clinical treatment c i pan i

AClinicalTreatmentGuideto10CommonBehavioralPediatric

Problems

EnnioCipani,Ph.D.

Copyright©2015EnnioCipani

e-Book2015InternationalPsychotherapyInstitute

CreatedintheUnitedStatesofAmerica

Forinformationregardingthisbook,contactthepublisher:

InternationalPsychotherapyInstituteE-Books301-215-73776612KennedyDriveChevyChase,[email protected]

http://www.freepsychotherapybooks.org

mailto:[email protected]

TableofContents

Preface

BriefAuthorBiography

Suggestedadditionalreadingforparents

Eatingtoomuch

Goingtobedontime

BedtimeStarChart:

Nightwaking(TheCipaniProximity-fadingMethod)

ParentJournalofTreatmentProgress:NighttimeWaking

Nighttimeaccidents

NighttimeAccidentsStarChart:

Siblingrivalryathome

ParentJournalofTreatmentProgress:SiblingRivalry

Cartrips(TheCipaniToleranceTrainingMethod)

Followingrulesofplayground

PuttinguptoysafterplayThe“Cipani3ToyRule”

Interruptingothersduringconversations(phoneorfacetoface)

Morningroutineforschooldays

ParentJournalofTreatmentProgress:MorningRoutine

ParentHandoutsforeachTreatmentPackage(canbepostedforeasyviewing)

Eatingtoomuch

Goingtobedontime


Nighttimeaccidents


Cartrips(TheCipanitolerancetrainingmethod)


PuttinguptoysafterplayThe“Cipani3toyrule”



Preface

Clinicians(pediatricians,mentalhealthprofessionals,familyphysicians)

who serve families are regularly presentedwith parental complaints about

child behavior management problems that involve certain settings, daily

activities, or time periods. For example, various bedtime problems are a

frequent behavioral pediatric concern expressed by parents. Some parents

reportdifficultyingettingtheirchildtobedatareasonabletime.Theformof

childproblembehaviorsduringthistimecanrangefromminorcomplaining

foraprotractedperiodoftime(complaintsaboutnotwantingtogotobed)to

moredisruptiveattemptstoescapegoingtobed(suchasextremetantrums

and disruptive behavior). Another common problem concerns their child’s

disruptiveepisodeuponwakingupatnight.

Tencommonbehavioralpediatricproblemareasarerepresentedinthis

clinicalresource.Eachareaisaddressedwithatreatmentpackageapproach.

Eachtreatmentpackageprovidesanumberofparentingtipsandsuggestions

(i.e., components) that form the basis of the clinical intervention for that

particular area. Some families may have problems in multiple areas. It is

suggestedthatiftherearemultipleproblemareas,thattheclinicianaddress

oneproblemareaatatime.Eachtipisexplainedintermsofitsrelationshipto

thesolutionoftheproblem,andiswrittenfromtheperspectiveoftheparent

readingthematerial.

Clinical Treatment Guide - Cipani 6

Thisresourcematerialforcliniciansiscomprisedofbehaviorally-based

solutions to such problems. It aims to solve such problems through the

clinicianteachingtheparentshowtomoreeffectivelymanagetheparticular

circumstance. The suggestions offered comprise a parental repertoire that

deals more effectively with the circumstance. Many of the treatment

componentscomefromtheresearch literature inappliedbehavioranalysis.

Whilenoteveryfamilywillrespondtosuchatreatmentpackagewithpositive

results(evenifsuchproceduresarecarriedoutwithintegrity),theresearch

literaturesupportsthedeploymentofparenttrainingasanefficaciousclinical

treatmentstrategyformanyfamilies.

Themodelusedforthisbehavioralapproachisoneofconsultationwith

parents.Theparentswillplayapivotal role in the solvingof theparticular

problem. Therefore, a substantial amount of the “therapy time” should be

spentreviewingeachrecommendationwiththeparent(s)andhowsuchcan

beputintopracticeintheirspecificcircumstance.Therearealsodatasheets

thatshouldformthebasisoftheclinician’smonitoringofthechild’sprogress

in the particular problem area during weekly therapy sessions with the

parents. Inmost cases, the parents should be encouraged to deploy all the

componentsofthetreatmentpackageinordertopossiblyrealizeasignificant

behavioraleffectforthatparticularproblemarea.

Clinicianswillalsofindtheformatofthematerialforeachproblemarea

freepsychotherapybooks.org 5

useful as handouts to parents (each of the ten areas also has a one-sheet

handoutinthebackforeasypostingontherefrigeratororwallifdesiredby

theparent).

Ifyouareaparentusingthismaterial

In some cases, parents may be able to effectively deploy these

procedures without any outside consultation for their preschool or

elementary-agedchild.Ofcourse,resultscannotbeguaranteed,butmanyof

these procedures have been found effective in the literature in applied

behavioranalysis.However,otherparentsmayrequiretechnicalassistancein

carryingoutthesuggestedprocedures/programandshouldseekhelpfroma

professionalskilledinthefieldofbehavioralparenttraining.Ifmoreserious

mentalhealthproblemsexist,aphysicianorothermentalhealthprofessional

mayneedtoevaluateyourchild,priortoorduringimplementation.

Spreadtheword!

Finally,ifyoufindthisclinicalresourceuseful,Iwouldappreciateyour

making others in your professional community (e.g., pediatricians, mental

healthprofessionals,familyphysicians)cognizantofitsfreeavailabilityat:

www.freepsychotherapybooks.com

Thankyouforyourendorsementanddisseminationefforts!


http://www.freepsychotherapybooks.com

BriefAuthorBiography

Ennio Cipani, Ph.D., a

graduate of Florida State

University, is a licensed

psychologist who has published

numerous articles, chapters,

instructionalmaterialsandbooks

(seeAmazonwebsiteforalisting

ofhisbooks).Dr.Cipanihasbeen

doing in-vivo behavioral

consultations inmany families homes since 1982 (see heading entitled, “A

Psychologistwhomakes housecalls” in the introduction section of his book

PunishmentonTrial(2004),availableforfreeonIPIwebsite(seebelow).He

hasgivenmanyworkshopsandcontinuingeducationcoursesfocusingonthe

effective management of problem child behavior. His email address is

[email protected]

Suggestedadditionalreadingforparents

I suggest that all clinicians using thismaterial encourage the parents

they work with to learn more about consequences and their role in child

discipline,byreadingthee-bookreferencedabove,PunishmentonTrial. It is


mailto:[email protected]

availableforfreethroughtheIPIwebsite,www.freepsychotherapybooks.com.

You can either give them this pagewith the url for them to download for

themselvesorsendthemadownloadedcopyviaanemailattachmentifthey

are unable to access the internet. Punishment (the use of effective

consequences for behavior) is a topic thatmany people (professionals and

parentsalike) aremis-informedon. If you read thisbook, youwill see that

there is considerable scientific applied behavioral research that provides

evidence tomany arguments that arisewhen discussing punishment. Also,

severalofthetreatmentpackagesinthisresourcerecommendacontingency

component, and the reading of this book will give you and the parent

additionalinformationonhowtopossiblyarrangeaneffectiveconsequence.


http://www.freepsychotherapybooks.com

Eatingtoomuch

1.Controlsnacking.

Inmanycases,theproblemwithchildrenwhoeattoomuchisthenumber and amount of snacks they are afforded (or obtain by othermeans).Ifyoubelieveyourchildneedsasnack,youshouldscheduleahealthy snack and require some effort to earn it. If needed, anutritionist canhelpwithyourmealplan foryour child.Youshouldalsoconsultwithyourphysicianonareasonableprojectedweightlossprogramforyourchildpriortostartingthisprogram.Tryingtomakeweight lossoccurrapidlycanbedangerous,andshouldnotbeconsidered. Missing meals is not wise and can be dangerous forchildren.Areasonable(andconsistent)lossofweightispreferred.

2.Designateachild-sizeportionforeachmeal.

Doesyourchildtakehugeportionsduringmealtime?Inadditionto possibly designating smaller portions for themeal, a new rule toinstitute isno seconds!Whenyour child isdonewith themeal, havehim or her immediatelywalk away from the table. In effect, removetemptation to fill the plate again. It would be helpful if there is anengagingplannedactivityforyourchildimmediatelyaftermealtime.

3.Slowdowntherateofeating.

Doesyourchildeatquickly?Slowingdowntherateofeatingcanbolster the desired result to eat less. By slowing down the rate ofspoontomouth,manypeoplefindthat itreducestheamountof foodthey eat at any given meal. To accomplish this, after each bite or


spoonful, your child should put down the utensil. Have your childcount to 10 and then proceed to take another bite or spoonful.Additionally,aftereveryfivebitesorspoonfuls,haveyourchilddrinkalittlebitofwaterorotherliquid(onewithfewcalories).

4.Activityrewardsforweightloss.

Havingyourchildgetonaweightscaleperiodicallyisagoodwayto monitor weight loss (or gain). In addition to the above threerecommendations, itmightbehelpful if your child isweighedone totwo times aweek, and such information is posted on a chart (like acalendar) in plain sight. Setting weekly weight loss goals incollaborationwithyourphysician isagoodstart,but itneeds follow-through.Havingaspecialweekendactivityconditionaluponachievingthetargetweightlossforthatweekcouldbeveryhelpful(readSectionIV in free downloadable ebook, Punishment on Trial, for furtherinformation on arranging consequences). It is strongly advised tohave your physician plan, monitor, and follow-up with yourchild’s weight loss. Ask your physician how frequently he or shewould like tomonitoryourchild’sweight loss. It is imperative thatareasonable weight loss program for your child be designed andsupervisedbyyourphysician.Rapidweightlosscanbedangerousforchildren!


Goingtobedontime

1.Setupaconsistentscheduleforbedtime.

Inmanycases,childrenwhohavedifficultygoingtobedontimehavenoconsistentbedtime.Therefore,anessentialfirststepingettingcontrol over bedtime problems is a bedtime schedule. You need todesignate a consistent schedule for bedtime for both weekdays andweekends.Infact,tofacilitatelearningappropriatebedtimebehavior,youmightinitiallyhavethesamescheduleforallsevendays.

2.Apre-bedroutineisnecessary.

Thepre-bedroutineshouldendinthechildbeinginhisorherbedatthedesignatedtime.Hereisasamplepre-bedroutine.At8:00p.m.,aseven-year-old child brushes his or her teeth, gets a drink of liquids(nothingwithcaffeine)andusesthetoilet.Thechildthengoestohisorher bedroom, puts on pajamas and gets in bed by 8:25 p.m. Thissequence of activities within the pre-bed routine should remain thesame,especiallyduringthefirst6-8weeks.

3.Bedtimestoriesareconditionaluponbeinginbedontime.

Manychildrenlovetohavebedtimestoriesreadtothem.Youcanusethistoyouradvantageinsolvingbedtimeproblems.Intheabovescenario,thechildwastobeinbedat8:25p.m.Ifthechildisinbedator before 8:25 p.m., the child earns a bedtime story.However, if thechild isnot inbedby8:26p.m., thenheorshegoestobedwithoutastory.The lengthof story time shouldbe fixedwith a timer to avoidarguments about how long you should read (have a timer by the


bedsideforthisreason).

4.Afterthebedtimestory,noothercompetingactivitiesshouldoccurinthebed.

If you are going to teach your child to fall asleep upon going tobed,youcannotallowthemtowatchTVorplayvideogamesonceinbed.Thoseactivitieswouldinterferewiththedevelopmentofaquicksleeponsetpattern(thisisalsotrueforadultswhohavedifficultywithsleeponset).

5.Abedtimepassisprovidedifthechildgetstobedbythedesignatedtime.

In addition to earning the bedtime story, the child also earns abedtimepassthatallowshimorhertoleavethebedjustonceforanyadditional need. The bedtimepasswas developed byDr. Pat FrimanandfellowresearchersattheUniversityofKansas,whofounditveryeffective in reducing behavior problems. The bedtime pass issurrenderedbythechildtoallowonetripoutofthebed.Thechildisnotallowedto leavethebedsubsequently. If thechildleavesthebedafterthepassissurrendered,anadditionalconsequenceiswarranted.

6.Astarchartsystemforadherenceisstronglyadvocated.

Highlypreferredweekendactivities canbeexchanged forpointsearnedbygoing tobedon timeandnotgettingupafter thebedtimepass has been surrendered. For example, each night that Billy(hypothetical child) gets to bed on time and does not leave the bedsubsequenttosurrenderinghispass,heearnsonestar.Ifheearnsfivestars(outofseveninaweek),hegetsadesignatedweekendprivilege.WhenBillydoesnot earn at least five stars, thedesignatedweekendprivilegeisnotavailableforthatparticularweekend.Ofcourse,every


week brings a new opportunity for your child to earn thatweekendprivilege(readSectionIVinfreedownloadableebook,PunishmentonTrial,forfurtherinformationonarrangingconsequences).Youshouldtrackthisweeklyinformationonacalendar(orotherdatasheetsuchastheonebelow)toreviewprogress.


BedtimeStarChart:

Ifchildwenttobedandstayed(usingbedtimepassonlyonce),placeastaron

thatdate

SUN MON TUES WED THURS FRI SAT

Date: Date: Date: Date: Date: Date: Date:






1. If your child is not initially falling asleep in their own bedwithout you, thatcouldcontributetothedifficulty.

If youallowyouryoungchild to fall asleepon the couchnext toyou, that is setting up the “going to sleep” condition as one whichrequires your presence. Youmay need to start putting your child intheirownbed(i.e.,tofallasleep)asalaterpartofthisprogram(oncetumultuousnightwakingshavebeensolved).

2.Ignoringworksbutishardinpractice.

When young children cry out at night for attention, they wanttheir parent(s) to come to their bed. I am sure you've heard thatignoringsuchattention-gettingbehavioristhewaytogo.Ignoringthisbehavior is theoretically sound but logistically difficult (if notimpossible)insomehouseholds.Ifyourchildiscapableofcryingandwhining in the middle of the night for 45 minutes or longer, yourattempttoignoresuchbehaviorwillresultinotherpeoplewakingupand creating havoc. I believemy approach delineated below ismoresuitable. My colleagues and I have used it in clinical practice withreferralsforsuchproblemsascryingandtantrumsuponwakingupatnight(wearetalkingaboutchildren,ofcourse).Especially ifyouhavetried ignoring these incidents of night waking and have beenunsuccessful,thisplanisforyou.Ifyoubelieveyoucanbesuccessfulatignoringthebehavioratnighttime,thenallpowertoyou.

3.Gotothechildimmediately,butdonotgetinhisorherbed.


Donotallowthechildtocryincessantlybeforeyougotohisorherbed. In fact, teach the child that simply saying “Mommy, I am up” issufficient to bring you. This should have the effect of quicklyameliorating lengthy and intense tantrums to get your attention andpresenceatnighttime.Gotothemrightaway.

4.Standclosetothechild’sbedandassurehimorherthatyouwillbethere.

Whenyougo to thechild’s room,standclose to thebedandsay“I'mhere.”However,donotget intothebed.Yourpresenceshouldhelpalleviatethechild’sconcernandfearofbeingawakeatnightwithnooneelseawake,withoutneeding toget intohisorherbed. Ifyouhavepreviouslymadethemistakeofsleepinginthechild’sbedwhenheorshewakesup,itmaytakeawhileforthechildtobecomfortablewiththisnewarrangement.Theremaybesomeinitialcrying,butyouneedtoavoidgettingintothebed.

5.Asyourchildcloseshisorhereyes,quietlymovebackafewsteps.

Whenyouseeyourchildnoddingtosleep,movebackafewsteps.Continuemovingawayfromyourchild’sbedasyouseethatsheorheis falling asleep. Eventually, youwill be out of the room. If the childawakensduringthisprocess,movebacktohisorherroomandassurethechild thatyouwere thereandwill stay thereuntil sheorhe fallsasleep.However,donotgetintheirbed!Eventually,youwillbeabletogobacktoyourbedoncetheyfallintodeepsleep.

6.Withnextawakening,stayafewstepsfurtherawayfromthebed.

Ifyourchildwakesupasecondtimeduringthenight, followthesame process, except you should be one or two steps further away


fromthebedthanyouwerethefirsttime.

7.Eachsuccessiveawakeningresultsinyoubeingfurtheraway.

Eventually,youshouldbeabletohearyourchildcalloutforyou,andyoucanrespondfromyourbed,“I’mupuntilyoufallasleep.”Thelengthoftimeitwilltaketogettothispointvariesbyfamily.Realizethat through thisprogressive fadingofyourpresence, your childhasbecomemoreandmorecomfortablewithjusthearingyourvoiceandnotseeingyou.

8.Keepa journal for the first one to twoweeks, delineatinghow theplanwenteachnight.

Youcanwriteinyourjournal(seesamplebelow)inthemorningabout howmany times your child awoke and howmuch progress isbeingmade.


ParentJournalofTreatmentProgress:NighttimeWaking

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:


Nighttimeaccidents

1.Prerequisitestonighttimetoileting.

Yourchildshouldbecapableofdaytimetoileting,withminimalornoaccidentsoccurringforaperiodofweeks.Ifyourchildisnottoilettrained to a sufficient level, you should implement daytime toiletingfirstbeforetacklingnighttimeaccidents.

1.Whenisyourchildeliminatingatnight?

Priortoanyformalstrategy,itisnecessarytoestablishthepatternofyourchild'snighttimeeliminations.Thisiscalledcollectingbaselineinformation. To accomplish this, you will designate three to five“checkpoints"inwhichyouwillcheckyourchildwhilesheissleepingto determine if she has had an accident. This definitely needs to berecordedonanighttimeaccidentdata sheet.Forexample, youmightschedulethreecheckpointsat10PM,12:30AM,and3AM.Dothisforleast10-15nights,togetanestimateofyourchild'snighttimepattern.

2.Teachingyourchildtoawakenatnight.

Youshouldwakenyourchildtogotothetoiletabout15minutesbeforethecheckpoint.Youmayhavetoadjustthisawakeningscheduleifyouseethatthebedisusuallywetwhenyouawakenyourchild.Thepremise is to catch them before they are usually eliminating andteachingthemtowakeupandeliminateinthetoilet.Haveyourchildgotothetoiletandsitforleast5to8minutes.Ifyourchildeliminatesinthetoilet,providepraise,cleanyourchildandsendherorhimbacktothebed.Ifyourchilddoesnoteliminatequicklywhileonthetoilet,


haveyourchildstayonthetoiletuntileightminuteshaveelapsed.Dothisforeachoftheimpendingcheckpointsduringthenight.Againitisnecessarytorecordbothaccidents,which involveseliminating inthebedpriortobeingawakenedaswellaseliminationsinthetoilet.Youcanstillusethenighttimeaccidentdatasheet.

3.Teachingyourchildtoselfawaken.

Onceyoustart tosee thatyourchild iswakingupaheadofyourprompt,youcanstartdelayingtheawakeprocessbywaiting15to20minutes from the initial time. Tell them before bedtime that if theywake up, they can call out and let you know they are going to thebathroom. Certainly provide praise and an additional incentive fortoileteliminations.Youwouldusethenighttimeaccidentdatasheettorecordaneliminationthatoccurredindependently.

4.Developastarchartfor“accidentfree”nights.

Foreachnightyourchild isaccident free,andeliminatesat leastonetimeduringthenight,heorsheshouldreceiveastar.Youcanusethe star chart to provide a reward contingent upon earning adesignated number of stars, for example, six stars earns a preferredvideorental.

5.Onceyourchildhasbeensuccessful,youcanremovethecheckpoints.

Depending on your child’s age, at a pointwhere she is accidentfreeforseveralnights,youcanremovethecheckpointsandjustallowhertowakeuponherown.Continueusingthestarchart.Ifaccidentsbecomeprevalentforseveraldaysinarow,gobacktostep#4above.


NighttimeAccidentsStarChart:

Ifchilddidnothaveanaccidentthatnight,placeastarthefollowingmorning

onthatdate

SUN MON TUES WED THURS FRI SAT







1.Planbreaksfromeachother.

When children play or interact together, the possibility ofargumentsandfightsexists.Thelongertheyplaytogether,thegreaterthe likelihood of arguments and fights. It is therefore important torealizethatinsomecases,childrenmayneedabreakfromeachother.Sometimesabsencemakestheheartgrowfonder!Iftheyarespendingalldaytogether,andeverydaytogether,itmightnotbeabadideatoplansomeperiodswheretheyplayindependently.Thiswillnotsolvetheproblemcompletely,butshouldhelpouttosomedegree.

2.BeVigilant!

Beonthelookoutforpotentialconflict!Ifyouareusuallycatchingthe argument way after the blows have been struck, then increasedvigilanceonyourpartisparamount.Youshouldbeawareofwhatyourchildren are doing, i.e., an open-ear for sounds that appear to beheaded for an argument. Your vigilance to potential escalatingargumentsisvital.

3.AdopttheMommy-courtapproachtodisputesregardingitemsortoys..

Manyargumentsandfightswithchildrenareovertwo(ormore)of them wanting the same item or toy at the same time. While wewouldlikeforourchildrentolearntoshare,leavingthemtoworkoutthesolutiontothisproblemusuallyleadstoargumentsandfights.Thebestwaytoteachthemtoshareistohavethembringtheircasetothejudge (you)before it comes toblows.This ishow itproceeds.At the


start of a dispute the children are taught to come to you (the judge)withtheircomplaintregardingthetoyinquestion.Getanoventimerand set it for a small length of time, allowing one child to have thatitemfirst.Yourotherchildgetsitafterthetimergoesoff,forthesamelength of time. The child who had the toy first must part with itwillingly.Ifthechildwhogetsitfirststopsplayingwiththetoybeforethetimerisup,thesecondchildmaygetthetoyatthattime.

4.Aggression should always result in the aggressor(s) not getting the toy (andtime-outremoval).

Once you have given your children a more acceptable way toresolvetheirdisputesandtheyfailtoresorttosuch,theconsequenceshould be loss of the desired toy for some specified period of time.Arguments and aggression should result in the children’s inability toget the desired toy in the immediate future. This would require aremoval fromtheplayarea forabrief timeout, inadditionto lossofaccesstothepreferreditemforadesignatedperiodoftime.

5.SolvingdisputesviaMommy-courtshouldbepraisedandreinforced.

Ifarguingandfightingaretodecreasedramatically,thenteachingyourchildrentocometoyoutosolveadisputeinafairandequitablemanner is necessary. Therefore, implementing a point system (alongwithpraise)whentheycometotheMommy-courtisstronglyadvised.Eachchildwhocomestotheparenttosolveadisputeandthenabidesbytherulingshouldbereinforced.Keeptrackofthisinformationinajournalformat.

6.Physicalaggressionshouldresultinamoresignificantconsequence.


If the children hit each other, you might consider the loss of aprivilege or early bedtime that day as a consequence for thetransgressor(s).Here isa realcaseexample.Cesar (notrealname),aseven-year-old boy, was referred to me for behavioral services as aresultofhismother’srequesttoreceivehelptocontrolhisaggressionto his younger brother. Likemany siblings arguments occur, but hismother felt she couldnot control his aggression towardshis brotherandwasworriedaboutitsomedaygettingoutofhand.Hismotherfeltthatnowwasthetimetoextinguishsuchabehavioralpatternfromhisrepertoire.

Aftercollectingabaserateofaggressivebehavior,wedesignedaplanofaction.TheplanwedesignedincorporatedbothusualbedtimeandTVaccessduringprimetimeasearnedprivileges.Eachaggressiveincident toward his sibling would result in one strike. When Cesarreached two strikes, he went to bed one hour early that night(effectivelymissingallhisfavoriteprimetimeshows).Cesardidnotgoto bed early for the first three weeks of the plan. Subsequently, hismother and I agreed to reduce the cut-off to one strike. Cesarcontinuedtosucceedontheplan(readSectionIVinfreedownloadableebook, Punishment on Trial, for further information on arrangingconsequences).


ParentJournalofTreatmentProgress:SiblingRivalry

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:


Cartrips(TheCipaniToleranceTrainingMethod)

1.Developchildtoleranceofcartripsgraduallyandprogressively.

Especiallyforyoungchildren,relativelylengthycartripsareoftennotfun.Additionally,beingrequiredtobeinachild-safetyseat(orseatbelt)addsadditionalburdentotheaversivenatureofcartrips.Ifyourchildhasextremedifficultystayinginhis/herseatbeltduringcartripsofvaryinglengthsoftime, itmightbenecessarytograduallydevelophis/hertolerancegradually.Iwouldsuggesthavingaonetotwoweektrainingprogramtoteachyourchildhowtorideinthecarinhisorhercarseat.Startwithshorttrips.Forexample,conductacartriparoundtheblock.Shortandsweet,right?Buthaveseveralofthesetripsadayeven though there is no purpose to the trip, other than a practicesession. By conducting practice sessions, your child has the frequentopportunity to begin to tolerate the situations inherent in car trips,albeit for a short duration. Going back to a preferred play activityfollowingasuccessfulpracticesessionisagoodidea.

2.Graduallyincreaselengthofcartrips.

Asyourchildgetsbetterattoleratingtripsthatlastafewminutes,youcanprogressivelyexpandthe lengthof thetripby increasingthedistancedriven.Dothisgraduallyoverthetwoweektrainingphaseoftheprogram.Don’t jump froma two-minute car trip tohalf anhour!Onceyourchild iscapableofcartrips involving10or15minutes,orlonger, you and your child will have a more pleasant experiencetravelingaboutduringyourweeklycommunityactivities.


3.Haveanalternativeactivityavailabletoreduceperiodsofboredom.

Even during training sessions, bring entertaining materials andactivitiesforyourchildtoengagein.Doingsomethingentertaininganddistractingduringcar tripscanbeofextremehelpwhen longer tripsare necessary. If the child is kept busy, the likelihood of problembehaviorduringthetripisless.

4.BePatient.

Realize that not every child responds in the same time frame tothesesuggestions.Isuggestthatduringthetrainingprogram(firsttwoweeks), several short car trips occur each day. Subsequent to thetraining program use these suggestions during “real” car trips. Oncethechildiscapableoftoleratingreasonablecartrips,(i.e.,thelengthofyourusual trips), youcan fadeout the trainingprogram.Remember,rightnow,yourchildrenwouldhavea tough timewith two-hourcartrips irrespective of the training program you have. But withprogressive tolerance training, your child can become moremanageablewithyourusualtripstothestore,park,Laundromat,etc.Goodluck!



1.Previewrulesbeforegoingtoplayground.

Yourrules for theplaygroundshouldbeashort list,sothat theyeasilyfitononeindexcard.Theyoungerthechild,theshorterthelist(especiallyinthebeginning).Youcanalwaysaddtothelistonceyourchild has learned how to respect your initial few rules. Also it isprobablyadvisabletohaveshorterlengthsoftimeontheplaygroundinthebeginning.Thisfacilitatesgettingyourchildusedtoleavingtheplayground appropriately because of a greater number ofopportunitiestodoso.

2.Theconsequenceforbreakingaruleisanimmediatebriefremoval.

Ifyourchildbreaksarule, immediatelygotoyourchild, indicatewhatruletheybrokeandprovideabriefremovalfromtheplaygroundarea.

3.Setalimitonbreakingrules.

Onsomedays, itmayseemthatyourchild is forevertestingyouand the rules. There needs to be a point at which the playgroundexperience is terminated as a consequence of such behavior.Therefore,tellyourchildthatifyouhavetoremovehimmorethanacertainnumberof times, theplaygroundactivitywillbe immediatelyterminated. For example, if you designate that three removals is thelimit,thefollowingwouldoccur.Thefirsttimeyourchildbrokearule,hewouldsimplyberemovedforashortperiodoftimeout.Thesamewould happen for the second time. However, with the third rule


violation, the playground experience is ended immediately and youbothproceedtogohome.

4.Whenitisover,itisover!

Whether it is an early departure (due to behavior) or thescheduledendingoftheplayactivity,whenyousay,“Itistimetogo,”thatisit.Tellyourchildhehastothecountoffivetocometoyou.Ifhecomplies,Iwouldsuggestgivinghimamonetaryreward(readSectionIV in free downloadable ebook, Punishment on Trial, for furtherinformationonarrangingconsequences).Dependingontheageofthechild,adimetoaquartercanaddupacrossseveralweeks.Ifthechilddoes not comply and either ignores you and engages in tantrums,immediately physically take her away from the playground, with nomonetaryreward.Youmightalsodesignateanadditionalconsequencethat day for failing to follow your directive to leave the playground,e.g.,earlybedtime,lossofTVprograms,etc.


PuttinguptoysafterplayThe“Cipani3ToyRule”

1.Haveaplacewheretoysarestored.

Doesyourchildhaveadesignatedplacewheretoput toyswhensheorhe isdoneplayingwith them?Beforeyourchildcandohisorher part, youmust do yours. Toys should be stored in a designatedarea,eitherinbins,orwhereappropriate,onshelves.Inotherwords,theremustbeaplaceforeachtoy.

2.The“Cipani3-toy”rule!

Don'tletyourchilddragouteverytoyandthenexpectthatheorshewillpickthemupwhentheplayactivityisconcluded!TheCipani3-toy rule: No more than three toys out at one time. If your childdesiresadifferenttoy,thenheorshemustputawayonetoytotakeitsplace.Pretty simple, but the toil is in your follow-through.When theplayactivityends,allofthetoys(threeorless)mustbeputup.Youcansetatimerforthecleanup.Ifthechilddoesnothavethetoyscleanedupinthedelineatedperiodoftimeforcleanup,thensometimeistakenoffthenextplayperiodtopractice;“howtoputuptoys.”

3.Havedefinedplayperiods.

It is much easier to monitor the “Cipani 3-toy” rule if they aredefinedplayactivities, especially in thebeginning.This requires thatyou designate the play activity schedule. I recommend this to anyparentwhohasdifficultyfollowingthe“Cipani3-toy”rule.



1.Provideasignalorinstructiontoyourchild.

Inorderforyourchildtobegintolearnwhenitisnotappropriateto interrupt, a signal and/or instruction indicating that interruptionsarenotpermissible isneededat thebeginningof theconversation.Abrief verbal explanation, such as, “Iwill be on the phonewith UncleHenry for the next 4minutes. Please do not interruptme until I amfinishedunlessitisanemergency,”shouldsuffice.

2.Delineatethelengthoftimeyourconversationwillentail.

Lettingyourchildknowhowlongyouwillbetiedupisimportant.Irecommendanoventimertoclearlydelineatethelengthoftimeyourchildmust gowithout interruption.Upon initiating the conversation,settheoventimerforthedesignatedlengthoftimeandshowittoyourchild.Theoventimeriskeptinplainviewsothatyourchildcanseethetime left when desired. Once the oven timer goes off, terminate theconversation shortly, or allowyour childanopportunity to interruptbrieflyand/orparticipate.

3.Pleaseuseanoventimerforthisbehavioralstrategy.

Thereasonforthegreatrelianceontheoventimer is thatmanychildren cannot wait with unpredictable amounts of time.Subsequently,theyinterruptyourconversationasamechanismtogetyou to end the conversation and engage them.Anoven timermakesthe“wait”requirementspecific.Inthismannerthelengthoftimeyour


childdoesnot interruptcanbeprogrammedprogressively for longerand longer periods of time. It also allows for an error correctionprocedure (delineated in step 6 below) which is highly effective inteachingyourchildself-controlinthisarea.

4.Developa signal that indicateswhen your child canbeallowed to enter intoconversation.

Once your child is capable ofwaiting a sufficient period of timeduringyourconversations,youcandeveloptheirabilitytoenterintoaconversationwhenitisappropriate.Thissocialgraceisfairlydifficulttoacquire,sincethecuesaresubtle.Therefore,priortoacquiringthissubtledistinction,childrenneedasignalwhichindicatesthatenteringtheconversationappropriatelyisacceptableatthispointintime.Thesignal can be verbal. For example, “O.K. Johnny you have waitedpatientlytotalk,wouldyouliketosaysomething?”

5.Teachyourchildthattheconsequenceofinterruptingisadelayingettingyourattention.

This can only be done with an oven timer (i.e., reliably andsystematically).Whenyourchildengagesinaninterruption,youpointthatouttohim/herimmediatelyandconcisely,e.g.,“Youinterrupted.”Noneedforadetailedexplanationhere.Withinasplitsecondofthatverbalfeedback,youthenaddextratime(determinedapriori)totheoven timer and say, “Now you will have to wait longer.” Your childlearnsthatinterruptingyouwhileonthephonenowresultsinadelaytoyourattention.

6.Tolerancetrainingtodevelopyourchild’sself-controlto“wait”.


To accomplish this, I have used “fake” phone calls. The parentreceivesmultiplephonecallsduringatrainingsession,withthechildbeing informed of this in advance. The child is told to try to refrainfrominterruptinguntiltheoventimersoundsandtheparenthashungupthephone.Thephonecallislimitedtoashortperiodoftime(e.g.,2minutes).Theuseofanoventimerduringthistrainingisparamount.Onceyourchildsuccessfullyhandles2minuteconversations,withoutinterrupting, the parent can progressively raise the bar (i.e., thestandard) to three minutes. You should continue these trainingsessionsforsomeperiodoftime.Romewasnotbuiltinaday!

7.Trynottochangethestandardtooquickly.

Don’tgofrom2minutesto20minutesinoneday,especiallywithyoungchildren.Thatspeedyprogressionisalmostinvariablydoomedtodefeat.Behappywithsmallsuccesses.Youcaneventuallygetto10minutesbut itmight take a fewweeksof training sessions.Considerthat youmay havewaited for three years for your child to learn torefrainfrominterrupting.Giventhisfact,waitinganotherthreetosixweeksisnotsobad.



1.Getyourchildupataconsistenttime.

Inmanycases,childrenwhoaredifficulttoawakeninthemorninghaveaninconsistentbedtimeschedule.Itispossiblethataconsistenttimescheduleforgoingtobedisallthatisneeded.Ifgoingtobedontimeisaproblemareainandof itself, thenyoumayneedtoaddressthis problem area first. Ask your physician for the following adviceform:Goingtobedontime.

2.Agradualawakeproceduremaybeneeded.

Some children just have difficulty waking up, even with aconsistentbedtimeschedule.Wakingthemupabruptlyoftenproducesbehavioralproblemsrightaway. In thesecases, Ihaverecommendedthat a clock radio be used. The decibel level of the music can beincreased gradually over a ten-minute period, thus providing aprogressiveawakeningofyourchild.Informyourchildeachnightthatyouwill set the alarm for a certain time, and themusicwill be veryfaint at first. Once the alarm goes off, you will alter the volume a“notch”every fewminutes.Afterseveralchanges inthevolume,yourchild will be expected to get up and turn off the clock radio. Thisprocedureshouldeventuallyteachyourchildtogetoutofbedwiththelowerdecibellevelsofmusic.

3.Keepthesamescheduleofactivities.

Someparentswhohavedifficultywiththeirchildonschooldaysdonothaveapredictablemorningroutine.Unfortunately, theyallow


theirchildmuchdiscretiononwhattasksgetperformedatwhattimes.Theresult is chaos in themorning! Inorder foryourchild to learnaroutineforschooldays,youmustdevelopone.Theroutineshouldbeinvariantuntil your child isdemonstrating theability toperform theroutinewithoutaproblem.Iwouldsuggestthatyouprintthespecificmorning activities on a page taped to the child’s bathroomwall, foreasyreference.

4.Bathroomactivitiesfirst.

I recommendthat the firstwalk in themorningshouldbe to thebathroom.Teachyourchildthatthisprocessofgoingtothebathroomfirstisadheredtoeachmorning.Ifyouhaveseveralchildrenyouwillneedto“play”withtheschedulingproblem.Youshouldhaveaspecificlistofactivitiesthatneedstobecompletedinthebathroom(postedifnecessary).Whileinthebathrooms/hetakescareofalltheactivitiesproscribedforthatroom,e.g.,usingthetoilet,handwashing,brushingteeth, etc. Once your child has successfully completed all therequirements, s/he leaves thebathroomandheads for thebedroom.The same process is carried out, i.e., take care of all the morningactivities for that room before leaving the bedroom. Note that thissequenceofeventsdoesnotallowyourchildtogowatchTV,untilsheis“readyforschool.”Takeaway(i.e.,remove)theopportunitytoplay,untilallthenecessaryactivitieshavebeencompleted.

5.Donotallowyourchildtoengageinacompetingactivity(e.g.,TVwatching).

YourchildshouldnotbeallowedaccesstotheTVorplaystationuntil everything that needs to be taken care of has been.This seemsobviousbutyouwouldbesurprisedhowoftenthisoccurs. It isoften


thecasethatachild(whohasdifficulty)isplacedinfrontoftheTV“towake-up.”Other parents use theTV as an interim event to entertaintheir child until they are ready to deal with them. Realize that thiscreatesaproblemwhenitistimetoswitchfromapleasurableactivity(TVwatching) to amarkedly less pleasurable activity (getting readyfor school).This switchingof activitiesoftendevelops the conditionsfortantrumsandfightsinthemorning.InsteadofhavingthemwatchTV first, use it as the outcome for finishing all tasks on time (seebelow).

6.Once your childhasperformedall theactivities except eating, then s/he eatsbreakfast.

A good plan is to structure a really tasty breakfast if your childgets all the morning activities done by a designated time in themorning. If theyare tardyandprocrastinate theymayonlyget toast,particularlysinceyouhadtohelpthemgetreadyinsteadofmakinganelaborate breakfast. Obviously, younger childrenwill need helpwithsomeofthetasks.Identifythosetasksandwhereonthescheduletheyoccur. This allows your child to complete other activitiesindependently, and getting your help where needed. Yourimplementationofsteps5&6teachyourchildavaluable life lesson:workfirst--thenplay!

7.Somelengthyactivitiesmightbescheduledforthepreviousnight.

If the morning routine is generally hectic in your household, itmight be necessary to have some of the child’s activities occur theprevious night. Bathing/showering is an activity that often isconductedthenightbeforetoavoidatimecrunch.Similarly,selecting


andplacingtheclothingforthenextday,aswellashavingallmaterialsinthebackpackcanalsobedonethenightbefore.


ParentJournalofTreatmentProgress:MorningRoutine

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:

Date: Entry:


ParentHandoutsforeachTreatmentPackage(canbepostedforeasyviewing)


Eatingtoomuch

1.Controlsnacking.

2.Designateachild-sizeportionforeachmeal.

3.Slowdowntherateofeating.

4.Activityrewardsforweightloss(tobeworkedoutwithprofessional).


Goingtobedontime

1.Setupaconsistentscheduleforbedtime.

2.Apre-bedroutineisnecessary.

3.Bedtimestoriesareconditionaluponbeinginbedontime.

4.Afterthebedtimestory,noothercompetingactivitiesshouldoccurinbed.

5.Abedtimepassisprovidedifthechildgetstobedbythedesignatedtime.

6.A star chart system for adherence is strongly advocated (tobeworkedoutwithprofessional).



1.Gotothechildimmediately,butdonotgetinhisorherbed

2.Standclosetothechild’sbedandassurehimorherthatyouwillbethere.

3.Asyourchildcloseshisorhereyes,quietlymovebackafewsteps.

4.Withnextawakening,stayafewstepsfurtherawayfromthebed.

5.Eachsuccessiveawakeningresultsinyoubeingfurtheraway.

6.Keepajournalforthefirstonetotwoweeks.


Nighttimeaccidents

1.Prerequisitestonighttimetoileting.

2.Whenisyourchildeliminatingatnight?

3.Teachingyourchildtoawakenatnight.

4.Teachingyourchildtoselfawaken.

5.Developastarchartfor“accidentfree”nights.

6.Onceyourchildhasbeensuccessful,youcanremovethecheckpoints.



1.Planbreaksfromeachother.

2.BeVigilant!

3.AdopttheMommy-courtapproachtodisputesregardingitemsortoys..

4.Aggressionshouldalwaysresultintheaggressor(s)notgettingthetoy(andtime-outremoval).

5.SolvingdisputesviaMommy-courtshouldbepraisedandreinforced.

6.Physical aggression should result in amore significant consequence (to beworkedoutwithprofessional).

Cartrips(TheCipanitolerancetrainingmethod)

1.Developchildtoleranceofcartripsgraduallyandprogressively.

2.Graduallyincreaselengthofcartrips.

3.Haveanalternativeactivityavailabletoreduceperiodsofboredom.



1.Previewrulesbeforegoingtoplayground.

2.Theconsequenceforbreakingaruleisanimmediatebriefremoval.

3.Setalimitonbreakingrules.

4.Whenitisover,itisover!

PuttinguptoysafterplayThe“Cipani3toyrule”

1.Haveaplacewheretoysarestored.

2.The“Cipani3-toy”rule!

3.Havedefinedplayperiods.



1.Provideasignalorinstructiontoyourchild.

2.Delineatethelengthoftimeyourconversationwillentail.

3.Pleaseuseanoventimerforthisbehavioralstrategy.

4.Developasignalthatindicateswhenyourchildcanbeallowedtoenterintoconversation.

5.Teach your child that the consequence of interrupting is a delay in gettingyourattention.

6.Tolerancetrainingtodevelopyourchild’sself-controlto“wait”.

7.Trynottochangethestandardtooquickly.


1.Getyourchildupataconsistenttime.

2.Agradualawakeproceduremaybeneeded.

3.Keepthesamescheduleofactivities.

4.Bathroomactivitiesfirst.

5.Donotallowyourchildtoengageinacompetingactivity

6.Onceyourchildhasperformedalltheactivitiesexcepteating,thens/heeatsbreakfast.

7.Somelengthyactivitiesmightbescheduledforthepreviousnight.


clinical treatment c i pan i

Documents