Children & Cochlear Implants Issues in Behavior Management James H. Johnson, Ph.D. Department of Clinical and Health Psychology University of Florida

Overview and Objectives The focus of this presentation is on the role of behavior management and other intervention approaches in the cochlear implant process. We will begin by briefly reviewing issues addressed in the pre-implant psychological evaluation. Examples of issues raised in this evaluation, that may suggest the need for intervention, will be highlighted. Finally, we will consider the nature of approaches to intervention that may be of value in addressing pre and post implant issues.

The Pre-Implant Psychological Evaluation Knowledge Assessment Motivation for Implant Family Agreement/Disagreement Appropriateness of Expectations Challenges to Compliance Parent-Child Communication Family/Psychological/Behavioral Issues Issues of Stress and Coping Questions/Concerns Regarding the Implant Process

Knowledge Assessment Do the parents ( and child, if older ) have reasonable knowledge of what the implant process involves? – What surgery will involve and the time necessary for healing. – The nature of post-implant activities (e.g., initial fitting/activation and mapping, auditory training, speech/language therapy, scheduled follow-ups). – The need for parental involvement in the child’s therapy? – What this will require in parental time and effort. Have parents gone beyond “passive learning” in an attempt to obtain information (e.g., internet searches, making contacts with others who have been implanted)? Any needed information?

Assessing Motivation for Implantation Do the parents (and child, if older) indicate a desire for the implant? Have they been active in seeking information regarding the implant? Have they been active in moving the implant process along? Do they show a willingness to do “whatever is necessary” to make the implant a success?

Family Agreement and Disagreements Do parent and child agree on the desirability of the implant? Do both parents agree on the desirability of an implant? Are both willing to be active participants in the implant process? Do other close family members support the idea of an implant?

Assessing Expectations Do parents and child (if old enough) convey an understanding that children vary in response to implants? Is there understanding that degree of success depends on parent and child being active participants in the process (e.g., auditory training, speech/language therapy, etc)? Do they understand that the child may not “hear” the same way as a non-hearing impaired individual? Is there implied acceptance of outcomes that may not involve; – the development of functional speech – a full understanding of speech without speechreading?

Challenges to Compliance Do parents/child convey a willingness to be an active participant in the implant process? Do they have a plan to deal with practical issues associated with implantation; – arrangements for surgery, – travel to doctor appointments, – auditory training, speech therapy, etc.? Is there a history of keeping appointments, active participation in prescribed communication programs, complying with the use of assistive devices, and dealing with other required medical treatments?

Assessing Stress and Coping Is there evidence of significant family stress? What are the nature of existing stressors? Do family members have adequate social supports to assist them in coping with ongoing stressors? Do family members appear to have adequate skills to cope with existing stressors? Considering both the level of stress and coping styles, is stress likely to compromise a successful outcome?

Assessing Other Psychosocial Factors Do parents appear to show evidence of deficits that could compromise successful outcome or require special assistance? Does the child show evidence of delays in development severe enough to compromise success? Do either parents or child show evidence of psychological/behavioral problems that could compromise success?

Psychological and Behavioral Issues: Implications for Intervention While not meant to be inclusive, listed below are selected examples of psychological and family issues, sometimes highlighted in the pre-implant evaluation, that may warrant family or behavioral intervention. – Family Disagreement Regarding Implantation Parent-child differences Parent-parent differences – Externalizing Disorders of Childhood Oppositional Defiant Disorder Attention Deficit Hyperactivity Disorder (ADHD) – Issues of Selective Noncompliance

Issues of Family Disagreement Sometimes parents have markedly different views regarding the desirability of an implant. In the case of older children or adolescents, parent and child may have different views regarding the implant decision making process. Such conflicts can potentially represent a significant challenge to a successful outcome and may, in some instances, represent a significant contraindication for implantation. In other instances, family based interventions may be recommended in an attempt to resolve issues prior to implantation. Case Examples

“Externalizing” Disorders of Childhood Externalizing disorders of childhood are conditions that are characterized by a constellation of behaviors that bring the child into conflict with his/her environment. Here, we will focus on two such conditions, – Oppositional Defiant Disorder (ODD) – Attention Deficit Hyperactive Disorder (ADHD). Special attention will be given to these conditions, as both can pose significant challenges for the child being considered for a cochlear implant. Discussing these conditions also provide a way to highlight behavior management approaches that can be useful in dealing with a range of implant related issues.

Oppositional Defiant Disorder Diagnostic Criteria - A pattern of negativistic, hostile, and defiant behavior lasting > 6 months, with four (or more) of the following present: – Often loses temper – Often argues with adults – Actively defies or refuses to comply with adults’ requests or rules – Often deliberately annoys people – Often blames others for his/her mistakes or misbehavior – Is often touchy or easily annoyed by others – Is often angry and resentful – Is often spiteful and vindictive

Attention Deficit Hyperactivity Disorder (ADHD) ADHD is a frequently occurring and chronic, neurodevelopmental disorder of childhood. Symptoms include developmentally inappropriate levels of activity, distractibility, and impulsivity. Children with ADHD have functional impairment across multiple settings including home, school, and peer relationships. ADHD has been shown to have long- term effects on school performance, vocational success, and social-emotional development

Treatments of Externalizing Disorders Treatment typically involves interventions derived from an operant behavioral model. Interventions may involve more general approaches to teaching parents principles of behavior modification or more structured approaches to parent training. Behavior management is often combined with other forms of intervention, with childhood ADHD being a case in point.

The Behavioral Model: Basic Assumptions and Features Abnormal behavior is learned! It is learned according the same principles that govern the acquisition of normal behavior. The focus is on one’s social learning history and on overt observable behavior rather than on putative internal or “intrapsychic” determinants of behavior. Emphasis is on those factors in the environment that elicit and maintain problem behavior. Much of abnormal behavior can be unlearned.

Basic Principles of Behavior Management Approaches for Increasing Behavior – Modeling/Observational Learning – Reinforcement Positive Reinforcement Negative Reinforcement Approaches for Decreasing Behavior – Extinction – Punishment

Modeling/Observational Learning Involves providing the child with models where he/she can learn new skills by observing the behavior of others. Most useful in teaching new behaviors to reduce skills deficits - can also be used to facilitate performance of previously learned behaviors and to decrease fear reactions. Is usually combined with reinforcement procedures.

Reinforcement: Increasing Behavior for Better or Worse The principle of Positive Reinforcement states that behaviors followed by a reinforcing state of affairs (rewards) are increased. The principle of Negative Reinforcement states that behaviors that result in the reduction of an aversive state of affairs will be increased. Example: At The Grocery

Using Rewards to Change Behavior: Some Basics Rewards need to be individualized to the child. – Some Children don’t like M&M’s and they do melt in your hand! Use a variety of rewards to avoid satiation. Rewards should be administered in small units. Rewards should usually be administered immediately after the desired behavior has occurred. If this is not possible, use points or tokens to bridge the gap between behavior and back-up reinforcement.

Still More Principles of Reward Reinforcers should be exclusively under the parent’s control. Rewards should be practical! They should be easily given, not too costly, and easy to obtain. Consistency is everything! Rewards should usually be given on a continuous reinforcement schedule (at least at the beginning). After a behavior is well learned you might switch to a partial reinforcement schedule.

Extinction Extinction: A decrease in behavior associated with the withdrawal of reinforcement. May result in the failure of some desired behaviors to be maintained. Can result in strong emotional reactions or response “Bursts”. Can be used to reduce problem behavior – Case Example.

Punishment Punishment: A decrease in behavior resulting from behavior being followed by an aversive state of affairs. Punishment can be of the physical variety, as in example to the right. It can involve the loss of rewards as in a loss of points for inappropriate behavior in token programs or when a child is put in “Time-Out”. Punishment procedures, when used, are generally combined with reinforcement for desired behavior.

Using Punishment: Some Negative Effects Used consistently with young children, punishment results in strong negative emotional responses that can lead to both avoidant behavior and decreased levels of attachment. Punishment is one way of modeling aggression and is associated with increased aggressive behavior in the child. Punishment often results in only a short term reduction in problem behavior.

Punishment: Additional Issues Punishment does not teach the child how to behave – what he or she is supposed to do. Punishment is often not needed, as alternative approaches, such as rewarding desirable behaviors that are incompatible with problem behavior can often bring about desired results.

Child Behavior Management: Two Approaches There are two primary treatment approaches for working with children displaying oppositional defiant behavior. One can be described as the “Patterson – Living with Children” Model. The second is Parent-Child Interaction Therapy, developed by Dr. Sheila Eyberg of the University of Florida. Both are “Empirically-Supported Treatments” as research has consistently documented their effectiveness.

Living with Children Model Based on the work of Dr. Gerald Patterson. Involves a therapist working with parents, teaching basic principles of behavior modification so they can effectively modify their child’s behavior. The program focuses on: – Targeting Problem Behavior – Increasing desirable behavior – Decreasing undesirable behavior – Documenting effectiveness. – Helping parents become effective behavioral trouble-shooters in managing their children.

More About the “Living With Children” Model The “Living with Children” Model is less structured that the Parent Child Interaction Training Model, to be described next. It can be used with parents of children of all ages, rather than only those below the ages of 6 or 7, as is the case with Parent Child Interaction Training.

Parent Child Interaction Therapy PCIT is a treatment for children with disruptive behavior disorders that emphasizes improving the parent-child relationship and changing parent-child interaction patterns. Parents are taught specific skills to establish a nurturing and secure relationship with their child while increasing positive behavior and decreasing negative behavior. Treatment is usually carried out in a playroom equipped with a one-way mirror so the therapist can guide the parent as he/she interacts with the child. Communication between therapist and parent is via a bug-in-the-ear device where the therapist can actively coach the parent in how to respond to the child’s behavior and reinforce the parents in-therapy behavior.

PCIT: Stages of Treatment In addition to the therapist providing parents with overviews of different stages of therapy and principles of behavior management, PCIT involves two stages: The first stage is Child Directed Interaction (CDI) where the focus is on parents engaging their child in nondirective play with the goal of enhancing the parent-child relationship. Here the child is allowed to take the lead with parents focusing on communication with the child by: – Praising the child’s behavior, – Reflecting the child’s statements, – Imitating and Describing the child’s play, – Being Enthusiastic, – Ignoring any negative behavior, and – avoiding any attempt to lead the play, give commands, ask questions or give criticism.

PCIT: Stages of Treatment II Parent Directed Interaction (PDI), where the parent takes a more active role, is designed to teach parents specific behavior management techniques for dealing with problem behavior. Here, the primary goals are increasing compliance and deceasing inappropriate behaviors. In PDI the parent learns to give clear and direct commands, to reward compliance, and to use time-out as a consequence for non-complaint or other disruptive behavior (while continuing to use elements of CDI between commands). Time-out initially involves setting on a chair (3 minutes), with a Time-out room used as backup, for refusals to stay in the chair. A major focus of therapy is on helping parents learn to use the skills developed in PCIT sessions in the home environment.

PCIT: Final Comments PCIT is generally used with children between the ages of 3 and 6. The length of treatment is determined by the length of time it takes parents to reach criterion in terms of skills development (usually 12 to 16 session). Many controlled research studies have provided strong support for the effectiveness of this approach. Another strength of this treatment is the “hands on approach” to teaching basic behavior management skills (reinforcement, extinction, punishment) that are easily transportable the home situation.

Treatment of ADHD As children with ADHD often display disruptive behavior, approaches like those just described may also be useful with these children as well. However, it is often the case that other approaches will also be necessary. These may include: – The use of medication to treat ADHD core symptoms. – Other treatments for comorbid conditions. – Educational accommodations to minimize problems with inattention and distractibility and problems with academic achievement.

Behavior Management: Other Areas of Applicability The use of behavioral principles discussed here is not restricted to children with serious behavior disorders. They are also applicable to other situations where it is desirable to either increase or decrease specific behaviors. One example might include a home-based reinforcement programs for children who are non-compliant in wearing hearing aids. Clinic based reward programs might also be useful with children who are poorly motivated to participate in auditory habilitation programs, speech therapy, and other training necessary for implant success.

That’s All Folks! Questions?