Eye Movement Densensitization and Reprocessing (EMDR) : A Treatment Modality for Behavioral Problems - A Dissertation Proposal

EYE MOVEMENT DENSENSITIZATION AND REPROCESSING (EMDR):
A TREATMENT MODALITY FOR BEHAVIORAL PROBLEMS

A Dissertation Proposal

i
Abstract of Dissertation Presented to the
Graduate School of Argosy University/Sarasota
in Partial Fulfillment of the Requirements for the
Degree of Doctor of Counseling Psychology

EYE MOVEMENT DENSENSITIZATION AND REPROCESSING (EMDR):
A TREATMENT MODALITY FOR BEHAVIORAL PROBLEMS

Department: School of Psychology and Behavioral Sciences

The purpose of this study is to examine EMDR as a treatment modality for addressing negative emotions and reducing ineffective emotional responses in adolescents with behavioral problems. This study also proposes to expand the existing research in the area of EMDR as a treatment modality for adolescents with behavioral problems and explore adolescents’ ability to practice EMDR in treatment sessions. Participants in this study are male and female adolescents from middle school through high school ranging in ages 11 to 17 who are experiencing behavioral problems at home and/or school and receiving counseling in an outpatient setting. These adolescents may also be experiencing symptoms such as anger, fear, low self-esteem and anxiety that may contribute to behavioral problems.

A demographic/intake form were used to gather information on the participants’ basic demographics, current diagnosis, presenting symptoms and/or behavioral problems, current medical conditions and medications.

The Burns Anger Scale, Burns Anxiety Scale, and Rosenberg Self-Esteem Scale were used as Pre and Post Measures for both the treatment and control group to assess change. Process measures were used to assess the EMDR experience at the conclusion of each session using SUDS and VOC Scales for the treatment group. The SUDS scale will be used to rate the negative cognition and memory of the event or presenting problem throughout EMDR and will be used to rate the negative cognition and memory of the presenting problem throughout EMDR after the sets of eye movements. The VOC Scale will be used at every EMDR session to measure intensity of the client’s emotions on a scale of one to seven when the memory is accessed. One represents “completely false” and seven represents “completely true”. Participants in the treatment group were also asked at the end of the EMDR sessions, “What was that like for you?” and, “How do you feel?”

A quasi-experimental mixed design was conducted using a sample of 18 children assigned to either a control group or treatment group, matching on gender and use of medication. This design was used so participants could be assigned to treatment so that the groups are comparable in both their composition and participation. Three sessions were used in order to minimize attrition. The bilateral stimulation, desensitization, and reprocessing of the EMDR protocol was used instead of the entire typical EMDR protocol, due to limited amount of sessions.

The findings in this study suggest that the EMDR session experience improved positive thoughts, beliefs, and feelings about self. The average level of anxiety and anger decreased for the treatment group by the third session and Self-esteem scores improved by the third session. However, due to the small sample size and results we cannot say descriptively that it is significant. It does suggest that EMDR is having some sort of positive impact. VOC scores on average did decrease with the treatment group in improving their positive thoughts, beliefs and feelings about self. The SUDS scores indicating level of disturbance decreased two points by session two and by three points upon the final session. Overall, there were positive changes and responses for the treatment group in response to the EMDR experience itself and their EMDR subjective experience responses.

CHAPTER ONE
The Problem
Between 30% and 50% of hyperactive children suffer from associated behavioral disorders. Children with Attention Deficit Hyperactivity Disorder (ADHD) experience additional problems that are as important as the fundamental symptoms of the disorder itself. Many children referred for problems with attentiveness also have a combination of aggression and hyperactivity. Research shows that those children with ADHD and conduct disorder have an especially severe form of ADHD (Biederman, Newcorn, & Sprich, 1991; Hinshaw, 1994). Hyperactive-aggressive children are problematic at home and school, and peer relationships are significantly affected (Gomez & Sanson, 1994). They also experience significantly more problems in adolescence and have a higher risk of criminal behavior and alcohol abuse (Klintenberg, 1997). The response of this group to medical and psychological treatment is low (Matieretal, 1992; Paniagua, 1992). According to Kendal et al. (1980), cognitive behavioral self-control therapy, including self-instructional training via modeling, problem-solving, and behavioral contingencies, allows for modification of self-regulatory deficiencies in ADHD children, but they do not directly treat the problem of ADHD in children who also have a significant amount of aggression (Miranda, 2000).
Problem Background
Fewell and Deutscher (2002) report that ADHD has become the most common neuropsychiatric syndrome in children. They report that it affects three to five percent of approximately two million school age children, according to the United States Department of Education (National Institutes of Health, 1998). The number of very young children who may later be diagnosed with ADHD will be higher among those who have already been diagnosed as having special needs, or those who get services because they are at high risk for poor school performance. This problem accounts for as much as 50% of child psychiatry in clinic patients (Fewell & Deutscher, 2002). According to Conners and Jett (1999), Attention Deficit Disorder (ADD) accounts for 30 to 40% of all referrals made to child guidance clinics.
ADHD is one of the most researched areas in child and adolescent mental health and research shows that it is a brain-based biological disorder. Brain imaging studies using positron emission topography (PET) scanners show that brain metabolism in children with ADHD is lower in the areas of the brain that control attention, social judgment, and movement. Scans and other imaging research also show that the brain of a child with ADHD differs consistently from those of children without the disorder. Many brain regions and structures tend to be smaller (i.e.: pre-frontal cortex, striatum, basal ganglia, and cerebellum). Overall brain size is generally five percent smaller in children affected by ADHD as opposed to those that are not affected by ADHD. These findings should not be used as the determining factor in diagnosing someone with ADHD (Zametkin, 1990).
Attention Deficit Disorder is common, appears more frequently in males than females, and is associated with disruption in school and at home (Kaplan & Sadock, 1998). It is characterized by a developmentally inappropriate poor attention span, developmentally inappropriate features of hyperactivity and impulsivity or both. In order to meet diagnostic criteria of ADHD, the disorder must be present for at least six months, and cause impairment in academic or social functioning.
The diagnosis is made by identifying numerous symptoms of inattention, hyperactivity-impulsivity, or both inattention and hyperactivity/impulsivity. A child may meet criteria for the disorder with symptoms of inattention only or with symptoms of hyperactivity and impulsivity only or combined symptoms of hyperactivity/impulsivity and inattention (The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM- IV-TR, 2004). The DSM-IV-TR lists three sub-types of ADHD. These subtypes include predominantly inattentive type, predominantly hyperactive-impulsive type, and combined type. To meet the criteria of the DSM-IV-TR, there must be a presence of two or more situations, such as school, home and/or work.
According to Kaplan and Sadock, children with ADHD are often explosive and irritable. The irritability may be set off by relatively minor stimuli, which may confuse the child. They are frequently emotionally labile and easily set off to laughter or to tears. Their mood and performance are likely to vary and be unpredictable. Impulsiveness and an inability to delay gratification are characteristic. These children are often accident-prone as well. Approximately 75% of children with ADHD consistently show defiance and aggression. Defiance and aggression are usually associated with adverse interfamily relationships and hyperactivity is more closely associated with impaired performance on cognitive tests requiring concentration (Kaplan & Sadock, 1998).
Maughan, Rowe and Messer (2004) state that many children and adolescents with ADHD have comorbid diagnoses of Oppositional Defiant Disorder and/or Conduct Disorder. This occurs often under the age of 12 in children who also meet the criteria for ADHD. Conduct disorder appears to be more prevalent in boys than in girls. This disorder also changes in the presentation of symptoms with increasing age. Some research suggests that Oppositional Defiant Disorder may be a precipitating disorder to Conduct Disorder (Maughan, Rowe, & Messer, 2004). It is important for researchers to consider this when examining the most effective ways to treat patients with co-morbid disorders. This also indicates a need for expanded research in techniques that can be used with any of these disorders and behavioral problems associated with them.
There are environmental factors to consider as well in the treatment of ADHD and other behavioral disorders. According to Kaplan and Sadock (1998), children with these disorders are frequently overactive and have poor attention spans. These signs result from prolonged emotional deprivation, and they disappear for a period of time when factors of deprivation are removed, such as through adoption or placement in a foster home. Environmental factors, such as disruption of family equilibrium and other anxiety-inducing factors contribute to the initiation or perpetuation of ADHD. Disorders involving reading, arithmetic, language, and coordination may occur in association with ADHD as well. Rates of development, deviations in development, and parental reactions to significant or stressful behavioral transitions should be noted, as they may help clinicians determine the degree to which parents may have contributed or reacted to a child’s inefficiencies and dysfunctions. School history and teachers’ reports are important in evaluating whether a child’s difficulties in learning and school behavior are primarily due to the child’s attitudinal maturational problems or to poor self-image because of feelings of inadequacy. These reports also reveal how the child handles problems. How the child relates to siblings, peers, adults, and to free and structured activities gives valuable diagnostic indicators to the presence of ADHD and helps identify the complications of the disorder (Kaplan & Sadock, 1998).
The adverse reactions of school personnel to the behavioral characteristics of ADHD can contribute to the feelings of inadequacy that may combine with adverse comments of peers to make school a place of unhappy defeat. This may lead to acting out, self-defeating and/or self-punitive behaviors. ADHD symptoms may persist into adolescence or adult life. They can remit at puberty or the hyperactivity may disappear for a period of time as well, but the decreased attention span and impulse-control problems may persist. Remission is unlikely before the age of 12. When remission does occur, it is usually between the ages of 12 and 20. In about 15% of all cases, symptoms persist into adulthood. Those with the disorder may show diminished hyperactivity, but remain impulsive and accident-prone (Kaplan & Saddock, 1998). Expanded research is needed to address these issues to allow the child and adolescent to cope with symptoms in the home, school, and the community.
Therefore, there is a need to broaden the limited research that has been done with Eye Movement Desensitization and Reprocessing (EMDR) as a treatment modality for adolescents who experience symptoms of low self-esteem, anxiety, anger, and behavior problems associated with behavioral disorders. It is also important to investigate whether or not it is an effective treatment that can be used and possibly replicate more studies thereafter.
Purpose of the Study

The purpose of this study is to investigate the effectiveness of EMDR techniques in reducing anger, and anxiety and increasing positive self-esteem in adolescents with behavioral problems and/or symptoms as compared to the effectiveness of other therapeutic techniques such as Cognitive Behavior Therapy (CBT), psychopharmacology, Social Skills Training, and Token Economies.
Research Questions

Approximately 15 clients will be selected to participate in 3 sessions of EMDR based therapy. A comparison group of 15 clients will participate in standard treatment. Scores on the Burns Five Item Anxiety Inventory, Burns Five Item Panic Scale, Burns Five Item Anger Scale, and Rosenberg Self-Esteem Scale from pre-intervention and post-intervention will be compared in order to examine the relative effectiveness of EMDR based treatment. Research questions that will be examined using these instruments are as follows:

R1: What is the effectiveness of EMDR as a treatment modality with adolescents?

R2: What is the effectiveness of EMDR as a treatment modality for managing anxiety in

adolescents with behavioral problems?

R3: What is the effectiveness of EMDR as a treatment modality for managing anger in

adolescents with behavioral problems?

R4: What is the effectiveness of EMDR techniques in improving self-esteem in adolescents with behavioral problems?
Limitations/Delimitations
As a general precaution, this study is exploratory and therefore, the findings should be preliminary. The bilateral stimulation, desensitization, and reprocessing of the EMDR protocol will be used. There will be three sessions instead of five due to the need to hold clients in therapy for this study as long as possible for the results to be valid and to avoid drop out. A more extensive protocol, diverse population, and different age groups should be studied in future research to strengthen external validity. This is an experimental design and random assignment along with a control group will be used, which will give a high level of control over procedures thereby making a stronger design. Personal benefits are expected from participation in this research. The EMDR therapy technique works quickly and has been proven to show positive results within as little as one to three sessions. This is to promote rapid healing of those individuals treated in therapy. Sometimes during research, unpleasant memories and/or feelings may come up and, if the participant needs therapy to address these memories or feelings, the therapist will assist them in doing so. Symptoms of behavioral problems, not behavior problems themselves, are being measured in this study and the scales used in this study may not address some of these behaviors. The measures of symptoms and memories are based on self-report. Another challenge in this study is the small sample size, which may be overlooking a potential treatment effect due to Type II error. There is bias in this study because the researcher is also the therapist who will be interviewing and administering treatment to the participants.
Some of the participants may be receiving medication as a part of their treatment when they enter this study which may influence the outcome of the results (i.e.: decrease in anger and anxiety and improved self-esteem may be somewhat influenced by medications prescribed and not just EMDR alone). The sample used will be a small sample and therefore, the effectiveness of EMDR with adolescents who have behavior problems cannot be generalized to the population. The sample is taken from a small rural community setting and the results of this study may not be the same in a larger community and cannot be generalized to the larger population. Therefore, we cannot assume that the results of this study will be the same in other populations.
There is some controversy about EMDR as a treatment modality. There are also some criticisms of EMDR that need to be considered in this study. Harvard psychologist and EMDR critic, Richard McNally (2003), insists that that much of the research in support of EMDR was poorly designed and that the more methodologically superior research indicates that it has less impact than its supporters maintain. However, EMDR’s critics admit that it does have some clinical impact, though they question whether it offers anything beyond the more established PTSD treatments. Others argue that EMDR has little impact beyond the simple relaxation and exposure to traumatic memories evoked in treatment, key elements of numerous other treatments. McNally criticizes that EMDR works the same way pink aspirin works. Pink aspirin will relieve headaches, but its efficacy will be due to its analgesic properties not the pink food dye.
In response, Francine Shapiro (2004) argues that the research does in fact strongly confirms the efficacy of EMDR, but that some researchers have left out key components of EMDR, such as cognitive components and free association, which ignores the fact that EMDR treatment does not work as well without all of its elements. Shapiro states that such research is not a fair test of EMDR. The research has in fact shown that EMDR compared to simple exposure methods has proven that EMDR has equivalent effects and that these studies show that EMDR works more efficiently, showing results in fewer treatments. EMDR has received support from neuropsychologists and from many other well-known therapists. According to Lebow (2003), the issue with this controversy lies with the fact that researchers in the debates about EMDR must understand the mind-set and working context of clinicians, so they can better communicate their findings to those who should be their primary audience.
Definitions
Attention Deficit Hyperactivity Disorder (ADHD). Characterized by a developmentally inappropriate poor attention span, developmentally inappropriate features of hyperactivity and impulsivity or both. In order to meet diagnostic criteria of ADHD, the disorder must be present for at least six months, cause impairment in academic or social functioning, and occur before the age of seven years. The diagnosis is made by identifying numerous symptoms in the inattention domain, the hyperactivity-impulsivity domain, or both. A child may meet criteria for the disorder with symptoms of inattention only or with symptoms of hyperactivity and impulsivity, but not inattention. The DSM IV-TR lists three subtypes of ADHD. These subtypes include predominantly inattentive type, predominantly hyperactive-impulsive type, and combined type. To meet the criteria of the DSM-IV-TR there must be a presence of two or more situations, such as school, home and/or work (Kaplan & Sadock, 1998).
Behavior Therapy. Behavior therapy consists of applying techniques, methods,
principles and assumptions of behavior theory to human problems. All types of interactions, including thoughts and feelings, are included as “behavior” (Gurman & Messer, 1995).
Cognitive Behavioral Therapy (CBT).This therapy approach identifies and changes in unrecognized beliefs and attitudes that contribute to the client’s distress. Thoughts and ideas can have an affect attached to them and emotional reactions to events are dependent on an individual’s goals, the degree of certainty with which they hold their beliefs, and the presence of negative automatic thoughts. These are basic and common principles for cognitive approaches that therapists commonly use in the treatment of child and adolescent behavioral disorders (Gurman & Messer, 1995).
Conduct Disorder. The DSM-IV-TR defines Conduct Disorder as involving a pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of 3 (or more) of the following criteria in the past 12 months, with at least 1 criterion present in the past 6 months: (a) aggression to people and animals, which includes things such as bullying, threatening, or intimidating others, physically cruel to others or animals, and stealing while confronting a victim; (b) destruction of property which can include deliberate fire setting; (c) deceitfulness or theft which includes breaking into another’s home, lying to obtain goods or avoid obligations, or shoplifting; and (d) serious violation of rules which is serious violation of curfew and running away. This disturbance must cause clinically significant impairment in social, academic or occupational functioning in order to meet criteria for Conduct Disorder.
Contingency Management. Reinforcement, time out, contracting and token economies (Gurman & Messer, 1995).
Eye Movement Desensitization and Reprocessing (EMDR).The client is asked to think of the disturbing/traumatic event, and the therapist then stimulates the client’s information-processing system so that the traumatic experience can be appropriately processed or “digested.” Insights arise during this process for which needed associations are made and the appropriate emotions take over. This information-processing system with EMDR can work quickly. Therefore, the client is able to heal quickly. EMDR reconnects the stored event with the physical information-processing system of the brain. Through the natural healing process, trauma is digested, and the mental wounds can be healed (Shapiro & Forrest, 2004).
Oppositional Defiant Disorder (ODD). The DSM- IV-TR defines ODD as a pattern of negativistic, hostile, and defiant behavior lasting at least six months, during which four or more symptoms of the following are present: often loses temper, often argues with adults, often actively defies or refuses to comply with adults’ requests or rules, often deliberately annoys people, often blames others for his or her mistakes or misbehavior, often touchy or easily annoyed by others, often angry and resentful, often spiteful or vindictive. This disturbance must meet the criteria of causing clinically significant impairment in social, occupational, and/or academic functioning.
Parent-Child Interaction Therapy (PCIT). Focuses on both attachment and social learning theories to change maladaptive parent-child interactions (Neary & Eyberg, 2002).
Rational Emotive Therapy (RET). Focuses on encouraging people to act in ways that are inconsistent with their attitudes and therefore, these attitudes are likely to change, and behavior change is likely to occur simply by making people aware that their undesirable behaviors are inconsistent with their attitudes, and that harmful peer influence can be counteracted by positive peer influences (Ellis & Harper, 1997).
Subjective Units of Disturbance (SUDS). This is an eleven-point scale where 0 represents neutral intensity and 10 equals the highest possible anxiety or disturbance. It is used to rate the negative cognition and memory of the event throughout EMDR after the sets of eye movements (Shapiro, 1995).
Token Economy. This is a technique in CBT that is a systematic reinforcement program in which tokens are used as reinforcers. Tokens are conditioned reinforcers such as money, points, or stars that can later be exchanged for an infinite variety of backup reinforcers. The individual is directly reinforced with tokens for desirable behavior, and these tokens can be used to purchase desired reinforcers, such as a fun activity. An effective token economy system requires that the target behaviors upon which the tokens are earned and the number of tokens that will administered for performing each behavior should be clearly defined (Johnson, Rasbury & Siegel, 1997).
Validity of Cognition (VOC). This is a seven-point scale where one represents “completely false” and seven represents “completely true.” These positive cognitions become more vivid and valid as the negative cognitions become less valid in EMDR treatment, and are rated and measured by the VOC Scale. The client is asked to choose a number on the scale that indicates the intensity of their emotions when the memory is accessed (Shapiro, 1995).
Importance of the Study

Research suggests that EMDR is quick and effective and results are apparent in as little as one to three sessions. This study will seek to explore the expansion of existing research in the area of EMDR as a treatment modality for adolescents with behavioral problems. Greenwald (1999) reports that EMDR with traumatized children and adolescents appears to be effective, even though documentation specifically relating to this population is limited. Hundreds of cases have been informally reported with generally positive results. Published case reports have been positive and consistent with findings of EMDR treatment with adults. The only difference is that treatment with children may be more rapid (Greenwald, 1999).
This study is significant because it will seek to support researchers’ findings that EMDR is an effective treatment strategy for adolescents and provides rapid recovery. EMDR is also significant because it addresses many problems that all adolescents encounter that elicit fear, anxiety, and anger, which are many times the root of behavioral problems in children and adolescents. EMDR also works quickly and has been proven to show positive results within as little as one to three sessions. This is important in today’s world of managed care and the need for effective therapy and rapid healing of those we treat.
The individual portion of treatment usually begins with EMDR for trauma and loss, followed by EMDR enhanced skill development for self-control and other desired behaviors related to doing well in school and social situations (Greenwald, 1999). These are skills necessary for adolescents to be successful academically and socially. These are also skills that make one more resilient. By helping adolescents deal with their traumas early in life, they may be less likely to experience significant mental health problems as adults, such as anxiety, depression, and other similar disorders.

CHAPTER TWO: REVIEW OF THE LITERATURE
Introduction

There are many theories about traditional therapies that claim to be effective in treating childhood and adolescent behavioral problems, including risk behaviors. The research in this study will address and expand upon common, traditional and non-traditional approaches to behavioral problems and symptoms of low self-esteem, anxiety, and anger exhibited by adolescents with behavior problems. Researchers have been paying more attention to adolescent risk behaviors. The primary reason for this is that the major causes of adolescent morbidity and mortality are not diseases, but preventable behaviors in interaction with social and environmental factors. These risk behaviors also have psychological and social outcomes because they interfere with the accomplishment of normal developmental tasks and the fulfillment of expected social roles (Jessor, 1991).
Self-Esteem
One possible antecedent of risk behaviors is self-esteem. Self-esteem is generally referred to as an individual’s evaluation of self, including feelings of self-worth (Coopersmith, 1967; Rosenberg, 1979). There is evidence that adolescent risk behaviors are interrelated which suggests that health-compromising behaviors in adolescents may have common underlying factors, and the identification of these factors is likely to have important implications for designing effective program interventions (Flisher, Ziervogel, Chalton, Legere, & Robertson, 1996; Jessor, 1991; McGee & Williams, 2000). Several theorists suggest that individuals with low self-esteem are predisposed to engage in risky behaviors. Kaplan (1975) proposed that adolescents who have negative experiences in their normative groups are led to feelings of self-rejection and lack motivation to conform to the conventional group’s norms. Other theorists have argued that people with low self-esteem may turn to risk behaviors such as substance abuse as a way to cope with or escape from the negative feelings associated with low self-worth (Baumeister, 1990; Jessor, Van den Bos, Vanderryn, Costa, & Turbin, 1995). This suggests that raising adolescents’ self-esteem will help protect them against adopting risk behaviors. Empirical evidence for a relationship between self-esteem and adolescent risk behaviors are uncertain (Wild, Flisher, Bhana, & Lombard, 2004).
According to Modcrin-Talbott, Pullen, Zandstra, Ehrenbergger, and Muenchen (1998), low self-esteem has been linked to many other adolescent risk behaviors such as smoking, drug use, and sexual activity. Adolescents engaging in these risk behaviors may have subsequent health problems, such as alcohol and drug addiction, as well as teen pregnancy. Formation of self-esteem is an important element in adolescence. During adolescence, self-esteem is influenced by the development of both abstract reasoning and identity. The central variable of self-esteem is conceptualized in this study by Modcrin-Talbott et al. (1998) to a work by Coopersmith (1967) who suggested that self-esteem refers to an evaluation a person makes and customarily maintains for him or herself. Self-esteem is an expression of self-approval or disapproval, indicating the extent to which a person believes he or she is competent, successful, significant, and worthy. Understanding self-esteem is basic to understand the adolescent’s behavior. It is important to know how adolescents perceive, value, and regard the self to interpret their behavior (Modcrin-Talbott et al., 1998).
Research by Coopersmith (1967) proposed that all aspects of a person’s life are affected by the level of self-esteem. Roy (1984) states that self-esteem profoundly affects the ability to adapt to changes in one’s life. If the adolescent is unable to adapt in one of the modes, low level of self-esteem may be the cause. Modrcin-Talbott et al. (1998) examined emotions in a group of adolescents ages 12 to 19. A descriptive correlational design examined the level of self-esteem and correlates of self-esteem. As the self-report of depression and anger in all age groups increased, the self-report of self-esteem decreased. Depression and great amounts of anger typically are responses that not only suggest ineffective coping by the adolescent, but also inappropriate stimuli. These emotions hinder the teen’s adaptation to day-to-day events and achievement of the tasks of the adolescent period. Therefore, it is evident that practitioners may want to develop and foster strategies that strengthen the adolescent’s coping abilities. It is important for health care providers to promote interventions that nurture a hardy self-esteem throughout childhood, especially in adolescence, and discover new directions that can assist in preventing future adolescent casualties.
During adolescence, there is a tendency of a reduction of emotional well-being. Therefore, adolescents may engage in dangerous behavior, extreme narcissism and individualization, exclusion, and social isolation. Another element playing an important role during adolescence is self-esteem. Low self-esteem could lead to apathy, isolation, and passivity. High self-esteem is associated with more active lives, greater control over circumstances, less anxiety, and greater capacity to cope with internal and external stress. Suicide rates have increased among adolescents over the past three decades and some aspects that have been identified as influencing this increase are the reduction of emotional well-being, certain degree of acceptance of suicide among young people, mass media, and psychosocial changes in short periods of time. These all could become a potential source of stress and vulnerability. Adolescents may engage in dangerous behavior, which could constitute attempts to overcome their feelings of helplessness, intense narcissism and individualization, exclusion, and social isolation. Self-esteem also plays an important role during adolescence because it leads to the development of a solid and stable personality. There is evidence that low self-esteem could lead to a state of apathy, isolation, and passivity. Many studies have shown the link between low self-esteem and suicidal behavior (Tapia, Barrios, & Gonzalez-Forteza, 2007).
Low self-esteem has also been linked with other health risk behaviors such as problem eating and suicidal ideation or behaviors (McGee & Williams, 2000). A study done by (Wild et al., 2004) included students in grades 8 and 11 and they were assessed using the multidimensional Self-Esteem Questionnaire (SEQ) developed by Dubois et al. (1996). Results showed that individuals who scored below the median on peer self-esteem scale were significantly more likely than those with higher self-esteem in the peer domain to report having been bullied at school in the last twelve months. Low self-esteem in respect to school was associated with an increased risk of drug use for girls. Boys with scores below the median on the school self-esteem scale were more likely than those with higher scores to report having bullied another student, been bullied, and engaged in risky sexual behavior. Boys with low self-esteem in respect to body image scored significantly higher and were more likely to be suicidal and to have been bullied at school than boys with higher scores on the body-image self-esteem scale. Low global self-worth was significantly associated with an increased likelihood of suicidal ideation in both sexes, of having been bullied and alcohol use in boys, and risky sexual behavior in girls. The final results of this study indicated that scores on each self-esteem scale were significantly associated with at least one risk behavior in male and female adolescents. The findings of this study also suggest that low self-esteem with respect to family and school are the most significant predictors of risk behaviors in adolescents (Wild et al., 2004).
Other research has argued that individuals with low self-esteem are prone to real world externalizing problems such as delinquency and antisocial behavior (Fergusson & Horwood, 2002; Rosenberg, Schooler & Schoenbach, 1989; Sprott & Doob, 2000). Three distinct traditions in the social science hypothesize that there is a link between low self-esteem and externalizing problems. Rosenberg (1965) suggested that low self-esteem weakens ties to society. Humanistic psychologists such as Rogers (1961) have argued that a lack of unconditional positive self-regard is linked to psychological problems, including aggression.
Neo-Freudians hypothesize that low self-regard motivates aggression. For example, Horney (1950) and Adler (1956) theorized that aggression and antisocial behavior are motivated by feelings of inferiority rooted in early childhood experience of rejection and humiliation. Tracy and Robins (2003) suggested that individuals protect themselves against feelings of inferiority and shame by externalizing blame for their failures, which leads to feelings of hostility and anger toward other people. Therefore, three theoretical perspectives hypothesize that externalizing behaviors are motivated partially by self-esteem. Donnellan, Trzesniewski, Robins, Moffitt & Caspi’s study (2005) examines the relationship between self-reports and teacher ratings of self-esteem and self-reports of delinquency in a sample of 11- and 14-year olds. Self-esteem was measured with the ten item Rosenberg (1965) Self-Esteem Scale. Individuals with low self-esteem were more likely to engage in antisocial behaviors as reported by their parents and teachers. The results of this study are consistent with the claim that low self-esteem leads to increased externalization of problems. The results indicated that self-esteem may foretell future externalizing problems due the fact that eleven year olds with low self-esteem tend to increase in aggression by age thirteen. Donnellan et al. (2005) in their three studies found a significant relation between low self-esteem and externalizing problems. This relationship held true for different age groups, different nationalities, and multiple methods of assessing self-esteem and externalizing problems when examining aggressive thoughts, feelings and behaviors. Rosenberg (1965) noted, “When we deal with self-esteem, we are asking whether the individual considers himself adequate, a person of worth, not whether he considers himself superior to others” (p. 62).
Tapia et al. (2007) conducted three studies that explored the existence of a relationship between low self-esteem and depressive symptomatology with suicidal ideation. Females showed a higher frequency of low self-esteem than males in two of the studies. In another, males had a significantly higher frequency of low self-esteem. Gender related differences in low self-esteem were found in only one of the studies, where males had a higher percentage than females. Self-esteem has been linked to anxiety, behavior and neurotic disorders and to a lack of parental support. Depressive symptomatology was related to suicidal ideation and although this relationship and that between depressive symptomatology and self-esteem have been reported before, it is important to note that there appears to be a domino effect among these problems. The problem could begin with depressive symptoms linked to suicidal ideation, which in turn could affect self-esteem, and subsequently trigger suicidal behavior (Tapia et al., 2007).
Anger
Anger is another common symptom in adolescents with behavior problems. General anger is associated with a variety of psychological problems in late adolescence. Compared with their less angry peers, high trait angry individuals are more frequently and intensely angered, with this anger entering many aspects of their lives (Deffenbacher, 1992). They tend to express anger in more dysfunctional, often intimidating and abrasive ways, leading them to experience more frequent and severe anger-related consequences. As a result, they are more likely to experience physical damage to themselves, others, and property and are more likely to have disrupted interpersonal relationships. They are also more likely to have school problems and experience low self-esteem. These adolescents not only report anger, they also report anxiety and depression and do not cope as well with stress in general. There is developing treatment literature that shows that anger can be effectively modified by interventions such as applied relaxation (Deffenbacher & Stark, 1992); cognitive restructuring (Achmon, Granek, Golcomb & Hart, 1989); and combined cognitive-relaxation coping skills training (Deffenbacher, Story & Hogg, 1988).
Anxiety
Existential anxiety is a core human issue and very little is known about the emergence of these concerns and their relation to emotional functioning in youth. Westenberg, Siebelink, and Treffers (2001) presented a model that suggests that by adolescence, youth have the cognitive capacity for insight into morality and broader world concerns that may give rise to existential concerns. Most relevant to the study of adolescents, the literature using surveys of youths’ specific fears and phobias suggests that when assessed by fear surveys and clinical interviews, the fear of death is one of the most commonly reported fears in youths (Ollendick, Matson & Hatsel 1985). Emptiness and meaninglessness is typically what has been at the core of the definition of existential anxiety in past writing in the existentialist tradition as well as previous research (Crumbaugh & Maholick, 1969; Good & Good, 1974; Sartre, 1957). Meaninglessness is an absolute concern and is about the loss of the significance of lies, the future, the world, and everything. Emptiness and meaninglessness have been the primary focus of existential anxiety scales. However, this is the least studied aspect of existential anxiety in youth (Berman, Weems, & Stickle, 2006).
Anxiety about guilt and condemnation is anxiety resulting from threat to our moral and ethical self-affirmation (Tillich, 1952). For Tillich, guilt is the relative anxiety that your behavior has not lived up to your standards. Condemnation is the ultimate concern that you or your life has not met certain universal standards. The development of guilt has been explored and the association between guilt and psychological symptoms has been investigated. This research suggests that guilt is associated with fear in young children and that it is present in children as young as twenty-two months old (Kochanska, Gross, Lin, & Nichols, 2002). Psychosocial developmental theory (e.g. Erikson, 1968) suggests that adolescence is a critical period in the development of life goals and values as well as in the establishment of a sense of direction and purpose in life. While a person develops their sense of identity, existential concerns should become prominent. Research by Berman et al. (2006) suggests that existential apprehension may be linked to depression and anxiety symptoms by similar apprehension and concern about the self (guilt/condemnation), the future (death/fate) and the world (meaninglessness/emptiness). Data were collected from a sample of adolescents aged 15 to 18 years of age where existential anxiety was measured using the Existential Anxiety Questionnaire (Weems, Costa, Dehon, & Berman, 2004). Results from this study support the viability of empirically examine Tillich’s theory of existential anxiety in youth and suggests the importance of further exploring the relation between existential anxiety concerns and the symptoms of depression and anxiety. Future research may benefit from employing interview schedules of depression and anxiety (Berman et al., 2006).
Excessive anxiety is a common problem among youth that can harm them in many areas of their lives, including school performance and social functioning. Research suggests that there is a link between high anxiety and impaired cognitive performance and a link between high anxiety and poor academic outcomes. Elevated anxiety produces a state of physiological arousal and a narrowing focus of attention on perceived threat. This arousal tends to impair concentration on non-threatening stimuli, such as academic tasks. High anxiety may also be associated with disturbance in recall of previously mastered academic knowledge (Malone, Sheikh, & Zito, 1999). Over the course of a school year, children with anxiety disorders may perform below their ability level which can lead to lower grades on report cards. Cross-sectional studies support this by showing association between child anxiety disorder status and school performance (Langley, Bergman, McCracken & Piacentini, 2004).
In addition to school performance, social functioning may be affected by anxiety. Researchers have identified cross-sectional links between elevated anxiety levels and impaired social functioning (Langley et al., 2004). There has been development of effective interventions for children with high anxiety on the basis of the cognitive-behavioral paradigm (Kendall, 1993). According to Wood’s (2006) research, approximately 50% to 80% of children who receive intervention through a program involving a cognitive-behavioral paradigm no longer meet criteria for an anxiety disorder at the end of treatment. The hypothesis that high anxiety plays an important role in poor school performance and social maladjustment indicates a need for an intervention that substantially reduces anxiety and might indirectly improve these outcomes.
In Wood’s (2006) study, a longitudinal design was used n the context of a short-term intervention for anxiety disorders to test whether reductions in children’s anxiety over time would predict improvements in school performance and social adjustment. Wood’s study tested the effect of reduction in anxiety over time on improvements in school performance and social adjustment in the context of participating in a cognitive-behavioral intervention. The initial sample included 40 children with high anxiety living in a major metropolitan area of the western United States, ranging from 6 to 13 years of age. Two variations of a CBT intervention program were implemented. Children were randomly assigned to a family-focused CBT or child-focused CBT. CBT for childhood anxiety consists of two elements of skills training and application (Kendall, 1993). During skills training, children are taught the coping strategies of emotion recognition, relaxation, and cognitive restructuring. The application and practice phase lasts for at least eight sessions and consists of in vivo exposure tasks. These tasks involve facing an increasingly challenging set of anxiety-provoking situations, applying coping strategies, and attaining mastery experiences until anxiety is reduced (Wood, 2006).
Longitudinal analyses suggested that reductions in anxiety over the course of an intervention predicted improvements in parents’ perceptions of children’s school performance. Wood’s study (2006) indicates that the independent evaluators’ rating of anxiety significantly predicted child rating and parent rating of social functioning, therefore, increasing confidence that reductions in anxiety are beneficial for children’s social outcomes. A primary implication of Wood’s study is that children’s school performance and social functioning may be enhanced as a result of a reduction in children’s anxiety over the course of time. These findings support theories that there is a role for anxiety disorders in the undermining of children’s academic and adaptive functioning. Parents, teachers, and counselors should be aware that anxiety could be an undetected accomplice in children’s academic problems and social difficulties.
Common Diagnoses Associated with Behavioral Problems
Common behavioral problems that professionals treat are Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder. There may also be other treatable behavioral problems which exist as a symptom of a specific disorder. An example of this may be Adjustment Disorder with disturbance in mood and conduct or with disturbance of conduct only. Regardless of the diagnosis, these are all behavioral problems that children and adolescents struggle with. The previous research in regards to how to effectively treat these disorders is extensive and there are many common reoccurring theories about how to treat these disorders.
ADHD is a commonly diagnosed mental disorder of children and has become the most common neuropsychiatric syndrome in children. It affects three to five percent of approximately two million school age children, according to the United States Department of Education (National Institute of Health, 1998; Aleman, 1991). The number of very young children who may later be diagnosed with ADHD will be higher among those who have already been diagnosed as having special needs, or those who get services because they are at high risk for poor school performance. According to Cantwell (1996), this problem accounts for as much as 50% of child psychiatry in clinic patients. According to Conners and Jett (1999), ADHD accounts for 30% to 40% of all referrals made to child guidance clinics.
ADHD is one of the most researched areas in child and adolescent mental health. Research shows that Attention Deficit Hyperactivity Disorder is a brain-based biological disorder. Brain imaging studies using positron emission tomography (PET) scanners show that brain metabolism in children with ADHD is lower in the areas of the brain that control attention, social judgment, and movement. Scans and other imaging research also show that the brain of a child with ADHD differs consistently from those of children without the disorder. Many brain regions and structures tend to be smaller (i.e.: pre-frontal cortex, striatum, basal ganglia, and cerebellum). Overall brain size is generally five percent smaller in children affected by ADHD as opposed to those that are not affected by ADHD. These findings should not be used as the determining factor in diagnosing someone with ADHD (Zametkin, 1990). ADHD is common, appears more frequently in males than females, and causes must be a disruption in school and at home. It is characterized by a developmentally inappropriate poor attention span, developmentally inappropriate features of hyperactivity and impulsivity or both. In order to meet diagnostic criteria of ADHD, the disorder must be present for at least six months, cause impairment in academic or social functioning, and occur before the age of seven years. The diagnosis is made by identifying numerous symptoms in the inattention domain, the hyperactivity-impulsivity domain, or both. A child may meet criteria for the disorder with symptoms of inattention only or with symptoms of hyperactivity and impulsivity, but not inattention. The Diagnostic and Statistical Manual IV (DSM-IV) lists three sub-types of ADHD. These subtypes include predominantly inattentive type, predominantly hyperactive-impulsive type, and combined type. To meet the criteria of the DSM-IV there must be a presence of two or more situations, such as school, home and/or work (Kaplan & Sadock, 1998).
Origin of Behavioral Disorders
No single factor is believed to cause the disorder, although many environmental factors may contribute to the disorder and many predictable clinical features are associated with this disorder. Reports on the incidence of ADHD in the United States have varied from 2 to 20 percent of grade school children and 3 to 5 percent of prepubescent elementary school children. In Great Britain, the incidence is lower (less than one percent). The ratio of males to females with ADHD ranges from three to one to as much as five to one. The disorder is most common in firstborn boys. Siblings of children with ADHD are also more likely than others to score more poorly on tests of academic achievement and to show evidence of school failures. Parents of children with ADHD show an increased incidence of hyperkinesis, sociopathy, alcohol use disorders and conversion disorder. The onset is usually by the age of three. However, the diagnosis is generally not made until the child is in elementary school and the formal learning situation requires structured behavioral patterns, including developmentally appropriate attention span and concentration (Kaplan & Saddock, 1998). Expanded research is needed to address these statistics in a way that would allow the child and adolescents to cope with symptoms of these disorders in all settings, including home, school, and the community.
Chemical differences are also present in the brain of someone with ADHD. Low levels of dopamine, which is a neurotransmitter, are found in children with ADHD. Researchers have found that a restricted diet from sugar and food additives only helps about five percent of children with ADHD, mostly young children or children with food allergies. Research also suggests that ADHD is genetic. Children who have ADHD usually have at least one close relative who also has a history of ADHD. One-third of all fathers who had ADHD in their youth have children who are diagnosed with ADHD. More research is currently being conducted on tracking the gene that may be involved in transmitting ADHD in some families with a genetic thyroid disorder (Zametkin, 1990). This is a critical factor to consider when looking at the total treatment of the child or adolescent and finding a combination of therapeutic approaches that work best for a particular child or adolescent.
Many neurotransmitters have been associated with ADHD symptoms. The stimulants affect both dopamine and norepinephrine, leading to neurotransmitter hypotheses that include possible dysfunction in both the adrenergic and the dopaminergic systems. Stimulants increase catecholamines by promoting their release and by blocking their uptake. Stimulants and some tricyclic drugs have been helpful in treating hyperactivity. There has not been any specific evidence or single factor that implicates a single neurotransmitter in the development of ADHD, but many neurotransmitters may be involved in the process. Positron emission tomography (PET) scans have found decreased cerebral blood flow and metabolic rates in the frontal lobe areas of children with ADHD compared with controls. One theory explains these findings by supposing that the frontal lobes in children with ADHD are not adequately performing their inhibitory mechanism on lower structures, an effect leading to disinhibition (Kaplan & Sadock, 1998). Therefore, it is important to address medication as a treatment modality in combination with therapy, especially in the treatment of ADHD.
There are environmental factors to consider as well in the treatment of behavioral disorders. Children in institutions are frequently overactive and have poor attention spans. These signs result form prolonged emotional deprivation, and they disappear when factors of deprivation are removed, such as through adoption or placement in a foster home. Disruption of family equilibrium and other anxiety-inducing factors contribute to the initiation or perpetuation of ADHD. When diagnosing ADHD clinicians should be alerted to the possibility of an ADHD diagnosis when the principal sign of hyperactivity exists. A detailed prenatal history of a child’s early developmental patterns and direct observation usually reveal excessive motor activity. To diagnose the disorder the hyperactivity should not be an isolated, brief, and transient behavioral manifestation under stress, but should have been present over a long period of time. Symptoms must be present in at least two settings to meet the diagnostic criteria for ADHD (Kaplan & Sadock, 1998). This is a significant part of assessment and the therapist’s ability to use this information to appropriately diagnose the child. It is also critical in providing the best possible plan of care for each child and their family.
Disorders involving reading, arithmetic, language, and coordination may occur in association with ADHD. Rates of development, deviations in development, and parental reactions to significant or stressful behavioral transitions should be noted, as they may help clinicians determine the degree to which parents have contributed to or reacted to a child’s inefficiencies and dysfunctions. School history and teachers’ reports are important in evaluating whether a child’s difficulties in learning and school behavior are primarily due to the child’s attitudinal maturational problems or to poor self-image because of feelings of inadequacy. These reports also reveal how the child handles problems. How the child relates to siblings, peers, adults, and to free and structured activities gives valuable diagnostic indicators to the presence of ADHD and helps identify the complications of the disorder (Kaplan & Sadock , 1998).
A child with an unrecognized temporal lobe seizure focus can have secondary behavior disorder. In this instance, several ADHD symptoms are present. Identification of the focus requires an electroencephalogram (EEG) be obtained during drowsiness and during sleep. In school ADHD children may rapidly attack a test, but may answer only the first two questions. They may be unable to wait to be called on in school and may blurt out answers in class. This can be very embarrassing for a child who is attempting to perform in front of his or her classmates or please their teacher. At home, they cannot be put off even for a minute. Children with ADHD are often explosive and irritable. The irritability may be set off by relatively minor stimuli, which may confuse the child. They are frequently emotionally labile and easily set off to laughter or to tears. Their mood and performance are likely to vary and be unpredictable. Impulsiveness and an inability to delay gratification are characteristic. These children are often accident prone as well. Approximately 75% of children with ADHD consistently show defiance and aggression. Defiance and aggression are usually associated with adverse interfamily relationships and hyperactivity is more closely associated with impaired performance on cognitive tests requiring concentration (Kaplan & Sadock, 1998). These issues of anxiety, irritability, and peer-relational problems indicate a need to explore various approaches for children who experience disturbing events such as these. Both traditional and non-traditional approaches should be explored.
The adverse reactions of school personnel to the behavior characteristics of ADHD and the lowering of self-regard due to the feeling of inadequacy may combine with adverse comments of peers to make school a place of unhappy defeat. This may lead to acting out and self-defeating, self-punitive behaviors. ADHD symptoms may persist into adolescence or adult life. They can remit at puberty or the hyperactivity may disappear as well, but the decreased attention span and impulse-control problems may persist. Remission is unlikely before the age of twelve. When remission does occur, it is usually between the ages of 12 and 20. In about 15% of the cases, symptoms persist into adulthood. Those with the disorder may show diminished hyperactivity, but remain impulsive and accident prone (Kaplan & Saddock, 1998).
History is full of references to people fitting the symptom pattern of inattention, restlessness, hyperactivity, and impulsivity. According to Amen, the hallmark assessment tool for ADHD is a detailed history by a clinician. Amen states that he has found that a life history is the most reliable diagnostic tool. He also uses other things such as checklists, brain-imaging studies, information from collateral sources (i.e. teachers and caregivers), and blood work. He finds that a good clinical history is essential to properly diagnose and treat ADHD. It is most helpful to take a biological, psychological, and sociological approach when evaluating any psychiatric, learning, or behavioral problem. If the clinician looks at problems in these three spheres they are more likely to obtain the best possible evaluation and set the stage for proper treatment (Amen, 2001).
There are many factors that Amen (2001) believes may cause ADHD and they may be different for each individual. Since ADHD tends to run in families, an assessment should begin with a good family history starting with the grandparents. One of the most common unrecognized factors that can cause ADHD is head injury, especially to the left front side of the brain. When the brain is exposed to a lack of oxygen or some toxic substance, it is much more likely to show symptoms of ADHD. Lack of oxygen can occur with premature babies who have underdeveloped lungs, babies born with the cord wrapped tightly around the neck, and individuals after a drowning accident. Certain medical problems, such as thyroid disease, can look like ADHD. Therefore, it is important for the doctor to assess the impact of medical problems on behavior. The therapist can assist in this process of gathering needed history and communicating frequently with physicians or the psychiatrist treating the child.
Hormonal influences play a major role in ADHD also. For instance, ADHD symptoms are generally worse around the time of puberty in both males and females. Many single photon emission tomography (SPECT) brain imaging studies have shown an overall decrease in brain activity when estrogen levels are low. Poor diet can have an influence on ADHD. Children today eat a diet high in carbohydrates (sugar and white bread), poor in lean protein, and deficient in vegetables. A diet high in simple carbohydrates makes attention problems worse for most people, especially with people vulnerable to ADHD. Most ADHD children simply do better on a high-protein, low and simple carbohydrate diet. A lack of protein causes a tremendous problem with the focus throughout the day. Exercise boosts the blood flow to the brain. Children and teens get much less exercise than they did twenty years ago, due to involvement in video and computer games. An inactive lifestyle makes someone more prone to exhibit ADHD symptoms. Therefore, it is important the child get a healthy amount of exercise weekly (Amen, 2001). The therapist can include diet and exercise as part of the treatment regime when treating ADHD, since this appears to be another way to effectively manage symptoms of ADHD.
Psychological factors such as physical and emotional neglect and abuse contribute to ADHD. The brain needs nurturing and appropriate stimulation to develop properly. When a baby is neglected or abused, the brain cannot develop properly and is at great risk for learning and behavioral problems. Low self-esteem, self-doubt, and lack of confidence can make some look as if they have ADHD. Having a diagnosis of ADHD can also make one more prone to these problems. Learned helplessness occurs when a person tries to do something important, such as study for school, but performs poorly. When they try again, it does not work. Then they try again, but it still does not work. Finally, they give up. This demoralization contributes heavily to ADHD symptoms and must be assessed. Evaluating the current family and social situation is also essential to get a compete picture of the person. The clinician should consider who the person is living with, what the relationships are like, what the financial health of the family is, the existence of any physical or emotional challenges, and if alcohol or drug abuse exists in the home (Amen, 2001). These problems with performance in these types of settings should be addressed in therapy in order to increase chances for success in therapy.
Amen (2001) summarized important points for parenting and family strategies to cope with ADHD. A few of these are to remain focused and set clear goals as a parent and for the child. A parent should spend “special time” with the child each day, even if it is 10 or 15 minutes, be a good listener, notice the child when they live up to the rules and expectations, mean what you say, make swift and clear consequences for broken rules, keep your promises, both parents support each other, and give the child choices between alternatives rather than dictating. Retraining difficult behavior patterns is an essential part of treatment for ADHD. Behaviorally many children learn to get other people upset with their difficult behavior. They learn on an unconscious and biological level that when there is turmoil between people, it stimulates their brain, making them feel more alert and awake. Retraining behavior patterns or behavior modification involves several clear steps. The first step is to define the desired and undesired behaviors specifically. The second is to establish a baseline period. Step three is to communicate the rules and expectations clearly. Step four is to reward desired behavior. Finally, step five is to give clear, unemotional consequences for the negative behavior.
Amen (2001) explains that your brain is involved with everything you do. How you think, feel, act, and how well you get along with other people. The way the brain works is intimately involved with determining the kind of person you are. We must understand all aspects of an individual’s life that may predispose them to the onset of ADHD, and become more knowledgeable about the various causes of ADHD and other behavior problems, and how to appropriately treat these disorders.
Psychopathologies have multiple causes that interact with one another as well as change over time. This continual and progressive interaction among variables is transactional in nature (Sameroff, 2000). The most common comorbid forms of child and adolescent internalizing problems are anxiety and depression. Comorbidity rates for anxiety and depressive disorder are as high as 70%, with typical rates from 20% to 50% (Zahn-Waxler, Klimes-Dougan, & Slattery, 2000).
Correlations between scores on anxiety and depression inventories are usually very high. Links between depression and anxiety include different directions: co-morbidity may indicate the presence of single underlying dimension, such as negative affectivity and attachment processes or anxiety and depression may be considered as separate and distinct disorders. Many mechanisms could describe the association between negative affectivity and psychological problems. For example, difficult child temperament could influence parents’ reactions to the infant’s needs and signals, and they also could affect the degree to which the infant requires such reactions. In this sense, anxiety and depression may co-occur because of common temperament and attachment factors that increase vulnerability to both types of problems. An easy temperament, secure parent-child attachments, and authoritative parenting are central protective factors for resilience in the face of stress (Vulic-Prtoric & Macuka, 2006). Research in this field indicates that child psychopathology needs to be understood in the context of family interaction patterns (Cummings, Davies, & Campbell, 2000). Anxiety and depression particularly appears to be associated with family environments characterized by an absence of supportive and facilitative interactions and by levels of conflict and angry situations (Carr, 1999).
The most widely reported finding is that depression and anxiety are inversely related to the level of support and approval provided by the family environment. This finding has been reported in both community and clinical samples (Rohner & Britner, 2002). One theory that attempts to predict and explain major personality or mental health related consequences with perceived parental acceptance and rejection is Parental Acceptance-Rejection Theory (PART) conceptualized by Ronald P. Rohner (1999). This dimension in the PART is viewed from two perspectives. One is from the subjective perception of either the child or the parent(s), and the other as objectively observable behavior. Accepting parents are described as those who show their love and affection towards children and induce the child to feel loved and accepted. Rejecting parents in the PART are those who dislike, disapprove of, or resent their children, which is manifested in two ways. One is in the form of hostility and aggression and the other is in the form of parental indifference and neglect. The results are the child’s feelings of being unloved or rejected (Vulic-Prtoric & Macuka, 2006).
Once psychological problems have developed, they may be maintained by different personal factors. Many personal maintaining characteristics play an important role in self-efficacy beliefs, cognitive distortions, dysfunctional attributes, immature defense mechanisms, and dysfunctional coping strategies (Carr, 1999). Active ways of coping such as problem solving, cognitive distraction, self-calming, and asking for help from others, contribute to better adaptation and decrease depressive and anxiety symptoms, instead of avoidance or social isolation (Compas, Malcarne & Fondacaro, 1988). Parental behavior and child rearing practices contribute to the child’s development of a perception and appraisal of the events and ways of coping with stressful situations (Kortlander, Kendall, & Panichelli-Mindel, 1997). Overprotective, anxious, or aggressive, disapproving parents provoke low coping in children. Clinically depressed and anxious children use less efficient coping strategies that eventually increase their problems (Vulic-Prtoric & Macuka, 2001).
Vulic-Prtoric and Macuka’s (2006) study investigated anxiety and depression with the goal of determining the specific family interactions and coping strategy variables that are related to depression and anxiety in children. It was hypothesized that different family relations and specific coping strategies are associated with depression and anxiety in children. It was also hypothesized that these processes would be helpful in the differentiation between children’s anxiety and depression. Correlation coefficients in this study show that all coefficients considering family variables show a higher correlation with depression. Among all family variables, father rejection had the highest correlation with anxiety and depression in boys and girls, and was the best and only predictor of their anxiety. Family satisfaction was found to be a significant predictor for both anxiety and depression scores. Results of this study indicate that both anxiety and depression are strongly correlated with perceived parental rejection, but appears that depressive children compared with anxious children perceive their families to be less pleasant to live with and that their parents are less accepting, supporting, and approving and more rejecting and controlling. These findings are largely supported by many studies showing that families of children with depressive or anxiety disorders are characterized by less cohesion and more conflict (Cummings, Davies, & Campbell, 2000). These families are also less likely to express feelings, are less democratic , and engage their family members in fewer pleasant activities (Stark, Humphrey , Laurent, Livinston, & Christopher , 1993).
Anxious children used more internal dialogue than depressed children in an attempt to control emotional tension and embarrassment (Lodge & Tripp, 1995). This internal dialogue can serve for the reduction of anxiety through self-encouragement, but also as a strategy of directing attention from stressful events to internal processes. The results of Vulic-Prtoric and Macuka’s (2006) study are conclusive with findings that have significance in planning psychological intervention programs for children and adolescents with anxiety and depression (Shochet & Dadds, 1997). Due to these findings, it is important to continue addressing anxiety in children by exploring treatment strategies that have shown to be effective.
Treatment of Behavioral Disorders
Cognitive Behavior Therapy (CBT)

According to previous research, the most common form of treatment for behavioral problems is Cognitive Behavioral Therapy. Behavior therapy was a therapy that evolved into the term, Cognitive Behavior Therapy, with specific techniques that many therapists use today. Behavior therapy consists of applying techniques, methods, principles, and assumptions of behavior theory to human problems. All types of interactions, including thoughts and feelings, are included as “behavior.” Behavior is viewed in terms of its function and not its form. Different forms of behavior are viewed as historical and situational. The historical and situational context completes the functional behavioral unit. For example, it is not enough to know that a client is passive. Clinicians must also know what function this passivity serves, and how these functions were acquired. This is why it is important to look at behavior from a historical perspective and understand what the individual is gaining from their behavior. In different contexts, entirely new forms of behavior may emerge and can be maintained under the right conditions. Behavioral tendencies are seen as ever evolving. Empirical evidence shows that taking the time to understand the function of disruptive behavior rather than counting the problem behavior leads to greater treatment success. If the client is disruptive to seek attention, it is important to teach them to attract attention appropriately (Hayes, et al., 1995).
Assessment in behavior therapy usually begins with a clinical interview where a history of the problem is gathered as well as when and under what circumstances did the problem start. Behavioral strengths and weaknesses are also identified. Behavior therapists tend to examine action directly in its context and use self-monitoring and self-report procedures with high face validity. For example, the therapist may ask the client or someone in their family to monitor the target behavior and note the corresponding circumstances or outcome of this behavior. Often one problem leads to another and therefore, there is a primary and secondary problem. Many behavior therapy methods have proven to be effective even when given a very limited course of treatment. Behavior therapy uses individual, family, and group formats or combinations of these. Behavior therapists place emphasis on therapeutic activity occurring outside of the session as well. Therefore, homework is a critical component of many types of behavior therapy. The goal of homework is to bring the client in contact with actual events that naturally affect the behavior of interest. Exposure based therapies are also used for anxiety producing thoughts and feelings. This may be helpful in the case of a child with ADHD who may have a fear of raising their hand in class or participating because they often are distracted and lose their place in class. This can be anxiety provoking and interfere with the child’s ability to cope with ADHD (Hayes, et al., 1995).
Desensitization has been used to treat negative emotions such as anger, which is a symptom and problem with many childhood disorders, including disruptive behavior problems, Oppositional Defiant Disorder, Conduct Disorder, and Adjustment Disorders. Systematic desensitization is graduated exposure treatment that involves three steps. These steps are construction of an anxiety hierarchy, training of an alternative response, and gradual exposure beginning with imagery. Clients are taught relaxation techniques as a way to reduce and extinguish the anxiety or fear. The therapist often directs the client through this imagery and relaxation reminding them to breathe and be aware of the calm feelings as they spread throughout the body. The client practices this relaxation between sessions until they have mastered the skill (Hayes, et al., 1995). These all are effective and common ways to treat ADHD and other behavioral disorders.
Self-control procedures through contingency management have also been used by behavior therapists. For example, short term consequences of studying are not long lasting, but the long term consequences include increased income, richer intellectual life and a more valued career. This situation is called a behavioral fence because of the short term consequences making it more difficult to engage in the desired behavior. For example, a client with ADHD may have a difficult time studying and would be asked to schedule studying time at the same time and place each day and to make sure that all materials are available and no distractions are present in that setting. The direct use of contingencies has been the most common treatment in children. These contingency management procedures include reinforcement therapy, time out, contracting, and token economies. If a clinician was looking at a functional analysis, it may show that a child is seeking the teacher’s attention in this inappropriate manner. Therefore, a behavioral program might be established with two components: time out and shaping appropriate attention getting. Shaping appropriate attention getting might include training the child to ask the teacher to come and look at things achieved throughout the day. The child may have to be prompted by the teacher first and then it should eventually become natural for them. The amount of evidence supporting the effectiveness of direct contingency manipulation is significant (Hayes, et al., 1995). These self-control and contingency management strategies are effective in teaching parents positive ways to handle problematic behaviors. This should be monitored throughout therapy to measure progress and maintain continuous parent involvement in therapy.
Behavior therapists are also keenly aware of the necessity for a positive working alliance. The therapist is expected as a behavior therapist to have warmth, empathy, and genuineness. Any of these qualities are necessary in developing the therapeutic relationship regardless of what type of therapy or technique a therapist uses. Behavior therapy is collaborative and focuses on developing new, more adaptive behavioral patterns. Behavior therapy is most effective when therapists have the ability to control the delivery of the natural reinforcers that control the behavior that is being addressed in treatment. For example, in young children, it is often possible to have someone in the client’s environment monitor and deliver reinforcers that can shape client behavior. Therefore, it is evident that behavior therapy appears to be one of the most reliable treatments for children with behavior problems (Hayes, et al., 1995).
Cognitive Therapy
Another type of therapy that has been shown to effectively treat behavioral problems, as well as other disorders such as depression, is cognitive therapy. The merging of cognitive therapy and behavior therapy has become the rule and not the exception. Cognitive approaches seem to be applicable cross culturally because they are process focused and phenomenological based. Cognitive theory was founded on the idea from traditions dating back to Stoic philosophers, such as Epictetus (1983), who stated, “What upsets people are not things themselves, but their judgments about the things.” Therefore, when we are upset or distressed we are never to blame someone else, but rather ourselves and our own judgments. Behavior in cognitive therapy is seen as goal directed, purposeful, active, and adaptive. The cognitive therapist works to give voice to the unspoken. Significant attempts are made to identify and change unrecognized beliefs and attitudes that contribute to the client’s distress. Freud (1892) explains that thoughts and ideas can have an affect attached to them and emotional reactions to events are dependent on an individual’s goals, the degree of certainty with which they hold their beliefs, and the presence of negative automatic thoughts. These are basic and common principles for cognitive approaches that therapists commonly use in the treatment of child and adolescent behavioral disorders (Freeman & Reinecke, 1995).
The role of the social learning process plays an important role in the development of emotional problems and cognitive therapy. The use of cognitive restructuring, development of social problem solving capacities, and the acquisition of behavioral skills in resolving them also serve as the basis of the clinical practice of cognitive therapy to treat behavioral reactions about themselves, their world, and their future. Individuals actively perceive or “construe” their behavior and generate abstractions about themselves, their world, and their future. These constructs determine how the individual will respond to events. From this perspective, a goal of therapy is to understand the client’s subjective interpretations or judgments about their experiences and to assist patients to construe them in a more adaptive manner (Freeman & Reinecke, 1995).
Meichenbaum’s (1977) techniques for “self-instructional” training via the rehearsal of “self-statements”, modeling, and self-reinforcement have proven particularly useful in treating depressed or impulsive children. Therefore, it is important to note that cognitive therapy is very useful in the treatment of behavioral problems such as Attention Deficit Disorder and Oppositional Defiant Disorder. There is also the “ABC” model, proposed by Albert Ellis (1985), which demonstrates that relationships between “Antecedent Events”, “Beliefs”, “Behavior”, and “Consequences” for the individual. This model suggests that neurotic or maladaptive behaviors are learned and are directly related to irrational beliefs that people hold about events in their lives. Ellis developed common cognitive distortions or errors, as well as numerous directive therapeutic techniques for changing them. This model assumes that by identifying and changing unrealistic or irrational beliefs, it is possible to alter one’s behavioral or emotional reactions to events. Confrontationally expressed interventions are necessary to dispute these irrational beliefs, especially if they are long standing. Basic assumptions of cognitive therapy are as follows: the way individuals interpret events and situations mediates how they subsequently feel and behave; interpretation of events is active and ongoing and allows individuals to derive a sense of meaning from their experiences; individuals develop idiosyncratic belief systems that guide behavior and are rendered sensitive to specific stressors including external events and internal experiences; the activation of maladaptive coping behaviors contributes to the maintenance of aversive environmental events and consolidation of the belief system; and the emotional states can be distinguished by the specific content of the belief system and cognitive processes that are activated (Freeman & Reinecke, 1995).
The concept of schemata also plays an important role in cognitive therapy for treatment of emotional and behavioral problems. These schemata are elements of past reactions and experiences which form a cohesive and persistent body of knowledge capable of guiding subsequent perception and appraisal. Even though we are not consciously aware of these schemata, these schemata direct our attention to those elements of our daily experiences that are most important for survival and adaptation. Individuals tend to make sense of new experiences in terms of what they already have experienced and believe, rather than by changing their existing views. Therefore, these schemata are established as an individual’s abstract similarities between events. Schemata are developed and consolidated over the course of an individual’s infancy and childhood. Behavior and emotions from this perspective are adaptive. Individuals behave in terms of outcomes that they desire and expectations that they maintain. Schemata play a central role in the expression of clinical disorders and account for consistencies in behavior over time and for continuities in an individual’s sense of self throughout their life. It is the therapist’s goal to ultimately change behavior by bringing awareness to these schemata and dispute these beliefs about the self and environment (Freeman & Reinecke, 1995). As therapists, we must help identify and address these events that provoke disturbing thoughts and feelings.
An individual’s perceptions, memories and thoughts can become distorted in many adaptive and maladaptive ways. For example, some may view life in an unrealistically positive way and perceive that they have control or influence that they may not actually possess in reality. These people may take chances that others would usually avoid such as taking big risks. This is applicable to behavioral problems in disorders such as Oppositional Defiant Disorder because these individuals too often act as if they have control over others and will act upon this. It is also applicable to those with ADHD because of their tendency to be very impulsive and take big risks, which can cause behavioral problems and social problems for them. One task in cognitive therapy is to make these distortions manifest and assist clients in recognizing the impact of these distortions on their life. These cognitive distortions represent maladaptive ways of processing information and may become symbolic of particular styles of behaving or of certain clinical disorders (Freeman & Reinecke, 1995).
The practice of cognitive therapy is structured, active, and problem oriented, time limited and strategic, employs a collaborative relationship, uses psycho-educational techniques, assists in skill acquisition, is based on thoughts and behaviors, and uses coping and mastery models. A typical agenda in a cognitive therapy session for those with behavioral problems and other disorders may include discussion of events over the past week and feelings about the prior session, review of self-report scales that the client completes prior to session, review of remaining items from a previous session, review of client’s homework and successes or problems in completing the homework, addition of current problems to the agenda which may include social skills, relaxation training, or assertiveness skills, and examination of dysfunctional thoughts. A review of what has been accomplished during the current session is also typical for a cognitive therapy session because it gives the therapist an opportunity to help the patient clarify goals and accomplishments of the session (Freeman & Reinecke, 1995).
A homework assignment for the next session can then be developed and the session is given closure. Chronic behavioral and emotional patterns are often seen by clients as “part of me.” Challenges to these core beliefs should stem from careful, guided, discovery based on collaboration with the client rather than on direct confrontation or disputing of these beliefs. Behavioral interventions that are used in cognitive therapy are activity scheduling which is used to more effectively plan use of time, self-rating the mastery of these tasks. Behavioral intervention also includes social skills or assertiveness training, graded task assignments which involve a series of small sequential steps that lead to a desired goal. An example of this would be exposing the client slowly to the situation that they are struggling with by starting to discuss it in the office, practicing these skills in session and then having the client practice these assertiveness and social skills outside the office by using them in “real life situations.” Another behavioral intervention is behavioral rehearsal and role playing where the therapist serves as a teacher and guide offering direct feedback on performance, such as rehearsing positive behavior and role playing positive behavior as well. In vivo exposure is also used where therapy takes place outside of the office and the therapist may assist in this by slowly exposing the client to situations along with relaxation training. Activity scheduling can be particularly useful in helping those with ADHD because they have difficulty organizing tasks and completing tasks. Clients with behavioral problems also tend to struggle with social skills, which is why social skills training is a useful technique to use with clients who have these problems (Freeman & Reinecke, 1995). The therapist and family must work as a team to implement and track these strategies in session and outside of sessions in other settings, such as school and home.
Rational Emotive Behavior Therapy (REBT)
There is research evidence that also supports another form of cognitive therapy. This is Rational Emotive Behavior Therapy. The Basic Behavioral Science Task Force of the National Advisory Mental Health Council (1996) issued a report that reviews psychological studies that support Rational Emotive Behavior Therapy practices. Conclusions from this report state that if people are encouraged to act in ways that are inconsistent with their attitudes, these attitudes are likely to change, that behavior change is likely to occur simply by making people aware that their undesirable behaviors are inconsistent with their attitudes, and that harmful peer influence can be counteracted by positive peer influences. Cognitive Behavior Therapy can also reveal disturbed individual’s self-defeating attitudes and demonstrate how to change them. Rational Emotive Behavior Therapy also mentions that when children who are devastated by failed experiences feel helpless because they see themselves as lacking ability, they can be shown to change their negative ideas about themselves and to feel significantly less inadequate. Therefore, it is evident that this could be a very useful therapy with children who have behavioral problems and may suffer from peer relation problems and social skills deficits as those with behavioral problems often do (Ellis & Harper, 1997).
Role of Behavior Therapist
A feature common to all behavioral methods is that they involve the application of empirically derived psychological principles, such as learning principles, in attempting to change dysfunctional behavior. The goal of the behavior therapist is to help the individual change these troublesome habits or thought patterns and to form new, more adaptive, patterns of behavior. The therapist must consider current factors that maintain the child’s maladaptive behavior in its current form. Intervention is directed at environmental and/or cognitive factors that are more readily accessible to change. Behavioral interviews obtain information about the behavior problem and events in the child’s environment that contribute to its instigation and maintenance. According to Bergan and Kratochwill (1990) and Gelfand and Hartmeann (1984), behavioral interviews usually focus on how often the problem behavior occurs, how it interferes with the child’s daily functioning, when and in what situations it occurs, the preceding events and events following the behavior and what has worked and what has not. These interviews include exploration of information pertaining to the child and family’s resources and level of motivation for change (Gross, 1984) and includes the child’s understanding of the problem (Braswell & Kendall, 1988). The child, parents and teachers are often asked to complete many different specialized questionnaires and rating scales which provide information about the severity and nature of the problem behaviors (Barkely, 1988). This information will also provide identifying factors associated with the presenting problem. These scales provide a global assessment of the child’s overall behavioral adjustment among many problem areas and may also be more specific to beliefs or attributes the child has as well (Johnson, et al., 1997). These measurements should be used when measuring effectiveness of treatment and recording accurate progress of the child or adolescent.
The therapist seeks to identify cognitive factors such as beliefs, expectations, and attributions that may be associated with maladaptive behaviors. The assessment process evaluates cognitions that systematically precede, occur with or follow problematic response patterns in the child (Kendall & Sessa, 1993). Assessment and treatment in behavior therapy are interrelated because behavior tends to happen in a gradual manner and therefore, continuous measurement of the problem behavior provides feedback on the extent to which the behavior has changed since the last assessment period. Even thought behavior may change during the course of treatment, there may be other factors that are uncontrolled and extraneous events in the client’s environment that have affected the behavior change. Cognitive behavior therapists recognize cognitive processes such as thought patterns, self-statements, expectations, attributes of one’s behavior, and attitudes and beliefs can affect how an individual behaves. Many influences, such as Beck (1976), Ellis (1962) and Meichenbaum (1977) have contributed to the development of intervention programs to modify a client’s thought processes. One technique that has been named as a cognitive intervention is punishment. Punishment may involve the removal of positive events contingent on the performance of the undesirable behavior. For example, a child may lose an opportunity to watch television or play outside because the child got into a fight with another child. Two behavioral procedures that involve removal of positive events are time out and response cost. Time out is when one is removed from the opportunity to engage in reinforcing activities contingent on the occurrence of an undesirable behavior. The individual is removed for a short period of time to an area where reinforcing events, including interaction with others, are not available (Johnson et al., 1997).
The second type of punishment, response cost, involves removal of positive events. A consequence would be imposed or reinforcers removed contingent upon undesirable behaviors. Examples of this would be loss of privileges or forfeiting tokens or points earned in a token system. This would not be used as the only intervention strategy. Reinforcement would also be used where the client is rewarded for alternative, positive behaviors. Punishment techniques have been effective in decreasing undesirable behaviors. Punishment procedures tend to rapidly decrease frequency of behavior and, therefore, this technique has been useful in the management of self-injurious behaviors and behaviors that are highly dangerous or disruptive to others. It is best to try other intervention strategies prior to punishment. Burchard and Barrera (1972) used a response cost program was used to reduce the frequency of swearing, noncompliance, and aggressive behaviors in eleven mildly retarded adolescents. When the child engaged in one of these undesirable behaviors, they were required to give up 5 to 30 tokens that had been earned or take a 5- to 30-minute time out. The results indicated that both response cost and time out were effective in significantly reducing the frequency of the target behaviors. Also, the higher response cost and the longer time out period were more effective than the lower response cost and shorter time out period.
An alternative procedure for reducing the frequency of undesirable behavior that includes a punishment component is over-correction. The purpose of over-correction is to teach the consequences of inappropriate behavior and to provide the opportunity to learn more appropriate behavior through compensation and positive practice. This technique requires that the client repeat and/or elaborate responses that have not occurred or that have been performed incorrectly. The positive practice over-correction is used only when the undesirable behavior produces no disruption in the environment. The token economy technique in Cognitive Behavior Therapy is a systematic and highly complex reinforcement program in which tokens are used as reinforcers. Tokens are conditioned reinforcers such as money, points, or stars that can later be exchanged for an infinite variety of backup reinforcers. The individual is directly reinforced with tokens for desirable behavior, and these tokens can be used to purchase desired reinforcers such as food, consumables, and activities. An effective token economy system requires that the target behaviors upon which the tokens are earned and the number of tokens that will administered for performing each behavior should be clearly defined (Foxx & Azrin, 1973).
Token economy programs have been used in a wide range of settings and have been particularly useful in motivating individuals with long standing behavior problems. These programs have been effective in teaching appropriate behaviors and reducing maladaptive behaviors with youth in group homes before delinquency, children in special education classrooms, and institutionalized retarded individuals. Therefore, this type of system would work well with children who have significant behavior problems. It is important to note that there is a high incidence of co-morbidity for many children who have Attention Deficit Disorder and are in special education classrooms because of their learning disability and/or Attention Deficit Disorder. The advantages of token systems are that they can be given immediately, the therapist can individualize reinforcers, and they can be used anywhere, anytime and do not lose their reinforcing value through repeated use because backup reinforcers are available. Other advantages are that with tokens no delay is required, they can be delivered without interfering with ongoing desirable behaviors, and they are effective where social reinforcement such as praise and attention are not adequate incentives for the individual to respond in appropriate ways. Token systems are usually viewed as a temporary method for promoting behavior change where other procedures are ineffective. It is important to gradually wean the individual from this system once the desirable behaviors occur at an acceptable rate because this system is not a typical one that happens in the natural environment (Kazdin, 1989).
A program that has put this into practice is a residential program called the Achievement Place (Wolf, Phillips, Fixen, Willner, & Schumaker, 1976), which is a home for adjudicated youth. This program is based on a flexible motivational point system in which a broad range of target behaviors such as completing homework, being aggressive and being disobedient, are followed immediately by either positive or negative consequences in the form of earned and lost points for appropriate and inappropriate behaviors. Points earned can be cashed in for various privileges such as getting an allowance, watching television, or being able to stay up later. When the adolescent has maintained an acceptable level of performance in the token economy system, they can graduate to a merit system in which points are no longer used and all privileges are free. Evaluations of this treatment program have indicated that it is highly effective in reducing recidivism rate, improving school attendance, and improving academic performance (Wolf et al., 1976).
Cognitive factors in the treatment of psychological problems in children is an area where the therapist implements a diverse set of procedures in an attempt to modify children’s thought processes and subsequently change behavior. These procedures attempt to teach children alternative methods of responding to problem situations by modifying their patterns of thinking. These procedures include techniques such as self instruction training and problem solving skills training. The goals of these cognitive treatment strategies is to develop cognitive mediation skills that enhance a child’s problem solving capabilities and facilitate their responses to previously problematic situations in a more adaptive manner (Johnson et al, 1997).
Intervention strategies that focus on a child’s cognitive processes usually are consistent with two basic approaches. The first approach is cognitive restructuring therapies which attempt to help a child modify distorted thoughts, attributions or beliefs by recognizing maladaptive cognitions, and substituting cognitions of a more adaptive nature. The second is cognitive coping skills therapies, which focus on teaching children adaptive responses both cognitive and behavioral, which enable them to respond more adaptively in situations where they are experiencing difficulties (Kendall, 1993). Researchers Meichenbaum and Goodman (1971) used a self instructional program to help seven- to nine-year-old impulsive children gain control over their inattentive and impulsive behavior through self-verbalizations. The training program was conducted over a two-week period and consisted of four half-hour individual sessions. Each child learned the self instructional procedures while performing a variety of perceptual motor tasks. The training program involved five steps. First the therapist performed the task while verbalizing aloud as the child observed. Then the child performed the same task as the therapist instructed aloud. Third the child performed the task while verbalizing instructions aloud themselves and then the child performed the task while whispering the instructions. Finally, the child performed the task while secretly verbalizing the instructions. This brief training program resulted in considerable improvement in the children’s performance on various tasks. These improvements also were maintained at a four week follow-up assessment.
Feindler et al. (1986) discussed another treatment program that was designed for adolescent males who were diagnosed with conduct disorder. Approximately 20 adolescents who were hospitalized in an inpatient psychiatric unit were randomly assigned to an anger control training group or a waiting list control group. Children in the anger control training group received 12 sessions over an 8-week period. This intervention consisted of teaching the adolescent to identify situational events that trigger anger, relaxation training, self-monitoring of daily anger arousal, self-instruction training, training of assertion responses, and anticipation of the consequences of their action. Following treatment, children in the anger control training group compared to the waiting list control group were found to be less cognitively impulsive, had higher staff ratings of self-control, increased their rates of appropriate requests and decreased their rates of inappropriate and hostile remarks and negative physical contact. They also significantly decreased their rates of rule violations on the inpatient unit (Johnson et al., 1997). Therefore, this type of cognitive, self-instructional training can be effective with children who experience various problems in many settings.
According to Kazdin (1989), there has been more research evaluating the effectiveness of behavior therapy procedures than is available for any other approach to the treatment of behavior disorders in children. Considerable research evidence is available supporting the efficacy of cognitive behavioral intervention techniques with a diverse range of populations and problems (Kendall, 1993; Werry & Wollersheim, 1989). Behavior therapy techniques have been effective in the home, school, institutional and community settings. Parents, teachers, and other paraprofessionals have also been trained to use numerous behavioral techniques with children directly in the setting where the behavior problems occur. Behavioral treatment programs have resulted in rapid and dramatic changes in problem behaviors that have been resistant to other treatment approaches. Problem areas in children that have been treated successfully with behavior therapy procedures are academic and school difficulties, hyperactivity and attention disorders, conduct disorders and juvenile delinquency, social skills deficits, fears, and phobic disorders. It has also been effective with many problems exhibited by children who are autistic and retarded (Johnson et al., 1997). Due to the fact there is a significant amount of research and support for this type of treatment of behavioral disorders in children, it is crucial that therapists and researchers examine other approaches with limited research that could also be effective in treatment.
Parents, teachers, and significant others play a significant role in treatment by serving as a primary change agent in many treatment programs. These parents and teachers can be trained to modify successfully many behavior problems in the natural environment of the child. In many cases it was demonstrated that social contingencies maintained the undesirable behaviors and the success of the intervention procedures were highly dependent upon the direct participation of significant members of the child’s environment in the treatment program. These changes also appear to be maintained for at least several years following the training programs (Gordon & Davidson, 1981; Wells, 1994). Therefore, training significant members of the child’s environment to serve as “co-therapists” with the cognitive behavior therapist in a “consultant-mediator” model of treatment has important implications for the maintenance of behavior change following treatment termination, as well as the potential for preventing the development of further behavior problems (Johnson et al., 1997).
It is important to make a distinction between uncontrolled case studies without systematic assessment and well-controlled, single-subject experimental designs. The latter experimental procedures enable the investigator to evaluate whether a change in the child’s behavior can be attributed to the treatment program rather than to some other events that might have occurred in time with treatment (Kazdin, 1992). However, many behavior problems are not readily agreeable to group research designs needed to assess more clearly the comparative effects of various treatment approaches. For example, several disorders are highly disruptive or present serious life threatening conditions for the child. As a result, many of these disorders require immediate and complete intervention, often at he expense of an adequate experimental design. There is also limited research in regards to long term studies of behavioral and cognitive behavioral treatment of behavior disorders in children. However, this type of research is needed to evaluate the extent to which treatment gains are maintained following termination of the formal treatment program. Individual approaches to behavior and cognitive therapy need to be compared to such interventions carried out within the context of parent training, family therapy, and group therapy. More research studies are also needed to address the cost effectiveness of various behavioral and cognitive behavioral therapies with children, including consideration of the resources needed such as finances and time, relative to the outcome of treatment (Johnson et al., 1997).
Dykeman (2000) examined the effectiveness of a school-based cognitive-behavioral program in treating components of anger expression in a small sample of 14- to 16-year-old adolescents with conduct disorder. Results indicated significant differences on measures of anger, expression, anger control and state of anger. The incidence of school violence and aggression continues to be a concern to educators, parents, community members, researchers, and legislators. Dykeman’s study examined the effectiveness of a cognitive behavioral intervention program in reducing expressions of anger and increasing strategies of anger control. The sample consisted of 8 male students, ages 14 to 16, previously diagnosed with conduct disorder by a mental health professional. The counselor’s role shifted from onset to conclusion of 24 sessions. In the beginning state, the counselor empowered students to develop a sense of power, efficacy and control over the therapeutic process. In the middle stage, the therapist mediated the student’s ability to engage in reciprocal problem-solving by encouraging each pair to recognize and identify a problem, consider possible options and outcomes, choose a problem-solving strategy, and plan on how to evaluate outcome. Results from this study demonstrate that students showing inappropriate expressions of anger can benefit from a cognitive behavioral intervention program. Data demonstrates in this study that an eight- week intervention program may be more successful in treating the situational aspects of anger expression than treating the underlying dispositions of anger expression. Additional research on this topic would benefit from the use of comparison groups to better establish treatment conditions contributing to the treatment’s internal validity. Subsequent research holds much promise for identifying the cognitive, behavioral, and psychodynamic factors of treatment that best modify the thoughts, feelings, and behaviors of students predisposed to acts of violence.
Medications and Behavioral Problems
There are various ways to treat ADHD and behavioral problems. The pharmacological agents most often used for ADHD are stimulants. Other medications used to the treat the disorder are tricyclic antidepressants, anitpsychotics, clonidine, serotonin-specific reuptake inhibitors (SSRI’s), and Welbutrin. The Food and Drug Administration approves the use of dextroamphetamine in children three years old and older and methylphenidate in those six years old and older. These are the two most commonly used drugs. Methylphenidate has been shown to be highly effective in up to three quarters of all children with ADHD and have relatively few side effects. Most common side effects are headaches, stomach aches, nausea, and insomnia. Some children may become mildly irritable and appear to be slightly hyperactive for a brief period when the medication wears off. Overall, stimulants remain the first drug of choice in the pharmacological treatment of ADHD (Kaplan & Sadock, 1998).
Kaplan and Sadock (1998) state that medication alone often is not enough to satisfy the comprehensive therapeutic needs of children with ADHD. Individual psychotherapy, behavior modification, parental counseling, and the treatment of any coexisting learning disorder may be necessary when treating ADHD. Children should be given the opportunity to explore the meaning of the medication. This helps eliminate the misconception of “I’m crazy.” The therapist plays an important role in this educational process with the child and family, ultimately minimizing this misconception with the child and family. When children are assisted in structuring their environment, their anxiety diminishes. Therefore, parents and teachers should set up a predictable structure of reward and punishment. They should use a behavior therapy model and apply it to the physical, temporal, and interpersonal environment. Group therapy should focus on social skills as well as increasing self-esteem and a sense of success may be very useful for children with ADHD who have great difficulties functioning in group settings, especially in school.
According to Hechtman (2000), ADHD affects 6 to 10 percent of school-aged children. There is impairment of academic and social functioning, and a growing body of data suggests that it is associated with considerable morbidity and poorer outcomes later in life. A MTA Cooperative Group Study funded by the National Institute of Mental Health (1999) demonstrated that careful, standardized drug therapy is associated with superior symptom reduction for most children compared with psychosocial interventions alone. Greenhill, Swanson, and Vitiello (2001) also suggest that stimulant therapy, which includes treatment outside of school (three times daily methylphenidate), is superior to drug therapy restricted to school hours (two times daily methylphenidate). Stimulants are efficacious and safe. There are other classes of therapy that are of considerable interest because some patients fail to respond to stimulants or are intolerant to them and there is controversy over the fact that stimulants are controlled substances. Compounds such as desipramine and bupropion affect noradrenergic and/or dopaminergic pathways and are efficacious in the treatment of ADHD. Wilens, Biederman, Abrantes and Spencer (1996) report that Atomoxetine is a potent inhibitor of the pre-synaptic norepinephrine transporter with minimal affinity for other noradrenergic receptors or for other neurotransmitter transporters or receptors. It is metabolized through the cytochrome P450 2D6 pathway and has plasma half-life of approximately 4 hours in cytochrome extensive metabolizers and 19 hours in poor metabolizers. Atomoxetine’s profile seems to differ from that of stimulants and it is being studied as a treatment for ADHD (Laws, Heil, Bickel, Higgins, & Faries, 2001). According to Heiligenstein, Spencer, and Faries, et al. (2000), several reports have provided evidence that atomoxetine is superior to placebo in reducing symptoms of ADHD in children and adults. A study done by Michelson, Faries, Wernicke, Kelsey, Kendrick, Sallee, Spencer, and the Atomoxetine ADHD Study Group (2001) hypothesized that atomoxetine would be superior to placebo for the treatment of ADHD and reported results of a fixed dose study comparing three different doses of atomoxetine with placebo.
This study was conducted at 13 outpatient investigative sites in the United States. Children and adolescents ages 8 to 18 were eligible to participate if they met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) criteria for ADHD confirmed by a clinical assessment and structured interview. Children were assessed for concurrent depression and anxiety as well. Important exclusion criteria included an IQ below 80, serious medical illness, history of seizure disorder, history of bipolar disorder, or ongoing use of psychoactive medications other than a study drug. Of the 381 patients screened, 297 met entry criteria and were randomized to treatment. At the end of the study, atomoxetine was superior to placebo on the primary outcome measure in both the 1.2 mg/kg/day and 1.8 mg/kg/day treatment groups. Outcomes were similar for the inattentive and hyperactive/impulsvie subscales and with other measures of outcomes. Atomoxetine was well tolerated at all doses (Michelson et al., 2001).
Several non-stimulants have shown to be efficacious in the treatment of ADHD, but dose- response, safety in children, and other questions have not been studied for these agents. Atomoxetine has been reported to be efficacious in children with ADHD. The study done by Michelson et al. (2001) provides additional significant evidence that atomoxetine is efficacious for use in the treatment of ADHD and extends the findings of previous reports by providing evidence of dose-response and optimal does, by including adolescents, and providing additional information about tolerability and safety. Several factors limit interpretation of the data. It is not possible to determine the time of onset of the initial response, because at the two higher and most efficacious doses, the target dose was not reached until the third (1.2 mg/kg/day group) or fourth week (1.8 mg/kg/day group) of the study. The researchers are also not able to compare the degree of symptom reduction associated with atomoxetine with that of stimulants, because no active comparator was included in the study. These data provide evidence of acute efficacy, but not about the value of longer-term therapy once patients have achieved a satisfactory initial response (Michelson et al., 2001). This supports the idea that medication alone is not the best treatment regime and that various therapeutic approaches should be explored and implemented in combination with medication as a part of the treatment process.
Teacher assessment was not a part of Michelson’s (et al., 2001) study and no direct conclusions about effects on classroom behavior can be concluded from this data. The population studied in this research had very few comorbid conditions other than Oppositional Defiant Disorder compared with previous studies. There was consistent evidence of dose effect, as well as statistically significant differences between each atomoxetine group and placebo. The 1.8 mg/kg/day did not appear to be associated with any overall gain in efficacy beyond the observed with 1.2 mg/kg/day, but there was also no decline and the higher dose was well tolerated. Atomoxetine is not a psychostimulant, and instead of directly releasing norepinephrine form neurons, it seems to induce a regulatory change in cellular homeostasis through blocking of the norepinephrine transporter. This effect depends on a consistent drug presence at the transporter and is based on the fact that the plasma half-life of atomoxetine should be achieved during the waking hours with twice daily dosing in most individuals. The main objective of this study was to define the dose-response and optimal dose for atomoxetine in the context of overall symptom reduction in all places of functioning (i.e. home, school, community). The researchers in this study believe that academic performance is a central aspect of the children’s lives and is crucially affected by ADHD, and that future studies that directly assess atomoxetine’s effects on school performance are in development. The data in this study provide additional evidence of the efficacy and safety of atomoxetine in older children and adolescents with ADHD and that successful treatment with atomoxetine is associated with both symptomatic and functional improvement (Michelson et al., 2001).
According to Bierderman and Spencer (1999), the pathophysiology appears to involve alterations in dopaminergic and noradrenergic pathways associated with control of attention and impulsivity. Symptoms of ADHD have responded favorably to many pharmacological interventions, especially those that affect dopaminergic and noradrenergic neurotransmission. Stimulants such as methylphenidate are currently the most widely used medications for ADHD (Popper, 2000). However, some patients fail to respond to stimulants or are unable to tolerate them. Some parents and physicians choose not to use stimulants because of the fact that they are controlled substances. Therefore, there has been considerable interest in developing new treatments for ADHD. Research suggests that several nonstimulants are efficacious in this disorder, including desipramine and bupropion (Biederman, Baldessarini, Wright, Knee, &Harmatz, 1989). These drugs have not been studied as much as methylphenidate and similar stimulants. Therefore, issues in regards to the magnitude of symptom reduction, durability of response over time, and tolerability compared with stimulants are poorly characterized.
A study conducted by Kratochvil et al. (2002), provides information about a variety of methodological and study design issues. The study incorporated an acute, open label comparison of atomoxetine (non-stimulant) and methylphenidate (stimulant). This study was conducted at 23 sites throughout the United States. Males aged 7 to 15 and females from ages 7 to 9 who met criteria for the diagnosis of ADHD participated in this study. Patients were randomized to open-label treatment with either atomoxetine or methylphenidate for 10 weeks. A total of 228 patients participated. The majority of the children in both groups met criteria for the combined ADHD subtype. The most common concurrent DSM-IV-TR (2004) diagnosis was Oppositional Defiant Disorder. The other common concurrent diagnoses were Major Depressive Disorder. Both atomoxetine and methylphenidate were well tolerated with no significant differences in discontinuations, due to adverse events. Inattentive and hyperactive-impulsive symptoms responded to treatment with atomoxetine and methylphenidate. Parent reports were also consistent with investigator assessments of the efficacy. Three studies of efficacy of atomoxetine in children have been previously reported, identical randomized double-blind placebo controlled studies and one randomized placebo-controlled, dose-response study (Kratochvil et al., 2002).
There has been some uncertainty as to whether non-stimulant therapies such as desipramine, which was previously shown to be efficacious with ADHD, reduces symptoms to a degree comparable to stimulants. The results in this study are supported by two double-blind studies with regard to the degree of symptom reduction found for both compounds. In these placebo controlled studies, nonspecific responses to treatment among children with ADHD tend to be low. Therefore, it seems likely that the observed outcomes in this study reflect an accurate estimate of the efficacy of these two treatments and provide preliminary evidence that atomoxetine’s efficacy is comparable to that of methylphenidate. Another important aspect of this study is the use of an investigator-administered, structure interview of the parent, in addition to direct parent reports. The investigator-administered instrument ensures that all patients are rated consistently by an experienced clinician who can rate symptom severity in a clinical context and integrate reports from several sources. Insomnia was more frequently reported among patients randomized to methylphenidate than those in the atomoxetine group. Both atomoxetine and methylphenidate were well tolerated. However the results of this study did not indicate significant differences in the efficacy between the two drugs. The results of this study are consistent with previous studies where there is evidence that atomoxetine is efficacious in reducing ADHD symptoms in children. A limitation in this study may be that investigator and patient expectations influenced outcome. Fewer patients were assigned to methylphenidate than to atomoxetine which diminished the ability to compare the treatments. The failure to obtain teacher ratings limited the ability to directly assess effects on school behavior. Behavioral outcomes in the home or other settings were obtained through parental reports on school functioning provided indirect evidence (Kratochvil et al., 2002).
According to Michelson, et al., (2002), ADHD affects three to seven percent of the school age children in the United States and that several pharmacological interventions, including stimulants as well as desipramine and bupropion, have shown to be effective. Only stimulants have been approved by the Food and Drug Administration and other regulatory agencies for the use in the treatment of ADHD. There has been a strong interest in developing new non-stimulant pharmacologic treatments that would not be controlled substances and broaden the therapeutic options available to physicians and patients. Atomoxetine does not accumulate in the great majority of individuals when administered twice daily, which was the regimen used in previous studies. Despite this, atomoxetine has been superior to placebo in each of three acute placebo-controlled studies conducted in children and adolescents. This study indicates that factors other than time on receptor could be important determinants of response or that pharmacokinetics in the central nervous system differ from those in the plasma. In this study, it is hypothesized that administering the total daily does at a singe time point could provide satisfactory efficacy for many patients. This study was conducted at nine outpatient sites throughout the United States.
Children and adolescents from ages 6 to 16 who met criteria for ADHD participated in this study. Co-morbid symptoms were assessed as well. Once again, those with a history of medical illness, bipolar disorder, alcohol or drug abuse within the past three months, and ongoing use of psychoactive medications other than the study drug were excluded from this study. They were all on a minimum five-day, medication-free evaluation period and received either placebo or atomoxetine for six weeks. They were then seen weekly for two visits and biweekly thereafter. Atomoxetine was administered as a singe daily dose in the morning. One hundred seventy one patients were randomly assigned to a treatment group. Fifty-six and half percent of the patients in the atomoxetine group and fifty-four percent of patients in the placebo controlled group reported having being previously treated with stimulants. One hundred sixty-eight were confirmed to have received at least one dose of atomoxetine. Response was superior in the atomoxetine group (59.5%) as compared with the placebo group (31.3%). Remission was also superior in the atomoxetine group (28.6%) as compared with the placebo group (9.9%). Both attentiveness and hyperactivity/impulsivity symptom clusters responded to atomoxetine. Outcomes were similar in patients who were previously treated with stimulants. Comparison of changes in individual items of the parent-rated daily diary did not demonstrate any differences between atomoxetine and placebo on early morning behavior, but did suggest drug-specific effects on two of the evening items (inattentive symptoms and difficulties settling in at bedtime). Adverse events frequently reported by the children receiving atomoxetine were primarily gastrointestinal with increases in fatigue as well. There were other reports of nausea and vomiting, but most of these episodes were limited, usually one to two days.
Michelson et al., (2002) has previously shown in studies that atomoxetine administered twice daily is an effective treatment for ADHD in children and adults. The results of this study are consistent with those findings and extend them by providing evidence of the efficacy and safety of once-daily dosing with atomoxetine, with drug-specific effects persisting late into the day. This is also the first study to provide evidence of the efficacy of atomoxetine based on teacher observations. One of the most profound results of this study is that once-daily dosing in the morning was associated with effects that persisted into the evening. This was assessed with a daily diary administered at initial interval and during the final visit interval. Items measuring in inattention during late afternoon and early evening and settling at bedtime showed greater improvement for atomoxetine than for placebo. This study proved that safety and tolerability were good. The results of this study confirm and extend the results of previous studies. Patients often prefer once-daily dosing to more frequent regimens because of the convenience and data presented in this study suggest that for patients with ADHD, treatment with once-daily atomoxetine will be a viable option.
The ADHD diagnosis has been shown to correspond largely to Conduct Disorder (Pendergrast, et al., 1988). Research shows that stimulants are not considered appropriate for the treatment of children with conduct disorders. The differences in stimulant effect between children with ADHD and Conduct Disorder led to the hypothesis that methylphenidate would not significantly improve symptoms of Conduct Disorder. This study hypothesized that children with Conduct Disorder and an absence of comorbid ADHD would fail to benefit from stimulant treatment which is a view shared by others (Klein, Gittelman, Quitkin, and Rifkin, 1980). It was difficult to study children with Conduct Disorder only because most of the children referred in this study were dually diagnosed with ADHD and Conduct Disorder. Therefore, the trial was modified to address whether symptoms of Conduct Disorder specially respond favorably to methylphenidate. Another goal was to examine whether drug-induced improvement was dependent on ADHD severity. This was a study that took place over a three year period. The results of this study indicated that children taking methylphenidate were rated significantly better by teachers on all Conduct Disorder measures with the exception of socialized aggression. This measure reflects severe delinquent behavior, such as gang membership. Methylphenidate did have a positive significant impact on teacher ratings of ADHD symptoms as hypothesized. Specific aspects of Conduct Disorder were significantly affected by methylphenidate (i.e. obscene language, attacks others, destroys property, and deliberately cruel). Self-ratings of negative mood were significantly low before treatment. Methylphenidate significantly improved 8 to 28 mood items. None became worse (Klein, Abikoff, Klass, Ganeles, Seese, & Pollack, 1997).
The results of this study indicate a significant reduction of a range of antisocial behavior with methylphenidate. These reductions were substantial and clinically significant. Treatment effects occurred on specific symptoms of Conduct Disorder, even those such as stealing and cheating. Teachers indicated significant changes in those children who received methylphenidate and little change for those taking placebo. The advantage of methylphenidate over placebo is similar for teachers and mothers, but mothers held a more favorable view of their children’s progress regardless of the treatment. It is also possible that counseling had credibility and may have influenced mothers’ perceptions of change. Since teachers observe children in a standardized functional setting, their reports of improvement with placebo are likely more valid. Adverse effects with methylphenidate were typical of those reported in ADHD. The most common adverse effects reported were decreased appetite and delay of sleep. Forty seven percent of those taking placebo reported at least one adverse event by the end of treatment (Klein et al., 1997).
There is no obvious behavioral model to account for methylphenidate efficacy on symptoms of Conduct Disorder. Impulsivity appears to be a key pathologic abnormality in both ADHD and Conduct Disorder and is specifically reduced by stimulant treatment. In children with Conduct Disorder, enhanced impulse control is likely to induce multiple positive secondary effects. Children who took methylphenidate were described by parents as more reasonable. This change may lead to improvement in some maladaptive social behaviors. The amount of evidence supports a close relationship between hyperactivity and Conduct Disorder. This relationship has important public health implications, since children who are comorbid for ADHD and Conduct Disorder are at high risk for sustained antisocial behavior compared with those with Conduct Disorder only (Farrington, Loeber, and Kammen, (1990). Successful treatment in this clinical population would represent an important advance in psychiatry (Klein et al., 1997).
A pilot study was conducted that studied methylphenidate, clonidine, or the combination of these medications in ADHD comorbid with aggressive, Oppositional Defiant, or Conduct Disorder. Children ages 6 to 16 diagnosed with ADHD and comorbid aggressive Oppositional Defiant, or Conduct Disorder were studied. The study was a three-month randomized group comparison with eight subjects per group. There was no placebo group. Stimulants are the primary pharmacologic intervention for ADHD as mentioned earlier in the review of literature related to pharmacologic interventions (Barkley, 1998). According to Barkley, 20 to 30% of ADHD children treated with stimulants do not respond, either because of medication non-efficacy, or unacceptable side effects. Therefore, there is a need to explore other treatment options for ADHD. An alternative to methylphenidate is clonidine. Clonidine acts in the central nervous system to down-regulate overall norepinephrine tone (Hunt, Capper, O’Connell, 1990). It is currently FDA approved for the management of hypertension. Clonidine has been studied “off-label” in children with ADHD and with those who are co-morbid with aggressive Conduct Disorder (Hunt, Mandl, Lav, & Hughes, 1991). Trials have shown that clonidine is effective in ADHD when studied alone and in comparison studies to placebo (Gunning, 1992).
According to Swanson, Flockhart, and Udrea, (1995), there has been great concern for the use of methylphenidate in conjunction with clonidine for the management of aggressive ADHD children and adolescents which centers on the cardiovascular and EKG effects of clonidine alone and in combination with methylphenidate questions whether this drug should be used in children (Swanson et al., 1995). The study by Connor, Barkley and Davis (2000) compares the response of those children diagnosed with ADHD and Conduct Disorder to the administering of clonidine alone, methylphenidate alone, and the combination of both medications given together to treat symptoms. Eleven of the twenty-four children in this study had a history of receiving methylphenidate as a pharmacological treatment. All participants were free of medication at baseline assessment. EKG’s were obtained for the clonidine only group at baseline and at the end of the first month with a drug titration period. These EKG’s were read by pediatric cardiologists. Outcome measures for this study included parent ratings, teacher ratings, child neuropsychological labs, and child physiological data. The results demonstrated continued improvement throughout a three month period which is longer than most acute-phase medication outcome studies for this disorder.
The three treatment groups showed significant improvements with time and treatment compared to their baseline scores which measured ADHD Oppositional Defiant Disorder, and Conduct Disorder symptom severity. Significant differences were found in all three treatment groups over time for teacher assessed number of problem settings in the school and the reports made by teachers for the impulse control measurement with results favoring those receiving methylphenidate alone or methylphenidate in combination with clonidine. Teachers reported that with methylphenidate there were stronger effects on attention span and impulse control alone and also in combination with clonidine. Clonidine therapy alone did not indicate this. The results of this study suggest that clonidine may improve cognitive aspects of attention and impulsivity in ADHD children. It is important to note that previous studies have suggested that conduct Disorder and impulsive aggression in the absence of ADHD may respond to clonidine (Kemph, DeVane, & Levin, 1993). The results of Connor, Barkley, and Davis (2000) study support previous studies that suggest that these disruptive behavior disorders may be medication responsive to methylphenidate, clonidine, or the combination of both, especially when they occur in the context of ADHD. It is also indicated that these drug therapies are safe and effective for ADHD in daily divided clonidine doses of 0 to 0.3 mg and methylphenidate doses up to 40 mg a day. Clinicians should be aware of the possibility of fine motor side effects with clonidine monotherapy, which could interfere with handwriting or other tasks requiring fine motor coordination and speed. Children who have cardiac conditions increasing risk for bradycardic arrhythmias, first degree A-A block, or a history of syncope should not be given clonidine.
According to previous research, controlled data on the treatment of aggression in youth with medication is scarce (Volavka & Citrome, 1999). Psychosocial interventions may be effective alone or in combination with pharmacological treatments. Psychotropic drugs such as stimulants, mood stabilizers, and beta blockers have also been shown to have limited efficacy in reducing aggression. Antipsychotics show substantial efficacy in the treatment of aggression in selected pediatric populations (Schur, et al., 2003). Pine and Cohen (1999) report that past reviews have focused on the pharmacological treatment of aggression and the current review concentrates on the use of atypical antipsychotics, which are commonly used in inpatient and day treatment settings to treat aggression and which have received greater attention with researchers in recent years. According to Schur et al. (2003), aytpical antipsychotics are commonly used in combination with other psychotropic drugs. Connor et al. (2002) states that aggression is a frequent cause of hospitalization for youth and is commonly associated with Conduct Disorder, Oppositional Defiant Disorder, and ADHD.
Psychosocial and environmental interventions are typically used to treat aggression in settings such as an inpatient facility, but also are used to treat those with less severe aggression (Irwin, Kline, & Gordon, 1991). Malone and Simpson (1998) report data from clinical trials which reveal that approximately 50% percent of youth show a significant reduction in symptoms shortly after being hospitalized. This is evident even without active medication treatment. In a double blind, placebo controlled study by Sanchez, Armenteros, Small, Campbell, & Adams, (1994), researchers discovered that this effect may be magnified among children from stressed home environments. According to Irwin et al. (1991), when psychotropic medications are prescribed, they are most effective when administered as a part of a comprehensive psychotherapeutic and educational program or within a therapeutic regime. Foxx (1998) reports that many specific psychosocial interventions have shown to be effective in reducing aggression. For example, contingency management programs (i.e. token economies for acceptable behavior) have had positive effects on behavior in a variety of settings. Systematic training for social skills, problem solving, and anger management and behavioral therapy enhance the patient’s ability to interact appropriately with peers and others (Kazdin, 1998). Interventions that teach parenting skills also help change the behavior of children with aggression.
A study done by Campbell, Small, and Green (1984), shows that in a double blind, placebo controlled study comparing lithium and haloperidol in children with Conduct Disorder (aggressive type) patients on haloperidol were less hyperactive, aggressive, and hostile than on placebo. Safety concerns about the use of typical antipsychotic in children come from associations between these medication and tardive dyskensias in long-term treatment (Campbell et al. (1997). Atypical antipsychotics include risperidone, clozapine, olanzapine, quetiapine, and ziprasidone. There is evidence regarding the pharmacological mechanisms of action through which the atypical antipsychotics may inhibit aggression. Some researchers prose that their anti-aggressive action comes from the atypical antipsychotics’ effects on the serotonin and/or dopamine neurotransmitter systems (Citrome & Volavka, 1997). Further research is needed to explain the mechanisms of action for atypical antipsychotics’ effect on aggression. Controlled research regarding the use of the typical antipsychotics to reduce aggression in youth is not abundant and the side effects associated with these medications are of concern (Schur et al, 2003).
The majority of controlled research on atypical antipsychotics for the treatment of aggression in children comes from studies of risperidone (Schur et al, 2003). Risperidone is associated with weight gain and in adults this weight gain is significantly less than that associated with olanzapine or clozapine (Findling, McNamera, & Gracious, 2000). It is not clear whether these differences are as significant in the pediatric population. It is also evident from research in this study and others that beta blockers, the agonist clonidine, and stimulants may be efficacious in reducing aggression in youth (Schur et al., 2003).
In another study by Pappadopulos, et al. (2003), treatment recommendations for the use of antipsychotics for aggressive youth were examined once again. Data shows that antipsychotic prescribing rates for children and adolescents in a Midwestern Medicaid population increased 63% from 1990 to 1996, primarily because of a significant increase in the use of atypical antipsychotics (Malone Sheikh, & Zito, 1999). This increase in use should alert researchers and treating physicians that careful examination should be used when prescribing antipsychotics, due to the risk of drug-related side effects which can be serious and is greater with antipsychotics than most other psychotropic drugs used in children (Pappadopulos et al, 2003). According to Citrome and Volavka (1999), aggression is often defined as any type of behavior that has the potential and often is intended to damage an inanimate object or harm a living being. The research in the Pappadopulos et al. (2003) study focuses on the treatment of impulsive aggression specifically, instead of predatory aggression. This difference is based on research that indicates that a predatory aggression is diagnostically different from impulsive aggression and indicates a need for a different course of treatment.
The development of treatment guidelines for children and adolescents with psychiatric disorders is lacking as compared to adults with psychiatric disorders. The lack of clinical trials and outcome data for childhood and adolescent disorders may account for this overall lack of progress (Conners, March, & Frances, 2001). The research in the Pappadopulos et al. (2003) study explains that treatment recommendations were created on the basis of synthesis of expert consensus and evidence based research methodologies. The results of this research explain that psychiatrists should use their own clinical judgment in treating each patient. Clinicians must also consider each patient’s unique clinical situation before following any treatment recommendations. This study examines and recommends several treatment guidelines that psychiatrists should use when considering prescribing an antipsychotic. One recommendation is that an initial diagnostic evaluation should be conducted before using pharmacological treatment. The parent or guardian should be a part of this diagnostic interview before consideration is given to prescribing, changing, or discontinuing medication. It is also recommended that one should assess treatment effects and outcomes. This can be done through administering standardized symptom and behavior rating scales with proven reliability and validity. These instruments would measure the severity and frequency of target symptom before treatments are initiated, at regular intervals throughout treatment, during acute episodes, and when treatments are changed or discontinued.
It is important to begin with psychosocial and educational interventions and should be continued even if subsequently medications are initiated to manage aggression. Use of appropriate treatment for primary disorders as a first option of treatment should be considered because symptoms of aggression are common in many psychiatric conditions. Aggressive patients who also present with persistent and clinically significant symptoms of hyperactivity, anxiety, depression, or mania should receive at least one adequate trial of a first-line drug as a treatment for these primary disorders before considering an antipsychotic. If an adolescent with current aggression also has severe and persistent hyperactivity or a history of ADHD that can be verified, the physician should consider using a stimulant before using an antipsychotic. It is suggested that the physician also consider using an atypical antipsychotic first rather than a typical antipsychotic to treat aggression. For example, when psychosocial and first-line medication treatments for primary non-psychotic conditions have failed, physicians initially should use first-line atypical antipsychotics as opposed to typical antipsychotics to treat severe and persistent aggression. This is important because treatment history and risk assessments for severity and frequency of aggressive acts should help determine the need for antipsychotic medications. First-line atypical antipsychotics such as risperidone, olanzapine, quetiapine, and zipradidone, should be used initially because they have a safer acute side effect profile than the traditional antipsychotics. Therefore, there is a lower risk for tardive dyskensia, neuroleptic malignant syndrome, and cognitive impairment (Gilbert, 2000).
It is also recommended by Pappadopulos et al. (2003) that physicians use a “start low, go slow, taper slow” dosing strategy when using antipsychotic medications to treat aggression. The reason for this is that youth can be very fatigued and tired on atypical antipsychotic agents. Children and adolescents usually require lower doses than adults to achieve a therapeutic response (Campbell, Rapoport, & Simpson, 1999). An atypical antipsychotic should be tried for a minimum of two weeks at an appropriate dose before it is considered ineffective for treating aggression in children and adolescents (Findling, et al., 2000). They should be tapered slowly before discontinuing the medication and clinicians should monitor for signs of withdrawal dyskensia (Lore, 2000). Side effects should be assessed routinely and systematically. Pappadopulos et al. (2000) recommend that physicians should ensure an adequate trial before changing medications, due to lack of or partial response. They should have received psychosocial interventions as well.
According to Pappadopulos et al. (2000), if patients fail to respond to an adequate trial of an initial atypical antipsychotic, physicians should first reassess the diagnosis and adequacy of behavioral interventions and administer a different atypical antipsychotic when appropriate. If patients continue to be dangerous or assaultive while on their first atypical antipsychotic and their behavior is not due to inadequately treated ADHD, anxiety, depression, or mania, a monotherapy approach with a different atypical antipsychotic should be tried. Physicians also may consider adding a mood stabilizer after a partial response to an initial first-line antipsychotic. They should evaluate the duration and dose of the medication trial when there is a partial response. If a patient is not responding to multiple medications, it is recommended that the physician consider tapering one or more of the medications, after re-examining the diagnoses and adequacy of behavioral interventions. Finally, it is recommended that the physician taper and consider discontinuing antipsychotics in patients who show a remission in aggressive symptoms for six months or longer. If the patient is able to tolerate the tapering of the dose, the antipsychotic medication should be discontinued. The presence of an underlying psychotic disorder or a history of recurrent relapse or treatment resistant symptoms typically precludes discontinuing antipsychotics. Due to these factors, therapist play an important role in monitoring progress with and without medications such as these while examining the other techniques in that are being used in therapy.
Other Behavioral Disorders and Treatment

According to Maughan, Rowe, and Messer (2004), co-morbidity of Conduct Disorder and Oppositional Defiant Disorder can impact treatment choice. Children with Oppositional Defiant Disorder typically exhibit a pattern of hostile and defiant behavior and are argumentative and resentful toward adult authority figures. Conduct Disorder symptoms usually include aggressive acts and non-aggressive acts (Maughan, et al., 2004). The DSM- IV-TR (2004) defines Oppositional Defiant Disorder as a pattern of negativistic, hostile, and defiant behavior lasting at least six months, during which four or more symptoms of the following are present: often loses temper, often argues with adults, often actively defies or refuses to comply with adults’ requests or rules, often deliberately annoys people, often blames others for his or her mistakes or misbehavior, often touchy or easily annoyed by others, often angry and resentful, often spiteful or vindictive. This disturbance must meet the criteria of causing clinically significant impairment in social, occupational, and/or academic functioning. Conduct Disorder as defined in the DSM-IV-TR states that it involves a pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past twelve months, with at least one criterion present in the past six months: aggression to people and animals which includes things such as bullying threatening or intimidating others, physically cruel to others or animals, and stealing while confronting a victim; destruction of property which can include deliberate fire setting; deceitfulness or theft which includes breaking into another’s home, lying to obtain goods or avoid obligations, or shoplifting; and serious violation of rules which is serious violation of curfew and running away. This disturbance must cause clinically significant impairment in social, academic or occupational functioning in order to meet criteria for Conduct Disorder (DSM-IV-TR, 2000).
According to Maughan, et al. (2004), an aggressive act would be destroying property and fighting. Non-aggressive acts include things such as lying or stealing. Status violations in Conduct Disorder are behaviors such as truancy or running away from home. Maughan’s et al. (2004) research shows that Disruptive Behavioral Disorders are comorbid with Attention Deficit Hyperactivity Disorder (ADHD) and found that Conduct disorder was significantly more common in boys (2.1%) than in girls (0.8%). There was a significant comorbidity with Conduct Disorder and Oppositional Defiant Disorder in the Maughan et al. study. Maughan et al. report that Conduct disorder appears to be more prevalent in boys than in girls and changes in presentation of symptoms with increasing age. Some research suggests that Oppositional Defiant Disorder might be a developing precipitating disorder to Conduct Disorder. It is important for researchers to consider this when examining the most effective ways to treat those with co-morbid disorders. This also indicates a need for expanded research in techniques that can be used with any of these disorders.
Maughan et al. (2004) conducted a study that focused on age trends, gender ratios, and patterns of co-morbidity. There was a large sample size for this study and a broad age range of methods and analysis which allowed researchers to study trends of individual symptoms for both disorders as well as specific trends related to Oppositional Defiant Disorder (ODD). The children were assessed using the Development and Well-Being Assessment (DAWBA). This consisted of a parental interview, child interview for children ages 11 and older, and a teacher questionnaire. A DSM-IV criterion for each disorder was used to explore trends in individual symptoms. Five symptom scales were developed were the total Oppositional Defiant Disorder symptoms (ODD), total Conduct Disorder Symptoms (CD), Aggressive CD symptoms, status violations, and other non-aggressive CD symptoms. Aggressive CD symptoms included bullying, fighting, weapon use, and cruelty to people and animals. Status violations were truancy, running away from home, and staying out late. Other non-aggressive CD symptoms included fire setting, vandalism, breaking and entering, lying, and stealing. This study found that Conduct Disorder was significantly more common in boys than in girls. There was also a steady increase in rates of Conduct Disorder in boys as they got older. Rate of Conduct Disorder were low in girls until age 12, where they began to increase similarly to the pattern observed in boys.
Trends in Conduct Disorder symptom profiles across several age groups showed that older boys ages 13 to 15, there was a significant rise in status violations and non-aggressive conduct problems and a significant decline in fighting. Rate of non-aggressive behaviors were significantly lower in the 13- to 15-year age group of girls as compared to boys. There were no observed gender differences in levels of status violations. However, rates of aggressive behavior, such as fighting, were reported equally for both girls and boys in the 13- to 15-year-old age group. Oppositional Defiant Disorder was diagnosed in significantly more boys (3.2%) than girls (1.4%). This difference appeared to come from data collected from teacher reports and no significant difference was reported in data from parent reports. The rates of Oppositional Defiant Disorder remained constant until age ten in both boys and girls which is when it started to decline. Levels of Oppositional Defiant Disorder appeared to persist beyond childhood into adolescence, showing a trend to be more severe in the older age groups. There was diagnostic overlap of Conduct Disorder and Oppositional Defiant Disorder in this study. Fifty-six percent of girls and 62% percent of boys with Conduct Disorder also met the Oppositional Defiant Disorder criteria. Children with this type of co-morbidity seem to have more severe patterns of presenting symptoms (Maughan et al., 2004).
Co-morbidity of other disorders was examined as well. Thirty-six percent of girls and 46% of boys diagnosed with Oppositional Defiant Disorder met criteria for at least one other disorder. Thirty-nine percent of girls and 46% of boys diagnosed with Conduct Disorder also met criteria for at least one other disorder. These findings suggest that oppositional symptoms or features often relate more closely to impulsive, hyperactive behaviors than delinquent behaviors. Children diagnosed with Oppositional Defiant Disorder alone were significantly more likely to have comorbid anxiety disorders compared to those with Conduct Disorder alone. It is challenging to choose the best treatment option due to the complex interactions of these disorders and their high co-morbidity with other disorders, especially ADHD. Kutcher’s et al. (2004) international consensus statement concerning Disruptive Behavior Disorders and ADHD, the optimal approach to treating these children is to target these symptoms with a combination of psychosocial intervention and pharmacotherapy, when indicated. It is also recommended that these children be treated by a specialist familiar with these disorders as well (Maughan et al., 2004).
Initial treatment options suggested in the consensus statement for a child with a Disruptive Behavior Disorder involve psychosocial interventions, such as parent training, classroom intervention, family therapy, social skills therapy and cognitive behavior therapy. An accurate diagnosis is critical before treatment with a pharmacological approach. Depending upon the presence or absence of comorbid disorders, the treatment options may differ substantially, especially with ADHD. For children diagnosed with Conduct Disorder only, the atypical antipsychotic risperidone (Risperdal) could be considered to treat aggression if symptoms were not reduced by previous interventions. However, there are no large controlled trials for use of this drug with children and adolescents of normal or average intelligence. Pharmacological treatment with Oppositional Defiant Disorder should not be considered except in cases where aggression is a significant problem. This study explains that caution should be used when considering psycho-stimulants in children with a primary diagnosis of Conduct Disorder due to the high risk of abuse in this population. However, in children with Conduct Disorder and ADHD, psycho-stimulant medication can be used to treat the core symptoms of ADHD (Maughan et al., 2004).
A supplemental review exploring the use of antipsychotics in the treatment of children and adolescents discussed the evidence for risperidone for disruptive behaviors. The finding reviewed came from several placebo-controlled trials of risperidone treatment of young patients with low IQs and behavioral problems. The conclusion was that in this population, risperidone has been used effectively. A meta-analysis of the effects of stimulants on aggression in children and adolescents with ADHD demonstrated that stimulants reduce aggression independent of their effects on ADHD symptoms. Two studies have shown lithium to be effective in hospitalized aggressive children with Conduct Disorder. There is also a report that lithium was superior to placebo in a double blind study of hospitalized aggressive children and adolescents with Conduct Disorder. These behavioral disturbances need to be accurately identified and diagnosed in order for children to receive effective treatment. Determining whether Oppositional Defiant Disorder is a factor in older children could impact the course of treatment and the development of services for children. Current evidence based treatments for Oppositional Defiant Disorder, such as parent training, are primarily designed for younger children. Other strategies need to be explored that can be equally effective in treating Oppositional Defiant Disorder with the older children.
Douglas (1988) states that ADHD is mediated by cognitive deficiencies and distortions, causing failures in the “Stop and Think” response, which may have important implications for the treatment of child and adolescents with ADHD. This problem that ADHD children have seems to originate from a deficiency in the activation of planned and systematic thinking, and not from active, but distorted thinking. In children showing aggressive behavior, there is an existence of both cognitive deficiencies and cognitive distortions (Kendall, Reber, McLear, Epps, and Ronan (1990). Therefore, the aggressive person’s limited capacity for alternative thinking and for finding adequate solutions to interpersonal problems demonstrates these deficiencies. The dysfunctions attributed to the behavioral intentions of others in these interpersonal situations show a tendency toward a distorted thought process (Miranda, 2000).
Miranda (2000) explains that in regards to ADHD being a cognitive deficiency, researchers such as, Kendall, Padever, and Zupan (1980) developed a cognitive behavioral training program in self-control that pairs the concepts of the deficiencies of hyperactive and impulsive children. Techniques included in this program were problem solving training, self-instruction, modeling, exercise in role-playing, and contingency management. Contingency management refers to self-reinforcement, social reinforcement, token systems, response cost, and reinforcement for carrying out household tasks. The results of this research of subjects with ADHD explain that the combination of cognitive and behavioral procedures considered in the program demonstrated a reduction in hyperactive problems (Kendall et al., 1990). There are a high percentage of persons with ADHD that experience a variety of additional problems that are as important as the fundamental symptoms of the disorder itself. Many children referred for problems with attentiveness also have a combination of aggression and hyperactivity. Between 30% percent and 50% percent of hyperactive children suffer from associated behavioral disorders (Biederman, Newcorn & Sprich, 1991).
Research shows that those children with ADHD and conduct disorder have an especially severe form of ADHD. Hyperactive-aggressive children are significantly problematic both at home (Gomez & Sanson, 1994) and school (Dyckman & Ackerman, 1993) and peer relationships are significantly affected (Miranda, Patenaude, & Lopez, 1995). They also experience a more significant amount of problems in adolescence and have a higher risk of criminal behavior and alcohol abuse (Klintenberg, 1997). The response of this group to medical and psychological treatment is low (Matier, Halperin, Sharma, Newcorn et al. 1992). Cognitive behavioral self-control therapy (Kendall et al., 1980), including self-instructional training via modeling, problem-solving, and behavioral contingencies, allows for modification of self-regulatory deficiencies in ADHD children, but they do not directly treat the problem of ADHD in children who also have a significant amount of aggression (Hugues, 1988). Thirty-two ADHD children participated in the Miranda’s (2000) study. The researchers applied one of the most complete self-control programs within the cognitive model and the “Stop and Think” program to 16 of the 32 children with ADHD. The other 16 were instructed with the same program and anger control training. Four groups were examined in this program one of each of the following conditions: hyperactive with treatment, hyperactive with the combined treatment, hyperactive-aggressive with treatment, hyperactive hyperactive-aggressive with combined treatment (Miranda, 2000).
The “Stop and Think” intervention program (Kendall et al., 1980) was used with some modifications in this process. This self-control therapy included cognitive and behavioral techniques, such as, self-instruction, modeling, and behavioral contingencies that were applied to solve various types of problems. The purpose was to improve concentration and reflection. The children were trained to use these techniques through problem-solving, considering possible courses of action, and to explore other options. The problem solving process was broken into five stages: problem definition (“What do I have to do?”), problem approach (“I have to think of all possibilities”), focusing attention on problem at hand, selecting an answer having considered all possibilities, and self-evaluation/self-reinforcement for correct performance or correction of mistakes. The program included the use of behavioral contingencies such as the token system, social reinforcement, and self-reinforcement for successful performance and appropriate behaviors to improve motivation towards tasks. The Kendall et al. (1980) program in combination with anger control techniques were then used to conduct the second part of the intervention program (Miranda, 2000).
The results of this study analyzed the effects on children with ADHD of two intervention programs of cognitive behavioral orientation: self-control program and a combination of this with anger control tech programs technique. It was hypothesized that the general procedures taught in both program would contribute to minimizing the self-regulatory deficiencies in hyperactive children. The results from this study support this hypothesis because both interventions produced considerable improvements in the children with ADHD, whether there was aggression or not. Positive effects were observed in the basic symptoms of ADHD and in difficulties frequently associated with this disorder, such as school problems and antisocial behavior. The combination of self-management procedures with reinforcement contingencies can be a powerful intervention to enhance behavioral control in children with ADHD. Neither of the programs increased social adjustment or school grades in hyperactive children. The results of Miranda’s (2000) study coincides with other research showing that cognitive behavioral modification procedures are useful in the treatment of hyperactive children. However, these techniques have their limitations regarding changes that can be achieved in such items as school grades or social adjustment, which are strongly influenced by the individual’s background and previous experiences (Miranda, 2000).
Both intervention programs achieved improvements in the aggressive hyperactive subgroup. These findings suggest that the aggressive hyperactive subgroup is particularly evasive to psychosocial treatment regimes. There were considerable differences between the two types of treatment. In the case of aggressive children with ADHD the subjects experienced a reduction in antisocial behavior and an increase in their social adjustment. According to the parents, the combined treatment program produces a significant decrease in the difficulties of children with ADHD who also suffer from aggression in personal and social environments. The teachers reported minimal differences with respect to the effectiveness of the two programs. The parents may have been more sensitive at the time of assessing immediate changes in the reactions of anger in the aggressive children with ADHD due to frequent and intense parent-child conflicts at home which may account for the significant changes notes by parents. Limitations to this study are that there was no control group without treatment or with placebo-attention control condition. Therefore, it is difficult to establish whether the behavioral improvements in the ADHD children are produced as a result of the cognitive behavioral treatment or are due to the passing of time, or the extra attention given to the children by the therapist. However, it is important to note that these types of cognitive behavioral treatments have shown to have significantly better results in other research studies that used control groups in their studies (Miranda, 2000).
Individualized behavioral contracts are another way that therapists address behavior problems in the school setting. We could refer to this as “Grandmas Law.” In other words, “When you finish your vegetables, you may have dessert,” or, “I would love for you to go out and play as soon as you have picked your toys up.” Behavior plans are formalized written versions of this reciprocal agreement adapted to deal with common classroom behavioral problems. Classroom behavioral contracts are developed for many purposes and are effective with both academic and social behaviors. Some of the things that behavioral contracts are used for are introducing and teaching new behaviors, increasing the rate of a desired behavior, maintaining and supporting application or generalization of skills, decreasing or extinguishing undesirable behaviors, monitoring completion of academic tasks, and/or documenting the results of problem-solving or crisis intervention sessions (Anderson, 2002).
Anderson (2002) states that individuals responsible for monitoring behavior contracts should be involved in determining specifics of these behavior plans. Their understanding of cause and effect are strengthened, by including the student and others in the planning process, it also increases their ownership of a successful outcome. There are some important things to consider when developing behavior plans or contracts. An area of concern should be identified and if the situation provides more than one choice, the behavior that will have the greatest positive impact on the student’s ability to be successful in the classroom and other settings should be selected. Circumstances under which the behavior occurs should be identified and described. Antecedent events that trigger the behavior should be considered. Antecedent events or consequences that are effective at decreasing or inhibiting the behavior should be discussed and determined. The therapist should form a reasonable hypothesis about why the student or client may be engaging in the behavior. Issues such as power, revenge, avoidance, and attention should be considered when forming a general hypothesis.
Collecting and summarizing information in regards to the current level at which the behavior is being exhibited needs to be taken into consideration when forming a behavior plan or contract. Collecting this information may include classroom observations, teacher notes, frequency counts, recording duration, and/or timing. Past recordings, rate of assignment completion, and past token economy point sheets, should be reviewed prior to using behavioral plans or contracts in order to establish a baseline for implementing an effective behavioral plan. These behavioral objectives to be introduced should be specific, observable, and measurable. For instance, a child remains on her own carpet square for a minimum of five minutes on four out of five consecutive days as determined by the teacher observation using a kitchen timer. Strategies that have been tried and failed with the target behavior in the past should be identified and less intrusive behavioral supports, instructional adaptations, and/or environmental modifications should be tired before implementing a behavior contract, especially if they are likely to impact the behavior (Anderson, 2002).
A list of reinforcers that are effective with the student should be noted. The teacher, parent, and student should determine what the child is willing to earn, how often they need reinforcement, and how quickly they become bored with the reinforcer. Younger children and students with behavioral problems may need to start with frequent reinforcers and gradually fade to a more intermittent schedule as the behavior becomes more consistent. There should be a wide range of reinforcers planned, such as having a student choose tangible reinforcers from a box in the room, especially if the behavior contract is expected to last more than a week or two. Situations in which another’s safety is at risk or the person is a risk to self should be handled with explicit negative consequences. Other natural consequences must take place at times, such as failure to turn in missing homework and receiving a zero or not receiving the promised incentive. The people involved in developing and implementing this behavior plan should be involved in signing and monitoring the contract. This may include the teacher, parents, guidance counselor, child and/or therapist. Success of this behavior contract or plan will be determined by making sure that a predetermined timeline and plan for evaluation are in place prior to implementation of this plan. Each individual behavior plan will vary in regards to length of contract. Frequent checkpoints to allow adjustments should take place with lengthy contracts. Once the goal is reached, the student and people involved in the behavior plan celebrate and move on to the next behavioral target with the same process (Anderson, 2002).
Parent and child influences are reciprocal and interdependent (Deater-Deckard, 1998). Therefore, changes in parent and family functioning can be expected throughout therapy. Childhood disorders are often associated with parent and family factors. For example, in children with conduct disorder parent clinical dysfunction, stress, strained family relations, and lack of parental warmth are often present (Kazdin, 1995; Stoff et al. 1997). Child, parent, and family functioning are interrelated and therefore, reductions in child deviance might influence parent and family functioning. Identifying common factors that predict changes in child, parent, and family functioning has implications for understanding therapeutic changes and the mechanisms through which these changes occur. Child, parent, and family functioning may change and/or respond in similar ways over the course of therapy because they are part of the same package. A study done by Kazdin and Wassell (2000) examines three predictors of therapeutic change. These were socioeconomic disadvantage, child severity of dysfunction, and perceived barriers to participation in treatment. Each has predicted a therapeutic change in children referred for conduct disorder (Kazdin & Wassell, 2000).
Kazdin and Wassell’s (2000) study examined whether the child, parent, and family functioning improved over the course of treatment, the magnitude and relations of these changes, and whether common antecedents predicted change. Treatment in this study involved the parents, but did not focus on parent symptoms or family functioning directly. It was predicted that there would be large changes in child outcomes. Parent symptoms and family functioning were expected to change, but to a lesser degree. It was also predicted that socioeconomic disadvantage, severity of child dysfunction, and perceived barriers would predict improvements in the children, parents, and families. A prospective study of those who completed treatment was conducted with children referred for oppositional, aggressive, and antisocial behavior. Conduct problems are a frequent reason for inpatient and outpatient referrals for children and adolescents and are estimated to be the most costly mental health problem in the United States (Robins, 1981). Participation in this study was initiated by families who contacted a triage center at a child psychiatry service or by direct contact with the clinic. Children referred for oppositional, aggressive, and antisocial behavior were seen at an outpatient clinic for children and families. After referral, children and families completed an initial evaluation to assess child, parent, and family functioning and then began treatment (Kazdin & Wassell, 2000).
Assessment measures evaluated changes in child, parent, and family functioning and factors hypothesized to predict these changes. Measures were completed before and after treatment and used multiple methods and informants. These methods included interviews, questionnaires, and direct observations. Informants included parents and therapists. At the end of the treatment, parents and therapists completed measures to evaluate barriers parents experienced over the course of treatment. Other clinic staff administered post treatment measures to avoid influences that the presence of the therapist might impose on the family. In this study, cognitive problem skills training for the child and parent management training were provided alone or in combination. In the cognitive problem skills training, children were seen for approximately 20 to 25 sessions and learned problem solving skills to manage interpersonal situations across all settings. These sessions included practice of skills, role-playing, corrective feedback, and social and token reinforcement. Children applied these problem solving steps to interpersonal relationships outside of sessions. For parent management training, parents were seen individually for approximately 16 sessions to develop adaptive parenting practices and child-parent interaction patterns and to alter child behavior at home and school. Practice, feedback, and shaping were used to develop these skills in session (Kazdin & Wassell, 2000).
The major findings were that child, parent, and family functioning improved over the course of therapy and that these effects were evident across multiple measures of child symptoms, parent symptoms and stress, and family relations, functioning, and support. It is also important to note that in this study, the magnitude of these changes indicated large effects for child outcome measure and smaller effects for parents and family outcome measures, changes in children, parents, and family measures were significantly and moderately correlated, and socioeconomic disadvantage child severity of dysfunction, and that perceived barriers to participation in treatment predicted therapeutic change. However, the patterns of predictors varied among child, parent, and family outcomes. Limitations to this study are that the children were all referred for conduct problems and the results may not apply to children referred for other presentations and that the measures omitted child report because of the age of the sample. This study is not significant due to its indication of parent, child and family dysfunction and how these problems are reciprocal, interrelated, and changed simultaneously (Kazdin & Wassell, 2000).
Solution-focused therapy is another type of therapy that clinicians use to treat many types of problems, including behavior problems (de Shazer, 1988). A study done by Corcoran and Stephenson (2000) examines the effectiveness of solution-focused therapy with children who have been referred from the school system for behavior problems. Solution-focused therapy is a model of brief therapy that continues to evolve as theoretical, process, and outcome-based information expands. The main philosophy of solution-focused therapy is that clients bring with them strengths and capacities they can access and develop to make their lives more satisfactory (O’Hanlon & Weiner-Davis, 1989). The therapist is responsible for developing a collaborative context and helping the client articulate desired changes. The therapist magnifies the client strengths, resources, and past successes, which leads to the construction of solutions (Berg & deJong, 1996). There is an orientation to the present and the future where solution-focused therapy uses techniques to address how problems will be solved rather than what caused the problem and how the problem is maintained (Berg & Miller, 1992).
Previous research was conducted in a children’s mental health outpatient facility where presenting problems included those related to family and relationships, school, children’s behavior, at home and difficulties with emotional regulation. Solution-focused therapy was utilized during treatment at this facility. At a six-month telephone interview 54% of participants indicated that their goals had been met, 11% that their goals had been partially met, and 32% that their goals had not been met. There are limitations to this and things to consider, such as the fact that those with access to telephone may have more resources than those without telephone access. Solution-focused therapy has also been examined in another study through eight week group sessions with children from elementary to high school range. A pre-test and post-test were given during this study. Eighty-one percent of students in this study reported goal attainment, and both self-esteem and coping also improved. In this study, there was a lack of information in regards to the types of problems children were being seen for in treatment and there was no comparison of child effects with a group of children who did not receive solution-focused therapy. Corcoron and Stephenson (2000) report that focusing on specific times that children display appropriate behavior cultivates a more positive parental view of their children and encourages future positive behavior. Solution-focused questioning engages children in developing treatment goals and taking responsibility for the work in therapy (Corcoron & Stephenson, 2000). This empowers children to help themselves and gain insight into the benefits of solution-focused therapy.
Behavior problems in the study conducted by Corcoron and Stephenson (2000) are defined as complaints involving classroom behaviors relating to conduct or completion of assignments, aggressive behaviors directed towards school personnel and/or peers, and problems in the home of a similar nature. Intervention in this study included normalizing, solution focused questioning, externalizing the problem, goals setting, and termination. As mentioned earlier, there was a pre-test and post-test. The Feelings, Attitudes, and Behaviors Scale for Children (FAB-C) (Beitchman, 1996) and the Connors’ Parent Rating Scale (Conners, 1990) were used as measurements. Dropout was a concern in this study because half of the sample did not complete the four to six sessions of therapy. Those who did complete therapy made improvements, according to parent reports. Subscales of the Conners’ Parent Rating Scale showed significant positive changes from pre-test to post-test results. These changes were seen in conduct problems, learning problems, psychosomatic problems, impulsivity, and hyperactivity. According to the child report, solution-focused therapy appeared to not demonstrate significant changes. No significant change was noted in most of the subscale scores and a negative change was found for conduct problems. Children reported that their conduct problems were more severe upon termination when compared to the baseline. The explanation for this might be the nature of solution-focused therapy. Many of the children reported in the beginning of therapy that they were unaware of their parents’ expectations for them (Corcoran & Stephenson, 2000).
Another type of therapy used with children who experience behavior problems is Parent-Child Interaction Therapy (PCIT). Richman & Graham (1971) found that 15% of three- and four-year-old children have mild behavior problems and 7% have had moderate to severe behavior problems. A 1996 sample of Midwestern, middle-class parents of toddlers revealed 23% reported clinically significant disruptive behavior (Obrien, 1996). In other studies, such as the Webster-Stratton (1998) study, similar high rates of clinically significant disruptive behaviors have been found. Disruptive behavior can originate from multiple interacting child and family factors. Child factors include difficult temperament (Bates, Bayles, Bennett, Brown, 1991), hyperactivity (Loeber & Keenen, 1994), neuropsychological abnormalities affecting social information processing (Crick & Dodge, 1994), and genetic factors that interact with family factors in developing and maintaining disruptive behavior (Kazdin, 1987). Neary and Eyberg (2002) report that family factors include maternal depression, single parent families and poverty, personality disorder, social isolation, stressful life events, and parent conflict about childrearing. Parental interactions with their young children are the most significant influence on a child’s behavioral development. According to Kellam, Werthamer-Larsson, Dolan, & Brown (1991), early disruptive behavior is the single most substantial risk factor for adolescent delinquency and adult criminal behavior (Neary & Eyberg, 2002).
According to Neary and Eyberg (2002) parent-child interaction therapy (PCIT) is an empirically supported treatment designed for families with preschool age children with various behavioral and emotional problems. PCIT has been used to treat behavior problems of children with a variety of primary diagnoses including neurological impairment, developmental disorders, chronic illnesses, victims of child abuse, mood disorders, and anxiety disorders. PCIT can be used concurrently with other treatments, including stimulant medications, individual therapy for a parent, and group social skills training for the child. PCIT focuses on both attachment and social learning theories to change maladaptive parent-child interactions (Foote, Eyberg, & Schuhmann, 1998). Parents are taught specific skills to establish a nurturing and secure relationship with their child while increasing the child’s pro-social behavior and decreasing negative behavior. Maladaptive parent-child attachments have been consistently linked to children’s aggressive behavior, low social competence, poor coping skills, low self-esteem, and poor peer relationships (Coie, Watt, West & Hawkins, 1993) as well as increased maternal stress and child abuse and neglect (Crowther, Bond, & Rolf, 1981). Parents first learn child-directed interaction. In this interaction, their part is similar to that of a play therapist. Parents use skills that restructure the play interaction in ways designed to create a secure attachment. Then they learn parent-directed interaction where they incorporate specific behavior management techniques based on social learning theory. These interactions are characterized by mutual and opposite behaviors resulting from the attempts of the parents and the child to control behaviors. These behaviors include arguing, whining, criticizing, and aggression (Neary & Eyberg, 2002).
In order for this cycle to end, there must be a change in parent behavior through clear limit-setting that is firmly and consistently enforced, during the early years, in the context of an authoritative relationship (Bauramind, 1996). Consistent contingencies for the child’s behavior are established and implemented in the context of positive parent-child attachment relationship established through child-directed interactions. PCIT is also an assessment driven treatment. Assessments provide information that helps determine treatment needs, evaluate treatment progress, and assess treatment outcome. Multiple forms of assessment are used including, multiple informants for gathering information’s and methods of measurement. Potential barriers to therapy are identified, during the assessment. Parents also complete self-report measures of their own psychological functioning, as well as their parenting style and behaviors that help in tailoring the treatment process. Standard parent-child interactions are observed in the playroom so that the specific behaviors that maintain the child’s disruptive behavior can be noted and the baseline data and can be charted. These behavioral observations are recorded throughout treatment (Neary & Eyberg, 2002).
PCIT is conducted with the child and parent together who are seen weekly for one-hour sessions. Role play and modeling are used to teach the parents alone in a teaching session. Parents practice these skills with the children in the playroom. The therapist coaches the parent in the playroom through a “bug-in-the-ear” microphone. Most coaching statements used by the therapist are brief and praises the use of the parents’ skills or the effect of the skills being used such as, “She is talking to you more as you reflect more.” Coaching also includes redirections, suggestions, and interpretations of the child’s behavior. Child-directed interaction allows the child to lead the play and parents learn to use social attention to apply the nondirective skills to the child’s positive behaviors. The acronym, PRIDE, helps parents remember skills that communicate positive attention. PRIDE consists of praising the child’s appropriate behavior, reflecting or repeating acceptable talk, involves imitating suitable child play, describing appropriate play, and being enthusiastic. Parents practice these skills outside of sessions for five minutes each day. As children become used to this type of interaction they are less resistant to the limits and rules that their parents learn to set in the second phase of treatment. The second phase, parent-directed interaction, is where parents learn to decrease disruptive behavior that is too dangerous to be ignored, is controlled by reinforcers other than the parents’ attention, or does not extinguish easily for some reason. They continue to use the PRIDE skills to reinforce positive behaviors, but learn to direct their child’s behavior when needed. They learn how to give commands effectively. Commands should be age appropriate and given one at a time (Neary & Eyberg, 2002).
PCIT is guided by a comprehensive treatment manual (Neary &Eyberg, 2002) that includes specific components of each treatment session as well as general guidelines for tailoring treatment to the individual differences and special needs of children and families. PCIT is one of many treatments for conduct problems in young children that have been indicated as an empirically supported treatment (Brestan & Eyberg, 1998). The evidence base for PCIT includes comparisons of treated children to wait-list controls, untreated classroom controls, modified treatment groups, treatment dropouts, and group parent training. Long-term maintenance of the effects of PCIT has been observed also. Parent ratings of child behavior problems, child activity level, and parenting stress have shown maintenance at a two year follow up, with most children remaining free of the diagnoses of disruptive behavior disorders over that time. Fewer symptoms of disruptive behavior disorders were found in the one to three year follow up with those who completed the treatment. Their mothers also reported less parenting stress. There was a higher incidence of occurrence of symptoms in those who dropped out of treatment. This is a therapy that would be useful with parents of young children with behavior problems (Neary & Eyberg, 2002). This type of research and development of programs for children with behavioral disorders are important in helping the child succeed in all settings and need to be continuously explored and expanded.
Social skills training is also used in treatment of children with behavioral problems. It has been used in children with Attention Deficit Hyperactivity Disorder. Children with Attention Deficit Hyperactivity Disorder often have problems in the social domain (Greene, Biederman, Faraone, Wilens, Mick & Blier, 1999). According to Landau and Moore (1991), they are often seen as bothersome, unpleasant, noncompliant, and socially inept. There are often interpersonal problems frequently reported by parents and teachers. Barkely (1998) concluded that they are also more likely to be rejected by their peers and are more deviant in their peer relations. Social skills training approaches have been demonstrated to be effective for improving the social functioning of aggressive and anti-social children (Webster-Stratton, Reid & Hammond, 2001). There are individual- (Coleton & Sheridon, 1998) and classroom-based (Coker & Thyer, 1990) social skills training models. A recent study was conducted to measure the effectiveness of social skills training with those children diagnosed with Attention Deficit Hyperactivity Disorder. There was a pre-test and post-test. This study consisted of a 10-week treatment program. They received ninety-minute group sessions every week. Multiple target social skills were modeled, role played, and coached to promote acquisition and generalization of skills. Modules that were covered during this period were cooperation with peers through learning how to take other’s perspective and share; problem solving which involved a five step procedure for identifying the problem, generating and implementing the solutions; recognizing and controlling anger; assertiveness through group entry techniques and assertive communication with others; conversations that involved giving and receiving compliments; and accepting consequences by acceptance of a perceived negative circumstance as a choice for dealing with frustrations (Antshel & Remer, 2003).
A review of how, why, and when to employ the skills in each session was followed with extensive child participation and a group challenge game. Points were earned for the ability to correctly reproduce the skill. This was used to reinforce participation and attention to task. The therapist also modeled these skills. The children role-played skills using brief scripts of common problem situations with peers or siblings, with parents, and in the classroom. Children evaluated each other’s performance (i.e.: thumbs up or thumbs down) of the social skill immediately after each role play and were called on to give specific reasons for their ratings. The children participated in a 15-minute free period where they were prompted to use positive social skills with one another, and they receive points for each correct use of a target skill. They were given a homework assignment to practice the skill at home and school and were held responsible for reporting on their homework at the next group meeting. Points during each session were exchanged for child-selected games or activities during the last 15-minute free period. Redirections and time-outs were used for destructive behavior. Parent sessions were included as well. Results from this study do not indicate significant efficacy for the use of social skills training, especially for those children with co-morbid Oppositional Defiant Disorder. However, improvement was noted in assertion skills. Preliminary results indicate that diagnostically heterogeneous groups produced greater improvements on parent report of their child’s cooperation and assertion abilities as well as children’s report of their own empathy skills. The success of social skills training in Antshel and Remer’s (2003) study may have been limited by the predominance of ADHD symptoms, particularly impulsivity. Another reason for limited efficacy in this study is that the social skills training used may have been the exclusive focus on the child with ADHD while neglecting the peer group (Antshel & Remer, 2003).
The National Institute of Mental Health has conducted a multimodal treatment study of Attention Deficit Hyperactivity Disorder and outcome strategies for ADHD. This study was designed as a randomized clinical trial comparing well-established and widespread treatments for children with ADHD. The children in this study ranged from ages 7- to 10-years and were randomly assigned to one of four treatments. These treatments included medication management, behavior modification, medication management and behavior modification combined, and routine community care comparison. The treatment phase was a 14-month treatment period. All four groups experience sizeable improvement over time, with significant differences among groups in the rate of improvement in areas. Combination treatment and medication management showed significant improvement in ADHD symptoms as compared to behavior management and community care comparison. Combination treatment and medication management did not differ significantly on direct comparisons, but in several situations combination treatment proved superior to behavior management and/or community care comparison, whereas medication management did not (MTA Cooperative Group, 2004).
Researchers in this multimodal treatment study concluded that ADHD symptoms, specific medication management maintained for 14 months was superior to behavior management alone, and the routine community care comparison that included medication. Combination treatment showed significant advantages over community care comparison in every domain, whereas medication management did not. However, it did not prove significantly superior to medication management for individual, specific outcome measures. Combination treatment did provide modestly greater benefits than medication management for non-ADHD symptom domains and positive functioning, and greater levels of parent satisfaction (Hinshaw, Owens & Wells, 2000). This effect was more pronounced for dually diagnosed children, including those with internalizing disorders such as depression, and disruptive behaviors (i.e. oppositional defiant disorder or conduct disorder) (Jensen, Hinshaw, & Kraemer, 2001). The status of these randomly assigned groups was examined 10 months after the end of the treatment phase to address whether or not treatment effects persisted after treatment (MTA Cooperative Group, 2004).
Primary and secondary analyses were conducted at the end of treatment and comparisons were made to help understand the overall treatment effect. Symptom ratings of inattention and hyperactivity/impulsivity and rating by parent and teacher were used in the analyses. The analyses revealed a persisting superiority for exposure to the conditions that included the MTA medication management approach which included combination therapy and medication management, over the conditions that did not demonstrate superiority. Behavior management and community care did not demonstrate superiority. The medication regime and decision making process involved in medication management did not affect negative parental discipline, social skills, or academic achievement. Non-significant but consistent trends in numerical superiority of combination treatment over medication management were noted for Oppositional Defiant Disorder symptoms, social skills, and parental discipline. This was also noted in overall rates of normalization. The pattern of statistically significant differences across the MTA treatment conditions endured. However, the magnitude of this medication management regime and decision making process effect was reduced by approximately half during the ten-month follow-up (MTA Cooperative Group, 2004).
Approximately 85% of the combination treatment and medication management participants continued to receive some form of medication, usually stimulants. Fewer of those receiving behavior management and community care, approximately 44% to 69%, were medicated during the 14- to 24-month interim. In those who were medicated, doses were higher in medication management and combination treatment than in behavior management and community care comparison. These results and the significant main effect of medication use in the mediator analyses and the loss of significance on Oppositional Defiant Disorder symptoms by co-varying medications status, suggests that part of the continuing advantage of the combination treatments and mediation management treatment is mediated by differential medication use in the 14- to 24-month interim. It is not entirely mediated by continued medication, due to the advantage of the combination and medication management groups for ADHD symptoms which withstood statistical control for interim and endpoint medication use. Therefore, some combination treatment and medication management families may have continued to benefit as a result of their early intensive medication experience, regardless of whether they continued to take medication after 14 months. The continued symptom benefit with reduced effect size may have resulted from some participants’ continuing to do well, after discontinuing intensive medication management, whereas others deteriorated. Upon follow-up, medication management dose levels were significantly higher than in combination treatment participants. These results suggest the possibility that early combination treatment interventions might allow reducing overall medication requirements, during later periods, consistent with findings that others have reported. This type of research and the results should continue to be studied as a possible way to keep doses lower to avoid side effects (MTA Cooperative Group, 2004).
There has also been some research in regards to peer-assessed outcomes in the multimodal treatment study of children with Attention Deficit Hyperactivity Disorder. There is a widely accepted trend in research that demonstrates that children with ADHD have problematic peer relationships. The mechanisms underlying these peer difficulties remain poorly understood. Factors noted in relation to this issue are deficits in social skills knowledge, performance, and self-control, and they have all have been assumed to be significant factors in peer relational difficulties. It is widely accepted that a major contributing factor to the peer problems of children with ADHD is their largely unrestrained, overbearing interaction style, characterized by hyperactivity, aggression, bossiness, and other forms of controlling behavior that make them highly avoidable when it comes to their peers (Hoza, et al., 2005). Stimulant medication is effective in reducing rates of these negative and controlling behaviors, but typically produces small increases in positive behaviors (Cunningham, Siegel, & Offord, 1985). This supports the idea that a combination therapy and medication is a more efficient approach.
Most psychological interventions for childhood peer problems are based on the social skills deficit model of peer rejection (Oden & Asher, 1977). This model attributes peer rejection to social skills knowledge or performance deficits, and hypothesizes that teaching social skills to the poorly accepted child will result in improvement of peer problems. Results of social skills training studies, mostly conducted with non-clinical or school samples, have been very different, especially for children with externalizing symptoms, such as aggression. Greater results are seen when social skills training is coupled with behavioral programs targeting negative behaviors or reinforcing use of social skills. However, generalization of gains beyond the treatment setting is rarely achieved. These results suggest that an effective intervention for the peer problems of children with ADHD may need to target skill and performance deficits through psychosocial interventions, address behavioral excess through medication, and address issues of generalization (Hoza, et al., 2005).
The initial outcome results and articles from the MTA peer-assessed outcomes were not emphasized. Therefore, it is important to examine how the four treatment groups from the MTA compared to the improvement of peer problems of children with ADHD, using peer-assessed outcome measures. There has been research in previous MTA studies that prove psychosocial therapies and stimulant medication when used alone in addressing peer problems of children with ADHD did not show the most promising results. Researchers in this study hypothesized that combined treatment would show the most significant results. They also hypothesized that stimulant medication would be proven to be a significant component of treatment for peer problems of children with ADHD, due to the research that proves its positive effect on reducing disruptive behaviors and improving relations between children with ADHD and their peers (Whalen & Henker, 1991). Behavioral treatment families received 27 group and 8 individual behavioral parent training sessions, an 8-week summer treatment program (Pelham & Hoza,1996), and school intervention that included 10 to 16 sessions of teacher consultation. The summer treatment program included daily social skills training, friendship intervention in dyads, performance of cooperative tasks with peers, anger management, and problem solving skills training. These were implemented in a point system based upon behaviors exhibited. There were children assigned to a medication group as well, which included a 28-day double-blind placebo-controlled dosage to determine the child’s optimal medication dose (Hoza, et al., 2005).
When comparing the treatment groups from the MTA, the researchers were not able to demonstrate much evidence of superiority of any of the treatments in regards to the peer-assessed variable studies. Two significant contrasts were found among the 18 variables researched. According to Hoza, Gerders and Mrug et al. (2005), prior research indicated that the primary MTA results indicate that all groups improved on some non-peer assessed outcomes. The researchers in this study examined the possibility that all groups improved in the peer-assessed domain and that these improvements across groups reduced the ability to identify differences between groups. Therefore, a post hoc analysis was conducted to determine whether any of the children from any of the four treatment groups had normalized peer relationships at the end of treatment. The conclusion was that children from all treatment groups remained impaired in their peer relationships. Previous research studies indicate that these same treatments were effective to varying degrees in reducing ADHD symptoms, oppositional, aggressive and internalizing symptoms, improving parent-child relationships, and improving academic functioning. One recent review examining social skills training as a treatment for aggressive children explains that peers may be often resistant to changing their feelings toward a child that they dislike, even when positive change has occurred (Nangle, Erdely, Carpenter & Newman, 2002). The implication of the results in this study is not that social skills training, behavior therapy, and other peer interventions are not worthwhile, but indicates that they are not sufficient (Hoza, et al., 2005).
The intensive interventions even with medication failed to normalize the peer-assessed outcomes of the treated children even though other outcome relate variables related to social performance indicated that behavior had changed. Ethnic minority children were also underrepresented in the sample of children for which they were able to obtain peer data. These results indicate that peer researchers and interventionists who are researching beyond the immediate treatment and the persistence of peer problems need to conduct further research in this area. The focus in future research should be on peer groups as a factor for preventing change in two ways. The first is that the reputations within a peer group persist, even after behavior has changed. The second is that these reputations influence perceptions of the peer group toward an individual child, as well as their reactions to the child. Social skills that are to be used in the natural environment once they are learned must be reinforced by the peers in that setting. Developing more effective interventions for peer problems in children with ADHD should be given high priority as a significant concern of those in the helping professions (Hoza, Gerdes, & Mrug, et al, 2005). In order to address this behavior change in peer groups, the events surrounding these feelings, thoughts, and behaviors need to be identified and further research on how to address these problems needs to be conducted.
EMDR as a Treatment Modality
There also has been some research using a more non-traditional treatment modality, Eye Movement Desensitization and Reprocessing, or EMDR, for ADHD and other behavioral disorders, such as Oppositional Defiant Disorder, Conduct Disorder and Disruptive Behavior Disorder in children and adolescents. The research regarding EMDR as a treatment modality for behavioral problems is very limited when compared to the wealth of research conducted with EMDR and disorders such as anxiety, depression and post traumatic stress disorder. Therefore, there is a need to broaden this limited research that has been done with EMDR as a treatment modality for behavior problems associated with behavioral disorders and to investigate whether or not it is an effective treatment that can be used and possibly replicate more studies. This can be significant to the treatment of children and adolescents when it comes to addressing the anxieties, poor self-esteem, irritability, peer relations and self-regulation that are typical issues of those with behavioral disorders. EMDR was discovered in 1987 by Francine Shapiro, Ph.D. who states that disturbing thoughts generally have a significant “loop” to them and play themselves over and over until you consciously do something to stop or change them (Shapiro, 1995).
EMDR consists of eight phases of treatment and integrates elements of other therapies in structured protocols. The client becomes in tune with past and present experiences in brief sequences while focusing on external stimuli. Instruction is then given to let new stimuli become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in session. The first phase of treatment is a history taking session. The therapist assesses the appropriateness of EMDR for that client and develops a treatment plan. Targets for EMDR processing are identified, which can include distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will need to be acquired by the client to use in the future when confronted with a triggering situation (EMDR Institute, Inc., 2005).
Phase two of EMDR treatment ensures that the client has methods of coping with emotional distress and that the client is in a relatively stable state. The client is then able to utilize stress-reducing techniques when necessary during or between sessions. A goal of EMDR is to not need these techniques once therapy is complete. Phases three through six are also important because this is when a target is identified and processed using EMDR procedures. The client identifies the most vivid visual image related to the memory, negative beliefs about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions. The client is instructed to focus on the image, negative thought and body sensations while simultaneously moving their eyes back and forth following the therapist’s fingers as they move across the client’s field of vision for 20 to 30 seconds or more. The therapist asks the client to note what happens and asks the client to let their mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session (Shapiro, 2005).
There are procedures to follow if the client becomes distressed as well. When the client reports no distress related to the targeted memory then the therapist asks them to think of the preferred positive belief and to focus on that belief while simultaneously engaging in the eye movements. After several sets, clients generally have reported an increase in confidence in this positive belief. The therapist checks with the client regarding body sensations as well. If there negative sensations, these are processed. If there are positive sensations, they are enhanced. Phase seven addresses closure, where the therapist asks the client to keep a journal during the week and document anything that arises that reminds them of the self-calming activities. Phase eight is re-evaluation of the progress since previous the session. It is important that profound treatment effects be achieved in the briefest amount of time possible while the client maintains stability. After participating in EMDR processing, clients usually report a decrease or omission of emotional distress related to the memory and that they have gained important cognitive insights. These insights usually result in spontaneous behavioral and personal changes that are enhanced with standard EMDR procedures (Shapiro, 2005).
EMDR in the group setting has also been found to be useful as well. The researcher will consider this when deciding how to deliver EMDR as a treatment modality for ADHD. Withers (2000) reports that she has been using EMDR with children for many years. She conducted an EMDR group with children who have a diagnosis of ADHD ranging from ages five to eight whom she also had seen for individual therapy. She began installing a “safe place” in their bodies through bilateral or full body movements instead of eye movements as in “regular” EMDR. She explained that children diagnosed with ADHD are traumatized on a daily basis, by peers for missing social cues, and by teachers, parents, and coaches for not paying attention and being impulsive. After two to three sessions when trust had been established, the group began processing these daily traumas according to the EMDR protocol. This technique helped them develop empathy for each other while empowering each child with a sense of leadership by having everyone follow their movements in a group. A part of each group session was spent teaching coping skills, such as the ability to feel the sensation of calm in their bodies when they need it and installing it through the “Butterfly Hug”, where hands are crossed at the chest to pat alternately on opposite shoulders. EMDR offered in this group setting allowed participants to control the process of therapy (Withers, 2000).
Greenwald (1999) reports that EMDR appears to be a reliable resource for children and adolescents recovering from trauma and loss. EMDR’s efficacy has been supported by more controlled studies than any other psychotherapy treatment for trauma. EMDR is becoming widely recognized as highly effective and is considered by many to be the treatment of choice for traumatic memories and related applications. A comparison study was conducted comparing EMDR wait-list, psycho-education and relaxation/biofeedback control groups for combat veterans with chronic Post Traumatic Stress Disorder. This study featured standardized comprehensive assessment pre-treatment, post-treatment, and at three month follow-up, and twelve treatment sessions. The researcher will consider using a similar method for assessment, follow-up and number of treatment sessions when designing this study. Following three treatment sessions the results were positive and substantial. Another study of 20 children and adolescents who were not randomly assigned to EMDR treatment were compared to delayed treatment groups and showed that results were positive. The researcher in this study conducted treatment and assessment using several measures at pre, post and one to two month follow-up. A study of 10 institutionalized sex-offender adolescents found that three EMDR session led to decreased disturbance, increased sense of cognitive control, and increased empathy for their victims. There also was a report of improved behavior in the school and the community up to a year after treatment (Greenwald, 1999).
These research studies show that there is a need for continued research in the area of EMDR as a treatment modality with children and adolescents. The fact that there was report of improved behavior in the school is a significant factor to consider when conducting further research with EMDR as a treatment modality for ADHD children or adolescents. Recent studies including children and adolescents are consistent with earlier studies and are comparable with adult studies. EMDR is not a “stand alone” technique, but a tool to be used by qualified clinicians in the context of an overall treatment plan (Greenwald 1999). Goldwasser (2000) states that EMDR has been helpful with ADHD by targeting failure experiences, criticism/abuse secondary to ADHD behaviors, and dysfunctional self-statements associated with ADHD that can all be effective in dealing with the poor self-esteem associated with ADHD.
The first phase of EMDR, as described by Shapiro (1995), includes an evaluation of the client safety factors that will determine client selection for EMDR treatment. This involves assessment of personal stability and current life constraints. The client should be able to deal with high levels of disturbance potentially precipitated by processing dysfunctional information. The client should also be physically able to withstand intense emotion. Cardiac condition and preexisting respiratory conditions should be considered. A treatment plan is then designed. There is an evaluation of the entire clinical pictures that includes the client’s dysfunctional behaviors, symptoms, and characteristics that need to be addressed. The therapist then determines specific targets that will need to be reprocessed. These targets are events that initially set the pathology in motion, present triggers that stimulate dysfunctional material, and positive behaviors and beliefs needed for the future. After the full evaluation is completed and a detailed treatment plan is in place, then EMDR is used to reprocess the information (Shapiro, 1995).
Phase two is preparation which involves establishing a therapeutic alliance, explaining the EMDR process and its effects, addressing the client’s concerns, and initiating relaxation and safety procedures. It is important that the therapist clearly inform the client of the possibility for emotional disturbance during and after EMDR sessions. This way the client is in a position to give informed consent. Therapists should consider the importance of the client having access to an audiotape that promotes guided relaxation exercises. This empowers the client to deal with disturbances between sessions and they become proficient in using these relaxation techniques with confidence. The therapist should also use guided visualization techniques before processing begins. If the client is unable to completely eliminate moderate levels of disturbance with these techniques, the therapist should not continue EMDR. Relaxation techniques may also be necessary to bring closure to an incomplete session, or help the client deal with memories or with unpleasant emotions that may emerge after session. During this phase, the therapist should explore with the client the possibility of secondary gain issues, such as what the client has to give up or confront if the pathology is resolved. If these are concerns, they must be addressed before any trauma reprocessing begins (Shapiro, 1995).
Phase three is the assessment phase. In this phase, the patient identifies the components of the target and establishes a baseline response before processing begins. Once the memory has been identified, the client is asked to select the image that best represents that memory. They then choose a negative cognition that expresses a dysfunctional or maladaptive self-assessment related to their participation in the event. These negative beliefs are actually verbalizations of the disturbing affect of the event. These verbalizations include statements such as, “I am useless, worthless, unlovable, bad.” The client then specifies a positive cognition that will later be used to replace the negative cognition during phase five, the installation phase. These would be statements such as, “I am lovable, worthwhile, a good person, in control.” The client assesses the validity of the positive statement using the seven-point validity of cognition (VOC) Scale. These negative thoughts are thoughts that adolescents deal with on a daily basis and this is why it is important to consider EMDR as a treatment modality for adolescents with behavior problems. The image and negative cognition are combined to identify the emotion and the level of disturbance. The client is asked to choose a number on the scale that indicates the intensity of their emotions when the memory is accessed. As reprocessing begins, both emotions and intensity will more than likely change and the disturbance often becomes temporarily worse. The client identifies the location of physical sensations that are stimulated when they concentrate on the event. This establishes a baseline response with the target memory and components necessary to complete processing (Shapiro, 1995).
Phase four is desensitization, which focuses on the client’s negative affect reflected in the Subjective Units of Disturbance Scale (SUDS). This phase of treatment includes all responses regardless of whether the client’s distress level is increasing, decreasing, or staying the same. During this phase, the therapist repeats the set, with appropriate variations, and changes in focus when indicated, until the client’s SUD level is reduced to 0 or 1. This indicates that the primary dysfunction involving the targeted event has been cleared. The information will need to be addressed again because reprocessing is still incomplete when the sets of eye movements may not be sufficient to complete reprocessing. Reports show that at least half the time the processing will stop and the therapist will have to use various additional strategies and advanced EMDR techniques to stimulate reprocessing again.
Phase five is the installation phase. The focus is on installing and increasing the strength of the positive cognition that the client has identified as the replacement for the positive cognition that the client has identified as the replacement for the original negative cognition. For example, the negative thought, “I am powerless,” may be replaced, and the new cognition, “I am now in control,” might be installed. The degree to which the client believes the positive cognition is then measured using the VOC scale. This phase starts once the client’s level of emotion in regards to the target event has dropped to 1 or 0 on the SUD Scale. This is when the therapist asks the client to hold the most appropriate positive cognition in mind with the target memory. The therapist then continues the eye movement sets until the client’s rating of the positive cognition reaches a level of 6 or 7 on the VOC scale. The client should be rating this cognition on how they feel on a “gut level.” This cognition can be one that was identified in the assessment phase or one that has emerged through successive sets of eye movements. The therapist should continue sets to strengthen the positive cognition. Positive cognitions should become more vivid and valid as the negative cognitions become less valid (Shapiro, 1995).
Phase six is the body scan which occurs after the positive cognition has been fully installed. The client is asked to think of the target event, positive cognition, and to scan their body mentally from top to bottom. They are asked to identify any remaining tension in the form of body sensation. These are then targeted for successive sets. Sometimes the tension resolves and sometimes additional dysfunctional information is revealed. There appears to be a physical quality to dysfunctional material, which may be related to the way it is stored physiologically. Identifying this sensation and targeting this through the body scan can help resolve any remaining unprocessed information.
Phase seven is the closure phase where the client must be returned to a state of emotional equilibrium by the end of each session, regardless of whether or not the reprocessing is complete. The therapist must remind the client that the disturbing images, thoughts, or emotions that could arise between sessions are evidence of additional processing, which is a positive sign. The client is asked to keep a log or journal of the negative thoughts, situations, dreams, and memories that may occur. This allows the client to cognitively distance themselves from emotional disturbance through the act of writing. The client is told to take a “snapshot” of any disturbances so they can be used as targets at the next session. It is important the client use a log, visualization techniques as taught by the therapist, and/or relaxation tape to maintain stability between sessions. If the therapist does not debrief the client, there is danger of decompensation or suicide if the client views themselves as permanently damaged. The therapist should provide the client with realistic expectations about the negative and positive responses that may surface both during and after treatment (Shapiro, 1995).
Phase eight is the reevaluation phase which should be implemented at the beginning of each new session. The therapist assists the client in re-accessing previously processed targets and reviews the client’s responses to determine if treatment effects have been maintained. The therapist should ask how the client feels about the previously targeted material and should examine the log reports to see if there are any aftereffects of the already processed information that needs to be targeted or addressed. The therapist can decide to target new material, but only after the previously treated traumas have been completely integrated. The reevaluation phase guides the therapist through various EMDR protocol and a full treatment plan. Successful treatment can only be determined after sufficient reevaluation of reprocessing and behavioral effects. Standard EMDR protocol guides the overall treatment of the client. Each reprocessing session must be directed at a particular target. The divisions of targets are described as the past experiences that have set the groundwork for pathology, the present situations or triggers that stimulate the disturbance, and the templates necessary for further action. Choosing a target is difficult when treating a multiple-trauma victim. In this case, the therapist should cluster the events into groups of similar events and choose a target that represents this incident for each group. Reprocessing the representative incident will result in a generalization, allowing the positive treatment effects to distribute themselves to all of the associated incidents. Asking clients to designate their 10 most disturbing memories allows them to sort through and consolidate their past experiences into manageable targets. The assessment of the SUDS level of each event and arranging them in order of increasing disturbance allows the therapist and client to decide together which memory to target and address first. The decision about whether to begin the first session at the high end of the continuum or the low end of distress will depend on the therapist’s preference and assessment of the client (Shapiro, 1995).
Shapiro prefers to target the most upsetting incidents first. Her rationale is that by preparing the client for the worst event and highest level of distress, there are no surprises later. Clients often feel a sense of great accomplishment by end of session because they have resolved the most traumatic memory, which means that subsequent sessions can only be easier. This reprocessing often results in generalization and reduction in fear and anxiety. EMDR should not be used with client who are unable to contain high levels of emotional disturbance or who are not in an appropriate therapeutic relationship with the therapist. In attempting to resolve trauma, the therapist should target the memory of the actual event, any flashbacks, nightmare images, and triggers, such as loud noises, that bring back feelings of fear and confusion associated with earlier trauma. Targets for EMDR sessions include any manifestation of the dysfunctional information. For example, a focal point of treatment is often nightmares. Clinical observation has shown that when a nightmare image is targeted, therapeutic effects are achieved even when the client is initially unsure of the dream’s actual meaning. The symbolic overlay of the dream is removed by EMDR. Clinical observation indicates that 40% of the time clients experience a continual, progressive shift toward a resolution of the target event. This may present itself in several ways. The client may report new memories that appear momentarily during the entire set, or that surface only at the end of the set. Memory networks are associatively linked channels of information. A targeted memory may be one of many incidents stored in a particular channel. As the eye movements begin and the information starts processing through the channel, new memories can rise to consciousness. These new memories may appear to the client in flashes, a collage of many events all at once, or as body sensations. The client is directed to the next set of eye movements with a statement such as, “Think of it,” as long as processing has continued. The therapist should address the targeted memory in whatever form the client presents it. As long as new associations are being made by the client, the sets may be continued (Shapiro, 1995).
Clients should be able to deal with high levels of emotional disturbance that may arise during or between EMDR sessions. It is recommended that the therapist determine the client’s capability of responding to self-control and relaxation techniques during the history taking process. The therapist should try a variety of these techniques with the client in session and should only proceed with EMDR if the client can use these skills effectively. When targeted material has been incompletely processed during any session, it is imperative that debriefing occur through guided visualization techniques, hypnosis, or relaxation audiotapes to regain emotional balance. If the client is unable to use self-control techniques, EMDR should not be attempted. Environmental stability is also important to consider. Therapists should not attempt to reprocess unrelated traumas if clients are currently undergoing major life pressures, such as family or social crises, or financial or career problems, and are unable to manage the additional disturbance. The therapist will need to determine if the earlier traumas are unrelated to the client’s present life conditions. Clients who are constantly in a state of crisis may be driven by earlier life experiences that need to be resolved before they can be relieved of their present problems (Shapiro, 1995).
Life supports are also very important when conducting any type of therapy techniques, especially EMDR. Clients must have life supports that include family and friends who can nurture and help them through any disturbances between sessions. If there is not life or social support then the therapist should proceed with much caution, and consider whether the client is able to sustain themselves psychologically or if they can be comforted sufficiently over the telephone. Physical health is another factor to consider. The client should be healthy enough to withstand the physical efforts of memory reprocessing. Age, medical conditions, and general overall physical health should be taken into account before conducting EMDR. The potential effects of aroused emotion in women who are pregnant is an example of a medical situation that should be considered. Respiratory or cardiac conditions should be explored with the client’s physician and the therapist should consult with the physician about possible negative effects of high levels of emotional responses. Therapists should always assess the need for appropriate restraint, medical attention, or medication when treating clients with schizophrenia, active drug or alcohol addictions, near-death experiences, physical impairments, or when in doubt about suicidal tendencies, personal stability, or appropriate life supports (Shapiro, 1995).
There are other factors specific to the client that the therapist needs to consider when administering EMDR as a treatment modality. Those with drug and alcohol addictions should be enrolled in a treatment program and/or have appropriate life supports before conducting EMDR. Therapists should be sensitive to any history of neurological impairments or organic brain damage. EMDR should not be continued with any client who reports eye pain. Some may be unable to continue treatment due to eye muscle weakness. These clients should be referred to an eye specialist. There have been no contraindications for the use of EMDR in clients with ADHD. If a crime victim, witness or police officer is being treated for a critical incident, then it is imperative to determine whether a legal deposition or any testimony might be required of that client. This is important because during EMDR the event may fade, blur or disappear. Informed consent should be obtained in this sort of situation with all significant parties, and the therapist should explain what may occur as a result of EMDR treatment (Shapiro, 1995).
The client should be informed that, as with any therapeutic technique, family and friends are also affected by these changes. The client needs to be equipped with the skills to cope with these changes. If possible, it may be a good idea to prepare the family or a close friend for changes that may occur. Secondary gains may need to be addressed also. The therapist should identify what the client will need to confront or give up when treatment is started or succeeds. The client’s stability and resources available should be addressed before beginning EMDR. There are no medications that are indicated to completely block EMDR processing. However, benzodiazepines have been reported to reduce treatment efficacy. Therefore, a client who is on medication for emotional distress should be monitored closely so that the medication can be reduced or discontinued at the appropriate time. As the disturbing material is processed and the symptoms are alleviated, the need for medication to treat the problem is reduced. The treated memory should be reassessed after the medication has been discontinued because it can return with 50% of its original associated disturbance. For example, a trauma victim that was given a rating of a 10 on the SUD scale may decline to a post-treatment level of 0 while the client is on medication, but once medication has been discontinued, the memory may produce a rating of 5. Therefore, these traumas should be processed again when the client is no longer taking medication (Shapiro, 1995).
Therapists should be aware of any abreactions that may occur during EMDR. This is a normal and potential part of the integrative emotional and cognitive processing of the target. This is not viewed as mandatory or unnecessary, but should be accepted as an integral part of the client’s subjective response during the processing of the dysfunctional information. These targeted memories are considered to be information packages, which are stored in the nervous system with the original perceptions and are held intact in a specific form. The client may notice both the sensory cues that were originally perceived and the thoughts that were occurring at the time of the event when these memories are stimulated. The physical sensations and emotions that are part of the information about the targeted memory may also be stimulated. These may be experienced with intensity that can mimic the intensity of the original experience or mimic just a glimpse of the memory. The focus of the session is to target and access the stored dysfunctional information. When these experiences are brought to consciousness they may be experienced at a high level of intensity necessary for sufficient processing. The client should not be encouraged to force an abreaction or to suppress one. This is where the therapist plays a significant role in the process. The therapist’s ongoing message should be, “Let whatever happens, happen.” If the client is forced to conform to a clinical standard, it could be detrimental to the full therapeutic efficacy (Shapiro, 1995).
The therapist must pay close attention to creating a safe psychological environment with the child to ensure the successful use of EMDR with this population. EMDR should not be used with children unless the therapist is comfortable working with children. During the history taking phase, it may be important for the parent to brief the therapist about the problem with the child present and then have the parent leave the room while the child presents their version of the event or problem. This gives the child a sense of being important when the therapist’s full attention is focused exclusively on the child. During the EMDR treatment session, the child should be seen without the parents present in order to maximize the child’s focus on the target. If the child has fears of separation, then the parent may need to be present at times. Having the child bring along a favorite stuffed animal or toy to the treatment sessions may help with the fear of separation or anxiety associated with being away from parents. It is important to provide the child with a sense of self-healing and efficacy. EMDR should not be referred to as a magical cure with children (Shapiro, 1995).
The child should establish a safe place before beginning EMDR. A feeling of safety is induced in the child through use of eye movement sets in the context of a positive experience. For example, the therapist might ask the child to remember a time when they were in control and felt good. The therapist might have the child imagine looking, feeling, and acting in a positive way. The child holds this image in mind and the sets are repeated until the child has a positive feeling as imagined in the image. This positive experience with the eye movements allows children to trust the process, since positive feelings are immediately evoked and they are positive associations to the therapeutic experience. The difficulties that therapists are faced with when counseling children are primarily due to concentration problems and somewhat short attention spans. The average EMDR treatment session with children is about 45 minutes, during which eye movements are often interspersed with other activities. Such sessions are likely to be therapeutically effective because children appear to respond favorably to EMDR quickly (Shapiro, 1995).
The standard EMDR procedure should be adjusted in many ways to enhance the child’s concentration. The therapist would need to engage many external stimuli as focal points. The SUD Scale is often too abstract for children and it is important to use concrete definitions of feelings for SUDS. The children can use their hands to indicate the magnitude of a feeling. For example, holding the hands at chest level, with arms parallel to the arms of the chair, can be defined as, “very bad, terrible, and awful,” or other words that will evoke the child’s negative experience. In children with ADHD, there is often tactile defensiveness that makes them uncomfortable when in close contact with the therapist. These children should be asked to move their eyes back and forth between two spots on the walls. To engage their attention these spots may be in the form of colored circles, cartoon figures, or comic book heroes. The therapist should also embrace the child’s imagination during sessions. For example, the EMDR treatment session may be initiated by asking the child to “imagine what happened,” or to “bring up the picture.” After the eye movement set, the child can be asked to “blow up the picture,” or “explode” it. The therapist can assist in this process by making the sound of an explosion or by using gestures that the child can mimic. The therapist then asks, “How does it feel now?” After redirecting the child’s attention to the picture, the clinician adds a set of eye movements and repeats the request to “blow up the picture.” The negative and positive cognitions should be elicited with school age children. The therapist initiates a set of eye movement after asking the child to imagine the scene and respond to a question, such as, “What thoughts do you have?” or, “What do you think about in the picture?” Usually, the child will respond with statement that indicates an external locus of control. For example, “The teacher hates me,” (negative cognition) or, “The teacher likes me,” (positive cognition). The therapist may ask the child to hold a picture of the “teacher hating” while one or two sets of eye movements are processed. The child is then asked, “What thoughts do you have,” or, “What do you think about yourself now?” Due to the fact that a child’s cognitive structure is not like that of an adult’s, the therapist should offer the child the closest approximations to self-efficacy statements, such as, “I am okay,” or, “I feel good,” without adhering completely to the guidelines about positive cognitions for adults (Shapiro, 1995).
A visualized container can be used to store skills or other resources for later when using EMDR with children and adolescents. The child or adolescent can rehearse accessing the container in a potentially challenging situation. This is part of the installation of a future success. One use for the container is in preparation for work on a memory that may bring the client’s anger out and is directed towards a parent. The container can be used to hold the “good parts” or positive attributes of the parent to keep them safe during the trauma work. Once the anger and other feared emotions have been processed, the contents of the container can be retrieved. These installations can be used in succession. One example is by combining an installation on schoolwork with a role model installation of someone who is good at taking tests. For children who refuse to consider upsetting memories or for those where it is important to focus on building skills and self-esteem, EMDR work may be restricted to positive installations. When EMDR work with a traumatic memory seems stuck, using a positive installation usually gets the process moving again (Greenwald, 1999).
When a session is coming to an end and the child is still working with unresolved material they can be asked, “Where do you want to put those feelings away until next time?” The image of packing them in a box, a safe, or therapist’s file cabinet can be installed. This can help the child to contain themselves following a disturbing session. It is important to be sensitive to the child’s sensitivity to frustration, failure, and threats to self-esteem. It is suggested that there should be an emphasis on positive installations designed to build self-esteem, social skills, and learning skills. For example, after working through the issue of performance anxiety, a memory of a good or successful feeling would be installed. If the child cannot recall one, the therapist helps to create this capacity by installing ego ideals or role models. This is also useful in installing appropriate social skills (Greenwald, 1999).
There are also risks and concerns with using EMDR with the child and adolescent population. EMDR for major trauma and loss can be a critical component of treatment for children and adolescents with behavioral problems. Many clients are often reluctant to try EMDR on even minor upsetting memories. Major concerns are the risk of being overwhelmed by affect leading to violent or self-destructive behavior, client’s fear of being overwhelmed, and a premature EMDR attempt leading to refusal to continue. These concerns are significant in a population with limited coping skills and habitual acting out. Therefore, the therapist should proceed with caution and establish a good therapeutic relationship, to include the client’s coping skills, before proceeding with work on major trauma or loss (Greenwald, 1999).
There is also some controversy about EMDR as a treatment modality. There are some criticisms of EMDR that need to be considered in this study. Harvard psychologist and EMDR critic, Richard McNally, insists that much of the research in support of EMDR was poorly designed and that the more methodologically superior research indicates that it has less impact than its supporters maintain. However, EMDR’s critics admit that it does have some clinical impact, though they question whether it offers anything beyond the more established PTSD treatments. Others argue that EMDR has little impact beyond the simple relaxation and exposure to traumatic memories evoked in treatment, key elements of numerous other treatments. McNally opines that EMDR works on the same way pink aspirin works. Pink aspirin will relieve headaches, but its efficacy will be due to its analgesic properties not the pink food dye. In response, Francine Shapiro argues that the research does in fact strongly confirms the efficacy of EMDR, but that some researchers have left out key components of EMDR, such as cognitive components and free association. This ignores the fact that EMDR treatment does not work as well without all of its elements. Shapiro states that such research is not a fair test of EMDR. The research has in fact shown that EMDR, compared to simple exposure methods, has proven that EDMR has equivalent effects and that these studies show that EMDR works more efficiently, showing results in fewer treatments. EMDR has received support from neuropsychologists and from many other well-known therapists. According to Lebow (2003), the issue with this controversy lies with the fact that researchers in the debates about EMDR must understand the mind-set and working context of clinicians, so they can better communicate their findings to those who should be their primary audience. This is a significant reason to continue research in the area of EMDR and it’s efficacy with children and adolescents as well as with adults.
Greenwald (1999) approaches assessment and treatment of children and adolescents a little differently. The individual portion of treatment usually begins with EMDR for trauma and loss, followed by EMDR-enhanced skill development for self-control and other desired behaviors related to doing well in school and socially. There are cases that warrant medication and/or a formal behavior modification program, or both. Greenwald usually begins assessment by drawing a genogram, which is a map of the family and their relationships to one another. The therapist attempts to get basic information without opening the child up to wounds. If the parents have discussed additional events not volunteered by the child, the therapist can ask about them as well. It is important to get a SUDS rating on each event, as well as the approximate age at which it happened. Possible trauma symptoms should be identified and noted because they may be distressing and, therefore, provide motivation for treatment. The “menu” approach is useful because children seem to find it easier to select from a menu than to initiate disclosure of such socially unacceptable things such as not having friends. If these problems reflect trauma effects, other causes should not be ruled out.
Connecting a problem behavior to specific experiences helps to forgive the child somewhat. It is not that the child was born “bad”, or that he wants to “be bad”; they are just stuck with some bad feelings from past experience, and do not know what else to do. This view of the problem allows for sympathy as well as expectation of change, and it sets the stage for both the individual and the family interventions. Parental support is very important in treatment. The therapist should point out the parents’ contributions at every opportunity, even pointing out in sessions that the parental support has made the child’s improvements possible. The therapist can establish a routine of disclosure for each session by checking in. They can ask, “Tell me about the best thing and the worst thing that happened since we met last.” This structure is reassuring for the child. The check-in encourages the child to reveal what is most pressing on their mind and supplies raw material for other interventions. The therapist can request more information as therapy progresses and the client becomes more comfortable with this routine (Greenwald, 1999).
Greenwald (1999) uses another technique in EMDR with children and adolescents with disruptive behavior disorders called “Getting Stronger.” The child’s sense of physical strength can give them the confidence to face difficult emotional material. The therapist can help the child to build up their sense of strength and confidence in many ways with EMDR integrated into these interventions. In the “Getting Stronger” intervention, the therapist may say something like the following: “We were talking about your getting stronger. How strong are you? Make a muscle, let me see.” The child then makes a muscle. The therapist may ask, “How many pushups can you do?” The child would reply a number, such as “five”. The therapist then asks them to show how they can do this and counts as the client demonstrates. The therapist praises this effort and then says, “I bet you can do even more when you come back next week.” The therapist may ask what things the child does to make themselves strong, such as riding a bike, playing tag, lifting weights (adolescent), or playing basketball. The therapist makes the point that the more exercise you get the stronger you get. The therapist tells the client that they are going to see if the client can do something that might be hard and see if it’s too hard or if they can do it. The therapist then explains they are going to move their hand back and forth and demonstrates a set of eye movements. The therapist then asks the child to put a picture with the thought of them getting stronger. The therapist then adds the statement, “I am getting stronger” for the client to think of during the eye movements and picture the client has put with getting stronger. The therapist does this a number of times and asks the client to list those things that make them stronger, like basketball or riding a bike. The therapist asks the client to pick one and installs this through EMDR. This is an example of what an installation of positive cognition might be like in using EMDR with children. Installations involving strength and strength-building may be repeated on various occasions throughout the treatment.
The therapist should have a list of trauma and loss memories, including age and SUDS level, from the evaluation phase of treatment. These should be worked through in chronological order or in order with a given theme. Training in self-control skills may include relaxation, self-talk, thinking about choices and consequences and problem solving, depending upon the therapists’ routine, available role models, and the child’s specific problem areas. Typical problem areas are academic challenges, feeling betrayed or put down, losing in a game, and not having one’s way. EMDR interventions are used to enhance the learning of control skills. The trauma-related triggers, which induce the child to overreact in challenging situations, may also get desensitized along the way. Latency-aged children generally have the best chance of mastering these skills only following resolution of traumatic memories (Greenwald, 1999).
The “Choices Have Consequences” intervention desensitizes the child to common situational triggers while raising their awareness that their impulsive responses are actually behavioral choices, and that they can do better. Imagery rehearsal of alternative and more effective behavioral choices are built in. The first step is to identify a typical challenging situation as well as positive behavioral alternative to the child’s habitual impulsive acting-out response. This response is determined through teacher reports, parent reports, and initial evaluation. The therapist can help the child come up with appropriate strategies, including imagery, self-talk, and behaviors, and can use role plays and cognitive reframes to help develop positive alternatives. This provides specific required material including the negative and positive behavioral alternatives along with the likely outcome associated with each choice. The intervention includes having the child concentrate on the typical challenging situation, and imagine viewing a “movie” of it during eye movements. The movie is viewed first with the child’s typical impulsive, acting out response, and paired with a typical bad outcome. Then the movie is viewed with a more desired outcome. The child is given the behavioral choice in the movie, but instructed as follows: “Bad choice, bad ending; good choice, good ending.” This intervention can be applied in many situations, such as getting frustrated during a school task (Greenwald, 1999).
Greenwald (1999) reports that EMDR appears to be effective with traumatized children and adolescents, even though documentation specifically relating to this population is limited. Hundreds of cases have been informally reported with generally positive results. Published case reports have been positive and consistent with findings of EMDR treatment with adults. The only difference is that treatment with children may be more rapid. Greenwald reports that five children treated with one to two EMDR sessions several months after a hurricane recovered to their pre-trauma symptom levels, with gains maintained at a one month follow-up. Chemtob and Nakashima (1996) reported positive results in using EMDR with children traumatized by Hurricane Iniki who had failed to respond to a generally effective previous treatment program. Participants averaged a 58% reduction on the primary trauma measure following three sessions, with results remaining several months later. Significant reductions were also found on anxiety and depression measures, as were visits to the school nurse. Puffer, Greenwald and Elrod (1998) also reported on a study of 20 children and adolescents ages 8 to 17, who were not randomly assigned to either an EMDR treatment or delayed-treatment groups. Treatment was a single session and focus was on a single trauma or loss. There was no change during the first month, no-treatment delay, and significant improvement between the first and last scores on all measures. On the best measure of trauma symptoms (Impact of Events Scale), 11 of the 17 participants moved to normal levels, 3 dropped 12 or more points and 3 stayed the same.
Greenwald (1999) reports that Rubin and Bischofshausen (1997) conducted a randomized study at a child guidance center, with EMDR added as an eclectic treatment for the experimental group. These participants had a variety of diagnoses, and all had a trauma history. Ratings ranged from adequate to good. Some researchers have targeted traumatic memories with EMDR in the hopes of reducing criminal or acting out behaviors. For example, Soberman, Greenwald and Rule (1998) provided three sessions of EMDR focused on a primary identified traumatic memory as an adjunct to standard care. The males in the study were ages 10 to 16 and were in residential or day treatment. The trauma measure referencing the treated memory showed greater change than the global trauma measure, probably indicating that additional trauma remained untreated. The EMDR group did significantly better than the control groups and reduced their primary identified problem behaviors by nearly half at the three month follow up. Scheck, Schaeffer and Gillette (1998) reported on EMDR treatment with high risk acting out females ages 16 to 19 and females ages 20 to 25. All reported a trauma history, and over three-fourths met criteria for Post Traumatic Stress Disorder. They were assigned to an EMDR group or an Active Listening treatment group. Post-treatment results indicated that EMDR treatment helped more significantly than that of the Active Listening treatment group. Three-month follow-up showed maintenance of gains (Greenwald, 1999). Therefore, it is apparent that EMDR is an effective treatment strategy for adolescents and children.
Greenwald (1999) reports that these findings suggest that EMDR seems to be as effective with children and adolescents as with adults, but may be even quicker; that EMDR treatment of traumatic memories can affect a wide range of behaviors; and that a different repertoire is needed to use EMDR with children. Greenwald (1999) makes a profound statement by pointing out that many adolescents are trying to cope with their anger and helplessness by harassing and fighting each other and that we, as therapists, are encountering many children with new anxieties and fears. Over time it is expected that we will see an increase in a range of problems relating to post-traumatic stress, mood, school performance, peer and family relations, aggression, crime, and substance abuse. Exposure to trauma and traumatic loss can have a wide range of negative effects on children and adolescents. Greenwald states that we are a traumatized nation and this is evident with the many occurrences of recent natural disasters and terrorist attacks. Children will experience the many negative effects of these traumatic events and other typical traumatic events that individuals and families experience. This is why it is important to put more time and effort into EMDR research and it’s effectiveness with children and adolescents.
Clients benefit the most from therapists who are willing to learn, expand skills, and experiment with innovative methods. This is why EMDR is worth exploring in the treatment of various childhood disorders even though it is a nontraditional therapy for children and adolescents. The originator of Eye Movement Desensitization and Reprocessing, Francine Shapiro, Ph.D, explains that clinical work with EMDR shows us how suffering can be transformed not only into art but also into life. This is a valuable tool for children and adults suffering from any disorder and makes EMDR’s application unique in exploring in the healing process. Eighty-five percent of a sample of 1200 clinicians who participated in an EMDR survey indicated that clients had more repressed memories emerge with EMDR than with any other method. It is important for therapists to understand what precipitates these memories and work to resolve them. Shapiro (1995) suggests that EMDR should be used with appropriate supervision and training. There is also a great need for extensive research to provide further validation that the EMDR method is indisputable. Therefore, studies that seek to broaden the limited research that has been done with EMDR as a treatment modality for behavioral disorders and investigate whether or not it is an effective treatment that can be used, and possibly replicate more studies, are a necessity to the field of psychology (Shapiro, 1995).
The individual portion of treatment usually begins with EMDR for trauma and loss, followed by EMDR enhanced skill development for self-control and other desired behaviors related to doing well in school and socially (Greenwald, 1999). These are skills necessary for adolescents to be successful academically and socially. These are also skills that make one more resilient. By helping adolescents deal with their traumas early in life, they may be less likely to experience significant mental health problems as adults, such as anxiety, depression, and other mental health problems. If we can equip them with the skills necessary to deal with past traumas, whether big or small, then we will decrease their fears, anxiety, anger, and behavioral problems and, ultimately, promote better emotional and social being.

CHAPTER THREE: METHODOLOGY
Introduction
The proposed study will examine EMDR as a treatment modality for addressing negative emotions and reducing ineffective emotional responses in adolescents with behavior problems. EMDR addresses many problems that many adolescents encounter which elicit fear, anxiety, and anger. EMDR has shown positive results within as little as one to three sessions. This study will seek to expand the existing research in the area of EMDR as a treatment modality for adolescents with behavioral problems and explore adolescents’ ability to practice EMDR in treatment sessions. A quasi-experimental mixed design is proposed using a sample of 30 children assigned to either a control group or treatment group, matching on gender and use of medication.
Research Design
A quasi-experimental mixed design will be used to study the effectiveness of EMDR to treat adolescents with self-esteem, anxiety and anger problems. Subjects will be randomly matched on gender and medication use allowing for equal distribution to either control group or treatment group. The treatment group will receive intervention consisting of the EMDR Protocol to address the presenting problem. The EMDR protocol is described in Appendix B. The presenting problem will be addressed in each session. Self-esteem, Anxiety and Anger Scales will be given at the beginning of each session. This intervention will be provided once a week for three weeks.
The control group will receive conventional counseling consisting of traditional therapy techniques. The Rosenberg Self-esteem Scale, and the Burns Anxiety and Burns Anger Scales will be given at the beginning of each session. The presenting problem will be addressed in each session with the control group. Traditional therapy techniques will be used to address the presenting problem. Pre-test and post-test measures of self-esteem, anxiety, and anger will be collected with both the treatment and control group to assess change. Process measures will be collected to assess the EMDR experience at the conclusion of each session using the SUDS and VOCS Scales. Other process measures collected with both the treatment and control group which will consist of two open ended questions will be assessed at the first session and the last session stated as follows: “How have you been feeling over the last week at home?” and, “How have you been feeling over the last week at school?”
Selection of Participants
Non-probability quota sampling will be used to select and enroll 30 participants both of female and male gender from ages twelve to sixteen years old in an outpatient private practice setting.
These adolescents will be selected because they are experiencing behavioral problems in the home and/or school setting. They may also be experiencing symptoms such as anger, fear, self-esteem and anxiety that may contribute to behavioral problems. The adolescents participating in this study are experiencing behavioral problems in the home and/or school setting. They may also be experiencing symptoms such as anger, fear, self-esteem and anxiety that may contribute to behavioral problems. The adolescents participating in the study with their parent or guardian’s consent will have already established a relationship with a counselor. They may or may not be taking under the supervision of a local physician or psychiatrist. It will be noted whether or not they are taking medication during this research study, and an attempt will be made to match on this variable. Participants will also be matched on gender.
Instrumentation
Several self-report measures will be used to collect data to document the entire experience and assess each EMDR session.
Intake. A demographic/intake form (See Appendix A) will be used to gather information on the participants’ basic demographics, current diagnosis, presenting symptoms and/or behavioral problems, current medical conditions and medications.
Process Measures. The Subjective Units of Disturbance Scale (SUDS) (See Appendix J) and Validity of Cognition Scale (VOC) (See Appendix J) will be administered at the beginning and end of each EMDR session (Shapiro, 1995). The SUDS is an eleven-point scale where zero represents neutral intensity and ten equals the highest possible anxiety or disturbance. It is used to rate the negative cognition and memory of the event or presenting problem throughout EMDR and will be used to rate the negative cognition and memory of the presenting problem throughout EMDR after the sets of eye movements. The VOC Scale will be used at every EMDR session to measure intensity of the client’s emotions on a scale of one to seven when the memory is accessed. One represents “completely false” and seven represents “completely true”. The client is asked to choose a number on the scale that indicates the intensity of their emotions on this VOC Scale. These are positive cognitions that become more vivid and valid as the negative cognitions become less valid in EMDR treatment and are rated and measured by the VOC Scale (Shapiro, 1995).
Pre and Post Measures. Three self-report measures will be used to assess change
from beginning to end of the three-session treatment experience in each session. These include: The Burns Five Item Anxiety Inventory (BAI), Burns Five Item Anger Scale (BAS), and the Rosenberg Self Esteem Scale (RSE). The effectiveness of treatment for these presenting problems will be measured through comparison of a pretests (using these inventories) prior to implementation of EMDR sessions and post test after completion of EMDR protocol.
The Burns Anxiety Inventory (BAI), the five item Brief Scale, will be used to measure changes in anxiety level in participants prior to EMDR treatment and post EMDR treatment (Appendix D). The five item BAI asks how much patients have experienced symptoms such as anxiety, nervousness or worrying, “during the past week, including today.” The response scale ranges from 0 (“not at all”) to 4 (“extremely). Scores on the five-item anxiety test range from 0 (not at all anxious) to 20 (severely anxious). The BAI has excellent internal consistency, with a Cronbach’s alpha of 0.90. Burns (1995) research shows the BAI is significantly reliable as well. Research shows that the BAI was highly sensitive in detecting anxiety.
The Rosenberg Self Esteem Scale (RSE) will be used to measure self-esteem in participants with behavioral problems prior to EMDR treatment and post EMDR treatment (Rosenberg, 1965) (Appendix F). It is a ten-item Likert scale with items answered on a four point scale. The items on the RSE represent a continuum of self-worth statements. The ten question scale has four response choices, ranging from “strongly agree” to “strongly disagree”. Research has shown that Rosenberg’s Self Esteem Scale has high reproducibility and scalability coefficients. Multiple studies have been conducted to investigate the validity and reliability of the RSE and found that factors were interdependent and had similar patterns of correlates.
Burns Five Item Anger Scale (BAS) will be used to measure level of anger difficulties prior to EMDR treatment and post EMDR treatment (Appendix E). The BAS five item scale asks how much patients have experienced feelings like “frustrated”, “annoyed”, or “angry” with response items ranging from 0 (“not at all”) to 4 (“extremely”). The scale refers to how they have been feeling over the last week and today. Total scores on the five item BAS range from 0 (no anger at all) to 20 (the greatest possible anger). The scoring key provides specific information about how to interpret specific scores. High scores indicate more anger (Burns, 1997).
Assumptions and Limitations
The focus of this research is on the changes in symptoms with the assumption that symptom reduction is associated with reduction in behavior problems. However, this is not being evaluated and is not a focus of this particular study. The focus is rather on the effectiveness of EMDR in symptom reduction of adolescents with behavior problems.
In this study, a non-random sample will be used which limits external validity. The target population, a private practice setting in Florence, S.C., is very limited in size and scope, so the researcher will utilize the first 30 adolescents who agree to participate. One of the assumptions of the quasi experimental mixed design is that the participants can be assigned to treatment so that the groups are comparable in both their composition and participation. The researcher has limited control over assignment of participants to the conditions because of the manner in which the participants are being recruited, and this will likely impact the homogeneity of the two groups at the pretest, increasing the risk of Type II error. In particular, participants in this study may have many different diagnoses and presenting issues and/or symptoms which may obscure the treatment effect. Attempts will be made to maximize the homogeneity of the participants using the matching procedure outlined above (Gliner & Morgan, 2000).
The study is also subject to the limitations of the administration of the intervention. The bilateral stimulation, desensitization, and reprocessing of the EMDR protocol will be used instead of the entire typical EMDR protocol. There will be three sessions rather than more in an effort to minimize attrition. There is some research to suggest that EMDR is effective in as little as one to three sessions (Shapiro, 1995).
It should also be noted that there is risk for research bias in this study. The experimenter and the researcher are the same, and the researcher has a pre-existing relationship with the adolescents. There are risks associated with using EMDR with adolescents. Many clients are often reluctant to try EMDR on even minor upsetting memories. Major concerns are the risk of being overwhelmed by affect, leading to violent or self-destructive behavior, client’s fear of being overwhelmed, and a premature EMDR attempt leading to refusal to continue. These concerns are significant in a population with limited coping skills and habitual acting out (Greenwald, 1999). This will be addressed by offering therapy after termination of research. Contact information will be provided to the participants that need follow-up therapy, as well as a referral to a counselor if needed.
Procedures
Permission has been obtained to conduct this study from the private outpatient practice where the participants in this study are currently being treated. An intake/interview will be conducted with each participant (client) and parent where informed consent will be obtained for participation in the study and presenting problem or symptoms will be identified. Confidentiality, benefits and risks of this treatment will be explained during this first interview session. Informed consent will be obtained as well. There will be a total of four sessions. The first session will consist of an interview, review of confidentiality, benefits from participation, and informed consent. Over the next three weeks, the treatment group will receive three EMDR sessions. The Adolescent Behavioral EMDR Protocol, or ABEP (see Appendix H), will be used for the treatment group in this study. This protocol is adapted from Shapiro’s (2005) Eight Phases of EMDR Treatment. The control group will receive conventional therapy, and EMDR will be offered at the concluding session.
A SUDS rating will be provided by the client at the beginning of each session to rate the negative cognition and memory of the presenting problem throughout EMDR after the sets of eye movements. A VOC rating will be provided by the client to measure intensity of the client’s emotions when the memory is accessed at the beginning and end of each EMDR session. The Rosenberg Self-Esteem Inventory, Burns Anxiety Inventory, Burns Anger Inventory and open ended questions will be given at the final EMDR session.
Data Processing and Analyses
The purpose of the research is to assess the effectiveness of EMDR as a treatment for behavioral problems for adolescents who may be experiencing symptoms low self-esteem, anxiety and anger. After conducting exploratory analyses to check for normality in the dependent variables, ANCOVA will be conducted on each dependent variable to determine the statistical significance of differences between the two groups. The specific hypotheses are:
The Burns Five Item Anxiety Inventory (BAI), Burns Five Item Anger Scale (BAS), and the Rosenberg Self-Esteem Scale (RSE).
Ho: There will be no difference between the treatment and control group in changes in anxiety, as measured by the BAI
Ha: The treatment group anxiety ratings will be lower than the control group in changes in anxiety, as measured by the BAI
Ho: There will be no difference between the treatment and control group in changes in anger, as measured by the BAS
Ha: The treatment group anger ratings will be lower than the control group in changes in anger, as measured by the BAS
Ho: There will be no difference between the treatment and control group in changes in self-esteem, as measured by the RSE
Ha: The treatment group self-esteem ratings will be lower than the control group in changes in self-esteem, as measured by the RSE
Results of the process measures will be presented graphically.

CHAPTER FOUR: RESULTS

Introduction

The purpose of this study was to examine EMDR as a treatment modality for addressing negative emotions and reducing ineffective emotional responses in adolescents with behavior problems. This study intended to expand the existing research in the area of EMDR as a treatment modality for adolescents with behavioral problems and explore adolescents’ ability to practice EMDR in treatment sessions. A quasi-experimental mixed design was conducted using a sample of 18 children assigned to either a control group or treatment group, matching on gender and use of medication. The research addressed the following questions:

1. What is the effectiveness of EMDR as a treatment modality for managing anxiety in adolescents with behavioral problems?

2. What is the effectiveness of EMDR as a treatment modality for managing anger in adolescents with behavioral problems?

3. What is the effectiveness of EMDR techniques in improving self-esteem in adolescents with behavioral problems?

4. What is the session experience of participants who are exposed to the EMDR intervention?

The sample size was intended to be at least thirty participants, but only 18 were recruited to participate in the study. The small sample size did not provide sufficient power to test hypotheses.
Characteristics of the Sample

Characteristics of the sample are summarized in Table 1. Half of the participants were male and half were female. Half were middle school students and half were high school students. More than half of the participants were Caucasian. These demographics are typical of the private practice in which the study took place.
Table 1
Demographic Characteristics of the Sample (n=18)
Category Frequency Percent
Males 9 50%
Females 9 50%

6-8th grade 8 44%
9-12th grade 10 56%

Caucasian 11 61%
African-American 6 33%
Other 1 6%

Characteristics of the primary and secondary diagnoses of this sample are summarized in Table 2. More than half (61%) of the participants had a primary diagnosis consisting of a mood disorder (Bipolar and Depression). Nearly 30% had a primary diagnosis of ADHD and Behavioral Disorders and approximately 10% of the sample had a primary diagnosis of PTSD. There were no participants in the sample that had a primary diagnosis of Adjustment Disorder. Fifty percent of the sample did not have a secondary diagnosis. Nearly 30% of the sample had a secondary diagnosis of ADHD or Behavioral Disorders, and less than 10% had a secondary diagnosis of Depression, Bipolar Disorder and PTSD. Approximately 10% of the sample had a secondary diagnosis of adjustment disorder. Nearly 70% of the sample was taking psychotropic medications in this sample which is typical for children with these disorders who are in treatment. This is typical of children receiving treatment in an outpatient private practice setting.
Table 2
Diagnostic and Treatment Characteristics of the Sample (n= 18)
Variable Name Freq. Percent
Primary Diagnosis
ADHD & Behav D/O 5 28%
Bipolar D/O 4 22%
Depression 7 39%
PTSD 2 11%
Adjustment D/O 0 0%

Secondary DX:
ADHD & Behav 5 28%
Bipolar D/O 0 0%
Depression 1 6%
PTSD 1 6%
Adjustment D/O 2 11%
None 9 50%

Use of Prescribed Medication
Yes 12 67%
No 6 33%

Characteristics of the family background are summarized in Table 3. Half of the participants in this sample came from a single parent family and the remainder of the sample lived with either both parents or another guardian. Nearly 80% of the participants had a family member(s) with a mental health history or diagnosis.
Table 3
Family Characteristics of the Sample n = 18
Category Frequency Percent
Both Parents 5 28%
Single Parent 9 50%
Guardian 4 22%

FMHX Yes 14 78%
FMHX No 4 22%

Characteristics of the social and environmental factors in this sample are summarized in Table 4. About 20% of participants were in a resource or self-contained class at school. Approximately 30% had a psychiatric hospitalization previously. Nearly 20% had some sort of legal involvement previously (DJJ/Law Enforcement) and nearly 40% had experimented or used substances.

Table 4
Social and Environmental Characteristics of the Sample n = 18
Category Frequency Percent
Resource/Self-contained class
YES 4 22%
Resource/Self-contained class
No 14 78%

Psychiatric Hospitalization
Yes 5 28%
Psychiatric Hospitalization
No 13 72%

Legal Involvement
Yes 3 17%
Legal Involvement
No 15 83%

Substance Abuse
Yes 7 39%
Substance Abuse
No 11 61%

Research Results
RQ#1: What is the effectiveness of EMDR as a treatment modality for managing anxiety in adolescents with behavioral problems?

All participants completed the Burns Anxiety Inventory measure before each of the three sessions. The mean scores presented in Table 5 and Figure 1 suggest a pattern of differences for the treatment group and that the scores continue to decline throughout these three sessions. This suggests that EMDR is having some positive effect on symptoms and level of anxiety, although we cannot say that it is statistically significant. The treatment group started with high level of anxiety and ended in the third session with lower anxiety. The control group began with high anxiety that was even higher in session two, but by session three had decreased. The biggest difference between the two groups was that there was more of a decrease in level of anxiety by the third session in the treatment group as opposed to the control group. There is not enough variance and large enough sample to determine if it is significant, but it does suggests that the treatment group’s anxiety symptoms did improve.
Table 5
Mean Scores of Participants Burns Anxiety Inventory
Mean (SD) Mean (SD) Mean (SD)
Time 1 Time 2 Time 3
Total Mean (n=18) 6.67 (3.97) 6.5 (4.83) 5.5 (3.63)
Control Group Mean 7.67 8.11 7.57
Treatment Group Mean 6.67 4.89 3.89

Figure 1. Mean Scores for Burns Anxiety Scale

RQ#2: What is the effectiveness of EMDR as a treatment modality for managing anger in adolescents with behavioral problems?

All participants completed the Burns Anger Inventory measure before each of the three sessions. The mean scores are presented in Table 6. Higher scores represent greater level of anger and lower scores represent lower level of anger. Table 6 and Figure 2 reveal differences between the two groups over time. Interestingly, the control group had a much higher mean than the treatment group at Time 1, and the biggest decrease in level of anger was by the third session. In contrast, the Treatment Group scores changed incrementally, slightly higher, then lower at the third session.
Table 6
Mean Scores of Participants Burns Anger Inventory
Mean (SD) Mean (SD) Mean (SD)
Time 1 Time 2 Time 3
Total Mean (n=18)
9.80 (5.48)
8.06 (5.20)
7.33 (5.46)

Control Group Mean 11.22 7.00 5.14
Treatment Group Mean 8.25 8.63 7.50

Figure 2. Mean Scores for Burns Anger Scale

RQ#3: What is the effectiveness of EMDR techniques in improving self-esteem in adolescents with behavioral problems?

All participants completed the Rosenberg Self-Esteem measure before each of the three sessions. The mean scores are presented in Table 7 and Figure 3. The increase in scores represents improved self-esteem and decrease in scores represents a decrease in self-esteem for participants. The Table seven and Figure 3 show that Self-Esteem improved for the treatment group and Control Group over the three sessions. The control group showed slightly improved self-esteem in two, but self-esteem stayed the same for control group with no improvement between sessions two and three. There is a slightly higher average score for the Treatment group, but descriptively does not reveal substantive differences.
Table 7

Mean Scores of Participants Rosenberg Self-Esteem Measure
Mean (SD) Mean (SD) Mean (SD)
Time 1 Time 2 Time 3
Total Mean (n=18)
20.35 (4.78)
21.12 (4.58)
22.20 (4.35)

Control Group Mean 21.25 22.00 22.00
Treatment Group Mean 20.13 21.00 22.75

Figure 3. Mean Scores for Rosenberg Self-Esteem Measure

RQ #4: What is the session experience of participants who are exposed to the EMDR intervention?

Participants in the treatment group completed the SUDS and VOC Scales at the beginning of each session and at the end of each session for three sessions. The median scores are presented in Table 8 to show the change over the three sessions. The SUDS Scale is an eleven point scale where zero represents neutral intensity and ten equals the highest possible anxiety or disturbance. It is used to rate the negative cognition and memory of the event or presenting problem throughout EMDR and will be used to rate the negative cognition and memory of the presenting problem throughout EMDR after the sets of eye movements. The VOC Scale was used at every EMDR session to measure intensity of the client’s emotions on a scale of one to seven when the memory is accessed. One represents “completely false” and seven represents “completely true”. The client was asked to choose a number on the scale that indicates the intensity of their emotions on this VOC Scale (Shapiro, 1995).
Table 8

Treatment Group - Average Change in SUDS and VOC Between Sessions (n=9)

Treatment Group
SUDS Total Mean VOC Total Mean
Session 1 9 4
Session 2 7 5
Session 3 6 7

Table 8 represents the average median score for change in between sessions for the treatment group on the Subjective Units of Disturbance Scale and the Validity of Cognition Scale. In SUDS session one the average median score was nine, which is a higher level of disturbance. This level of disturbance decreased two points by session two, and by three points upon the final session. In VOC session one, the average median score for the positive cognition/belief was a four (“How true does the positive thought/words sound to you”). It increased one point on average by the second session, and by the third session the average positive cognition/belief score was at a seven, a much higher level of positive belief. This data suggests that EMDR works to decrease level of disturbance/negative emotions in between counseling sessions and that it works to increase positive cognition/belief in between counseling sessions. This is not statistically significant, but according to the data available it suggests that EMDR is having some impact.
Table 9

SUDS (Subjective Units of Disturbance) Scores of Treatment Group for Three Sessions (n=9)

SUDSx1B SUDSx1A SUDSx2B SUDSx2A SUDSx3B SUDSx3A

Mean 9.33 6.44 8.33 4.56 6.89 4.11
Median 10 8 9 5 10 2
Mode 10 1 10 0 10 0
Standard Deviation 1 3.57 1.94 3.84 4.04 4.04
Kurtosis 3.64 -1.02 2.65 -2.09 -1.76 -2.06
Skewness -1.82 -0.78 -1.53 -0.06 -0.70 0.33
Range 3 9 6 9 9 10
Minimum 7 1 4 0 1 0
Maximum 10 10 10 9 10 10

B=Before Session Began A=End of the Session

Table 9 represents the change within sessions for the treatment group on the Subjective Units of Disturbance Scale with all descriptive statistics. The higher the score the more disturbing the thought or image is to that person (“How Disturbing is that thought or image to you now?”). Therefore, the table above shows that in the treatment group that the participants reported a decrease in the disturbing image or thought within each session. This table also shows that by the third session that the subjective unit of disturbance was even lower. This data is skewed due to the small sample size and not distributed normally, so the median was chosen to measure change in between and within sessions. This table shows that on average in session one subjects level of disturbance went down two points. On average, in session two the level of disturbance went down four points and by the third session subjects level of disturbance had decreased by an average eight points. This suggests that EMDR treatment was effective with the treatment group in decreasing negative thoughts and images. In summary, SUDS scores did decrease which gives the indication that EMDR has had some effect even though statistically we cannot say if it is significant or not.
Table 10

VOC (Validity of Cognition Scale) Scores of Treatment Group for Three Sessions (n=9)

VOCx1B VOCx1A VOCx2B VOCx2A VOCx3B VOCx 3A

Mean 3.50 5.22 4.56 5.67 6.33 6.67
Median 3 5 4 6 7 7
Mode 3 5 7 5 7 7
Standard Deviation 1.58 1.20 2.07 1.32 0.87 1.94
Kurtosis -1.34 0.27 -1.67 0.73 -1.08 3.26
Skewness 0.67 -0.54 0.12 -0.88 -0.82 1.27
Range 4 4 5 4 2 7
Minimum 2 3 2 3 5 4
Maximum 6 7 7 7 7 11

B=Before Session Began A=End of the Session

Table 10 represents the change within sessions for the treatment group on the Validity of Cognition Scale with all descriptive statistics. The higher the score the more positive the feeling and thought is on this scale (“How true does that positive thought or statement about yourself feel to you now?”). This table shows the scores for VOC before the session began and after the session ended for each of the three sessions given. Therefore, the table above shows that in the treatment group that the participants reported a slight increase in the positive thought and feeling within each session. This table also shows that by the third session that the subjective unit of disturbance was even lower. This data is also skewed due to the small sample size and not distributed normally so the median was chosen to measure change in between and within sessions for the VOC. This table shows that on average in session one subjects’ positive cognition or thought/belief improved by two points on the lower end of the VOC scale. In session two, there was an average of change of two points as well, but the subjects started out at a higher level of positive thought/belief. By the final session, on average the subjects started the session at the highest level of positive cognition/belief and there was no decrease by the end of the final session. The positive cognition remained the same. This suggests that EMDR treatment was effective with the treatment group in improving their positive thoughts, beliefs and feelings about self. In summary, VOC scores did increase which gives the indication that EMDR works even though statistically we cannot say if it is significant or not.
Subjective Session Experience

Participants in the experimental group were asked to talk about what the EMDR experience was like for them at the end of each EMDR session. They were asked, “What was that like for you?” and, “How did you feel?” Overall the participants reported positive experiences. When asked how they felt, many participants said it was “different”, “weird”, or “creepy”, but that it helped. Five of the participants in the EMDR group reported their experience to be, “good, okay or cool,” and that it was difficult to think in a negative way or of negative thoughts. Eight reported that it was different or that it changed by the end, and one reported that it changed their mind for a second and that they thought of positive things. Three reported that it was hard to think of it between sessions one and three, and that their mind went blank, making them unable to think of the negative thoughts or think of anything at all. Several also reported they felt calm or relaxed, and some described it as follows: “I am thinking of me being in the car like the movie Back to the Future”; “It was like yoga for the eyes”; and “It flowed right out of me”. There were two participants that were resistant to EMDR therapy itself and resistant to explore further their thoughts and feelings during their participation in the treatment group. Their resistance could have contributed to the lack of significant differences.
In summary, the results of this study suggest that the EMDR session experience improved positive thoughts, beliefs and feelings about self. Anxiety level in the EMDR treatment group continued to decrease throughout the three sessions, which suggests that EMDR is having some effect on level of anxiety, although we cannot descriptively say that it is a significant difference. The treatment group scores for the Burns Anger Inventory changed incrementally and slightly higher then lower by the third session and suggests that EMDR may have an effect on decrease in level of anger, but again we cannot say whether it is statistically significant or not. The treatment group did have a slightly higher average score than the control group for self-esteem showing a higher level of self-esteem. However, descriptively it does not reveal substantive differences. VOC scores on average did decrease with the treatment group in improving their positive thoughts, beliefs and feelings about self. VOC scores suggests that EMDR works to decrease level of disturbance/negative emotions in between counseling sessions and that it works to increase positive cognition/belief in between counseling sessions. This is not statistically significant, but according to the data available it suggests that EMDR is having some impact. This is not statistically significant, but according to the data available it suggests that EMDR is having some impact. The SUDS scores indicating level of disturbance decreased two points by session two and by three points upon the final session. The subjective session experience comments indicate that participants in the treatment group did have a positive experience and that their thoughts and emotions were affected and did change. Overall, there is neither enough variance nor large enough sample to determine if it is significant, but it does suggest that the treatment group’s symptoms of anxiety, anger, and low self-esteem did improve, as did positive thoughts, and suggests a decrease in level of disturbance of emotions and thoughts.

CHAPTER FIVE: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
Summary

Between 30% and 50% of hyperactive children suffer from associated behavioral disorders. Children with Attention Deficit Hyperactivity Disorder (ADHD) experience additional problems that are as important as the fundamental symptoms of the disorder itself. Many children referred for problems with attentiveness also have a combination of aggression and hyperactivity. Fewell and Deutscher (2002) report that ADHD has become the most common neuropsychiatric syndrome in children. They report that it affects three to five percent of approximately two million school age children, according to the United States Department of Education (National Institutes of Health, 1998).
This study examined EMDR as a treatment modality for addressing negative emotions and reducing ineffective emotional responses in adolescents with behavior problems. Eighteen adolescents in middle school through high school participated in this study. Half of them were males and half were females. Sixty one percent had a primary diagnosis that consisted of a mood disorder. These adolescents were experiencing behavioral problems and negative emotions and had various diagnoses. Nearly thirty percent of the sample had a secondary diagnosis of ADHD or Behavioral Disorders, and less than ten percent had a secondary diagnosis of Depression, Bipolar Disorder and PTSD. Approximately ten percent of the sample had a secondary diagnosis of adjustment disorder. Nearly seventy percent of the sample was taking psychotropic medications in this sample which is typical for children with these disorders who are in treatment.
Shapiro (2004) states that there can be large “T” (trauma) events and small “t” events. Shapiro reports that the large “T” events are those trauma experiences that justify a diagnosis of PTSD such as natural disasters, catastrophic illness and loss. The small “t” events refer to those experiences that make us feel unsafe or unloved. These can be humiliations, loss, or failure of any kind. For children, it can include being bullied, excluded from various things, or simply falling off their bike. Therefore, some participants in this study have experienced Large T’s” and some experiences were small “t’s”.
Another purpose of this study was to expand the existing research in the area of EMDR as a treatment modality for adolescents with behavioral problems and explore adolescents’ ability to practice EMDR in treatment sessions. A quasi-experimental mixed design was used with a sample of 18 adolescents assigned to either a control group or treatment group, matching on gender and use of medication. Non-probability quota sampling was used to select and enroll participants both of female and male gender in grades from middle school to high school in an outpatient private practice/contractual setting.
The adolescents selected in this study were selected because they were experiencing behavioral problems in the home and/or school setting. They also have been experiencing symptoms such as anger, fear, self-esteem and anxiety that contribute to behavioral problems. Three self-report measures were used to assess change from the beginning to end of the three-session treatment experience in each session. These included: The Burns Five Item Anxiety Inventory (BAI), Burns Five Item Anger Scale (BAS), and the Rosenberg Self Esteem Scale (RSE). The effectiveness of treatment for these presenting problems were measured through comparison of a pretest (using these inventories) prior to implementation of EMDR sessions and post test after completion of EMDR protocol.
The treatment group received intervention consisting of the EMDR Protocol to address the presenting problem. The presenting problem was addressed in each session. Self-esteem, Anxiety and Anger Scales were given at the beginning of each session. This intervention was provided once every session for the duration of three sessions.
The control group received conventional counseling consisting of traditional therapy techniques. The Rosenberg Self-esteem Scale, and the Burns Anxiety and Burns Anger Scales will be given at the beginning of each session. The presenting problem was addressed in each session with the control group. Traditional therapy techniques were used to address the presenting problem. Pre-test and post-test measures of self-esteem, anxiety, and anger were collected with both the treatment and control group to assess change. Process measures were collected to assess the EMDR experience at the conclusion of each session using the SUDS and VOCS Scales.
Other Process measures were collected about the treatment groups’ subjective experience to evaluate what their EMDR experience was like. This was done at the end of each EMDR session. Participants reported positive experiences along with other experiences as well. For example, some reported it was “different”, “weird” or “creepy”, but that it helped. Some other positive responses were that it was “good, okay or cool”. Participants also reported that they felt calm, relaxed, and that it was difficult to think in a negative way or of negative thoughts at the end the session. A few used metaphors to explain their EMDR experience such as, “It was like yoga for the eyes,” and, “It flowed right out of me.” Overall, based on EMDR participants’ responses, EMDR was a positive experience.
Conclusions
Personal benefits were expected from participation in this research and the results were mixed. Participants were given the Burns Anxiety and Anger Inventory and the Rosenberg Self-Esteem Scale measures before each of the three sessions to measure whether or not EMDR was an effective treatment modality in reducing anxiety symptoms in adolescents with behavioral problems. Some positive gains appeared in the Burns Anxiety Inventory and Rosenberg Self-Esteem Scale. Both the treatment and control group reported lower levels of anxiety by the third session. In the Burns Anxiety Inventory results, there was more of a decrease in level of anxiety by the third session in the treatment group as opposed to the control group. The treatment group’s anxiety level decreased throughout the three sessions and scores on average were lower than the control group throughout the three sessions. Some gains were not as apparent in the Burns Anger inventory which shows some mixed results. In the Burns Anger Inventory results, the control group started out with a higher level of anger than the treatment group on the anger scale, but then level of anger for control group had decreased by the third session. The treatment group’s level of anger increased slightly at the second session, but had decreased by the third session. Therefore, positive gains were not apparent in the Burns Anger Inventory until the third session. There was a slight positive gain for the treatment group in the Rosenberg Self-Esteem Inventory, due to the slight increase in the average score. However, this was not substantial evidence. The control group’s average self-esteem scored did not change between sessions two and three. Even though this is not substantial evidence, it suggests that EMDR does show some level of positive gains for improvement in self-esteem for adolescents with behavioral problems. Positive gains also appeared in the subjective responses given by participants in the EMDR treatment group, due to positive responses given by the treatment group. Some responses given that noted positive gains or changes were as follows: “It was different”, “weird” or “creepy”, but that it “helped” or “changed” at the end for the better; “I felt calm”; and “I felt relaxed.” Five of the participants in the EMDR group reported their experience to be “good”, “okay” or “cool”, and that it was difficult to think in a negative way or of negative thoughts. One reported that it changed their mind “for a second”, and that they thought of positive things. Several reported that it was hard to think of it between sessions one and three and that their mind went blank. They were not able to think of the negative thoughts or think of anything at all after EMDR session experiences. Some positive metaphors were reported by participants, such as, “I am thinking of me being in the car like the movie Back to the Future”; “It was like yoga for the eyes”; and “It flowed right out of me”. These responses in the subjective experiences implies that EMDR does work for adolescents experiencing behavioral problems by decreasing negative thoughts of self, and disturbing thoughts or events. Overall participants reported in their subjective experience that they felt better and that they felt “calm and relaxed,” which implies that they were less anxious, less angry, and felt better about themselves and the negative event/presenting problem that they received treatment for through EMDR sessions.
SUDS AND VOC Scales were also given at the beginning and end of each session for three sessions for the treatment group. The SUDS scale measured negative cognition and memory of event or presenting problem. The VOC scale measured intensity of emotions on a scale of one to seven of the memory of the problem/event when it is accessed with one representing “completely false” and seven representing “completely true”. The participant is asked when rating intensity of emotion, “How true do the positive thoughts/words sound to you?” The SUDS and VOC scale data suggests that EMDR works to decrease level of disturbance/negative emotions in between counseling sessions and that it works to increase positive cognition/belief in between counseling sessions.
The first SUDS session average median score was nine, which represents a higher level of disturbance. This decreased by two points by session two and by three points upon the final session. The first VOC session average median score for positive cognition/belief was a four when asked, “How true do the positive thoughts/words sound to you?” This average median score increased one point on average by the second session. By the third session, the average median VOC score was a seven, which is a much higher level of belief. SUDS scores did decrease, which gives the indication that EMDR works. However, statistically we cannot say if it is significant or not.
The SUDS and VOC data suggests that EMDR decreases level of disturbance of negative emotions and increases positive cognitions/beliefs in adolescents who are experiencing behavioral problems. The participants in the treatment group reported a decrease in disturbing thought or image within each session on the SUDS scale. Due to the small sample size and the non-normal distribution, the median score was used to measure change in between and within session. This data is also skewed due to small sample size. In the treatment group participants reported a slight increase in the positive thought and feeling within each session when asked, “How true does that positive thought or statement about yourself feel to you now?” and rated on the VOC Scale. By the third session, the subjective unit of disturbance was even lower. This data is also skewed due to the small sample size and not distributed normally, so the median was chosen to measure change in between and within sessions for the VOC. This data suggests that EMDR treatment was effective with the treatment group in improving their positive thoughts, beliefs and feelings about self. In summary, VOC scores did increase, which gives the indication that EMDR works even though statistically we cannot say if it is significant or not. Findings in this study suggest that EMDR may have a positive effect on behavior, and findings are consistent with research previously done by Shapiro (2004) and Greenwald (1999), which indicates that EMDR has a positive influence on reducing symptoms of anger and anxiety and improving self-esteem.
Greenwald (1999) reported that previous research suggests that EMDR seems to be as effective with children and adolescents as with adults, but may be even quicker; that EMDR treatment of traumatic memories can affect a wide range of behaviors; and that a different repertoire is needed to use EMDR with children. Greenwald (1999) stated, “Many adolescents are trying to cope with their anger and helplessness by harassing and fighting each other, and we, as therapists, are encountering many children with new anxieties and fears.” Over time it is expected that counselors will see an increase in a range of problems relating to post-traumatic stress, mood, school performance, peer and family relations, aggression, crime, and substance abuse.
Greenwald (1999) also reports that by helping adolescents deal with their traumas early in life, they may be less likely to experience significant mental health problems as adults, such as anxiety, depression, and other mental health problems. If we can equip them with the skills necessary to deal with past traumas, whether big or small, then we will decrease their fears, anxiety, anger, and behavioral problems and, ultimately, promote better emotional and social being. Therefore, according to Greenwald (1999) and this current study we can suggest that EMDR can have a positive effect on adolescents by addressing symptoms of anxiety, anger and self-esteem. Shapiro (2004) also stated that one advantage of EMDR is that it has been proven to work in as little as three sessions. Shapiro (2004) reports that research indicates decrease in distress during the first session and elimination of a single trauma in three sessions. The data in this study in not statistically significant, but shows that EMDR did have some positive effect on reducing anger and anxiety symptoms as well as reducing SUDS and improving VOC in as little as one to three sessions.
Goldwasser (2000) reports that EMDR has been helpful with ADHD by targeting failure experiences, criticism/abuse secondary to ADHD behaviors, and dysfunctional self-statements associated with ADHD that can all be effective in dealing with the poor self-esteem associated with ADHD. Greenwald (1999) reports that EMDR treatment with traumatized children and adolescents appears to be effective, even though documentation specifically relating to this population is limited. Hundreds of cases have been informally reported with generally positive results. Published case reports have been positive and consistent with findings of EMDR treatment with adults.
Chemtob and Nakashima (1996) reported positive results in using EMDR with children traumatized by Hurricane Iniki who had failed to respond to a generally effective previous treatment program. Participants averaged a 58% reduction on the primary trauma measure following three sessions, with results remaining several months later. Significant reductions were also found on anxiety and depression measures as well as visits to the school nurse. A comparison study to this current study of EMDR is that of Puffer, Greenwald and Elrod (1998) who reported on a study of 20 children and adolescents ages 8 to 17, who were not randomly assigned to either an EMDR treatment or delayed-treatment groups. Treatment was a single session and focus was on a single trauma or loss. There was no change during the first month, no-treatment delay, and significant improvement between the first and last scores on all measures. On the best measure of trauma symptoms (Impact of Events Scale), eleven of the seventeen participants moved to normal levels, three dropped 12 or more points and 3 stayed the same.
Another comparison study to this EMDR study was one noted by Greenwald (1999) who reported that Rubin and Bischofshausen (1997) conducted a randomized study at a child guidance center, with EMDR added as an eclectic treatment for the experimental group. These participants had a variety of diagnoses, and all had a trauma history. Ratings ranged from adequate to good. Some researchers have targeted traumatic memories with EMDR in the hopes of reducing criminal or acting out behaviors, such as Soberman, Greenwald and Rule (1998) who provided three sessions of EMDR which focused on a primary identified traumatic memory as an adjunct to standard care. The males in the study were ages 10 to 16 and were in residential or day treatment. The trauma measure referencing the treated memory showed greater change than the global trauma measures. The EMDR group did significantly better than the control groups and reduced their primary identified problem behaviors by nearly half at the three-month follow-up.
In another comparison study, Scheck, Schaeffer and Gillette (1998) reported on EMDR treatment with high risk, acting out females ages 16 to 19. All reported a trauma history, and over three-fourths met criteria for Post Traumatic Stress Disorder. They were assigned to an EMDR group or an Active Listening treatment group. Post-treatment results indicated that EMDR treatment helped more significantly than that of the Active Listening treatment group. Three-month follow-up showed maintenance of gains (Greenwald, 1999). Greenwald (1999) makes a profound statement by pointing out that many adolescents are trying to cope with their anger and helplessness by harassing and fighting each other and that we, as therapists, are encountering many children with new anxieties and fears.
Greenwald (1999) reports there are also risks and concerns with using EMDR with the child and adolescent population. EMDR for major trauma and loss can be a critical component of treatment for children and adolescents with behavioral problems. Clients are often reluctant to try EMDR on even minor upsetting memories. The main concerns are the risk of being overwhelmed by affect leading to violent or self-destructive behavior, client’s fear of being overwhelmed, and a premature EMDR attempt leading to refusal to continue. These concerns are significant especially in a population with limited coping skills and habitual acting out. Therefore, the therapist should proceed with caution and establish a good therapeutic relationship, to include the client’s coping skills, before proceeding with work on major trauma or loss (Greenwald, 1999).
There are some opposing views as well to the effectiveness of EMDR as a treatment modality. Harvard psychologist and EMDR critic, Richard McNally (2003), insists that much of the research in support of EMDR was poorly designed and that there is more methodological superior research that indicates it has less impact than its supporters maintain. However, EMDR’s critics admit that it does have some clinical impact, though they question whether it offers anything beyond the more established PTSD treatments. McNally (2003) reports there are other critics who argue that EMDR has little impact beyond the simple relaxation and exposure to traumatic memories evoked in treatment, key elements of numerous other treatments. According to Lebow (2003), the issue with this controversy and EMDR lies with the fact that researchers in the debates about EMDR must understand the mind-set and working context of clinicians, so they can better communicate their findings to those who should be their primary audience. This is a significant reason to continue research in the area of EMDR and it’s efficacy with children and adolescents as well as with adults.
As opposed to the EMDR non-traditional treatment, there are more traditional treatments that have shown to be effective as well. In a multimodal treatment study by the MTA Cooperative Group (2004), researchers concluded that ADHD symptoms and specific medication management maintained for 14 months, was superior to behavior management alone, and the routine community care comparison that included medication.
One traditional therapy that has been shown to effectively treat behavioral problems and other disorders, such as depression, is cognitive therapy. The cognitive therapist works to give voice to the unspoken. Significant attempts are made to identify and change unrecognized beliefs and attitudes that contribute to the client’s distress. There is also the “ABC” model, proposed by Albert Ellis (1985), which demonstrates that relationships between “Antecedent Events”, “Beliefs”, “Behavior”, and “Consequences” for the individual. This model suggests that neurotic or maladaptive behaviors are learned and are directly related to irrational beliefs that people hold about events in their lives. This model assumes that by identifying and changing unrealistic or irrational beliefs, it is possible to alter one’s behavioral or emotional reactions to events. This research says that confrontational interventions are necessary to dispute these irrational beliefs, especially if they are long standing (Freeman & Reinecke, 1995) which is not a technique of EMDR. However, EMDR does seek to address irrational/negative beliefs and change these to more positive beliefs about self based on the traumatic memory.
Cognitive Behavior Therapy can reveal disturbed individual’s self-defeating attitudes and demonstrate how to change them. Rational Emotive Behavior Therapy mentions that when children who are devastated by failed experiences feel helpless because they see themselves as lacking ability, they can be shown to change their negative ideas about themselves and to feel significantly less inadequate. This could be a very useful therapy with children who have behavioral problems and may suffer from peer relation problems and social skills deficits as those with behavioral problems often do (Ellis & Harper, 1997). Dykeman’s study (2000) examined the effectiveness of a cognitive behavioral intervention program in reducing expressions of anger and increasing strategies of anger control. Dykeman (2000) examined the effectiveness of a school-based cognitive-behavioral program in treating components of anger expression in a small sample of 14- to 16-year-old adolescents with conduct disorder. Results indicated significant differences on measures of anger, expression, anger control and state of anger. The sample consisted of 8 male students, ages 14 to 16, previously diagnosed with conduct disorder by a mental health professional. In the beginning phase, the counselor empowered students to develop a sense of power, efficacy and control over the therapeutic process. In the second phase, the therapist mediated the student’s ability to engage in reciprocal problem-solving by encouraging each pair to recognize and identify a problem, consider possible options and outcomes, choose a problem-solving strategy, and plan on how to evaluate outcome. Results from this study demonstrate that students showing inappropriate expressions of anger can benefit from a cognitive behavioral intervention program.
Another traditional treatment for adolescents with behavioral problems is reported in the results of a Miranda (2000) study, which analyzed the effects on children with ADHD of two intervention programs of cognitive behavioral orientation: a self-control program and a combination of this with anger control technique programs. It was hypothesized that the general procedures taught in both programs would contribute to minimizing the self-regulatory deficiencies in hyperactive children. The results from this study support this hypothesis because both interventions produced considerable improvements in the children with ADHD, whether there was aggression or not. Positive effects were observed in the basic symptoms of ADHD and in difficulties frequently associated with this disorder, such as school problems and antisocial behavior.
The combination of self-management procedures with reinforcement contingencies can be a powerful intervention to enhance behavioral control in children with ADHD. Neither of the programs increased social adjustment or school grades in hyperactive children. The results of Miranda’s (2000) study coincides with other research showing that cognitive behavioral modification procedures are useful in the treatment of hyperactive children. One limitation of the current EMDR study would be that concluded in the Miranda (2000) study. Miranda (2000) reports that techniques have their limitations regarding changes that can be achieved in things such as school grades or social adjustment, which are often influenced by one’s background and previous experiences. This is also a limitation of EMDR technique (i.e. environment and previous experiences).
Limitations/Delimitations

According to the data available, it seems that EMDR was having some impact due to decrease in level of anxiety and anger and the increase in self esteem scores. However, we cannot say descriptively whether it is a significant difference or not due to the small sample size. There are some threats to internal validity in this study. The researcher is also the person administering treatment in this study which could affect the outcomes of the study (ie: experimenter bias). Instruments such as the Burns Anxiety and Anger Scales, Rosenberg Self-Esteem scale and SUDS and VOC were used to help control some of this threat to internal validity. Subjects were randomly assigned and matched based on gender to either control group or treatment group to help control threats to internal validity. Repeated testing was used in this study and poses a threat to internal validity because it may alert participants as to how they are to behave. Events that occur in between sessions offer a threat to internal validity of this study since these adolescents are subjects have a history of experiencing negative events that affect behavior in the school and home setting. An individual’s family background and previous experiences may affect internal validity as well. Some participants were taking psychiatric medication as part of their treatment during this study which may have affected outcomes or responses. Maturation in regards to “common therapeutic experience” should be considered a threat to internal validity in this study since both the control group and the treatment group received some type of treatment even though they were different treatments and showed some improvements in some areas even thought they were not statistically significant.
The sample size was small and limited to adolescents in a small rural private practice and may not be generalized to other populations, which is a threat to external validity in this study. More studies would have to be conducted in different age groups and other types of communities and settings in order to demonstrate if it can be generalized to the larger population. The fact the same scales were given multiple times during the course of treatment may have affected participants’ responses. For example, a scale given at the beginning of treatment may affect scores later in treatment. Usually external validity would be compromised when the study is bound to a specific period of time. However, due to the previous research on EMDR, it has shown to be effective within one to three sessions, and, therefore, the “time limited” factor may not be a threat to external validity in this case. A three-month follow-up would give this study more strength to external validity and needs to be considered for future studies. A portion of the EMDR protocol was used in this treatment group, instead of the entire protocol.
In summary, the adolescents were able to demonstrate ability to participate in EMDR and negative symptoms did decrease as positive thoughts and self-esteem scores increased. According to the results of this study, EMDR participants’ average scores did improve over the course of three sessions. Anxiety scores continued to decrease for EMDR participants throughout the sessions (ie: lower level of anxiety). The biggest decrease in level of anger for EMDR treatment group was by the third session. Both the treatment and control group did not differ much in their mean scores with the Burns Anger Inventory. This suggests that EMDR does have a positive impact on level of anger, but we cannot descriptively say that it statistically is a significant impact. Self-esteem improved over the three sessions for the treatment group which indicates that EMDR has a positive influence on self-esteem, but is not statistically significant in this study. The subjective responses indicate that EMDR overall was a positive experience and allowed participants to increase positive thoughts and feelings about self, others, and disturbing events. A larger sample size would allow future researchers to explore the statistical significance of EMDR with adolescents who have behavior problems more effectively.
Recommendations
There are some things to consider for future studies with EMDR as a treatment modality for adolescents. The bilateral stimulation, desensitization, and reprocessing stages of the EMDR protocol were used instead of the entire protocol. The EMDR sessions were limited to three sessions to hold clients in therapy for the study as long as possible. A more extensive protocol for EMDR should be used in future studies. Research in this area with a more diverse population, such as participants who may be selected from other settings such as a larger community setting, inpatient psychiatric facility, or day treatment program should be considered. Adolescents who are experiencing only trauma without behavioral problems and/or adolescents who are experiencing depression and anxiety without behavioral problems should be studied in the future to expand EMDR research and its effectiveness with other types of adolescent populations. When considering future EMDR studies it would be beneficial to try and use a larger sample in order to measure change more effectively. Also a 3-month follow-up would be beneficial in measuring change over time.
Some participants were taking psychiatric medication during this study, which may have influenced outcome. Future research should take this into consideration and explore studies with EMDR and adolescents who are not taking medication or prior to being placed on medications. There are some situations in which this would be difficult to control for, depending on the nature of the adolescents’ disorder and need for medication management to help adolescent maintain a level of stability in order to benefit from therapy.
Therapists who are considering working with children or adolescents should explore EMDR as a treatment option in working with children or adolescents who are experiencing anxiety, depression, low-self esteem, various traumas, and/or behavioral problems. Often adolescents are experiencing more that just one of the issues listed above, which often contributes to behavioral problems at home and school. Often therapists have very little time and few sessions to achieve goals in a short amount of time and EMDR is another tool that allows therapists to address the presenting problem quickly, including thoughts and emotions, and results can be achievable within as little as one to three sessions.

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APPENDIX A
Oral Statement of Assurance to Participate in Research

Oral Statement of Assurance to Participate in Research

The purpose of your participation in this study is to examine the effectiveness of a therapy technique called EMDR technique as a treatment option for adolescents with behavior problems. This technique addresses many problems that all adolescents encounter which can include fear, anxiety, and anger, which are many times the root of behavioral problems in children and adolescents. EMDR also works quickly and has been proven to show positive results within as little as one to three sessions. This is to promote rapid healing of those individuals we treat in therapy. This study will seek to expand the existing research in the area of EMDR as a treatment modality for adolescents with behavioral problems. Adolescents with behavioral problems often are dealing with other issues that trigger these behavioral problems or occur as a result of behavioral problems. These issues will be addressed as well in regards to the effectiveness of EMDR in treatment and include such issues such as anxiety, anger, self-esteem, and fear.
If you participate in this research, you will be asked to participate in three therapy sessions that will target specific symptoms that you are experiencing. You will be asked to provide your age, race, gender and problems you are experiencing at home and/or school. You will be asked to take a pre-test and post-test which will measure the effectiveness of the three therapy sessions and will measure the progress during these treatment sessions.

Your participation will take consists of three therapy sessions which will last 45-60 minutes each over the course of six to eight weeks.
Your participation in this research is strictly voluntary. You may refuse to participate at all, or choose to stop at any point in the research, without fear of penalty or negative consequences of any kind.
The information and data you provide for this research will be treated confidentially (private), and all raw data will be kept in a secured file by the researcher. Results of the research will be reported as summary data only, and no individually identifiable information will be presented. You will have clinical notes that will remain in your file at Carolina Counseling Connection, LLC . The data from this research will be shredded and disposed of once the results have been collected.
You and your parent/guardian also have the right to review the results of the research if you wish to do so. A copy of the results may be obtained by contacting the researcher at the address below:

Renee Fitch MA, LPC
2554 West Palmetto Street
Florence, SC 29501

Page 2
Oral Statement of Assurance

*There will be personal benefits from your participation in this research. The EMDR therapy technique works quickly and has been proven to help within as little as one to three sessions. Sometimes during research, unpleasant memories and/or feelings may come up and if you need someone to talk to about these feelings and memories, we will help you in doing so.
I, , have read and understand the above information explaining the purpose of this research and my rights and responsibilities as a participant. My signature below is my agreement to participate in this research, according to the terms and conditions outlined above.
Participant’s Signature Date
Print Name:
Parent/Guardian’s Name:
Relationship to Child (circle): Male/Female Parent Male/Female Grandparent

Other Guardian (Specify)
Legal Guardian (appointed by)

Note: All informed consent statements should be designed to meet the need of each individual research project and sample group and are therefore, subject to change as needed.

APPENDIX B
Statement of Informed Consent to Participate in Research

Statement of Informed Consent to Participate in Research

The purpose of this research study is to examine the effectiveness of a therapy technique called EMDR technique as a treatment option for adolescents with behavior problems. The EMDR therapy technique addresses many problems that all adolescents encounter which can include fear, anxiety, and anger, which are many times the root of behavioral problems in children and adolescents. EMDR also works quickly and has been proven to show positive results within as little as one to three sessions. This is to promote rapid healing of those individuals we treat in therapy. This study will seek to expand the existing research in the area of EMDR as a treatment modality for adolescents with behavioral problems. Adolescents with behavioral problems often are dealing with other issues that trigger these behavioral problems or occur as a result of behavioral problems. These issues will be addressed as well in regards to the effectiveness of EMDR in treatment and include such issues such as anxiety, anger, self-esteem, and fear.
If you participate in this research, you will be asked to participate in three therapy sessions that will target specific symptoms that your child is experiencing. You will be asked to provide the age, race, gender of your child and problems they have been experiencing in the home and/or school setting. Your child will be asked to take a pre-test and post-test which will measure the effectiveness of the three therapy sessions and will measure the progress during these treatment sessions.

Your participation will take consists of three therapy sessions which will have a duration 45-60 minutes each over the course of six to eight weeks.
Your participation in this research is strictly voluntary. You may refuse to participate at all, or choose to stop your participation at any point in the research, without fear of penalty or negative consequences of any kind.
The information and data you provide for this research will be treated confidentially, and all raw data will be kept in a secured file by the researcher. Results of the research will be reported as aggregate summary data only, and no individually identifiable information will be presented. You will have clinical notes that will remain in your child’s file at Carolina Counseling Connection, LLC. The data from this research will be shredded and disposed of once the results have been collected.
You also have the right to review the results of the research if you wish to do so. A copy of the results may be obtained by contacting the researcher at the address below:

Renee Fitch MA, LPC
2554 West Palmetto Street
Florence, SC 29501

Page 2
Parental Informed Consent Continued
*There will be personal benefits from your participation in this research. The EMDR therapy technique works quickly and has been proven to show positive results within as little as one to three sessions. This is to promote rapid healing of those individuals we treat in therapy. Sometimes during research, unpleasant memories and/or feelings may come up and if your child needs therapy to address these memories or feelings we will assist you and your child in doing so.

I, , have read and understand the foregoing information explaining the purpose of this research and my rights and responsibilities as a participant. My signature below designates my consent for me and my child, ____________________________, to participate in this research, according to the terms and conditions outlined above.
Signature Date
Print Name:
If signing for a Minor Child, Print Child’s Name: ________________________________________
Relationship to Child (circle): Male/Female Parent Male/Female Grandparent

Other Guardian (Specify): _______________________________
Legal Guardian (appointed by)

Note: All informed consent statements should be designed to meet the need of each individual research project and sample group and are therefore, subject to change as needed.

APPENDIX C
Code Book

CODE BOOK

VARIABLE DESCRIPTION CODED
Case Number Case Number Case #
Gender Gender 0=Male 1= Female
Intervention Traditional Therapy and EMDR Therapy 0=Control (Traditional Tx)
1= Treatment (EMDR Tx)
Self-Esteem Rosenberg Self Esteem Inventory RSE x 1 = session one
RSE x 2 = session two
RSE x 3 = session three
Anger Burns Anger Inventory BANG x1 = session one
BANG x 2 = session two
BANG x 3 = session three
Anxiety Burns Anxiety Inventory BANX x 1 = session one
BANX x 2 = session two
BANX x 3 = session three
SUDS EMDR Subjective Units of Disturbance Scale SUDS x 1 = session one
SUDS x 2 = session two
SUDS x 3 = session three
VOC EMDR Validity of Cognition Scale VOC x 1 = session one
VOC x 2 = session two
VOC x 3 = session three
Grade Range of Grade 1= 6th-8th grade
2= 9th-12th grade
PMDX Primary Diagnosis 1= ADHD & Behavioral Disorders
2= Bipolar Disorder
3=Depression
4=PTSD
SDX Secondary Diagnosis 1= ADHD & Behavioral Disorders
2= Bipolar Disorder
3=Depression
4=PTSD
Race Race 1=Caucasian
2=African American
3=Other
Meds Taking Medications 1= Yes
2= No
LA Living Arrangements 1=Lives with Both Parents
2= Lives w/One Parent/Parents Divorced
3= Lives with Foster Parent/Guardian

CODEBOOK

Page 2 of 2
RSC Resource/Self-Contained 1= Yes
2= No
Susp Suspensions at School 1= Yes
2= No
PSYHSP Psychiartric Hospitalizations 1= Yes
2= No
AbuseHX History of Physical and/or sexual abuse 1= Yes
2= No
FMHX Family history of mental health diagnosis 1= Yes
2= No
SubstAbuse Substance Abuse 1= Yes
2= No
Legalinvolv Legal Involvement 1= Yes
2= No

APPENDIX D

EMDR as a Treatment Modality for Behavioral Problems

Screening/Demographic Information

EMDR as a Treatment Modality for Behavioral Problems
Screening/Demographic Information
Assigned Research ID#:

Child’s Name:

Parents Name:

Age:

Gender:

Ethnicity:

Phone Number: ( )

Currently Taking Medications: ______Yes ______No

Please List Any Medications they are taking:

_________________________________________________________

_________________________________________________________

Does Your Child have a history of seizures: _____Yes ______No
Does Your Child have any medical conditions: _____Yes ______No

Please specify:__________________________________________________

Child’s Diagnosis:_______________________________________________

Parents Concern/Presenting Problem (note at school and home):

______________________________________________________________

______________________________________________________________

Child’s Report of Presenting Problem:_______________________________

______________________________________________________________

EMDR SCREENING/INTAKE

PSYCHOSOCIAL HISTORY

Living Arrangements (Please check one):

___Lives w/Both Parents ____Lives w/one Parent (specify)____________________
___Parents Divorced

___Lives w/Foster Parent (specify for how long)________________________________

School Status:

Grade:___________________________

Resource or Self-Contained: ___Yes ___No

Suspensions: ___Yes ___No If Yes,please explain:_________________________

______________________________________________________________________

Mental Health History:

Family Mental Health History: ___Yes ___No (Please list relationship and diagnosis):

_______________________________________________________________________

Psychiatric Hospitalizations: ___Yes ___No If Yes, Please list dates below:

_______________________________________________________________________

Legal Involvement (DSS, DJJ, Law Enforcement): ___Yes ___No

If Yes, please explain:_____________________________________________________

Substance Use/Abuse history: ___Yes ___No

If Yes, Please note substances used and frequency:______________________________

_____________________________________________________________________

APPENDIX E
Rosenberg Self-Esteem Scale

Rosenberg Self-Esteem Scale (Rosenberg, 1965)

The scale is a ten item Likert scale with items answered on a four point scale - from strongly agree to strongly disagree.T he original samplef or which the scalew as developedc onsistedo, f 5,024 High School Juniors and Seniors from 10 randomly selected schools in New York State.
Instructions: Below is a list of statements dealing with your general feelings about yourself. If you strongly agree, circle SA. If you agree with the statement, circle A. If you disagree, circle D. If you strongly disagree, circle SD.

1. On the whole, I am satisfied with myself. SA A D SD
2.* At times, I think I am no good at all. SA A D SD
3. I feel that I have a number of good qualities. SA A D SD
4. I am able to do things as well as most people. SA A D SD
5.* I feel I do not have much to be proud of. SA A D SD
6.* I certainly feel useless at times. SA A D SD
7. I feel that I am a person of worth, at least on an
equal plane with others. SA A D SD
8.* I wish I could have more respect for myself. SA A D SD
9.* All in all, I am inclined to feel like I’m a failure. SA A D SD
10. I take a positive attitude toward myself. SA A D SD

Scoring: SA: 3, A: 2, D: 1, SD: 0. Items with an asterisk are reverse scored; that is, SA: 0, A: 1,
D: 2, SD: 1. Sum the scores for the l0 items. The higher the score, the higher the self esteem.
The scale may be used without explicit permission. The author's family, however, would like to be kept informed of its use:

The Morris Rosenberg Foundation
c/o Department of Sociology
University of Maryland
2ll2 Artlsoc Building
College Park, MD 20742-1315

References
References with further characteristics of the scale:
Crandal,R . (1973).T he measuremenot f self-esteema nd relatedc onstructsP, p. 80-82 in J.p.
Robinson & P.R. Shaver (Eds), Measures of social psychological attitudes. Revised
edition. Ann Arbor: ISR.

APPENDIX F
Burns Anger Scale

Burns Anger Scale

APPENDIX G
Burns Anxiety Scale

Burns Anxiety Scale

APPENDIX H
EMDR Protocol

ABEP Protocol
Session One:

___ Informed Consent (Consent to Participate) with client and parent, Confidentiality
Review, Benefits of EMDR (see Participant Informed Consent & Oral Assurance)

___ Complete EMDR Demographic Sheet

___ Explanation of EMDR:

“When a disturbing event occurs, it can get locked in the brain with the original
picture, sounds, thoughts, feelings and where we feel it in our body. These things can combine real events with images/pictures that stand for the actual event or feelings about it. EMDR seems to stimulate/trigger this information and allows the brain to process the experience. Sometime this happen in REM or dream sleep—eye movements and helps to process/”work through” the unconscious material. You may experience many different emotions. It is your own brain that will be doing the work and the healing. You are the one in control.”

____ Explanation of Scales that will be used in all sessions (ie: SUDS & VOC and Burns Anger and Anxiety Scale, and the Rosenberg Self-Esteem Scale)

____ Administer Burns Anger Scale, Burns Anxiety Scale and Rosenberg Self-esteem Scale

____ Presenting Issue/Symptoms Reviewed

____ Review Sitting Position, Distance, Eye Movement (Range, Speed, Direction)

____ Review Metaphor (train):

“In order to help you just notice the experience, imagine riding on a train and the feelings, thoughts, etc, are just scenery you notice as you are passing by”

____ Introduce Stop Signal and how to use it

____ Establish Safe/Calm Place

____ Begin first EMDR Session (See EMDR Practice Worksheet)

Session 2:

____ Administer Burns Anger Scale, Burns Anxiety Scale, Rosenberg Self-Esteem Scale
____ Review Presenting Issue

____ Review Image/Picture of the Disturbing Event That Goes With Issue

____ Negative Cognition Identified “What words go best with that picture/incident that express your negative belief about yourself now?”

____ Positive Cognition Identified “When you bring up that picture/incident, what would you like to believe about yourself now?”

____ Validity of Cognition (VOC): “When you think of that picture/incident, how true do those words (repeat the positive cognition participant stated) feel to you now on a scale of 1 to 7 where 1 feels completely false and 7 feels completely true?”

____ Emotion: When you bring up that picture/incident and those word (repeat negative cognition), what emotion do you feel now?”

____ Subjective Units of Disturbance (SUDS): “On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does the incident feel to you now?”

____ Location of Body Sensation: “Where do you feel it in your body?”

____ Desensitize: “I’d like you to bring up that picture, those negative words (repeat the negative cognition), and notice where you are feeling it in your body-follow my fingers.”

____ Set of EMDR movements/After Set “Blank it out”. Take a deep breath. What do you get now?”

____ Processing and checking for new channels: Continue processing with several sets of eye movements until no new disturbing material is coming up. Ask, “When you go back to the original experience what do you get now?” If there is no new, disturbing material, check the SUDS.

____ Check SUDS & move to Installation – Only if SUDS is a “0” (See EMDR Practice Worksheet).

____ Body Scan (See EMDR Practice Worksheet)

____ Use Closure Procedure for Incomplete Sessions that Includes Relaxation Exercise or “Safe Place” Exercise. (See EMDR Practice Worksheet)

Session 3:

Administer Burns Anger Scale, Burns Anxiety Scale, Rosenberg Self-Esteem Scale

____ Review Presenting Issue

____ Review Image/Picture of the Disturbing Event That Goes With Issue

____ Negative Cognition Identified “What words go best with that picture/incident that express your negative belief about yourself now?”

____ Positive Cognition Identified “When you bring up that picture/incident, what would you like to believe about yourself now?”

____ Validity of Cognition (VOC): “When you think of that picture/incident, how true do those words (repeat the positive cognition participant stated) feel to you now on a scale of 1 to 7 where 1 feels completely false and 7 feels completely true?”

____ Emotion: When you bring up that picture/incident and those word (repeat negative cognition), what emotion do you feel now?”

____ Subjective Units of Disturbance (SUDS): “On a scale of 0 to 10, where 0 is no disturbance or neutral and 10 is the highest disturbance you can imagine, how disturbing does the incident feel to you now?”

____ Location of Body Sensation: “Where do you feel it in your body?”

____ Desensitize: “I’d like you to bring up that picture, those negative words (repeat the negative cognition), and notice where you are feeling it in your body-follow my fingers.”

____ Set of EMDR movements/After Set “Blank it out. Take a deep breath. What do you get now?”

____ Processing and checking for new channels: Continue processing with several sets of eye movements until no new disturbing material is coming up. Ask, “When you go back to the original experience what do you get now?” If there is no new, disturbing material, check the SUDS

____ Check SUDS & move to Installation – Only if SUDS is a “0” (See EMDR Practice Worksheet)

____ Body Scan (See EMDR Practice Worksheet)

____ Use Closure Procedure for Incomplete Sessions that Includes Relaxation Exercise or “Safe Place” Exercise. (See EMDR Practice Worksheet)

APPENDIX I
EMDR Practice Worksheet

EMDR Practice Worksheet

APPENDIX J
SUDS and VOC Scales

SUDS and VOC Scales

APPENDIX K
Examples of Cognition