Difficult Children Research Articles

To Have and to Hold: Questions about a Therapeutic Service for Children

Therapies for children and young people that using 'holding' as an intervention for severe difficulties with attachments are controversial and raise many questions. At least one major professional organisation has stated that these therapies should be banned. This paper discusses the implications of a study of a service for children (and their families where appropriate) described as having attachment difficulties or a diagnosis of attachment disorder and where 'holding' techniques are employed as part of the therapeutic intervention. The views of a range of stakeholders (including children, young adults who had previously used the service, purchasers, outside professionals, and staff) about this service were collated directly by interview. The article identifies how this study can refine and inform the broader questions about 'attachment and holding' therapies. Proponents argue that the service offered provides effective assistance for some of the most hurt and difficult children in society. Opponents state that some of the techniques involved have not been evaluated, are ethically questionable and are not based on a validated theoretical mechanism. This paper highlights a number of core questions about attachment and 'holding' therapy and the findings of the study provide a commentary on these questions.

Involvement of parents in the education of children with reading and writing difficulties - Impact of an intervention

th standard were drawn from 14 schools. Total samples of 418 children were screened based on the child’s previous academic performance of the class tests and teacher’s rating. They were further tested and identified as difficult children (180 in reading and 114 in writing) using Kannada reading and writing tests. Normal children (165 in reading and 114 in writing) were also selected for comparison purpose. Findings of the study revealed that, at home, majority of children with reading difficulties (80%) studied on their own without any support from the family members. Only 39% of parents take care of their children’s studies as against 60% in case of normal children. Similar trend was observed in writing also. During intervention programme, parents were sensitized regarding the importance of their participation and encouragement in their child’s education. Results showed that parent’s involvement significantly improved experimental children to achieve better in schools than children of control parents.

Stability of maternal discipline practices and the quality of mother–child interaction during toddlerhood

This study examined the stability of maternal punitive/high-power discipline (PD) and inductive/authoritative discipline (ID) over the second and third years of life and the effect of maternal discipline on quality of mother–child interactions. Data from a longitudinal sample with 179 mother–toddler dyads were analyzed, and selected factors (i.e., child sex, temperament) that might moderate the association between maternal discipline and quality of mother–child interactions were also examined. Maternal discipline, quality of mother–child interactions, and temperamental moderators were measured at 16–18 months (Time 1) and 34–37 months (Time 2). Results showed that the stability of maternal use of discipline strategies over the toddler years was moderate. Lower maternal use of PD, higher maternal use of ID, and higher preference/reliance on ID (relative to PD) were associated with higher quality of mother–child interactions. Moderation effects of child temperament were also found. High ID and PD were associated with low quality of mother–child relationships in non-temperamentally difficult children but not in temperamentally difficult children.

Predicting Growth Curves of Early Childhood Externalizing Problems: Differential Susceptibility of Children with Difficult Temperament

Using an accelerated longitudinal design, the development of externalizing problems from age 2 to 5 years was investigated in relation to maternal psychopathology, maternal parenting, gender, child temperament, and the presence of siblings. The sample consisted of 150 children selected at age 2-3 years for having high levels of externalizing problems. Parenting was measured using observational methods, and maternal reports were used for the other variables. Overall, mean levels of externalizing problems decreased over time, and higher initial levels (intercept) were related to a stronger decrease (negative slope) in externalizing problems. Results showed that higher levels of maternal psychopathology were related to less decrease in early childhood externalizing problems. Parental sensitive behavior predicted a stronger decrease in externalizing problems, but only for children with difficult temperaments. A stronger decrease of externalizing problems in children with older siblings also pertained only to children with difficult temperaments. Thus, temperamentally difficult children appear to be more susceptible to environmental influences on the development of externalizing behaviors. Our results indicate that the role of siblings in early childhood externalizing problems deserves more research attention, and that intervention efforts need to take into account temperamental differences in children's susceptibility to environmental influences.

Airway reconstruction in children

Aim/Background:Airway anomalies are infrequent but potentially life threatening in children. A program to care for these difficult children was set up at our institution, and this paper summarizes our experience.Methods:A total of 34 children were enrolled in the program over a period of three years. These children were evaluated as per the standard protocols. Treatment was individualized.Results:Of these 34 children, 28 had their airways restored and are doing well. Four children continue to remain on tracheostomy and two will require long term tracheostomy. There were two deaths. All children are under surveillance as there is a risk of recurrence.Conclusions:Airway anomalies are complex problems with significant morbidity and mortality. Current therapeutic modalities allow for good results. Most children were successfully decannulated and did well.

Job stressors of New Zealand dentists and their coping strategies

Dentistry is understood to be a stressful profession. Although there has been recent research about stress and dentistry in the UK and the Netherlands, little is known about the job stressors and coping strategies of New Zealand dentists. To investigate job stressors and coping strategies among New Zealand dentists. A nationwide postal survey of a representative sample of 700 dentists. The response rate was 65%. The most commonly reported stressors were treating difficult children (52%), constant time pressure (48%) and maintaining high levels of concentration (43%). The strategies most utilized for managing work-related stress included interactions with people (78%), sports (64%) and forgetting about work (59%). Dentists who had graduated overseas reported more sources of stress than New Zealand graduates. There were differences in the strategies used by male and female practitioners to manage stress. There is considerable variation in the number of stressors experienced by dentists. Overseas-qualified dentists appear to be under more stress than New Zealand-trained dentists and may need greater professional support. Dentists should be encouraged to make greater use of active coping strategies.

Tips from the swamp

Obtaining frequency-specific assessments for young children can be like wrestling a crocodile! Even the best pediatric audiologist has been at wits' end attempting to evaluate an unruly 2-year-old. Read on for pointers on taming the child and getting ear-specific audiograms from even the toughest croc! ALL HANDS ON DECK Behavioral assessment of auditory function works best when it's a team effort. If the child is seeing a speech-language pathologist, then enlist the SLP's help. She or he may offer suggestions that enhance the test session, such as a particular game the child enjoys (e.g., throwing a basketball through a hoop). Also, the SLP can practice the desired conditioned response in therapy sessions, and, ideally, will accompany the child on audiologic visits. If the child isn't seeing an SLP, ask the family to help. Spoken or written instructions detailing the desired conditioned response along with a request to practice at home will familiarize the little one with the task at hand. The parent, clinic personnel, or even a trained receptionist can encourage the child's cooperation. An energetic, well-trained assistant is worth her weight in gold during pediatric assessments. FEELING AT HOME IN THE SWAMP Although children frequently associate clinics with negative experiences, you can structure the environment so it feels safe. Shedding your lab coat is a good place to start. Also, kid-friendly furniture can help. High chairs for infants or an inexpensive little folding table and chair designed for little people will help youngsters feel more comfortable and at ease. One important task is especially difficult with little ones: obtaining ear-specific data. Sound field testing won't provide ear-specific assessment of hearing sensitivity, and insert earphones are firmly established as the transducer of choice for children. Unfortunately, kids often resist the insertion of foam eartips. If they wear hearing aids, you can couple insert earphones to their personal earmolds. However, sometimes the tubing becomes stretched and is difficult to couple tightly to the insert earphone. Count on the DSL folks for a creative solution to couple insert earphones to “well-established” earmolds (see Figures 1a–c).Figure 1a: A foam tip for insert earphones is inserted into the tubing of the child's personal earmold.Figure 1b: The foam tip of the insert earphone is cut off near the tubing of the earmold.Figure 1c: The tubing of the insert earphones is coupled to the tubing of the foam tip.If you use personal earmolds to obtain audiometric thresholds, then use them also in measuring real-ear-to-coupler differences. When children don't have personal earmolds, let them feel and squeeze the foam eartip for themselves. Even more reassuring is a safety demonstration of eartip insertion on a willing sibling or parent. If all else fails, send the eartips home with the family and reschedule after they've had time to practice. MAKE IT FUN Never ask a child for permission to do something. The answer is invariably “NO!” So, be flexible and provide enjoyable ways to accomplish your mission. Some children never tire of dropping blocks into a bucket, but others lose interest quickly and require more alluring assignments. Even the most difficult children are intrigued by dropping plastic fish into a Gatorade jug filled with water when they hear the “beeps.” Bathtub color tints mixed in during the test can make the game even more exciting. Boys tend to enjoy dropping Matchbox cars into a used wrapping paper tube, while girls often prefer to stick plastic jewels with Velcro on the back of a felt crown. Some kids like to give a “high five” to the assistant upon hearing each tone, especially if the assistant occasionally acts as if it hurts (‘owwee, you're strong!). A simple sticker stuck to your nose can amuse the grumpiest Crocodilia. The same “games” may not work for every youngster, and some require a change of tasks within a session or from session to session. Keep an open mind and plenty of tricks up your sleeve. Obtaining audiograms from toddlers requires patience, dedication, and creativity. Although some days you may feel like a combination of clown, clinician, and animal wrangler, one thing's for sure: As we move closer to the goal of age-appropriate speech and language for every child with a hearing loss, providing successful pediatric audiologic assessment isn't a crock!

Assessment of Intranasal Midazolam Administration with a Dose of 0.5 mg/ Kg in Behavior Management of Uncooperative Children

Intranasal midazolam has been used to induce conscious sedation in children with negative and aggressive behavior The main goal of this study was to determine the effectiveness of intranasal administration of midazolam (with a dose of 0.5 mg/kg) in behavior management of uncooperative children. Thirty healthy, difficult children of 3-5 years were evaluated. At the beginning of each session, ordinary techniques of behavior management to treat patients were applied. In cases of unsatisfactory responses, intranasal midazolam was immediately employed. To determine the efficacy of the drug, child behavior was evaluated before and after administration of midazolam using Houpt rating scale of general behavior. A statistically significant difference was demonstrated in the patients 'behavior before and after administration of intranasal midazolam. this drug is effective in sedation and reduction of the anxiety of children under treatment.

Neurological Examination of Difficult and Poorly Cooperative Children

Many physicians consider examining the nervous system as one of the most difficult parts of the physical examination. Difficult and poorly cooperative children remain the most challenging group to examine accurately and completely. In this situation, the physician becomes less confident about the neurological findings and clinical evaluation. Several factors are predictive of difficult behavior during the evaluation, including anxiety when meeting unfamiliar people, short time to adjust to the medical situation, previous hospitalization, fear of injections, and parental anxiety. Limited neurological literature addresses the issues relating to the examination of difficult and poorly cooperative children. In this review, some practical tips and techniques are presented that can be used to improve the likelihood of obtaining accurate information about the neurological status of young and difficult children. Certainly, repeated examinations and experience play an important role; however, solid knowledge, strong communication skills, accurate observational skills, and use of proper techniques are crucial for eliciting and interpreting neurological signs in difficult children. Finally, a patient and empathetic physician and supportive guiding parents are needed for a successful neurological assessment.

The interactive effects of temperament and maternal parenting on toddlers' externalizing behaviours

AbstractThe present study aimed to determine the potential moderating effects of temperamental traits on the relation between parenting and toddlers' externalizing behaviours. For that purpose, this study examined the interplay between temperament and maternal parenting behaviours in predicting the level as well as the development of toddlers' externalizing behaviours. Participants were 115 boys (wave 1, M=16.9 months; wave 2, M=23.2 months) and their mothers, who were observed in a 13‐min structured play session at home. With regard to the prediction of the level of externalizing behaviours at wave 1, main effects were found for children's temperamental characteristics. In addition, maternal negative control interacted significantly with children's inhibitory control in predicting this level of externalizing behaviours. The findings with regard to the development of externalizing behaviours showed that the effects of maternal negative control and lack of maternal sensitivity were stronger for toddlers with a difficult temperament: maternal negative control and lack of maternal sensitivity were related to an increase in externalizing behaviours for temperamentally difficult children only. These results offer support for the goodness‐of‐fit hypothesis, stressing the idea that the effects of temperament and the social environment depend to a large extent on their interplay. Copyright © 2007 John Wiley & Sons, Ltd.

Difficult Children and Difficult Parents

As more mothers of young children work, concerns about child care have gained prominence. Analyses of this topic typically address availability, safety, and costs of care, or the impact of care on children's “outcomes.” When providers' input is included, it is generally used as an assessment tool to reinforce the researcher's conceptual framework. This study addresses the issue of nonparental child care by allowing the providers to tell their story of caregiving. We have conducted a series of hour-long interviews with 12 in-home child care providers. Their narratives show patterned perceptions of both the children and children's parents. Our analysis focuses on providers' constructions of difficult children and parents. Greater understanding of this aspect of care work may help to improve the quality of the work experience for providers, which may in turn contribute to a more positive care environment experienced by children.

The Emanuel Miller Memorial Lecture 2006: Adoption as intervention. Meta‐analytic evidence for massive catch‐up and plasticity in physical, socio‐emotional, and cognitive development

Adopted children have been said to be difficult children, scarred by their past experiences in maltreating families or neglecting orphanages, or by genetic or pre- and perinatal problems. Is (domestic or international) adoption an effective intervention in the developmental domains of physical growth, attachment security, cognitive development and school achievement, self-esteem, and behaviour problems? Through a series of meta-analyses on more than 270 studies that include more than 230,000 adopted and non-adopted children and their parents an adoption catch-up model was tested. Although catch-up with current peers was incomplete in some developmental domains (in particular, physical growth and attachment), adopted children largely outperformed their peers left behind. Adoptions before 12 months of age were associated with more complete catch-up than later adoptions for height, attachment, and school achievement. International adoptions did not lead to lower rates of catch-up than domestic adoptions in most developmental domains. It is concluded that adoption is an effective intervention leading to massive catch-up. Domestic and international adoptions can be justified on ethical grounds if no other solutions are available. Humans are adapted to adopt, and adoption demonstrates the plasticity of child development.

Re-Framing and de-Pathologizing Behavior in Therapy for Children Diagnosed with Psychosocial Disorders

The increasing number of children diagnosed with psychosocial disorders reflects a trend toward pathologizing behavior that is unusual, challenging or extreme. Although these behaviors may match items on the symptom lists for various disorders, a therapist must first consider the origin and context of those behaviors for an individual child through a non-pathological lens. This paper proposes a framework for understanding the behavior of difficult children based on core issues rather than diagnostic symptoms: arousal/excitability, range of focus, perfectionism, intensity, interpersonal sensitivity, sensory sensitivity, cognitive/perceptual style, perception of time, reaction style, and affiliation/integrity. Each trait is examined from two perspectives: how it can lead to or be interpreted as a problem, and how a therapist can re-frame the trait and build on it to identify effective interventions. This approach affirms children’s strengths and upholds social work values.

A SHORT COMMENTARY ON TIMOTHY M. TIPPINS AND JEFFREY P. WITTMANN'S “EMPIRICAL AND ETHICAL PROBLEMS WITH CUSTODY RECOMMENDATIONS

In this commentary, the call for clinical humility and judicial vigilance in custody recommendations is confirmed as valid and the Australian experience, where the child custody report writer has for some years been permitted to express an opinion on the ultimate issue, is considered. The inherent risks are briefly discussed, and the question of who of the judge and the social scientist might be better placed to decide the exquisitely difficult children's issues after family breakdown is touched upon. It suggests that a combination of the expert's opinion and judicial fact finding probably produces a result that is as good as it gets. But a greater danger is highlighted. It is the impact of the adversary system, and whether it is suitable in any event to these sensitive court decisions.

The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder

Continued questioning of the validity of a diagnosis of attention-deficit/hyperactivity disorder (ADHD) has created uncertainties about its management in the minds of many clinicians and the public. Inaccurate beliefs about the validity of ADHD hinder the clinical care of many ADHD patients and lead to confusion about the need to seek out or accept treatment. Critics describe ADHD as a diagnosis used to label difficult children who are not ill but whose behavior is at the extreme end of normal. They further contend that, far from having a biological basis, ADHD results from poor parenting and ineffective teaching practices. Such attitudes do much to further stigmatize patients and their families and increase the burden of this debilitating condition. This review attempts to address these challenges by presenting evidence to show that ADHD meets the criteria for a valid psychiatric diagnosis. Not only does it cause specific disabling symptoms that frequently persist into adulthood, but many studies show it has a biological basis and a characteristic response to treatment. Such data support the idea that ADHD is a valid diagnostic category.

Conscious sedation for children

Conscious sedation for children

Postural Control in Children With Developmental Coordination Disorder

The development of static balance is a basic characteristic of normal motor development. Most developmental motor tests include a measure of static balance. Children with Developmental Coordination Disorder (DCD) often fail this item. This study reviews the balance problems of children with DCD. The general conclusion is drawn that under normal conditions static balance control is not a problem for children with DCD. Only in difficult, unattended, or novel situations such children seem to suffer from increased postural sway. These findings raise the question of what happens when balance is lost. The present study addresses the strength of correlation between the electromyography (EMG) and force plate signals in one-leg stance over epochs of stable and unstable balance. Four groups of children were involved in the study: two age groups and a group of children with DCD and balance problems and their controls. The results show a clear involvement of tibialis anterior and peroneus muscles in the control of lateral balance in all conditions and groups. The group of children with DCD and balance problems,however, showed a weaker coupling between EMG and corrective force compared with control children, indicating non-optimal balance control. An evaluation of the existing data in terms of evidence of specific structural deficits associated with DCD provided converging evidence that suggests cerebellar involvement.

Pupils with emotional and behavioural problems as action researchers in foreign language teaching

Foreign language (FL) teachers, like most other teachers, are increasingly likely to experience conflict in their classrooms, which makes language teaching - an enormously complex process - yet more demanding. FL teachers need to know practical approaches to conflict prevention and resolution that are compatible with effective learning, but they often lack this knowledge, which necessarily affects their teaching quality and results. This often leads to teachers blaming students and to (even more) frustration on both sides. This article describes a 2 year project funded by the Austrian federal government in which FL teachers provide learning opportunities for difficult children which enable them to become action researchers in their lessons themselves, thus changing traditional patterns of teacher-pupil interaction. It stresses the importance of using ecosystemic methods that seek to include the pupils' perspectives, and discusses two examples of classroom action research modules that stem from this need.

Predicting toddler anxiety/depressive symptoms: Effects of caregiver sensitivity on temperamentally vulnerable children.

This research examines whether maternal sensitivity in early childhood reduces later anxiety/depressive symptoms for children with more temperamental vulnerability, and whether these effects are different for boys and girls. Data from the National Institute of Child Health and Human Development Early Child Care study with 1,226 subjects (631 boys, 595 girls) were analyzed. Mothers and other caregivers rated children's difficult temperament at 1 and 6 months. Trained observers scored maternal sensitivity when children were 6 and 15 months. Child anxiety/depressive symptoms were rated by mothers and other caregivers when children were 2 and 3 years of age. Maternal sensitivity in early childhood significantly predicted decreased 2- and 3-year-old anxiety/depressive symptoms. Children with more difficult temperament were significantly more likely to show decreased anxiety/depressive symptoms at 2 years of age if their mothers had been more sensitive. Maternal sensitivity also was a significant predictor of decreased anxiety/depressive symptoms for more temperamentally difficult boys, and temperamentally difficult boys with more sensitive mothers were found to be significantly more likely than girls to show decreased anxiety/depressive symptoms at 3 years of age. The findings of this pilot research suggest that facilitating and supporting increased sensitivity for mothers with more temperamentally difficult children could be beneficial. ©2005 Michigan Association for Infant Mental Health.

Reducing Assaults Among Hospitalized Youths

Back to table of contents Previous article Next article LettersFull AccessReducing Assaults Among Hospitalized YouthsEileen P. Ryan, D.O., Jeffrey Aaron, Ph.D., and Virginia Sparrow Hart, Ph.D.Eileen P. RyanSearch for more papers by this author, D.O., Jeffrey AaronSearch for more papers by this author, Ph.D., and Virginia Sparrow HartSearch for more papers by this author, Ph.D.Published Online:1 Nov 2004https://doi.org/10.1176/appi.ps.55.11.1318AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: Dr. Whelan raises several important points in his comments about our article. Caregivers, teachers, and hospital staff members often see oppositional behaviors as best met by behavioral contingencies designed to operantly teach adaptive behaviors. Such responses overlook the fact that such behaviors in children and adolescents, who are typically hospitalized because of significant problems with impulsivity, affect regulation, and behavioral dyscontrol, often reflect expressions of frustration, efforts to demonstrate autonomy, a desire for engagement, or some other meaningful interpersonal transaction.We appreciate Dr. Whelan's noting the importance of considering behavioral management systems as possible catalysts in negative interactions between patients and staff on a unit. We also agree with his observations and conclusion that the transactional nature of patient-staff interactions is typically not addressed in an effective manner. As clinicians who have worked in inpatient settings and have also observed firsthand the limitations of level-based behavioral management systems, we were still surprised by the high rate of assault on staff. In the hospital in which this study took place, there have been ongoing and successful efforts to decrease seclusion and restraint. However, we wonder whether such efforts may inevitably plateau in their success and even have the unfortunate "side effect" of facilitating other forms of dyscontrol within the confines of traditional level-based behavioral management systems.One of us attended a workshop at the annual meeting of the American Academy of Child and Adolescent Psychiatry in October 2003 (1) in which Ross Greene discussed CPS (2) and its role in eliminating the use of seclusion and restraint in an inpatient setting very similar to the one in our study. One of the many reasons that we perceive the CPS approach to be effective is that it addresses the main reason that people choose to work with difficult children for low pay—to help them. As Dr. Whelan states, CPS "emphasizes discovering the specific pattern of cognitive skill deficits implicated in a given child's inability to comply and works to remediate these deficits." Our observation has been that efforts to address the transactional component between staff and patients often convey to staff that they are doing something "wrong" and that they are somehow inappropriately implementing the otherwise effective unit management program. CPS focuses on therapeutic interactions rather than on limit setting, in which there is inevitably a winner and a loser.Dr. Whelan suggests that it would have been of value to record "situation-specific, verbatim data" for the verbal reprimands given to patients. Again, he makes a good point. However, such an effort would capture only one element of the transaction in the microclimate of the inpatient unit. There are many other facets of the interaction that would likely affect the transaction, such as a staff member's reputation with patients on the unit, the tone of voice used, the staff member's familiarity with that patient, and the patient's familiarity with the level system.