Parenting, Placement & Dysregulation

Transcription

1 Parenting, Placement & Dysregulation How executive functions impact behavior in children with disrupted attachments; strategies for change Art Maerlender, Ph.D. Dartmouth Medical School

2 You already know Most of what I am going to say Connect some dots

3 Introduction: why EF in foster- care? Parent-Generated Questions Why do some children not do well even when everyone involved with the child is doing the right things? Why do some children never seem to get it? What additional interventions are available to help children with chronic behavior problems when nothing works?

4 Children who were not doing well: Clinical observations in long-term care and in alternative school program Common Features: emotional volatility aggression impulsivity self-defeating and socially inappropriate behaviors inability to learn from experience difficulties with attachment problems with self-control

5 Backgrounds in common: Histories of: abuse neglect separations multiple placements unsuccessful treatment

6 Romanian institutionalized children Demonstrate high levels of anxiety and affective symptoms Developmental delays Growth delays Predictive factors of psychiatric symptoms were: Age of abandonment, physical stature, duration of institutionalization Ellis, 2004

7 Executive Dysfunction Due to Brain Trauma Studies of children with brain abnormalities have shown problems of self-control and other, related, higher brain functions known as Executive Functions: Traumatic Brain Injury ADHD

8 Non-physical Trauma and Brain Dysfunction Other studies have shown that trauma without brain injury can also cause abnormalities in brain function: abuse witnessing violence threats loss These abnormalities are similar to those thought to be important in the TBI and ADHD studies

9 What is executive functioning?

10 Executive Function: Executive Function: Orchestration of basic cognitive processes during goal-oriented problem-solving (Neisser, 1967)

11 Executive Function: "The planning and sequencing of complex behaviors, the ability to pay attention to several components at once, the capacity for grasping the gist of a complex situation, the resistance to distraction and interference, the inhibition of inappropriate response tendencies and the ability to sustain behavioral output for relatively prolonged periods (Stuss & Benson, 1984).

12 EF is the conductor of the brain

13 Where do executive functions live?

14 ADHD, EF: Alphabet soup? ADHD A categorical diagnosis Based on specific behaviors observed over time EF Presumed functions associated with frontal lobes Overlap Many of the specific behaviors of ADHD (as well as many other disorders) are executive function behaviors Meds work

15 Functional Domains of The Executive Based on Gioia, Isquith, Guy BRI Inhibit Shift Emotional Control Metacognitive Initiate Working Memory Planning Organization Monitoring

16 Inhibit- stop an action or not react to impulse

17 Emotional Regulation Defer gratification, selfsoothe, control emotions

18 Shift- move from one task or situation to another

19 Initiatebegin task, activity, attention, language

20 Working Memory- hold/ sustain information in mind for age-appropriate time

21 Plan- anticipate future events and develop steps

22 Organize- establish, maintain order

23 Self-monitor- attend to behavior/output; revise

24 EF FACTORS These basic functions clump into 2 big factors 1. Behavioral Regulation Inhibit, shift, emotional regulation 2. Metacognition Initiate, working memory, planning, organizing, monitoring problem-solving

25 Self-regulation is an executive skill Most closely related to the BRI factor

26 Back to foster care kids

27 EXECUTIVE FUNCTIONS AND POST-TRAUMATIC TRAUMATIC SYMPTOMS IN MALTREATED FOSTER CARE CHILDREN Robert J. Racusin 1, M.D., Arthur C. Maerlender 1, Ph.D., Anjana. Sengupta 1, Ph.D., Martha B. Straus 2, Ph.D. & Peter K. Isquith 1, Ph.D. 1 Dartmouth Medical School, 2 Antioch New England Graduate School 2003 Annual meeting of the American Academy of Child and Adolescent Psychiatry, Miami, FL.

28 BACKGROUND 50% of children in foster care have a history of abuse and neglect and are at high risk for psychiatric disorders and poor long-term functional outcomes (dosreis et al., 2001). Considerable research has focused on understanding the role of self-regulation in acquired and developmental disorders in children but it has not been directly explored in children placed in foster care.

29 This Study examined the diagnostic profiles, levels of everyday executive, emotional and behavioral functioning, and relationships between these characteristics and global functioning in a group of children with histories of trauma in long-term foster care.

30 Self-Regulation Poor self-regulation may limit children s capacity to form and sustain new attachments, cope with trauma-related hyperarousal and intrusive memories, achieve adequate behavioral self-control to successfully live in a family setting and respond to parenting or clinical interventions. These problems with self-regulation may be expressed as PTSD symptoms which are often accompanied by co-morbid diagnoses of anxiety, affective and/or disruptive behavior disorders.

31 METHODS 25 children (16 boys, 9 girls) histories of early trauma now aged 9-18 years (M = 13.31, SD = 2.84) and foster parents. Children had been with their foster families for at least one year.

32 Measures Foster parents completed: Behavior Rating Inventory of Executive Function (BRIEF) Behavior Assessment System for Children (BASC) Children s Global Assessment Scale (CGAS) Computerized Diagnostic Interview for Children (C-DISC) Foster children completed: Trauma Symptom Checklist for Children (TSCC) Computerized Diagnostic Interview Schedule for Children (C-DISC).

33 Results

34 Diagnoses 17 (68%) of the 25 children met DSM-IV criteria for one or more Axis I diagnoses: 4% 4% 30% 15% 32% 15% Anxiety ADHD/ODD Both No Dx PTSD Depression

35 Self-Regulation Relative to normative expectation, foster children had significantly greater difficulties with: Inhibitory control, emotional modulation and flexibility on the BRIEF Behavioral Regulation Index (M = 67.92, SD = 12.03, t(24) = 7.45, p <.01); 62% had clinically elevated scores (T > 65) Working memory, planning, organization and selfmonitoring on the BRIEF Metacognitive Index (M = 67.08, SD = 9.84, t(22) = 8.68, p <.01); 73% had clinically elevated scores (T > 65)

36 Behavior Severity of internalizing and externalizing problems was related to degree of self-regulatory deficits: BRIEF Behavior Regulation Index strongly correlated with internalizing (r =.61) and externalizing (r =.86) BASC Indexes BRIEF Metacognition Index was not significantly related to either internalizing (r =.43) or externalizing (r =.37) problems

37 Global Functioning Children s overall functioning on the CGAS was related to problems with inhibitory control, emotional modulation and flexibility (BRIEF Behavior Regulation Index r = -.71) CGAS scores were not significantly related to metacognitive aspects of self-regulation, including planning, organization, working memory and selfmonitoring on the BRIEF(r = -.21).

38 CONCLUSIONS Nearly 70% of children with histories of trauma currently in long-term foster care exhibited a range of anxiety and disruptive behavior disorders consistent with prevalence rates reported in the literature Only one child met criteria for a current diagnosis of PTSD One potential explanation is that, in the context of stable foster care, the aftermath of early trauma may be expressed instead as substantial self-regulatory deficits including problems with inhibitory control, emotional modulation, flexibility, and metacognitive aspects of executive function

39 Executive Deficits The fundamental components of behavioral and emotional regulation, are strongly related to internalizing emotional and externalizing behavioral difficulties and to global functioning in the everyday environment

40 Summary Clinicians working with maltreated children should consider the possibility that self-regulatory difficulties associated with early trauma may be expressed differently over time, with fewer expressed symptoms of PTSD as more symptoms consistent with anxiety and disruptive behavior disorders develop

41 The Role of Parenting

42 Parenting & Executive Functioning Baumrind s theory of parenting styles Authoritarian Permissive Authoritative

43 Permissive The permissive parenting style is characterized by warmth and lack of punishment (Ferrari & Olivette, 1993). These parents make fewer demands on their children than do other parents, and are less controlling (Buri, 1991). Permissive parents are lax about behavioral standards, fail to monitor children s activities, and have few requirements for their children (Shumow, Vandell, & Posner, 1998).

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45 Authoritarian The authoritarian parents tend to discipline through the use of harsh punishment, and tend to be forceful, overbearing, and very controlling (Ferrari & Olivette, 1993). This type of parenting is very directive (Buri, 1991), and these parents value obedience and respect for authority (Shumow, Vandell, & Posner, 1998).

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47 Authoritative The authoritative parent exerts a high degree of control while encouraging the child s autonomy (Ferrari & Olivette, 1993). authoritative parents establish expectations but are flexible in meeting developmental needs (Ferrari & Olivette, 1993). These parents are clear and firm, but their disciplinary action is marked by a verbal give-and-take (Buri, 1991). The standards set by authoritative parents are attainable (Shumow, Vandell, & Posner, 1998).

48 Authoritative Communication Autonomy Limits Includes monitoring

49 Optimal Parenting A large body of research supports that the optimal combination of parental behavior includes: a high level of support and monitoring, encourage open communication, and the avoidance of harsh punishment (Amato & Fowler, 2002).

50 An Exploratory Study of the Relationship of Parenting Behaviors to Children s Executive Functioning Jennifer Crawford, Eva Abel, Art Maerlender

51 OBJECTIVE This study examined a version of Baumrind s parenting theory to determine whether parenting behaviors predict childhood executive functions. Previous research has suggested that children of authoritative parents are more likely to demonstrate greater social competence, fewer adjustment problems, fewer behavior problems and better academic performance.

52 How does parenting impact the development of EF? Likely a bi-directional relationship

53 Parenting and EF 32 parent-child pairs (mothers) Compared parent rating of child s EF and parent s rating of their own parenting behaviors Do parenting behaviors predict specific EF behaviors?

54 RESULTS: Limit Setting predicted both Behavioral Regulation and Metacognitive abilities (BRI R 2 =.475, p =.000 and MI (R 2 =.298, p =.002). Autonomy ratings were strongly related to BRI Communication was related to MI. No other parenting behaviors showed significant relationships to executive ratings.

55 Parenting-EF Model Autonomy BRI Limit Commun. Meta

56 CONCLUSIONS: Consistent with Baumrind s theory of parenting, limit-setting behavior, parental communication and facilitation of autonomy appeared to be important variables in the development of children s executive processes, with limit-setting the most predictive. Further research is needed

57 Improving EF What can be done?

58 Structuring an executive function intervention program Use of everyday routines with (e.g., Goal-Plan-Do-Review) - Allowing child to become increasingly more active in formulating plans and reviewing their performance

59 Example with academic tasks Written statement of student s goal for the academic task Specific list of all the steps needed to accomplish the task Rate the performance (Self, Other) Discuss discrepancies in ratings Record what worked in one column and what didn t work in another column Retain the written Sheet in a notebook

60 Coordinating Executive Function Intervention between School and Home - Recognizing common executive routines between settings - Utilizing similar strategies (e.g., Goal-Plan- Do-Review) - Use of common Executive Routines notebook - COMMUNICATION

61 Strategies for Specific Deficits Note the recurrent themes of structure, consistency, anticipatory behavior management, positive reinforcement

62 Inhibiting: Increase structure in environment to set limits for inhibition problems Make behavior and work expectations clear and explicit; review with student Post milieu rules in view; point to them when child breaks rule Teach response delay techniques (counting to ten before acting)

63 Shifting: Increase routine to the day Make schedule clear and public Forewarn of any changes in schedule Give 2 minute warnings of time to change Make changes from one task to the next, or one topic to the next, clear and explicit Shifting may be a problem of inhibiting, so apply strategies for inhibition problems

64 Initiating: Increase structure of tasks Establish and rely on routines Determine minimal level of cue to help start and reduce cue over time Break tasks into small, manageable steps Place child with partner or group for modeling and cuing from peers Reframe "lack of motivation" as initiation deficit for child, parent, teachers

65 Sustaining: Increase salience in task- rely on high interest tasks Hands-on activities support sustained attention problems Ask child to choose among topics of interest to increase investment Use verbal mediation to help remain focused Write down list of what to attend to for a specific task

66 Sustaining b: Make time limits to work explicit (the never ending worksheet problem) Repeat instructions as needed, perhaps quietly to the child Keep instructions clear and concise Have child take frequent, brief breaks (30 seconds to one minute) Use variety- avoid lengthy, monotonous tasks

67 Planning: Practice with tasks with only a few steps first Teach simple flow charting as planning tool Practice with planning tasks (e.g., mazes) Ask child to verbalize plan before beginning work Ask child to verbalize second plan if first doesn't work Ask child to verbalize possible consequences of actions before beginning Review incidents of poor planning/anticipation with child

68 Organizing: Increase organization in milieu Increase organization of therapy to serve as model and help child grasp structure of novel material Present the framework of new information to be learned at the outset, and review again at the end of a lesson Begin with tasks with only few steps and increase gradually

69 Self-Monitoring Provide opportunities for self-monitoring task performance and social behavior. Provide cues, as subtly as possible, if necessary. Build in editing or reviewing as an integral part of every task Set goals for accuracy rather than speed Reward for accuracy Ask student to predict how well they will do on a particular task, compare prediction with outcome Encourage charting of performance and/or behavior Verbal mediation Review behavior when removed from the situation and from peers. Identify strengths and weaknesses for specific tasks or activities. Provide guided constructive feedback (teacher, parent, and peer) to increase self-awareness of strengths and needs for similar future activities.

70 Conclusions Children in foster-care, and particularly those with traumatic backgrounds, often have significant mental health issues and thus need a more proactive approach to treatment

71 EF reflects the degree of emotional and behavioral dysregulation observed

72 Parenting has an impact on the development of EF Yes, parenting IS important! duh Directionality is not yet established, but likely goes both ways

73 Addressing the behavioral dysregulation in these children appears to be best approach positive everyday supports or improving executive function/problem solving skills good parenting (authoritative) encourages the development of EF

74 Thank you.

75 Contact Art Maerlender, Ph.D. Dept. of Psychiatry Dartmouth-Hitchcock Medical Center 1 Medical Center Dr. Lebanon, NH Art.Maerlender@Dartmouth.Edu Slides available at > Depts. & Services>Psychiatry>Child & Adolescent Services> Pt. Care Services> Clinical School Services & Learning Disorders

76 Resources Dishion, TJ, McMahon, RJ (1998). Parental Monitoring and the Prevention of Child and Adolescent Problem Behavior: A Conceptual and Empirical Formulation. Clinical Child and Family Psychology Review, 1, Ellis, BH, Fisher, PA, Zaharie, S (2004). Predictors of Disruptive Behavior, Developmental Delays, Anxiety, and Affective Symptomatology Among Institutionally Reared Romanian Children. Journal of the American Academy of Child & Adolescent Psychiatry. 43(10): Gioia, G, Isquith, P New Perspectives on Educating Children with ADHD: Contributions of the Executive Functions Grafman, J, Litvan, I (1999). Importance of deficits in executive functions. Lancet, 354, Green, R. (1998). The explosive child. NY: Harper Collins. Racusin R, Maerlender A, Sengupta A, Isquith P, Strauss M (2005): Treatment of children in foster care: a review. Community Mental Health Journal, 41(2), Van Ijzendoorn, MH, Juffer, F, & Poelhuis, CW (2005). Adoption and Cognitive Development: A Meta-Analytic Comparison of Adopted and Nonadopted Children s IQ and School Performance. Psychological Bulletin, 131,