Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic Interventions within the Family and School Context [1 ed.] 9781614708414, 9781614707189

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Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved. Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

Copyright © 2011. Nova Science Publishers, Incorporated. All rights reserved. Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

CHILDREN'S ISSUES, LAWS AND PROGRAMS

BEHAVIORAL DISORDERS IN CHILDREN

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ECOSYSTEMIC PSYCHODYNAMIC INTERVENTIONS WITHIN THE FAMILY AND SCHOOL CONTEXT

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Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

CHILDREN'S ISSUES, LAWS AND PROGRAMS Additional books in this series can be found on Nova‘s website under the Series tab.

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Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

CHILDREN'S ISSUES, LAWS AND PROGRAMS

BEHAVIORAL DISORDERS IN CHILDREN ECOSYSTEMIC PSYCHODYNAMIC INTERVENTIONS WITHIN THE FAMILY AND SCHOOL CONTEXT

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ELIAS E. KOURKOUTAS

Nova Science Publishers, Inc. New York Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

Copyright © 2012 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers‘ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works.

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Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book.

Library of Congress Cataloging-in-Publication Data Behavioral disorders in children : ecosystemic psychodynamic interventions within the family and school context / editor, Elias E. Kourkoutas. p. cm. Includes bibliographical references and index. ISBN 978-1-61470-841-4 (eBook) 1. Behavior disorders in children--Study and teaching. 2. Child psychotherapy--Study and teaching. I. Kourkoutas, Elias E. RJ506.B44B436 2011 618.92'89142--dc23 2011026239

Published by Nova Science Publishers, Inc. †New York Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

To Nairi and Maite, To Lucy, for her patience and

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To our precious friends Nancy and Ron Rohner

Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

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CONTENTS Preface Chapter 1

Chapter 2

Children with Various Forms of Disabilities/Disorders and School Psychosocial (Mental Health) Services: Introductive Remarks and Reflections

1

Externalizing Problems and Aggressive Behaviors: Reflections on Taxonomic, Developmental and Contextual Issues

11

Chapter 3

Systemic Developmental Thinking and Behavioral Problems

19

Chapter 4

Risk Factors Associated with the Development of Behavioral Problems and Disorders in Infants and in School Age Children

27

Characteristics of Parents of Children with Behavioral Problems and Patterns of Interaction

57

Chapter 6

Risk and Protective Factors Related to School Environment

59

Chapter 7

Teachers‘ Emotional and Educational Reactions Toward Children with Behavioral Problems

65

Chapter 8

Classroom Interventions

71

Chapter 9

Psychosocial Interventions and Curriculum-Based Programs in Schools

79

Chapter 10

Specialized Psychotherapeutic and Psychosocial Interventions

83

Chapter 11

Holistic Psychodynamic Model

89

Chapter 12

Conclusions Regarding Psychosocial and Psychotherapeutic Interventions

99

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ix

Chapter 13

Issues Related to Critical Situations within the Classroom and the School Context

101

Chapter 14

Psychodynamic Systemic Principles and Child Psychotherapy

105

Chapter 15

Counseling Teachers Who Work with Students with Aggressive or Disruptive Behaviors

121

Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

Contents

viii Chapter 16 Chapter 17

Basic Principles of Psychotherapeutic and Psychoeducational Intervention for Children with Behavior Problems

127

Conclusions

139 143

Index

179

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References

Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

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PREFACE This book aims to present an extensive review of the available research evidence regarding children with behavioral problems, together with a synthesis of new theoretical and epistemological models whose purpose is to examine and address critical issues within the school and family context. The key elements that characterize the intrapsychic and interpersonal functioning, as well as the family dynamics of these children, are presented analytically from a developmental and transactional perspective. Additionally, the risk and protective factors related to schools and academic inclusion of children with behavioral problems are analyzed and discussed in the light of current research data. Particular emphasis is also given to presenting the main features of contemporary psycho-educational and psychotherapeutic interventions which address the wide range of disruptive behaviors in order to successfully include these children in mainstream schools. A central argument of this book is that professionals who work with these children should go beyond symptomatic reactions to meet the vulnerable and suffering child behind the disordered behavior. The final purpose of this work is to suggest a holistic model of treating behavioral problems using a meaningful synthesis of various theoretical approaches and techniques. More specifically, an ecological comprehensive child-centered model is proposed that takes into account each child‘s particular traits, vulnerabilities and strengths, as well as the dynamics of his/her family and school environment. Finally, the author argues against both the classical clinical approaches of behavioral problems that decontextualize and pathologize every behavioral deviation, and a strict adherence to manualized approaches that impose on teachers and other professionals an experimentally tested intervention model that often has little ecological validity. The book is enriched by a series of brief clinical cases aimed at outlining the emotional reactions of parents and teachers, as well as presenting the psychological interventions that might be appropriate in each particular case of behavioral difficulties. This is a thought-provoking book that integrates contemporary theoretical considerations with practical clinical and educational guidelines. For this reason, it can be useful for clinical and school psychologists, classroom teachers, special educators, and all mental health professionals who work or are in contact with children with varying degrees and forms of behavioral problems.

Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

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ABOUT THE AUTHOR

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Elias E. Kourkoutas is currently Associate Professor of Psychology and Special Education in The Department of Primary Education at the University of Crete. He received his Ph.D. in Clinical Psychology from the Department of Psychology at University of Liege, Belgium. He is also trained in Psychoanalytic Psychotherapy and Practice at the University of Liege and at the Freudian Institute (―Section Clinique‖) of Brussels-University of Paris-VII. He is a member of many International Scientific and Professional Societies and Associations for Psychology. He taught for several years at the Technological Educational Institute of Larissa (Greece), as well as in many European Universities, as Visiting Professor or invited Professor and through European Community-funded programs. He has published a series of books in Greek and many articles in peer-review journals in English, French, Spanish, and Italian on topics related to children and adolescents who display various forms of disorders/disabilities, as well as methods of treating them within the school context. He coauthored (with F. Erkman) a book in English (Interpersonal Acceptance and Rejection: Social, Emotional, and Educational Contexts. Boca Raton, FL: Brown Walker /Universal Press).

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Chapter 1

CHILDREN WITH VARIOUS FORMS OF DISABILITIES/DISORDERS AND SCHOOL PSYCHOSOCIAL (MENTAL HEALTH) SERVICES: INTRODUCTIVE REMARKS AND REFLECTIONS

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INTRODUCTION Many children growing up in Western countries cannot become healthy, self-sustaining adults without immediate attention and, in many cases, without specialized support (Smith, 2004). Depending on the severity and perseverance of the difficulty, a high percentage of children (3- to -25%) require this attention and support. Reports by Smith (2004) reveal that families and schools ―which have traditionally carried responsibility for raising and teaching children cannot fulfill their obligations adequately without assistance.‖ Over the past 20 years, the percentage of students with disabilities served in schools and classes with their nondisabled peers has gradually increased. As the percentage of students served in settings with nondisabled students rises, the number of special education, regular education teachers, and school psychologists prepared to provide inclusive services must also increase (OSEP, 2001). Teachers should be well-trained in order to be able to acknowledge the unique characteristics of their students. When teachers are adequately trained and sufficiently supported, they can plan and implement successful educational programs that address their students' individual strengths, needs, and vulnerabilities (Salend and Sylvestre, 2005).

THE ROLE OF SCHOOLS IN CHILD DEVELOPMENT WELL-BEING Schools are important social academic contexts in which children, families, educators, and community members have opportunities to interact, exchange views and ideas, learn, teach, and grow. Schools should become places where all children can freely play, learn, perform, and interact in constructive ways. Children should be taught in educational environments that permit them to fully develop their social-emotional and academic competencies. Furthermore, children at risk or diagnosed with social and/or emotional

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problems should have easy access to specialized school-based assistance in order to overcome their internal limitations or eventual external barriers. Children with problems who are provided such supportive educational environments are more likely to internalize positive social-emotional and academic experiences. When they are well-supported by caring and enthusiastic teachers or by specialized professionals, such students encounter less significant risk of developing mental-health problems during adolescence. Even today in many regular school contexts children with various forms and degrees of innate or acquired disorders/disabilities encounter significant risks and obstacles in their attempts to fulfill personal capabilities, as well as to be adequately included. Some of these students—e.g., students with externalizing disorders—may generate/elicit with their disruptive or defiant oppositional behavior strong negative reactions from their teachers and classmates. In such cases, these children encounter additional risk of being permanently excluded from the social academic processes. Exclusion from schools and school drop-out has been highly associated with serious forms of social-emotional and conduct problems, as well as with marginalized or antisocial pathways in adolescence (Karcher, 2004; Osborne, 2004).

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CHILDREN WITH PROBLEM BEHAVIORS IN SCHOOLS Children with disruptive or disorganized patterns of behavior entering school may face additional risks of developing more pathological interaction patterns because they are likely to be excluded from peer groups and rejected by their teachers. Peer and teacher rejection may have detrimental effects on a child‘s emerging sense of self and his developing interpersonal skills. Most of these children come from highly dysfunctional or in-crisis family environments and do not possess adequate skills to enter and maintain satisfying relationships with peers and teachers (Campbell, 2002; Kauffman, 2001; Mash and Wolfe, 2001; Patterson, Reid and Eddy, 2002). It is well-established that children coming from families where a ―coercive style of interaction‖ prevails are at much higher risk of developing these same disruptive behaviors within the school context—therefore reproducing the same coercive interaction patterns with their teachers and peers (McMahon and Forehand, 2003). When teachers react in negative ways or employ punitive techniques to deal with these children they actually reinforce coercive behaviors. In the absence of a system of intervention (e.g., an interdisciplinary team of well-trained specialists) which could identify these processes and design a suitable strategy, children and teachers may be trapped in a cycle of escalating negative or aggressive mutual reactions that further structure and crystallize these children‘s disruptive or coercive patterns (Kauffman, 2001; Kourkoutas, 2011). It has also been demonstrated that ―problematic‖ children progress from relatively mild or moderate (e.g., noncompliance, temper tantrums) to more serious (e.g., aggression, stealing) forms of conduct problem behavior over time. Later conduct problem behavior actually expands the child‘s problematic behavioral repertoire rather than replacing earlier behavioral dysfunctions (Patterson and Yoerger, 2002; McMahon and Forehand, 2003: 10). When entering school, pupils with academic, social, and emotional dysfunctions may be in need of specialized treatment depending on the form, type, severity, and persistence of the trouble-disorder exhibited. School is considered an ideal site to base specialized psychosocial intervention for

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Children with Various Forms of Disabilities/Disorders and School Psychosocial …

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children at risk for or with already entrenched mental-health problems (Erchul and Martens, 2010).

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SCHOOL BASED MENTAL HEALTH AND CONSULTANTS SERVICES As reported in several studies (see Roeser and Eccles, 2000), schools today face many challenges in a wide range of areas regarding their students‘ functioning. There is increased concern over ―school violence and discipline problems, unprecedented diversity reflected within student populations, heightened accountability for student and teacher performance, personnel shortages, and a substantial reduction in available funding‖ (Erchul and Martens, 2010, p. 11). These and other emerging issues strongly suggest that there will be a need for school-based consultants and relative school services for years to come in order to develop appropriate psychoeducational support and specialized assistance for both teachers and students in need (Christner et al., 2009; Erchul and Sheridan, 2008; Larson, 2008; Erchul and Martens, 2002; Power, 2002). Based on such considerations and research data, it has been suggested that the school should broaden its education mission in order to provide more specialized help for students with social, emotional, and academic problems (Christner et al., 2009; Dinkmeyer and Carlson, 2006; Erchul and Martens, 2002; 2010; Kourkoutas and Raul, 2010; Paternite, 2005). Dryfoos has proposed the establishment of a ―full-service school‖ (see Dryfoos, 1994; 1997). The full-service school could be a kind of multisystem institution integrating education, medical, social, and/or human services that are beneficial to meet the needs of children and youth and their families (Dryfoos, 1994: 142). A full-service school would provide high quality and comprehensive prevention, treatment, and support services that children and families at risk require in order to succeed. In addition, to be effective, services provided by schools should be built upon an interagency partnership and an inclusive philosophy. The inclusive and partnership model places particular emphasis on working in a cooperative way with at-risk families and their children, reinforcing and teaching parenting skills (Turnbull et al., 2000; 2006). Other authors have suggested different forms of organizing the relative services. For example, implementing various types of psychosocial programs that may include individual counseling sessions or combined psychoeducational approaches with clinical and familybased components (Sheridan and Kratochwill, 2007). These programs may have both a preventive and an interventive character, targeting students at risk and students with manifested psychosocial dysfunctions in need of a specified or more sophisticated treatment. A number of school-based mental health programs in the United States and in many other countries are supported by state authorities and are officially implemented within schools. Regardless of their theoretical and practical orientation, some of them are well evidenced as promoting children‘s psychosocial well-being and school inclusion, whereas some others are not. Some primarily employ specific psychoeducational techniques while others encompass a variety of interventions including teachers‘ and parents‘ support, coaching, or training (see Christner et al., 2009, for an extensive review). Some are part of the curriculum, whereas others represent targeted intervention by external teams in crisis situations or on specific student populations. Some of these programs are implemented by interdisciplinary teams;

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others are more education-centered and practiced with the contribution of special educators or classroom teachers. Most of these programs are child-centered; others may comprise interventions with parents as well. Some also provide an array of evidence-based psychosocial and biomedical treatments, as for example the Intensive Mental Health Programs (IMHP) (see Vernberg, Roberts, and Nyre, 2002; 2008). Such programs may include individual therapy, group therapy, evaluations of medication trials, social skills training, anger management, relaxation, and instruction for resolving problems or conflicts skills. Services for medically fragile children are also coordinated and implemented as needed in specific cases in the context of these programs (Jacobs et al., 2005, p. 61). The IMHP staff may also provide consistent consultation on the children‘s behavior across settings, therapeutic needs, and academic progress with parents, guardians, and other service providers in an effort to synthesize therapeutic modalities (Jacobs et al., 2005, p. 61). Such programs organize service coordination with all other service providers to prevent piecemeal services between agencies (Jacobs et al., 2005, p. 61). On the whole, it is suggested that school-based mental health services to be effective should encompass a variety of techniques, strategies, and multimodal methods of intervention. Services should also include strategies for parents and teachers, as well as promote interagency and professional partnership collaboration (Dinkmeyer and Carlson, 2006; Turnbull et al., 2000; 2006). A growing body of evidence suggests that for a school-based intervention to be effective, parents and teachers should be actively involved in the case conceptualization of the problem, as well as in implementation of the treatment (Dinkmeyer and Carlson, 2006; Dishion and Patterson, 2006; Greenberg et al., 2003; Kauffman, 2001; Kourkoutas and Raul, 2010; Nastasi et al., 2004; Reddy et al., 2009; Rhodes, 2007; Weare, 2005). School mental health investigation has flourished during recent decades, contributing to advancement of theoretical and practical considerations on how to organize better support services for students at risk for psychopathology (Dettmer, Thurston and Dyck, 2005; Hatzichristou et al., 2010; Paternite, 2005; Roeser and Eccles, 2000). Contemporary research has revealed a series of basic assumptions that should guide practitioners in the design of school-based psychosocial interventions in order to be effective. More specifically, preventive or intervention programs which attempt to foster the socialemotional competencies of vulnerable children and the emotional and behavioral problems of children at-risk should consider the following principles (Brehm and Doll, 2009; Browne et al., 2004; Dettmer et al., 2005; Dinkmeyer and Carlson, 2006; Greenberg et al., 2003, p. 470; Hatzichristou et al., 2010; Merrell, 2002; Nastasi, 2004; Ross, Powell and Elias, 2002; Weare and Gray, 2003): 

 

Schools should be open to and move toward considerable modifications of their organizational and inclusive philosophy, teaching theory. and educational methods in order to achieve the full-inclusion of children with exceptional problems; Support and reward positive social, health, and academic behavior through systematic school-family-community approaches; Foster a resilient and empowering perspective in school-based consultant and educational practice in order to enable students, parents, and teachers to develop their inherent potentialities and new competences;

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Children with Various Forms of Disabilities/Disorders and School Psychosocial …  

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Multi-year, multi-component interventions are more effective than single component short-term programs. Competence and health-promotion efforts are best begun before signs of risky behaviors emerge and should continue through adolescence. Programming that has multiple elements involving family, school, and community are more likely to be successful than efforts aimed at a single domain.

For several years Elias and colleagues have emphasized how important it is to the healthy development of children to implement processes within schools that integrate the academic with social-emotional learning (Barbarasch and Elias, 2009; Elias et al., 1997; 2003; Hatzichristou et al., 2010; Merrell, 2002). Traditional approaches to learning are founded on splitting curriculum learning and knowledge from life learning and knowledge (Schmidt Neven, 2010). In contrast, inclusive education has strongly recommended that educational communities develop partnership practices and a relative ethos that promotes the inclusive culture within schools for all troubled or exceptional children (Dinkmeyer and Carlson, 2006; Koller and Svoboda, 2002; Paternite, 2005). Schools should link the traditional curricula with innovative educational approaches which emphasize the communities of learning and alternative ways of developing academic and psychosocial skills (Barbarasch and Elias, 2009; Lunt and Norwich, 2009; Merrell, 2002). Association with families, communities, and practitioners to establish and promote inclusive practices is an essential part of the contemporary inclusive education and inclusive psychology philosophy (Befring, 1999; Dyson and Howes, 2009; Kourkoutas, 2011; Rhodes, 2007; Urquhart, 2009). Research data show how crucial is the partnership between parents and schools with the mediation of school-based interdisciplinary teams to face the challenges of prevention and inclusion of all children, including those with manifested social, emotional, and academic problems (Ysseldyke and Algozzine, 2006). Resilient classroom and skillful well-supported teachers may really foster therapeutic relationships even with the most troubled students. A positive relationship with a supportive teacher in combination with an early specialized intervention, before the children‘s pathological defense and coping mechanisms become reinforced and crystallized, reduces the risk for the child to enter into an endless cycle of mutual rejection within the school environment (Fell, 2002; Kourkoutas, 2007; Heller, 2000; Urquhart, 2009; Salend, 2005; Weare, 2000). Therefore, it is urgent for schools to radicalize their inclusive policy and curricula by linking emotional development and teaching skills with traditional learning and teaching processes. Furthermore, schools should be responsible to create a caring environment to foster students‘ inner potentials and competencies, as well as to contain their emotional and behavioral disruptions (Hanko, 2000; Kourkoutas and Raul Xavier, 2010; Urquhart, 2009; Ysseldyke and Algozzine, 2006). For this project to be realized, it is necessary to have teachers who are well-trained and who are committed to the inclusive culture, and willing to collaborate with school psychologists and other professionals. Taking on this perspective does not signify that the educational system and the schools should be transformed in clinical settings; it is rather the opposite. When educational staff is wellsupported to face everyday challenges of pupils with social, emotional, behavioral, and academic problems, teachers are less likely to display negative or burn-out reactions. They become more capable of ensuring a positive and strengthening educational environment that

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is helpful and satisfying for students. If schools are not supported or are incompletely equipped and organized to face new challenges, teachers are more likely to develop burn-out symptoms and be less productive and less caring and supportive toward their pupils. Evidence shows that students with psychosocial problems are better served by school-based interventions than by traditional psychiatric settings (Merrell, 2002). The traditional psychiatric setting usually provides services that are limited to individual treatment without fostering partnership with teachers and schools. As a result, psychiatric settings fail to provide any kind of professional support for teachers and schools; therefore the chances of a holistic comprehensive intervention are reduced. Though many therapeutic interventions out of school are useful for a child with problems, data show that individual treatment based on the medical approach has limited success with school age children (Merrell, 2002). It seems that teachers who are adequately trained and supported long-term by interdisciplinary teams become more competent to realize the inclusive project. When teachers are adequately trained and coached they are able to manage their students‘ behavioral problems within classroom and thus avoid referring them to external psychiatric settings (Kourkoutas, 2008a; Miller, 2003; Nastasi et al., 2004; Rooney, 2002; Ysseldyke and Algozzine, 2006). In brief, schools should preserve and enrich their educational role by promoting child- and family-centered inclusive practices together with professionals in order to reduce the number of referred students and the secondary effects (pathologizing, medicalization of symptoms, labeling) of this process (Ysseldyke and Algozzine, 2006; Weare, 2000). Our working clinical educational model within schools is based upon the previously described theoretical considerations. More specifically, on the basis of research and clinical data from long-standing work with ―multi-problem‖ pupils, parents, and teachers, we strongly support the hypothesis of a multimodal ecosystemic model as the most appropriate. A multimodal model which blends educational inclusive practices with specific clinical (group, family, individual) interventions aiming at buffering external and internal risks and promoting children‘s, as well as teachers‘ and parents‘ competencies (Kourkoutas, 2008a; 2008b; Kourkoutas and Georgiadi, 2011). Overall, to enhance the attainment and the social integration of all vulnerable or emotionally and behaviorally disturbed children, the following strategies identified by research (see Ainscow et al., 2004; Kourkoutas, 2008a; Lunt and Norwich, 2009, p. 99; Mcevoy and Welker, 2000; Power, 2003; Rooney, 2002; Weare, 2000; Ysseldyke and Algozzine, 2006), should be present in the school functioning and in the design of interventions:       

careful individual monitoring; flexible grouping; customizing provision to individual circumstances and strategies to for raising achievement; strategies that promote partnership among all involved practitioners; focus on academic, as well as on social, emotional processes of students at risk; teachers and professionals committed to help and support pupils with difficulties (e.g. wanting to ―do the best‖ for all children) (Lunt and Norwich, 2009, p. 99); promote learning achievement and performance together with emotional well-being;

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promote an inclusive ethos within school unit.

Regardless of levels of inclusivity, sensitized schools that foster strategies to become more inclusive may become more effective, though this calls into question ―traditional measures of effectiveness, and in particular those associated with government‘s drive to raise standards‖ (Lunt and Norwich, 2009, p. 99). In her turn, Schmidt Neven (2010) raises the question of the extreme instrumental adherence to evidence-based philosophy and practice which may foster a reductionist approach in the effort to implement specialized inclusive psychosocial programs for children with various problems. She also raises the question of the exclusive focus on manualized treatment that reduces the role of practitioners and teachers as well as of each child‘s specific symptomatic reactions. This reductionist approach risks promotion of strategies that are ―de-contextualized‖ and less meaningful for teachers and parents. The traditional ―expert‘s model‖ is less collaborative in spirit and reduces the possibilities of teachers and practitioners to develop their own skills, as well as to take initiatives based on the specificity of the case (Kourkoutas, 2007; McNab, 2009; Turnbull et al., 2000; Ysseldyke and Algozzine, 2006). Teachers have an important role to play in the assessment, design, and implementation of mental health intervention strategies targeting various groups of students with problems (Bloomquist and Schnell, 2002; Marshall and Watt, 1999; Weare, 2000). Noteworthy is evidence showing that the relationship of the teacher with a ―problematic‖ student is a key promoting factor in mental health issues (Bloomquist and Schnell, 2002; Jennings and Greenberg, 2009; Murray, 2001; Pianta, 1999). For instance, Reddy and his colleagues found that for both boys and girls with depressive symptoms, changes in perceptions of teachers‘ support reliably predicted changes in both self-esteem and depression (Reddy, Rhodes and Mulhall, 2003). Furthermore, Blankemeyer and his colleagues found, in their study on children‘s perceived relationships with their teachers, poor school adjustment to be associated with more negatively perceived child teacher relationships notably for boys than for girls. Moreover, the perceived child– teacher relationship among aggressive children was more favorable among those with high levels of school adjustment than among those who were poorly adjusted at school (Blankemeyer, Flannery and Vazsonyi, 2002). Additional data show that a positive relationship with teachers may significantly contribute to reducing children‘s psychosocial difficulties and promote their school adjustment (Jennings and Greenberg, 2009; Murray, 2001; Reddy et al., 2003; Pianta, 1999). Moreover, teachers together with school psychologists can essentially contribute to include and successfully educate students with behavioral problems—which seems to be the most challenging population in schools today (Coleman, Weber and Algozzine, 1999; Fell, 2002; Jennings and Greenberg, 2009; Kauffman, 2001; Kampwirth, 1999; Miller, 2003; Murray, 2001; Salend, 2000; 2004). Overall, research emphasizes the need to develop school-based psychosocial programs for the promotion of child and adolescent wellbeing which involve parents, peers, and educational staff (Adelman and Taylor, 2009; Billington, 2006; Carr, 1999; Elias et al., 2003; Fell, 2002; Jennings and Greenberg, 2009; Kampwirth, 1999; Miller, 2003; Power, 2003; Rooney, 2002; Ross et al., 2002; Schmidt Neven, 2008; 2010; Weare, 2000). ―Supportive supervision‖ is a term that we have introduced (Kourkoutas, 2007; 2008a; 2011) to describe the work done with teachers in the context of clinical counseling projects within Greek primary schools. These counseling intervention projects include a wide range of

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clinical and psycho-educational actions which target a range of cases of ―disturbed‖ or ―problematic‖ pupils. An essential component of these counseling projects is the ―working alliance‖ (cooperation) with teachers which encompasses both the emotional (support) and the coaching aspect aiming at helping them manage the intense emotions they experience when teaching challenging pupils (Fell, 2002; Kourkoutas and Raul Xavier, 2010). Teachers may become more skillful and aware of the type of intervention their students need when they are supported and trained through such child-specific intervention (Fell, 2002; Hanko, 2001; 2002; Heller, 2000; Jennings and Greenberg, 2009; Kourkoutas and Raul Xavier, 2010). Teachers need to attain better insight into students‘ problems in order to overcome their own personal prejudices, as well as their negative emotions regarding ―difficult students‖ (Fell, 2002; Hanko, 2002a; Kourkoutas, 2007a). By offering a supportive collaborative consultation, specialists may enable teachers to act in more productive ways and avoid being trapped in destructive interactions with ―difficult students‖ (Solomon and Nashat, 2010). A collaborative consultation approach can also enable teachers to develop further awareness of the inner psychological process of children with conduct problems and the way family dynamics shape their behaviors (Hanko, 2002; Heller, 2000; Kourkoutas, 2007). Notably, in the case of children who come from ―coercive families,‖ it is very common to see these patterns being reproduced with teachers, as these children are prone to elicit intense negative emotions with their antisocial and disruptive behavior. Therefore, it is crucial for professionals to help teachers avoid reproducing the same coercive patterns that these pupils have experienced in their homes. Actually, in such cases, careful and meaningful coaching may be very helpful for teachers to break the vicious cycle of mutual rejection and aggressive behaviors (Fell, 2002; Hanko, 2001; 2002; Heller, 2000; Kourkoutas, 2007). Regarding the design of strategies to implement within schools, many questions are raised by contemporary research concerning the way policy makers or even researchers and clinicians decide upon the type of intervention for children with problem behaviors. Wherever the medical approach is still dominant, interventions usually do not sufficiently consider ecological variables and complex interactional processes that take place within the school system and affect the development of the disorder. Unavoidably, this theoretical stance leads to a limited understanding or misdiagnosis of children‘s underlying dynamics and to overmedicalization of their troubles (Carey, 2007; Glicken, 2009; Heller, 2000; Schmidt Neven, 2010). As Wampold (2009) states, ―delivering psychotherapy to children and adolescents is a complex undertaking because of the institutional, political, and social context in which these services are provided.‖ Many researchers and clinicians have also begun to question the narrow interpretation of evidence-based philosophy. They are inclined to promote interventions that are comprehensive in nature (i.e., addresses multiple risks and protective factors) and intensive in scope (e.g., includes a variety of settings and school personnel, families, and mentors) (Young et al., 2004, p. 176). Schools are dynamic, multidimensional, and multi-level settings for development (Pianta, 2006). Consequently they require integrative, interdisciplinary models of school-based research that promote multilevel co-actions and interventions (Pianta, 2006; Young et al., 2004). School mental health services refer to the broad array of services designed to prevent and treat behavioral and emotional difficulties that may or may not be symptoms of specific mental disorders (Christner et al., 2009, p. 5). In some cases, interventions may be universal and apply to entire schools or school districts, whereas other cases may require targeted or

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Children with Various Forms of Disabilities/Disorders and School Psychosocial …

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intensive interventions geared toward specific students who are at risk for psychological problems (Christner et al., 2009). Working in a partnership perspective with mental health professionals who assume an inclusive perspective (see Kourkoutas and Xavier Raul, 2010), schools units should manage to build up an inclusive culture and foster an ―emotionally holding” environment for more vulnerable students or students with special educational needs (Heller, 2000; Urquhart, 2009). Many children who display conduct difficulties can profit from an educational environment that also provides comprehensive services for more serious problems. Without this academic emotional support, vulnerable children‘s capacity (including students with conduct problems who live in traumatizing family environments) for positive relationships, emotional growth, and learning is jeopardized by the impact of their anxieties and emotionally defensive behaviors (Urquhart, 2009). Current debates on education primarily focus on children‘s academic performance, often to the exclusion of any broader consideration of the child within a psychological and social context (Schmidt Neven, 2010). Such approaches to learning and an extreme adherence to a performance-evaluation philosophy may be associated with a preoccupation to identify eventual pathology in children in the health and welfare sector (Billington, 2006; Schmidt Neven, 2010). In addition, the educational staff‘s discourse on students‘ deviant and problematic behavior has been highly affected during the last decades by the dominant psychiatric approach which tends to ―over-pathologize‖ children‘s conduct problems (Salend, 2004; Schmidt Neven, 2010). Because of the heterogeneity of academic, social-emotional, and cognitive competencies of students in contemporary schools and the presence of many ―problematic‖ cases of children, educational institutions, as well as professionals, parents, and communities should be prepared to face these challenges by establishing suitable systems of care within schools. These systems could serve the most vulnerable and at-risk students. These structures may, for instance, take the form of interdisciplinary teams encompassing a broader spectrum of interventions focusing on counseling and coaching teachers, training and counseling parents, academically and emotionally supporting ―difficult‖ or ―suffering‖ students, teaching them social skills and problem-solving strategies. Such teams, composed of professionals trained in clinical systemic educational thinking, may foster specific clinical educational inclusive practices for the most vulnerable or challenging students. Working in an ecosystemic risk-resilient perspective—buffering contextual and personal risk factors, promoting and strengthening protective factors and personal skills—these professionals in partnership with teaching staff may significantly contribute to create collaborative communities and inclusive environments within schools. In order to achieve this kind of project and attain these goals, schools, school psychologists, and teachers should go beyond their traditional roles and foster an inclusive culture and ethos. This inevitably signifies a paradigm shift in the clinical school psychology and educational system field (Atkins et al., 2003; Weist, 2003; Weist and Evans, 2005).

CONCLUSIONS To sum up, early identification and intervention are important influences upon the outcome for children with behavioral and conduct problems (Hughes, Crothers and Jimerson, 2008). Recognizing early signs of conduct and behavioral problems and identifying risk

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factors is an important step in preventing a child‘s progression to serious conduct and antisocial disorders (Holmes, Slaughter, and Kashani, 2001; Hughes, Crothers and Jimerson, 2008). If early problem behaviors are not addressed, antisocial behaviors are likely to persist when the child becomes an adolescent or an adult (Carr, 1999; Hughes et al., 2008). Children with problem behaviors are usually placed in general-education settings. Given that support services may be offered in both the general- or special-educational settings regardless of eligibility status, it is typical that educational professionals in both contexts will be responsible for facilitating these children‘s education (Hughes et al., 2008). Educational professionals across the elementary, middle, and high school years must be knowledgeable and prepared to identify symptoms and to provide support services (Hughes et al., 2008). Hence, all educational professionals (in both special and general education) need to have upto-date information on behavioral and conduct problems and with the support of the school psychologist to develop adequate skills and techniques in order to successfully manage them (Blooqmuist and Schnell, 2002; Hughes et al., 2008). Overall, a significant step in preventing the progression from juvenile delinquency to adult antisocial behavior is understanding and recognizing risk factors and contributing influences in early and middle childhood (Hughes et al., 2008; Kracher, 2004).

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Chapter 2

EXTERNALIZING PROBLEMS AND AGGRESSIVE BEHAVIORS: REFLECTIONS ON TAXONOMIC, DEVELOPMENTAL AND CONTEXTUAL ISSUES

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THE ORGANIZATIONAL AND ECOLOGICAL APPROACH IN PROBLEMATIC, AGGRESSIVE AND ANTISOCIAL BEHAVIOR AREA In the introductory part of this section, we found it essential to cite the basic tenets of the organizational and ecological approaches in order to clarify two of our key theoretical assumptions of children‘s disordered development and of children‘s aggressive or antisocial trajectory. In later sections, we will refer in a more detailed and analytic way to all theoretical frameworks (cf. Psychodynamic, PARTheory, Trauma related theory, etc.) that have shaped our clinical-educational working model. More specifically, for the organizational approach the following are key assumptions (cf. Cavell, 2000; Mash and Dozois, 1996, p. 36): (a) The individual child plays an active role in his or her own developmental organization; (b) Selfregulation occurs at multiple levels, and the quality of integration within and among the child‘s biological, cognitive, emotional, and social systems needs to be considered; (c) There is a dialectical relation between the canalization (or crystallization) of developmental processes and the changes experienced throughout the life process; ; (d) Developmental outcomes are best predicted through consideration of prior experience and recent adaptations examined in concert; (e) Individual choice and self-organization play important roles in determining the course of development; (f) Transitional turning points or sensitive periods in developmental processes are most susceptible to positive and/or negative self-organizational efforts. Ecological theory and a multisystems perspective on child development suggest that aggressive behavior develops in the context of macrosocial and microsocial processes (Fraser and Williams, 2004, p. 105). The developmental and ecosystemic psychopathology model can be a useful heuristic for understanding a number of complex developmental issues that are important to the assessment and treatment of childhood aggression. Based on the interplay among genetic predisposition, physiological influences, internal processes, and conflicting forces in the proximal family and the distal social environments, behavior is thought to be transactional and subject to the dynamics of continuous interpersonal and social exchanges (Fraser and

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Williams, 2004, p. 105). More specifically, a developmental and ecological perspective posits that children grow and adapt through transactions with parents, siblings, peers, teachers, coaches, neighborhoods, and a variety of other persons (Fraser and Williams, 2004).

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THE DIMENSION OF EXTERNALIZING PROBLEMS There is clear evidence that a significant number of children and adolescents have severe and impairing emotional or behavioral problems (Frick and Silverthorn, 2001; Frick and Kimonis, 2008: 349). Research has evidenced that these children‘s problems can be conceptualized along two broad dimensions. One dimension has been labeled as externalizing and includes various acting out, mild or more serious disruptive, delinquent, hyperactive, and aggressive behaviors (Frick and Kimonis, 2008: 349). It has been found that within the externalizing dimension, there are two major categories of behavior: (a) problems of attention, impulsivity, and hyperactivity associated with the diagnostic category of attention deficit hyperactivity disorder (ADHD) and (b) conduct problems and aggressive behavior associated with the diagnostic categories of oppositional defiant disorder (ODD) and conduct disorders (CD). As reported by Frick and Kimonis (2008), these two problem domains can be separated in factor analyses since they have a number of different correlates. For example, ADHD seems to be more specifically associated with parental problems of attention and impulsivity, poor academic achievement, and problems in executive functioning, whereas conduct problems appear to be more specifically associated with parental criminality/antisocial behavior, socioeconomic disadvantage, and dysfunctional family backgrounds. Frick and Kimonis also report that these two types of externalizing patterns, though considered as separate, they overlap considerably, stressing how important is to recognize it in order to provide effective intervention to children who display such behavior problems (Frick and Kimonis, 2008, p. 350). It is crucial for the design of effective intervention to proceed to a meaningful and exhaustive assessment of the conduct problems. Clinicians and school psychologists should take into consideration the following points raised by contemporary research: a) heterogeneity in the types and severity of conduct problems; b) conduct problems and comorbid problems in adjustment; (3) the multiple risks associated with conduct problems; and, d) the multiple developmental pathways of conduct problems (Mcmahon and Frick, 2007, p. 132).

THE DYNAMICS OF AGGRESSIVE BEHAVIORS AND THE CHILD’S DEVELOPMENT Aggressive behavior appears to be relatively stable over time when it develops at an early age (Fraser and Williams, 2004; Moffit, Caspi, Rutter, and Silva, 2001). This behavior has a strong relationship to negative developmental outcomes, including school dropout, antisocial and delinquent behavior, and drug abuse, among others, and—in young adulthood—criminal offending (Fraser and Williams, 2004, p. 101; Patterson and Yoerger, 2002).

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Regarding the various forms of aggressive behaviors, the dynamics of child development unavoidably involve the existence of behaviors that have an "aggressive" character. Infants and young children often behave "aggressively" as they‘re not able to use the proper psychosocial skills in order to communicate and impose their desires and needs. Yet this aggression is considered "benign" and is a result of partially developed self-control mechanisms and the immature emotional-cognitive strategies of this age (Tremblay, 2003). However, as the child grows and increases interactions at various levels with the environment and under the impact of caregivers‘ teaching and reframing, his affective-cognitive schemas are increasingly organized and structured. From early infancy the child is able to internalize to a certain degree the environment‘s external expectancies, rules, and recommendations through the strong affective bonds that are established with caregivers. However, the complexity of experiences and interactions with the environment makes it almost impossible to avoid manifestations of aggressive acts, which may be intentional or not, during childhood (Campbell, 2002; Dodge and Pettit, 2003). Under usual circumstances, a high proportion of both parental and school education is dedicated to controlling and modifying unacceptable or disruptive behaviors, integrating them into a socially defined system of communication and exchange. In all cultural settings, preschool and school education makes every effort to give meaning, to socialize the child‘s behavior, and to help him to develop patterns of acceptable interaction and communication. The conversion of aggression and asocial behaviors into acceptable forms of communication and relationships with others is a key factor of successful socialization in childhood. As a result of the maturation of cognitive-affective mechanisms through continuous experiences with the outer world, children develop more self-control attitudes and appropriate emotional reactions. Parameters such as the ―place‖ and the ―role‖ of the child in the family, the type and quality of educational and rearing practices, quality of relationships with caregivers, and the way adults handle the "unacceptable" child‘s behavior are highly correlated with the quality of emotional, cognitive, and behavioral schemas and strategies (Sroufe et al., 2000). It seems that mechanisms such as imitation, assimilation, internalization, and modeling play an important role in the management of aggression and the development of acceptable forms of behavior (see Sroufe et al., 2005). Accordingly, aggression can be considered an essential part of a child‘s development and behavioral repertoire. It is related to a wide range of a child‘s reactions and can be differentiated on the basis of a number of specific characteristics (type, target, intensity, duration, extent, accompanying emotions, etc.) (Boxer and Frick, 2008; Gendreau and Archer, 2005; Tremblay, 2003). It is also linked to a series of other internal features of the child‘s functioning, such as neurological mechanisms and cognition, which are interconnected and interacting. A contemporary theory of aggression considers aggressive behavior as an inseparable part of adjustment mechanisms in a variety of contexts; extreme aggressive or dysfunctional maladaptive behaviors should be transmuted to more socialized forms (Boxer and Frick, 2008; Dodge and Pettit, 2003). The socialization process implies the development of a series of internal and external mechanisms and skills in order to face multiple intrapersonal and interpersonal challenges and to achieve successful adjustment during the life span (Rutter, 2001; Tremblay, 2003). Prevailing forms of dysfunctional or harmful-to-others aggressive and troubling behavior may indicate failure of the socialization process. Or it may indicate a person who has not developed adequate skills and coping mechanisms to deal with these

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internal or external challenges (Sroufe et al., 2005) for a series of reasons. Seen n this perspective, social adjustment is viewed as a dynamic process implying an endless and multidimensional interaction between a series of internal resources and features, and external factors that respectively shape children‘s own capacities and skills. The risk, resilience, the protective or promoting factors, and the transactional models have proved to be a very useful theoretical framework to shed light on these complex psychosocial phenomena (Fraser, 2004; Sameroff, 2000). This conception inevitably emphasizes a broader approach of the child‘s development; an approach that focuses on the psychosocial environment as a significant contributor to psychopathological organization; a conception which is in agreement with a series of up-todate research findings (Boxer and Frick, 2008; Dodge and Pettit, 2003; Sroufe et al., 2005). Thus aggressive or troubled behavior is not yet seen as the straight expression of genetic or neurological disorders; it is more seen as a result of complex multilevel interactions between the developing self-patterns of adjustment and an external context that is unable to provide the child the necessary framework for development of adequate skills (systemic view) (Sroufe et al., 2005). Moreover, aggressive or disordered behavior is regarded as part of a wide range of psychological disturbances that result from continuous and accumulated problematic interactions between external parameters and insufficient internal mechanisms or deficit skills (Carr, 1999; Gendreau and Archer, 2005; Williams et al., 2004). This concept goes far beyond the classical medical one-dimensional approach, providing a holistic ecosystemic view of the child‘s disordered and disruptive behavior by emphasizing the role of environment and the contextual (risk and protective) factors in childhood ―pathology‖ (Carey, 2002; Carr, 1999; Dishion, 2000; Fraser and Allen-Meares, 2004; Fraser, Kirby and Smokowski, 2004; Sameroff, 2000; Timimi, 200; Weare, 2000). From this viewpoint, behavioral problems should be seen and considered as part of the child‘s developmental trajectory. Behavioral problems are therefore considered to be the expression of the dynamic interactions between the developing child‘s psychosocial skills and weaknesses and the specific environmental features and reactions (Boxer and Frick, 2008; Carr, 1999; Compton, et al., 2003; Dodge, 2000; Dodge and Pettit, 2003; Fraser et al., 2004; Kauffman, 2001; Sameroff and Fiese, 2000; Williams et al, 2004; Wyman, 2003). This concept has significant implication for the way assessment and diagnosis should be carrying out. In contrast, the traditional psychiatric approach, based on a different paradigm model, has introduced a total distinction between pathological and normal behavior; accordingly, disordered behavior is primarily perceived as rooted in endogenous dysfunctions. As has been reported in previous works (Gibbs, 1982), the most significant lack in traditional psychiatric models is the absence of interactional labels. Children were and to a certain degree still are described as though they own the disorder. Since the problematic behavior is entirely seen as a manifestation of a personal pathology, this approach excludes the eco-transactional character of childhood disorders, promoting a rather simplistic model of practice and placing the focus exclusively on biochemical treatment (Kourkoutas, 2011). The medical based deficit approach still prevails in clinical and educational psychology. Though during the last few decades the social dimension of disorders has been widely recognized by psychiatric science, the emphasis in practice is still placed on individual clinical work. On the other hand, strong evidence is now available advocating for a more ecosystemic, developmentally based, and dynamic approach to childhood disorders, including family and

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school parameters. In this line of research, a recently-emerged social model of pathology/disability denotes a paradigm shift in clinical psychology and special education. This approach is based on the eco-transactional and risk-resilient research models and emphasizes the person-oriented and individualized intervention programs that also have family and school components (child-, family-, and school-centered programs)1. The most important contribution of this model is to challenge traditional categorical taxonomic systems which do not take into account the social-emotional needs of the child, as well as his developmental trajectory, his family and interpersonal history; parameters that usually have a significant contribution to the development of the disorder (Compton, et al., 2003; Patterson and Yoerger, 2002; PDM, 2006; Rutter, 2000; 2001; Wyman, 2003). The child, as a part of a psychosocial system of multifaceted relationships and longitudinal interactions (family, school, neighborhood, various social contexts and subsystems, etc.), is continuously evolving and changing, and pathology is one of the possible developmental outcomes (Dodge, 2000; Sameroff, 2000; Sroufe et al., 2000; 2005) (first psycho-systemic premise). Problem behavior can't be considered as an exclusively independent individual or personal disturbance without referring to the dynamics of the child‘s psychosocial functioning, to the role of the relational and social setting, as well as under which specific conditions this behavior occurs (Kourkoutas, 2006; Lynch and Cicchetti, 1998). Therefore, behavioral dynamics and reactions can only be fully understood within the particular framework they have emerged. Moreover, problematic behavior often has a symbolic and communicative character in the sense of a conscious or unconscious transmission/expression of something that comes from the psychic dynamics and the relational world of the child (negative or conflicting emotions and thoughts, distressing feelings, repressed needs, traumatic experiences, deficient basic relationships, etc.). Following the same logic, a child‘s problem behavior may be an indicator or may reveal something of his problematic emotional functioning and relationship system that is unable to be expressed or communicated in other ways (Campbell, 2002; Sroufe et al., 2000; Wachtel, 1994). Thus, problem behavior cannot be considered to be merely a reflection of inner psychophysiological processes. It should rather be examined in relation to the particular role that it plays in the child‘s psychic ―economy‖ and functioning within the family relationships and rearing practices system. Hyperactivity, for example, began to be regarded by many researchers not only as an expression of neuropsychological dysfunction (i.e., dysfunction of the executive function), but also as an expression of the child‘s uncontained anguish and the inability to master the psychological stress related to interpersonal exchanges (Brandy, 2005; Schmidt Neven, Anderson and Godber, 2002; Timini, 2004). Research data show that disruptive behaviors during the preschool years endorse different forms and present other characteristics than those of adolescence (Loeber and Hay 1997). Their evolution and transmutation is not only the result of internal forces or features, but also an outcome of the impact of external parameters, including parental and teacher reactions toward children‘s behavioral disruptions or difficulties, interactions with peers, provision or not of a professional and specialized treatment, and quality and type of intervention provided (Fine, 1992; Kauffman, 2001; Kourkoutas 2004a). 1

For an extensive review of the issues related to novel approaches of taxonomy and research design in developmental psychopathology/childhood disorder (risk-resilience model, person-oriented research models, ecosystemic approach, dynamic systems model, etc.) see Achenbach & Rescorla (2006).

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As previously suggested, the medical approach and the resulting psychiatric practice are considered to promote a linear one-dimensional interpretation of the phenomenon of pathological or disruptive behavior in childhood. This approach renounces the dynamic and symbolic character of the problematic behavior. Problematic behavior as a symptomatic reaction usually has a meaning and a function for the child‘s psychological organization that specialists should decode and understand; an unconscious or conscious meaning that refers both to internal psychological and contextual processes that are indistinctly correlated (such as unmet fundamental needs or negative conflicting emotions, tensions resulting from traumatic experiences, ambivalent feelings towards parents, adverse rearing practices, parental problems, etc.) (see Brady, 2005; Carey, 2002; Timimi, 2002; Timimi and Radcliffe, 2005). The problematic behavior is not yet seen as a simple reflection of biopsychological deficits—but rather a dynamic process that can inform us about a child‘s life and functioning. Therefore, novel approaches to the phenomenon of aggression and problem behavior in childhood and the resulting alternative practices are characterized by the importance given to the following (see Compton, et al., 2003; Fraser, 2004; Fraser and Williams, 2004; Lynch and Cicchetti, 1998; Pianta, 1999; Sameroff, 2000; Williams, Ayers, Van Dorn, and Arthur, 2004): a) The changing and developmental character of the problem behavior that is in close relation to the child‘s life contexts: the problematic behavior is shaped, strengthened, worsened or improved under the pressure of certain intrapersonal (intrapsychic) (e.g., developmental phase of the child) and interpersonal parameters (e.g., parental or teacher and classmates attitudes); it can also be positively changed or modified under the impact of specialized interventions (e.g., individual or family psychotherapy, psycho-educational intervention) or deteriorated in the absence of these interventions. b) The dynamic nature of problem behavior and its relationship to psychosocial functioning of the child: the behavior is an integral part of the general psychosocial functioning of the child (regardless if it promotes or complicates his psychosocial adaptation); it usually represents a specific way to cope with his internal or external reality (e.g., children behave aggressively in order to dominate others and thus strengthen a deficient or weak self-image; or to acting out feelings of anxiety, depression; children who provoke others to attract attention and combat their feelings of isolation and inferiority). c) The way the problem behavior is perceived and dealt with by the child's environment. d) The role and the place of the problematic behavior within the family dynamics/system (e.g., presence of dysfunctional communication patterns or inappropriate rearing practices, conflicting relations, negative affective climate, etc.). e) The problem behavior as an indicator of a family crisis or of a critical relationship between the child and the family context (shift from the concept of the child-problem to the context-problem concept). f) The impact of the broader socio-cultural contexts (macro level) on the psychosocial environment of the child.

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Additionally, resilience which indicates the child‘s capability to avoid psychopathology and develop sufficient internal mechanisms and psychosocial skills to deal with development challenges can only be conceived and considered in a broader ecological perspective. Most of the resilience eminent investigators sustain this conceptualization. Resilience cannot be identified, understood, or facilitated without consideration of context at many levels and in multiple ways. This conclusion is increasingly evident in the history of research on resilience in development, but it also follows directly from the basic tenets of developmental psychopathology and developmental systems theory (Riley and Masten, 2005, p. 22). To sum up, from the point of view of new epistemological approaches, childhood disorders are considered the result of continuous complex interactions among many external and personal risk or negative factors (Sroufe, 1997). For example, both child temperament and quality of the parent-child relationship shape social-competence and self-regulation skills (Marshall and Watt, 1999). Children who are socially competent are likely to demonstrate low reactivity to stress and have high self-control of their attention and behavior (Eisemberg et al., 1997; Marshall and Watt, 1999). However, the psychosocial context in which a child develops seems to play a central role in the maturation of interpersonal skills and selfemotions regulation systems (Sroufe et al., 2005; Steinberg and Avenevoli, 2000). Children living in supportive and encouraging family contexts are more likely to develop socialcompetencies and self-regulation skills (Carr, 1999). In contrast, children living in hostile environments with low self-competencies are more likely to develop social, emotional, and behavioral difficulties or conduct problems (Carr, 1999). The risk of a child with emotional-behavioral difficulties developing more serious conduct problems seems to increase with the child‘s exposure to additional risk factors. During infancy the parents‘ development of an affective, nurturing, stimulating, and positive relationship with their offspring sets the groundwork for avoiding coercive processes that are associated with inappropriate and ineffective discipline and early behavioral problems (Marshall and Watt, 1999; Patterson, Reid and Dishion, 1992). Children with mild emotional or social interpersonal and behavioral difficulties when they enter school may face increased risks and difficulties. It was found that early academic difficulties, poor social skills, and poor problem-solving abilities are associated with behavior problems (Marshall and Watt, 1999). Before closing this chapter, we emphasize that in the present work, a high percentage of cited research refers to conduct disorders—which are considered the most extreme and troubling form of disruptive behaviors. Children with conduct disorders may represent a smaller percentage of the total amount of behavioral problems encountered in schools. Actually, in this we also refer to a large number of children with less severe behavior problems, which seem to constitute the majority of school age pupils and which do not necessarily entirely correspond to classical psychiatric criteria for conduct disorders (Kauffman, 2001). The majority of research cited here comes from the Anglo-Saxon literature and usually involves groups of children with psychiatric features. However, much research on risk factors and on interventions concern cases of children with moderate symptomatic behaviors or disorders. Nevertheless, disruptive behaviors extend to a wide range of problematic symptomatic reactions (Lochman and Szczepanski, 1999). At one end of the spectrum lie extreme forms of disruptive behaviors and conduct disorders (physical abuse and violence, persistent delinquency) and at the other, mild or moderate forms of problematic behavior which include problems that school psychologists and teachers usually face in the school

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context (Kauffman, 2001). Children who belong to these categories display various psychosocial and family characteristics which may vary with the child‘s age and the severity of family dysfunction.

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Chapter 3

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SYSTEMIC DEVELOPMENTAL THINKING AND BEHAVIORAL PROBLEMS As has already been outlined, the problematic reactions of children and adolescents are no longer regarded as solely within the individual problem, but as the result of dynamic interactions among many complex factors that have created the conditions for the manifestation of conduct problems (Fraser and Williams, 2004; Sameroff and MacKenzie, 2003; Williams et al., 2004). These considerations promote a multifactorial model of behavior problems and disorders in childhood, without necessarily underestimating biological predispositions or temperament issues (Cadoret et al., 1995; Williams et al., 2004). At the theoretical level, most of these approaches have included the systemic and social interactive/transactional thinking of behavioral analysis (Costello and Angold, 2000; Dodge, 2000; Fraser, 2004; Lynch and Cicchetti, 1998; Sameroff, 2000; Snyder, 2002; Snyder, Reid, and Patterson, 2003). They‘re also based on data from longitudinal studies which during the last few decades have refined their methodological measures and statistical methods of analysis. The developmental dimension in contemporary psychopathology and special education includes the following characteristics (see also Steiner, 2004):        

Emphasis on capturing developmental changes Emphasis on examining contexts (macro-, meso-, and microsystems) Emphasis on continuities/discontinuities of normal and pathological processes Emphasis on historical aspects of children‘s functioning: pathways and trajectories of change (person + disorder) Emphasis on capturing adaptive and maladaptive functions and patterns Emphasis on social interactional processes and social learning Emphasis on synthesis across domains Building interventions on multisource and multifaceted assessments of children‘s functioning

It is increasingly recognized that children rarely experience isolated mental health problems and that most behavioral difficulties occur in combination with other psychosocial difficulties or disorders (Kauffman, Brigham and Mock, 2004). It is also widely recognized Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

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that multiple risk factors are implicated in the development of multiple behavior problems accompanying additional psychosocial or academic difficulties, thus requiring multiple strategies of assessment and intervention. As stated by Fornes (Forness, 2003, pp. 63-64):

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―School psychologists or special educators may often treat disruptive behavior disorders with relatively straightforward behavioral strategies. Such approaches may not be entirely adequate, however, if such disorders are accompanied or even preceded by significant comorbidity. The gradual mergence of such comorbidity may not always be readily apparent, unless school professionals are prepared to recognize its developmental trajectory‖ (see also Kauffman et al., 2004, p. 22).

Treatments for behavior problems need to include consideration of other conditions that preexist or coexist with the problems that were initially diagnosed (Kauffman et al., 2004). The extreme ―medicalization‖ of children‘s and families‘ difficulties/deficits during the past twenty years has brought significant changes in the way in which children‘s behavior problems have been described, diagnosed, and treated (Schmidt Neven et al., 2002). These changes have been particularly striking in North America where, according to Barkley (1998), three to five percent–and probably more today—of the school-age population has been prescribed psychostimulant drugs. Carey (2007) reports that the number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, and has certainly risen further since 2003 (see also Glicken, 2009, p. 4). According to Carey, in studies of doctors in private or group practice in New York, Maryland and Madrid, the numbers of visits in which doctors recorded diagnoses of bi-polar disorder increased from 20.000 in 1994 to 800,000 in 2003, about one percent of the population under age 20 (Glicken, 2009, p. 4). The overmedicalization of children‘s problems goes hand in hand with the exclusion of any contextual perspective and of any approach which could provide a more meaningful and profound insight into children‘s difficulties. Related to this strong pathologizing tendency is the issue of how professionals construct the mental health problems of children and families (Schmidt Neven et al., 2002). Unlike the traditional psychiatric approaches, there seems to be today in the field of childhood and adolescence psychopathology a considerable consensus among many researchers and clinicians about the benefits of understanding stressors or risks as representing complex situations (Fraser and Allen-Meares, 2004; Gore and Eckenrode, 1994). This led to an increasing number of research and theoretical studies on contextual preventive and interventive strategies/programs that attempt to buffer risk and strengthen protective factors (resilient approach). Building on the idea of modifying risk, two basic models of resilience have emerged. They are the additive and interactive models. The ―additive models,‖ in which protective factors are said to exhibit main or compensatory effects, posits that the presence of a risk factor increases the likelihood of a negative outcome and the presence of a protective factor increase the likelihood of a positive outcome (Fraser et al., 2004: 32). The ―interactional dimension‖ integrated in the interactive model is used often to describe risk and protective dynamics. Within this theoretical framework, protective factors are conceptualized in the following three ways: a) they may buffer risk factors (e.g., the school support of a child with difficulties that is thought to moderate the effect of a high-risk

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environment); b) they may interrupt a risk chain (e.g., an intervention that aims to reduce family conflicts and parental inappropriate rearing patterns may interrupt a chain of risks connecting family environment with youth‘s affiliation with antisocial peers), and c) they may operate to prevent the initial occurrence of a risk factor (e.g., a positive temperamental characteristic may protect children from abuse by enabling them to elicit positive responses from caregivers who are ―dysfunctional‖ as parents or are at high risk to be abusive)(Fraser et al., 2004, pp. 32-33). Contemporary models in child and adolescent disorders consider the risk and protective factors as embedded in systems at many different levels in the ecology and thus respectively requiring complex systems of thinking, research design, and data analysis. Identifying the common risk factors that produce risk and resilience in children was the first step both in conducting an ecologically based assessment and in designing ecologically focused services (Fraser et al., 2004, p. 36). To outline the way risk and protective factor are operating, we will refer to Marshall and Watt‘s definition:

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Risk factors are those characteristics, variables or hazards that, if present for a given individual, make it more likely that this individual, rather than someone selected from the general population will develop that disorder. Protective factors are those factors that modify, ameliorate, or alter a person‘s response to hazards that predispose a person to a maladaptive outcome (Marshall and Watt, 1999, p. 39).

Risk factors not only precede and correlate with behavior, but there is strong evidence that they have a causal relationship to the behavior, and their removal or reduction will reduce the likelihood or intensity of the problematic or antisocial behavior (Marshall and Watt, 1999, p. 39) (see also Carr, 1999; Dishion and Patterson, 2006; Fraser et al., 2004; Frick, 2006; Rutter, 2000). The identification of risk factors facilitates the detection of those children most in need, and help to focus for effective intervention programs (Carr, 1999; Dishion and Patterson, 2006; Frick, 2003; Marshall and Watt, 1999: 39). Risk factors may be heightened at particular stages of a child‘s course of development due to a combination of internal instabilities and external challenges (Carr, 1999; Fraser and Allen-Meares, 2004; Fraser et al., 2004; Marshall and Watt, 1999; Wilmshurst, 2009). It also appears that the cumulative risk may be a better and more powerful predictor of later difficulties or disorders (Carr, 1999; Marshall and Watt, 1999; Rutter, 2000). As stated by Marshall and Watt: There is sound evidence that risk status produces a cascading effect over time; the presence of a large number of risk markers at one developmental period greatly increases the chances of the next developmental risk marker being present through indirect accumulation (Marshall and Watt, 1999, p. 39).

During the early years, characteristics of the child and the family environment have great importance. As children move outside the family, influences from peers, school, and the community become increasingly significant (Marshall and Watt, 1999; Mash and Wolfe, 2001). One of the most important findings that these novel epistemological and research methodologies have revealed is the confirmation of clinical data showing multiple factors within and outside the child dynamically interact to generate developmental and psychosocial

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instabilities and dysfunctions (Avenevoli and Steinberg, 2000; Carr, 1999; Fraser, 2004; Fraser et al., 2004; Rutter, 2000; Wilmshurst, 2009). A second important finding is that a multitude of common factors can produce different outcomes regarding the behavior and general functioning of the child, including symptomatic and disordered reactions (Carr, 1999; Cicchetti and Rogosch, 1996). Moreover, it was found that for development of a disorder both in childhood or adolescence, there are multiple paths and differences as to the quality and severity of symptoms (Richters, 1997). Although contemporary developmental psychopathology considers the emotional and behavioral difficulties of children within the pathology or the disorder conceptual framework, it takes into account to a much higher degree variables that are related to developmental stages, transitions, and individual needs of children, as well as to intrapsychic and interpersonal dynamics and to family interactional patterns (see Carr, 1999; 2009; Dishion and Patterson, 2006; O'Connor, et al., 1998; Sroufe et al., 2000; 2005; Steinberg and Avenevoli, 2000; Wilmshurst, 2009; Wyman, 2003). The introduction of the concept of "risk factors" was one of the first paradigm shifts of developmental psychopathology towards a transactional ecosystemic view of childhood and adolescence disorders. The risk-protective factor model places emphasis on the child, as well as on the environment and on their systemic interactions (Farrington and West, 1993; Fraser, 2004; Lynch and Cicchetti, 1998; Thomlison, 2004). The concept of risk factor, considered in a dialectical perspective, has been a valuable methodological framework for contemporary clinical psychology and special education, insofar as it denotes a break with traditional linear medical models which place emphasis on individual traits and therefore exclude the transactional developmental perspective (Dodge, 2000; Zipper and Simeonsson, 2004; Wyman, 2003). In the same line of reasoning it is thought in the case of the disorder, that a wide range of contextual adversive factors operate at different stages of the child‘s trajectory and family life, in varying degrees of intensity and persistence. When it is about family and parental attitudes, it is thought that these variables contribute greatly to the development, as well as to the maintenance of the child‘s symptomatic behaviors. Although many authors argue that it may be the child‘s difficult temperament and challenging behavior that elicit the parental negative reactions, it is essential to recognize that parents‘ responses have a crucial impact on the child‘s social, emotional, and behavioral coping mechanisms, due to his profound dependence on his caregivers (Maccoby, 2000). In this sense, problematic parental attitudes and rearing practices are thought to represent a main predisposing as well as a maintaining negative factor for the child‘s primary behavioral and emotional dysfunctions (see Carr, 1999; Maccoby, 2000; Sameroff, 2000; Sroufe et al., 2005; Wyman, 2003). Moreover, introduction of the concept of "accumulative" and "additive risk factors" in psychopathology allowed the conceptualization of a theoretical framework that endorses a longitudinal perspective in the study of negative consequences (Fraser et al., 2004; Sameroff, 2000). There are cases of children who have survived in extreme adversive environments (e.g., chaotic families, a violent disordered father, social violence, etc.) without displaying any evident psychopathological trait or dysfunction. It is thought that in such cases external hazards are counterbalanced or neutralized by inherent internal capacities (such as a child's intelligence) and external positive factors (e.g., a strong emotional relationship with a significant other) (Fraser et al., 2004; Masten and Powell, 2003; Sameroff, Guttmann and Peck, 2003). In such cases, the presence of a series of external promoting factors associated

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with the development of self-protective and mental skills enabled the child to deal with the ―traumas‖ related to a hostile environment and to avoid psychopathology (Fraser et al., 2004; Mash and Wolfe, 2001; Sameroff, Guttmann and Peck, 2003). In contrast, based on data collected from their therapeutic work, many clinicians support the hypothesis that extreme traumatic experiences in early childhood indubitably affect and weaken the psychological structure of the individual, even with the lack of evident signs of psychopathology (Chartier, 2008). Overall, it is widely acknowledged that the more adversive factors are present in the life of a child, the greater the risk for developing various forms of disorganized behavior or failure (Fergusson and Horwood, 2003; Rutter, 2000; Sameroff and Guttmann, 2004). When disruptions in attachment bonds and relationships with significant others occur very early in infant life, there are many risks that the child will be unable to develop a coherent self-representation, positive cognitive schemata and mechanisms, as well as adequate social emotional skills and coping behaviors to effectively adjust in social environments and be connected to others. For instance, it was found that children with conduct problems display negative interpersonal schemata. Negative interpersonal schemata might stem from a poor, broken, or disrupted parent-child attachment relationship (c.f., an aggressive father or a withdrawn mother). The greater the negativity of children‘s schemata, the greater the likelihood that they will demonstrate dysfunctional social behavior and experience peer rejection (Rudolph et al., 1995; Scriva and Heriot, 2008). An earlier study of Speltz, DeKlyen and Greenberg (1999) which examined the association between attachment and psychopathology in samples of clinically diagnosed children showed that over half of the clinic boys with early onset conduct problems (54%) exhibited an insecure attachment strategy, as opposed to 18% of boys in a comparison group.

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RESILIENCY AND TRAUMA In investigating resiliency, researchers have sought to identify "protective factors" which reduce levels of impairment in high-risk or traumatic situations (individual or collective trauma). A recent study (Milani and Ius, 2010) on holocaust survivors (collective trauma) showed that those who have entirely or partially lost their families in early childhood and have achieved a thriving family, social, or professional life (resilience) have been supported by positive adoptive environments. In the case of collective trauma, the child does not necessary perceive parents as aggressors and the role of social or community support might be very crucial as a protective factor. On the other hand, in the case of parental abuse or maltreatment (individual trauma), the child is constrained to deal with the internal distress and the pain imposed by significant persons in his primary environment. In such cases the emotional burden to deal with is much stronger, more disturbing, and the trauma more disorganizing. The psychosocial development and achievement (emotional stability, selfregulation mechanisms, positive attachment, relational patterns, mentalization, and interpersonal skills, etc.) of the maltreated child is greatly impaired due to the intensity of his unbearable feelings and the lack of supportive relationships, thus leading to depression or to behavioral problems. In addition to sadness, depression or sorrow, maltreated children experience confusing, ambivalent, and anxious-aggressive emotions towards their parents, since they‘re continuously faced with threatening experiences. Developmental

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psychopathology perspective suggests that problematic, insecure, and confusing attachment and deviations from normative processes at earlier stages of development increase the likelihood of psychopathology later in development (Sroufe et al., 2005). It is widely acknowledged by contemporary resilience researchers, that resilience should be understood as a process involving a complex interaction among risk and protective factors, and not a trait of an individual (Rutter, 2008). To sum up, the development of self-protective mechanisms (resiliency) in children free of behavioral and emotional disorders is associated with the impact of (proximal) external positive factors (Sroufe et al., 2005; Yates, Egeland and Sroufe, 2003). For instance, it has been shown that the presence of a single supportive and nurturing caregiver (single positive factor) in an otherwise adversive family context may enable children to develop necessary basic self-protective skills and avoid psychopathology (Mash and Wolfe, 2001). Resilience is not yet thought of as simply possession of specific abilities, or features that protect the child from a distressing environment (Fraser et al., 2004; Yale et al., 2003). Resilience considered in a relational systemic, rather than in an individualist-trait perspective, is currently conceptualized as an outcome of the dynamic interaction between positive intra- and extrapersonal features and variables (Sroufe et al., 2005). For instance, stable and coherent mental representations (working models/interpersonal schemata) that give rise to relative cognitive, emotional, and relational skills and patterns are developed within an enduring nurturing relationship in early infancy (Fonagy, Target and Gergely, 2006). By contrast, the capacity of mentalization and of developing adequate psychological mechanisms to support a wide range of behavioral and relational skills is undermined in the case of harmful or disrupted primary relationships (Fonagy et al., 2006). In early childhood, one key challenge is the attainment of self-regulation of emotion, and ―difficulty with adaptive emotional self-regulation may portend later social and behavioral problems‖ (Trentacosta and Shaw, 2009, p. 357).

HOLISTIC APPROACHES AND EARLY INTERVENTION In a holistic/ecosystemic and psychodynamic, as in other similar models of intervention (multisystemic theory, ecological theory clinical model of social cognition) (see Henggeler et al. 1998; Munger et al. 1998; Seidman and Pederson, 2004; Sneider, Reid and Patterson, 2003), disorders in childhood are regarded as the result of a problematic relationship between the child as an evolving system and the environmental (proximal or distal) systems (parental couple, family, siblings, classmates, neighborhood, school system, peers, social institutions, society, etc.). This relationship is affected by the dialectic action of multiple endogenous and exogenous factors (Fraser, 2004; Garbarino, 1995; Pianta, 1999; Seidman and Pedersen, 2004). As family and child are dynamic evolving systems continuously interacting with other systems, a multitude of pathways to conduct problems and a multitude of types and forms of antisocial and aggressive behaviors associated with a series of emotional, relational, and personality disorders is possible (Boxer and Frick, 2008; Dodge and Pettit, 2003; Fraser et al., 2004; Frick, 2006). Overall, the problematic developmental outcomes (i.e., problem behavior) result from a variety of different risk factors that can operate on multiple levels of influence (Boxer and Frick, 2008, p. 243).

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To summarize, the ecosystemic framework allows broadening our perception of childhood disorders with significant implications in the design of treatment programs and therapeutic strategies. Actually, substantial data show that ―pathology‖ in childhood and adolescence results from multiple and intense negative interactions between a child with possible inherent or acquired deficits and an environment (familial, social, academic) that is not competent to positively and effectively respond to these children‘s socio-emotional needs and dysfunctions (Bloomquist and Schnell, 2002; Garbarino, 1995). Consequently, the risk for these children to develop more serious conduct and developmental disorders is increased. In this perspective, the child's antisocial behavior cannot be considered as exclusively located "within the child" (in person). Rather, it should be regarded as a social contextual problem since it results from multiple and continuous pathological "social interactions" (Sneider et al. 2003). Avoiding psychopathology is possible in part by development of adequate methods to prevent the behavioral and psychiatric problems or to intervene before they become severe (Reynolds and Ou, 2003). Hence, by identifying in time and assessing the psychosocial and behavioral difficulties of children within a holistic and multisystemic perspective becomes a crucial step in designing successful interventions. Indeed, the importance of considering multiple factors that might be involved in the development of conduct problems has important implications for serving children with this disorder (Frick, 2004). As stated by Frick, it makes it unlikely ―that any intervention that addresses only a single factor will be very successful for a large number of students, a fact that has been supported by a rather extensive body of treatment outcome research‖ (Frick, 2004, p. 825).

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Chapter 4

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RISK FACTORS ASSOCIATED WITH THE DEVELOPMENT OF BEHAVIORAL PROBLEMS AND DISORDERS IN INFANTS AND IN SCHOOL AGE CHILDREN The purpose of this chapter is to provide a macro- and microsocial framework of the risk factors that are thought to either generate or facilitate the appearance of behavioral problems in childhood. This is a comprehensive framework established from a great amount of data and on clearly formulated hypotheses and assumptions. This evidence-based model can be a useful frame of reference for professional and school personnel, because it can serve for the development of schoolwide programs for a) the socialemotional development of all students within a school; b) the prevention of emotional and behavioral disorders in students at risk or ―challenging‖ students; and, c) the treatment of students already struggling with serious emotional and behavioral difficulties (Young, Marchant and Wilder, 2004, p. 176). As suggested by many authors, the risk-protective model implies that certain individual and social characteristics, variables, and hazards (risk factors) present in a child‘s life make that child more likely than others to display behavioral problems or to engage in aggressive behaviors and antisocial activities or even to develop conduct disorders (Fraser et al., 2004; Williams et al., 2004, p. 209). Other characteristics and variables (protective factors) are known to reduce an individual‘s risk level or to buffer a child from the effects of risk (Williams et al., 2004). Risk and protective factors for childhood and adolescent conduct and behavior problems are known to exist in all domains of a child‘s life, including family, school, community, and peer group. At risk factors are factors that are highly related to the manifestation of various types of dysfunctional and defiant, as well as aggressive and antisocial behavior. Specifically, since risk factors are considered negative or adverse conditions in terms of social, family, parental, and individual parameters, it becomes more likely to be the exhibition of problematic behavior in childhood and adolescence. Risk adversive factors may seriously affect the child‘s social, emotional, cognitive, and behavioral development, leading to intense mental health problems (e.g. depression, dissociation, etc.) in childhood or adolescence; or partially

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affect the development of specific patterns and skills, hence jeopardizing children‘s personal achievement and endangering their social attachments and school integration. In addition, it is considered that risk factors aggravate the conditions under which a child with specific deficits is developing, therefore it is more likely that early emerged defiant or disruptive behaviors progressively transform into more problematic and antisocial patterns, if adversive conditions persist (additive risk model) (Gilmore et al. 1991; Williams et al. 2004; Young et al., 2004). Research adopting this perspective (risk factors-ecosystemic approach), has focused in recent years on the study of risk factors, as well on protective or promoting mechanisms that are related to the presence of conduct problems or, conversely, to the absence of manifested pathological forms of behavior (Masten and Powell, 2003; Wyman, 2003). Research in this direction is therefore (a) to provide a functional definition of risk factors and define the basic tools of research on these factors; (b) to show the negative sides and vulnerable children and protection mechanisms on an individual level; (c) to define the ways in which protective and risk factors are interrelated; and, (d) to define, based on empirical data, the framework and terms of the intervention (c.f. Cicchetti, 2003). A substantial body of research on children and adolescents documents a large number of factors that can place a child at risk for developing conduct problems. Risk factors for behavioral, aggressive or conduct and antisocial problems emerge across multiple levels (Alvarez and Ollendick, 2003; Bloomquist et al., 2005; Carr, 1999). Beyond theories that focus on the causal importance of one or relatively few factors, ―there is a general consensus that the development of problematic and antisocial behavior involves a prolonged process of interplay between the characteristics of the individual youth and their key social environments‖ (Capaldi and Eddy, 2005, p. 286). More specifically, risk factors that are considered to contribute to the manifestation of problematic behavior in childhood range from (a) individual risk factors (e.g., difficult temperament, poor impulse control, poor emotional regulation, low intelligence, lack of social-interpersonal skills, mild disability); (b) problems in the child’s immediate psychosocial context (e.g., poverty, parent-child attachment problems, poor emotional support and child monitoring, parental characteristics including psychopathology or various psychological problems and serious social difficulties, inadequate or harsh parental discipline and persistent maltreatment, coercive parenting and family interactions, discipline, marital difficulties, family instability, family violence, negative peer-child interactions, rejection by prosocial peers, affiliation with antisocial peers, association with a deviant/delinquent peer group); (c) problems in the child’s broader psychosocial context (e.g., stressful life events, living in a high crime neighborhood, exposure to community violence, lack of educational and vocational opportunities, inadequate or harmful school responses, rejection by school teacher, negative social position within classroom) (Alvarez and Ollendick, 2003; Dishion and Patterson, 2006; Dodge, 2000; Farmer, 2000; Fraser and Williams, 2004; Frick, 2006; Frick and Kimonis, 2008; Young et al., 2004; Williams et al. 2004). These risk factors are usually interrelated with each other, operating in concert in a transactional (e.g., one risk factor having an influence on another risk factor) or multiplicative fashion (Dodge and Pettit, 2003; Frick and Kimonis, 2008). An enormous body of empirical work has led to the identification of risk factors which predispose youngsters to develop conduct problems and to personal and contextual factors that maintain these problems once they occur. Based on an extensive review of studies of risk and protective factors associated with conduct problems, Alan Carr has proceeded to the

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following functional classification of risk factors (Carr, 1999, p. 338-339): (a) personal predisposing, (b) family predisposing, and (c) contextual predisposing risk factors; plus (a) personal maintaining, (b) family maintaining, (c) contextual maintaining, and, finally, precipitating risk factors. Personal predisposing risk factors may include (a) biological, such as low arousal level and genetic vulnerability, (b) psychological, such as, among others, difficult temperament, low intelligence, low-self esteem, external locus of control, hyperactivity, and learning difficulties. Family predisposing risk factors may include (a) parent-child factors in early life, such as attachment problems, lack of intellectual stimulation, authoritarian, permissive or neglectful parenting, inconsistent parental discipline; (b) exposure to family problems in early life such as parental psychological problems, parental criminality or substance abuse, parental separation, marital discord or violence, family disorganization, deviant siblings, large family size and middleborn; and (c) stresses in early life, such as bereavement, child abuse, institutional upbringing, social disadvantages. Individual psychological dysfunctions (risk individual parameters) are highly interrelated with family risk factors; child‘s features such as low self-esteem or extreme arousal, emotional instability, poor internal working models, and restricted skills for relationships are definitely affected, elicited, or reinforced by negative family functioning in early infancy (Rutter, 2000). Contextual maintaining factors include (a) treatment system factors, such as family denies the problem, family ambivalence about resolving the problem, family has restricted skills to cope with the problem, family rejection of formulation and treatment plan, lack of co-ordination and partnership among involved agencies and professionals; (b) family system factors, such as coercive interaction, authoritarian parenting, harsh or inconsistent discipline, and inadvertent reinforcement of problem behavior, insecure parent-child attachment, overinvolved or permissive parenting, confused communication patterns, chaotic family organization, triangulation, or father absence; (c) parental factors, such as parental psychological problems, antisocial behaviors or criminality, insecure internal working models for relationships, problematic self- and other representations/interpersonal schemata. Low parental self-esteem, depressive or negative attributional style, cognitive distortions, immature defense mechanisms and dysfunctional coping strategies; (d) social networks and school factors, such as, among others, poor social support network, high family stress, deviant peer affiliation, low quality education, inappropriate school response, lack of schoolbased specialized services and supportive treatment providers. Though there has been considerable confusion over the difference between risk and protective factors, conceptually, protective factors could be seen as simply the opposite of risk factors. Some authors have argued that for the study of resiliency to provide insight over and above that gained by the study of risk, we should look for interactions between risk and protective factors (Rutter, 2000; 2001). There is general agreement among researchers that protective factors insulate children from risks associated with the development of antisocial behavior (e.g., a positive interpersonal relationship and social support may mitigate the effect of stressful life events for children (Bloomquist et al., 2005; Fraser et al., 2004, p. 44)). They promote a more normative or resilient developmental pathway related to positive developmental outcomes despite the existence of risks (Bloomquist et al., 2005). Children‘s protective factors include academic success, positive social skills, prosocial peer relations, and positive attitudes toward school.

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Protective factors within a child‘s environment include ―having caregivers who employ supportive and authoritative parenting, teachers who encourage children to become connected to their school, and community institutions that provide opportunities and resources for children to develop prosocial skills and positive friendships‖ (Bloomquist et al., 2005, p. 202). The goals of early intervention and prevention programs for aggressive children who are at risk of developing antisocial behavior are to reduce the impact of risk factors and enhance the influence of protective factors. If these goals are accomplished, children are expected to develop more healthy outcomes as they mature into adolescence (Bloomquist and Schnell, 2002). For instance, a supportive and caring relationship with an adult has been consistently identified as a protective factor for children across a variety of risk conditions (Fraser et al., 2004). Accordingly, for the prevention of behavior problems in early infancy a supportive and enduring significant relationship of children at risk with an aware sibling, a skilled teacher, and/or a well- trained specialist may really re-enable children to be reintegrated in their social-school context and progressively develop their inherent competencies (Bloomquist and Schnell, 2002; Reddy et al., 2003). Actually, these kind of relationships can have significant (protective and promoting) therapeutic effects for children at risk or children coming from dysfunctional family environments, if they are well organized and monitored by interdisciplinary teams (Emde and Robinson, 2000; Kourkoutas, 2011; Schmidt and Neven, 2010). In order to be effective, these relational interventions should be integrated in a wider multimodal intervention project based upon a systematic and continuous analysis of the risks and strengths of the child‘s various contexts of living (Kourkoutas, 2008a). Increasingly, a ―developmental-ecological and multisystemic‖ framework has guided intervention and prevention of antisocial behavior; interventions that are based upon this theoretical-methodological model seem to be the more effective even for serious antisocial behaviors in adolescence (Bloomquist and Schnell, 2002; Frick and Kimonis, 2008; Henggeler, Schoenwald, Borduin, Rowland, and Cunningham, 1998; Tolan et al., 1995). One important lesson learned from discussions of longitudinal studies on childhood behavior and disorder is that children are integrated wholes rather than collections of traits (Sameroff, 2000). When they show evidence of serious dysfunction, it is not restricted to single domains unless they are only measured for single domains of dysfunctions. Issues related to comorbidity in childhood disorders are also raised. Traditional psychiatric hermeneutic systems are likely to continue to investigate and treat child‘s disorders as separate entities and in a decontextualized way. Therefore, a contemporary hermeneutic schema of childhood disorder requires a different system of thinking, of hypothesizing, of exploring and interpreting the data than the traditional categorical psychiatric thinking. The growing body of available evidence advocates for a more ecological systemic perspective of childhood disorder. A definition of risk that relies only on engagement in individual ―risky‖ behavior ignores other conditions– family, school, peer, and neighborhood environments—that predispose children to certain kinds of behaviors that may become behavioral dysfunctions under specific negative conditions (Alvarez and Ollendick, 2003; Dishion and Patterson, 2006; Carr, 1999; Fraser, 2004; Young et al., 2004). On the other hand, ecological theory focuses both on the individual and on the context and has an inclusive characteristic that is fully compatible with a risk and resilience perspective (Dishion and Patterson, 2006; Fraser, 2004, p. 5).

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In addition to consideration of a large number of risk or hindering factors, any intervention for conduct problems should take into account the extraordinary variability that occurs in populations of children with such difficulties (Carr, 1999). Available research suggests that variability in behavioral and conduct problems occurs along the following axes (see Carr, 1999, p. 314):           

Severity, from mild and infrequent to severe and frequent Chronicity, from recent to long-standing Pervasiveness, from home-based to home-, school- and community-based Age of onset of problems, from childhood onset to adolescent onset Peer influences on conduct problems, from peer-group-based socialized conduct problems to solitary conduct difficulties The level of deceit involved, from overt aggression to covert stealing and lying The presence or absence of attention problems The presence or absence of hyperactivity problems The presence or absence of depression and other negative mood states The presence or absence of specific learning difficulties The degree of family disorganization.

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To sum-up, it is widely accepted that multiple influences and factors contribute to the development and maintenance of behavior problems in young children (Alvarez and Ollendick, 2003; Dishion and Patterson, 2006; Carr, 1999; Mash and Wolfe, 2001).

PATHWAYS TO CONDUCT PROBLEMS OR DISORDERS IN ADOLESCENCE A very recent longitudinal study investigated the link between trajectories of externalizing behavior problems and early adolescent risk behavior in a sample of 875 child participants (Thompson et al., 2010). Data revealed five trajectory groups of children defined by externalizing behavior problems. The identified externalizing behavior categories were: Low, Low-Medium, Moderate, Increasing-High, and High. After controlling for demographics and maltreatment, violent or delinquent behavior was significantly predicted by membership in the Moderate and Increasing-High problem behavior groups. Substance use in early adolescence was significantly predicted by membership in the High behavior problem group. Based on these findings, authors suggest that there is a great deal of continuity between patterns of externalizing behavior in childhood and risk-taking in early adolescence (Thompson et al., 2010). Understanding the course of externalizing behavior in childhood can help identify children at particular risk for more serious behavior problems in early adolescence. Preventive strategies and primary interventions should focus on the youngest age groups, especially pre-schoolers, to prevent persistence of behavior problems (Carr, 2009; Frick, 2006; Mash and Wolfe, 2001). In summary, a wide range of available data strongly suggests the hypothesis of the context influence on childhood behavior disorder and that ―the context‖ has been vastly

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underestimated by traditional medical models (Fraser and Allen-Meares, 2004; Schmidt Neven et al., 2002; Schmidt Neven, 2010). There is still a need to develop a precise understanding in each child‘s case by taking a holistic perspective of the relationship between the contextual and individual factors, seen not simply as inherited or stable intrapersonal traits but rather as parts of a developing interactional system that is structured and organized upon and around the child‘s internal representations that have been shaped by early caring and emotional experiences (Fonagy et al.,, 2006; Kourkoutas, 2011). This requires a coping system that serves to help the child‘s adjustment and reflects the child‘s attempts to deal with external stimuli, as well as with his internal pressures and developmental needs. The failure of the child to develop a well-organized system of cognitive, emotional, social interpersonal skills or a system of stable and positive self- and other representations is equally a failure of his close and primary environment to help him structure and develop these capacities. A series of theoretical models focusing on emotion and attachment have attempted to interpret the pathways to behavioral and conduct problems. For instance, based on the strong available data regarding harsh and coercive parental discipline and dysfunctional maltreating families, Greenwald and colleagues have elaborated an interpretative model of conduct and antisocial disorders, placing key emphasis on the notion of trauma. Actually, a high number of prospective studies have identified trauma exposure as a significant risk factor for youth antisocial behavior (see Greenwald, 2002). Although not all traumatized youth become antisocial, studies on antisocial youth have found rates of self-reported trauma exposure ranging from 70% to 92% (Greenwald, 2002, p. 9). The trauma-informed perspective is based on this considerable body of literature documenting the relationship between trauma/maltreatment and subsequent aggressive/antisocial acting-out (Greenwald, 2002, p. 9). More specifically, trauma effects can last indefinitely and can become a primary focus around which personality and behavior are organized (Greenwald, 2002). In fact, there is substantial evidence for the adverse effects of psychological maltreatment, including a multitude of negative developmental consequences, such as low self-esteem and problematic or disorganized patterns of attachment in the case of intense and repeated maltreatment (Allen, 2001; Chartier, 1997; 2008; 2010). Internal working models, mentalization capacities, and behavioral patterns are constructed on the basis of repeated interactions with parents. Internal working models, self- and other-representation, emotional mechanisms or capacities, interpersonal skills, and behavioral repertory are all interrelated, and to a great extent they are shaped by the quality of interactions within family and social contexts, as well as by the child‘s perception of their relationship with parents. In the case of maltreatment in dysfunctional, abusive, or problematic on various level family environments (organizational, emotional, communicational, social, and so on), children are lacking the ability to form adequate internal working models that give rise to positive relational and behavioral patterns (Allen, 2001). Moreover, traumatizing bonding or traumatic experiences within family may cause affect dysregulation and consequent acting-out, which is characteristic of many aggressive children (Allen, 2001; Chartier, 1997; 2010; Greenwald, 2002; Kourkoutas and Tsiampoura, 2011). Some data suggest that affect dysregulation may be as powerful a predictor of antisocial behavior as parental reinforcement for coercive behavior, as ―children who are emotionally over-reactive are more likely to engage in confrontive, coercive, and noncompliant behaviors (see Greenwald, 2002, p. 11). Indeed, it was found that trauma exposure was higher among youth with oppositional defiant disorder than those with adjustment disorders or hyperactivity (without aggressive behaviors), even

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after controlling for other risk factors (Ford et all, 1999). As stated by Greenwald (2002, p. 12), trauma-related hypersensitivity to threat can lead to misinterpretation of social cues2, heightened arousal and anger, and inappropriate aggression. In the same vein of research and theoretical considerations, other authors have referred to troubling or disruptive behaviors by using the term of ―pain-based behavior" to describe the stressful and painful feelings concealed beneath such behaviors (Brendtro, 2004). Actually, recent research, including brain studies of emotional distress, has led to a new understanding of what is commonly called "disruptive" or "disturbed" behavior (see Brendtro, 2004). In this perspective, troubled behavior of children and youth is considered to be closely related to brain states of emotional distress (Bradley, 2000; Brendtro, 2004). Based on his study of ten residential treatment programs for youths with antisocial behaviors, Anglin concluded that ―every young person without exception was experiencing deep and pervasive emotional pain‖ (Anglin, 2003; Brendtro, 2004). Similar findings have been reported in a variety of studies of troubled students and of residents in juvenile justice settings (Brendtro, 2004; Brendtro and Shahbazian, 2004). Even from infancy, some children in specific family environments experience conflicting or painful emotions that affect their behavioral reactions, their relations to parents as well as their position within family system. They may also encounter serious difficulties in expressing and communicating their profound emotional and identity formation needs and hence tend to act them out instead of verbalizing them. For example, Children may also experience at home a variety of overt or covert traumatic conditions and incidences varying in intensity and duration, affecting their development in many ways and to different degrees. Besides the severe forms of parental maltreatment, children might experience as destabilizing or traumatizing or even as reinforcing of their inappropriate reactions apparently minor family changes and transitions (e.g. newborn, home, or school change), as well as specific family relational dynamics (e.g. conflict in relations with siblings, prolonged father absence, covert hierarchy-triangulations within family, labeling/stigmatization of children‘s behavior, position and role of the child within family, and couple relational dynamic, etc.). These incidents or family life dimensions may, in concert with other individual, family or school risk factors, lead the child to react in disruptive ways. Such disruptive behaviors may in turn elicit inappropriate or negative family and school responses, placing the child at additional risk for labeling, rejection, or even maltreatment (Kourkoutas, 2011). Parental acceptance-rejection theory (PARTheory) has convincingly shown the way in which children‘s perception of their parents‘ emotional attitude may seriously affect their psychosocial development and adjustment in various contexts (see Khaleque and Rohner, 2002; Rohner, 2004; 2005; 2010). Indeed, studies conducted using PARTheory and measures strongly support the hypothesis that perceived parental rejection has a significant negative contribution to a wide range of psychosocial dysfunctions (e.g. school adjustment, emotional and behavior problems, troubled intimate relationships, and the like) (Rohner, 2004; 2005; 2010; Rohner and Britner, 2002). Within a trauma-informed framework, this theory proposes to provide a comprehensive and meaningful interpretation of data on parenting practices that are associated with children‘s problematic behaviors. In addition, this conceptual model can

2

This is the ―hostile attribution bias‖ which characterizes many aggressive children (see Crick & Dodge, 1994).

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offer better clinical insight regarding the developmental course of behavior problems, conduct at home and in school, and antisocial behavior. Specifically, this model posits a basis for clinical and research hypothesis-testing concerning the potential relationship between traumatic victimization and problematic oppositional-defiance (Ford, 2002). The model postulates ―a chronological sequence from (a) victimization in childhood, to (b) escalating dysregulation of emotion and social information processing (‗survival coping‖), to (c) severe and persistent problems with oppositionaldefiance and overt or covert aggression which are compounded by post-traumatic symptoms (―victim coping‖)‖ (Ford, 2002, p. 25). As for the conceptualization of risk and promoting factors, although the related concepts of assets and strengths are widely accepted in social work and clinical practice, the exact nature of protective or promoting processes and their relationship to risk mechanisms is heavily debated in the mental health sciences (Williams et al., 2004). Research on resilience, from the other hand, has identified a series of protective factors that reduce the likelihood of maladaptive development among children who face risk factors, thereby leading to resilient developmental outcomes. Studies have shown that resilient children usually have high self-concept, good support systems, and they are closely supervised by their parents when not in school. A longitudinal study on resilient children showed that aggressive children whose parents utilized ―child-centered parenting‖ and who have a higher level of prosocial behavior have better adult outcomes (see Bloomquist and Schnell, 2002, p. 62). Another large study of adolescents across the USA investigated the power of ―developmental assets,‖ revealing four external and four internal factors that were associated with positive development in youth facing multiple risks (see Benson, 2006; Benson, Scales, Leffert, and Roehlkepartain, 1999; Benson et al., 2006; see also Bloomquist and Schnell, 2002). Two of these four external factors are ―support‖ (e.g. supportive families, adults, neighborhoods, and schools) and ―empowerment.‖ Supportive environments enable adolescents to develop the required social and emotional skills to adjust across school and social contexts. On the other hand, children living in traumatizing, maltreating, or dysfunctional family environments are seriously frustrated and/or disorganized at the emotional level. If not supported by a significant adult or by a child-centered social or specialized system (e.g., grandfather/grandmother, classroom teacher, school psychologist, school-based services, and the like), these children are in addition seriously impeded in developing their social, interpersonal, and academic competencies. It is well documented that when children and youths are exposed to a number of risk factors such as abandonment, physical abuse, exposure to violence, or to regular drinking parties at home, they are more likely to encounter emotional and behavioral problems or even to develop serious mental health disorders in the future (Benson, 2006; Cerutti and Manca, 2008). Quite the reverse, the more assets young people experience, the less likely they are to engage in a variety of high-risk or problematic behaviors, and the more likely they are to engage in thriving behaviors (Benson, 2006; Benson et al., 2006; Cerutti and Manca, 2008). Actually, Benson and colleagues found a linear relationship between the number of developmental assets that the youth reported and their level of adjustment within the context of adversity (Benson, 2006; Bloomquist and Schnell, 2002, p. 65). It is now widely acknowledged that interventions will be more successful if they not only reduce the risk factors associated with maladjustment and conduct problems, but also promote

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the protective factors observed in resilient children (Benson et al., 2006; Bloomquist and Schnell, 2002).

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PREVALENCE AND FORMS OF BEHAVIOR AND CONDUCT PROBLEMS IN SCHOOL-AGE CHILDREN It is widely recognized that in many European countries and the USA a large number of children and adolescents are experiencing serious academic difficulties, emotional and behavioral problems, and most likely all of these (Frick and Kimonis, 2008; Frick et al., 1991; Roeser and Eccles, 2000; Weist, 1997). It is also widely acknowledged that conduct problem is among the most frequently occurring, as well as one of the most impairing childhood disorders. Carr (1999, p.313) states that ―one of the most common referrals in child and family psychology is a boy in middle childhood who presents with conduct problems, specific learning difficulties, and related family and school problems.‖ Actually, a wide range from mild to more serious disruptive and problematic behaviors (such as noncompliant, challenging, defiant, oppositional, hyperkinetic, overt and covert aggressive, disorganized, instrumental aggressiveness, violent behavior, and conduct antisocial disorders) that vary in intensity, persistence, and severity, are present in infancy and childhood. However, determining accurate estimates of prevalence has proven to be quite difficult as a function of the various changes in diagnostic criteria for both ODD and CD over the various DSM revisions, whether an impairment criterion is included, the informant (i.e., youth, parent, teacher, and clinician), and the method of combining information from various informants (McMahon and Kotler, 2006: 162). Angold and Costello (2001) concluded that the prevalence of CD and ODD is somewhat higher, from five to ten percent. Of significance is the fact that the range in prevalence estimates across the population of studies is quite wide, from one to 20% (see also Capaldi and Eddy, 2005, p. 285). In Britain, one in ten children has, according to the DSM-IV, at least one disorder associated with unresolved psychological problems and dysfunctions that require specialized intervention (Ford et al., 2003). This percentage becomes higher if we consider that many school age children who display various psychosocial problems do not fall within a strict clinical psychiatric category. These children may remain unidentified, undiagnosed, and partially or inadequately supported and are thus more likely to meet serious problems of school adjustment, social exclusion, and impairment of their inner capabilities. In addition, as reported by the National Office of Public Health Surgeon General, 10.3% of children, aged 9 to 17 years in the U.S., have some form of dysfunctional or disorganized behavior (Hill and Maghan, 2001). Between 12% and 30% of children seem to display moderate or severe psychosocial problems requiring specialized intervention, according to a series of other studies (Marsh, 2004; Weist, 1997). Another study conducted in the late '90s in the USA showed that the rate of children considered as displaying emotional and behavioral problems and subject to specialized care varies between 0.5% and 2% of the total population (Kauffman, 2001). The presence of bullying in schools increases the chances of development of emotional and behavioral problems. In a study from elementary schools in England, of a total of 523 students, one third reported being the victim of offensive and aggressive stigmatization and peer exclusion, thus

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being at risk for further social, emotional, and behavior problems (Johnson et al., 2002; Kourkoutas, 2008c). Similar studies in Greece also showed high levels of bullying and social and emotional problems related to school and classroom climate (Giovazolias, Kourkoutas, Mitsopoulou and Georgiadi, 2010). It is estimated that the rate of behavior problems of children between five and 10- yearsold amounted to about 6.5% for boys and 2.7% for girls. It is also estimated that between a third and a half of incidents involving children referred to medical and educational services to be supported by a professional fall into this category (Farrington, 1995. Kazdin, 1995). It seems that there is also an alarming increase in the percentage of young children with problem behaviors in early childhood settings (Conroy, Hendrickson and Hester, 2004). Specifically, Webster-Stratton (1997) concludes that 7-25% of all preschool-age children demonstrate significant problematic behavior. In addition, another study reports that 24% of children participating in Head Start Programs exhibit externalizing behavior problems (e.g., overt, acting-out, disruptive behaviors) in the clinical or borderline range, and 6.5% have internalizing behavior problems (e.g., covert, withdrawn behaviors) (Conroy et al., 2004, p. 200). Lahey and his colleagues (1999) summarized 34 epidemiological studies of prevalence rates of behavior disorders in the general population for children 4-18 years in the USA and other countries. The research they reviewed was derived from child, peer, parent, and teacher sources and utilized dimensional ratings and diagnostic interviews methodologies (see also Bloomquist and Schnell, 2002: 19). It was found that Oppositional Defiant Disorder ranged between 3% and 22.5%, Conduct Disorders between 0% and 11%, and Attention Deficit Hyperactive Disorder between 0% and 16.6%. This review also found that the majority of studies revealed a high rate of comorbidity across categories and a higher prevalence rate for boys than girls. This finding has significant implication for the implementation of treatment strategies and policies within schools. In France, a study across 18 primary schools in the city of Chartres reported a prevalence of 6.5 % of children (9 % boys and 3 % girls) aged from 6 to 11 years with behavior problems and nearly 3 percent of them with serious conduct disorders (INSERM, 2005). According to international data, it is estimated that the percentage of children who required some form of psychotherapeutic or psychoeducational intervention and did not receive it is quite high (Patrenite, 2005). Behavior disorders, specifically problems of aggression and impulsivity, are the most common and frequent interpersonal dysfunctions that ultimately create serious adjustment problems in school (Institute of Medicine, 1994). Regarding the Greek population, there is no large-scale epidemiological research that can give a concrete picture of the behavior problems in school-age children and youths. Existing studies show that behavior problems and phenomena of violence (physical and psychological) are quite high in the Greek schools (Psalti, Papathanassiou, Konstantinou, and Deliyanni, 2005). On the other hand, the attitudes of Greek parents—especially the use of corporal punishment as a method of correction—are risk factors for developing various forms of oppositional or problematic behavior in family life and in school (Smith and Nika Papassidéri, 2004). Available data show high rates of corporal and aggressive punishment, especially toward young children. The risk of these children to develop some forms of problematic behavior (defiant, oppositional, relational) is increased in the presence of additional adverse factors, such as insecure emotional bonds with parents, parental divorce or separation, lack of parental control, monitoring, and tutoring, father absence, conflicting

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relations with siblings, and so on. Such adverse conditions actually reinforce the harmful effects of negative punitive strategies or harsh parenting, increasingly disabling young children in their social-emotional development and schooling. A study of the perceptions of a sample of 600 primary school teachers in Crete Island of their students‘ behavior showed high rates of challenging behaviors. Specifically, a high percentage of teachers reported behavior problems (89.1%), cognitive difficulties (83.5%), and lack of students‘ attention and motivation (75.9%), as the most challenging issues that these teachers face in their classroom. In addition, these problems constitute significant sources of anxiety and stress for teachers (Thanos, Kourkoutas and Vitalaki, 2006). A recent study conducted by the University of Athens with youths 12- through 16-years old showed that about 16% of preteen and teenage boys and girls reported experiencing internalizing or externalized difficulties. The association of academic pressure and of cognitive and psychological difficulties seems to undermine the adaptation of these children to school, as well as to jeopardize their social interpersonal development (Kourkoutas, 2011). In summary, there is substantial evidence that clinical patterns related to disruptive behaviors are evident as early as the first year of life (Wakschlag and Danis, 2009). Clinicians, teachers, and parents have long recognized that disruptive behavior problems in young children are real and impairing—disruptive behavior is the most common reason for mental health referral of young children (Wakschlag and Danis, 2009). According to all available evidence, an increasing number of infants and children exhibit behaviors that meet criteria for a clinical diagnosis of defiant oppositional or conduct disorder (Walker, Ramsey and Gresham, 2004). From the other side, a high number of children with mild disruptive behaviors (e.g., hyperactivity, sporadic tantrums, and disturbing behaviors) may not meet these criteria, although most of these behavioral difficulties remain quite impairing and challenge teachers', parents', and clinicians' capacities to deal with them. Children who display milder forms of disruptive or problematic behaviors may also require a variety of interventions in order for behaviors to be handled, modified, or improved, but also to effectively respond to their profound or unmet social-emotional needs or unresolved family problems. Above and beyond strictly behavioral treatment that many school-based services provide, a comprehensive psychodynamic intervention targeted to deepening in the child‘s intrapsychic and family dynamics is often necessary in order to enable these children to overcome their internal limitations and impairments and fully develop their social, emotional, and academic competencies.

TERMINOLOGICAL ISSUES AND TYPES OF BEHAVIORAL PROBLEMS IN SCHOOL AGE CHILDREN Regarding the terminology of behavior disorders, various terms have been used (e.g., oppositional, reactional, antisocial, disruptive, disturbed, aggressive behavior, conduct disorder) to describe the wide range of problematic or aggressive behaviors identified during childhood and adolescence (see Hinshaw and Lee, 2003; Τremblay, 2000). Disruptive behaviors during early school age include behavioral and conduct problems, defiant oppositional disorder and hyperactivity or ADHD (Walker et al., 2004). It is possible that these disorders appear all at once or in different combinations between them (American

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Psychiatric Association, 1994; Burke, Loeber and Birmaher, 2002; Farrington, 1998; Lahey, McBurnett and Loeber, 2000; Walker et al., 2004). Concerning difference of gender and type of problematic behaviors, it is generally suggested that boys are at higher risk to develop externalizing problem behavior than girls, who tend to display more internalizing dysfunctions in childhood and early adolescence. However, some authors have argued that girls manifest antisocial behaviors that are similar to those of boys but are less likely to experience the necessary pathogenic processes (e.g., high levels of impulsivity, deficits in conscience) that can lead to the development of antisocial behavior (Frick and Kimonis, 2008, p. 361; Moffitt and Caspi, 2001). According to classical psychiatric taxonomies, as for example the DSM-IV, conduct disorders, defiant/oppositional disorder and hyperactivity (ADD/HD) are considered the most common problems in childhood (APA, 2000; Carr, 1999; Frick, 2004; Frick and Kimonis, 2008). The term "conduct disorder" in the DSM classification refers to the most serious forms of behavior problems (Frick, 2004; McMahon and Kotler, 2004; Walker et al., 2004). Specifically, a conduct disorder is considered acts of the child related to enduring antisocial and aggressive patterns toward others (e.g., peers, parents, teachers, and others) (for a further presentation of psychiatric categorizations cf. Burke et al., 2002; Frick, 1998; 2004; Frick and Kimonis, 2008; Hinshaw and Anderson, 1996; PDM, 2006; Walker et al., 2004). Moreover, antisocial disorders include serious acts of violence against persons, vandalism and delinquency, use of illegal substances in adolescence, and in general serious social and interpersonal problems. The frequency, intensity, and extent of these acts are related to the severity of the disorder and psychological problems associated (Mash and Wolfe, 2001). Defiant oppositional disorder in childhood usually exhibits with a pattern of disobedience and negative provocative hostile behavior toward teachers, other adults, and especially the representatives of authority (McMahon and Forehand, 2003; McMahon and Kotler, 2006). More recent research has used the presence of a callous and unemotional interpersonal style (e.g., lacking empathy and guilt, constricted emotions) to designate a distinct group of children with severe and chronic conduct problems (Frick, 2006; Frick and Kimonis, 2008). While callous and unemotional traits seem to be more common in the childhood-onset group, they are characteristic of only about a third of these children (Frick and Kimonis, 2008). However, this minority of children with childhood-onset conduct problems seem to show a more severe, aggressive, and stable pattern of behavioral difficulties (Frick and Kimonis, 2008, p. 360). The presence of callous-unemotional traits appear to designate a more severe group of children within the childhood-onset group (Frick, 2006). These traits also may be a marker for a group of children who have different causal processes leading to their behavior problems (Frick, 2006; Frick and Morris, 2004; Frick and Kimonis, 2008). The dimensions of aggression and conduct problems include: a) Overt aggression, such as harmful verbal or physical acts of aggression directed toward other people and property, a wide spectrum of aggressive confrontation at home and school between the child and his parents/teachers/peers which can range from mild to severe oppositional behavior, fighting, and physical aggression (Blooqmuist and Schnell, 2002; Carr, 1999; Frick and Kimonis, 2008); b) Reactive/proactive aggression, such as an unplanned responsive aggressive behavior to an evoking stimulus or a planned aggressive behavior with the intention to get some profit or achieve a goal (Blooqmuist and Schnell, 2002);

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c) Relational aggression, which is characterized by the intentional actions of one child toward another that are designed to harm through manipulation and damage to relational status (Blooqmuist and Schnell, 2002); d) Bullying, which include a variety of overt and covert physical or psychological aggressiveness aiming at harming others; e) Violence, which involves an act or pattern of actions that inflicts serious physical harm on others; f) Covert stealing and firesetting with the intention to harm others; g) Child delinquency which refers to children who have committed a serious crime; h) Psychopathy involves children who exhibit aggression, as well as risk-taking and sensation-seeking behavior. Callous-unemotional traits are likely the most salient characteristics in psychopathic youths, though this disorder has not yet been extensively investigated in children (Blooqmuist and Schnell, 2002). It is worth noting that all children with behavior problems identified by teachers and specialists or parents do not necessarily meet the strict criteria of a defined clinical category. These children may display special difficulties that place them at risk to develop more serious mental health or adjustment problems if their needs and difficulties are not met and resolved in effective ways (PDM, 2006; Weare, 2000; Wyman, 2003). It is important to emphasize that an increasing number of children entering school are struggling with complex emotional and behavioral needs and difficulties. Moreover, a wide range of behavior problems varying in form, persistence, and severity are present within the school context. Such multifaceted behavioral problems reflect enormous variability on psychic and family dynamics. A high percentage of these children experience compound social, emotional, and behavioral difficulties and/or disorders not effectively dealt with by educational or professional staff. Therefore, these children may progressively experience significant additional symptoms (e.g., socially withdrawn, learning disabilities, depression, etc.) that vary in severity and persistence. They may also have different chances to progress and different pathways toward a more serious mental health disorder. Such multilevel heterogeneity of students‘ problems has important implications in the design of school-based prevention and intervention programs, as well as in children‘s response to intervention (Burke et al. 2002; Frick and Morris, 2004; Green et al. 2004; Hinshaw and Anderson, 1996; Loeber and Stouthamer-Loeber, 1998; Tremblay, 2003). For instance, children (especially boys) who have general behavioral dysfunctions or only ADHD (hyperactivity), without aggressive traits and come from supportive family environments, have significant differences on several levels in relation to children who have both oppositional defiant disorder, enduring patterns of aggression and hyperactivity syndrome and who come from very dysfunctional families (Kourkoutas, 2011; Waschbusch et al., 2002). Their fundamental difference is based on the intensity and severity of the disorders and the accompanying emotional problems, as well as on the resilient and adaptive skills that these children may display. Most children with persistent dysfunctional or challenging behaviors are lacking adequate emotional and interpersonal skills and a supportive environment that might enable them to develop these skills. Their advancement seems to be more "problematic" because of their negativity toward interventions and their exclusion from social and educational processes (Waschbusch et al., 2002).

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School psychologists, teachers, and other professionals must take into account these essential variations related to the co-morbidity, severity and extent of symptoms, as well as to the dissimilar developmental courses and contextual environments in which the child lives and functions (Fraser et al., 2004; Kazdin, 2000; Kourkoutas, 2008a; Kourkoutas and Georgiadi, 2009; Tremblay, 2000; Wyman 2003). The main goal in all such cases is to design and implement a child-centered intervention that is developmentally sensible. an intervention that attempts to not only address the symptomatic reactions of the child (problems/disorders), but to enable children with the use of appropriate psychosocial strategies to develop the required social, emotional, and academic skills (Elias, 2003; Hanley, 2003; Kourkoutas and Georgiadi, 2009; Weare, 2000; 2005). According to recent research data, traditional psychiatric approaches are not recommended for use within school context, since they are less likely to be effective, even in the most severe cases of behavioral problems (e.g., antisocial adolescents). In contrast, it has been shown that multidimensional multisystemic interventions are more effective for such disordered youths with extreme problematic behaviors (Dishion, and Stormshak, 2006; Ogden and Hagen, 2006). Traditional psychiatric approaches, being primarily symptom- and deficit- oriented, are less likely to consider and adopt a holistic view of the child's problems and to aim at fostering his positive psychosocial development (see also Gresham and Kern, 2004). These approaches are also less likely to systematically and thoroughly address external risk factors because they essentially focus on individual traits. Actually, Gresham and Kern (2004) identified four major difficulties using the DSM system –the basic diagnostic tool of the medical model- in school system to qualify students for services under the EBD in schools (p. 264). These are the followings: (a) the DSM terminology is based on the medical model view of human behavior in which disorders are considered to be ―within-person‖ problems; (b) the DSM system uses a structural or descriptive approach to behavior rather than a functional approach; (c) the DSM has significant weaknesses in terms of reliability issues; and (d) (the greatest weakness) the absence of treatment validity. Understanding children‘s emotional functioning and the relationship between internal self- and other-representations, and family and contextual dynamics (risk and protective factors), appears to be a key parameter of appropriate psychosocial and educational interventions for children with dysfunctional behaviors (Atkins et al., 2001; Fraser et al., 2004; Fraser and Williams, 2004; PDM, 2006; Kourkoutas, 2011; Kourkoutas and Georgiadi, 2009; Kourkoutas et al., 2011; Schmidt Neven, 2010; Young et al, 2004; Weare, 2005). To sum up, disruptive and problematic behaviors include noncompliant, challenging, defiant, oppositional, hyperkinetic, overt and covert aggressive, disorganized or instrumental aggressive, violent behavior, conduct, and antisocial disorders. These behaviors are accompanied by a multitude of affects including negative or very poor and cold emotions (e.g., sadistic feelings). They may be active and deliberate, or passive and disorganized. They can be triggered by relative external stimuli or by the child‘s distorted attributional style (distorted cognitive schemata) which are likely to interpret any neutral stimulus as threatening or dangerous. On the other hand, it is essential to remember that problematic or aggressive behaviors nearly always emerge or are elicited within multiple systems of overt and covert social, emotional, and interpersonal interactions that external observers are frequently not in a position to evaluate. Therefore, beyond psychiatric categorizations, it is crucial to develop a framework that describes both the deeper and surface levels of the child‘s personality,

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emotional and social functioning, and symptom patterns, as well as the risk and protective factors related to his life contexts (Fraser, 2004; Kourkoutas, 2008a; PDM, 2006; Schmidt Neven, 2010). Emerging evidence suggests that ―oversimplifying mental health phenomena in the service of attaining consistency of description (reliability) and capacity to evaluate treatment empirically (validity) may have compromised the laudable goal of a more scientifically-sound understanding of mental health and psychopathology‖ (PDM, 2006; Spiegel, 2005).

CHARACTERISTICS OF CHILDREN WITH BEHAVIOR PROBLEMS

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It is quite uncommon in clinical practice to introduce or impose an absolute dichotomy/splitting between emotional and behavior problems and to consider them as two totally distinct entities3. For instance, an increasing number of studies show that most children with behavior problems are characterized by more-or-less disordered, destabilizing emotional states or very poor socio-emotional functioning (Scriva and Heriot, 2008). Actually, these children often struggle internally with intense negative and conflicting emotions (e.g., painful and unbearable feelings, ambivalence towards parents, anger, depressive feelings, etc.). Hence, because they are emotionally less skillful, they are inclined to express such emotional conflicts in behavioral acting out (Kourkoutas, 2011; Scriva and Heriot, 2008). From the other side, clinical and research evidence show the prevalence of one or the other form of disorder, at the phenomenological level. Overall, children who display emotional and behavioral problems have one or more of the following characteristics (see Carr, 1999; Kauffman, 2000; Young et al., 2004; Walker et al., 2004):     

An inability to learn, which cannot be explained by intellectual, sensory, or health problems; An inability to build or maintain satisfactory interpersonal relationships with peers and teachers; Inappropriate patterns of behavior or feelings and emotional responses or interactions with others under normal circumstances; A general, pervasive mood of unhappiness or depressive tendencies; A tendency to develop physical symptoms, pains, or fears associated with personal or school problems.

A youngster cannot be socially maladjusted by any credible interpretation of the term without exhibiting one or more of the five characteristics to a marked degree and over a long period of time (Kauffman, 2000, p. 30). In an effort to provide a comprehensive view of children with emotional or behavioral disorders and for special education enrollment purposes, a new definition was proposed in the

3

It is for this reason that many of contemporary researchers frequently refer to emotional and behavioral problems, as a larger conceptual construction that better describe the clinical reality of a huge amount of students with significant differences in their symptomathology and psychic dynamics.

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late 1980s which includes in addition the following characteristics and information (see Kauffman (2000) for discussion): 

 

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 

Behavioral or emotional responses in school programs are so different from appropriate age, cultural, or ethnic norms that they adversely affect educational performance, including academic, social, vocational, or personal skills; EBD is more than a temporary, expected response to stressful events in the environment; EBD is consistently exhibited in two different settings, at least one of which is school-related; EBD persists despite individualized intervention within the education program; EBD can coexist with other disabilities.

It is also worth stressing that many aggressive children display internalizing difficulties or disorders (e.g., anxiety, phobias, or depressive tendencies); yet there is enough clinical and research data available to claim that the behavior problems often cover serious emotional problems and distortions in the representational (self and other) system (Scriva and Heriot, 2008). Moreover, the psychodynamic approach suggests that the externalizing disorder during childhood coexists in most cases, in various degrees and combinations, with internalizing /emotional disorders (anxiety, dysphoria, depression, and phobias) or disorganized and destructive affect (e.g. sadistic anger, rage, hostility). For instance, in cases of extremely antisocial aggressive youths who exhibit callous/unemotional traits, it is believed that due to significant deficits in the primary affective environment or due to traumatizing relationships, these youths are lacking in the necessary emotional /empathetic skills to form satisfactory and affective relationships with others (Ford, 2002). Such youths display destructive forms of relatedness to others, since they have never experienced supportive and nurturing attachments to internalize, enabling them to develop positive patterns of relationships. Since they didn‘t have the chance to internalize positive experiences and interactions with others, they also suffer from negative interpersonal schemata which facilitate the enactment of concomitant negative emotions. In the case of repetitive maltreatment, children are not able to form positive self-images and develop emotional skills, such as empathy and affection towards others. These children are continually exposed to threatening situations. Emotions such as fear, anxiety, and panic are confounded with rage and hostility. These children often refuse to be ―held‖ or even approached by positive adults because they experience the acceptance of loving relations as an indication of their internal vulnerability (Kourkoutas, 2011). Such children are continuously renouncing and defending against their profound and unmet emotional needs; oppositional or aggressive behavior serves as a protective mechanism in such cases. Actually, classical psychoanalytic theories (e.g., object relations theory) view conduct disorder revealing deficits in basic personality structures and relationships patterns of the child (Kernberg and Chazan, 1991). This model posits in general that children with conduct disorders tend to internalize negative parental images associated with negative feelings (Kernberg and Chazan, 1991)(see also Scriva and Heriot (2008) who focus on interpersonal schemata of aggressive and depressive children). Rage, hostility, anxiety, and concomitant negative self-images accrue to form a negative self-concept with low self-esteem and

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dysphoria (Kernberg and Chazan, 1991, p. 5). Many aggressive children or children who bully may display an inflated self-representation, which can be interpreted as a defense strategy in order to counterbalance or neutralize negative self-images and associated painful emotions related to previous traumatic experiences of violence, maltreatment, or rejection. Such youngsters may also exhibit cruel emotions and harsh attitudes towards their peers, remaining insensitive and untouched by others‘ pain and suffering. Actually, according to psychodynamic theories, the introjected negative representations of self and others tend to be projected onto the outside world. Thus, maltreated or rejected children come to perceive others as they have been perceived themselves (Kernberg and Chazan, 1991). Within family or school context, defiant, challenging, provocative, or aggressive children end up by inducing in others a secondary punitive aggressive reaction. Actually, the adults around these children, who are often unaware of these particular interactions and projections, assume the role of the aggressor. For instance, a teacher or a parent may begin to criticize or be directly negativistic and punitive, thus enacting for the child his own self-criticism (negative introjects), while the child feels himself to be the victim of misunderstanding and blame (Kernberg and Chazan, 1991). It is increasingly being suggested that the presenting characteristics of children within each of these subtypes vary significantly. Children with attention deficits without hyperactivity tend to be more anxious and shy, more prone to academic difficulties and more likely to exhibit slow and variable processing speeds. Those who exhibit hyperactivity are more likely to have concurrent conduct disorder, to be distractible and to lack many social skills (Schmidt Neven et al., 2002, p. 47).

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KEY CHARACTERISTICS OF CHILDREN WITH BEHAVIORAL PROBLEMS As far as self-esteem (self-esteem) is concerned, previous research has found that aggressive children, especially children who are introverted or socially "withdrawn," have significantly lower self-esteem than children without disorders or disabilities and behavioral problems (control group) (Schneider and Leitenberg, 1989). The main characteristics of many of aggressive children and antisocial youths are a devalued self-image, distrustful interpersonal relationships, a desire to be powerful, and low tolerance of frustration (Hayez, 2007). Other studies have shown that aggressive children who are rejected by their peers may, however, develop inflated self-concepts (self-esteem), distorted attributional style, and judgments regarding the way they think others see them (Rudolph and Clark, 2001). Consistent with these findings, other studies have shown that many children with behavioral disorders often display an exaggerated self-esteem, one that is extremely unrealistic (Baumeister, Smart and Boden, 1996). It can be argued that an inflated, unrealistic selfesteem functions as a defense mechanism against these children‘s low or negative selfconcept, concealing negative or unbearable self-emotions, because children with conduct problems often share a core feeling of being unloved and uncared-for (Kernberg and Chazan, 1991). When they are responded to in a way that is attuned to their needs they are certain that

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others will believe their low self-esteem and sense of worthlessness are their true qualities (see Kernberg and Chazan, 1991, p. 5). This means that reactional aggressive behavior may be interpreted to some degree as a shield, protecting the fragile or negative self-esteem of the child from external stimuli perceived as threatening to his psychological integrity (Baumeister, Smart and Boden, 1996). It can also signify that these children may not possess adequate interpersonal skills to gain a positive self-image through socially acceptable behaviors and relationships that are fulfilling. Research has revealed the presence of depressive feelings and depressive selfrepresentations in groups of children who display aggressive or antisocial behaviors (Capaldi and Eddy, 2005; Frick, 2006; Scriva and Heriot, 2008; Marshall and Watt, 1999). These data are consistent with the clinical picture of many of these children who appear to be emotionally disturbed or confused (Campbell, 2002; Wachtel, 1994). Other researchers argue that distorted self-concept and the inability of these children to behave in a sociallyacceptable manner may be interpreted to be the result of self-protective mechanisms (emotional defenses) they developed to deal with adverse experiences and perceived threats present in their close relationships (Allen, 2001; De Zulueta, 2000; Hughes, Cavell and Grossman, 1997; Zakriski and Coie, 1996). As far as their emotions are concerned, irritability and anger seem to be the most prevalent emotional states of children who are oppositional defiant and display conduct disorders (Behan and Carr, 2000; Campbell, 2002; Carr, 1999; Loeber and Coie, 2001; Pettit, Polaha and Mize, 2001). Additionally, physically aggressive children have been found to exhibit information- processing biases, relative to their non-aggressive peers (Delveaux and Daniels, 2000). These children are more likely to attribute hostile intent to their peers when presented with ambiguous situations (Crick and Dodge 1994); moreover, Crick and Dodge (1994) found that the key emotional elements involved in this attribution process /cognitive mechanism that holds others responsible for their displays of aggression are over-excitement and anger. Depression and anxiety also appear to be linked to both behavior problems and conduct disorders (Allen, 2001; Scriva and Heriot, 2008; Zocolillo, 1992) and to attention hyperactivity disorders (Nottelman and Jensen, 1995). Therefore, disruptive and aggressive antisocial behaviors may often mask lesser or more serious depressive emotional states related to post-traumatic disorders (Allen, 2001; De Zulueta, 2000; Schneider and Leitenberg, 1989). Moreover, aggression can be interpreted from a psychodynamic point of view as a reaction to depression (anti-depressive reaction) and phobias (anti-phobic strategy). The child, through his aggressive and disruptive behavior, may release and act-out his depressive or unbearable distressing emotions and thoughts, using at the same time this unconscious strategy to fight against his inner weakness and passivity (Kourkoutas, 2007; Kourkoutas and Georgiadi, 2009; Weisberg and Greenberg, 1988). Depressive trends might relate to strong internal conflicts and tensions, accumulated anxiety, and a deficient sense of self that pertains to the way these children are being raised by families. Lack of support on the part of parents and the negative behaviors they have experienced within the family contribute to negative self-esteem (Campbell, 2002; Wachtel, 1998). Long-lasting negative parental attitudes and the lack of stable emotional parental support these children have probably experienced within their family contribute to the development of emotional deficits, low or incoherent sense of self, problematic attachment patterns, and limited psychosocial skills (Campbell, 2002; Garbarino, 1995; Sroufe et al., 2005). Children who display behavior problems and are

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aggressive in school are also likely to be rejected by their non-aggressive peers, and face serious difficulties with their social-academic adjustment (Ladd, 1992). Peer rejection, school maladjustment and the inability to establish fulfilling and positive relations with their teachers and classmates may accentuate the depression and negative self-concept of these children, thus increasing the risk for some of them to exhibit increasingly serious aggressive and antisocial behaviors (Kaufmann, 2001; Pianta, 1999; Pianta, 2006; Rutter et al., 1999). Many aggressive children seem to suffer from stressful and disruptive emotions (Greenspan, 1995). It is not accidental that the stressful, insecure, or disordered and problematic patterns of attachment and the conflicting or ambivalent emotions towards others are key characteristics of the way in which aggressive children function (DeKlyen and Speltz, 2001; Kauffman, 2001; Sroufe et al., 2000; 2005; Wolfe, 2001). In addition, children who come from very insecure or dysfunctional family environments demonstrate severe emotional and behavioral problems. There are cases where specific traumatic events, such as a serious illness of a parent or a conflicting divorce, can have a destabilizing impact on the way the child functions and behaves. In these cases, intense feelings of insecurity, acute anxieties, threats, and painful depressive feelings may accompany aggressive behavior or be concealed by it, thus further impairing relations between the child and his environment. Clinical case: P. a 6.5 year old manifested aggressive and disruptive behavior; he was constantly hyperactive and refused to do anything because he claimed to be tired and exhausted. At the same time, he demonstrated a general psychosocial disruption, inability to relax, to concentrate, and to play with other children. P. was socially withdrawn, he often walked alone, and he did not allow others to approach him. Despite the efforts of his teachers to approach him in a friendly way, he was negative and oppositional, while at the same time he was irritable and became easily angry when he was told to behave himself. His teacher said that she tried repeatedly to help him, but he seemed to be an unhappy child and was unable to function within a group. When she tried to scold him, as there was no other way to calm him down, he cried. His parents did not communicate with the teacher for a long time. The father is a menial worker, while the mother does not work and stays home looking after the second child. A meeting with his grandmother and his aunt revealed that the family condition is tragic. The mother has cancer and suffers a great deal. At the same time, she worries about her health, does not go out, and obviously suffers from depression. On the other hand, the father works a lot in order to cover mounting medical expenses. According to relatives, P. was quite different when he was younger. His problems started after the birth of the second child and his mother‘s illness. Due to her condition, his mother cannot care for him and he occasionally stays with his grandmother and aunt. Obviously, the child is experiencing a traumatic event in his family. His mother is unable to take care of him, while on the other hand he does whatever he can to care for his little brother. The mother has been hospitalized for long periods. During the meeting of the family with the school‘s psychologist (the mother was unable to attend) it was clear that they never talk about the illness of the mother. They mentioned neither the way the illness was progressing nor the time it could last. At home, P‘s behavior is oppositional, refusing to go to sleep or eat, while at the same time there are moments that he cries or throws tantrums, leaving his grandmother and aunt unable to act. On the other hand, he often complains about stomach aches and headaches and then he cries. Even though he hasn‘t been seen by a doctor, his aunt suspects that P. fakes his problems so that he is allowed to see his mother. In the interview that follows, P. comes across as a child trapped in a dramatic family situation that he is unable to deal with. He

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seems to experience a really disruptive phase in relation to his family, and his emotions are intense and contradictory. On one hand, he claims to hate his aunt and grandmother, while on the other hand, he admits that he is very sad and he misses his mother. He also admits that he knows that his aunt loves him and she wants to take care of him, but he doesn‘t want to be with her at all. He knows that his mother is very ill, and when asked whether he is afraid that his mother will die, he answers affirmatively. He does not understand why the baby stays at home while he does not. He wants to return home in order to help his mom. On the other hand, according to what his grandmother said, he often bullies his little brother. As for P‘s father, he said nothing. During the interview, P. was serious and focused, his eyes were downcast and he listened carefully to the psychologist who told him that he thinks he is very angry with his family and at the same time he is very afraid for his mother and he feels very sad. He gets angry and outraged because nobody understands or trusts him, and this is the reason why he misbehaves and constantly keeps to himself. After these comments, P. remained silent and kept his eyes on the floor. His aunt reported that P. cried all day after his meeting with the psychologist. In this case it is clear that P. is disrupted by the family atmosphere, the inability of his mother to take care of him because of her illness, the absence of his father who is neither caring nor supportive, while the fact that his aunt and grandmother take care of him is experienced as a rejection by his family. He realizes the seriousness of his mother‘s condition, while the fact that the family avoids talking about the illness of his mother and his inability to express his feelings constitute a source of great stress and insecurity for him. All this is made worse by the inability of his teachers (and the absence of counselors) to get to the root of the problem that tortures P. His aggressiveness is rather superficial and it is a reaction to the unbearable feelings of pain and rejection he experiences, and the inability of the people around him to deal with his feelings and consequent reactions. The clinical evaluation showed that he is a vulnerable and tormented child (irritable, socially isolated, unable to function within groups), who is overwhelmed by anger and fears. The inability of his environment to support P. and give him the opportunity to express his fears and anxieties, while at the same time keeping silent about the progression of the disease of his mother, increased P‘s. feeling of insecurity and opposition such as anger, irritation, and despair. He feels forced to express himself in a defiant way, complaining about his physical condition, and refusing to accept the help of his teacher and of others who approach him. Boys who exhibit both conduct and anxiety disorders appear to be less aggressive than those who display only conduct disorder (Walker, Colvin and Ramsey, 1995). It is assumed that the presence of anxiety in children together with conduct disorder can reduce the amount and intensity of aggressive behavior (see Mash and Wolfe, 2001). In contrast, Barrett and colleagues (Barrett et al., 1996) found that children with defiant oppositional reactions interpreted external stimuli as threats much more than children suffering from anxiety. They were thus more inclined to employ even more aggressive solutions than stressed or "normal" children. Meanwhile, as clinical cases cited earlier demonstrate, the presence of anxiety in some cases probably increases the tendency children have to exhibit problematic reactions, especially when the child is unable to manage specific traumatic events that exceed the usual mechanisms of his defense (Fonagy and Target, Parsons and Dermen, 1999). In other words, children are likely to use problematic strategies to deal with situations that relate to painful emotions associated with past or present traumatic experiences.

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Researchers unanimously support that some children who bully other children share many characteristics in general with aggressive children. These characteristics usually include a hot temperament (Smith, Nika and Papassidéri, 2004), and especially a tendency to act out negative feelings (Greenberg and Weisberg, 1988). Children with behavior problems usually manifest:

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an adherence to role models that are exclusively oppositional or aggressive; very low or negatively exaggerated self-esteem ; distorted self concept; limited capacity to play creatively; use of a hostile/antisocial vocabulary; insecure internal working models; limited positive interpersonal skills; limited academic skills; and, in general, an unwillingness for social contact and positive interaction with other children of similar age or with adults (Mash and Wolfe, 2001; Rutter, Giller and Hagell, 1998).

Moreover, they display, compared to non-aggressive children, more negative and vindictive emotions, a strong inclination towards impulsive behavior, anxiety and depression, limited capacity in expressing and verbalizing feelings and emotions, and inability to emotionally invested to relationships which may subsequently limit their capacity to manage and resolve interpersonal difficulties with others (Behan and Carr, 2000; Carr, 1999; Caspi and Moffit, 1995; Frick, 1998; Garber, Braafladt, and Zerman, 1991; Loeber and Hay, 1997; Quiggle et al., 1992). Clinical example: G., who is 11 years old, presents one of the most serious problems for his school. The headmaster, in agreement with G‘s mother, turned to a psychologist in order to deal with his behavior problems because he is constantly involved in fights, and exhibits persistent opposition toward his teachers. G. can be very cooperative, and beyond a few superficial jokes—manifested by his initial embarrassment about talking with the psychologist—can open up during the sessions. He will talk, mentioning his problems and his feelings toward others (parents, teachers, and classmates). The psychologist helps the child to verbalize his feelings. He speaks freely for the first time without being judged or criticized for his ―awful‖ thoughts and unacceptable or deeper desires in front of others. The meeting with G. has shown that he is a child filled with fear, hatred, and vindictive emotions toward his father, who was always aggressive towards him - and G‘s mother. G‘s father had serious health problems and it seems that this somehow exacerbated his behavior. Through G‘s sessions with the psychologist the pain and desire for revenge that G. feels for the insults and bad behavior of his teacher are manifested, behavior that was confirmed by the school principal and his colleagues. Within the family, neither his father nor his mother—with whom G‘s relationship was disrupted—were able to help him express his desires and needs. Many authors have argued that violent and dysfunctional families do not allow their children to develop their executive, verbal, and cognitive skills to the extent they are able to do so, since communication is not systematically promoted and the emotional atmosphere is very hostile, disorganized, or conflicting (Nigg and Huang-Pollock, 2003). Moreover, G.

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tended to be isolated and melancholy, while at the same time he felt angry because most of his classmates did not accept him. Many of his actions constituted overt provocations toward his peers, expressing mixed feelings of anger along with his desire to be accepted.

MILD FORMS OF PROBLEMATIC AND AGGRESSIVE BEHAVIORS AS SYMPTOMATIC REACTIONS Beyond the medical approach, which considers disruptive behaviors exclusively as a manifestation of intrinsic neurobiological dysfunctions, the problematic behavior of a child when seen as an external symptom of internal dynamics can be considered to have ―meaning‖ and function for psychological wellbeing—and the way the child tries to deal with interpersonal relationships. Clinical and empirical research, as well as counseling data, demonstrate that children often consciously or unconsciously behave in a provocative, problematic, or reactive way for various reasons and, primarily, as a response to concrete intra- or interpersonal problems (Campbell, 2002; Kauffman, 2000; Kourkoutas, 2007; Kourkoutas and Georgiadi, 2009). Many researchers and clinicians believe that the oppositional problematic or aggressive behavior is used by the child to (Kourkoutas, 2011; Lanyado, 1999; Webster-Stratton, 1999):   

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attract the attention of others (parent, teacher, peer); prevent conflicts from happening between his parents; use it as an outlet or reaction to frustration he has experienced (from a teacher, parent, brother, peer); exact revenge upon certain people experienced as traumatic or provoking, or to use it in contexts where the child also experiences negative emotions (tension, anxiety, sadness, dismay) or severe frustrations; use it as a defense against fears and feelings of insecurity or weakness and powerless (―antiphonic reaction"), or even as self-protection against other classmates experienced as threatening; avoid certain tasks /obligations that might be difficult, painful, distressing, or boring or to avoid a task-related failure or self-exposure that can jeopardize self-image; control and test the intentions of others (e.g., teachers);

On the other hand, as mentioned, many problematic or aggressive behaviors in preschool and school age may be linked to a series of parameters referring to family, school, and social contexts, as to individual features, as well. Therefore, disruptive or problematic behaviors can (Campbell, 2002; Kauffman, 2000; Kourkoutas, 2007):   

stem from the child identifying himself with the model of an aggressive parent (father)/big brother/peer; be associated with intense competitive emotions towards a younger or older sibling, which his parents cannot understand and manage appropriately; be associated with a series of aggressive or problematic self- and otherrepresentations/working models which guide and shape behavior;

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associate with the conviction/representation of the child that by displaying these behaviors he may achieve his goals (instrumental aggression); be used by the child to gain prestige/status (find a place in the classroom or family which cannot be attained by other acceptable means) /power over his classmates, to restore his damaged self-image, or even because he finds it is fun to intimidate them and cause disruptions in the classroom; relate to the fact that the child is unable to form relationships with others based on trust, positive emotional exchanges, and mutual respect, since he hasn‘t the skills to do so; mask his weaknesses, his feelings of inadequacy, low self-confidence, or even strong anxiety disorders; reflect his inability to manage intense conflicting feelings or distressing and ambivalent emotional states related to significant others; result from cognitive deficits/distortions, academic failure, and/or serious school and psychosocial difficulties; express a specific family problem or a serious critical transition for the family or a traumatic event in the family (e.g., death, serious illness), or even family dynamic disorders and conflicts.

During the preschool years, it is clear that many disruptive and troublesome behaviors stem from the child‘s inherent inability to function appropriately in complex social situations or respond to the school requirements. This signifies the child‘s immaturity at the social, emotional, and cognitive levels. In other cases, problematic behavior persists as long as the critical or adverse conditions that have provoked it, and the resulting negative emotions continue to press. In such cases, obviously inappropriate behaviors do not necessarily relate to a persistent inner disorder. Rather, they are symptomatic of a series of emotional tensions that the child cannot manage or express and communicate in another way. When disturbing conditions that are considered to be the root of the problems , such as a family crisis or conflict, a bad or negative attitude of the teacher towards the child , do not exist anymore or have been treated, it is quite common to observe that the problematic behavior decreases or even disappears completely (Greenspan, 1995; Kauffman, 2000; Kourkoutas, 2007). Clinical example: S. is a 10-year-old boy in fifth grade, among the best students. The teacher calls his parent to school because S., without assaulting other children physically, becomes involved in fights, acting verbally provocative to others, creating very unpleasant and distressing situations in the classroom with his own classmates, and especially with children from other classes. Gradually, S. has become more and more involved with older children in fights and physical conflicts, apparently emotionally very upset, according to his teacher‘s comments, while teachers from other classes declare that they find this child very disordered. His classroom teacher is surprised and worried by the behavior of S., because since he first knew him, S .has been a ―modest,‖ ―self-contained,‖ and very polite child, who was always well-behaved. S. was quite a good student and an exceptional athlete. His parents consulted a psychologist and in their first meeting they discussed; their problems. The situation at home is unbearable, as the father every day comes home at midnight; the mother believes that her husband is involved in an extramarital affair. After a few sessions with the psychologist, the parents finally decide to divorce. The absence of the

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father from the house, and some conflict when he was at home, created a distressing and depressive climate at home for a long time. The mother is not at all aggressive, but she cannot stand this situation any longer, it has been going on for years. She has silently suffered, not reacting at all until this last year. Since S. was born, things went from bad to worse between his parents, but for the last five years the father has been totally absent from the family. The mother insists that S. should continue to see a psychologist "as long as this is necessary." She has focused on her child and she is very warm towards him and supports him. During the sessions, S. seems to be withdrawn and introverted; and it will take some time before he starts to open up. Despite this, he is very receptive to the psychologist and responds positively to any comments or interventions. After the first sessions, his bizarre and aggressive behavior completely disappeared. It was obvious in this case that there was no specific disorder, but a problematic response that expressed the negative feelings and the crisis that the family was going through for a long time. In a letter that S. wrote at Christmas and in some of his drawings that his mother saw, S‘s sadness and grief over the absence of his father were evident. He expressed hope that his father would come home. A holistic evaluation of the family dynamics is more necessary in such cases in order to expose underlying causes (e.g., parental problems) than on a simple behavioral diagnosis or assessment of the child‘s symptomathology. Actually, a systemic psychodynamic approach that considers all dimensions and aspects related to the problematic behavior (e.g., evaluation of child‘s psychosocial functioning, the couple relationship, parental rearing practices and skills, family history, and dynamics, etc.) seems to be imperative in order to gain a thorough insight for design of the intervention process. In fact, an important parameter in working with children is understanding the child‘s personal characteristics and style of functioning (child‘s psychic dynamics), dynamics of their family, and school environment as well (Kourkoutas, 2007; Kourkoutas and Georgiadi, 2009; Kourkoutas and Raul Xavier, 2010; Schmidt Neven, 2010).

RELATIONSHIP DYNAMICS AND FAMILY CHARACTERISTICS OF CHILDREN WITH BEHAVIORAL PROBLEMS Numerous studies have provided strong evidence for the indisputable correlation between negative and painful experiences early in childhood (such as parental psychological disorders, marital conflict, etc.) and the development of behavior problems in the future (Bank et al., 1993; Born, 2005;Cerutti and Manca, 2008; Cummings et al., 2002; Fiese, Wilder and Bicham, 2000; Frick et al. 1992; Christenson, Hirch and Hurley, 1997; Marshall and Watt, 1999; Maughan, 2001; Patterson, Capaldi and Bank, 1992; Rutter, Burge and Hammen, 1998). More specifically, parental inconsistency and emotional instability, parental inability to express clear expectations and set realistic and reasonable limits, lack of monitoring and guidance of children's behavior, harsh or inappropriate punishment, unpredictable, contradictory and coercive disciplinary measures, and lack of positive behavioral models are considered to be risk factors for the development of behavioral disorders in childhood and/or adolescence (Gardner, 1989; Forgatch and Patterson, 1998; Patterson, 1982). Harsh punishment seems to be a risk factor most common among families of children who have

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developed oppositional behavior, or where they are aggressive and hyperactive (BergNielsen, Vikan and Dahl, 2002; Stormshak et al., 2000). Other studies have found a strong correlation between the use of corporal and aggressive punishment on the part of parents and the manifestation of aggression in children. Similarly, another study has shown that lack of stable emotional support, critical parental attitude, and especially maternal rejection are the most persistent predictors of behavior problems in preschoolers (Shaw et al., 2001). Ge and his colleagues (1996) have shown that parental negativity may be considered a high risk factor for behavioral disorders and depression in adolescents as well. Webster-Stratton and Hammond (1997) found that, apart from parental criticism and inadequate emotional response, the inability of parents to resolve any conflict between them was the common characteristic of families whose children displayed troubling and disordered behavior. Erel, Margolin and John (1998) showed that restricted parental skills and use of aggressive ways to solve problems had a direct effect on children who then were much more inclined to reproduce these same aggressive behaviors in interactions with their peers. Parental conflicts (e. g., shouting, swearing, throwing objects, etc.) are the strongest variable, among a wide range of marital variables, to be associated with childhood behavior problems in school-age children (see Bloomquist and Schnell, 2002, p. 46-47). The higher the level of combined verbal/physical violence between parents, the more aggressive and socially emotionally maladjusted and disordered are preschool and school-age children (Bloomquist and Schnell, 2002). Severe family disorders or dysfunctions, such as parental psychopathology, antisocial values in the family, or a history of antisocial behavior of the parents, are linked to early onset development of problematic (oppositional, coercive, aggressive) patterns of behavior (BergNielsen, Vikan and Dahl. 2002; Frick, 1998; Mash and Wolfe, 2001). Research data are consistent with data from clinical practices for children with problems in Greece. These data show that parental aggression in general, and the exposure of children to violence or aggressive relations and conflicts in particular, are associated with early onset of various disorders, such as internalizing or externalizing, or both (Kourkoutas, 2007;see also Pears and Fisher, 2005; Wyman, 2003). There is evidence that children who have witnessed family conflicts or who are victims of parental violence are more psychologically vulnerable to developing externalizing and internalizing problems (Allen, 2001; Born, 2005; Cicchetti and Lynch, 1993; Hayez, 2007; Pears and Fisher, 2005). These same children are more likely to demonstrate violent behavior during adolescence or adulthood (De Zulueta, 2000; Farrington, 1991; Hayez, 2007; Patterson, Capaldi and Bank, 1991; Saltzinger et al. 1993; USDHHS, 2003). Currently there is concrete evidence for high rates of aggression and externalizing disorders in children who were abused, particularly those who were victims of physical abuse within their families (Conger et al. 2000; Peled, 1998). Other studies have demonstrated the link between physical abuse and manifestation of aggression when they play games with other children of similar age (Alessandri, 1991). It was also found that children who demonstrate the highest rates of aggression, antisocial behavior, and "malice," according to the opinions of their classmates and the evaluations of their teachers concerning their aggression and externalizing disorders, are those who have been physically abused within their family (Manly, Cicchetti and Barnett, 1994; Trickett 1993). It is clear that children who suffer physical abuse mimic their role models in their interactions with peers (USDHHS, 2003). It is reasonable to assume that in most families who systematically abuse or maltreat their children, there is no opportunity for the children to

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elaborate or express their negative feelings. Consequently, that leads them to demonstrate their repressed negative emotions (e.g., anger) toward parents, their internal tensions, conflicts, and anxieties as well, when interacting with their peers. In addition, according to research data (see Manly, Cicchetti and Barnett, 1994), children of similar age recognize in the behavior of these children an inherent malice/ malevolence or sadism as so often they intentionally cause harm to others. It becomes clear that children who are victims of abuse reproduce through imitation and identification the negative emotions and behavior they have experienced with their parents, in their personal interactions. It has been pointed out that children who suffered physical abuse display more disciplinary problems in school than children who were neglected or sexually abused (Kendall-Tackett, and Eckenrode, 1996; Hoffman-Plotkin and Twentyman, 1984). Obviously, children who have been victims of systematic physical violence have no chance to internalize constructive role models, because parents were unable to provide them with experiences of positive interactions and consistent patterns of behavior. Hence, such children become unable to develop essential interpersonal and coping skills (Cox, Paley, and Harter, 2001). Moreover, many of these children live in chaotic or unstructured family environments. Even if some maltreated children live in families where some kind of structure or rules exist, the inconsistent and insecure emotional climate does not help them to adequately interject and assimilate these rules (WebsterStratton, 1998). On the contrary, in such cases children tend to internalize aggressive models of behavior and usually suffer from emotional disorders, while at the same time self- and other-representations and capacities for relatedness are more or less seriously disturbed (Mash and Wolfe, 2001; Rogosch and Cicchetti, 2004; Scriva and Heriot, 2008; Wolfe, 1999). Inevitably, such children experience many difficulties in properly adjusting to school and social environments, which may lead them to additional conflicting or negative interactions with peers and teachers (Conger et al., 2000; Kourkoutas, 2011). Overall, children who experienced parental rejection and were involved in conflictual sibling relationships tend to be aggressive both at home and in school (Garcia et al., 2000). In conclusion, it appears that physical abuse has a closer relation to development of aggression in children's behavior than for those who are neglected or emotionally /psychological abused (Gershoff, 2002a; Hoffman-Plotkin and Twentyman 1984; Kaufman and Cicchetti 1989). This relationship is also evident in later periods of their life (Cox, Paley, and Harter, 2001). It is important to mention that children who suffered physical abuse are at greater risk to exhibit disruptive behaviors in adolescence than are other children (Cox, Paley and Harter, 2001; Young, Marchant and Wilder, 2004). The treatment of children with "traumatic experiences," such as psychological or physical abuse within the family, largely depends on the severity and type of manifested disorders. In cases where the child has developed externalizing disorders (behavioral problems), the interventions should be mainly focused on controlling, framing, and deconstructing the problematic behaviors by the use of various techniques which are meaningful and suitable to the specific child. At the same time, these children should be encouraged to elaborate their disabling or disturbing emotions and representations through a positive relationship with the specialist and the teachers or through systematic modeling and reframing. These children should also receive coaching to learn how to develop new skills and behaviors. In addition, the professional should provide to parents a special training or intervention aimed at helping them to develop their parental skills or overcome their own emotional and relational problems (Dishion and Stormshak, 2006; Wachtel, 1994). In the case of children who display internalizing disorders (phobias,

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depression, etc.), the therapeutic framework should be responsive and supportive to enable the children elaborate their negative family or school experiences and the related disabling emotions (phobias, anxiety, negative thoughts). The main goal of this approach is to enable them, through specific techniques, when necessary, to reconnect with their social environment, while gradually develop their inhibited or partially developed psychosocial skills (Kourkoutas, 2010; Maag, 2002; Margolis, Reynolds and Stark, 1987). Even in cases of children with behavioral problems it is important that the "therapeutic frame" (the specialist) be responsive and stable. The specialist should be sensitive, yet decisive and dynamic, so that he can enable the child to express and work through the negative, traumatic, and depressive feelings that are usually repressed, concealed behind a superficial, tough, or disordered behavior (Greenawald, 2002; Kourkoutas and Georgiadi, 2009; Lanyado, 1999). As explained earlier, such children are likely to experience as highly traumatic any demonstration of emotions or affectionate attitude. As for the family, we should add that empirical and clinical evidence shows that many preschool- and school-age children—as well as adolescents—exhibit various problematic behaviors which can be characterized as overt or covert aggression, although these children may come from families that are not necessarily pathological. These children usually come from family environments that may indirectly reinforce their aggressive or highly competitive and conflicting manners. Such parents are unable to adequately monitor their children‘s behavior or set clear rules and limitations (Carr, 1999). Overall, children from less pathological family environments may also experience difficulties in social and school context adjustment because their parents are incompetent, for various reasons, to provide them with a consistent rearing framework with clear rules and positive limits, or they are overprotective and too tolerant toward their immature reactions and misbehaviors. In addition, in many of these cases, parents and teachers end up using negative or aversive strategies in order to cope with and manage the behavior of the child, who progressively becomes noncompliant or defiant and disruptive. Consequently, such practices covertly intensify the negative environment-child interactions and reinforce the child‘s defiant oppositional reactions. The child is unable to use other means to protect himself or constructively resist what he experiences as frustrating or destructive for him (Kourkoutas, 2007; Whalen and Henker, 1999). Labeling of the child as noncompliant or of a challenging temperament is a natural consequence of less serious forms of coercive family and school practices. Seemingly, the child is not able by his own means to escape from this escalating interactional system. It is up to parents and teachers to become aware of the nature of this process to break this vicious cycle of negatively coping with the child. Clinical example: S. is a 7.5- year-old only child who has been referred to psychologists for noncompliance, hyperactivity, and oppositional problems. Meetings with his parents showed that his father was nearly always absent, while for the short time he was at home he did not spend time with S. His mother was very affectionate with him from birth. She never set any limits for him, while all these years she was exclusively involved with him, never refusing him any favor. Over time, and due to marital problems, the mother became more temperamental. As S. was growing up, his demands increased, and his inability to control his emotions became more evident. The situation became increasingly annoying and irritating for his mother, who often lost control of herself and took it out on him. Unfortunately, the father was not involved, and his indifferent attitude facilitated S‘s impulsive behaviors.

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It is of utmost importance that we understand the peculiar nature of each child‘s personal dynamic with behavior problems when we design intervention. This must be specialized and individualized based on the characteristics of the child‘s personality and family history (Cooper, 2000; Frick, 2004; Garbarino, 1995; Goldenthal, 2005; Greenhalgh, 2000; Wyman, 2003). Moreover, the importance of nuclear and wider family dynamics, parental rearing practices, relational and communication patterns within the family, and the way each parent relates or identifies to his or her children, are, among others, some of the variables which greatly affect the development of the child‘s emotional and behavioral dysfunctions (Sroufe et al., 2000; 2005). In order for interventions to be effective and ensure optimal management of behavioral problems, they must be holistic and individualized, taking into account specific systemic parameters aimed at modifying aversive situations and improving interactional patterns, as well as promoting the child‘s inherent capacities (Cooper, 2000; Garbarino, 1995; Goldenthal, 2005; Greenberg, Domitrovich and Bumbarger, 2000; Greenhalgh, 2000; Weare, 2005). At the counseling and clinical level, this can be translated into an understanding and analysis of all involved risk factors that produce ineffective or dysfunctional parenting which, in turn, increases the risk for children to develop inappropriate or troublesome behavior (Campbell, 2002; Schmidt Neven, 2010; Wachtel, 1994).-In terms of counseling and psychotherapeutic interventions, this means providing training assistance and emotional support to parents so that they can understand how their behaviors or strategies, instead of solving the existing problems, generate additional ones (Schmidt Neven, 2010; Wachtel, 1994). They must also be helped to understand the sources of their dysfunctional or impropriate attitudes, as well how the chosen rearing practices may refer to conflicting or problematic emotions and representations rooted into their own childhood; furthermore, wider family‘s dynamics and relational problems with siblings may emotionally disable and impede parental couple to adequately function with the child or may in addition create interparental conflicts which also place the child at risk of misbehaviors. The aim of such interventions is to provide to parents the necessary feedback so to better analyze and modify their own strategies and the way of thinking their child (Green, 2000; Horne, 2000; Kourkoutas, 2007; Greenspan, 1995). Clinical example: B. was a 6.5-year-old boy who demonstrated systematic disobedience and oppositional behavior at school. He would not follow rules and instructions, ending up being annoying and disruptive. He had problems with concentration, and though not overly aggressive with other children, he created constant tension and threw temper tantrums. A meeting with his mother showed that the family and marital problems of his parents had worsened their relationship with B., creating insurmountable difficulties in their daily life. The mother said she receives no help from her husband, while their various financial problems and his attachment to his own parents create a lot of anxiety and nervousness. The second child, a 4-year-old boy, made her daily life more difficult, and constant bickering and tension between the two boys discouraged her. The mother believes she suffers from depression. She is unable to control B., while at the same time she believes that her motherin- law is against her. Consequently, her relationship with B. "Went from bad to worse" and she often felt forced to hit him, as B. became increasingly uncontrollable. During the meeting that took place at school, she claimed that her husband is indifferent and uncaring; he is not truly involved in the everyday house routines, considering his manual work to be very tiring. Most importantly, he does not intervene to resolve his children‘s problems. Sometimes the only thing he does when the children go overboard is to reprimand or spank them. It is

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obvious that the climate of this family is not conducive to building stable forms of behavior in the children. There are no clearly set limits, the way the family treats problems is mostly negative, and the parents do not work toward changing or transforming the children‘s behavior--behavior characterized by covert or overt tensions. The father is symbolically and practically absent, while the mother is unable to cope with the demands of everyday life, most especially the upbringing of her children. She began to suffer from various psychological problems (depression). In this case, it was difficult to implement an effective intervention due to the father‘s refusal to get involved in a counseling process. The mother felt supported adequately by the psychologist because she was regularly consulting. The aim of intervention was to support her in dealing with the couple‘s problems and her children's daily life as much as possible. In addition, the intervention process aimed toward freeing herself from a self–destructive, competitive, and conflicting relationship with her mother-in-law. Primarily, though, she received help to cope with her feelings of weakness and despair that overwhelmed her. And of course it was crucial for her to improve her parenting skills and knowledge. In general, through the counseling intervention process parents become aware that systematic physical punishment and family conflict complicate and deteriorate their relationship with their child. Most of all, the result of such practices prevents the children from developing appropriate skills to behave and connect with their parents. Children from these homes are often emotionally confused or disturbed by the power of their own negative emotional reactions. When working with parents whose children demonstrate behavior problems, a primary goal is to help them avoid severe criticism and aversive incriminations or impulsive physical reactions. Unfortunately, such rearing practices are very often difficult to change over the long term, and parents might need consistent and enduring coaching and supervision to achieve such goals (Kourkoutas, 2011a; Webster-Stratton and Hammond, 1997). However, this work must be accomplished within the context of trust and genuine interest, and without criticism, with these parents needing additional training to become effective parents (Wachtel, 1994). Many obstructions or distortions hinder the therapeutic process when professionals work with highly problematic families. Such obstructions or distortions often stem from therapists‘ own emotional reactions and handling of the problems (counter-transference). Disorganizing family dynamics and maltreating parenting practices often induce strong emotional reactions to therapists and professionals, who are not always conscious and may result in therapeutic mishandlings. For example, a specialist or therapist who identifies himself with the "problematic" or suffering child may, consciously or unconsciously, ―attack‖ parents, thus destabilizing the working/therapeutic alliance with them. This alliance is a basic component of every successful intervention. Actually, therapists may use a scientific rationale to justify strategies that in reality are not based on an objective evaluation of the family and child‘s needs and dynamics, but are exclusively stemming from their own emotional counterreactions. If the professional or therapist develops counter reactions characterized by unconscious (not recognized) hostile feelings against parents, this may negatively impact the intervention process and outcome (e.g., not supporting or recognizing parental needs and qualities, being unresponsive or insensitive, being covertly rejecting, etc.) or may even result in treatment interruption.

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Regardless of the quality of their rearing practices, the quality of their relationship and emotional investment of their child, parents constitute the key emotional references and the main identification figures for their offspring (Wachtel, 1994). The therapist can play a crucial role in helping the children and their parents break out of the repetitive system of mutual traumatic, punitive, and aggressive reactions (Greenspan, 1995; Kourkoutas, 2011). Though, the therapist should not completely identify with the child, he should intuitively attune himself with him so as to further recognize the child‘s profound emotional needs and build an empathic relationship. The therapist, through this positive and ―holding‖ relationship with the child, can operate for a while as a positive identity reference—as a "transitional object" (Winnicott)—helping the child escape from the vicious cycle of mutual rejecting reactions, providing a new behavioral and relational model. By helping the child to reclaim his own ―psychological integrity,‖ the therapist also helps him discover inhibited or hindered skills or build new ones, abandoning the dysfunctional patterns of behavior that he learned to use within his family context (Goldenthal, 2005; Kourkoutas, 2007; Schmidt Neven, 2010). For this purpose, therapists can use a variety of techniques. For example, teaching psychosocial skills, role-playing, video modeling, behavioral strategies, or even art therapy techniques. Comprehensive intervention may also enhance parents ability to identify and better develop their own dynamic or interpersonal-parenting skills, and above all to discover the ―healthy‖ child behind the ―problematic/pathological‖ one—actually their real child (Papousek, 1995). A successful treatment process can provide new balance in the family relational and communication system. In all such cases, emphasis focuses on empowering the parents, enhancing their parenting awareness and skills (Papousek, 1995). It depends on the family dynamics and parental pathology (e.g., parents who have themselves a history of family maltreatment) if a training process is sufficient, or if additional therapeutic techniques are needed to be implemented in order to resolve parents‘ dysfunction (Kourkoutas, 2011a; Papousek, 1995).

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Chapter 5

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CHARACTERISTICS OF PARENTS OF CHILDREN WITH BEHAVIORAL PROBLEMS AND PATTERNS OF INTERACTION In brief, the characteristic of parents of children who display emotional or behavioral and antisocial problems are, among others, the following: (a) mild or more serious psychological difficulties or disorders; (b) anti-social behavior or aggressive patterns of interaction; (c) contradictory and inconsistent behavior and rearing practices; (d) low self-esteem; (e) depression; (f) interpersonal or social difficulties and restricted social skills; (g) dysfunctional or distorted cognitive patterns; (h) dysfunctional or inadequate emotional investment and relationships; and, (j) immature or pathological defense mechanisms and dysfunctional conflict or problem-solving skills. Regarding the characteristics of parent-child interactions, parents exhibit the following: (a) insecure or problematic attachment models and bonds; (b) inability to control and monitor children's behavior; (c) conflicting and immature or unrealistic expectations relative to behavior or to psychosocial development of children, and misunderstanding of the children‘s psychological reactions; (d) coercive or aggressive authoritarian patterns of interaction; (e) harsh and severe disciplinary strategies or contradictory and inconsistent punitive models (frequent use of corporal punishment); (f) dissociated or detached interactions and uncaring modes of connectedness; (g) neglect and maltreatment, with limits not clearly set; (h) implicit reinforcement of children‘s negative or challenging behavior; (j) puzzling or disordered models of communication; (i) father absent or not involved (single parenting). It is important to point out that there are families whose children demonstrate some behavioral or antisocial problems and characteristics, though such families do not display the typical family disorders or pathological dysfunctions described above (e.g., chaotic structure and organization, extreme maltreatment, delinquent or antisocial parents, etc.). Some research shows that children who grew up in environments without limits and deprivation of privileges are subject to development of inappropriate and antisocial behavior patterns (Keenan and Shaw, 2003). Obviously, children who have not learned to control their impulses and use socially acceptable ways to assert their desires and communicate their needs, risk developing deviant patterns of behaviors (Keenan and Shaw, 2003). Their oppositional behavior increases when they go to school where they are rejected by their peers or punished by parents and teachers, who are unable to manage their misbehaviors in other ways (see

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Bloomquist and Schnell, 2002). In many cases, parents continue to behave inconsistently and use corporal punishment, though teachers and professionals have pointed out the failure of such strategies. These behaviors create the risk of increasing or stabilizing children‘s challenging, defiant-oppositional or deviant, aggressive and antisocial behavior (Gershoff, 2002a). There is sufficient available evidence to demonstrate that parental attitudes and behaviors during the early stages of development largely affect the ways internal tensions can be managed and behaviors can be sketched (Galambos, Barker, and Almeida, 2003). There are significant data demonstrating a close and linear relation between self-control skills and the capacity to manage painful and negative emotions in children and those of their parents (see Gerhardt, 2004; Gronlick, Deci, and Ryan, 1997).

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Chapter 6

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RISK AND PROTECTIVE FACTORS RELATED TO SCHOOL ENVIRONMENT The school context is characterized by complex social interpersonal interactions, and it is the environment where emotional, cognitive, and behavioral processes and schemata of children are enhanced or developed. Schools therefore complement the family in the development and reinforcement of positive relational patterns, playing an important symbolic role in the construction of the psychosocial identity of the child (Pianta, 1999; Weare, 2000). In addition, school inclusion for all students is one of the most important contemporary challenges for educational staff and society as well, especially for those who experience particular difficulties. Educational and school processes relate to important risk factors for the psychosocial adjustment of students; such factors seem to contribute to the development, maintenance, and deterioration of interpersonal or social-emotional problems that children carry when entering school (Marshall and Watt, 1999; Morrison, Furlong and Morrison 1998). In addition, schools contribute significantly to the identification, assessment, and evaluation of children exhibiting behavioral and emotional problems of varying types and degree. Research has shown that the diagnosis of behavioral problems and hyperactivity disorder (ADHD) may be incomplete or partial if information about the way the child functions in school are not included (Tripp and Sutherland, 1999). Therefore, schools as well as teachers should play a key role in interventions for children with psychological difficulties and behavioral problems (Pianta, 1999; 2006). Many parents are reluctant to seek specialized assistance in psychiatric settings because they are frightened of their children being labeled. In addition, a lot of parents have difficulty recognizing their children's problems or relating these problems to their own attitudes and behavior. Empirical studies have shown that in some particular groups of children, school difficulties can generate feelings of disappointment, inferiority, anger and aggression which, coupled with other risk factors, may cause behavior problems and antisocial attitudes (Hinshaw, 1992; Maughan, 2001; Roeser and Eccles, 2000). In any case, school failure is an important predictor of an early onset of psychological disorders, delinquency, substance abuse, and dropping out of school during adolescence (Cernkovich and Giordano, 1992; Young Walking and Wilder, Morrison, Furlong and Morrison, 1998; Walker, Colvin and Ramsey, 1995).

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It was found that children who suffer from behavioral problems and tend to use aggressive or defiant oppositional behavior patterns in schools are often quickly rejected by their non-aggressive peers (Ladd, 1990). They may also experience various forms of rejecting attitudes from teachers (Kourkoutas, 2004a). Rejection from their peers and teachers may be explicit and/or implicit (e.g., negative expectations on the part of teachers), and seems to constitute an important risk factor for the psychosocial and academic development of these children, especially those who have already experienced some early difficulties adjusting to school (Morrison, Furlong and Morrison, 1998). In conclusion, negative expectations of academic abilities and school performance are considered to be an additional risk factor for school inclusion and development of such students because they feel isolated and worthless (Elliott and Voss, 1974; Kracher, 2004; Osborne, 2004). With regard to teacher-student relationships, it seems that children with antisocial behavior are rarely encouraged by their teachers to behave positively, while it is more likely that they are punished for behaving disruptively than children who are, in general, wellbehaved in similar situations (Walker and Buckley, 1973). Other studies have shown that students who are likely to exhibit antisocial behavior, especially boys and minority members, are more likely to be punished and excluded than to be supported or to be assisted with their problems in a therapeutic way (Walker et al. 1996: 197). It is widely accepted that problem behaviors when they have already been manifested by preschool-age, tend to generalize and worsen during elementary school years. A number of school risk factors seem to contribute substantially to children‘s behavior deterioration (Bloomquist and Schnell, 2002; Campbell, 2002; Goldstein and Conoley-Close, 1998; Laub and Lauritsen, 1998; Osborne, 2004; Roaser and Eccles, 2000; Richman et al., 2004). Researchers who have focused on ―disruptions‖ in childhood suggest that these behaviors escalate into increased teachers-students, covert or covert, hostile interactions, and into conditions that are very similar to the coercive practices and patterns these children have experienced with their families (Bloomquist and Schnell, 2002; Campbell, 2002; McMahon and Forehand, 2003; Hinshaw and Lee, 2003; Patterson, and Yoerger, 2002). In some extreme cases, conflicting relation with a teacher may be quite traumatic, leading the child to exaggerated disruptive reactions. Accordingly, teachers may also experience their relationship with these students or their families as very distressing. Actually, it has been supported that "aggressive children" tend to induce hostile, confusing, or ambivalent emotions from others and receive aggressive, aversive, or inappropriate responses from their teachers (Blanchard, Casagrande, and McCulloch, 1994; Dodge, 2000; Kauffman, 2000; Marshall and Watt, 1999; Roeser and Eccles, 2000; Rutter et al., 1998). Researchers are unanimous in that early teacher and peer rejection is a risk factor for an early or later onset of behavior problems. Such processes seem to be precursors of disorders in adolescence (Coie et al., 1993; Dodge, 2000; Kauffman, 2000; Marshall and Watt, 1999; Rutter et al., 1998). Children with antisocial behavior are often stigmatized by other students and educational staff as a consequence of their repulsive or inappropriate behavior and their deficient interpersonal skills because they are less competent in initiating and maintaining satisfactory relations with peers and adults (Bloomquist and Schnell, 2002; Campbell, 2002; Marshall and Watt, 1999; Vuchinich, Bank and Patterson, 1992). A teacher-student problematic relationship seems to be a serious risk factor for persistence of aggressive behavior. In one exemplary study, Hughes and colleagues found that those children with aggressive behaviors who had a poor relationship with their teacher were more likely to

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maintain aggression, while the opposite was true of children with behavior problems who experienced a positive teacher-student relationship (Hughes et al., 1999). Accordingly, children and adolescents with behavior problems who are accepted by their peers are particularly protected against future escalation of their emotional or behavioral difficulties (Criss et al., 2002). In addition, the use of peers as mediators, and the use of peer groups as support to children with school and social adjustment problems, turns out to be a very promising factor for improving their psychosocial adjustment (Sprinthal Hal and Erler, 1992; Twemlow, Fonagy and Sacco 2001). Research shows that the strengthening of interpersonal relationships may be protective factors for students with difficulties. Actually, the self-assertion that children receive from positive relationships with teachers and peers, as well as the opportunities they have to develop their academic abilities, are factors that can positively contribute to their school performance, social identity and status, and reduce antisocial behavior (Dowling and Osbourn, 2001; Marshall and Watt, 1999; McCovey and Welker, 2000; Roeser and Eccles, 2000). Academic or learning support, or the strengthening of ―problematic‖ students‘ selfconfidence seems not be sufficient to reduce their antisocial and aggressive behavior (McCevoy and Welker, 2000). The primary school risk factors associated with early behavior or adjustment problems, according to most recent data, are, among others, the following: (see Blanchard, Casagrande and McCulloch, 1994; Bloomquist and Schnell, 2002; Fraser, Kirby and Smokowski, 2004. Garbarino and Ganzel, 2000; Marshall and Watt, 1999; Young, Marchant and Wilder, 2004; Munger et al., 1998; Pianta, 1999): (a) the risk of isolation and rejection of children with behavior problems—a rejection that usually amplifies the intensity and severity of these behaviors; (b) the risk of academic maladjustment, which leads to secondary learning difficulties and low academic performance with serious consequences on children‘s selfconcept and self-esteem; (c) the risk that enough academic opportunities are not provided and that adequate specialized support for children with psychosocial and learning difficulties is lacking; (d) the risk of victimization by their peers of the more vulnerable or ―problematic‖ children who are likely to withdraw, become isolated, and thus be excluded from social and academic procedures; (e) the risk of teacher‘s rejection which may exacerbate their psychological problems and their tendency to react in an oppositional or provocative manner. If the child is not effectively treated and the teachers not assisted and coached to improve their educational and psychological strategies and attitudes, the risk of these children‘s social, emotional, and school development being hindered or altered is very high; therefore, their future adult life will be seriously affected in addition. Based on available research data and on comprehensive theoretical models, we can draw the general conclusion that problematic or antisocial behavior and school failure interact with and reinforce one another in a context of unsuccessful practices and strategies, predicts ongoing problems for both school and parents (Blomquist and Schnell, 2002; Dowling and Osbourn, 1994; Fine, 1992; Jahnukaine, 2001; Kracher, 2004; Marshall and Watt, 1999; McCovey and Welker, 2000; Osborne, 2004; Richman, 2004). For example, Rohner and his colleagues, in a series of recent studies on parental (paternal and maternal) and teacheracceptance rejection and adolescent‘s school adjustment and conduct problems, found significant and varying correlations among all such factors across a series of different cultural and educational contexts. Specifically, the most recent research conducted through the Ronald and Nancy Rohner Center (Connecticut, USA) and colleagues (see Rohner, 2010) validated

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the essential contribution of PARTheory to contemporary research on the way children and adolescents perceive their relationships with their teachers, and how these relationships are mediated by youth‘s perceptions of their relationships with parents—and vice versa. Many studies emphasize, from the other hand, the importance of caring, sensitive and safe school environments in fostering adjustment, particularly among children exposed to family stressors (Bloomquist and Schnell, 2002; Marshall and Watt, 1999; Pianta, 1999; 2006; Reddy et al., 2003). The capacity of supportive teachers and schools to buffer children from the impact of stressful family or life events is progressively recognized (Greenhalgh, 2001; Hanko, 2001; Heller, 2000; Ogden, 2001; Pianta,1999). The following curriculum and school, as well as educational practice characteristics may contribute, so that the risks associated with the development of social-academic problems in children is reduced: (a) curriculum that is meaningful for children and relates to their life experiences; (b) educational approaches that are adequately and sufficiently adapted to the learning style and academic skills of children; (c) opportunities for children to develop reflective and critical thinking; (d) implementation of social mental health programs within the school context and psycho-educational alternative practices embedded in the curriculum, in order to strengthen all students‘ abilities, especially those with exceptional problems (Elias et al., 2003; Webster-Stratton, 1999); (e) an individualized psycho-educational plan (IEP), based on a thorough evaluation of the social emotional abilities of children with particular emotional/behavioral difficulties (Greenhalgh, 2001; Hanko, 2001; Ogden, 2001); (f) opportunities for the implementation of programs aimed at a variety of problems with teachers‘ contributions as well (Cole, 2003; Greenhalgh, 2001; Hanko, 2001; Ogden, 2001; Weare, 2000; Weare and Gray, 2003). A child-centered approach, based on a thorough evaluation of the contextual variables and individual features/needs of students with behavior problems seems to be the most appropriate response, leading to better behavior management and enhancement of students‘ psychosocial skills, as well (Cole, Visser and Daniels, 2001; Cole, 2003; Hanko, 2001; Jahnukaine, 2001; Kuorelahti, 2001; McEvoy and Welker, 2000; Munger et al., 1998; Ogden, 2001; Weare, 2000; Weare and Gray, 2003). Summarizing the research on school inclusion and on the psychosocial development of young children, we can conclude that these results appear to support the idea that systematically providing early-on the opportunities to strengthen interpersonal relationships and psychosocial/academic skills of students with emotional/behavioral difficulties enhances their academic performance and reduces antisocial behaviors (see Bloomquist and Schnell, 2002; Cole, 2003; Marshall and Watt, 1999; McEvoy and Welker, 2000; Munger et al., 1998; Ogden, 2001; Rutter et al., 1998; Weare, 2000; 2005; Weare and Gray, 2003). This requires a series of significant structural and organizational changes at curriculum, services provision, and school-culture levels; as well as important modification of the way educational staff, professionals, and parents are involved to face challenges related to students with moderate or serious social, emotional, behavioral, and academic problems. Obviously, a wide range of parameters affect the way schools, as complex educational systems, and school-teachers respond to the needs and challenges of exceptional students in everyday school life. It is noteworthy that individual classroom teachers‘ response and school unit‘s inclusive practice have a strong psychological effect on these children‘s development. Ultimately, by not effectively dealing with students‘ challenging behaviors and other critical school phenomena often has a personal cost for the teachers themselves, and for the school

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unit. For this reason, educational staff, professionals, and school units should be prepared to introduce important modifications (e.g., work on a partnership model, interdisciplinary approach, teachers‘ role-widening, training in new psychoeducational methods, tactics, and techniques, etc.) of the way they perceive and conceptualize students‘ psychosocial and academic problems—and on the way they work and cooperate to face such challenges.

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Chapter 7

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TEACHERS’ EMOTIONAL AND EDUCATIONAL REACTIONS TOWARD CHILDREN WITH BEHAVIORAL PROBLEMS Most children who have severe conduct problems have failed to develop internal working models and social, emotional, and academic skills that meet the requirements of school life and interpersonal relations. Seemingly, these children have not developed or not learned to use alternative ways to deal with the interpersonal and school challenges/problems that elicit strong emotional reactions. This lack consequently leads them to exclusively antisocial and aggressive strategies. The use of aggressive or inappropriate approaches on the part of these children inevitably makes their peers and teachers react negatively. More often than not, these children reproduce at school the problematic interactional patterns practiced and learned at their home (Munger et al., 1998; Reid and Patterson, 1991). As previously explained, the “problem child” is more likely to be trapped in a distorted pattern of harmful interactions with classmates and teachers, as he is often both emotionally and behaviorally unable to effectively manage his impulses, to appropriately communicate his needs, and to positively invest his relationships with peers and adults. The escalation of hostile interactions and subsequent academic failure and experiences of rejection by peers and teachers affect these children emotionally to varying degrees. In the most serious cases (e.g., maltreated children), such accumulated negative school experiences exacerbate the psychological trauma of the child, the damaged self-identity (deficient self-concept and esteem), and the aggressive self- and other-representations/feelings; therefore, his interpersonal, cognitive, and behavioral capacities are similarly affected. The emotional response of these children in such situations varies in form and severity (from depression to disruptive antisocial acting-out) according to the child’s family/personal history and personality. In cases of problem behavior, the behavioral response of the child is elicited and intensified by his defense mechanisms, the aggressive or disruptive strategies that were learned within the family and which help him keep away the painful feelings of rejection. Extreme anger, sadistic rage, and aggressive despair often identified in clinical cases of disruptive and antisocial youngsters stem from continuing traumatic experiences (physical and emotional), and from a destabilizing sense of hopelessness and self-destruction that the child is unable to mentally cope with (De Zulueta, 2000; Kourkoutas, 2001). Actually, such children often fight against unbearable underlying depressive feelings that are related to their family and school experiences of rejection.

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Any intervention should primarily attempt to interrupt the vicious cycle of negative interactions that exaggerate psychological pain and consolidate the disruptive behavior and social isolation of these children. It is obvious that teachers involved in behavior management are not aware that by responding aggressively to an aggressive child implicitly intensifies coercive interactions and strengthens the aggressive behavior. Seemingly, teachers involved in such complex situations are increasingly convinced that these children are “pathological cases” requiring psychiatric intervention, because they are not aware that operating this way reduces the possibility of providing to the child an alternative model of connectedness and behavior, thus opening him to another form of relationship and communication. Aggressive children, from their own side, when experiencing such forms of rejection or counteraggressions also become convinced that adults are insensitive and uncaring, cruel and unfair, thus justifying their intrinsic antisocial and aggressive tendencies. An increasing group of studies has shown that challenging and disordered behavior of school children is a major source of anxiety and concern for their teachers (Borg, 1990; Farber, 1991; Kauffman, 2001; Walker et al., 2004). This means that, even in countries with more sophisticated special education programs and mental health services, teachers do not feel sufficiently prepared or trained to deal with disruptive forms of student behavior. It is therefore not surprising that much research has shown that pupils or students with disruptive acting out behavior receive less support and feedback from their teachers than those considered as behaving “properly” (Greenhalgh, 2001; Hanko, 2001; McCevoy and Welker, 2000; Munger et al., 1998). Many of these students do not receive adequate treatment suitable to their needs and difficulties/disorders (Cole, 2003; Walker et al., 2004). As for educational responses, it is more likely that teachers who deal with students with disruptive behavior use implicit or explicit punitive or remedial techniques instead of positive or more sophisticated and elaborate strategies, based on a specific evaluation of the case, when dealing with these students (Bear, 1998; Bloomquist and Schnell, 2002; Greenhalgh, 2001; Kauffman, 2000; Marshall and Watt, 1998;). The least effective teachers tend to deal with hostile-aggressive children, using a combination of negative strategies such as warnings, punishments, reprimands, or sending them to the principal’s office (Bloomquist and Schnell, 2002). The use of negative consequences is an important and sometimes effective class management technique, yet this strategy can be "problematic" and less effective when it is exclusively or permanently used and does not rely on a trusting and positive student-teacher relationship (Bloomquist and Schnell, 2002; Hanko, 2001; Kourkoutas, 2011). Aggressive students often perceive such strategies as unfair or extreme, and they may experience them as an intentional “attack” against themselves when they are practiced or implemented within a framework of a conflicting student-teacher relationship. This means that a multitude of alternative strategies that do not result in negative consequences or punishment are necessary and required in most cases of problem behavior children. The contemporary consideration of behavior management in schools, which traditionally was based on restricted behavioral principles, initiates new techniques of reward and punishment, focusing on positive alternatives to punishment. By this we mean that the child instead of being punished and intentionally deprived (which usually reinforces feelings of revenge) is called upon to perform tasks which relate to the common good. In reality, he is required to set himself at the disposal of the group, something that he has never done before. The teacher, along with the counselor, is invited to collaborate with the child to work on his emotions and experiences so

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that he will be progressively enabled, by the use of additional methods, to associate and work with others in non-destructive ways. In general, teachers everywhere consider that their basic training is not adequate in preparing them to manage challenging behaviors in the classroom (George et al., 1995). In a series of studies at the University of Crete, teachers reported that they had no awareness of the behavioral techniques which should be implemented to resolve difficult and disruptive behaviors in class, and to treat them (Kourkoutas, Georgiadi and Hatzaki, 2011; Thanos, Kourkoutas, and Vitalaki, 2006). In another study, teachers declared they do not feel confident, but rather they are “anxious" when they are confronted with children who exhibit behavioral or emotional problems (Kourkoutas, 2004a; Thanos, Kourkoutas and Vitalaki, 2006). Some teachers make sincere efforts to help children with behavioral problems adapt to the classroom and academic processes. A lack of response or inappropriate response on the part of the youngster can make teachers feel rejected (Green, 1995). Teachers can feel irritated and provoked when their efforts bring forth only partial or no results (Munger et al., 1998). A clue to the feelings of teachers brought forth by difficult, unresponsive students can be found in the various negative consequences administered in classroom. Whatever the means used, and whatever the rationale for the use of various pressure techniques (e.g., peer pressure) and visible warning to the child, in the end all these techniques make use of public shaming, increasing the aversive feelings of the child (anger, rage) as he feels less valued, rejected, and hopeless which leads to additional aggression (Kourkoutas, 2011; Munger et al., 1998). The teacher who has been made to feel “inadequate and rejected by the child responds with exasperated helplessness by returning the favor” (Munger et al., 1998, p. 420). Unfortunately, many of the emotionally “wounded” and disordered “disruptive” children (who have suffered from harsh or inconsistent rearing practices, family conflicts, and violent parental reactions) react with additional aggression in the face of a positive and accepting approach on the part of teachers, as they defend the “sensitive” part of themselves they consider weak. They prefer remaining detached from others in a cold, callous, unemotional position and being aggressive and rejecting toward adults and peers who positively approach them, because they usually carry experiences of traumatic attachments and relationships (Ford, 2002). Actually, these children are afraid of being overwhelmed by their heartbroken feelings and profound unmet emotional needs, afraid to enter into a closer relationship with others. The average teacher is not aware of such internal processes. Inevitably, he feels rejected, failed, inadequate, or even enraged by the child’s unresponsiveness. Hanko and other clinicians and researchers who have worked with traumatized children or groups of teachers who deal with maltreated disruptive students argue that these children’s distressing experiences are likely to induce strong emotions in educational staff, hindering their capacities to act and work adequately. These professionals often seem to internalize the powerful unmanageable feelings the children displayed. Only when the staff were helped to understand this “transference” and were themselves provided with support to contain their own distress, were they able to help these children (Hanko, 2001, p. 48). There is a link between some forms of antisocial behavior, conduct disorder, and depression (see Mash and Wolfe, 2001; Rohde et al., 2004; Van Vlierberghe et al., 2007). Many children and youngsters with antisocial tendencies and behaviors might also manifest signs of depression in adolescence, and the existence of a depressive subgroup characterized by specific parental schemas should be recognized (Van Vlierberghe et al., 2007). Actually, it is a commonly neglected issue the comorbidity of disruptive behavior disorders and

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depression, which has been well established in community and referred samples of youngsters (Van Vlierberghe et al., 2007). In these cases, antisocial behavior sometimes ‘masks’ the depression because it is mainly externalizing problems that lead to referral (Van Vlierberghe et al., 2007). In addition, clinical practice informs us that in many cases, even during childhood, children with behavioral disorders appear to suffer from depression or anxiety that remains misdiagnosed, as a result hindering their skills or competencies. In other cases, it is considered that behavioral problems and aggression may operate as antidepressant strategies in children who have serious problems with anxiety and hopelessness or disthymic mood (see Kernberg and Chazan, 1991; Kourkoutas, 2011a). In reality many of these children are struggling against such depressive feelings or feelings of impotence, powerless, and vulnerability. Teachers, with the help of professionals, should learn to recognize this phenomenon to gain better insight into the profound psychological processes of children who are likely to disrupt classroom procedures. A clinical supervision program aimed at supporting and coaching (supportive supervision) preschool- and elementary school-teachers who had to deal with “difficult cases of children” revealed a series of interesting findings that offer us a global insight into how educational staff perceives and copes with behavioral problems in classrooms and with students labeled as “challenging” (Kourkoutas and Georgiadi, 2011). Part of the study investigated participant teachers’ estimation of how their colleagues in Greek elementary school operate when they have to deal with such cases. Results revealed that: (a) there is strong conviction on the part of teachers that school is not responsible for such children’s behavior and its management, and that extreme problem or aggressive behaviors are inherited and pathological; (b) teachers are only partially-trained, have a significant lack of understanding of clinical practice, and do not recognize the complexity of intervention that should be implemented; (c) many teachers seem to believe in “magical solutions and behavior modification,” if appropriate strategy is applied; they are also likely to believe that psychologists should intervene independently, without the teacher’s involvement; (d) most teachers request simple recipes to organize their own interventions; they tend to believe in a unique “master key” intervention, tending to conceptualize behavioral difficulties/problems as a one-cause disorder; (e) many teachers are not aware of the complexity and variety of the intervention process that depends on the underlying dynamic, or of the preliminary work that has to be done in order to design really effective interventions; (f) teachers are neither aware of the ongoing evaluation of the intervention outcome and the serious modifications that sometimes are necessary to be done in the course of the process; (g) many teachers tend to underestimate the students’ underlying emotional dynamic /problems and the way these problems contribute to disruptive behavior—or to overestimate the pathological aspect of the behavior; (h) most teachers are eager to get specialized assistance, though only some of them are proceeding to do so; (j) many teachers feel inadequate, confused, anxious, or overly punitive and rejecting toward children with disruptive behaviors; and, (k) there is an urgent need to establish school-based interdisciplinary teams in order to help teachers adequately handle critical situations (Kourkoutas and Georgiadi, 2011). In addition, teachers found the clinical supervision process (a) very enlightening for understanding the underlying emotional processes and acting-out of children with acute family and behavioral problems; (b) useful to better handle their own difficult emotions and

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tensions (stress, anger, confusion, ambivalence, withdrawal, implicit rejection, embarrassment, etc.) and gain further awareness of the coercive interactional processes; (b) helpful for elaborating novel techniques based on their own knowledge of the child; (c) important in helping them gain self-confidence and take personal initiative; (d) an instructive training model for personal and professional development that can sharpen teachers’ awareness and self-introspection, allowing them to express and understand their own negative feelings (feelings of inadequacy, confusion, anxiety, stress, anger against parents, colleagues, or school principals, etc.); (e) an indispensable working practice for the contemporary educational system, which may enable teachers to effectively deal with challenging students and to cooperate with professionals (Kourkoutas and Georgiadi, 2011). One important conclusion of this study, based on in-service teachers’ reports, is the danger of overemphasis given by many school principals, teachers, and parents on managing behavior without attempting to understand the child’s feelings (see also Greenhagh, 2001) and resolve the individual-internal/family dynamic/problems. These problems may continue to impact the child’s functioning and reinforce his confrontation of the school context which, in turn, results in the teachers’ conviction that this is a “pathological or untreatable child case”(Kourkoutas, 2011). Many teachers reported that negative prejudices or stereotypical and ineffective attitudes their colleagues develop toward their “challenging pupils” relate to their lack of clinical knowledge, their inability to get insight in children’s problems, and the lack of experience of positive cooperation with professionals who have been effective in helping them (Kourkoutas and Georgiadi, 2011). Empirical studies have shown that many teachers are likely to refuse or hesitate to seek professional help in order to effectively approach and manage such behaviors in the classroom (Fell, 2002; Kauffman, 2000; Miller, 2003; Monsen and Graham, 2002). Their resistance to take on responsibility so that they could manage difficult situations and their refusal to seek professional help relates to a series of factors that pertain to the work of teachers in general. More specifically, it was found that the following factors inhibit the use of alternative strategies and prevent teachers from seeking help for managing behavior problems in children in more productive or sophisticated ways (Fell, 2002; Gray and Noakes, 1994; Hanko, 2001; Kauffman, 2000; Kourkoutas, 2004b; Kourkoutas and Georgiadi, 2011; Miller, 2003; Monsen and Graham, 2002; Roffey, 2002; Weare, 2000): (a) excessive and exclusive focus on the teaching process (overestimation of learning); (b) a belief that there are “good and bad characters or temperaments” which are innate and unchangeable in children; (c) a tendency to attribute the reasons for behavior problems to “within the children” factors, especially to the family—meaning that the school and the teachers are not held responsible; (d) strong negative emotional reactions (confusion, stress, ambivalence, hopelessness, despair, etc.) elicited by the problematic behavior which reinforces stereotypical attitudes toward children with conduct problems, because teachers often experience them as intentional attack on their personal or professional identity; (e) overestimation and idealization of personal experience and practices used by the teacher; (f) fear that teachers will be judged or criticized for the way they manage these children; and, (g) lack of experience of positive cooperation with and sufficient support from professionals (school or clinical psychologists, etc.). Teachers often need support and guidance because the emotional dimension constitutes an essential component of the educational process (Kourkoutas et al., 2011). In addition, the pedagogical relation with students inexorably implies a personal emotional involvement

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intensified by the responsibility teachers are requested to assume when they are faced with defiant oppositional or aggressive and antisocial behavior (Fell; 2002; Cole, 2003; Hanko, 2001; Kourkoutas et al., 2011; Monsen and Graham, 2002). Summarizing the outcome of research on factors that may negatively affect and hinder the psychosocial development and school inclusion of certain groups of children or, on the other hand, positively and implicitly reinforce aggressive and oppositional behaviors, we conclude that the following practices related to school, class and teacher behavior may play a decisive role (see Fraser et al. 2004; Young et al., 2004; Richman, Bowen and Wooley, 2004): (a) failure on the part of schools and teachers to establish clear rules and boundaries, while at the same time being unable to realize their expectations regarding the desired behavior and performance of children at school (Kauffman, 2000; Walker, Colvin and Ramsey, 1995; Young et al., 2004); (b) inconsistent or unrealistic expectations about the children’s abilities, that stem from the stereotypical or distorted perceptions of the teacher, the negative behaviors of the child, the information he gets from his colleagues. or even the results of a special diagnosis concerning the child (Kauffman, 2000; Young et al., 2004); (c) failure on the part of the school and teachers to adapt their responses to the special needs of children (Kauffman, 2000; Young et al., 2004); (d) a rigid stereotypical and unidimensional attitude toward students and their problems, for instance, inconsistent and contradictory techniques used to manage behavior problems (Bloomquist and Schnell, 2002; Hanko, 2001; Kauffman, 2001; Young et al., 2004); and, (e) failure to provide the child an appropriate educational setting (unclear instructions, poor or restricted curriculum, not focusing on psychosocial skills development, repulsive school activities, ineffective and outdated instructional strategies, failure to foster students’ creative and critical skills, extreme emphasis on the learning character of education, a school focused on a stereotypical learning environment, unpleasant or inappropriate facilities, etc.). Teachers must be aware that children with oppositional, disruptive, aggressive, or antisocial behavior do not constitute a homogenous group with common characteristics. On the contrary, each child has his own particular dynamic (psychological and behavioral), and each child typically requires a special approach and understanding of the underlying problems and functioning. There are cases where a strategy may be effective (e.g., set a punishment) and others where it may lead to the opposite results (reinforcement of aggressive behavior, strengthening and exacerbating negative feelings or tantrums).

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Chapter 8

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CLASSROOM INTERVENTIONS For students who experience emotional and behavioral difficulties, a series of strategies in the context of the classroom is often proposed. These strategies can help students build a sense of confidence in the teacher, a sense of academic identity, as well as a sense of selfcontrol and effectiveness. These children feel they are not in a position to control their behavior, and are often excluded from the learning process (Keller and Tapasak, 1997; Kourkoutas, 2011; Striepling, 1997, Webster-Stratton, 1999; Weare, 2000). These children are generally overwhelmed by disorganizing or negative emotions such as anger and feelings of revenge—or even acute anxieties and low self-esteem. A trustful and supportive relationship with the teacher, based on a genuine interest in helping the child, and an accepting, affirmative, but decisive attitude within the classroom (e.g., distinguishing inappropriate behavior from the child‘s deeper self, needs, and capacities) may strengthen the child‘s sense of self and worthiness. Although behavior modification and child‘s psychological dynamic improvement is not an easy task and cannot quickly be achieved, a warm teacher-student relationship often serves as a new relational model for ―the problem child.‖ Actually, the teacher recognizes that there is value in the child, seeing beyond the behavioral problems, providing a new identification model. In this way, the teacher can help, at least in less serious cases, the student to acquire, even temporarily, motivation to get involved in the classroom and the incentive to achieve some specific social or interpersonal goals and a minimum of behavior control (Webster-Stratton, 1999). Positive changes in the attitude of the teacher may also contribute to helping classmates become more tolerant of their ―problematic‖ peer, eventually cooperating in future psychosocial programs or interventions. Through this process the problematic student is given the chance to become familiar with positive aspects of school life (e.g., peer acceptance, acceptance by other teachers /adults, the opposite sex, etc.) from which children with oppositional and aggressive behavior are automatically excluded (Bloomquist and Schnell, 2002; Kauffman, 2000; Webster-Stratton, 1999). It has also been suggested that when a ―maltreated‖ ―problematic‖ child is accepted by his peers this may encourage him to identify himself with socially acceptable models, something that was not previously possible. This helps the child to become free of the negative identity and ―defensive aggressive resistances‖ behind which such children become entrenched. Children need to feel safe and accepted in order to exhibit their potential and the desire to learn; this requires some ―relative dependency‖ (positive dependency) of children upon their

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teacher (Greenhalgh, 2001). Maltreated children often experience ambivalent feelings towards their parents and have particular difficulties trusting key adults (e.g., teachers). Teachers need to make additional efforts to gain these children‘s trust and readiness for attachment. Children need to be well-supported and emotionally free of acute or conflicting internal tensions in order to explore and learn. They also need to be adequately guided so they are able to symbolize and learn. The capacity of mentalization and the subsequent symbolization skill are necessary (though underestimated) competencies that help pupils engage in both learning and social procedures within school (Fonagy et al., 2006; Greenhalgh, 2001). Many of these children encounter particular difficulties in achieving such processes; therefore they need additional assistance and specialized support and supervision in order to successfully manage their difficult conflicting feelings, to tolerate frustration and not to give up when something is difficult or when it goes wrong (Greenhalgh, 2001). Such children also need to develop sufficient ego-strength and social-emotional skills to allow them to manage internal and interpersonal difficulties and conflicts. The use of additional «behavioral» techniques and a structured classroom environment seems to be necessary to help children modify their disruptive behavior and participate in classroom activities (Pelham, Wheeler and Chronis, 1998). When behavioral methods within a classroom are coupled with teaching skills programs to provide alternative modes of behavior, this may increase the intervention effects. Children can easily imitate or reproduce behaviors that are available or taught to them through formal programs or constructive teachers‘ initiatives. Overall, the provision of an effective emotional climate in the classroom needs to be backed up by practical strategies for ensuring the necessary support and guidance to pupils (Greenhalgh, 2001). School psychologists should be able to provide such guidance and practical behavioral strategies, together with an evaluation of the child‘s internal and interpersonal functioning that makes sense for the teachers. Therefore, when "behavioral techniques" are applied, it is recommended that they not rely only on use of negative reinforcement (e.g., punishment), but also on the simultaneous promotion and teaching of positive models of behavior and psychosocial skills (Elias et al., 1997; Webster-Stratton, 1999). There is also evidence that the classic behavioral interventions produce only short-term changes in the behavior of these children, and that their positive attitudes do not extend to other settings (Carr, 2000; Kazdin, 2000). It has often been pointed out that there are no regular follow-up results of the implemented behavioral intervention, or such outcome evaluations are of short-term (Kazdin, 2000). Many research evaluations of the intervention outcome are exclusively focused on measuring symptom reduction, without necessarily taking into account a series of other parameters in the child‘s functioning or development, and without convincingly explaining the procedure of symptom modification. More research is necessary to focus on the nature of the mechanisms of change, so that it becomes clearer which methods to use and to what degree they must be applied, as well as exactly what additional interventions can be implemented that will provide support for the child in the best possible and most holistic way. Clinical practice has shown that in many less severe cases of emotional behavioral problems and disruptions, positive and decisive involvement of specialists or teachers and parents constitutes in itself an essential step in the psychosocial improvement of these children (see also Greenberg and Weisberg, 1988). Moreover, at a young age and before certain pathological reactions are consolidated, the use of behavioral interventions, without any sign of reproach, reinforces these children and helps them to see this support positively

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Classroom Interventions

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and differently from the traditionally hostile, rejecting attitude of teachers and other adults (parents, etc.) (Cole, 2003). However, the feeling that there is a different approach from adults does not seem in itself to be sufficient for stable and long-term changes on the level of overall functioning and behavior of the child (Greenberg and Weisberg, 1988 ). In any case, the use of structured and organized psycho-educational techniques is essential in the context of classroom management of disruptive behaviors, even very difficult ones (Ayers, Clarke and Murray, 1998; Gettings and Stoiber, 1997; Jones and Jones, 1998; McClelland, Morrison and Holmes, 2000). Effective behavior management in the classroom includes, among others, the following parameters: (a) provision of an inclusive, cooperative, and resilient classroom context that promotes communication, solidarity, and partnership among students, based on the positive behavior of the teacher as manager of class dynamics; (b) promotion and strengthening of the child‘s social, interpersonal, and emotional skills; (c) involvement and cooperation of the parents on various levels and in activities that relate to the psychosocial and academic performance of their children; (d) supervision and monitoring of the children‘s behavior (strengthening of the child does not mean absence of control or of limit-setting); (e) implementation of explicit rules and regulations, and consistent reference to them as a fundamental element of the classroom organization and dynamics; (f) provision of a structured and organized classroom, combining flexible attitudes and strategies (attitudes that reinforce the autonomous actions and initiatives taken spontaneously by the students and student-teacher relationships), and the use of formal or informal alternative instructional methods (e.g., drama techniques, role-playing, use of humor, and so forth); (g) use of rewards instead of disciplinary, punitive, or retaliatory management of disruptive behaviors in a calm but firm and authoritative way; (h) involvement of adults and specialists in the school so that they can guide or advise children with behavioral problems and learning difficulties and partly alleviate the classroom teachers‘ burden of emotionally and technically handling these problems (Miller, 2003); (i) implementation of interventions based on a thorough holistic functional assessment of the child (which takes into account the overall performance of the child, not just behavior); (j) flexible individualized approaches that fit each particular case of students with serious problems or behavioral disorders (Tolbin and Sprague, 2000; Walker, Colvin and Ramsey, 1995); and, (k) a personalized teaching intervention based on a personal relationship and a knowledge of the child that relates to specific characteristics of the case and the specific method of approach (e.g.. a child with very low self-esteem and provocative manners will need more time in order be able to accept any help from the teacher, and the teacher should emphasize special talents, the likes and dislikes of the child, etc.), but above all recognition and respect for the personal characteristics (weaknesses and strengths) of the child to an even greater extent. All the above mentioned parameters presuppose that there is a clear intention on the part of the school and the teacher to treat and prevent crisis situations, but also a philosophy and culture of the school that moves in this direction. It also requires flexibility in the school system, adequate teacher training, functional infrastructure and basic services (e.g., consultants, but also parents who want to get involved in school activities) and the cooperation and partnership involvement of parents in school activities (Atkins et al., 2001; Ross et al., 2002; Weare, 2000; 2005). In any case, so that the application of alternative education programs is possible, we need classes with a small number of pupils and children who are not emotionally seriously affected and do not exhibit severe behavior problems requiring specialized psychotherapeutic interventions (Tolbin and Spague, 2000).

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According to several studies, interventions that seem to be successful are those which promote proactive strategies, focusing in particular on positive behavior interventions and group teaching techniques that combine attractive instruction with controlled class behavior (Bloomquist and Schnell, 2002; CEBP, 2003; Kamps and Tankersley, 1996; Kauffman, 2000). A growing body of research shows that when opportunities that encourage learning are routinely offered to children, and the way that they are rewarded for changes (e.g., better support and reward for better efforts, empowerment of the child through the initiatives that are given to him, strengthening the relationship between teacher-student, reinforcing the positive image of the child in the eyes of his peers, etc.), the academic success of the students with behavior problems and learning difficulties is strongly enhanced, and at the same time their commitment to the school reality is promoted (Richman, Bowen and Wooley, 2004). Available data show that strengthening the relationship between the child and the school contributes to the decrease of disruptive/inappropriate behavior, and aggression (Carr, 2009; Fraser and Williams, 2004; Hawkins, Farrington and Catalano, 1998; Young et al., 2004; Walker et al., 2004). It is clear that academic progress strengthens the student‘s ties with school, as well as the feeling of being acknowledged by others and a sense of belonging. This reduces the likelihood that the child will experience rejection by the school and the school community (e.g., from other teachers, classmates, parents of other children, pupils of other classes, etc.) (Miller, 2003; Roffey, 2002). When a child with behavior problems is rejected or excluded either directly or indirectly (e.g., he is systematically punished or dismissed or he has no opportunity to grow and change) from the learning process, it is more likely that he then develops a negative attitude toward school, and he disinvests the learning process (Richman, Bowen and Wooley, 2004). This rejection may become widespread in the future, transforming into social rejection. The risk that he may aggressively reject society becomes even greater in cases where the child has been a victim of rejection by his family, or experienced severe family problems. According to research data, students who are emotionally and socially vulnerable are exposed to the risk of developing problematic antisocial attitudes during preadolescence and adolescence, when their performance at school is low and at the same time they fail to integrate into school life. The general conclusion of this research literature review is that specialized interventions, such as interventions in the context of the classroom for children with aggressive tendencies and behavior problems, may be more effective when they aim at promoting positive behaviors and emotional and interpersonal skills together with the use of various behavioral techniques so that aggressive, oppositional behaviors are reduced (Campbell, 2002; CEBP, 2003; Marshall and Watt, 1999; Weare, 2000). On the other hand, it is stressed that when measures are taken with the aim to reinforce the child‘s confidence they do not necessarily change his enduring problem behaviors (McEvoy and Welker, 2000). In conclusion, what all available data show is that when schools positively incorporate effective teaching methods with wider school based individualized psycho-educational interventions in classrooms, disruptive behaviors can be reduced (Bloomquist and Schnell, 2002; Fraser and Williams, 2004; Ross et al., 2002; Young et al., 2004; Walker et al., 2004).

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The fundamental principles that should guide the function of the school unit and the main goals to be achieved by the educational community to effectively include children with antisocial behaviors are, according to most recent findings, the following: a) Goals and expectations regarding student achievement must be stated clearly and in a manner understandable to the student. Classroom management must be efficient and productive, taking into account the dynamics and level of children's developmental and adjustment difficulties for some children, without being authoritarian and aggressive; b) A general positive school climate and sense that teachers are at the disposal of students, while respecting boundaries and individual differences; c) Teachers should not be left to feel alone or isolated when dealing with the behavioral problems of students; beyond specialized support, they also need a system of educational support like team meetings and collaboration with the school principal; d) Requirements and learning objectives set by the school and teachers should match the abilities of students. Often social pressures—which are expressed through parental expectations and demands—can influence teachers, making them more demanding or strict, more teaching-centered, thus abandoning alternative or childcentered approaches and techniques (e.g., contact with students, reserve time to address social or personal issues and so on); e) Delivery of class material must be clear and precise and specific educational processes must be followed; f) Individualized learning and student support are necessary, and efforts must be directed so that students are not rejected or excluded, directly or indirectly, either by the teacher, or by the student‘s peers. Enough time must be devoted to the teaching and learning process. Time must be used effectively, taking into consideration the concentration span and performance of children (which is something that many teachers disregard); g) Multiple opportunities for students to cope with the demands of school; h) The teacher must actively monitor the progress and abilities of the students; i) Student performance should be frequently and appropriately evaluated, free of criticism and negative attitudes towards the students themselves (distinction should be made between student performance and personality traits); j) Issues that relate to the principles of mental health, (Algozzine and Ysseldyke, 1992), the psychosocial development of children, family relationships, etc. should be taught, discussed and developed; k) The subject of interpersonal skills should be included in the material taught (systematic instruction and social skills, interpersonal education) (Algozzine and Ysseldyke, 1992); l) The use of peers/classmates for the support and implementation of certain psychoeducational processes and activities in which children with behavioral problems participate (Algozzine and Ysseldyke, 1992; Strayhorn, Strain, and Walker, 1993); m) Psycho educational activities beyond the official curriculum (e.g., role play, groups of self-expression and consultation, communication and cooperation groups, peer mediation groups, social skills activities) to support and strengthen the social

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n) o)

p)

q)

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r)

coherence of the class—especially the integration and acceptance of children with behavioral "issues" (McClelland, Morrison and Holmes, 2000); Regular contact and meetings with the family and the counselor to identify the characteristics and personal abilities of the child (Munger et al., 1998); Teachers should be supported to sharpen their empathetic skills, which can be strengthened by a thorough understanding of these problem children‘s internal processes and underlying repressed emotions or conflicts; Teachers should be aware of the problems associated with labeling students; these labels can limit the way that others perceive and interact with students, thereby disabling the students academically and hindering the development of their selfesteem; terms as "oppositional defiance disorder" locate problems within students rather than within the family and educational system and interactions among them (Sandler and Sylvestre, 2005, p. 33); Teachers should be adequately prepared by specific training programs in order to be able to effectively manage disruptive behavior and improving children‘s behavior by providing positive and corrective feedback for adaptive behavior Overall, according to the research literature, successful prevention and treatment of individual behavior difficulties in school depends on good social relations between teacher and student and on positive social bonding to school (Ogden, 2001).

Inevitably, a series of questions arise and many of them remain unanswered, including those that relate to the suitability of these principles and programs, and to the adequacy and nature of the teachers‘ basic education/training. These issues also pertain to the development of the teachers‘ personal skills, the quality and type of parental involvement, the change of social prejudices and stereotypical attitudes that have existed for decades, the shift of the school culture and the educational policy towards a global-child development that is less focused exclusively on learning skills enhancement. In addition, the possibility for these programs to remain exciting and flexible and not end up with a stereotypical and technocratic character is another crucial challenge for professionals and teachers. Despite the above issues concerning the management of problem behaviors in the classroom, there are strong indications that show that the combined setting of limits and negative punishment, careful guidance, and reinforcement are essential components for fundamental changes to occur in the overall behavior of students who tend to be antisocial (CEBP, 2003; Munger et al., 1998; Ogden, 2001; Young et al., 2004). All general practices and complementary specialized strategies should in any case be based on a relationship of trust and sincerity between the student and the teacher (Miller, 2003; Pianta, 1999; Weare, 2000) in order to be effective. Even in cases where the teacher is struggling to establish such a relationship, his emotions, moods, reactions, his conscious or unconscious attitudes, his physical and nonverbal communication with the student demonstrate the existence or absence of a genuine interest in the child, which in most cases the student seems to perceive (Monsen and Graham, 2002). Supportive supervision of the teacher in these cases is of paramount importance, so that he can work on and overcome reluctance and lack of enthusiasm, as he often finds himself overwhelmed by distressing emotions. Since the teacher is confronted with such troubling feelings and understands the origin of the child‘s troublesome or challenging behavior, that teacher is more likely to cooperate and function in a positive, decisive and productive way (Fell, 2002; Hanko, 2001; Kourkoutas and Georgiadi, 2011).

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Classroom Interventions

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To briefly summarize the main elements of effective classroom management, we should include the following (Doll, Zucker and Brehm, 2004; Ogden, 2001): (a) emotional support and consistent guidance of teachers by interdisciplinary teams; (b) support and encouragement of student learning behavior by the use of alternate resilient educational methods; (c) support and encouragement of student psychosocial and problem-solving skills; (d) effective negative—non-retaliating or not harsh—consequences; (e) clear rules and directions; (f) effective monitoring; (g) an empathetic, though authoritative teacher who makes essential efforts to create a partnership with school environment and an inclusive classroom; (h) possibilities for active participation of the student with difficulties in the social school processes; (j) individual skills needed for effective participation training; (k) acknowledgment of and reward for participation; (l) students who don‘t succeed academically may have alternative possibilities of accomplishment through social and cultural activities; and, (m) effective problem- solving and crisis intervention.

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Chapter 9

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PSYCHOSOCIAL INTERVENTIONS AND CURRICULUM-BASED PROGRAMS IN SCHOOLS School based academic interventions evaluated by empirical research include the following three groups of psycho-educational/psychosocial programs: (a) Programs aimed at enhancing and reinforcing the interpersonal/psychosocial skills in children, and the ability to solve social/interpersonal problems; (b) Programs exclusively targeted to reduction of violent or aggressive behavior; (c) Programs designed to enhance self-control and the limitation of negative emotions, such as anger (e.g., anger management programs), that are considered to be a source of aggressive behavior, impulsivity, and interpersonal problems (Burke, Loeber and Barmier. 2002; Rutter, Giller and Hagell, 1998; Wolfe, Wekerle and Scott, 1997). In addition, classroom-based interventions are classified in four types, according to the areas of children‘s functioning that target: (a) interventions that promote positive behavior, such as compliance; (b) interventions that aim at preventing problem behaviors such as talking at inappropriate times and fighting; (c) interventions that teach social and emotional skills such as conflict resolution and problem solving; (d) interventions targeted to prevent escalation of anger/acting-out behavior (Bloomquist and Schnell, 2002). Despite the many criticisms over the effectiveness and the conditions of implementation of school-based alternative psycho-educational programs (e.g., programs for the enhancement of emotional and social skills, problem-solving programs, anger management programs, PATHS Curriculum, programs for reinforcement of emotional intelligence, etc.) many positive results in various domains of children‘s functioning have been reported either short or long term (Barbarasch and Elias, 2009; Domitrovich, Cortes and Greenberg, 2007; Greenberg, Domitrovich, and Bumbarger, 2001; Jones, 2004; Hatzichristou et al., 2010; Hornby and Atkinson, 2003; Mcevoy and Welker, 2000; Webster-Stratton, 1998; Weare, 2000; Zins et al., 2004). Actually, there are a growing number of studies that present promising evidence for the effectiveness of such intervention programs (Barbarasch and Elias, 2009; Bloomquist and Schnell, 2002, Elias et al. 1997; Jones, 2004; Weare and Grey, 2003; Tolbin, and Sprague, 2000; Webster-Stratton, 1998). An example is the application of the School-Based Resolving Conflict Creatively Program (RCCP) in public elementary schools in New York, in a particularly representative sample of 1,160 children in first through sixth grade. Results showed that after the program implementation children were less likely to exhibit provocative and hostile tendencies toward peers in ambiguous social situations. They were also less likely to be aggressive during interaction, they showed fewer behavior

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problems, and they had significantly fewer symptoms of depression and aggressive fantasies (Aber et al., 1998). In addition, it was reported that incidents involving teachers‘ aggressive behavior problems in classes were significantly decreased (Aber et al., 1998). Walker, Gresham, and their colleagues, have suggested a Social Skills Intervention Program which teaches 43 social skills that teachers and parents broadly agree are important to the development and effective functioning of children and youths. Selected social skills interventions have four fundamental objectives: (a) promoting skill acquisition; (b) enhancing skill performance; (c) removing or reducing competing problem behaviors; and, (d) facilitating generalization and maintenance (Walker et al., 2004, p. 219). The program attempts to enhance a series of social skills across five domains of interpersonal functioning: (a) cooperation; (b) assertion; (c) responsibility; (d) empathy; and (e) self-control. The three key procedures used to remediate social skills acquisition deficits are coaching, modeling, and behavioral rehearsal. Authors recommend that these procedures be implemented in a tell-show-do sequence corresponding to coaching, modeling, and behavioral rehearsal, respectively (Walker et al., 2004). Coaching involves verbal instruction to teach social skills and utilizes students‘ receptive language skills. This includes three fundamental steps: (a) presenting social rules or concepts, (b) providing opportunities for practice or rehearsal of the target social skills, and (c) providing specific informational feedback regarding the student‘s performance of the social skill. Modeling is based on the principle of observational learning and vicarious reinforcement, whereas behavioral rehearsal–which can be used in three ways: covert, verbal, and overt—refers to practice of a newly-learned social skill within a structured and controlled role-play situation (Walker et al., 2004). As for other child-centered programs that target social competencies, the Interpersonal Cognitive Problem-Solving curriculum uses games ranging from simple word concepts to strategies for finding solutions to interpersonal problems, and for thinking consequentially and learning to empathize (see Wasserman, Miller and Cothern, 2000). Children in this program become less aggressive, more socially appropriate, and better able to solve problems. Programs that focus on academic skills enhancement produced studies with promising results. Specifically, a review of the effects of well designed programs on the academic and behavioral outcomes of at-risk youth found that these programs have a positive impact on academic functioning (Wasserman et al., 2000). Academic programs that target elementary or high school students who have already developed academic and behavioral problems are less likely to be effective (Wasserman et al., 2000). In any case, basic skills programs seem to be more effective when they are implemented early-on with younger children. Universal intervention programs that target serious conduct problems—the Seattle Social Development Project is one such program for elementary school children—and one of the few programs to report significant long-term reduction in violent antisocial behavior (see Wasserman et al., 2000). The program offered parent management training, social competence training, and support for academic skills to increase the child‘s attachment to school and family, reduce involvement with antisocial peers, and reduce aggressive behavior (Hawkins et al., 1999). They also reported higher academic achievement and less misbehavior in school (Wasserman et al., 2000). This program also offers intervention programs that target serious conduct problems, and is one of the few programs to report significant long-term reductions in violent criminal behavior (Wasserman, Miller and Cothern, 2000). The Collaborative for Academic, Social, and Emotional Learning (CASEL) issued a report on evidence-based social and emotional learning programs. CASEL searched the extant

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literature and asked for nominations of evidence-based programs that provide curriculum for schools to use to increase the social and emotional competency of the general student population. They identified 242 programs for review, and selected only those programs (a) that are school-based and provide curriculum (of at least eight lessons) for teachers to deliver to the general student population; (b) whose curriculum covers two consecutive grades or provides a structure that promotes lesson reinforcement beyond the first year; and, (c) are available nationally (Kutash, Duchnowski and Lynn, 2006).The common core of the 80 programs selected by CASEL is that they all increased children‘s sense of connectedness or attachment to school and increased skills for setting goals, solving problems, achieving selfdiscipline, character development, or responsibility. The 11 programs meeting the highest level of rigor are described in the results section of this chapter (Kutash et al., 2006, p. 38). The main criticism that has been addressed to a variety of such school-based prevention and intervention alternative psycho-educational programs go as follows and is mainly related to implementation and evaluation issues: (a) very short time and limited resources are allocated to staff training and the implementation of the programs; (b) lack of empirical evidence on the way such programs are implemented in school settings (e.g., often these programs are applied in a fragmented or incomplete way) (Witt, Vander-Heyden and Gilbertson, 2004); (c) lack of control and monitoring during implementation and systematic evaluation of the interventions; (d) lack of long-term follow-up studies on their effectiveness (Gresham, 2004); (e) assessment of the success that is usually based exclusively on measuring changes in perceptions about violent or aggressive behaviors and not on assessing long-term behavioral changes (McEvoy and Welker, 2000); (f) lack of focus on specific risk factors (Fraser and Williams, 2004); (g) lack of an individualized and precise strategy (most programs have a general preventive character rather than specific goals that target specific groups of children) (Walker et al., 2004); and, (h) lack of a coordinated strategy and partnership among teachers and professionals for the effective implementation of such programs. Brooks and Farley (1998), in a literature review on these interventions, came to the conclusion that many programs aimed at students with emotional and behavioral problems are fragmented and present a very narrow and limited aspect of the nature of the disorder or the student‘s problems (see Meadows and Steven (2004) for an extensive discussion of issues related to effectiveness and research validity of ―teaching skills programs‖). In addition, it has been suggested by many authors that though curriculum-based procedures for promoting social and emotional skill building and conflict resolution skills often increase children‘ knowledge, these have demonstrated only a modest effect on behavior (see Bloomquist and Schnell, 2002, p. 260). Greenberg and colleagues (2003) summarizing the effectiveness of school-based interventions aimed at increasing positive youth development and mental health, decreasing substance use, antisocial behavior, school nonattendance, and drug use; they have concluded that there is a solid research base indicating that well-designed, well-implemented, schoolbased prevention and youth services can be very effective. The conducted synthesis of the empirical literature showed that strategies development programming can positively influence a diverse array of social, health, and academic outcomes. This synthesis found that key strategies for effective school-based prevention programming involve student-focused, relationship-oriented, and classroom and school-level organizational changes (see Kutash et al., 2006). In addition, evaluations of the prevention programs targeting aggressive or

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antisocial youngsters and youths have brought to light a variety of problems, including recognizing developmental issues for children and adolescents, defining and measuring outcomes, relating selection criteria and targeted outcomes to risk-factor research, and other practical issues (see Wasserman, Miller and Cothern, 2000). In conclusion, schools can play a critical role in the development of emotional resilience and of social, communication skills in youths with problems. It is important to note that youths with antisocial, aggressive behaviors should be able to belong to and depend on a network of positive and supportive relationships with peers who are socially well integrated. Importantly, the school should be able to support and reinforce the self-confidence of academically failed students and to adequately guide them to reintegrate in academic and social processes (Raver and Knitzer, 2002; Walker et al., 2004). Undoubtedly, this requires important modifications in the ways schools work, function, and reason. Specifically, important changes should be realized in the ethos, culture, and mentality both on the part of the parents, the school, and society in general. Inclusive education attempts to transform and radicalize teachers‘ perceptions of children with particular difficulties, disorders or disabilities, as well as to revolutionary the educational policy (Ainscow et al., 2006; Dyson and Howes, 2009; Hornby et al., 2000; Salend, 2004; Sheridan and Gutnik, 2000; Quicke, 008). The progressive transformation of the school culture and rationale and therefore the changes in the attitudes of teachers and specialists toward children with disabilities, has led to the development of a series of intervention programs based on an alternative conceptualization of mental health and academic difficulties. These are relative to a more holistic pedagogy, one that does not consider the behavior problems or exceptionalities of children as "pathological" (Weare, 2000). The first outcomes of the implementation of programs of early intervention and prevention, based on these principles of enhancing and supporting positive behaviors, are encouraging (see Kamps and Tankersley, 1996; Munger et al., 1998; Walker Colyin, and Ramsey, 1995; Weare and Grey, 2003).

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Chapter 10

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SPECIALIZED PSYCHOTHERAPEUTIC AND PSYCHOSOCIAL INTERVENTIONS What is noteworthy is that there are a variety of psycho-educational and psychotherapeutic techniques (about 250) involving the treatment of psychosocial or mental health problems or disorders in childhood and adolescence (Kazdin, 2000). Some of them were evaluated by strict methodological criteria, others by less stringent criteria, while the majority of interventions had no external evaluation (Weisz, 2004). Evaluating the effectiveness of the intervention techniques is a very important parameter in the field of psychotherapy for childhood disorders. This does not mean that interventions that are not evaluated are not effective (Kazdin, 2000).With regard to behavioral disorders in childhood and adolescence, although they are considered to have negative prognoses and generally are not easily "cured," great strides have been made in this area over the past years (Carr, 1999). Many procedures and techniques are known to bring positive results (Bloomquist and Schnell, 2002; Carr, 1999; Kazdin, 2000; Weisz, 1997; 2004; Roth and Fonagy, 2005; Quay and Hogan, 1999). Four categories of interventions have been developed based on the treatment of children with antisocial tendencies and behavioral problems for which there are adequate research data: (a) behavioral parent training; (b) child-focused problem- solving skills training; (c) functional family therapy, and (d) Multisystemic Therapy for Antisocial and Delinquent Adolescents (Burke, Loeber and Birmaher, 2002; Carr, 2000, Henggeler et al. 1998; Kazdin, 2000; Rutter et al., 1998; Weisz, 2004). A first problem that relates to the outcomes of therapeutic interventions is the fact that although a certain amount of progress in the psychosocial functioning of the child is made, it is often not enough for the child to succeed in adapting normally and completely to the academic and social context (Roth and Fonagy, 2005). The second important issue in relation to the effectiveness of interventions is that it was found that most interventions applied do not bring any short term positive results (Behan and Carr, 2000; Kazdin, 1997; 2000; 2001; Kazdin and Nock, 2003; Mash and Wolfe, 1996; Roth and Fonagy, 2005). This means that no radical structural changes in the way the child operates are achieved, and the positive effects of these interventions occur at the level of external behavior for a limited time only. This issue was addressed by most researchers interested in the evaluation of psycho-educational and psychotherapeutic interventions for children with behavior problems.

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One question that remains unanswered regarding the action of psychotherapeutic interventions is the mechanisms that are mobilized by these interventions to bring about changes in the behavior of these children (Kazdin and Nock, 2003). Research concerning the results of some psychotherapeutic interventions appear to systematically ignore questions concerning the nature of these mechanisms, the way they work in order to bring about changes, and whether some interventions are effective while others are not (Kazdin, 2000; Kazdin and Nock, 2003). Another issue that arises in relation to children and families with problems concerns the difference between the clinical reality and the experimental conditions where these interventions are usually implemented and evaluated (Kazdin, 2001; Kazdin and Nock, 2003; Weisz et al., 1992). This means that it is not absolutely certain that the positive results achieved by research using planned interventions can also be achieved when these therapies are applied in the context of the everyday life of the child (Kazdin and Nock, 2003; Weisz, Weiss and Donenberg, 1992). Therefore, it is not quite clear the method by which implementation of successful interventions at research level can work in school and in the child's family. However, it has often been observed that successful research programs in the experimental stage do not have the same results when they are applied in the school or clinical reality. Actually, many of these programs lack the necessary ecological validity. Similarly, interventions that for various technical reasons have not been evaluated at an experimental stage may well have positive results in clinical practice (Kazdin, 2000). In any case, holistic approaches such as multimodal models and multisystemic therapy seem to be very effective, even for children and adolescents with severe behavior problems and antisocial tendencies, because they apply to all levels (individual, family, school), using a variety of techniques (Fine, 1992; Henggeler et al., 1998; Kourkoutas and Raul Xavier, 2010; Munger et al., 1998). Very generally, the principles and directions of multisystem holistic interventions are: (a) assessment and understanding of the relationship between the environment and the symptom (behavioral problems); the assessment and analysis of the factors related to school, family, peers, neighborhood, that possibly contribute to the persistence of challenging or problematic behaviors; (b) assessment and analysis of all the relationships with people that have a particular meaning for the child or significantly impact his functioning; (c) interventions on an individual, family and social-school level; interventions may relate to the processing of children's experiences in different settings, but usually they involve parents and teachers, and more rarely other classmates or educators; however, they can be associated with specialized psycho-educational interventions in school and classroom; (d) modifying behaviors by changing the elements and aspects of the ecosystem (the social and domestic) that contribute to problematic conditions; (e) for individuals and families the emphasis is on positive reinforcement and skill development; (f) interventions are planned so that appropriate and responsible behaviors are promoted, while all family members are guided and discouraged from adopting dysfunctional and immature attitudes; (g) interventions focus on the present time, on the development of specific actions and the achievement of specific goals; still, they may often center on resolving recent or past traumatic experiences and conflicts which have negative impact on the child; (h) interventions are individualized and customized to meet the child‘s developmental stages and take into account the peculiarities of each child; (j) interventions are dynamic, structured and require the regular cooperation and involvement of the family and other professionals; (i) application of an ongoing and dynamic assessment of

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the intervention outcome from different sources and aspects; (k) maintenance of positive results through continuous and systematic cooperation with parents and teachers, especially through consultation; (l) uninterrupted supervision of practitioners and special educators by external specialists, considered an important component of a successful intervention. Finally, we should emphasize that in order for the psychotherapeutic interventions with children and adolescents to be effective, according to empirical data, the following requirements must be met (see Alavarez, 2009; Atkins et al., 2001; Barbarasch and Elias, 2009; Carr, 2009; Drewes, 2009; Kourkoutas, 2009; Kourkoutas and Raul Xavier, 2010; Kutash et al., 2006; Levitt, 2009; Rhodes, 2007; Schorr, 1997; Solomon and Nashat, 2010):    

   

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  

They must be flexible and adopt a holistic perspective of the child; They must adopt a positive approach; They must suit the needs, and in particular evaluate and acknowledge the ―problematic‖ child‘s qualities and capacities; They must interpret the secondary reactions of the child as inappropriate adaptation strategy and recognize the coercive pattern that has been eventually established between school, family, and the child; They must be organized according to an ecosystemic perspective; They must adopt a long-term orientation and not exclusively focus on the immediate reduction or elimination of the symptoms ("quick fix"); They must relate to other strategies and intervention policies and practices (e.g. psycho-educational programs, classroom interventions, etc.); Specialists and professionals must be committed to a partnership working model, cooperative in planning for and carrying out interventions in a structured way; There should be mutual respect and trust among specialists, professionals and teachers; The educational staff has a pivotal role to play in effectively contributing to achieve the intervention goals; The parents‘ involvement is an essential component of effective intervention processes.

In addition, the work and studies of some other authors on alternative schools‘ functioning (Boreen and Niday, 2003, pp. 123-124) offer us the following basic assumptions which may also prove important to consider for schools which attempt to be more inclusive. More specifically, alternative schools:   



have administrators and teachers who are more aware of the need to respond to diversity issues that may affect student learning; understand the need for smaller classes and more student-to-student interactions as well as effective teacher-to-student relationships to foster a community of learners; are more flexible in terms of classroom setup, time issues, and curriculum; they can be more responsive to individual needs and challenge them accordingly; this, in turn, allows teachers to make the curriculum more relevant to students; use different types of management, usually more flexible approaches to keep students coming to school;

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 

give some students and families another option for providing the student with the education he or she needs; they accept the reality that many of these kids have fulltime jobs because they must have the income; these schools may provide an environment in which to ―start over‖; offer vocational tracks that seem to have disappeared from traditional schools; provide a service-learning component to help students understand that they‘re part of a community and that the members of that community can learn from each other.

In order to assess the empirical support for school-based mental health programs, Rones and Hoagwood (2000) conducted a review of the literature published between 1985 and 1999. The authors summarized the factors associated with the effectiveness of empiricallysupported strategies: (a) Consistent implementation (b) Multi-component programs (child, teacher, and parent components); (c) Multiple approaches (informational sessions combined with skill training); (d) Targeting specific behaviors and skills; (e) Developmentallyappropriate strategies (f) Strategies integrated into the classroom curriculum (see also Kutash et al., 2006). To determine common elements of mental health programs aimed at providing preventive or early intervention services to at-risk children, Browne, Gafni, Roberts, Byrne, and Majumdar (2004) synthesized 23 reviews describing the empirical literature on prevention strategies implemented in or involving schools. The authors found the following common elements of effective prevention and early intervention programs (see also Kutash et al., 2006, p. 44): (a) Programs aimed at developing protective factors have shown greater positive results than programs aimed at reducing pre-existing negative behaviors, but vary by age, gender, and ethnicity of children; (b) younger children show greater positive results than older children, but some programs are effective for older children; (c) programs directed to address a specific problem have greater effect than broad, unfocused interventions; (d) programming that has multiple elements involving family, school, and community are more likely to be successful than efforts aimed at a single domain; (e) strategies were enhanced when based on and informed by sound theoretical foundations; (f) fear-inducing tactics and delivering information in only a didactic format were generally less effective; and, (g) long-term strategies are more effective than short-term strategies when they have the continued presence of appropriate adult staff or mentors. Overall, professionals (school psychologists, social workers, family educators, special educators) who target students at risk or with already-manifested behavioral or other psychosocial problems should build strong partnerships with parents, school teachers, and amongst themselves. The work of Aper, Allen-Meares, and her colleagues reports that professionals working in an ecosystemic perspective might seek to achieve the following goals in their work (see Allen-Meares et al., 2000, p. 86):   

build new social skills or competencies on the part of adults, parents, and children identify new resources and social service agencies that will assist children and their families and to develop new programs in the school and the community change the perceptions of adults (such as teachers who may have a negative view of a pupil)

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   

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increase scientific knowledge and understanding (for example, provide in-service training to educators about child maltreatment or neglect, family problems, pupil‘s personal deficit) help involved practitioners (e.g., teachers) to be ―emotionally detached‖ from the ―problematic‖ student and contextualize the pupil‘s dysfunctional behavior (e.g., understand that the problematic behavior is related to acute family problems, intense anxieties, or to inappropriate parental practice and abuse) to structure child-centered individualized activities (modified educational schedules) link relevant community agencies with school-based services develop new roles for teachers, parents, and community agency personnel develop new and innovative programs where a need exists.

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We find such recommendations very useful. They are in agreement with some of our basic theoretical assumptions and clinical principles that guide the work we have attempted to realize within Greek schools during the last decade.

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Chapter 11

HOLISTIC PSYCHODYNAMIC MODEL

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Based on a high number of clinical interventions in Greek schools with children and adolescents and empirical data on the development and treatment of behavioral problems in children, a holistic model has been proposed for various groups of children with a multitude of problems and difficulties (Kourkoutas, 2007; 2008; 2011a; Kourkoutas and Georgiadi, 2009; Kourkoutas and Georgiadi, 2011a; Kourkoutas, Plexousakis and Georgiadi, 2009; Kourkoutas, Plexousakis and Georgiadi, 2010; Kourkoutas et al., 2011). At a theoretical level, this model incorporates the psychodynamic/interpersonal and social-cognitive perspectives in a wider multisystemic viewpoint (Kourkoutas, 2004a; 2004b; 2004c; 2007; 2008; 2011; 2011a). More specifically, this multidimensional model encompasses a series of key theories and synthesizes different approaches based on contemporary developmental psychopathology research evidence. Generally, the theoretical and research models upon which our working model is built are the following: 

     



Contemporary psychodynamic/object relations and representations theory (Fonagy, 2004; Fonagy et al.2006; Fonagy and Target, 2003; Fonagy et al. 2004; Sroufe et al., 2000; 2005); Internal working models of relationship/interpersonal schemata (Fonagy and Target, 1998; Scriva and Heriot, 2008); Ecosystemic theory/transactional models (Fraser et al., 2004; Sameroff, 2000; Sameroff and MacKenzie, 2003; Sameroff and Guttman, 2004); Theory of acceptance-rejection (parental/interpersonal) (PARTheory) (Rohner and Britner, 2000; Rohner and Britner, 2002; Rohner and Brothers, 1999); Trauma related theory (Greenwald, 2002; Ford, 2002); Theory of family psychopathology/family dynamics (Berg-Nielsen, Vikan, and Dahl, 2002; Cummings, Davies, and Campbell, 2000); Intergenerational transmission of disorders/dysfunctional parenting/ maltreatment (Lebovici, 1996; Serbin and Krap, 2004, Thornberry et al., 2003; Zoccolillo et al., 2005); Empirical research on contextual/social factors (e.g., social-academic risk/protective factors) (Fraser, 2004; Fraser et al., 2004; Garbarino and Ganzel, 2000; Sameroff and MacKenzie, 2003);

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Evidence-based holistic interventions that relate to the positive model of behavior and positive reinforcement (empowering model) (Pianta, 1999; Sameroff and Fiese, 2000; Sameroff, Peck, and Eccles, 2004; Weare, 2000, 2005; Weare and Gray, 2003); Inclusive Education perspective, that promotes a non-medical, non- pathologizing approach of working with students with difficulties, which in addition emphasizes the importance of school and teachers‘ involvement in the integration project of such groups of students and the radicalization of schooling towards a more child-centered and less exclusionary pedagogy and educational practice (Ainscow et al., 2006; Hick, Kershner and Farrell, 2009; Sheridan and Gutnik, 2000; Quicke, 2008)

Regarding the clinical intervention component, the model includes the application of different techniques applied by a multidisciplinary team and involve individual psychotherapy and counseling, the academic support of the children where it is necessary, counseling and supportive supervision of teachers and, of course, family psychotherapy, training, or counseling and emotional guidance (Kourkoutas, 2007; 2008; 2011a; Kourkoutas and Georgiadi, 2009; Kourkoutas and Raul Xavier, 2010). This holistic model is based on theoretical conceptualization and empirical studies regarding school-based psychotherapeutic/psycho-educational interventions and mental health services delivery already proven successful (Adelman and Taylor, 2009; Christner, Mennuti and Whitaker, 2009; Emde and Robinson, 2000; Epanchin, 1998; Fraser and Williams, 2004; Koller and Svoboda, 2002; Munger et al., 1998; Munger et al., 1998; Nastasi et al., 2003; Nathan, 1998; Paternite, 2005; Reddy and Richardson, 2006; Rhodes, 2007; Sharry, 2004; Smith and Fox, 2002; Smith and Lombardo, 1998; Young et al., 2004; Weare, 2000; 2005; Weare and Gray, 2003; Weist, 2003). More specifically, the fundamental theoretical assumptions guiding the philosophy of intervention on a clinical or school-based level are drawn upon the psychodynamic model and contemporary developmental psychopathology research (see Dodge, 2000; Emde and Robinson, 2000; Fonagy and Target, 2003; Fonagy, 2004; Fonagy et al.2006; Sroufe et al. 2005; Sameroff, 2000). These assumptions are: 

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The emotional processes are very important and relate to the school and psychosocial functioning and readiness of the child, without always being possible to evaluate or easily identify such internal processes; In most cases, the child with serious behavioral problems is primarily a child with disabling emotional difficulties/disorders, and with social, interpersonal, and cognitive deficits/distortions, who struggles to cope with adjustment challenges; Some children with conduct/aggressive problems are seriously damaged in their selfschemata-internal working models and emotional functioning, thus displaying truly harmful behavior(s) toward others; The experiences of the child within the family greatly affect the development of behavioral and relationship competencies. Social and interpersonal skills and selfand other representations are essentially shaped by the quality of primary attachments with caregivers;

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On the family level, many children have experiences of a negative or traumatic character that generate internal tensions, emotional conflicts, and hinder the development of basic psychosocial skills and school commitment; Distressing, conflicting, and harmful or ambivalent emotional interactions experienced within the family are the origin of many behavioral dysfunctions these children display; Inability to bear painful emotions is usually due to both the disorganizing effect and the severity of distressing family experiences, and the inherent social-emotional and cognitive distortions which, according to all available data, constitute a serious risk factor for a future delinquent pathway; At school, there is often a reproduction of the behavioral and relational patterns that were developed in the family (see Ford., 2002; McMahon and Forehand, 2004). Behind the problematic behaviors there are dysfunctional internalized working models and unmanageable emotional conflicts deriving from the family, and these worsen at school; Intervention of specialists is essential at all levels (individual, family, school) and in all domains (learning, cognitive, behavioral, and interpersonal); Focus is on resolving emotional conflicts, changing representations of self and others, modifying behaviors and emotional skills through the development of strong bonds with the teacher, psychologist/counselor, and the resolution of acute family problems (buffering contextual risk factors and enhancing self-protective psychosocial skills); the use of various techniques is often necessary; The "work" with the family is the keystone of any intervention process (Fantuzzo et al., 2004; Sherry, 2004); Modification of the behavioral problem at home can be achieved by remodeling/reframing the family dynamics, attitudes, and strategies (modification of coercive interactions), the expectations and emotional frustration/confusion of the parents, and parents‘ guidance and training on specific tasks or skills; The school and the teacher are considered to operate either as an extension of the specialist or as an extension of the family; The "work" with the school at all levels is a critical parameter and component of the intervention; Modification of problem behavior in school is often a pressing priority; it is usually performed by integrating various psycho-educational activities, techniques, and strategies both within and outside the classroom in cooperation with the teacher or the rest of the educational staff; work on more profound psychological (family, teacher, or child) issues is anticipated, when necessary; The "work" on the emotions and perceptions that parents and teachers maintain regarding the ―problem child‖ constitutes a fundamental dimension of the model; Establishment of a ―working alliance" with parents is therefore an absolute priority of the clinical/counseling process and is based upon an empathic and thorough understanding of the parents‘ psychological problems, their incapacities and deficits, as well as their qualities and competencies.

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Preliminary data based on a series of pilot interventions are promising. For example, a study conducted with a group of 26 children who were referred for family dysfunctions and behavioral problems in a period of two years, followed by an evaluation of the children‘s general functioning after one year, showed significant improvement of problem behavior in most cases of children (Kourkoutas, 2005; 2007; 2008). These children exhibited a range of disorders such as hyperactivity, social and interpersonal difficulties, learning problems, and general school adjustment problems. A second extensive study (Kourkoutas, 2011a) with children with hyperkinetic or disruptive behaviors without aggressive character also shows how a comprehensive intervention with the child, the family, and the educational staff results in significant improvements in children‘s functioning and reduction of oppositional reactions. Many other pilot programs or school-based clinical interventions have been realized during the last decade in Greek schools, in most cases with significant positive outcomes. Factors that seem to negatively affect or hinder the intervention positive outcomes are in general related to severity of the disorder and family dysfunctions or even pathology, parents‘ and teachers‘ refusal to regularly cooperate, and the inability to sustain a long-standing intervention when necessary. It is important to emphasize that the MHP takes on a multidimensional approach for each specific case, a multisource evaluation of each child's problems, and the intervention outcomes. For example, it is not acceptable to treat learning disabilities without considering the psychosocial side effects, as well as the way teachers and family deal with such difficulties (Kauffman, 2000). In addition, it is unlikely to modify the place these children have in the classroom, the school, and the family, without evaluating and strengthening their basic interpersonal skills or their self-confidence. Accordingly, it is also important to address teacher‘s or parents' attitudes and the way they respond (with high stress, frustration, or by rejection and aggressive behaviors) to both learning problems and behavior in general. The way parents (as well as teachers) behave toward the child and handle a series of other important issues related to social or school life should also be addressed. As previously stated, in the case of children with challenging behaviors, behavior problems are treated, to some extent, through the implementation of behavioral techniques and the establishment of an accepting and stable controlled educational framework—in collaboration with the teacher—setting clear limits and expectations. However, the psychoeducational and psychotherapeutic interventions are also focused on the internal processes of the child: e.g., on his negative feelings (such as anger and rage), as well as on their cognitive schemas and beliefs that may contribute to the maintenance and intensification of disruptive behaviors (Carr, 1999). It is widely suggested that effective intervention for pupils with behavioral difficulties is a question of striking good balance between internal and external behavior control. Internal control refers to bringing emotions under intellectual control and using language as a behavior regulating mechanism (Ogden, 2001). Students capable of reflecting on their own behavior may profit from interventions aimed at creating insight and afterthought (Ogden, 2001). Students‘ behavior is regulated both by their cognitive mechanisms and by the influences or actions of the environment. For this reason, beyond individual work with the child, MPH attaches special importance to cooperation with teachers. Specifically, emphasis is given to addressing their negative or conflicting and destabilizing emotions and reactions, to the extent that teachers' attitude toward children is an important risk or protective/facilitating factor for their development in school.

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Work with teachers similar to work with parents is based on a particular model of supportive supervision, where the responsibilities, obligations and limitations for the child are established in a firm and precise manner (Kourkoutas 2004a; 2004b). When planning interventions, the teacher's relationship with the child, intuitive empathic skills and initiatives, and knowledge of the child, are considered important elements and are taken into account. Working with parents is another critical parameter of any successful intervention. Parents, through their functioning and behaviors, contribute to the maintenance of the problem or its resolution. In addition, parents, through their positive attitude, involvement or detachment, can facilitate or impede, respectively, the course of psychotherapeutic interventions. At the same time, they can facilitate or annul any creative intervention and any initiative taken by the teachers. Actually, most available data show that interventions that address both individual and contextual risks show a range of positive outcomes (Carr, 2009; Fraser and Allen-Meares, 2004). Interventions at the family level relate especially to the modification of dysfunctional relationships and distorted beliefs about the child. Furthermore, intervening to modify problematic or pathological relational, communication, and emotional patterns between family members may need considerable effort and critical manipulation on the part of therapists. It is reasonable to believe that such technical manipulation and subsequently expecting outcomes for families who function for years with the same coercive or inappropriate models of parenting and relating, may take a long time for considerable changes to register. Though this is true for a number of families, there are a lot of cases in which the appropriate manipulation on the part of an experienced specialist may facilitate or enhance the inhibited potential and may lead to important modification of family functioning. We have developed a brief therapy program targeted at revealing and working the emotional ―blockages,‖ ―obstructions,‖ or impasses and ambivalences of parents, which very frequently are due to their own distressing experiences as children or to their personal history in general. Such past or recent experiences usually negatively impact their beliefs and conceptions of parental roles, their investment and expectations of their own children, as well as their rearing capacities. Overall, the main purpose of family counseling in most cases is to allow the family to get rid of pathological and dysfunctional roles and relational patterns, or the distorted and false self- and child-perceptions, or even of the emotional conflicts and confusions that harmfully impact child-parent relationships and healthy parental roles (Borduin, 1990; Campbell, 2002; Engelse Frick, 2000; Green, 2000; Horne, 2000; Kourkoutas, 2011; Papousek, 1995). In some cases, modifying the stereotypical beliefs of parents may automatically lead to a different attitude toward the child. In other cases, beyond shaping parental awareness of specific psychosocial process, the intervention may focus on helping them acquire parenting and management abilities that are lacking. Actually, the counseling-therapeutic process should allow parents to develop not only their external, but also—and most important of all—their internal resources (Schmidt Naven, 2010). One of the main purposes of our work with many ‗dysfunctional‘ parents is to offer them a ―therapeutic space for re-creating the child in their mind‖ and get in touch with their real child (Green, 2000). Indeed, a lot of parents come with a sense of shame which acts as a powerful reinforce of the sense of ―bad‖, ―imperfect‖ parent, an issue that has to be addressed in the parent‘s therapy (Horne, 2000). Some of them are deeply ashamed when confronted with therapists, and usually unconsciously reject their own responsibility. Actually, when

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they seek help from professionals, they believe that therapists will work exclusively with the child or will offer only practical tips to them. Therefore, many parents encounter enormous difficulties in admitting their ―bad‖ practices and to work on them. Hence, the counselingpsychotherapeutic work, in its initial phase, should give space to the process of ―containment‖ that allows ―primitive/tough‖ feelings and narratives of harsh parenting to be expressed. Therapists should receive such feelings or narratives with a high sense of empathy without criticizing the parents, placing such dysfunctional practices in the context of parents‘ own history and personal problems. For example, in the case of a hyperactive, challenging, and very intelligent 6 year- old girl, it was learned during parent meetings that her father was almost always absent and undertook no rearing responsibility. Because the couple had divorced with the birth of the child, he was seeing his daughter only one weekend every two weeks. During sessions with the mother the painful and disorganizing experiences that she experienced during the period after the birth of her baby came out. During that time she was depressed, left alone to care for the baby in the company of a very hostile and cynical mother-in-law who used to always criticize her for everything. At the same time, her husband was totally absent, having established an extra-conjugal relationship. She admits she refused and rejected her baby, she felt unable to demonstrate any affection or love. She still feels very guilty about that time, and is convinced that her daughter is defiant-oppositional because of the love she didn‘t receive during infancy from her. In reality, the relationship with her daughter was quite conflicted—she displayed a severely anxious and ambivalent attachment to her mother. What the mother brought to sessions were her own experiences as a child: she was the ―perfect angelic daughter‖ who didn‘t have a right to deceive her father, and as a consequence, she was ―condemned to succeed everywhere.‖ She was always a mature, well organized child who in addition, felt she had no right to demonstrate any feelings of weakness or to contest her father‘s authority. With her daughter, she is very easily upset and driven crazy over her minor weaknesses or mistakes on the part of the child. As a consequence, she is in permanent conflict with her daughter, apparently leading the child to react in oppositional hyperkinetic ways because she always feels unaccepted or rejected. The counseling therapeutic process with the mother focused on working thorough her self- and her daughter-representations based on her own childhood experiences and the relationship with her own father. After a long time she became less demanding, hostile, and implicitly or explicitly rejecting toward her daughter—who gradually became much more mature and self-controlled. As noted by Schmidt Naven (2010, p. 67), ―By recognizing that the child and adolescent ‗speaks‘ for the family, we resist the temptation to separate out the child or adolescent‘s problem as though this is disconnected from the family and has a life of its own.‖ This can prove to be a difficult task for counselors and specialists. They may be confronted by families and parents who want to find a solution for a specific problem they have identified in their child (Schmidt Naven, 2010), without being really involved in the therapeutic process, splitting their relationship with the child and their rearing practices away from the child‘s problems. In another similar example, the mother of an 8- year-old very reserved and introverted girl admitted to being very nervous, oppressing, tyrannizing her daughter, usually finishes up beating and maltreating her. The child is very aggressive toward her little brother. From the first session, the mother admitted rejecting her daughter (―I don‘t want this child‖), and

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feeling she is a ―failed parent.‖ Her daughter was always the ―problem child,‖ refusing to eat since she was a baby and driving her mother crazy (shouting, breaking dishes, etc.). In brief, the next two sessions revealed the many personal problems this woman had in her own adolescence and as a young woman. She experienced depression immediately after the birth of her daughter because of the death of her own father, to whom she was strongly attached. In addition, the death of her father followed her mother‘s cancer, which lasted for more than two years. She was forced to take care of her sick mother for all that period. And she admitted to always having a very conflicted relationship with her. On top of all this, in the previous year her husband lost his job and developed cancer. In this case, the counseling process helped the mother to reconcile with her own inner daughter first, recognizing her real capacities and problems (―recognize and acknowledge her real child‖). She confessed that she believed her daughter had low intelligence, though she was an excellent rhythmic gym athlete, very competitive in the official championship. She was rejecting her because she was very introverted and low-profile child, and at the same time, very aggressive and rejecting toward her brother. Actually, she confessed rejecting her because she was not the child she always dreamed of having—a very clever, lively, obedient, well-organized, and bright student—since the mother was also a teacher. Counseling meetings, from the very beginning, focused on supporting the child to articulate and verbalize her need to be accepted by her mother, and to see her stop shouting and hitting her. In a very touching meeting that followed she expressed this in front of her mother, who was deeply moved to become aware of how rejecting and aggressive she is with her child. The available research has shown that the effectiveness of early intervention programs is largely due to the development and analysis of all the parameters of family dynamics (Campbell, 2002; Carr, 1999; 2009; Kazdin, 1991; 1995; Nathan, 1998; Papousek, 1995; Weisz, 2004). Mattejat and Remschmidt (2001). During their research with a large number of children and adolescents who were in therapy, these researchers noted that their cooperation with the family was the most critical to the success of the intervention. There are also family interventions which focus on parental ―behavioral education/training" in order to modify their attitudes and rearing practices and enable them to effectively address behavioral challenges in children (Dishion and Stormshak, 2006; McCart et al., 2004). Interventions in families are considered in these cases as being more efficient in modifying the behavior problems of children, especially when implemented early, than interventions that focus exclusively on children (Dishion, 2007; McCart et al., 2004; Munger et al., 1998; Nathan, 1998), because so many parents are actually entrapped in an endless cycle of coercive interactions with their offspring. Interventions at the family level are considered by all researchers as important for activation of processes that will facilitate treatment of children‘s behavior problems. In this model it is considered a necessary and indispensable factor for the success of these interventions that a systematic and interactive approach is adopted (see Campbell, 2002; Dishion, 2007; Dishion and Stormshak, 2006; Goldenthal, 2005; Munger et al., 1998; Nathan, 1998; Sameroff, 2000). It is thus essential even in individual sessions with children and adolescents with behavioral problems, as long as the developmental psychopathology allows attaching greater importance to parental influence (Campbell, 2002; Dishion and Stormshak, 2006; Goldenthal, 2005; Sroufe et al. 2005; Wachtel and Wachtel, 1986). Moreover, research shows that even when the family is not systematically present in sessions, if interventions

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adopt a systemic perspective (where issues of family dynamics are worked on with the child or adolescent) this makes intervention much more effective (see Kazdin, 2000). In conclusion, integration of psychodynamic, interpersonal, social-learning, and cognitive-behavioral principles and techniques in the context of developmental psychopathology treatment, although at first glance may seem contradicting, creates conditions for a broader and more effective approach at both theoretical and clinical levels regarding the behavior problems of children (Goldenthal, 2005; Hammen and Rudolph, 1996; Rudolph, Hammen, and Burge, 1997; Shirk et al.1998). A key strategy of a contemporary transactional model of intervention (Patterson, Reid, and Dishion, 1992) and systemic understanding is to include "work" with professionals and teachers, and the philosophy/function of the school as critical parameters for the planning and implementation of interventions (Fox et al., 2003; Maital and Scher, 2003; Munger et al., 1998; Weare, 2005). On the other hand, individualized work with children and their families and interdisciplinary support of all involved persons and agencies seems to be a very promising approach to behavior problems and emotional difficulties (Bloomquist and Schnell, 2002; Fox et al., 2003; Fraser and Williams, 2004; Smith and Lombardo, 1998). Implementation of early prevention programs and educational support of children with challenging behaviors contribute to the school integration of such children (Dyson and Howes, 2009; Fox et al., 2003; McNab, 2009; Zero to Three, 2003; Zins et al., 2004). In addition to preventive and targeting interventions, the participation of children who are at risk to exhibit behavioral or antisocial problems in psychosocial skill training programs can significantly decrease tensions, frictions, and challenges, and increase the classroom integration of such children. Unfortunately, many of the services in most American States and European countries in which a high number of school-age children‘s parents are addressed cover only DSM disorders and are lacking an ecological systemic perspective that promotes the work described earlier. State-funded services are often poorly supported, ineffective, not research-based, and in some cases possibly iatrogenic (Dishion, 2007). For all these reasons, it has been suggested by a large number of clinicians and researchers to embed affordable and effective interventions in agencies that have wide access and repeated exposure to children and families (e.g. schools) (Dishion, 2007). Overall, children's mental health needs are not being met in the current model of service delivery in a great number of Western countries (Walker et al., 2004). It is has been suggested that school psychologists have to play a pivotal role in facilitating the move toward a comprehensive school-based mental health service model (Christner, et al., 2009; Heathfield and Clark, 2004). This model recognizes the importance of children's social–emotional functioning because positive mental health directly impacts the learning potential of children (Heathfield and Clark, 2004). Additionally, the comprehensive school-based mental health service model emphasizes the importance of prevention and early intervention. By focusing on preventing emotional and behavioral disorders and intervening early at the onset of symptoms, students will no longer have to wait until they are enrolled as special educational needs students to receive these much-needed services (Heathfield and Clark, 2004). In many countries of the world programs that focused on building the capacity of schools to meet the needs of students who have high support needs in the area of mental health have been gradually established (Adelman and Taylor, 2009; de Jong, 2005). The general key factors that were identified as important in building the capacity of the school to support

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students with high mental health needs include gaining the support of staff and school leaders, focusing on staff wellbeing, embedding mental health supports into the school curriculum and ethos of the school, developing strong relationships within the school and the community, developing a plan and taking small steps to achieve goals, and making a strong commitment to improving the support of students at risk (Anderson, 2005, p. 219). In addition, implementing meaningful for parents and teachers and comprehensive individual interventions may also significantly and effectively contribute in the treatment of more serious problems of specific groups of children.

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Chapter 12

CONCLUSIONS REGARDING PSYCHOSOCIAL AND PSYCHOTHERAPEUTIC INTERVENTIONS

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Based on available empirical data, researchers underline the importance of multidimensional and pluralistic interventions for the effective treatment of children and adolescents with behavior problems (Atkins et al., 2001; 2003Connor, 2002; Fraser and Williams, Kauffman, 2000; Munger, Donkervoet, and Morse, 1998; Nastasi et al., 2004; Nathan, 1998; Rutter et al., 1998; Williams et al., 2004; Young et al., 2004). Hence, psychosocial interventions should be multileveled, adopting different strategies each time based on evaluation of the child‘s needs and skills, but also on contextual protective and risk factors in need of strengthening or elimination, respectively (Fraser et al., 2004). The primary interventions referred to (see Connor, 2002; Hanko, 2001; Kampwirth, 1999; Kauffman, 2000; Ogden, 2001; Young et al., 2004) are: a) b) c) d) e)

Individual and group psychotherapy and counselling of children; Counselling/psychotherapy-training of families; Training and supportive counselling of teachers and educational staff; Implementation of preventive programmes; and, Individual intervention focused on specific groups of children within the school context.

However, available empirical data show that interventions should be multifaceted, multidisciplinary, concrete and flexible, focused on specific goals, strengthening general skills, combining a series of educational techniques and methods (e.g., encouraging adaptive behaviours, discouraging problematic ones) (Kamps and Tankersley, 1996). These are dynamic strategies of strengthening positive behavior and programs (e.g., programs that teach and allow students to practice interpersonal social skills through participation in group activities, programs for strengthening relationships between peers, individual learning support, etc.). Individualized specific interventions can focus on treatment of challenging and disruptive behaviours in children through cognitive, behavioural, or psychodynamic techniques (Loeber and Coie, 2001, Pettit Molaja and Mize, 2001), and on general psychological empowerment of children. This also occurs through elaboration of dysfunctional cognitive schemas, a relationship of trust with the therapist (Lanyado, 1999), and through strengthening of interpersonal and social skills and enhancement of their self

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esteem (Webster-Stratton, 1999; Wolfe, Wekerle and Scott, 1997). Many interventions are directed toward internalization and assimilation of specific social norms and behavioural models (encouragement and reinforcement of self-control) (Burke and Carr, 2000; Fraser and Williams, 2004; Frick, 2004; Jones, 2004; Kazdin, 2000; Nathan, 1998). Psychosocial interventions which combine multileveled approaches adjusted to every individual case, appear to be most promising techniques for children with behavioural problems (Connor, 2002; Kutash et al., 2006). Important parameters for the effectiveness of interventions prove to be the ensuring of a consistent long-term implementation of interventions, continuing evaluation of children‘s progress, and reestablishment and refinement of special techniques which are used, based on information from different sources (teachers, parents, observation of the child itself) (Frick, 1998; Kazdin, 2001; Marshall and Watt, 1999). Finally, the choice of intervention should be defined from the specific developmental level of each child as well as his needs, from the large number of environmental and personal risk and protective factors that specialist need to handle (Fraser and Williams, 2004; Frick, 2004; Frick and Morris, 2004; Greenspan, 1999; Marshall and Watt, 1999). Deeper comprehension and continuous evaluation of the general function of the child appears to be a significant dimension of a promising intervention (Frick and Morris, 2004; Kazdin, 2004). It is widely acknowledged that the effectiveness of long term intervention programs, in most cases is associated with exploration and treating of factors which produce or maintain problematic behaviours (see also, Frick, 1998). In conclusion, there are strong indications that multifaceted intervention strategies can be effective with children having various behavioral problems, and that school can play an important role for the promotion of their mental health. We can achieve that by posing under that spectrum holistic programs of counseling and creative psycho-educational activities, as well as training programs for reinforcement of children‘s social skills (Akins et al., 2001; 2003; Dryfoos, 1994, 1997; Dyson and Howes, 2009; Kampwirth, 1999; Kauffman, 2000; Laub and Lauritsen, 1998; Webster-Stratton, 1999; Zins et al., 2004).

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Chapter 13

ISSUES RELATED TO CRITICAL SITUATIONS WITHIN THE CLASSROOM AND THE SCHOOL CONTEXT The term critical school situations (or crisis situations for more extreme cases) is used to refer to processes and episodes in school life which can produce or represent unresolved institutional, social, or individual tensions and conflicts. Critical situation can also include covert phenomena which can result in more or less serious intrapersonal (emotional, behavioral, academic) or interpersonal and organizational dysfunctions. Overt episodes are possibly associated with:

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Disruptive, disturbing and aggressive behaviours that vary in severity, tension, and persistence; Chronic or occasional conflicts between students themselves, or with their teachers; Overt or covert conflicts between the educational staff members; Conflicts or serious problems between parents and teachers which concern the general function and academic performance of certain students; Incidents of an aggressive nature which could include corporal punishment or aggressive behavior on the part of teachers; Cases where teachers lose control of their behaviour which could make parents react and demand that measures be taken by school administrators; Phenomena where teachers become the object of overt or covert challenging and aggressive behaviours by students; Serious academic problems and school failure (student drop-out); Learning disabilities; Serious or moderate behavioural problems of specific students which may disrupt classroom processes or create problems in the function of the school; Overt or covert use of psychological or verbal abuse in the school yard as well as inside the classroom by certain groups of students; Recurring stigmatization, ostracism, and peer group exclusion of certain students who may also become victims of more serious violent acts; Occasional stealing of objects due to immature, challenging, or reactive behaviours; Systematic stealing and vandalism in the school; Emotional problems among a large number of students;

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Serious mental health problems (psychoses) of certain students; Health problems which influence students‘ self-image, their attitudes towards school, and their inclusion and integration into the academic and daily social life; Lack of essential school facilities and provision of services for children with special needs, which can result in classroom tensions or social and academic exclusion of these students; Serious family problems of certain students of a financial, social, or psychological nature:

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-parental alcoholism of one parent; -parental serious psychological problems or mental illness; -seriously disorganized or chaotic families; -death of a parent; -death of a sibling; -divorce, separation of parents; -serious financial and social problems; Cases of reported student abuse; Death of a student; Wider social or political conditions which may have a serious negative impact on family organization and the student‘s life; Conflicting cultural discrepancies (religious, social, national) between groups of students which jeopardize the social relational system of the school and may create overt or covert tensions with tremendous effect on school life and the academic community;

Many questions are raised about the way school units and each school teacher, individually, should respond to such critical situations at informal, individual or formal and systemic level. All the above phenomena represent serious potential risk factors which could undermine one way or the other the psycho-social and academic development of children, as well as the educational functioning of the school. One of the most serious challenges of contemporary school psychology, inclusive/special education, and education policy is the practices and procedures that should be developed in order to effectively deal with such phenomena, so that schools become a place where all students fully develop their social, emotional, cognitive, and learning potentials (Zins et al., 2004). Many schools are lacking adequate resources and appropriate knowledge or policy and practice for effective management of critical situations. In daily practice, each teacher and professional is faced with a dynamic and complex reality, which uniquely challenges intuitive and scientific knowledge, as well as academic and personal skills and abilities. Each case of a student with problems is different in terms of severity of the disorder, the personal pathway, and the individual and family dynamic. The specialist (educator, school psychologist, or counsellor) is called upon to decide how to approach and intervene. They are called upon to think, design, and act. If actions are taken without an intuitive interdisciplinary and cooperative partnership and understanding, based on a thorough evaluation of each child‘s problems, they cannot be fruitful and meaningful for the child and the parents. These

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dimensions are considered to be the most essential elements of each effective educational and psycho-social action or intervention (Monsen and Graham, 2002). Teachers‘ intuitive and empathic understanding of the child, based on long-lasting interactions with him, is an equally important tool that can provide new insights for a clinical scientific approach. But the teachers‘ perception of the child must not be based on prejudices and stereotypical preconceptions (Hanko, 2000; Monsen and Graham, 2002). Actually, many teachers usually intuitively feel how the child is deep inside, and what kind of emotions the child communicates implicitly to them. In psychodynamic clinic it is widely acknowledged that the negative emotions that the child elicits from others through his actions are reflections of his profound emotional states.

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Chapter 14

PSYCHODYNAMIC SYSTEMIC PRINCIPLES AND CHILD PSYCHOTHERAPY

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The following strategies or interventions can be applied within the school context in order to help and support children at risk or with behavior problems, and promote their social and school inclusion: a) Individual counseling and psychotherapeutic interventions with the child; b) Implementation of various types of curriculum-based or school-based social, emotional, and interpersonal skills programs; c) Counseling and psychotherapeutic interventions with the family; d) Counseling interventions with classmates or programs that target their involvement in order to positively affect classroom dynamics; e) Cooperation with groups of peers and older children for better school inclusion and guidance outside the classroom for children at risk or with behavior problems; f) Long-term emotional supportive supervision and coaching of parents and teachers; g) Counseling interventions with classroom teachers; and, h) Counseling interventions with the educational staff. As for type of specific applied strategies, a wide range of techniques (behavior, psychodynamic, social-cognitive, systemic, and alternative education oriented) are used on both the individual and group level. Such strategies and interventions should be integrated as part of a wider holistic/ecosystemic approach to students, which is not medical-based, but rather child-, family-, teacher-centered, and school inclusive (Dyson and Howes, 2009; Hanko, 2001; McNab, 2009). School-based counseling and psychotherapeutic interventions targeting students with behavioral problems constitute an important interpersonal experience, both for parents and children, but also for teachers, because teachers have an opportunity to attain better insight into critical situations—and to modify their views, attitudes, and ways of managing such problems in everyday school life (Cozzarelli, 1993; Faupel, 2002; Fell, 2002; Field, 1993; Hanko, 2001; 2002; Monsen and Graham, 2002; Saltzman, 1993; Weare, 2000). Besides, counseling and psychotherapeutic interventions may bring important modification to the educational staff‘s culture, in the school-unit philosophy, and organization, when these are

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integrated into a wider inclusive and collaborative project (Greenhalgh, 2001; Hanko, 2002; Kourkoutas and Raul Xavier, 2010; McNab, 2009; Monsen and Graham, 2002). Such intervention inclusive projects may enable teachers to create a ―holding‖ environment for pupils and families at risk or facing multiple problems against labeling and medicalizing exclusionary approaches (Heller, 2000; Quicke, 2008; Rustin, 2000; Solomon and Nashat, 2010; Urquhart, 2009). The teacher is an indispensable part of the interdisciplinary intervention team. They should be informed about the progress of counseling sessions; involvement in the design and implementation of interventions is considered essential (McNab, 2009; Kourkoutas and Raul Xavier, 2010; Salend and Sylvestre, 2005). Teachers, as has been suggested, should acquire basic counseling skills, and the school should, as well, develop a new philosophy integrating into the curriculum, principles of childcentered mental health and psychosocial skills practices. Research shows that this relationship of intermediation can be very effective for drawing out negative feelings of parents, children, and teachers—and for avoidance of conflicts between them (Cole, 2003). In any case, the mediation of an expert between parents and teacher, between the problematic child and the teacher, should take place through the counseling services of the school (Cole and Brown, 2003). A basic theoretical assumption related to our interventions with families at risk and children with various types of problems draws from psychodynamic theory. A continuing contribution from psychoanalytic tradition has been its focus on individuality and personal meaning. Exploring what is important for the individual and the family in particular circumstances and pursuing the complexities of meaning have been central in psychoanalytically-based interventions (Emde and Robinson, 2000, p. 161). Exploring meaning in this way to generate respect, increase self-confidence, and promote a sense of new beginnings can take advantage of newly- envisioned possibilities. The psychoanalytic tradition has emphasized the importance of relationship and basic attachment in psychological development not only in the experience of early mothering and dealing with later family conflicts, but also in the experience of making use of therapy and intervention (Emde and Robinson, 2000, p. 168). Using our emotions and relationships to advantage constitutes one of the main aspects of psychodynamic individual work. In this tradition, diagnosis is considered an ongoing process, not a static labeling of the child or the family (Douglas, 2007; Emde and Robinson, 2000). In addition, systemic contextual thinking offers us a frame of reference to perceive, analyze, and conceptualize the complex dynamics between individuals that are interdependent and related by strong emotional bonds within a series of wider contexts that affect their systems of relations and psychosocial dynamics. Systems sensitivity and training can represent an important creative skill of the early interventionists and professionals (Emde and Robinson, 2000). The contemporary psychodynamic approach with children encompasses a series of theoretical principles and practices that are different from those with adults. For example, the role of the therapist treating children—in contrast to treating adults—is much more active, and the therapeutic relationship may become very close and intimate. It has been suggested that pathological development is characterized by an elaboration or strengthening, both in the mind and behavior of the child, of beliefs and action tendencies associated with painful affects—feelings of anger, shame, anxiety, and sadness (Barish, 2009,

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p. 61). Painful emotions remain active in the mind of the child. The child‘s emotional life is characterized by qualities of urgency and inflexibility, and interactions with parents, teachers, and peers increasingly take the form of vicious cycles—of criticism and defiance, anger, exclusion, and withdrawal. Integrated holistic psychodynamic approaches attempt at an individual level to work with the traumatic relationships to buffer the effects of such past or actual experiences in a child‘s functioning. Actually, the first task of any effective clinical work with children is to engage the child in a process of open communication—therapeutic play or talk experience (Barish, 2009; Schmidt Neven, 2010). Psychodynamic-oriented psychotherapists seek to successfully engage children in some form of therapeutic dialogue or interaction by ―adopting two fundamental attitudes: (1) an empathic recognition of the child‘s distress and grievance and (2) equally important, the therapist‘s enthusiastic, affirming responsiveness to the child‘s interests and positive affects‖ (Barish, 2009, p. 62). As Barish states, these processes of engagement are more than a preparatory phase of building rapport; they are also beginning the process of therapeutic change (Barish, 2009). Creation of a transitional space of acceptance and expression of the child‘s distressing, ambivalent, or angry feelings in the school context in order to avoid oppositional/disruptive behaviors and actions is a basic parameter of each pedagogical, counseling, and psychotherapeutic intervention (Fell, 2002; Douglas, 2007; Heller, 2000; Kourkoutas, 2011; Solomon and Nashat, 2010). The counseling environment where meetings and the new relational model between the child and the professionals are taking place can have some significant initial therapeutic effects in a number of anxious, depressive, or angry and disruptive pupils, as modifications in family and school dynamics are produced. This space symbolically operates as a transitional model (Winnicott) in the sense that it is, on one hand, part of the school system and, on the other hand, an independent protected place where the child can fully express and progressively ―project‖ all his ―bad‖ and unbearable or angry feelings/parts and representations of himself that seem to foster and sustain behavioral disruptions, without been blamed, stigmatized, or attacked. The reception and containment of such angry and resentful disturbing feelings or fantasies and traumatic experiences is a first therapeutic step toward providing a sense of psychic coherence to the child (Douglas, 2007; Solomon and Nashat, 2010). For the first time in his life he is totally accepted (his ―bad‖ and the ―good‖ self), not forced to put into action aggressive defenses to protect himself or to show his anger or even to get rid of the ―bad‖ parts of himself, as was usually required or demanded. Through this therapeutic relationship the child can progressively reconcile with the vulnerable, weak, and traumatized parts of himself and his life, and notably feel safe enough to be rid of destructive defenses or responses. He is also gradually reconciling inside himself with ―bad‖, uncaring, or hostile and rejecting parents, teachers, or classmates. Undoubtedly, a number of such pupils need to be re-educated and taught to acquire or develop basic psychosocial (intra- and interpersonal) skills so that can be successfully reincluded in the social and school systems. Accordingly, the same transitional therapeutic ―space‖ can be provided to teachers and families with the same goals, namely to primary support them to overcome their negative or hostile reactions towards the child, to gain better insight of him, and, in addition, reduce the frictions and tensions among them that generate conflicts and unproductive responses. School psychologists have a decisive role to play as ―persons of reference‖ for each child

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with problems, contributing through specialized mediation to reconciliation among everyone involved, thus decreasing conflicts. Because teachers cannot handle the disruptive child, usually they are unable to deal with many of the parents of such pupils, who are easily upset or feel intimidated by both the school system and the teachers. The nature and severity of the child‘s disorder(s), his age, his personality (emotional, social skills, quality of his coping and defence mechanisms, level of ego strength and maturation), and family dynamics are, among others, some of the factors that will determine the orientation and goals of the intervention, as well as the form and specific tools to be applied (Chethik, 2000; Douglas, 2007; Drewes, 2009; Levitt, 2009; Malchiodi, 2003; Matot and Frisch-Demarez, 2007; Solomon and Nashat, 2010; Summers and Barber, 2010; Taub and Pearrow, 2005). The practical relevance of psychoanalytically-oriented approaches in child and adolescent psychotherapy has decreased considerably. Although many therapists still consider their work ‗psychoanalytic,‘ they tend to use various more-or-less psychoanalytically-oriented techniques rather than psychoanalytic psychotherapy in the strict sense (Remschmidt and Quaschner, 2001). Notwithstanding the theoretical heterogeneity of psychoanalytic based therapeutic approaches, there are core assumptions to which almost all psychodynamic therapists subscribe (Fonagy, 2004). These can be basically summarized as follows: (a) the notion of psychological causation; (b) the assumption of unconscious mental processes; (c) the assumption of a representational model of the mind; (d) the pathogenic significance of conflict; (e) the assumption of psychic defences; (f) the assumption of complex meanings; (g) the assumption of transference displacement; (h) the therapeutic aspect of the relationship (for further analysis see Fonagy, 2004, pp. 622-624). Accordingly, the basic therapeutic orientation and use of subsequent techniques draw upon these key assumptions. A psychodynamic approach for children, although it is based on an extensive but coherent theory (psychodynamic orientation), is significantly differentiated from classical psychoanalysis for adults. The use of play, projective techniques, and the therapist‘s active intervention, along with its basic theoretical assumptions such as the theory of internal conflicts, defense mechanisms, traumatic relations, and the like, are essential parts of childhood treatment (Chethik, 2000; Douglas, 2007; Kourkoutas, 2011; Solomon and Nashat, 2010). In general, various authors have suggested several guidelines for the treatment of children and adolescents (see Barish, 2009; Remschmidt and Quaschner, 2001):   

psychoanalytically oriented psychotherapy with children and adolescents should be directive; the therapist needs to be more flexible and active with his techniques than when treating adults; regression must be dealt with very carefully; the therapist needs to give older children much more assistance during reality-testing than with adults, and encourage and promote ego function and maturation and the acquisition of social-emotional skills.

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In addition, the pivotal role of emotions as a source of pathogenic and disordered behaviors and the focus on emotions as a key aspect of this therapeutic approach is widely recognized by all therapists in the field. As a result of the different role of the therapist treating children, in contrast to adults, the therapeutic relationship may become very close and intimate. The child‘s deep level of dependence on parents has significant influence on the nature of therapy (Barish, 2009). The therapeutic technique must generally be modified according to the child‘s age and developmental status. The use of play, in addition to verbal interactions, means that actions are also permitted during therapy (Barish, 2009). In contrast to these common characteristics of psychoanalytically orientated therapy with children, a number of issues continue to be a source of controversy: the degree to which parents should be involved in therapy, and how they should support treatment; the relationship between child therapy and parenting education; the relevance of transference in therapy; and, importance of interpretation. Regarding parents‘ involvement in the treatment process, an increasing number of psychodynamic psychotherapists believe that this is an essential component of the child‘s treatment (Green, 2000; Horne, 2000). In our work with children, we recognize the parental involvement and the way parents perceive and treat their child as the basis for any meaningful intervention. Meetings with parents can significantly contribute to enlightening about children‘s emotional reactions, behaviours, and ways of thinking and relating to others. Therefore, parents‘ cooperation is considered to be a driving force of the therapy (Green, 2000). The therapist needs to establish a ‗double therapeutic rapport‘ with both child and parents (see Remschmidt and Quaschner, 2001). The removal of resistance and reluctance in order to facilitate development of a positive therapeutic relationship, primarily with the family and then with the child, is a part of the challenges and the basic principles of this approach. This can be achieved with empathic and enthusiastic involvement of the therapist (Green, 2005; Solomon and Nashat, 2010). As stated by Barish (2009), engagement with children is fostered by two essential therapeutic attitudes: (1) the therapist‘s empathic recognition of the child‘s distress— including the child‘s distress at being brought for treatment—his worries, sadness, or disappointment, and perhaps particularly, his grievance; and, (2) equally important, the therapist‘s enthusiastic, affirming responsiveness to the child‘s interests and positive affect. These attitudes—affirming responsiveness and empathic recognition of the child‘s distress or grievance—are considered by many authors to be the basic therapeutic stance with children (Barish, 2009, p. 72). Though it has been suggested that the establishment of therapeutic rapport with children is more difficult and time-consuming than in adults, in our clinical work very rarely do we meet children who refuse to participate. Children‘s inability to engage in free association and free talk makes play the most important means of accessing the unconscious, although dreams, daydreams, and conscious recollections may also be helpful. Opinions differ widely with respect to assessing and interpreting play. It is suggested to distinguish between symbolic play and joint or common play. Symbolic play has always played an important role in psychoanalytically oriented therapy (see Remschmidt and Quaschner, 2001). Often unstructured, amorphous material is recommended to encourage the child‘s creativity and expression (see Remschmidt and Quaschner, 2001).

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As for the effectiveness of psychodynamic approaches, there are cases of children where psychodynamic interventions are more effective (e.g., children with depression, mild behavioral and emotional disorders, or psychosocial difficulties) (Fonagy, 2006; Roth and Fonagy, 2005). In children with behavior problems, some behavioral methods seem to work effectively on an experimental level (Kazdin and Nock, 2003; Weersing and Weisz, 2002), though many criticisms have been addressed in terms of the sample being able to retain the changes. Specifically, the criticism of many laboratory-based studies is that they do not reflect actual clinical practice; for example, it has been reported by Weisz and his colleagues, in their methodological analysis of youth psychotherapy outcome research from 1963 through 2002, that across disorders 13% of study sample participants had sought treatment or were self-referred, while 77% were recruited or had not sought treatment; only 1% of the studies reviewed met criteria for treatment representativeness (Weisz et al., 2005; see also Bamber and Porcerelli, 2006). Furthermore, evidence-based treatments cannot be automatically applied to daily practice because of a variety of reasons. Bridging the gap in youth psychotherapy outcome research between research findings stemming primarily from the tightly controlled research laboratory and the ―real world‖ clinical setting lately has been the virtuous and necessary focus of many mental health researchers and clinicians. In addition, Rosenfeld (2009, p. 17) argues that ―research supporting their superiority over other techniques has flaws that lead to questioning the power of the techniques and whether it is the technique that really causes the improvement.‖ In addition, Messer and Wampold (2002) argued that evidence-based techniques are embedded in a therapeutic relationship, which is what actually accounts for much of the treatment effect, and that CBT was no more efficacious than bona fide non-CBT treatments for depression (see also Rosenfeld, 2009; Spielmans, Pasek, and McFall, 2007; Wampold, Minami, Baskin, andTierney, 2002). Overall, evidence-based techniques may appear superior to controls because control groups have been inadequate (Rosenfeld, 2009). When evidence-based treatments are compared to well-designed controls, they have not been found to be superior (Baskin, Tierney, Minami, and Wampold, 2003; Rosenfeld, 2009). According to Rosenfeld (2009, p. xii), ―research indicates that (a) many theoretical approaches are equally effective, not just cognitive-behavioral and behavioral; (b) the treatment techniques supplied by the therapist contribute a small part to the change generated by psychotherapy; and, (c) other factors are a greater contributor to change than therapistselected treatment techniques.‖ The fundamental principles and assumptions of the theoretical psychodynamic background are essentially based on clinical data from specific cases, and less on empirical evidence, though a series of studies have brought significant promising results even for children with behavior problems (Bamber and Porcerelli, 2006). The number of effective therapies has led to eclecticism and integration (Rosenfeld, 2009). Integration has spawned exciting exploration to identify the elements that are common in effective treatments. It is widely acknowledged that multidimensional interventions which combine individual and family components function better with problematic children and adolescents (Atkins et al., 2001; Bond-Franklin and Bry, 2001; Born, 2005; Fraser and Williams, 2004; Carr, 2009; Frick and Kimonis, 2008; Kazdin, 2000; Taub and Pearrow, 2005; Weisz, 2004; Young et al., 2004).

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Integrated interventions which combine psychodynamic/behavioral principles with the training/psychotherapy of the parents and the teachers‘ counseling seem to have set a significant precedence regarding the long-term changes in the way children function (Bamber and Porcerelli, 2006; Barish, 2009; Douglas, 2007; Fraser and Williams, 2004; Rosenfeld, 2009; Young et al., 2004). In many cases specific changes need time to be established, and sustainability in therapeutic intervention constitutes an important parameter for reorganization of the behavior as well as the emotional and relational patterns of the child. Psychodynamic interventions focus on bringing to light deeper conflicts and emotional tensions which are considered to undermine healthy responses, producing problematic behaviors and dysfunctions. Contemporary child psychodynamic and systems-oriented techniques which combine work with parents and children should be not only focused on making conscious what remains unconscious, but also communicate to parents the underlying emotional processes and the factors (attitudes, behaviors, rearing practices, events, incidences) that generate dysfunctions and maintain or reinforce the child‘s emotional and behavioral disorders (Carr, 1999). They should attempt to both enable the child have better insight of what is going on inside and around him, how others react and treat him, and strengthen his emotional and psychosocial capacities. In addition, family intervention is an indispensable component of any meaningful treatment project aiming at breaking vicious and adversive interactions among family members, changing the way parents perceive and react toward their child. When the child tries to work out what is inside him, a significant part of his negative experiences and feelings opens up. This in turn helps him accept to learn and develop alternative behavior patterns towards others, as well as new ways to express his needs. There are cases where children find it difficult to get rid of the deeply- rooted patterns of behavior based on long-term negative experiences within the family. In these cases holistic approaches among child, family, and school and long-term interventions are needed to achieve changes in the child‘s behavior. It is also suggested that the child‘s involvement in supervised psycho-educational activities (e.g., drama-play, role-play, narratives or story-telling activities, self-expression group activities, interpersonal relationships and social skills groups, and self-esteem enhancement activities) are of utmost importance. These activities facilitate the child to develop a sense of mastery and control of his psychological and physical needs, as well as a sense of being accepted by others. When the child diminishes his reactional, oppositional, or disruptive behaviors toward classmates, their peers‘ acceptance and satisfaction is ensured, especially when he participates in activities under professional supervision. The positive experiences of being with others in non-conflicting and accepting relation situations and interactions may gradually lead these children to modify their attitudes. Feeling accepted can allow children with problem behavior to progressively modify their self- and other-perception which is based and shaped by past recurring coercive interactions. In addition, being accepted by others and being successful in self-expression supervised activities gives children with problems the opportunity to learn how to react with others in appropriate ways and how easy it is to be reintegrated into peer groups. Such positive interpersonal experiences often permit children to free themselves from the pressure they feel to be protected or hide their weaknesses with aggressive coping mechanisms. In role-playing, drama-play, or selfexpression groups, guided by experienced specialists, these children can feel safe to express themselves without being afraid of blame, criticism, or retaliation. In such groups,

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―problematic children‖ often express their negative feelings or experiences in an acceptable and very touching way (verbally or through actions and games), something that they have never been taught to do in the past. Many educators who lead such groups do not have adequate training and clinical knowledge to exploit the emotional and interpersonal processes and dynamics taking place within these activities in order to help these children. ―Problem children‖ are usually rejected for their disruptive behaviors and the way they express themselves to such an extent that their negative feelings are exacerbated. With their damaged self-image, inability to relate to others and control their behavior, these children end up refusing things that can be pleasurable, because of their fear of being rejected or because of their inability to handle resentful feelings and angry oppositional reactions. As clinical interviews with aggressive children show, they are often overwhelmed by these strong negative emotions (such as anger, rage against parents, teachers, and peers) that disable and prevent them from acting appropriately. Their negativity is quite often a reflection of unspeakable feelings, experiences, inner disorders, and distortions. As explained in preceding chapters, aggressive behavior in many of these children operates as a defense mechanism toward unbearable emotions or painful feelings of inferiority, acute fears of attachment, and (fantasies) of aggression from others. Such children are often overwhelmed by these feelings which usually have been generated within the context of traumatic family relations (Allen, 2001; Greenwald, 2002; Ford, 2002; De Zulueta, 2000; Kourkoutas, 2011). In cases of children with behavior problems it is important that the therapeutic space environment provided is stable, accepting, and facilitating in order to enable them to discover and express through various techniques and methods (put words or symbols on) adversive or traumatic experiences. This is true as well for hidden depressive feelings and the way such feelings affect their self- and others-perception and behavior (Douglas, 2007; Faupel, 2002; Berlin, 2005; Kourkoutas, 2007; Kourkoutas and Georgiadi, 2010; Schmidt Neven, 2010; Lanyado, 1999). The specialist should demonstrate an open, sensitive, and non-condemnatory attitude, as well as stability and determination. McWilliams (2004), talking about adult clients, refers to the sensibility of the therapist as the essence of psychodynamic psychotherapy. For her, the attitudes of curiosity and awe, respect for complexity, a disposition toward identification and empathy, valuing of subjectivity and affect, appreciation of attachment, and a capacity for faith are the fundamental grounds on which the dynamic therapist‘s approach rests (see also Summer and Barbet, 2010). These principles can also be applied in respect to the treatment of children. In fact, many of these children, especially boys, seek positive relationships and validation by adults, elements that are really lacking from their personal life, as so many are torn between their profound needs to be loved and accepted, and their struggle to fight against the vulnerable and sensible parts of themselves and rejecting others. Barish analyzes with exceptional accuracy the empathetic aspect of psychodynamic work with children. He states that ―empathic understanding therefore promotes reduced stress at the physiological level and increased flexibility at the cognitive-emotional level. Behaviorally, we see less withdrawal, less defiance, and less argument. Expressions of empathy also promote initiative (as opposed to stubbornness and refusal) and an explicit or implicit future orientation, essential components of a resilient self. Experiences of empathic understanding then allow maturing processes to take place—the child becomes, in small increments, more open to educative and socializing influences, to compromise and active problem-solving. In

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this way, empathic understanding facilitates a fulcrum shift in emotional development—away from urgent and insistent demands and toward tolerance for disappointments and frustrations, and acceptance of personal responsibility‖ (Barish, 2009, p. 93). Empirical data have shown that a father‘s problematic and aggressive behavior constitutes a significant risk factor for creation of behavior problems in boys, especially when the relationship with his mother is not appropriate or positive (Phares, 1995). Involvement of the father in therapy is considered to be significant for modification of the behavior in children with behavioral problems (Kourkoutas, 2007). In all cases, the specialist should not waste time in interpretation of problematic behavior. He should not focus on modification of the child‘s problematic behaviour through rationalization, moralization, or judgmental attitude. He shouldn‘t attack or focus exclusively on the behavior itself; rather he should try to comprehend the consequences and roots of the problematic behavior. Without development of an emotionally trusting relationship with the child, it is impossible for real internal changes to take place. To form a new relationship of acceptance with an adult is a rare but positive experience for these children. That positive relationship could bring some changes in the children‘s function. Quite often, the therapeutic session is the only time when children can express their negative thoughts, their anger, as well as their envy for their parents, teachers, and peers without being judged or blamed. That process (discussion with the therapist and the child‘s expression of his negative feelings verbally and through play) allows these children who usually act- out their tensions, to start using conversation instead. Through continuous meetings and systematic expression of emotional tensions, children are encouraged to voice their internal world. In many cases, the child is unable to articulate his deeper feelings and to realize the conflicting or ambivalent situations. In such cases the therapist is called upon to associate the emotional processes with the external traumatic reality or specific incidents from the child‘s history (e.g., ―I think that you are very angry not only with your father who is hitting you, but also with your mother who doesn‘t protect you—and she is always angry with you‖). In this way and within the context of a secure and trusting relationship, associations and realities which the child is unable to handle mentally and which overwhelm him can be articulated and contained by the therapist. Even younger children can become aware of their problems when they feel safe and calm. An illustrative example is the following one that relates to a 7- year-old girl with serious school problems (learning difficulties, refusal to go into the classroom, noncompliant and aggressive with her teacher), hyperactivity, and strong oppositional reactions against her mother. It was known from the first meeting with the parents that the mother feels quite isolated, stressed, and overwhelmed by everyday pressures, and as a result she becomes easily upset with her three young children, shouting and hitting all of them. She was married as a very young woman, and was forced to quit school. She was living away from her family home, and although her marriage was not unsuccessful, she was feeling quite distressed and sometimes depressed. Before the end of the second session with the child, the therapist asked her to reveal to him a secret4 which she would like him to communicate to her parents. The

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She initially mentioned how much she loves her parents and that she would like to write this message in a card for them. How bad she feels when her parents hit her, and notably, how terrified she is when her mother says to her every time she is noncompliant and when she gets upset ―now it‘s over,‖ which means that the family will break up.

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young girl revealed how ―insecure and frightened‖ she feels when she witnesses her parents‘ conflict and verbal fights. She admits being overexcited because she is afraid of eventual divorce of her parents. She feels responsible for that, because she is noncompliant and gets them upset. At the same time she tries to act foolishly and drive her parents crazy. Although she hates being hit, she feels she cannot control herself and avoid making stupid mistakes or being disobedient. She finally finds herself so frustrated, resulting in being more demanding (―I always ask them to buy me things‖; ―I want them to buy me everything I like‖) to make her parents show their love for her. Indeed, she confesses she always wants ―to have her parents‘ attention and love‖ and see them ―be cool and caring.‖ She also has a competitive and conflicted relationship with her old brother who is very aggressive with her and she ―cannot beat him.‖ Actually, she seems to be fighting to get a place within the family context (she is the middle—and the only girl—of three children). She admits she also struggles to get her father to buy her what she wants and show her she is his ―favourite child,‖ because she is ―the only girl.‖ During that session, she was asked by the therapist if she wanted to repeat (―to reveal her little secret‖) to her parents. In fact, she did it in a very moving way when they came back to the session room, running from the one parent to the other and assuring them of her love for both of them. At the same time, she was telling them how bad she feels when they hit her, how scared she feels, how she believes they will divorce; and, how foolish she tries to be with them, because she doesn‘t know how to express her love and her fears.‖ At school she was very oppositional with her teacher. It appeared that she was not able to get the place and recognition she wanted to have because of her learning difficulties, her immature behavior, and her overexcitement that hindered her school social and academic inclusion. Her classroom teacher admitted having been very demanding and strict with her because she too was easily upset and troubled by her student‘s disruptive and oppositional attitudes. In contrast, the special educator, being more receptive and positive towards her, created a good relationship with the child. A series of cooperative meetings with the school principal, the classroom teacher, and the special educator resulted in a common strategy of accepting the child, not confronting her, ensuring her learning support, and helping her to develop more mature behaviors in the school. They would promote her skills, as it was believed that she was a clever and competent child who was trapped in a cycle of coercive and confusing interactions with her family and teachers. Usually children with behavior problems are emotionally overexcited and unable to achieve mastery of their internal states. Hence, they are inclined to project their angry feelings and fantasies or feelings of inferiority onto the people around them such as teachers, peers, and professionals. They are unable to voice or express their profound needs by regular means, so they are more likely to enact their frustrations or traumas through aggressive and problematic behavior. Empathic understanding through a genuine approach and recognition of internal states and unmet needs, in combination with a thorough assessment of the child‘s developmental course and his family and school situation, may enable such children to rely on an adult figure, for the first time after so many repetitive experiences of rejection and failed relations, without being frustrated or forced to respond aggressively. Actually, the therapist‘s insight and first hypothesis-formulation about how the family works and what causes the behavioral disruptions is crucial in working with the child individually. On the other hand, the therapist should try to associate the child‘s behavior in school with analogous experiences in his family. The therapist should actively demonstrate acceptance of the child‘s negative/hostile feelings, without showing any approval for problematic behaviors

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which undermine relationships with others and put his academic and school inclusion in danger. In a number of cases, the understanding and treatment of problematic behavior requires additional structured interventions in the children‘s lives, such as targeted programs that are behaviorally oriented. The more disturbed the child‘s environment is, as far as protective factors are concerned, (a trustworthy adult, emotional bonds, and stable parent behaviors), the greater the difficulties in treatment and modification of child behavior are. In such cases, family therapy demands more specialized and often long-term multisystemic interventions, insofar as the parents are unable to acquire essential parenting skills, or adverse risk factors are so severe (extreme poverty or intense parental conflicts and family violence, or father absence) that they strongly undermine family cohesion and organization. There are cases of children who develop problematic and reactive/oppositional behavior because of actual specific experiences (Greenwald, 2002) or important modification in family life (death of a sibling, serious illness of a parent, or birth of a child) that may have a destabilizing effect on the child‘s functioning. When specific events emerge that help in the clearing up of the situation and the parents‘ awareness and attitude modification, then quite often problematic behaviors are likely to decrease or disappear. Without question, if the shock is complex, severe, or enduring this may contribute to the development of significant disturbances in the child‘s emotional and behavioral functioning (e.g. the case of a seven years old boy who demonstrated serious aggressive behavior and physical attacks against his classmates; the meetings with the boy, with his teacher and the mother revealed that his classmates have been systematically teasing him about his father‘s imprisonment (he was in prison since the boy was 3 years old); the boy had responded violently to his classmates because he was affected and traumatized by his father‘s absence; when the father came back 3 years later, the boy experienced an additional shock, as he was found in front of an unknown person; furthermore, as he was used to sleep every night with her mother in her bad, during the father‘s absence, he was forced to quit the mother‘s bad after his father came back; consequently, he was very rejecting and aggressive towards his own father; actually, the boy experienced a very ambivalent and complex situation that was unable to infernally handle and communicate). In many cases children can be aggressive toward a professional or psychologist, or be reluctant to get involved in a treatment process. To ask children to behave with sensitivity and honesty is not considered a successful strategy, as long as these children experience extreme internal pressures and feel that their feelings, needs, and sensitivities are not taken into consideration by others. The use of alternative techniques, such as ―games, objects, and constructions,‖ as well as supervised activities that are pleasant and meaningful for the child, are important tools for psychodynamic interventions insofar as they mediate the child-therapist relationship and symbolize or reflect the child‘s internal processes (Chethik, 2000; Schmidt Neven, 2010; Solomon and Nashat, 2010). By becoming involved in such activities the ―problematic child‖ puts his ―psychological self in action‖ and ―in disposition to others‖ while he is called upon to think, produce, and act in a very different way than usual, namely in a partnership manner within a supportive and accepting ambiance. He is called upon to act in a non-aggressive way, in a productive and cooperative way. Using the intermediary of creative alternative activities and productions, the child allows himself to experience new means to voice his emotions and needs. Through such repetitive, well-structured, and organized supervised programs, the child

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may acquire the necessary emotional and interpersonal skills, becoming less likely to use aggressive or inappropriate means to express himself and resolve conflicts. It is reasonable to believe that when the child is escaping from the vicious cycle of rejecting experiences and intense emotional frustrations, the need to use aggressive defenses or problematic reactions will decrease. In brief, the possibility given to the child to express feelings through creative, structured, and socially acceptable ways (play, drawing, story-telling, discussion with the therapist) is the first step to changing the way he functions (see also Peterson and Flanders, 2005). The efficacy of such techniques depends on the child‘s age and personality, inherent competencies, family cooperation, the severity and chronic nature of his troubles. Actually many of these skill training strategies have been found to be very effective in decreasing problematic behavior (Greenberg et al., 2004). In addition, Sukhodolsky, Kassinove, and Gorman (2004), in their meta-analytic work on program outcomes for anger-related problems, found that skills training, problem-solving, and multimodal interventions were more effective than affective education. They also found that skills training and multimodal interventions were particularly effective in reducing aggressive behavior and improving social skills. Another important parameter of work with children who have reactive, challenging, or problematic behaviors is the investigation of the family‘s history and past problems and experiences of the parents. According to this approach parents are likely to reproduce the same dysfunctional relationships and parenting with their children they had experienced in their own family (see Manzano, Palacio Espaca and Zilkha, 1999; Serbin and Krap, 2004; Thornberry et al., 2003). Problems, conflict, trauma features, and patterns of relationships with their own parents are usually repeated in their parenting role with their children (Manzano, Palacio Espaca and Zilkha, 1999). Parents who experienced long-lasting problematic relationships with their own parents, or bear intense conflict and unresolved grievances related to their parental figures are much more likely to apply dysfunctional rearing practices or project on their children unrealistic narcissistic expectations and fantasies (Manzano, Palacio Espaca and Zilkha, 1999). Receiving parents with an empathic, genuine and uncritical interest, recognizing their impasses and difficulties and containing their distress caused by the child, allows them quite often to open-up emotionally. In this way they are more likely to talk about their own experiences and receive the counsellor‘s comments in a positive way, thus more likely to realize some of their own problems and dysfunctions or their stereotyped reactions and unrealistic expectations towards their child. Thanks to supportive coaching, parents in optimal cases become progressively able to modify their own behavior toward their child and assume a more effective parenting role. Even in cases of families of very low social and economic status, parents can intuitively understand their own child‘s psychodynamics, and positively respond to such interventions by productively collaborating with counsellors. From the other side, there are many parents who express enormous resistance to understanding and accepting the reality of their child or their own contribution to the development of the problem situation. Many of them demand quite specific instructions or intervention techniques and are less inclined to get involved in more profound work on their own couple and parenting relationships. In most cases, these same parents, even if they were to be given concrete behavioral instructions, are not able to follow them successfully since they haven‘t resolved basic emotional aspects of their relationship with the child and of their parental role. Though it is important and necessary in most cases to enhance parents getting

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an insight to their offspring‘s and their own intra- or interpersonal psychodynamics, it is, on the other hand, essential to provide them with a comprehensive and meaningful set of instructions so they can set clear rules and limits for their child and deal effectively with everyday problems. We find these two dimensions of the counselling/therapeutic work with parents and children at risk correlated and interdependent, because when parents are able to effectively deal with their child‘s problem or when they see progress in him, they respond more positively to counselling. Concluding, we present the basic assumptions and parameters of the individual psychodynamic counselling/therapeutic intervention:   

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Particular emphasis should be placed on the relationships of the child with the family, since the child is greatly affected by parental functioning and attitudes; The counsellor/psychotherapist should focus both on individual work with the child and on work with parents and the family dynamics; Various materials and art techniques, such as games, drawing, role-playing, storytelling, theatre or drama-therapy. and so on, should be used in order to enable the children to express themselves, to symbolize their internal processes or conflicts, and enter into the process of learning and developing new communication and relational skills; A genuine empathic and trusting relationship with the child and his family should be established; The child should be accepted as a whole, in spite of his deficits and problematic behaviors (he should rather be seen as a suffering being, trapped in coercive interactions with his environment); A holistic and thorough evaluation of his skills/competencies, beyond his symptomatic reactions and parents‘ and teachers‘ opinion, should be adopted; The child should be provided a protected space, in both real and metaphoric sense, in order to voice or express his (negative) feelings and retire from often ―toxic‖ interactions with peers, teachers, and parents; a protected space that can operate as a transitional /relational model; Child‘s negative/hostile feelings relative to others (peers, teachers, and parents) should not be rejected; they should rather be recognized and accepted as part of the child‘s self and history; the therapist should not be pressed to get rid of the problematic child in a violent way, since the problem behavior many times ―speaks‖ the child‘s internal reality which has to be acknowledged and treated (see also Douglas, 2007; Schmidt Neven, 2010); The child‘s hostile, aggressive, and conflicting emotions, fantasies, and representations should be contained and ―metabolized‖ by the counsellor /therapist during individual sessions and with the parents‘ cooperation; To give a meaning to the child‘s distressing, ambivalent, or angry and destabilizing emotions, it is critical to associate them with his family history and developmental pathway; Counsellors/therapists should be careful to avoid putting extreme pressure on the child to reveal his experiences of maltreatment or to talk about his parents‘ hostile

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and inappropriate behaviors toward him; many children feel anxious about doing it because they are dependent on their parents; some other times, children may feel guilty for having revealed the family‘s secrets or ―denounced‖ the bad parent; they may refuse to come back to the therapist; Counsellors should become aware of such critical reactions and verbalize/communicate their opinion about the child‘s reactions to both the child and the family; Counsellors should be very careful to allow children to talk when they feel comfortable and ready to do it; in addition they should use a variety of techniques to allow them to convey in metaphoric ways their emotional experiences and unmet needs in the context of a trusting relationship; A new relational model between the child and adults should be provided based on respect and the child‘s recognition and positive response from adults, regardless of the child‘s deficits and disruptions (distinguish inappropriate behavior from his deeper self and needs); Particular emphasis should be placed on systematic promotion and acquisition of interpersonal skills and positive experiences with peers; The counselor/therapist operates as mediator in the relationship of child-parent in order to sort out and permit ―elaboration‖ of conflicts and mutual traumas with the goal of promoting their mutual emotional reconciliation; The child should be encouraged to participate in alternative psychoeducational programs to achieve better school and classroom inclusion by developing the required skills; Guidelines should be set for learning to support the child; The very specific nature, character, orientation, and course, as well as the specific details of the therapeutic relationship are to be determined from an ongoing multisource evaluation process; To obtain an accurate representation of the referred child‘s conduct problems, the therapist must rely on multiple assessment methods, including interviews with the parents, youth, and other relevant parties (e.g., teachers), and behavior rating scales completed by the same individuals. (McMahon and Kotler, 2006, p. 172)5.

The issue of when to terminate therapy is closely associated with the aims of treatment. Despite different opinions in matters of technique, most therapists agree that the aims of therapy are similar in most cases (Remschmidt and Quaschner, 2001). These include dissolution of anxiety, improved coping with impulses and drives, clarification of the child‘s position in relation to his parents, teachers, and classmates, improved reality testing, a higher 5

Actually, regarding assessment, the following practical principles are derived from the ecological psychodynamic framework (see also Allen-Meares, Washington & Welsh, 2000, p. 83): a comprehensive ecosystems assessment requires that data be collected about multiple ecosystems (school, home, and community); assessment should include data from all three data sources (person, significant others, and direct observations of the pupil in his or her environment)(multisource assessment); collection and assessment of data on all critical variables that describe the child‘s functioning (cognitive, affective, behavior, social-interpersonal, patterns of attachment, physical attributes, school performances, school integration, etc.); a comprehensive assessment should include as many components as is possible regarding the child‘s and the family‘s functioning; a thorough integration of all data into a comprehensive picture of the pupil‘s situation (personal, family, and interpersonal dynamics).

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degree of emotional stability, and better school and social inclusion (Remschmidt and Quaschner, 2001). A great deal is accomplished when therapy helps children to reduce their symptoms, become more realistic, advance to the next developmental stage, become less trapped in repetitive coercive patterns, are less overwhelmed by distressing worries and tolerate more affect so they do not subsequently resort to as many destructive behaviors and defenses, and are more able to participate and find pleasure in school, play, social activities, and relationships (Rosenfeld, 2009). In brief, the quality of the working alliance is found to be strongly predictive of positive therapeutic outcome (Orlinsky et al., 1994; Wahl, 2002). Therefore it is crucial to find ways to approach the child and establish a trusting and meaningful relationship. Many children described as disruptive, non-compliant, or aggressive in the classroom when they are met in private, in a different setting, are often polite, respectful, and helpful in the context of such individual meetings (Wahl, 2002). What makes the difference seems to be the context and the particular atmosphere of the meeting. In this sense, it is important to receive children privately in a personalized-individualized way and in a ―protected‖ space, free from hostile harmful interactions and distressing emotions that usually take place within school context. In this way we transmit the message to the child that he is respected, that we‘re interested in finding other means to resolve conflicts and inappropriate behaviors—going beyond blame, criticism, or exclusion and aggressive rejection. Professionals and teachers should give them the opportunity to invest time and ―thinking‖ in personal meetings with the child. These meetings can result in large gains if conducted and supervised adequately. Such private meetings can provide us with very useful information about the child‘s functioning and his unmet or disturbing emotional needs, and they may lead to better working alliances in the future. The counselor‘s/ therapist‘s/ teacher‘s intentions, if genuine, are easily and positively received by the ―problem‖ child, though this one may initially develop some resistance or defensive opposition to accepting our positive attitude. Teachers and other professionals are often reluctant to meet a child one-on-one, citing time constraints as the major impediment (Wahl, 2002). This is probably because they do not feel well-equipped or sufficiently trained to work at an individual level, or because individual meetings with the child usually do not show any positive or long term outcome. Meetings can often be taken up with moralizing guidelines on the part of the teacher, which the child immediate rejects (Kourkoutas and Georgiadi, 2011). Children with relationship difficulties rarely find ways of reaching out to us, so it behooves us to find unique and thoughtful ways to enlist their engagement (Wahl, 2002). The adult-child working alliance not only requires potent interventions to directly promote growth, but also requires a means of effectively containing or placing boundaries around the child‘s behavior. Building a strong working alliance also means intervening with an appropriate level of intensity (Wahl, 2002, p. 72-73). Overall, as stated by Wahl, ―children with problems need essentially three things from adults: (a) structure and encouragement, because offering children structure and encouragement helps them feel secure; (b) nurture, because nurturing helps a child to value themselves (i.e. self-esteem); and (c) teaching of interpersonal skills, because this provides a base of knowledge which allows children to cope successfully and develop rewarding relationships‖ (Wahl, 2002, p. 71).

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With troubled or aggressive children we must invent ways to approach them and successfully fulfill these needs. For this purpose, multimodal interventions are needed, embedded in an integrated inclusive project which emphasizes the professional-child working relationship, the family work/therapy, and buffering of risk factors in the school context. Such projects seem to be very promising in resolving critical situations in early childhood and preventing emotional or behavior problems from deteriorating.

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Chapter 15

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COUNSELING TEACHERS WHO WORK WITH STUDENTS WITH AGGRESSIVE OR DISRUPTIVE BEHAVIORS Specifically, the work of clinical-school psychologists and counselors with teachers should be based on developing an essential collaborative relationship with them, and on designing an inclusive holistic project for pupils with problems (Dyson and Howes, 2009; Kourkoutas and Raul Xavier, 2010). The school psychologist should approach the teacher on a personalized, individual level and devote enough time to connect with him and to realize the way in which the teacher approaches and treats children with problems (McNab, 2009; Tripp and Sutherland, 1999), The psychologist needs to understand the way the teacher works, his teaching concepts and professional representations, his profound thoughts and beliefs about problematic behaviors in pupils, as well as his own personal experiences with such pupils or with the specific case of a ―problem behavior‖ student. In order to achieve a working partnership with educational staff, it is essential to give responsibility to classroom teachers, making them feel part of the interdisciplinary team. It becomes crucial to share and communicate the case formulations or hypothesis and beliefs about the way in which the work should be done with the ―problem pupil‖ and his family in individual sessions. Many teachers feel puzzled and confused when they are excluded from clinical conclusions and evaluation data, and are simply requested to follow specific guidelines or tips without been previously consulted. Hence, teachers should be made aware of the assessment and evaluation process‘ conclusions regarding the child and his family. Moreover, it is necessary that the clinical and practical approach of the school psychologist should be clear and meaningful for the teacher. Reasons and background rationale of every suggested strategy should also be adequately specified, becoming the product of common decisions based on the teacher‘s knowledge and intuition about the specific case. In such cases the school psychologist bases his case formulation on clinical data provided by the psychometric assessment of the child, as well on his own sessions with the child and the family. Clearly, the teacher‘s conclusions and suggestions should be included as essential elements of every thorough and multisource evaluation of the child with problems. The school psychologist and professionals who work in schools should be clear and consistent about what they seek from teachers and the kind of collaboration and professional alliance they want to establish with them. School psychologists should be positive and non-

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critical toward educational staff‘s incompetence or mistakes and inappropriate choices and interventions. They should also avoid developing a dominant specialist position or an antagonistic and conflicting relationship with them, even in periods or moments of high stress and pressure that can characterize working with challenging pupils. The expert-centered model in work with pupils and families at risk, which exclusively emphasizes the clinician‘s knowledge, has been widely contested and replaced by broadened systemic and partnership models that promote an ecological and child-centered perspective. Clinical knowledge is coupled with other professionals‘ experience, knowledge, and practice, as well as with the family‘s experience and awareness (Turnbull et al., 2000; 2006). Respecting the teacher‘s knowledge, weaknesses, feelings of confusion, or even irrational reactions and beliefs, and avoiding personal comments or becoming judgmental are essential elements for developing a truly cooperative relationship and working alliance. Many school psychologists are not aware of their covert critical attitudes towards teachers, the professional superiority they may feel, and an implicit underestimation of the teacher‘s experience. Such attitudes are often rationalized and hidden behind clinical expertise that psychologists think they own, based on the tests‘ ―objective‖ data on which base their case formulation. In many cases, teacher‘s experience and knowledge of the pupil are consciously or unconsciously, explicitly or implicitly, omitted by the psychologist, and cooperative work with him is undermined. Teacher works with the student in the classroom every day, playing a pivotal role in the student‘s school inclusion which is an important protective factor for decreasing aggressive behavior. Many school psychologists are unaware of research concerning the effectiveness of school inclusion and the systemic ecological approach in reducing children‘s behavior problems and emotional disruptions (Weist et al., 2006). School psychologists used to rely on the expertise-model which exclusively prioritizes and focuses on within-the-child individual work (medical approach). These psychologists are not trained in systemic educational or psychodynamic issues, and are likely to reject the inclusive educational and partnership model as non-clinical. Thus, they tend to emphasize individual treatment, increasing the risk of producing ineffective responses because essential parameters of the student‘s environment are not taken into consideration and treated. When school parameters and contextual risk factors are omitted or excluded from the clinical case formulation and intervention the whole project risks resulting in significant impasses (Sheridan and Gutnik, 2000). Therefore, it is essential that the school psychologist work in tandem with teachers in child-centered and school-inclusive projects (Dyson and Howes, 2009; McNab, 2009). Overall, the psychologist should recognize and respect the experience of teachers, while at the same time being aware of his own negative feelings and antagonistic tendencies in interactions with the educational staff. Usually conflicts emerge because the teachers‘ experiences are undervalued. Quite often experts opt for tactics which are theory-based but do not necessarily correspond to specific case requirements. At the same time, they may not realize the special dynamics which develop within a school classroom, and between teachers and students with behavioral problems. Giving enough space and time to empathetic listening and understanding of the teacher‘s problems, convictions, and perceptions—primarily his feelings—is considered the first significant step for development of essential communication, enabling teachers to develop their professional capacities, knowledge, intuition, and creativity (Fell, 2002; Farber, 1991; Hanko, 2001). The main goal of working with teachers is to help them gain a psychodynamic insight into the case, and to handle conscious or unconscious hostile feelings and rejecting

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attitudes toward the ―problem‖ pupil. Consequently, an essential part of the work consists of trying to ensure a positive attitude from the teacher, avoiding any arguments in order to be productive and to find and implement the most effective solution (Fell, 2002). Moreover, counselors and school psychologists may have to work with teachers who are very hostile and rejecting of challenging pupils. In such cases, counselors should develop exceptional professional skills to gain trust, positively collaborate, and impact the work of the educational staff in order to reduce risk situations. Alternative solutions can be found in such cases, and school psychologists should make every use of their creative capacities. Frequently, teachers have no plan to refer to when children place themselves or others in danger or seriously disrupt learning. Besides counseling, a plan is often required with a structured ―back-up system‖ to contain a child‘s behavior, for those times when the staff involved lose control (Wahl, 2002). With a plan agreed to and contracted, a means of response can be implemented in a consistent manner. This provides staff (and the child) with the security of a having a structured response available which adults know can be followed through (Wahl, 2002). There are also teachers who are involuntary ineffective with problem children. Such educators might have tried a series of tactics and strategies, but failed to modify the child‘s behavior. As a result, they may feel emotionally disappointed or distressed by the children‘s negative responses. Some other teachers are not aware of their hostile or distressing emotions related to the behavior of such students. Therefore, they may easily be upset or entrapped in coercive interactions when they are not able to handle the stress induced by challenging behaviors. The acute stress usually leads to ineffective or hostile responses. Psychologists and counselors who opt for a psychodynamic systemic perspective are called upon to help teachers to be aware of such feelings and the impasses they present. Supervision is recommended for psychologists and other professionals who work in high stress and group-dynamics situations. This enables them to recognize their own emotional tensions and negative feelings generated from conflicts on a professional level. That supervision helps to deal with the stress they feel when they try to offer solutions and work with children‘s, parents, and teachers‘ resistance. Hanko suggests that in-service teachers may better understand the psychodynamic base of problem behavior and counseling work if they come to realize (a) that children with problem behavior are experiencing feelings they find difficult to bear, but that behavior is more likely to be managed through the extent to which these feelings are understood by those who are involved; (b) that children‘s difficult here-and-now (whether displayed overtly or masked in over-compliance or withdrawal) is a likely reaction to a present situation they perceive as unmanageably difficult because it echoes similar past events in perhaps damaging relationships; (c) what matters is that something changes in the way in which such a child is helped to perceive himself differently, becoming able to experience himself as valued in relation to others important to him; and; (c) a child‘s behavior in the classroom is further influenced by our responses to it and, in its turn, further influences ours. Thus the trained professional‘s response may be a major influence on whether the interaction becomes a virtuous or vicious cycle (Hanko, 2002a, p. 379). The lack of adequate psychodynamic insight on the part of teachers may lead them to overemphasize the pathological aspects of children‘s problems. Actually, it has been pointed out that many educators are likely to use psychiatrics terms (e.g. syndromes, ADHD, etc.), when they refer to children with difficulties. Such terms locate problems within students

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rather than within the educational system and interactions among them. These labels can also limit the way that others perceive and interact with students, thereby disabling the students academically and hindering the development of their self-esteem. Educators must recognize that no two students are alike and that each educational program must be based on individual strengths and behavioral challenges rather than on a label (Sandler and Sylvestre, 2005, p. 33). Concluding, we outline basic parameters of psychodynamic counselling work with teachers (see also Fell, 2002; Fish and Jain, 1992; Hanko, 2002a; Hinkle and Wells, 1995; Paget, 1992; Roffey, 2002):    

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Establishment of a positive personal and working relationship with the teachers, based on respect for their personal perceptions and weaknesses; Elaboration of the teachers‘ stereotyped conceptions and prejudices about the character or the goal and the meaning of the children‘s behavior problems; Recognition of the problems and negative feelings teachers experience with challenging pupils; Counseling meetings in order to elaborate the negative feelings (anger, rage, humiliation, and feelings of injustice), teachers may experience for the child‘s and his parent‘s behavior and attitude; Exploration of the teachers‘ personal knowledge and views of the pupil in order to proceed to a holistic case evaluation and formulation, to inform them about the clinical assessment and hypothesis, as well as about the family dynamics evaluation; Involve teachers in the design of effective interventions at the family, child, and classroom level; Involve teachers in the intervention project; Support and help teachers to broaden their perceptions about the child‘s internal emotional states, reasons for problematic behaviors, and family dynamics; Foster and support the teacher‘s personal intuitions and initiatives; Coaching teachers to develop specific classroom strategies and educational support in order to promote the child‘s school inclusion; Helping teachers develop positive strategies for the effective management of the child‘s behaviour inside the classroom; Developing and implementing in cooperation with the educational staff psychosocial skills programs that target the deficits of children with behavior problems; Strengthening the relationship of teacher-parent; Support the teacher to understand and overcome any difficulties or conflicts with the child‘s parents; Resist teachers‘ pressures for immediate solutions and formulate a comprehensive clinical hypothesis about effective strategies or effective solutions for specific problems without abandoning a long term and systemic perspective of the intervention project; Avoid the provision of ready-made solutions and design holistic strategies through partnership with the educational staff and other professionals.

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Regarding the theoretical and practical training of school psychologists and teachers in clinical educational psychology, it is suggested that psychologists and teachers should be taught and become familiar with:    

The basic clinical concepts related to children with various forms of emotional and behavioural difficulties/disorders; Clinical case analysis of children with difficult behaviors; The basic concepts of family and group dynamics; Research in relation to family organization and parental impact on the child‘s development of dysfunctional patterns and behaviours.

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Beyond basic and ongoing further education, continuous and long-term counselling supervision of teachers requires better and more effective training. Counselling supervision of teachers that school psychologists are called to carry out requires an additional supporting supervision of the psychologist from another professional or team of experts. This is due to the fact that children with behavior or conduct problems are likely to generate ambivalent reactions, engendering feelings of disappointment, failure, confusion, anxiety, or even extreme pressures and acute stress among the teams working with these children and their families.

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Chapter 16

BASIC PRINCIPLES OF PSYCHOTHERAPEUTIC AND PSYCHOEDUCATIONAL INTERVENTION FOR CHILDREN WITH BEHAVIOR PROBLEMS Key principles based on empirical and clinical data that are prevalent in a holistic psychodynamic counselling and psychotherapeutic approach for a child and his family are the following (see also Barish, 2009; Campbell, 2002; Douglas, 2007; Goldenthal, 2005; Green, 2000; Greenspan, 1999; Lee, 1994; Rosenfeld, 2009; Rustin, 2000; Wachtel, 1994; Wachtel and Wachtel, 1986): 

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Interventions should have a specific family-oriented approach, and explore family dynamics; Interventions with a family perspective seem to be more effective for children with behavior disorders. (Carr, 2009; Kazdin, 2000; Weisz, 2004); Interventions with a family orientation do not identify with the family therapy, and do not necessarily include systemic long-term therapy for the family (Kazdin, 2000); Family interventions and parent training in behavioral and cognitive techniques for the treatment of behavioural problems seems to be more effective in childhood than in adulthood (McCart et al., 2006); The way professionals connect with families and the quality of their relationships influence to a great extent the course of the therapeutic process and its outcome, since work with parents is a basic parameter of effective interventions with behavior problems (McCart et al., 2006; Young et al., 2004); Interventions for children with various forms of problem behaviours or emotional and school adjustment difficulties should always begin with a series of sessions (1-3) with parents; Sessions with parents should focus in the first phase, on the way they perceive their child‘s emotional states/needs, as well as the way they experience, interpret, and treat the problem behavior of their child; Sessions with parents may also—if necessary—further explore the parents‘ own family history and their own personal anxieties, couple difficulties, or complications in fulfilling their parental role;

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At the same time, the child‘s behaviour and his emotional dynamics have to be understood and elucidated in the context of continuing interactions with others; Parents should be helped to perceive their children‘s problems in a more contextual and dialectical perspective, in order to realize how many of their behaviors and reactions may negatively contribute to the development of or to maintain and deteriorate the child‘s challenging behavior; Parents should also be helped to realize specific reasons (facts, events, incidences, behaviors, etc.) driving the child to behave inappropriately or be disruptive and noncompliant; Parents should be helped to understand how family-based factors (parental rearing practices, couple relationship, family affective climate, number of siblings) can contribute to 6 the development or deterioration of behaviour problems in children ;  

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Regarding the school setting, the parent‘s experiences must be explored in relation to their child‘s behaviour; In the context of a positive trusting relationship with the parents, the counsellor/therapist may come across parents deeper underlying emotional dynamics relating to their child‘s development; the counsellor/therapist may be constrained to tackle issues related to the parents‘ emotional responses (emotional needs, investments, desires, fantasies, representations, or expectations) that nurture, trigger, or deteriorate the crisis situation and the child‘s problematic behaviours; In that first phase it is important that parents recognize the psychic dynamics of their child through the therapist‘s interpretations and clarifications.

Psychologists or counsellors and special educators should, on the other hand, be aware of a series of facts and parameters concerning the parents of children with disruptive behaviours and the way they can function during counselling /psychotherapeutic, and psychoeducational interventions (see Beal and Chertkov, 1993. Campbell, 2002; Dadds and McHugh, 1992; Dishion and Stormshak, 2006; Frost, Johnson, Stein, 1997; Goldenthal, 2005; Hinkle and Wells, 1995; Johnson, 1990; Lee, 1994; Pugh, De'Ath and Smith, 1994; Sharry, 2004; Shaw, 2003; Taub and Pearrow, 2005; Wachtel, 1994; Wachtel and Wachtel, 1986; WebsterStratton, 1999; Wolfendale, 1992).  

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Parents quite often feel unable to react effectively and handle the disruptive behaviours of their children; Parents experience intense ambivalent or conflicting feelings related to their children (guilt, anger, rage, sadness, confusion, and disappointment, among others); such feelings should be recognized and treated appropriately in order to enhance parents‘ self-confidence; Parents usually tend to attribute responsibility for problematic behavior either to their child‘s character, the school and classmates, or to other external factors; Experts should avoid being trapped into implicit or explicit criticism and blaming of parents, which could result in open confrontations or conflicting collaboration;

Many clinicians and counsellors focus on the formal individual assessment of the child, neglecting the family dynamics and the interactional character of the symptoms related to the child‘s ecology or contextual factors. Research shows that this approach is now old-fashioned and simplistic.

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When parents feel that they are being criticized or rejected, they easily become locked-up, retreat, or develop aggressive reactions toward the specialist, and the risk of abandoning the counselling process is increased; During the first meetings, experts must be prepared to be confronted with negative parental reactions, overt or covert criticism, or feel pressure on the part of parents for a specific type of work (e.g., give specific tips); therapists should be well-trained to recognize the defensive character of parents‘ attitude (e.g., not touching deeper problems such as couple relationships, parents‘ fights and quarrels, parents‘ inappropriate rearing practices); Counselors and therapists should be trained to be in a position to receive, contain, and transform the parents‘ negative feelings and emotional charges; they should be able to gradually offer parents remarks and explanations of new ways of understanding their child‘s reality and their own reality, as well; Counselors and therapists should be able to gradually provide to parents a new conceptual model of the child‘s disorders, reframing their perceptions and attitudes; Counselors may also explore the parents‘ experiences with teachers, other professionals, and siblings, because these experiences may also have a traumatic character, and parents need guidance to effectively respond to these challenges; Many times parents come to meetings with very ambivalent feelings because of previous ineffective consultations or even hurtful and ―traumatic‖ experiences with previous counsellors; Counselors and therapists must help parents to feel comfortable and experience positively the therapeutic/counselling process; they should work on their resistances by honestly and openly tackling issues related to their personal and couple life, recognizing the problems (e.g., couple quarrels and fights, ineffective parenting) without overdramatizing, simply focusing on the impact such problems have on the child and on finding solutions to resolve them; Actually, trust between counselors and parents can be established when therapists use a direct and realistic language recognizing the problems and dead-ends the parents find themselves in; they should be also careful to recognize and value the parents‘ efforts and attempts to treat their problems, as well as to recognize the deeper concerns of the parents, even in cases of harmful rearing practices; Failure to collaborate usually results from the specialist‘s inability to contain the parents‘ negative emotions, anxieties, or resistance and to adequately assess the family dynamics; in addition, many counsellors find themselves unable to work and guide parents in cases of maltreatment; Many times interruptions in the counselling process are related to the therapists‘ unconscious counteractions (counter-transference) or inability to deal with the parents; a part of the therapist may be likely to identify with the child (the childvictim, the frustrated or neglected child, the enraged child); Counselors should first reach an agreement with the parents regarding the factors and conditions that contribute to the development of the disruptive or aggressive behaviors of children;

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Even when parents seem convinced by the specialist‘s viewpoint, therapists should learn to work with the perspective that parents always consciously or unconsciously maintain preconceptions about causes of the problematic behaviors of their children; Usually therapists are consumed with trying to convince parents of the correctness of their view/assessment or the tactics to follow; Experts through their remarks/explanations and their attitude should help parents to gradually accept alternative views in relation to the problematic situations they face, but primarily they should help parents gradually abandon their stereotyped attitudes and conceptions; Experts should help parents realize that there are possibilities for change and that their collaboration is catalytic for modification of their child‘s emotions and underlying dynamics that promote problem behaviors; Experts should help parents reach a level of agreement and communication between themselves regarding their behavior toward the child, and to recognize contradictory, inconsistent, or awkward behaviors on their own part. Parents are not always aware of the acute frustrations and conflicts between them that the problematic behaviors of the child produce. In addition, problematic behaviors usually lead to school maladjustment and poor academic performance, as well as to teachers‘ and classmates‘ rejection. School-family conflicts or couple crises are often the natural outcome of such situations; therapists should guide parents to face such crises or realize the way parenting skills and self-confidence are affected or how such stressful situations may increase their inappropriate responses toward school or toward their child; The specialist should, on the other hand, help parents to accept the problems and opposition of their children, to see them as self-protective strategies or a result of the child‘s deficits in psychosocial skills and coping mechanisms; parents should be supported to understand how distressing or unbearable emotions may lead children to disruptive and disordered behaviors; Parents should be supported and guided to realize the coercive patterns they develop with their offspring or the negative emotions they experience that leads them to repetitive tantrums or harsh and tough responses (that in their turn, increase children‘s acting-out and disruption); Therapists should help parents clarify which child behaviors must be strengthened and reinforced and which must be transformed; quite often parents tend to reject the whole child, instead of focusing on specific challenging behaviors; they, consequently, risk labelling the child, underestimating his positive features or competencies, notably not recognizing the way he feels; therefore, they risk losing sight of their ―real child‖; Quite often through the analysis or handling of specific daily episodes, specialists help parents realize how their child feels and why he acts this way; As the process moves on the parents should be supported to get better insight into their child‘s behavior, in terms of «internal dynamics» and «deeply rooted patterns of reaction»; they should also be helped to realize the complex interactions and the many factors that impact their behavior;

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It is also important that therapists should help parents understand the relation between disruptive behaviors and conduct disorders of their children with family history, family experiences, as well as the nature of family interaction and communication patterns; Parents should be encouraged to understand the quality of their family structure and organization; Therapists/counselors should help parents get better insight concerning family interactions and their own behavior responses to the child‘s challenges; they should realize that quite often they demonstrate the same patterns of behaviors for which they accuse their children, because they are unable to act differently and avoid critical confrontations; Therapists/counselors are quite often faced with ―extreme phenomena,‖ such as the intergenerational transmission of antisocial patterns or dysfunctional and harmful rearing practices; such phenomena may vary in degree, severity, and pervasiveness (Kourkoutas, 2006; Shaw, 2003; Zoccolillo et al., 2005). Parents in dysfunctional families are likely to project and transfer unfulfilled personal experiences and issues from their own families to their children, thus placing the parent-child relationship in danger with their unrealistic expectations or harsh responses to frustrations (Manzano et el., 1999); Counselors should help parents form a clearer perception about the developmental processes, transitional phases, and challenges of specific stages or periods (e.g., adolescence) of the child; Quite often parents realize and accept the reasons and factors which are related to their own attitudes or to the family dynamics and the way they have contributed to the development of specific problem behaviors. Counselors should support the parents to realize which of their reactions strengthen covertly or implicitly the disruptive behaviors of their children or maintains the vicious cycle of hostile interactions; Counselors should not, on the other hand, consider parents as the exclusive source of the children‘s problems; they should at the same time place emphasis on the child‘s reactions and attitudes which may produce acute stress to parents or ―drive them crazy‖ and lead them to extreme reactions; Counselors should put emphasis on the specific dynamics that produce behavior problems and escalation of hostile interactions; Counselors should not overemphasize parents‘ erroneous or inappropriate behaviors; they need to facilitate collaboration and understanding of difficult situations and the child‘s viewpoint; alleviating the parents‘ role of additional emotional charges and accusations is a way to strengthen parents‘ self-confidence; Counselors should help parents realize and resolve their personal or intrapersonal problems, without being judgemental or intrusive; Many parents need to be supported to express and communicate their sorrow or suffering for their child; quite often parents remain angry or furious with the problematic child because they feel wounded and frustrated in their expectations, while often they fail to recognize that their children suffer as well, something that is not helpful for modifying the family dynamics;

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Parents need to be supported and guided to work on their hostile, aggressive emotions and denial of the child‘s internal difficulties; or on lack of recognition on their part of the positive efforts the child makes; Parents need to be supported and coached to adjust their behaviors and their expectations to the skills, wishes, and needs of their children; quite often parents carry on demanding, overvaluing, or undervaluing their children‘s adaptive skills, without recognizing their strengths and weaknesses; that means that parents should get some help to accept the limitations and difficulties of their children; Parents need to be guided and coached to modify their ineffective practices and implement more effective tactics with the child in everyday life; Counselors should avoid ready-made recipes and prove that they are able to resist the pressures and demands of parents to choose easy or ―magic‖ solutions for their problems without them becoming involved; Parents need to understand that each child, like every family, is different and that certain techniques, practices, or advice can apply to one family but not to another; Counselors should accept parents‘ negative reactions, their disappointment and their insistence on rapid changes, and they should give alternative answers and solutions; Counselors must be very careful and precise when they suggest guidelines or offer advice or interpretations about the relationship dynamics, the symptoms, or experiences of children or their parents; Counselors have to avoid using scientific terminology which can cause confusion, embarrassment, or anxiety for the parents, applying language according to the level of education and social status of the parents; The rules and limitations of the therapeutic relationship are defined from the psychological dynamics of the child and the severity of his problematic behaviour. In many cases it is difficult to impose boundaries during a counselling session; Counselors must be clear and reasonable in relation to parents‘ expectations and demands, they should be clear about the progress of the child, providing feedback and maintaining the trust of the family—which can occasionally be lost; Counselors must be conscious, especially during the first period of the work, about the parents‘ difficulties to accept their responsibility, to accept their behavior toward their child; in some case parents may maintain stereotyped reactions; Counselors must be in a position to discuss and analyze the consequences of counseling and guidance, and be able to understand the effect of their work on the family dynamics; Quite often they must be in a position to foresee consequences of the counselling process and the possible reactions of the parents; Counselors should be prepared for and not feel offended by possible negative comments from parents; instead, their reactions and negative attitude should be the object of analysis and elaboration; Counselors should support parents to achieve stability, but at the same time they must be flexible regarding implementation of rules and programmes; Quite often the expert‘s role is very difficult, requiring an understanding of the parents while at the same time being clear, strict, and decisive in terms of the validity and accurate implementation of interventions;

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Many parents complain that things at home do not change—while experts view the transformation of the child as the best proof of the interdependence of the child‘s problematic behavior and his environment; In many cases the defiant/oppositional behavior of the child may represent an unproductive way to affirm his autonomy and his needs for independence or to keep at a distance parents who are experienced as intrusive or overprotective; In other cases the child‘s problematic behavior may worsen for a period; this might be due to the parents‘ overanxious reactions about what is going on in the session room, or to a child‘s ambivalence (feeling guilty and relieved at the same time) about what was said in the session; counselors should be aware of such dynamics transformation in order to adequately scrutinize and verbalize it; Counselors must take care to check the possibility of parents misinterpreting their advice, using it to attack and control their noncompliant child; There are cases where parents respond effectively and changes are enormous, especially when family counseling is combined with appropriate individual and school-based interventions; When parents decide to consult an important step has been already realized; it depends on the counselor or therapist‘s abilities and training and on the general context and family situation for the counseling to advance in productive ways; Failure of the counselor/therapist to provide a meaningful, comprehensive, and effective intervention is generally due to the presence of a number of barriers and risk parameters (i.e., a violent father who refuses to collaborate) or to the counsellor having limited skills and training.

Failure of the counselor or therapist to provide a meaningful, comprehensive, and effective intervention is due in general to the presence of a number of insuperable barriers and risk parameters (i.e., a violent father who refuses to collaborate), or to limited skills and training on the part of the therapist. Child therapy is typically conducted with the child seen alone and the parents seen in collateral sessions. Many authors have proposed new and different ways to intervene with school-age children who have various problems/disorders: specifically, to address the parentchild attachment relationship dynamics that are integral to the child's developing sense of self. The theoretical rationale for applying this technique to older, more verbal children is based on attachment theory, in which a dysfunctional parent-child attachment is viewed as primary motivation for childhood aggression (Berlin, 2005). In the last few decades, many support programs for empowerment of family bonds and promotion of skills for parents and children with problematic reactions have been implemented in an attempt to help these children avoid risky behaviors (Dishion and Stormshak, 2006). We would like to summarize an essential part of our work with children at risk and their families by citing Vivian Green. Actually, she has suggested that an expert‘s work with parents consists mainly of his offering them a «therapeutic space» so as they «recreate the child in their mind» (Green, 2000).

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ISSUES RELATED TO EVALUATION AND EFFECTIVENESS OF SCHOOL-BASED INTERVENTIONS FOR CHILDREN WITH BEHAVIORAL PROBLEMS Clinical practice should be based on treatments that are backed by research, because research is the best protection against inadequate treatments (Rosenfeld, 2009). From the other side, therapists need to be critical consumers of treatment research, since it has been revealed that many methodological problems, biases, and political and economic forces have distorted the results of such research. (Rosenfeld, 2009). Actually, examination of available literature leads to questioning the field‘s present reliance on the medical model in which evidence-based techniques are applied to particular diagnoses (Rosenfeld, 2009, p. 13)7. In every case, the evaluation of intervention programs targeting children with behavior problems is a compelling challenge to contemporary science since a large number of child therapy techniques are proposed in the literature (Kazdin, 2000; 2004). Many current programs and interventions base evaluation on common methodological tools (Kazdin, 2000). Difficulty in implementation of valid evaluation methods is due in many cases to the nature (multitude) of intervention programs, but also to the difficulty of ensuring optimal experimental conditions (Kazdin, 2004). On the other hand, ensuring experimental conditions for evaluation of an intervention does not guarantee that valid implementation and effective intervention on the clinical level will take place (Kazdin and Wassel, 2000). Consequently, even though the majority of intervention techniques remain without a valuable external evaluation, this does not mean that these interventions are not effective (Kazdin, 2000). The available research data show that the effectiveness of the classical psychoanalytic method for children with disruptive behaviours (hyperactivity, behavior disorders and challenging-defiant disorder) is low compared to children with depressive tendencies (Roth and Fonagy, 2005). This means that the application of individual-centered psychodynamic techniques in childhood should be combined with active behavioral techniques and with broader approaches that promote social-emotional skills training and work with families and teachers (Boyd-Franklin and Bry, 2001; Young et al., 2004). Consequently, the behavioral methods combined with family-, and child-centered, psychodynamic and systems-inspired interventions in schools seem to be quite effective in treating a variety of problems (Schmidt Neven, 2010). During adolescence cognitive and behavioral techniques which aim at restructuring the negative cognitive (and interpersonal) schemes and the multisystemic approach seem to be more effective techniques for treatment of antisocial or delinquency problems (Hengeller et al., 1998; Weisz, 2004). However, cognitive-behavioural methods are not very effective with younger children, and usually emphasis is placed on understanding the child‘s internal mental states and the factors which contribute to development of behavior disorders. Some important parameters of effective interventions at that age are ones on the family level, creative inclusion of these children in school through several psychosocial and psychoeducational techniques, as well as alternative ways of handling conflicts (Atkins et al., 2003; Barbarasch and Elias, 2009; Billington, 2006; Carr, 2009; Connor, 2002). Factors which impede the successful implementation of psychotherapeutic interventions are: age, severity of the disorder, type of 7

For a further discussion of such issues see Rosenfeld (2009).

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family dynamics and structure, school organization, school inclusive practices, teacher‘s availability to cooperate, among others (Loeber and Farrington, 2000). Group psychotherapy for adolescents with serious behavior disorders are not approved, because groups can operate negatively whenever some negative identification develops between antisocial adolescents, thus reinforcing their antisocial tendencies (Dishion and Andrews, 1995). Scientific research also has contributed to the development of knowledge about the program facts, which are essential for any effective interventions. These are the following (see Carr, 1999; Connors, 2002; Fraser et al., 2004; Loeber and Farrington, 2000; Walker and Severson 2002; Walker et al., 2004; Williams et al., 2004; Young et al., 2004):

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a) Children who are exposed to accumulated risk factors are in danger of demonstrating serious social-school adjustment difficulties and behavioral disorders; b) Interventions should be designed to target risk factors that produce or exacerbate child problematic behaviors; c) Interventions must be multimodal, addressing child, family, and school issues. d) Interventions must be applied as soon as possible (early intervention), before any problematic and dysfunctional behaviors become apparent, and crisis situations develop leading to intense negative interactions between child and environment. e) Interventions for serious emotional-behavior disorders (e.g., delinquent youths) must be delivered on a constant basis (daily-weekly) and for an adequate time (at least two years). According to available data, psychiatric mental health centres usually provide fragmented and incomplete services to families and children at risk (see Dishion and Stormshak, 2006). It has been shown that such mental health services are unable to ensure a stable and comprehensive intervention for the child and the family that could adjust to the child‘s needs in a flexible way and be assessed properly. The medical character of these services contributes to the children being pathologized and labeled, especially in preschool and early school years, by teachers, specialists, and parents. This obstructs development of personcentered and individualized programs adjusted to the strengths and weaknesses of each family (Dishion, 2007). The creation of school-based counseling services should be a top priority of contemporary education policies, and they must have a clear child-centered and holistic perspective since it has been shown that similar interventions are definitely effective (Adelman and Taylor, 2009; Christner et al., 2009; Dryfoos, 1997; Vernberg, Roberts and Nyre, 2002). The importance of creating holistic psychosocial/ counselling services in schools, with clear psychoeducational and child-centered orientation has emerged through a series of studies where children with even milder, less serious problems can receive effective support and intervention (Elias et al., 1997; 2003; McMahon et al., 2000; Patentite, 2005). The establishment of school-based services reduces the stigma often related to seeking help on behalf of the parents from psychiatric services outside school (Adelman and Taylor, 2009; Christner et al., 2009; Nabors and Reynolds, 2000; Weare, 2000). In addition, the possibilities for provision of more comprehensive and sustainable intervention programs for teachers and parents (Evans, 1999) are increased. Furthermore, school-based services are better positioned to provide preventive psychosocial programs targeting wider groups of children at risk (Elias et al., 1997). It is widely suggested that counselling sessions with parents and teachers and

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provision of family-centered and child-centered intervention programs are implemented better within school. Such programs can also be open to other student populations with milder problems (Boyd-Franklin and Bry, 2001; Stormshak et al., 2005). Creating interdisciplinary psychosocial services enables all children, as well as teachers, to take advantage of the knowledge and strategies used by contemporary psychology for development of interpersonal, communication, and problem-solving skills (Kronick, 2000). Working within school context in a permanent way also gives school psychologists the possibility of more effective clinical interventions where they can formulate a clearer picture of the child‘s ecology and implement specific psychoeducational programs together with classroom teachers, targeting the child, peers, and other educational staff (Boyd-Franklin and Bry, 2001; Flaherty and Weist, 1999; Kourkoutas and Xavier Raul, 2010). Clinicians working within schools have the opportunity to promote a wider ecosystemic approach and a holistic intervention strategy through continuous contacts with family, teachers, and peers (Atkins et al., 2001). In a broader sense, the development of an ecosystemic clinical/ counselling approach of children with multiple problems is one of the most crucial challenges for mental health science, education, and psychotherapy (Dishion and Stormshak, 2006; Kourkoutas, 2008a; 2008b). It is also important to emphasize that the choice of specific interventions must be based on the multisource evaluation of the child‘s personality, symptom severity, developmental stage, any additional pathological symptoms, psychosocial skills /deficits and functioning, and family and school dynamics (Connors, 2002). In any case, it is widely acknowledged that continuous efforts in both clinical practice and research are needed to reveal the most appropriate specialized interventions based on evaluation of each child‘s specific psychosocial profile and dynamics—not on formal manualized or psychiatric approaches (Kourkoutas and Raul Xavier, 2010). Schools are ideal sites for the development of flexible, holistic, and partnership services which can combine psycho-educational with clinical models to foster meaningful and systemic approaches without necessarily medicalizing and pathologizing the child‘s problems and symptoms, as usually happens in classic child psychiatric settings (Douglas, 2007; Rosenfeld, 2009; Schmidt Naven, 2010; Kourkoutas, 2008a; Kourkoutas and Raul Xavier, 2010; Stormshak et al., 2005; Timimi, 2002; Weare, 2000). Vernberg and colleagues report the followings guidelines and features common to many programs as essential contributors to successful implementation of their school-based interventions: (a) maintain placement in the child‘s home and home school; (b) emphasize an empirical approach to guide interventions; (c) focus on cognitive and behavioral skills development; (d) attend to cross-setting linkages and events; (d) emphasize generalization and maintenance of treatment outcomes; (e) collaborate with everyone involved with the child; (f) view assessment and diagnosis as an ongoing process; (g) maintain developmental focus and cultivate an authoritative parenting style for adults involved with the child (Vernberg et al., 2002, p. 415-416). In addition, Rutter and colleagues (1998, p. 383) underline the following variables revealed by meta-analytic studies, as contributing to successful interventions at an early behavioral problem and pre-delinquency stage: a) need for multimodal intervention over long periods of time; b) projects should be focused, precisely targeted, and based on a causal model;

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c) combining the encouragement of prosocial behavior with discouragement of antisocial behavior may work best; d) families need to be included and convinced; e) building on existing services is likely to be easier and more effective than developing early new services; f) focusing only on high-risk samples will miss a substantial number of offenders; g) ensuring consistency of application and adherence to the original design is important when programs work for some people and not for others.

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The advantage to involving parents and teachers in prevention and intervention programs and inclusive projects is widely recognized and promoted by all researchers and clinicians in the field. In fact, evidence shows that the promotion of a combined eco-systemic and childfocused perspective in working with difficult and challenging or vulnerable/ at-risk children seems to be more effective than single-individual interventions (Carr, 2009). Overall, a systems-based approach has the important function of facilitating the capacity and responsibility of all concerned to become contributors and stakeholders in promoting learning and child and family wellbeing (Schmidt Neven, 2010, p. 103).

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Chapter 17

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CONCLUSIONS The need for a comprehensive and long-term set of coordinated prevention and interventions school-based services is especially critical for the prevention of conduct disorder. In the prevention and intervention field, researchers and professionals are calling for comprehensive prevention programs that have the potential to provide coordinated networks of services, and to bridge the efforts of education and mental health agencies (Conduct Problems Prevention Research Group, 2002). Important conclusions can be drawn from recent data on the impact of the Fast Track intervention on externalizing disorders across childhood, which suggests that targeted intervention can prevent externalizing disorders in order to promote the raising of healthy children (Conduct Problems Prevention Research Group, 2011). All authors (clinicians and researchers) highlight the need to use evidence-based treatments in our work with families, teachers, and children. Specifically, regarding therapeutic work with children, the problem is that much research is biased, flawed, indiscriminately applied, or ignored (Rosenfeld, 2009, p. 13). The risk in adhering to strictly laboratory-based evidence is to advance ready-steady manualized practices that simplify the child‘s experience and its ecology, because it overemphasizes a symptom-centered approach (medical pathology model). Behaviors cannot be disconnected from the child‘s complex internal/psychic processes—such processes are operating, embedded in multifaceted systems of important and meaningful emotional relationships. In addition, such models ignore complex interactions of real clinical practice, as well as a great number of factors that interfere and affect treatment outcome (Leitner, 2007; Rosenfeld, 2009; Schmidt Neven, 2010). Clinical wisdom gained from experience, creativity and intuition, acquired therapeutic skills, self- and professional development, as well as the emotional dimensions and processes of clinical work and involved professionals are ignored. Such strategies oversimplify the psychopathology phenomena and what such a (internal and external) crisis reflects about the personal development and ecology of the child. These approaches actually draw upon traditional medical systems of thinking and epistemology. In contrast, new integrated models argue for a different paradigm in childhood psychopathology, fortunately progressively recognized by contemporary science. These approaches are based on a different concept of childhood disorders and subsequent evaluation/assessment and intervention procedures focused primarily on mobilizing/empowering the internal and external resources of the child in environment,

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buffering risk (internal and external) factors by use of a wide range of multivariate techniques and strategies, involving all stakeholders (Achenbach and Rescorla, 2006; Aumann and Hart, 2009; Durlak and Weissberg, 2005; Fonagy, 2004; 2006; Fraser et al., 2004; Garbarino and Ganzel, 2000; Green, 2000; Greenberg et al., 2003; Greene and Ablon, 2006; Elias et al., 1997; Hart et al., 2007; Munger at al., 1998; Nathan, 1998; Sameroff, 2000; Schmidt Neven, 2010). Inclusive education and new psychopathology theories (dimensional taxonomy, riskprotective factors model, culture and developmental sensible diagnostic systems, transactional and resilient perspective, dynamic assessment) have led to a paradigm shift in conceptualization of childhood disorders and disabilities. As for conclusions regarding family interventions, Barish (2009, p. 139) accurately summarizes the core principles of the therapeutic plan for families, which largely coincide with the key core assumptions and practical guidelines of our work: (a) a respectful appreciation of parents‘ anxieties and concerns—their goals for their children (which we are likely to share) and their efforts to promote their child‘s success in life; (b) offer parents a new understanding of the sources of the child‘s distress—especially, greater appreciation of the child‘s anxiety, frustration, or discouragement; (c) an attempt to identify—and then ameliorate—ongoing patterns of family interactions that perpetuate painful emotions in the mind of the child, especially vicious cycles of criticism and defiance; help parents understand the importance of reparative moments in the life of the child—and the need for parents to initiate this repair; (d) work with parents to find opportunities for responsiveness to their child‘s interests and to create more moments of positive affect-sharing in their daily interactions with their children; (e) teach and encourage proactive problem-solving and support for the child‘s pro-social behavior. The child‘s, the family‘s, the professional‘s characteristics, the quality of the therapeutic alliance and the implemented techniques, as well as some other extra-therapeutic forces, are some of the key factors contributing to the positive outcome of the intervention process (Rosenfeld, 200). The process of implementing a joint systems approach to schools and achieving an inclusive project is not simply one of addressing the behavior of young people perceived to be experiencing difficulties, but a much more complex matter of supporting all pupils, classroom teachers, parents, and educational staff through the development of pedagogies and socialemotional programs and curricula in nurture- learning behavior for all (Dowling and Osbourn, 1994; Dowling and Pound, 1994; Dyson and Howes, 2009). Actually, what seems to prevent schools from becoming leading centers for the promotion of child and adolescent wellbeing are the following (Schmidt Neven, 2010, p. 102):     

A philosophy that splits curriculum learning and knowledge from life learning and knowledge; The marginalizing of emotional and social development of the child and young person as not part of the school‘s ―core business‖; Lack of training and support for teachers to understand the meaning of child and adolescent behavior; A readiness to focus on and identify pathology in the child and young person; A defensive and non-collaborative relationship with parents.

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In brief, schools need to be transformed at structural, organizational, cultural, curricula and relational dynamics levels in order to respond to cotemporary social challenges of treating children with various forms of social, emotional, behavioral, or academic problems and of achieving inclusive education. For this purpose, joint systems approaches and holistic child-, family-, and teacher-centered programs are necessary. The suggestions in this book provide a working model encompassing all these principles. The following axiomatic and practical assumptions are at the core of a school-based psychodynamic eco-systemic program rationale: (a) a shift from a deficit to a strength-based and empowering model for children with disabilities/disorders; (b) a shift from an individual to a context-centered approach; (c) interventions on multiple levels (cognitive, emotional, behavioral, academic level); (d) eclectic use of techniques (integration of various psychosocial techniques to deal with the child‘s problems): behavioral, psychodynamic, psycho-educational, individual or group techniques; (d) dynamic assessment of the child; (e) special emphasis on school inclusion (Kourkoutas and Raul Xavier, 2010). School psychologists/counselors working in a systemic psychodynamic and resilient perspective should also challenge the stereotyped perception of the teacher‘s role and avoid a unidirectional and asymmetric work relation by imposing their manual-based conceptions. Actually, school psychologists and professionals working in schools should also be trained in a different manner and be able to develop a series of essential counseling skills. Adapted from Dinkmeyer and Carlson (2006), below are some of the core skills that are necessary for counselors to work in a resilient, empowering and systemic perspective within school context: (a) empathy and understanding of how children, parents, and teachers feel and experience critical situations; (b) ability to relate to children and adults in a purposeful manner; (c) ability to contain their negative emotions and provide them a ―holding environment‖; (d) sensitivity to the needs of children, parents, and teachers for support and solution of specific problems; e) ability to recognize and acknowledge their limitations, difficulties, and resistances concerning children‘s problems and implementation of suggested strategies; (f) understanding of group dynamics and its impact on school organization and staff attitudes towards intervention implementation; (g) capability of establishing relationships that are characterized by mutual trust and respect, recognizing the importance of alliance in counseling/therapeutic work; (h) ability to establish necessary and sufficient conditions for a helpful relationship; (i) capability to inspire leadership at a number of levels and to work with the educational staff as a system; (i.a) capability to understand and deal with educational systems issues (group conflicts, stereotyped conceptions of children‘s difficulties, resistance to collaboration; (i.b) ability to combine sensitivity to relationships and still display firm, dynamic, and explicit attitudes when necessary in working with all stakeholders; (i.c) psychodynamic view of the children‘s problems and difficulties, a ―beyond child‘s symptoms‖ approach (Kourkoutas and Raul Xavier, 2010). In conclusion, the following issues raised by contemporary research challenge traditional school psychology practice: (a) greater emphasis on the social and contextual/situational determinants is needed in order to understand behaviors and symptomatic reactions, as well as students‘ school adjustment difficulties; (b) a comprehensive approach linking individual symptoms/deficits/disorders with family and school dynamics; (c) no clear connection is found between assessment and treatment, suggesting that formal diagnosis and classification are often unnecessary; (d) there is a growing reliance on therapeutic methods other than traditional psychotherapy; (e) services should be delivered in natural settings rather than in

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clinics; (f ) direct care providers and educational staff seem to be important change agents in collaboration with highly trained specialists; (g) effective psychological services for critical situations within school context can be delivered in a short time; (h) prevention can be wellserved through the provision of social and educational support; the multidisciplinary team approach has been considered to help professionals share their expertise and knowledge (Kourkoutas and Raul Xavier, 2010, pp. 123-124). Despite existing barriers for provision of comprehensive intervention models within educational settings, involvement of stakeholders (parents, teachers, special educators, peers, etc.) is considered to be of great importance for an effective school ―social-mental health‖  inclusive practice and program .



Special thanks to Nancy Rohner, Matina Psaroudaki, Caroline Fotopoulos, Stefanos Plexousakis, and Lucy Sirinian for their precious help in the language revision of the manuscript.

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INDEX

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A abuse, 21, 23, 51, 52, 87, 101, 102 academic difficulties, 17, 20, 35, 43, 82, 160 academic learning, 155 academic performance, 9, 61, 62, 73, 101, 130 academic problems, 3, 5, 62, 63, 101, 141, 163 academic progress, 4, 74 academic success, 29, 74 access, 2, 96 accountability, 3 acts of aggression, 38 acute stress, 123, 125, 131 adaptation, 16, 37, 85, 149, 172, 177 adaptations, 11 ADHD, 12, 37, 39, 59, 123, 146, 166, 170, 173 adjustment, 7, 12, 13, 14, 32, 33, 34, 36, 39, 45, 53, 59, 61, 62, 75, 90, 150, 159, 167, 168 administrators, 85, 101 adolescent behavior, 140, 171 adolescents, ix, 8, 12, 19, 20, 28, 34, 35, 51, 53, 61, 62, 82, 84, 85, 89, 95, 99, 108, 110, 135, 144, 145, 146, 147, 148, 149, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 174, 176, 177 adulthood, 12, 51, 127, 151, 161, 172 adults, 1, 13, 34, 38, 42, 43, 47, 60, 65, 66, 67, 71, 72, 73, 86, 106, 108, 109, 112, 118, 119, 123, 136, 141, 146 advancement, 4, 39 adverse conditions, 27, 37, 49 adverse effects, 32 affirming, 107, 109 age, 6, 12, 13, 17, 18, 20, 31, 35, 36, 37, 42, 47, 48, 51, 52, 53, 60, 72, 86, 96, 108, 109, 116, 133, 134, 155, 158, 159, 162, 175 agencies, 4, 29, 86, 87, 96, 139, 177

aggression, 2, 13, 16, 31, 33, 34, 36, 38, 39, 44, 49, 51, 52, 53, 59, 61, 67, 68, 74, 112, 143, 144, 145, 146, 148, 149, 151, 153, 154, 155, 161, 162, 164, 166, 172, 173, 174, 175, 177 aggressive behavior, 8, 11, 12, 13, 24, 27, 32, 37, 38, 40, 42, 44, 45, 46, 48, 50, 51, 60, 61, 66, 68, 70, 71, 79, 80, 81, 82, 92, 101, 112, 113, 115, 116, 122, 129, 146, 159, 161, 173 aggressiveness, 35, 39, 46, 161 alcoholism, 102 alternative behaviors, 163 ambivalence, 29, 41, 69, 133 American Psychiatric Association, 38, 144 American Psychological Association, 146, 150, 164, 166, 167 anger, 4, 33, 41, 42, 44, 46, 48, 52, 59, 65, 67, 69, 71, 79, 92, 106, 107, 112, 113, 116, 124, 128, 147, 151, 172, 175, 177 antidepressant, 68 antisocial adolescents, 40, 135 antisocial behavior, 10, 12, 21, 25, 27, 28, 29, 30, 32, 33, 34, 38, 44, 51, 57, 60, 61, 62, 67, 70, 75, 80, 81, 137, 143, 145, 146, 148, 149, 151, 153, 157, 164, 169, 173, 174, 175 antisocial children, 174 antisocial personality, 157 antisocial personality disorder, 157 anxiety, 16, 37, 42, 44, 46, 47, 48, 49, 53, 54, 66, 68, 69, 106, 118, 125, 132, 140, 177 anxiety disorder, 46, 49, 177 APA, 38, 149 arousal, 29, 33 arrest, 175 asocial, 13 assessment, 7, 11, 12, 14, 20, 21, 50, 59, 73, 81, 84, 114, 118, 121, 128, 130, 136, 139, 141, 143, 144, 146, 152, 157, 165, 176 assets, 34, 145, 168 assimilation, 13, 100

Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

Index

180 atmosphere, 46, 47, 119 attachment, 23, 28, 29, 32, 44, 54, 57, 72, 80, 81, 94, 106, 112, 118, 133, 145, 149, 174 attachment theory, 133, 145 attribution, 33, 44 attribution bias, 33 authority, 38, 94 autonomy, 133 avoidance, 106 awareness, 8, 56, 67, 69, 93, 115, 122

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B bad behavior, 47 barriers, 2, 133, 142, 151 base, 2, 81, 119, 122, 123, 134, 160, 176 basic education, 76 basic services, 73 battered women, 166 beginning teachers, 145 behavior modification, 68, 71 behavior of children, 33, 162 behavioral change, 81 behavioral disorders, 27, 41, 43, 50, 68, 73, 83, 96, 111, 135, 150, 154, 156, 158, 163, 165, 174 behavioral models, 50 behavioral problems, vii, 4, 6, 7, 9, 12, 14, 17, 23, 24, 27, 34, 35, 39, 40, 41, 43, 45, 52, 54, 59, 60, 67, 68, 71, 72, 73, 75, 80, 81, 83, 84, 89, 90, 92, 95, 100, 105, 113, 122, 158, 160 behaviors, vii, 2, 5, 8, 9, 13, 15, 17, 22, 23, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 44, 48, 49, 52, 53, 54, 57, 58, 60, 61, 62, 67, 68, 69, 70, 72, 73, 74, 84, 86, 91, 92, 93, 96, 107, 109, 111, 112, 114, 115, 116, 117, 118, 119, 121, 123, 124, 125, 128, 130, 131, 132, 133, 135, 141, 143, 147, 153, 154, 156 Belgium, ix benefits, 20 benign, 13 bias, 149 bipolar disorder, 20 blame, 43, 111, 119 blends, 6 bonding, 32, 76, 147 bonds, 13, 23, 36, 57, 91, 106, 115, 133 borderline personality disorder, 168 brain, 33 Britain, 35 bullying, 35, 151, 154, 166, 172 burn, 5, 151

C cancer, 45, 95 caregivers, 13, 21, 22, 30, 90 case examples, 176 case study, 160, 174 causal attribution, 170 causal relationship, 21 causation, 108 challenges, 3, 5, 9, 13, 17, 21, 59, 62, 65, 90, 95, 96, 102, 109, 124, 129, 131, 136, 141, 153, 162 Chicago, 151, 162 child abuse, 29, 177 child development, 11, 13, 76, 148, 150, 156 child maltreatment, 87, 147, 162 child rearing, 173 childhood, 10, 11, 13, 14, 15, 16, 17, 19, 20, 22, 23, 24, 25, 27, 28, 30, 31, 34, 35, 36, 37, 38, 42, 50, 54, 60, 68, 83, 94, 108, 120, 127, 133, 134, 139, 145, 147, 148, 149, 151, 152, 153, 154, 156, 157, 158, 160, 161, 162, 163, 165, 166, 167, 168, 169, 170, 172, 173, 174, 176, 177 childhood aggression, 11, 133, 165 childhood disorders, 14, 17, 25, 30, 35, 83, 139 classes, 1, 49, 73, 74, 80, 85 classification, 29, 38, 141, 154, 156 classroom, vii, 4, 5, 6, 28, 34, 36, 37, 49, 62, 67, 68, 69, 71, 72, 73, 74, 76, 77, 79, 81, 84, 85, 86, 91, 92, 96, 101, 102, 105, 113, 114, 118, 119, 121, 122, 123, 124, 136, 140, 143, 147, 158, 161, 164, 172, 174 classroom environment, 72 classroom management, 73, 77, 158 classroom teacher, vii, 4, 34, 49, 62, 73, 105, 114, 121, 136, 140 classroom teachers, vii, 4, 62, 73, 105, 121, 136, 140 clients, 112 climate, 16, 36, 50, 52, 55, 72, 128, 158 clinical assessment, 124 clinical diagnosis, 37 clinical interventions, 89, 92, 136 clinical psychology, 15, 22, 146 clinical trials, 175 close relationships, 44 coaches, 12 coercion, 148, 171 cognition, 13 cognitive deficit, 49, 90, 157 cognitive deficits, 49, 90, 157 cognitive level, 49

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Index cognitive perspective, 89, 152 cognitive skills, 47 cognitive style, 144 cognitive therapy, 175 coherence, 76, 107 collaboration, 4, 75, 92, 121, 128, 130, 131, 141, 142, 149, 174 collateral, 133 communication, 13, 16, 29, 47, 54, 56, 57, 66, 73, 75, 76, 82, 93, 107, 117, 122, 130, 131, 136 communication patterns, 16, 29, 54, 131 communication skills, 82 communities, 5, 9, 145, 156, 158, 167 community, 1, 4, 5, 21, 23, 27, 28, 30, 31, 68, 75, 85, 86, 87, 97, 102, 118, 147, 152, 162, 171, 176, 177 community support, 23 comorbidity, 20, 30, 36, 67 compensatory effect, 20 complement, 59 complex interactions, 17, 130, 139 complexity, 13, 68, 112 compliance, 79, 123 complications, 127 comprehension, 100 conception, 14 conceptual model, 33, 129 conceptualization, 4, 17, 22, 34, 82, 90, 140 conduct disorder, 12, 17, 27, 36, 37, 38, 42, 43, 44, 46, 67, 131, 139, 146, 148, 149, 153, 156, 157, 158, 159, 161, 164, 165, 168, 171, 173, 176, 177 conflict, 33, 49, 50, 51, 57, 79, 81, 94, 108, 114, 116, 143, 148, 156, 174 conflict resolution, 79, 81 confrontation, 38, 69 congruence, 144 consensus, 20, 28, 173 consent, 151 construction, 41, 59 consulting, 55 consumers, 134 control group, 43, 110 controlled research, 110 conviction, 49, 68, 69 cooperation, 8, 69, 73, 75, 80, 84, 91, 92, 95, 109, 116, 117, 124 coordination, 4 coping strategies, 29 core assumptions, 108, 140 correlation, 50, 51 correlations, 61 cost, 62

181 counseling, 3, 7, 9, 48, 54, 55, 90, 91, 93, 94, 95, 100, 105, 106, 107, 111, 123, 132, 133, 135, 141 counterbalance, 43 creativity, 109, 122, 139 criminal behavior, 80 criminality, 12, 29, 176 crises, 130 critical parent, 51 critical thinking, 62 criticism, 43, 55, 75, 81, 107, 110, 111, 119, 128, 129, 140 cross-validation, 153 crystallization, 11 cues, 33 culture, 5, 9, 62, 73, 82, 105, 140 curricula, 5, 140, 141 curriculum, 3, 5, 62, 70, 75, 80, 81, 85, 86, 97, 105, 106, 140 cycles, 107, 140

D danger, 69, 115, 123, 131, 135 data analysis, 21 defence, 108 defense mechanisms, 29, 57, 65, 108 deficit, 12, 14, 40, 87, 141, 146, 152, 173, 176 delinquency, 17, 38, 39, 59, 134, 136, 147, 149, 162, 164, 165, 166, 171, 173, 176 delinquent behavior, 12, 31 denial, 132 Department of Education, 174, 175 Department of Health and Human Services, 155, 174 depression, 7, 16, 23, 27, 31, 39, 42, 44, 45, 47, 51, 53, 54, 57, 65, 67, 68, 80, 95, 110, 156, 161, 162, 167, 175 depressive symptoms, 7, 154, 169, 174 deprivation, 57 despair, 46, 55, 65, 69 detachment, 93 detection, 21 developmental change, 19 developmental disorder, 25 developmental process, 11, 131, 177 developmental psychopathology, 15, 17, 22, 89, 90, 95, 96, 148, 152, 169 deviation, vii Diagnostic and Statistical Manual of Mental Disorders, 144 diagnostic criteria, 35 dichotomy, 41

Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

Index

182 direct observation, 118 disability, 15, 28, 160 disappointment, 59, 109, 125, 128, 132 disorder, 2, 8, 12, 14, 15, 19, 20, 21, 22, 25, 30, 31, 32, 35, 37, 38, 39, 41, 42, 46, 49, 50, 59, 68, 76, 81, 92, 102, 108, 134, 144, 145, 146, 147, 149, 152, 153, 155, 164, 169, 172, 173, 176 displacement, 108 disposition, 112, 115 disruptive behaviours, 99, 128, 134 dissociation, 27 distortions, 29, 42, 49, 55, 90, 91, 112 distress, 23, 33, 67, 107, 109, 116, 140 diversity, 3, 85 doctors, 20 drawing, 106, 116, 117 drug abuse, 12 drugs, 20 dynamic systems, 15 dysphoria, 42, 43

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E ecology, 21, 128, 136, 139, 149, 154, 171 economic status, 116 ecosystem, 84 education, 1, 3, 4, 5, 9, 10, 13, 29, 42, 70, 73, 75, 82, 86, 95, 102, 105, 109, 116, 125, 135, 136, 139, 140, 141, 150, 151, 156, 158, 160, 169, 171 education/training, 95 educational institutions, 9 educational policy, 76, 82 educational process, 39, 69, 75 educational programs, 1, 79, 81, 85 educational psychology, 14, 125 educational services, 36 educational settings, 10, 142, 145 educational system, 5, 9, 62, 69, 76, 124, 141 educators, vii, 1, 4, 20, 84, 86, 87, 112, 123, 128, 142 ego strength, 108 elaboration, 99, 106, 118, 132 elementary school, 35, 60, 68, 79, 80, 160, 167, 172 emotion, 24, 32, 34, 154 emotion regulation, 154 emotional conflict, 41, 91, 93 emotional disorder, 24, 42, 52, 110 emotional distress, 33 emotional experience, 32, 118 emotional health, 164, 175

emotional intelligence, 79 emotional problems, 2, 36, 39, 42, 59, 67, 163 emotional processes, 6, 68, 90, 111, 113 emotional reactions, vii, 13, 55, 65, 69, 109 emotional responses, 41, 42, 128 emotional stability, 23, 119 emotional state, 41, 44, 49, 103, 124, 127 emotional well-being, 6 empathy, 38, 42, 80, 94, 112, 141 empirical studies, 90 empowerment, 34, 74, 99, 133, 164, 173 encouragement, 77, 100, 119, 137 England, 35 enrollment, 41 environment, vii, 5, 9, 13, 14, 16, 21, 22, 23, 24, 25, 30, 32, 39, 42, 45, 46, 50, 53, 59, 77, 84, 86, 92, 106, 107, 115, 117, 118, 122, 133, 135, 139, 141, 154, 157 environmental influences, 169 environmental variables, 154 epidemiology, 148 epistemology, 139 ethnicity, 86 European Community, ix everyday life, 55, 84, 132 evidence, vii, 4, 7, 8, 12, 14, 21, 27, 30, 32, 37, 41, 50, 51, 53, 58, 72, 79, 80, 81, 89, 110, 134, 137, 139, 146, 152, 154, 162, 168, 171, 172, 176, 177 evidence-based program, 81 evolution, 15 exclusion, 9, 20, 35, 39, 101, 102, 107, 119, 158 executive function, 12, 15, 165 executive functioning, 12 executive functions, 165 experimental condition, 84, 134 expertise, 122, 142, 156 exposure, 17, 28, 29, 32, 34, 48, 51, 96, 152 external locus of control, 29 externalizing behavior, 31, 36, 173 externalizing disorders, 2, 51, 52, 139, 159 extreme poverty, 115

F facilitators, 172 faith, 112 families, 1, 2, 3, 5, 8, 20, 22, 23, 32, 34, 39, 44, 47, 50, 51, 53, 55, 57, 60, 84, 86, 93, 94, 95, 96, 99, 102, 106, 107, 116, 122, 125, 127, 131, 133, 134, 135, 137, 139, 140, 145, 149, 150, 154, 156, 158, 159, 160, 167, 168, 171, 174, 177

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Index family characteristics, 18 family conflict, 21, 51, 55, 67, 106, 130 family environment, 2, 9, 21, 30, 32, 33, 34, 39, 45, 52, 53 family functioning, 29, 93 family history, 50, 54, 117, 127, 131 family interactions, 28, 131, 140 family life, 22, 33, 36, 115 family members, 84, 93, 111 family relationships, 15, 75 family support, 153 family system, 29, 33, 144 family therapy, 83, 115, 127, 148, 152 family violence, 28, 115 fear, 42, 47, 69, 86, 112 fears, 41, 46, 48, 112, 114 feelings, 15, 16, 23, 33, 40, 41, 42, 44, 45, 46, 47, 48, 49, 50, 52, 53, 55, 59, 65, 66, 67, 68, 69, 70, 71, 72, 76, 92, 94, 106, 107, 111, 112, 113, 114, 115, 116, 117, 122, 123, 124, 125, 128, 129 fights, 47, 49, 114, 129 financial, 54, 102 flaws, 110 flexibility, 73, 112 force, 109 Ford, 33, 34, 35, 42, 67, 89, 91, 112, 152 formation, 33 foundations, 86 framing, 52 France, 36 free association, 109 functional approach, 40 fundamental needs, 16 funding, 3 future orientation, 112

G general education, 10 genetic predisposition, 11 genetics, 162 grades, 81 Greece, ix, 36, 51, 171 group activities, 99, 111 group therapy, 4 grouping, 6 growth, 9, 119, 167 guidance, 50, 69, 72, 76, 77, 90, 91, 105, 129, 132, 163 guidelines, vii, 108, 119, 121, 132, 136, 140 guilt, 38, 128 guilty, 94, 118, 133

183

H harmful effects, 37 hazards, 21, 22, 27 health, 2, 3, 4, 5, 7, 9, 41, 45, 47, 81, 96, 97, 135, 144, 150, 151, 156, 171, 172, 175, 176 health problems, 2, 3, 41, 47 health promotion, 176 health services, 135, 151 helplessness, 67 heterogeneity, 9, 12, 39, 108 high school, 10, 80 history, 15, 17, 51, 56, 94, 113, 116, 117, 166 holocaust survivors, 23 homes, 8, 55 honesty, 115 hopelessness, 65, 68, 69 hostility, 42 human, 3, 40, 145, 158 human behavior, 40 human development, 145 human nature, 158 husband, 49, 54, 94, 95 hyperactivity, 12, 29, 31, 32, 37, 38, 39, 43, 44, 53, 59, 92, 113, 134, 152, 173, 176 hypersensitivity, 33 hypothesis, 6, 23, 31, 33, 34, 114, 121, 124

I iatrogenic, 96, 147 ideal, 2, 136 idealization, 69 identification, 9, 21, 28, 52, 56, 59, 71, 112, 135, 151, 165 identity, 33, 56, 59, 69, 71, 146 image, 74 images, 42 imitation, 13, 52 impairments, 37 impotence, 68 imprisonment, 115 improvements, 92 impulses, 57, 65, 118 impulsive, 47, 53, 55, 175 impulsivity, 12, 36, 38, 79 incidence, 164 income, 86, 151 independence, 133 India, 146 individual differences, 75 individuality, 106

Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

Index

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184 individuals, 84, 106, 118 infancy, 13, 17, 24, 29, 30, 33, 35, 94 infants, 37 inferiority, 16, 59, 112, 114 information processing, 167 infrastructure, 73 ingredients, 163, 172 insecurity, 45, 46, 48 institutions, 30 instructional methods, 73 integration, 11, 28, 76, 90, 96, 102, 110, 118, 141, 161, 167 integrity, 44, 56 intelligence, 22, 28, 29, 95, 156, 165 intelligence tests, 156 interactional perspective, 165 interdependence, 133, 161 internal change, 113 internal mechanisms, 14, 17 internal processes, 11, 67, 76, 90, 92, 115, 117 internal working models, 29, 32, 47, 65 internalization, 13, 100, 156, 165 internalizing, 36, 37, 38, 42, 51, 52, 154, 159 interparental conflict, 54 interpersonal interactions, 40, 59 interpersonal processes, 112 interpersonal relations, 29, 41, 43, 48, 61, 62, 65, 111 interpersonal relationships, 41, 43, 48, 61, 62, 111 interpersonal skills, 2, 17, 23, 28, 32, 39, 44, 47, 60, 74, 75, 90, 92, 105, 116, 118, 119 intervention strategies, 7, 100, 167 introspection, 69 investment, 56, 57, 93 investments, 128 irritability, 44 isolation, 16, 61, 66 issues, vii, 3, 7, 11, 15, 19, 37, 40, 75, 76, 81, 82, 85, 91, 92, 96, 109, 122, 128, 129, 131, 134, 135, 141, 143, 151, 153, 158, 159, 161

J juvenile delinquency, 10, 147, 156, 159, 165 juvenile justice, 33

L labeling, 6, 33, 76, 106 lack of control, 81 language skills, 80

lead, 33, 38, 52, 68, 70, 93, 110, 111, 119, 123, 130, 131, 157 leadership, 141 learners, 85 learning, 5, 6, 9, 29, 31, 35, 39, 61, 62, 69, 70, 71, 72, 73, 74, 75, 76, 77, 80, 85, 86, 91, 92, 96, 99, 102, 113, 114, 117, 118, 123, 137, 140, 147, 148, 150, 151, 158, 160, 163, 169, 170, 174 learning behavior, 77, 140 learning difficulties, 29, 31, 35, 61, 73, 74, 113, 114 learning disabilities, 39, 92 learning environment, 70 learning process, 71, 74, 75 learning skills, 76 level of education, 132 life experiences, 62 light, vii, 14, 82, 111 longitudinal study, 31, 34 love, 94, 114 lying, 31

M major depression, 168 majority, 17, 36, 83, 134 maltreatment, 23, 28, 31, 32, 33, 42, 43, 56, 57, 89, 117, 129, 158, 166, 168, 173 man, 172 management, 4, 13, 54, 62, 66, 68, 73, 75, 76, 79, 80, 85, 93, 102, 124, 149, 159, 164, 165, 171 manipulation, 39, 93 marginalization, 143 marital conflict, 50 marriage, 113 Maryland, 20 materials, 117 matter, iv, 140, 154, 167 mediation, 5, 75, 106, 108 medical, 3, 6, 8, 14, 16, 22, 32, 36, 40, 45, 48, 90, 105, 122, 134, 135, 139 medication, 4 medicine, 175 membership, 31 mental disorder, 8, 143, 155, 158 mental health, vii, 3, 4, 7, 8, 9, 19, 20, 27, 34, 37, 39, 41, 62, 66, 75, 81, 82, 83, 86, 90, 96, 100, 102, 106, 110, 135, 136, 139, 142, 143, 144, 145, 146, 147, 149, 152, 155, 157, 158, 159, 162, 164, 165, 168, 171, 172, 176 mental health professionals, vii, 9 mental illness, 102

Behavioral disorders in children: Ecosystemic psychodynamic interventions within the family and school context : Ecosystemic Psychodynamic

Index mental processes, 108 mental representation, 24, 159 mental state, 134 mental states, 134 meta-analysis, 150, 159, 163, 167 metabolized, 117 Minneapolis, 145 mission, 3 misunderstanding, 43, 57 models, vii, 8, 14, 15, 20, 21, 22, 24, 32, 47, 48, 51, 57, 61, 71, 72, 84, 89, 90, 91, 93, 100, 122, 136, 139, 142, 145, 150, 152, 155, 164, 165, 170, 173 modifications, 4, 63, 68, 82, 107 morbidity, 40 motivation, 37, 71, 133, 166 multidimensional, 8, 14, 40, 89, 92, 99, 110 multiple factors, 21, 25 mutual respect, 49, 85

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N narratives, 94, 111 negative attitudes, 75 negative consequences, 22, 66, 67 negative emotions, 8, 42, 48, 49, 52, 58, 71, 79, 103, 112, 129, 130, 141 negative experiences, 111 negative mood, 31 negative reinforcement, 72 negativity, 23, 39, 51, 112 neglect, 57, 87, 159 nervousness, 54 neutral, 40 neutral stimulus, 40 North America, 20, 153

O observational learning, 80 obstacles, 2 offenders, 137, 147, 151, 171 opportunities, 1, 28, 30, 61, 62, 74, 75, 80, 140, 146, 150, 176 Oppositional Defiant Disorder, 36, 161 optimism, 170 organize, 4, 68 overlap, 12

185

P Pacific, 157, 162, 175 pain, 23, 33, 43, 46, 47, 146 paradigm shift, 9, 15, 22, 140 parental attitudes, 22, 44, 58 parental control, 36 parental criticism, 51 parental influence, 95 parental involvement, 76, 109 parental maltreatment, 33 parental support, 44 parenting, 3, 28, 29, 30, 33, 34, 37, 54, 55, 56, 57, 89, 93, 94, 109, 115, 116, 129, 130, 136, 149, 153, 154, 165, 175 participants, 31, 110 passive-aggressive, 162 pathology, 9, 14, 15, 22, 25, 56, 92, 139, 140, 143 pathways, 2, 12, 19, 24, 32, 39, 153, 164, 176 pedagogy, 82, 90 peer group, 2, 27, 28, 61, 101, 111 peer rejection, 23, 60, 145, 151, 161, 169 peer relationship, 148 permit, 1, 111, 118 perseverance, 1 personal development, 139 personal history, 65, 93 personal life, 112 personal problems, 94, 95 personal relations, 73 personal relationship, 73 personal responsibility, 113 personality, 24, 32, 40, 42, 54, 65, 75, 108, 116, 136, 144, 168 personality disorder, 24 personality traits, 75 Perth, 162 pessimism, 170 physical abuse, 17, 34, 51, 52, 158, 169 physical aggression, 38, 173 placebo, 175 playing, 59, 122 pleasure, 119 polar, 20 policy, 5, 8, 102, 161, 163, 176 policy makers, 8 policymakers, 167 population, 7, 20, 21, 35, 36, 81, 146 positive attitudes, 29, 72 positive behaviors, 74, 82 positive interactions, 52 positive mental health, 96 positive reinforcement, 84, 90

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186 positive relationship, 5, 7, 9, 17, 52, 61, 112, 113 poverty, 28 preadolescents, 171 preparation, iv preschool, 13, 15, 36, 48, 49, 51, 53, 60, 68, 135, 159, 166 preschoolers, 51, 143, 157 prestige, 49 prevention, 3, 5, 27, 30, 39, 76, 81, 82, 86, 96, 137, 139, 142, 143, 145, 146, 147, 148, 155, 156, 162, 164, 165, 167, 171, 177 primary school, 7, 36, 37, 61, 145 principles, 4, 66, 75, 76, 82, 84, 87, 96, 106, 109, 110, 111, 112, 118, 127, 140, 141, 150 problem behavior, 2, 8, 10, 15, 16, 24, 29, 31, 36, 38, 60, 65, 66, 74, 76, 79, 80, 91, 92, 111, 117, 121, 123, 127, 130, 131, 143, 151, 172 problem behaviors, 8, 10, 36, 60, 74, 76, 79, 80, 130, 131, 143 problem children, 76, 123 problem solving, 79 problem-solving, 9, 17, 57, 77, 79, 112, 116, 136, 140 problem-solving skills, 57, 77, 136 problem-solving strategies, 9 processing biases, 44 professional development, 69, 139 professionals, vii, 2, 5, 6, 8, 9, 10, 20, 29, 40, 55, 58, 62, 63, 67, 68, 69, 76, 81, 84, 85, 86, 94, 96, 106, 107, 114, 119, 121, 123, 124, 127, 129, 139, 141, 142, 144, 173 profit, 9, 38, 92 program outcomes, 116 programming, 81, 86 project, 5, 6, 9, 30, 90, 106, 107, 111, 114, 116, 120, 121, 122, 124, 131, 140, 150, 167 prosocial behavior, 34, 137 protection, 28, 48, 134, 156, 157 protective factors, vii, 8, 9, 20, 21, 23, 24, 27, 28, 29, 30, 34, 35, 40, 41, 61, 86, 89, 100, 115, 140, 151, 176 protective mechanisms, 24, 44 psychiatric disorders, 158, 170 psychiatry, 161, 167, 172, 173 psychic process, 139 psychoanalysis, 108 psychoanalytic theories, 42 psychoanalytic tradition, 106 psychoeducational intervention, 36, 128 psychoeducational program, 118, 136 psychological development, 106 psychological pain, 66

Index psychological problems, 9, 28, 29, 35, 38, 55, 61, 91, 102 psychological processes, 68 psychological self, 115 psychological stress, 15 psychologist, 10, 34, 45, 47, 49, 55, 91, 102, 115, 121, 122, 125 psychology, 5, 35, 136, 145, 158, 162, 165, 174, 176 psychopathology, 4, 11, 17, 19, 20, 22, 23, 24, 25, 28, 41, 51, 89, 139, 143, 146, 149, 152, 153, 154, 156, 158, 161, 162, 169, 172 psychoses, 102 psychosocial development, 23, 33, 40, 57, 62, 70, 75 psychosocial dysfunction, 3, 33 psychosocial functioning, 15, 16, 50, 83, 90 psychosocial interventions, 4, 99 psychotherapy, 8, 16, 83, 90, 99, 108, 110, 111, 112, 135, 136, 141, 144, 146, 148, 155, 157, 158, 161, 163, 165, 168, 169, 172, 174, 175, 176 punishment, 36, 50, 55, 57, 58, 66, 70, 72, 76, 101, 154

Q questioning, 110, 134

R race, 147 radicalization, 90 rating scale, 118 reactions, vii, 2, 5, 7, 13, 14, 15, 17, 19, 22, 33, 40, 46, 53, 55, 56, 57, 60, 67, 72, 76, 85, 92, 107, 112, 113, 116, 117, 118, 122, 125, 128, 129, 131, 132, 133, 141, 172 reactivity, 17 reading, 162 reality, 16, 41, 55, 66, 68, 74, 84, 86, 94, 102, 108, 113, 116, 117, 118, 129 reasoning, 22 reception, 107 reciprocity, 150 recognition, 73, 107, 109, 114, 118, 132 recommendations, iv, 13, 87, 159 reconciliation, 108, 118 reflective practice, 169 regression, 108 regulations, 73

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Index reinforcement, 29, 32, 57, 59, 70, 76, 79, 80, 81, 100 rejection, 2, 5, 8, 28, 29, 33, 43, 45, 46, 51, 52, 61, 65, 66, 69, 74, 89, 92, 114, 119, 130, 159, 164, 168, 177 relational model, 56, 71, 107, 117, 118 relatives, 45 relaxation, 4 relevance, 108, 109 reliability, 40, 41 repair, 140 representativeness, 110 reproduction, 91 requirements, 49, 65, 85, 122 researchers, 8, 15, 20, 23, 24, 29, 41, 44, 48, 67, 83, 95, 96, 99, 110, 137, 139 resilience, 14, 15, 17, 20, 21, 23, 24, 30, 34, 82, 146, 147, 148, 153, 155, 160, 163, 167, 168, 171, 176, 177 resistance, 69, 109, 116, 119, 123, 129, 141 resolution, 91, 93, 158 resources, 14, 30, 81, 86, 93, 102, 139, 177 response, 21, 29, 39, 42, 48, 50, 51, 62, 65, 67, 118, 123 responsiveness, 107, 109, 140 restructuring, 134 retaliation, 111 rewards, 73 risk, vii, 1, 2, 3, 4, 5, 6, 9, 10, 14, 15, 17, 20, 21, 22, 23, 24, 25, 27, 28, 29, 30, 31, 32, 33, 34, 36, 38, 39, 40, 41, 45, 50, 52, 54, 57, 59, 60, 61, 74, 80, 81, 82, 86, 89, 91, 92, 96, 97, 99, 100, 102, 105, 106, 113, 115, 117, 120, 122, 123, 129, 130, 133, 135, 137, 139, 140, 144, 147, 148, 149, 151, 152, 153, 154, 155, 156, 158, 160, 161, 163, 170, 171, 172, 173, 174, 175, 177 risk factors, 9, 10, 17, 20, 21, 22, 24, 27, 28, 29, 30, 33, 34, 36, 40, 50, 54, 59, 60, 61, 81, 91, 99, 102, 115, 120, 122, 135, 144, 147, 153, 161 risks, 2, 6, 7, 8, 12, 17, 20, 21, 23, 29, 30, 34, 62, 93, 122, 158, 170 risk-taking, 31, 39 role-playing, 56, 73, 111, 117 root, 46, 49 roots, 113, 161 routines, 54 rules, 13, 52, 53, 54, 70, 73, 77, 117, 132

187

S sadism, 52 sadness, 23, 48, 50, 106, 109, 128 safety, 164 schema, 30 schemata, 23, 24, 29, 40, 42, 59, 89, 159, 170, 171 school activities, 70, 73 school adjustment, 7, 33, 35, 61, 92, 127, 135, 141, 161 school climate, 75, 154 school community, 74 school culture, 76, 82 school failure, 59, 61, 101 school performance, 60, 61, 118 school psychology, 9, 102, 141, 147, 171 school success, 170 school support, 20 schooling, 37, 90, 166, 171 science, 14, 134, 136, 139, 146, 147, 148, 156 scientific knowledge, 87, 102 scope, 8 secondary school students, 149 secondary schools, 161 security, 123, 174 self esteem, 29, 100 self-concept, 34, 42, 43, 44, 45, 61, 65 self-confidence, 49, 61, 69, 82, 92, 106, 128, 130, 131 self-control, 13, 17, 58, 71, 79, 80, 94, 100 self-destruction, 65 self-discipline, 81 self-esteem, 7, 29, 32, 42, 43, 44, 47, 57, 61, 71, 73, 76, 111, 119, 124, 144, 170 self-expression, 75, 111 self-identity, 65 self-image, 16, 42, 43, 44, 48, 49, 102, 112 self-organization, 11 self-perceptions, 145, 149, 157 self-regulation, 17, 23, 24, 169, 171 self-schemata, 90 sensation, 39 sensitivity, 106, 115, 141, 174 sensitization, 171 service provider, 4 sex, 71 shame, 93, 106 shape, 8, 14, 17, 48 shock, 115 showing, 7, 21, 114 sibling, 30, 48, 52, 102, 115 siblings, 12, 24, 29, 33, 37, 54, 128, 129, 148

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188 side effects, 92 signs, 5, 9, 23, 67 skill acquisition, 80 skills training, 83, 116, 134, 172 social activities, 119 social adjustment, 14, 61, 148 social behavior, 23, 57, 140, 143 social cognition, 24 social competence, 80, 144, 145, 153, 162, 171, 175 social context, 8, 9, 15, 25, 32, 34, 48, 83 social development, 140, 144 social environment, 11, 23, 28, 52, 53 social exchange, 11 social exclusion, 35, 160 social identity, 61 social information processing, 34, 148, 175 social institutions, 24 social integration, 6 social interactions, 25 social learning, 19, 165, 171 social life, 102 social maladjustment, 157 social network, 29 social norms, 100 social problems, 102 social relations, 76, 169 social relationships, 169 social rules, 80 social services, 150 social situations, 49, 79 social skills, 4, 9, 17, 29, 43, 57, 75, 79, 80, 86, 99, 100, 108, 111, 116, 163 social skills training, 4 social status, 132 social support, 29 social support network, 29 social workers, 86 socialization, 13, 173 socially acceptable behavior, 44 society, 24, 59, 74, 82 solidarity, 73 solution, 94, 123, 141 space environment, 112 special education, 1, 9, 15, 19, 22, 41, 66, 96, 102, 160 specialists, 2, 8, 16, 39, 72, 73, 82, 85, 91, 94, 111, 130, 135, 142 Spring, 166, 167 stability, 112, 132, 174 staff members, 101 stakeholders, 137, 140, 141, 142 state, 3, 145, 170

Index state authorities, 3 states, 8, 31, 33, 35, 107, 112, 114 stigma, 135 stigmatized, 60, 107 stimulus, 38 stomach, 45 stress, 17, 29, 37, 46, 69, 92, 112, 122, 123, 145, 147 stressful events, 42 stressful life events, 28, 29, 161 stressors, 20, 62 structural changes, 83 structure, 2, 23, 32, 52, 57, 81, 87, 119, 131, 135, 174 student achievement, 75 student populations, 3, 136 style, 2, 29, 38, 40, 43, 50, 62, 136, 175 subjectivity, 112 substance abuse, 29, 59 substance use, 81 suicide, 152 supervision, 7, 55, 68, 72, 73, 76, 85, 90, 93, 105, 111, 123, 125, 160 support services, 3, 4, 10 survival, 34 sustainability, 111 symptoms, 6, 8, 10, 22, 34, 39, 40, 41, 80, 85, 96, 119, 128, 132, 136, 141 syndrome, 39, 168 synthesis, vii, 19, 81, 171

T tactics, 63, 86, 122, 123, 130, 132, 143 target, 8, 13, 79, 80, 81, 86, 105, 124, 135 taxonomy, 15, 140, 143 teacher performance, 3 teacher relationships, 7, 73 teacher support, 167 teacher training, 73 teacher-student relationship, 60, 61, 71, 164 teams, 3, 5, 6, 9, 30, 68, 77, 125, 147 techniques, vii, 2, 3, 4, 10, 52, 56, 63, 66, 67, 69, 70, 72, 73, 74, 75, 83, 84, 90, 91, 92, 96, 99, 100, 105, 108, 110, 111, 112, 115, 116, 117, 118, 127, 132, 134, 140, 141 temperament, 17, 19, 22, 28, 29, 47, 53, 158, 166 tension, 48, 54, 101 tensions, 16, 44, 49, 52, 55, 58, 69, 72, 91, 96, 101, 102, 107, 111, 113, 123, 162 testing, 34, 108, 118 theatre, 117 theoretical approaches, vii, 110

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Index theoretical assumptions, 11, 87, 90, 108 therapeutic approaches, 108 therapeutic change, 107 therapeutic effects, 30, 107 therapeutic interventions, 6, 83 therapeutic process, 55, 93, 94, 127 therapeutic relationship, 5, 106, 107, 109, 110, 118, 132 therapist, 55, 56, 99, 106, 107, 108, 109, 110, 112, 113, 114, 115, 117, 118, 119, 128, 129, 133, 143 therapy, 4, 56, 84, 93, 95, 106, 109, 113, 117, 118, 120, 127, 133, 134, 144, 152, 157, 159, 163, 165, 167, 172, 174 thoughts, 15, 44, 47, 53, 113, 121 threats, 44, 45, 46 throws, 45 time constraints, 119 training, 3, 9, 52, 54, 55, 56, 63, 67, 69, 76, 77, 80, 81, 83, 86, 87, 90, 91, 96, 99, 100, 106, 111, 112, 116, 125, 127, 133, 140, 151, 159, 163, 175, 176 training programs, 76, 96, 100 traits, vii, 22, 30, 32, 38, 39, 40, 42, 153 trajectory, 11, 14, 15, 20, 22, 31 transactions, 12 transference, 55, 67, 108, 109, 129 transformation, 82, 133 transmission, 15, 89, 131, 161, 173, 177 trauma, 23, 32, 33, 65, 116, 152, 156, 170 traumatic events, 45, 46 traumatic experiences, 15, 16, 23, 32, 43, 46, 52, 65, 84, 107, 112 treatment, 2, 3, 4, 6, 7, 11, 14, 15, 25, 27, 29, 33, 36, 37, 40, 41, 52, 55, 56, 66, 76, 83, 89, 95, 96, 97, 99, 108, 109, 110, 111, 112, 115, 118, 122, 127, 134, 136, 139, 141, 144, 145, 148, 150, 152, 154, 155, 156, 157, 159, 161, 163, 164, 165, 167, 168, 174 trial, 148, 149 triangulation, 29 tutoring, 36, 172

U

189 unhappiness, 41 United, 3, 144, 170 United States (USA), 3, 34, 35, 36, 61, 144, 170 urban, 144, 151, 177

V validation, 112 vandalism, 38, 101 variables, 8, 21, 22, 24, 27, 51, 54, 62, 118, 136 variations, 40 vein, 33 victimization, 34, 61, 145, 152 victims, 51, 52, 101, 160 violence, 3, 17, 22, 28, 29, 34, 36, 38, 43, 51, 52, 143, 144, 147, 151, 153, 155, 156, 159, 160, 161, 162, 164, 165, 166, 167, 171, 172, 173, 177 violent behavior, 35, 40, 51 visions, 151 vocabulary, 47 vocational tracks, 86 vulnerability, 29, 42, 68, 147, 151, 163, 167, 170, 171, 177

W Washington, 118, 144, 146, 149, 150, 153, 155, 158, 164, 166, 167, 168, 169, 173, 174, 175, 176, 177 waste, 113 weakness, 40, 44, 48, 55, 94 welfare, 9 well-being, 3, 156, 175 wellness, 169 Western countries, 1, 96 WIC, 149 withdrawal, 69, 107, 112, 123 witnesses, 114 workers, 151

Y young people, 34, 140, 169, 175

UK, 147, 150, 151, 153, 163, 164, 167, 170, 177 underlying mechanisms, 157

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