School Refusal: Exploring Why Children and Adolescents Refuse School

By Anita M. Schimizzi, Ph.D.

Wow!  It’s really that time of year again.  While there are a range of thoughts and feelings that students have about heading back to school, it is the students that have a true phobia about attending that I hope to reach in this post.  Hopefully, this will find its way to parents that have seen their child seriously resist school and it will provide other parents with good information so they recognize what they see if their child begins to truly resist school.

A preliminary study on children and adolescents that refuse school revealed that not only is this group more likely than their peers to suffer from an anxiety disorder, there is also a pattern in the way that they cope with their anxiety.  Researchers investigated something that psychologists call emotion regulation and they found that kids and teens that refuse school tend to have difficulty reframing safe situations as such and also hide their feelings about their fears from others.  These two phenomena are referred to as cognitive reappraisal and expressive suppression, respectively, and they both may contribute to a student’s ongoing school refusal.

The study took place in Australia and used a sample of children and adolescents in treatment at a school refusal clinic.  As opposed to truancy where students typically try to hide their absenteeism and also have behavior problems, this group of participants refused school for reasons of anxiety.  The study group was matched for age and sex to a same size group of peers that did not refuse school. 

As one might guess, the school refusal students had higher levels of anxiety when compared to their peers.  They met criteria for diagnoses such as generalized anxiety disorder, social phobia, and separation anxiety disorder.  Many of these students also had mood disorders (e.g., depression) and/or behavioral disorders (e.g., oppositional defiant disorder). 

The school refusal students were found to oftentimes view everyday situations as threatening in some way.   For example, something as routine as eating in the cafeteria or being called on in class could seriously overwhelm the students described in the study.  In addition, they were less able to reframe situations as safe.  In other words, they used cognitive reappraisal less frequently than their peers.  Also, the school refusal students hid their anxieties from others.  This expressive suppression is thought to serve two purposes.  One, the individual can avoid the uncomfortable emotion more easily.  Two, it can protect the individual from being ridiculed by others or other negative social consequences.

While the authors state that these results are just the beginning of understanding the possible role of emotion regulation in school refusal and that more research is needed in this area (including in the US), there are some takeaways worth noting.  First, school refusal in this study was closely linked to anxiety.  That anxiety was fueled further by an inability to reframe non-threatening situations as non-threatening.  Second, participants that refused school were also more likely to conceal their true feelings. 

Perhaps clinicians, parents, teachers, and others that encounter these students can bring some relief to them by working to increase a sense of emotional safety in the school environment as well as warmly and openly allow for honest discussion about the anxieties associated with attending school.  While this is where I would normally say more on recommendations, chronic school refusal problems would probably be best served by an experienced professional who is skilled at understanding and treating the underlying causes of school refusal.  This person could spend time getting to know your child as an individual and work directly with your child to help decrease anxiety, reframe the school experience in a more positive light, and promote effective emotional understanding, management, and communication.  Finally, he/she could work in conjunction with parents and school personnel and provide feedback and recommendations that can ease the transition back to regular school attendance.

Please bear in mind that this study is not describing the student that occasionally complains about going to school or wants to stay home now and then.  This post is addressing a much higher level of school refusal.  For any parent whose child is sometimes refusing school or tentative about going, however, looking at their worries about going may be a good place to start.

Thanks for reading.  -Anita

Source: Hughes, E. K., Gullone, E., Dudley, A., & Tonge, B. (2010). A Case-controlled Study of Emotion Regulation and School Refusal in Children and Adolescents, Journal of Early Adolescence, 301 (5), 691-706.

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Your child may not be sad, but is he happy?

By Nestor Lopez-Duran PhD

Historically, most academic and philosophical thinking about depression has been focused on sadness. For example, most interventions for depression attempt to reduce the thoughts and behaviors that make us sad. Likewise, many researchers are interested in examining the factors that make people feel sad or dysphoric. Yet, research studies from many laboratories, including my own research, are reaching the same conclusion: when it comes to depression, lack of happiness may be even more important than too much sadness.   Take a look for example the article I discussed last week showing that low levels parental happiness predicted teen depression, but high levels of parental sadness did not.

Today I want to tell you about a study we recently published with my colleagues at the University of Pittsburgh (Dr. Tom Olino is the lead author of this study). In the study, we examined the development of positive affect (e.g., happiness) and negative affect (e.g., sadness) in 200+ children at familial risk of depression and their low-risk peers. These children are at familial risk for depression because at least one of their parents has a history of depression. We consider such children at high-risk because statistically they are significantly more likely than their peers to develop depression. In fact,  about 40-50% of children whose parents have a history of clinical depression will develop depression by the end of their teen years.

So given that many of these high-risk kids will develop depression, studying how they differ from their low-risk peers may help us understand what factors contribute to the development of depression. For example, we may find that these kids have a particular gene variation that their low-risk peers do not have, so we can speculate that such gene variation may be involved in the development of depression.

But in our study we were not looking at genes, but instead we wanted to see the natural developmental trajectory of positive and negative affect during early and middle childhood. That is, we wanted to examine changes in positive and negative affect across childhood. We know for example that positive affect increases from infancy into early adolescence. In contrast, negative affect decreases from infancy into early adolescence. This may sound familiar to most parents. Think about the frequency of crying that you child has displayed throughout the years. How often did she cry when she was 6 months? How about when she was 2 years old? How about when she was 7? Most kids probably cry every day at 6 months, just multiple times per week at 2 years, and only rarely at age 7.

So the question for our study was: Are kids at high-risk for depression different than their peers in their development of negative and positive affect? We were expecting that at risk kids would show more negative affect and less positive affect than their peers. Specifically, we were expecting that at risk kids would not show the typical increases in positive affect or the typical decreases in negative affect across the years that are observed in typically developing kids.

We were wrong. At least partially.

To our surprise, the high-risk kids show the same developmental trends as their peers. Specifically, their negative affect decreased over time and the positive affect increased over time as is expected in most low-risk kids. Also surprisingly, the levels of negative affect in any given year did not differ between the high-risk and the low-risk kids.  So, the negative affect of the high-risk kids decreased over time in a typical fashion and these kids were not any sadder than their low-risk peers. 

But we saw a real difference when we looked at positive affect. The high-risk kids looked just like their peers in that their levels of positive affect increased over time. Each year, the high-risk kids showed more and more positive affect as expected in most low-risk kids. But at any given year, the high-risk kids showed significantly less positive affect than their low-risk peers. So although their levels of happiness increased over time, high-risk kids were significantly less happy than their peers.

We believe then that high levels of sadness may not be playing an important role in the development of depression among these high-risk kids. Instead, it is low levels of happiness that may be a contributor to depression in these kids.

The clear implication to parents is that we should be attentive to kids happiness just as much as we are to their sadness. Your child may not be sad, but is he happy?


The Reference: Olino, T., Lopez-Duran, N., Kovacs, M., George, C., Gentzler, A., & Shaw, D. (2011). Developmental trajectories of positive and negative affect in children at high and low familial risk for depressive disorder Journal of Child Psychology and Psychiatry, 52 (7), 792-799 DOI: 10.1111/j.1469-7610.2010.02331.x

Smile! Parental happiness and teen depression and other summer updates.

By Nestor Lopez-Duran PhD

Hello everyone! It has been a while since my last posts and I have a few updates before I share with you some thoughts on a recent study on parental emotions and teen depression.

I wanted to start by thanking Dr. Anita Schimizzi, who has done an incredible job keeping child-psych running throughout the summer. We are very lucky that she is part of this project and I appreciate her very thoughtful and useful parenting posts. As Im sure you are too, Im looking forward to reading her posts every week.

Personally, my summer has been quite busy. Early this summer my job at the University of Michigan kept me away from child-psych. However, Im now back but my role at child-psych will change slightly. Dr. Schimizzi will continue to post about parenting issues in general, while I will focus most of my posts on issues related to childhood and teen mood disorders (my primary area of research), and to a lesser degree, early childhood disruptive behavior problems (my primary area of clinical work).

On a more personal note, my summer was also quite busy due to some exciting life transitions. On May 29 I got married to an amazing woman and we spent some time traveling in Thailand and Japan. We are now settling back at home and getting ready to start the new academic year in September.

Ok, now for some quick thoughts on parental happiness and teen depression.

The Journal of Abnormal Child Psychology recently published a research report of a study by a team at the University of Melbourne in Australia that examined the impact of parental expression of emotions on their teens risk for mood disorders.

In sum, teens and their parents were asked to complete a psychological evaluation as well as two laboratory activities designed to elicit different types of parenting behaviors. In the first activity the teen and the parent were asked to plan a pleasant activity. In the second activity, they were asked to try to solve a problem that had been the source of conflict (e.g., chores, curfew, etc). The sessions were videotaped and the behaviors of the parents were later analyzed and coded into 3 groups: 1) aggressive (anger, belligerent, cruel, provocative, annoying). 2) dysphoric behaviors (sadness, anxiety), and 3) positive behaviors (happiness, caring, etc). Around 2 to 3 years later, the teens completed a second psychological evaluation.

The logic behind the study is that the behaviors displayed by the parents during the laboratory interactions likely reflect stable parental tendencies that are used in many contexts, including at home. For example, a parent who is highly aggressive during the laboratory task is likely also highly aggressive at home (although parents who are very nice in the laboratory are not necessarily nice at home!). So the ultimate goal of the study was to determine if these parental behaviors predicted whether the teens would develop mental health problems.

The results:

  • High levels of parental aggression predicted increases in depressive symptoms among the teens within 2 years.
  • Low levels of parental positive behaviors also predicted increases in depressive symptoms within 2 years.
  • Surprisingly, high levels of parental dysphoric behaviors (sadness) did NOT predict teen depression within two years.

The authors also examined whether these behaviors predicted anxiety, but I will limit these thoughts to the findings regarding teen depression.

I have to admit I was a bit surprised by these findings. Why? Because parental depression is usually a very strong predictor of teen depression. In fact, about 50% of teens whose parents have a history of clinical depression will develop depression by the end of their teen years. So it was surprising to me that high levels of dysphoric behaviors, such as sadness, did not predict teen depression.

After my initial surprise, my thinking began to shift towards mechanisms. That is, we know that parental clinical depression predicts teen depression, but we know much less about the mechanisms of transmission: What are the mechanisms that explain how parental depression leads to teen depression? Clearly the answer to this question is complex and is part of my entire research program, but the results of this study provide some interesting insight. The common view is that depressed parents usually display dysphoric emotions (they look sad) and that these displays of sadness may contribute to the kid becoming depressed. Yet, this study suggests that is not frequent displays of sadness, but instead a lack of happiness that may contribute to these kids becoming depressed.  

Interestingly, such findings are completely in line with our own findings regarding young children of depressed parents. For example, next week I will be writing about a recent article I published with my colleagues at the University of Pittsburgh, which examined happiness and sadness among very young kids of depressed parents.

More next week. Its good to be back. Nestor.
The reference: Schwartz, O., Dudgeon, P., Sheeber, L., Yap, M., Simmons, J., & Allen, N. (2011). Parental Behaviors During Family Interactions Predict Changes in Depression and Anxiety Symptoms During Adolescence Journal of Abnormal Child Psychology DOI: 10.1007/s10802-011-9542-2

Children’s Perceptions of Their Parents: Can They Predict Later Mental Health Issues?

By Anita M. Schimizzi, Ph.D.

We all know how subjective most aspects of life are.  One’s perceptions carry an immeasurable amount of weight as we work to understand and interact with this world around us.  A recent study in the Journal of Child Psychology and Psychiatry demonstrated the importance of perceptions in looking at how kids view their parents.

Young and colleagues did a study on the perceptions of almost 1,700 11 year-olds regarding parents’ emotional neglect and control.  They then related the findings to the development of mental health issues at the age of 15 years.  Whether or not parents actually were emotionally neglectful and controlling was not known, but the researchers did demonstrate that merely perceiving parents as such significantly related to later psychopathology.

Based on 11 year-olds’ responses of “almost always” to items on a parenting questionnaire, the authors generated four parenting styles (percentages of the study participants follow each): optimal (20%), typical (54%), moderate (also known as tougher and stricter than the aforementioned styles; 23%), and neglectful and controlling (3% ).

The questionnaire included topics such as how helpful, loving, understanding, and controlling kids felt their parents were.  As could be anticipated, the “neglectful and controlling” group perceived their parents to be the least helpful, least likely to let them do things that they like, least loving, least understanding, least likely to allow them to make decisions, most likely to be controlling, most likely to treat them like a baby, and the least likely to make them feel better.

Regardless of gender, socioeconomic status, family structure, and previous psychiatric and social problems, the “neglectful and controlling” group was found to have significantly higher levels of psychiatric disorder at age 15, more than twice that of the “optimal” group.  Interestingly, the “typical” group had a moderate increase in odds for developing a disorder when compared to the “optimal” group.  Also, the “typical” and “moderate” groups had modest increases in symptoms related to anxiety, depression, conduct problems, and ADHD when compared to the “optimal” group. Those in the “neglectful and controlling” group far exceeded the others in psychiatric symptoms, however.

Regarding the “neglectful and controlling” group, the authors state that “the overwhelming experience of these children and young people is of being ignored and failing to have their needs met by their parents – but also of being controlled.”  They go on to cite previous research that found this group to be angrier and less compliant as older children.

What do these findings tell us?  While a lot of parenting is good enough, so to speak, there is a style that appears to lend itself to the development of a host of mental health problems in our children.  That would be the “neglectful and controlling” style described here.  What else do the findings tell us?  Our children’s perceptions of us as parents are important, which makes it critical for both parents and mental health professionals to know and understand what those perceptions are.

As I’ve stated before, talking and connecting with our kids is a must if we want to nurture them into emotionally healthy beings.  We also want to give them the space to make mistakes and learn from them, with us standing there ready to support them rather than rescue or overly control them.

For those of you who are curious about the “optimal” group.  Here is what these parents looked like, in the eyes of their 11 year-olds anyway.  They were the most helpful, most likely to let their kids do things that they enjoy, most loving and understanding, most likely to allow their kids to make decisions, second most controlling, least likely to treat their child like a baby, and most likely to help their child feel better.  Tall order?  Perhaps.  Worth it?  Probably.

Source: Young R, Lennie S, & Minnis H (2011). Childrens perceptions of parental emotional neglect and control and psychopathology. Journal of child psychology and psychiatry, and allied disciplines, 52 (8), 889-97 PMID: 21438874

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Raising the Chronically Ill Child

By Anita M. Schimizzi, Ph.D.

While many of us are fortunate enough to have healthy children, not all families are so lucky.  They must confront the chronic illness of a child on a daily basis.  What are some key factors that can help them do this successfully?  Read on about an article that I came across. 

Marchs APA Monitor included an article about caring for children and adolescents with chronic illnesses.  The author, Elizabeth Leis-Newman, looks at the difficulty parents have with the switch from doing all of the child’s day-to-day treatment to having the child/teen manage his/her own treatment.   She discusses three things that are linked to parents handing over treatment responsibility, sometimes too early: not fully understanding the illness and treatments, the difficulty of raising the chronically ill adolescent, and parent depression and anxiety. 

In looking at parent knowledge of the illness, the author cites a study by Kristin A. Riekert, PhD and colleagues (2003) where the researchers found that poor doctor-parent communication led to less treatment adherence for asthma.  For example, when parents were not fully informed of the need for regular medication use they would discontinue it when the child appeared to be symptom free. 

 A current longitudinal study by Avani Modi, PhD at Cincinnati Children’s Hospital Medical Center is tracking treatment follow-through in young patients with epilepsy.  Current findings show that parents are often inconsistent with giving medication to their child.  Modi also talks about “white coat compliance” where parents restart medication when it is time to visit the doctor, oftentimes giving incorrect readings of drug levels and risking being prescribed the wrong dose.  

The bottom line appears to be that doctors and other medical professionals must take the time to fully discuss the details of the illness as well as the importance of keeping up with day-to-day treatments.  On the other hand, it would probably be a good idea for parents to ask their child’s health care providers as many questions as it takes to feel that they understand the child’s illness, ongoing treatment needs, and the risks of making any changes to day-to-day regimens.

Modi states that the rocky adolescent years can be quite exhausting for parents to cope with, especially when that adolescent has a chronic illness that must be managed.  Due to the challenges of this age group, adolescents may end up with more responsibility than they can actually handle.  While teens may resent it when they feel that parents are meddling in their lives, Alexandra Quittner, Ph.D. reports that her research shows that when parents are simply physically present it can make a big impact on whether or not the teen does the treatment and does it correctly.  In other words, just being in the same room matters.

Caring for a chronically ill child comes with many challenges and a lot of times caregivers, which are most frequently mothers, may not have the support they need and this can lead to more depression and/or anxiety.  Suzanne Bennett Johnson, PhD reported that research suggests that as mothers are more depressed, treatment adherence tends to go down.  Quittner concluded that medical professionals will need to watch out for signs of depression and anxiety and screen for it not only in the ill child, but also in caregivers so that good supports can be put in place. 

To sum up, parents of chronically ill children and teens would likely benefit from having a strong connection with medical providers.  Parents are encouraged to take small steps as teens work to take on more control over their treatment.  It is also recommended that parents stick around during treatment time even when the teen can do treatments on his/her own.  Finally, if parents are feeling overwhelmed with the medical, financial, and/or emotional stresses that can come with having a child with a chronic illness, do not hesitate to seek support.  It is out there.

Source: Leis-Newman, E. (2011, March). Caring for Chronically Ill Kids: Many Parents are Struggling to Manage Their Children’s Care. Here’s Why. Monitor on Psychology, 42 (3), 36-39

Antipsychotic and other medications for autism: The state of the evidence

By Nestor Lopez-Duran PhD

Hi all! In the last post I started summarizing a series of studies that look at the scientific evidence for the effectiveness of specific treatments for symptoms of autism. I began by discussing research that suggests that Secretin is not an effective treatment for autism. This week Im discussing 3 additional medications (or classes of medications): antipsychotics (such as Risperidone), SSRIs (such as Prozac), and psychostimulants (such as Ritalin).

The effectiveness of these medications was recently reviewed in an article published in the Journal Pediatrics. The authors examined all previous studies that used good research methods to investigate whether these medications were effective in the treatment of some symptoms of autism. In addition, the authors were interested in determining whether the medications were safe.

Here is a summary of their results:


Risperidone (Risperdal): The authors found 2 good randomized clinical trials (RTC) that compared Risperidone to a placebo (e.g., sugar pill) and 2 prospective studies that examined changes in challenging and repetitive behaviors after starting the medication. One of the studies was funded by the National Institutes of Health and the other was funded by the makers of the drug. In both studies, kids taking Risperidone improved significantly more than kids taking the sugar pill. Similar improvements were seen for hyperactive symptoms and repetitive behaviors. The authors concluded that evidence for the effectiveness of Risperidone in reducing challenging and repetitive behaviors was moderate. However, the was also significant evidence for adverse side effects including weight gain (an average of approximately 6 lbs. in 8 weeks), sedation, and some neurological symptoms.

Aripiprazole (Abilify): The authors found 2 good quality RTCs comparing Aripiprazole to placebos for the treatment of challenging and repetitive behaviors. In both studies, kids taking Abilify improved significantly more than kids taking the sugar pill. The authors concluded that evidence for the effectiveness of Aripiprazole in reducing challenging and repetitive behaviors was High. However, the was also significant evidence for adverse effects including weight gain (an average of about 4 lbs. in 8 weeks), sedation, and some neurological symptoms.

SSRI (Selective Seretonin Reuptake Inhibitors):

Citalopram (Celexa): There was one good quality study comparing Citalopram to a placebo. There was no difference between kids taking Celexa and those taking the sugar pill in their levels of repetitive behaviors after 12 weeks of taking the medication. However, the levels of challenging behaviors decreased more among those taking Celexa than among those taking the placebo. Since there was only one study showing these trends and the results were modest, the authors concluded that at this time there was insufficient evidence for the effectiveness of this medication .

Fluoxetine (Prozac): There was one good quality RTC comparing Prozac to a placebo. Kids taking Prozac showed a larger decrease in repetitive behaviors than did kids taking the placebo. There were no major adverse side effects. It seems, therefore, that Prozac may be more effective than Celexa in treating repetitive behaviors.


Methylphenidate (Concerta, Ritalin): There was one good quality RTC comparing Methylphenidate to a placebo for the treatment of hyperactivity and non-compliance. Kids taking the medication improved significantly more than kids taking the placebo, but this was mostly at medium to high dosages (dosages ranged from 7.5 to 50 mg per day). However, some major side effects were reported including irritability (18% of those who quit the study did so because of irritability), sleep problems, anxiety, depression, and diarrhea.

What is most surprising about this comprehensive review is how little we actually know about the effectiveness and safety of these medications. We know most about Risperidone and Aripiprazole. Both of these medications appear to be effective although they have some severe side effects. The authors concluded that future research is unlikely to change these findings. However, we know significantly less about the effects of SSRIs and psychostimulants and we need much more research before we can determine conclusively whether these medications are effective and safe for the treatment of some symptoms of autism.

The reference:
McPheeters, M., Warren, Z., Sathe, N., Bruzek, J., Krishnaswami, S., Jerome, R., & Veenstra-VanderWeele, J. (2011). A Systematic Review of Medical Treatments for Children With Autism Spectrum Disorders PEDIATRICS, 127 (5) DOI: 10.1542/peds.2011-0427

Secretin for autism: Another treatment to avoid?

By Nestor Lopez-Duran PhD

Hello all, todays post is going to be the first of a series of 3 short weekly posts discussing 3 autism-related studies recently published in the Journal Pediatrics. All 3 studies are systematic reviews of the effectiveness of specific interventions for autism. That is, all 3 studies merged the results of all previous studies that have tested whether an intervention is effective or not in order to reach some overall conclusion.

The study I will review today potentially answers the question whether Secretin is an effective treatment for autism. Secretin is a gastrointestinal peptide used to treat peptive ulcers, but the drug became often used to treat autism after 3 children with autism were reported to have improved after receiving this drug for unrelated conditions (see Horvath K, Stefanatos G, Sokolski KN, WachtelR, Nabors L, Tildon JT. Improved social and language skills after secretin administration in patients with autistic spectrumdisorders. J Assoc Acad Minor Phys. 1998;9(1):9 –15).

After that report numerous studies of the effectiveness of this drug have used more appropriate research protocols (such as randomly assigning participants to receive the drug or a sugar pill) but have failed to replicate the original findings. That is, they seem to suggest that the intervention may not  be effective.

So in a recent  issue of the Journal Pediatrics a team from Vanderbilt University reviewed 7 large studies of Secretin. Each of these studies included at least 30 children under the age of 12 who had been diagnosed using DSM-IV criteria via the Autism Diagnostic Observation Schedule (ADOS). The studies examined whether Secretin helped the children with receptive and expressive language, gastrointestinal symptoms, adaptive behaviors, cognitive functioning, social skills, and fine motor skills.

So does Secretin work?

The authors of this review explained:

No studies revealed significantly greater improvements in measures of language, cognition, or autistic symptoms when compared with placebo. Study authors who reported improvement over time did so equally for both intervention and placebo groups.

The above statement means that when a study showed that children improved after receiving Secretin, the improvement was no different than the improvement seen in response to the sugar pill.  In addition, the type of Secretin used (porcine or synthetic) did not make a difference. Simply, Secretin did not work as treatment for autism in any of the studies that used the proper research methodology.

The weight of the evidence against Secretin is such that the authors of this review argued that future studies on Secretin for autism are not warranted. Why? Because funding more research on Secretin  means spending money in an already discredited treatment and such money would be better spent examining a more promising intervention.

The study: Krishnaswami, S., McPheeters, M., & Veenstra-VanderWeele, J. (2011). A Systematic Review of Secretin for Children With Autism Spectrum Disorders PEDIATRICS, 127 (5) DOI: 10.1542/peds.2011-0428

Introducing the New Child-Psych

By Nestor Lopez-Duran PhD

Hello everyone!

Some of you have been asking what I have been doing during these past weeks as child-psych has been quite quiet. Well, here is the answer: A completely revamped!

Child-psych has been growing greatly during the last 2 years and for a while Ive been thinking carefully about the next step. I consulted some of you regarding what would you like to see in a new site and spent some time considering a variety of options. The result is a much improved and expanded site that hopefully will delight those of you used to the old child-psych while also providing some exciting changes. So, what is new?

1. New Image! As you can see, the new child-psych got a fashion makeover! Its not drastic, but enough to bring the site up to date . The major change came on our front page (dont miss it: and in the pagination of the two new blogs (see below).

2. A new writer! I am delighted to welcome Anita M. Schimizzi, PhD. to the child-psych team. Dr. Schimizzi received her Ph.D. from the University of North Carolina and is a licensed psychologist specialized in the treatment of children and families. She is also the mother of a wonderful 4-year-old boy bringing some real-life expertise to the site! Dr. Schimizzi will be primarily blogging about parenting issues in our new Research-Based Parenting Blog

3. New Areas! As the portal expands, we are now dividing the site into 4 areas. The original child-psychology research blog, Dr. Schimizzis new Parenting Blog, a section with monthly editorials, and a new How To area where we will post more applied articles about parenting issues.

We hope that you enjoy these changes! A few more surprises are coming in the next month or so!




Autism and ABA therapists: Why are some better than others?

By Nestor Lopez-Duran PhD

The research on ABA is consistent: ABA is a highly effective intervention for autism. What do I mean by that? That on average, kids with autism exposed to ABA will improve more than those who do not receive this intervention. However, the key word here is on average. The research is also very consistent in showing that for some children ABA may not be as effective.

Why does ABA work for some children with autism and less so for others?

This question is not unique to ABA or autism. Across the board, psychological interventions do not work for everyone. In fact, most interventions that we consider to be very effective barely work for 50% of those affected.

Why is this the case? Why is it that some people respond to psychological interventions while others do not?

Researches attempting to answer this question have often focused on what they call contextual or individual variables. For example, is it that the therapy works best for females than males, or for those living in urban settings as compared to rural ones? etc., etc., etc.

But the answer, or at least part of the answer, may not be with the individual (patient) but with the therapist. You could say that simply some therapists are better than others. There is no denying this. But there is another reason that is significantly more controversial: whether the therapist does therapy as the therapy was intended to be done or instead makes up his/her own version on the premise that flexibility is good.

Let me explain why this is controversial (and stay with me, I will get to the ABA issue soon). There is a consistent finding in psychotherapy research. When the research is conducted at academic centers with highly controlled randomized clinical trials using research therapists the effectiveness of the therapy is significantly better than when the research is conducted in the community using real practicing therapists. That is, specific interventions work much better in research settings than in more real-life clinical settings.

Some have explained this discrepancy by arguing that the patients used in research centers are not representative of the patients going to community clinics. For example, for years, clinicians have argued that patients at research centers are selected to be clean in their diagnosis, such as when only patients with major depression (but without anything else) are included in research on a therapy for depression. The argument is that in the real world, very few people have ONLY major depression. But this argument, albeit persuasive and clearly sticky, does not reflect reality. Since the mid 90s research patients are not clean in diagnosis and instead have all of the characteristics of community patients. In fact, it would now be difficult, if not impossible, to get funding for a research grant that evaluates the effectiveness of an intervention if the proposed population does not reflect the population in the community. I am currently collaborating in 2 studies of interventions for child depression and in both studies the patients look exactly like the patients seen in the community.

So what then could be the reason research therapists appear to be more effective than real-life therapists?

I believe the research is pointing to one factor: FIDELITY.

Fidelity refers to the extent to which a therapist follows the guidelines (or the dreaded word manual) of the therapy as it was originally conceived. At research centers, fidelity monitoring is an ongoing intense process. That is, research therapists are monitored to make sure that they are implementing the therapy as intended without making up their own version or significantly adapting the original plan. This does not mean that these research clinicians are not flexible within a therapy session (some community clinicians incorrectly believe that following a manual means reading from a script in a robotic fashion, which is incorrect). Instead, fidelity means following a plan and implementing the therapy as intended. However, at the community-level, fidelity monitoring is non-existent. Actually, I would argue that fidelity is a taboo word and adhering to a manualized approach is viewed as undesirable because it is seen as too rigid or too restrictive of the therapists own expertise. Many real-life clinicians simply do not implement therapists as they were developed and believe instead that their eclectic or flexible approach is better. I argue those who hold such views are mistaken and that it is precisely the high fidelity adopted by research therapists that makes them more effective.

And here we finally get to the issue of ABA therapists. Recently, there was a brief research report in the Journal of Autism and Developmental Disorders that touched on this issue. The researchers wanted to know whether allegiance to ABA and thus fidelity to the ABA treatment protocol on the part of the therapists predicted how effective the therapy was. To this end, the researchers provided an allegiance questionnaire to the clinicians that measure how much they truly believe in ABA and how much they have criticisms of ABA as intended, which would result in clinicians making their own adaptations to the intervention. Not surprisingly, children who received the ABA intervention from the clinicians who had highest allegiance to ABA (those who believe most in ABA) had significantly better outcomes in regards to their daily functions than did kids who received treatment from clinicians who had more concerns about ABA.

So the question then for parents providing ABA to their kids is how much does your clinician truly believe in ABA and how much does he/she follow the ABA protocol as intended? And is it possible that part of the reason that ABA is sometimes not effective in some people is simply that sometimes ABA is not provided as intended because the therapists feel that their own adaptation is best?

The reference:

Klintwall, L., Gillberg, C., Bölte, S., & Fernell, E. (2011). The Efficacy of Intensive Behavioral Intervention for Children with Autism: A Matter of Allegiance? Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-011-1223-z