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4/18/2015 12:00 AM

The brothers in the Boston Marathon bombing. Racketeer Whitey Bulger Jr. and his younger brother William, president of the Massachusetts Senate and then of the University of Massachusetts.

What do these two divergent tales of brothers teach us about sibling relationships? How is it that one pair of siblings bonds together to walk the same course while other siblings seek opposite pursuits?

On April 15, 2013, two homemade pressure-cooker bombs exploded near the finish line of the Boston Marathon. Three people, including an 8-year-old boy, were killed. Hundreds of others were seriously injured. The city of Boston was paralyzed by a gripping manhunt for two suspects — two brothers. Days later, 26-year-old Tamerlan Tsarnaev was killed during a shoot-out with police following the death of an MIT police officer and carjacking. Tamerlan’s younger brother, 19-year-old Dzhokhar Tsarnaev, was injured and subsequently captured. Dzhokhar was charged with using and conspiring to use a weapon of mass destruction resulting in death and malicious destruction of property resulting in death. Dzhokhar now awaits trial and is facing the death penalty in Massachusetts. At the time of the manhunt, the brothers allegedly were plotting together to detonate more explosives in Times Square in New York City.

Meanwhile in Boston, after decades on the FBI’s “Ten Most Wanted List,” James “Whitey” Bulger Jr. was about to stand trial on 32 counts of racketeering, money laundering, extortion, weapons, and murder charges. In the summer of 2013, Whitey was found guilty on 31 of the charges and was sentenced to two consecutive life terms. During Whitey’s trial, his younger brother, William Bulger, was in active retirement after 18 years as the president of the Massachusetts Senate as well as president of the University of Massachusetts, a position he resigned in the wake of controversy surrounding his refusal to testify about his brother. In contrast to Whitey, William was an army veteran and lawyer whose life was characterized by education and public service.

What do these two divergent tales of brothers teach us about sibling relationships? How is it that one pair of siblings bonds together to walk the same course while other siblings seek opposite pursuits?

Characteristics of sibling relationships

Children in the United States are more likely to grow up with their siblings than with their fathers. Over the course of their lifetimes, most children will spend more time with their siblings than they spend with anyone else, including their parents. Despite this reality, research and interventions for children focus on the parent-child relationship as the primary source of influence on child outcomes; the effects of siblings on child behavior and health are often underestimated. However, recent research reveals what brothers and sisters have recognized all along — that siblings play a key role in child development and behavior.

The differential power and roles between siblings are related to their broader cultural context. Cultures define who is considered a sibling, the meaning and importance of the relationship, and the obligations siblings have within the family and to one another. These cultural proscriptions are often dependent on immutable structural characteristics of the sibling relationship, such as birth order, gender, and age spacing. Prince William and Prince Henry (“Harry”) of Great Britain’s royal family provide a vivid public example of how the structural features of a sibling relationship can be institutionalized and shape expectations and life trajectories.

Sibling relationships are not elective; children pick their friends but not their brothers and sisters. Emotions between siblings are characteristically intense and can cycle rapidly between love and hostility. During early childhood, siblings are often primary companions as well as competitors. This is believed to provide a fertile training ground for the development of social skills and future relationships. The impact of a warm and supportive sibling relationship or a conflictual, unsupportive one is lifelong. Warmth in the sibling relationship is associated with significant social and emotional advantages in later life. For example, compared to only children, children who have at least one sibling at home display greater social competence and peer acceptance from kindergarten through their early school years. Adolescents who report positive sibling relationships have better peer relationships and fewer depressive symptoms later in life. Warmth and closeness in the sibling relationship are also associated with greater ease and intimacy in romantic relationships. Finally, during middle age and old age, mood, health, loneliness, and depression are related to how people feel about their sibling relationships. Having a close, positive relationship with one’s siblings is not only a source of life satisfaction, but can also provide a buffer from stressful events, such as parental absence, marital conflict, and illness. Younger siblings tend to imitate and “look up to” their older siblings. If the older sibling responds in an attentive and caring manner, the seeds of similarity are planted. If the older sibling is rejecting of the younger child, their paths are more likely to separate.

Conflict and aggression between siblings is very common. It has been suggested that one way siblings learn to manage competition and conflict is by differentiating themselves, carving out different identities or roles within the family. Thus, one child becomes known as the reckless, defiant one, while the other sibling becomes the easygoing, conservative one. Even when siblings pursue very distinct identities and life courses, their bond can be very enduring. Think of the case of the Bulger brothers. One brother led a life of crime and the other a life of public service. William was not able or willing to overcome the sibling bond to testify about his contact with his brother, thereby forfeiting his position as president of UMass. Physical aggression occurs among siblings in the majority of families (i.e., 70% of families). Sibling conflict has been measured up to eight times in a single hour and is the number-one reason for discord between parents and children. However, parents will also dismiss levels of violence between siblings that they would never conceive of tolerating if they occurred outside the context of a sibling relationship. Violence between siblings is the most common form of child abuse and is significantly related to later substance use and delinquency.

Sibling – strong effects within the family

Sibling relationships do not occur in a vacuum. Siblings share parents, relatives, and school and other social environments, as well as their genes. Siblings raised in a home with authoritarian, harsh parents are more likely to be at odds with one another. How parents handle sibling conflict has a significant impact on the sibling relationship. When parents intercede in sibling conflict to determine which child is most at fault or “who started it,” the sibling relationship sours. Siblings often compare themselves to one another and compare how they are treated by others, particularly parents. When children perceive favoritism or unfair differential parental treatment, the quality of the parent-child and sibling relationships suffers. For the less favored sibling, differential parental treatment is associated with lower self-esteem, more depressive symptoms, and more antisocial and delinquent behavior, as well as more substance use.

One area of particularly strong sibling influence, even stronger than the influence of parents, is in the development of antisocial attitudes and conduct, and health risk behavior. The process of “sibling deviancy training” refers to the situation in which (generally older) siblings model, encourage, and reinforce antisocial behavior in their younger siblings. Younger siblings who shadow and hang out with their older siblings are introduced to their antisocial peers and behavior and begin to display negative behaviors more than siblings who do not hang out with their antisocial siblings. Eventually, the sibling relationship transitions from deviancy training to partners in crime; older and younger siblings begin to conspire together in more antisocial behavior and substance use. Even after controlling for the effects of parent substance use, siblings are four times more likely to smoke if their older sibling smokes, and are twice as likely to drink alcohol if an older sibling does. Finally, younger sisters are five times more likely to become pregnant if they have an older sister who was pregnant. The power of the antisocial or behaviorally risky older sibling is magnified when parents are unstable or absent. Think back to the Tsarnaev brothers, whose parents, after years of struggling in the United States, returned to Russia, leaving the younger brother under the influence of his elder, radicalizing brother.

Conclusions and implications

Siblings hold the power to inspire as well as corrupt. Given the intensity and longevity of their bond, how can we engage this power for positive change? It is time to move beyond family interventions that are directed solely at parents (i.e., mothers). When working with children and adolescents, inquire about siblings — their relationships, strengths, and challenges. How much time do they spend together? How are they similar and where do their interests overlap? Be attentive and responsive to reports of sibling violence; do not dismiss these as “normal” and, therefore, acceptable. Consider how recommendations regarding one child might affect other children in the family. Is the heightened attention expected from parent-directed intervention likely to plant negative feelings of differential parental treatment among the other children? Actively help families understand that the investment made early in the sibling relationship has value that lasts a lifetime.

3/6/2015 12:00 AM

Parents are often concerned by certain behaviors they observe in their kids, such as crying, tantrums, difficulty following directions, shyness, difficulty separating, troubles with transitioning, and so on. But when do these behaviors warrant intervention?

Ally follows her mother wherever she goes. Lately, Ally’s been more tearful around leaving for school in the morning and keeps complaining that her stomach hurts. Ally always thinks she’s getting sick and worries every time she is around anyone who coughs or sneezes.

Sam has a hard time following directions. His room is a mess, his homework is incomplete, and it’s a struggle to get him to do daily things like brushing his teeth. Sam frequently argues with his younger brother, and his mother feels like she has to yell in order to get anyone to do anything.

Parents are often concerned by certain behaviors they observe in their kids, such as crying, tantrums, difficulty following directions, shyness, difficulty separating, troubles with transitioning, and so on. But when do these behaviors warrant intervention? All of the above can be considered within the realm of normal childhood development. It is when these behaviors co-occur with other patterns of symptoms, have a negative impact on functioning, and cause distress in either the child or those around him/her that therapeutic intervention may be helpful and warranted. For example, with Ally, her parents may want to seek help if distress in the mornings continues to the point where it’s difficult getting to school or if she becomes so clingy to her mother that it’s hard for her mother to be able to work, run errands, or do things at home. With Sam, his parents may want to seek help if he starts doing poorly in school or if the level of conflict and overall stress at home remains high.

What’s the next step?

The first step to effectively addressing concerning behaviors in kids is to do a thorough evaluation of the symptoms, circumstances, and functions in order to fully understand the nature of behaviors. For example, in children specifically, it is common for acting-out behaviors, such as arguing, temper tantrums, or anger, to be in reality driven by anxiety. Once the nature of symptoms is more fully understood, appropriate intervention can take place.

Cognitive behavioral therapy (CBT) is one of the most commonly evaluated treatments for a range of psychological problems in children and adolescents. CBT is a therapy framework that emphasizes the role and link between thoughts, feelings, and behaviors in order to improve functioning. While some youngsters may not be able to fully take part in the entirety of a CBT model of treatment due to their cognitive/developmental levels, tailoring components of CBT for a specific child and treatment focus can be helpful.

Components of CBT treatment

There are different components of CBT depending on the specific treatment model, but for the purposes of describing a general overview, they are conceptualized here by three overarching components: psychoeducation, coping skills, and behavior practice/management.

  1. Psychoeducation. This consists of helping to better understand emotions and normalizing the fact that people experience a range of them, which are sometimes advantageous (e.g., having some anxiety before a test so that you are alert and concentrating) and sometimes impairing (e.g., having so much anxiety before a test that you can’t focus on the questions). Psychoeducation also involves understanding similarities/differences between emotions and helping children learn to identify the cues in their thinking and in their body in order to correctly label the emotional experience. It’s also important to be able to differentiate between varying levels of emotions. If a child thinks of everything that makes him nervous/scared and sees it all as the same intensity of that feeling, it would be very overwhelming. In CBT, children learn to view their emotions as a thermometer where they can tease apart situations/stimuli that would create a “10” on their meter versus a “5” or a “1” so that tackling these experiences starts to seem more manageable.
  2. Psychoeducation also focuses on learning to identify the thoughts, feelings, and actions that occur in a situation so that kids can start to see how modifying one part can affect another. For example, if Ally thinks that the person next to her is sick because he sneezed, she will start to feel anxious that she will get sick too. But if Ally is able to come up with other thoughts, this could alter how she feels. How anxious would she be if she thought that the person next to her sneezed not because he was sick but because something just tickled his nose? In exploring thoughts, children start to recognize when they fall into thinking traps by identifying cognitive distortions and labeling them as such. Cognitive distortions can include thinking the worst will happen (catastrophizing), thinking you know what others are thinking (mind-reading), and believing something without any proof (jumping to conclusions), among others. By learning to recognize thinking traps, youngsters can start to challenge them and become more flexible in their thinking, which may then alter how they feel and act.

  3. Coping skills. After psychoeducation about thoughts/feelings/actions and the relationship between them, patients start to build a “toolbox” of skills to help them effectively manage emotional/physical distress. This component helps empower children to feel that they have the tools they need to conquer problems. Furthermore, in order to face stress-inducing situations, they may need to first learn to lessen their arousal level to the point where they can tolerate facing a stressful situation. The coping skills that are added to their toolbox may include things such as relaxation techniques (e.g., diaphragmatic breathing, progressive muscle relaxation, imagery) to help calm their bodies and minds enough to participate in treatment. Skills also include learning scripts to challenge cognitive distortions (e.g., “Do I know 100% that I will get sick?”, “Could there be other explanations why my brother threw the ball at me?”) so that ultimately children may become more flexible in their thinking instead of solely believing the automatic thought that comes to mind. Other distress-tolerance skills include proactive activities (e.g., taking a walk, listening to music, squeezing a stress ball) and positive thoughts to keep in mind in order to help manage distress.
  4. Behavior practice/management. The third component of CBT is where individuals get a chance to practice the skills that they have learned. It includes skill rehearsal, role-playing situations, and ultimately experiencing the situations. For some disorders, such as anxiety, the experiencing of a feared situation and habituating to it (i.e., anxiety lessening by remaining in the situation over time) is the key ingredient of treatment. However, some will need to use the psychoeducation and skills described above in order to even get to the point of being able to face a fear in any form. Another key aspect of this component of CBT is the idea of reinforcing a desired behavior, whether it’s facing a fear, complying with a direction, or reacting in a calm and appropriate way. Some children may respond to encouragement from adults and a feeling of self-efficacy, but most need external reinforcement in order to push through cognitive/emotional barriers to their goals. This typically involves parents setting up a reinforcement system in which kids can earn rewards for reaching certain goals. Rewards can be immediate or in the form of tokens that can be traded in for bigger rewards or privileges after earning a certain amount. It is essential that parents are always aware of what effect their response has on their child’s behavior so that they are not inadvertently increasing the likelihood of the problem behavior rather than the desired behavior. For example, if Sam argues around limits on videogame time, and his mother lets him keep playing so that he stops yelling, Sam has learned that the more he yells, the longer he gets to play. If Sam’s mother gives him a check mark for every time he turns off the game when prompted, Sam learns that by following directions, he earns tokens that he can then trade in for bigger rewards. Likewise, if Ally’s mother lets her stay home when she is crying, instead of fighting the anxiety, this will increase the likelihood that this pattern will continue. However, if Ally earns rewards for getting to school by a certain time, this may reinforce leaving home rather than staying home.


While childhood behaviors such as fears, tantrums, noncompliance, and the like may be part of normal development, patterns of behaviors may become distressing and start to impair functioning. When this happens, it’s important to seek help from a professional who can perform a thorough evaluation and determine appropriate intervention. CBT is an evidence-based treatment that can be applied to a variety of childhood problems. Developmental considerations, such as age and cognitive level, may determine whether treatment is more cognitive or behaviorally focused. CBT can be thought of as a skill set that children and parents both develop and improve over time with practice.


Christophersen ER, Mortweet SL. Treatments that work with children: Empirically-supported strategies for managing childhood problems. Washington, DC: American Psychological Association; 2001.

Creswell C, Waite P, Cooper P. Assessment and management of anxiety disorders in children and adolescents. Archives of Disease in Childhood 2014; 99(7):674–678.

1/30/2015 12:00 AM

When I was in second grade and living in Racine, Wisconsin, there was a rabies outbreak in the greater Chicago area that received extensive media coverage. Parents kept children indoors because of a perceived risk of marauding mad dogs, and stories about the horrors of having to undergo the treatment shots were widely discussed. Even though I loved dogs, I was petrified of being bitten by a rabid animal. A recurring image from the front page of the newspaper (which I still vividly recall) of a wild-eyed dog foaming at the mouth and fiercely biting the bars of its quarantine cage made it difficult to fall asleep many nights that fall. I’ve wondered whether that childhood experience of fearing a deadly illness I didn’t understand influenced my decision to go into medicine. I am certain, however, that a widespread concern about a scary disease, whether it’s rabies or Ebola, can affect children and adolescents in lasting ways.

While we can’t shield our children from everything that is worrisome, risky, or unpleasant, how we as adults react can have a greater impact on a child’s psyche than the actual reality of the situation. Nowhere is that more evident than in our societal response to the Ebola epidemic. The facts facing Americans (in contrast to many in West African countries) as I write this in late fall of 2014 contrast sharply with the anxiety, verging on panic, seen in some quarters.

The facts are fairly straightforward: Ebola is a viral disease we have known about for decades but not attended to intensely because outbreaks have only occurred in isolated areas of west and central Africa. It is contagious only from direct contact with bodily fluids (blood, vomit, diarrhea, etc.) of those showing symptoms of the illness; the sicker the patient, the higher the viral load and the more contagious he or she is. About half of those who contact Ebola will die, and they are especially contagious in the days immediately before and after their death. There is no specific treatment for Ebola, and effective vaccines, now being developed, will not be widely available for at least a year. Americans at the highest risk for Ebola are health care workers exposed to the virus when caring for sick patients; they comprise all of the handful of cases in the United States.

To judge from the media response and the way Ebola in the United States is consuming our consciousness way out of proportion to the current danger, facts seem to have little bearing on the American anxiety level. Scared parents, extreme governmental quarantine measures, and a national sense of panic are likely to cause unnecessary suffering for children; adult anxiety is more contagious than Ebola.

Instead of communicating dread and danger through what is said and through nonverbal communication (facial expression, affect, preoccupation), adults should present to children a measured and rational approach about Ebola. Knowledge is power, and helping children bolster their cognitive mastery skills goes a long way to allaying undue anxiety. The first step in this process is to create an open and supportive environment where children can ask questions and feel comfortable sharing what they know. Then we have to listen carefully and calmly to what they say. Youngsters’ ability to understand illness varies hugely with age, from a five-year-old’s magical thinking to many adolescents’ ability to deal with abstract concepts. It is critical to meet children where they are developmentally and to use words and concepts they can understand. Whatever the level of communication, it is important that the information we provide be accurate and honest, yet light on the graphic details. The horrible picture of the rabid dog stuck with me from my childhood because as an eight-year-old, I couldn’t understand the verbal explanations provided by the adults. We need to allow for repeated discussions of Ebola, as children can rarely process affect-laden information in a single session. Additionally, repeated questioning may be a child’s way of asking for reassurance. 

As with any challenge, the Ebola crisis presents children with an opportunity for mastery and growth. Understanding the conditions in Africa — while differentiating them from the situation in the United States — can promote empathy for those less fortunate. Appreciating the heroism of medical workers on the front lines of the epidemic helps to define courage and self-sacrifice. If children can contribute some of their own money to a charitable organization fighting Ebola, it reinforces their developing social conscience and allows a sense of active mastery.

We know from other crises what helps and what hinders children’s efforts to cope with unsettling news. In our approach to Ebola, we should manage our anxiety, monitor our behavior, and make decisions based on equal parts of science and compassion. Our children will be the beneficiaries.

Parents’ Guide
3/4/2016 12:00 AM

The largest annual meeting devoted to primary substance abuse prevention is held every year by Community Anti-Drug Coalitions of America (CADCA). One of the most notable aspects of this meeting, which features an impressive array of researchers and providers, is the cadre of youth leaders. These adolescents, ages from about 13 to 17, descend upon National Harbor, Maryland, every February for the CADCA National Leadership Forum. Melanee Piskai, a trainer for CADCA’s National Youth Leadership Initiative, talked to CABL about her work.

“This year we have 300 youth who are going through a process to learn leadership skills, and creating their own action plans for when they go back home,” said Piskai, who herself is in college, studying sociology and psychology at Ursinus College in Pennsylvania.

In addition to teaching leadership skills to the youth, who serve as positive role models for their peers, CADCA is teaching advocacy. These teens spent a day on Capitol Hill, meeting with their representatives.

“Youth-led, adult-guided” is the model of the National Youth Leadership Initiative, said Piskai. CADCA’s coalitions work to affect the lives of youth, but this can’t be done by a purely adult-led model, said Piskai. “Youth are the experts of what’s going on in their schools and lives,” she said. “When they see peer pressure having an effect, youth can tell adults the best way to reach out,” she said. “The youth have the expertise and knowledge, and when you give them the opportunity to make the change themselves, it’s empowering.” The youth of today are always called the “leaders of tomorrow,” said Piskai. At CADCA, they are viewed as the “leaders of today.”

Primary prevention — preventing drug use before it starts — can’t be done without young people participating in the process. And the youth leaders come from diverse backgrounds, said Piskai. “Sometimes they’re the best of the best students and sometimes they’re average, but what’s really remarkable about them is they love being involved, especially in their schools,” she said. Some are vulnerable and at risk, but they are not “nonchalant about substance abuse,” she said. “They really care.”

Gathering all of the youth together for the annual leadership forum has presented some important chances to exchange communication about marijuana. Some of the youth come from states where recreational use of marijuana is legal, some come from medical marijuana states, and some come from states where marijuana is still illegal. “Right off the bat, when they start talking about marijuana, they notice the differences” in their experiences, said Piskai. “For example, one said there is a recreational marijuana store right near the high school. It’s so different from people who are dealing with an invisible dealer.”

The youth are helped with intervention strategies and what they could be doing in their communities, said Piskai. “We try to direct them away from scare tactics, because they don’t work,” she said. Instead, the young people in CADCA coalitions are given skills that help them be mature, and reinforce them in being a positive influence in their communities, she said. “These youth have data, they’re using presentations, and they really know what is hitting their schools,” she said.

Parents may want to consider being part of a community coalition. Community coalitions are used to foster improvements in the health of communities, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

Community coalitions differ from other types of coalitions in that they include professional and grassroots members committed to work together to influence long-term health and welfare practices in their community, according to SAMHSA. They can also create a collaboration that is sustainable over time.

The federal government has increasingly used community coalitions as a programmatic approach to address emerging community health issues. Community coalitions are composed of diverse organizations that form an alliance in order to pursue a common goal. The activities of community coalitions include outreach, education, prevention, service delivery, capacity building, empowerment, community action, and systems change. The presumption is that successful community coalitions are able to identify new resources to continue their activities and sustain their impact in the community over time. Given the large investment in community coalitions, researchers are beginning to systematically explore the factors that affect the sustainability of community coalitions once their initial funding ends.

The Office of National Drug Control Policy and the SAMHSA Center for Substance Abuse Prevention support Drug-Free Communities (DFC) Support Program grants, which were created by the Drug-Free Communities Act of 1997 (Public Law 105-20). These programs constitute the CADCA members described above. The DFC Support Program has two goals:

  • Establish and strengthen collaboration among communities; public and private nonprofit agencies; and federal, state, local, and tribal governments to support the efforts of community coalitions working to prevent and reduce substance use among youth.
  • Reduce substance use among youth and, over time, reduce substance abuse among adults by addressing the factors in a community that increase the risk of substance abuse and promoting the factors that minimize the risk of substance abuse.

Long-term analyses suggest a consistent record of positive accomplishment for substance use outcomes in communities with a DFC grantee, according to SAMHSA, based on the prevalence of past-30-day use of alcohol, tobacco, and marijuana.

For more information about CADCA, go to

For more information on Drug-Free Communities, go to

Parents’ Guide
9/6/2015 12:00 AM

Parents of particularly defiant children are often unsure what to do about behavior problems. Somehow, they always feel as if they are losing the battle when they practice “no drama” discipline and positive parenting with a child who is hitting.

Parents of particularly defiant children are often unsure what to do about behavior problems. Somehow, they always feel as if they are losing the battle when they practice “no drama” discipline and positive parenting with a child who is hitting.

In fact, the time-out is still a very useful tool for certain children, according to psychologists presenting at the annual meeting of the American Psychological Association last month in Toronto.

“Parental discipline and positive parenting techniques are often polarized in popular parenting resources and in parenting research conclusions,” said Robert Larzelere, Ph.D., of Oklahoma State University, at a symposium at the August meeting. “But scientifically supported parenting interventions for young defiant children have found that time-outs and other types of assertive tactics can work if they’re administered correctly.”

Larzelere and his team interviewed 102 mothers of toddlers who described five occasions in which they disciplined their children for hitting, whining, defiance, negotiating, or not listening.

The researchers found a big difference between the short-term and long-term effectiveness of certain disciplinary techniques.

Immediate vs. long-term improvement

The best tactic to get immediate improvement regardless of the type of behavior was to offer a compromise.

For less severe behavior, such as whining or negotiating, reasoning was effective. For the toddler who was defiant or hitting, punishment — a time-out or taking away something — was the most effective method to get change. Reasoning was not effective at all for hitting or defiant behavior. For negotiating behaviors and whining, punishment was the least effective tactic.

But for long-term improvement, offering compromises too frequently can backfire, especially for children who were hitting or defiant. These children actually got worse with the frequent use of compromise. Over time, reasoning produced the most effective response for these children, even though it was the least effective in terms of getting an immediate response. Finally, a moderate use — less than 16% of the time — of time-outs or other punishments resulted in improved behavior, but only for defiant children.

Ennio Cipani, Ph.D., of National University, explained that time-outs don’t work because they are used improperly. As part of their in-home services, Cipani and colleagues have observed mistakes made in time-outs. It’s important to tell the child ahead of time which behaviors, such as hitting, will result in a time-out, and then to always follow through, he said. Parents who make a spur-of-the-moment decision to use a time-out don’t get good results, he said. “Our clinical case findings have shown that time-out used consistently for select behaviors and situations significantly reduced problem behaviors over time,” said Cipani.

Child behavior therapy

The Hanf method of parenting allows for first rewarding children for good behavior, and then moving toward more authoritative techniques such as a time-out. David Reitman, Ph.D., of Nova Southeastern University, and Mark Roberts, Ph.D., of Idaho State University, gave a presentation on the work of Constance Hanf, Ph.D., which gives the child a second chance “by offering a warning for noncompliance,” said Roberts. “Over time both parent instructions and warnings become increasingly effective, reducing the necessity of time-out for noncompliance.”

Parents of typically developing children may view behavior therapy as too much like punishment, said Reitman. “People who are critical of behavior therapists because they try to ‘control’ children’s behavior are not mindful of behavior therapists’ efforts to convey to parents the value of connecting positively with the child,” Reitman said. “Therapists can help parents understand the problem, facilitate changes in the environment and help the children acquire the skills they need to become successful.”

But children with disruptive behavior diagnoses do need help in managing their problems. Both positive parenting and consistent consequences can help not only them, but typically developing children as well.

Positive parenting by age

The American Psychological Association provides some useful advice for positive parenting, based on age.

  • Children from birth to 3 years old:
    • Always supervise your children.
    • Stop difficult behavior with a clear and firm voice.
    • Distract your children with other things.
  • Children from 3 to 8 years old:
    • Explain repeatedly your rules and the expected behaviors.
    • Give one command at a time; use a clear voice and keep it short.
    • Ignore behaviors that are not dangerous.
    • Distract children with something different.
    • Use “when” and “then” not as a threat.
    • Use time-out to calm children down; use 1 minute for each year of age.
    • Ignore the children in time-out.
    • Use natural and logical consequences to teach about consequences of behaviors. Use them immediately after the misbehavior.
      • Examples:
        1. A child breaks a toy and doesn’t get another one.
        2. A child colors the wall and has to clean it up.
    • Take away some privileges according to the children’s ages.
      • For example:
        • Age 3 — Fights repeatedly in the sandbox: stops going to the playground.
        • Age 4 — Drops sister’s doll in the toilet: can’t play with sister’s toys.
        • Age 5 — Sits on older brother: no stories at bedtime.
        • Age 6 — Rips up a sibling’s puzzle: stays indoors while sibling plays outside.
        • Age 7 — Talks back to parents: doesn’t watch favorite TV show.

The above advice is part of the ACT Raising Safe Kids Program developed and coordinated by the American Psychological Association’s Violence Prevention Office. Launched in 2001 and revised in 2006 and in 2011, the ACT Program teaches positive parenting skills to parents and caregivers, and is based on research showing that exposure to abuse and neglect in early life can have long-term emotional, cognitive, and behavioral consequences for children and youth.

Below are some helpful websites for more information about children and discipline:

7/29/2015 12:00 AM

At first, when I heard that the director of the National Institute of Mental Health (NIMH) was in favor of the burgeoning idea of a “growth chart for the mind,” I was concerned. Don’t kids who are too fat or too thin already feel stigmatized? What about kids who are at 5% for height — or 105% for that matter? Who is to say what is “normal” for the developing mind? Besides, as a parent, I can’t help but wonder whether it isn’t “normal” for kids to be “psychotic”?

But when I delved into it a little more, I learned that Thomas Insel, M.D., believes in such growth charts because they can help clinicians identify — and, most importantly, intervene in — children at risk for schizophrenia.

All of the experts say repeatedly that with children, exhibiting psychotic “symptoms” does not mean they have a psychotic disorder. Many of these symptoms, as parents learn pretty quickly, are actually developmentally normal. While it may be reassuring to know that your child who has conversations with an imaginary friend is normal, this is also the phenomenon that makes diagnosis of psychosis in children so difficult. In fact, the experts — child psychiatrists and child psychologists — are the only ones who can actually distinguish between normal and abnormal behavior, and this is usually done based on the child’s age.

I was surprised to learn that even clinical experts have a hard time interviewing children about possible psychotic experiences, because questions about hallucinations and other psychotic experiences tend to result in a high rate of false-positives. In other words, children, who don’t know anything about psychotic phenomena, may come across as abnormal because they don’t understand the questions. This is why behavioral observations can be more fruitful.

Parents are rightfully concerned about unnecessary use of antipsychotics — as it is, there has been quite an increase in the use of these medications in children. However, many of the prescriptions of antipsychotics for children are for attention-deficit hyperactivity disorder (ADHD), not for psychosis. When prescribed for psychosis, I am not concerned about the use being “unnecessary” — far from it. With ADHD, I am not so sure.

In the incredibly difficult decisions parents and caregivers have to make, it’s important that there be trust between the family and the clinician. Medications come with side effects, but untreated psychosis is dangerous, life-threatening, and incapacitating. No parent wants to have his or her child hospitalized, or have the child’s life as an adult left unfulfilled because of illness.

So a chart that can signal problems early on — perhaps before medications are necessary — is something to support.

Growth and genetics

Schizophrenia in children is rare before age 13, but it increases during adolescence. It is related to growth, and to genetics. There is no reason to wait until symptoms are obvious, and there are lots of reasons not to wait.

The growth chart all parents are familiar with is the low-tech graph of the “normal” ranges for height, weight, and head circumference. It helps pediatricians tell when there is a problem. It’s pretty useful for such a simple tool — for example, even for a child in the normal range but who moves from the 80th percentile at age 6 to the 20th percentile at age 8, there could be a problem.

However, it’s much more difficult to develop a tool that measures cognitive and emotional development. If there were a map that showed the development of brain functions, it might help care providers find out what children are at risk for psychosis, according to a paper published last year in JAMA Psychiatry, which attracted Dr. Insel’s attention — in part because the NIMH funded the study.

The paper, by Ruben C. Gur, Ph.D., and colleagues, involved the creation of neurocognitive age growth charts that are developed by calculating predicted age based on performance. When neurocognitive age is younger than chronological age, there is a problem.

The children were part of a cohort of 50,000 children who were seen for general pediatric services, not psychiatric services. The study found that youth with psychotic symptoms were more likely to have neurocognitive delays.

“Just as children with diabetes veer from the normal growth trajectory in a pediatrician’s growth chart, children and adolescents in the psychosis spectrum group had a lower predicted age relative to typically developing children, with a developmental lag observed especially in tests of complex cognition and social cognition,” Dr. Insel wrote in a blog last year when the paper was published. “The delay ranged from 6 to 18 months and was present as early as age 8.”

The study wasn’t perfect — it was cross-sectional, not longitudinal, making it difficult to pin down the trajectory of growth, wrote Dr. Insel, adding that a one-hour test can’t test for all cognitive domains.

Still, the study showed that such a map — a growth chart of the mind — is possible. Furthermore, the tool is freely available to researchers at

Dr. Insel hopes that the field uses this test to help develop normative data, as has been done for height, weight, and head circumference.

No parent wants to be told their child might have a psychosis. But there is a prolonged phase of subthreshold clinical symptoms before a diagnosis is made. Wouldn’t it be better to have a clinician stage an intervention before these symptoms manifest themselves overtly?

The NIMH is continuing to support such work. While prevention of schizophrenia is not yet on anyone’s radar — nobody knows what causes it — there are steps that can be taken by clinicians and parents to help.

For the study, see Gur RC, Calkins ME, Satterthwaite TD, et al. Neurocognitive growth charting in psychosis spectrum youths. JAMA Psychiatry 2014 April; 71(4):366–374. doi: 10.1001/jamapsychiatry.2013.4190.


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  • Meet the Editor

    Gregory K. Fritz, M.D.

    Dr Fritz is a professor of psychiatry and director of child and adolescent psychiatry at the Brown University School of Medicine, where he conducts research and teaches.
    Alison Knopf
    Managing editor

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