Boyd 8e

804

UNIT VII • Care of Children and Adolescents

Social Skills Training The nurse should communicate behavioral expectations clearly and enforce them consistently. Consequences of appropriate and inappropriate actions should also be clear. Specific approaches for improving social and problem-solving skills are fundamental features for school-aged children and adolescents. As far as children and adolescents with disruptive behavior issues fail to recognize the adverse effects of their verbal and nonver bal behavior, their deficit can be formulated as an inter personal issue. Social skills training teaches adolescents with these behavior disorders to recognize the ways in which their actions affect others. Training involves tech niques such as role-playing, modeling by the therapist, and giving positive reinforcement to improve interper sonal relationships and enhance social outcomes. Problem-Solving Therapy In contrast to social skills training, which proposes that issues of conduct are the result of poor interpersonal skills, problem-solving therapy conceptualizes conduct issues as the result of deficiencies in cognitive processes. These processes include assessment of situations, inter pretation of events, and expectations of others that are congruent with behavior. These children often misinter pret the intentions of others and may perceive hostility with little or no cause. Problem-solving skills training teaches these children to generate alternative solutions to social situations, sharpen thinking concerning the con sequences of those choices, and evaluate responses after interpersonal conflicts. Parent Training and Education Parent training begins with educating parents about disruptive behavior disorders, focusing particularly on impulsiveness, impaired judgment, and self-control. Children and adolescents with long-standing issues in these areas often elicit punitive responses and negative attributions about their behavior from their parents. Ironically, because these parental responses focus on the child’s failure, they may contribute to the child’s behavior issues. An important second step is to clarify parental expectations and interpretation of the child’s behavior. Parent training may be offered to a group of parents or to individuals. The aims of education are to provide parents with new ways of understanding their child’s behavior and to pro mote improved interactions between parent and child. The most commonly presented techniques include the importance of positive reinforcement (praise and tangible rewards) for adaptive behavior, clear limits for unaccept able behavior, and use of mild punishment (e.g., a time out) (Box 37.10).

BOX 37.10

Referral to Family Therapy Family therapy is directed at assisting the family with altering maladaptive patterns of interaction or improving adjustment to stressors, such as changes or loss in family membership (Nuntavisit & Porter, 2022). Multisystem family therapy, which considers the child in the context of multiple family and community systems, has shown promise in the treatment of adolescents with conduct disorder (Lee et al., 2024). Evaluation of Patient Outcomes The nurse can review treatment goals and objectives to assess the child’s progress with respect to verbal and phys ical aggression, socially appropriate resolution of conflicts, adherence with rules and expectations, and better man agement of frustration. As is true for the initial assessment, evaluation of treatment outcomes relies on input from parents, teachers, and other health care team members. Continuum of Care Children and adolescents with conduct disorders may be involved with many different agencies in the community, such as child welfare services, school authorities, and the legal system. Mental health services are requested when a child or adolescent’s behavior is out of control or when a comorbid disorder is suspected. Helping the patient and family negotiate their way through this maze of services may be an essential part of the treatment plan. Follow-up: The child is asked to recount why they were given the time out. The explanation need not be detailed, and no further discussion of the matter is required. Indeed, long discourse about the child’s behav ior is not helpful and should be avoided. Time-Out Procedure Labeling behavior : Identify the behavior that the child is expected to perform or cease. The aim of this statement is to make clear what is required of the child. It typi cally takes the form of a simple declarative sentence: “Threatening is not acceptable.” Warning: In this step, the child is informed that if they do not perform the expected behavior or stop the unac ceptable behavior, they will be given a “time out.” “This is a warning: if you continue threatening to hit people, you’ll have a time out.” Time out: If the child does not heed the warning, they are told to take a time out in simple straightforward terms: “Take a time out.” Duration: The usual duration for a time out is 5 minutes for children 5 years of age or older. Location: The child sits in a designated time-out chair without toys and without talking. The chair should be located away from general activity but within view. A kitchen timer can be used to mark the time, but the clock does not start until the child sits quietly in the designated spot.

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