster-Stratton & Reid, 2003). The goals of the parent-
training component are to promote parent competencies and strengthen
families. This is a videotape modeling/group discussion program. The
BASIC parenting training program takes 26 hours to complete (13 weekly
2-hour group sessions). The videotapes used in the program contain 250
short vignettes (one to two minutes each) of modeled parenting skills.
The vignettes are show to groups of 8 to12 parents with a therapist lead-
ing group discussion. The program focuses on teaching parents how to
enhance the parent–child relationship through the use of child-directed
interactive play, to use praise, and to use incentives. The program also
teaches parenting techniques such as monitoring, ignoring, use of effec-
tive directions, time-out, and natural and logical consequences.
Webster-Stratton has also developed an ADVANCE parent training
program (Webster-Stratton & Reid, 2003). This is a 14-session videotape-
based program that can be used following completion of the BASIC pro-
gram. The ADVANCE program has four primary components: personal
self-control, communication skills, problem-solving skills, and strength-

ening social support and self-care.
Triple P
Triple P (Positive Parenting Program) developed by Sanders (Sanders &
Ralph, 2004) is a unique parent-training program. Developed in Australia
and currently being used around the world, Triple P is a multilevel parent-
training program that targets children 2–12 years old. The program has
five levels. Level 1 is a universal parent information strategy that makes
general parenting information available to all parents through the use of
various strategies including tip-sheets and promotional media campaigns.
Level 2 consists of a brief one- or two-session primary healthcare-based
parenting intervention targeting children with mild behavior problems.
Level 3 is a four-session more intensive parenting intervention that targets
children with mild to moderate behavior problems. Level 4 is an eight- to
ten-session individual or group parent-training program targeting children
with more significant behavior problems. Level 5 is an enhanced behav-
ioral family intervention program that is utilized for significant behavior
problems that are complicated by other factors (e.g., marital conflict, high
stress).
Parent Programs That Target Internalizing Behavior Problems

As discussed previously, the vast majority of parenting programs have
been developed to address children’s externalizing behavior problems.
However, a limited number of parenting programs have been developed
to specifically address internalizing behavior problems. These parent pro-
grams, unlike the programs for externalizing problems, are often used in
an adjunctive manner to interventions that involve working with the child
directly. This reflects the belief that: (1) although parenting may be a con-
tributing factor to children’s internalizing problems it typically plays a less
central role than it does with externalizing problems; and, (2) other inter-
vention approaches working directly with children (e.g., cognitive-behavior
therapy) have been found to be effective.
In several studies researchers have found that the risk for the develop-
ment of internalizing disorders in children is associated with parent–child
interactions that involve parental overcontrol, less granting of autonomy,
and low maternal warmth (Hudson & Rapee, 2001; Rapee, 1997; Sique-
land, Kendall, & Steinberg, 1996). Child anxiety may also result in parental
distress and changes in parenting practices including changes in terms
of parental expectations and demands that may maintain or exacerbate
children’s anxious and avoidant behaviors through negative reinforcement
(Kendall & Ollendick, 2004). Therefore, although cognitive-behavioral ther-
apy has been found to be an effective treatment for childhood anxiety dis-
orders, researchers have recommended the involvement of parents in the
treatment process as a way to improve outcomes (Barrett & Farrell, 2007).
Barmish and Kendall (2005) reported several common components of
parent-focused interventions for childhood anxiety:
Removing the reinforcement of children’s anxious behavior. This included

teaching parents contingency management strategies to extinguish avoidant
behavior and expressions of fear and to reward courageous behavior. Specific
strategies included planned ignoring, verbal praise, privileges and tangible
rewards.
Modeling appropriate behavior. This included teaching parents how to
gain greater awareness of their own anxious behaviors and how to become
better models for the children. Parents were also taught problem-solving
skills, how to restructure their cognitions, and to engage in appropriate
responses to anxiety-provoking situations.
Reducing family conflict. This included teaching parents specific
strategies to improve communication, parent–child relationships, and
reduce conflict.
Other. Other techniques used by some programs included teaching par-
ents about the etiology of anxiety (and the role of the family), relaxation training,
and how to build a support network with other parents of anxious children.
Barmish and Kendall (2005) conducted a review and meta-analysis
of nine controlled studies that have involved parents in the treatment of
child anxiety. Unfortunately, there was large variability across the stud-
ies including such factors as the content of parent sessions, number and
format of sessions, and who attend the parent sessions. This variabil-
ity precluded any definitive conclusions to be drawn. The reported effect
sizes for CBT treatment without parental involvement ranged from small
to medium for self-reported data to large for parent-reported measures.
When the treatment programs involved parents, the effect sizes ranged
from small to large for self-reported measures to large for diagnostician
and parent-reported measures.
FRIENDS for Life Program

One program that targets internalizing behavior problems is The
FRIENDS For Life Program (Barrett & Farrell, 2007; Barrett & Shortt,
2003), which targets childhood anxiety, and includes a parent component.
This treatment program, which was initially designed to be a group-based
intervention (it has also been adapted for individual clinical use), has a
primary child-focused cognitive-behavioral component. That is, the pri-
mary focus is working with children directly to address their dysfunctional
cognitions. The parent and family skills component is designed to be run
in a group format for approximately 6 hours (typically four 1.5 hour ses-
sions). The major focus of the parent/family skills component (Barrett &
Farrell, 2007; Barrett & Shortt, 2003) is to:
- Encourage parenting strategies including attending to and reinforc-
ing their children’s coping, approaching behaviors, and parental
modeling of appropriate coping behavior to their children
- Teach parents self-awareness and appropriate management of their
own stress and anxiety.
- Increase parents’ awareness of at-risk time for their children, how

they can coach their children to cope, and reinforcing their chil-
dren’s appropriate attempts to cope.
The parent component follows along with the FRIENDS components for
the children. Barrett and Farrell (2007) have outlined the specific strat-
egies of the parent component for each component as indicated by the
FRIENDS acronym as summarized below.
Feelings. Parents are encouraged to focus on their own responses
to fear and anxiety and on learning the skills of anxiety awareness. The
importance of accepting individual differences, particularly in response to
feelings, is discussed.
Remember to relax. Have a quiet time. Parents are taught relaxation skills
and are encouraged to practice and coach other family members. Parents are
also encouraged to ensure that the family has regular periods of quiet time.
Parents are also encouraged to reinforce relaxation practice in children. Par-
ents are supported and encouraged to spend quality time with their children.
I can do it! I can try my best! Parents are encouraged to become aware
of their own cognitive style and how their responses to stress model opti-
mism or pessimism to their children. Parents are encouraged to use positive
thoughts and to notice and reward their children for positive thoughts.
Parents are also asked to use positive prompts (e.g., “You can do it, you’ve
done it before”) with their children.
Explore solutions and coping step plans. Parents are taught how to
help their child develop coping step plans (based on a fear hierarchy). They
are given examples of coping step plans and rules to help ensure the success
of coping step plans.
Now reward yourself! You’ve done your best! Parents are encouraged
to notice brave/confident behaviors and reward approach behaviors.
Parents are also taught to ignore complaining and avoidance behaviors.
Don’t forget to practice. Parents are taught to encourage their child to
use their FRIENDS plan. They are also encouraged to role-play with their
children how to utilize the skills to handle upcoming challenges.
Smile! Stay calm for life. Parents are encouraged to help their children
recognize they have effective strategies for overcoming challenges they will
face.
Parent Programs That Target Developmental Disorders

The role of parents in the treatment of children with developmental dis-
orders has significantly changed over the past several decades. Parents have
moved from being minimally, if at all, involved in their children’s treatment
to being integrally involved. This transition has been especially significant for
some disorders such as autism. In the not too distant past, parenting style
(cold and rejecting) was considered to be the cause of autism (Bettleheim,
1967). Fortunately, autism is no longer considered an emotional problem
related to parenting but rather a neurodevelopmental disorder for which
parents can play an important role in helping interventions succeed.
The literature on parent training for children with developmental dis-

orders and specifically autism has, for the most part, developed separately
from the parent training literature for areas such as disruptive behavior
disorders (Brookman-Frazee, Stahmer, Baker-Ericzen & Tsai, 2006). In
reviewing the literature on parent training and autism spectrum disor-
ders (ASD) Brookman-Frazee and colleagues (2006) identified some gen-
eral differences when compared to more traditional parent training studies
for disruptive behavior disorders. They report that parent groups for ASD
tend to be smaller and that studies often include single case examples,
single case design, and more descriptive reports. Programs for ASD tend to
include more modeling of behaviors for parents. They also tend to include
more home treatment components and fewer strictly didactic components
for parents.
The degree of parental participation varies significantly across treat-
ment programs for ASD and other developmental disabilities. The level
of parental involvement is discussed below for some of the most popular
treatment programs for ASD.
Planned Activities Training (PAT)

Planned Activities Training (Lutzker & Steed, 1998) is a parent-training
approach that focuses on antecedent prevention of challenging behav-
iors. Unlike many other parent-training approaches that rely primarily on
contingency management techniques, PAT teaches parents to plan and to
structure activities in order to prevent challenging child behaviors. PAT
has been used successfully to reduce inappropriate behaviors with vari-
ous groups including children with developmental disabilities (see Lutzker
& Steed, 1998). PAT involves teaching parents time-management skills,
how to choose activities, how to explain activity rules, incidental teach-
ing, feedback, and reinforcement. This training of parents is provided by a
therapist across five structured sessions with an individual family. Train-
ing initially involves teaching parents to use the techniques for activities
that are not problematic. As parents master the techniques more prob-
lematic activities and settings are targeted. Training involves extensive
modeling, parent practice, and performance feedback. Training sessions
are typically conducted in family homes and in settings where challenging
behaviors occur.
Parent Involvement in Lovaas’s Treatment Program

for Autism
The early applied behavior analysis (ABA) interventions focused on the
child and did not involve the parents. However, in an early study by Lovaas
and his colleagues (Lovaas, Koegel, Simmons, & Long, 1973) it was noted
that children who were discharged back to families who were eager to par-
ticipate in treatment did much better in maintaining skills (or improving
skills) learned during the one-year treatment program (Lovaas, 2003). This
anecdotal evidence was seminal in Lovaas’ understanding of the need for
parental involvement with the children diagnosed with autism. However,
the extensive demands of parental implementation of an ABA intervention
(for at least 40 hours a week) requires a lifestyle change that is impossible

for many parents.
It should be noted that the effectiveness of using parents for the deliv-
ery of an ABA program is not clear. A recent study compared the outcomes
of ABA intervention provided by parents with that provided by students
(Smith, Groen, & Wynn, 2000). At four-year follow-up the children enrolled
in the student therapist group made more gains than the children in the
parent therapist groups on IQ tests, visual spatial skills, and in specific
aspects of language. There is some evidence to suggest that parents who
participate in parent training for their children with autism continue to
use some of the behavioral techniques they were taught, but many tend
to stop using the complete set of operant learning procedures including
ongoing formal data collection (Harris, 1986).
Pivotal Response Training (PRT)

Pivotal Response Training (PRT) was developed as a modified behavio-
ral intervention for children with autism (Koegel, O’Dell, & Koegel, 1987).
PRT focuses on addressing pivotal areas of functioning that can lead to
widespread collateral changes in other behaviors (Koegel, Koegel, & Brook-
man, 2003). Although specific target behaviors are determined based on
individual needs, much of the focus is on communication skills and social
communication interactions. PRT differs from traditional operant train-
ing in several ways including: (1) that it allows the child to take the lead
in what toys/stimulus items are used in a session, (2) it rewards goal-
directed attempts at correct responses, and (3) it uses more direct/natural
reinforcers in training. PRT has been found to change not only the target
behaviors but also improve the affective relationship between parent and
child, resulting in lower stress during family interactions, and improve
positive communication (Koegel, Bimbela & Schreibman, 1996). The addi-
tion of a parent support group to the standard parent-training program
has been found to improve the performance of parents in the use of the
PRT techniques (Stahmer & Gist, 2001).
In Koegel’s PRT, parents serve as key coordinators and interventions
for the program. Initially, the individually tailored parent-training program
focuses on introducing basic behavioral interventions (e.g., antecedents,
behavior, and consequences), characteristics of the pivotal area of motiva-
tion, and identifying learning opportunities in the natural environment
(Koegel, Koegel, & Brookman, 2003). The training program involves exten-
sive parent practice with clinician provided feedback on parent implemen-
tation of each procedure. Specific skills taught to parents (Koegel, Koegel,
& Brookman, 2003) include:
- How to present clear instructions and questions, use child-selected
stimulus materials, and use direct natural reinforcers
- How to intersperse previously learned tasks with new acquisitions
tasks (interspersing maintenance trials)
- How to reinforce a child’s attempts to respond to instructional mate-

rials or natural learning opportunities
Koegel’s research indicates that most parents reach criterion (80% correct
use of the motivational procedures within the natural environment) within
25 hours of training.
TEACCH Program (Treatment and Education of Autistic

and related Communication-handicapped Children)
The TEACCH program, developed by Eric Schopler and his colleagues
at the University of North Carolina at Chapel Hill, can be conceptualized
as a network for the state of North Carolina that provides services for
children with autism, education and support for families, research and
training for professionals, as well as a base for international education,
research, and training. It is not a single intervention. Working with the
families of individuals with autism is a major component of this program
(Marcus, Kunce, & Schopler, 2005).
The initial work of Eric Schopler was a direct response to the psy-
choanalytic theories of the 1960s that parents were the cause of a child’s
autism. Some of his earliest research looked at parents of children with
autism and found that these parents did not have thought disorders as
originally reported in the literature (Schopler & Loftin, 1969a, 1969b).
His early research also found that parents of children with autism were
able to accurately evaluate the variations their children’s developmental
progress and that these evaluations were consistent with standardized
testing results (Schopler & Reichler, 1972). These studies were seminal in
incorporating parent involvement and parent report as part of the evalua-
tion and treatment of the child with autism.
Education, training, and parent support are included in the core mis-
sion statement of the TEACCH model. The key values of the TEACCH model
include: (1) respecting the parent’s knowledge of their child, (2) respecting
the individuality of each family, (3) respecting the love parents have for
their child, (4) respecting the resilience of parents in finding solutions in
the face of intense stress, (5) respecting the contributions parents make
in advocating and developing new services, and (6) respecting the needs
of parents for accurate information, emotional support, comprehensive
services, and professional guidance for their child with autism (Mesibov,
Shea, & Schopler, 2006).
The TEACCH program involves parents at various levels (Marcus,
Kunce, & Schopler, 2005). Parents are educated about autism, trained
to work directly with their child, and to participate in advocacy efforts.
Specific training efforts, in working with their child, include helping them
establish positive routines through structured teaching. The TEACCH pro-
gram utilizes a collaborative model in working with parents. The exact
content of parent training efforts varies based on the child’s stage of devel-
opment and individual family needs.
Stepping Stones Triple P (SSTP)

The Triple P (Positive Parenting Program; Sanders, 1999), which utilizes
behavioral family interventions and parent management training, has
been modified for use with children with autism (Roberts, Mazzucchelli,
Studman & Sanders, 2006). Stepping Stones Triple P (SSTP) modifies the
original program by including material sensitive to families of children
with disabilities. It also covers issues relevant to this population and addi-
tional factors that could contribute to behavioral issues (i.e., problems
with communication skills).
A randomized control trial of SSTP (Roberts, Mazzucchelli, Studman &
Sanders, 2006) with parents of children with autism found that the SSTP
program resulted in a decrease in child behavior problems. Parenting
changes included mothers becoming less overreactive and fathers becom-
ing more effective in their discipline strategies. Raters found parents to be
more positive in their praising of children’s behavior. These results were
maintained at a six-month follow-up.
The modification of existing parent training for uses with different
populations, as described above, is a trend that will most likely increase
in the future.
CONCLUSION
From its early development in the 1960s, parent training has made
great strides. It has grown from an intervention focused on helping parents
to address specific child behaviors to a method of intervention used for a
variety of child problems and disorders. No other psychological therapy
for children has been as extensively studied (Kazdin, 2005). Meta-analytic
reviews of the parent-training literature suggest that parent training is at
least moderately effective. These results are very favorable when compared
to the effects found for other psychotherapy approaches. Such research
findings have resulted in parent training being considered one of the rel-
atively few empirically supported treatments for children’s externalizing
behavior problems. The use of parent training in other areas of childhood
psychopathology and developmental disorders is less well established but
is rapidly gaining support.
Unfortunately, parent training is not a panacea nor is it consistently
effective. Much work remains to be conducted to fully understand factors
that impact the effectiveness of parent training interventions. A greater
understanding is needed of how contextual factors such as ethnicity/cul-
ture, socioeconomic status, parental psychopathology, and various family
stressors relate to parent training interventions. Parent-training interven-
tions certainly need to better address issues related to ethnicity and cul-
ture, which are known to affect parenting, if treatment outcomes are to be
maintained in our increasingly diverse society.
At this stage of the development of parent-training interventions, more
effectiveness trials are needed (the primary focus to this point in time
has been on efficacy trials) (Weisz & Kazdin, 2003). That is, there is a
growing need to move beyond assessing treatment outcomes in controlled

research settings to assessing outcomes when parent-training interven-
tions are used in “real world” clinical settings. Related to this issue is the
need to study how to most effectively train clinicians in parent-training
approaches. Most research studies to date (efficacy trials) have utilized
therapists who are extensively trained over long periods (e.g., graduate
students who are trained over years in a particular parent-training pro-
gram). How can therapists at the community-level be trained to a level of
proficiency that will maintain the effectiveness of the intervention? It is
questionable whether traditional continuing education methods (e.g., writ-
ten manuals, one- to two-day training workshops with no ongoing training
support or supervision) are adequate. Perhaps newer technologies (e.g.,
Web-based tutorials and/or booster training sessions, Web-based group
supervision) will be used to assist in training efforts.
Finally, there is a need for research involving direct comparisons of
different parent-training interventions to determine which approaches are
most effective under which conditions. At the present time, there are many
parent-training interventions that have been demonstrated to be effective;
however, it is often difficult for clinicians to know which approach is best
for a specific family with whom they are working.
In conclusion, parent training has come a long way but still faces
many challenges as this approach to intervention continues to evolve. The
future of parent training looks bright as researchers and clinicians will
continue to use, improve, and study this very promising intervention for
treating and preventing child problems.
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5
Conduct Disorders
CHRISTOPHER T. BARRY, LISA L. ANSEL,
JESSICA D. PICKARD, and
HEATHER L. HARRISON
INTRODUCTION
Disruptive behaviors—defined here as behaviors that are associated

with diagnoses of Oppositional Defiant Disorder (ODD) or Conduct Disorder
(CD)—are the most common reason for referral to mental health services for
children and adolescents (Kazdin, 2003). The behaviors that comprise these
diagnoses include argumentativeness, temper tantrums, often being angry
or resentful, lying, stealing, hurting or threatening to hurt others, cruelty
to animals, setting fires, and destruction of property (American Psychiatric
Association, 2000). Kazdin (2003) estimates “conservatively” that between 1.4
million to 4.2 million children in the United States meet criteria for CD alone.
Conduct problems or other externalizing behavioral difficulties constitute the
most common referral issues for children and adolescents for mental health
services (Brinkmeyer & Eyberg, 2003). The presence of these symptoms can
be detected early in childhood (Webster-Stratton & Reid, 2003), making them
amenable to treatment as long as candidates for intervention are identified
and followed through with the prescribed treatment recommendations.
ODD and CD encompass a broad array of acts, and young person
need not exhibit all, or even most, of the symptoms of ODD and CD
to warrant a diagnosis or be a candidate for intervention. Noncompli-
ant behavior is frequently demonstrated in children with ODD or CD;
however, many parents whose children do not meet diagnostic criteria
for these disorders commonly report seeking outpatient mental health
services for noncompliance in their children (McMahon & Forehand,
2003). One of the initial symptoms of conduct problems to emerge in
children is lying (Christophersen & Mortweet, 2001). Specific behaviors
CHRISTOPHER T. BARRY, LISA L. ANSEL, JESSICA D. PICKARD, and HEATHER

L. HARRISON ● The University of Southern Mississippi

108 CHRISTOPHER T. BARRY et al.
that are associated with ODD and CD may in and of themselves be

reason referring a young person for treatment, including bullying, rigid-
ity/stubbornness, and temper tantrums (Christophersen & Mortweet,
2001; McMahon & Forehand, 2003).
Researchers also suggest that oppositional behaviors, including argumen-
tativeness and temper outbursts, typically predate the onset of the more
severe behaviors that comprise CD (Greene, Biederman et al., 2002; Loeber,
Green, Lahey, Christ, & Frick, 1992). To wit, current and well-supported
interventions are geared toward early identification and treatment of oppo-
sitional and noncompliant behaviors more so than severe conduct prob-
lems which have a low base rate among young children (e.g., McMahon
& Forehand, 2003). It should be noted that we use the terms “conduct
problems, conduct disorders, and behavioral problems” essentially inter-
changeably and in reference to behaviors that comprise, or are similar to,
the symptoms of ODD and CD. The reason behind the above consideration
is that individual symptoms of either diagnosis may warrant intervention,
CD often encompasses symptoms of ODD, a diagnosis of CD supersedes
a diagnosis of ODD, and it may be difficult to clearly distinguish among
CD, ODD, and an exaggeration of typical developmental processes, partic-
ularly in preschool-aged children and adolescents (American Psychiatric
Association, 2000).
The designs of treatments for conduct disorders have not only been
an artifact of the theoretical perspectives that predominate at a given time
but more specifically reflect the presumed causal factors (e.g., environ-
mental, cognitive) at play in the onset and persistence of these behaviors.
For example, researchers point to infrequent use of positive parenting and
inconsistent or harsh parenting as factors in development and mainte-
nance of child conduct problems (Gardner, Sonuga-Barke, & Sayal, 1999;
Gardner, Ward, Burton, & Wilson, 2003). Therefore, as described below,
many treatments for conduct disorders focus on these very parent fac-
tors through discussion and modeling of positive parental strategies (e.g.,
labeled praise, positive reinforcement based on clear contingencies) as well
as effective, consistent punishment strategies (e.g., time out). Hart, Nel-
son, and Finch (2006) caution that these theoretical perspectives are just
that, and care must be taken to not be unduly biased or exclusive in our
assessment, conceptualization, and treatment of child conduct problems.
They describe the importance of the therapeutic relationship, the impor-
tance of family relationships and parents, the influence of peers, and the
consideration of an individual’s risk and protective factors as factors that
generally cut across various interventions for these problems.
Regardless of the presumed etiology of conduct disorders, the need
for effective treatment is evident in the numerous domains in which con-
duct problems are related to impaired functioning and the fact that many
conduct problem behaviors have a victim. Our discussion of treatment
for conduct disorders focuses on psychosocial, as opposed to pharma-
cological treatments, given (a) the lack of pharmacological treatments
geared specifically to ODD and CD symptoms; (b) the fact that the medici-
nal treatments that are implemented with children with conduct prob-
lems typically target comorbid conditions of these problems (e.g., mood
CONDUCT DISORDERS 109
disorders, Attention-Deficit/Hyperactivity Disorder [ADHD]) and (c) the

evidence supporting psychosocial interventions in the reduction of these
symptoms. The improvements in conduct problems that have been found
for psychopharmalogical interventions have typically been short in dura-
tion (Farmer, Compton, Burns, & Robertson, 2002). Thus, although more
research and treatment innovation are certainly needed, the evidence base
for psychological/behavioral treatments of youth conduct disorders is rel-
atively strong.
With the recent and still-emerging emphasis on evidence-based prac-
tice using empirically supported treatment strategies, there exists great
potential for both the expansion and synthesis of ideas on how to inter-
vene regarding specific problem behaviors at various developmental peri-
ods. The treatments that are considered empirically supported target both
the symptoms of ODD and CD, including a particular emphasis on parent-
ing strategies to reduce noncompliance as well as work on individual cop-
ing strategies for anger-provoking events (see Brestan & Eyberg, 1998).
However, the empirically supported psychosocial treatments for ADHD
also may be effective for reducing conduct problems insofar as they also
include strategies for reducing noncompliance and target the poor impulse
control that may be at the root of many child externalizing behaviors.
From the review of interventions that follows, it is apparent that many
of the empirically supported treatments for conduct disorders share a view
on some of the main causal pathways for problem behaviors among youth
and on the techniques that will abate conduct problem symptoms. Nev-
ertheless, key questions remain as to the most essential aspects of com-
mon strategies such as parent training (Anastopolous & Fairley, 2003), as
well as the extent to which therapist fidelity to these interventions occurs
and the extent to which it is necessary (Brinkmeyer & Eyberg, 2003). The
relevance of these questions for evidence-based practice and the further
advancement and innovation of such practice is discussed below.
What remains an ever-pressing issue is that of the influence of develop-
mental issues in determining the need for intervention and in the selection of
intervention strategies for conduct disorders. That is, there is much research
indicating that an onset of conduct problems prior to adolescence is associ-
ated with more persistent and severe problems than is a later onset (Loeber
et al., 1993; Moffitt, 2006). Therefore, the need for early intervention is clear.
Specific treatment programs such as those reviewed in these chapters are
typically most useful for specific developmental periods rather than one-size-
fits-all across childhood and adolescence. Treatments for conduct disorders
are only as effective as their appropriateness for the developmental level of
the child, thus making the consideration of development in the research on
which the interventions are based critical.
The goal of this chapter is to provide a description of the unique and
common elements of empirically supported interventions for conduct dis-
orders, as well as our view—in light of current research and theory—as
to the future directions that this work will likely take. Researchers have
indicated that a variety of approaches can be effective in reducing child
conduct problems (e.g., Nock, 2003). For example, the evidence supporting
cognitive-behavioral or behavioral parenting interventions for preventing or
treating child conduct problems is extensive. Therefore, we cannot provide

an exhaustive review of each treatment approach, its specific features, and
its empirical support in this chapter. Indeed, we seek to give an overview of
the issues inherent in treating child conduct disorders and of the current
strategies that are evidence-based. We begin with a discussion of parent-
based interventions given their utility for treating a variety of behavioral
problems in children beginning at a very young age.
PARENT-BASED TREATMENTS
Common Elements
That parent-based strategies are, or are part of, many of the empiri-
cally supported treatments for conduct problems speaks to the potential
influence of the youth’s immediate home environment in the development
of conduct problems and in the usefulness of environmental interventions
in the reduction of these problems. It is important,to note that regardless
of the specific hypothesized developmental pathway toward conduct prob-
lems for a given young person, parent-based interventions are develop-
mentally necessary for young children who generally lack the capacity to
directly participate in treatment in lieu of their parents. Indeed, consider-
ing the potential etiological effects of contextual factors, it has been argued
that intervention for children with an early onset of conduct problems
should have parent-based treatment as its central component (Beaucha-
ine, Webster-Stratton, & Reid, 2005).
Empirically supported parenting interventions generally target
child noncompliance and have some theoretical foundation based on
Patterson’s (1982) model of coercive parent–child interactions. Specifi-
cally, parenting practices that are thought to negatively reinforce child
noncompliance (e.g., withdrawing a request/command after repeated
refusals by the child) are replaced by clear commands and immediate
negative consequences for noncompliance. Furthermore, Patterson’s
model suggests that increasingly harsh parenting strategies are used as
child noncompliance increases, and such strategies are positively rein-
forced by the child’s eventual compliance in the face of harsh parenting
or threat thereof.
Parent-based interventions seek to emphasize positive reinforcement
for compliance in the form of praise, privileges, or larger, more long-term
rewards as well as to diminish the likelihood of increasingly aversive
parenting practices by promoting the use of immediate and consistent
punishment strategies such as time-out. Response cost (i.e., removing
tokens, privileges, or points when inappropriate behavior occurs) can pro-
vide an alternative to time-out (Forehand & McMahon, 2003). However,
the improvement of parent–child interactions through the use of positive
parenting strategies (i.e., parental attention, positive reinforcement) is
emphasized before the implementation of punishment strategies for misbe-
havior (cf., Webster-Stratton & Reid, 2003). Such models seem warranted
in light of evidence demonstrating that increases in positive parenting
practices are a mediating factor in improved child behavior (Gardner, Burton,

& Klimes, 2006) and that changes in parenting skills are a better predic-
tor of child outcome from parent-based treatment than change in parental
mood or parental confidence (Gardner et al., 2006; Hutchings, Lane, &
Gardner, 2004).
Specifically, parent training or family-based treatments for conduct
disorders routinely progress through the normal initial discussions and
modeling of positive attention and praise, to skills such as appropriate
commands, making attention and reinforcement contingent upon child
behavior, and use of a time-out for negative behaviors (see McMahon &
Wells, 1998). Additional treatment methods emphasize the use of ignor-
ing minor misbehaviors, the need for parents to be more proactive as
opposed to reactive in their plans to deal with problematic behaviors,
and the use of natural consequences for certain misbehavior (Webster-
Stratton & Reid, 2003).
Initial sessions of parent-based programs often begin with a psy-
choeducational component so that parents can better understand their
children’s difficulties and the rationale for the planned treatment. This
understanding may aid parents in being less emotionally reactive to the
child’s behaviors. Thus, parental anger management is often a component
of treatment, promoting a model of effective coping skills resulting in par-
ents being less likely to interact angrily—and thus problematically—with
his or her child.
Specific parenting techniques may be discussed didactically (e.g.,
Barkley, 1997), practiced and modeled in vivo (see Brinkmeyer & Eyberg,
2003), modeled using videotape (see Webster-Stratton & Reid, 2003), or
often, some combination of these approaches. Naturally, in-session mode-
ling and practicing of parenting skills will not be a component of treatment
once the child reaches a certain age. For example, Parent–Child Interac-
tion Therapy (PCIT; see below) is based on such in vivo practice but is
geared toward children ages three to six (Brinkmeyer & Eyberg, 2003).
It should be noted that these interventions are not synonymous with
family therapy approaches that emphasize problematic family boundaries
as factors that exacerbate a child’s problems such as in structural family
therapy (Minuchin, Montalvo, Guerney, Rosman, & Schumer, 1967) or that
emphasize family interactions across multiple generations and ways for
the child/adolescent to individuate adaptively as in a Bowenian approach
(see Hart et al., 2006). To date, these specific approaches have not dem-
onstrated empirical support for child conduct disorders, although a study
by Santisteban and colleagues (2003) found positive results particularly
in the reduction of adolescent substance use as well as peer-based delin-
quency and conduct problems for Hispanic adolescents who were treated
with a brief model of strategic family therapy. Furthermore, as discussed
below, family therapy that takes a multifaceted approach has shown some
benefits in terms of reducing adolescent problem behavior as well as in
addressing some of the risk factors for such behavior.
Finally, not all programs targeted at parents of children with conduct
problems focus exclusively on parenting practices in relation to the child’s
behavioral difficulties. Broader family-based approaches (see Kazdin, 1987)
have also targeted parental stress, parental problem-solving, and marital dis-
cord insofar as they exacerbate the child’s misbehavior (Lochman, 1990). Such
factors can be addressed within the context of individual parent treatment,
couples therapy, during the course of a child’s treatment for conduct prob-
lems, or in parenting groups designed for parents of children with conduct
problems. Such issues could be addressed generally in parenting groups, as
many of the empirically supported parenting interventions are group-based
and may include discussion of family issues that are often associated with
child problem behaviors. In fact, given their effectiveness, group therapy for
parents of children with externalizing problems have been touted as more
cost effective than individual parent-based treatment (Chronis, Chacko, Fabi-
ano, Wymbs, & Pelham, 2004) provided that the approach to parent training
is amenable to group work.
Examples of Empirically Supported Treatments

An important and influential approach to parent-based treatments for
conduct problems is the Living with Children program that was originally
developed by Patterson and Guillion in 1968 (Patterson & Guillion, 1968;
see Brestan & Eyberg, 1998). This program is conducted primarily with the
parents in an individual training format typically targeted at children ages
two to eight. This manualized treatment teaches skills such as attending
and rewards, ignoring, helping the parent with the effective use of differ-
ential attention regarding the child’s behavior, finding ways to eliminate
coercive cycles of parent–child interactions, establishing clear and consist-
ent rules, and behavioral generalization to other settings. That is, it follows
a sequence now generally adopted across parenting programs. Such skills
are taught using psychoeducation, homework assignments, role-plays,
and modeling. Living with Children and subsequent adaptations have
demonstrated positive outcomes in a variety of controlled studies (Brestan
& Eyberg, 1998), but recent studies on this specific program have not been
conducted (Farmer et al., 2002). Nevertheless, the innovativeness of the
theoretical foundation of this program and its approach has clearly influ-
enced more recently developed parent-based treatment programs.
A unique approach falling under the rubric of parent management
training is Carolyn Webster-Stratton’s “Incredible Years: Early Childhood
BASIC Parent Training” (see Webster-Stratton & Reid, 2003) which is
particularly oriented toward parents of children ages 6 to 12. However,
a similar program also developed by Webster-Stratton is geared toward
children who are younger (Webster-Stratton & Reid, 2003). This treatment
approach is unique in that it makes use of videotape modeling. It occurs in
a group setting rather in an individual format. It consists of ten videos that
demonstrate appropriate and inappropriate interactions to the parents
and can be used for parents of children of all ages. The videos facilitate
a group discussion with the parents. In addition to the traditional parent
management techniques that are taught, BASIC incorporates the skills of
logical consequences and response cost (Webster-Stratton & Reid, 2003).
Furthermore, a key tenet of this treatment is that parents can reduce
their children’s oppositional behaviors and even more significant conduct
problems by abandoning harsh or overly critical parenting and employing

consistent use of the kinds of strategies that are common to parent-based
programs (e.g., positive reinforcement, response cost, time-out, etc.). This
approach and variations of it have been shown to have positive effects on
child conduct up to one year later (Webster-Stratton & Hammond, 1997).
The intervention is particularly effective when combined with parent dis-
cussion groups or a child-focused component (see Farmer et al., 2002)
which is discussed below.
The program developed by Russell Barkley (1997) for parents of ele-
mentary school-aged children generally follows the above approach and is
based on the coercive cycle of parent–child interactions. Many of the spe-
cific strategies of this program (e.g., clear, short parental commands) are
geared toward accommodating the specific difficulties that children with
Attention-Deficit/Hyperactivity Disorder (ADHD) might have. In addition,
this program provides a good model for beginning treatment with psych-
oeducation on noncompliance and other conduct problems with a discus-
sion of both the child and familial factors that may lead to or help sustain
such behaviors.
The program progresses through discussion of attending to a child’s pos-
itive play behavior using a set-aside parent–child play time during which the
parent provides attention to the child’s behavior with very limited questioning
and no commands. In a subsequent session, parents are encouraged to fre-
quently praise and reinforce child compliance with commands—and to give
more opportunities for compliance—so that the child understands the contin-
gency between compliant behavior and the positive consequences that follow.
The sessions that follow are consistent with the sequence of steps described
above in which positive parenting skills are first introduced, followed by pun-
ishment strategies, with specific homework and handouts concerning each
skill being provided to parents (Barkley, 1997).
This intervention program is typically conducted in groups but can be
easily adapted to individual families. Relatively unique aspects of this pro-
gram include detailed discussions of the importance of praising/attend-
ing to a child’s independent play behaviors, managing behavior in public
places, and establishing effective home–school notes such that school
behaviors are subject to contingencies at home. As with other approaches,
much emphasis in this program is placed on clear consistent expecta-
tions and immediate praise for compliance and punishment (i.e., response
cost, time-out) for noncompliance. The importance of attending to positive
behaviors and ignoring/withholding attention from negative behaviors is
also a focus.
This program has been extended to adolescents in a separate treat-
ment format (Barkley, Edwards, & Robin, 1999), combining elements of
the parenting approach implemented for younger children just described
and family therapy centered on effective family communication and prob-
lem-solving skills. Each of the parenting skills discussed and practiced
in the program for younger children is presented first in the adolescent
program, with modifications made so that the strategies are developmen-
tally appropriate (e.g., grounding instead of time out). Behavioral contracts
are used as a version of a reward point system, but the adolescent is
involved in the planning of the contract. The rationale for the adolescent’s
increased involvement includes a more sophisticated understanding of the
approaches used to improve his or her behavior and family relationships,
the benefits of having the adolescent as part of the intervention process,
making the parent accountable for providing appropriate consequences
contingent upon the adolescent’s behavior, and making the adolescent
responsible for meeting the behavioral expectations set forth by the con-
tract (see Barkley et al., 1999).
The second phase of this program is family-focused and deals with
the importance of improving family communication habits in reducing
the teen’s problematic behaviors. In addition, unreasonable beliefs (e.g.,
expectations of perfect compliance, expectations of negative outcomes if
the adolescent is granted some autonomy) are discussed as a precipitant
of many hostile adolescent–parent interactions. Finally, the family mem-
bers practice their communication and problem-solving skills in sessions
with direction and guidance from the therapist. Of course, a wealth of
evidence supports the effectiveness of the parenting strategies introduced
in the first part of this program, although less is known about develop-
mental adaptations for adolescents. Recent evidence has also specifically
supported the benefits of family-based intervention such as that provided
in the second part of this program for symptoms associated with ADHD
and ODD (Anastopolous, Shelton, & Barkley, 2005).
An example of a parent-focused intervention with clear empirical sup-
port for reducing child oppositional and noncompliant behavior is PCIT
developed by Sheila Eyberg and colleagues (see Brinkmeyer & Eyberg,
2003). This program is oriented toward a variety of child acting-out behav-
iors ranging from talking back to authority figures to aggression and is
based on both attachment and social learning theories. More specifi-
cally, maladaptive parent–child attachment (e.g., low tolerance for child
emotional expressiveness) and patterns of escalating and aversive par-
ent–child interactions are thought to contribute to the child’s aggression,
poor coping skills, and noncompliance (Eyberg & Brinkmeyer, 2003). In
this approach, however, the parent is the agent of change in the child’s
behavior. In other words, PCIT does not focus on enhancing the child’s
coping skills per se.
As with many other parenting programs, PCIT begins with a focus
on child-directed interactions, a difference being that parenting skills
surrounding such interactions are modeled and practiced in vivo with
regular practice assigned between sessions as opposed to only being dis-
cussed and assigned as subsequent homework. Indeed, therapists in PCIT
serve as “coaches” in that they discuss and model parenting skills and
then observe the parents’ use of these skills in session (Brinkmeyer &
Eyberg, 2003). During child-directed interactions, the parent is charged
with “praising the child’s behavior, reflecting the child’s statements, imi-
tating and describing the child’s play, and using enthusiasm (i.e., PRIDE
skills; Brinkmeyer & Eyberg, 2003; p. 207). In other words, the parent
is cautioned not to make commands during this time or to control the
activities in which he or she engages with the child. Instead, the parent
ignores minor misbehavior during these interactions and discontinues the
interaction should the child’s behavior become difficult to manage. These

interactions are thought to target the attachment-related influences on
the child’s disruptive behaviors.
The focus of sessions—when the parent has mastered the skills neces-
sary during child-directed interactions—shifts to parent-directed interac-
tions. These interactions are based on social learning processes whereby
the parent’s skills for issuing effective commands, ignoring minor disrup-
tive behaviors, and implementing consequences for continued or more
severe disruptive behaviors are discussed, modeled, and practiced in ses-
sion. Parents are taught the importance of clear concise commands, and
as with other empirically supported parenting interventions, PCIT empha-
sizes consistency in the consequences provided for both compliant and
noncompliant behaviors.
PCIT is most effective and useful for children ages three to six
(see Brinkmeyer & Eyberg, 2003). Systematic progress monitoring is
a feature of this program that is essential given that PCIT is perform-
ance-based, not time-limited. That is, new parenting techniques are not
discussed, modeled, and practiced until previous skills have been mas-
tered. Progress is monitored through direct observations of parenting
behaviors and child disruptive behaviors in session. Research points
to the effectiveness of this approach in terms of both child behavior
and reports of parental satisfaction (see Brinkmeyer & Eyberg, 2003).
In addition to the parenting skills emphasis described briefly above,
PCIT, as do other programs for parents of children with conduct prob-
lems includes a parent relaxation component with the perspective that
parental stress will likely exacerbate problematic parent–child interac-
tions and child misbehavior.
A relatively recently developed program designed by Ross Greene and
colleagues (Greene, Ablon, & Goring, 2002)—also geared primarily toward
parents of school-aged children and known as collaborative problem-solving—has
a somewhat different approach and rationale from traditional parent-based
programs. Indeed, although the targets of this intervention (e.g., temper out-
bursts) are within the purview of traditional parenting programs, the presumed
cause of these behaviors is different, thus leading to different considerations
as to the families who would benefit from this approach.
In short, rather than an emphasis on contingencies to motivate
increased child compliance and decreased conduct problems as in tra-
ditional parent training, collaborative problem-solving emphasizes on
enhancing the abilities of both parents and children to resolve disa-
greements or issues that typically result in child outbursts (Greene et
al., 2004). The psychoeducational component of this program focuses
on the cognitive and intrapersonal factors that may be associated with
children’s aggressive outbursts such as poor frustration tolerance, poor
adaptability to change, and emotional dysregulation. A key skill for par-
ents to develop in this approach is to distinguish between situations in
which they must implement consequences for child misbehavior, situ-
ations that call for collaboration between parent and child in resolving
an issue, and situations in which the parent’s expectations are unreal-
istic (Greene et al., 2004).
Therefore, although traditional parent management strategies are

a facet of collaborative problem-solving, particularly for clear problem
behaviors (e.g., aggression toward others), the parent is called upon to
be flexible in which an expectation or rule is less clear or important but
that may make the difficult-to-adapt child quite frustrated. Collaborative
problem-solving has been shown to be at least as effective as parent train-
ing for reducing oppositional behaviors and may be a more appropriate
intervention strategy for parents of children who meet criteria for ODD in
addition to subclinical levels of mood symptoms (Greene et al., 2004). This
approach has recently been applied in inpatient settings, with the use of
collaborative problem-solving approaches on the part of direct care staff
being associated with reductions in the use of seclusion and restraint for
the youth in the facilities (Greene, Ablon, & Martin, 2006). The existence
of a program such as this and the evidence supporting it underscore a
need to tailor interventions geared toward conduct problems or conduct
problemlike symptoms as closely as possible to the presumed etiology of
those problems.
INDIVIDUAL-BASED TREATMENTS
Common Elements
The development of individual-based treatments (i.e., those that
involve direct work with the child or adolescent) for conduct disorders
speaks to the role of the youth’s individual tendencies in the develop-
ment and maintenance of many problem behaviors. In addition to various
familial risk factors for conduct problems, youth with such problems may
also have poor interpersonal skills as well as cognitive distortions or defi-
ciencies (Kazdin, 2003). Many treatment programs geared directly toward
youth with conduct disorders are born out of presumed interpersonal and
intrapersonal etiological factors. For example, the individual’s (perceived)
reinforcement and punishment history for a set of behaviors as well as his
cognitive appraisal of a situation and of the available consequences for a
set of behaviors may serve to shape some conduct problem behaviors such
as aggression.
Thus, individual-based treatments tend to emphasize cognitive and
behavioral strategies to reduce the frequency of problem behaviors and
to improve the youth’s positive coping responses to anger-provoking situ-
ations. The programs may be geared toward increasing cognitive activity
(i.e., impulse control) or altering maladaptive cognitive strategies (i.e., hos-
tile attributional biases) that may contribute to conduct problem, includ-
ing aggressive, behaviors (see Crick & Dodge, 1996; Lochman & Wells,
1996) These programs also typically include social skills training given the
social skills deficits that are often part of the clinical picture for children
with conduct problems (Kazdin, 2003) as well as social problem-solving
skills so that an individual can employ effective and prosocial behaviors in
difficult peer contexts.
Even authors who have discussed those individual factors recognize

the interaction of individual and environmental factors in explaining a
person’s clinical presentation (Barkley, 1997). The most influential of
these factors are most likely to be related to parent–child interactions and
parenting practices. Therefore, it is usual practice to include a parent or
family component with any child/adolescent individual treatment for con-
duct disorders. There exists a strong empirical basis for combining par-
ent and youth treatment components when developmentally and clinically
appropriate, as the combination of these components often outperforms
either component alone in the reduction of conduct problems (e.g., Kaz-
din, 2003; Webster-Stratton & Hammond, 1997). Benefits have also been
demonstrated for embedding individual-based treatments within univer-
sal prevention programs (e.g., teacher in-service; general parent meetings)
compared to individual-based programs without universal prevention
components (Lochman & Wells, 2002).
As noted above, parenting programs that have a group design could be
considered more cost effective than interventions administered to individ-
ual parents or sets of parents. However, some significant practical prob-
lems have been noted with group therapy with individual youth or with
parents. Those barriers include differential acquisition and understand-
ing of new skills across group members, differential practice of skills out-
side sessions, and inconsistent attention at settings (Kazdin, 2003). The
individual-based programs discussed differ in terms of their initial format
being group or individual; however, the key elements of these programs
and the rationale behind the skills thought to reduce conduct problem
behavior are very likely amenable to presentation in either format.

The Coping Power Program (Lochman & Wells, 1996) has an extensive
child component, although a formal parent component designed similarly
to those reviewed above is also part of the program. This program has
demonstrated positive outcomes particularly in terms of child aggression
and substance use (see Lochman, Barry, & Pardini, 2003). In short, the
individual-based program in Coping Power is an intervention that focuses
on anger management and social problem-solving skills and is conducted
in groups of late elementary school- to middle school-aged children identi-
fied at-risk based on teacher ratings of aggression. The program has both
cognitive and behavioral components, the latter exemplified by the reward
system that is based on the child’s weekly progress on targeted behavioral
goals. The emphasis on coping skills and social problem-solving skills and
the techniques for developing those skills (e.g., positive self-statements)
exemplifies the cognitive aspect of the program.
The program includes an initial psychoeducational component cen-
tered on identifying physiological cues to anger, differing levels of anger
and other emotions, and relaxation skills. The role of cognitions in facili-
tating or impeding effective anger coping is also introduced, and the pro-
gram proceeds with a substantial cognitive focus. Social problem-solving
skills are then introduced to emphasize the accurate identification of prob-

lems, considering all possible courses of action, and then consideration
of the positive and negative consequences of each behavioral choice. This
problem-solving model is repeated throughout the remainder of the ses-
sions. The program also has a significant modeling component whereby
not only do the individuals in the group learn coping skills from others
as well as model them in the group, but they also create a video illustrat-
ing the coping skills developed in the program as a sort of public service
announcement.
The final six to ten sessions focus on applying problem-solving skills
geared toward particular peer contexts, reviewing the progress of each
group member, and planning for the generalization of these skills to indi-
viduals’ various contexts. The group format allows for role-playing activities
that involve identifying problematic social cognitions (e.g., hostile attribu-
tional biases) and that allow practice of effective social problem-solving
skills (e.g., resistance to peer pressure; see Lochman & Wells, 1996).
A similar program to the Coping Power Program is an anger control
training program entitled the Chill Out Program (Feindler & Guttman,
1994) which has enjoyed considerable empirical support. However, this
program has been more specifically geared toward adolescents, whereas
the Coping Power Program is specifically geared toward aiding at-risk
youth in making the transition to middle school. The Chill Out Program
subscribes to the idea that adolescents lose control of their anger due to
deficits in both cognitive and behavioral skills (Feindler, Ecton, Kingsley,
& Dubey, 1986; Feindler, Marriott, & Iwata, 1984), and as such, it seeks
to rectify such deficits by focusing on the underlying cognitions (e.g., hos-
tile attributional bias) involved in the expression of anger and impulsiv-
ity that is typically associated with these cognitive distortions (Feindler
et al., 1986).
The Chill Out Program is designed for use with adolescents aged 13 to
18 who have already demonstrated aggressive behavior in their environ-
ment. It is a highly structured program conducted in a group setting with
typically eight individuals per group. There are ten sessions, each of which
focuses on a specific skills being taught, then modeled, rehearsed through
role-play, and then applied to the natural environment. The skills taught
at the ten sessions are rules and reinforcers, relaxation, self-monitoring,
triggers, refuting aggressive beliefs, assertion techniques, self-instruction
training, problem-solving training, thinking ahead, and program review
(see Feindler & Guttman, 1994).
Feindler and others (Feindler, 1990; Lochman & Lampron, 1988) have
noted that the anger control training may only be useful for a limited
period of time immediately following treatment and not as effective long-
term. In addition, it has been noted that anger control training tends to
be more effective when it is used in conjunction with other behavioral
strategies (e.g., consistent consequences for problem behaviors; Lochman
& Lampron, 1988). Another investigation demonstrated empirical support
for the Chill Out Program has also been indicated on self-report measures,
but reduction in aggression or other conduct problem behaviors has not

been clearly documented through direct behavioral observations. That is,
individuals’ own cognitive processes or self-efficacy may clearly change,
but the generalization to their actual behavior is not clear (Feindler &
Guttman, 1994).
Another individual-based approach with a similar theoretical founda-
tion is Problem-Solving Skills Training (PSST) developed by Alan Kazdin
(see Kazdin, 2003). PSST is a cognitive-behavioral therapy that has empiri-
cally demonstrated effectiveness for the treatment of conduct disorders
and is based on the theory that many youth conduct problems are related
to cognitive distortions (see Kazdin, 2003). The goal for PSST is to change
the ways in which adolescents perceive, code, and experience the world
based on research that has demonstrated that aggressive and antisocial
adolescents tend to make hostile and inaccurate attributions towards
other people’s behavior which creates problems in their social environ-
ments (Crick & Dodge, 1994). PSST is conducted in an individual format
and is targeted at children ages 7 to 13.
The treatment emphasizes teaching children how to cope effectively
in interpersonal situations that are frequently encountered but ones in
which the child experiences difficulty. It is a very structured approach that
teaches children five problem-solving steps to use in their interpersonal
relationships. These steps include identifying and defining the problem,
developing solutions to the problem, evaluating the solutions from the set
of solutions that the child generated, making a decision, and evaluated
the decision (Kazdin, 1996). More specifically, youth are taught to work
through common social problems or upsetting situations that they face in
their own environments, break the situation down into objective identifi-
able elements, and then develop response options that include prosocial
behaviors. The therapist facilitates the development of problem-solving
skills through modeling each set of skills during sessions. Through PSST
the cognitive work moves from being practiced out loud to becoming more
covert and automatic (Kazdin, 2003).
PSST has demonstrated many positive outcomes across multiple
measures and multiple settings up to one year later (Kazdin & Wassell,
2000), with favorable comparisons to a variety of control conditions and
other interventions (Kazdin, 2003). As noted above, PSST has also been
used in combination with parent management training techniques and has
shown to be effective when used in this manner as well (Christophersen
& Mortweet, 2001). It is important to note that PSST has been associated
not only with a decrease in aggression and other symptoms of conduct
disorders, but also with an increase in prosocial behaviors (Kazdin, 2003).
The moderators of treatment outcomes discussed more fully below also
seem to attenuate the outcomes associated with PSST, although the addi-
tion of some attempt to address parental stress has demonstrated benefits
(Kazdin, 2003). Therefore, some of the evidence base points to the need
to intervene simultaneously in different ways with different systems in
order to best target the factors contributing to the maintenance of conduct
problems.
MULTIFACETED PROGRAMS
Overview
Existing treatment approaches for child conduct disorders also include
multifaceted approaches that take either a broad multisystemic approach
(e.g., Henggeler & Lee, 2003) or have multiple related components that
target multiple recipients in multiple settings (e.g., Conduct Problems Pre-
vention Research Group, 1992). These programs have been influential in
how treatments for conduct problems are viewed. Specifically, they have
provided evidence that youth with conduct disorders can be effectively
treated in home-based interventions (e.g., Henggeler, Schoenwald, Bor-
dvin, Rowland, & Cunningham, 1998) and through in-school strategies
(Lochman, Lampron, Gemmer, & Harris, 1987), rather than automatically
equating conduct disorders with a need for treatment in more restrictive
environments.
For example, Multisystemic Therapy (MST; Henggeler & Lee, 2003)
has enjoyed considerable empirical support and approaches conduct
problems from a broad perspective, taking into account the influence of
the youth’s various contexts on her behavior problems. MST is particu-
larly oriented toward adolescents and comprises multiple levels of treat-
ment that include the individual, family, school, peers, and neighborhood.
Treatment is actually conducted in each of these contexts as appropriate
and feasible (see below).
The parent component of the Incredible Years Program was described
above, yet this program is an example of one with well-defined child and
teacher components. Therefore, it can function as a multifaceted program
or any combination of the three elements could be used in treatment
depending on the needs of the child and adults in his home or school
contexts. As does the parent component, the child component uses social
learning principles in developing basic coping skills as well as has an
emphasis on helping the youth set appropriate behavioral goals.
According to Webster-Stratton and Reid (2003), this program as a
whole promotes parent–teacher communication and encourages parents
to become involved in monitoring the child’s performance and behavior in
school. The school component is particularly geared toward classroomwide
interventions for the prevention of disruptive behaviors as opposed to tar-
geting one specific child or a small group of children for in-school interven-
tion. Researchers have demonstrated that the addition of parent, teacher,
and/or child components to the treatment package using The Incredible
Years Program enhances outcomes regarding the target child’s conduct
problem symptoms (Webster-Stratton & Reid, 2003).
In most multifaceted programs, parents are still exposed to tradi-
tional parent-training techniques, and although the presumed cause
of the youth’s problems is thought to be reciprocal between the youth
and his or her contexts, the parent may still be seen as the primary
agent of change. Such as discussed below, family-based work within
these models seeks to directly target family communication and con-
flict, and such an emphasis is thought to be associated with decrease
in adolescent problem behaviors such as substance use (Borduin et al.,

1995; Henggeler, Borduin, & Melton, 1991; Schmidt, Liddle, & Dakof,
1996). The degree to which schools and other contexts are formally
involved in treatment varies with the particular treatment approach
that is implemented.

As mentioned above, MST (Henggeler et al., 1998) is targeted at at-risk
adolescents who have previously engaged in severe misconduct and are at
risk for being removed from their homes. This approach believes the child
cannot be viewed outside the many systems of which they are a part (i.e.,
schools, families, neighborhood, culture, community). It stresses the need
to include all these symptoms in treating the individual child. The primary
goal of this approach is to decrease misconduct and to help the child func-
tion in his environment. It is an intensive program that makes use of many
clinicians and caregivers as well as careful monitoring of those involved
in the treatment of the child. This treatment is unique from others in that
quality assurance checks are embedded in the treatment protocol (see
Henggeler & Lee, 2003).
MST is conceptually based on five key assumptions, namely that
behavior problems are multidetermined, that caregivers are the key to
positive long-term outcomes, that effective treatment must be comprised
of treatment that has strong empirical support, that barriers to service
access and delivery must be addressed in regard to treatment, and that
treatment fidelity is maintained by quality assurance checks. Treatment
is targeted at all environments and systems in which the child is involved,
and as such, this treatment seeks to promote strong cooperation from all
(Henggeler & Lee, 2003). MST includes intervention in the home which
has increased participation and decreased attrition (Henngeler, Pickrel,
Brondino, & Crouch, 1996). There are nine core treatment principles that
guide treatment. These include finding the fit between problems and the
child’s broader system, being positive and strength-focused, increasing
responsibility, present focused/action-oriented and well-defined interven-
tions, fits child’s developmental level, continuous effort, evaluation, and
generalization (see Henggeler & Lee, 2003).
Although each aspect of MST (i.e., therapy, supervision, consultation)
is manualized and fidelity takes on particular importance, the extent to
which various contexts are involved varies by case (Henggeler & Lee, 2003).
However, for MST to progress, family engagement is crucial, and strate-
gies for forming meaningful partnerships among the treatment team and
additional systems are also needed. The treatment team is accountable for
monitoring progress and managing any factors that appear to be imped-
ing progress. Goals for treatment are established and monitored week by
week, with all relevant systems for attaining those goals being engaged in
treatment (Henggeler & Lee, 2003).
MST has been found to decrease criminal behavior, substance abuse,
and internalizing problems (Kazdin & Weisz, 1998; Stanton & Shadish,
1997; Farrington & Welsh, 1999). In a sample of youth presenting in psychiatric
emergencies, MST resulted in a 75% reduction in days hospitalized and a

50% reduction in days that the child spent in an out-of-home placement
(Schoenwald, Henggeler, Brondino, & Rowland, 2000). MST has also led to
improved family relations and parent–child interactions (Brunk, Henggeler,
& Whelan, 1987) as well as improving peer relations (Henggeler, Melton,
& Smith, 1992). Because of the intensive nature of MST, including having
an interventionist available for support at all times, treatment team mem-
bers keep low caseloads, and treatment is limited to three to five months
(Henggeler & Lee, 2003).
The FAST (Families and Schools Together) Track Program (Conduct
Problems Prevention Research Group, 1992) is an example of a program
that involves targeting risk factors for conduct problems such as parenting
practices, academic and social difficulties, and community factors. This
program is geared toward young elementary school-aged children and
includes strategies such as home visits to target parenting practices and
other familial factors relevant to child problem behaviors, social problem-
solving training for children, academic tutoring particularly in reading, and
classroom management strategies for teachers. The FAST Track Program
also includes a traditional parent management program that includes an
emphasis on fostering positive parent–school communications.
This program is designed from the standpoint that early intervention in
multiple domains that influence the child’s social and behavioral develop-
ment is optimal and that fostering consistency and communication across
the contexts will improve the child’s behavioral, social, and academic out-
comes (Conduct Problems Prevention Research Group, 1992). Each of the
components of the FAST Track Program has demonstrated positive short-
term effects; however, the long-term effectiveness, particularly of the pro-
gram as a whole, needs further investigation (Frick, 1998).
Similar to the approach for adolescents developed by Barkley and
colleagues (1999) and described above, a recent investigation by Hogue,
Dauber, Samuolis, and Liddle (2006) found that a family-based intervention
that included work with both parents and adolescents simultaneously (i.e.,
Multidimensional Family Therapy; Liddle, 2002) demonstrated positive out-
comes on adolescent substance use. It should be noted, however, that the
adolescent-focused strategies within this intervention (e.g., drug refusal
skills, anger management, impulse control) seemed to be particularly use-
ful in reducing family conflict and increasing family cohesion (Hogue et al.,
2006). Multidimensional Family Therapy (MDFT) has also demonstrated
usefulness for more varied adolescent behavior problems (e.g., Dennis
et al., 2004; Liddle, Rowe, Dakof, Ungaro, & Henderson, 2004). Therefore,
for adolescents with externalizing problems, it may be that approaches
which incorporate both individual and family-based work, rather than an
exclusive focus on either will be most likely to yield positive results. MDFT
fits that bill insofar as it includes individual, parent, and family interac-
tional domains (Liddle, Rodriguez, Dakof, Kanzki, & Marvel, 2005).
However, MDFT is truly multifaceted in that an extrafamilial domain
is included whereby direct attempts are made to address school fail-
ure and lack of positive community connections as risk factors for a
teen’s conduct problems. More specifically, MDFT interventionists
work directly with school officials regarding academic planning for the
adolescent and work with the family on ways to engage the adolescent
in positive extracurricular activities. The influence of peer affiliations
is also addressed in this intervention through discussions of friendship
choice and the influence of decisions in that domain on the youth’s
outcomes (see Hogue et al., 2006). A formal focus on community-based
factors is unique, even though tight control over how such extramilial
factors are implemented and the behavioral contingencies in place in
such contexts cannot be fully addressed. MDFT also seeks to address
parental risk factors for youth problems both within the intervention
(e.g., parenting skills; family communication) but also through addi-
tional resources (e.g., parental drug treatment; increasing social sup-
port; Hogue et al., 2006). An initial clinical trial of MDFT found it to be
as effective as a traditional cognitive-behavioral intervention but more
effective for the long-term maintenance of positive outcomes in the form
of reduced substance use (Liddle, 2002).
RESIDENTIAL TREATMENT
Overview
The term “residential treatment” has been used to describe a number
of varied approaches to intervention beyond outpatient care. We have thus
far focused our discussion on treatments that are applied in outpatient
settings, although elements of these treatments (e.g., Coping Power) could
be applied within a residential setting. Although obviously less intensive in
surroundings, outpatient treatments are not necessarily shorter in dura-
tion than residential treatments, particularly inpatient hospitalizations
(see Lyman & Barry, 2006). More restrictive than most outpatient treat-
ment models are day treatment models—also referred to as partial hos-
pitalization programs—which provide a therapeutic environment during
the day including academic instruction such that the child is not removed
from the home environment. The range of services available in these set-
tings are broader than those often employed in outpatient settings and
include individual therapy, group therapy, psychopharmacological inter-
ventions, and classroom accommodations.
Several additional treatment models involve removal of the youth
from the home environment at least for some period of time and in that
sense, are considered residential. These placements include short term
respite care, group-home care, residential treatment centers, inpatient
hospitalization, and institutionalization (Lyman & Barry, 2006). The
specific treatment strategies within each of these models are diverse
ranging from virtually nonexistent in some respite care or group-home
settings to quite intensive in any of these settings. For instance, and
depending often on local resources, group-home care may or may not
include a formal treatment regimen conducted by trained professional.
Each of these treatment models also varies in size and scope. It should
also be kept in mind that children may be placed in residential settings
primarily because of significant problems and/or safety concerns in

their home environments and not necessarily because they themselves
are exhibiting significant emotional or behavioral problems. Although
theoretically the more similar the residential treatment setting is to the
youth’s home setting (i.e., the more the setting mimics a home), the
more generalization of behavioral gains from the treatment setting to
the home environment. However, there are no data to indicate whether
this is the case.
Perhaps because of the numerous forms of residential or inpatient
treatments that are typically geared toward youth with the most severe,
persistent, or complex conduct problems, the research literature on these
programs is relatively limited. The large number of treatment models that
vary in structure, clientele, length, restrictiveness, and scope make well-
designed controlled studies very difficult to conduct (see Lyman & Barry,
2006). The limited evidence in support of these interventions may be a
consequence of the lack of close empirical examination. However, it has
also been argued that residential treatments are less likely than commu-
nity-based interventions to reduce child conduct problems because the
treatment focuses largely on the child and occurs in a separate context
than the one in which the problems developed (Hart et al., 2006). That
is, in light of the evidence supporting parent-based treatments for child
conduct problems, it would make sense to provide such interventions
first before resorting to a more restrictive placement for the child. Indeed,
although residential treatments offer immediate respite for both the child
and caretakers, the benefits may very well not be sustained both within
the program and upon discharge.
An argument can be made, on the other hand, that removal of the
child from a problematic environment can be beneficial, even necessary,
for the treatment of conduct disorders. Residential interventions provide
a controlled environment often with expansive behavioral contingencies,
as well as the opportunity for the youth to receive individual, group, and
pharmacological interventions. However, research does not support sig-
nificant improvements in symptoms for many youth, particularly if they
return to their previous environment (Hart et al., 2006; Lyman & Barry,
2006). The adjustment for both the child and family after residential care
has ended can be quite difficult, although the availability of wraparound
services that include the parents as part of the services provided by the
residential facility, particularly at the end of services, can aid in this tran-
sition (Lyman & Barry, 2006).
In addition, because of the external controls on the youth’s behavior
inherent in such settings, it is not clear to what extent the youth devel-
ops effective self-control or coping skills that she will then be able to uti-
lize once out of the residential setting (Barker, 1993). Similarly, although
residential treatments often demonstrate a decrease in conduct problems
within the milieu, it is unclear if such gains are above and beyond what
the youth would achieve through intensive behavioral interventions out-
side of the residential setting (Lyman & Barry, 2006). Still, some children’s
behavior problems can be so severe or have cause for safety concerns that
residential treatment may be viewed as a suitable short-term option.
Children served by the various residential treatment models present

with issues such as severe impulsivity, erratic or disorganized behavior,
severe internalizing problems, and/or threats to harm themselves or oth-
ers (Lyman & Barry, 2006). The available information on youth who attend
residential treatment facilities suggests that they often do not live with
both biological parents which includes coming from foster care or other
similar placements, have parents with a history of psychopathology and/
or substance abuse problems, have experienced and/or witnessed abuse
or violence, have families with little social support or cohesion, and have
a history of being involved in or around criminal activity (Lyman & Barry,
2006). Assuming that family instability is the root cause of the youth’s
conduct problems, it has been argued that alternative home placements—
particularly given the relatively low cost of such solutions—may make the
most sense (Hussey & Guo, 2002).
Given the concerns regarding the effectiveness, cost, and restrictive-
ness of residential treatment on the one hand, and the need for intensive
interventions in some instances on the other, Lyman and Barry (2006)
discuss four considerations based on those initially proposed by Wilson
and Lyman (1982). First, youth should be treated in the least restrictive
setting possible in light of the youth’s diagnosis, severity of conduct prob-
lems, and level of behavioral and emotional stability. Therefore, in some
instances (e.g., threat to harm self or others) intensive placements—even
if short term—are warranted. Second, the treatment components should
be related to the antecedents of the child’s problems, such that if coer-
cive parent–child interactions appear to be a main factor in the child’s
behavior problems, then home- or parent-based treatments are indicated.
Third, the treatment should be cost-effective based on considering the
effectiveness of the selected intervention, the monetary cost, the expected
duration, and the social cost of treatment failure. Finally, the treatment
structure, focus, and resources should match the youth’s problems and
developmental level.
In short, although some residential programs may be quite benefi-
cial for some children, particularly those with particularly severe conduct
problems and/or severely adverse environmental conditions, there is lim-
ited evidence supporting their long-term effectiveness. Moreover, in light
of the monetary expense involved with such interventions, their cost-
effectiveness relative to other community-based interventions is not favo-
rable. A general overview of residential treatment centers and inpatient
hospitalization is given below. In the past 15 to 20 years, a number of
more specified residential models have been developed (e.g., wilderness
therapy, boot camps). See Lyman and Barry (2006) for a more complete
discussion of these and other residential models, including their potential
benefits and drawbacks.
Examples of Residential Treatments

Again, because of the myriad philosophies, structures, and models
of residential treatments, it is not possible to discuss in detail a particu-
lar, easily replicated program. Nevertheless, because of the use of such
programs in the treatment of youth conduct disorders, it makes sense to

discuss some features of such programs and how they target behavioral
problems. As the term implies, residential treatment centers are typically
located in facilities that do not mimic a typical single-family home setting.
However, many models include locating client living quarters and activity
areas in smaller units consisting of approximately 15 to 20 youth (Lyman &
Barry, 2006). Peers also take on importance in residential centers through
their involvement in group therapy, the need for youth to practice appro-
priate self-control and coping strategies with others who may engage in
behaviors that are upsetting to the youth, and the ability of peers to model
and reinforce adaptive behaviors. Residential programs typically provide
an academic component, and formal therapeutic services administered by
trained staff (e.g., psychologists, psychiatrists, social workers) are also a
core component of these interventions.
Residential treatment centers also often incorporate contingency
management systems such that, for example, youth are provided different
levels of privileges for meeting certain behavioral goals. Therefore, direct
care staff training in residential programs is of utmost importance, as
staff members are called upon to administer both positive and negative
consequences for behaviors throughout the day and throughout activi-
ties. Furthermore, low resident-to-staff ratio appears to be important in
therapeutic effectiveness including settings in which the youth’s present-
ing problems are rather severe (Friman, Toner, Soper, Sinclair, & Shana-
han, 1996). Close contact between staff and residents likely serves both
therapeutic and safety functions. Because of the relative severity of youth
served in such centers and their close proximity to each other and to staff,
behavioral disruptions can occur often. However, residential treatment
centers typically have clear staff procedures for dealing with such inci-
dents to prevent them from escalating. These procedures include time-out,
restraint, and seclusion with the least restrictive strategy that will still
maintain safety being implemented first (Lyman & Barry, 2006).
Many programs also incorporate a psychoeducational model such
as originated by Hobbs (1966) wherein youth learn and practice cop-
ing skills as well as more prosocial behavioral choices rather than an
exclusive focus on managing behaviors as they occur in the milieu. In
such a model, the child still has contact with his family, and the family
is informed of treatment plans throughout the residential stay with the
hopes of treatment gains being more readily generalized to the home
setting after discharge.
Much less similar to a youth’s home environment is an inpatient
hospital setting. Daily activities in these settings tend to be much more
structured and monitored, with limited opportunity for recreational
activities or time outside the unit. Medical professionals necessarily
staff these settings, whereas psychologists, social workers, and teachers
may also be involved in service provision in inpatient settings. Inpatient
placements have moved more toward an emphasis on psychopharma-
cological than psychological treatments (see Lyman & Barry, 2006),
perhaps as a function of the emergent cases served and managed care
necessitating shorter-term stays in inpatient units. Therefore, they
are often effective and necessary for youth whose emotional and/or
behavioral state is dangerous to themselves or others and whose psy-
chological difficulties seem to have some organic component. Inpatient
hospitalization is primarily focused on crisis stabilization as opposed
to long-term treatment. The usefulness and cost-effectiveness of hos-
pitalization for conduct disorders is quite limited, although such an
approach may be warranted and effective for substance abuse problems
in particular (see Lyman & Barry, 2006).
EVIDENCE-BASED PRACTICE
The interventions discussed above, particularly the outpatient inter-

ventions with parent, child, and/or teacher components have enjoyed a
great deal of empirical support. The APA Task Force for identifying empiri-
cally supported treatments presents summaries of the treatments that
have met the criteria to be considered well established and those meet-
ing the criteria of being probably efficacious. These empirically supported
treatments, some of which are summarized above, are discussed on the
website: www.effectivechildtherapy.com. It is expected that the attention
to, and debate concerning, evidence-based practice will only further the
efforts of professionals and the public at large to consider what works in
designing, seeking, or implementing the treatments most likely to amel-
iorate child conduct problem symptoms. This evidence base also serves
as the foundation for further research and innovation in the design of
interventions that might demonstrate even more effectiveness, for longer
periods of time, and/or for a broader range of youth.
With well-developed supported interventions in existence, it becomes
the charge of practitioners and training programs to make evidence-
based practice the centerpiece of their work and training of treatments
for conduct disorders. For example, as noted above, empirically supported
parenting interventions generally include an emphasis on positive rein-
forcement and increasing positive behaviors first before an emphasis on
strategies to punish noncompliance. In part, the theoretical rationale for
such a strategy is to provide guidance to children on “what to do” instead
of only what behaviors not to engage in, as well as to improve the quality
of parent–child interactions (e.g., Barkley, 1997). Therefore, to emphasize
punitive strategies in parent training first would be doing so against the
preponderance of empirical evidence.
In addition to the mediating effects of positive parenting practices
resulting from parenting programs, these approaches to intervention are
also thought to be most effective through the reduction of coercive par-
ent–child interactions and when management strategies are more clearly
and consistently associated with the child’s behavior (Reyno & McGrath,
2006). Furthermore, parenting programs can be effective in not only reduc-
ing the target child’s conduct problem symptoms, but also in improving
parent–child interactions, parental consistency, and even sibling behavior
(see Gardner et al., 2006). More important, it appears that the effects of
evidence-based treatments for conduct problems maintain some level of
positive outcomes over time (Gardner et al., 2006). The length of treat-
ment varies with the approach and severity of the child’s problems, but for
parenting interventions in particular, having a greater number of sessions
is associated with poorer outcomes, often because of poor parental adher-
ence or performance while moving through the sequence of parent training
steps implemented in most programs (see Hogue et al., 2006).
Although fairly well-developed theoretical rationales exist for the treat-
ment of conduct disorders through psychoanalytical perspectives (e.g.,
self-psychology; see Liberman, 2006), the evidence supporting these inter-
ventions is lacking. Unlike the approaches outlined in this chapter, self-
psychology takes a nondirective approach whereby the therapist seeks to
understand the youth’s subjective world view. Such an approach is likely
quite limited for young children and/or youth who have difficulty with
verbal expression. It should also be noted that verbal reasoning deficits
are often associated with child conduct disorders (Lynam & Henry, 2001;
Speltz, DeKlyen, Calderon, Greenberg, & Fisher, 1999), further calling into
question the utility of this treatment for a sizable segment of the popula-
tion who exhibit conduct problems.
The presumed cause of child conduct problems from this perspective is
that of unrealistic, or immature, narcissism that develops—at least in part—
from inappropriate or absent parental response to child distress (Liberman,
2006). Although narcissism has been found to be related to child and ado-
lescent problem behaviors (Barry, Frick, & Killian, 2003; Barry, Grafeman,
Adler, & Pickard, in press), it is unclear how the self-psychology approach
to assessing child narcissism would fit with current approaches to common
approaches for assessing the construct in youth and adults. The intervention
itself seeks to alter the youth’s unrealistic self-perceptions and to foster resil-
ience in the face of adversity. Such goals could certainly reduce the likelihood
of acting-out behaviors, but the evidence of the presumed causal model and
the intervention itself are quite limited.
More recent efforts have sought to understand the intervening vari-
ables that indicate for whom and under what circumstances treatments
for conduct disorders are most effective. For example, Beauchaine and col-
leagues (2005) examined the short-term treatment outcomes for children
with an early onset of conduct problems. They found that parental risk fac-
tors (i.e., drug abuse, marital discord, maternal depression) and child risk
factors (e.g., comorbid internalizing problems) influenced treatment out-
comes. For example, although children with comorbid internalizing prob-
lems presented with higher externalizing problems than children without
internalizing problems, the rate of improvement of the former group was
greater. That is, children and families who present with multiple risk fac-
tors—thus complicating the clinical picture—can still, and often do, ben-
efit greatly from intervention targeting parenting skills and child conduct
problems. Kazdin and Whitley (2006) similarly demonstrated that children
with comorbid presentations exhibited the most change in response to
intervention and outcome symptom levels equivalent to children with a
single primary clinical problem.
Of course, clients presenting for treatment of child conduct disorders—or
any other clinical issue for that matter—vary in the degree to which they
present with other factors that might complicate treatment planning and
call into question the applicability of evidence-based treatments. With the
influence of such risk factors (e.g., comorbidity) on the severity of the child’s
presentation and response to intervention having been demonstrated (see
Beauchaine, Gartner, & Hagen, 2000; Kazdin & Whitley, 2006), it is clearly
indicated that interventions are not one-size-fits-all. Recent efforts to address
issues surrounding the influences of comorbidity and other indices of case
complexity (e.g., low SES) only serve to inform practitioners of the potential
benefits of many evidence-based interventions as well as instances in which
further examination and innovation are needed.
The design of interventions in terms of their target recipients and set-
tings does seem to influence the specific conduct problem behaviors that
are affected. In particular, for families of children with conduct problems,
a parent-based component is essential for reducing the child’s symptoms,
whereas teacher-based interventions appear to be particularly useful for
reducing disruptive classroom behaviors (see Beauchaine et al., 2005).
Based on the performance of standalone in relation to combined interven-
tions, it has been argued that for young children in particular, parenting
interventions should be the front-line intervention for younger children
with supplemental teacher- or child-based interventions as indicated
(Beauchaine et al., 2005).
However, research cited above has demonstrated the benefits of add-
ing components of treatment compared to a single intervention approach.
In addition, for older children and adolescents, it may be necessary to
include a direct intervention with the young person, considering parent
and teacher interventions as supplemental. Even with the most compre-
hensive approach to intervention involving all important systems or con-
texts, conduct problems remain difficult to treat. As noted by Beauchaine
and colleagues (2005), treatment nonresponders are of concern for prac-
titioners and researchers, but they also are the basis of all advancements
in treatment design. That is, moderators of treatment outcome for youth
with conduct disorders are variables that are present at the outset of treat-
ment. Therefore, awareness of the variables that appear to predict treat-
ment response allows for the selection of the most appropriate treatment
for the presenting child.
The age of the child is one such variable in regard to treatment for
conduct problems, not only in terms of with whom treatment is per-
formed but also with the general expectation that earlier intervention
increases the likelihood of meaningful reduction in conduct problems
(see Webster-Stratton & Reid, 2003). The youth’s developmental level
and developmental trajectory of problem behaviors is a similarly impor-
tant consideration. For example, a preschool- or early school-aged child
would likely not comprehend the cognitive coping strategies that are
the bedrock of treatment approaches such as Coping Power or PSST.
Likewise, older but developmentally delayed youth would likely ben-
efit less from such cognitive strategies than those that emphasize clear
behavior-consequence contingencies. Another such variable may be the
level of perceived social support experienced by families going through
treatment (Dadds & McHugh, 1992).
Similarly, family isolation, single parent status, and social disadvantage

have been found to interfere with progress in family therapy approaches
for treating child conduct problems (e.g., Brestan & Eyberg, 1998; Dumas,
1986; Miller & Prinz, 1990; Webster-Stratton, 1985). Conversely, parents
have reported qualitatively that increasing social support and being able to
discuss problems with other parents can be effective in enhancing parent-
ing skills and ameliorating child behavior problems (Stewart-Brown et al.,
2004). However, Dadds and McHugh (1992) have noted how difficult it is to
make meaningful changes in a family’s social support system or resources
within typical treatment approaches. The wider examination and dissemi-
nation of treatment approaches such as MST may help advance the field in
this direction from its focus on capitalizing on the strengths in each of the
child’s contexts and engaging more of those contexts to allow treatment to
most effectively work through systemic barriers to the improvement of the
youth’s behavior.
Because many of the empirically supported treatments for conduct
disorders appear to be most effective the earlier they are initiated, and
because researchers suggest that an early onset of conduct problems is a
predictor of persistence of such problems (e.g., Moffitt, 2006), comprehen-
sive evidence-based assessment of conduct problems becomes essential
(see McMahon & Frick, 2005 for a review). A lack of appropriate assess-
ment and intervention may result in problematic behavioral patterns
becoming less malleable and in the emergence of additional risk factors
(e.g., delinquent peer affiliations) that would make treatment more com-
plex (Beauchaine et al., 2005).
Not surprisingly given the vital role of parents in the treatment of con-
duct disorders, parental psychopathology has been shown to be not only
a risk factor for the development and maintenance of conduct problems,
but also a factor in treatment response (see Chronis et al., 2004; Reyno
& McGrath, 2006). Kazdin and Whitley (2006) found that greater familial
barriers to treatment participation were associated with worse outcomes
in a study of parent management training and problem-solving skills
training for children with ODD or CD. A recent study also demonstrated
that assessment of specific aspects of parental functioning better informed
intervention and improved outcomes for families receiving an empirically
supported treatment for conduct problems than did more global assess-
ments of family needs (Bierman, Nix, Maples, & Murphy, 2006).
It is not uncommon for parents to simultaneously seek parenting
interventions while also seeking individual treatment for their own dif-
ficulties. As described above, many parenting interventions have included
components that focus on parental stress and strategies to manage that
stress apart from an exclusive focus on the child’s behavior problems in
an attempt to target some of the parental/familial factors that might nega-
tively influence treatment response. Moreover, direct efforts at addressing
some of these factors (e.g., poor father involvement in treatment, the inter-
vening role of parental psychopathology) have been described (Chronis
et al., 2004), contributing further to the evidence base.
Additional research brings to light the need for comprehensive assess-
ment of the child, parent(s), and contexts so that optimal treatment plans
are implemented. A child factor that has been associated with poorer treat-
ment outcomes is the presence of psychopathy-linked characteristics, or
callous-unemotional (CU) traits (Hawes & Dadds, 2005). More specifically,
Hawes and Dadds (2005) found that CU traits were associated with poorer
outcomes among children with ODD following parent training, even when
controlling for parental education, child age, and parental adherence to
treatment. CU traits include a relative lack of empathy and guilt as well as
flat affect (see Frick, Bodin, & Barry, 2000).
Researchers have found that CU traits moderate the relation between
parenting practices and conduct problems (Wootton, Frick, Shelton, & Sil-
verthorn, 1997; Oxford, Cavell, & Hughes, 2003), thus perhaps predicting
the attenuated effects of parenting interventions for the conduct prob-
lems of children with these traits. CU traits are particularly important to
understand in light of intervention planning and design given the associa-
tion of these features with particularly severe, varied, and persistent child
conduct problems (Barry et al., 2000; Christian et al., 1997). Research-
ers in this area suggest that children with this interpersonal style tend
to be insensitive to punishment cues in laboratory situations (O’Brien &
Frick, 1996) and to respond more to rewards than to punishments such as
time-out (Hawes & Dadds, 2005). Thus, it is imperative that pretreatment
assessments consider the presence of CU traits and that interventions
be developed that effectively address the unique presentation of conduct
problem symptoms for this subset of youth.
CONCLUSIONS
Limited, although emerging, research has examined the effectiveness

of adaptations of existing interventions for conduct problems. Bierman
and colleagues (2006) have noted that individualized interventions are
quite appealing but that the evidence regarding these adaptations is lim-
ited. Greene and colleagues (2004) have referred to such adaptations as
“indispensable” (p. 1163), and some treatment approaches (e.g., collabora-
tive problem-solving) do not prescribe a particular topic or coverage of a
specific skill to a particular sequence of sessions.
Given the advocacy of evidence-based practice in psychology, not just
for treating child conduct disorders, and the evidence in support of these
interventions relative to usual clinical practice (Weisz, Jensen-Doss, &
Hawley, 2006), understanding if and how adapted treatment plans may be
useful is an essential question. A primary question in this regard is that of
therapist fidelity to a treatment program or protocol. The degree to which
therapists adhered to the guidelines of a particular program is unclear in
much of the research showing positive effects of treatment for conduct
disorders. On the other hand, it is unclear to what extent therapist fidelity
is necessary to achieve positive behavioral outcomes.
To further advance the knowledge, use, and effectiveness of evidence-
based interventions, successful adaptations must be disseminated, and
judgments regarding the need for making adaptations must follow guide-
lines that can be easily documented and followed by other professionals.
It has been shown that the more specific the areas of functioning on which
such judgments are based, the greater likelihood of positive outcomes for
adapted interventions (Bierman et al., 2006). Therefore, a call for evi-
dence-based practice is not to limit the flexibility of clinicians or the appli-
cability of interventions to specific clients with conduct problems, but to
ultimately allow our field to widen the evidence base and to enhance the
services provided to the youth and families who we serve.
A similar area of inquiry is the degree to which efficacious treatments
show effectiveness for a broader range of settings, trained professionals,
and clients. The generalizability of evidence-based treatments has been
called into question based largely on the relative homogeneity of clients
participating in clinical trials and heterogeneity of clients presenting in
clinical practice settings (Dulcan, 2005; Westen, Novotny, & Thomp-
son-Brenner, 2004). Chorpita (2003) has clearly described a number of
important practice considerations (e.g., supervision, addressing attrition,
demographics, payment options, client’s prior experience with treatment,
etc.) that must be made for efficacious treatments to most readily demon-
strate effectiveness.
Furthermore, an expanding body of literature has examined the
adaptability of existing interventions to clients from diverse backgrounds
(e.g., Forehand & Kotchick, 1996; Santisteban et al., 2003) or the effec-
tiveness of interventions developed for clients from nondominant cultures
(e.g., Non-English-speaking background; Sonderegger & Barrett, 2004).
Of course, direct investigations of the outcomes for interventions with
diverse clientele are preferable to assumptions that existing treatments
for conduct problems will translate directly to diverse clientele. A complete
consideration of the strides made in these areas as well as the numer-
ous unanswered questions for treatment and treatment outcome research
would be too extensive for the present discussion.
Because of the level of similarity among empirically supported treat-
ments for child conduct problems, it remains unclear as to which elements
of these interventions are more or less dispensable. To address this question,
dismantling studies that incorporate multiple intervention conditions and
that include frequent assessment of processes and outcomes are necessary
(Kazdin & Nock, 2003). Such an undertaking would be daunting but could
be useful in further streamlining interventions and informing practition-
ers as to the key aspects of treatment on which to focus. Without extensive
research on this issue, we still remain optimistic about the current state of
treatment for youth conduct problems in that the treatment packages that
exist—if imparted to the practicing public—have demonstrated that they
can improve the functioning and lives of youth and their families.
Perhaps the clearest conclusion from the literature on developmental
trajectories of children with conduct disorders and the treatment of these
problems is the need for early prevention/intervention. Webster -
Stratton and Reid (2003) noted that “the primary developmental pathway
for serious conduct problems in adolescence and adulthood appears to be
established during the preschool period” (p. 224). It is has been concluded
that such efforts—particularly for the youngest children—should include
a parent-based or family-based perspective with attention devoted to ways
in which services can be most accessible to families (Centers for Disease

Control, 2004). In light of the existing evidence-based interventions, sound
efforts in this regard can reduce the likelihood of the poor outcomes for
which children with an early onset of conduct problems are at risk. Early
treatment also has broader societal implications given the cost of juvenile
delinquency and adult antisocial behavior in the form of intensive residen-
tial treatments, incarceration, and the impact on victims.
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6
Treatment of
Attention-Deficit/
Hyperactivity Disorder
(ADHD)
DITZA ZACHOR, BART HODGENS, and
CRYSHELLE PATTERSON
Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common

neurobehavioral disorder affecting school-age children. Studies suggest
that approximately 8–12% of children (9.2 in males and 3.0 in girls)
meet diagnostic criteria for the clinical disorder of ADHD (Faraone,
Sergeant, Gillberg, & Biederman, 2003). Approximately 40–70% of those
diagnosed with ADHD will have persistent symptoms into adolescence
and adulthood with substantial risk of job instability, mood and anxiety
disorder, motor vehicle accidents and substance abuse. ADHD is
characterized by various symptoms of inattention, and/or impulsivity
and is conceptualized as a spectrum, with a range of severity from mild
variation of normal behavior to a chronic and severe condition. ADHD
affects the individual, the family, and society and can have negative
impact on multiple areas of functioning (Wolraich, Hannah, Baumgaertel
& Feurer, 1998, American Academy of Pediatrics, 2000). Children with
the disorder often suffer from impaired interpersonal relationships with
family and peers, academic underachievement and poor self-esteem
(Goldman, Genel, & Bezman, & Slanetz, 1998). In addition, children with
ADHD commonly exhibit other comorbid developmental and psychiatric
disorders that may complicate the intervention plan (Table 6.1; Pliszka,
1998; Spencer, Biederman & Wilens, 1999).
DITZA ZACHOR • Tel Aviv University, Tel Aviv, Israel.

BART HODGENS • Civitan International Research Center, University of Alabama at Birmingham.
CRYSHELLE PATTERSON • Sparks Clinics, University of Alabama at Birmingham.

140 DITZA ZACHOR et al.
Table 6.1. ADHD Comorbid Disorders

ADHD: Common Comorbid Disorders
Developmental Dimension
Poor academic performance
Learning Disability
Mental Retardation
Autism Spectrum Disorders
Tic Disorders (e.g., Tourette Syndrome)
Behavioral Disorders
Oppositional Defiant Disorder
Conduct disorder
Anxiety
Depression / Dysthymia
Obsessive Compulsive Disorder
Clinicians who diagnose and treat children with ADHD should develop
a comprehensive treatment plan that recognizes the complexity and
chronic nature of the disorder. First, a diagnosis of ADHD requires that
the child meet criteria from the Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition (DSM–IV) in terms of core symptoms, onset, duration,
and functional impairment in more than one setting (American Academy
of Pediatrics, 2001). During the initial assessment, clinicians should first
obtain information regarding the nature of the child’s symptoms (mostly
inattention, behavioral difficulties, etc.) and then determine the severity
of the core ADHD symptoms, existence of comorbidities, and the extent of
the impairment seen across the different environments.
Because the diagnosis of ADHD and the possible need for chronic
medical treatment may cause concerns and even anxiety for the family
and the child, it is important to provide counseling prior to initiation of
therapy. In addition, clinicians should be aware of the family expectations
from the treatment and their treatment preferences, thereby optimizing
compliance and clinical outcome.
Next, it is important to set individualized treatment goals. The American
Academy of Pediatrics (AAP) guidelines suggest several outcome measures
based on the most disabling core ADHD symptoms (e.g., decrease disruptive
behaviors, improve academic performance, improve relationship with family,
teachers, and peers and improve self-esteem). It is advisable to choose
measurable goals that can assess progress from a baseline state (American
Academy of Pediatrics, 2001).
Treatment of ADHD consists of two general categories, medication
management and behavioral treatment strategies. The following sections
describe these treatment strategies in detail, as well as the benefits of
a multimodal strategy. The multimodal approach combines the careful
medication management of ADHD with proven psychosocial interventions
such as parent education, educational intervention, and behavioral therapy
in a comprehensive approach. Throughout this chapter, frequent reference
is made to the Multimodal Treatment Study of children with ADHD (MTA),
the largest randomized clinical trial for the treatment of ADHD ever
conducted (MTA Cooperative Group, 1999a). Therefore, it merits particular
attention before discussing treatment approaches in detail.
TREATMENT OF ATTENTION-DEFICIT 141
NIMH MULTIMODAL TREATMENT STUDY OF ADHD (MTA)
In 1992, the National Institute of Mental Health (NIMH) and six

teams of investigators began a multisite clinical trial to systematically
investigate the effectiveness of medication and behavioral treatments for
ADHD. The MTA remains the largest ADHD clinical trial to date and its
findings continue to be reported and debated (e.g., Arnold, et al., 2004).
The design of the treatment protocols, study methodology, and research
design were all carefully considered by a steering committee composed
of representatives from the six clinical sites and reflected state-of-the-art
procedures at the time (Arnold, Abikoff, & Cantwell, 1997). Utilizing a
parallel group design, 576 children (96 from each site) ages 7–9 years were
randomly assigned to one of four treatment conditions: (1) a medication
management-only strategy, (2) a behavioral treatment-only strategy,
(3) a combination strategy, and (4) a community-care comparison group.
This large sample size nearly doubled the total number of children with
ADHD that had ever participated in a rigorously controlled clinical trial for
treatment of ADHD prior to that time (Jensen, Hinshaw, Swanson, et al.,
2001). The participating children were selected to reflect a broad range of
comorbid conditions (e.g., ODD, anxiety), a diversity of referral settings
(e.g., school, mental health clinic), and a range of socioeconomic levels.
The treatment period was 14 months. The MTA Medication strategy
involved an initial titration period, testing placebo versus three different
doses of methylphenidate (5 mg, 10 mg, and 15/20 mg, depending on child’s
weight). Other medications could be introduced after the first month if a
desirable response wasn’t achieved. Ongoing treatment involved monthly
meetings with the family and monthly contact with the child’s teacher.
The medication treatment was maintained throughout the 14-month
period. The MTA Behavioral treatment strategy was initially intense and
then faded to monthly meetings over the last 4–6 months of the treatment
period. Parents received behavioral parent training over 35 sessions (8
individual, 27 group sessions) to teach them behavior management tech-
niques and coordinating the child’s care in school.
Children also participated in an 8-week summer treatment program, an
intensive manualized program that is discussed in detail in another section
of this chapter. During the first 12 weeks of the school year, each child was
assigned a behavior aide who was directly supervised by the same therapist
who was responsible for the behavioral parent training and supervised the
counselors in the summer treatment program. This same therapist met with
each child’s teacher in the fall and spring on a consultative basis. An effort
was made to teach parents and teachers to “carry on” as the behavioral
treatment components were faded except for monthly follow-up visits.
The MTA Combined treatment strategy was a combination of these
two strategies with an emphasis on making their implementation as effi-
cient for the family as possible. The Community-care comparison group
was given a list of referral sources within the community and treatment
consisted of whatever was agreed to by the parents and the care provider.
Overall, the community care group had much less frequent contact (i.e.,
2.3/year) with care providers and took less medication on average (18.7 mg
total daily dose).
When considering treatment effects for the core symptoms of ADHD

(i.e., inattention, impulsivity, and hyperactivity), careful medication man-
agement was the most effective single treatment; that is, the Medication
and Combined strategies were clearly superior to the Behavioral strategy
and Community-care groups. The Medication and Combined groups did
not differ on any of the measures of ADHD symptom outcomes. However,
when other areas of functioning (e.g., social skills, academic functioning,
and parent–child interactions) were evaluated, the Combined treatment
appeared to offer some advantages although these were often not statisti-
cally significant based on the strict criteria initially established by the MTA
workgroup.
Using a composite score based on all outcome measures (Conners, et al.,
2001), as well as when measures were combined across settings (Hinshaw,
2007), the Combined treatment strategy was found to have significantly bet-
ter treatment effects than all other treatments. Parents and teachers also
provided much higher consumer satisfaction ratings for both behavioral
treatment strategies (i.e., Combined and Behavioral). Subsequent analyses
indicated that for children with a comorbid anxiety disorder, the addition of
a behavioral treatment strategy either alone or in combination with medica-
tion was clearly more effective. This finding also held true for families receiv-
ing public assistance. No other analyses of potential moderator effects were
found to be significant in the initial analysis.
The initial findings of the MTA were widely disseminated with some
news agencies reporting that behavioral interventions “didn’t work” in
treating ADHD (Arnold, et al., 2004). The principal investigators for the
MTA have clearly stated in subsequent articles that this is not the case
(Jensen, 2001). The MTA study did not include a “no treatment” control
group for comparison and all four treatment groups showed a substan-
tial reduction of symptoms over the treatment period. The results for the
behavioral treatment strategies are actually quite robust when considered
in the context of the strong effects consistently achieved with stimulant
medications on ADHD symptoms (Arnold, Chuang, Davies, Abikoff, Con-
ners, & Elliot, 2004). For example, children in the Behavioral group did
at least as well as children in the Community-care group, most of whom
were being treated with stimulant medications. Also, three-fourths of the
Behavioral group were satisfactorily managed for the 14-month treatment
period without taking any medication.
Another criticism of the initial MTA findings is that they report on
treatment effects after the behavioral intervention was faded and
medical treatment was still active (Pelham, 1999). This aspect of the
research design was based on the view that attempting to promote the
generalization of behavioral treatment effects as the intensive program
components were withdrawn was desirable and more closely reflected “real-
world” practice (Jensen, 1999). The impact of this aspect of the research
design in evaluating the true contribution of behavioral interventions to
the treatment of ADHD remains a subject of ongoing discussion (Arnold
et al., 2004). A primary goal of future research efforts is determining what
“dose” of behavioral intervention is sufficient to provide benefits; that is,
how intensive does the treatment have to be?
Regardless of the issues surrounding the evaluation of behavioral

intervention effects, the MTA study clearly demonstrated the very strong
effects of carefully managed medical treatment on symptoms of ADHD.
This finding is consistent with the results from previous studies (Schachar,
Tannock, Cunningham, & Corkum, 1997) demonstrating the short-term
robust efficacy of medication management out to a period of 14 months.
A follow-up of these treatment groups after 24 months revealed that the
two most beneficial groups who used medication show deterioration of
effectiveness because these groups had a larger number of cases that
stopped medication. This deterioration may reflect the lack of maintenance
of an effective intervention. The effects of the behavioral therapy although
smaller than that of medication, were maintained, suggesting that
generalization occurred (MTA Cooperative Group, 2004a).
MEDICATION
The neurobiological basis of pharmacotherapy in ADHD has been based

on the catecholamine mechanism of action in the central nervous system
(CNS). The frontal subcortical-cerebellar circuits are rich in dopaminergic
synapses and control a set of executive functions (inhibition, working mem-
ory, set shifting, planning and sustained attention, regulation of reward
systems and arousal states; Castellanos & Tannock, 2002). The pattern
of neuropsychological deficits in ADHD might originate from deregulation
of these CNS circuits. The underlying causes of ADHD are not well under-
stood, but there is considerable evidence indicating that dopaminergic and
noradrenergic neurotransmission are dysregulated in ADHD. Support for
this concept comes from different studies:
The action of drugs that increase the synaptic availability of dopamine
and norepinephrine on ADHD symptoms.
Animal models of ADHD (created via lesions in dopamine pathways).
Structural and functional neuroimaging studies showing that brain
regions rich in dopaminergic innervations are associated with ADHD.
Various genes coding for proteins involved in dopaminergic neuro-
transmission were associated with ADHD (Cheon et al., 2003; Cas-
tellano, & Tannock, 2002; Krause, Dresel, Krause, Kung & Tatsch,
2000; Solanto, 2002).
The main pharmacotherapy for ADHD has for decades been the
stimulant drugs methylphenidate and amphetamine, which are believed
to enhance neurotransmission of dopamine and epinephrine. Methyl-
phenidate is thought to act primarily by blocking reuptake of dopamine
transporters, whereas amphetamines are thought to exert their effect by
blocking noradrenergic transporters and by facilitating neurotransmitter
release. Because ADHD symptoms of inattention and hyperactivity/impul-
sivity reflect possible dysregulation of the monoamines system, stimulants
are thought to normalize the function of the relevant brain regions by
enhancing the neurotransmission of dopamine and norepinephrine in
therapeutic doses.
The AAP guidelines recommend that stimulant agents that have

been Food and Drug Administration (FDA)-approved as ADHD treat-
ments should be used to achieve the desired treatment goals in chil-
dren with ADHD. A large body of evidence supports the effectiveness
of stimulants in treating ADHD symptoms and endorses their use as
first-line treatment (reviewed in Biederman, & Faraone, 2005; Lopez,
2006). Randomized, controlled trials have consistently demonstrated
the efficacy of stimulants for reducing the core symptoms of hyperactiv-
ity, impulsivity, and inattention.
Studies also documented improvement in classroom behavior, aca-
demic achievements, conduct, and self-esteem of children and ado-
lescents with ADHD. The majority of children with ADHD (70%) are
effectively treated with stimulant medications. With appropriate dose
titration and selection of the most effective stimulant, up to 90% of
children with ADHD would respond favorably (Hechtman et al., 2004;
Mannuzza & Klein, 2000).
The most common stimulants in use are methylphenidate and amphet-
amine (Dexedrine and Adderall, a mixture of four neutral amphetamine
salts). Both drug groups are classified as Schedule II controlled substances
and are available in short-acting (4 hours), intermediate (8 hours), and
long acting (12 hours; Table 6.2). The immediate-release stimulants have
a relatively short duration of action, which is a challenging limitation dur-
ing the school day. Children treated with the short-acting stimulants will
often need multiple doses throughout the day to provide coverage of ADHD
symptoms both at school and during after school activities. The need for
an “in school” second dose, or a third dose for leisure time activities, may
cause embarrassment, stigma, and peer ridicule for the school-aged chil-
dren. This may result in lack of compliance, loss of effectiveness in the
afternoon, and more problems with symptoms control.
Stimulant medications have a rapid onset of action, a flexible dosing
schedule, and many choices of medications that facilitate the development
of an individual treatment plan. The decision with which type of medica-
tion to start therapy should take into account age, desired duration of
action, response type, side effects, and availability.
Table 6.2. Immediate Release Stimulant Medications

Duration
Active Ingredients Drug Name (Hours) Special Consideration
Methylphenidate (MPH) Ritalin 3–4 2–3 times a day
Maximal dose: 60 mg Methylin 2–3 times a day Chewable
tablets
Focalin 2–3 times a day d-MPH isomer
Amphetamine:
Dextroamphetamine DextroStat 4–5 × 2 daily
Maximal dose: 40 mg Dexedrine
Mixed salts of amphetamines Adderall 4–6 2–3 times a day depending on
Maximal dose: 40 mg dose Scored tablets
New Advanced System Delivery Stimulants

New developments in stimulant treatment have led to better quality
of care. One of the major advances in stimulant treatment has been the
development of long-acting formulations with range of action between 8–
12 hours (Table 6.3). These regimens provide coverage for most of the day,
prevent humiliation in front of peers, and enable the child to complete
his homework and participate in extracurricular activities. Recently, the
pharmaceutical companies have developed more technologically advanced
formulations of MPH, combining the advantages of both immediate release
(IR) and extended release (ER) MPH by using innovative delivery systems.
These advances permitted the production of long-acting medications that
provide rapid onset of effect with prolonged duration of action in a single
dose intended for once-daily administration.
Ritalin LA is an example of an intermediate release regimen, which
was designed to mimic a twice-daily regimen, releasing 50% of the dose
immediately and the other 50% approximately 4 hours later. Ritalin LA™
uses SODAS technology (IR beads contain MPH within sugar spheres and
delayed release beads that are coated with a polymer controlling the rate
at which the drug diffuses out of the pellet) to achieve bimodal release
profile. This drug offers a level of clinical efficacy similar to the effect of
immediate release MPH (Biederman et al., 2003).
Table 6.3. Sustained Release Stimulant Medications

Duration
Active Ingredients Drug Name (Hours) Special Consideration
Methylphenidate Ritalin SR 4–8 Tablets must be swallowed whole
(MPH) Maximal dose: 60 mg
Ritalin LA 4–8 Bimodal release system Capsules must
be swallowed whole or sprinkled on
applesauce
Maximal dose: 60 mg
Metadate ER 4–8 Tablets must be swallowed whole
Metadate CD 4–8 Capsules must be taken whole,
available in dose packs
Maximal dose: 60 mg
Methylin ER 4–8 Tablets must be swallowed whole
Focalin XR 4–8 d-MPH isomer
Maximal dose: 20 mg
Concerta 12 OROS delivery system
Maximal dose: 72 mg
Daytrana 9 wear Transdermal patch
time
Amphetamine:
Dextroamphetamine Dexedrine 6–8 Maximal recommended
Spansules daily dose: 45 mg
Mixed salts of Adderall XR 10–12 Maximal recommended
amphetamines daily dose: 40 mg
Amphetamine prodrug: Vyvance 10–12 Maximal recommended
Lisdexamfetamine daily dose: 70 mg
dimesylate
An example of an extended release drug is the osmotic release oral

system (OROS) that was designed to mimic three doses of MPH (12 hours)
duration of action (Concerta™). About 22% of the dose is contained in the
tablet overcoat and is released immediately, and the remainder of the dose
is released from a trilayer core through a controlled ascending osmotic
process (Wolraich, Greenhill & Pelham, 2001).
Another example is the controlled-delivery methylphenidate extended
release capsule (Metadate CD™), which utilizes Diffucaps technology, a
multiparticulate bead delivery system. Contained within each capsule is a
combination of IR MPH and ER MPH coated beads proportioned in 30:70
ratio yielding a biphasic, ascending dose-proportional pharmacokinetic
profile preventing tolerance development (Hirshey-Drisken, D’Imperio,
Birdsall & Hatch, 2002).
Another method of delivery is the MPH transdermal system (MTS) patch,
which permits sustained absorption of the drug through the skin and into
the bloodstream using DOT matrix technology that combines adhesive
properties and effective drug release vehicle (Anderson & Scott, 2006). MTS
delivery results in a uniform systemic drug delivery while avoiding first-
pass metabolism by the liver. The transdermal patch (Daytrana™) is the
only nonoral medication available for the treatment of ADHD and is FDA-
approved. MTS use allows physicians to control the daily dose and the
duration of effect by using different patch sizes and changing wear time.
The ability to remove the patch permits greater flexibility in dosing for those
children who need to stop and start treatment at different times of the day.
It may be a suitable solution for those who have difficulty swallowing pills,
have rapid metabolism of the drug, or suffer from late-day side effects.
The most widely prescribed medication for ADHD is the racemic mix-
ture of both the d-threo and l-threo enantiomers of MPH (National Insti-
tute of Health, 1998). However, the clinical efficacy of d,l-MPH is thought
to be mediated by the d-enantiomer (Weiss, Wasdell & Patin, 2004). Foca-
lin™ (d-MPH), a new formulation of the active d-isomer, was as effective as
d,l,-MPH for the treatment of ADHD even in half dose, thus providing use
of the lowest effective dose and possibly limiting the occurrence of serious
side effects.
In the amphetamine group, Adderall XR™ is a two-component
extended release capsule (50:50% beads), designed to produce pulsed-
release amphetamine salts mixture yielding a therapeutic effect that lasts
throughout the day and evening in one morning dose (Biederman, Lopez,
Boellner, & Chandler, 2002).
Lisdexamfetamine dimesylate (Vyvance™) is a prodrug of d-ampheta-
mine, which was recently approved by the FDA for use in ADHD. This
compound is a conditionally bioreversible derivative of amphetamine,
meaning that it is conjugated to a specific amino acid. The compound
is activated only when the amino acid is cleaved from the amphetamine
molecule during metabolism. Following ingestion, the pharmacologically
active s-amphetamine molecule is gradually released by rate-limiting
hydrolysis. This medicine provides an extended duration of effect that is
consistent throughout the day, with reduced potential for abuse, over-
dose toxicity, and drug tampering. Clinical studies documented significant
improvements in the children’s behavior throughout the day on ADHD rat-

ing scales for three examined doses (30, 50, 70 mg) compared with placebo
(Biederman, Krishnan, Zhang, McGough, & Findling, 2007).
Modafinil™ is a new stimulant that is structurally and pharmacologi-
cally different from other stimulant medications for ADHD and has low
potential for abuse. Modafinil has been used to promote wakefulness for
narcolepsy. The mechanism of action is not entirely known, but it appears
that Modafinil alters the balance of gamma-aminobutyric acid and gluta-
mate, which results in activation of the hypothalamus, and increases the
metabolic rate in the thalamus, amygdala, and hippocampus (Rugino &
Copley, 2001; Rugino & Samsock, 2003). In a double-blind placebo-con-
trolled study in children with ADHD, one 300 mg dose of Modafinil per
day greatly improved symptoms that were rated by teachers, clinicians,
and parents. A larger dose of 400 mg did not add greater effect than
the lower dose. All the doses were well tolerated and the most common
adverse effects were insomnia, headache, decreased appetite, abdomi-
nal pains, cough, fever, and rhinitis (Turner, Clark, Dawson, Robbins, &
Sahakian, 2004).
Adverse Effects of Stimulant Medications

Adverse effects of stimulants are usually mild and can be managed
by changing the dose, the timing, or the type of stimulant. The most
common side effects are decreased appetite, transient headache and
stomachache, sleep problems, and behavioral rebound. Somatic
complaints described on the first days of use, typically resolve within one
to two weeks of treatment. Rarely appetite suppression will lead to weight
loss and growth suppression. Published reports on the effect of long-
term stimulant therapy on growth are controversial. Some early reports
suggested stimulants may induce growth suppression (Poulton & Powel,
2003). The MTA study found mild growth suppression in height after
ten months of consistent use of stimulant medication (MTA Cooperative
Group, 2004b). More recent reports using standardized tools such as
body mass index (BMI) charts and Z-scores, have not reported significant
effects on height or weight growth over time. In addition, several long-
term studies suggested that deficits in weight and height are reversible
and not of clinical significance even with continued treatment for two to
three years (Faraone, Biederman, Moonuteau, & Spence, 2005; Zachor,
Roberts, Hodgens, Isaacs, & Merrick, 2006).
Infrequently, children can become socially withdrawn, extremely unre-
sponsive, dizzy, and extremely focused on trivial information as a side
effect of stimulant medication. These side effects are more common in
young children with mental retardation or with other developmental prob-
lems. Most of the side effects abate with long-term treatment. In very rare
cases, side effects that are more serious can occur, such as hallucinations,
exacerbation of tics, and adverse cardiovascular events.
About 20% of children with ADHD are affected by chronic tic disorder,
whereas about half of the cases with chronic tics or Tourette syndrome
also meet criteria for ADHD. Usually, ADHD is diagnosed two to three years
before first tic onset. Some concerns exist that stimulants may increase
the risk of first-onset tics or worsening of pre-existing tics. Early reports
showed stimulants might raise the risk for tics in patients with a personal
or family history of tics (Lowe, Cohen, Deltor, Kremenitzer, & Shaywitz,
1982). These authors claimed that Tourette syndrome or tics in a child are
a contraindication to the use of stimulants. However, recent reports chal-
lenge this view and a metaanalysis of studies with high methodological
quality (double-blind placebo-controlled) revealed that there seems to be
no elevated risk of first-onset tics during stimulant treatment (Roessner,
Robatzek, Knapp, Banaschewski, & Rothenberger, 2006)
In addition, stimulants are believed to lower the threshold for sei-
zures but a diagnosis of epilepsy is not an absolute contraindication to the
use of stimulants. Although several studies have revealed that stimulants
do not exacerbate well-controlled epilepsy, children should be monitored
closely for exacerbation of seizures while on the medication. A recent study
reported 2% seizures in a stimulant-treated group of children diagnosed
with ADHD. This rate is not exceptionally high given that an estimated 1%
of unselected children will have at least one afebrile seizure by 14 years
of age. This study found that epileptiform EEGs identified a subgroup of
children with ADHD with seizure risk of up to 20%, whereas normal EEGs
indicated minimal risk (<1%) for seizures. The risk was not attributable to
stimulant use (Hemmer, Pasternak, Zecker, & Trommer, 2001).
Stimulant drugs are controlled substances with addictive potential and
therefore parents have raised their concerns about their children being
prone to abuse and addiction after long-term treatment. Studies looking
at these questions have shown that the pharmacotherapy of ADHD has
a significant “protective effect” and instead of causing substance abuse
actually reduces the risk for this disorder by 50% (Wilens, Faraone, Bied-
erman, & Guanawardene, 2003).
Recently, a warning was added to the label of Adderall XR cautioning
that misuse of amphetamines can lead to serious cardiovascular events
and to sudden death. Although these cases are rare, it is important to
verify underlying structural cardiac abnormalities, inquire about family
history of unexplained cardiac deaths before initiation of treatment with
stimulants, and provide adequate cardiac monitoring afterward. A recent
study that evaluated cardiovascular safety of mixed amphetamine salts
extended release on about 3,000 children with ADHD demonstrated both
efficacy and cardiac safety (Donner, Michaels, & Ambrosini, 2007).
Titration of Therapy for ADHD and Strategies for Managing

Adverse Effects
The decision regarding which agent to initiate therapy with should take
into account age, desired duration of effect, and availability. Both methyl-
phenidate and amphetamine are each about 70% effective in alleviating the
symptoms of ADHD. A trial of both types in succession before giving up on
stimulants can increase collective effectiveness to 90%. It is recommended
to start at the lowest-level dosage available. In the absence of significant side
effects, it is possible to titrate up a dose every week until a positive effect
is achieved. Parents and teachers reports, verbally or preferably through

ADHD-rating scales, are important to maximize the medication response.
Children with ADHD, Combined Type, particularly those with behav-
ior problems, will benefit from 12 hours therapy duration ideally with one
single morning dose. Treatment can continue on weekends or vacations
to improve the child’s function in leisure and family times if needed. Chil-
dren with ADHD, Inattentive Type may take the medication only during
school time or while engaging in academic activities (short or intermediate
drugs). In special circumstances, such as having poor weight gain or loss
of weight, medication holidays are necessary.
It is recommended to monitor growth by measuring height, weight,
and blood pressure every six months or more frequently in extenuating
circumstances (loss of weight, poor appetite). Studies do not support the
need for regular blood tests (such as complete blood count or liver and
renal profiles). However, the pediatrician should decide to perform such
tests in case of medical problems (growth suppression, abdominal pains).
If the side effects of the medication do cause substantial problems for
the child, physicians can try alternative approaches to reduce the discomfort.
For example, if sleep problems occur, it is possible to reduce or eliminate the
afternoon dose or move dose to earlier time. If there is behavior rebound with
the immediate-release regimen, a trial of a sustained-release medication can
improve the problem, or adding a small dose in the afternoon may address
this situation. When appetite is severely affected, the child can take the dose
after meals, or he can have frequent high-caloric healthy snacks during the
day. Drug holidays should also be considered in this case.
Nonstimulant Medications
Although 80–90% of children who are diagnosed with one of the ADHD
subtypes will respond to one of the stimulant medications favorably, some
children will not show effective control of the symptoms or will be intolerant
of stimulants. Nonstimulant medications such as Atomoxetine (Strattera),
antidepressants, and alpha-adrenergic agents have shown benefit in con-
trolling symptoms of ADHD, although the response has not been as effec-
tive as that of stimulants (Table 6.4).
Table 6.4. Nonstimulant Medications

Group’s Name Medications
Tricyclic Antidepressants Amytriptline
Desipramine
Imipramine
Clomipramine
Nortriptyline
Alpha 2 agonists Clonidine
Guanfacine
Others Atomoxetine
Modafinil
Bupropion
The most established and extensively studied nonstimulant treat-

ments for ADHD have been the tricyclic antidepressant group. Studies
show these medications are superior to placebo in controlling ADHD symp-
toms. Their use is not approved in pediatric ADHD because of their low
margin of safety, possible cardiac side effects, and the requirements for
careful monitoring of levels and adverse effects. The tricyclic antidepres-
sants have a potential risk for serious cardiovascular adverse events (i.e.,
unexplained deaths in four children treated with desipramine), although
the link between the treatment and the events remained uncertain
(Biederman, Thisted, Greenhill, & Ryan, 1995).
Atomoxetine (Strattera™), a selective norepinephrine reuptake inhibi-
tor with no significant effect on dopamine, is another relatively new
nonstimulant approved for ADHD treatment by the Food and Drug
Administration (FDA) in children and adults. Controlled trials have
shown superiority of Atomoxetin to placebo for the treatment of ADHD
symptoms and in improving self-esteem, interpersonal and family rela-
tionships, and overall functioning (Barton, 2005). Therefore, Atomoxetine
can be an alternative for children who cannot tolerate or do not respond
to stimulants. The degree of response to atomoxetine is slightly lower
than that to stimulants and therapeutic effects may appear after several
weeks of treatment.
Advantages are the long duration of action, little or no abuse potential,
no effect on sleep, and good tolerability. In addition, atomoxetine is not
a schedule II controlled substance. The half-life of atomoxetine is about
five hours but after two to four weeks of therapy, when maximal response
is achieved, clinical effects appear to be long lasting. Tapering is neces-
sary when discontinuing the medicine. There is no major effect on growth
with atomoxetine. In addition, atomoxetine (a weak antidepressant) may
be useful for children with comorbid anxiety, sleep disorder, or tics as
no increase in tics has been documented. The most common side effects
reported with atomoxetine use include upset stomach, decreased appetite,
nausea, dyspepsia, vomiting, tiredness, dizziness, somnolence, and mood
swings. These side effects tend to be transient occurring during initiation
and titration of the medicine. The FDA required that atomoxetine carry a
black box warning indicating the possibility of severe liver injury in rare
cases, and of increased risk of suicidal thinking in children and adoles-
cents (http://www.fda.gov).
The group of α adrenergic agonists, such as clonidine and guanfacine,
is occasionally a useful option for ADHD treatment. Both drugs are not
presently approved by the FDA for ADHD treatment but are used to augment
stimulant therapy especially to control extreme impulsivity. Clinicians
should consider treatment with α agonists when ADHD is associated
with tic disorder or Tourette syndrome and especially if treatment with
stimulants makes the tics worse. A meta-analysis of clinical trials involving
clonidine (a weak blood pressure medicine) concluded that this medicine
is effective as a second-line therapy, although the clinical effect is lower
than that of stimulants. A high rate of side effects are associated with
clonidine treatment including, sedation, irritability, sleep disturbance,
blood pressure drop, hypotension (new onset blood pressure lower than
the 5th percentile for age and gender), dry mouth, and dizziness (Connor,
Fletcher, & Swanson, 1999).
Guanfacine is less sedating and has a longer duration of action than
clonidine. A randomized placebo control study of guanfacine for children
with ADHD and tic disorder found guanfacine was well tolerated, and
improvement of ADHD symptoms was similar to or better than with other
nonstimulant medications but less than with stimulant treatment (Schahil
et al., 2001). Dosing of guanfacine should start low and move upward
slowly to avoid sedative and hypotensive effects. In addition, abrupt with-
drawal of guanfacine is not recommended and frequent blood pressure
monitoring is suggested.
Report of sudden deaths that have occurred after patients took α
agonists with methylphenidate raised concerns about the safety of these
drugs combination. A phase III clinical trial examining the benefit of an
extended-release formulation (once daily) of guanfacine has concluded
and documented clinical significance. However, the adverse effects profile
of these new drugs needs to be further examined before their routine use
in ADHD treatment.
Bupropion, an atypical antidepressant, has modest efficacy in improv-
ing symptoms of ADHD as shown in open label and controlled small trials
(Wilens et al., 2005). Some studies suggest bupropion could be helpful for
patients with comorbid depression, bipolar disorder or substance abuse
(Wilens, Prince, Spencer, et al., 2003). The drug may exacerbate tics and
increase the threshold for seizures with increasing doses. Therefore, it is
contraindicated in children with seizure or tic disorders.
Omega-3 fatty acids are a family of long-chain polyunsaturated fatty
acids. Several natural observation studies have found lower levels of omega
3 fatty acids in persons with ADHD. Randomized controlled small studies
of enhanced dietary intake of the fatty acids have had ambiguous results.
Two studies found no improvement in ADHD-related symptoms and one
study showed improvement only in a few measures. Serious side effects were
not reported with omega-3 treatment (Hirayama, Hamazaki, & Terasawa,
2004; Richardson & Puri, 2002). The current approach is that dietary
supplementation with omega-3 fatty acids may have some theoretical beneficial
effects for children with ADHD. However, there is insufficient evidence at this
time to substantiate the efficacy and safety of this treatment.
TREATMENT OF ADHD AND COMMON CO-MORBID

DISORDERS (TABLE 6.1)
The presence of ADHD with one or more comorbid disorders is asso-

ciated with significant additional morbidity and therefore complicates
treatment of ADHD (Spencer, Biederman & Wilens, 1999). The treatment
approaches to some of the comorbid disorders are discussed, with an
emphasis on medical treatment: ADHD with disruptive behavior disorders
[oppositional defiant disorder (ODD); conduct disorder (CD); aggressive
outbursts].
ODD manifests as a persistent pattern of negative and defiant

towards adult authority, whereas CD presents as a repetitive pattern of
more severe rule breaking and violation of social norms. Sometimes these
disorders occur with more severe ADHD symptoms. The primary treatment
approach for ODD alone is behavioral intervention. However, the treatment
approach of psychostimulants and atomoxetine for some of the comorbid
disorders can be very effective in treating a range of disruptive behaviors,
including both ODD and CD symptoms, although they are only labeled
for ADHD. The MTA study found that ADHD symptoms respond robustly
to stimulant medication in the presence of ODD or CD. MTA subjects
with ADHD, CD, or ODD responded best to a combination of behavior
and medication treatments (MTA Cooperative Group, 1999 b). Children
who display ADHD symptoms along with aggression or other disruptive
behavior disorder symptoms, but are not responsive to treatment with
stimulants, may benefit from combined therapy of stimulants and other
groups of medications.
A variety of pharmacotherapeutic agents can be added to stimulants.
The group of selective serotonin reuptake inhibitors (SSRI) can improve
symptoms of aggression, as studies implicated serotonergic mechanisms
in aggression; anticonvulsant mood stabilizers such as carbamazepine
and sodium valporate are also effective as adjunct therapy for ADHD and
episodic dyscontrolled behavior (reviewed in: Newcorn, & Ivanov, 2007).
The best data are for risperidone and quetiapine (antipsychotics) in
treating CD and/or aggression with comorbid ADHD (Aman, DeSmedt,
Derivan, L yons, & Findling, 2002; Findling et al., 2007).
ADHD with Mood Disorders

Many children with ADHD experience demoralization because ADHD
symptoms may lead to impaired academic, social, and athletic success. A
demoralized mood often improves as the ADHD symptoms resolve. However,
pharmacologic treatments for ADHD have little impact on prominent
depressive symptoms because the two disorders appear to have independent
trajectories (Biederman, Mick, & Faraone, 1998). When the depressive
symptoms are mild it is reasonable to treat the ADHD first as stimulants
have a faster rate of onset than antidepressants. Then, the mood symptoms
need to be re-evaluated and if present, a more targeted treatment should be
implemented. If the child has marked depression or suicidal ideation, a mood
treatment should be initiated first and only when improved, treatment for
ADHD symptoms should follow. Psychosocial treatments (such as cognitive-
behavioral therapy) combined with medication are usually the most effective
intervention for mood disorders. When pharmacotherapy is considered,
the most common treatment for ADHD with depression is a combination of
stimulant with a drug from the SSRIs group (TADS Study Team, 2003).
ADHD and Anxiety

The combination of ADHD and anxiety has been reported in many studies
(reviewed in Waxmonsky, 2003). Initial studies found that stimulants were
typically less effective and possibly anxiogenic. However, recent studies

and especially the results of the MTA study found that stimulants were
robustly effective for ADHD symptoms and did not worsen anxiety symp-
toms. In addition, the MTA study showed that behavioral intervention
was very effective for children with anxiety and ADHD, and had a positive
impact on their academic and social functioning. In fact, children with
anxiety responded to all treatments in the MTA (behavioral and medica-
tion) better than children with only ADHD did (Jensen et al, 2001). When
children with ADHD had combined comorbidities of anxiety and ODD/CD
behaviors, the combination of medication and behavioral intervention was
superior to either treatment alone.
ADHD with Autism Spectrum Disorder (ASD)

The co-occurrence of these two complex disorders is common and can
occur in up to 50% of children with ASD. The ADHD-like symptoms in
ASD often impair functioning and interfere with the ability of the affected
children to benefit from behavioral and educational intervention. There
are few studies that examined the safety and efficacy of stimulant medica-
tion in ASD. Earlier studies reported little benefit and a large number of
adverse effects including increased irritability, stereotypies, and hyperac-
tivity (Sporn & Pinkster, 1981).
More recent studies have been generally more promising with respect
to both effectiveness and side effects. The gains included improved atten-
tion span and diminished hyperactivity, explosive rage, oppositionality and
aggression and to some extend decline in stereotypies and inappropriate
language. Side effects reported in recent studies included irritability, tan-
trums, tearfulness, social withdrawal, aggression, and skin picking. Clini-
cal benefits with few side effects were observed with lower-dose stimulants
use (Posey et al., 2007).
Overall the approach for stimulant use in ASD and ADHD is that they
can provide effective adjunctive therapy for more than 50% of the children.
Therefore, physicians should try them first and closely monitor children
for unwanted effects that may be higher than the rate seen in children
with ADHD alone.
Recent studies examined the effectiveness of atomoxetine in children
with ASD. Significant improvement in ADHD symptoms was documented,
but lesser improvement in irritability, social withdrawal, stereotypy, and
repetitive behaviors was noted (Arnold et al., 2006; Posey et al., 2006).
The group of α adrenergic agonists has been frequently used in ASD to
treat hyperarousal symptoms. Drowsiness and sedation are common side
effects of this group. Very few small size studies have looked at the benefit
of this group of medications in ASD, however (Frankhauser, Karumanchi,
German, Yates, & Karamanchi, 1992). Atypical antipsychotics (risperidone)
are sometimes used to treat hyperactivity and inattention in ASD (Williams
et al., 2006). In one double-blind placebo-controlled study, treatment with
omega-3 fatty acids supplements for children with ASD produced signifi-
cant improvement on the hyperactive and stereotypy measures without
side effects (Amminger et al., 2007).
It is likely that with the implementation of any of the aforementioned

medication regimens, children with ADHD-like symptoms and a diagno-
sis on the autism spectrum could then benefit from intensive behavioral
interventions. Interventions for children diagnosed with an Autism Spec-
trum Disorder include small-group or one-on-one behavioral and edu-
cational interventions that are delivered for at least 10–15 hr per week.
They include well-known treatment models such as the UCLA Young
Autism Project, Treatment and Education of Autistic and Related Com-
munication Handicapped Children, and the Denver Model (Shattuck &
Gross, 2007).
PSYCHOSOCIAL INTERVENTIONS
Numerous interventions and therapies have been developed and touted

as effective treatments for ADHD but only three interventions have stood
the test of randomized clinical trial in controlled scientific studies and
consistently been found to provide meaningful benefits to the child with
ADHD: behavioral parent training, classroom behavior management, and
summer treatment programs (e.g., Chronis, Jones, & Raggi, 2006; Pelham &
Fabiano, 2008). These evidence-based treatment approaches are reviewed
in detail in the following sections.
Behavioral Parent Training: Overview

Raising a child diagnosed with ADHD places strain on family relation-
ships and family functioning, necessitating the use of a family-based treatment
approach such as parent training (Pelham, Wheeler, & Chronis, 1998).
In these families, elevated levels of parental stress and diminished parental
sense of competence are often present (Mash & Johnston, 1990). Behavioral
parent training is now a well-established treatment for children diagnosed
with Attention-Deficit/Hyperactivity Disorder (ADHD; Pelham & Fabiano,
2008). Although previously deemed probably efficacious (Pelham et al.
2008), a recent review by Pelham and Fabiano (2008) provides evidence
that behavioral parent training is a well-established treatment for ADHD.
In the review article by Pelham and Fabiano (2008), 22 studies, published
since 1998, assessing the effectiveness of behavioral parent training, were
examined. The cited studies used mostly group-based behavioral parent
training programs, consisting of 8–16 sessions. Behavioral parent training
was found to be more effective than other conditions, including attention
placebo, nondirective parent counseling, and wait-list control. In addition
to treating children with ADHD, behavioral parent training has a history
of successfully treating Oppositional Defiant Disorder (ODD) and Conduct
Disorder (CD; Brestan & Eyberg, 1998).
Parent training improves parental child management skills (Barkley,
Guevremont, Anastopoulos, & Fletcher, 1992; Pelham & Fabiano, 2008;
Wells, Chi, Hinshaw, Epstein, Pfiffner, Nebel-Schwain, et al. 2006), reduces
overall child symptoms of ADHD, and improves other disruptive behavior
problems (Anastopoulos, Shelton, DuPaul, & Guevremont, 1993). There is
also thought to be an increase in parental confidence, a reduction in par-

ent stress, and an improvement in family relationships (Anastopoulos
et al., 1993).
Parent training is typically most effective with children 4 through 12
years of age (Anastopoulos & Farley, 2003). In addition, it can typically be
delivered in 8 to 12 sessions in a group or individual format. Sessions typi-
cally range from one hour, when conducted individually, to 90 minutes,
when conducted in a group setting. Individual behavioral parent train-
ing is thought to offer several advantages over group-based approaches,
including an increased ability to be flexible with the pace and content
of the sessions. Group sessions are, however, thought to be more cost-
effective, provide parents with a greater level of social support, and often
produce effects equivalent to individual parent-training sessions (Chronis,
Chako, Fabiano, Wymbs, & Pelham, 2004). Chronis and colleagues (2004)
suggest an approach to parent training which first includes all parents
being enrolled in group-based behavioral parent training with additional
individual sessions scheduled as needed for parents who do not maximally
benefit from group-based treatment or for those parents who drop out of
group-based treatment.
A variety of behavior management strategies is presented throughout the
parent training sessions. Parents are asked to practice these strategies
daily at home, at their children’s school, and in public places. Although
there are many different programs (Cunningham, Bremner, & Secord,
1997; Forehand & McMahon, 1981; Pfiffner, Mikami, Huang-Pollock,
Easterlin, Zalecki, & McBurnett, 2007) for parent training they share many
features in common. The following discussion of the specific components
of behavioral parent training will use those from the program developed by
Barkley and Anastopoulos (Barkley, 1987; Anastopoulos & Barkley, 1990;
Barkley, 1997) as a representative example.
Components of Parent Training

In the initial session of parent training, an overview of ADHD is pro-
vided. This discussion includes the neurological bases of ADHD, diagnostic
criteria for the disorder, typical comorbid features, and the developmental
course of the disorder. Parents are provided additional Web and literary
resources as well, in order to facilitate the ongoing development of their
knowledge of ADHD and associated features.
During the second session of the program, there is a discussion of
family factors that often lead to parent–child conflict. More specifically,
child characteristics (i.e., temperament, ADHD diagnosis), parental char-
acteristics (i.e., parental psychopathology, medical illness, temperament),
family stress (i.e., time management, financial strains), and parenting
style (i.e., ability to set up situations: antecedents; ability to respond to
appropriate and inappropriate behavior: consequences) are discussed. A
great emphasis is placed on a parents’ own ability to alter their parent-
ing style, whereas the other family factors are less amenable to change.
General behavioral principles are discussed in this session, including how
antecedents and consequences can be altered to elicit appropriate child
behavior. Positive reinforcement, ignoring, and punishment strategies are

also discussed in detail.
In the third session, positive attention is covered, as well as the spe-
cific positive attention strategy of Special Time. Special Time is designed to
increase the parents’ positive attention toward appropriate child behavior.
The importance of positive attention is highlighted with the discussion of
the tendency for children diagnosed with ADHD to have negative interac-
tions with their parents, peers, and teachers. As a result of these negative
interactions, these children often function in environments that are nega-
tive, overly directive, and corrective. Special Time is introduced as a strat-
egy that allows parents to dispense positive attention in a nondirective and
noncorrective manner. In addition, these opportunities help to improve
parent–child relationships, which are often damaged by negative, overly
directive, and corrective interactions. Outside of Special Time, parents are
encouraged to “catch their child being good” and praise any instance of
appropriate behavior noted.
In the fourth session, additional relevant discussions ensue with
respect to positive attention. Parents are encouraged to positively attend to
their children while their children are engaging in independent play. The
child is given appropriate expectations (e.g., “I have a phone call to make.
I need you to sit here quietly and play with your toys.”). While parents are
engaging in the phone call, they are to interrupt themselves and praise
the child for playing quietly before the child has a chance to interrupt
the phone call. This way, the child gets positive attention for engaging in
appropriate behavior, rather than for interrupting.
Also discussed is the importance of paying attention to children’s
compliance. Parents are encouraged to set up sessions where there is a
high probability that their children will comply (e.g., bring the cookies to
the table, give the dog a treat) and then positively attend to instances of
compliance. Commands are also discussed, within the context of neces-
sary characteristics of commands for children diagnosed with ADHD (e.g.,
initiate eye contact with the child to ensure he or she is listening, use one-
step commands, issue commands that will be followed through on, issue
simple commands, make directive statements). Parents are encouraged to
have their children repeat the command back to them, to ensure that they
heard and understood the command.
In the fifth session, a home-reward system is established. Parents dis-
cuss privileges that their children have access to at home, which are often
found to be noncontingent on the children’s appropriate and inappropriate
behavior. Next, a request list is created highlighting up to ten chores or
rules that the child is expected to engage in/follow at home. Another list is
developed with rewards/privileges that the child earns on a daily, weekly,
and long-term basis. Point values are assigned for both the reward list and
the chore list.
The system is designed to promote child compliance by allowing
the child access to rewards and privileges in a manner contingent on
appropriate behavior. In terms of rewards, children nine years and
younger use plastic tokens, and children above nine use a point reward
system. Tokens/points are earned when a child engages in a chore on
the first parental request. Children are allowed to “cash in” their points
or tokens for privileges on their list. Bonus chips/points can also be
dispensed when children follow rules/complete chores without parent
request or when children complete chores with a positive attitude. Set-
ting up the home-reward system is often a difficult step in the parent-
training program, as parents may often feel as if they have attempted
to implement similar systems in the past with no success. Parents are
reminded of the impact of consistency with such a strategy and are also
provided additional phone support by the therapist outside the session
if necessary.
The sixth session introduces the response cost condition. It is impor-
tant to note that up until this point in the program, there have been no
negative components. Parents are encouraged to begin to remove tokens
or points for noncompliance for one or two behaviors on the request list.
The response cost condition will often increase children’s levels of compli-
ance with parental requests, as they often do not want to lose tokens or
points that they have earned. Parents are cautioned not to get into a nega-
tive behavior spiral with their child. More specifically, if a child does not
comply with a command on the third request, the parent is encouraged to
no longer remove tokens or points and instead remove privileges or insti-
tute a time out.
The seventh session covers time out in great detail. First parents
are asked to discuss their experience with the use of time out from rein-
forcement, in order to gauge the parents’ experiences with the strategy.
Although many parents often reveal that they have used their own time
out procedure unsuccessfully in the past, the therapist encourages the
parent to consider the components of this time out procedure. Parents
are asked to think of one or two more serious behaviors (i.e., hitting,
destroying property, repeated noncompliance) that would warrant the
use of time out. The components of time out are then discussed, which
include: the child serving a minimum amount of time in time out (i.e.,
one minute for one year of age); parents only approaching the time out
area when the child has been quiet for the last thirty seconds of time
out, in order to avoid reinforcing inappropriate behavior; parents reis-
suing the command that led the child to time out, which at times begins
the time out procedure again, if the child refuses to comply with the
command again.
The eighth session explores the use of behavior management strategies in
public places (e.g., grocery stores, department stores, libraries, churches).
The public situations are first discussed, and parents are asked to think
ahead about situations that may be potentially problematic, bringing
about difficult behavior. Next, parents are asked to set up their expecta-
tions for the situation and clearly explain these to the child. An incentive
for compliance in the situation is established, along with a negative con-
sequence for noncompliance. The parent must have the child repeat back
the discussed expectations, reward for compliance, and punishment for
noncompliance.
The ninth session explores any issues the parent and/or child may be
having within the school domain. General education about parental rights
and classroom accommodations or curriculum modifications (i.e., Section

504 Plans; Individualized Education Plans; IEP) is provided. In addition,
preparations for treatment termination are made. First in this session,
however, school issues are discussed. Parents are encouraged to establish
and maintain positive and collaborative relationships with their children’s
teachers and schools. Specific parental and child rights are also covered.
In addition, empirically supported classroom accommodations (i.e., daily
report card; DRC) for children diagnosed with ADHD are presented. A dis-
cussion about the steps to setting up a DRC then ensues, including setting
up a meeting with the teacher, establishing appropriate target behaviors
for the daily report card, establishing blocks of times when the child’s
behavior will be rated, and determining classroom and/or home contin-
gencies for appropriate behavior.
Strategies covered during the course of the parent-training program
are then reviewed. Parents discuss situations that they believe might be
problematic in the future, along with ways that they might address such
situations. Parents are strongly encouraged to adhere to the program for
a period of time, prior to eventually implementing a system that relies
on more natural consequences and contingencies. Any issues related to
termination are then discussed, including the necessity for additional
services (e.g., medical evaluation, school consultation). A booster ses-
sion is then scheduled.
The tenth and final session is typically a booster session, which is
likely to occur nearly one month after the ninth session. During this ses-
sion, strategies covered during the course of the parent-training sessions
are again reviewed, with particular attention given to situations or strat-
egies that have presented difficulties for the families. At the end of this
session, families and the therapist determine whether additional booster
sessions might be necessary (Anastopoulos & Farley, 2003).
Factors Influencing Treatment Effectiveness

The location of treatment delivery may be an important factor in
treatment adherence (Pelham & Fabiano, 2008). In a study by Barkley
et al. (2000), behavioral parent training delivered in a medical setting was
not found to be effective. Further analysis of this study revealed that a
majority of the parents contacted did not choose to participate in the program
in this setting. Another program, the Cunningham’s COPE: Community
Parent Education Program (1998), has found success in providing parent-
training programs in the school, early childhood education settings, and
community centers, locations that are more accessible to families. In
addition, this program provides the flexibility of day and evening group
times. The COPE program also offers a children’s social skills group along
with each session of the parent program (Cunningham et al., 1998).
Although initial studies have found that this is an effective approach
for parent training, further research with the COPE program is necessary
in order to establish empirical support for providing such treatment in
community settings (Chronis et al., 2004). Nonetheless, the location of
parent training groups, flexibility in scheduling sessions, along with avail-
ability of child programs are important factors contributing to treatment

adherence and possibly treatment effectiveness.
In addition, many uncontrolled factors may also affect treatment out-
come. More specifically, moderators of treatment effectiveness include
child and family characteristics (e.g., gender, age, comorbidity, socioeco-
nomic status, parent psychopathology), therapist characteristics (e.g., level
of training), and treatment dosing (e.g., treatment intensity). A potentially
negative moderator of treatment effectiveness is parental psychopathol-
ogy; however, the evidence in support of negative effects is less clear-cut.
More specifically, some studies found no effect for parental psychopathol-
ogy (Pelham & Hoza, 1996), whereas others found negative moderating
treatment effects for maternal ADHD (Sonuga-Barke, Daley, & Thompson,
2002). It is speculated that parents with symptoms of ADHD may experi-
ence difficulty sustaining attention during sessions and difficulty consist-
ently implementing behavioral strategies and medication (Chronis et al.,
2004).
Maternal depression is also suspected to have a negative impact on
behavioral parent training for mothers of children diagnosed with ADHD;
however, there are no empirical findings suggesting a relationship between
maternal depression and decreased effectiveness of parent training. Some
research has been done (Sanders & McFarland, 2000; Chronis, Gam-
ble, Roberts, & Pelham, 2002) where there were components designed to
address maternal depression added to a behavioral parent training pro-
gram. These studies state that the interventions had a positive effect on
outcome for families. An issue with the research that has been done to
date assessing these factors is that most of the extra components/ inter-
ventions for maternal depression have been done after the parent-training
groups. Thus, it is difficult to say whether this is an appropriate approach
to addressing maternal depression or whether treatment interventions
would be more effective if they occurred prior to the mother’s participation
in behavioral parent training. Further research is needed to address these
treatment issues.
Also important to consider is parental expectations regarding paren-
tal involvement and child improvement during behavioral parent training
(Plunket, 1984). As a result of such moderating factors, treatment compo-
nents addressing these issues have been added to existing parent-training
programs. Additional research is needed in order to determine the effec-
tiveness of adjunctive interventions, which specifically target parent and
child factors not covered in parent training (Chronis et al., 2004). None-
theless, these factors must be considered when assessing family adher-
ence to and benefit from parent training programs.
CLASSROOM BEHAVIOR MANAGEMENT: OVERVIEW
Children with ADHD often experience difficulties in the school set-

ting. More specifically, while at school, children are required to have
the skills to plan, control their coordination, evaluate the procedures
involved in following the norms in appropriate interactions with adults
and classmates, and actively participate in the teaching/learning proc-

ess. These tasks are often more difficult for children diagnosed with
ADHD. As a result of such difficulties, children with a diagnosis of
ADHD often deal with social rejection in the school setting (Miranda,
Jarque, & Tarraga, 2006). Thus, school-based interventions are an
important adjunct in addition to behavioral parent training and medi-
cation management (Chronis et al., 2004). Stimulants, although help-
ful in reducing symptoms of ADHD, have not been demonstrated to
produce long-term changes in the general academic performance or the
interpersonal functioning of children with ADHD. Pelham and Gnagy
(1999) noted that “simply medicating children, without teaching them
the skills they need to improve their behavior and performance, is not
likely to improve the children’s long term prognosis (p. 226).”
Classroom behavior management strategies include token econo-
mies, contingency contracting, response cost, and time out. Self-evalu-
ation is also a strategy that has some efficacy in improving behavior
among children diagnosed with ADHD. In addition, other instructional
strategies are often effective (e.g., social skills training, task modifica-
tion). These strategies are explored toward the end of this section; how-
ever, first there is a brief review of the existing literature of classroom
behavior management.
Literature
There is substantial evidence that behavioral classroom management
is a well-established intervention for children diagnosed with ADHD
(Pelham & Fabiano, 2008). Studies by Barkley et al. (2000) have
demonstrated the effectiveness of classroom behavior management
strategies. In fact, in the study conducted by Barkley and colleagues
(2000), only the groups that included a school-based component
benefitted from treatment. These authors assessed ADHD symptoms
rated by teachers, teacher-rated social skills, and independent
observations of classroom behavior. All measures showed significant
improvement relative to control conditions.
In addition, a study by Van Lier, Muthen, Van der Sar, & Crijnen,
(2004) used a behavior management game called the Good Behavior
Game, where the children earned rewards for contingent good behavior.
Teachers and children chose the norms (rules) for the classroom and
the rewards for following them. The children were divided evenly into
teams. As a result of the system, ADHD-related problems were signifi-
cantly reduced. Another study by Northup et al. (1999) showed interac-
tive effects of methylphenidate and multiple classroom contingencies.
The program consisted of four conditions (1) contingent teacher rep-
rimands; (2) brief nonexclusory time out: child was turned away from
the desk, people, and all other activities if a specific negative behav-
ior occurred; (3) no interaction: ignoring all student behavior; and (4)
alone: children were assigned a task alone, which they did without a
teacher present.
Student’s behavior was significantly less disruptive in conditions where

there were contingent behavior management strategies (e.g., reprimands
and time out) than in other conditions. There was also a medication con-
dition, which was alternated for students. Children appeared to perform
better during the medication and behavior management condition when
compared to their behavior during the placebo and behavior management
condition alone.
DuPaul and Hoff (1998) looked at self-evaluation, and considered it a
possible alternative to a contingency management approach for address-
ing the disruptive behavior of students in elementary school exhibiting
ADHD behaviors. In this study, disruptive student behaviors were first
brought under the control of a contingency management system and then
they were later transferred to the self-management system. With the use
of self-evaluation, students maintained their behavioral changes in the
absence of teacher feedback. Ardoin and Martens (2004) examined the
accuracy and sensitivity of students’ ratings before and after self-evalu-
ation training. All students accurately rated their target behaviors after
training, which was found to decrease disruptive behavior. Despite these
studies, there is limited evidence that self-management strategies are con-
sistently successful for children diagnosed with ADHD.
Social skills training is an instructional component of school intervention.
Training can occur daily in the classroom, through a paired-buddy system
approach, and through other sports-related activities. Overall, it is reported
that parents and teachers endorse fewer behavioral problems and symptoms of
inattention (Anahalt, McNeil, & Bahl, 1998; Evans, Axelrod, & Langberg, 2004)
and normalization of peer relationships after such classroom interventions/
instructions (Hoza, Mrug, Pelham, Greiner, & Gnagy, 2003).
Some researchers have investigated multiple strategies in the class-
room including: token economy, response cost, time out, self-instruction,
reinforced self-evaluation, training in social skills, training in study skills,
or instructional management procedures (Anahalt et al., 1998; Barkley
et al., 2000; Shelton et al., 2000; Hoza et al., 2003). In general, these inter-
ventions showed positive results according to parent and teacher meas-
ures (e.g., fewer problematic behaviors, improved adaptive functioning).
The studies that included follow-up demonstrated continued improvement
up to two months after the interventions (Miranda & Presentacion, 2000);
however, long-term follow-up (two years after) of children previously in
treatment conditions showed no differences between those children who
received treatment and those that did not (Shelton et al., 2000). These
findings highlight the need for continual treatment and classroom support
for children diagnosed with ADHD, given the chronic and pervasive nature
of this disorder. Given that these studies had multiple components, it is
also difficult to determine which specific techniques produced improve-
ments (Miranda et al., 2006).
Next, there is a discussion of classroom behavior management strate-
gies including token economies, contingency contracting, response cost,
and time out. Self-evaluation and other instructional strategies are also
briefly discussed.
BEHAVIORAL CLASSROOM MANAGEMENT

STRATEGIES: OVERVIEW
The goal of classroom interventions is to optimize the behavioral and

social functioning of children diagnosed with ADHD, while also addressing
the academic achievement and performance in the classroom. As this is
being accomplished, it is important to take an educative approach where
we not only focus on reducing problematic behavior, but also teaching
alternative prosocial behaviors. In all, this type of approach will require
the development and implementation of behavior plans, which require
classroom and teacher support (DuPaul & Stoner, 2003).
Teachers should be trained on the intervention design, delivery, and
outcome evaluations. It is important that the development of a treatment
plan be empirically based. It is also important that appropriate evaluation
measures be used in the classroom. More specifically, reinforcement
values and the function of problematic behavior should be assessed
systematically. Guidelines set forth by DuPaul and Stoner (2003; p.142)
suggest the following for the development of classroom interventions.
(1) Intervention development, evaluation, and revision are data-based
activities; (2) intervention development, evaluation, and revision are driven
by child advocacy and focused on attainment of clearly defined, socially
valid child outcomes; (3) intervention procedures must be thoroughly
identified and defined, as well as implemented with integrity by persons
with clearly delineated responsibilities; (4) Effective interventions produce
or lead to increased rates of appropriate behavior and/or improved rates
of learning, not solely decreases in undesirable behavior; (5) prior to its
implementation, an intervention’s effects on the behaviors of the identified
child, the teacher, and on the classroom are unknown.
Contingency management (i.e., altering antecedents and con-
sequences) is thought to have the most positive effects on behavior.
In addition, positive reinforcement is thought to be the cornerstone
of classroom-based behavior management programs. Most programs
include contingent social praise; however, with children diagnosed with
ADHD, more powerful contingencies (e.g., token economies, contin-
gency contracting, response cost, and time out from reinforcement) are
often necessary to promote behavioral change (Barkley, 1998). DuPaul
and Stoner (2003) recommend a more proactive and reactive approach,
where events that precede inattentive and disruptive behaviors should
be manipulated to prevent problematic behaviors from arising. Reactive
strategies should not only include a punitive response, but also positive
when appropriate behavior is noted to occur. Another important factor
for interventions in the classroom is that they are most effective when
introduced at the point of performance (Goldstein & Goldstein, 1998).
Thus, the strategy must be implemented in close proximity to the target
behavior.
In addition, interventions need to be individualized, taking into
account the child’s academic skills, the function of the behavior, the tar-
get behaviors, and any limiting factors related to the setup of the class-
room (i.e., teacher’s approach). An effective approach to intervention for
children with ADHD is one where a number of individuals help to imple-

ment the program (i.e., teachers, parents, peers, identified student; Teeter,
1998). Working in this manner provides a more comprehensive approach
to problematic behavior, where the teacher is not solely responsible for
implementing programs and rewarding all classroom behavior.
Before creating a classroom program for children diagnosed with
ADHD, DuPaul and Stoner (2003, pp. 145–147) suggest that the child’s
treatment team consider the following issues.
(1) There should first be a thorough assessment of the presenting

problem, including a functional assessment.
(2) Children diagnosed with ADHD typically require more frequent
and specific feedback. Thus, contingencies should be delivered
in a continuous manner. Gradually, reinforcement schedules can
become less dense.
(3) The programs should be based on contingent positive reinforce-
ment. Verbal reprimands are also effective if they are given in a
neutral, consistent, and immediate manner following the problem
behavior (Pfiffner & O’Leary, 1993).
(4) When the target behavior is one that occurs during independent work
periods, task instructions should not involve more than a few steps.
The child should be asked to repeat the steps back to the teacher.
(5) Goals in the classroom should include academic products and
performance (i.e., accuracy and work completion) rather than
specific task-related behaviors (i.e., attention to task or staying in
one’s seat). This is important because it promotes accurate teacher
monitoring and organizational skills. Also, these behaviors are
incompatible with inattentive and disruptive behaviors, and may
lead to a reduction in these behaviors (Pfiffner & O’Leary, 1993).
(6) Preferred activities should be used as reinforcers (i.e. free choice,
access to classroom computer). Reinforcers should be rotated as
needed, in order to keep the children interested in them. A reward
“menu” should be created from direct questioning from the child,
regarding what he or she would like to earn. The teacher can also
observe the child engaging in his or her preferred activities in order
to create the reward menu.
(7) In order to increase the likelihood that the child will engage in
appropriate behavior during academic periods, “priming” is rec-
ommended. This includes the teacher reviewing a list of possible
rewards for appropriate behavior prior to beginning the academic
work. This way, the child has a clear idea of what he or she will
earn following the work period, if he or she meets the target
behavior.
(8) Finally, the intervention program must be routinely monitored and
evaluated. Changes in the contingency program could be based on
teacher-observed problems in the system. In addition, independ-
ent observers may also be enlisted to evaluate effectiveness and
fidelity of the program. Such information will help to determine
whether additional teacher training or support is necessary.
A discussion of classroom management strategies in greater detail

now follows.
Token Economy
Token economies provide immediate reinforcement, specific rewards,
and potent rewards, which are often required for children diagnosed with
ADHD. In a token economy, one or more problematic behaviors are tar-
geted for intervention. Target behaviors that focus on academic products
(i.e., completion of a specific number of problems, at a specific rate of accu-
racy) or specific actions (i.e., appropriate interactions with a peer) are often
appropriate. Behaviors that can be easily monitored should be selected.
In addition, the type of secondary reinforcer should be identified. These
can include poker chips, check marks, stickers on a card, or points. For
younger children, more tangible rewards are often recommended, whereas
older children may respond well to check marks or points. A token econ-
omy is not recommended for children under the age of five, rather primary
reinforcers (i.e., praise, social attention) are often suggested. The values
of target behaviors can then be determined. That is, the number of tokens
earned for completion of a target behavior is established.
The teacher and child then develop a list of rewards or privileges
for which the tokens can be exchanged. This list should include
low, medium, and high-cost items. Parents should be encouraged to
participate in this process, and also provide similar reinforcement
contingencies in the home setting. The child should then be taught the
new system. Initial targets are to be set at a level to ensure child success.
Tokens should be exchanged for classroom privileges at least once
daily. In addition, an ongoing evaluation of such a system is necessary,
where new behaviors could be added, mastered behaviors deleted, and
rewards changed or updated. A response cost (i.e., removal of tokens)
system may be incorporated when some appropriate behavior has been
achieved. The system should continue to be changed in order to promote
behavioral improvement and generalization. For example, as a child
masters a multistep task, the child should begin to receive tokens for
task completion and tokens for completion of each step should be faded
(DuPaul & Stoner, 2003).
Contingency Contracting
Another method of classroom behavior management is contingency
contracting. With this technique, there is a negotiated contractual agree-
ment between a student and a teacher. Desired behavior and consequences
contingent on this behavior are discussed. This strategy is most effective
with children above the age of seven. In addition, a contingency contract
with children diagnosed with ADHD should not include an extended delay
between the behavior and designated consequences. Reinforcements at
the end of a work period or at the end of the school day may be most
appropriate (DuPaul & Stoner, 2003).
Response Cost
Response cost includes the loss of privileges and points or tokens contin-
gent upon negative behavior. Response cost, used in concordance with posi-
tive reinforcement procedures, is often successful. When used with positive
strategies, response cost increases on-task behavior, seatwork productivity,
and academic accuracy in children diagnosed with ADHD (DuPaul, Guevre-
mont, & Barkley, 1992). An important point to consider when implementing
a system that includes a response cost condition is that the program should
emphasize positive aspects (i.e., earning points/tokens/stickers) over the
negative response cost component. This will be important in order to con-
tinue to motivate the child to engage in appropriate behavior.
Time Out
Time out is another type of mild punishment strategy that may be used
for the classroom. This technique involves restricting a child from positive
reinforcement. In order to be effective, this approach must be used when
there is a reinforcing environment to be removed from, when the function
of the child’s behavior is to gain teacher attention, when it is implemented
immediately after the negative behavior occurs, and when the smallest
amount of time for the strategy to be effective (e.g., one to five minutes) is
used. Similar to the use of response cost strategies, time out should only
occur with ongoing positive reinforcement. Time out should only be used
if more positive and less restrictive behavioral strategies have failed to
address the negative behavior. However, more aggressive or severely dis-
ruptive behaviors should immediately result in the use of strategies such
as time out (DuPaul & Stoner, 2003).
Daily Report Cards

Home–school communication systems, such as daily report cards,
are effective in promoting behavioral change in the classroom. The benefit
to such systems include the child receiving direct contingent feedback
on behavior, daily feedback from a child’s teacher is received by parents
(Chronis et al., 2004), and the possibility of reinforcement for appropriate
behavior in both the home and school environment is present. Please see
an example of a daily report card [adapted from Barkley (1997)] in Figure
6.1. Target behaviors are established for the child. These behaviors are
rated across subject areas throughout the school day.
The ratings include a 1–5 rating pertaining to how well the child per-
formed the behavior in question. This lends itself nicely to both a school
and home token economy system, where the child can earn a certain
number of tokens per appropriate rating. Likewise, response cost condi-
tions could be employed, where the child loses tokens or points for nega-
tive ratings. Although teachers can control the rewards for behavior in the
school setting, they have little control over the home-based rewards for
school behavior. Another drawback to this system is the delay involved in
Date:_____
Daily Report Card
Please rate behavior today in the areas listed below.
Use the following 1-5 ratings:
5 = excellent 4 = good 3 = fair 2 = poor 1 = very poor
Initial the box at the bottom of the column rated.
Send this card home each day! Add comments about
behavior on the back or bottom of the card.
Examples of Behaviors to be rated: Class periods
8–9 9–10 10–11 Lunch 12–1 1–2 2–3

1. Turned in homework/class
work
2. Began assignment with 3 or
fewer prompts.
3. Completed assignment with
80% accuracy
4. Followed Classroom Rules
Teacher’s initials
FOR _____ (Check them as you do them):
Wrote homework assignments

Teacher checked off homework assignments
Packed books needed for homework
Homework folder
Math book
Science book
Reading book
Social Studies book
Spelling book
Teacher Comments or Updates:

Figure 6.1. Daily Report Card (adapted from Barkley, 1997).
the home-based rewards, which may be difficult for children diagnosed

with ADHD (DuPaul & Stoner, 2003).
In order for this type of system to be successful, target behaviors/goals
should be stated in a positive manner. In addition, academic and behavioral
goals should be included in such a system. One or two of the target behaviors
should be readily attainable by the child. This will help the child to be moti-
vated by the system, and make it more probable for him or her to eventually
achieve more difficult target behaviors. In addition, it is important for the sys-
tem to only include three to four target behaviors in order to keep the teacher
and child from becoming overwhelmed. The daily report card allows for fre-
quent, specific quantitative feedback throughout the school day. In addition,
frequent feedback prevents the loss of motivation for children. For example,
if the child does not meet his target behaviors in the morning, there are still
several chances for him to meet the target behavior throughout the school
day. In addition, there must be long- and short-term rewards implemented
at home for such a system to be successful. Parental involvement in a daily
report card system is essential in its success. Ongoing monitoring and evalu-
ation is also important with such a system.
SELF-MANAGEMENT SYSTEMS
A goal for the treatment of children with ADHD is often to increase

self-control, which is quite difficult for children diagnosed with ADHD,
given their difficulties with inattention, hyperactivity, and impulsivity.
Self-management systems for ADHD include self-monitoring and self-rein-
forcement. These strategies are often referred to as cognitive-behavioral
interventions, given that they focus on changing cognitions and behavior.
Given the difficulties that children with ADHD have with internalization
of language, these strategies are not commonly used with this population
(Miranda et al., 2006). Research has not found these strategies to be con-
sistently successful (Abikoff, 1985), thus, they are only briefly discussed.
Self-Monitoring
This strategy includes the observation and self-recording of instances
of target behaviors. Typically an auditory or visual cue is used to remind
the child to record her behavior at a specific time. The child would then
record the behavior on a graph on her desk. Attention-related behaviors
have been found to increase with the use of such a strategy (Barkley,
Copeland, & Sivage, 1980). However, some suggest that self-monitoring
is most effective when a child is monitoring task completion or accuracy
instead of attentive behavior.
Self-Reinforcement
With self-reinforcement, children are required to monitor, evaluate,
and reinforce their own performance. This type of system is often useful
when other more externally based systems are being faded out (Barkley,
1989). In addition, this type of strategy may be more acceptable at the
secondary level, given that children in this age range are likely to be reluc-
tant to engage in an overt contingency management system (DuPaul &
Stoner, 2003). It is important to keep in mind that children diagnosed with
ADHD often have difficulty accurately rating their own behavior. Often
there is a tendency to remember positive behaviors rather than negative or
off-task behavior. Thus, it will be important to have a discussion with the
child regarding expectations for behavior, including what might warrant
a lower rating. The child will also need to be informed of privileges that
may be earned. The goal of such as a system is to eventually train the
child to monitor his or her own behavior, without constant feedback from
a teacher (DuPaul & Stoner, 2003).
Instructional Strategies
In addition to contingency management strategies, children with
ADHD also benefit from more instructional strategies in the areas of aca-
demics, learning, and study and social skills (DuPaul & Stoner, 2003).
Peer tutoring is an instructional strategy that can be helpful for children
diagnosed with ADHD. This consists of two students working together on
an academic activity, with one student providing assistance, feedback,
and/or instruction. For this strategy to be successful, it is important for
there to be a one-to-one ratio, that the instruction remain self-paced by
the learner, that there is continuous prompting, and that there is frequent
and immediate feedback about the quality of performance.
In addition, task modifications can also help to improve the performance
of children diagnosed with ADHD. This involves revising the curriculum or
aspects of it in an attempt to reduce problem behaviors. One such strategy
is choice-making, where a student chooses an academic task from two or
more options. Dunlap et al. (1994) examined this modification and found
that it resulted in reliable and consistent increases in task engagement and
a reduction in disruptive behavior. Increased task structure is also noted to
improve behavioral functioning in the classroom (Zentall & Leib, 1985).
Social skills instruction is also another important strategy for children
diagnosed with ADHD, given their difficulties with making and keeping
friends. Typically social skills training consists of role-playing a variety of
skills, such as asking questions, listening, cooperating, complimenting, and
so on. Researchers have approached social skills trainings from many fronts.
More specifically, at times the children practice the skills daily in the classroom
(Anahalt et al., 1998). Other methods include a social skills review with a peer
through a buddy system (Hoza et al., 2003). Social skills training can also be
woven into sports activities, where students practice their social skills in a
less-structured environment (Evans et al., 2004; Hoza et al., 2003).
In summary, classroom behavior management strategies include token
economies, contingency contracting, response cost, and time out. Self-evalu-
ation and other instructional strategies have also led to some behavioral and
social improvement for children diagnosed with ADHD. Such systems should
include an individualized approach to addressing child needs, while using
data to guide the creation, implementation, and revisions of the program. The
most successful school-behavior plans for children diagnosed with ADHD are
those which include a team approach (i.e., teachers, parents, peers), where
there is adequate support and training for each member of the team. In addi-
tion, classroom behavior plans should be implemented in an ongoing man-
ner, given the chronic nature of ADHD.
SUMMER TREATMENT PROGRAMS
There is a consensus from numerous empirical sources that behavioral

parent training and behavior contingency management in the classroom
are well-established treatment approaches for children with ADHD (e.g.,
Chronis, Jones, & Raggi, 2006; Lonigan, Elbert, & Johnson, 1998; Pelham
& Fabiano, 2008). More recently, convincing evidence for the treatment
efficacy of intensive summer treatment programs has been presented (Pel-
ham & Fabiano, 2008). These programs are peer-based interventions and,
therefore, emphasize the development of social skills within an appropriate
social context. In this way, they are similar to other social skills programs
that utilize peers but these other programs have generally failed to meet
the stringent criteria for a well-established, evidence-based intervention
for ADHD (e.g., Antshel & Remer, 2005). Summer treatment programs dif-
fer from other behavioral peer interventions in terms of the intensity and
comprehensiveness of the intervention.
Summer treatment program (STP) interventions are typically day-
long programs conducted for multiple weeks (e.g., five to eight weeks)
thereby delivering hundreds more hours of treatment compared to the
typical outpatient program. The intervention adopts a broad skills-
building approach conducted concurrently with contingency manage-
ment systems such as a point or token system and time out procedures.
The focus on the development of socially important functional skills
and the use of direct observational methods during group peer interac-
tions are hallmarks of the program.
Figure 6.2 illustrates a daily schedule for a STP with three groups.
The typical STP program is multifaceted and incorporates numerous
intervention components including social skills training, problem-solv-
ing discussions, sports skills and team membership development, aca-
demic and art instruction, contingency management systems, parent
education, and a home-based reward program (Pelham, Greiner, &
Gnagy, 2004). The program’s extensive procedures have been manual-
ized and incorporate features for daily monitoring of a broad range of
child behaviors and daily monitoring of counselors and teachers for
treatment fidelity (Pelham, et al., 2004). Because of the intensity and
comprehensive nature of the program, however, it is considerably more
difficult to implement than typical psychosocial interventions, a factor
that may currently limit its clinical utility in typical community settings
(Pelham & Fabiano, 2008).
The STP model was designed as an intensive summer day-treat-
ment program primarily for children with ADHD and related disorders.
The model for the STP has been developed over a period of 25 years by
William Pelham, first at Florida State University, then the University of
Pittsburgh, and currently at SUNY Buffalo (Pelham et al., 2004). This
program has also been established and replicated in sites across the
country, as well as internationally (Yamashita et al., 2006). The STP
was an integral component of the psychosocial treatment package of
the Multi-modal Treatment Study, the largest randomized clinical trial
ever conducted for the treatment of ADHD (MTA Cooperative Group,
1999a). As a result of its exceptional record in clinical, training, and
research endeavors, the STP was named in 1993 as a Model Program
for Service Delivery for Child and Family Mental Health by the Section
on Clinical Child Psychology and Division of Child, Youth, and Family
Services of the American Psychological Association (Pelham, Fabiano,
Gnagy, Greiner, & Hoza, 2005).
Prior to 1998, the evidence base supporting the effectiveness of STPs was
relatively weak, relying primarily on uncontrolled pre–post studies (Pelham &
Hoza, 1996) and analogue studies (e.g., Pelham & Bender, 1982). A number
of these earlier studies also focused on ADHD medication trials because the
STP model provides an excellent setting in which to evaluate medication
effects (e.g., Pelham, McBurnett, Milich, Murphy, & Thiele, 1990). For exam-
ple, STPs have been an important site for the development of the methylphe-
nidate transdermal patch, now approved for the treatment of ADHD by the
FDA (Pelham, Manos et al., 2005). More recently, however, attention has been
focused on the systematic and well-controlled study of the treatment efficacy
of behavioral components of STPs and establishing the empirical support for
their therapeutic potential. This is due in part to the inclusion of the STP as
a component of treatment for the MTA study.
As discussed in another section of this chapter, debate continues over
how best to interpret the results of this large multisite collaborative study
(e.g., Pelham, 1999) but the empirical support for the role of intensive
behavioral interventions such as STPs in improving the functional impair-
ments associated with ADHD appears to be quite strong (e.g., Chronis,
Fabiano, & Gnagy, 2004). In fact, several recent studies have found that
STPs yield treatment effect sizes that are comparable to those reported for
stimulant medications.
Pelham et al. (2000), as part of the MTA study, examined the incre-
mental effect of a well-controlled medication regimen when combined
with the intensive STP treatment across a broad range of measures,
including parent and teacher ratings, classroom observations, and
academic performance. This study differed from earlier MTA reports
because it measured treatment effects while each intervention (i.e.,
behavioral and medication) was active. In 1999, the initial report of
the MTA (MTA Cooperative Group, 1999a,b) showed large incremen-
tal effects of medication over behavioral intervention alone and small
incremental improvement for the combination of treatments over medi-
cation alone, however, it was conducted when most of the behavioral
treatment package (including the STP) had been stopped or faded.
The Pelham et al. (2000) study compared the two treatments when
both were active and found that the introduction of adjunctive stimulant
medication to an ongoing STP had no effect on the rate of improvement
and produced relatively few incremental gains on measures of acute
Morning Afternoon
8:00–8:15 – Social Skills 12:15–1:15 – Softball
8:15–9:00 – Soccer skills 1:30–2:30 – Art/Snack
9:15–10:15 – Soccer game 2:45–3:00 – Yoga
10:30–11:30 – Learning Center 4:00–5:00 – Recess/ Departure
11:30–12:00 – Computer Skills
11:45–Noon – Lunch
Figure 6.2. A typical STP schedule.
functioning. On 30 of 35 treatment outcome measures the combination

treatment group did not differ from the behavioral intervention of the STP
and parent training. A notable measure showing an incremental benefit
for medication was peer ratings of acceptance, suggesting peers may have
been more sensitive to some aspect of medication response. The study
authors argue that the traditional approach to behavioral interventions
that involve fading and stopping the more intensive procedures may not
be appropriate for externalizing behavior disorders such as ADHD, given
the known chronicity of this disorder.
Only two studies to date have evaluated the entire multicomponent
behavioral STP intervention to a control condition in which treatment
components are removed. Kolko, Bukstein, and Barrett (1999) manipu-
lated both medication and behavioral interventions in classroom and
recreational settings in a STP located in an urban setting with children
exhibiting ADHD and comorbid disruptive behavior disorders. They
reported that medication and behavioral intervention each demon-
strated unique and incremental effects on behavior that differed across
settings and individual children. The behavioral intervention improved
oppositional behavior in both settings and improved ADHD symptoms,
prosocial behavior, and peer conflicts in the classroom. Behavioral
intervention resulted in incremental effects beyond the effects of medi-
cation on negative behavior in the recreational setting.
Medication improved ADHD symptoms in both settings, and oppo-
sitional behavior and peer conflicts in the recreational setting. There
were no incremental effects of medication beyond behavioral interven-
tion in the classroom. Chronis et al. (2004) utilized a BAB treatment
withdrawal experimental design in which the behavioral components of
the STP (i.e., contingency management procedures, time out, and social
skills training/problem-solving) were withdrawn in the sixth week of
the program. Four groups comprising 44 children participated in the
study. The withdrawal phase left the remaining aspects of the program
intact (i.e., close adult supervision, high staff-to-child ratio, feedback
on behavior, sports skills training). The treatment phase was reintro-
duced after two days and even earlier for two groups whose disrup-
tive behavior presented safety concerns. Across numerous measures
of behavior, academic functioning, and teacher, counselor, and child
ratings, substantial behavioral deterioration occurred during the with-
drawal period. Behavior returned to previous levels when the behavio-
ral intervention procedures were reinstated.
The STP incorporates a wide range of specific behavioral procedures
with proven evidence-based efficacy, including: time out, a point system,
individualized target behaviors, daily report cards, social skills training,
and a parent-training program. The parent-training component involves
weekly sessions throughout the duration of the program and is char-
acterized by a very high attendance rate. Parents are given challenging
parenting problems and encouraged to problem-solve in small groups
(Cunningham, Bremmer, & Boyle, 1995). Regarding the social skills
training component, the STP has typically emphasized a small number
of general social skills (e.g., validation, cooperation) that are discussed in
role-playing and problem-solving sessions at the beginning of each day

then discussed before and after each activity.
More recently, the STP at the University of Alabama at Birmingham
developed a more comprehensive social skills training component that
incorporates 14 specific behaviors, scripted role plays for counselors and
children, and weekly rewards (Patterson & Guion, 2007). The time out pro-
cedure in the typical STP is notable for having built-in incentives for com-
pleting a time out appropriately (i.e., reduced time) and disincentives for
lack of cooperation with time out (i.e., additional time added). Individual
target behaviors are developed for each child at the end of the first week
Therefore, it is difficult to determine the effect of any specific pro-
cedure within this broad context without systematically evaluating the
impact of each procedure while holding other components of the program
constant. This was the goal of a recent study by Fabiano et al. (2004) of
the time out procedure. The STP time out procedure is used when children
exhibit any of three behaviors: intentional physical aggression, intentional
property destruction, or repeated noncompliance.
A relatively unique aspect of the STP time out procedure (at least in
terms of researched variables) is the opportunity for the child to earn
an incentive for appropriate behavior during time out, that is, reduced
time. For example, if the child is issued a 20-minute time out for physical
aggression and goes immediately to the time out area without complaint
and remains there quietly, the time out is reduced to only 10 minutes. On
the other hand, the child can also have their time out escalated if they
exhibit any negative behaviors during the time-out, up to a maximum of
one hour.
Fabiano et al. evaluated the effectiveness of three types of time
out procedures versus a no time out condition in which no time outs
were issued. The three types of time-out were the typical escalating/
de-escalating procedure described above, a short (5-minute), and long
(15-minute) time out with no contingency on time out behavior. All three
types of time out were more effective than the no time out condition in
reducing the occurrence of physical aggression, property destruction, and
repeated noncompliance in both classroom and recreational settings. These
results were obtained while all other aspects of the intensive treatment
remained in effect. There were no group differences between the three time
out procedures, suggesting that the commonalities (e.g., removal from
a reinforcing activity) were more important than the parameters under
investigation. In evaluating the impact of adding the time out procedure
to the treatment package, the study authors found effect sizes that were
comparable if not superior to the effect sizes obtained when stimulant
medication therapy was added.
The effects of STP behavioral interventions versus stimulant medi-
cation therapy have been evaluated more specifically in the program’s
classroom environment in two studies (Carlson, Pelham, Milich, & Dixon,
1992; Pelham, et al., 1993). Both studies employed a crossover experi-
mental design in which behavioral intervention procedures were imple-
mented during some weeks but not others, and behavioral intervention
was crossed with stimulant medication therapy.
Both studies reported significant improvements across a wide range of

objective and teacher-reported measures when the behavioral intervention
procedures were in effect. However, the effects of the behavioral interven-
tion were not significant for all measures and were smaller in size than
the effects of high doses of stimulant medication. A possible explanation
for the relatively weak effect is that the children continued to receive the
full behavioral intervention when they were not in class (e.g., during rec-
reational activities and art class) and this may have had a carryover effect
into the classroom.
More recently, Pelham, Burrows-MacLean, et al. (2005) extended this
research design to the entire STP and crossed it with four doses of stimulant
medication, including a no-medication condition. Behavioral interventions
were removed for alternating weeks for four weeks and medication conditions
were varied across days for each child. The results showed significant effects
of medication and behavioral interventions across classroom and recreational
settings. When combined with behavioral interventions, the lowest dose of
medication produced effects similar to those associated with the highest does
of medication alone. Employing odds ratios, Pelham et al. demonstrated that
the combined use of medication and behavioral interventions produced sig-
nificantly better treatment response than either treatment used alone. For
example, the sequence of adding the behavioral intervention to a low dose
of medication improved the odds of obtained a positive daily report card by
ten times, whereas the sequence of adding the low dose of medication to the
behavioral intervention improved the daily report card odds by four times.
The empirical support for the treatment efficacy of summer treatment
programs is impressive. Concern has been expressed, however, regard-
ing the lack of evidence for the generalization of treatment gains into the
school and home environments (Barkley et al., 2000). This concern has
been addressed to some extent by advocating for the implementation of
STPs within the context of a comprehensive approach to the treatment of
ADHD, one that recognizes the need for intensive interventions and poten-
tially long-term involvement (Pelham, Fabiano, et al., 2005).
Pelham et al. report an approach to treatment that includes a Sat-
urday Treatment Program following the STP. This is a bi-weekly program
that meets September through May with a format and goals similar to the
STP. This program is coupled with school meetings for the establishment
of interventions in the classroom to which the child is returning and peri-
odic booster sessions for parents, all of which provides an ongoing level of
support for the child and family throughout the school year.
Another possible concern regarding STPs is the cost/benefit ratio for
this type for service (Jensen, Hinshaw, Swanson, et al., 2001). This is an
important issue that can be furthered delineated into two more specific
questions: what is the minimal level of behavioral intervention required to
achieve desired results, and which children are going to benefit most from
these interventions? Current research is focused on answering these two
questions. Pelham and his research group are systematically evaluating
the effects of altering the length, staff-to-child ratios, and other aspects of
the STP model to determine the most important parameters for behavior
change and how to most efficiently deliver an intensive service.
SUMMARY
There have been many methods and procedures highly touted as effec-
tive treatments for ADHD (e.g., Feingold, 1974) but only a handful have
stood the test of randomized and well-controlled clinical trials and repli-
cation. These are the evidence-based approaches described in this chap-
ter, that is, medication (primarily stimulants), parent behavioral training,
classroom management strategies, and intensive peer-based interven-
tions such as the summer treatment program that incorporate all of these
approaches in a comprehensive package. Even among these scientifically
validated approaches, it appears they are effective only when active and
may not lead to enduring changes if stopped.
Increasingly, researchers and clinicians in the ADHD field recognize
the chronic and intractable nature of this disorder as they attempt to
further develop and refine intervention methods that provide the needed
level of support and treatment on a continual and long-term basis. The
heterogeneity and variability in both the behavioral phenotype of ADHD,
its likely underlying neural bases, and the many genetic, physical,
and psychological contributing etiological factors are also increasingly
recognized as adding to the complexity of devising treatment strategies
that will apply effectively to the disorder as a whole (e.g., Nigg & Casey,
2005). It is clear that a unitary treatment approach will likely never be
the case and the continuing developments in neuroscience, molecular
genetics, and other scientific fields will likely lead to further refinements
and the identification of important ADHD subtypes, which have direct
implications for treatment.
Currently, clinicians are encouraged to carefully monitor the treat-
ment response of each child with ADHD and consider the relative mer-
its of a multimodal approach that incorporates some combination of the
strategies described in this chapter. Researchers are currently evaluat-
ing the critical components of the multimodal approach, in particular the
sequence with which different treatments are introduced and the relative
“dose” of each treatment that is required to produce the desired level of
change and sustain it over time. Parents of children with ADHD have made
it clear that the level of change they desire for their families goes beyond
the simple reduction of ADHD symptoms and includes the improvement of
functioning in all important areas of daily living.
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7
PTSD, Anxiety,
and Phobia
THOMPSON E. DAVIS III
INTRODUCTION
The treatment of childhood anxiety disorders is one of the most interest-

ing and gratifying experiences in clinical psychology. For example, by using
techniques such as exposure to feared stimuli, a clinician can regularly effect
significant reductions of psychopathology in many youth in as little as a single
session for some disorders (e.g., specific phobias; cf., Öst, Svensson, Hellström,
& Lindwall, 2001). Moreover, the clinician is afforded the invigorating oppor-
tunity to handle and manage various stimuli (e.g., snakes, dogs, and insects)
that defy the common treatment session stereotype. Although certainly not all
anxiety disorders are so quickly amenable to treatment efforts, there has been
something of a renaissance in child anxiety treatment research since the intro-
duction of evidence-based practices (EBPs) over a decade ago and the identifi-
cation of the first empirically supported treatments (ESTs) for children.
Simultaneously, however, this attention and research is overdue and
deserved. There is an urgent need to continue child treatment research,
particularly with anxiety disorders. Based upon a recent review, it has
been estimated that between 2.4% and 23.9% of preadolescent children
have anxiety disorders depending on the disorder(s), sample, time period,
and methodologies used (Cartwright-Hatton, McNicol, & Doubleday, 2006).
Moreover, results of at least one study indicate that by 16 years of age 36.7%
of children will meet diagnostic criteria for at least one DSM-IV disorder
(i.e., Diagnostic and Statistical Manual of Mental Disorders–fourth edition,
American Psychiatric Association, 1994), and that 9.9% will meet criteria for
an anxiety disorder (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003).
Anxiety disorders in children have been associated with interference
in academic endeavors (Last, Hansen, & Franco, 1997) and even include
THOMPSON E. DAVIS III • Louisiana State University

184 THOMPSON E. DAVIS III
statistically and clinically significant decrements in intellectual ability (i.e.,

IQ) when compared to children with no psychopathology (Davis, Ollendick,
& Nebel-Schwalm, 2008). Childhood anxiety disorders are also commonly
associated with social (e.g., social incompetence) and emotional (e.g., depres-
sion) difficulties that can further affect healthy development (e.g., Grills &
Ollendick, 2002; Kovacs, Gatsonis, Paulauskas, & Richards, 1989; McGee,
Feehan, Williams, & Anderson, 1992). Moreover, the effects of anxiety have
been found to continue into young adulthood and include increased risks
for added psychopathology and educational difficulties (Cantwell & Baker,
1989; Seligman & Ollendick, 1999; Woodward & Fergusson, 2001).
Even though child anxiety treatment research has flourished over the
last decade with 26 randomized clinical trials (RCTs) included in the review
that follows, much of the extant literature remains dated with monumen-
tal gaps in our understanding of how to best treat child anxiety disorders.
For example, although studies are underway, no RCTs have been pub-
lished to date specifically examining the effects of treatment on generalized
anxiety disorder, separation anxiety disorder (note: several studies have
examined them in combination with other disorders; e.g., Kendall, 1994),
or panic disorder.
This chapter briefly reviews anxiety and its disorders affecting children
and then elaborates on the current state of the empirical evidence sup-
porting behavioral and cognitive-behavioral treatments. Those interested
in more detailed descriptions of cognitive-behavioral therapy or pharma-
cotherapy are directed to Chapters 3 and 5 in this volume. Additionally,
the reader is directed to Chapter 10 in the companion volume (Matson,
Andrasik, & Matson, in press) of this work and to the recent review by
Silverman and Ollendick (2005) for more detailed assessment procedures
and recommendations.
ANXIETY DISORDERS IN CHILDHOOD
Normative and Diagnostic Considerations

Anxiety and fear are common emotional responses and not typically
the focus of clinical attention unless they are experienced with unusual
intensity, frequency, duration, or content (DSM-IV-TR, American Psychi-
atric Association, 2000). Nonclinical fear and anxiety are even adaptive
and healthy emotional experiences and display a normative pattern across
development. The occurrence and intensity of fears typically decrease with
age (Gullone, 2000), whereas the capacity for worry increases with age
and cognitive development (Muris, Merckelbach, Meesters, & van den
Brand, 2002). Children’s development emotionally can be loosely tied to
their development cognitively (i.e., tied to developmental capabilities from
concrete to increasingly elaborate and abstract thought). Children move
from very specific, concrete fears of the surrounding environment during
infancy (e.g., loud noises, separation); to fears of the supernatural, physi-
cal harm, and criticism in childhood; and finally to fears of social situa-
tions, global events, and more abstract or anticipatory concerns (Gullone,
PTSD, ANXIETY, AND PHOBIA 185
2000). Most of these fears subside with age, however, a fear of death and
danger generally persists throughout development (Gullone, 2000).
Clinical levels of fear and worry typically distinguish themselves from
this common developmental course by an undue persistence and intensity
of fearful and anxious reactions. Most fears and anxieties are presum-
ably corrected through disconfirmatory experiences (e.g., corrective infor-
mation, positive encounters, experience coping with negative encounters,
repeated exposures) in concert with increases in cognitive-developmental
capabilities. As a result, strong lingering fears and worries are typically
the subject of clinical attention. DSM-IV-TR attempts to incorporate this
developmental understanding of psychopathology through the setting of
somewhat arbitrary duration criteria for children. Depending upon the
anxiety disorder, symptoms must be present for one to six months in chil-
dren before a diagnosis can be made. For example, given the normative
development of fear outlined above, psychopathological fear in children
must persist for at least six months before a diagnosis is warranted (cf.
specific phobia; DSM-IV-TR). Unfortunately, beyond this and other minor
developmental adaptations, the assessment, diagnosis, and treatment of
children is still overly influenced by theories and practices from the adult
literature, although approaches based on children are slowly emerging
(Barrett, 2000).
Depending upon how one counts disorders in the DSM-IV-TR, there
are as many as 13 broad anxiety-related diagnostic categories applicable
to children: separation anxiety disorder, panic disorder, agoraphobia, spe-
cific phobia, social phobia, obsessive-compulsive disorder, posttraumatic
stress disorder, acute stress disorder, generalized anxiety disorder, anxiety
disorder due to a medical condition, substance-induced anxiety disorder,
anxiety disorder not otherwise specified, and adjustment disorder with
anxiety or mixed with anxiety and depressed mood. Although the valid-
ity of the DSM nosology has been repeatedly challenged (e.g., Achenbach,
2005), these anxiety disorders are generally meant to capture variations in
the focus of the anxiety or fear and its maladaptive expression (e.g., social
worries, separation worries, pervasive worry). The present chapter focuses
on several disorders that have been the primary focus of research with
children (see Table 7.1).
Etiology
Even though anxiety disorders are among the most prevalent mental
health concerns in children, the various paths leading to their acquisition
have not been completely determined at this time. The literature is divided
into associative, nonassociative, and integrated accounts. Although a
detailed discussion of this debate is beyond the scope of this chapter (see
Fisak & Grills-Taquechel, 2007; Muris, Merckelbach, de Jong, & Ollen-
dick, 2002), four pathways of acquisition have been suggested that can
work individually or in combination: acquisition by way of direct condi-
tioning experience, acquisition by way of vicarious learning, acquisition by
way of information about the stimulus, and acquisition by nonassociative
means (Ollendick & King, 1991; Rachman, 2002).
Table 7.1. Characteristics of DSM–IV–TR Anxiety Disorders Chosen for Review

Disorder Description
Separation SAD is the only specifically childhood anxiety disorder in the DSM-IV-TR.
Anxiety The primary feature is persistent concern, excessive distress, and/or
Disorder (SAD) worry associated with real or imagined (e.g., kidnappers) separation
from home or primary attachment figures.
Panic Disorder The primary feature of PD is the presence of an intense, recurring, and
(PD) generally unpredictable, physiological reaction and anxious sensation
(i.e., a panic attack) that leads to significant concern, worry, or avoid-
ance behavior.
Specific Phobia The primary feature of SP is a markedly intense fear of specific identifia-
(SP) ble objects, animals, situations, environments, and the like that evoke
an anxiety response and lead to significant avoidance and/or distress.
Social Phobia The primary feature of SoP is a markedly intense fear of social situations
(SoP) or performances in which social evaluation may take place leading to
an anxiety response and significant avoidance and/or distress.
Obsessive- The primary features of OCD are persistent obsessions (thoughts or
Compulsive impulses) or compulsions (repetitive compensatory behaviors), and
Disorder (OCD) typically both, that significantly interfere with life for more than one
hour each day.
Posttraumatic The primary features of PTSD follow exposure to death or a life-threaten-
Stress Disorder ing situation in which helplessness, fear, hopelessness, or horror were
(PTSD) intensely experienced. Features fall into re-experiences of the trauma,
avoidance of trauma cues and situations, numbing, and increased,
persistent physiological hyperarousal.
Generalized The primary feature of GAD is persistent (occurring more days than not),
Anxiety excessive, uncontrollable worry regarding myriad domains and topics
Disorder (GAD) that is associated with intense somatic symptoms or disturbance.
In addition, the case may be that learned and innate accounts of fear and
anxiety acquisition are merely different extremes on the same continuum
(Marks, 2002). Developmental experiences and the unique predispositions
of a child may lead to an acute, innate, defensive fear or anxiety at one end
or a traditionally conditioned disorder resulting from traumatic experience
at the other. In essence, the developmental question regarding the etiology
of anxiety may be how much association to a stimulus is required given a
particular child or adolescent’s innate predisposition and intensity of phys-
iological response to the stimulus (Marks, 2002).
Family
Family also plays a role in the development and maintenance of anxiety.
The child is most often seen as the patient in therapy, however, the
effects of the family environment and relational ties to its members can
have varying influences on child anxiety. The literature on the rela-
tionship between family and anxiety in children has generally focused
on parental acceptance, overcontrol or overprotection, and the parental
modeling of anxious behaviors. According to a review of nonretrospective
studies by Wood, McLeod, Sigman, Hwang, and Chu (2003), parents

who were observed to be more critical and less accepting were associ-
ated with children with anxiety or anxiety disorders. Similarly, anxiety
in children has been associated with parents observed to be overcon-
trolling or overprotective. Finally, parental modeling of anxiety was also
associated with increased child anxiety in the literature. Generally,
findings were stronger for studies using behavioral observation com-
pared to self-report (Wood et al., 2003).
Although the direction of these influences has yet to be established, the
family environment and its members are variables that the clinician must
incorporate into treatment. For example, slightly better long-term treat-
ment response has been found for children receiving a cognitive-behavio-
ral treatment designed to address these family issues than for children not
receiving the family component (Barrett, Dadds, & Rapee, 1996).
Theories
Throughout a typical day discussions regularly focus on “feeling” a
certain way. Objectively, this “feeling” is a very complex event composed of
physiology, behavior, and cognition (Lang, 1979) and has been the subject
of decades of psychological theory and empiricism. Several theories of
emotion have been developed to explain the relative contributions of physi-
ology, behavior, and cognition to an emotional response. For example, Beck
and Clark (1997) proposed a three-stage schema-based model in which
the initial perception of threat is increasingly elaborated upon through
automatic and strategic processing. Accordingly, anxiety is thought of as
a system of cognitive biases and inaccurate or excessive threat determina-
tions. Barlow (2002) has advanced a triple vulnerability theory in which
biological, generalized psychological, and specific psychological vulner-
abilities interact with stress and chance pairings of panic symptoms (i.e.,
“false alarms”) to produce psychopathology. Similarly, Mineka and Zinbarg
(2006) have updated the learning model by incorporating prior learning
experiences and temperament with more emphasis on social learning
and vicarious learning experiences, in addition to direct experiences and
elaborating on common misconceptions of the associative approach.
Recently, however, an information-processing approach has been dem-
onstrated to be a particularly relevant theory for evaluating treatments for
childhood anxiety (Davis & Ollendick, 2005). Bioinformational theory is
based on an information-processing model of fear in adults, but has grown
to become a theory of the organization of emotion and emotional response,
especially as adapted and elaborated into Emotional Processing Theory
(EPT; Foa & Kozak, 1986, 1998). According to Lang, Cuthbert, and Bradley
(1998), emotions are “action dispositions” that are cued by the stimulation
of relevant associative networks contained in long-term memory (p. 656).
These networks differ from other knowledge structures by incorporating
direct connections to motivational components and are organized within
the broad appetitive and aversive systems (Lang et al., 1998).
Emotional networks and emotional responses can be categorized
broadly as belonging to either approach and pleasure networks or fight
and flight networks. These networks, in turn, are composed of associations

of concepts and units of information. These units of information are sub-
divided into three conceptual types: response, stimulus, and meaning
(Drobes & Lang, 1995; Foa & Kozak, 1998; Lang et al., 1998). Response
units evolved from Lang’s early work and are associated with the three
components of an emotional response: physiology, behavior, and cognition.
Stimulus units contain information relating to the sensations associated
with a stimulus and serve to cue much of the associative network. Mean-
ing units serve to connect sensations and responses and contain semantic
or declarative knowledge (Drobes & Lang, 1995; Lang et al., 1998).
Lang et al. (1998) stated two main assumptions of bioinformational
theory. First, emotional networks are triggered by an accumulation of
information that matches units of information represented in long-term
memory. Given the context and qualities of this incoming information,
little, part, or all of an emotional network may be activated. Also, lan-
guage is not a necessary component in this process (Lang et al., 1998).
An emotional network is composed of a great deal of information broadly
categorized into the three types mentioned previously. Language is utilized
to encode and activate some parts of an emotional network; however, lan-
guage is not the sole means of encoding or processing emotion.
Emotional networks are composed of complex associations among units
of information, such as conditioning experiences, representations of stim-
ulus qualities, behavioral responses, physiological responses, and verbal
responses. The conscious processing of many of these associations is not a
prerequisite of their encoding or activation. Causal connections frequently
elude the attention of the conscious mind (e.g., classical conditioning). As
such, language is but a small part of the information that can trigger the
activation of an emotional network (Lang et al., 1998). The theory does, how-
ever, allow for representations to be processed by the conscious mind. These
representations are interpreted to be the subjective experience of emotion.
Second, Lang et al. (1998) assume that increased coherence within an
emotional network will increase the likelihood for activation of that net-
work. More specifically, when units of information in an emotional network
have increased associative strength among them (i.e., greater coherence),
the activation of a single unit is more likely to facilitate the stimulation of
other representational units in the network and evoke the emotion. In addi-
tion, the repeated activation of an emotional network potentiates its activa-
tion and has a priming effect. The resulting coherence allows vague stimuli
to more readily access the emotional network and activate varying degrees
of the emotional response. For example, a curled hose detected in weeds
will readily initiate the processing of a snake phobic individual’s associated
emotional network (Lang et al., 1998). In this way, a variety of different
stimuli may activate an emotional network that has greater coherence.
Any of the three types of units stimulate the activation of associated
units in the emotional network. The emotional network is activated when
incoming information increasingly overlaps with units of information con-
tained in that network. The matching information begins to aggregate in
working memory until an emotional network is triggered. The subsequent
constellation of physiological, behavioral, and cognitive responses is an
emotion. The emotional intensity, verity, and response depend on the

type and number of units of information activated within a network. The
result is that an emotion is a differentially assembled amalgam of sensory,
motoric, physiological, and semantic elements.
The process described above is a dynamic one. One part of the process
does not occur in a void without the others. Incoming information leads
to the activation of emotional networks which further leads to emotional
responding which leads to more incoming information and so forth. The
processing of these emotional networks is key to the actual structure of
that network changing or remaining the same (Lang, 1977). Moreover, ini-
tial findings have indicated children may process aspects of emotion in
behavioral, cognitive, and physiological ways similar to that of adults (e.g.,
affective pictures; McManis, Bradley, Berg, Cuthbert, & Lang, 2001).
As described above, bioinformational theory provides an account of
the activation of fear and anxiety networks and associated responses. In
essence, fear and anxiety are conceived of as neural programs that facili-
tate escape and the avoidance of danger or threat (Foa & Kozak, 1986).
Everyone experiences fear and anxiety, and in most circumstances that
fear and anxiety dissipate as the potential for harm decreases. Patho-
logical fears and worries differ, however, from other networks in several
meaningful ways. Pathological networks incorporate inaccurate views of
the world that are accompanied by exaggerated emotional responses, the
avoidance of harmless stimuli, and an overall resistance to change (Foa &
Kozak, 1986, 1998).
Bioinformational theory also incorporates an explanation for incom-
plete emotional responses to stimuli. Rachman (1976) suggests that
there are eight possible combinations of physiological disturbance, avoid-
ance behavior, and subjective fear (cognition) when considering emo-
tional responding. When all three components of an emotional response
are concordant (i.e., positively correlated) and synchronous (i.e., change
together; Rachman & Hodgson, 1974), then the network has been fully
activated (Lang, 1977). However, when the characteristics of the stimu-
lus are insufficient to activate the entire network, no response or a par-
tial response may result (Lang, 1977). The lack of covariation among the
response components is called discordance, and the potential for emo-
tional responses to change independent of one another or change inversely
is termed desynchrony (Rachman & Hodgson, 1974). The properties of
the stimulus situation are not sufficient in these instances to evoke the
full emotional response. Additionally, desynchrony may be the result of
a particular response being potentiated after repeated activation. In this
instance, the associative network is organized primarily around stimuli
that activate a particular response component.
Desynchrony depends on several factors. Specifically, “it is a function
of the intensity of emotional arousal, level of demand, therapeutic tech-
nique, length of follow-up, and choice of physiological measure” (Hodg-
son & Rachman, 1974, p.325). Desynchrony is thought to decrease during
high arousal, increase during high demand (i.e., increasing motivation),
and vary by treatment modality. Even so, a critical component of treat-
ment outcome seems to be the activation of the entire emotional network
(Foa & Kozak, 1986, 1998; Lang, 1979). Therapeutic technique (e.g., expo-
sure) may, however, necessitate the uncoupling of fear (i.e., physiological-
affective response and verbal-cognitive response) and behavioral avoidance
(Hodgson & Rachman, 1974). Even so, the synchrony of heart rate (physiol-
ogy) and subjective units of distress (cognitions) has been associated with
greater treatment benefit and desynchrony between these components with
a lack of response to treatment (Vermilyea, Boice, & Barlow, 1984).
Applying Theory to Practice

Treatment as Modification of an Emotional Network
According to bioinformational theory and EPT (Foa & Kozak, 1986,
1998), a lack of emotional processing is a critical element in the main-
tenance of pathological fear and anxiety. Emotional processing prompts
alterations in emotional networks that can lead to an increase or decrease
in emotional responding (Foa & Kozak, 1986). Lang (1977) suggested that
the modification of an emotional network is dependent upon at least partial
activation of that network. Vivid imagery or representations of a stimulus
will activate more information units and lead to increasingly comprehen-
sive processing of the network.
In order for emotional processing to occur, the network must be
accessed and new information must be introduced (Foa & Kozak, 1986). It
is important to note that this new information should be considered just
that—new learning—and not the “unlearning” of previous responses (e.g.,
Myers & Davis, 2002). Essentially, a new context-dependent inhibitory
response has been learned that does not destroy previous learning, but
rather provides an alternative to it (Bouton, 2004). The avoidance associ-
ated with an anxious or phobic response not only negatively reinforces the
behavior (i.e., reinforcement for leaving an anxiety-provoking situation)
but also interrupts any activation that would lead to emotional process-
ing. Emotional processing can also lead to the exacerbation of an existing
pathological fear network. If the activation of a pathological fear network
were associated with the introduction of new negative information, then an
increase in phobic responding would be expected to occur (Foa & Kozak,
1986). For example, existing dog phobia symptoms would be expected to
become more severe subsequent to a dog bite.
Emotional processing is also integral to any successful therapeutic
intervention according to EPT. As before, the memory network must be
engaged and new information must be assimilated into the network. In
therapy, however, the information introduced into the emotional network
must be inconsistent with previous phobic experience and associated mem-
ory structures (Foa & Kozak, 1998). Meaningful therapeutic benefit occurs
as the result of network modification. If treatment were successful and the
pathological fear network were activated and modified, then the intensity of
the fear response should decrease. For example, systematic desensitization
could be described as accessing memory through exposure and offering
new physiological and behavioral information (i.e., relaxation) that is coun-
ter to the physiological information held in the pathological network.
Developmental Psychopathology
A complete approach to treating childhood anxiety requires consider-
ation of developmental psychopathology and the broader context of how
psychopathology interacts with the child’s emotional, cognitive, and social
growth. Successful development requires negotiating myriad developmental
milestones and integrating each successive achievement into an increas-
ingly adaptive outcome. Conversely, incomplete milestones, trauma, and
insults can impede development leading to maladaptive outcomes from the
failure to traverse developmental milestones during key sensitive and critical
periods (Ollendick & Vasey, 1999; Toth & Cicchetti, 1999). In particular, the
individual differences in any one child must be considered through notions
of equifinality (i.e., that different developmental pathways and experiences
can lead to the same outcome) and multifinality (i.e., that similar develop-
mental pathways and experiences can lead to different outcomes).
As a result, treatment of any one disorder in any one child becomes a
complex endeavor in which the child’s memories, experiences, family, rela-
tionships, traumas, responses, etc. are all integrated into unique emotional
networks that have become maladaptive and pathologized and have been
associated with unique developmental insults. For example, an older child
with a fear of separating from a parent (i.e., separation anxiety) not only
presumably suffers from a resistant and maladaptive emotional network
in need of corrective information (i.e., therapy), but has also likely suffered
from social and emotional insults associated with failing to obtain norma-
tive experiences away from the parent. Moreover, treatment for this child
may not just involve providing corrective information through child therapy
and attempting to remedy any developmental insults or deficiencies through
psychoeducation and social skills training, but also may require addressing
the context in which the psychopathology has developed and been main-
tained (e.g., addressing overcontrolling parental behavior). In sum, child
therapy becomes reliant on a thorough and complete assessment of the
child and family in order to plan the best treatment and attempt to remedy
any variables maintaining psychopathology.
Summary
According to bioinformational theory and EPT, pathological fear and
worry, consistent with a diagnosis of an anxiety disorder, are types of
emotional networks composed of various conceptual units. These highly
coherent conceptual units are stored in memory and represent various
aspects of the stimulus, responses to the stimulus, and knowledge about
the stimulus. Stimuli that are insufficient to fully activate the emotional
network (i.e., mildly evocative) or that activate only one or two response
components create desynchronous responding.
Therapy leading to emotional processing can be most effective when
there is a concordant pattern of emotional responding and access to the
entire emotional network is achieved. This is typically best achieved through
exposure (e.g., Kendall et al., 2005). With network activation, erroneous
associations and beliefs, avoidant behaviors, and intense physiological
responses may be countered by new information about the stimulus. In

this way, new information is integrated into the information structure
providing alternate inhibitory learning to decrease the intensity of patho-
logical emotional responses (i.e., reduction of subjective fear, physiological
symptoms, avoidant behaviors, and catastrophic cognitions).
A developmentally informed approach is also necessary in which a
child’s psychopathology is considered within context of the family, the
attainment of developmental milestones, and individual differences due to
equifinality and multifinality. Finally, a thorough assessment is necessary
in order to understand the individual differences unique to any one child
and plan for comprehensive treatment.
ASSESSMENT
Evidence-Based Assessment (EBA)

Given that anxiety can be thought of as resistant networks of exag-
gerated emotional responses (Foa & Kozak, 1986, 1998), it follows that
an assessment should include a thorough evaluation of the emotion and
the components of the anxiety response—namely, physiology, behavior,
and cognition—in addition to the overall subjective emotional experience
(Davis & Ollendick, 2005). Current evidence-based guidelines with children
include a variety of techniques: (1) using structured or semi-structured
diagnostic interviews in addition to open clinical interviews to determine
the presence or absence of anxiety disorders, (2) using rating scale infor-
mation from multiple-informants to quantify symptoms and monitor treat-
ment progress, and (3) using direct observation or behavioral avoidance
tasks to offer additional information and assist in planning for treatment,
especially when exposure is to be used (Silverman & Ollendick, 2005).
Some of the more widely utilized assessment instruments for child-
hood anxiety include the Anxiety Disorders Interview Schedule for Children
for DSM-IV, (ADIS-C/P; Silverman & Albano, 1996), the Child Behavior
Checklist and other Achenbach forms (CBCL; Achenbach, 1991), the Mul-
tidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan,
Stallings, & Conners, 1997), and the Revised Children’s Manifest Anxiety
Scale (RCMAS; Reynolds & Richmond, 1978; see Silverman & Ollendick,
2005 for a review of evidence-based assessment of anxiety in children).
Assessment for childhood anxiety should always utilize multiple
informants from differing environments. Within the anxiety disorders (and
childhood disorders generally) there is commonly disagreement among
reporters as to the presence, absence, and severity of disorders (e.g., Grills
& Ollendick, 2002; Jensen et al., 1999; Silverman & Ollendick, 2005). At
the same time, these disagreements are not trivial and may not represent
misconceptions on the part of the child. For example, Jensen et al. (1999)
reported that when discrepancies existed between parents and children
regarding the presence of an anxiety disorder, clinician verification sug-
gested that both the parents and the children were equally good at accu-
rately identifying an anxiety disorder in roughly 60% of cases.
In other words, children were accurate in reporting anxiety disorder

symptoms their parents did not and vice versa. This finding may impli-
cate differential findings for certain anxieties at certain ages based on the
informant: for example, young children may not realize the unusualness
of their responses although their parents do, whereas adolescents may
be too embarrassed or secretive to outwardly appear anxious (Jensen et
al., 1999). However, support for the hypothesized role of age in explaining
informant discordance is mixed at present (e.g., Choudhury, Pimentel, &
Kendall, 2003; Grills & Ollendick, 2003). In addition, there may be better
agreement between parents and children on symptoms of disorders than
the disorders themselves (Comer & Kendall, 2004). Even though informant
disagreement seems the rule, certain fear- or anxiety-evoking stimuli may
only be encountered in isolated or specific situations making information
from additional respondents valuable (e.g., teacher-report). Although the
issue of digesting information from multiple informants is more compli-
cated than this brief review (cf. De Los Reyes & Kazdin, 2005; Grills &
Ollendick, 2003; see Silverman & Ollendick, 2005 for a review), the need
for multiple sources of information in addition to independent clinician
verification is apparent.
A discussion of the dimensional versus diagnostic assessment of
disorders is beyond the scope of this work (i.e., continuum or rating scale
versus categorical or diagnostic assessments of psychopathology), however,
valid and reliable assessment from both a dimensional and diagnostic per-
spective is crucial in current EBP, and the two are not necessarily mutu-
ally exclusive (Achenbach, 2005). As Silverman and Ollendick (2005) point
out, “if one wishes to use the treatment that possesses the most research
evidence, it is important to first have confidence … that the youth … with
whom one is working [is] in fact suffering primarily from clinical levels of
anxiety” (p. 384). This confidence and certainty is even more crucial given
the field’s increasing receptiveness to ESTs. As a result, both dimensional
and categorical considerations of child psychopathology are important.
An empirical investigation of the necessity of EBA procedures in plan-
ning treatment and their relation to therapeutic outcome has yet to be
conducted (e.g., does using diagnostic interviews result in better treat-
ment outcomes; Nelson-Gray, 2003). Even so, it is important to consider
that empirically supported treatments typically derive their evidence from
RCTs that employ specific and detailed assessments. Consequently, the
failure to use evidence-based assessment in clinical practice, even when
one intends to use an empirically supported treatment, can foreseeably
lead to less than ideal outcomes. Given the heterogeneity of the categorical
diagnostic system (e.g., children with the same diagnosis sometimes meet-
ing almost no overlapping criteria), poor assessment practices could lead
to convergence on a diagnosis and selection of a treatment that may have
limited or no effect. Essentially, assessing children in ways other than
those used in the RCTs might mean one is treating an altogether different
anxiety (although again this has yet to be tested).
For example, imagine a child with a history of anxiety presenting
to you with symptoms of panic and lightheadedness. In particular, she
presents for symptoms primarily following a surgical procedure in which
anesthesia was ineffectually administered (i.e., she reported being semi-

conscious, feeling surgical tugging, etc. but minimal pain). Discussion of
the case may converge upon panic disorder or posttraumatic stress dis-
order focusing on either her history or the traumatic experience; how-
ever, an accurate assessment is needed to also rule out a specific phobia
(i.e., blood-injection-injury type). Although evidence-based therapies exist
for all three diagnostic possibilities, the effective use of these therapies
hinges on obtaining an accurate diagnosis, in particular because the expo-
sures would differ in clinically meaningful ways that could be detrimen-
tal if applied inaccurately (e.g., relaxing in the presence of the stimulus
compared to learning to apply tension or tense muscles when exposed).
Inaccurate diagnosis could lead to the incorrect, although evidence-based,
treatment of having an individual with a specific phobia (and vasovagal
syncope; i.e., propensity toward fainting) relax during exposure.
In addition, it has been pointed out that both dimensional and categor-
ical systems do not readily address the functions of child psychopathology
(Scotti, Morris, McNeil, & Hawkins, 1996). These functions are frequently
addressed either directly or indirectly in treatment, but not reflected in
the treatment literature or in the current diagnostic systems. Even though
functional analysis has been used extensively with children with intel-
lectual and developmental disabilities to assess problem behavior (for a
review see Hanley, Iwata, & McCord, 2003), little has been done to bring
this important behavioral assessment to other disorders.
Functional analysis involves “the identification of variables that influ-
ence the occurrence of problem behavior” (Hanley et al., 2003, p.147).
Problem behavior is thought to have certain functional attributes: to obtain
tangible items, escape demands, receive attention, and/or for reasons that
cannot be determined (i.e., an automatic function). These functions can be
assessed through careful and lengthy experimental sessions that carefully
alter the contingencies of a situation (e.g., experimental functional analy-
sis; cf. Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994) or more
efficiently through interviews (e.g., Questions About Behavioral Func-
tion, QABF; cf. Matson, Bamburg, Cherry, & Paclawskyj, 1999). Although
these practices have become the gold standard of behavioral assessment
for those with disabilities, practices involving the functional assessment
and treatment of typically developing children with psychopathology have
trailed far behind (see Chapters 7, 14, and 15 in Volume 1 for a review of
behavioral assessment techniques in those with intellectual or develop-
mental disabilities; Matson, Andrasik, & Matson, in press).
Likewise, limited attempts have been made to address the functions
of anxious behavior, and although treatments may broadly incorporate
family components they fall short of advances seen with other popula-
tions (e.g., in those with intellectual and developmental delays). Even so,
functional analysis has become more common in the assessment of school
refusal/phobia in children (e.g., Kearney & Silverman, 1993). Also, cogni-
tive-behavioral functional analysis has become a common practice prior to
cognitive-behavioral interventions, but these unstructured interviews are

far from the systematic observations reviewed above. A cognitive-behavio-
ral functional analysis interview typically involves six broad components:
(1) probing for the origins of the anxiety disorder, (2) determining what cat-
astrophic cognitions typically accompany exposure to feared stimuli, (3)
cataloguing the behavioral responses to exposure, (4) obtaining a descrip-
tion of any panic or physiological symptoms experienced, (5) attempting to
uncover any environmental contingencies that might maintain anxious or
fearful behavior, and (6) creating a fear hierarchy for graduated hierarchi-
cal exposure (Ollendick, Davis, & Muris, 1994).
This process is typically completed prior to offering the child and/or
caregiver a rationale for cognitive-behavioral treatment and can be helpful
in individualizing the description of how treatment will proceed. Cognitive-
behavioral functional analyses can be conducted with the child, parent(s)/
guardian(s), or both depending on how much detail any one informant can
provide. In addition, the presence of parents during or after these inter-
views can be helpful in resolving disagreements and discrepancies that may
emerge during assessment (see discussion on multiple informants above).
EVIDENCE-BASED TREATMENT AND ANXIETY

DISORDERS IN CHILDREN
No introduction to treatments for childhood disorders is complete without

discussing evidence-based practice (EBP; i.e., evidence-based assessment,
EBA; evidence-based treatment, EBT; and more specifically empirically
supported treatment, EST). EBP began in the 1990s as practices from the
medical community crossed over into psychology, in particular, efforts to
study treatments in order to subsequently provide the most efficient and
effective care to patients. Propelled by reviews and meta-analyses indi-
cating the positive impact of psychotherapy with children and the need
for more research (e.g., Casey & Berman, 1985; Kazdin, Bass, Ayers, &
Rodgers, 1990), the movement reached a zenith with the release of a key
report by the Task Force on Promotion and Dissemination of Psychological
Procedures (i.e., the Task Force; Task Force, 1995).
This report and subsequent updates set forth varying levels of criteria
by which evidence for the efficacy of psychotherapies could be evaluated
and also reported various “empirically supported (validated) treatments”
based on the literature at that time (Task Force, 1995; followed by Chamb-
less et al., 1996, 1998; and Chambless & Ollendick, 2001; also see the
Journal of Clinical Child Psychology, Volume 27, 1998 and the Journal of
Consulting and Clinical Psychology, Volume 66, 1998 for special issues on
ESTs). Interventions were classified as either “well-established,” “probably
efficacious,” or “experimental” according to their support in the literature.
Treatments found to be well established meet the highest criteria set
forth by the Task Force (1995). In at least two randomized clinical trials or
a series of rigorous case studies (more than nine), well-established treat-
ments must be found equivalent to other established treatments or superior
to pill, psychological placebo, or other therapies of lesser empirical support.
Equivalency must also be with adequate sample sizes to detect differences

(i.e., approximately 30 participants per group; Kazdin & Bass, 1989).
Additionally, the studies for a well-established treatment must use a
treatment manual and must specify the characteristics of the participants.
Finally, the randomized clinical trials supporting a well-established treat-
ment must be conducted by at least two different investigators or investiga-
tory teams. Investigations supporting probably efficacious treatments have
been found lacking in meaningful ways and have not met the rigorous cri-
teria required for well-established status. The studies supporting probably
efficacious treatments need only find treatment superior to wait-list control
conditions. Alternatively, it may be that well-established criteria were met,
but the research was carried out by one investigator or investigative team.
As for experimental treatments, the studies supporting these treatments do
not meet the criteria or methodology necessary to meet probably efficacious
status or may have not yet been examined in the literature.
Following the clarion call for the empirical study of treatments, however,
it was not predicted that stalwart opposition to the EBP movement would
develop from within the field itself (Ollendick, King, & Chorpita, 2006). The
push toward the empirical substantiation and evaluation of clinical practice
has been an unexpectedly controversial one. As a result, a brief review of this
debate does have bearing on the review of ESTs for child anxiety disorders
which follows and is in order to provide context for the chosen review criteria.
Even among those who support an evidence-based approach, there is
disagreement about what should be the focus of review: treatments (i.e.,
ESTs) or therapeutic components/techniques (i.e., empirically supported
principles of change, ESPs). Initially, the major EST reports emphasized
identification of ESTs (cf. Task Force, 1995; Chambless et al., 1996, 1998;
Chambless & Ollendick, 2001) although that emphasis was not applied
consistently (see Rosen & Davison, 2003 for a review). Critics rightfully
indicated that this effort neglected discernment of mechanisms of change
and also created an opportunity for abuse (e.g., Tryon, 2005). In their
depiction of “Purple Hat Therapy,” Rosen and Davison (2003) point out that
using EST criteria could lead to the inappropriate repackaging of ESTs for
gain while neglecting the mechanism of change (e.g., taking an efficacious
exposure treatment and adding in a purple hat worn by the patient so as
to create a “new” EST which can be proprietarily marketed). A meaningful
debate is then whether EBT research should focus on ESTs or ESPs.
Research addressing both approaches is needed, but an inappropriate
assumption is made when studies of multicomponent treatments are used to
support the efficacy of individual treatment components. For example, Men-
zies and Clark (1993) used reinforced practice and modeling to treat children
with water fear. This study has been construed as supporting “exposure for
simple phobia” (Chambless et al., 1998, p.11). As exposure was not examined
independently from the reinforced practice or modeling conditions, conclu-
sions about exposure itself cannot be made (e.g., were results due to exposure
alone or a necessary combination of exposure with reinforced practice?).
There is even considerable debate as to what constitutes exposure
(e.g., format, duration, mechanisms of change; see below, Facing Your
Fears: Exposure). As a result, studies carefully examining the components
of treatments in isolation are necessary in order to advance this question.

Moreover, it remains to be demonstrated whether cobbling together ESPs
in clinical practice is an effective approach. A compromise, however, can
be seen in the efforts to evaluate modular therapy that manualizes various
cognitive-behavioral techniques in a single program that can be individu-
alized (e.g., Chorpita, Taylor, Francis, Moffitt, & Austin, 2004).
Although there has been disagreement and controversy about using EBP,
others have advocated even stricter evaluations of the treatment literature.
Particularly in the area of childhood anxiety, work by Davis and Ollendick has
attempted to advance an empirically and ethically based approach to treating
children. Realizing that ESTs may not exist for all disorders, an evidence-
based approach to practice is advanced whereby clinicians have an ethical
obligation to assemble and work from the available evidence (Ollendick &
Davis, 2004). A system of Web-based searching strategies and updated EST
websites are highlighted to facilitate and expedite use by busy professionals.
As a result, they have asserted that failure to use ESTs when they do exist
and persist in the use of “invalidated treatments is not only bad practice but
also unethical” (Ollendick & Davis, 2004, p.293).
Citing criticisms and weaknesses of the current EST criteria, Davis and
Ollendick (2005) have gone on to propose even more detailed evaluation by
hybridizing EST criteria with emotion theory (i.e., bioinformational theory; see
previous description). Using EST criteria, they reviewed both the overall empirical
support for a particular intervention and also the support for an intervention’s
effects on the individual components of an emotional response (i.e., physiology,
behavior, and cognition, as well as the overall subjective emotional experience).
Their review of treatments for phobias and fear in children found that almost
all of the studies reviewed included measures of behavior and subjective fear;
however, most did not include measures of cognition or psychophysiology. This
finding was surprising and it was concluded that a “disconnect” exists between
efficacy research and theory (Davis & Ollendick, 2005, p.156).
Studies on treatments meant to specifically target certain components
of the phobic response frequently did not measure theorized mechanisms
of change or even the specific targets of the interventions (e.g., only one of
six studies of cognitive-behavioral therapy included a measure of cogni-
tion). Although there is disagreement as to whether treatments must dem-
onstrate efficacy across all emotional response components (e.g., Bergman
& Piacentini, 2005), there does appear to be agreement that researchers
must begin to include measures of these components in future treatment
studies if the debate is to be advanced.
TREATMENTS FOR CHILDHOOD ANXIETY DISORDERS
Facing Your Fears: Exposure

Description
Exposure has become a central component of most treatments for
anxiety disorders. Exposure, simply defined, is merely encountering or
experiencing fear- or anxiety-provoking stimuli. Unfortunately, consensus
on exposure quickly dissipates beyond acknowledgment of its centrality to

anxiety treatments and this most basic definition. Specifically, two main
questions about exposure exist: how should exposure be implemented and
by what mechanism(s) does exposure have an effect?
Implementation
Exposure can be conducted via two media. In vivo exposure involves
actually exposing an individual to an evocative stimulus and is contrasted
with imaginal exposure (also called in vitro exposure) which involves
the individual imagining the stimulus. Bioinformational and emotional
processing theories would generally advocate the use of in vivo exposure
so as to activate more of the emotional network; however, the nature of the
anxiety disorder, the safety and well-being of the individual, and the avail-
ability of stimuli must also be considered.
For example, in vivo exposure may be better suited to specific fears,
the characteristics surrounding a traumatic event (e.g., the setting and
environment), and easily obtained and manageable stimuli (e.g., dogs).
This is in comparison to, for example, myriad generalized worries, the
actual traumatic occurrence (e.g., assault), and more unique or prohibitive
stimuli (e.g., finding tall buildings in rural areas for fear of heights or the
prohibitive cost and lack of access for fear of air travel) for which imaginal
exposure may be more appropriate. Finally, a combined approach can be a
viable alternative in which imaginal exposure can be used to supplement,
accentuate, and amplify the effects of in vivo techniques.
Exposure has also been administered in two “doses” in the literature:
either all at once or gradually. Exposure can be administered all at once
in procedures termed “flooding” (in vivo) or “implosion” (imaginal). Flood-
ing and implosion involve exposure to the most challenging or evocative
presentation of a stimulus or situation all at once. For example, an indi-
vidual phobic of heights would be taken to the top of a very tall building
or guided to imagine being on such a building. By contrast, gradual expo-
sure involves using either in vivo or imaginal techniques to slowly guide
an individual through a hierarchy of increasing fear or anxiety. Using the
same examples, graduated in vivo exposure may involve gradually pro-
gressing from exposure at the second floor of a building to the third and
so forth whereas imaginal exposure may involve envisioning the same.
Currently, consensus exists that flooding or implosion may be needlessly
aversive, whereas a graduated approach is more humane, inviting, and
less of a threat to motivation and possible attrition, especially with chil-
dren (Kendall et al., 2005).
Another question relevant to the use of exposure therapy is the “dosing”
or schedule for any particular “dose.” The literature is mixed and unclear at
this point as to whether a massed or spaced approach to exposure is pre-
ferred, especially with children. Is exposure best administered all in a sin-
gle session of extended duration, or across several sessions with little time
between exposures (i.e., massed exposure), or during trials more approximat-
ing the typical one-hour weekly session across multiple weeks (i.e., spaced
sessions akin to most manualized treatments)? Although controversial, the
adult literature can be construed as supporting a massed approach or mini-

mizing the intervals between exposures (e.g., Chaplin & Levine, 1981; Foa,
Jameson, Turner, & Payne, 1980; Lang & Craske, 2000).
Even so, at the very least no support has been found for needlessly
spacing sessions (Chambless, 1990; Herbert, Rheingold, Gaudiano, &
Myers, 2004; Lang & Craske, 2000). In children, one study was identified
that examined massed and spaced exposure. Davis, Rosenthal, and Kel-
ley (1981) found that children receiving three hours of massed exposure
therapy using actual stimuli (i.e., as opposed to approximations/toys) had
superior outcomes to those children receiving exposure therapy in three
weekly one-hour doses.
Similarly, Öst et al. (2001) found that children responded well to a three-
hour massed intervention for specific phobia, although they did not make
comparisons to spaced exposures. Moreover, most children reported that the
treatment had gone as they had expected it would (75.4%) and were satisfied
with the intervention (82.1%; Svensson, Larsson, & Öst, 2002). Accordingly,
it seems that children are at least capable of participating in massed treat-
ment and that they may not find it unduly cruel or aversive. It may be more
effective than spacing sessions. Currently, best practice may come down to
a combination of the anxiety disorder(s) to be treated, current EST manuals
and formats, clinical judgment, and patient and parent choice.
Mechanisms of Change
Although exposure is easily defined in the most basic of terms, questions
remain as to what aspects or mechanisms of change in exposure impart
therapeutic benefit. Several potential mechanisms have been advanced:
such as counterconditioning, habituation, extinction, cognitive change, and
the development of coping skills (Kendall et al., 2005; Tryon, 2005). These
various mechanisms of change are theoretically wed to different therapeutic
interventions, but may occur to varying degrees in all exposure therapies
whether acknowledged or not. Even so, only one study has even examined
potential mediators of outcome, although any of the RCTs reviewed below
could have (Treadwell & Kendall, 1996; for a review see Prins & Ollendick,
2003). As a result, the review that follows focuses on the main ESTs for
childhood anxiety disorders and the degree to which these therapies tar-
get various components of the emotional response. The reader is reminded,
however, that even though many interventions are decades old, little effort
has been made to resolve the disconnect between theory and research that
would better elucidate mechanisms of change (cf. Davis & Ollendick, 2005).
Systematic Desensitization (SD)

Description
SD is based on classical conditioning theory and deep muscle relaxation
(Jacobson, 1938). Wolpe (1958) based treatment procedures on etio-
logical principles similar to those observed in laboratories. The assumption
is that a previously unconditioned stimulus, through stimulus pairings or
traumatic exposure, has become a conditioned stimulus leading to the

conditioned phobic response. From this perspective, therapeutic inter-
vention should make “use of particular responses that, through inhibit-
ing anxiety, weaken neurotic habits” (Wolpe, 1958, p. 112). As a result,
the goal is to engage in counterconditioning. A clinician frequently starts
by developing a fear hierarchy and then choosing a counterconditioning
agent or technique (e.g., relaxation training). Whereas the anxiety-inhib-
iting response is typically some form of relaxation or breathing, Wolpe
(1958) indicated that any anxiety-inhibiting response performed during
the hierarchical exposure might be appropriate (e.g., humor, eating, and
even sexual behavior). Once an inhibiting response is chosen, the patient
progresses through either imaginal or in vivo hierarchical exposures while
performing the response. As a result, the associative strength between the
conditioned stimulus and the unconditioned stimulus decreases because
it ceases to predict the response in the presence.
Wolpe (1958) indicated that the goal of SD is to inhibit the “automatic
response pattern or patterns that are characteristically part of the organ-
ism’s response to noxious stimulation” and thereby eliminate avoidance
behavior (p. 34). This elimination of avoidant behavior through inhibition
is accomplished by physiological training (e.g., relaxation) as the new
response is gradually paired with each step of the fear hierarchy. Although
there is also a secondary goal of slowly augmenting exposure without sub-
sequent avoidance, it is clear that this intervention primarily targets the
“autonomic response patterns” and, hence, the physiology of the emo-
tional response (Davis & Ollendick, 2005). Little impetus is placed on the
behavioral component beyond merely adjusting exposure intensity so as to
prevent avoidance; almost no emphasis is placed on changing the cogni-
tive component (Davis & Ollendick, 2005).
Of relevance, support for a counterconditioning approach to the treat-
ment of anxiety has been under increasing scrutiny. Theoretically, the
inclusion of techniques whose purpose is to interfere with the activation
of the emotional network should impair the effectiveness of the exposure
(Lang, 1977). In practice with adults, relaxation has been shown to be
less effective than exposure with cognitive techniques (Craske, Brown, &
Barlow, 1991), and in children has been shown to be less effective than
other behavioral techniques using exposure (Bandura, Blanchard, & Ritter,
1969). As a result, some have concluded a counterconditioning explana-
tion of SD is not supported by the extant literature (Tryon, 2005).
Reinforced Practice (RP)

Description
Research in the 1960s and 1970s indicated that graduated repeated
practice, positive reinforcement, and clinician direction and feedback all
served as powerful techniques for attenuating anxiety (Ollendick & Cerny,
1981). In combination, these procedures came to be called “reinforced
practice” or “contingency management” and included repeated hierarchical
exposures (i.e., “practice”) during which patient approach behavior was
encouraged using reinforcement and verbal feedback (Leitenberg &

Callahan, 1973). Use with fears and phobias increased and a direct link
to operant principles could be observed in conceptualizations of “fear [as]
not only a response of glands and smooth muscles, [but as] a reduced
probability of moving toward a feared object and a heightened probability
of moving away from it” (Skinner, 1988, p.172). RP for fear and anxiety
is focused on schedules of reinforcement, learning histories, and similar
operant considerations with little attention devoted to feelings, sensations,
or thoughts co-occurring with the fear or anxiety.
As a result, RP is carried out by using reinforcement to strengthen
positive associations to the fear- or anxiety-evoking stimulus thereby
weakening negative associations. The sole goal is to achieve an increased
probability of approach behavior through operant principles (Davis &
Ollendick, 2005). Emphasis is placed on the behavioral component of the
emotional response with little to no emphasis on cognition or physiology.
Of note, RP and SD are occasionally confused in the literature, either for
each other or for “distraction” during an exposure. This confusion is espe-
cially apparent when SD uses a tangible item instead of relaxation training
(e.g., Rapp, Vollmer, & Havanetz, 2005). The key determinant in whether
an intervention is RP or SD is when the tangible item is provided to the
child. For example, a clinician may decide to use a child’s favorite doll
during an exposure session. If the doll is provided at the beginning of the
exposure, then it presumably has a counterconditioning effect during the
exposure (i.e., SD); however, if the doll is only provided contingent upon
the completion of a step in the hierarchy, then the clinician would be using
the doll as reinforcement for approach behavior (i.e., RP).
Modeling and Participant Modeling (PM)

Description
Ritter (1965, 1968) developed PM (also called “contact desensitiza-
tion”) based on work grounded in social-learning theory. PM is rooted in
modeling or the theory that learning can occur vicariously by observing
others (i.e., models). Modeling, as described by Bandura (1969), is success-
ful by altering behavior and its consequences through the observation of
social models. As applied to treatment, anxiety and fear can be assuaged by
watching a model interact with a feared stimulus or situation. The result of
the observation is vicarious extinction (i.e., new inhibitory learning) as the
associations between the conditioned stimulus and unconditioned stimu-
lus are weakened (Bandura, 1969; Bouton, 2004; Myers & Davis, 2002).
In PM, the clinician goes beyond the role of mere social model and
takes a more interactive approach. The goal in PM is to integrate the
patient into the task with added verbal and behavioral instruction from
the clinician. In this way, a clinician frequently models a response and
then assists the patient in completing the response. PM has the benefit of
allowing a clinician to disassemble a complex task into manageable and
directed interactive steps. For example, the larger step of petting a dog
during exposure becomes one of having the clinician model the task and
then gradually shape successive approximations in the observer through

physical and verbal direction.
The object of modeling is to alter behavior (Bandura, 1969), although
with the added participant component there is a notable skill-building
component. The elimination of avoidance is also important and crucial in
modeling and PM as the observer must observe the model to benefit. “PM
requires a patient to view, approximate, and undertake various behavioral
experiments that eventuate in no aversive outcomes” (Davis & Ollendick,
2005, p. 150). Although this process is grounded in social-learning theory,
there is also a significant component that can be conceptualized as cog-
nitive. Therapy also involves testing and disconfirming distorted beliefs
about the stimulus or situation as “the absence of anticipated negative
consequences is a requisite condition for fear extinction” (Bandura, Blanchard,
& Ritter, 1969, p. 174; italics added). Adding anticipation to the disconfirm-
atory process suggests an emphasis that is distinctly cognitive and beyond
strict notions of vicarious extinction.
Cognitive-Behavioral Therapy (CBT)

Description
As the name implies, CBT integrates two distinct and influential
interventions: cognitive therapy and behavior therapy. CBT capitalizes
on any or all of the previously mentioned behavioral techniques but
adds techniques to address faulty cognition. This integration is achieved
through an understanding that psychopathology reflects an information-
processing bias and that these biases become incorporated into stable
schemas (cognitive structures) which direct behavior and cognition (Beck,
1993). Integration is achieved when a relationship is posited in which
information-processing biases and dysfunctional behavior and distress
are reciprocally linked (Beck, 1993). As a result, CBT challenges chil-
dren’s cognitive distortions while simultaneously implementing behav-
ior therapy techniques (e.g., modeling, exposure, operant conditioning,
relaxation; Kendall, 1993; Kendall et al., 2005). Essentially, a hybrid
approach is achieved; therapy focuses on eliminating avoidance behav-
ior while also identifying, testing, and countering automatic thoughts
of threat, vulnerability, and danger plaguing the conscious mind (Beck,
1991, 1993).
As a result, psychopathology is the emergence and dominance of a
negative cognitive structure (i.e., schema) in conjunction with disordered
or dysfunctional behavior (Beck, 1991). Cognitive aspects of treatment
are focused upon altering these cognitive structures or developing new
structures to “re-interpret” the environment (Kendall, 1993). According
to Kendall and Suveg (2006), the primary cognitive structures that need
to be addressed are distortions (e.g., catastrophic thought, maladaptive
thoughts and expectations) and deficiencies (e.g., incomplete attainment
of developmental milestones, poor problem-solving, impulsivity). Even so,
behavioral techniques are used to varying degrees.
In isolation, this is simply behavior therapy; however, techniques using

exposure, social learning, and operant and classical conditioning can be
very effective when combined with treatments designed to address cog-
nitive distortions and deficiencies. Behavioral interventions can provide
concrete opportunities to test cognitive distortions or incorporate psych-
oeducation, problem-solving, and skill-building to assist with deficiencies.
In addition, family-based techniques can be incorporated as necessary to
accentuate treatment effects and alleviate potential familial confounds to
treatment success and generalization.
Borrowing from the previous discussion on EPT (Foa & Kozak, 1986,
1998), theoretically, CBT for anxiety disorders allows a clinician to acti-
vate relevant emotion networks and incorporate additional information
into these structures. Information may be related to stimulus properties,
meaning, or the components of the emotional response: cognitive (e.g.,
challenges to and information not supporting catastrophic or distorted
thought), behavioral (e.g., information regarding new schedules of rein-
forcement or punishment based on exposure or new contingencies in
effect), or physiological (e.g., the results of habituation during steps in a
fear or anxiety hierarchy).
For example, cognitive-behavioral exposure therapy for a child with
fears of public speaking can be corrective in many ways. First, CBT can
introduce new meaning and cognitive responses by challenging and test-
ing catastrophic thoughts (e.g., “I’ll mess up.”). Second, it can impart skills
used for coping, addressing others, and for public speaking (e.g., how to
handle stress and worry, use a podium and a microphone, use proper
etiquette). Third, CBT can be used to reduce avoidance behavior and rein-
force successive approximations of the task (e.g., using a fear hierarchy to
make approach more manageable and by using verbal reinforcement so as
to increase the probability of approach). Finally, it offers the opportunity to
experience and habituate to physiological symptoms (e.g., pounding heart,
sweating). In this example, these various components of CBT are woven
together almost seamlessly. Ideally, CBT will evoke the full network and
offer corrective information on various aspects of the stimulus, its mean-
ing, and one’s response (Davis & Ollendick, 2005). As a result, CBT places
some degree of emphasis on altering all three components of the anxiety
response (Davis & Ollendick, 2005).
EMPIRICALLY SUPPORTED TREATMENTS

FOR CHILDHOOD ANXIETY DISORDERS
The following review of treatments for childhood anxiety focuses on

ESTs (i.e., not ESPs) for anxiety and incorporates a review of both overall effi-
cacy and response component efficacy (i.e., componential analysis; Davis
& Ollendick, 2005). This review also firmly applies the EST criteria as
originally stated (Task Force, 1995) and refined by Chambless and col-
leagues (Chambless et al., 1996, 1998). Namely, that from “a research
perspective, no treatment is ever fully validated; there are always more
questions to ask” and that the primary goal is better patient care through
“… the decision on whether a particular treatment has sufficient empiri-
cal validation to warrant its dissemination for widespread clinical training
and implementation …” (Task Force, 1995, p. 3).
This goal of setting the agenda for dissemination, training, and patient
care necessitates that a high standard be used for determining empirical
status. This emphasis is especially urgent given that even recent exami-
nations of the literature continue to indicate that EBTs for youth produce
better outcomes than care as usual, even in those with severe levels of
psychopathology (Weisz, Jensen-Doss, & Hawley, 2006). Unfortunately,
as it stands, the evidence-based movement has become mired in political
debate and efforts to obtain the “prize” of EST status (Rosen & Davison,
2003) at the expense of the original intentions of disseminating and train-
ing the best practices for treating children.
Subsequently, the following review focuses on RCTs for anxiety disor-
ders in children using the original criteria (cf. Task Force, 1995; Chambless
et al., 1996, 1998) in an effort to determine those treatments for which the
most rigorous evidence has accrued. An emphasis is placed on studies that
either verify diagnostic status in their samples or where a specific diagnosis
or diagnostic category can be reasonably assumed through a preponderance
of the clinical assessment evidence and sample description (cf. Chambless
& Ollendick, 2001). Studies were excluded from the review if they did not
clearly indicate randomization of participants to a condition, did not specify
even the most basic characteristics of the sample (e.g., age, male vs. female),
assessed and treated symptoms that could not be verified as in the clinical
range and/or indicative of a particular anxiety disorder (e.g., “test anxiety”
or social isolation studies), and/or had equivalent results between or among
conditions but insufficient power to detect differences and invoke the EST
equivalence criterion (cf. Kazdin & Bass, 1989). Moreover, as little research
has attempted to isolate ESPs, this review focuses on identifying ESTs with
the most support in the extant literature.
Finally, in addition to reporting overall empirical status for the treat-
ments reviewed, a componential analysis is presented of the effects of
treatment on the components of the emotional response (cf. Davis & Ollen-
dick, 2005). Specifically, outcome data are examined and the effects of
treatment on the subjective experience, physiological response, behavio-
ral response, and cognitive response of the emotion are categorized using
EST criteria guidelines. Outcome data for this analysis need also not be
in any one strict form or use a single type of informant or medium. For
example, the behavioral component could be examined using a behavio-
ral task, observational coding, self-report, or parent-report. The results of
these reviews are summarized in Tables 7.2 and 7.3. Table 7.2 shows the
evidence from each study leading to the conclusions regarding empirical
support, and Table 7.3 indicates the actual levels of support merited for a
particular treatment for a particular disorder.
To date, no published RCTs with children that met these review
criteria were identified for Panic Disorder/Agoraphobia (see Ollendick,
1995 for results of a multiple-baseline design study), separation anxiety
Table 7.2. Examination of Empirical Support for Various Anxiety Disorder

Treatments.
Evidence for Efficacy at Treating Response
Component Symptoms
Disorder/Treatment Study Physiology Behavior Cognition Subjective
Specific Phobia
ISD vs. W-L Cornwall NR TX > W-L * TX > W-L
et al.
(1996)
ICBT vs. EMDR Muris et al. ns CBT > TX * CBT > TX
(1997)
ICBT vs. EMDR vs. Psychological Placebo
Muris et al. * = * CBT > TX
(1998)
ICBT vs. ICBT+ParCBT Öst et al. ns TXs > W-L * TXs > W-L
vs. W-L (2001)
Social Phobia
I+GBT vs. Psychological Beidel et al. * TX > Pla- * TX > Placebo
Placebo (2000) cebo
GCBT vs. GCBT+Par vs. Spence et al. NR ns * TXs > W-L
W-L (2000)
GCBT vs. W-L Gallagher * TX > W-L * TX > W-L
et al.
(2004)
Obsessive-Compulsive Disorder
ICBT vs. Med de Haan * = NR *
et al.
(1998)
ICBT+Med vs. ICBT vs.
Med vs. Pill Placebo
POTS (2004) * NR NR *
ICBT vs. GCBT vs. W-L Barrett et al. NR NR NR =
(2004)
Posttraumatic Stress Disorder

ICBT vs. ParCBT vs.
ICBT+ParCBT vs. Com
Deblinger * ns * ns
et al.
(1996)
ICBT vs. ICBT+ParCBT King et al. NR TXs > W-L ns TXs > W-L
vs. W-L (2000)
GCBT vs. W-L Stein et al. * ns * TX > W-L
(2003)
ICBT+ParCBT vs. Child- Cohen et al. * CBT > TX * ns
centered (2004)
Childhood Anxieties (combined)

ICBT vs. W-L Kendall NR TX > W-L TX > TX > W-L
(1994) W-L
ICBT vs. ICBT+ParBT Barrett et al. NR TXs > W-L * ns
vs. W-L (1996)
(continued)
Table 7.2. (continued )

Evidence for Efficacy at Treating Response
Component Symptoms
ICBT vs. W-L Kendall et al. NR TX > W-L TX > W-L TX > W-L
(1997)
GCBT vs. GCBT+ParBT Barrett * TXs > W-L * ns
vs. W-L (1998)
ICBT+ParBT vs. W-L King et al. NR TX > W-L TX > W-L TX > W-L
(1998)
GCBT vs. W-L Silverman et NR TX > W-L * TX > W-L
al. (1999)
ICBT vs. GCBT vs. W-L Flannery- TX > TX > W-L TX > W-L
Schroeder W-L
et al.
(2000) NR
GCBT+ParCBT vs. W-L Shortt et al. NR TX > W-L * TX > W-L
(2001)
GCBT vs. Psychological Ginsburg et * * * TX > Placebo
Placebo al. (2002)
GCBT vs. Psychological Muris et al. * * * TX > Placebo
Placebo (2002)
ICBT vs. ICBT+ParCBT Nauta et al. * TXs > W-L * TXs > W-L
vs. W-L (2003)
GCBT vs. Spence et al. NR TXs > W-L * TXs > W-L
GCBT+Internet vs. (2006)
W-L
Key: “*” = not measured, “=” = groups were equivalent, Com = Community Care/Treatment as usual, E/
RP = exposure with response prevention, G = group, I = individual, Med = medication, NR = component
was measured but not reported (e.g., a total score was reported but not a subscale containing the needed
information), ns = no significant differences, Par = parents involved with treatment, TX(s) = treatment or
treatments, SD = systematic desensitization, W-L = wait-list control.
disorder, or generalized anxiety disorder as separate diagnostic entities

(i.e., in RCTs specifically designed to determine the effects of treatment
on that disorder). However, several studies have examined various anxiety
disorders in combination (e.g., the well-known CBT RCT by Kendall, 1994).
Given this, the review focuses on the empirical support for treatments of
specific phobia, social phobia, obsessive-compulsive disorder, posttrau-
matic stress disorder, and a final category deemed “childhood anxieties.”
This combined group is composed of studies that meet the Task Force’s
(1995) guidelines, even for specificity of the sample; however, the studies
did not focus on a single anxiety diagnosis (e.g., GAD, SoP, and SAD in a
single sample).
Specific Phobia (SP)

Utilizing the review criteria specified, four RCTs were identified that
lend empirical support to the behavioral treatment (BT) and cognitive-behavioral
treatment of clinically significant specific phobias. For BT, Cornwall, Spence,
and Schotte (1996) examined the effects of SD (specifically emotive
Table 7.3. Empirically Supported Treatments for Anxiety Disorders Affecting

Children and Their Effects on the Components of an Emotional Response
Level of Empirical Support
DSM–IV–TR
Disorder and
Treatments Overall Status Physiology Behavior Cognition Subjective
Specific Phobia
SD Experimental Exper Exper Exper Exper
CBT Probably Exper Prob Exper Prob
Efficacious
Social Phobia
BT Probably Exper Prob Exper Prob
Efficacious
CBT Probably Exper Exper Exper Prob
Efficacious
Obsessive-Compulsive Disorder
CBT Well Established Exper Exper Exper Exper
Posttraumatic Stress Disorder
CBT Well Established Exper Prob Exper Prob
Childhood Anxieties (combined)
CBT Well Established Exper Prob Prob Well Est
Key: BT = behavior therapy, CBT = cognitive-behavioral therapy, Exper = experimental empirical status,
Prob = probably efficacious empirical status, Well Est = well established empirical status, SD = systematic
desensitization.
imagery: a technique involving hierarchical exposure with an imagined

“superhero.”) on children with phobias of the dark. Results indicated signif-
icantly better outcomes in behavior and on self-reports with SD compared
to a wait-list group, warranting experimental status (i.e., needs replica-
tion or comparison to a more rigorous intervention/placebo). Three stud-
ies examined the effects of CBT on specific phobias (Muris, Merkelbach,
Holdrinet, & Sijsenaar, 1998; Muris, Merkelbach, Van Haaften, & Mayer,
1997; and Öst et al., 2001). Although the studies by Muris and colleagues
were crossover studies, information regarding comparisons from pretreat-
ment to posttreatment prior to the crossover does produce results consist-
ent with an RCT design. Overall, results from these RCTs indicate CBT for
childhood-specific phobia merits probably efficacious status as it has been
found superior to another treatment in two studies and to a wait-list control
on a third. Specifically, CBT was superior to eye movement desensitization
and reprocessing (EMDR) in the studies by Muris and colleagues and supe-
rior to wait-list on a variety of measures (Öst et al., 2001).
An analysis of the effects of SD on the components of the emotional
response indicates experimental status for all three responses (i.e., physi-
ology, behavior, and cognition) as well as the subjective experience of
anxiety. Cornwall et al. (1996) included measures of behavior and rating
scales of subjective fear that indicated treatment was superior to wait-list;
however, these findings require replication in clinical child populations.
Moreover, a measure of psychophysiology was obtained (i.e., physiological

anxiety: Revised Children’s Manifest Anxiety Scale, RCMAS; Reynolds &
Richmond, 1978) but not examined. Componential analysis for CBT indi-
cates experimental status for both the physiological and cognitive com-
ponents (i.e., no significant differences in groups in two studies). CBT for
the behavioral component can be considered probably efficacious given
its demonstrated superiority to two other treatment conditions but only in
one group of researchers (see Tables 7.2 and 7.3), whereas probably effica-
cious status is warranted for the subjective experience of fear and anxiety.
Of note, these conclusions regarding EST status and the studies included
for review differ from those of Davis and Ollendick (2005) and from Ollen-
dick and King (1998). Difference can be directly attributed to the more
stringent criteria being applied in the current review and the emphasis
on examining studies using children with actual specific phobias and not
analogue fears.
Social Phobia (SoP)

RCTs supporting the treatment of SoP in children include two using
CBT conducted in a group format (Gallagher, Rabian, & McCloskey, 2004;
Spence, Donovan, & Brechman-Toussaint, 2000) and one utilizing BT in a
mixed individual and group format (Beidel, Turner, & Morris, 2000). The
CBTs incorporated a variety of techniques including exposure, cognitive
challenges/therapy, social skills, modeling or participant modeling, and
psychoeducation (Spence et al., 2000 also included relaxation). Results
of both CBT trials indicated treatment gr oups were superior to wait-list
conditions on numerous measures, including diagnostic outcomes. As a
result, group CBT for SoP merits probably efficacious status. The BT trial
included a variety of techniques similar to the other trials including psy-
choeducation, social skills training, modeling, and exposure, but did not
reportedly include an explicitly cognitive component. BT trial results were
also significant and superior to a study skills psychological placebo. As a
result, BT also merits probably efficacious status by having met a more
rigorous standard. Specifically, according to EST criteria, Beidel et al.
(2000) met all the criteria for a well-established treatment with the excep-
tion of independent replication.
Componential analysis of the three studies indicates that none con-
tained a measure that could be considered cognitive. Spence et al. (2000)
included a measure of physiology but did not report on those data (physi-
ological anxiety, RCMAS). All three RCTs did, however, include measures
of the behavioral component and of the subjective emotional experience.
In addition to rating scale data, Beidel et al. (2000) included a behavioral
observation. Results from these data indicate that BT is probably effi-
cacious at treating the behavioral response given BT was superior to a
psychological placebo on these measures and observations. Furthermore,
BT was superior to psychological placebo on several self-reported meas-
ures of the subjective experience of anxiety, thereby meriting probably
efficacious status. Turning to CBT, Spence et al. (2000) assessed phobic
behavior using both parent-report questionnaires and direct observation;
however, they found no significant differences between CBT and wait-list

conditions. On a parent-report measure Gallagher et al. (2004), however,
did find CBT superior to wait-list. Taken together and given the level of evi-
dence (i.e., one significant comparison to a wait-list), CBT for SoP still war-
rants experimental status for the behavioral response. In contrast, CBT’s
effects on the subjective experience of anxiety merits probably efficacious
status as both studies found a wait-list inferior to CBT on numerous self-
report measures.
Obsessive-Compulsive Disorder (OCD)

Three RCTs meeting the review criteria were identified and used to
determine the overall and componential EST status for this disorder
(Barrett, Healy-Farrell, & March, 2004; de Haan, Hoogduin, Buitelaar,
& Keijsers, 1998; POTS, 2004). All three of these studies used forms of
manualized CBT that included psychoeducation, cognitive interventions,
and exposure and response prevention (E/RP). Overall, results from these
studies indicate individual CBT is more effective than clomipramine
(de Haan et al., 1998), pill placebo (POTS, 2004), and a four- to six-week
wait-list condition (Barrett et al., 2004). These effects were also obtained
across two different groups of researchers and all three used participants
diagnosed with OCD. Group CBT was provided by Barrett et al. (2004) and
was found to be equivalent to individual CBT and superior to the wait-list
condition. Given this level of evidence, CBT for OCD meets the criteria for
a well-established intervention.
Of note, these conclusions are made tentatively and are in need of
replication. Even though CBT is considered the treatment of choice for
OCD based on the results of this review and numerous other studies (e.g.,
open trials; for a review see Turner, 2006) further RCTs are necessary.
The results of POTS (2004) are intriguing as a combined approach to OCD
(i.e., both medication and CBT) was found to be superior to both CBT
and sertraline administered separately, which did not differ from each
other (although site differences were apparent). As a result, it may be that
the actual best practice is a combination approach, especially for serious
cases. Finally, parents were involved to varying degrees in all three trials
which may have contributed to treatment success.
Componential analysis of EST status led to conclusions that CBT
provided either in individual or group format merited only experimental
status for addressing the components of the emotional response. This
finding was especially disappointing given all three studies included the
Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Goodman
et al., 1989; Scahill et al., 1997) and one study included a measure hav-
ing a physiological symptoms scale (Multidimensional Anxiety Scale for
Children, MASC; March, 1997). Specifically, studies consistently reported
and analyzed only the total score instead of also examining the obses-
sions severity and compulsions severity scores which might have added to
empirical support for the cognitive and behavioral components. Barrett et
al. (2004) did include a measure of subjective anxiety; however, no differ-
ences between groups over time were observed.
Posttraumatic Stress Disorder (PTSD)

Cohen, Deblinger, Mannarino, and Steer (2004), Deblinger, Lippman, and
Steer (1996), King et al. (2000), and Stein et al. (2003) all reported on trials
of CBT for PTSD or clinically significant PTSD symptoms. As with the pre-
vious reviews, all four included manualized CBT and included techniques
such as cognitive coping skills, psychoeducation, graduated exposure, cog-
nitive therapy, and other techniques. Outcomes from these studies indicate
CBT for PTSD in children meets well-established status. Parent and child
CBT was found superior to child-centered therapy (Cohen et al., 2004) and
the combination of child CBT and child and parent CBT (i.e., two separate
groups collapsed) was superior to a combination of parent-only CBT and
care as usual in the community (Deblinger et al., 1996). In addition, two tri-
als found CBT superior to wait-list conditions (King et al., 2000; Stein et al.,
2003). As a result, CBT for PTSD has been found superior to another treat-
ment or placebo in at least two trials by two different research groups.
The effects of CBT on the components of the emotional response indi-
cate it meets experimental criteria for physiology and cognition; however,
probably efficacious status is warranted for the behavioral component and
the subjective experience of anxiety. King et al. (2000) was the only study
to measure cognition (i.e., coping self-efficacy; no significant differences
among groups) and physiology (i.e., RCMAS; physiological anxiety scale not
examined). The effects of PTSD on behavior were measured in all four tri-
als, but only two found differences: King et al. (2000) found significant dif-
ferences with CBT superior to a wait-list and Cohen et al. (2004) found CBT
superior to another treatment. Finally, all four trials measured subjective
anxiety with only King et al. (2000) and Stein et al. (2003) finding CBT
superior to wait-list conditions leading to probably efficacious status.
Childhood Anxieties
Frequently, studies in this category compared CBT to CBT with an
alteration (i.e., group vs. individual format, child and parent or family
treatment vs. child treatment) and/or to wait-lists. CBT to CBT comparisons
were often difficult to separate and appeared to suffer from insufficient
power to obtain differences (cf. Kazdin & Bass, 1989). As a result, gen-
eral impressions of outcomes are conservatively reported in an attempt
to summarize frequently inconsistent (e.g., mother vs. father vs. child vs.
clinician reports) or vacillating results (e.g., changes in the superiority of
a group from post to follow-up to later follow-up). Moreover, preference
in interpreting outcomes was given to the results of diagnostic depictions
and widely used measures (e.g., CBCL, RCMAS, FSSC-R).
Excluding some studies where results generally appeared to be equiv-
alent (e.g., Manassis et al., 2002), 12 RCTs were identified and examined.
As a whole, well-established status for CBT with children is warranted as
Ginsburg and Drake (2002) and Muris, Meesters, and van Melick (2002)
all found CBT superior to a psychological placebo intervention. Moreover,
the 10 additional studies included for review found CBT superior to vary-
ing wait-list conditions in every instance (see Tables 7.2 and 7.3; Barrett,
1998; Barrett et al., 1996; Flannery-Schroeder & Kendall, 2000; Kendall,

1994; Kendall et al., 1997; King et al., 1998; Nauta, Scholing, Emmelkamp,
& Minderaa, 2003; Shortt, Barrett, & Fox, 2001; Silverman et al., 1999;
Spence, Holmes, March, & Lipp, 2006). Conservatively, however, it may be
more appropriate to assert that group CBT merits well-established status
and that individual CBT or CBT with a family or parent component merit
probably efficacious status (see Table 7.2).
Componential analysis of CBT for these combinations of childhood
anxiety indicates experimental status is warranted for the physiological
response. None of the 12 studies reviewed reported on or examined physi-
ological results, even though 8 included measures that could have been
tapped. Behavior was measured in some form in 10 of the 12 studies
with all 10 finding CBT superior to a wait-list condition, resulting in prob-
ably efficacious status. Only four studies included a measure of cognition;
however, results all supported the superiority of CBT to a wait-list and
probably efficacious status. Finally, all 12 studies included a measure of
the subjective experience of anxiety with eight RCTs finding CBT superior
to wait-list and two RCTs finding CBT superior to a psychological placebo.
Given this level of evidence, CBT’s effects on the subjective experience of
anxiety are well established.
Notably, the use, influence, or adaptation of the CBT by Kendall was
clearly observable to varying degrees in almost all of the 12 studies (i.e.,
Coping Cat Workbook; Kendall, 1990; Kendall & Hedtke, 2006). Briefly,
this CBT focuses on “recognizing anxious feelings and somatic reactions
to anxiety, clarifying cognition in anxiety provoking situations, developing
a plan to cope with the situation, and evaluating performance and admin-
istering self-reinforcement as appropriate” (Kendall, 1994, p. 103). With
the Coping Cat program, children are taught to use the acronym FEAR
to guide their coping and exposure in session and through weekly home-
work assignments: “F”eeling frightened, “E”xpecting bad things to happen,
“A”ttitudes and actions that can help, and “R”esults and rewards (Kendall,
1990). Approximately one-half of the 16 or more sessions are devoted to
psychoeducation, coping, relaxation training, and so on with the remain-
ing sessions focusing on exposure.
CONCLUSIONS AND FUTURE DIRECTIONS
The preceding review of empirically supported treatments for child-

hood anxiety disorders attests to the benefits of the growth in treatment
research over the last decade. Of the four specific anxiety disorders for
which RCTs have been conducted using clinical child samples, probably
efficacious or well-established treatment options exist for each disorder.
Moreover, for the combined childhood anxiety disorder studies, prob-
ably efficacious support or better exists for a variety of treatment options
including formulations with the individual child, the child and the family
or parent, or variations with a group format.
Overall, although these studies have excelled in including measures
of the behavioral component and the subjective anxiety experience, more
focus needs to be placed on the physiological and cognitive components. In

particular, only 2 of the 26 RCTs examined measures that could be consid-
ered physiological. Even more disappointing, 12 of the remaining 24 RCTs
included measures that address psychophysiology only to neglect or not
report their examination in treatment outcomes (e.g., RCMAS physiological
anxiety). Similarly, 5 of the 26 RCTs included measures of cognition, with
3 others not reporting treatment outcomes (i.e., CY-BOCS obsessions).
Summarizing, it would seem Davis and Ollendick’s (2005) conclu-
sion of a disconnect existing between treatment theory and RCT prac-
tice applies broadly to all disorders of childhood anxiety included in this
review. In addition to including cognitive and physiological assessments
in CBT RCTs, more effort also needs to focus on the use of alternate treat-
ments or placebos over wait-list controls and CBT to CBT comparisons.
An examination of Table 7.3 reveals that even with 24 RCTs examining the
behavioral component (included and reported in 22 of the 26 RCTs), stud-
ies made such frequent use of wait-list conditions, CBT to CBT compari-
sons, or suffered from inadequate power (cf. Kazdin & Bass, 1989) such
that well-established status was achieved for no intervention.
Of note, a potentially rich focus for future RCT examination would be
the comparison of CBT to the behavioral techniques of past decades. These
techniques (e.g., PM, RP, and SD) showed considerable empirical promise
in mostly analogue fear samples in previous reviews (cf. Davis & Ollendick,
2005; Ollendick & King, 1998) and are frequently incorporated into CBT
protocols. It would be beneficial and timely to examine their merit singly
against CBT in demonstrably clinical child samples.
Similarly, it is also disappointing that the studies reviewed generally
did not include examinations of the mechanisms of change and potential
ESPs. Such examinations would be easy to accomplish with the exist-
ing datasets and have been fruitful (Treadwell & Kendall, 1996, and the
impact of treatment on negative self-talk). Moreover, such mediational
testing (cf. Baron & Kenny, 1986; Holmbeck, 1997; Kraemer, Wilson, Fair-
burn, & Agras, 2002) would assist in the study and empirical support of
ESPs as well as the ESTs being examined. Such analyses and refinements
are crucial for further treatment development and refinement, especially
for the children with anxiety receiving therapy. Specifically, in examin-
ing the 12 studies of combined childhood anxieties for which arguably
the most widely studied and disseminated CBT or an adaptation/variant
was used (i.e., The Coping Cat), on average across the studies roughly
43% of children receiving CBT still met criteria for their primary anxiety
disorder at posttreatment assessment (range 11.8% to 50.0%). This very
rough estimate (e.g., differences in samples, time of assessment, meas-
ures), however, indicates a great deal more needs to be done for even well-
established interventions.
The criteria implemented in the current study were necessarily strict
in adherence to the important function of ESTs: to identify those treat-
ments deserving emphasis for training, dissemination, and practice. An
effort to avoid questing for the “prize” of EST status was embodied in the
conservative approach taken (e.g., adherence to the Task Force criteria,
preponderance of evidence suggesting clinical disorders or symptoms for
inclusion). Although this approach led to results that are generally more
conservative than those of previous EST reports and reviews, it is believed
these more accurately reflect the state of the science in treating psychopa-
thology. For example, as previously mentioned, Menzies and Clarke (1993)
was used to suggest probably efficacious status for “exposure” (cf. Chamb-
less et al., 1998) for “water phobia” (Menzies & Clarke, 1993), but also did
so using arguably analogue participants who on average at pretreatment
could at least proceed down to about neck depth in a pool, if not farther
with hesitation.
A developmental approach to childhood anxiety disorders and their
treatment is also needed. Future researchers should aspire to move RCTs
toward a more developmentally sensitive and informed model, compared
to the continuing downward extension of adult treatments (Barrett, 2000).
Such work can be advanced by examining moderators and mediators of
treatment, and has begun by examining various treatment techniques
designed to target potential etiological and maintenance factors of anxiety
particular to children (e.g., family treatment in Barrett et al., 1996) and
by examining the effects of CBT for anxiety on those with severe intellec-
tual, emotional, and developmental delays (e.g., Davis, Kurtz, Gardner,
& Carman, 2007). However, the study of the effects of childhood anxi-
ety on development and of the ability of treatments to remediate psycho-
pathological developmental insults is also necessary. A developmentally
appropriate approach involves moving beyond a mere diagnostic assess-
ment to incorporate outcome measures of the entire emotional response
and indicators of a child’s developmental functioning and trajectory. This
observation points to a gap in the current treatment literature: the need
to consider factors beyond psychopathology including a child’s emotion
regulation, progression through developmental milestones and develop-
mental capabilities, and overall environment (Southam-Gerow & Kendall,
2000, 2002).
In sum, research into the treatment of childhood anxiety disorders has
blossomed over recent years with cognitive-behavioral EBTs at the forefront.
Although this renaissance has led to the development and study of elegant
therapies, controversy still surrounds their evaluation and study. Future
research should focus on the mechanisms of change and moderators of
outcome (i.e., for what individuals does treatment work or is treatment
most effective?). The various refinements and formats of CBT for child-
hood anxiety will likely prove beneficial considering the equifinality and
multifinality of psychopathology. Given the heterogeneity of pathways to
childhood anxiety, it is likely that specialized treatments addressing these
moderating and mediating variables will be ideal (e.g., cognitive-behavioral
family interventions for families in which anxious functional behavior is
reinforced or individual CBT for children from chaotic families for whom
little familial support of treatment procedures exists). These more complex
questions of applicability of ESTs (i.e., treatment effectiveness) are likely to
be ones of greater interest to practitioners and critics of EBP.
In closing, a framework for future EBP progress is offered using the
following circular process: (1) planners of RCTs should actively attempt
to address weaknesses pointed out in the literature, (2) active treatment
or placebo comparison conditions should be incorporated into RCTs in

addition to wait-lists for more rigorous comparisons, (3) measures of the
various components of anxiety and development should be purposefully
included and examined, (4) mediational and moderational analyses should
be undertaken to elucidate ESPs and mechanisms of change and to exam-
ine developmental variables, (5) future evaluations of these treatment
studies should adhere strictly to Task Force criteria, and (6) efforts should
be made to disseminate EST findings to academic, research, and practice
communities.
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8
Treatment
Strategies for
Depression in Youth
MARTHA C. TOMPSON and
KATHRYN DINGMAN BOGER
There is a well-developed literature on depression in adults, including

risk factors, phenomenology, correlates, course, and biological substrates
(Kessler et al., 2003). Examination of both psychopharmacologic and
psychosocial treatments is extensive (de Maat, Dekker, Schoevers & de
Jonghe, 2007), and treatment guidelines have been developed to direct cli-
nicians’ interventions (American Psychiatric Association, 2006). However,
examination of depression in youth has commenced much more recently,
and the research literature to guide treatment is less well-developed. The
last 25 years have seen a surge in our understanding of the phenomenol-
ogy, course, correlates and etiology of youth depression. Despite the many
questions that remain, the field has moved forward in the development of
efficacious treatment strategies.
Recent data support the use of selective serotonin reuptake inhibitors
(SSRIs) in the treatment of youth depression (Emslie, et al. 1997; 2002;
Keller et al., 2001; Wagner et al., 2003, 2004) but do not suggest efficacy
for tricyclic antidepressants (Keller et al., 2001). Given the rates of adverse
events in clinical trials with youth (Cheung, Emslie & Mayes, 2005), their
limited efficacy (Hamrin & Scahill, 2005), and recent concerns about the
potential for increased risk of self-harm associated with SSRIs in youth
(United States Food and Drug Administration, 2004), there is a strong
need for the development of effective psychosocial treatments as treatment
alternatives and supplements to medication in the comprehensive treat-
ment of depressed youth.
MARTHA C. TOMPSON and KATHRYN DINGMAN BOGER ● Boston University.

222 MARTHA C. TOMPSON and KATHRYN DINGMAN BOGER
Although depression appears to be relatively rare prior to adolescence,

representing only 3% of school-aged youth (Costello et al., 1996), its incidence
increases significantly post-puberty (Costello et al., 1996; Lewinsohn, Hops,
Roberts, Seeley & Andrews, 1993; Kessler & Walters, 1998), with 20% of
youth expected to experience a depressive episode by age 20 (Lewinsohn et al.,
1993). Literature to date suggests important differences in adolescent-onset
and preadolescent-onset depression. First, earlier onset depression may be
associated with a more pernicious course than later onset depression (Kovacs,
Feinberg, Crouse-Novak, Paulauskas, & Finkelstein, 1984).
Second, early-onset depression frequently disrupts important develop-
mental processes during the elementary school years and is likely to result
in reduced psychosocial competence (Puig-Antich et al., 1985a; 1985b).
Thus, compared to nondepressed school-aged youth, depressed school-
aged youth are more likely to enter adolescence with fewer skills to cope
with an increasingly demanding environment.
Third, although research generally supports the role of negative attribu-
tional processes in adolescent depression (Garber & Flynn, 2001), the data on
the role of cognitions in preadolescent depression is less clear (Nolen-Hoek-
sema & Girgus, 1995). During the elementary school years children are still
developing schemas for understanding and making sense of events.
Fourth, although the data suggest strong continuity between adolescent
and adult depression (Bardone, Moffitt, Caspi, & Dickson, 1996; Fleming,
Boyle, & Offord, 1993; Lewinsohn, Rohde, Klein, & Seeley, 1999; Pine,
Cohen, Gurley, Brook, & Ma, 1998; Weissman et al., 1999), studies of pre-
adolescent-onset depression suggest high rates of ongoing maladjustment
and psychiatric disorders but less specificity for later depression. In sum,
there is evidence that adolescent-onset and preadolescent-onset depression
differ in important ways. For these reasons we have chosen to examine treat-
ments for adolescent and preadolescent depression separately.
In this chapter we describe the primary psychosocial treatments
approaches that have been investigated for depression in youth. First,
we outline some of the critical issues to consider in treatment for youth
depression. Second, we review the literature on treatment efficacy. Third,
we outline directions for future research.
CRITICAL ISSUES IN TREATMENT OF DEPRESSED YOUTH
Discovering and deciding upon the important issues that contribute

to a child’s depression is not only one of the first steps in determining
the course of treatment but it is also one of the most difficult tasks to
undertake. Although children might acknowledge some symptoms or
issues, they often may be dismissive or unaware of issues that feed the
depression. However, understanding the context within which the child
develops, including developmental phase effects, comorbidity, familial
processes, stress, and cultural background is essential to conducting an
assessment that adequately informs treatment.
As evidenced by the paucity of preadolescent treatment studies outlined
in the treatment outcome tables in this chapter, the majority of the treatment
TREATMENT STRATEGIES FOR DEPRESSION IN YOUTH 223
outcome literature on youth depression has focused on adolescents.

Although a few treatment development studies have been conducted with
diagnosed school-aged youth (Flory, 2004; Kaslow, Baskin, Wyckoff, &
Kaslow, 2002; Kovacs et al., 2006; Tompson et al., 2007), there has not
been a single randomized control trial that exclusively targeted preadoles-
cents with diagnosed depression. The few existing trials conducted with
preadolescents have focused on those with high levels of depressive symp-
toms rather than diagnosable disorders.
In addition, research findings on the relationship between the child’s
age and treatment outcome have been mixed. Weisz and colleagues (Weisz,
Thurber, Sweeney, Proffitt, & LeGagnoux, 1997) found that therapy was
more effective for children (ages 4–12) than for adolescents (ages 13–18).
However, in their review of 150 different studies of the effects of psychotherapy
with children and adolescents, Weisz and colleagues (Weisz, Weiss, Han,
Granger, & Morton, 1995) found that treatment outcomes were superior for
adolescents compared to children. More specifically, they reported a mean
effect size of 0.48 for children under the age of 12 and a mean effect size of
0.65 for children over 12.
A recent meta-analysis (Weisz, McCarty & Valeri, 2006) specifically
examining treatment for depressed youth found that, excluding trials with
mixed child and adolescent samples, the effect size for studies of youth
under age 13 was not significantly different from the effect size for treatment
of adolescents (0.41 versus 0.33). However, the effect size for the younger
children (vs. adolescents) was based on a very small number of trials (n = 7)
all of which were selected based on depressive symptoms versus diagnoses,
which likely led to less severe depression in the child samples.
Clearly, there is a need for a better understanding of the relation-
ship between age and treatment outcome, particularly in relation to youth
depression. Such research should be informed by the developmental tasks
and changes associated with preadolescence and adolescence and the
ways in which they interact with various treatment approaches.
Each developmental phase brings with it tasks to be completed in order
for the youth to successfully move toward the next developmental stage.
These particular tasks interact differently with the youth’s vulnerability
and symptom expression at various stages of development. For example,
specific developmental considerations that differ between youth’s preado-
lescent years and adolescent years include their changing cognitive capac-
ity and social influences.
The preadolescent’s cognitive development may contribute to an
expression of depressive symptoms that differs from that of adolescents or
adults (Harter, 1999). It has been suggested that preadolescents have not
yet gained capacity for formal operational thinking and abstract reason-
ing necessary for the formation of internal, global, and stable explanation
cognitive styles that are associated with depression (Turner & Cole, 1994).
For example, preadolescents endorse hopelessness less frequently than
adolescents, likely due to the fact that they have not yet gained the level of
generalization necessary for an understanding of the concept (Carlson &
Kashani, 1988; Stark, Sander, & Hauser, 2006). In addition, although pre-
adolescents tend to rely heavily on their parents for guidance, feedback,
and support in negotiating the outside world, adolescents are shifting their
focus from family to peers as the primary unit of socialization.
During adolescence, youths begin to increasingly attend to environ-
mental information from their peers, leading to higher levels of peer-related
stress (Rudolph & Hammen, 1999; Wagner & Compas, 1990). Adolescents’
advanced cognitive perspective-taking abilities also cause social com-
parisons to become a central means of evaluating their self-worth (Stark,
Sander, & Hauser, 2006). Effective treatment strategies should therefore
be tailored to the specific socialization needs and cognitive capacities of
youth at different developmental stages.
Adolescent depression frequently presents with comorbid conditions.
Indeed, research suggests that upwards of half of the youth with diagnos-
able depression also meet criteria for another Axis I disorder (Lewinsohn,
Rohde & Seeley, 1998). Comorbidity may be even higher in younger chil-
dren (Kovacs, 1996). Common comorbidities include anxiety disorders and
attention deficit disorders in both preadolescent and adolescent youth,
as well as substance abuse during adolescence (Kovacs, 1996). Risk for
depression may be particularly heightened in individuals with Asperger’s
syndrome, Autism and associated development disabilities (Ghaziuddin,
Ghaziuddin, & Greden, 2002; Matson & Nebel-Schwalm, 2007; Saulnier
& Volkmar, 2007), and there is a strong need to enhance strategies for
assessing depression in these individuals (Matson & Nebel-Schwalm,
2007). Knowledge of the disorders that both parallel and likely contribute
to and interact with youth depression is crucial to understanding chil-
dren’s ongoing depression and psychosocial difficulties.
Familial processes are also key factors associated with youths’ risk
and vulnerability to depression. Parental psychopathology has often been
associated with youth depression (Beardslee, Versage, & Gladstone, 1998).
Research suggests that children of depressed parents are three times
more likely to develop depression than children of nondepressed parents
(Downey & Coyne, 1990). Findings from multiple studies also show that
children of depressed parents have higher rates of depression diagnosis,
recurrence, and chronicity than those of nondepressed parents (Ham-
men, Burge, Burney, & Adrian, 1990; Wickramaratne & Weissman, 1998;
Beardslee, Keller, Lavori, Staley, & Sacks, 1993; Billings & Moos, 1986;
Lee & Gotlib, 1991).
In addition to the genetic and biological risk factors that may account
for these associations, psychosocial factors in families may also contrib-
ute (Goodman & Gotlib, 2002). First, parental depression may affect the
parents’ ability to effectively care for the child (Downey & Coyne, 1990).
Observational data show that mothers who are depressed exhibit more
sad and irritable affect than nondepressed mothers during interactions
with their children (Cohn, Campbell, Matias, & Hopkins, 1990; Hops et
al., 1987; Radke-Yarrow & Nottelmann, 1989). Second, parental depres-
sion may increase stress within the family, thereby affecting the child’s
stress level. For example, children of depressed mothers report more epi-
sodic and chronic stressors than those of nondepressed mothers (Adrian
& Hammen, 1993). Taken together, these studies underscore the need to
understand the complex role of the family in the etiology and maintenance
of youth depression. Such understanding should inform treatment plan-

ning in terms of determining the target of treatment (child, parents, both)
and the most appropriate treatment strategies (medication, family-focused
treatment, or individual treatment).
Researchers have indicated that stress is one of the predominant path-
ways to the development of and manifestation of youth depression (Stark,
Sander, & Hauser. 2006, Stark et al., 2005). Knowledge of the role that
stress plays in the youth’s environment is therefore crucial in designing
and implementing effective treatments. In terms of the etiology of youth
depression, the diathesis-stress model posits that stress activates under-
lying vulnerabilities to produce the disorder (Monroe & Simons, 1991).
There has been some research to suggest that youths’ maladaptive cogni-
tions are the diathesis in this model. For example, research by Rudolph
and colleagues (Rudolph, Kurlakowsky, & Conley, 2001) shows youth
stress to be a precursor to control-related beliefs that are then associated
with higher levels of depressive symptoms.
In addition to its causal role, stress may also contribute to the main-
tenance of depression. Depressed youth report more negative life events
and chronic stress on both questionnaires (Compas, 1987) and on objec-
tive ratings of stress based on life stress interviews (Garber & Robinson,
1997; Hammen, 2002). Families of depressed youths even report high lev-
els of stress and negative life events (Hammen, 2002). Childhood depres-
sion is particularly associated with negative interpersonal events (such
as conflicts with peers) (Monroe, Rohde, & Seeley, 1999) and events that
are caused by the depressed youth himself or herself (such as failure in a
class; Rudolph et al., 2000). Comparisons between depressed children and
those with externalizing disorders show that depressed children report
more dependent, interpersonal stress than children with externalizing dis-
orders. However, no differences emerge between the groups on independ-
ent life stress (Rudolph et al., 2000).
Other research has shown that some stressors that are independent
of the child’s control are associated with depressive symptoms in chil-
dren. For example, researchers indicate that children in families with
less money are relatively more likely to experience depressive symptoms
(as indicated by teacher reports) than those with more money (Aber,
Brown, & Jones, 2003). In addition to experiencing heightened stress,
depressed children and adolescents are also more likely to use avoidant
coping strategies to manage stress (Chan, 1995). Conversely, children’s
use of more adaptive coping strategies for managing stressors is asso-
ciated with fewer depressive symptoms (Jeney-Gammon, Daugherty, &
Finch, 1993). In response to the powerful role of stress and coping in
youth depression, key components of certain evidence-based treatments,
such as Interpersonal Psychotherapy for Depressed Adolescents (IPT-A;
Mufson et al., 1999, 2004), include careful assessment of negative situa-
tions and problems as well as the implementation of coping strategies and
skills for managing them.
Cultural background is another key factor that relates to the manifes-
tation of youth depression and its treatment. Existing research on ethnic-
ity and depression indicates that various racial groups experience differing
levels of depression severity, varied symptom expression, and different

likelihoods of receiving treatment (Stark, Sander, & Hauser, 2006). For
example, Iwata, Turner, and Lloyd (2002) found that African American,
U.S.-born Hispanic, non-U.S.-born Hispanic, and non-Hispanic white ado-
lescents and young adults provided different responses to symptoms as
reflected on the Center for Epidemiologic Studies Depression Scale (CES-
D). More specifically, they found that the African American respondents
scored low on depressed affect symptoms and high on somatic symptoms,
whereas the U.S.-born Hispanic respondents scored low on the interper-
sonal symptoms but had higher levels of low positive affect.
In addition, researchers have found differences in the level of men-
tal health service utilization across racial groups. For instance, Cuffe
and colleagues (Cuffe, Waller, Cuccaro, Pumariega, & Garrison, 1995)
found that although African American adolescents had higher scores on
a measure of depression, they were less likely than European American
adolescents to receive outpatient treatment for any disorder and were
more likely to drop out of treatment early. Taken together, these find-
ings indicate that response to treatment might differ according to the
client’s ethnic background. In fact, some of the authorities on ethnicity
and culture have argued that findings from the majority of the current
clinical trials may not generalize to minorities (Bernal, Bonilla, & Bellido,
1995; Bernal & Scharron-Del-Rio, 2001; Hall, 2001; Sue, 1998). Clearly,
depressed youths (and likely their treatment providers) hold beliefs and
values about psychopathology and treatment that are influenced by their
various cultural backgrounds (Weisz, Jensen Doss, & Hawley, 2005).
Therefore, a sensitive understanding of these differences is essential to
accurate assessment and effective planning of treatment and treatment
research.
EFFICACY OF TREATMENTS FOR YOUTH DEPRESSION
Adolescent Depression
As reviewed briefly above, research on correlates of depression in youth
emphasizes its association with negative cognitions (review, Garber & Flynn,
2001), disturbed interpersonal relationships (review, Kaslow, Jones, Palin,
Pinsof, & Lebow, 2005), and stress (Rudolph et al., 2000). Accordingly,
treatments for adolescents have focused broadly on changing maladaptive
cognitions or on improving interpersonal functioning. Studies vary in their
inclusion of subjects with diagnosed depressive disorders versus subjects
with high levels of depressive symptoms. It is not clear the degree to which
findings from studies of youth with high depressive symptoms generalize
to youth with a diagnosable depressive disorder. Table 8.1 includes studies
conducted with youth with diagnosed depressive disorders. The 17 stud-
ies include 12 with a cognitive behavioral intervention condition, 3 with an
interpersonal therapy condition, 2 with social skills conditions, and 2 with
family therapy conditions. Four studies include comparison with medica-
tion conditions. Table 8.2 includes interventions conducted with youth
experiencing high levels of depressive symptoms and reviews six interven-

tions all of which are cognitive behavioral in their approach.
Maladaptive Cognitions
As illustrated in Tables 8.1 and 8.2 cognitive behavioral interven-
tions have been more thoroughly investigated than any other intervention
approach for adolescent depression. The specific cognitive interventions
used have varied across treatment studies. These studies have compared
cognitive behavioral treatment with different conditions, examined its
delivery in different formats (group vs. individual), looked at longer-term
follow-ups, and examined the role of parallel parent groups in enhancing
treatment efficacy.
Of the 12 studies of diagnosed depressed youth that included a cogni-
tive behavioral treatment condition, nine support the superiority of CBT
in comparison to control conditions. The efficacy of cognitive-behavioral
interventions has been demonstrated when compared to wait-list or no-
intervention conditions in three studies. CBT showed superiority in all
studies comparing it to wait-list control (Clarke, Rohde, Lewinsohn, Hops,
& Seeley 1999; Lewinsohn, Clarke, Hops, & Andrews, 1990; Rosello & Bernal,
1999), but in only one of the three studies comparing it to usual care
(Asarnow et al., 2005).
In one of the studies in which CBT did not show an advantage (Clarke
et al., 2005) the usual care consisted primarily of medication (SSRI) inter-
vention. Both studies (Clarke et al., 2002; 2005) underscore the impor-
tance of understanding what participants are receiving in “usual care”
conditions.
Five studies have compared CBT to other psychosocial treatments, and
it has been shown to be superior to systemic family therapy, supportive
therapy (Brent et al., 1997), relaxation training (Wood, Harrington, & Moore,
1996), and life skills training (Rohde, Clarke, Mace, Jorgensen, & Seeley,
2004). However, in one study comparing it to Interpersonal Therapy (IPT),
IPT had a larger effect size and greater enhancements in social functioning
and self-esteem (Rosello & Bernal, 1999).
In the three studies that included medication arms, one was not
designed to compare the two interventions (Asarnow et al., 2005), one
found medication alone to be superior to CBT (TADS team, 2004), and one
found CBT to be superior to medication intervention (Melvin et al., 2006).
In the study by Asarnow and colleagues (2005) 418 adolescents in primary
care settings (ages 13–21) were randomly assigned to a six-month “quality
improvement” intervention or usual care. Those in the quality improve-
ment intervention had access to a care manager, who educated them about
depression and treatment options, and participants could select medica-
tion or CBT treatments. Although the study was not designed to evaluate
the relative efficacy of CBT and medication, the quality improvement inter-
vention overall was associated with significantly lower depressive symp-
toms, and adolescents were somewhat more likely to prefer CBT.
In the study conducted by Melvin and colleagues (2006) 73 adoles-
cents (ages 12–18) were randomly assigned to the CBT alone, medication
Table 8.1. Randomized Clinical Interventions Trials for Adolescents with Diagnosed Depression
Diagnostic/ Treatment Post-treatment
Reference Subjects Risk Assessment Format(s) Intervention Type(s) Assessment Impact of Treatment
Asarnow, Jaycox, Ages Either: (1) Endorsed Individual (1) 6-month quality Immediate Intervention patients, compared
Duan, 13-21 “stem items” for MDD improvement with usual care patients, reported
LaBorde, Rea, (n=418) or DD from the CIDI-12, intervention significantly higher mental health
Murray, et al., 1 week or more of (2) Usual care care utilization, fewer depressive
2005 past-month depressive symptoms, higher mental
symptoms, and a total health-related quality of life, and
CES-D score≥16, or greater satisfaction with mental
(2) CES-D score≥24 health care.
Brent, Holder, Ages Diagnosis of MDD based Family (1) Systematic Immediate The CBT group had faster response,
Kolko, Birmaher, 13-18 on K-SADS Interview Individual Behavior Family fewer cases of diagnosable MDD
Baugher, (n=107) and Therapy at the end of the treatment,
Roth, et al., 1997 BDI ≥ 13 (2) CBT a lower number of depressive
(3) Supportive symptoms, and were more likely
therapy to be remitted than other groups.
No difference between family and
supportive therapies.
Clarke, Rohde, Ages Diagnosis of MDD or DD Group (1) Adolescent Immediate; CBT was associated with higher
Lewinson, Hops, 14-18 based on the Coping with 12 months; depression recovery rates
& Seeley, 1999 (n-=123) K-SADS interview Depression 24 months (66.7% vs. 48.1% in wait list
Course (CWD-A) condition) and greater reduction
(2) CWD-A with in depressive symptoms.
nine-session Addition of parent group had
parent group no significant effect. Booster
(3) Wait list control sessions accelerated recovery
among youth still depressed at
the end of acute treatment but
did not reduce recurrence.
Clarke, Hornbrook, Ages Diagnosis of DSM–III–R Group (1) Usual care plus Immediate; No significant differences between
Lynch, Polen, 13-18 MDD and/or DD group CBT 12 months; CBT and usual care, either for
Gale, O’Conner, (n=88) based on the K-SADS program (CWD-A) 24 months depression diagnoses, continuous
et al., 2002 interview (2) Usual care depression measures, nonaffective
mental health measures, or
functioning outcomes.
Clarke, Debar, Lynch, Ages Diagnoses of DSM–IV Individual (1) Brief CBT plus Immediate; CBT program showed advantages
Powell, Gale, 12-18 MDD based on the treatment as 26 weeks; on the Short-Form-12 Mental
O’Conner, et al., (n=152) K-SADS-PL interview usual (primarily 52 weeks Component Scale and reductions
2005 SSRI) in treatment as usual outpatient
(2) Treatment as visits and days’ supply of all
usual medications. No effects were
detected for MDD episodes; a
nonsignificant trend favoring
CBT was detected on the CES-D.
Diamond, Reis, Ages Diagnoses of DSM–III–R Family (1) Attachment- Immediate; At post-treatment, 81% treated no
Diamond, Sique- 13-17 MDD based on the Based Family 6 months longer met criteria for MDD vs.
land, & Isaacs, (n=32) K-SADS Therapy (ABFT) 47% of patients in the waitlist
2002 (2) Minimal-con- group. The ABFT patients showed
tact, waitlist greater reduction in depressive
control group and anxiety symptoms and family
conflict. At follow-up, 87% of the
ABFT patients continued to not
meet criteria for MDD.
Fine, Forth, Gilbert Ages Diagnosis of MDD or Group (1) Therapeutic Immediate; At posttest both groups improved;
& Haley, 1991 13-17 DD based on K-SADS Support Group 9 Months TSG significantly more effective
(n = 66) Interview (TSG) vs. than SSG in reducing depression
83% (2) Social Skills on K-SADS with more subjects in
female Group (SSG) non-clinical range. Group differ-
ences disappeared at follow up.
Lewinsohn., Clarke, Ages Diagnosis of major, Group; (1) Adolescent only Immediate; Significantly fewer youths in the
Hops & Andrews, 14-18 minor, or intermittent Family CBT training 1 month; treatment groups met criteria
1990 (n = 59) depression based on group 6 months; for depressive disorders after
K-SADS interview with (2) Adolescent- 12 months; treatment and at follow up.
mother and adolescent parent CBT 24 months Significantly improved on self-
training groups reported depression, anxiety,
(3) Wait list control number of pleasant activities,
and depressogenic thoughts.
Trend for adolescent-parent
condition to out-perform
adolescent only group.
(continued)
Table 8.1. (continued)
Diagnostic/ Treatment Post-treatment
Reference Subjects Risk Assessment Format(s) Intervention Type(s) Assessment Impact of Treatment
Melvin, Tonge, King, Ages Diagnosis of DSM–IV Individual (1) CBT Immediate; All groups showed significant
Heyne, Gordon & 12-18 MDD, DD, or DDNOS (2) Antidepressant 6 months improvement on outcome
Klimkeit, 2006 (n=73) based on the K-SADS medication measures and this was
(Sertraline) maintained at follow-up.
(3) Combined CBT Combined group was not superior
and medication to monotherapy. CBT alone was
superior to medication alone.
Mufson, Weissman, Ages Clinician diagnosis of Individual (1) Interpersonal Immediate IPT-A patients reported greater
Moreau, & 12-18 MDD based on the psychotherapy decrease in depressive
Garfinkel, 1999 (n=48) HRSD for depressed symptoms, improved social
adolescents functioning, and improved
(IPT-A) problem-solving skills
(2) Clinician compared to controls. In the
monitoring IPT-A condition 74% recovered
compared to 46% in the control
condition.
Mufson, Dorta, Ages DSM–IV diagnosis of Individual (1) IPT-A Immediate IPT-A associated with fewer clinician-
Wickramaratne, 12-18 MDD, DD, adjust- (2) Treatment as reported depression symptoms
Nomura, Olfson, (n=63) ment disorder with usual on the HAMD, better functioning
& Weissman, depressed mood, on the C-GAS, better overall
2004 or DDNOS and social functioning on the Social
HAMD≥10 and a Adjustment Scale-Self-Report,
C-GAS score≤65 greater clinical improvement,
and greater decreases in clinical
severity on the Clinical Global
Impressions scale.
Reed, 1994 Ages Clinician diagnosis of Group (1) Social skills Immediate; Skills group participants scored
14-19 MDD or DD training 6-8 weeks significantly higher on clinicians’
(n = 18) (2) Attention rating of improvement. Male
placebo control subjects improved, but female
subjects deteriorated.
Rohde, Clarke, Ages DSM–IV diagnoses of Group (1) CWD-A Immediate; Post-treatment MDD recovery rates
Mace, Jorgensen 13-17 MDD and Conduct (2) Life skills 6 months; better in CWD-A group (36%),
& Seeley, 2004 (n=91) Disorder based on the tutoring/control 12 months compared to ife skills/tutoring
K-SADS-E-5 (19%). CWD-A participants
reported reductions in BDI-II
and HDRS scores and improved
social functioning post-
treatment. Group differences in
MDD recovery rates at follow-up
were nonsignificant.
Rosello & Bernal, Ages Diagnosis of MDD, DD, Individual (1) CBT Immediate; Both active treatments were
1999 13-18 or both (2) IPT 3 months associated with significant
(n=71) (3) Wait list control reductions in depression when
compared to wait list. IPT was
superior to CBT in enhancing
social functioning and self-esteem.
TADS Team, 2004 Ages DSM–IV diagnosis of Individual Twelve weeks of: Immediate There were significant differences
12-17 MDD based on the K- (1) Fluoxetine between combination treatment
(n=439) SADS-PL alone and placebo on the CDRS-R.
(2) CBT alone Combined treatment was superior
(3) CBT with when compared with fluoxetine
fluoxetine alone and CBT alone. Fluoxetine
(4) placebo alone was superior to CBT alone.
Vostanis, Feehan, Ages 8-17 Diagnosis of MDD, DD, Individual (1) Depression treat- Immediate; No difference in remission rates;
Grattan, & Bicker- (n=56) or minor depression ment program 9 months remission rates were high in
ton, 1996 based on K-SADS (2) Attention placebo both groups.
Wood, Harrington, & Ages Diagnosis of MDD or Individual (1) CBT Immediate; Post-test revealed greater
Moore, 1996 9-17 RDC minor depression (2) relaxation 6 months reductions in depressive
(n = 48) based on K-SADS training symptoms and an advantage
interview with both in overall outcome in the CBT
parent and child group. At follow-up, group
differences were attenuated.
Note: MDD = Major Depressive Disorder; DD = Dysthymic Disorder; DDNOS = Depressive Disorder Not Otherwise Specified; K-SADS = Schedule for Affective Disorders
and Schizophrenia for School-Aged Children; BDI = Beck Depression Inventory; CDI = Children’s Depression Inventory; GAF = Global Assessment of Functioning Scale;
CES-D = Center for Epidemiologic Studies - Depression Scale; CDRS-R = Revised Children’s Depression Rating Scale; RADS = Reynolds Adolescent Depression Scale; BID =
Bellevue Index of Depression.
Table 8.2. Randomized Clinical Interventions Trials for Adolescents with Depression Symptoms or Risk Factors for Depression
Diagnostic/Risk Treatment Post- intervention
Reference Subjects Assessment Format(s) Intervention Type(s) Assessment Impact of Treatment
Ackerson, Scogin, Ages CDI≥10 and Self- (1) Cognitive Immediate; Treatment produced statistically
McKendree-Smith, 14-18 HRSD≥10 administered Bibliotherapy 1 month and clinically significant
& Lyman, 1998 (n=22) (reading improvements in depressive
“Feeling Good”) symptoms that were maintained
and weekly at follow-up, and a significant
monitoring decrease in dysfunctional,
phone calls but not in negative automatic,
(2) Delayed- thoughts.
treatment
control
Clarke, Hawkins, 9th and CES-D >23 but does Group (1) CWD-A Immediate; Significantly fewer CWD-A
Murphy, 10th not meet criteria (2) No intervention 6 months; adolescents diagnosed MDD or
Scheeber, graders for MDD or DD 12 months DD. Higher GAF and lower CES-
Lewinsohn, & (n=150) (K-SADS) D for CWD-A group at posttest
Seeley, 1995 but no differences at follow-up.
Clarke, Hornbrook, Ages Symptomatic Group (1) Usual HMO Immediate; Group intervention decreased
Lynch, Polen, 13-19 adolescent care plus 12 months; depression symptoms and
Gale, Beardslee, (n=94) offspring (CES- group cognitive 24 months episode rates to the community-
et al., 2001 D>24) of recently therapy normal range and decreases
depressed (2) Usual HMO care in the incidence of MDD at
parents, assessed followup.
using the F-SADS
Kerfoot, Harrington, Contact with social Individual (1) Brief CBT (2) 17 weeks No significant differences between
Harrington, services within Routine care after initial groups in depression or global
Rogers, & the previous assessment; adjustment. At post-treatment,
Verduyn, 2004 2 years; Mood 33 weeks 77% of the CBT group and 80%
and Feelings after initial of the routine care group had
depression assessment residual depressive symptoms or
questionnaire≥23 disorder.
Marcotte & Baron, Ages CDI≥15 on two Group (1) Rational-emotive Immediate; No difference between the two
1993 14-17 administrations (2) No treatment 8 weeks treatments: Depressive
(n=25) and elevated symptoms reduced at
score on post-treatment in both groups.
semistructured
interview focusing
on depressive
symptoms
Reynolds & Coats, 9th-12th (1) BDI score > 11; Group (1) CBT Immediate; Both active treatments showed
1986 graders (2) RADS > 71; (2) Relaxation 5 weeks significant decreases in
(n=30) (3) BID > 20; Training depressive symptoms and
(4) no other current (3) Wait-list control improved academic self-concept
treatment compared to wait list. Relaxation
associated with reductions in
anxiety as well.
alone (sertraline), or a combined CBT and medication intervention. CBT

alone was superior to medication alone and the combined treatment was
not superior to either treatment alone. The authors have noted that the
poor showing for medication in this study may be a function of inadequate
dosing.
Finally, the Treatment of Adolescent Depression Study (2004) com-
pared CBT alone, fluoxetine alone, CBT combined with fluoxetine and
placebo. Although the combination treatment was superior to all other
conditions, fluoxetine was superior to CBT alone, and CBT alone was not
significantly better than pill placebo. It has been noted that the effect size
for the CBT intervention in the TADS study was significantly smaller than
in other studies of CBT, and the version used may have been “low potency”
(Weisz, McCarty, & Valeri, 2006). In fact, other investigators have ques-
tioned the implementation of the specific CBT intervention in the TADS
study, suggesting it may have been overly structured and not have allowed
the flexibility necessary for maximally effective implementation (Hollon,
Garber, & Shelton, 2005). At this time, given the conflicting findings, the
role of medication–psychotherapy combination treatments for adolescent
depression remains unresolved.
Six studies have examined group cognitive behavioral interventions in
adolescents with high levels of depressive symptoms rather than diagnosed
depressive disorders. In the studies where treatments have been applied
to participants who are not diagnosed, samples were frequently hetero-
geneous. Using cutoffs on continuous measures of depressive symptoms,
some researchers may include many youth with diagnosable depression
(Kerfoot, Harrington, Harrington, Rogers, & Verduyn, 2004; Reynolds &
Coats, 1986; Marcotte & Baron, 1993) but for practical reasons are unable
to provide specific diagnoses. Others, in an effort to focus on the prevention
of morbidity in at risk-samples—secondary prevention studies—have pur-
posely excluded diagnosed youth and focused on subsyndromal depression
(Clarke et al., 1995, 2001). Due to this heterogeneity, it is difficult to deter-
mine whether findings from these studies can be generalized to youth with
diagnosable depressive disorders. In four of the studies cognitive behavio-
ral treatment was superior to a no-treatment comparison group.
Clarke and colleagues (1995, 2001) examined the 15-session Coping
with Depression Course (CWD) in two studies. In the first study 9th- and
10th-graders, who had high CES-D scores but did not meet criteria for
a depressive disorder, were randomly assigned to CWD or a no-interven-
tion group and followed up at 6- and 12-month intervals after treatment
completion. In the second study, youth ages 13 to 19, whose parents had
recently been depressed and were themselves currently symptomatic (but
did not meet criteria for Major Depressive or Dysthymic Disorders) were
assigned to usual care or usual care plus CWD and followed at 12 and 24
months after treatment was completed. In both studies the rates of depres-
sive disorders at follow-up were significantly lower in the CWD-treated
groups and comparable to community rates of depression.
In a small study of youth with mild to moderate depressive symp-
toms, Ackerson and colleagues (Ackerson, Scogin, McKendree-Smith, &
Lyman, 1998) found a significant advantage of implementing cognitive
bibliotherapy over no treatment, suggesting the possible utility of brief,

inexpensive, cognitively-focused interventions for milder depressive symp-
toms.
Finally Reynolds and Coats (1986) compared cognitive behavioral
therapy to relaxation training and to no intervention. Although the cogni-
tive behavioral intervention was superior to the no-treatment condition,
it showed no advantage over relaxation training. Overall, these studies
of cognitive behavioral interventions in youth with depressive symptoms
provide support for these treatments; however, they are unable to address
whether psychosocial treatments generally or cognitive behavioral treat-
ments specifically are superior to no-treatment conditions.
Two studies found no advantage for cognitive treatments. Kerfoot and
colleagues (Kerfoot, Harrington, R., Harrington, V., Rogers, & Verduyn,
2004) found no differences between brief cognitive behavioral therapy and
routine care in a sample of youth seen through social service agencies.
However, chronicity, comorbidity, and residential instability led to high lev-
els of treatment noncompletion in this challenging sample. Indeed, fewer
than one half of participants in the study completed four sessions of cog-
nitive behavioral therapy. Marcotte and Baron (1993) compared Rational
Emotive Therapy to no treatment in a small sample of teens with high
depressive symptoms. Symptoms reduced in both groups posttreatment;
however, the extremely small sample and limited statistical power make it
difficult to draw meaningful conclusions.
Cognitive interventions have been implemented in different formats,
including individual and group. Of those studies conducted with diag-
nosed depressed adolescents, eight were conducted in an individual for-
mat and four in a group format, and all were associated with significant
improvements in depressive symptoms. Of those studies of adolescents
with high depressive symptoms, four used a group format and three found
significant advantage to CBT over a no-intervention control (Clarke, Rohde,
Lewinsohn, Hops, & Seeley, 1999; Clarke et al., 2001; Reynolds & Coats,
1986). Indeed, meta-analysis supports the observation that both formats
may be useful in the treatment of adolescent depression (Weisz, McCarty,
& Valeri, 2006).
Although the immediate effects of cognitive behavioral interventions
for youth depression have been evaluated, fewer studies have examined
longer-term impact. Indeed, as revealed in Tables 8.1 and 8.2, a limited
number of studies have provided follow-up evaluations. Clarke and col-
leagues have included the longest follow-up intervals, ranging from 12
months (Rohde et al., 2004) to 24 months (Clarke et al. 1999, 2002, 2005;
Lewinsohn et al., 1990). Results are mixed. In two studies in which there
were initial group differences, treatment effects were maintained through-
out a 24 month follow-up in one (Lewinsohn et al., 1990) but attenuated
by 12 months in another (Rohde et al., 2004). Two studies showed no dif-
ference between CBT and usual care conditions either immediately or at
24-month follow-up (Clarke, 2002, 2005). One study examined the use of
booster sessions to promote recovery in youth who remained depressed
following the 8-week group CBT intervention and to prevent recurrence
in recovered youth (Clarke et al., 1995). Booster sessions significantly
reduced time to recovery in symptomatic youth but failed to prevent recur-

rence. Alternatively, in a small pilot study, Kroll, Harrington, Jayson, Fra-
ser, and Gowers (1996) found much lower rates of relapse among youth
receiving continuation CBT compared to an historical control group. Over-
all, the degree to which CBT interventions are sustained over time is not
clear, and future studies need to include substantial follow-up periods.
Finally, two studies have examined the role of parent involvement in
cognitive behavioral therapy. Both studies compared the Adolescent Cop-
ing with Depression (CWD) course alone both to a waitlist control group
and to CWD supplemented with cognitive behavioral training for parents.
In both studies treated groups had higher rates of recovery from depres-
sion and greater reductions in depressive symptoms. However, there was
not strong support for the addition of parental involvement. One of these
studies found no difference between CWD alone and CWD with the sup-
plemental parent group (Clarke et al., 1999), and the other revealed only
a slight trend for the adolescent-parent condition to outperform the ado-
lescent-only condition (Lewinsohn et al., 1990). Thus, while it is generally
agreed that parent involvement in youth treatments is important, exten-
sive parent involvement in the delivery of cognitive behavioral interven-
tions is not supported.
Interpersonal Functioning
Therapies focused on enhancing interpersonal functioning vary widely
and include group-based social skills training, individually based Inter-
personal Psychotherapy, and family-based interventions. Although they
share common goals of improving interpersonal relationships, decreasing
social isolation, and enhancing interpersonal skills, these interventions
vary greatly in their formats, techniques, and foci.
Two studies examining the efficacy of social skills training for depressed
adolescents have yielded mixed results. First, Fine, Forth, Gilbert, and
Haley (1991) compared a 12-session social skills training group to a thera-
peutic support group. Although both groups had improved significantly
posttreatment, contrary to expectation, the therapeutic support group was
superior in reducing depressive symptoms to the nonclinical range. Sec-
ond, Reed (1994) compared social skills training to an attention placebo
control condition. Although participants in the overall skills group showed
a greater improvement in clinicians’ ratings, there were significant gender
effects with boys showing some improvements and girls deteriorating. The
small sample size in this study (18 participants) makes it is difficult to
draw firm conclusions. Overall, the limited available data do not suggest
that social skills training alone is an efficacious treatment for adolescent
depression.
Three studies have examined Interpersonal Psychotherapy (IPT) for
the treatment of adolescent depression and all show strong support for
this intervention. In IPT clinicians focus on reducing depressive symp-
toms and enhancing interpersonal functioning using an active collabora-
tive approach and focusing on one or two primary interpersonal problem
areas. In an initial study, Mufson and colleagues (Mufson, Weissman,
Moreau & Garfinkel, 1999) compared IPT to clinician monitoring in 48

depressed adolescents. Those patients in IPT showed greater improve-
ments in depressive symptoms, social functioning, and problem-solving
compared to those in the clinical monitoring condition. Significantly more
patients in IPT showed recovery from depression as well. Second, Ros-
selló and Bernal (1999) adapted the IPT model specifically for Puerto Rican
adolescents. They compared IPT to CBT and wait-list control conditions.
Both CBT and IPT were superior to the wait-list in reducing depression,
and IPT was associated with greater gains in social functioning and self-
esteem compared to the wait-list condition and exhibited a larger overall
effect size (.73) than did CBT (.43). Third, Mufson and colleagues (2004)
replicated their original findings by comparing IPT to treatment as usual
in a school-based health clinic. Those receiving IPT showed greater reduc-
tions in symptoms of depression and improvements on social and global
functioning.
Overall, IPT appears to be a powerful treatment for depression in youth
that is flexible in its adaptation to other cultural settings. Given its focus
on interpersonal functioning, IPT necessarily emphasizes family relation-
ships and often includes parents in some sessions (Mufson et al., 2004).
However, the long-term effects of IPT have yet to be established, as follow-
ups either occurred only immediately (Mufson et al., 1999; 2004) or up to
three months following treatment completion.
The importance of family support and involvement in treatment of
youth is often considered a clinical given, but few studies have exam-
ined the role of family treatments in adolescent depression. Brent and col-
leagues (1993) demonstrated that a two-hour psychoeducational session
for parents was associated with their greater knowledge and fewer dys-
functional beliefs about depression and its treatment. Most parents (97%)
found such psychoeducation to be worthwhile. Indeed, in their large ado-
lescent depression treatment study, Brent and colleagues (1997) included
brief family psychoeducation in all treatment conditions with the goal of
minimizing dropout and supporting treatment. However, the outcomes of
more extended interventions aimed at altering family relationships have
been more mixed.
First, Brent and colleagues (1997) compared systemic-behavioral fam-
ily therapy to individual CBT and individual nondirective supportive ther-
apy for the treatment of adolescents with major depressive disorder. The
systemic-behavioral family therapy focused on altering family interaction
patterns through the use of reframing and communication and problem-
solving skills interventions. However, this family therapy was significantly
less effective than CBT and comparable to nondirective supportive ther-
apy. Second, Diamond and colleagues developed and examined Attach-
ment-Based Family Therapy (ABFT; Diamond, Reis, Diamond, Siqueland,
& Isaacs, 2002), a family treatment model for depressed adolescents that
is derived from attachment theory. This treatment focuses on building
alliances between the therapist and both the parent and the adolescent,
repairing the parent–child bond, and (with parental support) building the
adolescent’s competencies. An initial evaluation of this model, comparing
it to a wait-list control group, found substantially greater rates of recovery
(81% vs. 47%) from depression; these recovery rates were maintained at
six-month follow-up.
Overall, interventions that focus on interpersonal functioning appear
promising in the treatment of adolescent depression. However, the appro-
priate role of family involvement has yet to be clarified in treating depres-
sion during this developmental period, and clinicians tread a difficult path
in balancing the need to enhance family support and functioning while
supporting the adolescent’s burgeoning autonomy.
Preadolescent Depression
Although an increasingly well-developed literature exists on treatment
of adolescents with depression, far less exists to guide the treatment of
preadolescents with depression. In fact, we found only one study in the
literature that included any children younger than 8 years of age. Further-
more, as illustrated in Table 8.3, the few published studies of preadoles-
cents focused on those with high levels of depressive symptoms, and not
one study has exclusively targeted preadolescents with diagnosed clini-
cal depression. Two studies included some children 12 years of age and
younger with depressive diagnoses in their samples (Wood, Harrington, &
Moore, 1996; Vostanis, Feehan, Grattan, & Bickerton, 1996), but neither
included separate analyses of these groups, precluding an examination
of treatment effects in younger children. One study included only eight
prepubertal subjects (Wood, Harrington & Moore, 1996), and the other,
although they did not administer a measure of pubertal status, included
six 12-year-old participants and 13 participants under the age of 12 years
(Vostanis, Feehan, Grattan, & Bickerton, 1996; Vostanis, personal com-
munication, February 2007). Although a few treatment development stud-
ies have been conducted with diagnosed school-aged youth (Flory, 2004;
Kaslow et al., 2002; Tompson et al., 2007) much work remains to be done
in this area.
Unlike the studies examining treatments with adolescents, those
conducted with preadolescents frequently include cognitive behavioral
interventions that are also strongly focused on improving interpersonal
functioning. Most of the studies have focused on cognitive-behavioral and
skills-building interventions and have been delivered in a group format.
As illustrated in Table 8.3, in all examined treatments, group formats
allow practice of skills and interventions are designed to be active and
interactive. Indeed, most often the cognitive-behavioral components are
part of a larger skills-building package. Skills targeted include problem-
solving, self-monitoring, and social abilities. For example, Asarnow and
colleagues (Asarnow, Scott, & Mintz, 2002) include a segment on building
friendships that specifically targets the developmental social challenges of
late-elementary and middle-school youth. Thus, these cognitive-behavioral
interventions are frequently heterogeneous and broad-based.
In terms of efficacy, in eight of nine intervention studies, treated groups
showed significant improvements over untreated groups in reduction of
depressive symptoms (Asarnow et al., 2002; Butler, Meizitis, Friedman,
& Cole, 1980; DeCuyper, Timbremont, Braest, Backer, & Wullaert, 2004;
Table 8.3. Randomized Clinical Interventions Trials for Preadolescents with Depression
Diagnostic/Risk Treatment Post-intervention
Asarnow, Scott, & 4th-6th School screening; CDI Group (1) CBT and family Immediate Children in the intervention group
Mintz, 2002 graders education were more likely to show reductions
(n=23) (2) Wait-list control in depressive symptoms, negative
cognitions, and internalizing coping.
Butler, Miezitis, 5th-6th Teacher referral; high Group (1) Role Play Immediate Role play group showed significant
Friedman, & graders scores on CDI Problem Solving reduction on CDI and improved
Cole, 1980 (n=56) (2) Cognitive classroom functioning. One of two
restructuring groups in cognitive restructuring
(3) Attention showed significant reductions on
control CDI.
De Cuyper, Ages CDI score≥11 and/or Group (1) CBT program Immediate; Four-month follow-up comparisons
Timbremont, 10-12 T score≥23 on (‘Taking Action’) 4 months; with baseline measures, showed
Braet, De Backer, (n=20) CBCL Internalizing (2) Wait-list Control 12 months significant improvement on the CDI
& Wullaert, 2004 and Anxious/ group and the Self-Perception Profile only
Depressed for CBT group. At the 12-month
subscale; at least follow-up, CBT group showed
one MDD criterion further improvement and significant
but without other decreases on the CDI, STAI, and
apparent Axis-I CBCL.
Jaycox, Reivich, Ages Z-scores on CDI + Group (1) Cognitive Immediate; No differences between treated groups
Gillham, & 10-13 Child Perception (2) Social Problem- 6 months; who had fewer depressive symptoms
Seligman, 1994; (n=143) Questionnaire > Solving 12 months; at post-test and at follow up and
Gillham, Reivich, 0.50 (3) Combined 18 months; improved classroom behavior
Jaycox, & (both above 24 months (teacher report) than untreated
Seligman, 1995 treatments) groups. Effects more pronounced
(4) Wait-list control among children from high conflict
(5) No participation homes. Follow-up revealed even
control greater group differences in
depressive symptoms over time.
(continued)
Diagnostic/Risk Treatment Post-intervention
Kahn, Kehle, Ages Multistage Gating: Group (1) Cognitive- Immediate; All active treatment groups showed
Jensen, & Clark, 10-14 Stage 1: CDI>14; behavioral (2) 1 month significant improvement in
1990 (n=68) RADS>71. Stage Relaxation depression compared to control.
2: Reassessment 1 Training 3) Self- Most children in CBT and relaxation
month later with modeling 4) Wait groups went from dysfunctional
CDI and RADS. list control to functional range on depressive
Stage 3: Interview, symptoms; self-modeling group less
BDI>19. No improved than other groups.
other depression
treatment
King & Grades Children who scored Group (1) Social skills Immediate Combined program showed reduced
Kirschenbaum, KG- 4 above a cutoff training plus depressionas compared to
1990 (n=135) on the Activity consultation consultation only. Multidimensional
Mood screening with parents ratings of behavior and skills
questionnaire and teachers (2) improved across both groups.
Consultation
only
Liddle & Spence, Ages CDI ≥ 19 CDRS-R ≥ Group (1) Social Immediate; No group differences at pretest,
1990 7-11 40 competence 3 months post-test, or follow-up. All groups
(n=31) training declined on CDI scores and
(2) Attention increased on teacher’s reports of
placebo (3) Wait- problem behavior.
list control
Stark, Reynolds, & 4th-5th CDI scores>12 on 2 Group (1) Behavioral Immediate; 8 Both active treatment groups showed
Kaslow, 1987 graders administrations problem solving weeks significant reductions in depressive
(n=29) (2) Self-control symptoms; however, in Behavioral
(3) Wait-list control Problem Solving both mothers
and children reported differences,
whereas in self-control only children
reported differences.
Weisz, Thurber, 3rd-6th CDI≥10 and/or Group (1) Primary and Immediate; 9 At post-test and follow-up, treated
Sweeney, Proffitt, graders identified by secondary months group showed significantly greater
& LeGagnouz, (n=48) teachers/counselor control reductions on both CDI and
1997 as depressed; and enhancement CDRS-R.
CDRS-R interview training
score≥ 34 (2) No treatment
control
Note: MDD = Major Depressive Disorder; DD = Dysthymic Disorder; DDNOS = Depressive Disorder Not Otherwise Specified ; K-SADS = Schedule for Affective Disorders and
Schizophrenia for School-Aged Children; BDI = Beck Depression Inventory; CDI = Children’s Depression Inventory; GAF = Global Assessment of Functioning Scale; CES-D =
Center for Epidemiologic Studies - Depression Scale; CDRS-R = Revised Children’s Depression Rating Scale; RADS = Reynolds Adolescent Depression Scale; BID = Bellevue Index
of Depression.
Jaycox, Reivich, Gillham, & Seligman, 1994; Kahn, Kehle, Jenen, & Clark,
1990; King & Kirschenbaum, 1990; Stark, Reynolds, & Kaslow, 1987;
Weisz et al., 1997). One study found no difference between children treated
with social competence therapy, attention control, and no treatment, as
all groups showed improvement over time (Liddle & Spence, 1990). In con-
trast, of the five studies comparing different treatments, only two showed
group differences. Both Butler and colleagues (1980) and Stark and col-
leagues (1987) showed an advantage of problem-solving interventions over
both self-control and cognitive restructuring interventions, potentially
suggesting superiority of problem-solving. However, another investigation
(Jaycox et al., 1994; Gillham et al., 1995) failed to support the superiority
of social problem-solving over more cognitive-focused interventions. Thus,
although at this time studies support the overall efficacy of psychosocial
interventions for depression in preadolescent youth, they do not currently
support differences between depression-specific and more general inter-
ventions.
Although most of the studies are limited in their follow-up, focusing
only on immediate treatment effects, three studies completed evaluations
over a longer period. First, Jaycox, Gillham, and colleagues (Jaycox et al.,
1994; Gillham et al., 1995) compared five groups: a cognitive interven-
tion, social problem-solving, a combined group, a wait-list control, and a
no-participation control. At immediate posttest, all treated groups showed
superiority to untreated groups and at two years posttreatment the dif-
ferences were even more striking. Second, after comparing an 18-session
CBT protocol to wait-list, DeCuyper and colleagues (2004) followed the
school-aged participants for one year and found continued increases in
positive self-perception and decreases in both child and parent reports
of symptoms. Third, Weisz and colleagues (1997) followed school-aged
youth for nine months following a trial of Primary and Secondary Control
Enhancement Therapy, which focuses on the development of both prob-
lem-solving and cognitive restructuring skills. Group differences contin-
ued to be evident at the nine-month follow-up point.
The goal of skills-building interventions is to increase coping and
competence, and we would anticipate that such interventions may have
increasing effects over time. Indeed, these limited follow-up data suggest,
at minimum, maintenance of treatment gains and possibly enhancement
of these gains over time. Longer-term follow-up evaluations need to be
included in all studies to understand durability of intervention effects.
The role of the family in the treatment of depression in school-aged
youth remains to be clarified. Although the interventions examined at
this point have focused on group formats, several have included family
involvement (Asarnow et al., 2002; Stark, 1990). Given the embedded-
ness of school-aged youth within their families, there are strong reasons
to believe that family-based approaches may be particularly potent during
this developmental period. Indeed, in a study of family intervention for
childhood anxiety disorders comparing individual CBT, CBT plus family
treatment, and a wait-list control group, Barrett, Dadds, and Rapee (1996)
found a significant age effect; younger children showed better outcomes in
CBT plus family treatment whereas older children did equally well in both
active treatments. These findings highlight the importance of examining

family-based treatments in school-aged youth.
Three treatment development studies have been published describing
family-based treatments for depressed preadolescents. First, Schwartz,
Kaslow, Racusin, and Carton, (1998) have described a sophisticated family
therapy model that integrates theory and techniques from family systems
perspectives, cognitive-behavioral approaches, attachment theory, inter-
personal therapy, and elemental psychopathology. Interpersonal Family
Therapy seems to decrease depressive symptoms, change maladaptive
cognitions, and improve family affect and communication. To our knowl-
edge, it has not yet been tested.
Second, Kovacs and colleagues (2006) developed Contextual Emo-
tion Regulation Therapy (CERT) specifically for school-age children with
chronic depression. CERT is individually tailored using “contextual map-
ping” of dysphoric emotional responses and emphasizes the development
of skills to enhance the down-regulation of dysphoric emotional responses.
In an open trial of 20 chronically depressed youth, CERT was associated
with significant remission of depression, decreases in symptoms of both
depression and anxiety, and reduction in maternal symptoms of depres-
sion and anxiety.
Third, Flory (2004) described Emotionally Attuned Parenting, an inter-
vention aimed at improving the parent–child relationship in youth with
internalizing psychopathology. The intervention, with its focus on enhanc-
ing parental empathy, included parents only. In a small open trial, a mixed
sample of children with depressive and anxiety symptoms displayed sig-
nificant symptom improvement and their parents reported reductions in
parenting stress, with gains maintained six months posttreatment.
Fourth, and finally, Tompson and colleagues (2007) have developed
Family-Focused Treatment (FFT) for depressed children. The treatment
integrates family systems and cognitive-behavioral models and provides
expanded family psychoeducation and skills building within a family
context. Interventions are focused on understanding the family’s unique
interactional processes and increasing positive and decreasing negative
interactional sequences. The treatment includes modules that are focused
on: (1) educating family members about depression, focusing on its
interpersonal nature; (2) enhancing positive interactions; (3) practicing
communication skills; and (4) teaching problem-solving skills. Initial open
trial data suggest that FFT was associated with remissions in depression
and associated syndromes, reductions in self- and parent-reported
depressive symptoms, and improvements in family functioning. In sum,
pilot interventions suggest the promise of the family-based approaches in
the treatment of depressed school-aged youth.
DIRECTIONS FOR FUTURE RESEARCH
Treatment research to date supports the value of psychosocial

approaches for the treatment of youth depression. However, many issues
remain and further research is necessary to determine optimal strategies
for the comprehensive treatment of depression. Areas of concern include

limited treatment efficacy, insufficient examination of continuation treat-
ment strategies, narrowly defined treatment outcomes, lack of research
examining treatments for younger children with depression, lack of treat-
ments for special populations, and limited data examining treatments in
“real-world” clinical settings.
First, treatments to date have demonstrated limited efficacy. Although
earlier meta-analytic studies of psychosocial treatments for youth depres-
sion optimistically suggested very large effect sizes (Lewinsohn & Clarke,
1999; Reinecke, Ryan, & DuBois, 1998), a more recent metanalysis with
more comprehensive inclusion of treatment studies indicates effect sizes
in the small to medium range (Weisz, McCarty, & Valeri, 2006). Current
data with clinically depressed youth suggest that approximately 40 to 50%
fail to show significant recovery or remission in trials of either psychosocial
or pharmacologic treatments. These findings highlight the critical need to
develop new efficacious treatment strategies and enhance the impact of
current treatments.
Second, most treatment studies with depressed samples have focused
on acute treatment impact and few studies have followed youth for any
substantial time following treatment completion. Data on the high risk
of relapse following both psychosocial (Vostanis et al., 1996; Wood et al.,
1996) and pharmacologic intervention trials (Emslie et al., 1997) suggest a
need to examine continuation treatment strategies. Very few studies have
included significant follow-up periods, and even fewer have examined con-
tinuation treatment strategies for maintaining and enhancing treatment
gains over time.
Third, most studies examining psychosocial treatments for youth
depression have focused primarily on symptom outcomes. It is not clear
the degree to which symptomatic improvement is accompanied by improve-
ments in functional outcomes. Recent evidence of enhanced social func-
tioning following IPT (Mufson et al., 1999; Roselló & Bernal, 1999) are
encouraging and, it is hoped, will spur additional evaluation of such out-
comes. Future studies need to assess multiple outcome domains, includ-
ing associated syndromes and social and academic functioning.
Fourth, as has been emphasized throughout this review, most of the
clinical trials examining treatments of youth depression have focused on
adolescents. There is a strong need for additional studies examining opti-
mal treatment strategies for younger children with depression. Develop-
mental considerations during middle to late childhood, including greater
dependence on parents and rapidly changing cognitive capacity, make it
unlikely that adult treatments can simply be extended downward, point-
ing to a need for developmentally-informed treatment specifically for chil-
dren. Treatment development work to this point has generated promising,
developmentally targeted intervention strategies for preadolescent youth,
and there is a strong need for clinical trials in this area.
Fifth, there is currently a paucity of research on depression in indi-
viduals with developmental disabilities and mental retardation (Lowry,
1998). Although limited studies suggest that individuals with developmen-
tal disabilities and/or mental retardation can experience high levels of
depressive symptoms, and those with Asperger’s syndrome may be at par-

ticular risk (Ghaziuddin, Ghaziuddin, & Greden, 2002; Matson & Nebel-
Schwalm, 2007; Saulnier & Volkmar, 2007), there are no clinical trials
examining depression treatments for these special populations. Some case
studies suggest the utility of behaviorally-based approaches for individu-
als with mental retardation (Frame et al., 1982; Matson, 1982) and autism
spectrum disorders (Matson & Nebel-Schwalm, 2007). There is a strong
need to develop and test treatments for these populations.
Finally, although randomized clinical trials indicate efficacy for CBT
interventions for depressed youth, effectiveness trials have documented
weak effects of CBT in community settings (Clarke et al., 2002, 2005; TADS,
2004; Weisz et al., 1995). On the other hand, recent work comparing youth
receiving care in community mental-health centers to youth receiving CBT
in depression clinical trials does suggest greater benefits for the CBT-treated
youth (Weersing & Weisz, 2002). Overall, findings highlight the need to both
examine and enhance depression treatment in real-world settings.
CONCLUSIONS
Our understanding of depression in youth has advanced significantly

in the past 20 years, treatments have demonstrated efficacy, and guide-
lines for clinical practice have been developed. In addition to medication
strategies, interpersonal interventions and both individually based and
group-based cognitive behavioral interventions are treatment options
for depressed youth. More limited data suggest the utility of brief family
psychoeducation, and further studies are examining the utility of more
extended family interventions. However, additional research is required to
enhance and develop treatment approaches, to examine combined treat-
ments, to delineate algorithms for making treatment decisions, and to
develop longer-term interventions aimed at preventing relapse and pro-
moting recovery. Finally, there is a strong need to ensure that treatments
developed for the laboratory setting are available and effective for youth in
the wide range of real-world clinical settings where youth receive care.
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9
Medication Treatment
Of Bipolar Disorder In
Developmentally Disabled
Children
and Adolescents
ZINOVIY A. GUTKOVICH and
GABRIELLE A. CARLSON
INTRODUCTION
If systematic data on the treatment of bipolar disorder in children and

adolescents is meager, information on treatment of bipolar disorder in
developmentally disabled children is virtually nonexistent. Not only are
many of the challenges to diagnosing young children relevant to persons
with autism and intellectual disability of any age, but also, accumulat-
ing a sample size large enough to randomize to treatment alternatives
would require financial resources that are not likely to be forthcoming
any time soon. This chapter, then, begins with a review of the treatment of
bipolar disorder (BD) in normally developing youth, summarizes current
treatment of BD in adults with developmental disabilities (DD), and then
moves to the review of available literature on the treatment of developmen-
tally disabled children and adolescents with BD. We conclude with our
thoughts about treatment in this vulnerable population.
ZINOVIY A. GUTKOVICH • Assistant Professor of Clinical Psychiatry, Attending Child

Psychiatrist, St. Luke’s Roosevelt Hospital, 1090 Amsterdam Avenue, 17th Floor, New York,
NY 10025.
GABRIELLE A. CARLSON • Stony Brook University School of Medicine, Stony Brook, NY,
USA.

254 ZINOVIY A. GUTKOVICH and GABRIELLE A. CARLSON
Our understanding of BD as a recurrent disorder in which mood and

activity level are either significantly increased (hypomania and mania) or
decreased (depression) with return to premorbid levels of functioning in
between emerged largely from the vast clinical experience of psychiatrists
such as Kraepelin in the early 20th century recognizing syndromal simi-
larities of hundreds of his patients. Our initial understanding of BD in
youth, however, emerged from attempts to find pediatric equivalents of
what adult psychiatrists appeared to be describing (see Glovinsky, 2002;
Carlson, 2005). This form of manic depressive illness did indeed exist in
youths, occurred mostly in adolescents, was depressive, and familial. In
the early 1950s, a volume of a journal called The Nervous Child raised the
issue of an “alternative form” of manic depression, children whose behav-
ior fluctuated and might be construed as cycling. Anthony and Scott
(1960) explored the question of strictly defined, classical “manic depres-
sive psychosis” in preadolescents in a literature review, and they found it
to be uncommon, generally beginning to emerge at around age 11.
In the past 30 years, with the adoption of DSM–III–IV–TR, diagnosis
has been made cross-sectionally, using a checklist of symptoms rather
than pattern recognition. With this approach, more adults and more chil-
dren have been given the diagnosis of BD, and a spectrum of severity and
intensity of symptoms as well as co-occurrence with many other condi-
tions has been found. The degree to which this redefined population is the
same as earlier descriptions of manic-depressive illness is the source of
some dispute (Carlson and Meyer, 2006; Andreasen, 2007).
In adolescents, the diagnosis of acute mania or severe depression
used to be missed because of confusion with schizophrenia (e.g. Carl-
son and Strober, 1978). In preadolescents, the diagnostic conundrum
has been separating mania from a variety of behavioral disorders in
children in which activation, short attention span, and irritability co-
occur chronically. The essential question then becomes whether the
frequent and brief episodes of intense mood volatility and irritability
that is being called “prepubertal mania” or “juvenile bipolar disorder”
is the same illness as bipolar disorder in adults (Leibenluft, Charney,
Towbin, Bhangoo, & Pine, 2003; McClellan, 2005). The further one
diverges from the description of BD as it has been conceptualized for
the past century, the more difficult it becomes to extrapolate those find-
ings to children. Diagnostic issues become even more challenging in
the developmentally disabled. Interestingly, as shown, classic manic-
depression/BD is readily identifiable in the case histories of older chil-
dren and adolescents regardless of their developmental age, something
observed in adults with BD and DD as well (Carlson, 1979).
CLINICAL MANAGEMENT OF NORMALLY DEVELOPING

CHILDREN AND ADOLESCENTS
The first step in treatment of BD, regardless of the chronological or

developmental age of the patient is a good assessment. It is necessary to
MEDICATION TREATMENT OF BIPOLAR DISORDER 255
clarify if treatment is addressing mania or depression, if the target symp-

toms are acute or chronic, or are characterized mainly by aggression,
mood instability, depression, insomnia, or other symptoms. The frequency,
intensity, number, and duration of periods of significant symptoms must
be captured at baseline and followed with intervention in order to deter-
mine whether intervention is having an impact. Finally, an understanding
of the environmental context of the condition is imperative: how do symp-
toms/behaviors change at home, in school, in residential treatments, time
of day, with and without structure, and with some people and not others.
Although people like to talk about “mood swings” as if they are imposed by
divine interference, they almost invariably have triggers that increase their
frequency and intensity, and moderators that decrease it.
Evaluating the Evidence Base

Compared to what is known about the risks and benefits of medica-
tion for mania, hypomania, and depression in adults, what is known for
normally developing children and adolescents is still meager, although
growing, as is briefly summarized below. The “gold standard” of evidence
for treatment safety and efficacy has been the randomized, double-blind,
placebo-controlled study.
The prototype of this study has a number of standardized components
including:
(1) A clinical history to screen the patient for bipolar disorder and exclude
other conditions, such as schizophrenia, substance abuse, eating disorder,
and medical and neurological conditions felt to compromise the integrity of
the study. Relevant to this chapter, intellectual disability (IQ below 70) and
pervasive developmental disorder are invariably exclusionary criteria.
(2) Structured/semistructured interviews are often used to ensure the
presence of mania or depression (depending on what phase of the condi-
tion is being addressed).
(3) Finally, a number of standardized rating scales are administered to
gauge the severity of the condition(s). In the case of mania, the Young Mania
Rating Scale (Y-MRS, Young et al., 1978) has been most frequently used, and
a cutoff score of 20 is needed to enter the mania study to ensure the patient
is sick enough for treatment. This is an interview scale where answers are
determined by the interviewer either observing or speaking to the patient,
caregiver, or both. For depression in youth, the Children’s Depression
Rating Scale-revised (CDRS-R) (Poznanski et al., 1984) is most often used
with a score of ≥40 for depression as the entry criterion. In adults, a variety
of scales are used. Mania trials are usually three to eight weeks depending on
the drug’s pharmacologic properties (i.e., what dose and how long it takes
to work). Trials are kept as short as possible to minimize the untreated
time for the placebo-treated patients but if they are not long enough, a fair
appraisal of drug efficacy is not possible. Although remission of symptoms
is highly desired (for the Y-MRS scores it should be <12, for the CDRS-R,
less than 28), “response” or a predetermined decrease in symptoms (e.g., a
50% decrease over baseline) is usually accepted as a reasonable goal. In many
studies, a global improvement measure (the child improved/worsened a lit-

tle, much, very much) is also used. Both a comparison of rating scale scores
at the end of treatment between the drug and placebo groups, and the per-
cent of people with the response rate is compared.
Although there are a growing number of such randomized, double-
blind, placebo-controlled trials in youth, most of our knowledge base
still comes from open trials. In the best of these, a thorough psychiat-
ric/developmental assessment is done at the outset, along with severity
measures of the construct in question. At points during or at the end of
the trial, the measures are repeated so that it is possible to determine how
much change has occurred over time. Baseline and treatment measures of
“adverse events” are also obtained.
TREATMENT RECOMMENDATIONS FOR NORMALLY

DEVELOPING YOUTH WITH BIPOLAR DISORDER
The American Academy of Child and Adolescent Psychiatry recently

updated and published Practice Parameters (McClellan, Kowatch, & Fin-
dling, 2007). Prior to that, a consensus conference was convened in July,
2003 initiated and supported by the Child and Adolescent Bipolar Foun-
dation. Experts in child and adolescent bipolar disorder summarized rec-
ommendations for the field based on interpretation of extant information
(Kowatch et al., 2005). There is considerable overlap in recommendations
given that many of the same experts were involved in both documents.
Acute Treatment of Mania/Hypomania

Although “bipolar” has come to be synonymous with mania, it is important
to make the distinction inasmuch as the former can imply past or current
episodes of mania, and the patient may be in remission, or be currently
experiencing mania, hypomania, depression, or dysthymic disorder. The
Food and Drug Administration (FDA) has become more specific in what
drug is being approved for what condition, so that “acute mania” consti-
tutes a major indication at the moment. In 2002, Congress passed the
“Best Pharmaceutical Act for Children” mandating, basically, that adult-
approved drugs likely to be used in children and adolescents needed to
be tested for safety and efficacy in the pediatric age group. For doing so,
the drug company could receive a 180-day patent extension. The surge of
medications that have received FDA approval for treatment mania in adults
prompted the FDA to issue written requests to relevant drug companies to
perform such studies in youth ages 10 to 17. This age group was chosen
based on a consensus conference held in 2002 (Carlson et al., 2003). Other
guidelines for drug studies were also published. Table 9.1 summarizes the
current status of information for children and adolescents on drugs used
to treat mania in adults, organized by the level of evidence.
Treatment algorithms recommended by Pavuluri et al. (2004) and
adopted in Practice Parameters (AACAP, 2007) as well as an algorithm by
Table 9.1. Summary of the Evidence for Drugs to Treat Mania in Children and
Adolescents
Status in Bipolar Disorder
Li FDA approved for treatment of mania in adults and in youth down

to age 12; Placebo-controlled trials in samples that contain
some children and adolescents with acute mania but acute
mania was not specifically studied; results mixed; otherwise,
open and discontinuation trials which are mostly positive.
Divalproex FDA approved for treatment of mania in adults; safety data in
youth because of approval for treatment of seizures; for mania
in children and adolescents, positive open trials,
discontinuation trials, add-on trial, and randomized controlled
trial; recent industry sponsored, Double-blind, placebo-
controlled trial (DBPC) did not show separation from placebo.
A smaller, NIMH funded trial did.
Carbamazepine Off-label in adults and children; Safety data in youth because of
approval as anticonvulsant in children and adolescents; for
mania, open randomized trial and case reports in children and
adolescents that are positive.
Topiramate Off-label in adults and children; some safety data because of
approval for partial onset seizures in children 2–16; for mania,
one placebo controlled trial in adolescents part of an adult
study; inconclusive results because underpowered.
Oxcarbazepine Off-label in adults and children; some safety data in youths
because of approval as adjunctive treatment for partial
complex seizures in youths ages 4–16; for mania, case report;
DBPC trial did not show separation from placebo.
Risperidone FDA approved for mania in adults; Chart review series; positive
open trials; positive add-on trial; placebo-controlled trials in
children with irritable aggression in conduct disorder and
autism; FDA approval for the autism-irritability indication.
The FDA has recently approved this medication for treatment
of acute and mixed mania down to the age of 10.
Olanzapine FDA approved for mania and maintenance in adults; in children
and adolescents, positive ten trials, case reports; DBPC trial in
adolescents aged 13–17 found olanzapine is significantly
better than placebo in reducing the symptoms of mania.
Quetiapine FDA approved in adults for treatment of mania; in adolescents,
positive add on study and randomized comparison with
divalproex; ongoing DBPC trial for youths ages 10–17.
Ziprasidone FDA approved in adults for treatment of mania; in children and
adolescents, chart reviews and small case series; DBPC trial
underway in youths age 10–17.
Aripiprazole FDA approved in adults for treatment of mania; in children and
adolescents, chart reviews;DBPC trial underway for youths
ages 10–17 has been completed. The FDA has recently approved this
medication for treatment of acute and mixed mania down to age 10.
Clozapine FDA approval only for treatment-resistant schizophrenia in adults;
off-label for mania in adults; in children and adolescents, case
series.
Lamotrigine FDA approved for the maintenance treatment of adults with
bipolar I disorder to delay the time to occurrence of mood
episodes (depression, mania, hypomania, mixed episodes);
Safety data in youths because approved for patients 2 years
and older with simple or complex partial seizures; for bipolar
disorder, chart review and add-on study for bipolar depression
in teens.
(continued)
Table 9.1. (Continued)

Status in Bipolar Disorder
Symbyax (combined FDA approved for treatment of bipolar depression in adults; no

olanzapine and studies of bipolar depression in children and adolescents
fluoxetine) though fluoxetine is FDA approved for the treatment of major
depression in children and adolescents.
Kowatch et al. (2005; JAACAP, 2005) closely follow guidelines for adults
with mania. There are two treatment algorithms, depending on whether
the mania presents with or without psychosis. When a child or adolescent
presents with manic or mixed symptoms without psychosis, monotherapy
is generally preferred initially, for reasons of safety. Treatment can be initi-
ated with lithium, a sedating anticonvulsant (valproate has the most data)
or an atypical antipsychotic (such as olanzapine, quetiapine, risperidone,
and aripiprazole (soon) which currently have the most data). When the
clinical response is only partial, augmenting with a drug of a different class
(adding an atypical to a mood stabilizer or vice versa), with appropriate
dose adjustments to minimize additive side effects is recommended. If
there is no response to the initial monotherapy, switching to a drug of a
different class (from lithium to an anticonvulsant or from lithium or anti-
convulsant to an atypical) is suggested. If the second agent fails to produce
a satisfactory response, the evidence in child and adolescent psychiatry
supports combined therapy.
If the manic or mixed syndrome presents with psychotic features and/or
prominent symptoms of severe agitation and aggression, it is recommended
that treatment be initiated with a combination of a mood stabilizer and an
atypical antipsychotic. Based on data from adults, when a partial response is
encountered, a mood stabilizer is usually added (i.e., three medications: an
anticonvulsant plus lithium plus an atypical.) In the case of a nonresponse
(or intolerance) to the initial mood stabilizer + atypical combination, trying
an alternative mood stabilizer (lithium for anticonvulsant non-response and
vice versa) or an alternative atypical agent can be tried.
For children and adolescents who have not responded to combinations of
treatment with three medications, clozapine is recommended. Haloperidol
has also been used as an adjunctive treatment in several trials (Kafantaris,
Coletti, Dicker, Padula, & Kane, 2001). Electroconvulsive therapy is rec-
ommended for adolescents only (Ghazziuddin et al., 2004).
Although hospitalization is not a psychiatric medication, clinical expe-
rience suggests that some children and adolescents need the structure,
decreased stimulation, or removal from stress that this intervention provides.
Treatment of Bipolar Depression

When the first phase of BD is depression, the fact that one is dealing with
bipolar manic depression may not be evident. Moreover, the depressive phase
of BD is challenging to treat even in adults both because antidepressants are
not greatly effective (Sachs et al., 2007) and there is a risk of “switching”
the depressed person into a manic state (Ghaemi, Hsu, Soldani, & Good-
win, 2003). Medications used to treat bipolar depression in adults include
lithium, which has some antidepressant efficacy, and most recently, lamo-
trigine, quetiapine, and combined fluoxetine and olanzapine (Calabrese et
al., 2005; Goodwin et al., 2004; Tohen et al., 2003).
In young people, lithium did not improve the depression of prepuber-
tal children or adolescents with or without predictors of future bipolarity
(Geller et al., 1998; Ryan, Meyer, Dachille, Mazzie, & Puig-Antich, 1988;
Strober, Freeman, Rigali, Schmidt, & Diamond, 1992). In one open trial of
adolescent inpatients, only 30% met response criteria after 6 weeks (scores
≤ 28 and CGI improvement ≤ 2). Interpretation of the apparent treatment
response is complicated by the absence of placebo control (and depression
has a notoriously high placebo response in youth), as well as by the fact
that the major improvement in mood symptoms took place within the first
two weeks of hospitalization, itself a potent intervention.
Lamotrigine has received little study in youth. Open trials and case
series suggest some improvement in bipolar depression (Carandang Max-
well, Robbins, & Oesterheld, 2003; Chang, Saxena, & Howe, 2006; Kusu-
maker & Yatham, 1997). The use of lamotrigine is complicated by the need
to start with very low doses and increase gradually in order to lessen the
risk of a rare and sometimes fatal complication, Stephens-Johnson Syn-
drome (Messenheimer, 2002).
Unfortunately, there is a risk of precipitating a manic episode and in a
young person a risk for a bipolar course, so the doctor must weigh the risks
of precipitating a mania/hypomania/bipolar course with an antidepres-
sant versus treating with a mood stabilizer alone (for which there is either
minimal or no data regarding effectiveness in children or adolescents) ver-
sus treating the child or adolescent with two drugs, one of which might not
be needed. The clarity of a history suggestive of a bipolar diathesis (includ-
ing clear bipolar history in first-degree relatives), the reliability of parent
observation and child compliance with treatment, and family preference
should all be carefully weighed in the decision making process.
Maintenance
The consensus panel described earlier (Kowatch et al., 2005) observed
that, given the high lifetime recurrence rates in untreated BD, for patients
with the authentic disorder, medication treatment should be recommended
for the long term and that patients and families be educated to understand
both the high rate of relapse in young people as well the especially noxious
contribution of illicit drugs in perpetuating mood episodes. For patients
with less classical forms of BD, the “lifetime medication” recommendation
is much less clear. However, patients stable on medication are encour-
aged to continue treatment until completion of high school/college/trade
school, or until they are beyond an anticipated major life stressor (start-
ing a new job, getting married, etc). Medication discontinuation should
be undertaken gradually to decrease the likelihood of rebound mania or
emergence of suicidality and be timed so as to have the least impact on

life and when ongoing monitoring and social support are available to pro-
vide prompt referral if an episode recurs (Suppes, Baldessarini, & Faedda,
1991; Baldessarini, Tondo, & Viguera, 1999).
Summary of Treatment Studies in Developmentally Disabled

Adults
Lithium
Most of the reports and case series addressing BD in people with
DD (comprising between 30–40 patients, usually adults with intellectual
disability) took place before 1980 and were based on DSM–II phenome-
nology, and shortly after lithium became a major treatment intervention.
These were open studies, the focus of which was to describe the clinical
picture of manic-depression in this handicapped population and delineate
the unique issues involved with diagnosis. Cases described were clearly
episodic with activated/energetic, noisy periods alternating with with-
drawn, even stuporous periods. In the most profoundly retarded people,
verbal content was not meaningful but behavioral shifts were often quite
striking and helpful diagnostically.
By way of validation, family histories often contained cognitively
normal relatives with affective disorders, and some response to lithium
was observed (Carlson, 1979; Hasan & Mooney, 1979; Naylor, Donald,
Le Poidevin, & Reid, 1974; Reid, Naylor, & Kay, 1981; Sovner & Hurley,
1981), with or without neuroleptics. In some cases, response to lithium
was miraculous. In other words, responses in mentally handicapped peo-
ple were similar to what was observed in cognitively normal adults.
Valproate and Carbamazepine

Beginning in the late 1980s, scattered reports appeared of use of the
anticonvulsants, valproate (VPA) and carbamazepine (CBZ) in DD adults
(including some with autism) (Sovner, 1989; 1991). These patients were
more likely to have nonepisodic illness, or rapid cycling illness, and posi-
tive VPA response was noted with blood levels between 50–100 ug/ML.
CBZ was used in heterogeneous samples of DD patients with severe
overactivity with or without a possible mood component, rapid cycling,
or the depressed phase of bipolar disorder with mixed responses (Reid
et al., 1981). Doses were kept fairly low (400–600 mg/day) because of con-
cerns about behavioral toxicity (irritability or mania) (see discussion under
psychiatric adverse events). Glue (1989) reported that in some lithium
nonresponders with ID and rapid cycling affective disorders, adding car-
bamazepine produced clinically meaningful improvement.
Gabapentin
A number of case reports and uncontrolled studies of gabapentin
(GP) in manic and mixed-state cognitively normal adults have suggested
a beneficial effect when the drug is used as an adjunctive medication

(Altshuler et al., 1999, Ketter, Wang, Nowakowska, & Marsh, 2004). How-
ever, Pande and colleagues (2000) found that GP was less effective than
placebo as an adjunctive agent for mania in patients taking lithium, VPA,
or both. In developmentally disabled outpatient adults with either bipolar
or schizoaffective disorder, Hellings (2006) added GP to either VPA (n =
13) or VPA and lithium (n = 17) and determined whether, using a Clinical
Global Imrovement Scale, there had been improvement in three months,
a year, and some time later. Those in whom GP had been added to val-
proate appeared improved. Those in whom GP was substituted for lithium
showed mixed results. Almost half were unable to tolerate the substitution
of GP for lithium without relapse of their bipolar symptoms. The remain-
ing patients appeared stable on 400–2400 mg (median 1200 mg) of GP.
In addition, for these patients, the side-effect rate, which had prompted
the substitution for lithium in the first place, was lower. Because this
was an open trial, the patients were not randomized, and it is likely that
the patients taking both lithium and VPA had more difficulty managing
symptoms (indeed, 46% of the VPAe plus GP group had additional antip-
sychotics; 82% of the patients given valproate plus lithium substituted
with GP had additional antipsychotics), it is difficult to conclude much
more than there are occasions when these medications can be combined
with possible improvement.
Several relatively large case series of people of all ages (mostly
adult) with rapid cycling (i.e., four or more episodes per year) have been
described relatively recently. Their results are summarized in Table 9.2.
The report by Vanstraelen and Tyrer (1999) is a literature review of cases
and includes child and adult cases treated with lithium and/or anticon-
vulsants. Overall, response was poor. King’s case series (2000) was one
of few where an atypical antipsychotic, risperidone, has been added to
the regimen.
Atypical Antipsychotics
There have been very few reports of atypical antipsychotic used in DD
adults with mania. Antonacci and Groot (2000) performed retrospective
chart review on 33 adult patients with intellectual disability and comorbid
psychiatric disorders treated with clozapine. Four patients in their sample
had Bipolar I Disorder. The study does not address outcome by diagnosis
although all patients showed clinically meaningful improvement appar-
ently including those with BD. Side-effects were mild and transient. Buzan
et al. (1998) published a comprehensive review of the existing literature
and reported their own clinical experience with the use of clozapine in
10 adults with intellectual disability and psychiatric comorbidities. Three
patients in their sample had Bipolar I Disorder; in one of them clozaril was
discontinued after two weeks because of agranulocytosis. Two patients
with BD treated with VPA remained on clozapine and showed moderate
to marked improvement on doses of 350 mg and 650 mg with follow-up
between two to three years. The remaining patients with other disorders
including schizoaffective mania also improved.
Table 9.2. Rapid Cycling Bipolar Disorder (RCBD) in Developmentally Disabled

Sample Psycho-
Size and pathology
Author Age Addressed Methodology Results Comments
Authors
Vanstrae- N = 40 Manic Systematic Li alone: N = 25: 4
con-
len and Age episodes: review of improved markedly,
cluded
Tyrer 5–59 insomnia, published 5 improved partially,
that
(1999) years increased case studies 13 showed little or
overall
16 activity, and small no improvement: 2
response
females agita- case series on became worse, in 1
was poor
and 24 tion and patients with Li stopped because
males pressure dual diagno- of side effects CBZ
of speech sis of RCBD alone: N = 15 12 – no
Depressive and DD improvement, in 1
episodes: Only stud- CBZ stopped because
hypersom- ies providing of rash, 2 had ben-
nia, social information efit for epilepsy VPA.
with- on individual alone: N = 6 1 – com-
drawal, cycles and pletely remitted, 2 –
hypoactiv- indicating the marked or significant
ity, mute- length and improvement; 3 – no
ness and frequency of change Li + CBZ: N
stupor the episodes = 10 6 – no improve-
over one year ment, 1 – complete
were included improvement 2 – par-
tial improvement
1 – attenuation of
symptoms after addi-
tion of thyroid hor-
mone VPA. + CBZ: N
=1; No improvement
Li + VPA: N = 1; No
improvement
King N = 26; Mood Retrospective A positive outcome Note addi-
et al. age changes, case series; as evidenced by a tion of
(2000) 16–71 aggres- outcomes decrease in hospi- risperi-
10 sion, sleep reported on talizations, cycling done to
females disorder, the patients frequency, and/or 5 cases
and 4 psychosis, with RCBD intensity of acute
males self-injury, only; N = 14 symptoms was
12 with overactivity (age 21–71) documented in the
non- Dosages and majority of cases (12
rapid levels when out of 14): Respond-
cycling available: ers: VPA. only: N = 4
courses VPA: 750 mg– VPA + R: N = 2 VPA
and 14 2500 mg, + CBZ: N = 1 VPA +
with level 158– CBZ + R: N = 3 VPA +
RCBD 701 µmol/L CBZ + Li: N = 1 CBZ
(therapeu- + Li + R: N = 1
tic range
350–690)
CBZ: 200–
1600 mg, level
17–49 µmol/L
(therapeutic
range 17 to
(continued)

Sample Psycho-
Size and pathology
Author Age Addressed Methodology Results Comments
50 Li: 300–
1350 mg,
level 0.30–
1.11 mmol/L
(therapeutic
range 0.5 to
1.5)
Li = Li: CBZ = carbamazepine, VPA. = valproate, R = risperidone.
Electroconvulsive Therapy
Electroconvulsive treatment (ECT) has been used with some success
in mood disorders in DD adults. In a chart review Reinblatt et al. (2004)
reported on 20 adults, 12 of whom had mood disorders. Using strict
response criteria of a clinical improvement score of 1 or 2 (the absence
of illness or borderline illness, respectively), 66.7% of the mood disorders
group responded to ECT treatment. No side-effects were observed. A few
case reports also described psychotic patients who responded to ECT. Sev-
eral other reports described patients with intellectual disability and affec-
tive symptoms who generally had a positive response to ECT.
The absence of standardized measures of symptom intensity and
treatment outcome make it impossible to compare effectiveness of one
treatment over another in all of these reports. However, the general mix-
ture of responses again suggest that medications in the DD population are
subject to the same miracles and disappointments as they are in develop-
mentally normal adults with this difficult form of bipolar disorder.
TREATMENT OF BIPOLAR DISORDER IN DEVELOPMENTALLY

DISABLED YOUTH
Bipolar disorder further impairs individuals who are already severely

disabled. Matson et al. (2005) reported that DD patients with BD had sig-
nificantly more social skill deficits than those without. Symptoms such as
“exhibits inappropriate repetitive vocalizations”, “makes embarrassing com-
ments”, “curses”, “demands excessive attention or praise”, and “disturbs
others” appear to be associated with symptoms of mania (e.g., irritabil-
ity, pressured speech, increased goal-directed activity). Attention-seeking
behavior, intrusive behavior, and difficulty interacting with peers and/or
staff are equally disabling at all levels of intellectual disability (Cain et al.,
2003; Ruedrich, 1993; Lowry, 1993). Interestingly, these features, when
they occur in patients with autism may make the autistic features appear
to have diminished (Kerbeshian, Burd, & Fisher, 1987). Initial presenta-
tion in adolescents has sometimes included psychosis and/or depression
(McCracken and Diamond, 1988), and, as with normally developing teens,

some were misdiagnosed with schizophrenia.
Bipolar Disorder in children with pervasive developmental disorder
(PDD), remains largely underrecognized although, with careful evaluation,
clearly occurs (DeJong & Frazier, 2002 for review; Towbin, Pradella, Gor-
rindo, Pine, & Leibenluft, 2005). PDD exists as a spectrum, and the broad-
ening of its boundaries has contributed to the much greater prevalence
than heretofore believed. Bipolar disorder also exists as a spectrum. The
frequency of this comorbidity, then, will depend on how liberally each is
defined and will include children with pervasive developmental disorder
and problems with emotion regulation as well as classic autism or Asperg-
er’s disorder and bipolar disorder (Wozniak et al., 1997).
Aggressive and irritable behaviors are the leading symptoms that bring
bipolar children to mental health care and children with PDD may have
symptoms of irritability, elevated and labile mood, distractibility, psychomo-
tor agitation, excessive involvement in their perseverative interests without
regard for consequences, and even grandiosity (Towbin et al., 2005). If these
behaviors occur during episodes that represent a change from the person’s
usual function, both PDD and bipolar disorder are diagnosed (e.g., Gutkovich,
Carlson, Carlson, Coffey, & Wieland, 2007; Wozniak et al., 1997).
However, there are times when such symptoms are intertwined with
the emotion regulation and language processing problems that are char-
acteristic of PDD (Carlson and Meyer, 2006; Sovner, 1986). That is, such
children become overwhelmed by certain sensory inputs, environmental
changes, and transitions that may seem to the untrained eye like a “mood
swing”. Furthermore, concrete language and difficulties with recognizing
and expressing feelings and beliefs make it difficult to get an accurate
description of euphoria, grandiosity, depression, and anhedonia. As with
all comorbidities, disentangling symptoms of the primary disorder from the
comorbidity and determining the extent to which the two conditions are
actually co-occurring is especially difficult with the developmental com-
plexities extant in PDD. As we discuss below, the construct of “irritability”
(basically volatile aggressive behavior) in autism has become a focus for
pharmacological treatment and it is no coincidence that the same medica-
tions that have been approved for the treatment of adult mania may be
effective in treating irritable mood in children with PDD.
Lithium
Assessment and differential diagnosis are discussed in Volume I, Part
III, Chapter 8. Nevertheless, we have chosen to detail descriptions of chil-
dren and adolescents in tables rather than simply summarizing treatment
findings so that the reader has an appreciation of the phenomenology of
patients described. More is known about lithium monotherapy in devel-
opmentally disabled young people as it is the agent that has been used
for the longest time. Tables 9.3 and 9.4 summarize early placebo-control-
led lithium trials in diagnostically heterogeneous samples of children and
teens with small case series and case reports.
Table 9.3. Early Placebo-Controlled Trials of Lithium (Li) in Children and Ado-
lescents with a Variety of Conditions
Psycho-
Sample Size pathology
Author and Age Addressed Methodology Results Comments
Gram and N = 18 Ages “Psychosis 2 groups: Li 8-unchanged; Probable

Rafaelsen 8–22; 13 or pro- for 6 months 1 best on autism or
1972 males, 5 nounced then placebo; 9 psychotic
females; psychotic placebo and best on Li; spectrum
pupils at traits” vice versa; 7 worsened disorders;
a special 7 with Li levels when Li no bipolar
school in autism/ 0.6–1.0 mEq/ stopped. but mood
Denmark PDD; 2 L Parent/ Significant component
“border- teacher rat- improvement important;
line”; 2 ings on 11 by chi square 2 respond-
psychosis; items: hyper p < 0.001 ers (age
1 per- or hypoactiv- “No patient 10 and 22)
sonality ity; elevated became had family
disorder; or depressed totally free of history of
1 speech mood; symptoms”; BD and
and anxiety; improvement showed
language obsessive in aggression, significant
disorder, behavior or depressed/ improve-
two had stereotyp- elevated ment in
MR. ies; speech mood; in shifts in
disturbances; school, mood and
aggression to speech dis- activity. No
others/self; turbances significant
concentra- and side effects
tion; school stereotypies observed.
performance.
Campbell et N = 10 Ages Severely Children Using global “Margin
al., 1972 3–6 inpa- disturbed matched on improvement: between
tients pre- hyper- and Li-1 with toxic and
schoolers; hypoactivity; marked, 4 “optimal”
Develop- Li compared with slight, doses
mental with chlo- 5 with no small;
quotients rpromazine improvement improve-
under 60 (CPZ); 7–10 and 1 worse; ment
in 50%; weeks for CPZ – 3 with didn’t
Mostly each drug, 4 marked, 6 outweigh
autistic/ weeks drug with slight toxicity. A
PDD; 2 free between (1 got thi- very tough
“hyper- before the othixine), population
kinetic”, 1 crossover; Li 1 with no to treat,
“organic” levels 0.25– change. however.
with 1.19 meq/l; P = ns Li
“with- CPZ about may have
drawing 90 mg. improved
reaction” explosive-
ness, aggres-
siveness,
hyperactivity,
psychotic
speech
Table 9.4. Case Reports and Case Series About Use of Lithium (Li) Primarily in Developmentally Disabled Children and Adolescents
Number of
Patients and
Author Age Psychopathology Addressed Medication Used Response and Comments
Adams et al. N = 1 18- Depression: depressed mood, worth- Dose of Li and level not Improvement in mood symptoms; mother manic
(1970) year-old lessness, social withdrawal, insom- reported depressive
female with nia, 20 lbs weight loss, academic
mild MR, decline. Few months later mania:
and chro- pressured rambling speech, hyper-
mosome activity, awake for 3–4 nights, pro-
rearrange- miscuity, spending much money
ment on phone calls, argumentative and
aggressive.
Kelly et al.
N = 1 15- “Highs” 2–3 hours sleep, disorien- Li 900 mg/day for four Marked improvement in disruptive manic
(1976)
year-old tation, rapid eating, pressured years (level ranged from behavior, mood stabilized. Improved cognitive
adolescent speech, flight of ideas, frequent 0.5 to 1.1 mEq/L) and psychomotor ability; prior treatment with
girl with changes of clothes, decreased antipsychotics was un-successful
mild MR attention span and hostility
“Lows”: depressed mood, tear-
fulness, lethargy, and various
somatic complaints
Goetzl et al.
N = 2 (1) 16 y. (1) Agitation, hyperactivity, marked Li 900 mg; level 0.8 mEq/L Marked improvement in all symptoms; then Li
(1977)
o. adoles- pressure of speech, sleep 3–4 2 months treatment; (2) d/c-d because of GI side effects; symptoms
cent boy hours Li level between 0.6 to reemerged and then abated with Li reintro-
with mild (2) Hyperactivity, aggression, very 0.7 mEq/L; 7 months duction. Prior history of mood swings and
MR(2) 20 labile mood, belligerence, sleep 3 treatment; Li was dis cyclical behavioral changes Family history of
y.o. male hours continued by community alcoholism, possible depression in the father
with mod- physician Stable in one Marked improvement in all symptoms Prior to
erate MR year follow-up on anti- index episodelong history of cyclical pattern
convulsants only of hyperactive and aggressive behavior; Grand
mal seizures;
Fluphenazine could not control target symptoms
Diphenylhydantoin and phenobarbital con-
trolled seizures but not the behavior
MEDICATION TREATMENT OF BIPOLAR DISORDER
Kerbeshian N = 2, (1) Case 1: cyclical periods of days to Li 975 to 1050 mg/day, Dramatic improvement in target symptoms;
et al. ages 4 y. weeks with giggling, laughing, level 1.0 mEq/L + CBZ Increased social responsiveness with improved
(1987) 10 months decreased sleep, physical aggres- 100 mg qid Follow-up eye contact, spontaneous affection toward
and (2) 5 sion, irritability and marked for 2 years. Marked parents; History of seizures; CBZ controlled
y.o. with increase in motor stereotypies increase in target seizures but not mood symptoms (2) Dra-
autism/ Case 2: pervasive overactivity: ran symptoms when Li level matic improvement in pervasive overactiv-
MR; family continuously, clapped her hands, dropped; normalization ity. Improvement in speech and language.
history of Li dangled strings, would stick her with return of Li level to Became affectionate, stereotypic mannerisms
response hands in her mouth, rub her 1.0 (2) Li carbonate with decreased. (put theory in text)
groin, and lick objects levels 1.0 mEq/L
Steingard N = 2 1) age 9 Case 1:onset age 6 of intense Li 1,200 mg/day; level Agitation, insomnia, expansive affect, inap-
and Bie- autism/MR agitation, insomnia, elatedness, 1.0 mEq/L started at age propriate behavior, and aggressive outbursts
derman Case 2: age frequent inappropriate loud laugh- 6 + 200 mg of thiori- disappeared. Improved school and family
(1987) 24 ter, fear lessness, serious man- dazine; 4 year follow function. Return of original symptoms with
agement problem Case 2: onset up (2) Li - levels of 1.0 reduced Li level or reduction in thioridazine
age 20 unmanageable behavior, to 1.2 mEq/L started at Positive family history of manic-depressive dis-
insomnia, agitation, head banging, age 20 + chlorpromazine order (2) Sleep normalized, seasonal exacerba-
expansive affect, intrusiveness, 800 mg/day; follow-up tions disappeared, required less supervision;
unusual and excessive smiling for 4 years. Destabilization with attempt to reduce either
and laughter: disorder; had sea- drug and return to stable condition with dose
sonal quality, worst in autumn adjustment Neither had depressive episodes;
antipsychotic alone was not enough to stabi-
lize the condition
Fukuda et al. N = 2, adoles- Rapid cycling episodes were seen in Dose of Li unknown, dura- A two-year Li therapy was able to control them
(1986) cents with early adolescence and a long duration of treatment 5 and 9 fairly well but did not work as a prophylaxis
MR tion of episodes appeared in late years
adolescence
Linter N = 1, 12 y.o. Cyclical pattern of depression: Li treatment, Dose and Marked attenuation of symptoms and improve-
(1987) boy with reluctance to eat or speak, insom- levels are not specified ment in school progress; Li stopped after
MR nia, crying, incontinence, head 12 months at parent’s request. Within two
banging Manic episodes with jolly weeks he became manic; reinstitution of Li
mood, waves of noisy hilarity, stopped episode.
(continued)
267
268
Number of
Patients and
Author Age Psychopathology Addressed Medication Used Response and Comments
rapid speech with fantastic content,

distractibility, restlessness, flight
of ideas; bursts of aggression; Nor-
mal interepisodic functioning
McCracken Hospitalized (1) Rapid cycling: Depression: (1) Li thium 800 mg/d (1) Partial improvement with attenuation of
and adolescents poor self care, social withdrawal, (1.2 mEq/L). CBZ cycling; side-effect: TSH elevation treated
Diamond (1) 18 y.o. poor concentration, academic 1600 mg/d 12 µg/ml), with thyroxine (2) Full remission; Side-
ZINOVIY A. GUTKOVICH and GABRIELLE A. CARLSON

(1988) moderate decline Mania: agitation, hyper- thioridazine 300 mg/d: effect: weight gain (3) Full remission (4) Full
MR male (2) activity, screaming, incontinence, thyroxine 0.2 mg/d (2) remission; side effect: polyuria (5) Partial
17 y.o. mild decreased sleep, paranoia, gran- Li 1,200 mg/d remis- improvement during acute phase; full stabi-
MR female diose delusions; Normal interepi- sion for 15 months; lization after 2.5 years Haloperidol eventu-
(3) 15 y.o. sodic functioning(2) Onset age stopped Li; decom- ally stopped because of EPS; CBZ stopped
moderately 14 bizarre somatic delusions pensated 9 months because of severe rash
retarded and auditory hallucinations; later; restabilized on Li
female elation alternatied with irrita- 1,500 mg/d (0.9 mEq/
(4) 21 y. bility; diagnosed with schizo- L) and neuroleptic; 8
o. male phrenia, unsuccessfully treated months later, euthymic
moderate with antipsychotic.(3) onset: on Li alone (3) Li
MR; history hyperactive; pressured speech, 1,200 mg/d (1.0 mEq/L)
of cerebral incoherent; decreased need for (4) Li 1,500 mg/day
palsy (5) sleep, argumentative, impulsive; (0.9 mEq/L) ; follow-
17 y.o. hypervigilant, disorientation to up 10 months (5) Li
severely time ideas of reference, grandiose 2,100 mg/d (1.2 mEq/
retarded delusions, Index admission: L; CBZ 600 mg/d;
male alternating anxiety, and para- haloperidol 110 mg/d,
noia; elated (kissing classmates); thioridazine; follow-up
irritable mood states. Overt- 3 years
alkativeness, decreased need
for sleep. Minimal response to
antipsychotic (4)
History of 5 months of depressive
stupor with insomnia, psychomotor
retardation, poor self care, mute-
ness, confusion, hallucinations fol-
lowed by Mania with rapid speech,
giddiness, hyperactivity, decreased
need for sleep, grandiose delusions
(5) Rapid cycling Depression: stu-
por, refusal to eat, incontinence,
posturing, tremor, drooling, marked
insomnia, fearfulness, hallucina-
tions, delusional guilt; misiden-
tified family members Mania:
hyperactivity, increased sexual
interest, aggression, jocular mood
Frazier 13.5 y.o. boy Chronic sleep Disturbances; Stabilized on 2,100 mg/ Reduction in his aggressive, compulsive and
et al. Asperger’s obsessions, sadness, irritability, day of Li (1.0 meq/L), disruptive behavior.
(2002) disorder aggression and racing thoughts, 3 mg/day of risperidone,
disorganized. Loud and anxious 1 mg b.i.d. clonazepam,
speech; Mind-reading and reli- risperidone
gious delusions; Visual hallucina-
tions; obsessed with non-existent
girlfriend
Gutko- N = 1 14 y.o. Long history of ADHD, hyperthymia; Li 600 mg BID (level Resolution of target symptoms, in social relat-
vich et al. boy with Agitation, physical aggression, 1.02 mEq/L) Risperidone edness, marked academic improvement
(2007) Asperger’s loud speech, grandiosity, para- 1.25 mg BID, Tenex
disorder noia; academic decline 1.5 mg BID; Follow-up
2 years
269
In the 16 cases we report, response was achieved at lithium levels

around 1.0 mEq/L, at doses >1200 mg/day. Treatment with lithium was
successful in cases with both depressive and manic states as well as in
cases with manic states only, but not for other conditions, or for rapid
cycling. Duration of treatment and follow-up allows for the tentative
conclusion that lithium was overall effective for maintenance. As with
normally developing youth, accompanying psychosis required addition
of antipsychotic drug during the most acute phase. Lithium was used
safely, with manageable side-effects. As with normally developing chil-
dren (e.g., Campbell et al., 1984; Malone, Delaney, Luebbert, Cater, &
Campbell, 2000) there is some evidence that lithium reduces aggression,
impulsivity, and severe excitement in some youth with intellectual dis-
ability.
Dostal and Zvolsky (1970) reported a 65% reduction in acute out-
bursts for the group and statistically significant reduction in affectivity,
aggression, psychomotor activity and undisciplined behavior with lithium
at .92 meq/L. Nine patients developed reversible polydipsia and polyuria.
Sovner and Hurley (1981) conducted an extensive review of the litera-
ture and reported two cases of their own,,a total of five cases on the use
of lithium carbonate for “chronic behavior disorders” in people with ID.
In their two cases they used ABA design with return of symptoms with
discontinuation of lithium carbonate and stabilization after reintroduc-
tion of lithium treatment. The authors conclude lithium carbonate may be
safe and somewhat effective for symptoms such as long-standing hyperac-
tivity, aggression, and/or self-mutilation. Polydipsia and polyuria proved
to be the most difficult side-effect to manage. In summary lithium has
been used with positive results in classically appearing bipolar disorder
in developmentally disabled youth and adults. Effects are more modest in
those with broader affect dysregulation.
Valproate: Monotherapy and Combined Treatment

When anticonvulsant treatment entered the medication armamentar-
ium for bipolar disorder, its use in DD youth has also increased. Kastner
et al. (1993) conducted an open prospective trial of VPA for affective symp-
toms in children, adolescents, and adults. Hollander et al. (2001) conducted
an open trial in ten autistic patients with mood instability, impulsivity, and
aggression, four of whom were diagnosed with Mood or Bipolar Disorders.
Two of four of these latter patients improved including a 15 year-old
adolescent with autism, mild ID, and co-morbid Bipolar Disorder.
Eight of the ten patients overall were rated as having a sustained response
to valproate with doses ranging from 250 to 1000 mg/day and levels between
50 to 85 µg/ml). Two patients were discontinued because of behavioral acti-
vation but VPA was otherwise well tolerated. Open trials on VPA are summa-
rized in Table 9.5 and case reports are presented in Table 9.6.
Interestingly, data suggest that the effect of valproate may be lim-
ited to a specific effect on symptoms of bipolar disorder in developmen-
tally disabled youth. Hellings et al. (2005) studied VPA efficacy and safety
for aggression in children and adolescents with PDD. In this prospective
Table 9.5. Two Open Trials of Valproate (VPA) in People with MR/Autism with
Affective Illness
Sample Size Psycho-
Author and Age pathology Methodology Results Comments
Kastner Total N = 18 Inclusion Open 2 Children:1 8 patients

et al. with mild to criteria: year trial; very much needed
(1993) profound MR 3 of the Assessment improved; additional
Children N 4 symp- with semi- 1 no medications
= 2 (both F) toms: structured improvement. (CBZ, Li,
Adolescents irritabil- interview of Adoles- verapamil,
N = 10, age ity, sleep caregiver; cents: 8/10 buspirone,
13–18 distur- Main improved or or thiori-
(F = 3; M = 7) bance, outcome very much dazine); VPA
Adults N = 6 aggressive measure improved; associated
or self- CGI-Improve- 2/10 - little with lower
injurious ment scale improvement. doses.
behavior, VPA therapy Adults: 4/6 A history of
behavioral with levels much or epilepsy or
cycling of 50 to very much a suspicion
125 µg/ml improved 2/6- of sei-
(dose not no change zures was
reported) or worse; No strongly
difference in associ-
serum VPA ated with
a favorable
response to
VPA
Hollander PDD with Impulsivity/ Retrospec- Child: 10 Adolescent
et al. comorbid aggres- tive review y.o.boy also took
(2001) Mood Disor- sion, of DVP in autism, mood fluoxetine
der (1 child), mood autism; disorder NOS, 20 mg/d
3 with BP lability main OCD, impulse and
( 1 teen, 2 and 3 core outcome control disor- alprazolam
adults) autistic measure der; IQ = 87 1 mg prnv
dimen- CGI-I – minimally
sions worse
(social, Adoles-
com- cent: 15 y.o.
munica- autism,
tion and IQ = 55; BP;
repetitive agitation,
behaviors) insomnia,
impulsivity,
hyperactivity,
very much
improved VPA
level 66 µg/
ml),
Adults: N
= 2 with BP
and BPNOS;
1 very much
improved;
1 – no change
Table 9.6. Case Reports/Series on Use of Valproate in Developmentally Disabled Children and Adolescents with Bipolar Disorder
272
Number of Patients
Author and Age Psychopathology Addressed Medication Used Response and Comments
Kastner et N = 3 (1)16 y.o. (1) Irritability, aggressiveness, (1) VPA 2750 mg/d; level (1) No further symptoms of mania. 4 episodes of
al. (1990) adolescent with decreased sleep, severe fre- 109 µg/ml; stable for head banging due to environmental stress (2)
moderate MR quent head banging more than 10 months Excellent clinical response, face gouging
and blindness (2) (2) History of 7 years of (2) VPA 3,000 mg/day eliminated. Improved family relationship
13 y.o. girl with hyperactivity, irritability, -level 75 µg/m-Follow- (3) Became very calm, in good control,
profound MR, mildly aggressive up 7 months (3)VPA elimination of self-injury Was able to return to
visual and hear- behavior, self-injurious 1,500 mg/day-level foster family All 3 had failed Li trial; 2 became
ing impairment, behavior (face gouging); 111 µg/ml-Follow-up “manic” on CBZ
spastic quadra- worsened on Nortriptyline 8 months
paresis (3) Severe self-injurious
ZINOVIY A. GUTKOVICH and GABRIELLE A. CARLSON

(3) 8 y.o. girl with behavior, hyperactivity,
profound MR and irritability, distractibility,
Down syndrome unmanageable,
Placed into RTF
Kastner and N = 1 18 y.o. boy Onset severe sleep disturbance VPA 2,750 mg/d- level Patient failed adequate trials of Li and CBZ. Initial
Friedman with severe MR age 4; severe self injuri- 111 µg/ml; verapamil response to VPA, not sustained with
(1992) and blindness ous behavior- age 8; age 18 320 mg/d monotherapy. Augmentation with Verapamil
increased activity level, mood provided long-lasting effect. It is important to
lability with inappropriate note that the patient had nonparoxismal EEG
bouts of crying changes (general slowing)
and laughung, irritability,
hyposomnia, and severe
self-injurious behavior
Whittier et N = 1 13-year- Onset age 12 MDD ; treated VPA 1250 mg/d - Rapid (starting within 24 hours) and dramatic
al. (1995) old mentally with sertraline 50 mg/d. (level 109.2 µg/ml). response with decrease in total scores on Young
retarded girl Then developed mania with Perphenazine and Mania Rating Scale from 29 to 11; on Hamilton
pressured speech, flight of benztropine Rating scale for Depression from 27 to 9, and
ideas, grandiosity, marked (duration of treat- improvement in GAF from 25 to 55. Antipsy-
increase in energy, insomnia, ment not reported) chotic medication introduced after patient had
hyperactivity lasting 4 days. significant reduction in her symptoms
Stopped treatment; .
3 months later presented with
extreme irritability, suicidal
ideation, pressured speech,
flight of ideas, grandiosity,
marked increase in energy, and
insomnia, auditory and visual
hallucinations
Damore N = 3 Children (1) Hypomanic episode after (1) VPA 250 mg/day Marked improvement within 3 weeks with
et al. with fluoxetine- 5 weeks on fluoxetine 20 mg/ (level not reported) disappearance of impulsivity, aggressive
(1998) induced manic d with marked impulsivity, (2) VPA 500 mg/day behavior, and irritability; significant family
symptoms aggressive behavior, mood (level not reported) history of affective illness (2) Manic symptoma-
(1) 10 y.o. boy lability and irritability Methylphenidate tology ceased after 2 weeks; marked improve-
with Asperger (2) After 2.5 months on 20 mg/day VPA ment in social relatedness, isolative behavior
Disorder, ADHD fluoxetine 20 mg/day florid 250 mg BID (level not and significant decrease in anxiety (3) Within
(2) 9 y.o. boy hypomania with pressured reported) 3 weeks noticeable improvement in his
with Asperger speech, marked circumstan- behavior, was able to return to his class Patient
Disorder, ADHD tiality, sexual inappropriate- had significant family history of affective illness
and OCD ness, and irritability
(3) 9 y.o. boy (3) Patient had severe
with Asperger depressive episodes. After 1
Disorder, meet- month on fluoxetine 10 mg/
ing DSM–IV day he became increasingly
criteria for Bipo- hyperactive, irritable impul-
lar II Disorder sive and unmanageable, with
silly and inappropriate
behavior in school, removed
from classroom
273
Table 9.7. Double-Blind Trial on Use of VPA in Aggressive Youth with PDD
Sample Size Psychopa-
Author and Age thology Methodology Results Comment
Hellings Total N = 30 Significant Randomized, con- No statis- Large placebo

et al. children aggres- trolled trial of 8 tically response,
(2005) and ado- sion to self, weeks duration. significant subject
lescent others, or Baseline improve- heteroge-
outpa- property at measures: ment on neity, and
tients with least three DSM–IV-based any of the small group
ASD, 6–20 times per interview; measures size were
years of week Autism Diag- problems in
age (M = nostic Inven- this study
20, F = 10) tory— Revised,
average Autism Diag-
IQ = 54. nostic Observa-
tion Schedule
Primary out-
come measure
- parent and
teacher rated
Aberrant Behav-
ior Checklist—
Community
scale (ABC-C)
weekly
Secondary
outcome
measures: the
description of
each aggres-
sive outburst
by parents and
teachers as it
occurred on the
Overt Aggres-
sion Scale (OAS)
and CGI—
Improvement
Subscale
double-blind, placebo-controlled study, 30 participants (20 boys, 10 girls)

6–20 years of age with PDD and significant aggression were randomized
and received treatment with VPA or placebo (PBO) for eight weeks as
outpatients. No treatment difference was observed statistically between
VPA and PBO groups (Tables 9.6 and 9.7).
Carbamazepine, Monotherapy and Combined Treatment

Data in the child literature are extremely limited. Komoto et al. (1984)
reported dramatic improvement of mood symptoms in two children with
autism treated with carbamazepine. It is of note that in their report patients
suffered primarily from depression although one of them had mild manic
episodes as well (Table 9.8).
Table 9.8. Case Reports on Use of Carbamazepine (CBZ) in Developmentally

Disabled Adolescents with Bipolar Disorder
Number of Psychopathology Medication Response and
Author Patients and Age Addressed Used Comments
Komoto N = 2 (1) !3-year- Onset: Since age 9 mild CBZ 400 mg/ Episodes
and old adolescent depressive episodes day CBZ stopped Prior
Usui autistic male for 2–3 days following 300 mg/ trial of Li at
(1984) with MR, mild manic episodes day dose 600 mg/
untestable on lasting 1–2 weeks once day produced
WISC (2) 13 a month periodically no response
½ -year-old Depressive episodes: Depressive
autistic female sad appearance, long episodes
with moder- crying spells, would stopped except
ate MR, IQ on not eat or talk, motor for a single
WISC = 49 activity remarkably episode at
diminished, would not 12 years 2
get up from bed Manic months of
episodes: inappropri- age when she
ately cheerful and silly, had menarche
would often laugh and Patient had
parrot TV commer- first time con-
cials, ate voraciously, vulsion dur-
extremely hyperac- ing her fifth
tive and sleepless depressive
Onset: Since 10 years episode and
9 months had mild second convul-
depressive episodes sion episode at
lasting a week once age 13 years 5
a month periodically. months. EEG
Depressive episodes: was abnor-
Typical course starting mal. Diphe-
from sobbing, cry- nylhydantoin
ing, “Yuki (her name) 60 mg/day
scared,” keeping her was added
face down; then not Family history
talking and not getting negative in
out of bed, not eating, both cases
disturbed sleep
Atypical or second-generation antipsychotic medications have not
been studied even on a small scale in developmentally disabled youth
with bipolar disorder. Two case reports (Frazier & Jackson, 2008;
Gutkovich, Carlson, Carlson, Coffey, & Wieland, 2007) describe risperi-
done’s efficacy in autism spectrum youth with bipolar disorder. On the
other hand, and very relevant for treatment of behaviors characteristic of
mania, risperidone has been studied extensively in children and adoles-
cents with irritable and agitated behavior in autism (e.g., McCracken et
al., 2002) and has recently received FDA approval for treatment of irrita-
bility and self-injurious behavior in autism. In particular, an eight-week,
double-blind, placebo-controlled study found risperidone to be superior
to placebo for treating aggression, tantrums, and self-injury in children
with autistic disorder (McCracken et al., Research Units on Pediatric

Psychopharmacology Autism Network, RUPP, 2002). The study included
101 youths ages 5 to 17 (82 boys and 19 girls). Treatment with risperi-
done (dose range 0.5 to 3.5 mg/day) resulted in a 56.9 percent reduction
in irritability score in the Aberrant Behavior Checklist (Aman, Singh,
Stewart, & Field, 1985) as compared to 14.1 percent decrease in the pla-
cebo group.
Hellings et al. (2006) conducted a 46-week placebo-crossover inves-
tigation of risperidone of safety and efficacy for aggressive and destruc-
tive behaviors in a mixed sample of children (N = 13), adolescents (N = 8),
and adults (N = 19) with all levels of ID and PDD. This longer-term
study which utilized the same primary outcome measure as the study
by RUPP yielded very similar results. During the acute 22-week phase
out of 40 subjects 23 (57.5%) responded fully (50% decrease in Aberrant
Behavior Checklist-Community Irritability subscale score), whereas 35
subjects (87.5%) showed a 25% decrease. Pattern of response in chil-
dren and adolescents was similar to the whole group. It is important
to note that the presence of comorbid mood disorder did not alter the
results. Children had overall poorer response during the 24-week main-
tenance phase compared to adolescents and adults (adolescents and
adults did not differ). Low dose risperidone (mean optimal dose for chil-
dren and adolescents 1.67 mg/day) was effective for aggressive behav-
iors and irritability.
Increased appetite and weight gain (7.9 kg for children and 8.3 kg for
adolescents) were the most problematic side-effect especially in children
and adolescents. The authors comment that weight gain is an especially
serious problem in the DD population because individuals with ID have
less autonomy and ability to take control of the weight gain side-effect.
However, a recent study by Klein and collegues (2006), which included
some children with ID and PDD, demonstrated the utility of metformin for
controlling weight gain.
Risperidone has also been studied extensively (randomized, double-
blind, placebo-controlled trials) in lower IQ youth with conduct disorder
(i.e. irritable aggression). Aman et al. (2002) conducted a placebo-control-
led trial in children with severely disruptive behaviors and subaverage
intelligence. Risperidone at doses up to 0.06 mg/kg per day was associ-
ated with significantly greater improvement than placebo on measures
of irritability and aggression. Risperidone was safe and well tolerated.
Turgay et al. (2002) conducted a long-term extension open trial of ris-
peridone (dose range 0.02–0.06 mg/kg/d) in a similar sample. Risperi-
done was well tolerated, safe, and showed maintenance of effect in the
treatment of disruptive behavior disorders in children aged 5 to 12 years
with subaverage IQs.
Other atypical medications have been/are being studied including
a registry trial for aripiprazole (www.clinicaltrials.gov). Two retrospec-
tive chart reviews (Corson, Barkenbus, Posey, Stigler, & McDougle, 2004;
Hardan, Jou, & Handen, 2005) addressed efficacy and safety of quetiapine
in the DD population. Doses ranged from 25 to 600 mg/day. Target symp-
toms of irritability, self-injury, aggression and hyperactivity diminished in
8 out of 20 patients in the former and 6 out of 10 in the latter. Weight gain
and tardive dyskinesia were the main adverse events.
In general, it appears that, in the absence of specific studies on effi-
cacy of medication for mania in DD youth, the positive responses in cogni-
tively normal adults and teens with mania, and positive results in autistic
youth with irritability would make it likely that manic symptoms in DD
youth would also be responsive.
Electroconvulsive Treatment
Thuppal and Fink (1999) described five inpatients with mild to moderate
intellectual disability with catatonia and affective and psychotic disorders
who were treated with bilateral ECT after they failed to respond to medica-
tion trials. Affective and aggressive symptoms improved. One 18-year-old
male with moderate ID and Bipolar Disorder received 17 ECT treatments,
was discharged markedly improved. He then received four continuation
ECT treatments and then remained stable on clozapine 300 mg/day. This
is the only publication reporting treatment of an adolescent patient with
intellectual disability and Bipolar Disorder that we were able to identify
in the literature. Guze et al. (1987) reported use of ECT in treatment of
21-year-old man with bipolar depression, mild intellectual disability, and
cerebral palsy. Depressive symptoms resolved but the patient switched to
mania, which was stabilized on lithium.
CURRENT STATUS OF PSYCHIATRIC ADVERSE EVENTS IN

CHILDREN AND ADOLESCENTS
Medication-induced behavioral toxicity, e.g. activation/disinhibition/

manic symptoms and suicidal behavior, is not uncommon in youths. Rates
of activation vary, but appear to be more common in children (around 10%,
Carlson & Mick, 2003) than adolescents (around 3%), at least in clinical
trials of antidepressants (Safer & Zito, 2006). Rates of occurrence in adults
with bipolar depression are higher, about 20%, although rates vary widely
(Goldberg, 2003). Studies in adults appear to suggest that rapid cycling
bipolar patients are especially vulnerable to destabilization (Ghaemi, Hsu,
Soldani, & Goodwin, 2003). This is relevant to pediatric bipolar patients,
among whom the percentage with a rapid cycling course ranges from from
19% (Faraone, Biederman, Wozniak, Mundy, Mennin, & O’Donnell, 1997)
to 83% (Tillman, Geller, Bolhofner, Craney, Williams, & Zimerman, 2003)
depending on the study.
In the DD population, carbamazepine was most associated with behav-
ioral toxicity. Friedman et al. (1992) found that 6 of 65 DD patients (9.2%)
experienced medication side-effects, ranging from irritability to mania,
occurring predominantly in patients being treated for psychiatric disorders
(4 of 20 psychiatric patients (20%) vs. none of the 21 patients treated sei-
zure disorders). The incidence of behavioral side-effects of medication was
not associated with age, sex, or serum carbamazepine level. The authors
suggest that the chemical structure of carbamazepine which is similar to

tricyclic antidepressants contributed to behavioral side-effects. It is also
worth remembering, however, that in patients with pre-existing emotional
lability, it is difficult to separate medication effect from course of illness.
The question of antidepressant-induced “suicidal behavior” has been
a contentious and confused topic. Although medication-associated suici-
dality has not been examined at all in the DD population, in 24 pediat-
ric trials of antidepressants, the FDA (2004) found an increased risk for
suicidal behavior of about 2% in placebo and about 4% in SSRI-treated
subjects. (There were no suicides; Hammad, Laughren, & Racoosin, 2006).
This small but significant elevated rate is apparent through young adult-
hood according to a recent FDA warning (February, 2007).
RELEVANT MEDICAL ADVERSE EVENTS IN THE USE

OF BIPOLAR MEDICATIONS IN CHILDREN AND ADOLESCENTS
An extensive discussion of medication side-effects is beyond the scope

of this chapter. Several observations are relevant to young people and people
with DD. For instance, although lithium may be tolerated as well in this
population as any other (Pary, 1991), lithium toxicity, a potentially lethal
risk, is greater in this population because of difficulties with self-monitor-
ing and poor ability to report symptoms of all sorts. In addition, possible
worsening of seizures already common in this population, disabling tremor,
polydipsia, polyruria, and incontinence need close attention (Elliot, 1986;
Hellings, 2006; Maruta, 2003). Tremor or incontinence are more likely to
occur in children with severe or profound intellectual disability because
they may have cerebral palsy, movement disorder, or difficulties with blad-
der control (Kastner, Friedman, Plummer, Ruiz, & Henning, 1990). We
suggest however that decisions on lithium use in children with the most
severe ID should be made on a case-by-case basis because, as reported
earlier in this chapter, some of them have positive response to lithium
with manageable side-effects. As with normally developing people, renal
disease and thyroid suppression may occur, although the latter is quite
treatable with thyroid supplementation. Combining lithium with valproate
worsens some of these symptoms.
Initial concerns about valproate-associated polycystic ovary syn-
drome (PCOS; chronic anovulation and hyperandrogenism, with or
without actual polycystic ovaries, is associated with oligomenorrhea, hir-
sutism, and acne) were raised in people with seizures, some of whom
had DD (Isojarvi, Timo, Laatikainen, Pakarinen, Juntunen, & Myllyla,
1993). Given that menstrual irregularities are common in adolescents, it
is important to obtain a baseline menstrual history when evaluating the
impact of valproate.
The Stevens-Johnson syndrome, a life-threatening skin condition,
although rare in young people, has been associated with lamotrigine
(Messinheimer, 2002). With low dosing and gradual increase, the risk is
reduced but treatment still warrants close observation.
Significant weight gain, especially in young people, is associated with

atypical antipsychotics, lithium, and divalproex. The occurrence of the
metabolic syndrome in young people predicts early atherosclerosis and
vascular disease as adults, and obesity during adolescence predicts later
coronary artery disease and colorectal cancer even more strongly than
obesity as an adult. Data from adults (ADA Consensus Development Con-
ference 2004; Allison et al. 1999 Casey, Haupt, Newcomer, Henderson,
Sernyak, & Davidson, 2004) and from an ongoing, large scale naturalistic
study in children and adolescents (Correll et al., 2005) suggest the follow-
ing rank order in terms of ability to promote weight gain and development
of the metabolic syndrome: Clozapine = Olanzapine >> Risperidone >/=
Quetiapine > Ziprasidone >/= Aripiprazole.
Undoubtedly caution and close monitoring should be exercised when
one deals with developmentally disabled patients especially the most
severely retarded individuals who are not able to verbally report their
complaints, those with known organic brain injury, and especially when
lithium is used in combination with neuroleptics or anticonvulsants.
CONCLUSION
Aman et al. (2000) concluded that in lieu of “woeful lack of empirical

data … clinicians will often be forced to extrapolate from data on adults
having intellectual disability and from typically developing children. The
best policy is probably to treat such patients cautiously, while gathering
data on the effects of such therapy.”
The largely anecdotal reports we found showed effectiveness of mood-
stabilizing agents in people with all degrees of intellectual disability includ-
ing profound ID. Nor did etiology of the developmental disorder appear to
matter (Adams, Kivowitz, & Ziskind, 1970, Kastner et al., 1990; Reid et
al., 1981; Sovner, 1991). Patients with more clearly delineated mood states
with normal interepisodic functioning (i.e., more classic bipolar disorder)
had a better response. As in normally developing adolescents, initial mani-
festation of the disorder often includes frank psychotic symptoms that can
be easily misdiagnosed as schizophrenia. History of depressive episode pre-
ceding mania is also common as it is documented for nondevelopmentally
disabled population. We cannot, of course, address frequency of response
to various bipolar regimens because these case reports were published
precisely because patients responded, often dramatically, to treatment.
With regard to safety of treatments, affective illnesses themselves often
cause regression (e.g., incontinence), confusion, and disorientation mak-
ing it difficult to separate the toxicity of illness from the potential toxicity
of treatment.
We have reviewed somatic treatment of 191 patients with develop-
mental disabilities and Bipolar Disorder, among them 12 children and 27
adolescents, including three double-blind trials, one single-blind trial, two
open trials, five retrospective chart reviews and the rest single case reports
or small case series.
We offer the following tentative observations.

1. Lithium appears to be effective medication for treatment of manic-
like symptoms, more so than nonspecific hyperactivity and aggres-
sion in the developmentally disabled population. Caution and close
monitoring should be exercised in all cases, but especially in those
with known organic brain injury, or with medication combinations,
because this vulnerable group is often not able to verbally report
their symptoms. Tremor or incontinence can have a profoundly
negative effect on the ability of these children to function. Data are
suggestive for usefulness of lithium in maintenance.
2. Valproate appears to be an effective and safe agent and is prefer-
able to Lithium in cases with seizure disorder or nonparoxismal
EEG activity
3. Carbamazepine may be useful in some cases alone although more
likely to be helpful as adjunctive treatment. It may be more use-
ful in patients with depressive symptomatology. Behavioral toxicity
may be a problem.
4. Anticonvulsants alone or in combination may be more effective in
patients with rapid cycling although nothing is truly effective in
this form of illness.
5. Gabapentin might be considered as adjunctive treatment in combi-
nation with valproate, especially if lithium is not tolerated.
6. Some of the atypical antipsychotics will be systematically tested
for people with pervasive developmental disorders and irritable dif-
ficult behavior, which can certainly describe bipolar disorder even if
not specifically identifying it. So far risperidone has the most data.
7. Clozapine may be considered in treatment-resistant cases.
8. More data are needed on ECT treatment, which appears to be prom-
ising in adults.
As with normally developing children and adolescents comorbidities must
be addressed and appropriate psychosocial and educational interventions
provided.
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10
Treatment of Autism
Spectrum Disorders
MARY JANE WEISS, KATE FISKE,
and SUZANNAH FERRAIOLI
INTRODUCTION
This chapter provides an overview of the treatment of autism spectrum

disorders. This is both an exciting and confusing time within treatment for
autism; early identification continues to allow for more intensive and effective
early intervention, prevalence estimates of autism are suggesting increased
incidence, and claims for effective treatment abound. Consumers are faced
with myriad choices for treatment, and have difficulty navigating the claims
and opinions of professionals from multiple perspectives and disciplines.
In this chapter, we review the evidence for the effectiveness of behavior
analytic interventions for autism. We also review the evidence for nonbe-
havior analytic interventions. In addition, we describe interventions that
have been targeted to individuals with Asperger’s syndrome, and we dis-
cuss the relevance and use of functional assessment procedures for devel-
oping effective behavior intervention plans for individuals with ASDs. We
also highlight new directions within treatment, including some social skill
interventions and information on early identification.
AUTISM SPECTRUM DISORDERS: AN OVERVIEW
The most widely accepted criteria for autism are contained in the Diag-
nostic and Statistical Manual of Mental Disorders–Fourth Edition Text
Revision (DSM–IV–TR; American Psychiatric Association, 2000). According
to this resource, autism has three central defining characteristics:
Qualitative impairment in reciprocal social interaction
MARY JANE WEISS, KATE FISKE, and SUZANNAH FERRAIOLI ● Rutgers, The State
of New Jersey

288 MARY JANE WEISS et al.
Qualitative impairment in verbal and nonverbal communication and in

imaginative ability
Markedly restricted and repetitive repertoire of behavior, activities, and
interests
The ways in which these characteristics are manifested, however, are
extremely divergent. Whereas some individuals with autism are aloof
and socially disinterested, others are affectionate, attached to others,
and desirous of interaction. Whereas some individuals with autism lack
vocal language ability, others may engage in simple echoing or may use
vocal speech communicatively. When speech is used communicatively,
however, there are often still idiosyncratic uses of the speech, or the
speech may fail to represent the full range of communication potential.
For example, a child may only request wanted items and not be able to
hold conversations, or may converse only about topics of special inter-
est. Restricted behaviors and interests may manifest themselves as clas-
sically autistic rocking or flapping. Alternately, it may present as lining
up toys, adhering to a routine, or becoming fixated on a single object or
topic.
It is estimated that about 75% of children with autism have develop-
mental delays (APA, 2000). There is also a tendency for the development to
be uneven, with clear strengths and weaknesses evident. Behavioral dif-
ficulties occur in about 90% of individuals with autism, and at least 10 to
20% exhibit severe behaviors such as aggression and self-injury (Lovaas,
1987; Smith, McAdam, & Napolitano, 2007).
DSM–IV–TR (APA, 2000) also classifies other Pervasive Developmental
Disorders (PDDs) along with autism: Rett’s Disorder, Childhood Disin-
tegrative Disorder, Asperger’s Disorder, and Pervasive Developmental
Disorder–Not Otherwise Specified (PDD-NOS). Rett’s Disorder is a degen-
erative disorder that occurs in girls, and is characterized by a different
course and prognosis than autism (Kerr & Ravine, 2003). Childhood
Disintegrative Disorder is not well defined and is rare (Mouridsen, 2003).
The current diagnostic criteria for Asperger’s Disorder highlight
impairments in nonverbal communication and in social interaction with
an absence of delays in cognitive or language skills (APA, 2000). Indi-
viduals with Asperger’s Disorder do experience a variety of problems in
communication and interaction, such as poor reciprocal conversational
abilities, difficulties in comprehending figurative and abstract language,
and perseveration on topics of special interest that impede the develop-
ment of true reciprocal exchanges with others. Individuals classified as
PDD-NOS generally exhibit features of autism, but fail to meet the full
diagnostic criteria for Autistic Disorder.
In recent years, many clinicians and researchers have begun to dis-
cuss autism, PDD-NOS, and Asperger’s Disorder as a spectrum. We do not
yet have reliable criteria for distinguishing among these groups, and it may
be that the same disorder essentially varies in presentation and severity
along the continuum (Wing, 1988). We refer to ASDs in the remainder of
this chapter.
TREATMENT OF AUTISM SPECTRUM DISORDERS 289
BEHAVIORAL TREATMENT OF AUTISM

SPECTRUM DISORDERS
Behavior analytic treatment of children with autism began in the 1960s.

Ferster and DeMyer (1962) first demonstrated that behavioral principles
could be used to increase appropriate behavior in children with autism.
At the time, this was a radical notion, as autism was perceived as essen-
tially unchangeable. In the years that followed, behavioral intervention
was demonstrated to be effective in increasing skills (e.g., Wolf, Risley, &
Mees, 1964) and in reducing challenging behaviors (e.g., Lovaas, Freitag,
Gold, & Kassorla, 1965). Applied Behavior Analysis (ABA) appeared to be
very effective in increasing skills and in remediating deficits.
It became clear that children with autism were capable of learning
and of altering their behavior, and that certain procedures worked better
in helping children with autism learn than did others (e.g., Lovaas, Sch-
reibman, Koegel, & Rehm, 1971). In particular, it became clear that indi-
viduals with autism learned well in a form of teaching in which there were
clear instructions, repetition and practice, and immediate reinforcement
for correct responses.
Discrete Trial Training

Discrete trial training (DTT) uses repetition and sequenced instruction
to build a variety of skills in students with autism (Lovaas, 1981; Lovaas,
Koegel, Simmons, & Long, 1973; Smith, 1993). It has been effective in
teaching a wide variety of core skills in a structured formalized context.
Elements of its effective use include errorless learning procedures (e.g.,
Etzel & LeBlanc, 1979; Lancioni & Smeets, 1986; Terrace, 1963; Touchette
& Howard, 1984) and task variation and interspersal (e.g., Dunlap, 1984;
Mace et al., 1988; Winterling, Dunlap, & O’Neill, 1987; Zarcone, Iwata,
Hughes, & Vollmer, 1993). These strategies diverge from some historical
applications of DTT, which often utilized blocks of identical target trials
and procedures that allowed for repeated errors. State-of-the-art clinical
application of DTT procedures generally involves the mixing of new and
mastered material, as well as the prevention and interruption of errors.
Discrete trial training remains very useful for teaching a wide variety
of skills to children with autism spectrum disorders, and its utility should
not be obscured by the recent emphasis on more naturalistic approaches.
DTT is well matched to teaching skills requiring repetition, to teaching
skills that are not intrinsically motivating, and to building solid reper-
toires of tacting, imitation, and receptive skills (e.g., Sundberg & Parting-
ton, 1998; 1999).
In addition, discrete trial teaching is much more effective if utilized
with strategies for effective generalization to the natural environment
(Smith, McAdam, & Napolitano, 2007; Stokes & Baer, 1977). Teaching
proceeds more effectively if instruction is conducted across environments,
if parents and peers are involved in training, and if discrete trial teaching
is used in combination with other, more naturalistic approaches.
Naturalistic Teaching Methods

Over the past 25 years within ABA, there has been a strong focus
on the development and use of naturalistic teaching methodologies to
meet the needs of learners with autism. The best researched and oldest
of these approaches is incidental teaching. Incidental teaching empha-
sizes receiving an elaborated response from the individual, after they
have initiated interest in an item or a topic (Hart & Risley, 1982). Inci-
dental teaching has been shown to be a successful teaching methodology
for building initiation skills and a wide variety of language and conversa-
tion skills (e.g., Farmer-Dougan, 1994; McGee, Krantz, & McClannahan,
1985, 1986). Perhaps most important, incidental teaching procedures
have been shown to have substantial generalization benefits, compared
to discrete trial teaching (McGee et al., 1985). This is a substantial advan-
tage, as the strength of DTT is in building responsivity. DTT is relatively
weak in increasing initiations and in generalizing skills without addi-
tional training.
In incidental teaching, the teacher arranges the environment to cre-
ate learner interest. The learner then initiates a request or a conversation
about a particular item or topic. The teacher prompts an elaboration of
that initiation, and the learner’s more elaborate communication results in
immediate access to the desired item (Fenske, Krantz, & McClannahan,
2001). One of the most substantial advantages of an incidental approach
over a DTT approach is that the learner is leading the teaching interaction.
The learner’s interests create the opportunity for the instruction (Fenske
et al., 2001). Incidental teaching is an excellent way to increase initiation
and spontaneity and to augment the complexity of communication.
Other naturalistic methodologies within ABA have emphasized learner
interests. Pivotal Response Training (PRT) and Natural Language Paradigm
(NLP) emphasize using high-interest and motivating materials, teaching in
natural situations, and capitalizing on the child’s interests to target defi-
cits in language (Koegel & Koegel, 2005; Koegel, Koegel, & Surrat, 1992;
Koegel, O’Dell, & Koegel, 1987; Laski, Charlop, & Schreibman, 1988).
Natural Environment Training (NET; Sundberg & Partington, 1998),
as do NLP and PRT, focuses on the use of intrinsically motivating materi-
als and on following the child’s lead in language instruction. NET also,
however, uses Skinner’s Verbal Behavior language classification system
to guide language instruction (Skinner, 1957). The use of this classifica-
tion system increases the comprehensiveness of the attention given to the
functions of language. Sundberg and Partington’s emphasis on building
manding (requesting) skills targets this very important response class of
initiations. Other behavior-analytic approaches to building communica-
tion skills have also used Skinner’s classification system, with good results.
One example of this is the Picture Exchange Communication System (Frost
& Bondy, 2002), which teaches individuals with autism to interact with a
listener in order to communicate through the exchange of pictorial repre-
sentations. PECS has been shown to increase functional communication
and reduce behavior problems (Charlop-Christy, Carpenter, Le, LeBlanc,
& Kellet, 2002; Bondy, Tincani & Frost, 2004).
DTT and naturalistic methods such as incidental teaching target dif-

ferent deficits within autism spectrum disorders. Each methodology has
distinct advantages and unique applications. Although DTT is efficient and
effective in teaching a wide variety of skills, there is almost always a need
for additional generalization training procedures. Responsivity improves
dramatically within DTT, however, it is likely that initiation skills, request-
ing, and conversation may be best taught within more naturalistic meth-
odologies.
Outcome Data
To date, a number of reports of long-term outcome with behavior-
analytic intervention have been published. In the best-known study of
this type, Lovaas (1987) compared a group of children under age four
who received 40 hours of intervention per week for two or more years
with groups of children who received either fewer hours of such inter-
vention or no intervention. Almost half of the children in the intensive
intervention group were able to be placed unassisted in regular educa-
tion classes and achieved IQs in the average range. Other researchers
have documented that early intensive behavioral intervention results in
significant gains for some children (e.g., Green, Brennan, & Fein, 2002;
Smith, 1999). More research is still needed to completely understand
the effective elements and intensity levels of intervention, and how such
variables affect outcome. It is also true that outcome remains highly
variable, and that reliable predictors of outcome have not been confi-
dently identified.
Other Directions
In recent years, behavior analytic treatment of autism has begun to
incorporate elements of rate-building to achieve fluency. Fluency has been
defined as responding accurately, quickly, and without hesitation (Binder,
1996; Dougherty and Johnston, 1996). Although fluency has been a goal
of Precision Teaching, a field within the discipline of ABA instruction that
has existed for many years and served many populations (e.g. Lindsley,
1992), it has only recently been focused on as a goal for learners with
autism (Fabrizio & Moors, 2003). Rate-building procedures are used to
build fluency in the demonstration and availability of skills.
Rate-building addresses the specific deficits and needs of learners
with autism. Many learners on the autism spectrum exhibit motor dysflu-
encies. Although they may be able to achieve mastery when accuracy is
used to gauge success, they may still perform the task laboriously, inef-
ficiently, or slowly. Furthermore, many individuals with ASD demonstrate
a long latency to respond to instructions or to social initiations and bids.
Slow response times can lead to missed opportunities, especially in social
contexts (Weiss, 2001, 2005).
Rate-building procedures focus on rate of response, and utilize coaching
to build performance. Practice sessions begin as very short sprints
(e.g., ten seconds), and increase as performance increases. A performance

aim is used to guide daily progress (Fabrizio & Moors, 2003), and may be
determined by a celeration line on a Standard Celeration Chart (or may be
more individually determined by a learner’s own rate.) Progress is tracked
on a daily basis, and the learner is actively engaged in tracking progress.
The attainment of fluency has been associated with a number of out-
comes of learning, which represent true mastery (Binder, 1996; Fabrizio &
Moors, 2003; Haughton, 1980; Johnson & Layng, 1992). Johnson & Layng
(1992) emphasized the outcomes of stability (capacity to engage in behav-
ior in face of distraction), endurance (capacity to engage in behavior for
extended periods), application (broadly, ability to generalize and combine
skills), and retention (ability to maintain skills).
Research shows that rate-building is essential to achieving fluency,
yet nearly all instructional models for children with autism attend only to
accuracy (and not to rate) to evaluate mastery (Fabrizio & Moors, 2003).
Fabrizio and Moors (2003) have suggested the use of frequency aims in
teaching students with autism, and have provided suggested aim ranges
for core skills in this population of learners.
Advantages to rate-building, and to achieving fluency, include the out-
comes of fluency instruction (stability, endurance, application, retention),
the addition of rate data, and the capacity to track and target errors sepa-
rately from correct responses.
There is some debate within the field about whether fluency is achieved
as a function of rate-building or is an artifact of another element of instruc-
tion (Doughty, Chase, & O’Shields, 2004). In fact, several potential con-
founds and explanatory variables may be responsible for the effects. These
include the experience of practice itself, as well as rate of reinforcement.
Practice itself has been shown to facilitate learning (Samuels, 2002). The
type and amount of practice opportunities offered to learners does affect
mastery (Ericsson, Krampe, & Tesch-Romer, 1993). Learners given specific
immediate feedback and multiple trials improve both their accuracy and
speed. Furthermore, the high rates of reinforcement used in rate-building
may be responsible for the positive effects and outcomes. Finally, some of
the benefits of rate-building may be achieved simply by sensitizing staff
to fluency building procedures (Binder, 1996) or tracking latency as an
important qualitative aspect of response.
Another related instructional approach that has been discussed
as potentially relevant for learners on the autism spectrum is Direct
Instruction. Direct Instruction’s focus on specific behavioral targets,
scripted teaching formats, and data-based decision making fits well
with other ABA approaches to teach skills to this population of learn-
ers. In addition, several commercially available curricula that utilize
elements of this approach may improve how learners with autism are
taught basic skills.
Direct instruction has been applied to a variety of curricular areas,
including language, reading, mathematics, and writing. Although the
intervention and research done in these areas exists outside the realm of
ASDs, there may be utility for these procedures with learners on the autism
spectrum. Many of the curricula that exist for children with autism do not
adequately or completely emphasize academic skills. Direct Instruction

approaches may meet the needs of learners with ASDs in effective ways,
but scripted available curricula may need to provide methodical manuals
for teachers of learners with autism spectrum disorders to follow to effec-
tively meet the needs of these learners. It is also very likely, however, that
several elements of the DI curricula approaches would need to be modified
for this population of learners.
Summary
The treatment of autism spectrum disorders continues to receive a
great deal of attention in the professional and lay communities. Applied
Behavior Analysis has substantial documentation of its effectiveness in
remediating the deficits associated with autism. There is no other treat-
ment approach that even approaches ABA in terms of empirical validation,
scientific support, or confidence of findings.
Within ABA, Discrete Trial Training has been used to build core skills,
with increased emphases in recent years on using task interspersal pro-
cedures, errorless learning procedures, embedded generalization strate-
gies, and high rates of instruction (Weiss, 2001, 2005). DTT continues to
be effective in building responsivity and in establishing a wide variety of
core skills, and is best used in combination with other ABA procedures
that target different deficits. Naturalistic ABA teaching procedures such as
Incidental Teaching facilitate generalization and increase initiation. Rate-
building procedures may help to address problems in speed of response
and/or in latency to respond, which are critically important to ensure the
functional availability of responses in the natural environment. Further-
more, Direct Instruction’s foci on effective instructional design, individ-
ual assessment of progress, and scripted curricula may also benefit this
population. The use of all of these procedures provides a comprehensive
approach to addressing the diverse profiles and characteristics encoun-
tered among learners with ASDs.
NONBEHAVIORAL APPROACHES
Applied behavior analysis’ foundations in evidence-based principles

may be its most compelling quality to parents and practitioners. However,
the widespread implementation of interventions lacking empirical support
has been well documented (Levy, Mandell, Merhar, Ittenbach, & Pinto-
Martin, 2003). Smith and Wick (2008) suggest that the popular media’s
focus on such treatments as opposed to those that are data-driven may
contribute to this phenomenon. Their investigation of reports on alterna-
tive treatments in the media since 1990 yielded frequencies in the high
hundreds, most of which presented a positive or neutral perspective of
these therapies. Although these numbers have declined in the past few
years, parent utilization of alternative treatments that lack empirical
evidence of effectiveness for children with autism has been estimated at
74% (Hanson et al., 2006).
Sally Rogers (1998) differentiates two types of treatment for children

with autism. Behavioral treatments target certain autism-related skill def-
icits (e.g., social skills, imitation, play, communication, etc.) as well the
reduction of positive symptoms (e.g., inappropriate behaviors). The second
type aims to address the global severity of autism and its associated symp-
toms. The latter is of interest in this review; we present information on a
variety of biomedical, sensory-motor, and quasi-behavioral treatments.
Biomedical Interventions
The Gluten-Free Casein-Free (GFCF) Diet
The rationale behind the GFCF diet stems from a variety of studies
and anecdotal reports of gastrointestinal abnormalities in children with
autism. Panksepp (1979) linked excesses of opiates in animals to the types
of social deficits and aberrant behavior observed in the autistic popula-
tion. The theory further posits that inadequate digestion of gluten and
casein in individuals with autism can lead to opiatelike peptides in the
gut that are likely to seep back into the system to limit social relatedness
and cause maladaptive behaviors (the “leaky gut” theory). Indeed, findings
of urinary peptide abnormalities in this population (Knivsberg, Reichelt,
Hoien, & Nodland, 2003; Reichelt et al., 1981; Shattock et al,. 1990) as
well as amino acid deficiencies (Arnold, Hyman, Mooney, & Kirby, 2003)
have been documented.
As the name implies, the GFCF diet removes all gluten (a mixture of
proteins found in wheat products) and casein (a milk protein) from the
diet. Individuals on the diet must also avoid touching products contain-
ing gluten and casein (e.g., Play-Doh®) that may transfer the compounds
through the skin. This is an important consideration for children in a
school setting who may encounter exposure to gluten or casein from class-
room items (e.g., Play-Doh, glue) or from another student.
Data on the GFCF diet have been mixed. Evaluations of the efficacy
of this intervention are based on parent- and teacher-report (Cade et al.,
2000; Whiteley, Rodgers, Savery, & Shattock, 1999), urinary analysis of
peptides (Elder et al., 2006; Knivsberg, Reichelt, Nodland, & Hoien, 1995;
Knivsberg, Wiig, Lind, Nodland, & Reichelt, 1990), or a variety of behavio-
ral observation scales (Elder et al., 2006; Kinvsberg et al., 1990; Lucarelli
et al., 1995). Knivsberg and colleagues’ randomized control trial of dietary
intervention yielded significant improvements in behavior, nonverbal
cognition, and motor difficulties.
In their 2006 review, Christianson and Ivany detail six studies that
reported significant improvements of children with autism on the GF CF
diet based on parent- and teacher-reports, urine peptide analyses, and
assessments of autistic behavior and cognitive skills. These analyses,
however, do raise some methodological concerns. Four of the studies did
not include a control group; one performed an unblinded comparison
and then based improvements on teacher and parent ratings (Whiteley
et al., 1999). Other studies have found no differences in symptom sever-
ity or urine peptides between diet and control groups (Elder et al., 2006)
or reported mixed results (Whiteley et al., 1999). The literature also doc-
uments frequent discrepancies between parent- and teacher-reports or
between parent-/teacher-reports and scores on standardized measures.
Other types of dietary interventions are also occasionally implemented.
The ketogenic diet (Wilder, 1921), more commonly used for individuals
with seizure disorder, is high in fat and low in carbohydrates. There is
limited preliminary evidence that the ketogenic diet may be useful in chil-
dren with autism (Evangeliou et al., 2002). More general elimination diets
also exist in which children are tested for sensitivity to a variety of foods,
which are then eliminated from their diet. Frequently tested foods include
soy, milk, nuts, corn, eggs, and chocolate; these diets may elicit behav-
ior improvements in children with autism (Torisky, Torisky, Kaplan, &
Speicher, 1993). Without more extensive controlled analyses these results
are considered very preliminary; currently the use of these types of inter-
ventions is not empirically supported.
Vitamin Therapy
It has been proposed that individuals with autism require more nutrients
than their typical peers, and that nutritional deficiency may impede normal
processing of sensory information (Rimland & Larson, 1981). Vitamin ther-
apy involves the administration of specific compounds, most commonly vita-
min B-6 (pyridoxine) and magnesium. The benefits of this intervention have
been suggested over the past 25 years for decreasing symptomatic behavior
(Barthelemy et al., 1981; Lelord, Muh, Barthelemy, Martineau, & Garreau,
1981; Martineau et al., 1989; Rimland, Callaway, & Dreyfus, 1978) and nor-
malizing antibody deficits (Menage, Thibault, Barthelemy, Lelord, & Bardos,
1992). Ascorbic acid supplements have also resulted in decreases on abnor-
mal sensory motor scores on a commonly used behavior measure (Dolske
et al., 1993). Opponents of vitamin therapy argue that existing literature does
not standardize dosage or units of measurements and criticize the methodol-
ogy (e.g., unblinded, absence of control, lack of random assignment; Pfeiffer,
Norton, Nelson, & Shott, 1995). More recent studies have shown no benefits
of vitamin therapy in double-blind, placebo-controlled clinical trials (Findling
et al., 1997; Tolbert, Haigler, Waits, & Dennis, 1993).
Medication
Children with autism may receive medication as a supplement to other
treatments. Commonly administered medications include atypical antip-
sychotics (e.g., risperidone, aripiprazole), psychotropics (e.g., methylphe-
nidate), and SSRIs (e.g., fluoxetine). These drugs are typically prescribed
to target specific behaviors such as aggression, rituals and compulsions,
and attention deficits.
Risperidone is one of the most well-studied medications currently
approved by the FDA. It is tolerated well by children as young as
preschool age with minimal side-effects, the most common being weight
gain, excessive appetite, and hypersalivation (Aman et al., 2005; Luby
et al., 2006; Williams et al., 2006). Several studies have suggested the
efficacy of risperidone in reducing hyperactivity and repetitive behaviors
(Barnard, Young, Pearson, Geddes, & Brien, 2002), aggression (Bernard
et al., 2002; AJP, 2005), autism severity (Luby et al., 2006) and self-injuri-
ous behaviors (Research Units on Pediatric Psychopharmocology Autism
Network, 2005), and promoting increases in communication, daily living
skills, and socialization (Williams, et al., 2006). There is also evidence
that risperidone may be more effective than alternative atypical anti-
psychotics (Barnard et al., 2002). Because of the lack of control in these
studies, there is a need for randomized control trials to further evaluate
the efficacy of this medication.
Selective Serotonin Reuptake Inhibitors

SSRIs are frequently used to treat obsessive and compulsive behaviors
in children with autism. The literature presents mixed findings regarding
the efficacy of a variety of these medications. In recent randomized
trials, Hollander and colleagues found that children who were administered
fluoxetine showed a reduction in repetitive behaviors on the Yale-Brown
Obsessive-Compulsive Scale (2005), and the Autism Diagnostic Observa-
tion Schedule (2006) but no significant reductions on global measures.
Similar decreases in repetitive behaviors were observed with fluvoxamine
(McDougle, 1996), although not all individuals may respond to treatment
(Martin, Koenig, Anderson, & Scahill, 2003). Other drugs, such as paroxetine
(Posey, Litwiller, Koburn, & McDougle, 1999) and sertraline (Steingard, Zim-
nitzky, DeMaso, Bauman, & Bucci, 1997), have been related to decreases in
aggression and self-injurious behaviors. As with atypical antipsychotics, the
effects of SSRIs should be further examined in placebo-controlled studies.
Secretin Therapy
Secretin is a hormone that regulates the pH balance of the stomach
and the pancreas; it was originally administered to children with autism to
alleviate gastrointestinal difficulties. Parent reports of salutary effects on
the core features of autism led to the use of secretin to directly target these
symptoms. In 1998, Hovarth and colleagues reported gains in language
and socialization in three children with autism who received one dose of
secretin therapy.
Randomized controlled trials of the effects of secretin generally sug-
gest that there is no causal relationship between secretin and changes
in autism symptomology. Although some have reported positive results
(Kern, Miller, Evans, & Trivedi, 2002), in most cases no changes in behav-
ior were reported (Dunn-Geier et al., 2000; Sandler et al., 1999) or con-
current benefits were observed in both treatment and placebo groups
(Handen & Hofkosh, 2005; Unis et al., 2002). In some instances, treat-
ment groups suffered deterioration of skills (Carey, Ratliff-Schaub, Funk,
Weinle, Myers, & Jenks, 2002) and increased autism severity when paired
with other medications (Ratcliff-Schaub, Carey, Reeves, & Rogers, 2005).

Esch and Carr (2004) and Sturmey (2004) offer comprehensive reviews of
the literature on secretin.
Regardless of the data, there is continuing support for the use of secre-
tin therapy with individuals with autism. Although Handen and Hofkosh
(2005) found inconsistent performance and, in some cases, worsening
scores on the Gilliam Autism Rating Scale, improvements in communi-
cation and social relatedness were anecdotally reported in seven out of
eight participants. Sandler and colleagues (1999) note that 69% of parents
whose children participated in their study sustained interest in secretin
therapy, despite the lack of significant improvements in behavior.
Chelation
Chelation is a detoxification process created to remove heavy metals from
the body, in circumstances such as lead poisoning. Proponents of its use
with children with autism attribute its alleged efficacy to the link between
heavy metals (principally mercury) and autism symptoms (e.g., language
deficits, motor difficulties, sensory abnormalities, repetitive behaviors;
Bernard, Enayati, Redwood, Roger, & Binstock, 2001). It is purported that
the inclusion of the preservative thimerosol in the MMR and other child-
hood vaccines facilitates this mercury leak into the body.
Currently, there are no published clinical trials on the efficacy of chela-
tion or any other evidence to suggest that chelation may be an appropriate
treatment for individuals with autism (Sinha, Silove, & Williams, 2006).
Further arguments suggest that the underlying theory is flawed, that the
symptoms of mercury poisoning do not mimic specific autism symptoms
(Nelson & Bauman, 2003), and that chelation has not been shown in any
instance to reverse neurological damage (Shannon, Levy, & Sandler, 2001).
Shannon and colleagues also highlight the dangers of this treatment, cit-
ing possible kidney and liver damage, and severe allergic reaction. The
recent death of a five-year-old boy during chelation therapy also cautions
against the blanket administration of this procedure (DeNoon, 2005).
Sensory-Motor Treatments
Sensory and auditory integration are posited to alleviate symptoms
that arise from abnormal processing of sensory input in individuals with
autism. There is evidence to suggest that the autistic population experi-
ences hypo- and hyperarousal to usual sensory stimuli (Frith, 1989; Ke,
Wang, & Chen, 2004; Ornitz, 1974); these atypical processes may affect
development and account for attentional difficulties, social deficits, and
maladaptive behaviors (Ornitz, 1974).
Sensory Integration
Implementation of sensory integration therapy can vary; it may be
proprioceptive (e.g., deep pressure massage), tactile (light touching, brushing),
or vestibular (swinging, rolling, jumping). There is mixed evidence of the
effects of sensory integration on attentional and behavioral outcomes in

children with autism. Case-Smith and Bryan (1999) reported gains on
measures of engagement, play behavior, and adult and peer interactions,
as well as decreases in nonengagement following an intervention of swinging,
brushing, and deep pressure massage. Linderman and Stewart (1999)
documented overall gains in social interaction, approach, and response.
However, the use of an AB design without reversal may caution our inter-
pretation of their results.
In a brief report on touch therapy, 22 children with autism showed
decreased aversion and off-task behavior as well as collateral gains in
joint attention, behavior regulation, social behavior, and imitation (Field
et al., 1997). Watling (2004) reported more mixed findings: increases in
engagement but no effect on maladaptive behavior following thirty-three
40-minute sessions of sensory therapy. Others have found no positive
effects on behavior (Gillberg, Johansson, Steffenburg, & Berlin, 1997;
Kane, Luiselli, Dearborn, & Young, 2004) and have even noted increases in
stereotypy as a result of the weighted vest intervention (Kane et al., 2004).
Until more consistent evidence is presented under controlled conditions,
the outcomes of sensory integration training should be considered uncer-
tain and the treatment possibly contraindicated.
Auditory Integration Training (AIT)

Auditory Integration Training provides the child with a device that fil-
ters out certain frequencies to which he or she is supposedly hypersensitive.
Randomized high and low frequencies then “exercise” the inner ear and brain
to decrease atypical sensitivity to frequencies above or below the sensitiv-
ity threshold across twenty sessions of 30 minutes listening time (Berard,
1993). Again, mixed results typify the literature. Positive outcomes in
cognitive scores (Bettison, 1996), observational measures (Rimland & Edel-
son, 1995, 1994), and decreases in problem behavior (Rimland & Edelson,
1994; Zollweg, Palm, & Vance, 1997) were observed in response to AIT,
under the conditions of random assignment. Subsequent findings suggest
that there are no clinically significant benefits to AIT (Gillberg et al., 1997;
Link, 1997; Mudford et al., 2000), and it is therefore not recommended.
Facilitated Communication (FC)

This intervention stems from Rosemary Crossley’s work with individuals
with physical disabilities and was later adapted to aid individuals with
autism who cannot verbally communicate (Biklen, 1993a). In facilitated
communication a person with autism types words on a keyboard with the
physical guidance of an assistant positioned behind him. It is hypothe-
sized that individuals can use FC to convey previously unexpressed needs
and wants, as well as reveal formerly unexposed intelligence (Biklen &
Schubert, 1991; Bilken, 1992d).
A small number of studies have reported some limited success of FC with
individuals with autism (Biklen, Saha, & Kliewer, 1995; Cardinal, Hanson,
& Wakeham, 1996; Janzen-Wilde, Duchan, & Higginbotham, 1995; Simon,
Toll, & Whitehair, 1994; Simpson & Myles, 1995b). Many more investigations
have indicated that performance with FC is largely due to facilitator influ-
ence (Kezuka, 1997; Oswald, 1994; Shane & Kearns, 1994; Perry, Bryson, &
Bebko, 1998) and that collateral improvements are unlikely (Beck & Pirovano,
1996; Myles, Simpson, & Smith, 1996a). Indeed, other methods of encourag-
ing communication, such as the Picture Exchange Communication System,
are evidenced to be preferable (Simon, Whitehair, & Toll, 1996). FC is consid-
ered not only ineffective, but possibly harmful, and is not recommended.
Psychoeducational / Psychosocial Treatments

TEACCH
The TEACCH strategy, developed by Mesibov, Schopler, and colleagues
at the University of North Carolina, focuses on providing services to indi-
viduals with autism throughout the lifespan. The fundamentals of TEACCH
include highly structured environments and routines, an abundance of
visual cues, parent collaboration, and individualized assessment (Schopler,
1998). However, this structure also provokes the main critique that TEACCH
does not specifically target the reduction of problem behavior.
To date there are few extensive assessments of this approach in the
published literature. Some examinations have yielded gains in play skills
(Francke & Geist, 2003), task mastery (Hungelmann, 2001), independent
functioning and interpersonal behavior (Persson, 2000), academic and cog-
nitive functioning (Ozonoff & Cathcart;, 1998; Schopler & Hennike, 1990),
and decreases in self-injurious behavior (Norgate, 1998). However, Smith
(1999) suggests that these data are limited as a result of quasi-experimental
design, potential confounds, or pretest group differences. Other efforts to
validate TEACCH yielded mixed results; Van Bourgondien and colleagues
(2003) found no increases in skill acquisition in the experimental group,
but decreases in abnormal behavior (albeit, author proclaimed “exploratory
findings”). It has also been suggested that skills acquired in these programs
do not generalize reliably (Tutt, Powell, & Thornton, 2006).
There are fairly strong findings supporting parental satisfaction in
the TEACCH model (Van Bourgondien, Reichler, & Schopler, 2003), per-
haps because parents are so integrated into this approach. Furthermore,
TEACCH programs may provide good long-term support for adults with
autism. An investigation of the supported employment program under
Division TEACCH found an 89% retention rate among adults with autism
(Keel, Mesibov, & Woods, 1997). This program has been crucial in employ-
ing individuals with autism and other related disorders, roughly a third of
whom had no prior placement.
Developmental Individual Difference, Relationship-Based

Model (DIR)
Also called “floor time,” this play-based approach targets social inter-
actions between children with autism and their parents and therapists to
increase communication and social relatedness (Greenspan, 1992). DIR is a
child-directed treatment; parents and therapists play with the target child
on the floor with preferred materials to promote manding, eye contact,
conversation, and other social interfaces. Greenspan and Wieder (1997)
conducted a chart review of 200 children with autism who received DIR
treatment and compared outcomes with those of children who received
traditional (unspecified) services. After two years, they found that 58% of
children were categorized as “good to outstanding” compared to 2% in
traditional services. Their recent 10- to15-year follow-up of the 16 most
high-functioning participants revealed long-term positive outcomes in social
and school competence, low rates of comorbid depression and anxiety,
and variable outcomes on sensory motor profiles (Wieder & Greenspan,
2005). Limitations of these studies include a nonexperimental design and
a lack of information on concurrent treatments, making it very difficult to
confidently attribute gains to the approach.
Relationship Development Intervention (RDI)

RDI is a family-centered treatment that proposes to enrich an individual’s
life with empathy and emotion sharing, suggested prerequisites to typi-
cal social interaction. Rather than targeting individual skills, RDI utilizes
a broader approach. A comparison of 17 children with autism in an RDI
program to 14 children receiving alternative early intensive interventions
yielded positive outcomes on the Autism Diagnostic Observation Schedule
(ADOS) for 12 participants in the experimental group (Gutstein, 2005). No
other empirical analyses of RDI have been published to date.
Conclusion
The widespread use of alternative nonbehavioral treatments warrants
our attention. Because these interventions are so prevalent, and because
rigorous scientific data are largely absent, additional empirical analyses
are necessary. Until more data are collected, service providers, teachers,
physicians, and parents should be aware of these treatments and of their
potential benefits, risk of harm, and possible shortcomings.
ASPERGER SYNDROME
Asperger syndrome (AS) is characterized by deficits in social behavior,

insistence on sameness, poor nonverbal language development, inappropri-
ate affect, and stereotyped behavior (Asperger, 1944; Wing, 1981). Accord-
ing to the American Psychological Association (APA), differential diagnosis
of AS and autism lies in the diagnostic criterion that individuals with AS—
unlike those with autism—generally do not demonstrate communication,
language, imagination, cognitive, or self-help deficits (APA, 1997). Regard-
less, researchers and clinicians point out that the differentiation between
individuals with autism and AS is often unclear, and requires additional
research before a firm conclusion can be made regarding the differential
diagnosis (Barnhill, Hagiwara, Myles, & Simpson, 2000).
In parental report of selected groups of children with AS and autism

diagnoses, children with AS seem to engage in more prosocial behavior,
make more eye contact, and demonstrate more willingness to engage
in friendships and play than do children with autism. Although fewer
children with AS demonstrate delayed onset of language as compared to
children with autism, both groups demonstrate significant disturbances
in communication skills, as reported by parents. Such communication
deficits are evident in the children’s use of repetition, poor prosody, literal
translation of peers’ language, and an inability to sustain conversation.
Overall, although both groups appear to exhibit deficits in social skills and
communication, children with AS typically exhibit greater social interest
and less delayed communication than would be expected of a child with
autism (Eisenmajer et al., 1996).
Social Deficits
As indicated by Myles and Simpson (2002), “AS is foremost a social
disorder” (p. 132). The authors report that one of the primary differentiat-
ing characteristics of children with AS, when compared to children with
autism, is that individuals with AS desire and seek social interactions.
Difficulties in initiating and sustaining relationships, however, are evident
at an early age. Church, Alisank, and Amanullah (2000) conducted an
analysis of individuals with autism from preschool to teenage years. The
authors reported that, even in preschool, parents indicated that although
the children interacted well with adults, they had difficulty interacting
with children their age and seemed more comfortable on the periphery of
social groups. This difficulty in initiating and maintaining relationships
seemed exacerbated by difficulty reading social cues and situations and
regulating behavior. Through middle school, individuals with AS exhibit
inappropriate affect, resulting in inappropriately loud, aggressive, and
often silly behavior.
Much of the difficulty experienced by children with AS stems from
their inability to learn and understand what Myles and Simpson (2001)
term the “hidden curriculum.” Rules of social interaction and behavior
are learned rigidly by children with AS and are inflexibly applied to all
situations regardless of setting and audience. The ability to flexibly apply
these rules of interaction—which is demonstrated effortlessly by typical
children—is a skill that is never directly taught but is expected of all indi-
viduals. As a result, children with AS appear socially awkward and often
inappropriate (Myles & Simpson, 2001).
One approach for improving social skills in this population is the
development of social skills groups for children and adolescents that tar-
get appropriate behavior, recognition of verbal and nonverbal social cues
(Barnhill, Cook, Tebbenkamp, & Myles, 2002), and understanding the
“hidden curriculum” (Myles & Simpson, 2001). For example, Myles and
Simpson (2001) suggest that the hidden curriculum can be taught to
children with AS using a variety of methods, including direct instruction—
comprised of methods such as providing a rationale for behavior, presenta-
tion of skills, modeling, evaluation, and assessment of generalization—and
social stories written to describe information about specific situations,

appropriate behavior in those situations, and the thoughts and beliefs of
others in the situation (Gray, 1995).
Other skill-building activities may include acting lessons, in which
they learn to openly express emotions and receive consistent feedback
on performance from peers and instructors; cartooning, to help a child
identify different perspectives; “social autopsies” (Bieber, 1994, as cited in
Myles & Simpson, 2001, p. 283) in which the child and an adult meet to
analyze recent social mistakes and develop steps to ensure that the mis-
take does not occur again; and problem-solving behavior.
Many of these methods are widely used in social skills groups, but the
outcomes of such social skills groups remain mixed. Although the chil-
dren in some groups evidence an improvement in social skills within the
group, measures of improvement such as performance on psychometric
tests may not capture the improvement (Barnhill et al., 2002). Addition-
ally, many children show limited generalization of skills learned in social
skills groups to new settings and situations (Barnhill et al., 2002). Church
et al. (1999) point out, however, that in a sample of elementary-aged chil-
dren with AS, only 23% were receiving a social skills curriculum when the
deficit is arguably one of the most profound in the disorder. In contrast,
76% of children in the middle-school sample received the social skills cur-
riculum. Social skills and the utilization of social skills groups may need
to be introduced during the child’s early development to attain optimal
acquisition and generalization of these difficult but crucial skills.
Aside from reliance on social skills groups, teachers may be able to
improve social interactions by increasing the sensitivity of other children
to the child with AS. For example, the teacher may educate other children
on the difficulties experienced by an individual with AS. By developing
cooperative learning groups in which children must work together toward
a common goal, or creating a “buddy system” in which children must work
together during the course of the day, children with AS can be paired with
appropriate models. Furthermore, these contexts provide an opportunity
for children with AS to demonstrate their academic strengths in social
environments. This approach may increase the social acceptance of these
children and increase their self esteem (Barnhill & Myles, 2001; Tsatsanis,
Foley, & Donehower, 2004; Williams, 1995).
Behavioral Difficulties
Young children with AS often exhibit rigid behavioral routines and
rituals, becoming preoccupied with stereotypical body movements and inap-
propriate object use. Interruptions of and transitions from these routines
often result in maladaptive behavior such as tantrums (Church et al.,
1999). Many of these behaviors appear to dissipate as the children grow
older, however, they are often still evident in times of high frustration;
elementary-aged children frequently engage in behaviors such as self-talk,
humming, and pacing. These children remain extremely literal and rule-
based in their interactions with others (Church et al., 1999). Managing
these restricted interests can be difficult, but promoting a predictable
environment for the child with AS by creating a consistent routine and

avoiding unexpected changes may minimize maladaptive responses in
response to changes in routine. When change is inevitable, one should
expose individuals with AS to the change gradually so as to shape appro-
priate behavior in the new setting or situation (Williams, 1995).
In addition, many children develop an intense preoccupation with
specific topics that dominate a child’s interest (Myles & Simpson, 2001).
Frequently, parents and teachers find difficulty in motivating a child without
the use of these interests (Williams, 1995). Several hypotheses have been
developed regarding the emergence of these restricted interests: children
may develop these interests to facilitate conversation, to provide the indi-
vidual with an enjoyable activity, for relaxation, and for order and consist-
ency (Barnhill, 2001b). Regardless, the development of these interests will
often last into adulthood.
To manage this behavior, parents and teachers may implement rules
to limit the child’s perseveration on a given topic. For example, a parent may
allow the child to talk about the perseverative interest only at specific times
of the day, reinforcing appropriate alternative behavior in the absence of
perseveration. In addition, a teacher may also be able to use the restricted
interests to motivate a child to complete a task by tailoring the task to
the child’s interests or linking other skills to the restricted interest. For
example, writing a history report for a child who perseverates on trains
may be more tolerable if he is allowed to write a report on the history of
the railroad, and writing this report may be linked to learning about the
development of the western United States following the expansion of
the railroad. Ultimately, the teacher will have to set rules regarding work
that must be performed outside the child’s interests, and reinforce the
child for completing such work independently (Williams, 1995).
Many children with AS have difficulty regulating their emotional behav-
ior, and as a result are prone to emotional outbursts and tantrums. Because
these children have difficulty reporting their own internal states (Barnhill,
Hagiwara, Myles, Simpson, Brick, & Griswold, 2000) and often do not indi-
cate increasing stress through either voice or body language, emotional
situations may escalate quickly without warning (Myles & Southwick, 1999
as cited in Myles & Simpson, 2002). Family and teachers may be able to
prevent such outbursts by maintaining a predictable structured environ-
ment for children with AS. In addition, children with AS should also be
taught how to self-manage their own behavior using coping strategies such
as problem-solving skills and de-escalation techniques (Tsatsanis, Foley,
& Donehower, 2004; Williams, 1995). The assessment and treatment of
problem behavior will be discussed more extensively later in this chapter.
Language and Cognitive Skills

The APA diagnostic manual indicates that children with AS are not signif-
icantly delayed in either language development or cognitive development, but
in fact a range of deficits do occur. Church et al. (1999) report normal or early
language emergence in 88% of children with AS, but also report that 90%
of children with AS exhibit language pragmatic problems in preschool years.
In elementary school and middle school, 96% and 76% of children, respec-
tively, receive speech and language services to address difficulty with conver-
sational skills, vocal regulation and modulation, and language expression.
Although these children often perform above average in academics,
the individual performance of students with AS varies widely. Griswold,
Barnhill, Myles, Hagiwara, and Simpson (2002) conducted an assessment
of children ages 6 to 17 years old with AS using the Wechsler Individual
Achievement Test and found that, whereas the aggregate score for the chil-
dren fell within the average range, individual scores ranged from signifi-
cantly below to significantly above average. Children with AS demonstrated
specific weaknesses in language and reading comprehension (Church
et al., 1999; Barnhill et al., 2000; Griswold et al., 2002) and mathematical
concepts and principles (Barnhill et al., 2000; Griswold et al., 2002). Such
deficits may arise from difficulties with social and communication related
tasks, literal thought and interpretation, and poor problem-solving skills
(Frith, 1991; Siegel, Minshew, & Goldstein, 1996).
These children appear to demonstrate above-average performance in tests
of nonverbal reasoning and factual recollection (Barnhill et al., 2000), as well
as reading. Teachers should note, however, that reading proficiency is not an
indicator of strong comprehension; these children often demonstrate weak-
ness in this area (Griswold et al., 2002). In addition, they are often unable to
differentiate between general knowledge and personal thought, responding
both verbally and in writing with responses that may be incomprehensible by
a teacher due to their reliance on personal thought (Williams, 1995).
Researchers caution that knowledge of the AS diagnosis will not provide
information about specific strengths and weaknesses; rather, comprehensive
assessment must be conducted for all students (Griswold et al., 2002). Many
children with AS, because of their myriad strengths and deficits in unpre-
dictable areas, will require individualized programs to ensure success in an
academic setting. These children may require additional explanation and
instruction, especially of abstract concepts. Care should be taken to assess
a child’s comprehension of spoken and written material (Williams, 1995).
Additional supports can be implemented in the general classroom area
to increase skills in concentration, an area of difficulty for the child with AS.
A structured predictable classroom setting may increase a child’s attention,
as might seating arrangements that facilitate concentration (e.g., seating near
the teacher, seating with a classroom “buddy”). Visual prompts for these chil-
dren may be especially helpful in facilitating adherence to instruction and
smooth transitions to new activities (Williams, 1995). Visual prompts may
also be useful in improving performance in auditory tasks, as many children
with AS may have difficulty processing auditory instructions and descrip-
tions. A lecture format may be especially difficult for a child with AS to attend
to, and additional visual strategies such as the use of role-play and videos
may make information more salient to the child (Griswold et al., 2002).
Emotional Characteristics
Of great importance in the discussion of AS is the profound impact
that the disorder has on the emotional adjustment of the individuals. As has
been mentioned previously, unlike their peers with autism, children with
AS have a desire to develop social relationships but often fail at doing so.
These children also have the insight to understand that they are different
from others and do not “fit in” (Myles & Simpson, 2002). Such realiza-
tions have effects on the individuals’ self-esteem and self-concept and put
children, adolescents, and adults with AS at increased risk for a number
of comorbid disorders, including depression and anxiety (Barnhill et al.,
2000; Kim, Szatmari, Bryson, Streiner, & Wilson, 2000). Up to 20% of
adults with AS have experienced a period of depression at some point in
their lives (Kim et al., 2000; Tantam, 2001), but research indicates that
often these children are poor reporters of such internal states.
Barnhill et al. (2000) conducted an analysis of internalizing and external-
izing problem behavior among adolescents with AS and revealed that, although
parents and teachers indicated that children were at risk for internalizing
problems, the adolescents did not report any internalizing difficulties. Such
poor insight may make it difficult to diagnose these problems in AS individu-
als, but the identification of these diagnoses is critical to ascertain treatment.
Much research has focused on the underlying cause of depression in
children and adolescents with AS. Recently researchers have indicated
that adolescents with comorbid AS and depression indicate a greater pro-
pensity to view situations in a way that indicates both helplessness and
hopelessness. They perceive many events as beyond their control and
take personal responsibility for the negative events in their lives (Barnhill
& Myles, 2001). Additionally, authors have found that IQ is negatively
related to this finding, in that adolescents with high IQ are less likely to
make these attributions and to instead realize the impact external situa-
tions have on one’s social success (Barnhill, 2001a).
As a result of these findings, researchers have begun to examine the
use of cognitive behavior therapy (CBT)—a problem-oriented therapy in
which focus is placed on psychological and environmental contributors
to emotional distress—for treatment of AS individuals with comorbid dis-
orders. CBT places focus on the alteration of thoughts and behavior to
improve symptoms such as anxiety and depression. For example, Sof-
ronoff, Attwood, and Hinton (2005) found that the use of a CBT package,
which included teaching children with AS to identify emotions, thought
patterns, and behavior and instructing them in ways of controlling anxiety
using a variety of coping skills and social stories, was effective in decreas-
ing anxiety symptoms in children with AS. The treatment was most effec-
tive when paired with parental involvement in therapy.
Research in the use of CBT with individuals with AS, however, is still
emerging. In an investigation of the use of CBT in individuals with AS,
Anderson and Morris (2006) reported that only five published studies—
four of which were case studies—have examined the use of CBT in indi-
viduals with AS. More research is required in this area to fully understand
the intricacies of utilizing the therapy within this population. Researchers
speculate that the highly structured format of the therapy and the focus
on the development of affect recognition and thought evaluation may be
beneficial to AS individuals suffering from comorbid disorders, especially
when enhanced by visual materials, emphasis on rules rather than on
abstract concepts, a directive approach, and family involvement (Anderson

& Morris, 2006).
Although further research is required to gain a better understand-
ing of diagnosis and treatment of AS, researchers agree that treatment
for AS should begin early in development. Because of the high academic
functioning of many children with AS, diagnosis can occur later than it
does in children with autism (Eisenmajer et al., 1996). Early detection and
intervention in areas of social understanding and social skills is essential
in the treatment of AS. Again, one should recognize the importance of a
detailed assessment of the strengths and deficits of each child to develop
the most appropriate individualized education plan. Family members
should be involved at all stages of treatment to facilitate generalization of
learned skills, and to increase family understanding and management of
challenging behavior (Tsatsanis, Foley, & Donehower, 2004). Comprehen-
sive treatment in the areas of social, behavioral, cognitive, and emotional
development may vastly improve the quality of life for the child with AS.
Functional Assessment and Treatment

Children on the autism spectrum exhibit a wide range of challenging
behavior, including aggressive, self-injurious, and disruptive behavior.
Some behavior may be severe and intrusive enough to warrant a behavior
intervention plan informed by a functional behavioral assessment (FBA).
An FBA is defined as “a process which searches for an explanation of the
purpose behind a problem behavior” (OSEP Questions and Answers, 1999)
and is mandated by the Individuals with Disabilities Education Act (IDEA)
Amendments of 1997 in cases in which a child’s behavior has resulted
in negative educational outcomes. Specifically, FBAs are mandated when
the behavior has resulted in the child’s suspension or placement in an
alternative setting either for 10 consecutive days or because a due process
hearing officer has determined the behavior is dangerous to the student
or others, or when a student is placed in an alternative setting for 45 days
when he or she has been involved in a weapons or drug offense.
Although children with autism may infrequently meet these extreme
requirements, IDEA also stipulates that if an individual’s behavior inter-
feres with his or her learning or the learning of others, or poses a danger
to the individual or others, then the student’s individual educational plan
(IEP) team should implement a behavior intervention plan informed by a
functional behavior assessment to address the behavior. These stipula-
tions apply to many children with autism. Unfortunately, IDEA does not
specify what elements constitute either an FBA or an effective intervention.
We summarize here the components of a functional behavioral assessment
and also discuss the importance of using the results of an FBA to inform
and develop a function-based intervention for challenging behavior.
Iovannone, Dunlap, Huber, and Kinkaid (2003) conducted a review of
comprehensive treatments for children with autism and found that one of the
components common to all effective treatments was a functional approach

to challenging behavior. Although a child’s behavior may often appear
unpredictable and random, most professionals in the field agree that all
adaptive and maladaptive behavior is functionally and lawfully related to
events in the environment and serves a purpose for the individual (Northup
et al., 1991). An FBA is used to identify this function of a behavior so that
an appropriate, function-based treatment can be implemented.
In the context of functional assessment, behavior is maintained by
either positive reinforcement or negative reinforcement, that is, by envi-
ronmental stimuli that are either added to (i.e., positive reinforcement) or
removed from (i.e., negative reinforcement) the environment following the
occurrence of a behavior that subsequently increases the likelihood of that
behavior occurring again in the future. Examples of positive reinforce-
ment may include the presentation of attention, desired items, or pleasur-
able sensory input, and examples of negative reinforcement include the
removal of demands or other aversive environmental stimuli or physical
sensations. A behavior may function to gain access to any of these forms of
reinforcement and, additionally, the behavior may function to gain access
to several forms of reinforcement simultaneously (Northup et al., 1991).
The purpose of a functional assessment is to determine which of these
myriad functions currently maintains a maladaptive behavior so that an
effective intervention can be developed.
Prior to either the functional assessment or development of a behavior
intervention plan, one must develop an operational definition for the chal-
lenging behavior. An operational definition defines the behavior as a meas-
urable observable event, thus reducing biased reporting of the behavior and
increasing the reliability of measurement of the behavior (Cooper, Heron,
& Heward, 2007). Accurate assessment and treatment of the behavior will
rely heavily on accurate data collection and measurement of the behavior.
Without data and measurement, one cannot determine conclusively that a
behavior has been reduced.
Indirect Assessment
Functional assessments can be conducted using three types of assess-
ment: indirect assessment, descriptive assessment, and functional anal-
ysis (O’Neill, Horner, Albin, Sprague, Storey, & Newton, 1997). Indirect
methods include assessment techniques such as rating scales and inter-
views which require an individual who is familiar with the child to provide
information about environmental antecedents and consequences. Ante-
cedents, or events that frequently occur before the onset of the behavior,
may include the time of day, the presence of a specific person or activity, or
inclusion in a particular setting. Consequences, or events that frequently
occur following the behavior, might include examples of positive or nega-
tive reinforcement as discussed above (e.g., access to attention, removal
of attention, etc.). The informant should also be asked to provide informa-
tion about the child’s current skill level and ability to communicate. All of
these responses will be helpful in informing a function-based intervention
(O’Neill et al., 1997).
Although rating forms and interviews are frequently easy and efficient
to conduct, they should not be the sole form of assessment on which treat-
ment is based. Both rating scales and interviews are subject to bias or error
on the part of the informant and may provide unreliable results (LaRue &
Handleman, 2006; Sturmey, 1994; Zarcone, Rodgers, Iwata, Rourke, &
Dorsey, 1991). As a result, such methods of indirect assessment should
be used as a preliminary step to inform subsequent assessment and, with
very few exceptions (e.g., suicidal behavior), an intervention should not be
based solely on an indirect method of assessment.
Descriptive Assessment
In contrast to indirect methods of assessment, descriptive assessment
involves the direct observation and recording of the target behavior in the
natural environment. A frequent method of descriptive analysis is Ante-
cedent-Behavior-Consequence (ABC) recording, in which the observer
watches the child in vivo in the natural setting and records the antecedents,
behavior, and consequences, all of which must be operationally defined
to ensure accurate recording (LaRue & Handleman, 2006; Sasso et al.,
1992). The observer is then able to calculate the conditional probability of
each antecedent and consequence by calculating the percentage of behav-
ior episodes that were preceded by a specific antecedent and followed by a
specific consequence. The most frequent antecedent and consequence for
the behavior, or those with the greatest conditional probability, indicate a
function (e.g., escape from demand, gain access to tangible, gain access to
attention) of the behavior (LaRue & Handleman, 2006; Sasso et al., 1992).
If the data indicate a clear functional relationship between environmental
events and behavior, the descriptive analysis may be the terminal step of
the functional assessment (LaRue & Handleman, 2006).
Descriptive analysis provides more objective information about the
behavior as compared to indirect methods of assessment. By observing
the behavior in the natural environment, the observer decreases the likeli-
hood that identification of the function of behavior is biased. Criticisms of
descriptive analyses, however, include the fact that they offer little control
over the behavior and thus one cannot assume functional relationships
between events and behavior (Sasso et al., 1992). The temporal contigu-
ity of two events does not indicate a relationship, as the two events may
be completely unrelated and occur temporally proximate to each other
by coincidence only. In addition, many events may occur simultaneously
prior to or following the occurrence of the behavior, making observational
recording and analysis of antecedents and consequences difficult (LaRue
& Handleman, 2006).
Functional Analysis
A functional analysis evinces significantly more control over environ-
mental events through the systematic manipulation of environmental
antecedents and consequences (Carr & Durand, 1985; Iwata, Dorsey, Slifer,
Bauman, & Richman, 1982/1994). These manipulations, referred to as
conditions, are representative of reinforcement contingencies that may

occur in the natural environment. Behavior is recorded during various
conditions, and conditions in which the highest rate of behavior occurs
indicate a function for the target behavior.
Conditions commonly implemented in a functional analysis include
social attention, demand, tangible, alone/ignore, and toy play control
(LaRue & Handleman, 2006). In the social attention condition, the child is
antecedently allowed to play with neutral items, but receives no attention
from the therapist/teacher. Upon the occurrence of the target behavior, the
therapist/teacher provides the child with attention. High rates of behavior
in this condition imply that the behavior is maintained by social attention.
In the demand condition, the child is antecedently engaged in a
demand activity, and as a consequence for the target behavior the thera-
pist removes all demands from the child and provides her with a break.
High rates of behavior in this condition imply that the behavior is main-
tained by escape from demands.
In the tangible condition, the child is antecedently deprived of pre-
ferred tangible items, and the consequence for the behavior is delivery
of the items. High rates of the behavior in this condition imply that the
behavior is maintained by access to preferred items.
In the alone/ignore condition, the child is allowed to play with neu-
tral items and no consequences are provided upon the occurrence of the
behavior. High rates of behavior in this condition imply that the behavior
is automatically reinforced, that is, the student receives sensory input
that acts as positive reinforcement (e.g., pleasurable sensation) or nega-
tive reinforcement (e.g., alleviates bodily discomfort, such as eye pressing
might alleviate sinus pressure). All conditions are compared to the toy play
condition, in which the child receives constant access to preferred tangible
items, social attention, and is not presented with demands. No conse-
quence is provided for the behavior. This condition serves as the control
condition, as the behavior should occur at a low rate in this condition.
In a review of published functional analysis outcomes through the year
2000, Hanley et al. (2003) reported that functional analysis was shown to
be overwhelmingly successful in identifying functions of problem behav-
ior; 95% of outcomes were interpreted by the authors as “differentiated
outcomes,” meaning a maintaining variable had been identified for the
target behavior. Despite the success of the assessment method, common
criticisms include the suggestion that the method is too complex and that
the procedure takes too long to complete (Axelrod, 1987). In response to
this, several studies have revealed that the use of brief forms of functional
analyses have vastly reduced the amount of time required for assessment
and have also reliably identified maintaining contingencies for behavior
(Derby et al., 1992; Northup et al., 1991).
Another concern regarding the functional analysis is that the sterilized
procedure may not utilize contingencies that maintain the behavior in the
natural environment (Mace & Lalli, 1991). Results indicate, however, that
functional analyses run by teachers in the classroom environment pro-
duce differentiated results that match those of analogue functional analy-
ses and ABC data. In addition, the teachers reported that this technique
allowed the assessment in the natural environment with control over the
environmental events controlling the behavior (Sasso et al., 1992).
Function-Based Behavior Intervention

IDEA specifies that behavior intervention plans intended to decrease
challenging behavior should be based on a functional behavior assessment.
Although IDEA does not specify the components of a successful behavior
intervention plan (Drasgow & Yell, 2001), many effective behavior interven-
tion plans include antecedent-based components, such as noncontingent
reinforcement and functional communication training, and consequence-
based components, such as extinction. Each component can be implemented
in a variety of ways depending on the function of behavior, and thus require
that one understands and is able to translate the principles of behavior
change based on different functions of behavior (Iwata, Pace, Cowdery, &
Miltenberger, 1994).
Noncontingent Reinforcement
Noncontingent reinforcement is the time-based, response-independent
delivery of an activity or item that is known to be a reinforcer for the
individual (Vollmer, Marcus, & Ringdahl, 1995; Vollmer, Iwata, Zarcone,
Smith, & Mazaleski, 1993). The frequent delivery of this reinforcement
is intended to decrease an individual’s motivation to engage in the chal-
lenging behavior; if he receives the reinforcing activity at a rate that is the
same or higher than that achieved by using the maladaptive behavior, his
motivation for engaging in the behavior may subsequently decrease, and
lower rates of the behavior may occur (Vollmer et al., 1993).
For noncontingent reinforcement to be effective, it is paramount that
the child receives reinforcement that is matched to the function of her
behavior. For example, if a child’s noncompliance is maintained by access
to attention, a teacher might provide the child with noncontingent atten-
tion every ten minutes. Alternatively, if the noncompliance functions to
help the child escape from work tasks, the teacher may provide the child
with a noncontingent break from work every ten minutes. Researchers
have also found that the delivery of stimuli that may provide the same
sensory input as an automatically reinforced challenging behavior may
also decrease the target behavior. Again, a comprehensive assessment of
the reinforcement received from engagement in the behavior is required to
identify a form of noncontingent sensory reinforcement that may reduce
the behavior (Piazza, Adelinis, Hanley, Goh, & Delia, 2000)
Functional Communication Training

To further reduce a child’s motivation to engage in challenging behavior,
he should be taught to secure his own reinforcement using an alternative
behavior. The behavior should be matched to the maladaptive behavior so
that it is effective in soliciting the same form of reinforcement acquired
using the maladaptive behavior. Functional communication training is a
method frequently used to teach a child replacement skills. Through func-

tional communication training, a child learns to solicit his own reinforce-
ment using communication, be it through sign language, picture exchange,
or a verbal response (Carr & Durand, 1985). In teaching this skill, the
alternative behavior must be as efficient—if not more efficient—than the
maladaptive behavior. That is, the alternative behavior must result in more
consistent, reliable reinforcement delivery than the maladaptive behavior
to result in a decrease of challenging behavior (Carr & Durand, 1985).
The advantage of functional communication training is that it puts
the child in the active role of securing reinforcement. By instructing the
child in the use of a functional communication skill, she is able to gain
access to reinforcement independently and perhaps at a more frequent
rate than might be determined by a noncontingent reinforcement schedule
(Carr & Durand, 1985). Functional communication training can be effec-
tive when used as the sole element in a behavior reduction plan (Carr &
Durand, 1985), but many researchers recommend the use of FCT in addi-
tion to other procedures (e.g., extinction) to decrease maladaptive behavior
(Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998).
Reinforcement Procedures
In addition to delivering reinforcement noncontingently or in response
to an alternative behavior, positive or negative reinforcement can also be
delivered contingently on the absence of a student’s behavior (Lalli et al.,
1999). Function-based reinforcement may be delivered when the child has
not engaged in the behavior for a specified period of time (Vollmer et al.,
1993) or when the child has engaged in a behavior incompatible with the
maladaptive behavior (e.g., placing hands in pockets instead of engaging
in repetitive motor movements) (Cooper, Heron, & Heward, 2007) to fur-
ther increase motivation for engagement in appropriate behavior.
Extinction
One of the most critical components of behavior intervention plans
is that of extinction. Extinction refers to the elimination of reinforcement
for the maladaptive behavior, and takes place when reinforcement that
previously maintained a behavior is withheld following the occurrence of a
behavior (Iwata et al., 1994). Extinction is especially potent when combined
with other intervention components, such as functional communication
training and reinforcement procedures, because it eliminates the contingency
maintaining the behavior while the child’s motivation to engage in appro-
priate behavior increases (Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc,
1998; Mazaleski, Iwata, Vollmer, Zarcone, & Smith, 1993).
Extinction takes on many forms, and each is specific to a different
function of behavior. For instance, in the case of behavior that is main
tained by attention, extinction would take place when attention was
withheld (i.e., “planned ignoring”) following the occurrence of the behavior.
For a behavior maintained by escape from demands, “escape extinction”
would be implemented by prompting a student through the current task
following the occurrence of behavior (e.g., Iwata, Pace, Kalsher, Cowdery,

& Cataldo, 1990). Automatically reinforced behavior would be placed on
extinction by implementing a procedure that would block or eliminate
the automatically reinforcing properties of a behavior, for example, by
placing a helmet on a student who engaged in automatically reinforced
head-hitting.
The importance of identifying the function of a behavior prior to
implementing an extinction procedure must be stressed, as arbitrarily
implemented procedures may be ineffective or contraindicated. For example,
planned ignoring following the occurrence of a behavior that functions to
escape from demands will perpetuate the reinforcement of that behavior
(Iwata et al., 1994).
Summary of Functional Assessment and Analysis

Although individuals with autism frequently exhibit maladaptive beha-
vior, extensive research supports the use of functional assessment and
function-based behavior intervention plans. Initial indirect assessments
greatly inform further descriptive assessment and functional analysis,
allowing parents, teachers, and other service providers a method by which
they can identify the underlying motivation for an individual’s maladap-
tive behavior. With this valuable information, effective treatments may be
developed that are solidly function-based. The inclusion of noncontingent
reinforcement, functional communication training, reinforcement, and
extinction in behavior intervention plans—if matched to the function of
the behavior—have been demonstrated as highly effective in decreasing
maladaptive behavior.
Further research will continue to assess the most effective meth-
ods of conducting assessments and implementing treatments in various
settings, including the classroom and the home. Although the utility of
function-based assessment and treatment cannot be questioned, and the
mandates set forth by IDEA ensure that the use of functional assess-
ment and treatment cannot be dismissed, researchers and professionals
should continue to develop methods that increase the ease of use of this
science. This future work will ensure that individuals with autism receive
access to the most informed and appropriate assessment and treatment
possible.
FUTURE RESEARCH IN THEORY OF MIND AND

JOINT ATTENTION AND EARLY INTERVENTION
There are several areas that are very exciting in the identification and
treatment of autism spectrum disorders. Social skills remain the most
difficult deficits to have an impact upon, however, there has been some
progress in how such deficits are conceptualized and treated. In particu-
lar, there has been great interest in how skills in both perspective taking
and joint attention might be increased. In addition, there has been great
progress in the early identification of autism spectrum disorders in tod-

dlers, making it possible for treatment to begin at younger ages.
THEORY OF MIND
Theory of mind (ToM) refers to both the ability to understand the

presence of others’ mental states (e.g., beliefs, desires, intentions) and
the capacity to reasonably predict these mental states in various situa-
tions. Impairments in ToM are evident in individuals with autism, and
some argue that in these impairments lies a core deficit of autism. Recent
studies have brought into light new possible mechanisms, constructs,
and implications of ToM, thus creating an exciting new realm for future
research.
Biological Mechanisms
The prefrontal cortex (PFC) has been connected to certain core deficits
of autism, as it is implicated in the development of social, emotional, and
memory skills. Currently, researchers aim to substantiate hypotheses of
domain specificity in areas of the brain as they relate to ToM. Sabbagh
(2004) examined event-related potentials (ERP) in individuals with autism
during an emotional mental state judgment task. His results specifically
implicate the inferior frontal and anterior temporal regions of the right
hemisphere in mental state decoding. In contrast, the left PFC is associated
with executive function, inhibitory control, and the development of emotional
quality in social interactions. The PFC is also related to other constructs
related to ToM, including joint-attention and visual perspective shifting.
Sabbagh’s findings suggest that the cognitive processes of ToM may
not be a result of deficits in general neural systems, but domain-specific.
Future research may focus on the need for a developmental trajectory of
cortical brain activity in individuals with autism. Sabbagh’s final com-
ments target mental state decoding as a core deficit in autism. In typi-
cal development, decoding emerges prior to reasoning; the similarities
between the cortical localizations in decoding and other ToM and social
skills processes (e.g., mental state reasoning, facial emotion recognition)
justify additional attention to this area of research.
Other investigations have targeted neural functioning to explain
ToM. A recent study of Von Economo neurons (VENs) suggests that ToM
deficits may be explicated at this level (Allman, Watson, Tetreault, &
Hakeem, 2005). VENs transmit output of the fronto-insular and anterior
cingulate cortex to the frontal and temporal cortex; they are believed to
be related to intuition, or the ability to make quick judgments in complex
social situations. Allman and colleagues suggest that VENs are especially
vulnerable to dysfunction due to their late emergence in the evolution-
ary development of humans. VENs may be responsible for integrating
the balance between rewards and punishments derived from a variety of
inputs in social situations, a kind of rapid cost-benefit analysis based on
expectancy and experience. Analyses of VEN location and distribution in
the brains of individuals with autism will extend this line of investigation
and may further link specific brain abnormalities to ToM difficulties.
Cognitive Processes of Theory of Mind

There are varied theories as to the specific process deficits in ToM,
although they may not all be mutually exclusive. Weak Central Coherence
(WCC) has been proposed as a cognitive style underlying the social diffi-
culties in autism (Frith, 1989). This theory posits that individuals cannot
integrate unique details into a more global context. Research by Burnette
and colleagues (2005) highlights the mixed evidence of WCC as a sound
construct. In their analysis, verbal aspects of WCC (e.g., ability to correctly
interpret and pronounce homographs) were directly correlated with
performance on ToM tasks; however, this was not true of visual spatial
aspects (block design, pattern recognition, identification of embedded
figures). Furthermore, WCC was not correlated with symptom presentation,
as has been hypothesized. The authors predicted that comorbid anxiety may
have acted as a moderating variable, but the results refuted this theory.
This study added to mixed findings on the relationship between WCC and
ToM (Brian & Bryson, 1996; Ozonoff, Pennington, & Rogers, 1991a). WCC
may be measuring similar deficits as ToM, such as the need for inhibition.
If this is true, more research is needed to determine whether this common
paradigm may lead to fallacious correlations, or whether the integrative
processing difficulty is in fact the key construct.
The “three-element schema” is a more fundamental model that focuses
on the specific factors that influence behavior at each level of a ToM task
(Bowler, Briskman, Gurvidi, & Fornells-Ambrojo, 2005). The theory stemmed
from results the authors obtained from the performance on two types of
false-belief games by children with autism. One of the games was “agent-
less,” in that it involved deciding the location of a train based on color. The
other was the Sally-Anne task; Sally puts her marble in one of two boxes
and then leaves the room. Anne comes in and moves the marble to the
other box. A child is then asked, “Where will Sally look for her marble?”
A child who answers “in the first box” has demonstrated ToM. Children
with autism performed significantly better on the agentless task than on
the Sally-Anne task. The correspondant theory breaks down this task into
three main components: the goal (marble), the signal (Sally’s belief), and the
agent (Sally’s behavior). According to Bowler and colleagues, the agent adds
a third dimension to the train task; in this case the response should change
contingent upon a change in the goal based on information provided by the
signal. The authors assert that an understanding of this relationship does
not lie within a capacity to understand mental states (social deficits), but in
integrating changing information from two sources (processing deficits). The
ability to pass an agentless task was seen as a prerequisite on a ToM hierar-
chy of situation complexity. A longitudinal examination of this phenomenon
may explicate the validity of the degrees of ToM.
Are ToM deficits social in nature or indicative of more general rep-
resentational difficulties? This is one of the central questions in ToM
research. Impairments have been reported on both social (e.g., face
processing, identifying emotions) and nonsocial domains (e.g., ambigu-

ous figure perception, pattern recognition), suggesting that ToM is specific
to neither. To address the representational deficit theory, Sobel, Capps,
and Gopnik (2005) presented an ambiguous figure task to children with
and without autism to measure their capacity for perceptual shifts. In
typically developing children, successful perception of ambiguous figures
has been linked to ToM performance (Gopnik & Rosati, 2001). The 2005
study found no differences across diagnosis in the perception of a single
image or in the informed perception of multiple images. However, children
with autism were significantly less likely to spontaneously identify multi-
ple images (reversal) than their typical peers. On a variety of ToM tasks,
results were mixed; in individuals with autism there was no relationship
between reversals and a false-belief task, but a correlation was present
between image reversals and discrimination between literal and non-
literal stories. Although, the results support a link between ToM and
executive functioning as opposed to specific social or representational def-
icits, the mixed results warrant further study.
Theory of Mind and Other Social Constructs

The relationship between ToM and other social qualities has also been
a recent focus of the literature. For example, interesting links between
ToM and cooperation and fairness have been posited. In individuals with
autism, successful performance on second-order ToM tasks were signifi-
cantly correlated with cooperation (Sally & Hill, 2006). One theory of coop-
eration suggests that cooperation happens when a person can anticipate
that another person will also cooperate, to both their benefits (an under-
standing of intentions). It is therefore surprising that performance on first-
order ToM tasks was negatively correlated with cooperation. An additional
bargaining task was presented, in which a player had the opportunity to
offer a certain number of his points to another player. ToM correlated with
mutually beneficial offers, even at the expense of short-term gain. Chil-
dren with autism were bimodal in their offers, being more likely to offer
either half their points (fairness) or none at all. They were also more likely
to decline “fair” offers and to accept “unfair” offers. Differences between
groups may lie in the ability to understand the offerer’s intentions.
A strong link between ToM and language abilities has been supported
(Tager-Flusberg & Sullivan, 1994), suggesting that language may be a reli-
able precursor to perspective-taking skills. Recent findings indicate there
may be a reciprocal relationship between ToM and discourse in children
with autism (Hale & Tager-Flusberg, 2005). The authors found concur-
rent reciprocal relationships between performances on a variety of ToM
tasks and contingent discourse, but these predictors were not reliable
across time. There is existing evidence that language predicts contingent
discourse over time, so further analyses may want to examine longitu-
dinal relationships of both ToM and discourse as a function of language
development. The authors also found that the quality of the conversing
partner effected differences in contingent discourse. These results may
have implications for parent-training interventions. Because children
make longitudinal developmental gains in language, parents are the most

obvious choice to implement consistent interventions. However, it may be
necessary to teach the components of a strong discourse so that these
children can maximally benefit from conversations with their parents.
Sibling Research
To further the argument that ToM difficulty is a core feature of autism,
researchers have turned to typically developing siblings to examine parallel
deficits in this construct. Shaked, Gamliel, and Yirmiya (2006) presented
false-belief and strange story tasks to siblings of children with autism and
typically developing children. They found that the relationship between
receptive verbal language and performance on ToM tasks was upheld
in both sibling groups, but no significant differences in performance
were found between groups. These results were both consistent with and
contradictory to previous evidence. Longitudinal research is needed to
identify group differences across the developmental span and across other
populations with developmental disabilities, learning disorders, and
cognitive impairments.
A deficit in theory of mind is undoubtedly a fascinating feature in
individuals with autism. The ample current literature delineates many
future research directions to further examine its mechanisms, related
constructs, and the implications for individualized treatment. Because
theory of mind represents a core deficit in children with autism, remedia-
tion of these skills may have important implications for more developmen-
tally advanced social skills (e.g., emotion recognition and interpretation,
reciprocal discourse) and possibly for academic skills as well (e.g., reading
comprehension, number sequencing). The nature of theory of mind as a
critical prerequisite skill underlines the need for future research into the
mechanisms of this phenomenon, so we can better identify the critical
components of effective interventions.
Joint Attention
Joint attention is generally defined as one’s ability to use gestures or
eye contact to share an interest in or desire for an object or event with
another person.
Children with autism historically have difficulties interpreting others’
eye gaze and alternating their own between a person and an object, to indi-
cate interest. This deficit in joint attention has been the focus of numerous
studies, and there is much yet to be explained. Furthermore, joint atten-
tion is seen as a critically important social behavior that aids the develop-
ment of reciprocity and social interactions.
As with ToM, the underlying processes of joint attention are subject to
much debate. At the most fundamental level, amygdala dysfunction may
be implicated in joint attention difficulties. The amygdala primarily regu-
lates emotion processing and memory, as it relates to emotion. Research-
ers have also suggested that dysfunction in this area may inhibit certain
rewarding qualities of social interaction, making the individual less likely
to seek out or sustain social interactions (Berger, 2006). A relationship

between joint attention and face processing, specifically attending to a per-
son’s eyes, has also been proposed. Eye gaze development may be delayed
in children with autism, which would explain concurrent deficits in joint
attention. Facial processing is also regulated by the amygdala, suggesting
a shared biological mechanism. Future research may examine this rela-
tionship across time to see if gains in eye gaze would have collateral effects
on joint attention. Biological abnormalities also have implications for early
diagnosis (Dawson, 2008). Berger proposes that electrophysiological meas-
ures of facial processing in infants may contribute to earlier identification
of autism, if such a reliable relationship can be established. These findings
have exciting implications for early intervention; if these social deficits can
be identified in infants, we could potentially initiate interventions much
earlier than is currently possible.
Is joint attention indicative of a general processing deficit or is it
resultant of specific social or attentional impairments? There is evidence
to suggest that children with autism have an impaired ability to switch
their attention between two stimuli (Siller & Sigman, 2002); this suggests
that joint attention difficulties may stem from trouble shifting attention
between an object or event and another person. However, this theory does
not eliminate the possibility that social skills are also a factor. It has been
proposed that joint attention should be considered less as an outcome and
more as an indicator of the grander social development process (Mundy
& Crowson, 1997). Such a model explains the relationships observed
between joint attention and other social skills, such as imitation, pretend
play, affect, theory of mind, and communication. The evidence supporting
these links still requires replication.
Whalen and colleagues (2006) detected collateral gains in imitation,
affect, and language after implementing joint attention training with chil-
dren with autism; Ingersoll and Schreibman (2006) found joint attention
benefits as a result of imitation training. Future directions of this research
should examine the reciprocity of these associations within datasets.
The contingent relationship between certain social domains may have a
significant influence on how social skills interventions are planned and
sequenced.
A significant body of research is also concentrating on improving treat-
ment techniques to target joint attention. Generalization is of paramount
importance in any treatment for autism, and current joint attention inter-
ventions have shown limitations in this area. There are several factors to
consider in promoting generalization. Longitudinal research should focus
on current joint attention skills and joint attention teaching in the natu-
ral environment (at home, in the classroom, etc.) to see in what settings
and with whom are the greatest gains observed (Tsao & Odom, 2006).
This line of research also has implications for parent, peer, and sibling
training. Typically developing siblings have been shown to effectively teach
social skills to children with autism (Celiberti & Harris, 1993; Pierce &
Schreibman, 1995; Tsao & Odom, 2006), and children with autism may
be more likely to respond to initiations made by siblings (El-Ghoroury
& Romanczyk, 1999). Joint attention training may therefore be more likely
to generalize when taught by siblings or peers in their naturally occur-

ring environments. Upcoming research may also investigate what types
of interventions yield robust gains; currently many methods are used to
teach joint attention (e.g., pivotal response training, discrete trial training,
video modeling, reciprocal imitation).
Lastly, there is a need for component analyses of both joint atten-
tion interventions and joint attention as an outcome. To maximize inter-
vention benefits, it is crucial to know where these gains are occurring
and where they are not. Future studies should break down joint attention
into its bipolar components (bids vs. responses, mands vs. shared atten-
tion, dyadic vs. triadic interactions) and see where progress is observed.
These individual components may also be interesting as they may relate
to ancillary gains in social skills and generalization. It may be that certain
interventions target specific aspects of joint attention, and that gains in
those areas may have particular concurrent benefits for other skills. Fur-
thermore, certain domains of joint attention may be more longitudinally
robust than others. These questions are all relevant to future research in
joint attention.
Summary on Theory of Mind and Joint Attention

The field has made innumerable gains in process-specific and treat-
ment-oriented research on social skills in children with autism. Ongoing
evidence continues to explicate the functions and mechanisms of theory of
mind and joint attention. These two skill areas are of central importance in
understanding the social deficits of autism. Theory of mind describes the
perspective-taking deficit that nearly universally characterizes the popula-
tion of individuals with autism, whereas joint attention describes the lack
of shared social interest so often seem among members of this population.
It is likely that our difficulties in effecting social change are due, at least in
part, to our difficulties in effecting change in these core skill areas. Thus,
research into the mechanisms that explain these deficits, and into inter-
ventions that remediate these deficits is of critical importance for clini-
cal interventions. It is likely that continued research will yield interesting
findings that may fuel innovative clinical approaches to building skills in
the focal areas of social skills training.
Early Intervention
One of the more exciting developments in recent years in ASDs has
been the ability for clinicians to diagnose ASDs at earlier ages. The earlier
identification of ASDs leads to earlier, effective treatment, and may increase
positive outcomes of intervention.
It is generally thought that autism can be diagnosed as young as 20
months (Cox et al., 1999). Early signs include limitations in eye contact,
poor reciprocity in smiling, and impaired joint attention (Robins, Fein, Bar-
ton, & Green, 2001). Poor imitation and play skills are also associated with
ASDs (Rogers et al., 2003). In general, early diagnosis has been shown to
be stable over time (Eaves & Ho, 2004; Moore & Goodson, 2003). Intensive
early intervention produces the best treatment results (McEachin, Smith,

& Lovaas, 1993; Sallows & Graupner, 2005). Treatment includes a high
number of hours, lots of structure and consistency, and a focus on the
development of functional language, imitation, and social skills (Dawson
& Osterling, 1997; Rogers, 2001).
The Baby Siblings Research Consortium is a network of researchers
who study infant siblings of children with autism and other very young
children who are at risk for developing ASDs (Yirmaya & Ozonoff, 2007).
One clear indicator of emerging ASD is an impairment in social commu-
nicative development, which co-exists with atypical sensory and/or motor
behaviors (Bryson et al., 2007; Loh et al., 2007).
Another indicator of emerging ASDs is a low level of responsiveness
to joint attention at 14 and 24 months, and a lack of improvement in
response to joint attention between 14 and 24 months of age (Sullivan et
al., 2007). In particular, these authors suggest that children who are not
responsive to pointing cues for responding to joint attention by 24 months
of age should be considered at-risk for developmental delay and should
receive intervention to address deficits in joint attention.
Although there is great excitement about identifying early markers,
there is also some need for caution. It is certainly the case that broad-
based screenings will yield some false positives (Watson, Baranek, Crais,
Reznick, Dykstra, & Perryman, 2007). Clinicians are urged to be honest
and cautious with parents about the limits of available screening tools.
SUMMARY
The treatment of Autism Spectrum Disorders has grown immensely

over the last 20 years. ABA is clearly the treatment of choice for ASDs,
with substantial and significant evidence of its effectiveness for this popu-
lation. Within ABA, there is good evidence for the positive impact of dis-
crete trial teaching and for naturalistic approaches such as incidental
teaching. Recently, there has also been interest in the potential relevance
of rate-building to achieve fluency and of direct instruction approaches
for building core academic skills. ASDs have also received a great deal of
attention from nonbehavioral treatment providers. Treatments commonly
used include biomedical interventions, sensory-motor interventions and
psychoeducational/psychosocial treatments. The majority of parents of
children with autism will use several of these approaches, despite the fact
that most lack empirical support or verification.
In recent years, there has been progress in identifying the specific
needs of and effective intervention for individuals with Asperger’s Disor-
der. Furthermore, the technology of Functional Behavioral Assessment
has greatly improved the precise assessment of challenging behaviors, the
functions of challenging behaviors, and the link between the assessment
and the treatment of challenging behaviors.
Areas of future growth include more explication of how joint atten-
tion and perspective-taking deficits help to explain the clinical profiles of
individuals with ASDs. It is likely that our understanding of social deficits,
and of how to have an impact upon or remediate such deficits, will improve
over time. Finally, as detection of ASDs occurs earlier and earlier, our
understanding of how to best serve the youngest group of individuals with
ASDs will likely change substantially.
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11
Treatment of
Self-injurious
Behaviour in Children
with Intellectual
Disabilities
FREDERICK FURNISS and ASIT B. BISWAS
INTRODUCTION
Definitions of self-injurious behaviour (SIB) generally describe such

behaviour as comprising nonaccidental self-inflicted acts causing damage
to or destruction of body tissue and carried out without suicidal ideation
or intent (Yates, 2004). For the clinician working with children with severe
intellectual disabilities, such behaviours are likely to be a frequent cause
for concern. Between 4% and 12% of such children exhibit SIB (Oliver,
Murphy, & Corbett, 1987), which may present as repetitive head banging
or face slapping, self-biting to the hands or other parts of the body,
removing scabs from old wounds, self-pinching or scratching, hair-pulling
and eye-poking, often presented in multiple forms in the same child. Self-
injury may emerge as early as 11–13 months of age (Berkson, Tupa, &
Sherman, 2001; Hall, Oliver, & Murphy, 2001a), increases in prevalence
and severity throughout the school-age years and young adulthood (Oliver
et al. 1987), and once established in adulthood is likely to be chronic
in nature (Emerson et al., 2001). Presentation of SIB is associated with
FREDERICK FURNISS ● The Hesley Group, Doncaster, UK and School of Psychology,

University of Leicester. Mallard House, Sidings Court, Doncaster DN4 5NU, United Kingdom.
ASIT B. BISWAS ● Leicestershire Partnership NHS Trust and University of Leicester,
Leicester Frith Hospital, Groby Road Leicester LE3 9QF, United Kingdom.

334 FREDERICK FURNISS and ASIT B. BISWAS
a range of negative physical and social consequences (Emerson, 1992).

Timely, comprehensive, and, where necessary, persistent intervention is
therefore indicated when a child with intellectual disabilities presents with
SIB. After discussing the range of treatment options currently available
to the professional, this chapter briefly reviews recent research on the
aetiology and developmental course of SIB and resulting implications for
treatment.
Self-injury is seen in a wide variety of disorders (Bodfish & Lewis,
2002), and may be categorised as major, stereotypic, compulsive, or
impulsive (Yates, 2004), distinctions which may be helpful in considering
the general direction of strategies for assessment and treatment. Any attempt
to treat SIB should be preceded by a prior comprehensive assessment
(Vollmer, XXXX) covering social and medical contextual factors, history,
phenomenology including comorbidity with other emotional and behav-
ioural difficulties, and detailed assessment of functional relationships
among SIB and antecedent and consequent environmental events.
Detailed assessment is necessary in designing effective behavioural
treatment and in considering possible psychopharmacological interven-
tions. It may, however, often be useful to have an overview of possible
underlying mechanisms or causes of SIB in a particular individual and
a working hypothesis regarding causation, as preliminary treatment
may need to be initiated quickly to prevent further injury.
SCREENING FOR AND TREATING CONTRIBUTING

MEDICAL AND SOCIAL CONDITIONS
A variety of physical and social contexts has been demonstrated or

suggested to be implicated in some cases of SIB in children and adults.
Medical conditions which may have an impact on SIB include otitis media
(O’Reilly, 1997) and pain related to a variety of other conditions (Symons,
2002). Examination for and treatment of possible related physical com-
plaints is therefore indicated as part of the assessment of SIB. Sleep dep-
rivation and disturbance are also associated with SIB (O’Reilly & Lancioni,
2000; Symons, Davis & Thompson, 2000), and in at least some cases
behavioural intervention to stabilise sleep patterns may have a beneficial
effect on SIB (DeLeon, Fisher & Marhefka, 2004).
Attention to other physical conditions such as menstrual discomfort
may be useful in designing multicomponent interventions (Carr, Smith,
Giacin, Whelan & Pancari, 2003). Where SIB occurs episodically, assess-
ment may reveal relationships with social factors whose mechanism of
effect remains obscure but which can be modified to reduce SIB. O’Reilly
(1996), for example, identified a relationship between the episodic SIB of a
young man with moderate intellectual disabilities and use of a respite care
facility the previous evening. Arrangement of alternative, family-based res-
pite eliminated SIB. Consideration of a broad range of physical and social
factors may therefore contribute to effective treatment.
TREATMENT OF SELF-INJURIOUS BEHAVIOUR IN CHILDREN 335
PSYCHOPHARMACOLOGICAL TREATMENT
A variety of neurotransmitter systems, alone and in interaction, has been

implicated in self-injurious behaviour. These include the dopamine, serotonin,
opioid, and noradrenaline systems, and basic research on dysregulation of
these systems in clinical disorders and in animal models has suggested a
number of approaches to psychopharmacological treatment of SIB.
Rationale for the Use of Dopaminergic and Serotonergic

Drugs in Treatment of SIB
In a number of specific syndromes often associated with intellectual
disability, prevalence of SIB, sometimes at least initially of rather specific
topographies, is elevated well beyond overall rates typical in total popu-
lation surveys of people with intellectual disabilities. Recent interest in
animal models of SIB has been stimulated by findings in the neuropathol-
ogy of Lesch-Nyhan disease, an X-linked genetic disorder involving drasti-
cally reduced levels of hypoxanthine-guanine phosphoribosyl transferase.
Among the characteristic features of the disorder are dystonia, dysarthria,
intellectual disability, and behavioural disturbance including aggression,
disturbing interpersonal behaviours, and SIB (Schretlen et al., 2005).
Development of SIB in children with Lesch-Nyhan disease usually
begins at a young age with biting of lips and fingers, but a wide vari-
ety of other topographies including head-banging and head-hitting is also
frequently seen (Hall, Oliver, & Murphy, 2001b; Robey, Reck, Giacomini,
Barabas, & Eddey, 2003). A combination of post-mortem (Lloyd et al.,
1981; Saito, Ito, Hanaoka, Ohama, Akaboshi, & Takashima, 1999) and in
vivo (positron emission tomography; Ernst et al., 1996; Wong et al., 1996)
studies has demonstrated reduced levels of dopamine in the striatum.
These findings renewed interest in the earlier findings of Breese and his
colleagues (see Breese, Knapp, Criswell, Moy, Papadeas, & Blake, 2005, for
an overview) who had demonstrated that rats in whom dopaminergic neu-
rons had been destroyed in the neonatal period using 6-hydroxydopamine
showed severe self-biting when given L-DOPA in maturity.
Further studies examining the effects of agonists and antagonists with
differential effects on D1 and D2 receptor subtypes suggested that the self-
injury produced by L-DOPA is mainly produced by activation of the D1
subtype, although activation of the D2 subtype, although not leading to
SIB in isolation, might facilitate expression of SIB produced by D1 activa-
tion. In addition to depletion of dopamine levels, the neonatal lesioning
of dopaminergic neurons results in increases in striatal serotonin, and a
variety of evidence suggests that both serotonin modulation of D1 receptor
activity and changes in GABAA receptor function in the substantia nigra
reticulata may be involved in the increased susceptibility to SIB in neona-
tally 6-hydroxydopamine-lesioned rats (Breese et al., 2005).
Although both antipsychotics and serotonergic drugs have long been
used in attempts to treat a variety of behavioural disorders in individuals
with intellectual disabilities, the specific implication of the D1 dopamine
receptor subtype in the self-injury observed, and the increases in striatal

serotonin, in neonatally 6-hydroxydopamine lesioned rats has led to par-
ticular interest in the possible utility of the “atypical antipsychotics” and
serotonergic agents in treating SIB.
Clozapine, olanzapine, and quetiapine all block both D1 and D2
dopamine receptor subtypes, together with several types of 5-HT receptor
and a variety of other receptors including adrenergic receptors, whereas
risperidone blocks D2, 5-HT, and adrenergic receptors (Aman & Madrid,
1999). In a systematic review of studies using atypical antipsychotics to
treat persons with intellectual disabilities and/or autism published up
to and including 1999, Aman and Madrid (1999) identified nine studies
on children and adolescents or on mixed child/adult samples, seven on
risperidone, and one each on olanzapine and clozapine. Several of these
studies reported improvement in SIB in some participants. The majority of
these studies, however, had multiple methodological problems. All but one
were case series reports or open label studies, and in most cases participants
were taking other medications throughout the trial. Sedation and weight
gain were frequently observed and dyspepsia and hyperprolactaemia were
also reported. Since Aman & Madrid’s review, however, a number of better-
controlled studies of the use of atypical antipsychotics with children with
developmental disabilities, especially of risperidone, have appeared.
Risperidone
Table 11.1 summarises the results of two recent placebo-controlled
double-blind evaluations of risperidone with children aged 5–12, with
I.Q.s between 36 and 84, and presenting severely disruptive behaviours,
and the subsequent open-label follow-ups. A post hoc analysis (LeBlanc et
al., 2005) of data from 163 participants in the Aman et al. (2002) and Sny-
der et al. (2002) studies confirmed that risperidone-treated participants
showed significantly greater decreases than placebo-treated participants
on an “aggression score” derived from six core aggression items on the
NCBRF, but no analysis was presented on change in a similarly derived
“self-harm score”.
These studies reported convincing evidence for a beneficial effect of
risperidone on behavioural difficulties in young children with moderate,
mild, or borderline levels of intellectual disability. Measures of stereotyped
behaviour and SIB have, however, frequently shown either no significant
change or changes of less significance than those shown for externally
directed aggression. Aman, Buitelaar, De Smedt, Wapenaar, & Binder
(2005), examining pooled data from these studies, showed that only one
item from the NCBRF self-injury/stereotypic subscale showed improve-
ment with risperidone. The above studies also excluded children with a
diagnosis of pervasive developmental disorder.
An eight-week, double-blind, placebo-controlled study by Scahill et al.
(2002), however, examined the effect of risperidone (in doses between 0.5
Table 11.1. Recent Evaluations of Risperidone for Behavioural Difficulties in Young Children
with Moderate-Borderline Intellectual Disabilities
Participants (in Design (in parentheses:
parentheses: number dose range in double- General Outcome Selected Side Effects
Study completing study) blind phase if any) Measures Specific Sib Measures Reported
Aman et al. 115 (87) children, ages 6-week double blind NCBRF conduct problem (1) BPI self-injurious Weight and (boys only)
(2002) 5–12, I.Q. 36–84, parallel and all other subscales, behaviour subscale: no prolactin levels increased
with severely placebo-controlled ABC irritability, difference in change with risperidone vs.
disruptive (0.02–.06 mg/kg/ lethargy & hyperactivity between groups. placebo; transient heart
behaviours day) subscales, BPI (2) NCBRF self-injury/ rate increase also noted.
aggressive/destructive stereotypic subscale: Somnolence, headaches,
behaviour subscale: greater improvement vomiting, dyspepsia
greater improvement with risperidone vs. in 15% or more with
with risperidone vs. placebo risperidone. No between
placebo. group difference in
extrapyramidal symptoms
Snyder et al. 110 (85) children, ages 6-week double blind NCBRF conduct (1) BPI self-injurious Weight and prolactin
(2002) 5–12, I.Q. 36–84, parallel problem and most behaviour subscale: no levels increased with
with severely placebo-controlled other subscales, all difference in change risperidone vs. placebo.
disruptive (0.02–.06 mg/kg/day) ABC subscales, BPI between groups. Somnolence, headaches,
behaviours aggressive/destructive (2) NCBRF self-injury/ dyspepsia in 15% or
behaviour subscale: stereotypic subscale: more with risperidone. No
greater improvement greater improvement between group difference
with risperidone vs. with risperidone vs. in extrapyramidal
placebo. placebo symptoms
(continued)
Participants (in Design (in parentheses:
parentheses: number dose range in double- General Outcome Selected Side Effects
Study completing study) blind phase if any) Measures Specific Sib Measures Reported
Findling, 107 participants from 48-week open label All NCBRF subscales NCBRF self-injury/ 91% reported adverse events
Aman, Aman et al. (2002) follow-up to improved by stereotypic subscale: including somnolence
Eerdekens, study Aman et al. (2002) comparison with greater improvement (33%), headache (33%),
Derivan baseline of double-blind with risperidone vs. rhinitis (28%) and weight
& Lyons, phase. placebo (smallest increase (21%). Eleven
(2004) subscale change) withdrew from trial after
adverse events including
weight gain (N = 4),
depression (N = 3), suicide
attempt (N =2). Prolactin
increased but within
normal limits by end.
Turgay, 77 children from 48-week open-label Children receiving NCBRF self-injury/ Somnolence (over 50%),
Binder, Snyder et al. (2002) follow-up to risperidone in stereotypic subscale: headache (over 35%).
Snyder & study. Snyder et al. (2002) double-blind phase: improved for children Prolactin levels increased,
Fisman all subscales of receiving risperidone but levels at endpoint
(2002) NCBRF improved during double-blind within or just above
by comparison with from double-blind normal range. Mean
double-blind baseline. baseline to endpoint; weight increase 8.5 kg
Children receiving not improved for from baseline of 30.7 kg,
placebo in double-blind children receiving half attributed to normal
phase: all subscales of placebo in double- growth. Mild-moderate
NCBRF except self- blind from open-label extrapyramidal symptoms
injury/stereotyped and baseline to endpoint in 26%.
self-isolated ritualistic
subscales improved
from follow-up baseline
to endpoint.
NCBRF: Nisonger Child Behavior rating form (Aman, Tassé, Rojahn, & Hammer, 1996); ABC: Aberrant Behavior Checklist (Aman, Singh, Stewart, & Field, 1985); BPI: Behavior
Problems Inventory (Rojahn, Matson, Lott, Esbensen, & Smalls, 2001).
and 3.5 mg/day at the end of the study) on the behaviour of 49 children
with autism (76% of whom had mild–severe intellectual disabilities) com-
pared with 52 children receiving placebo. Participants were aged between
5 and 17 years and engaged in tantrums, aggression, SIB, or multiple
behaviour problems. Repeated assessment on the ABC irritability subscale
showed a significant group by time interaction, with a mean 57% decrease
in irritability score in the risperidone-treated group compared with a 14%
decrease in the placebo group.
The ABC stereotypy and hyperactivity subscales also showed signif-
icantly greater reductions for the risperidone than the placebo group.
Reporting of increased appetite, fatigue, and drowsiness were all signifi-
cantly associated with risperidone treatment, and weight gain was sig-
nificantly greater in the risperidone group. Clinical assessment using
structured scales showed no extrapyramidal symptoms in either group.
Parental reports of tremor and tachycardia were significantly associ-
ated (p = 0.06) with risperidone useage. A 16-week open label follow-up
(Research Units on Pediatric Psychopharmacology Autism Network, 2005)
of 63 children previously treated with risperidone in the double-blind trial
or given eight weeks of open-label treatment following placebo showed
small but significant increases in ABC irritability subscale score, although
the mean score remained well below the baseline level of the double-blind
phase. Participants showed a mean six-month weight increase of 5.1 kg.
A subsequent eight-week double-blind placebo-substitution phase showed
relapse rates of 13% with ongoing risperidone and 63% with placebo sub-
stitution.
Anderson et al. (2007) confirmed that although the initial increase
in prolactin levels decreased over the course of treatment, approximately
one-third of participants had values above the normal range at 22 months
of treatment. Further analyses also showed greater improvements with
risperidone than placebo on measures intended to capture some of the
“core” symptoms of autism, including a modified form of the Children’s
Yale-Brown Obsessive-Compulsive Scale (McDougle et al., 2005).
Shea et al. (2004) reported results from an eight-week, double-blind,
placebo-controlled trial involving 79 children, aged between 5 and 12, all
with PDD, 69% having diagnoses of autistic disorder. Forty participants
(30 of whom had mild–severe intellectual disabilities) received risperidone
and 39 (29 with intellectual disabilities) received placebo. At study end-
point all scales of the ABC showed significantly greater decreases for the
risperidone group than for the placebo group, as did the conduct prob-
lem, hyperactive, insecure/anxious, and overly sensitive subscales of the
NCBRF. There were no significant differences between groups in change
on the self-isolated/ritualistic or self-injurious/stereotypic subscales of
the NCBRF. Somnolence was reported for over 70% of the risperidone
group, but was reported to resolve in most cases (usually following dose
rescheduling or reduction). Increases in weight, pulse rate, and systo-
lic blood pressure were all significantly greater at study endpoint for the
risperidone versus the placebo group.
Although therefore the above studies have produced evidence sugges-
tive of a beneficial effect of risperidone on the behaviour of children with
intellectual disabilities and behaviour problems, they provide little evidence

specifically relevant to the impact of risperidone on SIB. Although several
of the above studies, in addition to using standardised rating scales, have
demonstrated improvements with risperidone on carer visual analogue
ratings of severity of “most troublesome symptom”, none has presented
outcomes by type of symptom, and for children with PDD “aggression” and
“tantrums/negative mood” were the problems most frequently identified
(Shea et al. 2004).
Two recent sets of studies have in different ways attempted to focus
more precisely on the effects of risperidone on specific problem behav-
iours. Zarcone et al. (2001) reported the results of a 22-week double-blind
crossover design involving 11 children and 9 adults, all with some degree
of intellectual disability. The study involved baseline, variable length initial
placebo, randomly ordered high and low dose, and final placebo phases,
followed by a six-month open follow-up. Total scores on the ABC were
higher in the first placebo phase than during risperidone for both dos-
age orders, and placebo 2 scores were higher only for the low-high dose
sequence.
For five participants, direct observation of problem behaviour in their
everyday environment was undertaken for 30 minutes approximately three
times a week during the acute phase of the study. The behaviours observed
included aggression towards persons and property, SIB, and disruption.
Two participants showed higher frequencies of problem behaviour during
drug than in placebo phases, two showed inconclusive results, and one
showed higher frequency behaviour with risperidone than in both placebo
phases.
Zarcone et al. (2004) further reported on direct observation of problem
behaviour (aggression, SIB, disruption, and elopement) during approxi-
mately weekly experimental functional analyses (based on the methods
of Iwata, Dorsey, Slifer, Bauman, & Richman, 1982) conducted with eight
children and five adults with autism and other developmental disabilities
who participated in the Zarcone et al. (2001) study. Zarcone et al. (2004)
presented data on mean rates per minute of all “destructive responses”
combined for each acute study phase, concluding that for ten individuals,
rates of destructive behaviour were reduced with at least one dose level of
risperidone when compared with the first placebo phase. Their data also
show, however, that for two of these “responders”, rates of problem behav-
iour were lower during the second placebo phase than under either risp-
eridone dose, and in two further cases there was little difference between
rates of behaviour in the second placebo phase and in the drug phase with
the lowest rate of behaviour (no second placebo phase data were available
for one participant).
Arnold et al. (2003) pursued an alternative approach to assessing
change in specific behaviours. Parents of 87 children participating in the
Scahill et al. (2002) study were asked at baseline to describe and quantify
their two greatest concerns regarding their child’s behaviour. After four
and eight weeks, descriptions of the child’s current status with respect
to these problems were rated for degree of change by a panel of blinded
clinical judges. SIB was selected as a primary concern by parents of
11 children receiving placebo and 8 receiving risperidone. The mean

improvement rating for SIB was significantly higher for the children receiv-
ing risperidone, showing the greatest effect size of all target symptoms.
A large-scale one-year open-label study of 504 children aged between
4 and 14 with moderate–borderline intellectual disabilities (Croonenberghs,
Fegert, Findling, De Smedt, & Van Dongen, 2005) has confirmed and
extended many of the findings from the above studies. The 367 children
completing the trial (73%) showed significant improvement on all scales of
the NCBRF and on ABC total score, with the smallest subscale change on
the NCBRF for the self-injury/stereotypic subscale. Adverse events were
reported by 92% of participants, with somnolence (30%), rhinitis (27%),
headache (22%), and weight increase (17%) the most common.
Adverse events led 43 children (8.5%) to withdraw from the study,
with weight gain (N = 9), increased appetite (N = 4), gynaecomastia (N = 3),
somnolence (N = 3), and headache (N = 3) the most common reasons.
There was no increase in mean level of extrapyramidal symptoms over the
course of the study, although five children (1%) required antiparkinso-
nian medications in the course of the study, and for 6 (1%) extrapyrami-
dal symptoms resulted in discontinuation. Two children developed tardive
dyskinesia which resolved rapidly after study medication was withdrawn.
Mean serum prolactin increased early in treatment but for both boys and
girls was within the normal range by study endpoint. A total of 205 boys
had prolactin levels above the normal range. Mean body weight increase
was 7 kg, of which 50% could be attributed to normal growth.
Despite a considerable amount of well-controlled research indicat-
ing a beneficial effect of risperidone on behavioural difficulties of children
and adolescents with intellectual disabilities and/or autism, it therefore
remains difficult to evaluate the specific effectiveness of risperidone for
treatment of SIB. The one study which has used reported clinician rat-
ings of change in specifically described behaviour problems (Arnold et al.,
2003) reported a larger effect size for risperidone treatment related to SIB
than for any other behaviour problem considered, but this figure relates to
only 8 children treated with risperidone and 11 given placebo.
Studies of children with intellectual disabilities both with and without
autism have, however, found mixed results on standardised ratings
specifically related to SIB, with some finding significant advantage for
risperidone over placebo on the self-injury/stereotypic scale of the NCBRF
but not the self-injurious behaviour or stereotypic behaviour subscales
of the BPI (Aman et al., 2002; Snyder et al., 2002), and some finding no
advantage for risperidone on the self-injury/stereotypic subscale of the
NCBRF (Shea et al., 2004; Turgay et al., 2002, for the group starting
risperidone in the open-label phase). Where an advantage has been found
for risperidone on the self-injury/stereotypic subscale of the NCBRF, the
change observed in this subscale is typically small relative to change on
other subscales (Aman et al., 2002; Croonenberghs et al., 2005; Snyder
et al., 2002). In the studies on nonautistic children (Aman et al., 2002;
Snyder et al., 2002), this pattern of results may be explicable by relatively low
baseline scores on the NCBRF self-injury/stereotypic and BPI self-injurious
behaviour subscales leaving limited scope for improvement, but this
explanation seems unlikely to hold for the studies involving children with
autistic spectrum disorders.
Studies employing direct observation (Zarcone et al., 2001, 2004) have
unfortunately contributed little to our knowledge of the specific effect of
risperidone on SIB owing to small numbers of participants and reporting
which collapses together differing forms of challenging behaviour. When
SIB has been a specific focus, direct observation during blinded trials of
medication for individual cases has suggested both a specific beneficial
effect of risperidone on SIB greater than that on aggression (Crosland
et al., 2003) and a negative effect (Zarcone et al., 2004). Further research
on this question is clearly warranted, both because of the mixed results
to date and because the specific role for the D1 dopamine receptor in self-
injury suggested by the 6-hydroxydopamine lesioned rat would suggest
that if this animal model has validity as a general model for SIB, then
owing to its lack of affinity for the D1 type receptor, risperidone may be a
less effective treatment for this specific behaviour than other drugs with
D1 affinity. The most efficient way forward on this issue would appear to
be for double-blind trials to employ ratings of change on specific behaviour
problems as demonstrated by Arnold et al. (2003).
Other Atypical Antipsychotics

There is considerably less evidence regarding the effectiveness of the
other atypical antipsychotics for behavioural difficulties in children with
intellectual disabilities. Use of clozapine in children and adolescents is
associated with risks of agranulocytosis and seizures (McDougle, Stigler,
Erickson & Posey, 2006) and the need for frequent blood samples for white
cell counts is particularly undesirable in children with intellectual dis-
abilities and/or autism.
Olanzapine has a high affinity for dopamine D1, D2, and D4 receptors as
well as various 5-HT, alpha-1 adrenergic, H1 histaminic, and multiple mus-
carinic receptor subtypes (McDougle et al., 2006). In view of its ability to block
the dopamine D1 receptor, McDonough, Hillery and Kennedy (2000) suggested
that olanzapine might be an effective treatment for chronic, stereotyped SIB.
An open, 15-week add-on trial of olanzapine with seven adults with severe to
profound intellectual disability and long-term repetitive SIB produced overall
improvement in a standardised measure of number and severity of lesions
related to SIB, but not carer estimates of the frequency of the behaviours.
Short-term open-label studies of 8 children and adults with PDD, most
with intellectual disabilities (Potenza, Holmes, Kanes & McDougle, 1999)
and 16 adolescents, 12 of whom had intellectual disabilities (Handen
& Hardan, 2006) reported improvements on standardised measures of
problem behaviour such as the ABC irritability and hyperactivity subscales.
Malone, Cater, Sheikh, Choudhury, and Delaney (2001) randomised
12 children with PDD/autism, 11 of whom had intellectual disabilities, to
6 weeks of open treatment with olanzapine or haloperidol. The Children’s
Psychiatric Rating Scale (National Institute of Mental Health, 1985)
showed improvement for the olanzapine, but not the haloperidol group,
on anger/uncooperativeness and hyperactivity factors.
A small double-blind placebo-controlled trial with six children with

PDD, four of whom had intellectual disabilities, receiving olanzapine,
found no evidence for an effect of olanzapine on standardised measures of
irritability or aggression, but had low power (Hollander et al., 2006).
All the above studies noted problems with weight gain and sedation,
and Handen and Hardan (2006) also noted a significant increase in pro-
lactin levels. There have to date been no published controlled studies of
the atypical antipsychotics quetiapine, ziprasidone, and aripiprazole with
young people with developmental disabilities; McDougle et al. (2006) have
reviewed retrospective and open-label studies with young people with
PDD.
In summary, despite the specific rationale for use of dopamine D1
receptor blockers in treatment of self-injury, there is no stronger evidence
for the effectiveness of olanzapine than for risperidone in the treatment of
SIB, and side effects of weight gain, sedation, and increases in prolactin
levels are of equal concern. Evidence for the potential utility of the other
atypical antipsychotics in behaviour disorders in children with PDD
and/or intellectual disabilities is currently very limited.
Serotonin Reuptake Inhibitors

The rationale for the use of serotonin reuptake inhibitors (SRIs) in
treating SIB is much less specific than that for use of the atypical antipsy-
chotics. Interest in the possible utility of the SRIs is based on (1) general
evidence for abnormalities of serotonin function in persons with autism
and intellectual disabilities (Aman, Arnold, & Armstrong, 1999; Posey,
Erickson, Stigler & McDougle, 2006), (2) the suggestion that in some
cases SIB in persons with severe intellectual disabilities might be an indi-
cator of depression (Marston, Perry & Roy, 1997), and (3) the suggestion
that in some cases SIB may have similarities to obsessional behaviours
(King, 1993).
Aman et al. (1999) reviewed studies to that date on use of clomipramine
and the selective serotonin reuptake inhibitors (SSRIs) with people with
developmental disabilities, noting the preponderance of case reports or
uncontrolled trials and suggesting the need among others for further
study of possible age differences in responsivity. The potential serious side
effects of clomipramine (Aman et al., 1999) have led to more recent inter-
est being focussed on the SSRIs, with most evidence available regarding
fluvoxamine and fluoxetine.
Recent reviews by McDougle et al. (2006) and Posey et al. (2006) sug-
gest that although there may be some evidence for the effectiveness of
SSRIs in treating repetitive behaviours in adults with developmental dis-
abilities there are still few well-controlled studies, whereas for children
the results of both open-label and double-blind placebo-controlled stud-
ies of fluvoxamine suggest limited effectiveness and frequent adverse
reactions including insomnia, behavioural activation, and aggression.
The few well-controlled studies which report beneficial effects of SSRIs
(Hollander et al., 2005; Sugie et al., 2005) do not suggest any specific
utility in treating SIB, and recent reports of positive effects of SSRIs on
SIB (e.g., Carminati, Deriaz, & Bertschy, 2006) are uncontrolled stud-
ies of the addition of SSRIs to other treatments relying on limited out-
come measures. For children with developmental disabilities the lack of
evidence of effectiveness, frequent occurrence of adverse reactions, and
uncertainties about appropriate dosage (Posey et al., 2006) do not sup-
port the utility of currently available SSRIs in treatment of SIB.
Naltrexone hydrochloride
A variety of evidence has suggested dysregulation of the hypothalamic-
pituitary-adrenal stress system in persons with autism and others with
developmental disabilities who engage in SIB (Sandman & Touchette, 2002),
with recent interest in the pro-opiomelanocortin (POMC) system. Enzyme
cleavage converts the POMC molecule into a number of biologically active
products including the opioid β-endorphin and adrenocorticotrophin (ACTH),
and in adults plasma levels of these products of the POMC molecule are
normally highly correlated. Recent studies have suggested, however, that this
normal “coupling” of β-endorphin and ACTH is reduced following episodes of
SIB in adults with developmental disabilities (Sandman, Touchette, Lenjavi,
Marion, & Chicz-DeMet, 2003), with levels of β-endorphin elevated with
respect to levels of ACTH, and that the extent of this uncoupling is related
to the extent to which occurrence of SIB is predicted by previous SIB events
rather than by other behaviours or social environmental events (Sandman
& Touchette, 2002). It has been argued that this phenomenon may indicate
that persons showing SIB experience enhanced opioid-mediated analgesia
and/or that SIB produces an opioid-induced state of euphoria.
Administration of the opiate antagonist naltrexone hydrochloride
would be expected to reduce both of the above effects. Although naltrex-
one may cause a number of side effects (Matson et al., 2000), research
involving both nondisabled people and those with developmental disabili-
ties suggests that the major possible serious side effect of naltrexone use
is liver toxicity; however, signs of possible toxicity have been observed in
people without disabilities treated for addictions and using substantially
larger doses than those used to treat SIB in people with intellectual dis-
abilities (Symons, Thompson & Rodriguez, 2004).
Reports on the effectiveness of naltrexone in treatment of SIB have
been extremely mixed (Symons et al., 2004). In contrast to much other
work on psychopharmacology of SIB, the technical quality of research into
naltrexone has been rather high; Symons et al. (2004) reviewed 27 stud-
ies from which information on individual participants could be extracted
and reported that 85% of the total of 86 children and adults treated with
naltrexone had received the drug in a double-blind study. Comparison
of quantitative measures of SIB during baseline and during naltrexone
administration showed that 47% of participants showed improvement of
50% or greater, and a further 33% showed smaller decreases, during nal-
trexone treatment. In addition, there is some evidence that for some peo-
ple limited-term administration of naltrexone can produce reductions in
SIB which persist after the medication is withdrawn (Crews, Bonaventura,
Rowe & Bonsie, 1993; Sandman et al., 2000).
Despite this promising overall picture, however, in addition to many

reports of cases in which naltrexone has not improved SIB (e.g., Bodfish
et al., 1997), there are also reports of paradoxical worsening of frequency
and/or severity of SIB during naltrexone treatment (e.g. Benjamin, Seek,
Tresise, Price & Gagnon, 1995). The specific mechanism of action of
naltrexone is not well understood. Dose–response relationships appear
to be complex (Symons et al., 2004), and people showing long-term
improvement in SIB following time-limited naltrexone treatment may
show worsening of SIB if treated again with naltrexone (Sandman et al., 2000).
Topography of SIB does not appear to predict response to naltrexone
(Symons et al., 2004).
Sandman and his colleagues (Sandman et al., 2000; Sandman, Tou-
chette, Marion, Lenjavi & Chicz-DeMet, 2002; Sandman et al., 2003) have
suggested that baseline levels of β-endorphin relative to ACTH may be
associated with patterns of SIB suggesting relative insensitivity to social/
environmental events and may predict response to naltrexone. However,
the relationship between the direct opiate blocking effect, possible adjust-
ments in receptor sensitivity, and operant learning mechanisms in the
effect of naltrexone remains to be elucidated. Benjamin et al. (1995), report-
ing a case in which naltrexone appeared to markedly worsen severity of
SIB in a young adult, suggested that his deterioration in behaviour might
be an operant extinction-induced process caused by the failure of SIB
to produce β-endorphin-related effects. Although therefore there is good
evidence that naltrexone can be helpful in some cases of SIB, response to
treatment and most effective dosage are difficult to predict, little is known
regarding optimal duration of treatment, and paradoxical effects are possi-
ble. In addition, there is evidence that in some cases naltrexone may both
reduce level of SIB and increase the strength of the relationship between
carer behaviours and SIB, and it has been suggested that this effect may
specifically compromise the utility of carer reports of the effectiveness of
naltrexone (Symons et al., 2001). Particular attention to objective evalua-
tion of treatment effect and dose parameters, as well as consideration of
sensitivity to liver toxicity, are therefore needed with any trial of naltrexone
in treatment of SIB.
Psychopharmacological Treatment of SIB in Children

with Intellectual Disabilities: Cautions and Conclusions
The most direct rationales for the use of psychopharmacological treat-
ments of SIB relate to the dopaminergic and opioidergic sytems, and to
date the strongest available evidence of treatment effectiveness relates to
drugs targeting these systems. Of the atypical antipsychotics, by far the
most extensive evidence base concerns risperidone. Despite a substantial
number of well-controlled studies, the evidence regarding the utility of
risperidone specifically for treatment of SIB both in children with autism/
PDD and in other children with intellectual disabilities remains incon-
clusive, mainly owing to the reliance of most studies on global ratings of
improvement and generalised behaviour rating scales which do not focus
on specific topographies of behaviour.
Increases in weight and appetite, raised prolactin levels, and somno-

lence/sedation are frequently reported adverse events associated with ris-
peridone treatment, although post hoc analyses suggest that the positive
effects reported for risperidone are independent of the presence/absence
of somnolence (Snyder et al., 2002; Turgay et al., 2002). Other side effects
including effects on heart rate have also been reported. In considering
the use of risperidone with children, the possible long-term health con-
sequences of these effects warrant serious consideration. The possible
negative consequences of weight increase are obvious, and although eval-
uations of risperidone (e.g., Croonenberghs et al., 2005) commonly advise
clinicians to provide counselling on diet and exercise, in their open-label
study of olanzapine Handen and Hardan (2006) noted that weight gain
was observed despite provision of such counselling.
The possible long-term effects of the increases in prolactin levels asso-
ciated with risperidone treatment require further study. Extrapyramidal
symptoms have been reported in up to 26% of participants in one-year
follow-ups of children using risperidone (Turgay et al., 2002), and longer-
term research will be needed on the question of whether long-term use
of risperidone may be associated with development of tardive dyskinesia.
Monitoring for other less frequent adverse events such as neuroleptic
malignant syndrome remains important with the atypical antipsychotics.
Careful consideration of the likely long-term benefits and risks of risp-
eridone use is particularly warranted given that withdrawal of risperidone
after periods of up to six months from children with autistic spectrum dis-
orders who have been judged to respond positively to initial treatment has
been reported to be associated with deterioration in behaviour in approxi-
mately two-thirds of cases (Research Units on Pediatric Psychopharma-
cology Autism Network, 2005; Troost et al., 2005). Observational studies
suggest that the effects of risperidone treatment may be partially mediated
by changes in carer–child interaction related to the reduction in irritabil-
ity associated with risperidone (Zarcone et al., 2001). Together with the
observation that in one-third of cases it appears that risperidone treat-
ment can be successfully withdrawn, these observations suggest that if
risperidone is used in treatment of SIB its effects should be carefully moni-
tored, there should be frequent review to determine whether medication
can be withdrawn without negative effects on behaviour, and prescription
of risperidone should be accompanied by behavioural interventions.
The evidence for the effect of naltrexone hydrochloride on SIB sug-
gests that in cases where SIB is chronic and assesssment does not identify
functional relationships with social/environmental events, consideration
of naltrexone treatment may be warranted. The effects of naltrexone, how-
ever, vary dramatically across individuals, are clinically difficult to pre-
dict for the individual case, and include the potential for adverse as well
as beneficial effects on SIB. Again therefore careful monitoring of effec-
tiveness and frequent review are appropriate where naltrexone is used in
treatment of SIB. The evidence regarding adverse events with naltrexone
is largely drawn from its use with nondisabled adults and close monitor-
ing for possible such events is appropriate where the drug is considered
for use with children with developmental disabilities. The rationale for use
of naltrexone suggests that its use may increase SIB-related pain and/or
decrease SIB-related euphoria, and its use has been reported to increase
signs of negative affect during SIB (Benjamin et al., 1995). Given that
some level of SIB will usually continue to occur in most cases even of suc-
cessful treatment with naltrexone, and that social/environmental factors
may be implicated in the maintenance of the behaviour (Symons et al.,
2001), it is therefore both practically and ethically important that consid-
eration of naltrexone use in cases of SIB is accompanied by behavioural
intervention.
BEHAVIOURAL TREATMENT
Rationale for Behavioural Intervention

Behavioural interventions for SIB were originally developed on the
basis of demonstrations that rates of SIB in children with developmental
disabilities could be increased by contingent social attention and reduced
when such attention was witheld contingent on SIB but available at other
times (Iwata, Roscoe, Zarcone, & Richman, 2002). Subsequent studies
have demonstrated that SIB may also be maintained by socially medi-
ated negative reinforcement (e.g., escape from task demands). Automatic
reinforcement, that is, reinforcement produced directly by the SIB without
social mediation, has also been implicated in maintenance of SIB, and
again both positive reinforcement (e.g., sensory stimulation) and negative
reinforcement (e.g., pain blocking or attenuation) have been suggested to
be involved in individual cases (Iwata et al., 2002).
Current approaches to the behavioural treatment of SIB have been
profoundly influenced, firstly by a seminal review by Carr (1977), who
reviewed evidence suggesting that SIB could be maintained by a variety of
consequences in different individuals and argued that treatment should
therefore be individualised with respect to the function of the behaviour
for the specific individual; and secondly by a landmark article in which
Iwata, Dorsey, Slifer, Bauman, & Richman (1982) described a method for
assessing behavioural function prior to treatment planning. Iwata et al.’s
(1982) method (see Vollmer, XXXX, for a detailed discussion), variously
described as experimental functional analysis (EFA) or “analogue assess-
ment”, involved briefly placing clients into a variety of highly structured
social situations, each of which was designed to evoke high rates of prob-
lem behaviour maintained by specific functions. For example, one condi-
tion involved the presence of carers who interacted with the client only
consequent upon SIB; this condition was predicted to lead to high rates of
any behaviour typically reinforced by contingent carer attention.
The advent of the methodology of experimental functional analysis
led to a major shift in perspective in the treatment methods employed
in clinical research. Instead of relying on use of reinforcers and pun-
ishers empirically demonstrated to be effective but possibly unrelated to
the consequences maintaining SIB, treatment shifted to interventions
based on identification of the reinforcer maintaining SIB in the client’s
natural environment. Key elements in such interventions have frequently

included (a) modification of antecedent motivating operations (Michael,
2000) in order to reduce the reinforcing value of the events which have
previously reinforced SIB, (b) teaching and/or increasing the density of
reinforcement for prosocial behaviours which compete with SIB for the
reinforcer(s) which have maintained the SIB, and (c) increasing the effort
involved in SIB and reducing or eliminating reinforcement of the behav-
iour (Iwata et al., 2002).
Recent research has concentrated on identifying more precisely the
behavioural mechanisms underlying the effectiveness of established treat-
ment procedures with a view to improving the effectiveness, durability, and
generalization of treatment effects. The remainder of this section illustrates
how these principles have been applied in treatment of SIB maintained by
socially mediated positive and negative reinforcement, and automatic rein-
forcement. Examples are largely drawn from treatment of SIB. Although
operant theorists acknowledge the involvement of specific neurobiological
processes in the aetiology and maintenance of SIB, the functional perspec-
tive assumes that the processes involved in the establishment and mainte-
nance of SIB are essentially identical to those involved in the development
of other problem and prosocial behaviours, and research into other behav-
iour problems will therefore generally be relevant to treatment of SIB. Sim-
ilarly, because the functional approach considers that common processes
control the behaviour of children and adults (although the development
of language is associated with additional processes), treatment studies
involving both children and adults are discussed.
Treating SIB Maintained by Socially Mediated Reinforcement

Two types of socially mediated positive reinforcement have frequently
been reported to be involved in maintenance of SIB in children with severe
intellectual disabilities; attention from/interaction with carers and delivery
of tangible items (e.g., food, toys), access to which is controlled or medi-
ated by caregivers. The negative reinforcement process which has received
most attention is escape from or avoidance of task demands, although
escape from or avoidance of a variety of other aversive events and from
people or situations which have been associated with such events is also
frequently implicated in maintenance of SIB (Reese, Richman, Belmont &
Morse, 2005).
Modification of Antecedent Motivating Operations

Vollmer, Iwata, Zarcone, Smith and Mazaleski (1993) treated the long-
established SIB (head banging and hitting, body hitting, or hand-mouthing)
of three women with severe/profound intellectual disabilities. After EFA
had shown in each case that SIB was reinforced by contingent carer atten-
tion, Vollmer et al. (1993) provided attention on a fixed-time (FT) sched-
ule; that is, attention was provided at fixed intervals irrespective of the
womens’ behaviour. Attention was initially provided continuously and
gradually reduced to 10 s of attention each five minutes, with reduction
dependent on low rates of SIB in the previous session. For all three par-
ticipants, rates of SIB were substantially reduced during the fixed-time
treatment sessions.
Van Camp, Lerman, Kelley, Contrucci, and Vorndran (2000) demon-
strated that variable-time schedules in which interreinforcement intervals
varied randomly around a mean value were as effective as the correspond-
ing fixed-time schedules in reducing aggression and SIB which were main-
tained by access to leisure materials in two people with severe intellectual
disabilities, increasing the utility of this approach for applied settings in
which rigorous fixed-time schedules might be difficult to sustain.
Kahng, Iwata, DeLeon, and Wallace (2000) further demonstrated that
the reduction in frequency with which reinforcers were delivered could be
achieved more rapidly than using the fixed-step approach of Vollmer et al.
(1993), and without compromising intervention effectiveness, by a proce-
dure in which the interval between reinforcer delivery was adjusted based
on the mean interval between participants’ self-injurious behaviors.
Time-based schedules have also been used to reduce SIB main-
tained by socially mediated negative reinforcement. Vollmer, Marcus, and
Ringdahl (1995) treated the SIB of two young males with developmen-
tal disabilities for whom EFA had suggested that SIB was maintained by
contingent escape from instructional activities. Provision of brief breaks
from required activities on fixed-time schedules with the interval between
breaks progressively increased, dependent on rates of SIB in previous ses-
sions, to 10 minutes for one participant and 2.5 minutes for the second,
produced substantial reductions in rates of SIB for both.
Although discussed here in terms of modifying motivational processes,
the procedures employed in the above studies may reduce problem behav-
iour through extinction (removing the contingency between the behaviour
and the reinforcer) and by increasing tolerance of delay to reinforcement
through the schedule thinning process (Vollmer et al., 1998). To the extent
to which these additional processes are involved, use of fixed-time sched-
ules may produce reductions in the level of problem behaviour extending
beyond the period in which the motivating operation is modified. Where
SIB occurs extensively, however, use of fixed-time schedules may risk
maintaining the behaviour though adventitious reinforcement when SIB is
occurring immediately before a scheduled reinforcer delivery, but in such
situations briefly postponing reinforcement when a scheduled delivery
is immediately preceded by SIB should avoid this possibility (see Carr &
LeBlanc, 2006, for a thorough discussion of issues in use of FT schedules).
Where SIB is maintained by escape from or avoidance of scheduled
tasks or activities, modification of instructional activities may produce sub-
stantial reductions in the behaviour. Pace, Iwata, Cowdery, Andree, and
McIntyre (1993) produced rapid and substantial reductions in levels of SIB
for three young people with intellectual disabilities by initially completely
withdrawing demands and then gradually increasing these over sessions to
baseline levels while preventing escape from activities contingent on SIB.
Zarcone, Iwata, Smith, Mazaleski, and Lerman (1994), working with three
adults with developmental disabilities and instructional escape-maintained
SIB, demonstrated that withdrawal and progressive reintroduction of demands
without preventing escape for SIB was initially successful in reducing levels
of SIB, but that levels of SIB increased as the intervention progressed and
that periods of escape prevention were necessary to achieve desired levels
of control of SIB. Problem behaviours including SIB may also be reduced
by identifying specific tasks which elicit SIB and interspersing requests to
complete these among tasks less likely to elicit SIB (Horner, Day, Sprague,
O’Brien, & Heathfield, 1991).
Other instructional procedures which may be helpful in reducing lev-
els of demand-escape maintained SIB include increasing levels of rein-
forcement for task engagement (Hoch, McComas, Thompson, & Paone,
2002; Lalli et al., 1999), preceding demands which elicit SIB by a sequence
of demands with which the child typically cooperates (although prevent-
ing escape from the demand contingent on SIB may again be important
to the effectiveness of this approach; see Zarcone, Iwata, Mazaleski, &
Smith, 1994), increasing levels of assistance with tasks, embedding task
demands in reinforcing activities, increasing the predictability of demands,
and increasing choice of activity (Miltenberger, 2006).
Systematic evaluation of rates of SIB across activity or instructional
conditions may also enable such activities to be scheduled so as to reduce
levels of SIB. O’Reilly, Sigafoos, Lancioni, Edrisinha, and Andrews (2005)
found that the SIB of a 12-year-old boy with autism and intellectual dis-
abilities, normally elevated in the task demand condition of an EFA in
comparison to other conditions, did not occur when the task demand con-
dition was preceded successively by no interaction and play conditions.
Introduction of a similar structure (a repeating schedule of five minutes
each of no interaction, play, and task demand) into the classroom situa-
tion produced substantial reductions of SIB in the classroom which were
maintained at five-month follow-up.
Where motivating operations cannot be directly modified, it may be
possible to increase tolerance of them or neutralise their effects. McCord,
Iwata, Galensky, Ellingson, and Thomson (2001) reduced problem
behaviours (including SIB) maintained by escape from noise by programmes
involving progressive exposure to increasing noise levels accompanied by
extinction (problem behaviour did not lead to noise termination) and, in
one case, differential reinforcement for absence of problem behaviour in
the presence of noise. Horner, Day & Day (1997) found that the escape-
maintained aggression and SIB of two of the three children with severe
intellectual disabilities who participated in their study occurred in response
to error correction only following earlier delay or postponement of planned
preferred activities. Implementation of individually developed calming
routines (e.g., formally rescheduling the activity and reviewing pictures
from the past) following such events reduced levels of problem behaviour
in later instructional sessions.
Even when the specific motivating operations which increase the
reinforcing value of escape from demands cannot be isolated, their rel-
evance may be inferred by systematically rating the mood of the person
presenting problem behaviour and preceding task demands by mood-
enhancing activities where relevant (Carr, McLaughlin, Giacobbe-Greco,
& Smith, 2003).
Teaching and Reinforcing Competing Prosocial Responses
In one of the first studies to focus on teaching competing prosocial

responses, Carr and Durand (1985) reduced the behaviour problems
(including aggression, tantrums, and self-injury) of four children with
developmental disabilities whose problem behaviours were maintained by
either positive or negative (escape from difficult tasks) social reinforce-
ment by teaching them to verbally solicit attention and/or assistance from
adults. Carr and Durand (1985) showed that the effect of such functional
communication training (FCT) depended on teaching the child to verbally
solicit the reinforcer maintaining the problem behaviour and also dem-
onstrated that the positive effects of training on the children’s behaviour
problems occurred with carers naïve as to the purpose of the study. Carr
and Durand argued that the potential of functional communication train-
ing to improve behaviour in the presence of naïve carers offered an impor-
tant potential advantage by comparison with approaches which required
systematic changes in carer behaviour.
Especially with individuals with limited behavioural repertoires, a
single topography of problem behaviour may be maintained by several
distinct reinforcers. Day, Horner, and O’Neill (1994) demonstrated that
the SIB (or aggression) of three individuals with autism or severe intellec-
tual disabilities was in each case maintained both by escape from tasks
and by access to preferred items, and showed that establishing a commu-
nicative response appropriate to each function was necessary to reduce
problem behaviour across both contexts in which problem behaviour was
displayed.
It should, however, be noted that there is no reason to expect that
acquisition of a prosocial functional equivalent to SIB, even if that response
is consistently reinforced, will necessarily reduce the level of SIB. If both
behaviours elicit qualitatively similar responses from carers, the propor-
tion of responses which are prosocial and self-injurious will be determined
by the effort (and other costs) associated with each response (Richman,
Wacker, & Winborn, 2001), the magnitude of the reinforcer, and the latency
and schedule (reliability) with which reinforcement is delivered (Symons,
Hoch, Dahl & McComas, 2003).
A number of studies of FCT have found that FCT reduced problem
behaviour only when extinction or time-out contingencies were in effect
for problem behaviour in addition to positive reinforcement of the com-
municative response (Shirley, Iwata, Kahng, Mazaleski, & Lerman, 1997;
Wacker et al., 1990). Even if the alternative response is well established
simultaneously with SIB being placed on extinction, levels of SIB may
increase to pretreatment levels if it is again reinforced (Shirley et al., 1997).
Worsdell, Iwata, Hanley, Thompson, and Kahng (2000), treating the SIB
of five adults with profound intellectual disabilities, showed that for one
participant FCT (with every prosocial communication reinforced) reduced
rates of SIB even when SIB continued to be continuously reinforced, but
for four others substantial reductions in SIB were achieved only when
the appropriate communication was continuously reinforced and rate of
reinforcement of SIB was reduced, in two cases to one reinforcement per
20 responses. These are important considerations in planning behavioural

treatment programmes in many settings, where even given a high level of
training and support for families and other carers, SIB may be at least
intermittently reinforced.
Additional complexity and importance is given to this issue by the fact
that the unit of behaviour strengthened by reinforcement is the operant,
defined as the class of all responses with the same functional relation-
ship to the reinforcing event. Both appropriate and problem behaviours
may belong to the same functional class, and if a member of that class
is selected as the prosocial behaviour to be reinforced in FCT, the entire
functional class including SIB may be strengthened in terms of rate of
occurrence and resistance to extinction (Derby, Fisher, Piazza, Wilke, &
Johnson, 1998). For optimal effect, FCT should therefore preferably teach
a novel communicative response which has no history of membership of
the same functional class as SIB (cf. Winborn, Wacker, Richman, Asmus,
& Geier, 2002). Furthermore, to avoid or minimise the possibility of the
communicative response joining the same functional class as SIB, rein-
forcement of SIB should be eliminated or minimised and attention may
need to be given to the possibility that SIB may be maintained by rein-
forcement of other, apparently unproblematic, members of the preexisting
functional class (Derby et al., 1998).
A further possible difficulty with FCT is that the alternative commu-
nicative response may occur sufficiently frequently that to reinforce every
occurrence is impracticable in the long term. Hanley, Iwata, and Thompson
(2001) compared several methods for addressing this problem following
FCT treatment of the SIB and aggression of three adults with profound
intellectual disabilities. The most effective method proved to be establishing
the communicative response using continuous reinforcement and then
introducing and progressively lengthening periods of (signalled) extinction in
which a coloured card indicated that the communicative response would
not be reinforced. Hanley et al. showed that low rates of problem behaviour
could be maintained under this arrangement with up to four minutes of
signalled nonreinforcement of the communicative response alternating
with one-minute periods of reinforcement.
Reducing or Eliminating Reinforcement of SIB

Although eliminating or reducing the reinforcement maintaining SIB
is likely to be essential to successful treatment using FCT, any attempt
to treat SIB using extinction alone faces major ethical and practical
problems. The transition from reinforcement to extinction of operant
behaviour is frequently accompanied by an extinction burst, a temporary
increase in the rate and intensity of the behaviour, and by aggression
(Lerman, Iwata, & Wallace, 1999). Examining 41 datasets for children
and adults with moderate to profound intellectual disabilities whose SIB
was treated by behavioural interventions in a specialist day programme,
Lerman et al. found evidence for extinction bursts in 62% of cases
treated by extinction alone versus 15% of cases in which antecedent
change and/or reinforcement procedures were used in combination
with extinction. Aggression was also more commonly observed when

extinction was used alone than when it was used in combination with
other procedures.
Behavioural accounts of the development of severe SIB (e.g., Oliver &
Head, 1990) propose that it evolves through a process of operant shaping
in which carers initially respond to SIB and then progessively reinforce
increasingly severe forms of the behaviour by ceasing to respond to milder
forms but reinstating their response to the more severe and/or frequent
behaviour which occurs in the ensuing extinction burst. There are there-
fore both ethical and practical problems in any attempt to use extinction
in isolation, and even when it is used together with reinforcement-based
procedures such as FCT, care is needed to ensure that an extinction burst
does not lead carers to reinstate reinforcement of SIB and inadvertently
increase the severity of the behaviour.
Treating SIB Maintained by Automatic Reinforcement

Experimental-epidemiological studies implicate automatic (nonsocially
mediated) reinforcement as the major process maintaining SIB and other
problem behaviour in approximately one-quarter to one-third of cases
(Derby et al., 1992; Iwata et al., 1994). Assessment and treatment of auto-
matically reinforced behaviour is challenging because it is typically diffi-
cult to identify precisely the nature of the reinforcement maintaining the
behaviour (Vollmer, 1994). Nevertheless, some success has been reported
with behavioural interventions analogous to those used with socially rein-
forced behaviour.
Modification of Antecedent Motivating Operations

Where EFAs use the conditions originally described by Iwata et al. (1982),
automatic reinforcement of SIB may be inferred if rates of SIB are highest
when the client is left alone without activities or if SIB occurs at a high
rate in all conditions. Such an analysis provides no information regard-
ing the nature of the reinforcer. In the absence of this information, the
most frequently investigated behavioural intervention has been providing
noncontingent access to sensory and other stimuli. The items used are
typically selected using structured preference assessments in which the
child’s preferences from a range of sources of stimulation are assessed by
systematically observing either choices when items are presented simulta-
neously (e.g., in pairs; Fisher et al., 1992) or the length of time for which
the child interacts with items presented individually (DeLeon, Iwata, Con-
ners, & Wallace, 1999) or simultaneously (Roane, Vollmer, Ringdahl, &
Marcus, 1998).
Vollmer, Marcus, and LeBlanc (1994) showed that noncontingent
access to preferred items reduced levels of SIB in three young children
with developmental disabilities, although additional procedures, includ-
ing brief (5 s) restraint of one child’s hands, were necessary to achieve
acceptable reductions in SIB for two of the children. Vollmer et al. (1994)
reported positive results after training family members to implement the
resulting treatment packages during particularly problematic periods of

the day, but noted that treatment effectiveness might reduce owing to
satiation if such treatments were used over extended time periods. Sub-
sequent studies have, however, reported that where necessary, providing
access to a variety of sources of stimulation and/or rotating the objects
provided can produce long-term reductions in extent of SIB (DeLeon,
Anders, Rodriguez-Catter, & Neidert, 2000; Lindberg, Iwata, Roscoe,
Worsdell, & Hanley, 2003).
Others (e.g., Goh et al., 1995; Patel, Carr, Kim, Robles, & Eastridge,
2000) have conducted additional assessments to identify aspects of the
stimulation produced by the problem behaviour. Goh et al. (1995) for
example, searching for sources of stimulation to reduce hand-mouthing,
provided objects to manipulate to four adults with profound intellectual
disabilities and showed that for all four hand–object contact was more
extensive than mouth–object contact, suggesting that hand stimulation
was the reinforcer maintaining hand-mouthing. Such assessments may
suggest items likely to compete as sources of reinforcement with SIB to be
further evaluated through stimulus preference assessment
Although a variety of evidence suggests that pain may be a factor in
some cases of SIB, with one possibility being that SIB attenuates pain
(Symons, 2002), treatment of negatively automatically reinforced behav-
iour has received little attention. Fisher et al. (1998) showed that applica-
tion of transcutaneous electrical nerve stimulation to a frequently injured
area produced a transient reduction in the long-term, severe, apparently
automatically reinforced SIB of a young man with Down’s syndrome.
Although the effect reduced over sessions, pain was not identified as a fac-
tor in this report, and alternative mechanisms of action including positive
automatic reinforcement were suggested, the results suggest a possible
role for a treatment commonly used for chronic or untreatable pain in
some cases of SIB.
Teaching and Reinforcing Competing Prosocial Responses

In treatment of automatically reinforced SIB, noncontingent presen-
tation of competing stimulation has been studied more extensively than
differential reinforcement of alternative behaviour (DRA) using such
stimulation, probably because early studies suggested that even where
competing stimuli could be identified, attempts to use them in differen-
tial reinforcement programmes were ineffective (Shore, Iwata, DeLeon,
Kahng, & Smith, 1997). Shore et al. suggested that the increased response
effort involved in DRA was responsible for this effect. This analysis sug-
gests that reducing the response effort required to produce the alterna-
tive stimulation, for example, by use of microswitches, may be effective.
Steege, Wacker, Berg, Cigrand, and Cooper (1989) reduced the damaging
hand-mouthing of a child with severe multiple disabilities by teaching
him to use a microswitch to activate reinforcing stimuli (a radio or a
fan). For a recent review on use of microswitch-activated stimulation to
enhance wellbeing more generally, see Lancioni, Singh, O’Reilly, Oliva,
and Basili, (2005).
Reducing or Eliminating Reinforcement of SIB

A number of studies in which apparently automatically reinforced SIB
was reduced by blocking self-injurious behaviours, or application of pro-
tective clothing, have interpreted consequent reductions in SIB in terms
of reduction of automatic reinforcement produced by the behaviour (e.g.,
Mazaleski, Iwata, Rodgers, Vollmer, & Zarcone, 1994; Moore, Fisher, &
Pennington, 2004; Van Houten, 1993), but the mechanisms involved in
such effects are often obscure, possibly including punishment.
Fading of Mechanical Restraints

In cases of severe SIB, even in children, carers may have resorted
to use of protective equipment such as helmets or mechanical restraints
such as arm splints to reduce tissue damage. Such equipment is generally
socially stigmatising and may limit engagement in constructive activities.
Fisher, Piazza, Bowman, Hanley, and Adelinis (1997) with three clients
including two children, and Oliver, Hall, Hales, Murphy, and Watts (1998)
with three adults, all of whom showed SIB including head-hitting, replaced
previous mechanical restraints with arm splints which initially prevented
arm flexion but could be progressively modified to allow greater degrees
of flexion.
The results of both studies were mixed. Oliver et al. (1998) increased
the flexion allowed by the splint to 100% while maintaining SIB at zero
levels for two participants, although self-restraining behaviours were seen
in both cases. For the third participant, levels of SIB were initially reduced
but increased as restraint fading progressed. Fisher et al. (1997) reported
that complete restraint fading was successfully achieved for one participant,
but a second required other treatment to reduce SIB as restraints were
faded, and a third responded to the introduction of the novel restraints by
developing another topographical form not prevented by the restraint, a
problem also noted by Kahng, Abt, and Wilder (2001).
In a different approach O’Reilly, Murray, Lancioni, Sigafoos, and Lacey
(2003) demonstrated that providing sensory stimulation demonstrated to
reduce attempts at SIB with protective equipment in place reduced SIB
when the protection was removed for brief periods. In at least some cases
therefore where mechanical restraints have been used these can be suc-
cessfully reduced while maintaining low rates of SIB.
Treatment of Self-Restraint
Many individuals with intellectual disabilities who engage in self-
injurious behaviour (SIB) also engage in behaviours which may appear
to observers to represent attempts by the person to prevent themselves
engaging in SIB; such behaviours are generally referred to as self-restraint
(SR). Topographies of SR, including entangling limbs in clothes, holding one
body part with another, and seeking external mechanical restraints may be
seen in as many as 75% of those who self-injure (Oliver, Murphy, Hall, Arron,
& Leggett, 2003). Self-restraint may occur very extensively, severely limit
involvement in constructive activities, and warrant intervention together

with the SIB which may be observed if restraint is physically interrupted.
A number of hypotheses concerning the relationship between SIB and
SR have been suggested (Fisher & Iwata, 1996; Isley, Kartsonis, McCurley,
Weisz, & Roberts, 1991). Firstly, SR may be reinforced by termination
of, or avoidance of, SIB. Fisher and Iwata (1996) have speculated that
in many cases SIB may be controlled by both positive and aversive con-
sequences and that SR may emerge when the effects of reinforcement of
SIB are outweighed by its aversive consequences. Secondly, access to
self-restraint may reinforce SIB (Fisher & Iwata, 1996). Thirdly, SIB and
SR may be functionally equivalent members of response classes main-
tained by positive or negative social reinforcement (Fisher & Iwata, 1996),
or alternatively may be functionally independent (Rapp & Miltenberger,
2000). In these cases, if maintaining consequences can be identified, SR
may be successfully treated by methods similar to those used for SIB,
such as fixed-time schedules of reinforcement (Derby, Fisher & Piazza,
1996). In other cases, it may be possible to gradually shape the form
of self-restraint into one which is less restrictive and socially stigma-
tizing. Pace, Iwata, Edwards, and McCosh (1986) progessively modified
self-restraint involving wearing rigid tubes on the arms to wearing of ten-
nis wrist bands while maintaining low levels of SIB. However, additional
intervention including shaping and reinforcement of behaviours involving
removal of hands from restraint may also be necessary (Lerman, Iwata,
Smith, & Vollmer, 1994).
Behavioural Treatment of SIB in Children with Intellectual

Disabilities: Cautions and Conclusions
Reviewing research on behavioural treatment of SIB published between
1964 and 2000, Kahng, Iwata, & Lewin (2002) noted that most interven-
tions produced reductions in SIB of at least 80% from baseline to the end
of treatment, with a mean reduction of 83.7%. Clearly, behavioural treat-
ments can be highly effective in reducing SIB. A number of issues arise,
however, in considering these impressive results. Firstly, most evaluations
of behavioural interventions use single-subject experimental designs, and
these may be particularly susceptible to bias in publication of studies with
positive rather than negative outcomes (Kahng et al., 2002).
Secondly, although complex interventions can be successfully imple-
mented by service staff such as teachers (e.g., Sigafoos & Meikle, 1996),
some of the evidence for treatment effectiveness comes from data collected
during defined time periods with interventions implemented by highly
skilled staff, and only a minority of studies report data on generalization
of treatment effects (DeLeon, Rodriguez-Catter, & Cataldo, 2002; Kahng
et al., 2002). The extent to which generalization of treatment effects
requires systematic re-implementation of treatment across carers, settings,
and tasks varies substantially across individuals (Shore, Iwata, Lerman &
Shirley, 1994).
Thirdly, although behavioural interventions are less associated with
adverse events than most psychopharmacological treatments, a variety
of problems including inadvertent reinforcement of functional classes

including SIB, extinction bursts, emergence of new topographies of SIB,
and difficult-to-manage levels of alternative responses taught to replace
SIB, may occur in the course of behavioural treatments, which therefore
require supervision by professional staff with sufficient expertise to pre-
dict, recognise, and appropriately manage such events.
Finally, only in a minority of cases do behavioural interventions com-
pletely eliminate SIB (DeLeon et al., 2002), and the overall effectiveness
of behavioural interventions has not increased since the 1960s (Kahng
et al., 2002).
RELATING TREATMENT TO FORMULATION

AND DIAGNOSTIC SUBTYPING
Assessment and treatment with SIB should generally first involve

screening for possible contributing physical illness and a thorough func-
tional assessment which will indicate directions for behavioural treatment.
Where initial treatment fails, this should be regarded first of all as indicat-
ing the need for more detailed and individualised functional assessment to
identify possible idiosyncratic functional relationships (Harding, Wacker,
Berg, Barretto, & Ringdahl, 2005) rather than as requiring “default thera-
pies” (Mace & Mauk, 1995).
In general, current psychopharmacological approaches should be preferred
only where detailed functional assessment suggests insensitivity of the
SIB to environmental contingencies, (although sensitivity to one condition
combined with a high rate of SIB across other conditions may suggest a need
for combined behavioural and psychopharmacological interventions; Mace
& Mauk, 1995), or where individualised behavioural interventions repeatedly
fail to reduce levels of SIB. Where psychopharmacological intervention
is considered, little evidence-based guidance is available to the clinician
regarding initial choice of treatment for the individual client.
Mace and Mauk (1995) suggested four subtypes of “possibly biologic”
SIB selectively related to impairments in the opioid, dopamine, serotonin,
or noradrenaline systems alone or in combination and corresponding pre-
ferred initial approaches to psychopharmacology. For subtype 1, involving
extreme self-inflicted tissue damage (e.g., a history of severe self-injury
involving biting off chunks of tissue, self-inflicted amputation of digits,
extensive and multiple wounds, scarring, broken bones, “cauliflower ears,”
etc.), disturbance of the opioid system may be implicated and treatment
with naltrexone considered. For subtype 2, repetitive or stereotypic SIB,
dysfunction in dopaminergic pathways may be suspected and a trial of
low-dose atypical antipsychotics considered.
Mace and Mauk (1995) suggested two further “biologic” subtypes of
SIB, “high rate with agitation when interrupted,” and “SIB co-occurring
with agitation,” for which they proposed use of SSRIs, and propanalol or
mood stabilisers, respectively. However, the current evidence base regard-
ing the utility of adrenergic drugs or mood stabilisers in treatment of SIB is
very limited (King, 2000; McDougle et al., 2006). Furthermore, despite the
face validity of Mace and Mauk’s subtyping of “biologic” SIB, there are no
well-controlled studies demonstrating selective impact of specific agents
on specific subtypes of SIB. Improvement of our ability to analyse the
dynamics of individual patterns of SIB and relate these to possible rational
pharmacotherapies remains an important goal for research (Thompson &
Symons, 1999). Meanwhile, the fact that neither current behavioural nor
psychopharmacological treatments typically eliminate established SIB,
thus requiring extended treatment, and the fact that both may produce
adverse effects, implies that both require expert management and careful
monitoring.
AETIOLOGY, DEVELOPMENT, AND PHENOMENOLOGY OF SIB.
Whereas the current evidence base supports the effectiveness of

behavioural interventions, the lack of systematic improvement in out-
comes attained clearly implies a need for better understanding of the fun-
damental processes involved in development and maintenance of SIB. The
final section of this chapter briefly reviews selected recent research on the
development and phenomenology of SIB and discuss implications for fur-
ther development of effective behavioural interventions.
Age of Onset and Early Development

Repetitive behaviours such as body rocking and self-injurious or
potentially self-injurious behaviours such as head banging have long been
known to be relatively common in both typical developing young infants
and those at risk for developmental delay (Kravitz & Boehm, 1971). These
observations, together with the association between stereotyped behav-
iours and SIB in adults with severe intellectual disabilities, have provided
the foundations for theories suggesting that SIB may develop from early
repetitive behaviours through a process in which repetitive behaviours
first develop homeostatic functions in regulating overall degree of stimu-
lation and are then shaped into SIB through socially mediated operant
reinforcement (Guess & Carr, 1991; Kennedy, 2002).
Four groups of researchers have recently reported data from longitu-
dinal studies of groups of infants with intellectual disabilities at risk for
developing self-injurious behaviours. Berkson and colleagues (Berkson,
2002; Berkson et al., 2001) followed up 39 children selected from a total of
457 children with developmental disabilities enrolled in early intervention
(birth to 36 months) programmes as showing, or being at risk of develop-
ing, stereotyped and/or self-injurious behaviours. The children were fol-
lowed up at weekly (or less frequent owing to practicalities) intervals and
multiple sources of data (weekly reports on the child’s behaviour from par-
ents and programme staff, direct observation, clinical records, and paren-
tal retrospective reports) were used to document trends in prevalence of
various behaviours with age.
Berkson et al. distinguished three categories of behaviour relevant
to SIB: transient SIB (producing actual tissue damage), long-term SIB
(producing actual tissue damage), and proto-SIB (behaviours with the

same topographical form, e.g., head-hitting, as SIB, but not producing
actual tissue damage). The proportion of the sample showing body-
rocking declined slowly between the ages of 9 and 36 months. The two
forms of SIB or proto-SIB most commonly observed were head banging
or hitting and eye pressing or poking. The proportion of the sample
displaying eye- oriented SIB declined between the ages of 12 and 36
months, whereas the prevalence of head-directed SIB increased. The
mean age of onset of long-term SIB (13 months) was lower than that
for transient SIB (20 months) and proto-SIB (23 months). Mean age
of onset of different topographies of SIB (Symons, Sperry, Dropik, &
Bodfish, 2005) was 14 months for eye poking/pressing, 18 months for
head banging, and 23 months for head-hitting.
Murphy and colleagues (Hall, Oliver, & Murphy, 2001a; Murphy, Hall,
Oliver, & Kissi-Debra, 1999; Oliver, Hall, & Murphy, 2005) studied a group
of 17 children with a mean age of 67 months selected from a pool of 614
potential participants attending schools for children with severe intellec-
tual disabilities and/or autism as having started to display SIB or “poten-
tial SIB” (equivalent to Berkson’s proto-SIB) within the three months prior
to the beginning of the study. Murphy et al. also studied a comparison
group of ten children identified by teachers as similar in age, ability, and
degree of ambulation to the SIB group, but not displaying SIB or proto-
SIB. The children’s stereotyped behaviours and SIB, and teacher attention
and demands, together with other categories, were observed for three to
four hours every 3–6 months over an 18-month period for the SIB group
and on a single occasion for the comparison group.
Comparisons of characteristics of children in the SIB and comparison
groups were confounded by the fact that direct observation showed that
nine of the ten comparison children also showed SIB topographies, albeit
at a lower rate than the children in the SIB group. Twelve of the SIB group
showed increases in the amount of time spent in SIB over the course of the
study, four showing significant increasing trends on regression analysis.
When data from all 26 children in both groups actually observed to show
SIB were combined, the percentage duration of SIB at school correlated
negatively with developmental age and extent of ambulation.
Hall et al. (2001a) showed by further analysis of the longitudinal data
for the 16 children in the SIB group that the children whose SIB increased
over time showed elevated probabilities of SIB under conditions of reduced
social contact. Finally, Oliver et al. (2005) demonstrated that the degree of
increase in SIB over time was greatest for the children showing patterns
of conditional probability of social contact before, during, and after SIB
which were most consistent with those to be expected if SIB was evoked by
decreasing probability of social interaction and reinforced by subsequent
increase in the probability of such contact.
Richman and Lindauer (2005) focussed further on the functional prop-
erties of early stereotypy, proto-SIB, and SIB in following up 12 children
aged 12 to 34 months who displayed such behaviours over a period of 2–23
months and examining functions of these behaviours using brief experi-
mental analyses (Iwata et al., 1982). Five participants developed proto-SIB
in the form of head-hitting and/or banging in the course of the study, with
at least four of the total of seven topographies emerging apparently related
to a pre-existing stereotyped behaviour (e.g., head-hitting developing in a
child previously showing stereotyped arm-waving).
Four children engaged throughout the study in behaviour initially
observed as proto-SIB but eventually resulting in tissue damage, and
one developed proto-SIB which eventually produced tissue damage. Most
functional analyses showed undifferentiated patterns across conditions,
and some degree of responding was observed in the “alone” (i.e., no social
contingencies presented) condition for most behaviours evaluated, suggest-
ing that the behaviours studied were at least partly maintained by nonsocial
variables. One participant did show a pattern of responding consistent with
positive social reinforcement of proto-SIB and SIB; this child, however, had
presented SIB on entry to the study.
Kurtz et al. (2003) reported the results of individualised experimental
functional analyses conducted on the SIB (and other problem behaviours)
of 30 children aged 10 months to 4 years 11 months (M = 2 years 9 months).
Caregivers reported the mean age of SIB onset as 17 months (range, 1–36
months), with head banging the first topography of SIB observed for 70%
of participants. Experimental functional analysis produced results con-
sistent with socially mediated reinforcement in 14 cases (of 29 completed
analyses) and automatic reinforcement in 4 cases. Undifferentiated pat-
terns of response were observed in the remaining 11 cases.
Detailed comparison of the results of these studies is difficult because
of differences in methodology and groups studied (e.g., in ability, numbers
of participants with specific diagnoses associated with presence of SIB,
population-based samples vs. clinical samples). Taken together, however,
the results of these studies suggest that, as would be expected on the
basis of studies of older children (e.g., Iwata et al., 1994), the SIB of young
children may be maintained by operant processes, with positive socially
mediated reinforcement (in contrast to negative reinforcement processes
frequently observed with older children) most often seen as the maintain-
ing process.
Although it seems likely, however, that cases occur where social rein-
forcement processes have shaped SIB from stereotyped or “proto-SIB”
responses, it seems rather less likely that such shaping processes are ini-
tially involved in the development of SIB (although they may be involved
in subsequently increasing its severity). It seems that many young chil-
dren with intellectual disabilities display “proto-SIB” (Hall et al., 2001a).
Furthermore, the reported age of onset of SIB appears to be similar (or
perhaps even earlier) than that of motor stereotypies and “proto-SIB.”
Finally, substantial numbers of young children show undifferentiated
patterns of responding in experimental functional analyses (Kurtz et al.,
2003; Richman & Lindauer, 2005). The implication for the treatment of
SIB is that although SIB clearly frequently acquires operant functions,
it may initially develop through other processes which may continue to
be important even after operant functions are acquired. Further insight
into the nature of these processes may be gained from studies of the
phenomenology of SIB.
Phenomenology of SIB and Comorbidity with Other Conditions

Severe/profound intellectual disabilities, severity of autistic features,
and severity of communication difficulties all appear to be risk factors for
presence of SIB (McClintock, Hall, & Oliver, 2003). An association between
presence of SIB and stereotyped behaviours has long been noted (Berkson
& Davenport, 1962; Rojahn, 1986). Bodfish and colleagues (see Bodfish
& Lewis, 2002, for an overview), using rating scales which operationally
distinguish (on the basis of topography) different forms of repetitive behav-
iour, have shown that in adults with intellectual disabilities, by compari-
son with those who do not engage in SIB, people with SIB show increased
prevalence not only of stereotyped behaviours (Bodfish et al., 1995), but
also other repetitive behaviour patterns including “compulsive” behaviours
(Powell et al., 1996). Powell et al. (1996) further showed that people who
showed self-restraining behaviours in addition to SIB showed higher lev-
els of compulsive behaviour than those showing SIB but no self-restraint,
and in a national survey of people with Cornelia de Lange syndrome in
the United Kingdom, Hyman et al. (2002) found that for 12 participants
showing no compulsive behaviours presence of SR was not associated with
presence of SIB, although such an association was found for the 77 who
did show compulsive behaviours.
The fact that SIB often co-occurs with other forms of behavioural dis-
turbance has often been reported in population-based studies of adults
with severe intellectual disabilities (see, e.g., Collacott, Cooper, Bran-
ford, & McGrother, 1998). A recent study of behaviour rating scales (the
Behavior Problems Inventory (BPI); Rojahn et al. 2001; and the DASH-
II; Matson, 1995) completed on 180 adults with severe and profound
intellectual disabilities living in a residential centre (Rojahn, Matson,
Naglieri, & Mayville, 2004) found that SIB as measured by the BPI was
strongly associated with aggression and property destruction, but the
SIB/aggression factor was substantially independent of a stereotypy
factor. Having any item on the BPI SIB scale rated as serious raised the
risk of having any sign of depression, mania, signs of organic syndomes,
or impulse control difficulties (as assessed by the DASH-2) by a ratio of
two or more.
Interpretation of the results of studies such as the above is compli-
cated by the number of different conditions associated with SIB and the
fact that individual studies considering the relationship between SIB and
some other factor do not always control adequately for the effect of third
factors which may be associated with both. For example, a diagnosis of
autism is associated with increased prevalence and/or severity of both
stereotyped behaviours and SIB by comparison with adults with severe
intellectual disability without autism (Bodfish, Symons, Parker, & Lewis,
2000), but severity of autism has not always been controlled for in exami-
nations of the association between stereotypy and SIB. Nevertheless, stud-
ies of phenomenology and comorbidity suggest that close attention to these
aspects of SIB may be important in treatment selection.
Specifically, there is evidence associating SIB both with compulsiv-
ity and impulsivity. The distinction between “impulsive” and “compulsive”
types of SIB has been suggested to be important in understanding self-

harm in adults without intellectual disabilities, and the distinction has
been supported by factor analytic studies (Bodfish & Lewis, 2002). Treat-
ment of choice in both behavioural and pharmacological interventions
might be expected to depend on the context of comorbidity within which
SIB is presented. Aman et al. (2005) have, for example, suggested that
risperidone may be useful primarily in treatment of “impulsive” rather
than “compulsive” forms of SIB.
Implications for Treatment of Recent Research on Aetiology,

Development, and Phenomenology
Recent developmental research has supported the relevance of the
operant shaping hypothesis (Kennedy, 2002) for some cases of the devel-
opment of SIB. In other cases, however, SIB (of severity sufficient to occa-
sion tissue damage) seems to emerge at a similar or even younger age
than “proto-SIB.” Anecdotal reports from parents suggested that the initial
emergence of these behaviours (especially head-banging) was associated
with tantrums “following frustration of a desire and/or rapid situational
transitions” (Berkson, 2002, p. 476). Recent evidence from phenomenogi-
cal studies suggests that SIB may be associated with aggression and dif-
ficulties with impulse control (Rojahn et al., 2004).
It has long been known that elicited (nonoperant) aggression is seen
in response to extinction of (Azrin, Hutchinson, & Hake, 1966), or shifts
in reinforcement schedules for (Hutchinson, Azrin, & Hunt, 1968), other
behaviours. Aversive stimulation (Azrin, Rubin, & Hutchinson, 1968), also
elicits nonoperant aggression. These effects (where they can be ethically
demonstrated) are seen in humans as well as nonhuman animals (Kelly &
Hake, 1970), and such aggression may come to be elicited by previously
neutral stimuli through Pavlovian conditioning (Lyon & Ozolins, 1970)
and may be directed to a variety of targets (Macurik, Kohn, & Kavanaugh,
1978). Physical disability, and specifically difficulties with ambulation,
appear to be a specific risk factor for development of SIB (Emerson, 1992;
Murphy et al., 1999). Recent data on development and phenomenology
of SIB are consistent with the rather old suggestion that one dynamic
in the development of the disorder may be Pavlovian conditioning of
aggression which is originally elicited by aversive stimulation or denial of
expected reinforcement but which may become conditioned to a variety of
stimuli associated with such situations (Romanczyk & Matthews, 1998;
Schroeder, Reese, Hellings, Loupe, & Tessel, 1999). The aggression may
be self-directed simply because the child with ambulation difficulties can-
not access any other target.
The data supporting the operant shaping account of the development
of SIB (Kennedy, 2002) are mainly provided by the success of behavioural
treatments including noncontingent presentation (or avoidance) of pre-
sumed motivating variables and FCT which teaches the child to request
availability of (or withdrawal of) such variables. These interventions should
be as effective with elicited as with operant behaviour. The suggestion
that Pavlovian conditioning of elicited behaviour may be one mechanism
underpinning SIB is not inconsistent with the operant hypothesis, inas-

much as establishment of aggression elicited by aversive stimulation is
particularly rapid where the aggression is also reinforced by escape from
the aversive stimulus (Azrin, Hutchinson, & Hake, 1967).
The presence of a process of elicitation underlying SIB would, how-
ever, be consistent with the clinical observation that even where bursts of
SIB are clearly provoked by an aversive environmental event, immediate
withdrawal of that event may not end the behaviour (Thompson & Caruso,
2002). The implication of Pavlovian conditioning of responses to aversive
stimulation or changes in reinforcement schedules in development and
maintenance of SIB would suggest that in addition to interventions based
on operant conceptualisations, behavioural interventions well-established
as treatments for other problems, such as graduated exposure (with or
without counterconditioning) to aversive stimuli (e.g., McCord et al., 2001)
and/or delay to reinforcement may in some cases usefully be added to
operant-based interventions. Integration of interventions based on Pav-
lovian principles with the established operant technology may further
enhance the effectiveness of behavioural interventions.
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12
Communication,
Language, and Literacy
Learning in Children with
Developmental Disabilities
ERNA ALANT, KITTY UYS,
and KERSTIN TÖNSING
INTRODUCTION
This chapter deals with communication, language, and literacy learning

in children with developmental disabilities by integrating two perspectives,
firstly that of information processing and the impact of specific impair-
ments on information processing and interpretation of symbols used in
interaction and, secondly, the role of sociocultural factors in facilitating
learning and literacy learning. The use of augmentative and alternative
communication (AAC) strategies is discussed by means of a case study to
illustrate the interaction between individual and sociocultural factors in
intervention. A differentiation is made between engagement and interac-
tive behavior to enhance understanding of children’s participation, and
intervention strategies based on these concepts are explored. Finally the
importance of emergent literacy is discussed with reference to the impor-
tance of the sociocultural context within which families live.
The term neurodevelopmental or developmental disabilities refers to
a heterogeneous group of disabilities that include the long-term effects of
delay and deviance as a result of some damage to the neurological proc-
esses responsible for developmental functioning (Yeargin-Allsop & Boyle,
2002). Conditions that generally are included in this group are cerebral
ERNA ALANT, KITTY UYS, and KERSTIN TÖNSING

Center for Augmentative and Alternative Communication University of Pretoria

374 ERNA ALANT et al.
palsy, communication disorders, mental retardation, autism, auditory and

visual impairments, emotion disorders, disorders of attention and hyper-
activity, learning disabilities, chronic orthopedic conditions, and epilepsy
(Capute & Accardo, 1996). This indicates a broad range of conditions, and
the costs associated with these are tremendous as families endeavor to find
the appropriate professional services and support for their children. In addi-
tion, indirect costs such as emotional costs to families cannot be measured.
The importance of early intervention in limiting the impact of the neu-
rological impairment on long-term development of the child is thus evi-
dent. Intervention strategies, however, not only need to take into account
the neurological processes on the development of the young child, but also
the cultural and social relevance of these intervention strategies within the
ecological context in which the family lives.
COMMUNICATION AND LEARNING
Communication is often described as the essence of life as it is the way

in which individuals can break their isolation to develop relationships with
others, experience love, and ensure their own development and independ-
ence. Apart from being able to communicate interpersonally, the ability to
communicate through print also provides access to the broader outside
world of public participation and employment. As an initial point of depar-
ture, the acquisition of language, the ability to express oneself (in one way
or another) is vitally important to facilitate understanding and participa-
tion in activities of daily living.
Within the past decades, increasing attention has been paid in the liter-
ature of learning difficulties to the importance of language and communica-
tion skills as a basis for learning. This realization grew from the notion that
children’s ability to receive and interpret information as well as the ability to
express themselves form a pivotal part of their learning experiences as they
are able to co-construct with others the world in which they live. Making
sense of what happens around one is a most important part of being able to
understand, problem-solve, and adapt to circumstances of daily living.
Basic to the process of sharing and expressing oneself is the ability to
understand specific codes used for social interaction. This means that young
children need to learn a specific language, its conventions, and rules in order
to use these in a way that is understandable to others, allowing them to
become part of a family and social group. Communication can be described
as an intentional process through which individuals use symbols to interpret
and express ideas in order to develop meaning. To participate in this process
requires that the child has moved from the use of nonsymbolic to symbolic
communication. The ability to interpret and use symbols will have an impact
on the level of meaning that will be derived from the interactions.
Various authors have described the different levels of communication
behaviors by referring to the continuum of intentional communication. For
example, Romski and Sevcik (2003) use the differentiation between perlocu-
tionary (unintentional communication, e.g., gazing, crying, laughing,
movement), illocutionally (becoming intentional through physical manipu-
lation, pointing, vocalization with inflection), and locutionary (intentional
COMMUNICATION, LANGUAGE, AND LITERACY 375
through using words, signs, gestures, thus conventional communication)

to describe the progression of behavior from least intentional to intentional.
Typically a child would move through the perlocution and illocutionary
stages approximately between the ages of 18–21 months of age. Rowland,
Schweigert, and Stremel (1992) adapted these categories in working with
children with multisensory impairments and describe the following behaviors:
Primitive behaviors: Earliest behaviors that children may use to com-
municate. These are behaviors that most children use before they start to
communicate. Children with multi-sensory impairments might use these
beyond infancy. They include gross vocalizations, simple body movements,
simple actions on people and simple actions on objects.
Conventional behaviors: These are gestures agreed upon by society.
Most adults use these to supplement oral communication, such as point-
ing, raise hand/wave, extend hands (receive an object). and nod/head
shake and other conventional gestures.
Symbolic behaviors: These are symbols that are used purposely for
communication. The child thus understands the relationship between the
symbol and the referent even though the referent is not present. Symbols
stand for objects, people, activities, and concepts and allow us to commu-
nicate about things not present in the context.
Symbolic behaviors include:
Object symbols, three-dimensional objects that are used to represent
people, concepts, activities, or other objects
Picture symbols, for example, photos, line-drawings, or abstract graph-
ics used to represent other referents
Manual signs, any formation of one or both hands that represents
words or letters
Spoken words
Printed letters or words
Braille letters or words
Prior to the child having 50 words (about 21 months) the focus of the
communication development would typically be on the pragmatic aspects
of language (i.e., the interactional aspects) as well as on language content
(i.e., vocabulary and semantic relationships) rather than on grammatical
aspects (Romski, Sevcik, Cheslock, & Hyatt, 2002). However, with children
with developmental delays, individual profiles will vary largely due to the
influence of biological status and environmental influences.
Before school-going age much attention is directed at facilitating communi-
cation and language learning in preparation for academic learning. At the time
of more formal learning in school, these language and communication skills
become the medium for advanced learning through information exchanges
and increasing levels of abstraction required as part of this process. The basic
concept is thus that before school-going age, children generally learn to
communicate, whilst during school they use communication skills to learn.
Clearly this is not a linear process, particularly not for children with
developmental disabilities who not only might have a developmental
delay, but could also show patterns of atypical development which persist
throughout a lifetime. Coping with the transition from the use of language
for communication to the use of language for learning can therefore pose
significant challenges to young children who, for the first time, have, to
develop the awareness of language to enable them to identify words, play
around with sounds, and make the connection between what is spoken
and how the spoken word is represented in written form.
This metalinguistic ability or awareness of language not only requires
that the child has sufficient understanding of language as a means and
object of learning, but also requires that the child is able to think analyti-
cally about symbols used in communication. The child needs to be able to
interpret different types of information transferred via different modes of
transmission. For example, the child not only needs to listen or hear the
spoken word, but also needs to interpret the nonverbal or graphic symbols
that accompany the spoken word. When any of the sensory channels of
the child are thus impaired, the information process is modified which can
affect the young child’s interpretation and experience of reality.
DEVELOPMENTAL DISABILITIES, COMMUNICATION,

AND INFORMATION PROCESSING
The neurological processing problems of children with developmental

disabilities can have an impact on information processing in various ways,
which in turn would have an impact on the way in which the young child
perceives and relates to the world. The child’s ability to decode, receive,
monitor, and interpret different codes used (e.g., auditory and visual signs)
as well as the ability to encode and formulate messages using different
codes with intra- and interpersonal feedback loops significantly influence
the level of meaning derived from the interaction. However, even for the
child with developmental disabilities whose processing abilities are rela-
tively intact, the strategies used to enhance interaction and learning might
have an impact on this process.
The way in which information processing occurs and the different fac-
tors that could affect this are represented in Figure 12.1, which shows
how the sender sends a message using different communication modes,
for example, speech, writing, signing, and facial expressions. These dif-
ferent communication modes get transmitted through the transmission
environment by, for example, using auditory waves (speech), light waves
(writing, signing, facial expressions), or as a physical entity (passing an
object or a Braille ‘letter’). Through the internal feedback loop, the indi-
vidual is able to monitor his or her own production of messages to ensure
that what is expressed is indeed what was intended.
These signs are then received and interpreted by the communication part-
ner by means of the different sensory systems (mainly auditory, visual, and
tactile) and interpreted to develop meaning. This new information received
is integrated into the existing experiences and frameworks of the individual
and stimulates a response, such as the construction of another message to
send back to the sender. This process is, however, not linear as simultaneous
feedback (external feedback) between the two participants takes place all the
COMMUNICATION, LANGUAGE, AND LITERACY
Socio-cultural environment
External feedback loop
Sender / Receiver /
Receiver • Speech Sender
Message
Message sent • Writing/typing
received by
via: • Signing Via the
- ears
• Gesturing transmission
- eyes
• Pointing environment - touch
• Facial expressions
Message • Posture and movement
received by • Speech Message sent
- ears • Writing/typing
- eyes Internal feedback loop via:
Via the • Signing
- touch
transmission • Gesturing
environment • Pointing
• Facial expressions
• Posture and movement
Internal feedback loop
Figure 12.1. The communication process.
377
time. The mere fact that the one individual communicates a specific message
does not mean that the other can’t give some feedback via facial expression
or other nonverbal and verbal means. This process of external feedback is
important to enable the communicator to adjust the messages sent to prevent
communication breakdown and facilitate effective communication.
For the typically developing child, symbolic representation begins with
speech developing from vocalization and eventually expands to include
orthography. A significant number of children with developmental disabili-
ties, however, are exposed to the use of manual signs, graphic symbols,
or speech-generating devices as early forms of receptive and/or expressive
communication. This modified interaction process can have an impact on
the information processing demands placed on the child and thus influ-
ence the experience and meaning derived from interactions.
McNaughton and Lindsay (1995) described the impact of the use of
graphic communication symbols, for example, Bliss symbols on the sym-
bolic representation process of the child who has little or no speech and uses
graphic symbols to supplement existing vocalizations or speech. Unlike the
child who uses speech to communicate, this child will be using graphic sym-
bols to facilitate expression. Whereas the typically developing speaking child
will, for example, verbalise “more” and get the auditory and proprioceptive
feedback related to the speech act, the child using graphic symbols will be
pointing to a graphic symbol of “more” on a communication board to indicate
to people what is required. The feedback that the child using a communica-
tion board receives from this communication act is thus much different, as
pointing at a line drawing provides mostly visual feedback with some proprio-
ceptive feedback from the pointing. Similarly the child who makes a manual
sign for “more” would get visual and proprioceptive feedback from the manual
sign used to transmit the message. The question is thus how these different
modes of communication affect information processing, language learning,
and literacy learning of the child.
Similarly, Von Tetzchner and Grove (2003) describe the asymmetry
that exists between the communication modes used for receptive lan-
guage input and expressive language output in children who can hear, but
have little or no speech and use alternative modes to supplement speech.
Receiving and understanding oral language whilst not being able to use
speech to communicate can once again have an impact on language learn-
ing. In addition to the impact that the modes of communication have on
information processing and interpretation, the sociocultural environment
of the child also plays a most significant role.
SOCIOCULTURAL ASPECTS OF COMMUNICATION,

LEARNING, AND LITERACY
Use of Symbols in Context

Just as specific impairments have an impact on the communication
and language learning of young children with developmental disabilities,
so also do the environment and rehabilitation strategies used.
The ability to intentionally manipulate symbols for communication

and learning implies that young children are able to participate in a con-
structive way in the world around them. For learning to take place the
individual’s participation in the environment is required by using symbols
in interaction as well as being engaged in activities.
Dunst (2001) emphasised that children are exposed to experiences
that can be described as either development-enhancing or development-
impeding in their consequences. These experiences all occur within the
sociocultural context within which the individual lives and they provide
the opportunities for interactions and learning. He describes activity set-
tings as the context within which a child can express interests, engage-
ment, and develop competence as well as a sense of mastery. These activity
settings provide the context for communication and learning, and also for
literacy development of the young child. These activity settings are impor-
tant not only in relation to the type of activities that the child is exposed
to, but also in relation to the opportunities they present and the level of
engagement of the child during these activities.
The extent to which the child is acknowledged and encouraged to par-
ticipate during an activity could make a significant impact on the learning
outcomes for the child. However, interaction in activities is often determined
by sociocultural factors as well as personality-related variables. Wachs (2000)
refers to the concept of “niches” as the way in which the individual relates
to specific situations, people, and settings around him or her. These unique
ways in which a child relates to the environment significantly affect the way in
which learning and experiences develop in interaction with the environment.
The assumption that children of a same age or ability will relate to a
specific learning context in the same way is thus questioned. These unique
ways in which a child relates to the environment significantly affect the
way in which learning takes place. For example, Dada, Granlund, and
Alant (2007) describe how the response of four children exposed to the
same treatment resulted in different outcomes and hypothesised that the
way in which the children related to the context, thus their niches, might
have differed based on their unique experiences. This focus on the indi-
vidualised experiences of children is important in facilitating understand-
ing of varied outcomes of intervention of children who seemingly have a
similar profile of diagnoses and environmental contexts.
Literacy Learning as a Social Process

When talking about literacy skills as a sociocultural process, the focus
is on the process of learning to read and write as part of a complex set of
social and cultural interactional patterns. These include not only the abil-
ity to read and write, but also the ability to respond appropriately to spe-
cific social situations as well as to know how much information to provide
within a specific context and how to relate to printed matter. Heath (1984)
gave an account of the different ways in which families from two different
social groups related to the process of reading and writing within their own
communities. It emphasised how the groups differed in relation to the type
of literacy activities to which children were exposed.
In addition, Hall (1976) also elaborated on the difference between a

context-dependent and context-independent interactional style. Context-
dependent refers to those types of interactions that require the presence of
a communication partner to understand the meaning of the interaction, for
example, “You have to go from here to there.” Context- independent refers
to a more detailed description to ensure people who are not in the context
can understand the message, for example, “You have to go from Pretorius
Street to Church Street.” Written communication clearly calls for a much
more context-independent style in order for a message to be conveyed suc-
cessfully. Children who have been exposed to a context-independent style
thus have an advantage as they approach the task of becoming literate.
This research highlights the need for researchers and interventionists to
also be cognizant of the impact of sociocultural factors on the language
and literacy learning of children with developmental disabilities.
The acknowledgement of the link between sociocultural orientation
and the acquisition of reading and writing skills revolutionised the under-
standing of factors having an impact on children’s literacy achievements
at school. The emphasis moved away from viewing reading and writing as
essentially being located within the individual to understanding that the
social context within which the individual lives largely affects the individu-
al’s attitude and orientation towards the literacy learning process. This is
particularly relevant for children with disabilities, as the label “develop-
mentally disabled” often means that exposure to formal literacy instruction
is minimal. The expectation of these children to achieve any meaningful
literacy levels is thus often very low. It is therefore not always the child’s
ability that is the primary barrier in acquiring literacy skills.
In a similar vein, Hunter and Harman (1979, p. 9) stated that poverty and
the power structures of society are more responsible for low levels of literacy
than the reverse and that the elimination of illiteracy among many would
not necessarily have an appreciable effect on the other factors that perpetu-
ate poverty in their lives. The realization that the ability to acquire reading
and writing skills is necessary but not sufficient to secure improved access
to employment or other social contexts emphasised the need to understand
the sociocultural issues involved in the process of literate environments.
Issues of social power, exclusion, and disempowerment became quite promi-
nent in understanding individuals’ failure in learning literacy skills.
In recent years, there was a shift away from “readiness for reading and
writing” (thus whether the child had acquired the visual and auditory per-
ception and processing skills as well as motor coordination skills to cope
with the process of reading and writing) to “emergent literacy” (whether the
social environment was congenial to literacy development) in an effort to
facilitate early literacy education for children. Focus was therefore not so
much on whether the child had acquired the necessary underlying infor-
mation-processing skills for reading, but whether the child was exposed
to sufficient literacy experiences in the home and preschool contexts as a
basis for learning how to read and write.
The challenge of communication and literacy learning in children
with developmental disabilities, however, also often relates to an inability,
resistance, or lack of interest to participate in activities related to reading and
writing due to difficulties in deriving meaning from the symbols or activities.

In these scenarios, the use of augmentative and alternative communica-
tion strategies can be useful; not just to assist individuals to expand their
communication, but also to give them easier access to the literacy process
by introducing line-drawings and other symbol systems.
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION

AND ITS ROLE IN FACILITATING COMMUNICATION
AND LITERACY DEVELOPMENT
What is Augmentative and Alternative Communication?

A significant proportion of people with disabilities are unable to use
speech and/or writing to fully meet their communicative needs. They thus
have a need to use augmentative and alternative communication (AAC),
defined by Lloyd, Fuller, and Arvidson (1997) as the supplementation or
substitution of natural speech and/or writing by symbols, strategies, and
techniques which are not used or at least not relied on to the same extent
by speaking individuals.
As communication and literacy learning implies the use of specific
symbolic codes to transmit and interpret meaning, the use of alternative
signs and symbols in this process needs to be monitored and understood.
The success with which AAC systems and strategies are used largely
depends on their relevance and appropriateness for the child and fam-
ily and the way in which child and family are able to accommodate these
strategies in their own world. The introduction of strategies to augment
existing communication not only affects the content of what is communi-
cated and how communication takes place, but also on the way people in
the environment relate to the individual.
It is for this reason that the social and cultural factors of family and
community life need to be reflected in the communication boards or strat-
egies introduced so that the individual and family can optimally integrate
them into everyday life.
The following case illustration aims at demonstrating the process of
AAC implementation within a particular sociocultural context.
Case Study
Kagiso is a 4-year-old girl with a diagnosis of spastic quadriplegia.
She presents with very low tone in her trunk, and increased tone in all
four limbs. Kagiso lives with her mother, grandmother, and younger
sister in an urban township in South Africa. Her mother is unem-
ployed. The family income consists of the grandmother’s pension,
a care dependency grant received for Kagiso, and a childcare grant
received by unemployed parents. Kagiso has been attending a main-
stream crèche for about 1 year now. Together with her mother, Kagiso
(continued)
Case Study (continued)

has been attending group sessions at a weekly outreach clinic since
the age of 2. The clinic is held in the community and run by an occu-
pational and speech therapist from a nongovernmental organisation.
During the group sessions at the clinic, it became obvious that
Kagiso’s cognitive functioning and understanding of language were
strengths in her skills profile. Her motor involvement was severe, and
this also affected her speech. She initially used only undifferentiated
vowel sounds and very slowly added some bilabial and lingual-alveolar
consonants to these. Currently she is able to utter bisyllabic word-
approximations given much time and effort. Although her mother can
understand these in context and after some guessing, most others cannot.
Kagiso also uses eye gaze and yes/no signals to communicate.
AAC intervention commenced with an exposure to key word signs
in the context of songs. Kagiso was attentive to the signs. However, her
motor limitations made production slow, and she struggled with the
fine motor aspects. Within the group, the children were also prompted
to use the gestures for MORE, MINE/MY TURN/ME, and OPEN. Kagiso
learnt to use approximations of the signs and would consistently use
the signs when the opportunity was created. Her mother was asked
to create opportunities for Kagiso to use the sign for MORE at home,
by withholding, for example, food until she made the sign to ask for it.
However, her mother clearly found this concept strange. Rather, her
mother took this exposure as a cue and taught Kagiso to wave good-
bye as well as to clap hands as a way of requesting (saying please).
The latter is commonly observed in African cultures as a way of polite
requesting, and the former is also culturally applicable.
It became clear quite quickly that Kagiso needed more strate-
gies than key word signing to expand her expressive communication.
With the knowledge that Kagiso could identify magazine pictures, her
mother was shown how to make choice boards for food as well as
choices for routine activities (brushing hair, brushing teeth, bathing,
etc.) using pictures from magazines. These choice boards were, however,
not found useful by her mother, other than being used for ‘show me’
activities. Within the daily routine, choices were not really offered,
and when requesting food, Kagiso successfully used a combination of
vocalisations and eye gaze to direct her mother to the desired item.
Together with her mother, ‘Telling mum about school activi-
ties’ was identified as a communicative situation where breakdown
occurred and where intervention was necessary. In order to achieve
this, Kagiso was first given exposure to a commercially available set
of line-drawings, Picture Communication Symbols (PCS), to allow
access to more concepts. These PCS depicted mainly nouns and
verbs that were related to language themes (clothing, animals, etc.)
as well as therapy activities (singing, ball play, exercises, book read-
ing). The aim was receptive exposure (i.e., Kagiso could observe ther-
apists pointing to or showing pictures to convey a message), as well
as matching (e.g., plastic horse to PCS picture: children had to point

out the picture on their own board).
Following this, and in interaction with Kagiso’s teacher and mother,
a communication board was made for Kagiso, which she used success-
fully to communicate about school activities with her mother. This
was followed by other boards being developed around activities Kagiso
engaged in and enjoyed, such as ‘shopping’ and ‘visiting’. The ‘shopping’
communication board is shown in Figure 12.2. Kagiso started using
these communication boards with the therapists at the clinic, to tell,
for example, about her shopping of the past week. However, therapists
and her mother were the only communication partners with whom she
would use the boards. Her grandmother, for example, still found the
boards too foreign. According to Kagiso’s mother, her grandmother was
not literate, and found it hard to understand the PCS pictures.
In school, it was also difficult for Kagiso to use her boards. They were
not always available, and Kagiso’s teacher was often distracted by Kagiso’s
talking peers, who were much better at demanding attention. The teacher
also did not give many opportunities to individual children to talk or
answer questions. A lot of unison chanting and repetition was the norm.
A digital speech-generating device, which had been sponsored
by a private sponsor, was introduced. The specific device was chosen
because it was robust, and very easy to program, while still having
relatively many message recordings (eight messages could be recorded
onto each of eight levels, thus allowing for a total of 64 messages).
Kagiso was able to access eight messages (prerecorded by an adult) at
a time. Kagiso’s mother was taught to program and charge the device.
Her teacher would not try, for fear of breaking it. Song time was chosen
as the first activity during which the speaker was to be used, and the
parts of a song were simply recorded in sequence on the eight but-
tons. Kagiso could now experience herself as a ‘speaker’ and could join
with the other children in the particular song. Snack time was then
identified as a time when there was potential for interaction. Kagiso
became quite skilled at pressing 2–3 buttons in sequence to formulate
sentences. Peer interaction drastically increased, as all her classmates
were fascinated by the ‘talking machine’, and would seek opportunities
to initiate interaction with Kagiso to see her use her speaker.
From this case illustration, certain factors which need considera-

tion for appropriate AAC intervention can be highlighted. Firstly, Kagiso’s
background and context need to be considered. She has a supportive and
involved mother, who has time to spend with her, and who is able to bring
her for regular intervention. Her mother gives input on vocabulary selec-
tion and feedback on the appropriateness of the systems and strategies.
Kagiso’s main communication partners include her mother, grandmother,
teacher, and classmates, and her communicative contexts are mainly
home and school. Alant (2005a), in her description of AAC intervention as
a support-based process, further elaborates on the importance of taking
cognizance of partners and contexts.
Secondly, her skills profile gives an indication as to the purpose of

AAC, this being mainly to increase her ability to express herself, as recep-
tive language seems age-appropriate. Kagiso thus falls into the so-called
‘expressive group’ (von Tetzchner & Martinsen, 2000), where a significant
gap exists between receptive and expressive language (further explained
in the following).
The case study illustrates the need for multimodal communication,
and for continuous ‘fine tuning’ and expansion of AAC symbols and sys-
tems as more and more contexts and partners are involved. As various
benefits and drawbacks of the different systems become evident, inter-
ventionists need to introduce enough variety in order provide a robust
and versatile system. This principle of working toward sustainability of
the communication strategies is discussed in Alant (2005b) and focuses
on the difference between effectiveness, sustainability, and versatility, the
latter of which refers to the impact of skills acquired over time.
In this case study, key word signing was first introduced, as this strat-
egy is more ‘natural’ and easier for caregivers to implement than picture-
based systems. However, due to motor problems this strategy was soon
found to be too limited. Magazine pictures of food and daily activities were
also too limiting, as Kagiso was able to convey those concepts using eye
gaze, vocalizations, and pointing.
Line drawings on paper-based communication boards gave Kagiso
access to a much broader range of vocabulary, but these boards were
again found difficult to implement with certain partners (e.g., her grand-
mother) and in certain contexts, such as school. Fuller and Lloyd (1997)
give a detailed description of characteristics of various symbols, and
issues in symbol selection, and Alant (2005c) describes the importance
of cultural appropriateness of graphic symbols use in specific settings.
Please see Figure 12.2 as an example of a communication boards devel-
oped for this case.
Strategies for generalizing the use of AAC to other contexts need to
take culture and preferences of partners into consideration. It is clear
that interventionists need to gain knowledge not only of routine activities,
but also about the way in which interaction happens within these activi-
ties. Whereas in Kagiso’s case eating and feeding was a routine activity,
Kagiso’s mother did not see this as an opportunity for Kagiso to ask for
‘more’, and felt uncomfortable about withholding food to this purpose.
Her mother did, however, see the potential of using signs/gestures, and
took initiative to teach Kagiso those which she found culturally appropri-
ate. Using hand clapping to politely request made Kagiso more socially
appropriate within her community, and was thus seen by her mother as
a gain for Kagiso. Similarly, ‘food choices’ was not an appropriate activity
to introduce as a picture system, as Kagiso was already communicating
successfully in this activity.
The introduction of technology needs to take into account the resources
to support and sustain the process of implementation; in this case, charg-
ing and programming of a device. Although a more sophisticated device
might be beneficial to Kagiso, her family and community might not be able
to support implementation. Also, although the device is accepted by peers,
Figure 12.2. A communication board for the topic ‘shopping’, devised for a young child
with cerebral palsy living in South Africa (gloss in Northern Sotho and English).
it is not accepted by Kagiso’s grandmother. Similarly, it is not practical to

use it in community settings. Alant (2005d) gives a detailed description
of factors that need consideration for introducing technology particularly
into a low-income context.
Who Can Benefit from AAC Strategies?

As children with motor impairments, developmental language disor-
ders, learning disabilities, autism, and Rett syndrome often experience
communication problems, issues surrounding communication inter-
vention remain pertinent. In an attempt to understand the spectrum of
communication problems that children with developmental disabilities
might present with, this aspect is dealt with in more detail.
Von Tetzchner and Martinsen (2000) identified three functional groups
of children with disabilities in need of communication intervention and
in particular in need of augmentative and alternative communication.
Their description is slightly modified and used as a basis for the present
discussion.
The first group is called the expressive language group. This group of
students displays a significant gap between receptive and expressive lan-
guage. It could include children with motor impairments, Down syndrome,
learning disability who have different cognitive abilities, but have a defi-
nite gap between their expressive and receptive language ability. These
children could be severely physically impaired and thus use AAC as a per-
manent means of communication or could be using AAC as a temporary
means of communication until speech has sufficiently developed.
The second group is referred to as the developmental group. This
group of children displays a general delay in language development on
both a receptive and expressive level without any significant gap between
the two. Typically this would include children with cognitive disabilities
whose development is generally delayed. Intervention strategies should
thus be used to enhance receptive and expressive language skills.
The third group is referred to as the alternative language group. This
group of students has difficulty in acquiring language and communication
and is often not able to speak. They have limited ability to use symbolic
language in spite of having normal hearing abilities. This group will typi-
cally rely on AAC strategies to communicate and could include children
with severe and multiple disabilities as well as children with autism.
Although it is possible to further differentiate smaller groups in some
of the categories, differentiating the three main groupings is useful in facili-
tating understanding of the different roles that AAC can fulfil in intervention
with this heterogeneous group of children with developmental disabilities.
AAC INTERVENTION: THE ASSOCIATION BETWEEN

ENGAGEMENT AND INTERACTION
As mere exchanges of messages do not necessarily reflect significant

levels of engagement from the individual, the differentiation between engage-
ment and interaction behavior could be important to facilitate intervention
outcomes. This point can be illustrated with a study recently conducted by
Sigafoos, Ganz, O’Reilly, Lancioni, and Schlosser (2006) where two students
with developmental disabilities were taught to request snack items.
Whilst both students learned to request using an exchange-based
communication system, only one showed a high level of correspondence
between the request and the outcome. They concluded that the one stu-
dent still required explicit correspondence training. Although there could
be various explanations for why these outcomes differ, a difference in the
level of engagement between the two children during the process of inter-
vention could provide one of the explanations.
Even though both children behaved similarly in that they utilised the
exchange-based system, a difference in the way in which they related to
the process is evident. Some assessment of the level of engagement of
both children in the above study might have rendered some explanations
of how their participation during the intervention might have affected the
outcomes. The one child might have participated in the exchanges as an
empty ritual, thus with minimal levels of engagement, whilst the other
might have been more engaged in developing meaning within the context.
Raspa, McWilliam, and Ridley (2001) identified various levels of
engagement in observing children in different contexts. These included
sophisticated, differentiated, focused, and unsophisticated engagement.

Taking cognizance of the concept of engagement in addition to the fre-
quency of exchanges seems to be most important in enhancing under-
standing of the participation process. Two components of participation
can be identified: these being engagement and the interactive behavior
observed as part of the process. Engagement, although important, largely
focuses on the relational component of participation. As this relational
component could manifest in different ways during the process of partici-
pation, a second component of participation (i.e., interactive behavior) is
important. Understanding the level of participation seems to be dependent
on a dynamic interaction between engagement and interactive behavior.
In an attempt to develop this argument further, Figure 12.3 represents
participation with engagement on the one axis and interactive behavior on
the other to describe the association between these two components of par-
ticipation. According to this matrix, meaningful levels of participation will
require high levels of engagement and differing levels of interactive behav-
ior depending on the individual’s expressiveness and cultural context.
Interactive behavior can manifest through verbal and nonverbal means
and can vary from low (few observable interactive behaviors) to high (high
frequency of interactive behaviors). Although the frequency of observed
communication behavior can be high, this level of activity does not neces-
sarily provide an adequate impression of the individual’s level of engage-
ment in the process (as per the above example in Sigafoos et al., 2005).
A high frequency of interactive behavior thus does not necessarily reflect
a high level of engagement, just as a low level of interactive behavior does
not necessarily infer a low level of engagement. This is particularly impor-
tant in view of varied interaction styles prevalent in different social and
cultural contexts (Alant, 2005b).
High
Active-engaged Active-disengaged
Interactive
High Engagement Low

behavior
Passive-engaged Passive-disengaged
Low
Figure 12.3. Components of participation.

From Figure 12.3, four combinations of the association between

engagement and interaction behavior can be identified in describing par-
ticipation:
- Active-engaged implies a high frequency of interactive behavior with
a high level of engagement. This pattern would be characteristic of
individuals who demonstrate a high number of exchanges with the
interventionist, whilst at the same time indicating a high level of
engagement. According to Seligman (2002), a high level of engage-
ment could be evident from the level of gain and application of what
was learned.
- Passive-engaged implies a low frequency of interactive behavior with
a high level of engagement. This pattern would be characteristic of
individuals who are less demonstrative in their exchanges during
intervention, but at the same time maintain high levels of engage-
ment by reflecting understanding and application of what is gained
as part of the process.
- Active-disengaged implies a high frequency of interactive behavior,
whilst being relationally distant. This pattern would manifest as
individuals who demonstrate a high number of exchanges in inter-
action, but demonstrate low levels of meaning development. Whilst
rituals might be taught, application will be limited.
- Passive-disengaged implies low frequency of interactive behavior,
whilst also remaining relationally distant. This pattern would typi-
cally manifest as individuals who have a low motivation and/or com-
mitment to the process.
Although the four identified combinations represent ideal types, they
provide some guidelines for the recognition of similar trends within the
intervention process to enable interventionists to develop some hypoth-
eses in relation to the level of participation (i.e., engagement and interac-
tive behavior) during intervention. As with the application of any model,
the practical manifestation of ideal types needs to be flexible to account
not only for contextual variables but also for individual differences. The
personality, interests, past experiences, and cultural background of the
person will all add to the way in which the individual relates to the process
(Super & Harkness, 1986; Wachs, 2000).
Intervention: Observing and Understanding Engagement

Patterns of the Child
Engagement and interaction form the two basic constructs on which
participation is built. McWilliam et al. (2001, p. 1) described engagement
as the “amount of time children spend interacting with adults, other chil-
dren, or materials in an appropriate manner.” Although time spent can be
an important indicator of engagement, the quality of the involvement is
also important. The reference to “appropriate manner” can be seen as an
attempt to capture some aspect of the relational component in describing
engagement. To understand the engagement patterns of a child, we have
to observe him interacting with people and activities in ways that not only
give information on time spent, but also the level of gains or enjoyment
derived from the experiences.
The use of purposeful activities such as play activities for young chil-
dren to observe participation is not a novel concept. Play is the occupa-
tion of a child and has motivational value. A child experiences satisfaction
when engaged in a purposeful activity, which leads to sustained perform-
ance, self-reward, and intrinsic motivation. This positive cyclical process
of enjoyment through engagement contributes towards the development of
new skills, mastery of skills, and the experience of a sense of control over
the environment (Uys, Alant, & Lloyd, 2005).
Enjoyment is an abstract concept and therefore difficult to meas-
ure, but an analysis of the construct reveals measurable behaviors, that
is, attention to a task and performance on the developmental domains
(social, emotional, sensory, motor, cognitive, and communication). For
enjoyment to occur there should be a match between the child’s abili-
ties and the environmental or activity demands and the activity should be
culturally valued. Csikszentmihalyi (1990) explained in his epic research
on optimal experiences that a person would be maximally engaged in an
activity when there is a “just right challenge” between the abilities and the
demands. However, the demands should always be a little higher than the
skills to press for development of mastery of skills. Mastery motivation is
defined as a “psychological force that stimulates an individual to attempt
independently, in a focused and persistent manner, to solve a problem or
master a skill or task which is at least moderately challenging for him or
her” (Morgan, Harmon, & Maslin-Cole, 1990, p. 319).
The question arises when observing children: what elements should
be observed during play, the end product or the process of activity partici-
pation? McWilliam et al. (2001) indicated in a research study on teaching
styles and engagement, that teachers who were product-focused inhibit
learning opportunities for children and their students scored lower on
developmental scales than those children exposed to teachers who are
process-oriented. McWilliam et al. (2001) also found in their research that
preschool children (3–6 years) presented with more sophisticated engage-
ment than toddlers who were performing on an unsophisticated level.
They suggest nine levels of engagement but only focused on five levels in
their most recent research: sophisticated, differentiated, focused atten-
tion, undifferentiated, and nonengaged (McWilliam, et al., 2001). Table
12.1 presents the characteristics of each level.
Two essential features in promoting child engagement seem to be the
interventionist’s interactive behavior and the quality of the environment.
Facilitating Interaction
Three key elements are intertwined in the learning process of young
children, these being firstly the demands presented in the environment,
secondly the child’s abilities and motivational level, and thirdly, the inter-
ventionist who has to integrate these elements to facilitate participation.
Each element has the potential to be adapted or modified to suit the context.
Adaptation is viewed as an external agent necessary for changing the
Table 12.1. Levels of Engagement

Sophisticated Involves problem-solving and the child either uses changing strate-
behavior gies or the same strategies to solve the problem or reach the goal.
The child uses language, pretend play, sign language, drawings, etc.
that allows him or her to reflect on the past, present, and future and
construct new forms of expression through combining symbols or
signs. The child can communicate about something or someone not
physically present.
Differentiated The child has a set of behaviors that permits adaptation to environ-
behavior mental demands and expectations. This includes active interaction
with the environment (materials, tools, and people). At this stage the
child is becoming more outcomes-focused.
Focused Includes watching or listening for features in the environment. Paying
attention attention to the features is a requisite. Serious facial expression and
quieting of motor activity characterise this level. Implies selectivity
and intensity of attention.
Unsophisticated There is no clear differentiation in the child’s behavior. Behavior is
behavior repetitive and exploratory in nature. Attention is poorly focused and
action is not aimed at a specific outcome.
Nonengaged The child is seemingly uninvolved in any activity and tends to be
behavior destructive and aimless. Focus of attention seems fleeting.
Based on McWilliam et al. (2001).
environment to fit the person as well as an internal change that occurs

when a person learns new behaviors. It is therefore the adjustments that
are made between an individual and the environment that boost personal
survival.
To encourage interaction requires a close relationship between the
challenges inherent in the activity and the child’s skills. The environment
should therefore be structured to meet the abilities of the child to experi-
ence success. If the challenges are too high, the child can withdraw as
anxiety is experienced, but if the challenges are too low, the child will be
bored with the activity which could also lead to withdrawal (Csikszentmi-
halyi, 1990). Structuring of activities includes making items such as toys
physically accessible (Uys, 1998), as well as presenting the activity in an
accessible way to the child, especially to the child with developmental dis-
abilities.
Table 12.2 summarises some of the principles for adaptation used in
intervention. From this table it is evident that adaptations can be made to
play materials and presentation methods. Both these forms of adaptation
need to be considered to ensure meaningful participation in an activity.
Just as stabilisation of a toy for a child with coordination problems could
facilitate access to toy manipulation, so can time delay or animation facili-
tate joint interaction. When successfully engaged in activities, the feed-
back from the activity would encourage the child to repeat the activity and
practice new skills to enhance skill mastery.
The function of internal systems influences a person’s desire for
mastery and consequently the level of engagement. Personal capabilities
include the skills of different developmental domains: sensory, motor,
cognitive, socioemotional, and communication. A child has to integrate
Table 12.2. Adaptation of Play

Adaptation of Play Materials Adaptation of Presentation Methods
Stabilisation Requesting
Enlargement Commenting on objects
Providing a prosthesis Commenting on actions
Reducing required response Protesting/denying
Making it more concrete Describing objects/actions
Making it more familiar Presentating an obstable
Removing distracting stimuli Making a general statement
Adding cues Introducing time delay
Increasing safety and durability Using incidental teaching
Giving more time to respond
Initiating joint activity
Using animation
Using imitation
information from all the domains to perform effectively in a social con-

text. A deficit in one domain has a direct influence on the other domains
with subsequent impact on the general functioning. Because play is the
child’s occupation, intervention’s main goal needs to include enjoyment
through participation to enhance mastery. Children have an internal
desire to become a master of the environment. To elicit this internal
desire, meaningful activities need to be selected to accommodate each
child’s interest.
Children with developmental delays experience distress in relation to
environmental challenges, which in turn interferes with all aspects of the
learning process. These children are often unable to use learning situ-
ations optimally due to their inability to access the environment. They
can be unable to initiate new responses to environmental demands, thus
negating the process of differentiation and integration. It is against this
background that interventionists need to remain cognisant not only of
ways in which to facilitate interaction with a child, but also of the level of
engagement of the child during interaction.
Interaction between the child and the environment implies press for
mastery. Ideally the interventionist should aim to create a match between
the desire for mastery (child) and the demand for mastery (environment).
Interaction (active participation in the environment) is the pivotal point for
learning to occur. Interaction challenges the child’s abilities and presses
for the improvement of behaviors indicative of development. When the
children respond to stimuli from the external environment (e.g., a play
activity), they have to use their internal abilities (systems) to interpret,
integrate, and organise the stimuli, to give meaning to it and to respond
accordingly. When these responses are effective, learning occurs and posi-
tive feedback is received from the external environment either through
the activity itself or through interaction with the adult. This internal
experience creates satisfaction, which increases self-esteem and engage-
ment (Csikszentmihalyi, 1990).
EMERGENT LITERACY: THE IMPORTANCE

OF HOME-BASED LITERACY EXPERIENCES
Just as communication and learning takes place as part of the daily

interaction between family members and the young child, so also do these
interactions provide opportunities for the development of the basic orien-
tation to literacy development. Teale and Sulzby (1986) adopted the term
‘emergent literacy’ to signal a break from the approach of reading readi-
ness where the focus was on the acquisition of specific skills associated
with reading and writing to focus more on the informal learning in holistic
activities at home, preschool, and kindergarten. The approach of emergent
literacy is thus primarily concerned with the link between language and
communication development and written language. It includes early skills
relating to book orientation, early print awareness, and knowledge of print
prior to the acquisition of formal literacy skills (Teale, 2003). During this
time the child acquires knowledge on the functions, uses, and significance
of text, which form the foundation for later conventional literacy learning
(Whitehurst & Lonigan, 1998).
Early reading and writing activities are considered as equal compo-
nents of this complex process involving both production and reception
of written language. Koppenhaver, Coleman, Kalman, and Yoder (1991)
described reading and writing as cognitive activities embedded in social
and linguistic contexts that involve communication, listening, speaking,
reading, and writing within everyday life irrespective of the communication
mode used by the young child. That the young child is able to participate
in these activities is much more important than how (which mode of com-
munication) the child is going to access the activities.
The initial part of the 21st century has emerged as a period offering
unprecedented attention to emergent literacy largely due to the realiza-
tion of the importance of these activities for later literacy development
and the impact that lack of early exposure to literacy activities has on the
development of literacy skills of children with developmental disabilities.
Light and Kelford-Smith (1993) for example, compared the home literacy
experiences of physically disabled preschoolers who use AAC systems
to the experiences of their typically developing peers. They found that
the experiences of preschoolers using AAC differed significantly from the
experiences of their typical peers. These children do not have the same
access to communication and thus find it more difficult to respond during
these activities. Story-book reading, which in the case of typically devel-
oping children can be highly interactive and enjoyable, often becomes
more parent-dominated and directive in nature when parents interact
with their child who has little or no functional speech. The engagement
of the young child within this context also becomes more difficult as the
child does not necessarily relate to the symbols or pictures used in the
same way as the parent.
Various authors have also conducted research on the early literacy
experience of deaf children. The studies of Ewoldt (1985), Andrews and
Taylor (1987), Akamatu and Andrews (1993), and Williams and McLean
(1997) acknowledged the importance of storybook reading as part of emergent
literacy development in children who are deaf. Gioia (2001), however, found
that although literacy practices were established in the homes, shared
reading rituals between parents and their deaf children were not always
established. Although parents enjoyed reading with their children who
are deaf they experience obstacles in the reading process (Heinemann-
Gosschalk & Webster, 2003).
Mirenda and Erickson (2000) also explored the use of AAC in facili-
tating literacy in children with autism. They emphasised the importance
of a sociocultural model of literacy learning and acknowledged that
the attitudes and expectations of those in the individual’s immediate
environment, the availability of reading and writing materials, and the
nature of interactions between the individual and his literacy partners
are important. These partners do not only include parents or teachers,
but also siblings. Lenhart and Roskos (2003) documented the literacy
learning and interaction between two siblings in literacy activities and
found that the older sibling was significant in demonstrating literacy
skills to the younger child and that to a large extent the older sibling
shaped the young child’s perception towards print and books. The role
of siblings as part of the emergent literacy process is thus acknowledged
as important in the process of literacy learning in the young child with
developmental disabilities.
Perhaps the most important strategy for enhancing the home literacy
exposure of children with developmental disabilities is an understand-
ing of the context within which families live and their perceptions of the
importance of literacy learning of the young child. One of the first steps in
this process is to make parents aware of their own literacy routines in the
home to guide them in how to use these as a basis for further expansion.
Awareness of Literacy Exposure at Home

Light and Kelford-Smith (1993) identified four contexts that form a
part of early literacy experiences at home. Literacy learning is seen as
embedded in multiple contexts which affect both child and literacy event.
These contexts can be described as follows.
- The physical and functional context: Although the physical aspect
refers to the elements of the physical environment and the nature
of the activities and material in the home, the functional aspect
refers to the interpersonal interaction with the family around these
activities.
- The language context refers to the interaction patterns between the
adult and child during the literacy activities at home.
- The affective context refers to the parents’ values and beliefs about
literacy and their expectations of literacy development.
- The educational context refers to the collaboration between the par-
ent and the teacher in facilitating literacy experiences of the child. It
also includes the identification of strengths and challenges of inter-
action surrounding literacy activities as a basis for further guidance
of parents.
Based on these four contexts, Stobbart (2005) developed a questionnaire for

parents that can be used as a basis to facilitate parents’ reflection on literacy
exposure of their deaf child at home. Table 12.3 outlines some questions
(based on Stobbart, 2005) that can be asked to assist parents in reflecting
on home literacy exposure of children with developmental disabilities.
Table 12.3. Increasing Parents’ Awareness of Home-Based Literacy

Experiences of Young Children with Developmental Disabilities
Emergent Literacy
Contexts Examples of Questions
The physical and func- What are your child’s favorite reading activities?
tional context: reading How interested are you and your family in reading?
How often do you or others in your home read in the presence
of your child with developmental disabilities?
What printed materials are available in your home?
How often does your child with developmental disabilities make
use of the above-mentioned printed material?
Is your child interested in reading activities?
Does your child own any books? How many?
Physical and functional Is writing or drawing something you or other members of your
context: writing family enjoy?
How often do you or others in your family write or draw at
home?
Which writing or drawing materials are readily available in your
home?
How often does your child use any of the above materials?
Is your child interested in writing and drawing activities?
Language Context When your child is involved in reading and writing activities,
does anyone else participate? Who?
Who usually initiates the reading and writing activities?
How do siblings participate in reading and writing activities
with your child with developmental disabilities?
When you or other family members read to your child, what
types of books do you usually read?
When you read with your child, what does your child usually
do?
When you read, how does your child communicate with you?
How is your child usually positioned during story reading
activities?
When you read to your child, what do you usually do?
Affective context How important do you rate the following aspects of your child’s
development at present?
Ability to communicate
Ability to speak
Understanding
Use of alternative ways of communicating
Learning to read
Learning to write, etc.
Educational context Do you have any difficulties in finding suitable books to read to
your child?
Do you have any difficulty in communicating with your child?
Do you have any difficulty in determining whether your child
understands the stories you read?
Based on Stobbart (2005).
Based on information gained from dialoguing around these questions,

some strategies can be developed – in collaboration with the parents –
aimed at increasing emergent literacy exposure of the young child.
The key to successful intervention, also in this context, is for profes-
sionals to take the lead from the parents. Rogoff (1990) coined the term
“guided participation” which refers to the process through which children,
their caregivers, and other companions learn and extend their knowledge,
skills, and values in a community. Rogoff, Mistry, Göncü, and Mosier
(1993) provided empirical evidence showing that there are both similari-
ties and variations in guided participation across communities. Whilst the
similarities include the structuring of joint engagement, the variations are
more prominent in relation to the assignment of whether adults or chil-
dren are responsible for a child’s learning, goals of development, and the
means of communication. They emphasised that the term ‘guided par-
ticipation’ is not intended as a classification scheme by which one can
evaluate whether guided participation is effective, but rather a perspective
through which to study change within the family or community. It thus
promotes not just dyadic communication, but a system of relationships.
Using Graphic Symbols to Increase Early Literacy

Experiences as a Meaning-Based Process
Parents often regard reading and writing activities in relation to traditional
orthography and learning of the ‘alphabet’. Whilst this is important in later
stages of the process, emergent literacy requires a complex set of underlying
orientations and skills that can be acquired through the use of different graphic
symbols to facilitate the experience of reading as a meaningful event.
Abbott, Detheridge, and Detheridge (2006) described the use of sym-
bols in literacy and social justice contexts. They were particularly con-
cerned with the use of graphic symbols to support the inclusion of children
and adults with a range of disabilities by providing them with access to
literacy. They regarded access to literacy, thus to reading and writing, as
vital as the ability to communicate face to face. Access to the information
in public spaces such as shopping malls could also include browsing the
Web for information or reading books and magazines for pleasure. They
emphasised that these are issues relating to social justice and that par-
ents need to be involved in facilitating their children’s access into commu-
nities by becoming more familiar with the ways in which different graphic
systems can be used to facilitate this process.
There are varied ways in which children can gain access to literacy as
part of a meaning-based process. These strategies can include:
Picture or symbol reading
Container or product discrimination by means of identification of labels
Reading to make choices, for example, reading the menu in a restau-
rant, or reading the TV program
Reading for mobility by recognizing familiar street signs, or indicators
for elevators and bathrooms
Gaining access to writing their name or develop a distinctive mark to
sign their names
Figure 12.4. Examples of symbol sets that can be used to facilitate reading through sym-
bols.
Figure 12.4 provides some examples of different graphic symbol sets

that can be used to facilitate reading through symbols.
With an increase of software focused on providing young children with
developmental disabilities with access to literacy through graphic sym-
bols, the role of computer-based intervention strategies cannot be overem-
phasised. More detail on software programs that can be used to facilitate
reading and writing development of children with developmental disabili-
ties can be obtained in Smith (2005).
CONCLUSION
This chapter focused on the importance of providing young children

with developmental disabilities with access to communication and lit-
eracy development by firstly understanding the impact of their impair-
ments on their use and interpretation of symbols as well as taking heed
of the sociocultural factors that might have an impact on performance. It
also discussed communication and participation from two perspectives,
these being engagement and interaction. The mere fact that messages are
exchanged does not guarantee that meaning is derived from the context.
The ability to observe the level of engagement within the activity or situa-
tion is thus critical in understanding the participation of young children
with developmental disabilities. This approach is explored further in terms
of its application to play and emergent literacy intervention.
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13
Eating Disorders
DAVID H. GLEAVES, JANET D. LATNER,
and SUMAN AMBWANI
INTRODUCTION
Eating problems or irregularities are common among children and

adolescents. When the problems reach the point of being gross distur-
bances in eating behavior and when accompanied by some form of body
image disturbance, we enter the realm of the Eating Disorders (EDs). The
current Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR;
APA, 2000) distinguishes between three primary ED types: Anorexia Ner-
vosa (AN), Bulimia Nervosa (BN), and Eating Disorder Not Otherwise Spec-
ified (EDNOS). The latter refers to cases that meet some but not all the
criteria required for the diagnosis of either AN or BN. Binge-Eating Disorder
(BED) is a more recently recognized disorder that is technically a variant
of the EDNOS category (although research criteria have been developed).
There are, however, numerous possible manifestations of EDNOS other
than BED.
In earlier versions of the DSM, up to and including the Third Edi-
tion–Revised (American Psychiatric Association, 1987), the EDs were listed
within the Disorders Usually First Evident in Infancy, Childhood, or Ado-
lescence section. Given their prominence among adults as well, their own
section was created in the most recent edition. However, their origins in
childhood or adolescence should not be forgotten and they are, in many
ways, disorders of adolescence.
In this chapter, we cover these above-mentioned disorders. There are
also numerous other eating-related disorders that frequently occur in
DAVID H. GLEAVES • University of Canterbury

JANET D. LATNER • University of Hawaii
SUMAN AMBWANI • Texas A&M University

404 DAVID H. GLEAVES et al.
childhood. These include pica, rumination disorder, or feeding disorder of

infancy or early childhood (sometimes referred to as failure to thrive). See
Piazza (in press) for a discussion of treatment of these problems. Another
common eating related problem among children is obesity. See Henderson
and Schwartz (2007) for a review of the literature on treatment of child-
hood obesity.
ANOREXIA NERVOSA (AN)
The central feature of AN is a “refusal to maintain a minimally normal

body weight” (APA, 2000, p. 583). The full DSM–IV–TR diagnostic criteria
are listed in Table 13.1. Typically the minimum weight threshold is set
at 85% of the person’s expected weight for his or her age and height.
However, the weight criterion may also be expressed in terms of body mass
index (BMI; weight in kilograms/height in meters2). A BMI of 17.5 or lower
is considered to meet the body weight criterion for AN. However, BMIs are
often difficult to interpret with children and adolescents, and there is often
a need for some flexibility regarding an absolute cutoff. A percentage of
expected weight may be more appropriate for this age group (Fisher et al.,
1995). A person may be at a minimal body size through having lost weight
or through never having gained the weight that would be expected with
normal development. The latter may be more common among children and
young adolescents although it would not be uncommon for older adoles-
cents to lose a significant amount of weight. Persons diagnosed as having
AN may use a variety of weight control mechanisms including intentional
starvation, excessive exercising, or purgative behaviors (self-induced vom-
iting, and misuse of laxatives, diuretics or enemas).
Table 13.1. DSM–IV–TR Diagnostic Criteria for Anorexia Nervosa
A. Refusal to maintain body weight at or above a minimally normal weight for age and
height (e.g., weight loss leading to maintenance of body weight less than 85% of that
expected or failure to make expected weight gain during period of growth, leading to
body weight less than 85% of that expected).
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue
influence of body weight or shape on self-evaluation, or denial of the seriousness of the
current low body weight.
D. In postmenarchal females, amenorrhea, that is, the absence of at least three consecutive
cycles. (A woman is considered to have amenorrhea if her periods occur only following
hormone, e.g., estrogen administration.)
Specify type:
Restricting Type: During the current episode of anorexia nervosa, the person has not
regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the
misuse of laxatives, diuretics, or enemas).
Binge-Eating/Purging Type: During the current episode of Anorexia Nervosa, the person
has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or
the misuse of laxatives, diuretics, or enemas).
Note: From APA (2000, p. 589). Reprinted with permission from the Diagnostic and Statistical Manual of
Mental Disorders, Fourt Edition, Text Revision, (Copyright 2000). American Psychiatric Association.
EATING DISORDERS 405
In addition to the refusal to maintain a normal weight, individuals

with AN also experience an intense fear of becoming fat or sometimes of
gaining any weight (APA, 2000). This fear does not seem to diminish, and
may even worsen, as the individual loses weight (Walsh & Garner, 1997).
Individuals with AN may experience their bodies in a distorted way, feeling
“fat” or extremely dissatisfied with their body shape and they may base
their total self-worth on their body size. Such individuals may monitor
their body weight and shape and experience strong negative emotional
reactions if they gain weight. Another criterion of AN is the presence of
amenorrhea (in postmenarchal girls). In young anorexic adolescents, the
onset of menstruation may be delayed.
Two subtypes of AN are described in the current DSM–IV–TR, and the
typology is based on the presence or absence of binge eating as well as
on the principal method of weight control. Restricting anorexics restrict
only whereas Binge-Eating/Purging anorexics engage in purging which
is usually associated with binge eating. However, excessive dieting and
exercising may occur with either type of anorexia (APA, 2000). The distinc-
tion between subtypes appears to be quite valid (DaCosta & Halmi, 1992;
Gleaves, Lowe, Green, Cororve, & Williams, 2000).
Recognizing AN in children and adolescents presents many chal-
lenges. First, in a prepubescent female (or a male) the amenorrhea
criterion is not applicable. Second, there may not be a noticeable weight
loss but rather, a failure to achieve normal weight or to gain weight
at a normal rate. As noted above, normal weight is also sometimes a
challenge to determine and quantify. A related concern is that severe
anorexia may inhibit normal skeletal development; thus height may be
affected.
BULIMIA NERVOSA (BN)
According to the current DSM, BN is characterized by repeated (at least

twice a week for three months) episodes of binge eating followed by some
sort of inappropriate compensatory response to prevent weight gain (APA,
2000). Full criteria are listed in Table 13.2. As with AN, there is some sort
of body image disturbance. Although the DSM–IV defines a binge as “eating
in a discrete period of time an amount of food that is definitely larger than
most individuals would eat under similar circumstances” (p. 589), the
requirement that binges be necessarily large has been questioned by some
researchers (Rossiter & Agras, 1990). A perceived loss of control during
the binge episodes must also be present and may be the more important
factor (rather than size; Latner, Hildebrandt, Rosewall, Chisholm, & Hayashi,
2007). Binges are triggered by a variety of factors including hunger, stress,
negative mood, feelings and thoughts associated with body image, and
food cravings (Schlundt & Johnson, 1990; Walsh & Garner, 1997).
As with the bingeing criterion, the compensatory behaviors need
to occur on average at least twice a week for three months to meet the
threshold for diagnosis. As with AN, persons with BN may be classified as
Table 13.2. DSM–IV–TR Diagnostic Criteria for Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both

of the following: (1) Eating, in a discrete period of time (e.g., within any two-hour period),
an amount of food that is definitely larger than most people would eat during a similar
period of time and under similar circumstances. (2) A sense of lack of control over eating
during the episode (e.g., a feeling that one cannot stop eating or control what or how
much one is eating).
B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as
self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications;
fasting or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at
least twice a week for three months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Specify type:
Purging type: During the current episode of bulimia nervosa, the person has regularly
engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Nonpurging type: During the current episode of bulimia nervosa, the person has used
inappropriate compensatory behaviors, such as fasting or excessive exercise, but has
not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or
enemas.
having one of two types; in this instance, it is based on the type of com-
pensatory behavior. If the person engages in self-induced vomiting or the
use of laxatives, he or she is considered to have the purging subtype. If
the person only uses excessive exercise or starvation (or similar methods),
the nonpurging type of BN would be diagnosed. There is less support for
the validity of this distinction (Gleaves et al., 2000) than there is for the
subtypes of AN described above. However, the purging type, in general,
appears to be associated with more pathology than the nonpurging type
(e.g., Willmuth, Leitenberg, Rosen, & Cado, 1988).
The DSM body image criterion for BN is less specific than for AN,
and worded only as “Self-evaluation is unduly influenced by body shape
and weight” (APA, 2000; p. 594). There is, however, evidence that, when
controlling for actual body size, persons with BN seem very similar to
those with AN in terms of body image (Williamson, Cubic, & Gleaves,
1993). Women with BN overestimate their current size and desire to be
excessively thin, relative to same-sized women without BN (Williamson,
Davis, Goreczny, & Blouin, 1989). However, it is no doubt also true that
their self-evaluation is overly influenced by their body image, as stated
in the criterion.
In earlier versions of the DSM, it was possible for a person to be diag-
nosed with both AN and BN. With the current system, BN cannot be
diagnosed if it occurs only in the context of AN. Such an individual would
be diagnosed as having the binge-eating/purging subtype of AN. There is
evidence that BN occurs on a continuum with the binge-eating/purging
subtype of AN whereas the restricting subtype is qualitatively different
from both other disorders (Gleaves et al., 2000).
BINGE EATING DISORDER (BED)
As noted above, BED is not currently accepted as a formal diagnosis in

the DSM–IV but rather would be a subtype of EDNOS. However, it is also
listed in the “Criteria Sets and Axes Provided for Further Study” (p. 759)
section; thus a set of research criteria has been developed (see Table 13.3).
These generally refer to the presence of recurrent binge eating (as seen with
BN) but in the absence of the compensatory behaviors that occur with BN.
Persons with BED may not be as restrictive in their eating as persons with
BN, and a large percentage of individuals are consequently obese. Persons
with BED are very often dissatisfied with their bodies. The body image dis-
turbance in BED may seem more commensurate with patients’ actual size
rather than exaggerated as in instances of AN or BN. However, the shape
and weight concerns of obese individuals with BED, as well as their eat-
ing-related and general psychopathology, quality of life, and even physi-
cal health, are significantly more impaired than those of obese individuals
without BED (Wilfley, Wilson, & Agras, 2003). Some researchers (e.g., Hay &
Fairburn, 1998) may consider BED to be less severe than BN. However, the
range and frequency of comorbid psychopathology for BED is similar to that
for BN. Furthermore, the mortality rates for BED may actually be higher
than with BN because the former is associated with obesity (Agras, 2001).
EATING DISORDER NOT OTHERWISE SPECIFIED (EDNOS)
Although EDNOS is a residual category in the DSM, it warrants its

own section here because it appears to be the most common ED encoun-
tered in clinical practice (Fairburn & Bohn, 2005). It may also be more
Table 13.3. DSM–IV–TR Research Criteria for Binge-Eating Disorder
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of

the following.
(1) Eating in a discrete period of time (e.g., within any two-hour period) an amount of
food that is definitely larger than most people would eat in a similar period of time
under similar circumstances.
(2) A sense of lack of control over eating during the episodes (e.g., a feeling that one can-
not stop eating or control what or how much one is eating).
B. The binge eating episodes are associated with three (or more) of the following.
(1) Eating much more rapidly than normal
(2) Eating until feeling uncomfortably full
(3) Eating large amounts of food when not feeling physically hungry
(4) Eating alone because of being embarrassed by how much one is eating
(5) Feeling disgusted with oneself, depressed, or very guilty after overeating
C. Marked distress regarding binge eating is present
D. The binge eating occurs, on average, at least two days a week for six months.
E. The binge eating not associated with the regular use of inappropriate compensatory
behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively dur-
ing the course of Anorexia Nervosa of Bulimia Nervosa.
common among adolescents than among adults (Fisher, Schneider, Burns,

Symons, & Mandel, 2001). There are no positive criteria for EDNOS, and
the DSM–IV–TR defines these only as “disorders of eating that do not meet
the criteria for any specific eating disorder” (APA, 2000, p. 594). There are
six examples (see Table 13.4) in the DSM of possible EDNOS presentations
(with one being BED).
Fairburn and Bohn described two subtypes as being particularly com-
mon. The first are instances where the individual’s presentation closely
resembles AN or BN nervosa but (s)he fails to meet their diagnostic thresh-
olds (body weight or frequency of bingeing). However, these cases are
severe enough to warrant clinical attention and should not be thought of
as subthreshold eating disorders in general. The second subtype are cases
that might be instances of mixed AN and BN in which the clinical features
of AN and BN are combined in ways other than in the two recognized syn-
dromes. Williamson, Gleaves, and Savin (1992) provided empirical sup-
port for the existence of such clusters, in addition to BED. Specifically in
the adolescent literature, Binford and le Grange (2005) recently describe
another subtype, that of individuals who purge but do not binge (similar
to #4 in Table 13.4).
EPIDEMIOLOGY
Prevalence
Although Hoek and van Hoeken’s (2003) review of the ED literature
reported average prevalence rates of 0.3% (AN) and 1% (BN) for young
women, and 0.1% (BN) for young men, among at-risk women, prevalence
estimates typically range from 3% to 10% (i.e., ages 15–29 years; Polivy
& Herman, 2002). The averages reported by Hoek and van Hoeken (2003)
were not specific to eating disorders among adolescents, but most of the
Table 13.4. DSM–IV–TR Eating Disorder Not Otherwise Specified
The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not
meet the criteria for any specific eating disorder. Examples include:
1. For females, all of the criteria for anorexia nervosa are met except that the individual
has regular menses.
2. All of the criteria for anorexia nervosa are met except that despite significant weight loss
the individual’s current weight is in the normal range.
3. All of the criteria for bulimia nervosa are met except that the binge eating and inappro-
priate compensatory mechanisms occur at a frequency of less than twice a week or for
duration of less than three months.
4. The regular use of inappropriate compensatory behavior by an individual of normal body
weight after eating small amounts of food (e.g., self-induced vomiting after the consump-
tion of two cookies).
5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.
6. Binge-eating disorder: recurrent episodes of binge eating in the absence if the regular
use of inappropriate compensatory behaviors characteristic of bulimia nervosa.
Note: From APA (2000, pp. 594–595). Reprinted with permission from the Diagnostic and Statistical Manual
of Mental Disorders, Fourt Edition, Text Revision, (Copyright 2000). American Psychiatric Association.
literature reviewed included adolescent samples. Research exclusively

conducted with children and adolescents suggests varying prevalence
rates. For instance, a study with community adolescents reported that 3%
met criteria for an eating disorder (not including EDNOS), of which 33.3%
were male and 66.7% were female (Zaider, Johnson, & Cockell, 2000).
In contrast, in a study of 1,960 adolescents aged 14–15 years in
Norway, Kjelsås, Bjørnstrøm, and Götestam (2004) reported the overall
lifetime prevalence of EDs to be 12.5%–12.9%, depending on whether
DSM–IV or DSM–III–R criteria were used. Whereas the overall lifetime
prevalence for girls ranged from 17.9%–18.6%, for boys, the prevalence
rate was estimated at 6.5%. The authors reported the prevalence of AN
among girls and boys to be 0.7% and 0.2%, respectively, whereas the
prevalence of BN among girls and boys was 1.2%–3.6% and 0.4%–0.6%,
respectively. As expected, relatively larger prevalence rates were detected
for EDNOS, with estimates ranging from 12.9%–14.6% for girls, and
4.8%–5% for boys. Finally, BED prevalence rates were estimated at 1.5%
for girls, in comparison to 0.9% for boys. An earlier study in Norway
estimated somewhat lower prevalence rates: 1% BED, 0.7% BN, 0.3%
AN-BP subtype, and 0% AN-R subtype (Rosenvinge, Borgen, & Börresen,
1999). Notably, in this latter study, none of the male students met cri-
teria for an eating disorder, although 0.9% of the boys were categorized
as “at-risk.”
More recent studies of female adolescents in Italy (Cotrufo, Gnisci,
& Caputo, 2005) and Spain (Ruiz-Lázaro, Alonso, Comet, Lobo, & Velilla,
2005) have estimated the following prevalence rates for eating disorders:
0.55%–0.77% (BN), 3.47% (partial BN), .38% (partial BED), 0.14% (AN),
5.79% (subclinical AN), and 3.83% (EDNOS). Similar lifetime prevalence
rates have also been reported among adolescent girls in Iran, including,
0.9% (AN), 3.2% (BN), 1.84% (partial AN), and 4.79% (partial BN; Nobakt &
Dezhkam, 2000) and female adolescents in Greece and Germany, includ-
ing, 1.26%–1.18% (AN), 3.15%–3.54% (BN), and 13.84%–19.45% (EDNOS;
Fichter, Quadflieg, Georgopoulou, Xepapadakos, & Fthenakis, 2005).
In addition to studies of the prevalence of ED diagnoses, several
researchers have examined the prevalence of eating disordered behaviors
among adolescents. For instance, Croll, Neumark-Sztainer, Story, and
Ireland’s (2002) research on disordered eating behaviors (i.e., binge-
eating, or, using any of the following to control or lose weight: fasting/skip-
ping meals, using diet pills or amphetamines, laxatives, vomiting, and/or
smoking cigarettes) among 9th- and 12th-grade students in Minnesota
(N = 81,247) revealed a high prevalence of such behaviors. For instance,
among 9th-graders, 56% of the girls and 28% of the boys reported engaging
in disordered eating behaviors. The estimates were slightly higher among
12th-graders, as 57% of the girls and 31% of the boys reported disordered
eating. One limitation of this research is that it included a fairly broad
definition of disordered eating. However, as the authors noted, engaging
in any of the above behaviors would constitute risk-factors for the subse-
quent development of eating disorders.
One limitation of such research is that in practice, recognizing and
detecting EDs may often be restricted by the secrecy associated with binge
eating and purging behaviors. Moreover, some have suggested that the
prevalence of some EDs (particularly BN) may be lower among children and
adolescents than adults for practical reasons, such as not having access
to money or privacy required for binge eating (Netemeyer & Williamson,
2001). Similarly, although AN may be more obviously detectable because
of patients’ extreme low weight, such detection may be more difficult when
the low weight is a manifestation of a failure to gain weight. Overall, we view
proper assessment as critical for diagnosis and treatment, and there are
many issues specific to assessment of children and adolescents with eating
problems. See Netemeyer and Williamson (2001) or Zucker et al. (2008 and
with a 2009, publication data) for a more in-depth discussion of assessment
of eating disorders among children and adolescents.
Incidence and Time Trends

Lewinsohn, Striegel-Moore, and Seeley (2000) reported the incidence
of EDs to be less than 2.8% by age 18, and 1.3% for individuals aged 19–23
years. In contrast, Rastam et al. (1989) screened the entire population of
school children in an urban region of Sweden (N = 4,291), and reported
3 cases of BN, 17 cases of AN, and 3 cases of a partial AN syndrome. In
their review of the research, Hoek and van Hoeken (2003) reported the
incidence of AN to be 8 cases per 100,000 population per year, and noted
that the incidence rates for AN are the highest for females in the 15–19
age group. They estimated the incidence of BN to be 12 cases per 100,000
population per year.
With regard to time trends, van Son, van Hoeken, Bartelds, van Furth,
and Hoek (2006) assessed the incidence of EDs in the Netherlands dur-
ing two time periods, 1985–1989, and 1995–1999. The authors reported
that although the incidence of AN was fairly stable for the general popu-
lation (i.e., 7.4 to 7.7 per 100,000), the incidence for the 15–19-year-old
female age group significantly increased, from 56.4 to 109.2 per 100,000.
Of the individuals diagnosed with AN between 1995–1999, only one (2%)
was male. In contrast, they reported that the incidence of BN decreased
somewhat (nonsignificantly) from 8.6 to 6.1 per 100,000, a finding that
has been corroborated by other recent research (Keel, Heatherton, Dorer,
Joiner, & Zalta, 2006).
Regarding trends in ED-related symptomatology, Fichter, Quadflieg,
Georgopoulou, Xepapadakos, and Fthenakis (2005) reported significant
increases in weight phobia and bulimic behaviors from approximately 1979
to 1998 among Greek girls in Germany, but interestingly, observed the
reverse for the male adolescents, whose weight phobia scores decreased
from the first to second assessment.
Gender Differences
As reflected by the incidence and prevalence rates, EDs typically occur
less frequently among males than among females. One possibility is that
the prevalence of AN is higher among boys than it appears to be, but is
not readily recognized due to its reputation as a stereotypically female
disorder. Thus, research examining eating disorders among men and boys
may have been limited by the tendency towards misdiagnosis, although
greater attention has been devoted to this problem in recent years.
In general, data suggest that boys with EDs typically strive for a more
muscular body ideal, rather than the thin ideal typically pursued by girls
(McCreary & Sasse, 2000; see Labre, 2002, for a review on adolescent boys
and the muscular ideal). Although EDs have been diagnosed among indi-
viduals of all sexual orientations, bisexual and homosexual orientation
may be particular risk factors for developing EDs (Austin et al., 2004). The
prevalence of homosexuality and bisexuality is higher among men with
BN than in the general population (43% versus 10%; Carlat, Camargo, &
Herzog, 1997), however, it is not clear whether this applies to adolescents.
Furthermore, athletes and other individuals for whom physical appear-
ance and body shape are especially important (e.g., body builders) are at
a higher risk of developing BN because they need to maintain their weight
at or below specific thresholds (Carlat et al., 1997).
For boys, the following estimates are available for lifetime prevalence
rates: 6.5% (any ED), 0.2% (AN), 0.4% (BN), and 0.9% (BED) (Kjelsås,
Bjørnstrøm, & Götestam, 2004). Among children and adolescents, con-
sistently higher proportions of female than male patients present to eating
disorder treatment programs (e.g., Geist, Heinmaa, Katzman, & Stephens,
1999; Peebles, Wilson, & Lock, 2006), but there may be some gender dif-
ferences in the presentation of these disorders. For instance, Geist et al.
(1999) reported that male adolescents presented with significantly lower
drive for thinness and body dissatisfaction than their female counterparts.
However, the authors noted that in the absence of adolescent male norms
on the instrument used, their results may be difficult to interpret.
In comparing a large sample (N = 959) of children and adolescents
ages 8–19 years in an eating disorder treatment program, Peebles et al.
(2006) reported that, compared with older adolescents (mean age = 15.6
years, SD = 1.4), younger patients (mean age = 11.6 years, SD = 1.2) were
more often male, presented at a lower percentage of ideal body weight,
and lost weight more rapidly. Specifically, in the younger sample, 16.5%
was male, whereas 7.8% of the older sample was male. In the entire sam-
ple, most of the patients were female (91.1%), and presented with EDNOS
(51.3%), although there were also large proportions presenting with AN
(35.8%) and BN (12.9%).
Ethnicity, Culture, and Eating Disorders

Overall, research on children and adolescents suggests that Hispanic
and Asian American females are more likely than White/Caucasian females
to report disordered eating, and that Black/African American students are
least likely to report such behaviors (Croll et al., 2002; Robinson, et al.,
1996). For instance, in one study, more Latina students reported binge-
eating and/or vomiting in the past 28 days in comparison to the Caucasian
and African American students, and Latina and Caucasian students exhibited
higher levels of eating concerns, weight concerns, shape concerns, and global
eating pathology in comparison to their African American counterparts
(Pernick, et al., 2006). Similarly, Granillo, Jones-Rodriguez, and Carva-

jal (2005) evaluated data from 1,866 adolescent Latina adolescents, ages
11–20 years (median = 16), and reported fairly high prevalence rates for
various behaviors placing them at risk for the development of eating dis-
orders, including, dietary restraint (53.3%), low BMI (<17; 2.5%), amenor-
rhea (5.5%), and self-reported bulimic symptoms (1.9%).
Although some researchers view eating disorders as purely Western
syndromes, increasing reports attest to the prevalence of eating psychopa-
thology in non-Western cultures. For instance, Huon, Mingyi, Oliver, and
Xiao (2002) assessed 12–19-year-old girls in various regions of China (N =
1,246). The authors found that 1.8% and 2.2% of their sample used vomit-
ing and laxatives, respectively, in order to control their weight. Nishizono-
Maher, Miyake, and Nakane (2004) reported that Japanese girls (13–16
years) maintain a similar distribution of drive for thinness as their West-
ern counterparts. Similarly, a study assessing South African adolescents
and young adults (N = 895) reported that 14% of the respondents main-
tained high levels of maladaptive eating attitudes and behaviors, and 4.6%
reported engaging in bulimic behaviors (Le Grange, Louw, Russell, Nel, &
Silkstone, 2006). A study in the United Arab Emirates reported somewhat
higher rates of maladaptive eating attitudes and behaviors among adoles-
cent girls (23.4%), and noted that adolescents in the older age group (16–
18-year-olds) were more likely to maintain these high levels (27.8%) than
their younger counterparts (13–15-year-olds; 19.2%; Eapen, Mabrouk, &
Bin-Othman, 2006).
Research in Europe also suggests that maladaptive eating attitudes
and behaviors among children and adolescents are prevalent. For instance,
a survey revealed that Danish adolescent boys and girls experience sub-
stantial dissatisfaction with their body weight: 49% of the girls and 21.5%
of the boys reported wanting to lose weight, 17.9% of the boys and 7.4%
of the girls sought weight gain, and several adolescents also endorsed
extreme weight loss behaviors, including self-starvation or fasting, using
diet pills, and inducing vomiting to lose weight (Waaddegaard & Petersen,
2002). Similarly, one study reported that 15.8% and 2.8% of Italian school-
aged female and males, respectively, exhibited high levels of maladaptive
eating attitudes and behaviors (Miotto, De Coppi, Frezza, Rossi, & Preti,
2002), and another study indicated that a large proportion of Swiss female
adolescents (62%) sought to lose weight, felt too fat (36%), and engaged in
binge eating (9.1%) and self-induced vomiting (1.6%) at least once a week.
Finally, estimates of disordered eating attitudes among children and ado-
lescents in Croatia (Knez, Munjas, Petrovečki, Paučić-Kirinčić, & Peršić,
2006) and Spain (Alonso, Rodríguez, Alonso, Carretero, & Martin, 2005)
have been remarkably similar, ranging from 7.5% to 7.8% of the sampled
populations, with a higher prevalence among females than males.
Social Class
Although EDs are seen across different social classes, early observa-
tions were that certain forms of eating dysfunction, such as AN, occurred
more commonly among women of middle to high social classes (e.g., Crisp,
Palmer, & Kalucy, 1976). Although Gard and Freeman (1996) called this
a myth, more recent data do support the observation with regard to AN
(Fisher, Schneider, Burns, Symons, & Mandel, 2001; McClelland & Crisp,
2001). Fisher et al. compared female patients treated for eating disor-
ders at an adolescent medicine unit between the years 1980 and 1994,
and reported that among the adolescent patients (aged 9–19 years) who
reported parental occupation, most fell in the middle (47.9%) and upper
(44.5%) classes using the Hollingshead Four Factor Social Index, with sig-
nificantly fewer falling in the lower class (7.6%). However, it still may be
the case that BN is actually more prevalent among lower socioeconomic
groups, as suggested by Gard and Freeman (1996).
Comorbidity
Eating disorders in general seem to be accompanied by a wide range
of medical and/or psychological problems. Perhaps the greatest attention
has been devoted to the co-occurrence of EDs with mood disorders (Stice,
Hayward, Cameron, Killen, & Taylor, 2000; Stice, Presnell, & Bearnman,
2001) and substance abuse disorders (Dansky, Brewerton, & Kilpatrick,
2000). For instance, in a study with adolescents, Zaider, Johnson, and
Cockell (2000) reported that individuals with dysthymia, panic, and major
depressive disorder were significantly more likely [than those without
these disorders] to have an eating disorder, and even after controlling for
the effects of other Axis I and Axis II psychopathology, dysthymia inde-
pendently predicted EDs.
EDs also do appear to be highly comorbid with substance use problems
(Bulik et al., 2004), and approximately 20% to 46% of women with EDs
report a history of problems with alcohol and/or drugs (Bulik et al., 2004;
Conason, Brunstein Klomek, & Sher, 2006). Researchers have suggested
that the powerful drive for thinness that is central to eating disorders may
increase the likelihood of abusing stimulant drugs for weight-loss reasons
(Measelle, Stice, & Hogansen, 2006). Moreover, if binge eating and subse-
quent compensatory behaviors engender feelings of guilt, the individual
may turn to substance use to modulate his or her negative affect.
In terms of research specific to adolescents, Wiederman and Pryor
(1991) reported that approximately 1/3 of a sample of adolescents with BN
smoked tobacco and marijuana and drank alcohol at least weekly. Among
those with AN, a much lower percentage (1.7 %) reported drinking on a
weekly basis. Consistent with these data, restricting anorexics reported
less substance use than the general (nonclinical) population (Stock, Gold-
berg, Corbett, & Katzman, 2002). Finally, in their recent longitudinal study
with adolescent girls, Measelle et al. (2006) reported that initial eating
psychopathology predicted increases in substance abuse symptoms over
a five-year period.
EDs are also commonly associated with personality disorders. Godt
(2002) reported the comorbidity of EDs and Axis II disorders at 33%. Bor-
derline personality disorder may be particularly common. Although vari-
able across studies, rates of BPD and ED comorbidity often range from
4.3% to 10% for AN, and 6.2% to 28% for BN (Godt, 2002; Sansone, Levitt,
& Sansone, 2005). Personality disorders may also predict the development
of eating disorders (Johnson, Cohen, Kasen, & Brook, 2006).
In addition to comorbid psychological conditions, individuals with
eating disorders are prone to experience a host of significant medical
consequences and correlates, such as gastrointestinal complications,
dangerously low body weight, and dental caries. Specifically, individu-
als with AN are susceptible to experiencing osteoporosis and osteopenia,
cardiovascular problems, and orthopedic problems due to the combined
effects of excessive exercise and nutritional deficiencies (Agras, 2001;
Brambilla & Monteleone, 2003). Individuals with BN are likely to expe-
rience various medical complications including electrolyte imbalances,
dental problems, and cardiovascular problems (Agras, 2001; Brambilla
& Monteleone, 2003).
Costs of Eating Disorders

Research on the costs of EDs overwhelmingly suggests rising medi-
cal costs and inadequate hospital stays covered by insurance companies.
For instance, according to one report, the average length of hospital stay
for adolescent inpatients with AN was 51 ± 30 days, and the average cost
(total hospital and professional charges) was US$105,853 per patient
(Kalisvaart & Hergenroeder, 2005). Patients were not discharged based
on insurance criteria, and the authors noted that all of the insurance
companies failed to provide coverage for the number of requested days.
On average, insurance companies reimbursed 62% of the total charges
out of the patients’ medical policies, but the reimbursement was insuf-
ficient to continue treatment until the patient reached 85% of his or her
body weight. Thus, the authors argued, poor reimbursement by insurance
companies interferes with the ability of clinicians to provide ideal inpatient
treatment for individuals with AN.
In another example, the authors of a study involving insurance claims
from almost 4 million patients in 1995 reported that outpatient treatment
was the norm across all EDs, and only 21.5% and 18.4% of female and
male patients, respectively, were hospitalized for treatment of AN (Striegel-
Moore, Leslie, Petrill, Garvin, & Rosenheck, 2000). For BN, 12% of females
and 22% of males received inpatient treatment, and average numbers were
even lower for EDNOS (12.3% of females and 6.8% of males). For female
inpatients, the average number of hospitalized days were 26.0, 14.7, and
19.9 for AN, BN, and EDNOS, respectively. For female outpatients, the
average number of days for treatment was 17.0, 15.6, and 13.7, respec-
tively. Use of services was somewhat less by male patients, who averaged
9.2, 9.1, and 10.6 days, respectively, for AN, BN, and EDNOS. Notably,
these averages (particularly for males) are considerably lower than the
20 or so treatment sessions that are typically used in many empirically
based treatments. The authors approximated the average yearly costs for
inpatient and outpatient treatment of AN, BN, and EDNOS among women
to be $6,045, $2,962, and $3,207, in contrast to the estimated annual
cost for treating schizophrenia ($4,824) and OCD ($1,930). One limitation
of these data, however, is that they do not account for treatment paid for
by individuals (rather than by insurance companies) and thus may not

accurately reflect the entirety of treatment time and cost.
In a study of adolescents (ages 9 to 17 years) treated for eating disor-
ders in hospitals in the state of New York in 1995, Robergeau, Joseph, and
Silber (2006) reported that during the course of that year, 352 individuals
were hospitalized, of which 88.6% were female and 79.3% were Cauca-
sian. Most of the patients had commercial insurance (69.9%), although
some also had Medicaid (19.3%) and other (10.8%) sources of insurance.
Across diagnostic categories (AN, 242; BN, 59; EDNOS, 63), the average
stay was 18.43 days, and the median was 7 days. Costs per patient ranged
from $341.78 to $148,471, with an average of $10,019 and a median of
$3,817. Notably, there was a significant relationship between length of
stay and insurance status, and Medicaid insurance was associated with a
longer stay in treatment.
Course and Outcome

In evaluating the longitudinal course of EDs, Kotler, Cohen, Davies,
Pine, and Walsh (2001) reported that BN during early adolescence is asso-
ciated with a 9-fold and 20-fold increase in risk for BN in late adolescence
and adulthood, respectively. Moreover, BN in late adolescence was found
to be associated with a 35-fold increase in risk for BN in adulthood. In
another longitudinal study on female adolescents (aged 12–15 years at
initiation of study), Measelle, Stice, and Hogansen (2006) examined the
course of co-occurring disorders, including eating disorders, over a five-year
period. They reported that eating disorder symptoms increased substan-
tially over time, at fairly constant rates. Overall, the course and outcome
for EDs varies as a function of the disorder and a host of other predictive
factors. Among patients with AN, deaths are due to either physical com-
plications or suicide, and of all psychiatric disorders, AN appears to have
the highest mortality rate, approximately 5.6% per decade (Agras, 2001).
In terms of ED treatment outcome, Steinhausen (2002) reviewed data from
119 patients with follow-ups of greater than 10 years, and reported mean
values of 73.2% for recovery, 8.5% for improvement, 13.7% for chronicity,
and 9.4% for mortality.
In their follow-up (average of 9.6 years) of children and adolescents
with AN (N = 87), Saccomani, Savoini, Cirrincione, Vercellino, and Rav-
era (1998) reported zero deaths, and assessed good/intermediate/nega-
tive outcome following the Morgan-Russell Outcome Schedule. The results
suggested good outcome in 53% of cases, intermediate outcome in 34% of
cases, and negative outcome in 14% of cases. The authors noted that poor
outcome was associated with greater severity of the disorder at initial pres-
entation, the length of in-patient treatment, and comorbidity with mood
and personality disorders. One limitation, however, is that two patients
could not be found and four refused to participate in the follow-up. Thus,
it is possible that there may have been some mortality without the knowl-
edge of the researchers.
Although longer-term outcome seems to be better for individuals
with BN than for AN, BN is still associated with a considerable amount
of relapse and chronicity (Agras, 2001). In his review of the literature,

Agras surmised that only 10% of bulimic individuals continue to expe-
rience the full syndrome at 10-year follow-up, and that less than 1%
develop AN. At 10-year follow-up, about 60% of individuals are in full
or partial remission from the disorder, but between 30% and 50% con-
tinue to have a clinical ED.
In comparison to AN and BN, the course and outcome for BED appears
to be more promising. In following a sample of young women with BN or
BED over five years, Fairburn, Cooper, Doll, Norman, and O’Connor (2000)
observed that the outcome of those with BN was relatively poor, but that
the majority of the BED group made a full recovery despite not having
received treatment. Finally, less is known about the course and outcome
of EDNOS. Among a sample of ED patients enrolled in the Collabora-
tive Longitudinal Personality Disorders Study (CLPS), Grilo et al. (2003)
reported that the two-year course for EDNOS was better than for BN (40%
remitted for BN versus 59% for EDNOS). Notably, Grilo et al. (2003) also
found that the course for both BN and EDNOS appeared to be unrelated
to the presence, severity, or change in comorbid personality disorder or
other Axis I disorder. Given the paucity of research in this area, further
research is needed to better understand the course and outcome of BED
and EDNOS.
INTERVENTIONS AND EMPIRICAL EVIDENCE
Inpatient Treatment
Outpatient treatment is the norm for children and adolescents with
eating disorders; however, a relatively small proportion of these patients
require inpatient treatment in psychiatric or pediatric units. The admis-
sion criteria, goals, treatment methods, and duration of stay vary widely
across inpatient settings, and such treatment decisions are based on lim-
ited research evidence. Anzai, Lindsey-Dudley, and Bidwell (2002) sug-
gested the following admission criteria for inpatient psychiatric care for
individuals with AN: (1) poor medical status, but not so severe as to war-
rant medical hospitalization (low pulse, temperature, blood pressure, or
potassium; dehydration); (2) low body weight and refusal to eat (BMI <17
or weight < 75% of expected for height/weight; or, for children and adoles-
cents, food refusal or rapid weight loss); (3) low motivation and compliance
(denial of problems, refusal to eat more than minimum amount); (4) poor
family support (absent or not sufficient to make progress); (5) purging
behavior (to the point of jeopardizing health, with an inability to stop or
decrease behavior); and (6) comorbid psychiatric complications (suicid-
ality or severe comorbid disorders warranting hospitalization). They also
noted that individuals with AN require hospitalization more often than BN
patients, and whereas treatment for AN emphasizes refeeding and weight
gain, BN inpatient treatment focuses on providing a structured setting for
patients to eat adequate meals without engaging in bingeing and purging.
Thus, guidelines for inpatient treatment are mostly relevant for AN, as
most patients with BN can be treated on an outpatient basis (Fairburn,

Marcus, & Wilson, 1993).
A primary goal of inpatient treatment for EDs is medical and nutritional
management, particularly in cases where patients present for treatment at
a late stage of their ED and have multiple weight and metabolic problems
(Patel, Pratt, & Greydanus, 2003). For instance, patient symptoms such as
dehydration, electrolyte and fluid imbalances, hypotension, cardiac dys-
rhythmias, and seizures require urgent medical care, and thus, the basis
of the medical management approach to EDs is nutritional rehabilitation
(Patel et al., 2003).
Anzai et al. (2002) suggested that the first components of AN treat-
ment, refeeding and weight normalization, may be best administered in
inpatient settings. Moreover, they noted that recovered AN patients who
were never hospitalized often reported that if they could start again, they
would choose to begin treatment via hospitalization, as it would facilitate
sooner recovery with less suffering. However, given the dramatic changes
in inpatient psychiatric services and managed care in the United States,
the previously typical 3–6-month admission for AN treatment has changed
substantially. For instance, Anzai et al. reported that AN patients typi-
cally stay in an acute inpatient unit for 7–10 days, after which they are
transferred to a partial hospital program for 1–3 weeks, and then finally,
transitioned to outpatient treatment. In most cases, patients with AN can
receive oral refeeding, with the objective of gaining 1–3 pounds per week of
inpatient treatment (Patel et al., 2003). Davies and Jaffa (2005) assessed
weekly weight gain among adolescents with AN in an inpatient unit (N =
53) and reported that the average weight gain was 0.82 kg/week. Patients
did not differ in average weight gain based on whether they had received
prior inpatient treatment, but those with an initial lower percentage of
expected body weight were faster to gain weight.
Although inpatient treatment is typically more appropriate for patients
with AN than BN, there are some instances in which hospitalization for BN
is necessary. Some reasons for the hospitalization of children or adoles-
cents with BN may include: (1) severe cardiac or physiological disturbances
caused by binge eating and purging; (2) persistent suicidal ideation/
attempts, self-harm, or psychosis; (3) intractable binge eating and purging
that have not responded to outpatient treatment or partial hospitalization;
or (4) serious comorbid conditions that interfere with treatment (Robin,
Gilroy, & Dennis, 1998). For BN patients, the main treatment objective is
to establish normal nutritional intake without purging, binge eating, or
restricting (Fisher et al., 1995).
A limitation of extant research on inpatient treatment outcome is that
there have only been uncontrolled investigations on outcome for adoles-
cents with AN. In one study of treatment outcome, adolescents with AN
(N = 34) were treated in an inpatient setting and assessed at three time
points: baseline, 3-year follow-up, and 7-year follow-up (Herpertz-Dahlmann,
Wewetzer, Schulz, & Remschmidt, 1996). The investigators noted that
more than half of the former AN patients remitted within 3 years of dis-
charge from the inpatient treatment. Meanwhile, 14 patients’ diagnoses
changed from AN to BN or EDNOS between the 3- and 7-year follow ups.
Overall, the authors reported that 58% had a good outcome, 21% had an
intermediate outcome, and 21% had a poor outcome.
In another study of adolescents with AN (N = 69), Herzog, Schelberg,
and Deter (1997) reported that for 50% of the patients, there was no initial
recovery until 6 years after the inpatient treatment. The authors also noted
that whereas patients with purging behavior and social disturbances had
a relatively lower chance of recovery, those with AN-R and low serum cre-
atinine levels were more likely to experience early recovery. In a natural-
istic comparison of adolescents with AN treated as inpatients (n = 21) and
outpatients (n = 51), Gowers, Weetman, Shore, Hossain, and Elvins (2000)
reported that the outpatients demonstrated a better outcome 2–7 years
after initial presentation, and the primary predictor of poorer outcome was
admission to inpatient care. Although this study was not randomized and
inpatient treatment may have simply reflected greater severity, its results
suggest that caution is necessary in prescribing inpatient care (Gowers &
Bryant-Waugh, 2004).
In a naturalistic outcome study, among patients who were assessed
at an average of 4.5 years after treatment (N = 113), 72 were considered
“healthy,” 25 still had an eating disorder, 11 refused contact, and 5 had
died (Steinhausen & Boyadjieva, 1996). Finally, in a study comparing
inpatient and outpatient (individual and family therapy, or, group therapy,
both conditions combined with dietary counseling) treatment for adults
with AN, Crisp et al. (1991) reported that many of the patients assigned to
the inpatient treatment refused to receive this form of care and, similarly,
several individuals randomized to the no-treatment condition refused to
not seek treatment elsewhere. The authors reported that the ED symptoms
and weight improved for all three treatment groups relative to the no-treat-
ment control; however, the methodological limitations of their research
exemplify some of the difficulties in conducting controlled investigations
of AN treatment.
To understand the experience of adolescents undergoing inpatient
treatment for AN, Colton and Pistrang (2004) conducted semi-structured
interviews with young women (N = 19) in inpatient ED units. The authors
reported that the patients maintained positive as well as negative views on
their treatment and that the views were characterized by five overarching
themes. First, participants reported feelings of confusion about their AN,
and difficulty understanding how the disorder had taken control of them.
Second, they believed that the key to their recovery was a desire and readi-
ness to get well, not for others, but for themselves. Third, participants
discussed the advantages and disadvantages of living with other patients
with AN; whereas being with other AN patients offered support, it was also
a source of distress. Fourth, they expressed their belief that being recog-
nized by the staff as an individual, rather than just another AN patient on
the “conveyor belt” was helpful. And finally, participants mentioned that
a central component of their experience involved being a collaborator in
treatment versus being treated.
In sum, most hospitalization programs for EDs are multidisciplinary
and include a mixture of treatment components. The foremost goal is to
achieve medical and nutritional stabilization, weight gain, and regular
eating. Nasogastric feedings are infrequently required but may be needed

when the patient is unable to tolerate food orally to gain sufficient weight.
Treatment also focuses on facilitating fundamental change to attitudes
about weight, shape, and appearance and also disrupting the binge–purge
cycle. In addition to focusing on specific ED symptoms, inpatient treatment
promotes individual change and growth (affect regulation, self-identity)
and assists with the acquisition of skills needed to deal with life issues
(e.g., communication, conflict resolution).
Partial Hospitalization
In a stepped-care framework, treatment that constitutes the least
restrictive alternative, but is still believed to be helpful, is the first treatment
attempted (Davison, 2000). A form of treatment that is more intensive than
outpatient treatment but less intensive and less restrictive than inpatient
treatment is partial hospitalization. Partial hospitalization programs, also
known as day treatment programs, have the additional advantage of being
less costly than inpatient treatment programs.
Partial hospital programs often use the same treatment strategies
and have the same treatment goals as inpatient programs. A descriptive
report noted that in three typical day treatments for eating disordered
patients of all ages, these programs regularly use group meals, nutri-
tion and cooking education groups, body image and counseling groups,
and groups that address social skills, assertiveness, family issues, and
relationships (Zipfel et al., 2002). However, because patients return
home in the evening, they spend less time on the unit. Thus, such
programs permit patients to remain in their natural environments dur-
ing the course of treatment. Staying in the natural environment may
facilitate more rapid learning and generalization of therapeutic skills to
home and school settings. These programs also allow patients to con-
tinue to function in their everyday social roles and to have continued
family contact and support (Zipfel et al., 2002).
Howard and colleagues (1999) examined a number of prognostic indi-
cators of treatment failure among 59 patients in partial hospitalization
treatment. These patients had been transferred from inpatient treatment.
Reviewing these patients’ charts revealed that long duration of illness
(>2.5 years), amenorrhea, and low body mass index (<19) increased the
likelihood of treatment failure and readmission to inpatient treatment
(Howard, Evans, Quintero-Howard, Bowers, & Andersen, 1999). However,
the patients examined in this study were adults, and it is possible that, for
children and adolescents, additional factors such as age of onset or level of
family conflict might influence treatment outcome in day programs.
Outcome research on day treatment programs for children or ado-
lescents with eating disorders, and even for adults, is limited. Danziger,
Carcl, Varsano, Tyano, and Mimouni (1988) described a follow-up of 32
girls with AN in a pediatric day-treatment program that involved parents
as participants and providers in the therapy. Nine months after treatment,
the majority of cases showed a healthy restoration of weight, menses, body
image, eating and exercise habits, and social functioning.
Two of the three day-programs described by Zipfel and colleagues (2002)

have been examined in uncontrolled research trials. These programs have
shown preliminary evidence of efficacy in a range of age groups. Among
51 adult women with AN, BN, or subthreshold variants of these disorders,
treatment outcomes and direct costs of inpatient and partial day hospital
treatment were compared (Williamson, Thaw, & Varnado-Sullivan, 2001).
Based on disorder severity, patients were assigned to either inpatient or
day treatment. Although the outcome of the two treatments was similar,
the day hospital program was substantially less costly. Savings per patient
in the day hospital program were $9,645 (43% of the cost of inpatient
cases). The proportion of patients classified as recovered across the two
treatments was 63%.
Similarly, a follow-up of patients who began a partial hospitalization pro-
gram between 6 and 33 months earlier recruited 65 out of 106 patients with
AN, BN, or EDNOS who had initiated treatment (Gerlinghoff, Backmund, &
Franzen, 1998). Again, patients were primarily adults. Significant improve-
ments in weight (for those with AN), eating disorder symptoms, and general
psychopathology were reported. These findings from a small number of non-
randomized studies suggest that partial hospitalization programs might be
an effective and less costly alternative to inpatient care. However, randomized
controlled studies are needed to compare the efficacy of day treatment with
other treatment modalities, inpatient, and outpatient treatments. This is a
particular research priority for the treatment of children, as day programs
allow patients greater time with their family and more opportunity to partici-
pate in normal activities outside the hospital.
Outpatient Treatment
In this section we highlight four forms of outpatient treatment for
childhood and adolescent eating disturbances. Certain caveats should be
noted, however. First, the research base concerning these treatments is
limited, due to factors such as the rarity of these disorders and the dif-
ficulty in recruiting and retaining patients in treatment trials. In addition,
several studies on AN that have found no differences between groups have
had small sample sizes. In such studies, it is important to not automatically
interpret a lack of significant differences across conditions as treatment
equivalence (Fairburn, 2005).
Family-Based Treatment
Most children and adolescents with eating disorders are treated on
an outpatient basis. The most widely researched form of outpatient treat-
ment for childhood eating disorders is family-based therapy (FBT). Clinical
researchers at the Maudsley Hospital in the United Kingdom developed FBT
and it is based on a model of mobilizing family resources to help the family
refeed the patient (Lock, LeGrange, Agras, & Dare, 2001). This treatment
has support from well-conducted clinical studies. The recently issued APA
(2006) guidelines for the treatment of eating disorders called family treat-
ment the most effective treatment for child and adolescent AN.
Early in treatment, the therapist emphasizes that the family is not at

fault for the illness, but that they must take responsibility for helping to
overcome it. Treatment consists of three major phases. First, it focuses on
the primary goal of refeeding the patient. During this phase, the therapist
aims to strengthen the bond between the two parents in their joint refeed-
ing efforts, and between the patient and any siblings available to provide
support. During the second phase of treatment, family issues that may be
interfering with refeeding are identified and addressed. The third treat-
ment phase is initiated only after healthy weight and eating patterns have
been achieved. At this final stage, treatment centers on building a healthy
relationship between the adolescent and the family that is not focused
primarily around the eating disorder (LeGrange, 1999).
FBT has been tested in a number of randomized controlled trials.
These studies have investigated its efficacy as well its ideal length and for-
mat. It is still unclear what components of family therapy might account
for its efficacy. Such components could include parental control over eat-
ing, changes in the family dynamics, or other unknown factors (Lock &
LeGrange, 2005).
In a controlled trial comparing individual supportive psychotherapy
to family therapy focused on eating, Russell, Szmukler, Dare, and Eisler,
(1987) examined a subgroup of 21 adolescents with AN who had a short
duration of illness (<3 years) and whose body weight had been restored
by inpatient treatment. In this subgroup of patients, those randomized to
family therapy had greater weight gains and superior psychological out-
comes than those randomized to individual treatment. Even at a five-year
follow-up, when most patients had improved over the course of time, the
advantage of family therapy over individual therapy persisted in this group
of patients (Eisler et al., 1997).
In contrast, another subgroup of patients in this study had much
poorer outcomes. Twenty-three adults with BN accompanied by low body
weight were also randomly assigned to individual or family therapy. Only
three patients in this subgroup achieved a good outcome at five years,
using the Morgan-Russell definition of good outcome (achieving a healthy
body weight, menstruating, and having no bulimic symptoms; Morgan &
Russell, 1975). In addition, individual therapy did not differ from family
therapy in its efficacy with these BN patients. Thus, family therapy may
not be efficacious for patients with BN or for older patients.
Subsequent research has investigated the optimal format and length
of family therapy. Eisler et al. (2000) compared two forms of family ther-
apy: conjoint family therapy (CFT) and separated family therapy (SFT). In
CFT, 19 adolescents with AN were seen together with their parents, and in
SFT, 21 adolescents with AN were seen separately from their parents. SFT
parents had regular sessions with the same therapist. The goals and tech-
niques used in both therapy types were similar between the groups. The
SFT group showed small and nonsignificant differences in eating disorder
symptoms. However, more substantial benefits in general psychopathol-
ogy (mood, obsessionality, and psychosexual adjustment) followed CFT.
On the other hand, SFT might be more appropriate in families with high
levels of conflict: in families where frequent criticism from mothers was
directed at the patient, SFT was significantly superior. Only four patients
in this study required concurrent hospitalization. In a smaller study,
these treatment formats were also compared among 18 adolescents with
AN randomly assigned to CFT or SFT (Le Grange, Eisler, Dare, & Russell,
1992). Inpatient treatment was also required during the course of treat-
ment. Both treatments brought about clinically significant improvements
in weight and psychological functioning, with few differences between the
treatment formats.
Lock, Agras, Bryson, and Kraemer (2005) examined the ideal length and
dose of family therapy. These investigators compared the standard therapy
length of 20 sessions over 12 months to a short form of therapy offering
10 sessions over 6 months. Whereas the standard length therapy covered
all three phases of treatment, the short form of therapy primarily focused
on the first and second phases with less time for general adolescent con-
cerns and building the family relationship. In this randomized controlled
trial, 86 adolescents with AN showed similar gains in BMI, eating disorder
psychopathology, and general psychopathology across both the short and
long treatment conditions at 12 months. Although 19 patients required
hospitalization during treatment, these were distributed evenly across
the two treatments. Patients with high levels of eating-related obsessional
thinking gained more weight in the longer treatment. Similarly, those from
nonintact families experienced greater improvements in eating psychopa-
thology in the longer treatment.
Across the two groups at one year, 96% of patients no longer met cri-
teria for AN, and 67% achieved a healthy BMI (>20). Thus, for the majority
of AN patients (especially those from intact families and those who are not
exceptionally high on eating-related obsessionality), a short form of FBT is
likely to be as effective as standard-length treatment. These findings were
maintained at a long-term follow-up (on average, four years), when no sig-
nificant differences between the groups were found and 89% of all patients
were at a healthy weight (Lock, Couturier, & Agras, 2006).
Additional forms of family therapy have been examined as well. Geist,
Heinmaa, Stephens, Davis, and Katzman (2000) compared a family group
psychoeducation treatment and a standard family therapy among 25 ado-
lescent girls with AN and their families. Both treatments were adminis-
tered in eight sessions over four months, and psychoeducation treatment
involved education classes and professionally led discussion groups on
eating disorders (Geist et al., 2000). Both groups achieved comparable
improvements in ideal body weight, eating disorder psychopathology, and
general psychopathology. However, all patients in this study required con-
current hospitalization for medical reasons (for an average of eight weeks),
so it is difficult to attribute their improvement to the outpatient family
therapies administered.
A version of family therapy entitled Behavioral Systems Family Ther-
apy (BSFT), has also been compared with an individual treatment, Ego
Oriented Individual Treatment (EOIT, described below under psychody-
namic treatment). BSFT was similar to the Maudsley model of FBT, with a
few subtle differences. Robin and colleagues (1999) compared these treat-
ments among 37 adolescents with AN, 16 of whom required concurrent
hospitalization (11 BSFT and 5 EOIT patients). Immediately after treat-

ment and at a 12-month follow up, patients in the BSFT group had gained
more weight. A greater proportion of BSFT patients resumed menstrua-
tion after treatment (94% vs. 64%). This difference was no longer sta-
tistically significant at follow-up, when both groups had similar rates of
menstruation recovery. However, the more rapid response of menstruation
and weight gain to family therapy suggests that BSFT was quicker acting
than individual treatment. In a disorder as medically compromising as AN,
speed of recovery can be an important consideration, and a faster-acting
treatment would generally be more advisable.
Although AN in younger children is rare, a large case series also pro-
vided recent support for the use of FBT in this population. Thirty-two
children of an average of 11.9 years showed clinically significant improve-
ments in eating disordered thinking patterns and body weight gain fol-
lowing family therapy (Lock, LeGrange, Forsberg, & Hewell, 2006). These
patients closely resembled those in a comparable adolescent sample before
and after treatment. This study suggested that efficacy of FBT did not
depend on addressing issues of adolescent development, and these issues
may not be crucial to treatment, even with adolescents.
There have been no randomized controlled trials of family therapy for
adolescents with BN. The results from the adult BN subgroup examined
by Russell et al. (1987) are discouraging. However, a case series described
eight adolescents with BN treated with FBT (Dodge, Hodes, Eisler, & Dare,
1995). Standard FBT for AN was modified to address compensatory behav-
iors and shift the focus from weight gain to regular eating. (For a descrip-
tion of the treatment strategies used in FBT for adolescent BN, see Le
Grange, Lock, and Dymek, 2003). At 12 months after the start of treat-
ment, there were significant reductions in eating pathology and in the
level of self-harm behaviors, which were initially present in half of the
patients. However, only one patient achieved a good outcome as defined by
the Morgan-Russell criteria listed earlier (Morgan & Russell, 1975). There-
fore, further research is needed before recommending FBT to children or
adolescents with BN.
Cognitive Behavioral Therapy

CBT focuses on identifying and modifying dysfunctional thoughts
and behaviors related to eating, weight, and body shape. Therapists chal-
lenge patients’ thoughts in treatment through cognitive restructuring and
behavioral experiments (Garner, Vitousek, & Pike, 1997). Another primary
goal of treatment is to establish regular eating patterns, with the assist-
ance of self-monitoring and dietary planning. Gowers (2006) argued that
eating disorders are a classic example of a problem in which abnormal
thoughts and behaviors combine to result in physical and social disability;
thus he argued that CBT should, in theory, be effective.
A randomized controlled trial known as the Trial of Outcome for Child
& Adolescent Anorexia Nervosa (TOuCAN) project is underway in England
(see Gowers, 2006). In it, manualized CBT is being compared with spe-
cialist inpatient treatment and treatment as usual. Over 200 participants
were initially recruited. Thus, the final results (apparently due in 2008)
will no doubt be a meaningful contribution to the literature. However,
because no other randomized controlled trials have been conducted for
childhood or adolescent AN or BN, its efficacy with these populations can
only be predicted based on existing data from adults. However, the estab-
lished efficacy of CBT, particularly in the treatment of BN, suggests that
investigations of this treatment with adolescents and children should be
an important research priority.
CBT for AN has been tested in a small number of clinical trials. For
example, in 24 adult AN patients, Channon, de Silva, Hemsley, and Perkins
(1989) compared CBT to both behavior therapy (BT) and a low-contact
treatment administered by psychiatrists. Not surprising considering the
small sample, the three treatments did not statistically differ from each
other on outcome. All patients improved significantly on nutritional sta-
tus, menstrual functioning, and body weight. However, patients had better
treatment attendance with CBT than with BT. CBT also resulted in fewer
early drop-outs in a 12-month comparison of CBT and nutritional coun-
seling in adult AN patients following hospitalization (Pike, Walsh, Vitousek,
Wilson, & Bauer, 2003).
CBT patients remained significantly longer without relapsing (44 vs.
27 sessions); 22% versus 53% of patients relapsed in CBT versus nutri-
tional counseling. Similarly, a comparison of CBT and dietary counseling
found a much lower drop-out rate with CBT; indeed, all patients dropped
out of dietary counseling by three months (Serfaty, Turkington, Heap, Led-
sham, & Jolley, 1999). In addition, all patients refused to provide data for
a six-month follow-up. This study dramatically illustrates some of the dif-
ficulties encountered in conducting research with such a relatively treat-
ment-resistant group of patients. In addition, Fairburn (2005) argued that
nutritional counseling without concurrent psychotherapy is not a suffi-
ciently rigorous comparison group against which to test CBT.
Interestingly, the results of a recent study cast doubt on the superior-
ity of CBT in a comparison to another manualized psychotherapy, inter-
personal therapy (IPT), and to a nonspecific clinical management condition
providing supportive psychotherapy (McIntosh et al., 2005). Patients were
55 women (aged 17–40) diagnosed with AN using a slightly higher than
usual weight criterion to define the disorder (BMI <19). Thirty percent of
all patients were considered much improved or had minimal symptoms
after treatment. However, despite the authors’ predictions, the nonspecific
control treatment was superior to CBT and IPT on global measures of eat-
ing disorder symptoms. Thus, there is not yet strong support for the use of
any specific individual psychotherapy for AN, even with adults (see Wilson,
Grilo, and Vitousek, 2007, for a review).
For adults with BN, CBT (Fairburn, Marcus, & Wilson, 1993) is con-
sidered the treatment of choice. For example, both the APA (2006) and also
the National Institute for Clinical Excellence (NICE, 2004) recommended
CBT as the leading evidence-based treatment for BN in their recently issued
evidence-based guidelines for the treatment of eating disorders. This was
the first time that NICE endorsed a specific psychotherapy as a treat-
ment of choice. The efficacy of CBT for BN has been supported by strong
evidence from randomized controlled trials. CBT involves weekly individ-

ual sessions over four to five months and typically results in complete
remission in about 40% of cases (Wilson & Fairburn, 2002). Treatment
does not typically affect patients’ body weight. The majority of therapeutic
gains occur in the first few sessions of treatment, significantly sooner than
in comparison treatments (Wilson et al., 1999). This finding suggests that
CBT is relatively fast acting. Similarly, more patients achieved remission
by the end of CBT than by the end of IPT, although this difference leveled
off by a 12-month follow-up (Agras, Walsh, Fairburn, Wilson, & Kraemer,
2000; Fairburn, et al. 1995).
Again, although inferences can only be made from research with
adults, CBT is also established as a treatment for BED, efficacious in
reducing binge eating and associated psychopathology, even over long-
term follow-up (Agras, Telch, Arnow, Eldredge, & Marnell, 1997). Gener-
ally, CBT does not produce clinically significant weight loss (Wilson, 2005)
and thus does not effectively treat the obesity often associated with BED.
Descriptive research has now documented the presence of BED among
a proportion of children presenting for obesity treatment (Decaluwé and
Braet, 2003). Therefore, evaluating the effect on childhood BED of weight
control treatment and other therapies should be a research priority.
Although experts recommend CBT for adolescents with BN (NICE,
2004), it is important that age-related modifications be made to fit the ado-
lescent patient’s level of development and circumstances. It is also essen-
tial that the patient’s family be included as appropriate. In addition, Robin
and colleagues (1998) have cautioned that patients need to have developed
certain requisite cognitive abilities to engage in this treatment: (1) the abil-
ity to think abstractly about beliefs and attitudes regarding weight, shape,
and appearance, and (2) the ability to consider alternative possibilities to
presently held beliefs and a willingness to test these alternative hypoth-
eses. These cognitive skills are usually present by age 14–15 years. Cogni-
tive treatment strategies can be made more concrete for children who do
not yet have these skills. For example, simple behavioral experiments can
be used to disconfirm distorted beliefs. Concrete cognitive strategies such
as overt self-statements or self-instruction can be used to help patients
cope with negative automatic thoughts.
Psychodynamic Therapy
One randomized trial has examined a form of psychodynamic therapy
for adolescents with AN. The study by Robin et al. (1999), described earlier,
compared a version of family therapy to ego-oriented individual treatment
(EOIT). EOIT emphasized developing ego strength, learning coping skills,
individuating from the family, and identifying and modifying any dynam-
ics that may be blocking eating. EOIT led to decreases similar to family
therapy in conflicts during family interactions even though sessions were
individually conducted; however, EOIT took effect less immediately than
family therapy.
Time-limited versions of psychodynamic treatment for AN have also
been tested in two studies with adults. A randomized controlled trial
investigated three specialized treatments and a low-contact control treat-

ment in 84 women with AN (Dare, Eisler, Russell, Treasure, & Dodge,
2001). Focal psychoanalytic therapy addressed the meaning of the
patients’ symptoms in light of their history and family relationships, as
well as the effect of these symptoms on their relationships (including the
relationship with the therapist). This treatment was compared to cognitive
analytic treatment (CAT), in which components of cognitive therapy were
integrated with components of psychodynamic therapy such as interper-
sonal and transference issues. Family therapy was the third specialized
treatment tested in this investigation.
After 12 months, the three specialized treatments were similar in
outcome, and both focal psychoanalytic therapy and family therapy were
superior to the control treatment. However, patients did poorly in all treat-
ments. Only 30% of patients in the three treatment groups no longer met
criteria for AN (compared to 5% of patients in the control treatment). The
study may have had insufficient power to detect differences among the
specialized treatments, and patients had a long history of illness (6.3 years
on average), indicating poor prognosis. Similarly, Treasure and colleagues
(1995) found no differences between CAT and another specialized therapy,
behavior therapy (emphasizing psychoeducational techniques), adminis-
tered to 30 adult AN patients. This study, as well as that of Dare et al.
(2001), may have been underpowered. Based on the research so far, there
is no compelling evidence that psychodynamic therapy is more effective
than alternative specialized treatments for AN with adolescents or adults.
Interpersonal Therapy
IPT is a specific, time-limited form of psychodynamic treatment that
focuses on resolving interpersonal difficulties that contribute to the onset
or maintenance of the disorder. Four potential problem areas typically
constitute the focus of treatment: grief, interpersonal disputes, role transi-
tions, and interpersonal deficits. The study discussed above, which com-
pared CBT, IPT, and nonspecific clinical management in adult women with
AN, found IPT to be the least efficacious of these three treatments (McIn-
tosh et al., 2005). IPT has shown similar efficacy to CBT in adults with
BN, but its benefits may be more delayed (Agras et al., 2000; Fairburn et
al., 1995). Research also supports the use of IPT for BED in adults (Wilfley
et al., 2002). As with CBT, the use of IPT for adolescents or even children
would need to be carefully modified to suit the age and maturity level of
the patient, as well as to place special emphasis on relevant family rela-
tionships. However, the lack of research on IPT for this age group suggests
that this treatment would not be an optimal choice for eating disorders in
youth.
Summary of Treatment Literature

The principal limitation with the current literature on treatment of child
and adolescent eating disorders is that the majority of it has been based
on adults rather than children and/or adolescents. Extrapolating from
the adult literature may or may not be appropriate. Gowers and Bryant-
Waugh (2004) recently listed four arguments in favor of such extrapola-
tion and five reasons why such extrapolation may not be warranted. Until
there is more research, we should proceed with caution.
Overall, the state of the research-base varies depending on which dis-
order and which age group is being considered. The prognosis is probably
better for children and adolescents than for adults but there is still limited
research with younger ages. The prognosis is worse for AN than for BN or
BED. Regarding AN, in a recent systematic review of randomized controlled
trials of psychosocial interventions for adolescents with AN, Tierney and
Wyatt (2005) concluded that very few conclusions could be drawn from
the small body of research. Many studies have been small and possibly
underpowered to detect differences between interventions; no published
research has included no-treatment control conditions; and most studies
lacked a follow-up assessment. Thus, there is not yet strong support for
the use of any specific intervention for AN.
For BN, there is also a notable lack of research specifically with
adolescents or children, although two randomized trials of family ther-
apy for BN are in progress (Gowers & Bryant-Waugh, 2004). However,
the efficacy of CBT for BN among adults (whose samples often include
adolescents) has been well established, and NICE (2004) recommended
CBT as the leading evidence-based treatment for BN. They recom-
mended that CBT be used for this group, but with age-related modifica-
tions to suit the patient’s level of development and circumstances, and
including the family as appropriate.
BED may have the best prognosis, although more research with chil-
dren and adolescents is clearly needed. More research with other variants
of EDNOS particularly given that it is the most common ED encountered
in clinical practice. We either need more research on treatment of various
subtypes of EDNOS or more research on the transdiagnostic approach
recently described by Fairburn, Cooper, and Shafran (2003).
CONCLUDING REMARKS
The EDs are potentially life-threatening conditions that are also poten-
tially treatable. Early detection and intervention may be the key; thus,
expertise in assessment and treatment of eating disorders is valuable
for those working with children and adolescents. However, much more
research is also needed with these age groups so that we do not have to
rely on extrapolations from the adult literature.
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14
Treatment of Pediatric
Feeding Disorders
CATHLEEN C. PIAZZA, HENRY S. ROANE, and
HEATHER J. KADEY
TREATMENT OF FEEDING DISORDERS
“Don’t worry, he’ll grow out of it.” This statement represents one of the
most commonly delivered pieces of advice given to parents of young chil-
dren who have difficulties at mealtime. As indicated in the chapter on the
Assessment of Pediatric Feeding Disorders, the feeding difficulties of most
children do, in fact, resolve over time. However, there are some children
whose feeding problems will not resolve without intervention, and it is on
these children that this chapter is focused. The data from our interdiscipli-
nary Pediatric Feeding Disorders Program at the Munroe-Meyer Institute
at the University of Nebraska Medical Center shows that the mean age of
children referred for assessment and treatment of severe feeding problems
is three. We think that it is about this time that parents and professionals
realize that the child is not going to “grow out of it” and therefore, needs
treatment.
Eating is a complex process, consisting of a chain of behaviors that
begins with accepting solids or liquids into the mouth, retaining solids or
liquids in the mouth, forming a bolus of the solids and liquids, chewing
solid food (when necessary), swallowing the solids or liquids, and retaining
the solids and liquids in the gastrointestinal tract. Dysfunctional eating
may be the result of difficulties anywhere along this chain of behaviors.
Thus, an important first step in the successful treatment of children with
feeding problems is to identify which specific behaviors are problematic
for the child and then to set measurable goals for those individual behav-
iors. &$$$;Goals should be individualized for each child. Some examples
CATHLEEN C. PIAZZA, HENRY S. ROANE, and HEATHER J. KADEY ● Munroe-Meyer

Institute for Genetics and Rehabilitation and University of Nebraska Medical Center

436 CATHLEEN C. PIAZZA et al.
of measurable goals might be to increase oral intake of solids and liquids

to 100% of the child’s caloric and nutritional needs. This might be an
appropriate goal for a child who is failing to thrive due to insufficient
intake. Another goal might be to increase acceptance of 16 new foods
(four from each of the food groups: fruit, proteins, starches, vegetables) to
greater than 90%. This might be an appropriate goal for a child who is a
selective eater (e.g., a child who only eats French fries). Other goals might
focus on decreasing inappropriate behavior, increasing levels of swallow-
ing, and teaching chewing or self-feeding to name a few.
Children with food refusal have a different history or experience with food
than typically eating children. That is, even though many children will have
bouts of feeding problems from time to time, their problems resolve over time
without intervention. By contrast, the feeding problems of a small number of
children persist and worsen over time (Lindberg, 1996). Therefore, the tech-
niques or recommendations that are used for typically eating children may
not be effective with children with chronic or severe feeding problems.
Using functional analysis methods, Piazza, Fisher, et al. (2003) showed
that the consequences parents use to get their children to eat (i.e., allowing
escape from presentations of solids and/or liquids and providing atten-
tion or access to preferred items or food following inappropriate behavior)
actually worsened their child’s inappropriate mealtime behavior in almost
70% of the children in the study. Most children in the Piazza, Fisher,
et al. (2003) study had higher levels of inappropriate behavior when that
behavior resulted in escape from eating or drinking. Inappropriate behav-
ior also was higher for many of the children when it produced access to
adult attention or preferred items and/or food (tangibles). Thus, treat-
ment development should bear in mind the important role that negative
reinforcement in the form of escape from eating plays in the maintenance
of feeding problems and the possible role of positive reinforcement in the
form of adult attention and access to tangibles for some children.
A number of studies have shown that procedures based on extinction
of negative reinforcement (so-called escape extinction) is effective as treat-
ment for children with feeding disorders (Ahearn, Kerwin, Eicher, Shantz,
& Swearingin, 1996; Cooper et al., 1995; Hoch, Babbitt, Coe, Krell, &
Hackbert, 1994; Patel, Piazza, Martinez, Volkert, & Santana, 2002; Piazza,
Patel, Gulotta, Sevin, & Layer, 2003; Reed et al., 2004). The underlying
rationale for “escape extinction” procedures is that children with feeding
disorders engage in inappropriate mealtime behavior such as batting at the
spoon and head turning to avoid eating (Piazza, Fisher, et al. 2003). The
child is more likely to continue these inappropriate mealtime behaviors in
the future when inappropriate mealtime behavior results in removal of the
food (e.g., from the child’s perspective, “the food goes away if I bat at it or
I turn my head”). Thus, escape extinction involves teaching the child that
inappropriate mealtime behavior no longer makes the food go away (i.e.,
inappropriate behavior no longer produces escape, thus the term escape
extinction).
One limitation of early studies on extinction of negative reinforcement
is that escape extinction was combined with other procedures such
as differential reinforcement (Ahearn et al., 1996; Cooper, et al., 1995
TREATMENT OF PEDIATRIC FEEDING DISORDERS 437
Hoch et al., 1994; Luiselli, 2000; Luiselli & Gleason, 1987); therefore,
the individual effects of the procedures on acceptance and inappropriate
behavior were not clear. In fact, a careful examination of the literature
reveals that there are no studies that we could find that clearly dem-
onstrate the effectiveness of positive reinforcement alone with multiple
participants with severe feeding problems. For example, in a study by
Riordan, Iwata, Finney, Wohl, and Stanley (1984), inappropriate behavior
resulted in escape from bite presentations in baseline. During treatment,
participants received positive reinforcement (e.g., access to preferred
items) contingent upon consumption of presented bites; however, this
positive reinforcement contingency was paired with no differential con-
sequences for inappropriate behavior (i.e., escape was no longer provided
for inappropriate behavior) which may have approximated escape extinc-
tion for this response.
Piazza and colleagues examined the effects of positive reinforce-
ment and escape extinction alone and in combination on acceptance and
inappropriate behavior (Piazza, Patel, et al., 2003; Reed et al., 2004) to under-
stand how positive reinforcement alone, escape extinction alone, and
positive reinforcement and escape extinction combined affected feeding
behavior. Piazza, Patel, et al. compared an escape condition (i.e., inappro-
priate behavior resulted in a 30-s break from bites of solids or liquids) to a
condition in which swallowing bites of solids or liquids resulted in differ-
ential positive reinforcement (i.e., 30-s access to a preferred toy). Levels of
acceptance of solids and liquids remained low and inappropriate behavior
remained high in both conditions.
Next, the authors added escape extinction to the differential positive
reinforcement procedure (DRA) and compared DRA plus escape extinction
to escape extinction alone. Levels of acceptance increased and inappropriate
behavior decreased in both conditions (DRA plus escape extinction and
escape extinction alone). Levels of acceptance decreased and inappropriate
behavior increased when the escape extinction procedure was removed.
These results suggest that increases in acceptance and decreases in
inappropriate behavior occurred as a result of the escape extinction
procedure, independent of the presence or absence of a differential
positive reinforcement contingency. However, inappropriate behavior and/
or negative vocalizations (e.g., crying) were lower for some participants
when treatment consisted of escape extinction and differential positive
reinforcement relative to escape extinction alone.
Reed et al. (2004) used a similar preparation to compare the effects of
noncontingent reinforcement (NCR) alone, NCR plus escape extinction, and
escape extinction alone. The results of Reed et al. were similar to those of
Piazza, Patel, et al. (2003) in that levels of acceptance increased and inap-
propriate behavior decreased when escape extinction was implemented,
independent of the presence or absence of NCR; however, inappropriate
behavior and/or negative vocalizations were lower for some participants
when NCR was combined with escape extinction. Thus, the results of
Piazza, Patel, et al. and Reed et al. suggested that escape extinction may
be a critical component of treatment for some individuals, but that the
addition of a positive reinforcement component (i.e., either differential or
noncontingent) may be beneficial for some individuals by attenuating the

negative side effects of escape extinction procedures (cf., Lerman, Iwata,
& Wallace, 1999).
The two procedures that have been evaluated most frequently as
escape extinction for feeding problems are nonremoval of the spoon
(NRS; Hoch et al., 1994) and physical guidance (PG; Ahearn et al., 1996).
During NRS, the feeder presents the spoon or cup at the child’s lips and
the cup remains at the lips until the child allows the feeder to deposit
the bite into the child’s mouth. During PG, the feeder applies gentle
pressure to the mandibular joint and deposits the solid or liquid into
the child’s mouth if the child fails to accept the bite within a prespecified
time period. Both of the procedures theoretically eliminate the child’s
opportunity to escape from bite presentations via inappropriate mealtime
behavior and produce relatively rapid increases in acceptance and
decreases in inappropriate behavior. In addition, Ahearn et al. showed
that both NRS and PG were associated with relatively few side effects
and were rated as acceptable treatments by caregivers.
Even though the results of Ahearn et al. (1996) suggested that caregivers
rate both NRS and PG as acceptable, our experience suggests that caregivers
and professionals sometimes equate escape extinction procedures with
“forced feeding”. This criticism raises important ethical questions about
“right to treatment” issues for children with feeding problems. The online
medical dictionary (http://medical-dictionary.thefreedictionary.com/
Force-feeding) defines forced feeding as “administration of liquid food
through a nasal tube passed into the stomach” and “forcing a person to eat
more than desired.” The first definition obviously suggests that feeding via
nasogastric (NG-) and gastrostomy (G-) tubes, one of the most commonly
used treatments for children with severe feeding problems, is a form of
forced feeding. Nevertheless, it is rare to hear parents or professionals
characterize NG- or G-tube feedings as “forced feeding”.
The second definition suggests that forced feeding occurs when a per-
son is compelled to consume more food than is desired. Thus, if a child
“desires” to engage in refusal behavior (i.e., as measured by refusal to eat
any food, refusal to eat less than what is needed to gain weight or grow,
refusal to eat nutritious foods, refusal to drink liquids), then any method
that results in increased intake of solids and/or liquids might be consid-
ered “forced”. Nevertheless, as a caregiver, one must ask if it reasonable to
“allow” your child to engage in behavior that could result in malnutrition,
cognitive and behavioral deficits, dehydration, and perhaps even death?
Just as a caregiver would not allow a child to choose to engage in a dan-
gerous behavior (e.g., running into the street if a car was coming), why
would they allow the child to choose to refuse to eat if it were detrimental
to their health? In both cases, the behaviors (running in front of a car,
refusing to eat) are life-threatening. Why do we attempt to prevent one,
but not the other?
The answer is that caregivers are repeatedly told by others not to “force
feed” their child. This recommendation probably is derived from the notion
that forced feeding will cause mealtimes to become aversive for the child
(i.e., the child will demonstrate more “distress”), which will result in lower
levels of consumption. However, the available empirical data from pub-

lished studies do not support the notion that children demonstrate more
“distress” (i.e., inappropriate behavior, crying) or refusal when escape
extinction is used as treatment for feeding problems.
Careful examination of data from most studies on escape extinction
(Ahearn et al., 1996; Cooper et al., 1995; Hoch et al., 1994; Patel et al.,
2002; Piazza, Patel, et al., 2003; Reed et al., 2004) show that levels of
inappropriate behavior (e.g., crying, head turning) are much higher under
baseline conditions when treatment of the feeding problem is absent (i.e.,
the child can choose not to eat). Thus, under a choice condition (“I don’t
have to eat”), children with feeding problems tend to have higher levels of
head turning, batting at the spoon, and crying, and lower or zero levels of
acceptance, suggesting that these baseline conditions (i.e., the child can
choose not to eat) may, in some cases, have more aversive qualities than
some treatment conditions. By contrast, when escape extinction-based
treatments are implemented, crying, head turning, and batting at the
spoon tend to decrease and levels of acceptance tend to increase, suggest-
ing that these treatment conditions may be relatively less aversive than
the baseline conditions in which the child can choose not to eat. Another
advantage of the escape extinction treatment is that it results in learning
(i.e., the child learns a new way of behaving during meals). By contrast,
tube feedings do not provide the opportunity for learning during meal-
times.
Even though a number of investigators have shown that escape
extinction is effective as treatment for food refusal, some children may
not respond to escape extinction alone. Therefore, a number of studies
have been conducted that have evaluated the effectiveness of treatment
packages that combine escape extinction with other procedures. Kern and
Marder (1996) and Piazza and colleagues (Piazza et al., 2002) showed that
simultaneous presentation of preferred and nonpreferred foods (e.g., plac-
ing a piece of nonpreferred broccoli on a preferred potato chip) was more
effective than sequential presentation (e.g., giving the child a preferred
potato chip following consumption of a nonpreferred piece of broccoli).
Mueller, Piazza, Patel, Kelley, and Pruett (2004) and Patel, Piazza,
Kelly, Ochsner, and Santana (2001) extended the work of Kern and Marder
(1996) and Piazza et al. (2002) by demonstrating that blending (i.e., mixing)
preferred and nonpreferred foods (Mueller et al.) or liquids (Patel et al.) was
an effective method of increasing consumption of nonpreferred solids or
liquids when combined with escape extinction. The children in the Muel-
ler et al. study consumed one or two foods (referred to as preferred foods)
and refused all other foods (referred to as nonpreferred foods). Therefore,
Mueller et al. initiated treatment by presenting a mixture consisting of
90% preferred food and 10% nonpreferred food (i.e., a 90/10 blend). The
ratio of the amount of preferred to nonpreferred foods then was altered in
10% increments (e.g., 80/20, 70/30, and 60/40 blends) when the child
consumed the previous ratio of preferred and nonpreferred food at high
levels.
Patel et al. (2001) combined a high-p sequence with escape extinction
to increase acceptance of solids and liquids for three children. A high-p
sequence is a set of instructions with which the child demonstrates a high

level of cooperation or compliance (Mace et al., 1988). By contrast, the low-
p sequence for a child with a feeding problem typically would involve an
instruction related to consumption of solids or liquids (e.g., “take a bite”).
The high-p instructions used by Patel et al. were similar topographically to
the low-p instructions (i.e., the high-p instruction was to “take a bite” for
all children while simultaneously presenting an empty utensil for a child
who refused food, liquid on a spoon for a child who refused liquid in a cup,
water on a spoon for a child who refused food from a spoon).
By contrast, a high-p sequence consisting of simple motor tasks (e.g.,
touch head) combined with escape extinction did not produce increases in
acceptance relative to escape extinction alone for one child in a study by
Dawson et al. (2003). It is possible that the differences in the effectiveness
of the high-p sequence in the studies by Patel et al. and Dawson et al. was
a function of the similarity (Patel et al.) or the dissimilarity (Dawson et al.)
of the high-p and low-p responses. That is, the high-p sequence may be
more likely to be effective with children with feeding problems when there
is a high degree of similarity between the high-p and low-p instructions
as was the case in Patel et al. However, that conclusion is speculative.
Additional research is needed to determine the conditions under which
the high-p sequence is an effective treatment for children with feeding
problems.
Response effort (altering the difficulty or effort associated with eat-
ing) is another variable that has been shown to influence consumption
of food (Kerwin, Ahearn, Eicher, & Burd, 1995). Kerwin et al. altered the
volume of food on a spoon in the presence and absence of escape extinc-
tion. Levels of acceptance generally increased as the volume of food on
the spoon decreased (i.e., higher levels of acceptance when the amount on
the spoon was smaller), suggesting that manipulations of response effort
may represent a viable option in the treatment of feeding disorders. In our
clinical setting, we typically arrange the mealtime to minimize the effort
required of the child during the initial phases of treatment. Some variables
to consider when arranging the mealtime environment that will affect the
effort of the meal include the utensil size, bolus size of solids or liquids,
texture of presented food, number of presentations of solids or liquids, and
whether the child self-feeds, to name a few. However, these variables have
not been demonstrated empirically to alter the effectiveness of treatment.
Most studies on escape extinction procedures either alone or in com-
bination with other procedures produce increases in acceptance and
decreases in inappropriate behavior. However, there are a number of other
problematic mealtime behaviors that interfere with consumption, such as
expulsion (spitting out food) or packing (pocketing or holding accepted
food in the mouth). Coe et al. (1997) and Sevin, Gulotta, Sierp, Rosica, and
Miller (2002) used a re-presentation procedure to treat expulsion, which
consisted of placing the expelled food back into the child’s mouth until the
child swallowed the bite (a procedure that is similar to what parents do
with infants in the early stages of feeding). The re-presentation procedure
was effective for reducing expulsion in both studies. Patel et al. (2002)
demonstrated that modification of the texture of food reduced expulsion
for one child. The child in the Patel et al. study expelled meats but not
other types of food (i.e., fruits, vegetables, starches). Reduction of the tex-
ture of the meats resulted in low levels of expulsion and also allowed the
child to continue to advance her oral motor skills with the other foods at
a higher texture.
Packing is a behavior that may emerge simultaneous with the intro-
duction of treatment for acceptance (Sevin, Gulotta, Sierp, Rosica, & Miller,
2002) or subsequent to treatment of other response topographies of prob-
lematic feeding behavior (Gulotta, Piazza, Patel, & Layer, 2005). Sevin et al.
used a redistribution procedure, which consisted of removing the packed
food from the child’s mouth, then replacing the packed food back on the
tongue, to reduce packing. Gulotta et al. replicated and extended the find-
ings of Sevin et al. by using the redistribution procedure to increase intake
and reduce levels of packing in four children.
Packing may be an avoidance behavior that allows the child to escape
eating by holding food in his or her mouth, or it may occur because the
child lacks the prerequisite skills (e.g., tongue lateralization and elevation)
necessary to swallow (Gulotta et al., 2005). In either case, the redistribu-
tion procedure may affect behavior by altering motivation to swallow or by
promoting the development of the swallow response. That is, redistribu-
tion may increase the child’s motivation to swallow because the child then
can avoid the implementation of the redistribution procedure. The redis-
tribution procedure may also foster skill development for other children by
approximating one of the early behaviors in the chain that is necessary for
swallowing (i.e., forming the food into a bolus and moving it back on the
tongue). Swallow facilitation (placing food on the posterior of the child’s
tongue, which may elicit the swallow response; Lamm & Greer, 1988;
Hoch, Babbitt, Coe, Ducan, & Trusty, 1995) is an alternative method of
promoting the swallow response. Swallow facilitation should be used with
caution by clinicians who are trained to monitor aspiration risk.
Texture selectivity or difficulties advancing texture is another prob-
lem that is exhibited by many children with feeding problems (Munk &
Repp, 1994). Shore, Babbitt, Williams, Coe, and Snyder (1988) showed
that texture fading was effective for increasing one child’s acceptance of
gradually increasing textures. Shore et al. advanced the child’s texture
from pureed to chopped, while maintaining high levels of acceptance and
swallowing and low levels of packing and expulsion. Data from the other
three children in the study were less clear with respect to the necessity of
the texture fading procedure.
We rarely use texture fading in our clinical practice. We have observed
that chewing skills often do not emerge in children with feeding disorders
as we increase the texture of foods in the absence of training the child in
chewing skills. That is, many of the children we treat simply swallow the
presented bites of food without chewing, independent of the presented
texture, which is unsafe. Therefore, we do not increase the texture of food
presented during meals until we have taught the child to chew, and the
child demonstrates that he or she can masticate a variety of foods to a wet
ground or lower texture and swallow those masticated bites in a timely
manner.
Shore, LeBlanc, and Simmons (1999) increased the rate of chewing

for one individual with a differential reinforcement procedure. The ther-
apist delivered social praise and a sip of juice if the participant chewed
a prespecified number of times. The authors set the number of chews
required for reinforcement based on the mean number of chews in the
previous two meals. Mean chews per bite increased steadily throughout
treatment.
Finally, many children with feeding problems refuse to or cannot feed
themselves. Problems with self-feeding may occur as a result of skill defi-
cits, motivational deficits, or both. Piazza, Anderson, and Fisher (1993)
taught five girls with Rett syndrome to self-feed, using a 3-step prompting
procedure. The 3-step prompting procedure consisted of sequential verbal,
modeled, and physical prompts with verbal praise when the participants
took the bite following the verbal or modeled prompt. The 3-step prompt-
ing procedure has the advantage of addressing both skill and motivational
deficits. Skill deficits are addressed via the modeled prompt (individuals
who cannot follow spoken instructions have the benefit of a demonstra-
tion of the requested response) and the physical guidance (individuals who
cannot follow a spoken instruction or imitate a model have the benefit of
physical assistance to complete the response). Motivational deficits are
addressed via 3-step prompting in that an individual can avoid subsequent
prompting (e.g., physical guidance) by complying with the instruction ear-
lier in the 3-step prompting sequence (e.g., after the spoken instruction).
Parent training is essential for successful long-term outcomes for chil-
dren with feeding problems. Parent training has been the focus of several
studies on the treatment of children with feeding problems (Anderson &
McMillan, 2001; Mueller et al., 2003; Stark, Powers, Jelalian, Rape, &
Miller, 1994; Werle, Murphy, & Budd, 1993). For example, Mueller et al.
(2003) evaluated four multicomponent training packages to teach parents
to implement treatment protocols for children with pediatric feeding dis-
orders. The training packages consisted of (a) written and verbal instruc-
tions, modeling, and rehearsal; (b) written and verbal instructions and
modeling; (c) written and verbal instructions and rehearsal; and (d) writ-
ten and verbal instructions. Parental integrity with the treatment proto-
cols increased following all four training packages. The training procedure
consisting of written and verbal instructions was the most time efficient.
The authors suggested that effective training should consist of at least two
training components to insure high treatment integrity.
CONCLUSIONS
Taken together, the studies reviewed above suggest that treatments

based on theories of operant conditioning appear to be effective for children
with feeding problems. This conclusion is supported by several other stud-
ies evaluating the outcomes of behaviorally based treatments (Benoit, Wang,
& Zlotkin, 2000; Byars et al., 2003; Irwin, Clawson, Monasterio, Williams, &
Meade, 2003; Kerwin, 1999). For example, Kerwin reviewed the literature on
the assessment and treatment of feeding problems. The results of Kerwin’s
analysis showed that the only treatments that have empirical support were
those based on reinforcement of appropriate eating and extinction (non-
reinforcement) of food refusal. Benoit et al. compared behaviorally based
treatments with nutritional education for children with food refusal who
were G-tube dependent. Forty-seven percent of children in the behaviorally
based treatment group were weaned from their tube feedings after 15 weeks
of treatment compared to zero in the nutritional education group.
Other reports on behaviorally based treatments of groups of children
with feeding disorders have shown positive effects as well. Byars et al.
(2003) showed that a behaviorally based, intensive interdisciplinary feed-
ing program was successful in increasing intake and decreasing G-tube
feedings for nine patients. Irwin et al. (2003) showed that children with
cerebral palsy and feeding problems improved in the number of bites
accepted, weight, and height following intensive interdisciplinary treat-
ment combining behavioral strategies and oral motor techniques. These
summative studies, combined with those described elsewhere in this chap-
ter, suggest that procedures based on the principles of operant behavior
have been shown to be the most effective strategies for treating children
with feeding disorders.
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Index
A Antidepressants, 17–18
AAC. See Augmentative and alternative Antipsychotic medication, 19
communication Antipsychotics, 18–19
ABA. See Applied behavior analysis Anxiolytics, 19
Abbott, C., 395 Anzai, N., 416, 417
ABC. See Antecedent-behavior-consequence Applied behavior analysis, 7, 29, 95, 293
ABC model, of human emotions, 14 antecedent approaches to treatment, 43
ABFT. See Attachment-based family therapy definition, 30–31
Abolishing operation (AO), 44 treatment approaches, 31–32
Ackerman, S. J., 68 consequence-based intervention
Ackerson, J., 234 strategies, 34–43
Acquisto, J., 39 consequence-based procedures, 32–34
Active-engaged and disengaged, behavior Ardoin, S. P., 161
of children, 388 Argumentativeness, 107
Adaptation in intervention, principles for, Arnold, L. E., 342
390, 391 Arvidson, H. H., 381
Adderall XR™, 146, 148 AS. See Asperger syndrome
ADHD comorbid disorders, 140 Asarnow, J. R., 227, 238
ADOS. See Autism diagnostic observation Asmus, J. M., 50
schedule Asperger’s disorder, 288
Adrenocorticotrophin (ACTH), 344 Asperger syndrome, 300. See also Autism
ADVANCE parent training program, 91 spectrum disorders, in children
Agras, W. S., 422 behavioral difficulties, 302–303
AIT. See Auditory integration training emotional behaviour and, 304–306
Alant, E., 383, 385 language and cognitive development,
Alicke, M. D., 65 303–304
Alisank, S., 301 social deficits in, 301–302
Alternative language group, of children Atkeson. B. M., 83
with disabilities, 386 Atomoxetine, 149, 150
Altman, K., 40 Attachment-based family therapy, 237
Aman, M. G., 276, 336, 343 Attention-deficit/hyperactivity disorder
Amanullah, S., 301 (ADHD), 109, 113, 139
American psychological association task The American Academy of Pediatrics (AAP)
force, 83 guidelines, 140
AN. See Anorexia nervosa behavioral classroom management,
Anastopoulos, A. D., 155 162–164
Andelman, M. S., 40 contingency contracting, 164
Anderson, G. M., 339 daily report cards, 165–167
Anderson, S., 305 response cost, 165
AN, inpatient psychiatric care for, 416–417 time out, 165
Anorexia nervosa, 403–405 token economy, 164
Antecedent-based intervention, 47 classroom behavior management, 159–160
Antecedent-behavior-consequence, 308 literature, 160–161
445
446 INDEX
Attention-deficit/hyperactivity disorder sibling research and joint attention

(ADHD) (cont.) processes, 316–318
co-morbid disorders, and treatment, 151 and social qualitities, 315–316
and anxiety, 152–153 treatment and functional assessment of
with autism spectrum disorder (ASD), descriptive and functional analysis
153–154 of, 308–310
with mood disorders, 152 functional assessment, 306–307
(DSM–IV) criteria, 140 indirect assessment, 307–308
medication for, 143–144 Ayllon, T., 40
immediate release stimulant Azrin, N. H., 9
medications, 144
stimulant medications, adverse effects B
of, 147–148 Baby Sibling Research Consortium, 319
sustained release stimulant Baer, D. M., 30
medications, 145 Bandura, A., 201
NIMH multimodal treatment study Barkley, R. A., 155, 160
of, 141–143 Barkley, R., 113
psychosocial interventions, 154 Barlow, D., 187
behavioral parent training, 154–155 Barmish, A. J., 92, 93
components of parent training, 155–158 Barnhill, G. P., 304, 305
factors influencing treatment Baron, P., 235
effectiveness, 158–159 Barrett, B. H., 8
self-management systems, 167–168 Barretto, A., 40
summer treatment programs, 168–173 Barrett, P. M., 70, 242
titration of therapy and managing adverse Barry, C. T., 125
effects, 148–151 BASIC parenting training program, 91
treatment of, 140 Bauman, K. E., 347
Attwood, T., 305 Baumeister, A. A., 10
Auditory integration training, 298 BD. See Bipolar disorder
Augmentative and alternative Beauchaine, T. P., 128
communication, 373 Beauchamp, K., 46
in children, 381–386 Beck, A. T., 57, 187
intervention, in children, 386–388 Beck depression inventory, 72
Autism diagnostic observation schedule, 300 BED. See Binge eating disorder
Autism spectrum disorders (ASD), 4, 95 Bedell, J. R., 63
Autism spectrum disorders, in children Behavioral and learning-based therapies,
behavioral treatment of development of, 7
discrete trial training, 289 Behavioral parent training (BPT), 80, 83
naturalistic teaching methods, 290–291 Behavioral problems, 108
outcomes of, 291 Behavioral psychology, 6
rate-building procedures, 291–292 Behavioral systems family therapy, 422–423
characteristics of, 287–288 Behaviorism, doctrine of, 7
developmental individual difference in, Behavior management strategies, 80
299–300 Behavior problems inventory, 361
early diagnosis of, 318–319 Behavioural intervention, for SIB, 347–348,
function-based behavioral intervention, 356–357
310–312 Benjamin, S., 345
future research for, 312–313 Benzodiazepines, 19
nonbehavioral approaches Berkson, G., 358–359
biomedical intervention of, 293–295 Berman, J. S., 65
medications for, 295–297 Bernal, G., 237
psychoeducational/psychosocial Best Pharmaceutical Act, 256
treatments for, 299 Bidwell, R. J., 416
relationship development intervention, 300 Binet, A., 4
sensory-motor treatments, 297–299 Binet–Simon scale, 4
and theory of mind, 313 Binford, R. B., 408
biological mechanisms of, 313–314 Binge eating disorder, 403, 407, 425
cognitive processes of, 314–315 Bioinformational theory, 189
INDEX 447
Bipolar disorder, 253 emotional response, effects of, 207

Birnbrauer, J. S., 8 examination of, 205–206
Bjornstrom, C., 409 obsessive-compulsive disorder
Bjou, S. W., 8 (OCD), 209
Blanchford-Rogers, W. J., 19 physiological and cognitive components,
BN. See Bulimia nervosa 208
Body mass index (BMI), 147, 404, 416, 419, posttraumatic stress disorder (PTSD),
422, 424 210
Bohn, K., 408 psychopathology, 204
Bonfiglio, C. M., 48 social phobia (SoP), 208–209
Bordin, E. S., 67 specific phobia (SP), 206
BPI. See Behavior problems inventory evidence-based treatment
Brent, D. A., 237 modular therapy, 197
Brookman-Frazee, L., 95 psychotherapy, 195
Bryan, T., 298 randomized clinical trials, 196
Bryson, S., 422 participant modeling (PM)
BSFT. See Behavioral systems family social models, 201–202
therapy reinforced practice (RP)
Bulimia nervosa, 403, 405–406 contingency management, 200
Bullying, 108 phobias, 201
Bupropion, 151 systematic desensitization (SD)
Butler, L., 242 conditioning theory, 199
Buzan, R. D., 261 traumatic exposure, 200
Buzas, H. P., 40 treatment of, 183
change mechanisms, 199
C exposure, 197–198
Campbell, M., 19 implementation, 198–199
Carolyn Webster-Stratton’s Incredible Childhood disintegrative disorder, 288
Years, 112 Child mental health movement, 5
Carr, E. G., 10, 347 Child psychopathology, 4, 5
Carr, J. E., 297 Children, autism spectrum disorders
Carton, E. R., 243 in, 288. See also Children with
Case-Smith, J., 298 developmental disabilities; Eating
Casey, R. J., 65 disorders, in children; Pediatric
Casey, S. D., 44 feeding disorders, treatment of; Self-
CAT. See Cognitive analytic treatment injurious behaviour (SIB), in children
Cataldo, M. F., 37 behavioral treatment of
Catecholamine, 143 discrete trial training for, 289
Cathcart, K., 20 naturalistic teaching methods, 290–291
Cedar, B., 85 outcomes of, 291
Central nervous system (CNS), 143 rate-building procedures, 291–292
CFT. See Conjoint family therapy characteristics of, 287–288
Chaffin, M., 86 developmental individual difference in,
Chelation process, for autism, 297 299–300
Child characteristics, for behavioral early diagnosis of, 318–319
therapy, 69–71 function-based behavioral intervention,
Childhood anxiety disorders 310–312
assessment future research for, 312–313
evidence-based assessment, 192–194 nonbehavioral approaches
functional assessment, 194–195 biomedical intervention of, 293–295
cognitive-behavioral therapy (CBT) medications for, 295–297
catastrophic thoughts, 203 psychoeducational/psychosocial
dysfunctional behavior and distress, treatments for, 299
202 relationship development intervention,
development of, 211–214 300
empirically supported treatments sensory-motor treatments, 297–299
CBT, analysis of, 211 and theory of mind, 313
diagnostic depictions, 210 biological mechanisms of, 313–314
448 INDEX
Children (cont.) Clark, D. A., 187

cognitive processes of, 314–315 Clarke, G., 235
sibling research and joint attention Clarke, G. N., 234
processes, 316–318 Clarke, J. C., 12, 213
and social qualitities, 315–316 Clonidine, 150
treatment and functional assessment of CLPS. See Collaborative longitudinal
descriptive and functional analysis personality disorders study
of, 308–310 Coats, K. I., 235
functional assessment, 306–307 Cobham, V. E., 70
indirect assessment, 307–308 Cognitive analytic treatment, 426
Children’s aggressive outbursts, 115 Cognitive and behavioral strategies, for
Children’s anxious behavior behavior problems, 116
removing reinforcement of, 93 Cognitive behavioral approaches
Children’s behavior problems general characteristics of, 56
aggression and disruptive behavior, 80 Cognitive behavioral interventions, 72, 235
psychosocial treatment for, 79 Cognitive-behavioral models
Children’s depression inventory, 72 for treatment of youth, 70
Children’s depression rating scale-revised Cognitive-behavioral self-control therapy, 83
(CDRS-R), 255 Cognitive-behavioral treatments (CBTs), 14,
Children with developmental disabilities 52, 56, 152, 305, 423–425
AAC intervention in, 386–388 numerous assessment techniques for
AN in, 403–405 behavioral observations, 59–60
augmentative and alternative cultural considerations, 61
communication in, 381–386 functional assessment, 58–59
awareness of literacy exposure at home, interviews, 59–60
393–395 outcome assessments, 60–61
BED in, 403, 407 self-report measures, 60
BN in, 403, 405–406 therapeutic techniques for
communication and information affective education, 61–62
processing in, 376–378 behavioral rehearsal, 63
communication and learning in, 374–376 cognitive restructuring, 62
EDNOS in, 403, 407–408 contingency management, 62–63
EDs in, 403–404 problem-solving, 63–64
emergent literacy in, 392–393 self-monitoring, self-evaluation,
empirical evidence and interventions self-reinforcement, 64–65
inpatient treatment, 416–419 Cognitive distortions, 118
outpatient treatment, 420–426 Cohen, P., 415
partial hospitalization, 419–420 Coleman, P.P., 392
engagement and interaction patterns Collaborative longitudinal personality
in, 388–391 disorders study, 416
epidemiology of, 408–416 Collins, R., 40
graphic symbols role in, 395–396 Combined therapies
literacy, communication and learning, ADHD, 20
sociocultural aspects of, 378–381 ASD, 20–21
Child’s disruptive behaviors., 115 Combining antecedent and consequence-
Child’s treatment team, factors based treatments, 47–48
for consideration, 163 generalization, 48–49
Child treatment models, 56 Community Mental Health Centers Act, 5
Child vs. adult therapy, 68 Comorbidity psychological conditions and
Chill out program, 118–119 EDs, 413–414
Choice-making opportunities, 47 Compliance training skills, 89–90
Chorpita, B. F., 66 Conduct disorder (CD), 19, 107
Choudhury, M. S., 68 array of acts in person, 107
Christianson, G. W., 294 designs of treatments for, 108
Chronic behavior disorders, 270 diagnosis of, 108
Chronis, A. M., 155 evidence-based practice, 127–131
Chu, B. C., 187 Individual-based treatments
Church, C., 301–303 common elements, 116–117
INDEX 449
empirically supported treatments, Developmental group, of children with

117–119 disabilities, 386
multisystemic therapy (MST), 120 Developmental individual difference,
empirically supported treatments, 299–300
121–123 Developmentally disabled adolescents
key assumptions, 121 bipolar disorder
oppositional behaviors occurrence in, 108 carbamazepine, use of, 275
parent-based treatments valproate, use of, 272–273
common elements, 110–112 Developmentally disabled children, 1
empirically supported treatments, bipolar disorder
112–116 valproate, use of, 272–273
parent training, 109 lithium, use of
psychosocial treatment vs. case reports, 266–269
pharmacological treatments, 108 Developmentally disabled youth
residential treatment, 123–127 bipolar disorder, treatment of
Conduct problems, 107 anticonvulsant treatment, 270
Conjoint family therapy, 421–422 antipsychotic drug, 270
Context-dependent and independent, in antipsychotic medications, 275
communication, 380 appetite and weight gain, 276
Contextual emotion regulation therapy carbamazepine, monotherapy and
(CERT), 243 combined treatment, 274
Contingent reinforcement, 58 electroconvulsive treatment, 277
Contrucci Kuhn, S. A., 43 exhibits inappropriate repetitive
Conyers, C., 33 vocalizations, 263
Cooper, J. O., 30, 31, 34, 36, 46, 48 lithium, 264–265
Coping power program, 117–118 pervasive developmental disorder, 264
Coping with depression (CWD), 236 valproate monotherapy, 270
Cornwall, E., 13, 207 Diagnostic and Statistical Manual of Mental
Corsaut, S., 48 Disorders (DSM-IV ), 183, 287,
Cowdery, G. E., 37 288, 403
Crijnen, A. A. M., 160 Diament, D. M., 84
Croll, J., 409 Dibley, S., 47
Csikszentmihalyi, M., 389 Differential attention skills, 89
Cuffe, S. P., 226 Differential positive reinforcement
Cunningham, M. A., 23 procedure, 437
CU traits moderating relation, 131 Differential reinforcement of alternate
behavior (DRA), 9, 39, 354
D Differential reinforcement of diminishing
Dadds, M. R., 70 rates (DRD), 41
Daly, E. J., 48 Differential reinforcement of incompatible
Data from adults (ADA), 279 behaviors (DRI), 40
Dauber, S., 122 Differential reinforcement of low rates of
Davies, M., 415, 417 behavior (DRL), 41
Davies, S., 417 Differential reinforcement of other behavior
Davis, A., 199 (DRO), 9, 42
Davis III, T. E., 208 Differential reinforcement programs, 38
Day treatment programs. See Partial DIR. See Developmental individual
hospitalization programs, for EDs difference
Deitz, S. M., 41 Direct instruction approach, in autism
DeMyer, M. K., 8, 289 learning, 292–293
Denver Model, treatment for ADHD, 154 Discrete trial training, 289
Depressive disorders, 70 Disruptive behaviors, 107
Derby, K. M., 39 Dodo bird verdict, 65, 66
Desipramine, 150 Donenberg, G. R., 67
Desmopressin, 19 Dopamine, 143
Detheridge, C., 395 Dopamine, in SIB treatment, 335–336
Detheridge, T., 395 Dorsey, M. F., 347
Developmental disabilities (DD), 253, 373 Dostal, T., 270
450 INDEX
Down syndrome, 18 Event-related potentials, 313

Drug’s pharmacologic properties, 255 Evidence-based assessment, 192–194
DSM-IV-TR diagnostic criteria Evidence-based practices (EBPs), 183, 195
for AN, 404 Exhibits inappropriate repetitive
for BED, 407 vocalizations, 263
for BN, 406 Experimental functional analysis, 347
for eating disorder, 408 Expressive language group, of children with
DTT. See Discrete trial training disabilities, 385–386
Dumas, J. E., 83, 87 Extinction, in behavior intervention plans,
Dunlap, G., 47, 168 311–312
Dunst, C. J., 379 Extinction procedure, 37–38
DuPaul, G. A., 161–163 Eyberg, S., 86, 114
Durand, V. M., 10 Eyberg, S. M., 86
Durlak, J. A., 69 Eye movement desensitization and
Dykens, E. M., 16 reprocessing (EMDR), 207
Eyesnick, H., 11
E
Eating disorder not otherwise specified, F
403, 407–408 Fabiano, G. A., 154, 172
Eating disorders, in children, 403 Fabrizio, M. A., 292
comorbidity psychological conditions, Facilitated communication, 298–299
413–414 Fairburn, C. G., 408, 416, 424, 427
costs of, 414–415 Falcomata, T. S., 34
ethnicity and culture, 411–412 Family-based therapy, 420–422
gender differences role in, 410–411 Family-focused treatment (FFT), 243
inpatient treatment for children and FAST (Families and Schools Together) Track
adolescents, 416–419 Program, 122
outpatient treatment for children and FBA. See Functional behavioral assessment
adolescents with, 420–426 FBT. See Family-based therapy
partial hospitalization programs for, FC. See Facilitated communication
419–420 FCT. See Functional communication
social class and, 412–413 training
EBA. See Evidence-based assessment Fear-inducing stimulus, 13
EDNOS. See Eating disorder not otherwise Feindler, E. L., 118
specified Ferster, C. B., 8, 289
EDs. See Eating disorders Field, C. E., 37
EFA. See Experimental functional analysis Finch, Jr., A. J., 108
Ego oriented individual treatment, 422, 425 Fine, S., 236
Eikeseth, S., 49 Fink, M., 277
Eisenstadt, T. H., 86 Fischer, K., 46
Electroconvulsive therapy, 258 Fisher, M., 413
Electroconvulsive treatment (ECT), 18, 263 Fisher, W. W., 36, 39, 436, 442
Ellis, J., 37 Fixed-ratio (FR) 1 schedule, 43
Emergent literacy, in children, 392–393 Fixed-time (FT) reinforcement schedule, 44
Emotional processing theory (EPT), 187 Flory, V., 243
Empirically supported treatment (EST), 195 Fluoxetine, 17
Emslie, G. J., 18 Focalin ™ (d-MPH), 146
Engagement and interaction patterns, Food and Drug Administration (FDA), 256
in children, 388–391 Forehand, R., 83
Enuresis, 19 Forehand, R. L., 88
EOIT. See Ego oriented individual treatment Forth, A., 236
Erickson, K. A., 393 Fraser, J., 69, 236
ERP. See Event-related potentials Freeman, B. J., 13
Escape extinction” procedures, Friedman, D. L., 277
in children, 436 Friends for life program, 93–94
Esch, B. E., 297 Friman, P. C., 37, 40
Establishing operation (EO), 44 Fueyo, V., 46
Ethnicity, culture, and EDs, 411–412 Fuhrman, T., 69
INDEX 451
Fuller, D. R., 381, 384 Healy, W., 5

Functional behavioral assessment, 306–310 Heath, S. B., 379
Functional communication training, 9, Hellings, J. A., 261, 270, 276
39, 351 Helping the noncompliant child (HNC), 88–91
in behavior intervention plans, 310–311 Henderson, H., 37
Funderburk, B., 86 Hepburn, S., 16
Heron, T. E., 30
G Heward, W. L., 30
Galiatsatos, G. T., 35 Hillery, J., 342
Gamliel, I., 316 Hilsenroth, M. J., 68
Ganz, J. B., 386 Hinton, S., 305
Geist, R., 411, 422 Hispanic adolescents, 111
Gender differences, role in EDs, 410–411 Hobbs, N., 126
GFCF diet. See Gluten-free casein-free diet Hoek, H. W., 408, 410
Gibson, L., 35 Hoff, K. E., 161
Gilbert, M., 236 Hogansen, J. M., 415
Gillham, J. E., 242 Hogue, A., 122
Gioia, B., 393 Hollander, E., 270, 296
Gleaves, D. H., 408 Hollingshead four factor social index, 413
Gluten-free casein-free diet, 294–295 Holmbeck, G. N., 70
Goddard, H. H., 4 Holz, W. C., 9
Göncü, A., 395 Homework assignments, 112
Gonzalez, N. M., 19 Houlihan, D., 49
Goodman, J., 15 Hovanetz, A. N., 34
Götestam, K. G., 409 Hovarth, K., 296
Gowers, S., 236 Human emotions, ABC model of, 14
Gowers, S. G., 423 Hunter, C. S. J., 380
Graff, R. B., 35 Hurley, A., 270
Granger, D. A., 66 Hwang, W. C., 187
Graphic communication symbols,
for disabilities, 378, 395–396 I
Graziano, A. M., 84 IDEA. See Individuals with Disabilities
Greenspan, S. I., 300 Education Act
Grilo, C. M., 416 IEP. See Individual educational plan
Griswold, D. E., 304 Imipramine, 19
Group discussion with parents, videos’ Incidental teaching, 290
role, 112 Individual educational plan, 306
Group-home care, 123 Individuals with Disabilities Education
Grove, N., 378 Act, 306
Grow, L., 34 Initial MTA findings, criticism of, 142
Guanfacine, 150–151 Inpatient hospitalization, 123
Guided participation, in children with Inpatient treatment, for children and
developmental disabilities, 395 adolescents, 416–419
Guze, B.H., 277 Institutionalization, 123
Intellectual ability (IQ), 184
H Intellectual disability (ID), 3, 4
Hagiwara, T., 304 Interactive behavior, in children, 387–388
Hagopian, L. P., 39, 43 Interpersonal psychotherapy (IPT), 236
Haley, G., 236 Interpersonal therapy, 424, 426
Hall, E. T., 380 Interresponse time (IRT), 41
Handwerk, M. L., 37 Irritability, 264
Hanf, C., 91 Ivany, K., 294
Hanley, G. P, 309 Iwata, B. A., 38, 50, 347
Han, S. S., 66 Iwata, N., 226
Harman, D., 380
Harrington, R., 69, 236 J
Hart, K. J., 108 Jaffa, T., 417
Hays, P. A., 71 Jaycox, L. H., 242
452 INDEX
Jayson, D., 69, 236 LeBlanc, L. A., 39

Johnson, K., 292 Le Grange, D., 408
Johnson, W. L., 10 Lenhart, L., 393
Joint attention training and ToM, 316–318 Lennox, S. S., 63
Jones, M. C., 6 Lerman, D. C., 38
Joseph, J, 415 Lesch-Nyhan disease, in children, 335
Jureidini, J. N., 17 Lesch–Nyhan Syndrome, 40, 49
Juvenile bipolar disorder, 254 Levant, R. F., 85
Levin, L., 46
K Lewinsohn, P. W., 410
Kabot, S., 20 Lewis, S., 13
Kahng, S. W., 33 Liddle, H., 122
Kalman, S. L., 392 Light, J. C., 393
Kalsher, M. J., 37 Lim, L., 47
Kane, M. T., 15 Linderman, T. M., 298
Karver, M., 68 Lindsay, P., 378
Kaslow, N. J., 243 Lindsey-Dudley, K., 416
Kastner, T., 270 Lindsley, O. R., 8
Kates, K., 44 Linscheid, T. R., 32
Katz, R. C., 46 Lisdexamfetamine dimesylate, 146
Kazdin, A. E., 107, 128 Literacy exposure awareness, of children,
Keeney, K. M., 34 393–395
Kelford-Smith, A., 393 Literacy learning, in children, 379–381
Kelley, J., 199 Living with Children program, 112
Kelley, M. E., 36 Lloyd, D. A., 226
Kendall, P., 202 Lloyd, L. L., 381, 384
Kendall, P. C., 15, 68, 92, 93 Lock, J., 422
Kennedy, N., 342 Long, E. S., 43
Kerfoot, M., 235 Long, T. S., 33
Ketogenic diet, 295 Lovaas, O. I., 21, 291
Kettering, T. L., 34 Lovaas’s treatment program for autism,
Kidder, J. D., 8 95–96
King, N. J., 66 Lovejoy, M. C., 82, 85, 86, 87
Kjelsås, E., 409 Luiselli, J. K., 14, 35
Klotz, M. L., 65 Lundahl, B., 82, 86, 87
Knivsberg, A. M., 294 Lundahl, B. W., 84, 85
Knoff, H. M., 45 Lyman, R. D., 125
Kodak, T., 34
Kohlenberg, R., 14 M
Kolko, D. J., 171 Mace, F. C., 357
Komoto, J., 274 Madrid, A., 336
Koorland, M. A., 46 Magee, S. K., 37
Koppenhaver, D. A., 392 Mangus, B., 37
Kotler, L. A., 415 Marcotte, D., 235
Kovacs, M., 243 Marcus, B. A., 48
Kowatch, R. A., 258 Martens, B. K., 48, 161
Kraemer, H. C., 422 Martinsen, H., 385
Kroll, L., 69, 236 Masi, W., 20
Matson, J. L., 49
L Mauk, J. E., 357
Lalli, J. S., 43, 44 McDonough, M., 342
Lampman, C., 69 McLeod, B. D., 187
Lancioni, G. E., 386 McMahon, R. J., 88
Lang, A. J., 188 McNaughton, S., 378
Lang, P. J., 11, 190 McNeil, C. B., 86
Layng, T. V. J., 292 McWilliam, R. A., 386, 388, 389
Lazovik, A. D., 11 Measelle, J. R., 415
Learning and communication, in children, Medication discontinuation, 259
378–381 Medication side-effects, bipolar, 278–279
INDEX 453
Meichenbaum, D., 15 Normally developing adolescents, clinical

Melvin, G. A., 227 management, 254–256
Menzies, R. G., 12, 213 Normally developing children
Mesibov, G. B., 299 clinical management of
Metabolic syndrome, 279 BD, treatment of, 254
Methylphenidate, 146 evidence base, evaluation, 255–256
Miltenberger, R. G., 33 mania rating scale (MRS), 255
Mineka, S., 187 neurological conditions, 255
Mirenda, P., 393 Normally developing youth
Mistry, J., 395 bipolar disorder, treatment for
Modafinil™, 147 drugs, evidence for, 257–258
Modernization Act, 16 lifetime medication, 259–260
Mood stabilizers, 18 mania/hypomania, acute treatment
Moors, A. L., 292 of, 256–258
Morris, J., 305 manic depression, 258–259
Morton, T., 66 treatment of
Mosier, C., 395 atypical antipsychotic, 261–263
Motivating operation (MO), 44 electroconvulsive therapy, 263
MPH transdermal system (MTS) gabapentin (GP), 260–261
patch, 146 lithium, 260
MTA behavioral treatment strategy, 141 rapid cycling bipolar disorder (RCBD),
MTA combined treatment strategy, 141 262–263
Mufson, L., 236 valproate and carbamazepine, 260
Multisystemic therapy (MST), 120 Northup, J., 34
Muris, P., 207
Murphy, G., 359 O
Muthen, B. O., 160 Oberdorff, A. J., 36
Myles, B. S., 301, 304 Obler, M., 13
Olanzapine, in SIB treatment, 342, 343
N Ollendick, T.H., 66, 184, 192, 193, 208
Naltrexone hydrochloride, in SIB treatment, Olson, L., 49
344–345 Omega-3 fatty acids, 151
Nash, H. M., 37 Oppositional defiant disorder (ODD), 19, 86,
National Institute for Clinical Excellence, 424 107, 154
National Institute of Mental Health O’Reilly, M., 386
(NIMH), 141 Osmotic release oral system (OROS), 146
Natural environment training, 290 Öst, L. G., 199
Naturalistic teaching methods, 290–291 Outpatient treatment, for children and
Natural language paradigm, 290 adolescents, 420–426
Nelson, III. W., 108 Overanxious Disorder, 15
Nesset, R., 49 Ozonoff, S., 20
NET. See Natural environment training
Neumark-Sztainer, D., 409 P
Neurodevelopmental disorder, 94 Pace, G. M., 37
Newcomb, K., 86 Pande, A. C., 261
NICE. See National Institute for Clinical Panksepp, J. A., 294
Excellence Parent–child interactions, 59, 112, 115, 117
Nimer, J., 84, 85 coercive, 80
NLP. See Natural language paradigm complexities of, 80
Noncompliant behavior, 107 maladaptive, 81
Noncontingent reinforcement, in behavior Parent child interaction therapy (PCIT), 84,
intervention plans, 310 91, 114
Non-Dodo verdict, 66 Parent effectiveness training program (PET), 85
Non-Freudian hypothesis, 11 Parent programs
Nonlaboratory-based treatment clinics, 66 that target developmental disorders, 94–95
Nonstimulant medications, for ADHD, that target externalizing behavior
149–151 problems, 88–90
Nonverbal communication, for child, 10 that target internalizing behavior
Norepinephrine, 143 problems, 92–93
454 INDEX
Parents awareness of literacy, in children Preadolescents depression

with developmental disabilities, 394 randomized clinical interventions trials
Parent training for, 239–241
empirical evidence of, 87–88 Prefrontal cortex, 313
empirical support for, 81–82 Problem-Solving Skills Training (PSST), 119
generalization effects, 85–86 Pro-opiomelanocortin, 344
immediate effects of, 82–85 PRT. See Pivotal response training
intervention model Pryor, T., 413
development of, 80 Psychiatric adverse events
empirical support for, 81–82 in children and adolescents
moderator effects, 86–87 activation/disinhibition/manic
overview of selected programs for, 88 symptoms, 277
subgroup of, 83 suicidal behavior, 277, 278
Parsons, B., 84, 85 Psychiatric disorder, 21
Partial hospitalization programs, for EDs, Psychiatric medication, 258
419–420 Psychodynamic therapy, for adolescents
Participation, in children, 387 with AN, 425–426
Partington, J. W., 290 Psychoeducation, 112
Pary, R. J., 18 Psychological disorders
Passive-engaged and disengaged, behavior adults and children with, 57
of children, 388 Psychosocial interventions, for children, 81
Patterson, G., 80 Psychostimulants, 16–17
Patterson, G. R., 110 Psychotherapy by Reciprocal Inhibition, 11
Patterson’s model, 80 Psychotherapy, forms of, 65
Pavlovian conditioning, 6 Psychotropic medication, prescription of, 16
Pavuluri, M. N., 256 Punishment
PCS. See Picture communication symbols negative, 33–34
PDD-NOS. See Pervasive developmental positive, 32–33
disorder–not otherwise specified
PDDs. See Pervasive developmental R
disorders Rachman, S., 189
Pediatric feeding disorders, treatment Racusin, G. R., 243
of, 435–442 Randomized clinical trials (RCTs), 66
Peebles, R., 411 bioinformational theory
Pelham, W. E., 154, 170, 173 developmental psychopathology, 191
Pervasive developmental disorder–not emotional networks, treatment, 190
otherwise specified, 288 etiology, 185–186
Pervasive developmental disorder family, 186–187
(PDD), 264 normative and diagnostic considerations,
bipolar disorder 184–185
in children, 264 psychological theory, 187–190
VPA, Use of, 274 treatment, effects of, 184
Pervasive developmental disorders, 288 Rapp, J. T., 33, 50
PFC. See Prefrontal cortex Raspa, M. J., 386
Phobic symptoms, 13 Rastam, M., 410
Phonological disorder, children with, 49 Rate-building procedures, in autism
Piazza, C. C., 36, 436, 437, 439, 442 treatment, 291–292
Picture communication symbols, 382, 383 Ray, K. P., 45
Picture exchange communication Rayner, R., 6
system, 290 RDI. See Relationship development
Pillai, V., 19 intervention
Pine, D. S., 415 Reaven, J., 16
Pivotal response training (PRT), 96–97, 290 Reed, G. K., 40, 437
Planned activities training (PAT), 95 Reed, M. K., 236
Play activities, for children with Reid, J., 120
developmental disabilities, 389 Reinblatt, S. P., 263
Polycystic ovary syndrome (PCOS), 278 Reinforcement procedures
Polydipsia, 270 negative, 35–36
POMC. See Pro-opiomelanocortin positive, 35
INDEX 455
Reinforcement procedures, in behavior Self-injurious behaviour (SIB), in children

intervention plans, 311 aetiology, developement and
Relationship development phenomenology, 358–363
intervention, 300 behavioural interventions for, 347–348,
Repp, A. C., 41 356–357
Residential treatment centers, 123, 125 characteristics of, 333–334
Rett’s disorder, 288 diagnostic subtyping of, 357–358
Rett syndrome, 442 psychopharmacological treatment for
Revised children’s manifest anxiety scale clozapine and olanzapine in, 342–343
(RCMAS), 192 considerations for, 345–347
Reynolds, W. M., 235 dopamine and serotonin in, 335–336
Richman, G. S., 347 risperidone, 336–342
Ridley, S. M., 386 serotonin reuptake inhibitors in,
Ringdahl, J. E., 40, 42, 47 343–345
Risley, T. R., 30 screening and treating, 334
Risperidone, in autism treatment, socially mediated positive reinforcement for
295–296 antecedent motivating operations,
Risperidonem, in child behavioural disorder, 348–350, 353–354
336–342 automatic reinforcement, 353
Risser, H. J., 82, 86, 87 competing prosocial responses,
Ritalin LA, 145 351–352, 354
Ritter, B., 201 mechanical restraints, reduction of, 355
Rivera, M. O., 46 reinforcement elimination, 352–353, 355
Roane, H. S., 34 self-restraint treatment, 355–356
Robergeau, J., 415 Self-restraint (SR), treatment for, 355–356
Robinson, E. A., 86 Seligman, M. E. P., 388
Rogers, S., 294 Sensory integration therapy, for autism,
Rogoff, B., 395 297–298
Role-plays, 112 Separated family therapy, 421–422
Rolider, A., 36 Serketich, W. J., 83, 87
Romski, M., 374 Serotonin, in SIB treatment, 335–336
Rosenthal, T., 199 Sevcik, R. A., 374
Roskos, K., 393 SFT. See Separated family therapy
Rosselló, J., 237 Shabani, D. B., 46
Rowland, C., 375 Shaked, M., 316
Ruch, K. S., 43 Shapiro, D., 65
Rudolph, K., 225 Shapiro, D. A., 65
Shea, S., 339
S Shirk, S. R., 68
Sabbagh, M. A., 313 Short term respite care, 123
Samuolis, J., 122 Sigafoos, J., 386
Sandler, A. D., 297 Sigman, M., 187
Sandman, C. A., 345 Silber, T. J., 415
Santisteban, D., 111 Silverman, W., 184, 192, 193
Savin, S. M., 408 Simon, T., 4
Scahill, L., 336, 339–341 Simpson, R. L., 301, 304
Schizophrenia, symptoms of, 18–19 Skinner, B. F., 7, 8
Schlosser, R. W., 386 Skinner, C. H., 45
Schopler, E., 97, 299 Skinner’s classification system, 290
Schotte, D., 13 Slifer, K. J., 347
Schwartz, J. A. J, 243 Smith, M. L., 65
Schweigert, P., 375 Smith, T., 293
Secretin therapy, for autism, 296–297 Social class and EDs, 412–413
Seeley, J. R., 410 Sofronoff, K., 305
Segal, M., 20 Sovner, R., 270
Selective serotonin reuptake inhibitors, 17, Specific problem behavior, treatment of, 50
152, 221, 296, 343 Specific treatment strategies, effectiveness
Self-injurious behavior (SIB), 9, 50 of, 50
treatment of, 32 Spence, S. H., 13, 70
456 INDEX
SSRIs. See Selective serotonin reuptake Therapeutic relationship, 67–68

inhibitors Therapist characteristics, 68–69
Stanford-Binet intelligence test, 4 Thinning differential reinforcement
Stark, K. D., 15, 242 schedules, 42–43
Stepping Stones Triple P (SSTP), 98 Thuppal, M., 277
Stereotyped behaviours and SIB, 361 Titchenor, E. B., 6
Sterling, H. E., 42 ToM. See Theory of mind
Stewart, K. B., 298 TOuCAN. See Trial of outcome for child &
Stice, E., 415 adolescent anorexia nervosa
Stimulant agents Traditional parent management strategies,
AAP guidelines recommend that, 144 116
adverse effects of, 147–148 Treatment and education of autistic and
FDA approval for, 144 related communication handicapped
immediate release stimulant, 144 children (TEACCH), 20
new advanced system delivery stimulants, Treatment methods, 5–6
145–147 behavior therapy, 11
sustained release stimulant, 145 classical conditioning, 6–7
Stimulant agents, AAP guidelines cognitive behavior therapy, 14–16
recommend that, 144 operant conditioning/applied behavior
Stimulus control approaches, 44–46 analysis, 7–11
Stobbart, C. L., 394 systematic desensitization, 11–14
Stoner, G., 162, 163 Trial of outcome for child & adolescent
Story, M., 409 anorexia nervosa, 423
Strattera, 149 Triple P (Positive Parenting Program), 92
Strattera™, 150 Turgay, A., 276
Stremel, K., 375 Turner, R. J., 226
Striegel-Moore, R. H., 410
Sturmey, P., 297 U
Substance use, behavior problem, 121 UCLA Young Autism Project, 154
Sullivan, M. T., 39 Ultee, C. A., 12
Sulzby, E., 392
Sundberg, M. L., 290 V
Suveg, C., 202 Valproate (VPA), trials of, MR/autism, 271
Symbolic behaviors, in children, 375 Van der Sar, R. M., 160
Symbols, in children with developmental van Hoeken, D., 408, 410
disabilities, 378–379 Van Houten, R., 36
Symons, F. J., 344 Van Lier, P. C. A., 160
Synder, R., 336 VEN. See Von Economo neurons
Systematic desensitization, variants of, 12 Vitamin therapy, in autism treatment, 295
Vollmer, T. R., 34, 48, 50
T Von Economo neurons, 313
Tague, C., 8 Von Tetzchner, S., 378, 385
Taylor, B. A., 44, 46 Vyvance™, 146
Taylor, C. R., 46
TEACCH program, 97 W
TEACCH strategy, for autism, 299 Wachs, T. D., 379
Teale, W., 392 Wacker, D. P., 40
Temper outbursts, 108 Wallace, M. D., 38
Temper tantrums, 107, 108 Walsh, B. T., 415
Terman, L. H., 4 Water phobia, 12
Terwilliger, R. F., 13 Watling, R. L., 298
Tharp, R. G., 80 Watson, J. B., 6
The incredible years (TIY), 91–92 Watson, T. S., 42, 45
Theory of mind Weak central coherence (WCC), 314
biological mechanisms of, 313–314 Webster-Stratton, C., 120
cognitive processes of, 314–315 Wechsler Individual Achievement Test, 304
sibling research and joint attention Weiss, B., 65, 66
processes, 316–318 Weisz, J. R., 65–67, 223, 242
and social qualities, 315–316 Werry, J. S., 19
INDEX 457
Wetzel, R. J., 80 mental health service utilization, 226

Whitley, M. K., 128 meta-analysis, 223
Whittington, C. J., 17 parental psychopathology, 224
Wick, J., 293 symptoms, 222
Wiederman, M. W., 413 efficacy of
Wieder, S., 300 cognitive behavioral interventions,
Wilder, D. A., 46 234, 235
Williamson, D. A., 408 contextual emotion regulation therapy
Williams syndrome, 12, 16 (CERT), 243
Wilson, D. R., 125 coping with depression (CWD), 236
Witmer, L., 3, 5 immediate effects, 235
Wolf, M. M., 30 interpersonal functioning, 236–238
Wolpe, J., 10, 11, 199, 200 interpersonal relationships, 226
Wood, A., 69 maladaptive cognitions, 227
Wood, J. J., 187 preadolescent depression, 238
Wundt, W., 6 randomized clinical interventions trials
for, 228–233
Y social problem, 242
Yirmiya, N., 316 future research, directions for, 243–245
Yoder, D. E., 392 psychosocial competence, 222
Young mania rating scale (Y-MRS), 255
Youth depression treatments Z
antidepressants, 221 Zarb, J., 59
clinical trials, 221 Zarcone, J. R., 340
critical issues in Zinbarg, R., 187
manifestation of, 225 Zvolsky, P., 270

Child Psychopathology Treatment

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Child Psychopathology Treatment

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Treating Childhood

ISBN: 978-0-387-09529-5 e-ISBN: 978-0-387-09530-1

Library of Congress Control Number: 2008931350

© Springer Science + Business Media, LLC 2009

Printed on acid-free paper

Chapter 1. History of Treatment in Children

Chapter 2. Applied Behavior Analysis and the Treatment

Chapter 3. Cognitive Behavior Therapy .......................................... 55

Chapter 4. Parent-training Interventions ........................................ 79

PART II. CHILDHOOD PSYCHOPATHOLOGY

Chapter 5. Conduct Disorders ....................................................... 107

Chapter 6. Treatment of Attention-Deficit/

Chapter 7. PTSD, Anxiety, and Phobia ............................................ 183

Chapter 8. Treatment Strategies for Depression in Youth................ 221

Chapter 9. Medication Treatment of Bipolar

Chapter 10. Treatment of Autism Spectrum Disorders ................... 287

Chapter 11. Treatment of Self-Injurious Behaviour

Chapter 12. Communication, Language, and Literacy

PART III: BEHAVIORAL MEDICINE

Chapter 13. Eating Disorders ......................................................... 403

Chapter 14. Treatment of Pediatric Feeding Disorders ................... 435

Index .............................................................................................. 445

Kathryn Dingman Boger

Thompson E. Davis III

Mary Jane Weiss

The history of modern child psychopathology and developmental dis-

JONATHAN WILKINS and JOHNNY L. MATSON • Louisiana State University

J.L. Matson et al. (eds.), Treating Childhood Psychopathology 3

Intelligence testing is one of the first and best established areas of

The establishment of the first juvenile court in the United States in

MODERN TREATMENT METHODS

The primary means of intervention for children have involved learning-

applied behavior analysis, behavior therapy/cognitive behavior therapy,

Operant Conditioning/Applied Behavior Analysis

Skinner’s research and ideas have even become an international move-

Although these procedures were usually highly successful at eliminat-

outcome as the challenging behavior and ultimately reduces the frequency

began to wane as the number of published studies dropped dramatically

developing children, this renders the application of traditional systematic

(video of peers) and participation to be more effective than either modeling

Cognitive Behavior Therapy

was found to be superior to a traditional counseling approach at reduc-

was cited as having a favorable risk–benefit profile in children with noted

treatment of young persons with antipsychotic medication specifically

indicates that children with ID have responded unfavorably (Aman et al.,

Another notable comprehensive treatment package for autism was

Psychopathology is a common problem for children and adolescents,

Recognizing these disorders in such individuals is difficult because

Fuller, P. R. (1949). Operant conditioning of a vegetative human organism. American

Werry, J. S. (1999). Anxiolytics in MRDD. Mental Retardation and Developmental Dis-

This chapter provides a description and examples of the use of applied

JOEL E. RINGDAHL and TERRY S. FALCOMATA ● The University of lowa.

J.L. Matson et al. (eds.), Treating Childhood Psychopathology 29

associated with developmental disabilities. As an approach to treatment,

APPLIED BEHAVIOR ANALYSIS DEFINED

Baer, Wolf, and Risley (1968) outlined seven dimensions of applied

Accountable: “The commitment of applied behavior analysis to effec-

DESCRIPTION OF ABA TREATMENT APPROACHES

In this section, an overview of many of the frequently used ABA-based

Consequence-Based Procedures: Punishment

Kahng et al. (2001) described the implementation of a positive pun-

Consequence-Based Intervention Strategies: Reinforcement

the individual must meet a particular response requirement (e.g., two

Field, Nash, Handwerk, and Friman (2004) implemented a token economy