Young children with severe behavioral problems at home
Recent epidemiological studies have suggested that psychiatric disorders in preschool-aged children are quite common, with prevalence estimates between 16–21% (Egger & Angold, 2006). Moreover, approximately 12% of preschoolaged children present with psychiatric disorders that significantly impair their ability to function in everyday activities. This rate is comparable to rates observed in adolescents (13%) and adults (16%).
Lifespan similarities also extend to the nature and range of emotional and behavioral symptoms that preschoolers with psychiatric impairments might display, despite differences in their developmental expression. Specifically, these preschoolers may demonstrate severe and persistent aggressiveness (e.g., repeated acts of aggression toward caregivers, siblings, peers, and animals); out-of-control behaviors (e.g., tantrums, destructive behavior); self-harming behaviors (e.g., head banging, scratching, or biting self); acute impulsivity (e.g., running from caregivers, eloping from the home); persistent noncompliance and defiance; and emotional dysregulation.
Case study-Part I
Paul is a 4-year-old boy who has become increasingly aggressive at home and in his preschool classroom. He also behaves impulsively, putting himself in danger. For example, he has recently been attempting to run through parking lots and into busy intersections. His parents report that he screams, hits, kicks, and throws objects at family members when frustrated. These episodes occur several times each day, and last up to 1–2 hours. Paul’s parents also note that he has been increasingly withdrawn at home, preferring to be alone in his room.
He often mentions themes of death. His parents report long-standing irritability in Paul, and note that he was fussy and difficulty to soothe during infancy.
Previously, Paul had been seen weekly by a mental health professional for several months, and more recently, was receiving 2–3 hours of intensive home-based treatment and case management services on a weekly basis. But Paul’s parents state that they have “tried everything and nothing has worked,” and report not knowing what to do next to ensure his safety and manage his behavioral and emotional difficulties.
Challenges in treating young children
In the absence of appropriate treatment, symptoms such as Paul’s are likely to persist or worsen and lead to a range of problematic short-term outcomes such as preschool expulsion, academic difficulties, and poor school readiness. Longer-term consequences are also possible. For example, extremely aggressive behavior in preschool may persist into the primary school years, constituting an early starter pathway to antisocial behavior, substance abuse, and depression in adolescence and adulthood.
Although preschoolers with significant mental health problems are familiar to community healthcare providers, these children present unique challenges to our mental healthcare system. Young children with serious emotional disturbances often fail to respond to traditional outpatient treatment, or even to more intensive treatment provided at their home and preschool or daycare placements. In many cases, these children present with clinical problems and impairments consistent with criteria for admission to inpatient or residential treatment programs.
Out-of-home treatment programs, however, require children to be separated from their families, an experience that may be traumatic for very young children. Moreover, inpatient and residential treatment programs provide highly restrictive treatment environments that pose significant challenges to addressing core family and relationship issues that may underlie children’s behavioral dysregulation and distress. Such programs are also seldom equipped to meet the other developmental needs of very young children. As such, it is important to identify viable alternatives to out-of-home treatment placements for very young children. This is a particularly laudable goal given the relationship between frequency of out-of-home placements and longer-term impairments.
Psychiatric partial hospital treatment
Specialized partial hospitalization programs offer a unique treatment opportunity for very young children presenting with acute psychiatric symptoms and imminent behavioral risk. Specifically, partial hospital programs allow children to remain at home with their families while receiving daily, intensive therapies and services. Although varied in their primary orientations and intervention approaches, most partial hospital treatment programs for children provide multidisciplinary and integrated treatment services including intensive milieu-based and family therapies (Tse, 2006).
When serving very young children, these programs must also be tailored to the unique developmental needs and social contexts of this age group and may include a number of interrelated treatment components:
Intensive family treatments: Although incorporated into most partial hospital programs for children, family therapy must be an organizing component of treatment for very young children. These family treatments are critical to crisis stabilization, given the influence of the immediate social context on young children’s behavior. Intensive family-based treatments should provide crisis stabilization, including interventions to manage aggressive and dangerous behavior safely and effectively.
In addition, these treatments should address the impact of acute stressors on family problem-solving skills, structure, and roles, and increase positive family and parent–child interactions. To accomplish the latter, parents may also need to perceive their child’s disruptive or dangerous behavior differently; for example, to understand that misbehavior may not be willful, but rather a reaction to stress or the result of ineffective problem-solving skills.
Treatments may also incorporate a parent–child interactive component to help parents recognize their child’s often confusing verbal and nonverbal behaviors as reflecting their feelings and intentions. Parents can then be coached to respond with empathy and problem-solving strategies.
Daily milieu therapies: Most partial hospitalization programs for children place heavy emphasis on milieu therapies, which include a range of activity-based interventions provided within a highly structured and supportive therapeutic setting. These interventions are designed to promote safety, behavioral self-control, and competent functioning in daily activities.
For very young children, behavioral treatment approaches may include individualized token reinforcement systems and use of developmentally appropriate de-escalation strategies (e.g., guided deep breathing, distraction), as well as emotion-and relationship-focused interventions, such as child-centered play activities.
Additionally, milieu therapies should incorporate interventions to facilitate the development of emergent skills for emotion regulation (e.g., identifying and coping with the full range of feeling states), peer-group interaction (e.g., peer-group entry and play skills), and school readiness (e.g., basic preacademic skills). Importantly, although these interventions are implemented within the milieu context, programs can facilitate generalization of learned skills through the use of regular home visits, and visits to schools or daycare placements in anticipation of discharge.
Attention to family and parent psychiatric functioning: Many of these children live in multirisk environments, which may include caregiver psychiatric difficulties, marital and coparenting conflicts, domestic violence, child maltreatment, and poverty. These issues often impact the capacity of family members to engage adequately in the partial hospital program, which is intensive and may involve multiple treatment contacts each week.
These broader issues should be addressed in the child’s family-focused treatment plan, and could include coordination of care with other family mental health providers, as well as referrals for individual or couples therapy or psychiatric evaluations. Short-term parent psychotherapy may also be provided, when appropriate, to address immediate obstacles to implementing treatment recommendations.
Social skills and peer group interventions: Early childhood is a period of rapid social development. As such, interventions that promote social skills development may provide an efficient mechanism for decreasing impairment associated with psychiatric symptoms. Interventions may include instruction and in vivo practice of social skills that help children to interact effectively with same-age peers (e.g., play skills, coping and problem-solving strategies).
Psychopharmacological treatment: Despite a limited evidence base, psychopharmacological treatment can be an important component of a multimodal treatment program to address severe, treatment-resistant mental health problems in preschool-age children. Full-day programs provide close monitoring of medication effectiveness and side events, and permit prompt adjustment of dosing to changing clinical status in response to concurrent interventions.
Outreach and systems consultation: Given the central importance of immediate and consistent environments in the care of very young children with serious emotional disturbances, close coordination of care with community mental health professionals, school teachers and teams, and social service agencies is likely to promote successful functioning and adaptive development within the community setting.
Case study-Part II
Four-year-old Paul arrived to our partial hospital program on the first day hiding behind his mother’s legs, screaming, and turning away repeatedly whenever his mother tried to help him take his coat off. His mother tried to comfort him, but Paul pushed her away and started hitting. Paul began to settle after an hour of individualized staff attention, which included relaxation guidance, calm limit setting, prompt time-outs (staff and mother looked away for 10 seconds while quietly counting), and help in considering more appropriate behavior options. Within a week, Paul safely separated from his mother upon arrival and started to engage in the structured therapeutic group activities.
On the program, Paul’s parents learned and practiced specialized strategies for aggressive behavior. With staff guidance, they began to apply these strategies at home with growing success. As Paul became safer, his parents were able to work on identifying Paul’s distressing feelings (e.g., anger, sadness, and fear) more accurately and coaching him to use words, rather than dangerous actions, to express them. Over a 3½ week period, Paul’s parents felt they understood him better and were more confident that continuing progress could be achieved with less intensive treatment.
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John Boekamp, PhD, is the Clinical Director of the Pediatric Partial
Hospital Program at Bradley Hospital and a Clinical Assistant Professor
in the Department of Psychiatry and Human Behavior at the Warren Alpert
Medical School at Brown University.
Sarah Martin, PhD, is an Assistant Professor at Simmons College and a
Psychologist at the Pediatric Partial Hospital Program at Bradley
Egger HL, Angold A: Common emotional and behavioral disorders in preschool children: Presentation, nosology, and epidemiology. J Child Psychol Psychiatr 2006; 47:313–337.
Tse J: Research on day treatment programs for preschoolers with disruptive behavior disorders. Psychiatr Serv 2006; 57:477–486.