School is often the only safe place for young children who live with domestic violence. Witnessing or being exposed to physical abuse can have a significant impact on the well-being of a child. Whether it is sexual, verbal, or physical abuse, when a child witnesses this type of abuse between their parents or caregivers, the effects can be far-reaching. Many children who are exposed to violence are fearful and anxious. They may also have difficulty forming relationships in school or performing academically. A teacher can be the first person to recognize these signs in a student. Although teachers, educators, and educational psychologists (EPs) receive extensive training to arm them with the tools necessary to address these issues in their students, it is unclear how this type of disclosure affects these professionals.

Gemma Ellis of the Luton Burough Council at Unity House in the UK recently led a study to gain the educators’ perspectives on domestic violence revelations from their students. Ellis wanted to find out if the professionals felt capable of identifying a child experiencing domestic abuse, and if they were comfortable receiving that information and responding to it. She also wanted to know how they felt about training, what fears they had, and what changes they would make to the current procedures in place.

Ellis interviewed a group of elementary school educators and found that one important need was that of more time for the teacher to emotionally process what the child revealed. Many teachers explained that they were overwhelmed and struggled with having to send the children back to a potentially abusive home. Ellis believes this finding is in line with secondary trauma theories, which suggest that confidants of abuse victims may themselves experience trauma. The teachers and EPs in this study benefited from the procedures in their schools. In an uncontrollable and emotionally taxing situation, having a protocol to follow helped them contain their own emotions so that they could best serve their students.

They did, however, have fears related to family retaliation. In particular, the teachers relied heavily on parent participation for the success of the child. They worried that accusations against the family would decrease participation. They also feared that the abusers would turn their abuse toward the teachers. Ellis believes these findings provide insight into the concerns teachers and EPs have with regard to supporting abuse victims and that this study will serve as a preliminary step in future discussions. “It is hoped and expected that through the dissemination process the topic of domestic abuse will be elevated in both teachers’ and EPs’ consciousness,” Ellis said.

Reference:
Ellis, Gemma. The impact on reachers of supporting children exposed to domestic abuse. Education & Child Psychology 29.4 (2012): 109-20. Print.

There is a question that has been asked of me multiple times over the past few months that I would like to answer. The question is: “Should a child’s foster parent(s) be granted access to their child’s psychotherapy notes?” The answer is not as straightforward as it may seem.

The short answer is: “No, a child’s foster parent(s) should not be granted access to their child’s psychotherapy notes.”

First, we must understand what the HIPAA privacy rule is, as it will ultimately answer the question. The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, is a federal law which resulted in the establishment of the HIPAA Privacy Rule in December 2000. The HIPAA Privacy Rule is designed to protect information about individuals’ health care treatment. To understand privacy protections in the United States, you must start with this federally established framework and then consult state laws to determine whether there are any additional requirements to observe.

Second, we must understand what the HIPAA Privacy Rule has to say about “individual personal representatives.” An individual personal representative is any person with the authority to receive or access another individual’s protected health information (PHI).

In some cases, adults and emancipated minors have individual personal representatives, such as someone holding “power of attorney” or in a court-appointed adult guardianship or conservatorship. Otherwise, adults and emancipated minors do have uniquely boundaried privacy protections, whereas minors (children under 18 years old, with the exception of children—typically 16 or 17 only—who have been formally “emancipated” from dependency status by a court of law) always have at least one individual personal representative.

Children and adolescents in foster care tend to have many individual personal representatives, including representatives from Child Protective Services, attorneys, designated child-placing agency representatives such as case managers, foster parents acting as medical consenters, and, in some cases, juvenile probation officers. In rare cases, even court-appointed special advocates (CASA) may obtain status as medical consenters through a court and would, then, hold the distinction of an individual personal representative.

In addition, foster kids benefit from an extensive continuum of care including doctors, dentists, psychiatrists, clinical psychologists, school psychologists, school counselors, collaborative treatment team participants such as child-placing agency treatment directors (such as myself), and other consultants (at my agency, we have psychiatric fellows and residents as well as a program manager, intake coordinator, and, in some cases, a higher-level program administrator who all may participate in the ongoing treatment staffing related to a child’s case planning), therapists (individual, sibling, family, group), early childhood interventionists (speech, physical, and occupational therapists), and skills trainers. Each of these treatment providers freely accesses PHI of other providers in the course of treatment, which is necessary and beneficial for collaborative treatment.

Ultimately, these supports are beneficial, but often, along this stream of care, the “minimum necessary requirement,” a best-practices principle generally recognized and affirmed through the HIPAA Privacy Rule, is not sufficiently revered, and foster kids’ private and protected health information may not always be protected in practice with the same degree of diligence that it is in so many other sectors of health care. It is in this current that foster parents often believe that they, too, are entitled to the most private of health care information, their child’s therapy providers’ psychotherapy notes. I know this to be true from my own professional experience.

The third thing that you must understand to answer this question is that psychotherapy notes are given unique privacy protections within the HIPAA Privacy Rule, more so than all other protected health information (PHI), including purely diagnostic or evaluative information, case notes, other treatment services such as developmental therapies (speech, physical, occupational), as well as other treatment summaries or reports. Even reports via email from a therapist summarizing general or overall progress of therapy—or any other generalizing or summarizing report—are not given the same protections as psychotherapy notes themselves (U.S. Department of Health & Human Services [HHS], 45 CFR 164.508, 2006).

There is one final piece of this puzzle: The HIPAA Privacy Rule clarifies that, in certain circumstances, parents are not privileged to act as their minor children’s personal representatives—with respect to certain protected health information—and thus neither control the child’s health care decisions nor the protected health information related to that care:

1. If no existing state statute or binding legal precedent requires a parent’s consent prior to a minor child obtaining psychotherapy treatment, and if the minor child then consents to his or her own psychotherapy treatment without the expressed consent of a parent, then, with respect to the minor child’s participation in that psychotherapy treatment, no parent acts as the child’s personal representative and, thus, the parent(s) will not be provided access to the psychotherapy notes without the child’s written consent.
2. If a court grants or other law authorizes another adult to act as the personal representative for a minor child as it relates to the child’s health care, then the minor child may obtain consent for such psychotherapy treatment from another personal representative, as provided, without consent from a parent. Similarly, in this case, with respect to the minor child’s participation in that psychotherapy treatment, the parent(s) will not be provided access to the psychotherapy notes without the child’s written consent.
3. If a parent provides a written and signed waiver expressly relinquishing his or her own right to participation in a confidential relationship between their minor child and a psychotherapist, then the privacy of the psychotherapy notes—as well as, in some cases, other protected health information—will remain boundaried and protected between the provider and the minor child, and parent access will be restricted unless the minor child provides written consent to the access of these protected records.

Further clarification in the Code of Federal Regulations (CFR) should be noted: “Even in these exceptional circumstances, where the parent is not the ‘personal representative’ of the minor, the Privacy Rule defers to state or other laws that require, permit, or prohibit the covered entity to disclose to a parent, or provide the parent access to, a minor child’s protected health information. Further, in these situations, if state or other law is silent or unclear concerning parental access to the minor’s protected health information, a covered entity has discretion to provide or deny a parent with access to the minor’s health information, if doing so is consistent with state or other applicable law, and provided the decision is made by a licensed health care professional in the exercise of professional judgment”(U.S. Department of Health & Human Services [HHS], 45 CFR 164.502, 2003).

Because foster children do not require the consent of foster parents before they can obtain psychotherapy services—and may obtain consent, if required, by way of other representative adults (such as child welfare caseworkers, child-placing agency case managers, etc.), whether the child independently consents or secures a nonparent consent to participate in such therapy, then, under the HIPAA Privacy Rule, the foster parent(s), for the purposes of this particular health care service, will not be provided distinction under the law as the child’s personal representative, and, thus, will not be provided the right to access documentation from the treatment record.

However, again, it is not that the HIPAA Privacy Rule expressly denies that foster parents have access to their children’s therapy notes, and, in fact, a “covered entity,” or provider (meaning, the child’s therapist) does retain prerogative to provide or deny a parent access with discretion if doing so is consistent with state and other applicable laws. Yet, this should be justified therapeutically.

In most cases, it is difficult to make a case that it is in the best interests of the child, therapeutically, to take away what is typically the only confidential outlet a foster child or teen has within the convoluted and institutional system in which they live and, thus, it is best practice in my state (K. Teutsch, personal communication, January 4, 2013) and in every state to preserve the therapeutic relationship by preserving the boundaries of confidentiality within that relationship and of privacy concerning the psychotherapy notes.

References:

1. K. Teutsch, Division Administrator for Medical Services, Texas Department of Family and Protective Services, personal communication, January 4, 2013.
2. U.S. Department of Health & Human Services – Office for Civil Rights (2006). HIPAA Administrative Simplification: Regulation Text [45 CFR 160, 162, & 164]. Washington, DC: US Government.
3. U.S. Department of Health & Human Services – Office for Civil Rights (2003). OCR HIPAA Privacy: Personal Representatives [45 CFR 164.502(g)]. Washington, DC: US Government.

Housing options for low-income families are limited. Research has shown that disadvantaged communities can contribute to emotional and behavioral challenges for children. But few studies have looked at the quality and kind of housing affects the developmental trajectory of children. Rebekah Levine Coley of the Applied Developmental and Educational Psychology Department at Boston College decided to explore this issue in a recent study. Coley looked at housing contexts including stability, housing quality, renting versus owning, and subsidized housing. She examined how these factors affected well-being in both the children and the parents.

Coley used data from over 2,400 participants ranging in age from 2 to 21 years old. The data was collected over a 6 year period and was used to determine how cognitive, behavioral and emotional well-being was affected by housing. The study revealed that several aspects of housing affected childhood development. Coley said, “Within the four characteristics of housing considered in this research, poor quality housing was the most consistently and strongly predictive of children’s well-being across the span of childhood.” Poor housing quality affected the emotional and behavioral development of the younger participants the most and had a strong negative impact on adolescents’ reading and math skills. Stress from living in poor conditions also contributed to negative outcomes. Coley believes that parental stress from inadequate living resources, as well as stress from neighborhood factors, including crime, violence, and drugs, could culminate to decrease parental emotional availability. Combined with the stress of the child, the result could be decreased coping skills and higher levels of internalizing and externalizing behaviors.

Housing stability was examined and revealed mixed results. For instance, multiple moves led to more externalizing and internalizing. But a move within the prior year led to lower maladaptive coping and better reading skills. This could be the result of moving to a better home or better community. Although Coley didn’t fully examine the details of the stability, these contradictory findings should be explored in future research. Finally, the developmental differences of children who rented versus owned, or who lived in subsidized versus non-subsidized housing, were minimal. The cost to own a home may put a financial burden on families that outweighs the benefits of owning. And aside from the environment in which subsidized housing is located, private versus subsidized renting did not directly affect developmental outcomes. Coley hopes that future research will further examine the impact of the home, in all its contexts, on overall development and well-being in children from all socioeconomic classes.

Reference:
Coley, R. L., Leventhal, T., Lynch, A. D., and Kull, M. (2012). Relations between housing characteristics and the well-being of low-income children and adolescents. Developmental Psychology. Advance online publication. doi: 10.1037/a0031033

According to a recent study led by Tara M. Chaplin of the Department of Psychiatry at Yale University School of Medicine, boys and girls have very different emotional tendencies, but these fluctuate depending on age and context. In her study, Chaplin reviewed data from over 21,000 participants from over 160 separate studies focusing on emotional expression from birth to adolescence. Chaplin looked at internalizing and externalizing emotions as well as positive and negative expressions. The study revealed some interesting and novel results. Chaplin said, “Our findings suggest that there are small but significant gender differences in emotion expressions, with larger gender differences emerging at certain ages and in certain contexts.” She found that in infancy, the boys and girls exhibited similar emotional displays. However, as the children aged, significant differences emerged.

Specifically, Chaplin found that the girls internalized their emotions more than the boys, but they also displayed more positive emotions. For instance, the girls had higher rates of anxiety and sadness than the boys, but outwardly expressed more cheerfulness and joy. The boys, on the other hand, were more likely to exhibit anger and aggression than the girls. But these variances were only evident when the children were in the presence of strangers. When they were with their parents, the children expressed a wide range of emotions, making the gender differences virtually non-existent. Chaplin believes that children may feel more comfortable with parents and may feel free to express all of their emotions. In social settings, children may feel the need to conform and therefore may not freely express their true emotions, leading to internalizing behaviors.

Although these emotional differences were very noticeable during the toddler and elementary school ages, they were less apparent as the children matured. For instance, externalizing behaviors diminished in the boys and increased in the girls, almost to the point of being equal. Two other findings revealed concerning patterns. The adolescent girls had higher levels of shame than the boys. Because shame and guilt have been shown to be a factor in several psychological problems, including depression, self-harm, and disordered eating, this should be a key point of focus for educators and clinicians working with teen girls. Also, boys felt more joy than girls when they were provided the opportunity to taunt or tease another individual. This is disturbing too because this could increase the risk for these boys to engage in bullying and aggressive behavior. Because the trajectory of emotional expression changes as children mature, and because it is heavily influenced by family environment, social factors, and other external conditions, children will display a wide range of emotions as they develop. However, Chaplin believes it is also important to be able to identify which expressions are normal and which are signs of concern.

Reference:
Chaplin, T. M., and Aldao, A. (2012). Gender differences in emotion expression in children: A meta-analytic review. Psychological Bulletin. Advance online publication. doi: 10.1037/a0030737

Evidence has shown that not only are many children with autism spectrum (ASD) highly intelligent, demonstrating creative and cognitive abilities that far exceed those of their non-ASD peers, but autistic children are also better able to process details than other children. In many tests, autistic children outperform their peers on local processing tasks, or tasks that require identification of parts of a whole. This is especially true when there are clear delineations between the individual segments of a global picture. When there is less distinction, the ASD children tend to perform equal to that of their non-ASD peers. Some researchers believe that this local processing skill is a trait of ASD and accounts for the high levels of artistic talent among children with ASD. But Jennifer E. Drake of the Department of Psychology at Boston College hypothesized that perhaps this local processing strength is a trait of artistic talent and not exclusive to individuals with autism.

To test her theory, Drake enlisted 30 children, half of whom had ASD, for a drawing and visuospatial test. She used the Block Design Task and the Group Embedded Figures Test to determine local processing, and also had the children create still life drawings. She found that the children with more drawing talent had higher levels of local processing abilities, regardless of whether they had ASD or not. Drake also noticed that the tests she administered were more predictive of drawing talent than they were of ASD. In other words, tests that are sometimes used to identify ASD traits in children may actually be indicating artistic abilities and not autistic tendencies.

Drake believes that her findings have significant clinical implications. Many children are assessed for autism at a very young age. It is at this time that strengths first appear as well, including artistic strengths. She believes it is possible that many young children with strong local processing abilities may actually be exhibiting artistic strengths when they take these types of tests. In the absence of global deficits, these children may not be demonstrating true characteristics of autism. “Thus, the superior local processing seen in ASD may be due to the drawing talent so often present in those with ASD,” Drake said. But Drake cautions that any deficits or strengths that are outside of the normal range should not be ignored in young children, especially if the children exhibit other reasons for concern.

Reference:
Drake, J. E. (2012). Is superior local processing in the visuospatial domain a function of drawing talent rather than autism spectrum disorder?  Psychology of Aesthetics, Creativity, and the Arts. Advance online publication. doi: 10.1037/a0030636

Childhood anxiety is a serious but often undiagnosed condition. Separation anxiety, social phobia and generalized anxiety are among the most common mental health issues affecting children and adolescents. Anxiety in childhood often predicts the occurrence of such problems later in life.

Identifying and treating anxiety and other mood disorders at early as possible is therefore an important goal of psychiatric research. Undiagnosed mood issues represent a large public health burden and result in a poor quality of life of those affected. The standard treatments for childhood anxiety are antidepressant medications and cognitive behavioral therapy.

Zoloft (sertraline) belongs to the class of antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs), and researchers have identified it as the medication of choice for treating most instances of childhood anxiety. Compared with similar medications, Zoloft offers the greatest benefit to anxiety sufferers with the lowest incidence of adverse side effects. However, as with many antidepressant medications, there is a small risk of suicide or self-harm in children and young adults at the start of a new drug regimen. Those with anxiety rather than depression are less likely to experience these effects. Children and adolescents should be assessed for suicide risk before beginning any antidepressant medication.

Several clinical trials have offered strong evidence that a combination treatment including Zoloft and cognitive behavioral therapy offers the most substantial improvement for children who have been diagnosed with anxiety issues. In one such study, 80% of participants receiving combination treatment saw significant improvement after 12 weeks. Researchers theorize that therapy and medication have a synergistic effect with one enhancing the effects of the other.

Regular therapy sessions also provide an opportunity for children and parents to report side effects from the children’s medication. In the previously mentioned study, both therapy and Zoloft alone also led to improvements on an anxiety rating scale that far outperformed placebo. Most importantly, participants receiving Zoloft did not report more adverse side effects than participants receiving placebo did, and none considered or attempted suicide.

When considering childhood anxiety, the rewards of effective treatment for outweigh the potential risks of medication. A combination of weekly cognitive behavioral therapy sessions and prescription of the antidepressant medication Zoloft seems to promise the best results for the greatest number of patients. As always, attending physicians must prescribe drugs like Zoloft cautiously, especially to children and adolescents.

References:

1. Sertraline – PubMed Health. (n.d.). National Center for Biotechnology Information. Retrieved April 6, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001017/
2. Walkup, J.T., Albano, A.M., Piacentini, J., Birhamer, B., Compton, S.N., Sherrill, J.T., Ginsburg, G.S. et al. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359, (26), 2753-2766.

The American Psychiatric Association has approved changes to the Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the DSM. The fifth edition of the flagship guide to psychiatric diagnosis, due for release in May 2013 and known as the DSM-5, features several controversial revisions.

The DSM establishes criteria for the diagnosis of mental health conditions. Because changes to the manual can affect insurance coverage for certain issues and help define “normal” behavior, advocacy groups are often concerned about the effect additions and alterations will have. The latest revision is no exception.

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Children and Mental Health
Diagnosing children with mental health conditions is often dicey because of concerns about stigma and the use, or overuse, of psychiatric drugs. At a time when some groups argue that fewer children should be diagnosed with mental health issues, the DSM-5 adds new diagnostic criteria for children. Those over the age of 6 who display irritability or frequent angry outbursts now qualify for a diagnosis of disruptive mood dysregulation disorder. While some mental health professionals emphasize that this new diagnosis could make it easier to plan early intervention for children who have extreme difficulties controlling their emotions, some advocacy groups have expressed concern that such a diagnosis could stigmatize normal childhood behavior or lead to the prescribing of unnecessary drugs to young children.

Autism Spectrum Disorder
The DSM-5 eliminates Asperger’s syndrome, folding it into a broader category called autism spectrum disorder. Diagnoses of Asperger’s and autism have been steadily increasing over the past several years, and many children with less severe symptoms of autism have been diagnosed with Asperger’s. The DSM-5, however, incorporates several autism-like issues, including Asperger’s, into the diagnosis of autism spectrum disorder. Not everyone is happy with this change. Many people with Asperger’s view the issue as part of their identity and do not want it to be lumped in with other issues. The APA, however, argues that this change will make diagnosis of autism more consistent and access to treatment easier.

Grief and Depression
Previous versions of the DSM incorporated a bereavement exception into depression diagnoses. This exclusion prevented mental health professionals from diagnosing a person who was grieving the death of a loved one with depression. The DSM-5, however, permits depression diagnoses in the bereaved. Members of the APA argued that the old bereavement exception excluded grieving people who had been diagnosed with chronic depression from being diagnosed with, and receiving treatment for, depression. But some people worry that the new changes pathologize grief and turn normal grieving—which often looks a lot like depression—into a mental health diagnosis.

Other Changes
The DSM-5 adds hoarding and excoriation disorder—a diagnosis for people who compulsively pick their skin. The APA also rejected several proposed disorders, including parental alienation syndrome, hypersexual disorder, and anxious depression. While the APA emphasized that the revisions—like all changes to the DSM—are intended to clarify diagnostic criteria and improve consistency in diagnosing, mental health advocacy groups argue that many diagnostic criteria have been loosened and that the DSM-5 will increase the number of people diagnosed with mental health conditions.

Which changes to the DSM did you find most controversial? Please share your comments below.

References:

1. Asperger’s syndrome dropped from American Psychiatric Association manual. (n.d.). MedPage Today. Retrieved from http://www.medpagetoday.com/Psychiatry/DSM-5/36206
2. Gever, J. (n.d.). DSM-5 wins APA board approval. MedPage Today. Retrieved from http://www.medpagetoday.com/Psychiatry/DSM-5/36206
3. Gupta, P. (n.d.). Controversial changes to stay in DSM-5. Salon. Retrieved from http://www.salon.com/2012/12/02/controversial_changes_to_stay_in_dsm_5/
4. Spiegel, A. (2012, November 30). Weekend vote will bring controversial changes to psychiatrists’ bible. NPR. Retrieved from http://www.npr.org/blogs/health/2012/11/30/166252201/weekend-vote-will-bring-controversial-changes-to-psychiatrists-bible

Last month, we talked about how figuring out why someone is doing something is key to changing his or her behaviors. We learned that most behaviors are motivated by getting something, getting away from or stopping something, feeling good, or are simply automatic (a reflex, for example).

In order to change behaviors, we must learn about reinforcement, not merely the functions of the behaviors.

Case Example
Imagine this scene, one that is played out in countless grocery stores every day around the world. Picture, if you will, a harried mother trying to get the shopping for the house completed. She is tired and in a rush to get home. With her is her young son. In the checkout line, as Mom tries to load the groceries on the little conveyor belt, her child asks for a candy bar (located conveniently an arm’s reach away, at child eye level). Mom, being a kind and benevolent mom, says, “No, we’re going home and having dinner. You don’t need a candy bar right now.” Her son, being like most children of his age, doesn’t like this state of affairs. In response to the denial of sucrose refreshment, he starts wailing at the top of his lungs, “PLEEAAAASEE! I WANNA CANDY! I WANNA CANDY! I WANNA CANDY!”

Other store patrons stare at the impending debacle. Mom feels embarrassed and more than a little ticked off. She still has to get the groceries home, get them unpacked, and make dinner. Dealing with a tantrum is the last thing she wants to do. At first she tries to calmly explain to her child that dinner will be soon, but the child screams louder. Then she commands him to cease his tantrum. That works about as well as can be expected (not at all). Finally, Mom gives in and buys her little angel the candy bar, at which point he immediately ceases his caterwauling.

Can you name all the reinforcement that occurred in the above example? What do you think will happen next time Mom brings her son to the grocery store?

What Is Reinforcement?
The technical definition of reinforcement is anything that occurs after a behavior that increases the chances of that behavior occurring again. Simply put, when your child does something (a behavior) and you do something immediately afterward, if your child repeats the behavior, whatever you did was a reinforcer.

This idea is key to behavior change. We want to provide rich and powerful reinforcement for the behaviors we wish to see (start behaviors) and avoid reinforcement for the behaviors we do not wish to see (stop behaviors). This interaction is at the heart of everything we wish to accomplish.

Important points:

• Reinforcement occurs only if you see the behavior again. You might feel you are rewarding your child, but if the reward does not result in increased frequency, intensity, or other improvement in the behavior, then the reward is not reinforcing.
• Reinforcement can be anything. It doesn’t have to be pleasant, either. For example, a person who likes fighting might enjoy when he is in a fight and find getting hit or yelled at reinforcing.
• Reinforcement always increases behaviors. Anything that decreases the chances of seeing a behavior is called a punisher.

The bottom line? Reward your kids when they do what you want them to do and they will do those things more. If you simultaneously remove the rewards from the behaviors you want to see less of, you will see less of those behaviors.

Isn’t this just bribery, you may ask? Nope. There are some key differences between bribery and reinforcement. Bribery is typically something (often money) given to someone in advance of behavior. It is generally given to get a person to do something unethical or illegal. Reinforcement always occurs after a behavior, and we are not using it to get our children to do anything unethical or illegal (hopefully!).

You might also ask: Why should I be rewarding my kid for doing what he is supposed to do? Shouldn’t he just do it? In a perfect world, yes, your child would do what he or she is supposed to do. However, in the real world, children are compelled by the “drive-your-parents-nuts accord” to not always follow directions. If we, as parents, want to keep our sanity, it behooves us to use all the tools at our disposal to encourage and reward our children, and ultimately to teach them what to do and when to do it.

Types of Reinforcement

• Positive: This is the most common type. It is something that is added to the situation (money, candy, praise). Basically, if you give your child something because he did something good, that’s positive reinforcement. In the case example, the mother positively reinforced her child’s checkout-line tantrum behavior by buying him the candy.
• Negative: This not punishment. (That decreases behaviors.) It is the removal of something. In the case example, the child negatively reinforced his mother’s candy-buying behavior by ceasing his tantrum when she gave in and bought it.

Classes of Reinforcers

• Primary: These are typically those things that all people need—food, air, companionship, etc.—and are often tied to basic survival. These are good because almost everybody will respond to them. However, they suffer from the “too-much-of-a-good-thing” effect, also known as satiety. When you’ve had enough of something, it loses its reinforcing qualities.
• Secondary: These are learned reinforcers. Typically paired in some way with primary reinforcement, these can be anything. Money is perhaps one of the most prevalent secondary reinforcers in the world. It always amazes me what people will do for colored bits of paper.

Putting This Information to Use

Follow these simple steps:

1. Ask yourself: Is this a start behavior or a stop behavior? (Do you want to see this more or less?)
2. Ask yourself: What is the function of the behavior?
3. For stop behaviors, the answer to question No. 3 will tell you what you need to decrease or eliminate from the situation to make the behavior go away. Do that.
4. For start behaviors, the answer to question No. 3 will tell you what you need to do to get the person to do the behavior more (or better).

As with all things simple, there is a lot more to look at, but it ultimately comes down to these four points. (We will discuss more about reinforcement and how to set it up and deliver it in future articles.)

What’s the Best Reinforcer?
The best reinforcer is the one that works in a given situation. However, my preference is praise. I will cover praise in more detail in a future article, but here is why I like it as a reinforcer: Just about everybody responds to praise. The more you praise someone, the more he or she likes you. The more he or she likes you, the more he or she will respond to you. Praise is free. It takes up no space. People rarely get tired of it. It pairs well with every other kind of reinforcer (thus making the praise and the other reinforcer more effective). In your experiments with reinforcement, try adding a little praise to your efforts and see how it enhances things.

I hope this information helps make your day-to-day challenges less challenging. Please comment below, ask questions, or make suggestions. Let me know about creative ways you have found to reinforce your children (or anyone else, for that matter). Hang in there, parents!

Two weeks removed from a Halloween that inspired thousands of people to dress as reality television’s Honey Boo Boo, child beauty pageants have again entered the national consciousness. From small festival- and fair-based competitions to elaborate, expensive, national endeavors, child beauty pageants are a $5 billion industry. Parents who enroll their children in such pageants fiercely defend them as the child’s choice, and many participants—particularly on pageant-centered shows such as TLC’s Toddlers & Tiaras—seem thrilled to be involved. But what effects do beauty pageants have on children and their impressionable minds?

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Why Children Enter Beauty Pageants

Children are the masters of fantastical ideas, so it’s no wonder that many girls involved in the pageant circuits relish spending a few days a year as Cinderella. But children can’t enter pageants without their parents’ blessing, so involvement ultimately hinges on parental choice rather than the child’s. In a new paper published in the Journal of the American Academy of Child and Adolescent Psychiatry, University of Arizona professor Martina M. Cartwright emphasizes this point. She calls the phenomenon “princess by proxy,” explaining that the real attraction of pageants is for parents who can gain social status, self-esteem, and money when their children participate.

Potential Effects of Beauty Pageants: Eating Disorders and Body-Image Distortion

Pageants, particularly those designed for younger children, focus primarily on appearance, attire, and perceived “cuteness.” Talent competitions occur in some pageants and often are a secondary component of the experience. Thus, pageants suggest to young children that there is value in focusing on their appearance as judged through the eyes of others. This can lead to significant body-image distortions, and adults who once participated in child beauty pageants may experience low self-esteem and poor body image.

As with most adult pageants, child pageants often require crash dieting. Parents may encourage children to quickly lose weight so they can fit into small costumes or display tiny bodies in swimsuit-centered fitness competitions. Some parents put their kids on crash diets designed to help them gain energy and enthusiasm. These diets may consist solely of sugary snacks and sports drinks for several days. This can harm both short- and long-term health and teaches children unhealthy approaches to food that can contribute to the development of eating disorders.

Beauty Pageants and the Sexualization of Young Girls

Sexualization is the tendency to view oneself as a sex object, and children who participate in beauty pageants are sexualized very early. Children may dress in highly suggestive costumes and learn that they gain attention and status when sexualized. This may lead to premature sexual activity and can teach the unfortunate lesson that women’s worth is determined at least in part by their status as sex objects.

The Unhealthy Values Built by Beauty Contests

While some pageants are brief events that require little preparation, the world of pageants can be cutthroat and extremely competitive. Children learn a host of unhealthy values, including the desire to defeat their competition at all costs. Tantrums and meltdowns—by children and parents alike—are common backstage at beauty pageants, and long-term participation in pageants can teach children that their primary source of worth is how many pageants they win and how “beautiful” they are perceived to be. Academic achievement, empathy, social skills, athletic pursuits, and other age-appropriate activities may take a backseat in the world of pageants. And because precious few pageant participants grow up to become models or entertainers, this early experience can stunt their development by focusing their attention on something they are unlikely to be able to do as adults.

References:

1. Giroux, H. A. (2009, May 11). Child beauty pageants: A scene from the “other America.” Truthout. Retrieved from http://archive.truthout.org/051109A
2. Sinpetru, L. (n.d.). Child beauty pageants foster adult body dissatisfaction, eating disorders. Softpedia. Retrieved from http://news.softpedia.com/news/Child-Beauty-Pageants-Foster-Adult-Body-Dissatisfaction-Eating-Disorders-302540.shtml

For children and adolescents with attention deficit hyperactivity (ADHD), Ritalin (methylphenidate) is typically the medication of choice. As a psychostimulant drug, Ritalin increases the concentration of the neurotransmitters dopamine and noradrenalin in the brain. These neurotransmitters are partly responsible for impulse control and attention, among other things.

Studies in both rats and humans have verified that Ritalin effectively controls the three primary symptoms of ADHD: inattention, hyperactivity, and impulsivity. When ADHD goes into remission, the person’s quality of life and performance in work or school measurably improve.

Despite these benefits, critics have wondered about the potential negative effects of this heavily prescribed medication. For one thing, no one fully understands how Ritalin functions in the brain. More importantly, little information exists as to the long-term effects of a psychostimulant drug on the developing brain. A recent study with rats highlighted a possibly adverse effect of Ritalin that had previously been overlooked.

Adolescent play behavior is important in terms of both mental and social development. Through play, children learn the basic “rules” of social interaction and receive the rewards of companionship. Isolated children often have difficulty adjusting to adult life and navigating social situations. Researchers investigating Ritalin’s effect on social play found that the medication significantly reduces the behavior in rats.

Adolescent rats treated with low doses of Ritalin were apt to ignore invitation to play, instead remaining focused on their general environment. The effect was surprisingly specific. Rats demonstrated the same overall activity levels as untreated counterparts, but less overt play behavior and social interaction. Some rats were isolated for up to 24 hours before release into a play area. Researchers believed a long period of isolation would enhance play despite the effects of Ritalin, but they were mistaken. Regardless of isolation period, Ritalin proved to be a powerful blocker of normal, social play behavior.

The beneficial effects of Ritalin for people with ADHD are inseparable from the possibly negative effects of inhibited play. By its very nature, play is a complex, dynamic, but not necessarily focused activity. One of the primary aspects of Ritalin’s overall effect is to inhibit “unfocused,” freewheeling behaviors—including play, apparently. This calls for more research and possibly long-term studies of the potential consequences of Ritalin prescription throughout childhood and adolescence. It’s possible that this medication poses more risks than previously believed.

References:

1. Attention deficit hyperactivity disorder (ADHD) – PubMed Health. (n.d.). National Center for Biotechnology Information. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/
2. Vandershuren, L., Trezza, V., Griffioen-Roose, S., Schiepers, O., Van Leeuwen, N., De Vries, T.J., and Schoffelmeer, A. (2008). Methylphenidate disrupts social play behavior in adolescent rats. Neuropsychopharmacology, 33, (12), 2946-2956.

When parents view their child’s “problematic” behavior, attitudes, or troubles as a reflection of them, it can be a terrible blow to the ego. For parents with positive self-feelings, anger, hurt, and disappointment can occur when they don’t see themselves reflected in their children. (“My child should be just like me.”) For parents who do not feel very good about themselves, seeing a child as being “just like me” can feel devastating. Parents who lack self-esteem often feel like their child’s problems are their fault. Their inability to differentiate themselves from their children can also result in guilt and painful feelings of responsibility that are often overstated and inaccurate. Many parents who struggle with the idea that their child is a reflection of them (for better and worse) have not separated from their children. These parents tend to feel some responsibility for their child’s situation. Most often they believe that, either in their early behavior with their children or in their biological contribution (or both), they have profoundly affected their child’s life and character.

“Peter” came to his therapy session in a rage about “Adam,” his 25-year-old son. He had just come from his son’s apartment and was disgusted about the dirt and disarray he encountered: “What is the matter with that kid? He’s such a slob. There is stuff everywhere. It feels so chaotic! I have the same feeling when I think about how he gets drunk with his friends on the weekend. He’s a mess!”

When I asked Peter what made him so angry about this, he began to express remorse about being so enraged. Choking up, he said, “I guess I’m really hurt. I feel like Adam is being disrespectful to me. He knows I hate his messes and his drinking behavior. I feel like he’s on a terrible path of disorganization and disaster. I keep asking myself, ‘How did he turn out this way?’ ”

I asked Peter what he thought about why Adam was like this. “I don’t really know,” Peter said. “But I honestly believe it’s my fault. You know I was a terrible workaholic during Adam’s first 10 years. I neglected him when he was growing up. Then I think, if I was a workaholic, will he be an alcoholic? I know I made him this way. I’m a mess of a father.” Peter was tortured by his painful feelings and disappointment that his son hadn’t turned into the ideal adult that Peter wished he could be.

Over time, as we explored Peter’s feelings, it became apparent that he put all the responsibility for the person Adam was at age 25 on himself. He found it very difficult to see Adam as a separate individual with his own reasons for behaving the way he did. Slowly, Peter was able to consider that his influence hadn’t only been negative and that he wasn’t the only influence on Adam’s development. Adam’s mother was nurturing; Adam had many friends growing up. Peter could even recall some teachers who were influential in Adam’s life. He acknowledged, for example, that a high school teacher had encouraged Adam to stay with his music, and Peter admitted that Adam was a successful musician.

“I guess I haven’t focused enough on Adam’s successes, just on the ways I see him as a failure and blame myself,” Peter said. “Sometimes I still think that maybe Adam is punishing me when he messes up in ways he knows I hate. I guess I really have to admit that it isn’t all about me. Adam is a different person from me. It’s just hard to be OK with that. But I do want to get there. I know that would be best for our relationship.”

Peter is slowly beginning to separate from Adam and experience Adam’s successes and failures as more about Adam than him. He is also beginning to take Adam’s character and behavior less personally. Giving up the idea that “it was all my fault” makes space for Peter to see Adam as a separate individual.

“Rose,” another client, began to talk about her 10-year-old daughter, “Jessica,” in our therapy sessions.  Rose was obsessed with worry that Jessica, who had learning disabilities, would never have a successful life. She said with some sadness: “Her brain is damaged. How will she ever be OK?”

“What do you mean, ‘Her brain is damaged’?” I asked.

“You know that we had her tested and she has so much trouble focusing and organizing her thoughts,” she responded.

“Yes, I know she has some learning disabilities, but seeing her as ‘a person with a damaged brain’ seems a rather extreme way of defining your daughter,” I said.

“I sort of know what you’re saying is true,” she said. “But you know I had learning disabilities as a kid. No one identified them; no one did anything about it. I still struggle at work and in my life in general with being focused and organized. I get so depressed and anxious when I forget things or don’t get stuff done like I promise my husband or my boss. I know my brain is messed up, and Jessica is just like me. Why would I think her fate is going to be any different?”

Rose had a very strong belief that biology was determining her future as well as her daughter’s. She was reluctant to consider that her daughter’s life could take a different path from hers. She had a difficult time thinking about Jessica as a separate person with her own unique characteristics. I reminded her that she and her husband had been addressing Jessica’s learning problems and getting help for her. I also pointed out that this was very different from her own experience growing up. I emphasized that there are many influences other than biology that influence a person’s development. I also asked Rose to tell me anything she could think of about Jessica’s accomplishments. We both listened to the list Rose came up with: “Great piano player, really good artist, hula-hoop champion, kind person, good swimmer, and I guess other stuff, too.” Rose reluctantly acknowledged, “Yes, I suppose her brain works OK in some ways.”

Rose and I spent a lot of time talking not only about Jessica, but also about Rose’s negative sense of self. It was harder for her to take seriously that she has her own accomplishments. It was even more difficult to consider that Jessica was like her in some ways and not others. (Rose is a terrible artist and swimmer!) Our work has centered on Rose’s struggle to experience herself in positive ways and on seeing Jessica as a separate, differentiated individual. We have also been talking about how painful it is to see your child have areas of deficit, and even worse when you feel you are the cause. Helping Rose to talk about her impaired sense of self and its development has allowed her to make distinctions between her own experience and Jessica’s. I have tried to help Rose consider that while there could be some biology at work in regard to Jessica’s learning disabilities, so much more than being “just like me” is involved in what makes Jessica who she is.

We are familiar with parents feeling great pride in how they played a role in their children’s successes. But when parents boast incessantly about their children’s accomplishments to the extent it doesn’t feel like typical parental pleasure, we typically consider them to be narcissistic. For Peter and Rose, their great dismay in what they perceived as their children’s deficits, problems, and failures was also narcissistic.

The term narcissism comes from the Greek myth of Narcissus, in which Narcissus falls in love with his own reflection in a pool. The notion of reflection is pertinent to the experiences of Peter and Rose. Rather than experiencing narcissistic pleasure, these distraught parents experienced a narcissistic wound. They couldn’t tolerate the pain of looking into the pool (i.e., at their child who also represents the parent) and seeing something that is not “beautiful” reflected back. When they looked at their children, they saw a reflection of themselves. It was intolerable that the reflection they saw was “a mess” or had a “damaged brain.” It was not “beautiful.”

These parents are responding narcissistically, and they have not differentiated themselves from their children. One has to wonder how parents, who view their children as reflections of themselves, may have influenced their child’s separation/individuation process. As parents become more aware that their beliefs that their children are or are supposed to be “just like them” are assumptions, they will be in a better position to examine those beliefs. As a result, parents will experience less pain, and their children will be helped to develop into separate, unique individuals.

The average age of sexual initiation is roughly between 16 and 19. Although some teens wait until much later, many begin engaging in sexual behavior before the age of 15. Numerous studies have looked at the negative consequences associated with early sexual initiation, such as emotional problems, HIV/AIDS, pregnancy, and intimate partner violence. But recently, researchers at the University of Texas looked at how sexual-initiation age could benefit people later in life. In a study led by Paige Harden, 1,659 sibling pairs were evaluated from middle adolescence through young adulthood. They were asked when they began having sexual intercourse, how many partners they had, and, if they were in current relationships, how happy they were.

Harden found that the participants who were in satisfying, committed relationships in adulthood were those that started having sex in their late teens or early twenties. These individuals reported less relationship conflict and more respect, affection, and love for their partners than the participants who had earlier sexual-initiation ages. Harden tested this outcome further by including factors such as physical appearance, body mass index, and education and came up with the same results. She believes that people who begin sexual activity after they have reached physical and cognitive maturity may make better partner decisions and be more discriminating in their choices. They may also have stronger communication skills that can benefit their overall relationship.

The results of this study don’t suggest that earlier sexual initiation can increase negative outcomes. Rather, these findings demonstrate that being a late bloomer can act as a protective factor. “We still don’t understand precisely why delaying sexual intercourse is correlated with more satisfied adult relationships,” Harden said. She hopes that future research will look at the flip side of her study, and in particular if early sexual activity among teens decreases their chances of having satisfying, positive relationships in adulthood.

Reference:
Ochsner, David. Does true love wait? Age of first sexual experience predicts romantic outcomes in adulthood. (n.d.): n. pag. The University of Texas at Austin. 18 Oct. 2012. Web. 18 Oct. 2012. http://www.utexas.edu/news/2012/10/18/does-true-love-wait-age-of-first-sexual-experience-predicts-romantic-outcomes-in-adulthood/