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For children with behavior issues, getting help early is key

Caleb-Ray Richmond came into this world prematurely, but by the time he was 2 years old, he was the ruler of his family's Milwaukee home.  When things didn't go his way, when his fatigue spiraled into hyperactivity, toys would fly across the room, fists pounded the floor and the tears seemed never-ending.

"Caleb was boss and we were doing what Caleb wanted," said his mother, Kayla Richmond.

He raged in temper tantrums many times a day. Playtime with his 9-year-old cousin routinely dissolved into heated arguments. Caleb's parents and Richmond's mother sought help.

For eight straight weeks, a counselor came to the Richmond home, working with Caleb and his mom, teaching how to let Caleb lead in playtime and how Richmond should use consistent discipline tools, such as timeouts and ignoring any whining.

The Behavior Clinic, which is based in Milwaukee and jointly run through Penfield Children's Center and Marquette University, focuses on treating children up to age 6 with therapy in families' homes. It's one of the few in-home children's therapy programs in the Midwest.

For young children with severe behavioral issues, getting help early on is considered essential to success in school and life as an adult. Children with severe behavioral issues face increased risk of expulsion from preschool and child care programs.

The Behavior Clinic treats more than 100 children each year and has a waiting list of 70.

"Our approach isn't rocket science. It's teaching parents how to manage kids in a successful way," said Robert Fox, director of the Behavior Clinic and a professor in the counseling and educational psychology department at Marquette.

Essentially, counselors coach parents with hands-on training each week with developmentally appropriate techniques. Parents catch their children doing good things; they have systematic consequences, such as a timeout for writing on the wall and then making sure the child helps clean the wall; and they stick with the same consequences for less-than-ideal behavior.

On a recent follow-up visit with Caleb and his mom, family counselor Kimberly McCormick watched Caleb, who turns 3 this spring, and Richmond play with big Lego blocks, dump trucks and cars. Caleb shrieked with joy after successfully balancing toys on top of each other and delivered high-fives to his mom, McCormick and other visitors.

"Kayla is the epitome of what we want people to do," McCormick said. "She's been really on top of things and consistent."

Consistency is key, and for it to be effective, everyone in the household has to be on board. Richmond said she and Caleb's father and her mother all teamed up. Her mom watches Caleb during the day while his parents are at work.

"It was a learning process for all of us," Richmond said. "It's different when you share the rules with three people."

She said they had to make sure they all were practicing the same concepts with him.

And it's worked.

His tantrums have diminished and he cries much less. He plays much better with his cousin, Richmond said, with much less quarreling. He does still have some issues, such as calming down at night to get to sleep.

Nearly half of families that start out the program drop out before the end - it takes on average 11 or 12 weeks for families to complete the program. Those who drop out typically go four or five weeks, Fox said.

"We front-load all the stuff at the beginning," he said. "We get in as much as we can in as short a period as we can."

In other clinics around the country, in which families must go to a clinic each time for services, the dropout rate ranges from 40 percent to 80 percent, he said.

Many factors come into play that make it difficult for some families to stick with the in-home sessions - maturity, and barriers such as living in poverty, having several young children at home and very little social support, and living in high-risk neighborhoods, according to Heather Rotolo, clinical director.

Families also may have very little structure or routines in the home.

"Everybody's off. They're off schedule and they're off emotionally," Rotolo said.

By the time they seek help at the Behavior Clinic, "sometimes parents will say they don't even like their kid anymore," she said.

In the first session, parents learn to thrive with their children again, Fox said, primarily through non-directed play.

Play therapy helps change children's behavior when they're too young for talk therapy, said Andrea Begodka, who works with children as part of the psychiatry and gastroenterology departments at Children's Hospital of Wisconsin in Wauwatosa.

When children start in the Behavior Clinic program, Fox said, 85 percent of them will meet the criteria for a psychiatric diagnosis. By the time they complete the sessions, less than 20 percent will have a formal psychiatric diagnosis.

But even if families don't complete the full program, they can still see some meaningful changes quickly.

"With these kids, if you can get the parents on board, you can see change in three or four weeks because the kids are so young," Fox said.

Denee Harvey of Milwaukee watched her 3-year-old daughter Teagan transform from throwing tantrums when she didn't get her way to being more social, loving school and having far fewer tantrums.

"I felt like she was the bully," Harvey said. "It got progressively worse. We'd go to a store and she'd throw a fit if she didn't get her way. Me being a mom, I'd give in."

Teagan was diagnosed with oppositional defiant disorder. She also has a slight delay in her speech development, so she was often frustrated when trying to talk, Harvey said. Before they started the Behavior Clinic program, Teagan would have tantrums three or four times a day. Now she has a tantrum at most once every couple of weeks, her mom said.

"It's made a world of difference. We communicate a lot better," Harvey said. "We do our child-led play and it gives her the feeling that she's in control for once."

Harvey has watched Teagan flourish in preschool. She loves her teacher.

Harvey said she worried that Teagan's behavior issues would affect her education. To Harvey, higher education is important; she, her siblings and her mother all went to college.

"My greatest fear was that she'd be one of those kids that acted out in school and wouldn't learn," she said.

Her fear is legitimate - preschool expulsions have been increasing nationally. Behavioral issues such as biting and hitting can lead to kids' dismissal from preschool programs.

According to a 2005 study, "children in state-funded pre-kindergarten programs are expelled at more than three times the rate of students in grades K-12. Expulsion of preschoolers, infants and toddlers in less-regulated private child care can be as high as 13 times the rate of older children and youth," cites a report by the federal Substance Abuse and Mental Health Services Administration.

That 2005 study "showed that mental health consultation to early care and education programs helps prevent expulsion," said Janna Hack, infant mental health consultant with the Wisconsin Alliance for Infant Mental Health.

The alliance works with early childhood teachers and child care providers to make sure they have the skills and knowledge of mental health care for infants and young children.

Wisconsin's organization is one of 16 states to purchase a competency system to verify that professionals working with infants and young children have the skills they need and understand infant development, Hack said. Home visitors, welfare workers, child care providers and others submit their professional portfolios and exams, which the organization reviews.

Wisconsin has been "significantly behind" in the field of infant mental health care, she said. "There have been recent attempts to increase the public awareness, which is also part of our mission."

That awareness brings referrals to the Behavior Clinic from 25 different agencies as well as by word of mouth. Ten full-time and part-time graduate students from several Milwaukee-area colleges and universities work at the clinic, which is funded externally by foundations.

Still, children's mental health appears to have taken a back seat to adult mental health care.

"The research is clear," Rotolo said. When it comes to mental health, "little kids have been pretty much ignored."

The stats show that in general, 10 percent to 15 percent of kids will be a handful without treatment, Rotolo said.

"Half will continue that as they go into school. It tends to escalate," she said. "It's not something that time will heal."

Becky Lang
17 March 2011




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