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What to Consider before Starting Childhood Behavioral Therapy

September 5th, 2017 | 1 Comment | Blog

Aly’s sleep problems were becoming so challenging that now her parents were losing sleep. For years, the five-year-old had woken up several times nightly. When a pediatrician’s advice failed to alleviate the problem, her parents sought help from an agency that offered their daughter sleep training. After just three weeks, Aly was sleeping through the night.

Or so her parents thought.
After the girl repeatedly dozed off during kindergarten class, the parents installed a video monitor in her bedroom to monitor her at night. Their surprising discovery: Aly spent most of each night awake, staying in bed in order to earn her reward, but repeatedly looking at her clock until daylight came.

Aly’s story illustrates the potential limitations of certain behavioral therapies—techniques that focus solely on altering an individual’s behaviors—on young children. And while seeking early help for children’s challenges is important, many parents are unaware of the widely differing treatment methods available. To begin with, all therapies should be considerate of each child’s unique and individual needs.

As a child psychologist, I have observed children as young as two treated with behavioral therapies. But as Aly’s story illustrates, when we ask children to do things that exceed their developmental capacity, we risk causing new problems, such as an increased stress load.

It’s important to watch for indicators that a child or teen is not ready for behavioral therapies that rely solely on reinforcement schedules, including:

  • Immature social-emotional development. Many professionals don’t use a roadmap of social-emotional development to determine the type of treatment a child needs. To truly understand behavioral consequences, a child must first have adequate emotional and physiological regulation (ability to calm one’s mind and body), the ability to engage in relationships, and the capacity for verbal and/or non-verbal back-and-forth communication. These abilities, known as “bottom-up” processes, allow children to develop social problem-solving skills and—eventually—executive functioning.
  • Past experience of developmental or environmental trauma. Developmental anxiety and trauma often stem from difficulties in how the brain is wired. For instance, some professionals utilize rewards/consequences to treat instinctual sensory or motor responses. We should be cautious in introducing behavioral therapies, as they may cause additional stress for the child. The neuroscientist Stephen Porges emphasizes that it’s important to understand that “adaptive physiological reactions may result in maladaptive behaviors.” It’s simply wrong to punish or issue a negative consequence for a child’s subconscious survival mechanisms.
  • Sensory-processing challenges or disorders. Children with sensory-processing challenges (under- or over-reactivity in how they experience the world through their sensory systems) often exhibit “fight-or-flight” behaviors. Providers then attempt to use behavioral techniques to change this behavior. No amount of consequences or reinforcers will truly help a child whose sensory system is wired in such a way that the world feels like a threatening place.
  • Compromises in volitional motor control. These include apraxia of speech or motor planning challenges; autism spectrum disorder; and other motor difficulties that affect an individual’s communication channels. Professionals often recommend behavioral therapies as initial treatment for autism spectrum disorders. But as one researcher, Anne Donnelan, points out, it’s overly simplistic and not appropriate to use behavioral techniques that rely on punishment (including planned ignoring and time outs) for individuals who have compromised volitional movement control.

There are plenty of options to help children with developmental, behavioral and mental health challenges, including:

  • Determine the child’s level of social and emotional development when planning all treatment strategies. Organizations such as ICDL and the Profectum Foundation offer free online training in social-emotional development for parents and professionals.  I also describe an easy way to measure the child’s level in other posts and my book on social-emotional development.
  • Figure out whether a child has experienced developmental or environmental trauma (including relational trauma). If so, make it a top priority to help the child experience the feeling of safety in relationships as the top priority across all therapies. As Dr. Stephen Porges says, “treatment is safety and safety is treatment”.
  • Determine the child’s capacity to take in the world around him and respond to it from a sensory standpoint. A large portion of toddlers I see experience undetected sensory challenges that contribute to their confusing behaviors. Most childhood providers, including pediatricians, know little about sensory or motor processing, even though it is a significant contributor to behavioral difficulties. An occupational therapist trained in sensory processing and integration can assist in determining the child’s individual differences in this area.
  • Try to assess, understand, and compassionately learn more about individuals with limited control over their physical movement, including apraxia, dyspraxia and autistic persons who are non-speaking. Find experts who can help the child/teen access technology and facilitated/augmented communication. It’s not appropriate to use behavioral techniques dependent on a functional motor system for individuals who do not have adequate movement control.

If we pay attention to the precursors of healthy social-development, then, ultimately, we may not need to employ stand-alone behavioral techniques. Instead, we can use organic interactions—such as hugs, smiles, and reassuring nods—that naturally promote a sense of cooperation and well-being. These keys to mental health are hallmarks of supportive relationships and crucial factors in helping all children to develop resilience.

If you are a provider, my new book describes how we can all embrace principles of social-emotional health across disciplines.

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  • Alex James

    Trying to fix sleep problems with behavioural therapy is ridiculous. It assumes a level of control that just isn’t there. A five year old isn’t deciding to wake up at 3am. What five year old could decide that and follow through? That kind of thing is evidence of a SLEEP DISORDER. It’s probably fixable with low dose melatonin, like many of the sleep disorders common among autistic people. JFC please will people stop assuming everything is “behavioural”. I had sleep problems for fucking years, no amount of desperately trying to sleep actually worked, medication did.

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