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Health & Wellness

Web Therapy for Problem Preschoolers

Advice for parents from a long-distance observer


Renee knew there something was wrong. Just asking her son to put his shoes on could spark a three-hour tantrum of screaming and kicking. She tried timeouts, she tried ignoring his tantrums, and she tried just about every bit of advice she could get from other mothers. Nothing worked.

“He was running the show,” says Renee, who asked BU Today not to use her full name. “All day was spent trying to get him to do those two things he really needed to do.”

When her son turned three, a pediatrician recommended a neuropsychological evaluation, which yielded a diagnosis of attention deficit hyperactivity disorder (ADHD) and sensory processing disorder, with both conditions exacerbated by his temperament.

Renee was then handed a flyer for Boston University’s Center for Anxiety & Related Disorders (CARD), where Jonathan Comer, director of the early childhood intervention program, and Jami Furr, clinical director of the child program, are conducting trials on preschool oppositional defiant disorder. These behavioral therapy trials, supported by more than $1 million from the National Institutes of Health and the Charles H. Hood Foundation, address a condition that afflicts about 5 percent of preschool-aged children, and they help alleviate symptoms for up to 75 percent of participants.

Children with preschool ODD, says Furr, a postdoctoral associate in the College of Arts & Sciences psychology department, often also have ADHD. They refuse to comply with requests, like to annoy others, and may hit, bite, or throw things, and in more severe cases, they are physically cruel to animals. For obvious reasons, they are often kicked out of preschool. It’s no surprise that parents of such children “are often pretty defeated by the time they get to us,” she says.

Therapists typically use parent-child interaction therapy (PCIT) to treat preschool ODD in a clinical setting, where the therapist observes behind a one-way mirror and coaches parents, via an earpiece, as they play with their child. But such therapy isn’t an option for families who live far from clinics. Children in those families are particularly likely to be prescribed medicine with unfortunate side effects.

“What we’re seeing is skyrocketing rates of antipsychotic medications to treat aggression in young kids, in preschoolers even,” says Comer, a CAS research assistant professor of psychology, adding that such medications are associated with concerning metabolic, circulatory, and endocrine effects in young children.

As a postdoc at Columbia University, Comer had been part of an innovative team that provided PCIT to military families at Fort Drum in Jefferson County, N.Y., near the Canadian border. Distance (more than five hours by car) and the lack of appropriately trained local clinicians made traditional therapy impossible, so doctors turned to technology. They gave each family a web camera, scheduled meeting times, and conducted telehealth sessions online.

The technique worked so well that Comer wondered if it couldn’t trump therapy even in places where therapy was available. “I thought this might very well be advantageous anywhere,” he says. “If the family lives down the street, maybe we would still prefer to treat them in their home.”

Watch this video on YouTube

In the video above, CARD staff and volunteers demonstrate a telehealth coaching session. Video provided by Jonathan Comer View closed captions on YouTube

Back at BU, Comer and Furr—a husband and wife team with a toddler themselves—are halfway through five-year trials that compare the two options: clinical therapy versus telehealth, and telehealth versus delayed treatment. More than 20 families have signed up already, Comer says, and “it looks like the internet-delivered options are equally credible.” It’s possible, he says, that telehealth could be a lifeline for families of defiant preschoolers nationwide.

Before being admitted to the trials, families undergo a thorough assessment to determine whether their child has preschool ODD. Renee remembers when she and her three-year-old arrived at CARD and were put in a small observation room. “It was the first time ever that I was hoping he’d act out,” she says. She didn’t have to worry. Complying with the therapist’s request, she asked her son to take blocks and build a tower. Instead, he flipped the table, emptied nearby shelves, and started hitting her.

“You’re in!” the therapist told them.

Once families are “in,” they receive a technology packet with a webcam, a room microphone, a Bluetooth device, and a mobile hotspot, if necessary. Therapists schedule weekly one-hour sessions with the family, preferably when both parents are available, and everyone signs in through an encrypted site called WebEx.

The first phase of these “special playtimes” focuses more on rebuilding the fractured relationship between parent and child than on changing discipline patterns. For several weeks, therapists watch parents playing with their children—first coding their positive or negative interactions, then coaching them on phrases to use during play. Parents score points for repeating what their child says, giving labeled praise (“That’s great sharing!”), or describing their behavior back to them (“Good job building that tower!”). When bad behavior breaks out, parents are advised to ignore it—with three exceptions, Comer says: “blood, bruises, and destruction of property.”

Once they master those skills, families establish house rules (“No hitting, kicking, or spitting”) and start practicing a detailed timeout sequence when their child misbehaves. “This is really a learning process not only for the parents, but also for the children,” Furr says. “What we’re really emphasizing is consistency, predictability, and follow-through.”

Amy, another parent in the trial, says her son would never sit through a timeout. But after beginning therapy, he started putting himself in timeout for violating a house rule, like hitting his younger sister. “He wasn’t able to control the action, but he knew it wasn’t right,” she says.

The last stage is practicing timeout sessions outside the home, a realm most families avoid for fear of explosive and embarrassing tantrums. Therapists use walkie-talkies to coach parents as they practice their newfound skills in the middle of a restaurant, store, or park.

Most families master these skills within six months. And the earlier families start therapy, the better. “When left untreated,” Comer says, “these behaviors can snowball into more serious conduct problems and then antisocial problems later on in adulthood.”

Amy and her husband completed therapy last year, and she says they learned valuable lessons about parenting and have strengthened their relationship with their son. They still struggle at times, she says, but “we’re able to connect on a different level and understand each other.”

Meanwhile, Renee’s family is seven weeks into therapy, and they are already seeing results. Her son now asks for special playtime and even helps with simple tasks like putting away toys, which used to be a daylong battle.

“It saved our life,” Renee says. “As a family, we were being thrown apart. It’s been a savior for us to deal with him, understand him, and know that this kid has potential, and we want to help him achieve it.”

For more information about CARD’s telehealth program, contact the center at 617-353-9610. Evaluations are free. Qualifying families also receive free therapy.

Leslie Friday, BU Today, Boston University
Leslie Friday

Follow Leslie Friday on Twitter at @lesliefriday.

7 Comments on Web Therapy for Problem Preschoolers

  • ECE professional on 03.01.2013 at 7:23 am

    This is very exciting news. I have worked with young children and their families for 30 years. The ability to privately and conveniently access therapy AND have it conducted in the natural environment is a huge leap forward in early intervention. Bravo CARD and Bravo BU! If we could just find a way to make care more affordable…SAR? SMG?

  • Preschooler Parent on 03.01.2013 at 9:36 am

    CARD is unquestionably a great service for some folks however as a parent of a preschooler I immediately winced at the title of this article – do you think any of the families involved would appreciate the term “problem preschoolers”? These kids are four years old or younger – they are not problems, they’re little people trying to make sense of a world around them where everything is decided by someone else, they often have difficulty expressing their thoughts and emotions and life in general (common expressions, what behavior is appropriate where, etc.) can be very confusing.
    Please try to be a bit more thoughtful and compassionate, BU Today.

  • Are on 03.01.2013 at 10:16 am

    Interesting article. It seems that problems not with prescoolers but with their parents and therapy needs more for them rather then for kids. I’d recommend to parents who face such kind of problems with their kids to read more articles like mentioned above and special books because the kids are merely reflection from parents’ mirror. One important thing in article but not disclosed in full is problem with “…skyrocketing rates of antipsychotic medications to treat aggression in young kids…” – who is gaining by stuffing kids with medicine?

    • Leslie on 03.01.2013 at 11:41 am

      Thanks for reading. I think your comment questions the cause of this behavior. From what Drs. Comer and Furr said, the cause stems both from biology and culture. Some of these children are more irritable by nature, they have been diagnosed with ADHD, and have exhibited these types of behaviors since infancy (some of them had colic). But there also is an element, yes, of training parents how to properly discipline a strong-willed child.

  • Anonymous on 03.01.2013 at 4:01 pm

    I wish this web-coaching had been available when I was raising my preschooler. Finally at 20, he was diagnosed with the biological condition, schizophrenia. I know I needed help in managing his behavior, but ultimately, it turns out that he had other issues, besides ADD, that made it difficult for him to listen, comprehend, and behave in a group. A little coaching would undoubtedly have made parenting and growing up easier for both of us! By the way, he’s doing much better with medication and a number of years of counseling. I was moved to write because of the comment on parents needing the help, not the children. I’ve heard that all my life, thought like that at one time, and learned through experience how harmful that attitude can be. It discourages people from seeking help for things that often have nothing to do with them, like the brain a child is born with.

  • Binkie on 03.02.2013 at 12:12 pm

    This is not rocket science, age old stuff basic stuff,I think people are making a whole lotta money out of this.

  • Jim in NOLA on 03.02.2013 at 4:16 pm

    Binkie from a cognitive behaviorist perspective, granted it is not rocket science; given that, why have I never heard of it before? I have been a SPED teacher/administrator for just over 30 years now, and this is the first time I have seen this anywhere. I grant you it is an idea that someone should have conceived some time ago, but the technology may not have been available? FWIW, anything that is going to involve technology will cost some bucks. Do you have data to indicate how much the therapists are making to substantiate your claim? The therapy is free for qualifying families, so what the hell. I think it is an awesome idea. As an advocate for students with emotional/behavior disorders, I have always thought that the best therapies take place in the home. Having a therapist talk to the parent through an earpiece instead of being at the house in person is so much more effective; more cost-effective as well.

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