Luiza Mali, used with permission
Source: Luiza Mali, used with permission

This guest post was written by Luiza Mali, a doctoral student in clinical psychology at the University of Southern California.

“You are mean! I hate you! I hate these vegetables!” Plate shatters on the ground. Creamed spinach splatters everywhere. “I want a different babysitter – a fun one, not you!” Anyone who has spent time with preschoolers has witnessed one form or another of disruptive, disrespectful, and at times hurtful, behavior. From temper tantrums and defiance to full-out aggression, most caregivers at some point have questioned (and ultimately doubted) their ability to address these challenging behaviors.

Whereas all kids have demonstrated oppositional behavior at some point in their lives, for some parents this is a stressful daily occurrence. Disruptive behavior and conduct problems are among the most common problems affecting young kids. Close to 10 percent of preschoolers meet criteria for a disruptive behavior disorder. These are the kids whose tantrums frequently gather an audience at the grocery store, and who tend to be repeatedly reprimanded, and occasionally expelled, from their preschool. Disruptive behavior disorders have been associated with many negative long-term consequences, including mental health difficulties, family stress, academic problems, and criminal behavior. In order to avert these long-term risks, it is imperative to detect and intervene early with kids who show signs of defiant and aggressive behavior. Research has demonstrated that the younger a child is at the time of intervention, the less entrenched their behavior, and the more positive treatment response can be.

 Mindaugas Danys, Creative Commons license
Source: Mindaugas Danys, Creative Commons license

So how should we handle kid’s disruptive behavior? Worryingly, a growing number of very young kids are being prescribed potent medications without proper psychiatric or psychological evaluation. A meta-analysis conducted by Mark Olfson, Stephen Crystal, Cecilia Huang, and Tobias Gerhard, published in the Journal of the American Academy of Child and Adolescent Psychiatry, suggests that the use of off-label antipsychotic prescriptions in the treatment of aggressive behaviors and temper tantrums in kids ages 2-5 is on the rise. The rates of antipsychotic medications prescribed to young kids almost doubled between 1999-2001 and 2007, despite the fact that controlled evaluations of the efficacy of such treatments during early childhood are either lacking or very limited. Alarmingly, kids who were prescribed psychotropic medication had very limited access to psychosocial services - less than half of them received some type of mental health assessment or treatment from a psychotherapist or psychiatrist during the study period.

The lack of psychosocial services for young kids with conduct problems is staggering considering we know these treatments work. Based on a synthesis of 36 controlled empirical studies evaluating 3,042 children, Jonathan Comer and colleagues from the Early Childhood Interventions Program at Boston University proposed that psychosocial treatments, and behavioral treatments in particular, should be considered the first-line of treatment for early disruptive behavior problems. Psychosocial treatments had a large and sustained effect on externalizing problems, oppositionality, and noncompliance. Psychosocial interventions had a weaker, but significant effect on symptoms of impulsivity and hyperactivity, suggesting that though there might be a role for stimulant medications in the treatment of such difficulties, psychosocial treatments should remain the preferred treatment for preschool-aged youth.

So what do we mean by “psychosocial interventions”? One of the most frequently studied examples of such an intervention, Incredible Years (IY), was developed by Carolyn Webster-Stratton at the University of Washington 33 years ago, and has been successfully used to treat kids’ problem behavior. The IY training series is designed to strengthen protective factors and counteract risk factors known to contribute to child conduct problems. Some of their areas of emphasis include coaching parents to be more effective and helping to prevent vicious coercive cycles, wherein parents’ over-the-top response to a disruptive kid actually fuels the disruptive behavior. With three types of training interventions (i.e., parent-, child-, and teacher-focused programs) that can be used alone or in combination, IY uses video vignettes and group discussions to teach specific parenting skills. In particular, IY helps parents learn to forge more positive relationships with their kids by modeling empathy and being attentive and involved in their play. Parents of difficult kids often feel like they’re stuck in a loop of correcting, punishing, and saying “no.” Instead, IY teaches parents to hone in on, and reward, kids’ positive behavior and to engage in child-directed play sessions where the kid gets to feel in control. After building a base of positive connection, parents find it easier to set and reinforce logical consequences when difficult behavior does crop up. Numerous randomized controlled trials, the gold standard for evaluating an intervention’s effectiveness, have demonstrated the positive effects of the IY training program in the prevention and treatment of childhood disruptive behaviors.

Given its demonstrated efficacy, how can we explain the continuing trends away from psychosocial interventions and toward off-label medication use in treating early disruptive behavior problems? The answer lies in dissemination and the many barriers in accessing psychological care. Many cities in the U.S., particularly rural towns, don’t have enough qualified treatment providers who have been trained to deliver treatments that have been proven effective by research. Lack of funding and long waitlists in community mental health clinics also contribute to the bleak picture of mental health care in America. Given the positive results obtained by cost-effective group interventions like IY, it would be great to see mental health agencies fund the dissemination of psychosocial treatments known to be effective with very young kids.

Luis Marina, Creative Commons license
Source: Luis Marina, Creative Commons license

In the long run, it’s costly to prescribe medication rather than behaviorally treat disruptive behavior. Antipsychotic treatments in childhood have been associated with a number of dangerous physical health side effects, including metabolic, endocrine, and cerebrovascular risks.

Many of these medications haven’t been studied for the purposes that they are being prescribed, and more often than not they haven’t been properly tested in young kids. So if you are a caregiver struggling with a difficult child -- and wanting to avoid a faceful of creamed spinach -- keep in mind a few tenets of IY's training program: 1) use specific and enthusiastic praise liberally; 2) ignore, distract, or redirect inappropriate behavior when needed; and 3) administer natural consequences and loss of privileges sparingly. Frequently using the teaching and positive interaction skills that are at the base of the IY Parenting Pyramid (see picture) and limiting the use of corrective techniques that are at the top can go a long way. Remember, the foundation for effective correction is effective teaching! We are all deserving of a time-out if we continue to fail to search and utilize the many validated treatment resources and techniques that are at our disposal.

If you would like to learn more about Incredible Years go to www.incredibleyears.com for checklists, handouts, and program inquiries.

References

Comer, J. S., Chow, C., Chan, P. T., Cooper-Vince, C., & Wilson, L. A. (2013). Psychosocial treatment efficacy for disruptive behavior problems in very young children: a meta-analytic examination. Journal of the American Academy of Child & Adolescent Psychiatry, 52(1), 26-36.

Egger, H. L., & Angold, A. (2006). Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry, 47(3‐4), 313-337.

Olfson, M., Crystal, S., Huang, C., & Gerhard, T. (2010). Trends in antipsychotic drug use by very young, privately insured children. Journal of the American Academy of Child & Adolescent Psychiatry, 49(1), 13-23.

Webster-Stratton, C & Reid, M. J. (2010). The Incredible Years parents, teachers, and children training series: A multifaceted treatment approach for young children with conduct disorders. In J. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents, (pp.96-161). New York: Guilford Press.

Incredible Years, Used With Permission
Source: Incredible Years, Used With Permission