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Family-based therapy can help with children's disruptive behavior

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PHILADELPHIA - Last year, 10-year-old John Stagliano of Newark, Del., was so anxious that he no longer wanted to play baseball, speak up in class, or sleep alone.

But, after 16 weeks of treatment that included his parents, John is back on his own at night, looking forward to school, and building a batting average that's better than ever.

And his parents have learned how to change some behaviors to help their son.

The family's experience at a Temple University clinic shows how children do not become anxious or fearful in a vacuum. Their problems can be greatly influenced by interactions with their family. And parents can be critical to turning around a child with problems ranging from depression to attention deficit, a new research summary suggests.

"Kids are highly influenced by their context," said Guy Diamond, associate professor at the University of Pennsylvania School of Medicine and lead author of the study, which was discussed for the first time earlier this month at a joint meeting in New York of the American Medical Association and the National PTA. "Even if it's not the cause, the family context can exacerbate symptoms."

Diamond's study, a review of the last 10 years of the best research, showed that family-based therapy could help with children's disruptive behavior - from conduct and attention deficit hyperactivity disorder to depression, anxiety and eating disorders.

While the findings may seem intuitive, families are often not included in psychotherapy. Diamond estimates that many treatments fail to embrace the family, although parents are included more than they used to be.

One in 10 U.S. children and adolescents suffers from a mental illness serious enough to affect daily life, according to the National Institute of Mental Health.

Traditional family therapy - treating the family solely as a unit - is the most involved type of family-based treatment, and one that does not have much scientific support, experts say.

But families can be incorporated in a child's treatment in other ways. They may be viewed as consultants or co-therapists to their child's therapy. Or, they may receive treatment themselves as individuals or parents.

Experts stress that involving parents in treatment does not mean parents are at fault for the child's disorder. There are multiple potential causes of mental illness involving complex interactions between biology and environment.

"This is not about blaming families, judging families," said Robert Berkowitz, chief executive director of the behavioral health center at Children's Hospital of Philadelphia. "This is about supporting youth and mental health."

Enlisting parents can demystify therapy and keep up the child's motivation to change, said Stephen Hinshaw, psychology professor at the University of California at Berkeley.

"The message too often is, families don't have much to do with it," Hinshaw said. "That's simply not true either. Non-optimal parenting might have a lot to do with the long-term outcome of an individual who has a biologically based condition."

Parents' actions can end up encouraging the very behavior that they don't want even though they are trying to help "from the goodness of their heart," said Philip C. Kendall, director of the Child and Adolescent Anxiety Disorders Clinic at Temple, where John Stagliano was treated.

When John began having anxiety about sleeping alone, his parents "made a lot of concessions," said his mother, Kerry.

She slept in his room, left his light on, and always tried to be there for him when he was anxious. But the attempted remedy - keeping him company - backfired.

"I got so used to it, it was freaky to do without it," John said.

Interactions like these can be changed in family-based treatments.

Working with therapist Tony Puliafico at the Temple clinic, John learned to decrease his anxiety by challenging himself in small ways to do things he feared and to cope with anxiety by using relaxation skills.

His parents checked in briefly with Puliafico every week and had two sessions alone with the therapist in which they were educated about their son's treatment and how to reinforce what he was learning.

Treatments that involve parenting differ by disorder. For aggressive behaviors, the goal is usually to get parents more involved with their children. But for other disorders, such as anxiety, the key is to have parents give their child space, Kendall said.

One type of well-researched treatment, called parent management training, helps children with "conduct disorder" - severely age-inappropriate, aggressive behavior. Parents are trained to reward the behaviors they want to see in their child.

The parents are told directly, "You're not responsible for the problem, but there are many things we can do to change it," said Alan Kazdin, director of the Child Study Center at Yale University School of Medicine, who developed the treatment.

In research on children with ADHD, medication at the right doses reduced attention deficit symptoms to the same degree as combination treatment of medication plus intensive family-behavioral program, Hinshaw said.

But, when additional markers of improvement - aggressive and anxious symptoms, school performance, relationships with peers - were added, the combination treatment proved to be superior to medicine alone.

"Involving families, and getting families and schools to communicate, this makes a difference for the whole functioning of a child with ADHD," Hinshaw said.

Schools are unable to give the intensive therapy required. But they can identify problems, enlist parents' help and make referrals. The Lower Merion School District, for example, gives parents a summary of their child's behavior throughout the day when the staff thinks that a child is struggling.

"Many times, parents will say, thank you for your help," said Bruce Barner, supervisor of guidance in the Lower Merion schools.


(c) 2005, The Philadelphia Inquirer. Distributed by Knight Ridder/Tribune News Service.

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