Behavioral Therapy with a child who is unwilling to talk about behaviors...

[nature girl]

Have any of you gone through therapy with a stubborn kid reluctant to open up? Do therapists have methods of engaging children and making them more comfortable and willing to talk about their feelings and behaviors?

 

Anna will talk about anything with anyone, extremely outgoing, but as soon as I or anyone else (including our occupational therapist) try to talk with her about how she's feeling, she starts acting extremely silly, making raspberries, climbing on things, etc. I don't know if it's that she knows she has problems in these areas and isn't like other kids, so is trying to bury the issue and not think about it...but she's said many times she hates Zones, and hates talking about feelings. It's the same when she has a misbehavior and I try to get her to talk about what she might do differently next time, or after she's been frustrated/angry and I try to talk about tools she could have used...She just refuses to participate.

 

So will a therapist be able to do anything I, and our OT, haven't? Since we'd be paying $150 a week OOP, I really don't want to be wasting our life savings for her to spend 50 minutes blowing raspberries at a stranger. But I know she needs therapy so badly, it could be so good for her if she'd just open up.

 

(So far my husband and I have tried talking about our own frustrations/angers, etc. in the hopes she'll come to understand the feelings are universal and nothing to be ashamed of, and we've been really careful not to name feelings as bad. The discomfort is all from her own self-judgment.)

[PeterPan]

You might want a behaviorist instead of a talk therapist. She doesn't sound ready for talking based approaches. Our OT tried and ds had a HUGE meltdown. She's not being bad; she's just not ready.

[nature girl]

I'll have to look more into the methods a behaviorist actually uses. I have some vague preconceived image of someone sitting with a child, watching their behavior and finding the antecedents, then talking about how to address them...If that's true, she'd have to sit all day with Anna because the misbehaviors aren't that frequent, and actual meltdowns are few and far between. And antecedents are almost always just being asked to do something she doesn't want to do, or being refused something she really wants (although she usually accepts this without issue.)

 

One example  incident: Yesterday Anna was picking her nose, I asked her to get a tissue. She refused, kept picking, I asked her to get a tissue and wash her hands. She yelled at me and wiped her hands on my shirt. Is this the kind of misbehavior a behaviorist could help at all with?

[nature girl]

dp

Edited January 27, 2016 by Anna's Mom

[albeto.]

She needs a play therapist, or a child therapist who understands when kids are uncomfortable talking about their feelings, one doesn't cajole them into talking about their feelings! It doesn't matter how nice they are about it, no carrot will work, no stick will work, this is the wrong approach, and frankly, an absurd one to use for a child like this (or most children, imo). A therapist should first make their space a safe place. That means no matter what happens, that place is safe from uncomfortable scenarios, and that includes uncomfortable topics. To make it safe, the therapist should be following the child's lead, then, as opportunities come up, a general, vague, safe statement or question would be introduced. The child's response dictates the therapists roll here. 

 

One example from a personal experience: Therapist and child were looking through science book (child's interest), and they'd simply talk about it. Child led the conversation. In general, he shared with the therapist what he knew. Sometimes he got it wrong. When the therapist would make a correction, he'd note the child's increased frustration. The therapist took a moment to comment out loud about how the child felt ("Say, you look pretty frustrated right now. It looks to me like you don't like to be corrected."). Child would respond (usually angrily), and the therapist, rather than explain the importance of accepting correction in the vein in which it's meant, blah blah blah lecture lecture adults do this all. the. time, he'd ask, "So... what do you think most fellas do when they get frustrated?" That made the child stop and think, not of his feelings, but of the practical application of feelings in general. It was removed from him, it was hypothetical, and there was no "wrong" answer. It was a safe conversation to have, even within an uncomfortable situation. Then when the moment passed, the conversation continued.

 

These kinds of interjections happened when ds was young, young enough to prefer *anything* to talking about his feelings. His feelings were strong, they were powerful, they came with impulses that got him into trouble. The *last* thing he wanted to talk about was his feelings. The last thing he wanted to do was acknowledge them. He wanted to ignore them and simply do something fun for once. This therapist slowly, consistently, and patiently combined the two, but it was many months before he could approach the subject of feelings without an emotional backlash. The process started very, very slowly, but over time has been, for ds, a life-changer. There have been many other approaches, one being a behaviorist who didn't focus on what ds thought or felt, but on teaching effective but socially appropriate behaviors as alternative to effective but socially inappropriate behaviors. There are different niches that address different skills, but in my experience, talk therapy is best for those who are motivated to talk about their feelings. Not every child has an inner Woody Allen jumping at the chance to lay on the cot and unleash their anxieties, kwim?  

[albeto.]

 Is this the kind of misbehavior a behaviorist could help at all with?

 

Yes, absolutely. The first thing to do is keep track of data so you're not reliant on memory or impressions. They can be misleading, inspired by fears, worries, hopes, or any other natural biases to which we are simply blind. Let's say she is defiant X times per day on average. The behaviorist will help you come up with a plan that will reduce that amount by considering what the antecedents are, what the behaviors generally are, and what the consequences are. This gives the behaviorist a trend of behavior to work with, allowing him or her to help you spot danger ahead and either avoid it (hunger, sleep), or prepare her. Sometimes we can get what we want when we ask nicely, sometimes fortune smiles on us and we get what we want without us having to do anything at all, and sometimes we don't get what we want, or even need. Being prepared for these feelings and having an alternative way to express frustration are things behaviorists can help with.

[OneStepAtATime]

Agree with Albeto, start a journal.  If you can, do some sort of short hand so it won't take up so much time you don't record anything.  Include time of day, hopefully surrounding circumstances, etc.  The more ACCURATE data a therapist has to work with, the better off you all will be.  I also agree, play therapy may be far more productive than talk therapy for your daughter.  

[Princess Ariel]

I agree that play therapy can reveal a lot of what is going on with a child.  Any kind of "talk therapy" doesn't work with a young child.  One of mine worked with a play therapist for years and continues to see her (she's really good) now as a teen, no longer doing play therapy. But she did say there are areas that this kid just will not open up about and it cannot happen if the teen isn't willing to open up.  It is frustrating.

[nature girl]

Thank you so much, Albeto, that's so helpful!

 

I've been focused on behavioral therapy because it's considered the gold standard for ADHD (I remember reading somewhere that play therapy is usually ineffective.) But I think the real trick will be finding a therapist of whatever kind, who knows how to gently engage her and talk about behaviors. (I'm going to try implementing your therapist example the next time she gets angry at me for making corrections during schooling...which happens every day. She's good about talking about other people's feelings, especially characters in books, it's much less threatening for her, so using 3rd-person examples and helping her find solutions for others might be a perfect technique.)

 

I'll look around for behaviorists in the area, try to feel out on the phone what they might do. (I'd never really heard of using a behaviorist for ADHD, mainly ASD. I wonder if insurance might cover some of it...)

[Crimson Wife]

One example  incident: Yesterday Anna was picking her nose, I asked her to get a tissue. She refused, kept picking, I asked her to get a tissue and wash her hands. She yelled at me and wiped her hands on my shirt. Is this the kind of misbehavior a behaviorist could help at all with?

 

Yes, this is exactly the kind of thing that Applied Behavioral Analysis targets.

 

Talk therapy wouldn't work for my DD yet because she doesn't have the language skills. But ABA has been amazingly helpful.

 

[Crimson Wife]

I'll look around for behaviorists in the area, try to feel out on the phone what they might do. (I'd never really heard of using a behaviorist for ADHD, mainly ASD. I wonder if insurance might cover some of it...)

 

The "gold standard" for ADHD treatment is medication. I realize that's not what you want to hear, but it's the truth. CBT is considered the "gold standard" for anxiety and/or obsessive-compulsive disorder (both of which can be co-morbid with ADHD) but it's not for ADHD.

 

According to the neuropsych at Kennedy Krieger, ABA is helpful for a wide range of issues, not just ASD. One of the reasons why she did not run any ASD tests for my daughter is because she didn't want to jeopardize the funding we have in place for ABA.

[nature girl]

The "gold standard" for ADHD treatment is medication. I realize that's not what you want to hear, but it's the truth. CBT is considered the "gold standard" for anxiety and/or obsessive-compulsive disorder (both of which can be co-morbid with ADHD) but it's not for ADHD.

 

I think the gold standard is both, medication alone isn't considered good treatment, but I know what you're saying. From everything I've read, many psychiatrists won't even prescribe meds to young kids without them trying some therapy first. And since my daughter's issues at this point are more with behaviors than attention (from what I understand, meds might help with impulsivity but not as much with emotional regulation), I wanted to at least try a few months of therapy before we go any further.

 

I'm trying to find an behaviorist in the area...From what you're saying, it sounds like insurance might not approve it, but it will at least be worth discussing options with whoever I can find.

[albeto.]

You might consider keeping your data simple and organized with an ABC chart. A: Antecedent. Simply write down what events happened just prior to the targeted behavior. B: Behavior. Simply write down what you observe. Do not consider intention or desire. C: Consequence. This is not to keep you on your toes, but to give an idea of what your dd experiences. If the consequences are generally lectures, she may consider that a natural consequence that simply must be tolerated in order to have solve the problem. You may also see what works and what doesn't with regard to inspiring her to change. The behaviorist should help with this. I would target a specific behavior, or kind of behaviors. Don't record every time she does something that's inappropriate or irritating, only those behaviors you really need to target first. Define them so you can determine if a behavior is worth recording or not. A sample might look like this, for the behavior "Defiance" as defined by protesting or refusing to comply to request or demand.

 

A: Getting out of car. Late for lunch, finished errands, Anna complaining about math she has to do later.

B: Refused to help bring in groceries. Stomped feet, hit car with palm of hand, screamed, shook head.

C: Reminded her if she does not help with groceries, she won't get her ipad time later today. After 10 minutes of screaming and yelling, she picked up one bag of groceries. She lost ipad time for the day.

 

These kinds of things might show you a) keep a snack in the car! b) when she is defiant, threats of loss of privileges in the future tend to rile her up more (just random thoughts, not implying anything). 

 

We had an If/Then flowchart posted on our refrigerator. We never mentioned it, because why beat a dead horse? Kids notice stuff. Well, we went over it once, and that was it. Well, okay, to be honest, we went over it once, it was ripped up, we calmly waited, then pulled out another one, this one covered with tape (faster than contact paper, no stupid bubbles). We had about a hundred printed just so the ripping wasn't going to solve his problem (his problem being, he didn't want to be reminded of these choices and consequences). He got over it, we all forgot about it on the fridge, it's long gone. The point had been made without much fanfare. We also had things like the Anger Thermometer and emotional cards and things that were constant reminders that we all feel a variety of emotions, some intense, and we have options in how we chose to express those feelings. 

 

Therapists come in all shapes and sizes. Some are fantastic and I swear, they make the world go round. Some are so awful that if the imagination had any power, at least one of them would have been slapped so hard they would have ended up in 1972, lost, alone, and with no one who wouldn't laugh at their stupid ideas of kids sitting on the couch talking about their Id. Kids don't like to talk about their feelings any more than they like to talk about taxes and international maritime law. That stuff is boring! And unpleasant, and sometimes downright scary. They like to play. They're kids. A good therapist knows how to draw out of them something useful within the play, while maintaining a safe place. Always a safe place. It may take some time to find the right therapist. I understand data shows therapy doesn't have any statistically noticeable effect with ADHD, but that doesn't mean it is useless for everyone. A good therapist just might help her identify these feelings that precede unwanted impulses. Medical intervention might help control those impulses, and again, you might have to try a variety of kinds before you find one works. They don't always work, so keeping up with therapy is, imo, a good plan. 

[albeto.]

I'm trying to find an behaviorist in the area...From what you're saying, it sounds like insurance might not approve it, but it will at least be worth discussing options with whoever I can find.

 

Find a local advocacy group and they'll help you navigate the insurance rodeo. 

[kbutton]

A good ABA person is going to listen to what you say and help figure it out. If you tell that person that the behaviors are intermittent, they can roll with that.

 

I would not rule out play or CBT down the road though. They all have their place.

[nature girl]

You crack me up, Albeto. Thank you. (And you have some wonderful ideas there.)

 

I'll have to start logging, it just seems like many of her behaviors either have a very obvious antecedent (frustration, usually, she's so easily frustrated and always overreacts to frustrating events, and there's not much I can do to prevent those) or don't really have an antecedent that I can see. For example she just closed our cat in the bedroom on purpose, for no reason I can discern...She wasn't even in a mood, just went from playing happily to going down the hall and trapping the cat. I didn't realize till a half hour later when the cat started complaining. It was just an impulsive move that I'm pretty sure came from nowhere. So I'm not sure how much logging is going to tell me, but it's worth a shot.

 

I'm trying to work with her on mindfulness, might even try some mindfulness meditation, because I'm hoping it'll help her become more self-aware. I think that might help with whatever type of behavioral intervention we try.

[albeto.]

Keep the data anyway. You might find a pattern in there that you wouldn't have noticed relying on your memory alone. I've discovered the value of looking at inappropriate behavior as a means of solving a problem. I'd think to myself, what problem did the cat produce in her opinion, and how would shutting it away have been a solution? "Every behavior has a function" was the mantra drilled into my head. Figure out the function of the behavior - the purpose of it - and you're half way there. If not more. 

 

When we discovered the function of ds' behavior, we discovered the inspiration behind his behavior, it was eye-opening to see the least. We probably assumed two or three ideas before ultimately concluding the most accurate one. Nevertheless, I fully agree with CM and medication that curbed that impulsive behavior made all the difference in the world. It allowed ds to apply all the things he had been learning. Before, he could understand the value of certain behaviors (like using words instead of action), but couldn't stop himself because his brain simply responded before his mind had time to think it through. I think of it like hiccups. When we have them, we know another one is coming, we just don't know when. We can learn to keep our lips closed to muffle the sound, but that doesn't stop the spasm. Only when the diaphragm is relaxed and working properly can we continue breathing and talking without those impulsive hiccups that really are very much out of our control. Our kids with ADHD can't help themselves as much as we'd like, but if we can help suppressing some of the inappropriate impulses, we give them the opportunity to apply what they know. We empower them to be in control. 

[PeterPan]

No, the meds can help with impulsivity *and* emotional regulation.  

 

Good luck with the mindfulness.  With my ds, his impulsivity is way too high.  Maybe if we keep trying, haha.  The Sitting Like a Frog book suggests getting them after a bath at night, like when they're at their most relaxed.  

[Crimson Wife]

We started ABA first and added the meds about 6 months later. The ABA was helpful on its own, but the progress improved dramatically once we started ADHD treatment. Think of it like a kid who has a major vision issue receiving glasses- he/she is going to be able to benefit so much more from everything else because the glasses remove the obstacle of the poor vision.

 

I was VERY reluctant to try pharmaceuticals for my DD but once we did, it was like night and day the difference they made.

[nature girl]

This is all wonderful information. I do feel like we need to try therapy first, just so I can feel like we've tried absolutely everything. I made an appointment this morning with a pediatric psych I found who actually does take our insurance, so even if she's spending the hour rolling on the floor I'll be paying $50, instead of $150, to watch her roll. :closedeyes:

 

The impulsivity is so awful, isn't it? For years before the diagnosis, she'd do something crazy, I'd ask what she'd been thinking and she'd give me with this haunted look and say she didn't know. I should've realized something else was going on, that it wasn't just misbehavior, that she really couldn't help herself. That's where getting the diagnosis has been so good for us, helped us so much in understanding.

 

I started a notebook to write down behaviors. Of course, ever since I started she's had NO real misbehaviors, which figures. (She did run and hide before we started school this morning, but...it was right before we were starting school so the antecedent was pretty obvious.) I'm actually making that my first rule in the If/Then flow chart you recommended above, Albeto, because she does like to run and hide whenever I'm asking her to do something she doesn't want to, even something as simple as getting her hair brushed. Coming up with a consequence that makes sense is going to be hard, though. I don't want to send her to time out or take away a toy for something as silly as that...

 

Good luck with the mindfulness.  With my ds, his impulsivity is way too high.  Maybe if we keep trying, haha.  The Sitting Like a Frog book suggests getting them after a bath at night, like when they're at their most relaxed.  

 

I actually got Sitting Like a Frog from the library a few months ago when I saw it mentioned here. I read through it, and then couldn't imagine her sitting still for more than 20 seconds so didn't even try, but I really do want to give it a shot. Finding a relaxed time is a good idea. (After baths she's absolutely insane, though. Something about being naked and the feeling of water gets her into a crazy-hyper mood. Before bed, after story, might work well.) I also have the Mind Up curriculum, which I think she might be ready for.

 

If I try mindfulness and therapy, and we're still in the same place a few months from now, then yes I'll consider meds. I feel like she's such a happy kid in most ways, but also like she's missing out on so much. It's such an incredibly hard decision.

[albeto.]

 I'm actually making that my first rule in the If/Then flow chart you recommended above, Albeto, because she does like to run and hide whenever I'm asking her to do something she doesn't want to, even something as simple as getting her hair brushed. Coming up with a consequence that makes sense is going to be hard, though. I don't want to send her to time out or take away a toy for something as silly as that...

 

A behaviorist will help with this. We applied the notion that no stick is as motivating as a good carrot, and no carrot was worth considering if there was no hope of it being internalized eventually. With that in mind, our resolve was to ignore inappropriate behavior and reward the appropriate choice. In this case, not brushing hair wouldn't be met with punishment, but the reward would be lessened, or she would have to wait or otherwise earn it through compliance elsewhere. 

[nature girl]

Okay, that makes a lot of sense. We do have a daily reward system in place, but I've been meaning to set up a shorter-term reward system, have her earn points for periods of good behavior, every couple of hours (even every hour if necessary) she'll get a reward. (Rewards are so motivating for her, most days even incentives as simple as having Mommy dance around the room with her for 5 minutes can be enough to get her through math. :)  )

 

Being more specific with what constitutes good behavior (rather than just lack of bad behavior) might work quite well. "IF you don't run away before we start school, THEN Mommy will act like a fool with you as soon as we're done..."

Edited January 28, 2016 by Anna's Mom

[Lecka]

Don't say what you don't want her to do, I think.  Say what you expect.  If you want her to come the first time you call, then say that. 

 

Sometimes a little dose of "and of course you will come the first time you call!" goes a long way, vs. seeming like you think "maybe you will come the first time, maybe you won't." 

 

Keeping that confident expectation is hard, but I think kids really respond to it a lot of the time. 

[albeto.]

Okay, that makes a lot of sense. We do have a daily reward system in place, but I've been meaning to set up a shorter-term reward system, have her earn points for periods of good behavior, every couple of hours (even every hour if necessary) she'll get a reward. (Rewards are so motivating for her, most days even incentives as simple as having Mommy dance around the room with her for 5 minutes can be enough to get her through math. :)  )

 

Being more specific with what constitutes good behavior (rather than just lack of bad behavior) might work quite well. "IF you don't run away before we start school, THEN Mommy will act like a fool with you as soon as we're done..."

 

Absolutely. It's so hard to figure out what to do when the goal is "Don't make people mad." When the goal is "Come within 30 seconds called," or "Respond to request with 'yes,' 'please wait,' or 'I'd rather not because...," then it's easier to hit the target. Be very specific. "Don't be bad" is really amorphous, arbitrary, and subjective. Punishing for being "bad," consequently, is confusing, belittling, and realistically less effective. 

[PeterPan]

Yeah, instead of consequences for the hiding (which we've had, I know it's wearying, sigh), I'd think in terms of *replacement* behaviors.  So what *function* is the hiding serving and can we replace that we something?  Like be more proactive and totally short-circuit the hiding, heading it off, getting her going into something she IS into BEFORE she has the chance to think about it and leave, kwim?  

 

In our house, I can't let ds off onto his own thing.  If I do, then I'm pulling him from his preferred thing (what he ran to) to the thing I need him to do (obviously less preferred!).  So I have to be ready and get him onto The Plan BEFORE, BEFORE, BEFORE he even goes into his own mode.  If I don't, it's over.  And maybe someday we'll have so much behavioral support, so much instructional control, whatever, that it won't be that way.  I'm just saying that's my reality.  He has to know the plan, know it is the plan, see the visual schedule, and have his body moving into it.  I can't let him go onto ANOTHER plan and then say oh come back and do this plan, kwim?  

 

And this is just me and your free tip of the day, but I finally realized that no one, even well-meaning and awesome, could ultimately come into my homeschool and solve these problems.  *I* have to accept that *I* have to learn the tools.  If I'm not going to learn them, then I have to send him away to someone who has those tools.  And I don't think an hour of talk therapy a week with a p-doc is going to fix your dynamic either.  If that therapist isn't doing ABA, what are they bringing to the table?  You need those better tools (replacement behaviors, visual schedules, looking for the function of the behavior, etc.).  You can't just send her to therapy for a week and solve this.  It just won't work.  It's going to take multiple things.  You can't FIX her, which means you need better tools to work with her.