Web Therapy for Problem Preschoolers

Jonathan Comer, director of CARD’s early childhood intervention program (left), and Jami Furr, clinical director of its child program, lead clinical trials for families of children with preschool oppositional defiant disorder. Photos by Vernon Doucette

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.”

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.