The Professional Counselor
From the National Board for Certied Counselors, Inc. and Aliates
Volume 5, Issue 2
The refereed,
online, open-source
journal promong
scholarship and
academic inquiry
within the profession of
counseling
Special Issue: Counseling Children With Special Needs and Circumstances
National Board for Certied Counselors
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Susan A. Adams
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Jamie Crockett
Stephanie Crockett
Joel F. Diambra
Peggy A. Dupey
Judith C. Durham
Mark Eades
Bradley T. Erford
Syntia Santos Figueroa
Courtney E. Gasser
Edwin R. Gerler, Jr.
Gary G. Gintner
Samuel T. Gladding
Barry Glick
Yuh-Jen Martin Guo
W. Bryce Hagedorn
Lynn K. Hall
George E. Harrington
Stephen Hebard
Tanya Johnson
Laura K. Jones
Joseph P. Jordan
Michael Alan Keim
Budd L. Kendrick
Branis Knezevic
Joel A. Lane
Jeffrey S. Lawley
Sonya Lorelle
Amie A. Manis
Mary-Catherine McClain
Matthew J. Mims
Keith Morgen
Adele Logan O’Keefe
Jay Ostrowski
Fidan Korkut Owen
Richard L. Percy
J. Dwaine Phifer
Verl T. Pope
Theodore P. Remley, Jr.
James P. Sampson, Jr.
Stephen R. Sharp
Ann K. Thomas
Alwin E. Wagener
Jeffrey M. Warren
Editorial Staff
Thomas W. Clawson, Publisher
J. Scott Hinkle, Editor
Traci P. Collins, Managing Editor
Verl T. Pope, Associate Editor
Michelle Gross, Associate Editor
Carie McElveen, Editorial Assistant
Jay Ostrowski, Technical Editor
About
The Professional Counselor
The Professional Counselor
(TPC) is the ofcial, peer-
reviewed, open-access
electronic journal of the
National Board for Certied
Counselors, Inc. and Afliates
(NBCC), dedicated to
research and commentary
on empirical and theoretical
topics relevant to professional
counseling and related areas.
TPC publishes original
manuscripts relating to the
following topics: mental and
behavioral health counseling;
school counseling; career
counseling; couple, marriage
and family counseling;
counseling supervision;
theory development;
ethical issues; international
counseling issues; program
applications; and integrative
reviews of counseling and
related elds. The intended
audience for TPC includes
National Certied Counselors,
counselor educators, mental
health practitioners, graduate
students, researchers,
supervisors, human services
professionals and the general
public.
Editorial Board 2015
The Professional Counselor
© 2015 NBCC, Inc. and Afliates
Volume 5, Issue 1
Table of Contents
Volume 5, Issue 2
Table of Contents
195
Children With Special Needs and Circumstances: Conceptualization Through a
Complex Trauma Lens
Edward Franc Hudspeth
200
Addressing the Needs of Students Experiencing Homelessness: School Counselor
Preparation
Stacey Havlik, Julia Bryan
217
The School Counselor and Special Education: Aligning Training With Practice
Jennifer Geddes Hall
225
Trauma and Treatment in Early Childhood: A Review of the Historical and
Emerging Literature for Counselors
Kristen E. Buss, Jeffrey M. Warren, Evette Horton
238
All Foreign-Born Adoptees Are Not the Same: What Counselors and Parents Need
to Know
Yanhong Liu, Richard J. Hazler
248
Parent–Child Interaction Therapy for Children With Special Needs
Carl Sheperis, Donna Sheperis, Alex Monceaux, R. J. Davis, Belinda Lopez
261
Advancements in Addressing Children’s Fears: A Review and Recommendations
Monica Leppma, Judit Szente, Matthew J. Brosch
273
Professional Counseling for Children With Sensory Processing Disorder
Emily Goodman-Scott, Simone F. Lambert
293
Counseling Children With Cystic Fibrosis: Recommendations for Practice and
Counselor Self-Care
Cassandra A. Storlie, Eric R. Baltrinic
304
Because “Mama” Said So: A Counselor–Parent Commentary on Counseling
Children With Disabilities
Sherry Richmond-Frank
Special Issue: Counseling Children With Special Needs and Circumstances
Guest Editor: Edward Franc Hudspeth, NCC
195
The Professional Counselor
Volume 5, Issue 2, Pages 195–199
http://tpcjournal.nbcc.org
© 2015 NBCC, Inc. and Affiliates
doi:10.15241/efh.5.2.195
Edward Franc Hudspeth, NCC, is an Assistant Professor of Counselor Education at Henderson State University and served as the guest
editor for the special issue of The Professional Counselor on children with special needs and circumstances. Correspondence can
be addressed to Edward Franc Hudspeth, Department of Counselor Education, Henderson State University, 1100 Henderson Street,
Arkadelphia, AR 71999, [email protected].
Edward Franc Hudspeth
Children With Special Needs and
Circumstances: Conceptualization
Through a Complex Trauma Lens
When conceptualizing this special issue, we had a basic idea of what might be included; however, as submissions
arrived, it was evident that our basic denition of special needs was limited and could include much more when
broadened. Therefore, the issue was reconceptualized as “Children with Special Needs and Circumstances.” It is
my hope that when practitioners, researchers and faculty read this issue, each begins to see that the term special
needs encompasses more than we think, because anything that hinders the optimal growth and development of a
child constitutes a special need. In this issue, readers will nd articles concerning fears, trauma, sensory processing
disorder, foreign adoption, cystic brosis, spina bida, homelessness, special education and parent–child interaction
therapy.
Keywords: counseling, children, special needs, complex trauma
To set the stage for this special issue, to provide a foundation for understanding and to link the various
articles, I encourage readers to conceptualize the impact of a special need through a complex trauma or
developmental lens. Over the past 15 years, countless articles have reported and described the impact of
chronic stress and adverse childhood experiences (Anda et al., 2006; Edwards et al., 2005) and the subsequent
development of complex trauma.
Complex and Developmental Trauma
The National Child Traumatic Stress Network (n.d.-a) has dened complex trauma as a series of traumatic
experiences that are usually interpersonal in nature and lead to numerous long-term adverse effects on health
and well-being. Similarly, van der Kolk, Roth, Pelcovitz, Sunday and Spinazzola (2005) described experiencing
repeated traumatic events during childhood as developmental trauma. The duration and intensity of the
traumatic experiences, as well as the age of onset of these experiences, can determine the outcome of both
complex trauma and developmental trauma. Neuroscience research provides ample evidence of neurochemical
and brain structural changes caused by complex trauma that result in affective and behavioral dysregulation
(Lanius, Bluhm, & Frewen, 2011).
Though the terms developmental trauma and complex trauma were originally used to represent repeated
abuse or an accumulation of traumatic experiences, recent neuroscience research has extended these terms
to other conditions and experiences. Copeland, Keeler, Angold, and Costello (2007) noted that a long-term
physical illness may lead to complex trauma, while D’Andrea, Ford, Stolbach, Spinazzola, and van der Kolk
(2012) and Finkelhor, Ormrod, and Turner (2007) reported that bullying also may lead to similar outcomes.
196
Courtois (n.d.), as well as Ford and Courtois (2009), Vogt, King, and King (2007), and the National Child
Traumatic Stress Network (n.d.-b), offered a more descriptive explanation and extensive list when they stated
the following:
Cumulative adversities faced by many persons, communities, ethno-cultural, religious, political, and
sexual minority groups, and societies around the globe can also constitute forms of complex trauma.
Some occur over the life course beginning in childhood and have some of the same developmental
impacts described above. Others, occurring later in life, are often traumatic or potentially traumatic and
can worsen the impact of early life complex trauma and cause the development of complex traumatic
stress reactions. These adversities can include but are not limited to:
• Poverty and ongoing economic challenge and lack of essentials or other resources
• Community violence and the inability to escape/relocate
• Homelessness
• Disenfranchised ethno-racial, religious, and/or sexual minority status and repercussions
• Incarceration and residential placement and ongoing threat and assault
• Ongoing sexual and physical re-victimization and re-traumatization in the family or other contexts,
including prostitution and sexual slavery
• Human rights violations including political repression, genocide/“ethnic cleansing,” and torture
• Displacement, refugee status, and relocation
• War and combat involvement or exposure
• Developmental, intellectual, physical health, mental health/psychiatric, and age-related limitations,
impairments, and challenges
• Exposure to death, dying, and the grotesque in emergency response work (para. 7)
Cook et al. (2005) stated that as a result of complex trauma, individuals experience impairments in (a)
attachment, (b) affect regulation, (c) behavioral control, (d) cognition, (e) self-concept, and (f) sensory and
motor development. Treatment recommendations include (a) being developmentally sensitive, (b) building on
the safety and security of caregivers and community (e.g., teachers), and (c) addressing affective and behavioral
dysregulation.
Special Issue: Children with Special Needs and Circumstances
The articles in this special issue provide implications for counselors and ways that specic special needs and
circumstances may be addressed with individuals, families, schools and communities.
In order to support the educational and emotional development of children and youth experiencing
homelessness, Havlik and Bryan indicate that school counselors must rst identify which students are
experiencing homelessness in their school and then determine their specic needs. Some of these needs, to name
a few, include violence, abuse, neglect, mental and physical health issues, and mobility issues. The authors
note that once homeless children and their individual needs are identied, school counselors should engage the
students within their schools and assist with collaborative efforts between school and community resources.
Havlik and Bryan challenge schools counselors to seek out and participate in professional development
regarding the policies related to individual needs of homeless students.
Geddes Hall states that less than half of school counselor preparation programs include content related
to special education in their training. Geddes Hall encourages school counselors to have a comprehensive
knowledge of the specic needs of those receiving special education services, and she offers precise
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197
recommendations for how counselor educators can infuse special education content throughout a school
counseling curriculum. She reects that it is in the best interest of future school counselors, as well as the special
students they will serve, to receive support and supervision during such experiences as they complete their
programs.
Buss, Warren, and Horton provide in-depth coverage of the short- and long-term impact of trauma on the
physical, mental, emotional and social development of traumatized children that includes associated trajectories
to adult mental and physical health conditions. The authors indicate that early intervention and treatment can
minimize the social and emotional impact of a child’s exposure to a traumatic event. The authors also discuss the
advantages of numerous evidence-based treatment strategies as well as the realistic limitations of these strategies.
Across treatment methods, factors such as safety and attachment are paramount.
Liu and Hazler delineate differences noted among adoptees from various countries. These differences include
behavioral, social and emotional characteristics, as well as the adoptees’ proclivity to form an attachment with
a primary caregiver. The authors demonstrate that pre-adoption characteristics are associated with smooth
transitions during the adoption process as well as post-adoption integration. Liu and Hazler discuss ways that
counselors may emphasize adoptee–parent relationships in which trust is a fundamental element. They provide
specic recommendations for counselors and adoptive parents that ease the transition and support successful
attachment.
Sheperis and colleagues acknowledge that counselors, whether working with children who have disruptive
behavior or providing parenting training to families, should be knowledgeable of the application of various
behavioral techniques in order to utilize them effectively and to teach them to parents. In their article, the authors
review a wealth of research information related to one evidence-based method and demonstrate how this method
may be useful when working with children with special needs. Sheperis and colleagues describe a session-
by-session application of this model as well as report contemporary research about the model’s application to
working with children with special needs.
Leppma, Szente, and Brosch provide an overview of the current landscape of children’s fears to help delineate
a contemporary, adaptive and holistic approach to treatment. The authors convey an image of fear and anxiety
development that can be physically and mentally paralyzing for individuals who experience these states. In their
treatment section, the authors outline an approach that addresses affect regulation and development of positive
emotions, as well as inoculating the client against stress and supporting the development of resilience. They
report on several studies that demonstrate the value of play in the development of self-efcacy, optimism and
positive affect.
Despite the fact that few within the world of counseling have written about the subject, Goodman-Scott and
Lambert pull together many resources to conceptualize the special needs of children with sensory processing
disorder (SPD). The authors provide a detailed description of the disorder and its subtypes and describe in detail
appropriate assessment of the disorder. Goodman-Scott and Lambert recommend that counselors collaborate with
occupational therapists in order to address the unique needs of children with SPD. They report that counselors
can provide individual, group and family counseling modalities using solution-focused and cognitive-behavioral
techniques to address children’s mental health needs and co-occurring disorders.
Storlie and Baltrinic’s article illuminates the impact of a chronic disease on the individual, the caregivers and
the counselors working with the family. They indicate that counselors working with children and families affected
by cystic brosis (CF) should consider the physical and psychosocial challenges facing this special-needs
population. The authors encourage counselors to be knowledgeable about CF so that they will be sensitive to the
198
traumatic impact of this life-shortening disease on the child or adolescent with CF and caregivers. Storlie and
Baltrinic offer suggestions for compassionate counseling as well as for avoiding compassion fatigue.
In a personal account of rearing a child with spina bida, Richmond-Frank expresses both the successes
and shortcomings that she has experienced over nearly 3 decades. The author provides a thorough account of
her experience as a parent of a child with special needs, as well as what she has to teach others who may be
working with a child with special needs. As a professional counselor, as well as a parent of a special-needs
child, Richmond-Frank provides readers with specic and realistic suggestions. She shares that a systemic,
strengths-based counseling model respects the inherent worth of the child with a disability by not presuming
that he or she is the identied patient.
Conclusion
From the special issue editor’s point of view, issues that are prolonged, intense and cumulative, and
vary over developmental periods should be conceptualized through lenses that address the complexity of
intermingled systems. By failing to see this complexity and all of its aspects, we fail to fully address the
complexity of children with special needs and circumstances.
Conict of Interest and Funding Disclosure
The author reported no conict of
interest or funding contributions for
the development of this manuscript.
References
Anda, R. F., Felitti, V. J., Walker, J., Whiteld, C. L., Bremner, J. D., Perry, B. D., . . . Giles, W. H. (2006). The enduring
effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and
epidemiology. European Archives of Psychiatry and Clinical Neurosciences, 256, 174–186. doi:10.1007/s00406-
005-06244
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., . . . van der Kolk, B. (2005). Complex trauma
in children and adolescents. Psychiatric Annals, 35, 390–398.
Copeland, W., Keeler, G., Angold, A., & Costello, J. (2007). Traumatic events and posttraumatic stress in childhood.
Archives of General Psychiatry, 64, 577–584.
Courtois, C. A. (n.d.). Understanding complex trauma, complex reactions, and treatment approaches. Retrieved from
http://www.giftfromwithin.org/html/cptsd-understanding-treatment.html
D’Andrea, W. D., Ford, J., Stolbach, B., Spinazzola, J., & van der Kolk, B. A. (2012). Understanding interpersonal trauma
in children: Why we need a developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry,
82, 187–200. doi:10.1111/j.1939-0025.2012.01154.x
Edwards, V. J., Anda, R. F., Dube, S. R., Dong, M., Chapman, D. F., & Felitti, V. J. (2005). The wide-ranging health
consequences of adverse childhood experiences. In K. A. Kendall-Tackett & S. M. Giacomoni (Eds.), Child
victimization: Maltreatment, bullying, and dating violence prevention and intervention (pp. 8-1–8-12). Kingston,
NJ: Civic Research Institute.
Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglect component in child victimization.
Child Abuse and Neglect, 31, 7–26. doi:10.1016/j.chiabu.2006.06.008
Ford, J. D., & Courtois, C. A. (2009). Dening and understanding complex trauma and complex traumatic stress
disorders. In C. A. Courtois & J. D. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based
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guide (pp.13–30). New York, NY: Guilford Press.
Lanius, R. A., Bluhm, R. L., & Frewen, P. A. (2011). How understanding the neurobiology of complex post-traumatic
stress disorder can inform clinical practice. A social cognitive and affective neuroscience approach. Acta
Psychiatrica Scandinavica, 124, 331–348. doi:10.1111/j.1600-0447.2011.01755.x
The National Child Traumatic Stress Network. (n.d.-a). Complex trauma. Retrieved from http://www.nctsn.org/trauma-
types/complex-trauma
The National Child Traumatic Stress Network. (n.d.-b). Types of traumatic stress. Retrieved from http://www.nctsn.org/
trauma-types#q2
van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The
empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18, 389–399.
Vogt, D. S., King, D. W., & King, L. A. (2007). Risk pathways for PTSD: Making sense of the literature. In M. J.
Friedman, T. M. Keane, & P. A. Resick (Eds.), Handbook of PTSD: Science and practice (pp. 99–115). New York,
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Stacey Havlik is an Assistant Professor at Villanova University. Julia Bryan is an Assistant Professor at Pennsylvania State
University. Correspondence can be addressed to Stacey Havlik, 800 East Lancaster Avenue SAC 356, Villanova, PA 19085,
stacey[email protected].
Stacey Havlik
Julia Bryan
Addressing the Needs of Students Experiencing
Homelessness: School Counselor Preparation
This study of 207 school counselors revealed signicant relationships between types of counselors’ training, number
of students in counselors’ schools experiencing homelessness, and counselors’ perceived knowledge and provision
of services regarding students experiencing homelessness. In-service training and professional development, but
not graduate training, were related to counselors’ knowledge of the McKinney-Vento Homeless Assistance Act
and their advocacy for and provision of services to students experiencing homelessness. Differences also existed by
school level and school setting. Implications of these ndings are discussed.
Keywords: school counselors, homelessness, McKinney-Vento Homeless Assistance Act, advocacy, professional
development
Homeless, although a difcult term to clearly dene, refers to those who “lack a xed, regular, and adequate
nighttime residence” (U.S. Department of Education, 2004, p. 2). Families with children are the fastest
growing homeless population in the United States, comprising one third of the homeless population (National
Coalition for the Homeless, 2009). Twenty-two percent of all sheltered persons experiencing homelessness are
under the age of 18, with over half of this group under the age of 6 (U.S. Department of Housing and Urban
Development, 2010). Some live doubled-up with other families, in transitional housing such as shelters or
in inhumane conditions (U.S. Department of Education, 2004). In 2012, the National Center for Homeless
Education (NCHE) reported that 1,065,794 children in schools experienced homelessness, an increase of
over 50% since 2007. The rapidly increasing gures, due in part to the economic recession in the United
States, are cause for grave concern because homelessness is detrimental to the emotional, social and cognitive
development and well-being of children (Coker et al., 2009; Grothaus, Lorelle, Anderson, & Knight, 2011).
Families who experience homelessness are more likely to experience separation from each other, violence
and serious health conditions (National Center on Family Homelessness, 2011). Children experiencing
homelessness may face high rates of abuse, neglect and mental health issues, as well as barriers that make it
nearly impossible for them to succeed academically and emotionally without additional systemic supports
(Buckner, Bassuk, Weinreb, & Brooks, 1999; Gewirtz, Hart-Shegos, & Medhanie, 2008; Swick, 2008;
U.S. Department of Education, 2004). Due to the challenges of homelessness, students can be worse off
academically and socially than their middle-class peers (Obradović et al., 2009; Shinn et al., 2008). Unlike
most of their peers, they may lack supports such as before- and after-school services, mentors, transportation
to and from school, and attendance support (Hicks-Coolick, Burnside-Eaton, & Peters, 2003; Miller, 2009;
U.S. Department of Education, 2004). Higher levels of mobility and absenteeism make it difcult for homeless
students to acquire a consistent education (Hicks-Coolick et al., 2003; Miller, 2009; Rafferty, Shinn, &
Weitzman, 2004; U.S. Department of Education, 2004). Students experiencing homelessness, and those who
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are highly mobile, have lower reading and math scores from second through seventh grade than students living
in poverty (Obradović et al., 2009). Further, relative to their peers, students experiencing homelessness are less
likely to aspire to postsecondary education (Rafferty et al., 2004).
In response to the growing crisis among children experiencing homelessness, policymakers designed
the McKinney-Vento Homeless Assistance Act (U.S. Department of Education, 2004) to provide access to
education and remove barriers in order to ensure that schools address the unique needs of students experiencing
homelessness. The provisions of the act require that school districts provide transportation to and from the
school of origin for students experiencing homelessness, even when the students relocate to an area outside
of their home school. Further, the act allows students to enroll in school immediately without the required
paperwork (e.g., immunization records, educational records, lease or deed), assigns a homeless liaison to
schools to ensure that provisions under McKinney-Vento are being met, and assigns a State Coordinator to
coordinate services for students experiencing homelessness.
School counselors, teachers and administrators can help support students experiencing homelessness at the
school level and ensure that the provisions of the McKinney-Vento Act are met. In their roles, they provide
supportive services that address the academic, personal, social and career planning needs of all students
(American School Counselor Association [ASCA], 2012). Interventions and services provided by school
counselors include individual and group counseling, classroom guidance, academic advisement and planning,
consultation with teachers and staff, collaboration with outside services, and parental support (ASCA, 2012).
According to ASCA (2010), an important role of school counselors is to promote awareness and understanding
of the McKinney-Vento Act and the rights of students experiencing homelessness. School counselors collaborate
with other service providers in children’s education to address the academic, career planning and personal/
social needs of students experiencing homelessness (ASCA, 2010; Baggerly & Borkowski, 2004; Daniels,
1992, 1995; Grothaus et al., 2011). They should be knowledgeable about the issues faced by children and
youth experiencing homelessness and be equipped to provide appropriate services to these students (Grothaus
et al., 2011; Walsh & Buckley, 1994). In particular, school counselors must be aware of the McKinney-Vento
program requirements (Baggerly & Borkowski, 2004) and understand how to advocate for their effective
implementation. However, without knowledge of the policies that impact students experiencing homelessness
and the interventions necessary to help them, school counselors may nd it difcult to serve this population.
In order to develop comprehensive school counseling programs that systemically address the needs of children
and youth experiencing homelessness, school counselors need awareness of the policies that pertain to these
students, and the emotional and educational issues they face.
To date, limited research exists concerning school counselors’ knowledge of the McKinney-Vento Act,
knowledge about the educational and emotional issues that homeless students face, and service provision for
these students (Gaenzle, 2012). Also, limited research exists on whether school counselors receive training
regarding homelessness and the source of that training, whether graduate training, in-service training or
professional development. Further, little is known about the size of school counselors’ caseloads of students
experiencing homelessness and whether these caseloads differ in some locations (e.g., urban schools, high
schools). Given that 77% of the homeless population is found in urban areas (Henry & Sermons, 2010), perhaps
school counselors in urban schools face larger caseloads and greater demands for services from students
experiencing homelessness. Exploring school counselors’ knowledge, service provision and experiences
regarding students experiencing homelessness would help to better focus service delivery at the school level to
this student population. To this end, this exploratory study attempts to investigate school counselors’ knowledge
and service provision regarding students experiencing homelessness and to examine related variables (e.g.,
school level, school setting, years of experience, training received). The results of this study may help to guide
202
future research and improve counselor preparation and interventions regarding homelessness. The following
questions guided this research:
1. What is school counselors’ knowledge about
• the McKinney-Vento Homeless Assistance Act?
• the emotional and educational needs of students experiencing homelessness?
2. What services and interventions are school counselors providing for students experiencing
homelessness?
3. What are the relationships of demographic and other variables (e.g., school type, school setting, school
level, number of students in the school who are homeless, years of experience as a school counselor,
type of training received and knowledge of location of homeless shelters) to school counselors’
knowledge and provision of services related to students experiencing homelessness?
Methods
Participants
Participants included 207 respondents from a random sample of 1,000 school counselors who were listed
in the ASCA member directory. Of the participants, 72 (36.4%) worked in elementary schools, 35 (17.6%) in
middle schools, 86 (43.4%) in high schools and 5 (2.5%) in both middle and high schools. Fifty-nine (29.6%)
of the participants worked in urban settings, 55 (27.6%) in rural settings and 85 (42.7%) in suburban school
settings. Most respondents (185 or 93%) worked in public schools while 7 (3.5%) worked in private schools and
7 (3.5%) worked in parochial schools.
Instrumentation
The survey (see Appendix) was developed by the rst author to assess school counselors’ perceived
knowledge of the McKinney-Vento Act and the needs of students experiencing homelessness as well
as counselors’ provision of services to these students (Baggerly & Borkowski, 2004; Strawser, Markos,
Yamaguchi, & Higgins, 2000; Walsh & Buckley, 1994). The survey was piloted on 12 second-year master’s-
level school counseling students at a large East Coast university who were completing their internships at
the time. After students completed a paper version of the survey, they provided feedback on the clarity and
comprehensibility of the survey items. Minor adjustments were made to improve clarity on several items.
Demographic items. Three items assessed school setting (urban, rural, suburban), school level (elementary,
middle, high) and years of experience as a school counselor. Years of experience was reported as a continuous
variable with a mean of 9.35 years (SD = 7.25) and a range from 1–31.
Training. Two items assessed training. The rst item assessed the extent of training in work with students
experiencing homelessness and was rated on a scale from 1 (no training) to 3 (extensive training). The second
item assessed type of training (i.e., in graduate school, in-service training at their school, required professional
development outside of school, voluntary professional development outside of school, two or more sources of
training, and no training).
Number of students experiencing homelessness. One item measured the number of students experiencing
homelessness that counselors reported as enrolled at their schools. Participants were asked to select a category
that best t the amount. The categories were 0, 1–5, 6–10, 11–15, 16–25, 26–35, 36–45, 46–55 or over 55
students.
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Perceived knowledge of McKinney-Vento and emotional and educational issues. Seven Likert scale
items were written specically to assess school counselors’ perceived knowledge of the McKinney-Vento Act
and the emotional and educational issues of students experiencing homelessness. Participants were instructed
to rate their knowledge on a scale from 1 (no knowledge) to 5 (extensive knowledge). Items were designed to
measure school counselors’ perceptions of their knowledge on specic requirements under the McKinney-Vento
Act, as well as their knowledge on general emotional and educational issues affecting students experiencing
homelessness.
Provision of services. Two items focused on the services and interventions that participants reported
implementing with students experiencing homelessness. One item prompted participants to report the frequency
of their engagement in these interventions on a scale from 1 (not at all) to 5 (always), where interventions
signied nine specic services to students experiencing homelessness. The second item required school
counselors to indicate any of 25 interventions provided to students experiencing homelessness, including the
option I have not provided any services or interventions. The services and interventions were selected based on
the McKinney-Vento requirements and the literature on education and homelessness.
Procedures
Using Survey Monkey (www.surveymonkey.com), the survey was e-mailed to 1,000 randomly selected
ASCA members selected via the ASCA member directory (www.schoolcounselor.org). Of the 1,000 surveys
sent, 80 e-mails bounced back or were invalid, while 713 recipients did not reply and 207 responded. The total
response rate was 22.5%, with 19.8% (N = 182) completing all sections of the survey. Completing the survey in
its entirety included lling out one qualitative section (for results see Havlik, Brady, & Gavin, 2014). Several
participants did not complete this section.
Data Analysis
Descriptive analyses. To answer research questions one and two, we examined frequencies and means of
school counselors’ responses to survey items.
Analyses of variance (ANOVAs). To answer question 3, we conducted four one-way ANOVAS: (1) one
to examine whether elementary, middle and high school counselors differed in the extent of training they
received for working with students experiencing homelessness; (2) a second to examine whether urban, rural
and suburban school counselors differed in the extent of training they received for working with students
experiencing homelessness; (3) a third to examine whether elementary, middle and high school counselors
differed in the number of students experiencing homelessness at their school; and (4) a fourth to examine
whether urban, rural and suburban school counselors differed in the number of students experiencing
homelessness at their school.
Regression analyses. To answer the fourth research question, we conducted simultaneous multiple
regression analyses to examine the relationships among the demographic variables (e.g., school setting, school
level, number of students experiencing homelessness at school, years of experience as a school counselor,
type of training received) and school counselors’ knowledge and provision of services related to students
experiencing homelessness.
Factor analysis. Prior to conducting the multiple regression analyses, we conducted a principal component
analysis (PCA) of the seven items assessing counselors’ perceived knowledge of McKinney-Vento and students’
emotional and educational needs, and the nine items assessing the extent to which counselors provided nine
specic services for students experiencing homelessness (see Tables 1 and 2). The PCA with varimax rotation
was conducted as a data reduction method (Costello & Osborne, 2005) to determine how participants’ responses
204
were structured. The components or factors derived from the PCA comprised the dependent variables in the
study. Decisions to retain the factors were based on (a) the scree test, (b) eigenvalues greater than one (Kaiser
criterion) and (c) the conceptual meaning of each item.
Post hoc analyses. One-way ANOVAs and Crosstabs analyses were used to take a closer look at any
interesting ndings from the multiple regression analyses.
Results
Descriptive Analyses
In Table 1, we present the means and standard deviations for the 16 items used to assess school counselors’
knowledge and provision of services regarding students experiencing homelessness.
Question 1a: Perceived knowledge of McKinney-Vento. The average response to the ve items that
assessed school counselors’ knowledge of McKinney-Vento was 2.90 (SD = 1.38), slightly below the midpoint
of 3 on the 5-point scale (1 = no knowledge to 5 = extensive knowledge). More specically, school counselors
reported about average knowledge of the McKinney-Vento Act (M = 2.86, SD = 1.47). They also reported lower
levels of knowledge of the role of the State Coordinator (M = 2.04, SD = 1.19), but slightly above average
knowledge of the role of the homeless liaison (M = 3.19, SD = 1.45). Counselors reported above average
knowledge of registration policies for students experiencing homelessness (M = 3.45, SD = 1.25), and about
average levels of knowledge of transportation requirements (M = 2.97, SD = 1.53).
Table 1
Means, Standard Deviations and Factor Loadings of Knowledge and Provision of Services
Factor loadings
Component
Item
M SD
1 2 3
Knowledge of McKinney-Vento
a
2.86 1.47
.83
.16 .25
I review the McKinney-Vento Act policies to ensure homeless students’ needs are
being met
b
2.77 1.54
.80
.35 .12
Knowledge of transportation requirements under McKinney-Vento
a
2.97 1.53
.76
.16 .30
Knowledge of role of the State Coordinator
a
2.04 1.19
.67
.26 .23
I have contact with my school’s homeless liaison
b
3.48 1.66
.59
.21 .40
Knowledge of the role of the homeless liaison
a
3.19 1.45
.58
.15 .59
Knowledge of registration policies for homeless students
a
3.45 1.25
.51
.24 .52
I assess the emotional needs of homeless students
b
3.86 1.21 .08
.81
.33
I make contact with homeless families
b
3.42 1.32 .20
.71
.33
I ensure that homeless students with whom I work have equal opportunities
compared to their non-homeless peers
b
4.31 1.00 .07
.68
.40
I assist with the registration of homeless students
b
3.45 1.25 .26
.64
-.01
I ensure that homeless students have transportation to attend before- or after-school
programs
b
3.01 1.57 .35
.62
.12
I provide mentorship programs for homeless students at my school
b
2.43 1.34 .15
.57
.08
I visit shelters where homeless students at my school live
b
1.44 .88 .41
.46
-.11
Knowledge of emotional/social issues
a
3.85 .97 .23 .16
.87
Knowledge of educational issues
a
3.87 .96 .29 .25
.83
a
On these items the scale ranged from 1 = no knowledge at all to 5 = extensive knowledge.
b
On these items the scale ranged from 1 = not at all to 5 = always.
The Professional Counselor/Volume 5, Issue 2
205
Question 1b: Perceived knowledge of emotional and educational issues. The average response to the two
items written to assess school counselors’ knowledge of emotional and educational issues faced by homeless
students was 3.86 (SD = 0.97), above the midpoint of 3 on the 5-point scale used (1 = no knowledge to 5 =
extensive knowledge). School counselors reported above average knowledge of emotional issues (M = 3.85,
SD =. 97) and knowledge of educational issues (M = 3.87, SD = .955), suggesting that counselors may perceive
themselves as fairly knowledgeable about the emotional and educational issues faced by students experiencing
homelessness.
Question 2: Provision of services and advocacy. The average response to the nine items written to assess
school counselors’ provision of services was 3.10 (SD = 1.35), slightly above the midpoint of 3 on the 5-point
scale used (1 = not at all to 5 = always). School counselors provided responses close to average regarding their
frequency of assisting with registration (M = 3.20, SD = 1.58). Their responses were above average for their
frequency of assessing the emotional needs of students experiencing homelessness (M = 3.86, SD = 1.21).
However, most school counselors reported infrequently conducting shelter visits (M = 1.44, SD = .88) or
providing mentorship programs (M = 2.43, SD = 1.34). The highest average was of school counselors’ reports
on the extent to which they ensured equal opportunities for students experiencing homelessness (M = 4.31, SD =
1.04).
Types of interventions. In response to the item that requested for participants to report on their engagement
in 25 types of interventions provided to students experiencing homelessness, nearly 70% of all participants
reported making referrals to community resources (69.5%) and providing individual counseling (68.0%). Other
frequent interventions reported included providing academic support (57.9%), teacher consultation (52.8%),
parent consultation (50.3%) and advocating for homeless students (43.7%). Interventions infrequently reported
included parent education workshops (6.6%), workshops/training for teachers (7.1%), behavioral skills training
(13.7%), mentor programs (16.2%), communicating with shelter staff (17.8%), after-school programs (20.3%),
college planning (21.8%), small group counseling (22.8%) and IEP (Individualized Education Program)
planning (23.9%). Only 3% of counselors reported conducting shelter visits, while 13.2% of school counselors
reported not providing any services at all to students experiencing homelessness.
ANOVAs
Question 3a: Training received for working with students experiencing homelessness. No signicant
differences existed among school counselors by school level or school setting in the extent of training received
for working with students experiencing homelessness.
Question 3b: Number of students experiencing homelessness at their school. No signicant differences
existed among elementary, middle and high school counselors in the number of students experiencing
homelessness at their schools. However, signicant differences existed among urban, rural and suburban school
counselors in the number of students at their schools experiencing homelessness, F(2, 196) = 7.14, p = .001,
with a very small effect size, η
2
= .07. Urban school counselors had signicantly higher numbers of students
experiencing homelessness (M = 3.09, SD = 2.34) than rural (M = 1.98, SD = 1.82) and suburban (M = 1.89,
SD = 1.72) school counselors. A rating of 3 is equivalent to 11–15 students, a rating of 2 is equivalent to 6–10
students, and a rating of 1 is equivalent to 1–5 students experiencing homelessness.
Principal Component Analysis
A PCA of the 16 items resulted in three components or factors, which were the dependent variables in
subsequent regression analyses. A four-factor model was initially considered; however, the three-factor model
was selected based on the scree test and eigenvalues greater than one. The Kaiser-Meyer-Olkin measure of
206
sampling adequacy was .88, indicating that factor analysis of these variables was appropriate. Barlett’s Test
of Sphericity was signicant, indicating that the items were excellent candidates for PCA. The factor loadings
of each factor are presented in Table 1. Factor 1, perceived knowledge of McKinney-Vento, comprised seven
items with factor loadings ranging from .83–.51 with 24.2% of the variance explained and a Cronbach’s alpha
of .91. Items loading on this factor measured school counselors’ perceived knowledge of McKinney-Vento
and the policies that schools must implement under McKinney-Vento. Factor 2, advocacy and provision of
services, comprised seven items with factor loadings from .45–.81 with 21.19% of the variance explained and
a Cronbach’s alpha of .81. Items on this factor described services and forms of advocacy that school counselors
provided for students experiencing homelessness. Factor 3, perceived emotional and educational issues,
comprised two items with loadings of .87 and .83 with 17.78% of variance explained and a Cronbach’s alpha
of .96. Factor scores were created for each factor using the regression method approach so that participants
had a score on each factor. The factor score is a linear combination of the items that load on that factor and is
a standardized score. Therefore, the three factors used in the following regression analyses were standardized
variables, each with a mean of zero and a standard deviation of one.
Multiple Regression Analyses
Following the PCA, we conducted three simultaneous multiple regression analyses with each factor serving
as a dependent variable in each regression. The B coefcients and standard errors for each regression analysis
appear in Table 2.
Table 2
Regression Analyses of Variables Related to School Counselors’ Knowledge and Service Provision Regarding
Students Experiencing Homelessness
Variables
Perceived knowledge of
McKinney-Vento
Knowledge of emotional
and educational needs
Advocacy and provision
of services
B SEB B SEB B SEB
Intercept -1.83
***
.33 -1.44
***
.30 -1.99
***
.36
Elementary .32
*
.15 .22 .15 .15 .16
Middle .19 .18 .10 .19 .21 .20
High (reference category)
Public .38 .30 .50 .29 .70
**
.32
Private/parochial (reference category)
Urban -.12 .16 -.12 .16 -.23 .17
Rural .13 .16 -.21 .16 .26 .18
Suburban (reference category)
Years of experience .01 .01 .01 .01 .00 .01
1–25 homeless students .58
*
.26 .52
**
.24 .80
**
.27
26–55 homeless students .61 .34 .72
**
.34 .87
**
.36
55+ homeless students 1.08
**
.40 1.13
**
.37 1.37
**
.40
No homeless (ref)
Graduate training .28 .25 .66
**
.26 .58
*
.28
In-service training 1.16
***
.17 .83
***
.18 .65
**
.19
Professional development .93
***
.19 .54
**
.19 .65
**
.21
Two or more sources 1.11
***
.20 .96
***
.21 .82
***
.23
No training (ref)
R
2
(adj. R
2
)
.45
***
(.41)
.28
***
(.23)
.28
***
(.23)
***p < .001. **p <. 01. *p < .05.
The Professional Counselor/Volume 5, Issue 2
207
Perceived knowledge of McKinney-Vento. The independent variables explained 47% of the variability in
school counselors’ perceived knowledge of McKinney-Vento, R
2
= .45, Adjusted R
2
= .43, F(23, 146) = 10.87, p
= .000. Participant grade levels, β = .15, t = 2.18, p = .003, numbers of students experiencing homelessness and
training predicted knowledge of McKinney-Vento. Relative to school counselors who had received no training,
responses of having received in-service training, β = .54, t = 7.32, p = .000, professional development outside
of school, β = .39, t = 5.65, p = .000, and two or more sources of training, β = .43, t = 6.03, p = .000, predicted
perceived knowledge of McKinney-Vento. However, no relationship with perceived knowledge of McKinney-
Vento existed among those who received their training in their graduate program and those who had no training.
Perceived knowledge of emotional and educational issues. The independent variables explained 30%
of the variability in school counselors’ perceived knowledge of emotional and educational issues, R
2
= .28,
Adjusted R
2
= .23, F(12, 175) = 6.24, p = .000. Number of students experiencing homelessness predicted
participants’ perceived knowledge of emotional and educational issues in schools with 1–25 students, β = .32, t
= 3.50, p = .001, in schools with 26–55 students, β = .22, t = 2.62, p = .010, and in schools with more than 55
students, β = .32, t = 4.00, p = .000. Type of training received also predicted perceived knowledge of emotional
and educational issues in participants who received their training in their graduate program, β = .14, t = 2.11, p
= .000, as well as those who received in-service training, β = .39, t = 5.13, p = .000, professional development
outside of school, β = .27, t = 3.74, p = .000, and two or more sources of training, β = .36, t = 4.92, p = .000.
Advocacy and provision of services. The independent variables explained 30% of the variability in school
counselors’ reported advocacy and provision of services, R
2
= .28, Adjusted R
2
= .23, F(12, 151) = 5.31, p =
.000. Number of students experiencing homelessness in the school and type of training received both predicted
school counselors’ reported advocacy and provision of services. As expected, when compared to participants
who reported having no students experiencing homelessness, the number of homeless students at each school
predicted advocacy and provision of services from participants who reported having 1–25 students experiencing
homelessness, β = .39, t = 3.72, p = .000, 26–55 students, β = .24, t = 2.47, p = .014, and 55 or more students,
β = .36, t = 4.02, p = .000. Type of training received also predicted advocacy and provision of services.
Compared to participants who had received no training on homelessness, training responses that included in-
service training, β = .31, t = 3.69, p = .000, professional development outside of school, β = .29, t = 3.61,
p = .000, and two or more sources of training, β = .43, t = 4.06, p = .000, predicted advocacy and provision
of services. However, no relationship was reported in advocacy and provision of services among those who
received their training in their graduate program and those who had no training on homelessness.
Post Hoc Analyses
To take a closer look at the signicant differences between elementary, middle and high school counselors
on perceived knowledge of McKinney-Vento, we conducted a one-way ANOVA, F(2, 157) = 6.44, p = .002, η
2
= .07. Elementary school counselors fell signicantly above the mean on perceived knowledge of McKinney-
Vento (M = .33, SD = .91), while high school counselors fell signicantly below the mean (M = -.27, SD =
.97). Middle school counselors (M = -.10, SD = 1.06) also fell below the mean, although the difference was not
signicant. To shed further light on this relationship, we conducted a crosstabs analysis with school level and
source of training. Although the previous ANOVA (see research question 3a) revealed no signicant differences
in extent of training by school level or setting, a post hoc examination of the frequencies regarding source of
training revealed that elementary school counselors (59.3%) were more likely than high school counselors
(29.6%) or middle school counselors (11.1%) to receive training from two or more sources (i.e., from some
combination of graduate school, professional development outside of school and in-service training). High
school counselors (52.9%) were more likely to report that they had received no training from any source than
were elementary school counselors (28.6%).
208
Discussion and Implications
This national study explored school counselors’ perceived knowledge of the McKinney-Vento Act,
perceived knowledge of the emotional and educational needs of students experiencing homelessness, and
perceived involvement in advocacy and provision of counseling services. In general, school counselors
in the current study appear to view themselves as less knowledgeable about the McKinney-Vento Act and
its requirements, but more knowledgeable about the general emotional and educational issues of students
experiencing homelessness. However, due to the general nature of the questions, reporting greater knowledge
of emotional and educational issues may be a result of self-report bias, since specic knowledge was not
solicited. A lower level of knowledge about McKinney-Vento is not surprising given that about 40% of school
counselors in the study reported never having received training related to working with students experiencing
homelessness. In addition, whether they had no or some training, school counselors reported working in various
ways with students experiencing homelessness, including enrolling them in school and assessing their needs.
However, regarding more collaborative services such as visiting shelters and involving students in mentoring
programs, school counselors reported less involvement. As recommended in the school counseling literature
on homelessness (Baggerly & Borkowski, 2004; Strawser et al., 2000; Walsh & Buckley, 1994), these school
counselors appear to provide more services such as referrals, individual counseling and teacher consultation
to students experiencing homelessness. Yet, Miller (2009, 2011) emphasized the importance of school
personnel’s collaboration with families and community stakeholders and building bridges to connect homeless
students to after-school programs and community services to improve their academic and emotional outcomes.
Previous research suggests that training specically related to building partnerships is a prerequisite of school–
community collaboration and that 40% of school counselors lack this type of training (Bryan & Grifn, 2010).
Overall, while 90% of school counselors in the current study appear to work with students experiencing
homelessness, school counselors in urban settings appear to face larger caseloads of homeless students than
counselors in rural and suburban schools. Yet, no differences exist between the surveyed urban, rural and
suburban school counselors’ levels of knowledge about McKinney-Vento and about emotional and educational
issues or advocacy and provision of services. Given the increasingly large number of families experiencing
homelessness in urban areas (Henry & Sermons, 2010), though a variable not investigated in this study, one
might expect that with larger caseloads, urban school counselors would report higher levels of advocacy and
provision of services. Provision of services and levels of advocacy are related to training. Without adequate
training, counselors in urban schools may nd themselves ill-equipped to perform the boundary-spanning
role that is integral to providing these students with adequate support—that is, linking them to information,
resources and programs (Miller, 2009, 2011). Note that the numbers related to participants’ school location
should be interpreted with caution due to the lack of specic percentages of students experiencing homelessness
on their caseloads available for this study.
In general, elementary, middle and secondary school counselors appear to face similar situations regarding
the numbers of students experiencing homelessness and their perceived training for working with this
population. However, elementary school counselors reported above average knowledge of the McKinney-Vento
provisions, signicantly higher than high school counselors, although these groups do not differ in the perceived
extent of training received. The ndings suggest that their knowledge of McKinney-Vento may be attributed
to the source or type of training they are receiving. Also, this difference may reect the fact that most school
counseling publications on students experiencing homelessness, although few, have focused on elementary
school counselors (e.g., Baggerly & Borkowski, 2004; Daniels, 1992, 1995; Strawser et al., 2000).
The Professional Counselor/Volume 5, Issue 2
209
According to the results of this study, training on homelessness is positively related to school counselors’
knowledge of McKinney-Vento, knowledge of emotional and educational issues, and advocacy and provision
of services. Overall, school counselors with no training regarding students experiencing homelessness
reported less knowledge of McKinney-Vento and of their emotional and educational issues, and less advocacy
and provision of services compared to counselors who with some training (with the exception of those who
received their training in graduate programs). For the participants in this study, graduate program training
regarding homelessness is only indicative of higher knowledge of emotional and educational issues of students
experiencing homelessness when compared to counselors with no training. These ndings suggest the need for
an intentional focus in counseling graduate programs on the McKinney-Vento Act and its provisions as well as
on specic practices for advocating and implementing service delivery to students experiencing homelessness.
Graduate students in school counseling programs and related degree programs in education would benet from
specic training that helps them develop skills as effective boundary spanners and information brokers who
function within and across the contexts of families and children experiencing homelessness (Miller, 2009,
2011).
Taken together, the relationships between the number of students experiencing homelessness, school
counselor training, and advocacy and provision of services are particularly interesting. These ndings suggest
that school counselors’ exposure to issues related to homelessness, through both training and direct contact
with students experiencing homelessness, may compel them to learn about homelessness and to advocate
for and provide recommended services to these students. Indeed, as their caseloads of students experiencing
homelessness increase, school counselors may feel compelled to nd resources and supports for these students.
More importantly, for counselors who have caseloads with only a few students experiencing homelessness,
these ndings highlight the value of training and its implications for services. Perhaps these ndings hint at
the need to couple school counselor training on homelessness with direct exposure to students experiencing
homelessness—that is, with immersion experiences. Intentional and coherent integration of service learning
experiences with families and children experiencing homelessness into counselor education programs
can provide school counseling trainees with appropriate and invaluable real-world learning experiences
for developing the requisite skills for working with students experiencing homelessness (Baggerly, 2006;
Constantine, Hage, Kindaichi, & Bryant, 2007).
Implications for School Counselor Practice
The ndings of this study have several implications for the practice of school counselors. We recommend
that school counselors (a) seek professional development to enhance their knowledge of the policies and
needs related to students experiencing homelessness, (b) build relationships with the students experiencing
homelessness in their schools, and (c) build partnerships with families experiencing homelessness, homeless
liaisons, homeless shelters, and community organizations in order to better advocate for and provide services to
students experiencing homelessness.
Professional development on homelessness. School counselors are required to promote awareness and
understanding of McKinney-Vento and the rights of students experiencing homelessness and provide services
aligned to meet their needs (ASCA, 2010). Based on the results of this study, school counselors who do not
receive training regarding students experiencing homelessness may lack knowledge of McKinney-Vento.
Without knowledge of policies that impact students experiencing homelessness and the interventions necessary
to work with them, counselors may provide students with ineffective support.
School counselors must take the initiative to seek training on the McKinney-Vento Act and the specic needs
and challenges faced by students experiencing homelessness. They may seek this knowledge by attending state,
regional or national conferences on homelessness, and should advocate for the topic to be included at state,
210
regional and national conferences of counseling associations. In the absence of these opportunities, school
counselors may arrange to meet with the local homeless liaison to discuss the provisions of the McKinney-
Vento Act and the needs of students experiencing homelessness and to explore available services in the school
district.
Build relationships with students experiencing homelessness. In order to support the educational
and emotional development of children and youth experiencing homelessness, school counselors must rst
identify which students are experiencing homelessness in their school and then determine their specic needs
(Daniels, 1992). Identifying students experiencing homelessness requires that all stakeholders, including
teachers, know the variety of denitions that qualify students as experiencing homelessness (U.S. Department
of Education, 2004; Zerger, Strehlow, & Gundlapalli, 2008). Educating all teachers and staff on the denitions
of homelessness will allow them to quickly and condentially report if they suspect a student is experiencing
homelessness and recognize issues that may arise due to their housing status. When students and families are
identied as experiencing homelessness, school counselors may then plan interventions accordingly to support
their educational and developmental needs.
Build partnerships with stakeholders. One critical way in which school counselors can support the needs
of students experiencing homelessness is by building collaborative relationships with partners in the community
(ASCA, 2010; Grothaus et al., 2011). Determining student needs may require visiting shelters to nd ways to
connect with families and children. Given that shelters offer families a variety of resources that may or may
not adequately meet their needs (Shillington, Bousman, & Clapp, 2011), it is important for school counselors
to know what services local shelters provide in order to understand what additional supports are needed. For
instance, determining what educational support is available at the shelter (e.g., whether there is allotted space
for students to study) may help counselors determine what academic enrichment and support programs (e.g.,
tutoring, computer access, homework help) are needed at the school level.
As previously mentioned, McKinney-Vento requires that every local educational agency has a designated
local homeless liaison. This person ensures that students experiencing homelessness are identied and have
equal opportunities to be successful. Therefore, when coordinating services and planning interventions for
students, counselors should collaborate with the assigned homeless liaison at their school (Grothaus et al.,
2011; Strawser et al., 2000). Counselors and homeless liaisons can collaborate to plan appropriate interventions
for meeting the identied needs of students experiencing homelessness. They also may partner to educate
staff members about the emotional and educational challenges that homeless students face. In some cases,
school counselors may be assigned as the local homeless liaison, which requires them to better understand the
requirements of McKinney-Vento and initiate partnerships between all stakeholders.
School counselors also might partner with teachers and community stakeholders to provide supportive
services for students experiencing homelessness. They may collaborate to coordinate tutoring or mentoring
programs and to develop safe classroom and school environments for students (Bryan, 2005). They also can
plan culturally sensitive classroom guidance units that relate to the personal and social issues faced by students
experiencing homelessness. For example, a classroom lesson on the topic of developing social skills might be
particularly benecial for all students, including those experiencing homelessness (Baggerly & Borkowski,
2004).
Limitations and Future Research
The limitations of this study include self-report bias, sample bias, low response rate, and the validity and
reliability of the survey itself. The survey measures participants’ perceptions of their knowledge rather than
their actual knowledge, which may have led to self-report bias in reporting levels of knowledge. Further, the
The Professional Counselor/Volume 5, Issue 2
211
low response rate might render these ndings ungeneralizable to all school counselors. The response rate may
be due to the e-mail-only method of sending out the survey, which has been shown to generate lower response
rates than mailing surveys (Dillman et al., 2009; Kaplowitz, Hadlock, & Levine, 2004; Kongsved, Basnov,
Holm-Christensen, & Hjollund, 2007; Shih & Fan, 2009). For instance, one study suggested that e-mail surveys
have a response rate approximately 20% lower than that of mail surveys (Shih & Fan, 2009). However, the
response rate also may suggest that the counselors who chose not to participate in the survey did so because
they did not have or were not aware of any students experiencing homelessness on their caseloads. Another
limitation concerns the selection of respondents exclusively among ASCA members. Thus, this sample may
not be representative of all counselors in the United States. As a caveat, the results of this study should not be
interpreted in causal terms because the ndings suggest relationships between variables, not specic causality.
Finally, since the survey is newly developed, its reliability and validity should be considered with caution.
Though there are several limitations, due to the exploratory nature of this study, the results provide insight into
school counselors’ work with students experiencing homelessness and guide future research on this important
subject.
This exploratory study is one of only two studies (e.g., Gaenzle, 2012) to examine the relationship between
counselor demographics and their knowledge, advocacy and provision of services for students experiencing
homelessness. This initial information lays the foundation for further research on the topic. It is possible that
other variables, such as actual (rather than perceived) knowledge, may predict school counselor advocacy
and provision of services. The omission of certain variables may explain the low R squares (e.g., R
2
< .30)
in some of the regression models. Future research should use a larger sample to explore school counselors’
knowledge about and advocacy for students experiencing homelessness as well as examine additional variables
that may inuence school counselors’ and other service providers’ advocacy and service provision for students
experiencing homelessness. Further, this study suggests a need for future research that examines the efcacy of
current school counseling programs with students experiencing homelessness.
Conict of Interest and Funding Disclosure
The authors reported no conict of
interest or funding contributions for
the development of this manuscript.
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Appendix
Knowledge and Skills with Homeless Students Survey
Self-Administered Questionnaire
The following survey will be on the topic of homeless students. Please take some time to answer each item. The survey
should take you 3–5 minutes to complete. You will not be asked for any identifying information. Therefore, all responses
to this survey are anonymous.
This survey is about your work with homeless students. For your information, the following is the denition for homeless
students:
The McKinney-Vento Homeless Assistance Act (U.S Department of Education, 2004) denes homeless children
and youth as those who are sharing housing of other persons due to loss of housing, economic hardship or a similar
reason (sometimes referred to as doubled-up); living in motels, hotels, trailer parks or camping grounds due to lack
of alternative adequate accommodations; living in emergency or transitional shelters; abandoned in hospitals; or
awaiting foster care placement (p. 2). This additionally includes children or youth who reside in locations that are
not suitable for humans and those who live in places such as in cars, substandard housing, or places like bus or train
stations, and migratory children who fall into any of the above descriptions (U.S. Department of Education, 2004).
Please read carefully and respond to the following items:
1. For the following items, please check the category that best applies to you:
Your current school setting (select one): ___ Urban ___ Rural ___ Suburban
Your current school type (select one): ___ Private ___ Public ___ Parochial
Your current school level (select one): ___ Elementary ___ Middle ___High
2. Please ll in the blank: How many years have you been a school counselor? _____
3. Estimate the number of homeless students in your school. Please check the range that best ts (if you are not sure,
take your best guess!):
Training
1. Have you received training to work with homeless students (no training, some training, or extensive training)? Rate
this item on a scale from 1–5, 1 being no training, 5 being extensive training:
No training 1--------------2--------------3--------------4--------------5 Extensive training
2. If you marked a 2, 3, 4 or 5, please answer the following question (if not, move onto the next section): Where did you
receive training? Check all that apply.
___ Graduate school
___ In-service training while at my school
___ Required professional development outside of school
___ Voluntary professional development outside of school
___ Other: _____________________________________
___ 0
___ 1–5
___ 6–10
___ 11–15
___ 16–25
___ 26–35
___ 36–45
___ 46–55
___ 55+
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Knowledge
1. For the following items, please rate your knowledge on a scale from 1–5, 1 meaning that you have no knowledge and 5
meaning that you have extensive knowledge
No knowledge 1--------------2--------------3--------------4--------------5 Extensive knowledge
___ The McKinney-Vento Act
___ The registration policies for homeless students entering your school
___ The role(s) of the local homeless liaison for your school
___ The role of the State Coordinator for homeless services
___ The transportation requirements for homeless students under the McKinney-Vento Act
___ The emotional and personal/social issues (e.g., feelings of isolation, difculty making friends,
embarrassment) faced by homeless students in schools
___ The educational issues that homeless students face in school (i.e., the academic issues)
2. Do you know the location of homeless shelters near the school where you work? Please check the category that best
applies to you.
___ I know none of them.
___ I know some of them.
___ I know all of them.
___ There are no shelters near my school.
3. Can you identify the students who are homeless on your caseload? Please check the category that best applies to you.
___ I can identify none of them.
___ I can identify some of them.
___ I can identify all of them.
___ There are no homeless students on my caseload.
4. Do you know where homeless students in your school reside? Please check the category that best applies to you.
___ I know where none of them reside.
___ I know where some of them reside.
___ I know where all of them reside.
___ There are no homeless students in my school.
Interventions
1. What types of programs/interventions do you provide to homeless students and parents? Check all that apply.
___ I have not provided any services or interventions.
___ Parent consultation
___ Parent education workshops
___ Teacher consultation
___ Community partnerships
___ Mentoring program
___ Academic support
___ Small group counseling
___ Individual counseling
___ Communication with shelter staff
___ Shelter visits
___ Home visits
___ After-school programs
___ Tutoring
___ Referrals to community resources
___ Provided workshops/training for teachers
___ Classroom guidance
___ Career exploration
___ Behavioral skills training
___ IEP planning
___ 504 planning
___ Advocating for homeless students
___ Postsecondary planning
___ College planning
___ Other (please specify): ____________________
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2. Is there anything else you would like to add about your interventions with homeless students? Please write below.
Knowledge and Experience
1. List the FIVE most important academic/educational, personal/social and career/college planning needs of homeless
students. If you are unable to list 5, list as many as you can.
a. ____________________________________
b. ____________________________________
c. ____________________________________
d. ____________________________________
e. ____________________________________
2. Please answer the following items on a scale from 1–5, 1 meaning not at all and 5 meaning always.
Not at all 1--------------2--------------3--------------4--------------5 Always
___ I ensure that homeless students with whom I work have equal opportunities compared to their non-homeless
peers.
___ I assist with registration of homeless students.
___ I assess the emotional needs of homeless students.
___ I visit the shelter(s) where homeless students in my school live.
___ I ensure that homeless students have transportation to attend before- or after-school programs.
___ I have contact with my school’s homeless liaison.
___ I make contact with homeless families.
___ I provide mentorship programs for homeless students at my school.
___ I review the McKinney-Vento Act policies to ensure homeless students’ needs are being met.
217
Jennifer Geddes Hall, NCC, is a doctoral candidate at the University of North Carolina-Charlotte. Correspondence may be addressed to
Jennifer Geddes Hall, College of Education Suite 241, 920 University City Boulevard, Charlotte, NC 28223, [email protected].
Jennifer Geddes Hall
The School Counselor and Special Education:
Aligning Training With Practice
The intent of this article is to discuss the importance of training school counselors in providing adequate services
to students with special needs, as mandated by special education law and supported by school counseling standards
created by the American School Counselor Association (ASCA). In addition, the lack of adequate and unied
training for school counselors in this area will be explored. This article suggests implementing a more consistent
school counselor education program across institutions that would include coursework and experiences in special
education that are in alignment with the standards of ASCA, legal obligations, and daily counselor roles. Examples
of ways to incorporate such experiences and assignments into courses across counselor training programs are
provided.
Keywords: counselor education, school counselor, special education, counselor training, American School Counselor
Association
The enactment of special education laws and mandates such as the Education for All Handicapped Children
Act of 1975 (PL 94–142) and the Individuals with Disabilities Education Act (IDEA), which require schools to
provide free appropriate public education to all students within the regular education setting, have immensely
impacted the school counseling profession (Bowen & Glenn, 1998; Dunn & Baker, 2002; Milsom, 2002;
Owens, Thomas, & Strong, 2011). The number of students identied as appropriate to receive special education
services is growing (Dunn & Baker, 2002; McEachern, 2003; Owens et al., 2011). Therefore, school counselors
are now required to provide equal services to more students with special needs within the regular education
setting. Similarly, school counselors are required to take a more active role in the Individual Education Program
(IEP) process, from identication to implementation, than what was previously expected in the past (Dunn
& Baker, 2002; Milsom, Goodnough, & Akos, 2007; Owens et al., 2011). School counselors’ involvement in
special education is not only required by specic legislation, but also poses ethical considerations regarding
to direct and indirect services for students with special needs. In response to legislation, the American School
Counselor Association (ASCA) has advocated for school counselor involvement in special education and
published guidelines for servicing students with special needs (Isaacs, Greene & Valesky, 1998; Myers, 2005;
Studer & Quigney, 2005).
Despite a study conducted by Studer and Quigney (2003) which showed that school counselors are
becoming more involved with special education by serving on teams that assist with disability identication and
implementation of services, counselor education programs are not adequately training future school counselors
to deal with changing roles and responsibilities included in servicing students with special needs (McEachern,
2003; Milsom & Akos, 2003; Romano, Paradise, & Green, 2009; Studer & Quigney, 2005). Additionally, there
is a dearth of recent research in the literature addressing concerns that special education is not being adequately
addressed in school counselor preparation programs. Although there is an increasing trend in school counselor
training programs to include some instruction about special education (Studer & Quigney, 2005), no specic
suggestions for implementing such content into the curriculum have been published to date. In response, this
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Volume 5, Issue 2, Pages 217–224
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© 2015 NBCC, Inc. and Affiliates
doi:10.15241/jgh.5.2.217
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article provides ideas and recommendations for infusing special education content throughout the school
counseling curriculum required by the Council for Accreditation of Counseling and Related Educational
Programs (CACREP). Counselor education programs must recognize the importance of the school counselor in
the lives of students with disabilities, and adequate training should become a priority.
Students with Special Needs, the School Counselor and the Law
Since the enactment of special education laws and mandates such as the Education for All Handicapped
Children Act of 1975 (PL 94-142) and IDEA, the role of the school counselor has continued to evolve (Bowen
& Glenn, 1998; Dunn & Baker, 2002; Milsom, 2002; Owens et al., 2011). The aforementioned laws require
school counselors to provide services to students with disabilities and their parents, thus increasing the need for
school counselor involvement with students who have been labeled as having special needs (Dunn & Baker,
2002; Owens et al., 2011). Findings by Studer and Quigney (2003) indicated that legal and ethical issues,
participation in multidisciplinary pre-referral teams, and IEP development and review were among the top 10
activities involving school counselors. With the passage of IDEA, schools are now required to include students
with disabilities within the school in the least restrictive environment through mainstreaming and inclusion.
A greater population of students with disabilities within the regular education setting increases the likelihood
of school counselor contact. An additional aspect of IDEA is that it requires transition planning for students
in secondary schools. Therefore, it is logical for special educators to collaborate with school counselors when
making such plans, as school counselors are trained in career and lifespan development (Milsom et al., 2007).
Students identied as needing special education services are estimated to account for 10–18% of the school
population and are expected to increase (Dunn & Baker, 2002; McEachern, 2003). Schools are required to write
IEPs for these students and implement appropriate supports and accommodations outlined in IEPs. School
counselors are increasingly taking a greater role in the process of identifying students and developing IEPs,
as well as implementing aspects of IEPs (Milsom et al., 2007; Owens et al., 2011). School counselors bring
invaluable skills and knowledge such as understanding of group dynamics, facilitation of communication,
awareness of community resources, and collaboration to IEP and pre-referral multidisciplinary teams (Milsom
et al., 2007). School personnel roles and responsibilities within the team should be shared, in that the special
educator should be viewed as the expert in content, while the school counselor should be viewed as the
expert in process and transition services. School counselors also are equipped to make connections between
student personal and social factors in relation to academic performance, which may come up in IEP meetings.
Additionally, school counselors are viewed as leaders in the school and act as advocates for students, both
directly and indirectly, and are therefore a notable asset to students and multidisciplinary teams (Owens et al.,
2011).
In addition to legal responsibilities, school counselors also have a professional and ethical obligation to
provide adequate direct and indirect services to students with special needs. Dunn and Baker (2002) stated that
as members of multidisciplinary teams, school counselors are called upon to “engage in advocacy, consultation,
diagnosis, assessment, development of delivery system, and provision of support services for students, parents
and teachers” (p. 227). Therefore, it is clear that advocating and supporting students of all abilities in personal,
social, academic and career domains are requirements for professional school counselors. Similarly, ASCA also
supports professional and ethical guidelines concerning students with special needs.
ASCA Guidelines for Servicing Students with Special Needs
ASCA has delineated specic roles and responsibilities of school counselors regarding involvement with
students identied as having special needs (Isaacs et al., 1998; Myers, 2005; Studer & Quigney, 2005). Roles
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may include many tasks, from serving on multidisciplinary teams to providing direct counseling services to
students. School counselors are required to participate in the identication of students with disabilities by
serving on screening teams and assisting in evaluation where appropriate. By serving as a member of the
multidisciplinary team, the school counselor is able to provide input on planning and placement for identied
students. For example, school counselors may assist with the preparation of IEPs by discussing student levels
of functioning in academic, personal or social domains. The school counselor also may provide services such
as consulting with outside agencies to coordinate supportive services for families and students. Additionally,
for students identied within the school, school counselors may provide direct services such as individual and
group counseling. These services must be consistent with services provided for all students, regardless of ability.
Indirect services include consulting with personnel about identied students’ educational and affective needs
as well as developing and implementing professional trainings for staff working with exceptional students.
Moreover, ASCA encourages school counselors to advocate for students with special needs in the school and
community.
Changing school counselor roles and responsibilities are evident in the literature. Studer and Quigney (2003)
examined professional school counselors’ time regarding students with special needs. Among the top ve
activities performed were the following: (a) providing individual counseling, (b) meeting with administrators or
supervisors about students with special needs, (c) utilizing problem-solving and conict resolution techniques
regarding students with special needs, (d) scheduling classes, programs and services, and (e) providing career
counseling and education. The role of advocate is infused into many of these activities, which is viewed by both
professionals in the eld and ASCA as an essential function of school counselors (Milsom, 2006; Myers, 2005;
Owens et al., 2011).
School counselors are in a position to advocate for students with special needs in a variety of ways, both
directly and indirectly. Through active involvement in the appropriateness of educational planning during the
IEP process, school counselors give these students a voice and work to facilitate an understanding of students
with special needs among school personnel. Raising awareness and understanding about disabilities among
professionals in the school as well as among parents and students is another imperative role, since students
with special needs are often stigmatized, which can create negative experiences and barriers for them (Milsom,
2006; Scarborough & Deck, 1998). Through activities such as assessment of systems, programs, policies and
attitudes, school counselors can better support students with special needs academically, personally and socially
by working to shift negative school climates and perceptions (Bowen & Glenn, 1998; Milsom, 2006; Quigney
& Studer, 1998; Scarborough & Deck, 1998). Implementation of programs for both school personnel and
students aimed at examining self-awareness of bias, increasing sensitivity towards differences, accepting others,
and positively supporting students with special needs can assist in adjusting attitudes as well as school climates
(Milsom, 2006; Quigney & Studer, 1998; Scarborough & Deck, 1998).
Additionally, school counselors can directly support and advocate for students with special needs through
providing individual and group counseling, as well as classroom-based lessons and interventions. Such
initiatives should focus on the areas of development in tolerance and respect, empathy, self-esteem, anger
management, diversity, cooperation, as well as other anti-bullying and character education themes such as
citizenship, fairness and caring (Milsom, 2006; Milsom et al., 2007; Myers, 2005). School counselors also
should begin to help students with special needs develop skills that encourage them to eventually become
self-advocates (Owens et al., 2011). Progress monitoring, as outlined in the ASCA Model’s management and
accountability sections, should entail collecting and measuring data for the interventions previously mentioned
in order to assess areas of effectiveness, need and improvement (Myers, 2005). Along with these emerging
roles and shifts in school counselor responsibilities, there is added responsibility for counselor educators and
counselor education programs to adjust accordingly.
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School Counselor Education Programs and Students with Special Needs
Although involvement of school counselors in the special education process and interactions with students
who have special needs is increasing, there are ndings suggesting that counselor education programs are not
adequately training future school counselors to deal with these changes (McEachern, 2003; Milsom & Akos,
2003; Nichter & Edmonson, 2005; Romano et al., 2009; Studer & Quigney, 2005). McEachern (2003) found
that less than 40% of school counselor preparation programs required students to take coursework that included
special education topics and subjects related to students with special needs. In other studies, results indicated
that school counseling programs are inconsistent regarding coursework pertaining to special education and that
more programs are infusing such content into already required classes instead of creating additional required
special education classes (Milsom, 2002; Milsom & Akos, 2003; Studer & Quigney, 2005). However, the types
of content, how it is infused, and to what extent have not been revealed or regulated. Despite the increase in
coursework pertaining to special education from 28% to 40% and the infusion of special education content into
coursework, training programs for school counselors continue to fail to address the needs of today’s students
(Korinek & Prillaman, 1992; Nichter & Edmonson, 2005; Studer & Quigney, 2005).
Coursework and experiences related to working with students with disabilities have been shown to
correlate with school counselors’ perceptions of their readiness to work with this population (Isaacs et al.,
1998; Milsom, 2002; Milsom & Akos, 2003; Nichter & Edmonson, 2005). Several studies have indicated that
school counseling programs are not thorough enough in providing training regarding special education issues
and students with special needs (Dunn & Baker, 2002; Milsom, 2002; Nichter & Edmonson, 2005; Studer
& Quigney, 2005). School counselors have indicated a desire for more training in supporting students with
disabilities from programs before graduation. A study conducted by Studer and Quigney (2005) revealed that
only 5.9% of ASCA members surveyed had completed one or more courses about special education in their
graduate programs and that 59% had never completed a course or taken a workshop about special education.
Participants indicated that they did not feel prepared to support students with special needs. Areas that were
viewed as receiving little attention in training included the following: (a) participation in development and
review of IEPs, (b) collaboration with special education and general education teachers, and (c) consultation
with outside agencies or professionals. These areas are all are integral in educational programming and the
success of students with special needs, and therefore should be addressed in school counselor preparation
programs. A study conducted by Nichter and Edmonson (2005) produced similar results, indicating that 89% of
counselors surveyed in Texas felt that more training in special education would help them feel more competent
and prepared to work with this population. Topics reported as potentially helpful in additional training included
the following: (a) special education law and legal issues, (b) disability characteristics, (c) techniques for
working with students in special education, and (d) information about medication and side effects. Additionally,
82% of participants indicated that counselor education programs should require special education instruction.
Counselor preparation programs appear to have similar concerns. Over 60% of counselor education programs,
when surveyed by Korinek and Prillaman (1992), indicated needing adjustment in school counselor training
requirements for their programs in order to increase student capability in working with special education
requirements. Similarly, McEachern (2003) surveyed counselor educators at various universities and colleges
across the country and 55% stated that their coursework needed improvements regarding providing special
education curricula.
Several recommendations have been made to address the lack of special education coursework for school
counselors. Studer and Quigney (2005) suggested that it may be advantageous for school counselors to enroll
in a class designed for special education teachers in which essential information is taught about this population
and the areas discussed above. Additionally, enrollment in a course with pre-service special education teachers
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would provide school counselors the opportunity to practice collaborating with teachers. Recommendations
also have been made for school counseling programs to increase coursework covering the ASCA Model and
strategies related to students with special needs (Isaacs et al., 1998; Milsom & Akos, 2003; Studer & Quigney,
2005). Similarly, it is recommended that school counselor preparation programs require experiences with
exceptional students to increase competency and positive attitudes (Milsom & Akos, 2003; Studer & Quigney,
2005).
Recommendations: Infusing Special Education into the School Counseling Curriculum
Students being trained in counseling programs to become school counselors can build their knowledge
and experience related to special education throughout their counselor education coursework. An integrative
approach may be provided in which material about special education is infused into required studies (Studer
& Quigney, 2005). However, coursework must be organized and comprehensive across all courses in the
program, including core courses and those specically designed for school counseling students. Courses that
lend themselves to infusion of special education activities and assignments include the following: learning
and development, career, group, ethics, theories, multiculturalism, techniques, assessment, practicum and
internship, as well as courses specically designed for school counselors like introduction to school counseling
or a leadership and advocacy course. Infusing activities will be discussed in depth below, and requires creativity
and exibility on the part of counselor educators in the eld. Assignments and teaching styles may need to
be adjusted to incorporate special education material into the standard counseling curriculum. It should be
noted that when training school counselors in special education concerns, a combination of requiring specic
disability coursework in conjunction with infusing such information into existing coursework is more effective
(Milsom & Akos, 2003). Designing such a course is beyond the scope of this article; therefore, suggestions for
infusing special education material into existing courses required by CACREP will be discussed.
Course Assignments Related to Special Education
Counselor educators can adjust class requirements for assignments to include aspects of special education.
For example, students could compare and contrast typical child development and its implications regarding
specic disability categories for children. School counseling students also could locate a specic student
with special needs and formulate a case study about that child in which various aspects of developmental
and learning theory would be identied. Assignments for a career course could require students to identify
considerations for children with special needs when applying career theories and engaging in career planning
(e.g., closely analyzing strengths and needs to align with viable career options when applying Holland’s
approach). Students would then design a career exploration activity with these considerations for a student
with special needs in mind. When completing an assignment such as group counseling planning, students could
design a group for children with special needs. The group would address specic issues that these children
face and for which they may need support (e.g., self-esteem), and include appropriate activities that would be
accessible for the children involved (e.g., for activities that require reading or writing, replace the language
with pictures, or create activities based on reading ability). Additionally, school counseling students could
design a group and discuss how they would make accommodations for students with special needs in a group
consisting of regular and special education students (e.g., pairing students for activities or reading content aloud
to the group). Likewise, when completing an assignment for a school counselor course, such as developing
a classroom guidance lesson, school counseling students could learn about accommodations similar to those
discussed above that would ensure that all students could fully participate to their ability level.
Laws and ethical issues surrounding special education can be addressed in a professional issues class, ethics
course or course specic to school counselors through the discussion of case studies and scenarios. The cases
used should depict various school counseling ethical and legal dilemmas involving students with special needs
222
(e.g., teacher is not following accommodations outlined in the IEP). Students would then apply ASCA special
education guidelines and special education laws to issues presented, in order to illustrate how those involved
are or are not acting in accordance with established professional mandates and what action should be taken.
Additionally, students would then describe what the person in the scenario could have done differently and
how the school counselor should intervene. In a theories class, school counseling students could critique the
effectiveness of various theories for students who are identied as having special needs, through applying
theoretical concepts, reviewing research, and considering qualities associated with different disability diagnoses
that could impact treatment. A case study could also be developed, to which school counseling students
would apply various theories to address issues faced by students with special needs (e.g., anxiety, depression).
Similarly, in a techniques class, school counseling students could identify techniques that they found to be the
most effective with special-needs students and practice applying them in class role-plays. Linking strategies to
specic theories and disabilities may help school counselors feel more prepared and condent (Myers, 2005).
Moreover, to increase competence and condence, school counseling students should be exposed to assessments
routinely used in the school setting with students identied as having special needs. During an assessment
course students could practice utilizing and interpreting tools such as the Child Behavior Checklist (CBC),
Behavior Assessment System for Children (BASC) and Connors Rating Scale through role-plays in pairs or
small groups. School counseling students enrolled in the assessment course also could be required to look at
mock IEPs and evaluation reports and discuss how accommodations and ndings outlined in the documents
would impact their services with the students.
The assignments described in this section can be used as in-class activities or outside assignments and also
may utilize technology (e.g., slide shows, discussion boards). Requiring assignments such as those discussed
above provides a foundation for infusing more experiential activities into other courses as well.
Exposure Activities to Enhance Student Learning About Special Education
Direct experiences with students who have special needs have been recommended in past research and is
thought to increase school counselor competence, understanding and positive attitudes in working with this
population (Bowen & Glenn, 1998; Isaacs et al., 1998; Milsom & Akos, 2003). Various interactive experiences
with students with disabilities could be a required part of many courses throughout the school counseling
program. Students could participate in interactive experiences both in schools and in community settings.
For example, students could be assigned to participate in an immersion experience for a multicultural class
that would require students to spend an established amount of time with children who have been identied
as having special needs (in schools or advocacy group settings). Students would then be required to reect
upon their experience, examine their own biases and stereotypes, and consider how their interactions had
impacted their multicultural development. This assignment could be done through journaling (written or
video), arts projects (e.g., collages, drawings, poems) or through a research paper tied to counselor professional
development. Additionally, students could interview parents of these children or older children with special
needs to gain insight into the barriers and discrimination that these individuals face because of their disabilities.
School counseling students could volunteer at a local community agency such as a center for individuals who
are deaf, blind, or developmentally disabled that offers services for teens with disabilities. Students would
then use the information from their visit to outline and develop a specic program they could implement in
the school to better support special-needs students and their families (e.g. partner with the special education
teacher and provide a parent support night in which parents are able to discuss issues they are facing or provide
representatives from various community agencies that support different needs for people with disabilities).
Students also could visit a college campus center for student disability services and support. During the visit
they could interview a staff member as well as a student seeking services in order to help develop a perspective
on how to better serve individuals with special needs during high school and transition planning.
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223
The experiences outlined above might help school counseling students become more sensitive to the
needs and issues faced by individuals with special needs and might reinforce the need for advocacy in school
counseling. Advocacy for students with special needs could be explored by requiring counseling students to take
part in activities run by community groups for special populations, or to design a workshop presentation for
school staff that raises awareness about disabilities, discrimination and attitudes. School counseling students also
could work with a school counselor to develop a disability awareness week for the school that included activities
such as a pep rally, guest speakers and classroom guidance lessons. Additionally, students could observe a school
counselor during the transition planning process, attend a transition meeting and develop a transition plan as
part of career course requirements. During this process they would be required to reect upon how the school
counselor acted as an advocate for the student.
Specic school counseling coursework and practicum and internship experiences also provide many
opportunities for infusing the activities described above as well as others that will be discussed. Students
involved in courses specic to school counseling could be required to observe a school counselor for a day and
interview him or her about daily requirements involving special education, experiences with special education
and suggestions for working with this population. Students should be required to attend a multidisciplinary team
meeting and discuss the IEP process with a special educator or job shadow various special educators who serve
students with different disability levels and categories. Requiring school counseling students to gain experiences
during their practicum and internship with special-needs students should be a priority in school counselor
training. These experiences provide an opportunity for school counseling students to interact with children in
special education, while supervision is provided to effectively address issues that may be faced by this population
(Milsom & Akos, 2003). Students should be required to log an established number of direct and indirect hours
in which they are involved in the special education services that have been discussed throughout this article.
Completion of a log, along with journal entries in which students reect upon their experiences, could be used as
a portfolio assessment upon graduation. Similarly, this documentation might be used for gatekeeping purposes or
to measure student development in competency with special education and as a future school counselor.
Conclusion and Recommendations
Lack of coursework and experiences in special education can result in school counselors’ limited self-efcacy,
feelings of frustration and anxiety, erosion in morale, and interference with other counseling duties (Romano et
al., 2009). Therefore, in an effort to unify the eld and produce more condent and competent school counselors,
it is imperative that school counselor education programs collaboratively reexamine, regulate, and redene
program requirements. Today, school counselors not only need a solid knowledge base, but also need to be given
opportunities to develop skills involved in collaboration, referral, advocacy, problem-solving, team-building,
leadership and working directly with students who have been identied as having special needs (Bowen &
Glenn, 1998; Dunn & Baker, 2002).
As suggested by Milsom and Akos (2003), providing a combination of practical experience with coursework
related to special education appears to be the most effective way to prepare future school counselors. It is in the
best interest of future school counselors, as well as the students they will serve, to offer support and supervision
during such experiences as they complete their programs (Korinek & Prillaman, 1992). If the professionals in
school counseling would like to grow and develop in a way that is consistent with the state of the educational
system today and beyond, then it is clear that changes in training at the counselor education level must be made.
Additionally, more research must be done to assess present trends in school counselor education programs and
preparedness of practicing school counselors regarding special education. Research in this area would be useful
in examining what improvements have been made, if any, and where adjustments need to be made in school
224
counseling coursework. This article sought to provide specic recommendations to support change by outlining
ways that counselor educators can incorporate special education training throughout their curricula. Including
special education in counselor education programs must become a priority that is consistent across training
institutions. This shift in counseling program requirements not only works to ensure adequate training for future
school counselors, but also to provide exceptional services and support that special-needs children need and
deserve.
Conict of Interest and Funding Disclosure
The authors reported no conict of
interest or funding contributions for
the development of this manuscript.
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Kristen E. Buss, NCC, is a counselor at Hope-Thru-Horses, Inc. in Lumber Bridge, NC. Jeffrey M. Warren, NCC, is an Assistant Professor at
the University of North Carolina-Pembroke. Evette Horton is a clinical instructor at the UNC OBGYN Horizons Program at the University
of North Carolina-Chapel Hill. Correspondence can be addressed to Jeffrey Warren, The University of North Carolina-Pembroke, P.O. Box
1510, School of Education, Pembroke, NC 28372, jeffrey[email protected].
Kristen E. Buss
Jeffrey M. Warren
Evette Horton
Trauma and Treatment in Early Childhood:
A Review of the Historical and Emerging
Literature for Counselors
Young children are especially susceptible to exposure to trauma. Rates of abuse and neglect among this population
are staggering. This article presents a review of relevant literature, including research ndings specic to early
childhood vulnerability to trauma, symptoms associated with traumatic events, diagnostic validity of early
childhood trauma, and treatments for young children. In the past, misconceptions about the mental health of young
children have hindered accurate diagnosis and treatment of trauma-related mental illness. Due to the prevalence
of trauma exposure in early childhood, counselors are encouraged to become familiar with ways that clients and
families are impacted and methods for treatment. Implications for future research also are presented.
Keywords: early childhood, trauma, treatment, mental health, mental illness
Children from birth to age 5 are at a particularly high risk for exposure to potentially traumatic events
due to their dependence on parents and caregivers (Lieberman & Van Horn, 2009; National Child Traumatic
Stress Network, 2010). Traumatic events are incidents that involve the threat of bodily injury, death or harm
to the physical integrity of self or others and often lead to feelings of terror or helplessness (National Library
of Medicine, 2013). The American Psychological Association (APA) Presidential Task Force on Posttraumatic
Stress Disorder (PTSD) and Trauma in Children and Adolescents (2008) indicated that traumatic events
include suicides and other deaths or losses, domestic or sexual violence, community violence, medical trauma,
vehicle accidents, war experiences, and natural and manmade disasters. With more than half of young children
experiencing a severe stressor, they are especially susceptible to accidents, physical trauma, abuse and neglect,
as well as exposure to domestic or community violence (National Child Traumatic Stress Network, 2010).
Over 20 years ago, Straus & Gelles (1990) estimated that three million couples per year engage in severe
in-home violence toward each other in the presence of young children. The Administration on Children, Youth,
and Families (2003) reported that in 2001, 85% of abuse fatalities occurred among children younger than 6
years of age, and half of all child victims of maltreatment are younger than 7. More recently, the Child Welfare
Information Gateway (2014) indicated that 88% of child abuse and neglect fatalities occurred among children
7 years of age and younger. Often, there is an overlap between domestic violence and child physical and sexual
abuse (Osofsky, 2003). In addition to domestic violence, young children also are vulnerable to community
violence.
A study conducted by Shahinfar, Fox, and Leavitt (2000) suggested that the majority of young children
enrolled in Head Start experienced violence in their communities. Young children also are exposed to traumatic
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© 2015 NBCC, Inc. and Affiliates
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stressors such as accidental burns or falls resulting in hospitalization or death (Grossman, 2000). It is common
for children to experience more than one traumatic event (APA Presidential Task Force on PTSD and Trauma in
Children and Adolescents, 2008).
Young children birth to age 5 are especially vulnerable to adverse effects of trauma due to rapid
developmental growth, dependence on caregivers and limited coping skills. However, despite decades of
statistical data, counselors generally have limited knowledge of the impact of traumatic events on younger
children in comparison to older children and adolescents (De Young, Kenardy, & Cobham, 2011). Reasons for
this disparity in knowledge include a historical resistance to the notion that early childhood mental health is
important and concerns about diagnosing young children with mental disorders.
Research in early childhood mental health has developed rapidly over the past 20 years. Practitioners and
researchers who work with this population continue to contribute to the understanding of trauma and early
childhood mental health. However, the broader counselor population seems less informed which hinders
referrals for this vulnerable population of young children. For example, a counselor may work with a victim
of domestic violence who has young children. However, due to the counselor’s limited knowledge of early
childhood trauma and the impact of domestic violence, the counselor may not consider support services for the
children. The present article examines the history and diagnostic validity of trauma-related mental illnesses in
young children, the symptoms of trauma in early childhood, the longitudinal impact of early childhood trauma,
the protective and risk factors associated with trauma in early childhood, and current and emerging treatments
for this vulnerable population.
Mental Health, Trauma and Young Children: A Historical Perspective
Historically, researchers have spent little time and energy researching the effects of trauma exposure in early
childhood. A widely held misconception has been that infants and young children lack the perception, cognition
and social maturity to remember or understand traumatic events (Zeanah & Zeanah, 2009). Additionally, mental
health counselors have been hesitant to diagnose trauma-related mental illness as a result of the associated
stigmas that plague young children. In some cases when a child is diagnosed with mental illness, society focuses
on the diagnosis and not the child.
Today it is widely accepted that children have the capacity to perceive and remember traumatic events. From
birth, the tactile and auditory senses of a child are similar to those of an adult, which suggests that a child can
experience stressful events (De Young et al., 2011). At 3 months of age, a child’s visual sensory development
increases exponentially. A study by Gaensbauer (2002) suggested that infants as young as 7 months of age
can remember and reenact traumatic events for up to 7 years. By 18 months of age, children begin to develop
autobiographical memory; however, it is unlikely that memories from before that age can be recalled verbally
(Howe, Toth, & Cicchetti, 2006). Researchers have demonstrated that infants and young children have the
perceptual ability and memory to be impacted by traumatic events (De Young et al., 2011; Howe et al., 2006).
While research ndings have conrmed that traumatic events can impact children, clinicians without proper
training in early childhood mental health may have difculty diagnosing trauma-related mental illness in
childhood. Children younger than 5 years of age typically experience rapid developmental changes that often
are misinterpreted or not fully accounted for which hinders proper diagnosis and intervention (Zero to Three,
2005). Given time and insurance reimbursement constraints, there can be difculties observing children’s
behaviors across settings (Carter, Briggs-Gowan, & Davis, 2004). Although verbal skills develop rapidly in
early childhood, children may lack the communication skills necessary to accurately express their thoughts,
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emotions and experiences (Cohen, 2010). When conducting assessments, mental health professionals rely on
parental feedback, inventories and reports from multiple sources, thus increasing the accuracy of the assessment
(Carter, Briggs-Gowan, Jones, & Little, 2003).
There is a lack of psychometrically sound diagnostic tools for directly assessing trauma symptoms in
children (Strand, Pasquale, & Sarmiento, 2011). Those tools currently available do not appropriately consider
the developmental levels of young children (Carter et al., 2004; Egger & Angold, 2006; Strand et al., 2011).
However, there are well-designed instruments for early childhood that utilize indirect assessments such as
clinician observations and parent/teacher reports (Yates et al., 2008).
Diagnostic tools and assessments developed for children over age 5 are not suitable for assessing young
children. For example, young children may not fully understand the directions or the vocabulary used in certain
assessment tools. Furthermore, the diagnostic criteria for specic mental health issues (e.g., PTSD) are not
developmentally appropriate for children younger than 5 (Scheeringa & Haslett, 2010). The APA Presidential
Task Force on PTSD and Trauma in Children and Adolescents (2008) argues that children are not being
appropriately identied or diagnosed as having trauma histories and do not receive adequate help.
From a historical perspective, mental health counselors as well as society as a whole have hesitated to
acknowledge the plight that young children face in terms of trauma exposure. Several historical factors have
contributed to counselors’ general lack of knowledge and expertise regarding this population. However, recent
advances in research and in the counseling profession, such as the new American Counseling Association
division, the Association for Child and Adolescent Counseling, have begun to broaden counselor knowledge in
this area.
Symptoms of Trauma in Early Childhood
Trauma reactions can manifest in many different ways in young children with variance from child to child.
Furthermore, children often reexperience traumas. Triggers may remind children of the traumatic event and a
preoccupation may develop (Lieberman & Knorr, 2007). For example, a child may continuously reenact themes
from a traumatic event through play. Nightmares, ashbacks and dissociative episodes also are symptoms of
trauma in young children (De Young et al., 2011; Scheeringa, Zeanah, Myers, & Putnam, 2003).
Furthermore, young children exposed to traumatic events may avoid conversations, people, objects, places
or situations that remind them of the trauma (Coates & Gaensbauer, 2009). They frequently have diminished
interest in play or other activities, essentially withdrawing from relationships. Other common symptoms
include hyperarousal (e.g., temper tantrums), increased irritability, disturbed sleep, a constant state of alertness,
difculty concentrating, exaggerated startle responses, increased physical aggression and increased activity
levels (De Young et al., 2011).
Traumatized young children may exhibit changes in eating and sleeping patterns, become easily frustrated,
experience increased separation anxiety, or develop enuresis or encopresis, thus losing acquired developmental
skills (Zindler, Hogan, & Graham, 2010). There is evidence that traumas can prevent children from reaching
developmental milestones and lead to poor academic performance (Lieberman & Knorr, 2007). If sexual trauma
is experienced, a child may exhibit sexualized behaviors inappropriate for his or her age (Goodman, Miller, &
West-Olatunji, 2012; Pynoos et al., 2009; Scheeringa et al., 2003; Zero to Three, 2005).
The symptoms that young children experience as a result of exposure to a traumatic event are common to
many other childhood issues. Many symptoms of trauma exposure can be attributed to depression, separation
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anxiety, attention-decit/hyperactivity disorder, oppositional deant disorder or other developmental crises (see
American Psychiatric Association, 2013). It is important for counselors to consider trauma as a potential cause
of symptomology among young children.
Long-Term Consequences of Early Childhood Trauma
Recently, researchers have focused on how trauma during early childhood impacts mental and physical
health later in life. Symptoms of mental illness can manifest immediately after a trauma, but in some cases
symptoms do not emerge until years later. PTSD, anxiety disorders, behavior disorders and substance abuse
have all been linked to traumatic events experienced during early childhood (Kanel, 2015). The types and
frequencies of traumatic events and whether they were directly or indirectly experienced also can have various
effects on physical and mental health later in adulthood. In a review of literature, Read, Fosse, Moskowitz and
Perry (2014) described support for the traumagenic neurodevelopmental model. This model proposes that brain
functioning changes following exposure to trauma during childhood. These biological factors often lead to
psychological issues and physical and mental health concerns in adulthood.
Mental health professionals are often challenged to accurately diagnose PTSD in early childhood, leading
to inconclusive reports of the actual prevalence of post-traumatic stress (De Young et al., 2011). Still, there is
a clear relationship between PTSD diagnoses and trauma experienced in childhood. For example, higher rates
of PTSD are reported among children residing in urban populations where neighborhood violence is prevalent
(Crusto et al., 2010; Goodman et al., 2012). Briggs-Gowan et al. (2010) found an association between family
and neighborhood violence exposure and oppositional deant disorder, attention-decit/hyperactivity disorder,
conduct disorder and substance abuse. Additionally, noninterpersonal traumatic events (e.g., car accidents,
burns, animal attacks) are associated with PTSD as well as anxiety, phobias, seasonal affective disorder and
major depressive disorder (Briggs-Gowan et al., 2010).
Violence exposure is associated with externalizing problems while nonpersonal traumatic events are
associated with internalizing problems (Briggs-Gowan et al., 2010). In a more recent study, Briggs-Gowan,
Carter, & Ford (2011) found that exposure to neighborhood and family violence in early childhood is associated
with poor emotional health and poor performance in school. Low socioeconomic status and traumatic events in
early childhood also are correlated with low academic achievement in school (Goodman et al., 2012). Similarly,
De Bellis, Woolley, and Hooper (2013) found maltreated children demonstrated poorer neuropsychological
functioning and aggregate trauma was negatively related to academic achievement.
According to Schore (2001a), children and adults who experienced relational trauma during infancy are
often faced with the struggles of mental disorder due to right brain impairment (p. 239). More recently, Teicher,
Anderson, and Polcari (2012) found exposure to maltreatment and other types of stress as a child impacts
hippocampal neurons leading to alterations in the brain and potential developmental delays. Additionally,
there is evidence of relationships between mistreatment, bullying and accidents in early childhood and
the development of delusional symptoms in later childhood (Arseneault et al., 2011). Young children who
experience trauma and later use cannabis in adolescence are also at a higher risk for experiencing psychotic
symptoms (Harley et al., 2010). Other studies have shown a correlation between early childhood trauma and
development of schizophrenia later in life (Bendall, Jackson, Hulbert, & McGorry, 2008; Morgan & Fisher,
2007; Read, van Os, Morrison, & Ross, 2005). Changes in the brain may mediate these relationships between
trauma exposure and mental health, as suggested by Schore (2001a, 2001b) and others.
Infants exposed to trauma are often inhibited by emotional and behavioral dysregulation in childhood and as
an adult (Ford et al., 2013; Schore, 2001a, 2001b). Dysregulation resulting from trauma is predictive and related
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to substance use and functionality (Holtmann et al., 2011). For example, ndings from a study by Strine et al.
(2012) suggested that early childhood trauma and substance abuse are directly correlated. Children who had
experienced more than one traumatic event were found to be 1.4 times more likely to become alcohol dependent.
Strine et al. (2012) noted that females who experience trauma are more likely than males to abuse or become
dependent on alcohol. The relationship between trauma and alcohol use and dependence often stems from
untreated psychological distress (Strine et al., 2012).
In addition, there is ample evidence that early childhood trauma impacts later physical health. Some of the
most well-known data on this topic come from the adverse childhood experiences study (Edwards et al., 2005).
Multiple studies have found that early childhood trauma is associated with autoimmune disorders (Dube et
al., 2009), headaches (Anda, Tietjen, Schulman, Felitti, & Croft, 2010), heart disease (Dong et al., 2004), lung
cancer (Brown et al., 2010) and other illnesses. In fact, these studies often have found that the more frequent
the exposure to early childhood trauma, the higher the risk of poor health outcomes in adulthood (Felitti et al.,
1998).
Researchers have found clear evidence that children who experience traumatic events in early childhood
are impacted well beyond their youth. Mental health disorders as well as alcohol and substance abuse emerge
intermittently with age. Changes in brain functioning and physical health issues are also associated with early
childhood trauma.
Risk and Protective Factors
Researchers have begun to explore factors that interact with trauma and the effects they may produce in
young children. Environmental and demographic factors as well as parent–child relationships signicantly
impact outcomes for young children exposed to traumatic events (Briggs-Gowan et al., 2010). These factors may
either insulate a child from adverse effects of trauma or increase the child’s risk for developing psychological
distress.
Briggs-Gowan et al. (2010) found that symptoms of psychopathology and trauma were related to factors such
as economic disadvantage and parent depressive and anxious symptoms. While ethnicity of the minor, parental
education level and number of parents were associated with violence exposure, those factors were not associated
with symptoms of mental illness. A more recent study found that young children exposed to a traumatic event
along with a combination of socio-demographic factors (e.g., poverty, minority status, single parent, parental
education less than high school, teenage parenting) are at greater risk for mental illness (Briggs-Gowan et
al., 2011). Additionally, Crusto et al. (2010) found that high levels of parental stress are associated with
adverse trauma reactions in young children. Parental dysfunction, family adversity, residential instability and
problematic parenting can increase the impact of traumatic events as well (Turner et al., 2012). Young children
exposed to chronic and pervasive trauma in addition to these risk factors are especially vulnerable to adverse
effects (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008).
There are factors that may help protect young children from the negative impact of exposure to trauma.
Turner et al. (2012) found that nurturing familial relationships can insulate children from psychological distress
associated with traumatic events. Other factors such as safety and stability also might serve as protective
factors. Safety implies that the child is free from harm or fear of harm, both physically and socially. Stability
indicates consistency in the family environment, while nurturing suggests availability, sensitivity and warmth of
caregivers or parents. Well-established, secure parent–child relationships are likely to provide protection from
negative effects of trauma experienced by young children. A secure parental attachment has been shown to help
children effectively regulate emotional arousal (Aspelmeier, Elliot, & Smith, 2007). Emotional regulation may
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be a mechanism that protects young children from extreme trauma reactions (De Young et al., 2011). Similarly,
Crusto et al. (2010) found that caregiver support and healthy family functioning reduce the risk of psychological
distress in young children after a traumatic event.
Treatment
Early intervention and treatment can minimize the social and emotional impact of a child’s exposure to a
traumatic event. Professional counselors should consider making referrals to counselors trained in providing
early childhood mental health support. If the professional counselor has difculties nding a referral source,
the counselor’s basic counseling skills can provide the foundation for a safe, secure and trusting relationship
between the counselor, family and child. Demonstrating empathy, genuine care and acceptance also fosters
rapport among stakeholders (Corey, 2009). Mental health counselors can emphasize strengths and resources for
the child and family.
Incorporating existing coping strategies can serve to minimize family stress and foster rapport with the child.
Providing information about community support groups or other mental health agencies and resources also can
help support and encourage the family. Informing parents and caregivers about symptoms common to young
children exposed to traumatic events can foster awareness and allow for adequate support during the treatment
process. Counselors can help the family establish or reestablish routines that begin to restore stability for the
child, minimizing the adverse effects of the trauma (APA Presidential Task Force on PTSD and Trauma in
Children and Adolescents, 2008; Clay, 2010).
There are several evidence-based methods available to counselors treating trauma symptoms in young
children. Evidence-based approaches are rooted in theory, evaluated for scientic rigor and tend to yield
positive results (National Registry of Evidence-Based Programs and Practices, 2012). Trauma-focused
cognitive behavioral therapy (TF-CBT) is a popular evidence-based treatment used with children aged
3–18. Based on cognitive behavioral therapy, humanism and family systems theory, TF-CBT includes many
therapeutic elements for children and caretakers (Child Welfare Information Gateway, 2012). This form of
therapy helps children develop different perceptions and a more adaptive understanding of the traumatic event
(APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008). Caretakers learn
parenting and communication skills as they play active roles throughout the TF-CBT process. Multiple studies
demonstrate the effectiveness of TF-CBT in reducing symptoms of trauma in early childhood (see Cohen &
Mannarino, 1996, 1997; Deblinger, Stauffer, & Steer, 2001).
While TF-CBT is an established treatment for children and adolescents, there are evidence-based treatments
developed specically for treating trauma in children between birth and 6 years of age. Child–parent
psychotherapy (CPP), one of the most widely used interventions for young children, was created to address
exposure to domestic violence, although it can treat a variety of traumatic experiences (Lieberman & Van Horn,
2008). In this form of dyadic therapy, the child and the caregiver reestablish safety and security in the parent–
child relationship (Lieberman & Van Horn, 2008). CPP is one of the few early childhood treatments validated
for use with ethnic minorities (Lieberman & Van Horn, 2008). The primary goal of CPP is to equip parents to
meet the psychological needs of their child and maintain a secure relationship after treatment has ended.
Attachment and biobehavioral catch-up (ABC) is another treatment option that is designed primarily for use
with young children who have experienced neglect (Dozier, 2003). This approach was developed specically for
low-income families and later adapted for use with foster families. ABC is based on the neurobiology of stress
and attachment theory. The goal of ABC is to foster the development of the child’s optimal regulatory strategies
by equipping parents with tools for effective response (Dozier, 2003; Dozier, Peloso, Lewis, Laurenceau, &
Levine, 2008).
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Counselors also can utilize parent–child interaction therapy (PCIT) when working with traumatized youth.
PCIT is a structured technique for children ages 2–8 years in which the counselor teaches the parent or caregiver
how to interact with the child and set effective limits (Chafn et al., 2004). In this form of therapy, the counselor
often assumes the role of coach, instructing the client on specic skills. Counselors frequently use PCIT when
working with children abused by a caregiver. PCIT has been implemented successfully with various populations
including Hispanic and Latino clients (Chafn et al., 2004). The focus of PCIT is on improving the quality
of the parent–child relationship as well as child behavior management (Chafn et al., 2004; McCabe, Yeh,
Garland, Lau, & Chavez, 2005).
The treatment interventions previously mentioned are geared toward very young children, all incorporating
play as a treatment modality. Since young children do not have extensive vocabularies, they often communicate
information about themselves, their trauma and relationships with their caregivers through play (Landreth,
2012). Play therapy intervention research using samples with children between birth and 5 years of age is
scant; however, several case studies indicate that play therapy is effective with trauma in early childhood. For
example Dugan, Snow, and Crowe (2010) utilized play with a 4 year old exhibiting PTSD symptomology after
experiencing Hurricane Katrina in 2005. Anderson and Gedo (2013) provided a case study in which play was
used to treat a 3 year old with aggressive behaviors who was separated from his primary caregiver. There also
are intervention examples of using play therapy with young children exposed to domestic violence (Frick-
Helms, 1997; Kot, Landreth, & Giordano, 1998).
Finally, there are emerging approaches specically for treating young children exposed to trauma. Tortora
(2010) developed Ways of Seeing, a program combining movement and dance therapy with Laban movement
analysis to create a sense of regulation and homeostasis for the child exposed to a traumatic event. The Ways of
Seeing program does not yet have empirical evidence of its effectiveness. However, it is rooted in attachment
theory, multisensory processing, play and sensorimotor psychotherapy. Counselors can use this program to
determine how a parent and child experience each other, implement creative interventions for healthy bonding,
and renew a sense of efcacy for the parent and child. While much more research is needed, this program
appears to be a promising approach to treating trauma in early childhood (see http://www.suzitortora.org/
waysofseeing.html).
Another emerging treatment, known as Honoring Children, Mending the Circle (HC-MC), is based on TF-
CBT. The HC-MC approach was developed to address the spiritual needs of young Native American and Alaska
Native children exposed to trauma. This method emphasizes preestablished relationships, wellness and healing
during the treatment process. Spirituality is a critical component of healing and is integrated throughout the HC-
MC approach. The goal of HC-MC is to help the traumatized child attain and reestablish balance (BigFoot &
Schmidt, 2007, 2010). Additional research is needed on the efcacy of the HC-MC approach in working with
Native American and Alaska Native youth.
A third emerging treatment, Trauma Assessment Pathway, is an assessment-based treatment that focuses
on providing triage to young children exposed to traumatic events (Conradi, Kletzka, & Oliver, 2010). In
this approach, the counselor uses assessment domains to determine the focus of treatment, provides triage to
identify an appropriate pathway for intervention and establishes referrals to community resources if needed
(Chadwick Center for Children and Families, 2009). The trauma assessment pathway method, which includes
the trauma wheel, is a versatile mode of treatment available for the child and family. However, in many
instances counselors may determine that an evidence-based practice, such as CPP, is the most appropriate mode
of treatment (see Chadwick Center for Children and Families, 2009).
232
Each method of treatment offers specic strategies for working with traumatized young children and
their families. However, ndings from most studies investigating the effectiveness of these treatments are
inconclusive (Forman-Hoffman et al., 2013). The strength of evidence for these and many other interventions
are relatively low while the magnitudes of treatment effects are small (see Fraser et al., 2013). Common to the
treatment models presented is the emphasis on system support, the importance of relationships in the recovery
process and developmentally appropriate intervention modalities. These factors likely will serve as integral
components of future methods focused on the treatment of traumatized young children.
Discussion and Implications
Young children are at high risk for exposure to traumatic events and are particularly vulnerable for several
reasons. They are dependent upon caregivers and lack adequate coping skills. Children also experience
rapid development and growth, leaving them particularly impressionable when faced with a traumatic event.
Young children benet from preventive psychoeducation aimed at teaching parents and caregivers about child
development and parenting skills (McNeil, Herschell, Gurwitch, & Clemens-Mowrer, 2005; Valentino, Comas,
Nuttall, & Thomas, 2013). Counselors who work with this population endeavor to increase protective factors
and decrease risk factors while exploring preventive methods, which may reduce young children’s exposure to
traumatic events. Similarly, legislators can inuence public policy related to enhancing childhood mental health.
For example, legislation can address prevention and offer incentives to parents participating in psychoeducation
focused on enhancing protective factors and reducing childhood trauma exposure.
In recent years research has emerged that provides an understanding of how trauma impacts young children.
Researchers and clinicians know that infants, toddlers and preschoolers have the capacity to perceive trauma
and are capable of experiencing psychopathology following a traumatic event. Although these children can
experience mental illnesses often associated with older children, adolescents and adults, the symptomology can
manifest in various ways. Additionally, professional counselors working with children in a variety of settings
should consider the residual impact of traumatic events experienced in early childhood. School-aged children
may experience behavioral problems and have difculty learning and forming relationships as a result of early
childhood trauma (Cole, Eisner, Gregory, & Ristuccia, 2013; Cole et al., 2005). A number of studies indicate
that trauma is a strong predictor of academic failure (Blodgett, 2012). Therefore, school counselors serving
as mediators between academics and wellness should explore ways to advocate for and support students with
known or suspected exposure to traumatic events in early childhood. For example, the trauma-sensitive schools
initiative provides school counselors with a framework for fostering schoolwide awareness and creating a safe
and supportive environment (Cole et al., 2013). School counselors can easily embed these types of preventive
measures as part of a comprehensive school counseling program. These efforts will presumably result in
increases in student success, wellness and awareness, three outcomes that will benet all children exposed to
traumatic events.
While great strides have been taken recently in understanding and treating early childhood trauma, there are
clear gaps in the dissemination of information to counselors. Professional counselors should receive training
in specically designed interventions and attempt to raise public awareness of early childhood trauma in hopes
that young children will receive necessary treatment. The ndings of this literature review suggest that various
methods of treatment might effectively reduce symptoms experienced by traumatized children. Parent–child
relationships and other environmental factors also can have signicant inuence on children’s reaction to
trauma.
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233
A major purpose of this article is to educate counselors about the impact of trauma in early childhood and
advocate for appropriate assessment and treatment of these traumatic exposures. While not all counselors choose
to work with this vulnerable population, they often work with clients who have extended families with young
children. Counselors who work with adult clients can provide psychoeducation about this important issue and
initiate referrals to counselors trained to work with early childhood trauma. There is a body of information about
trauma in early childhood available for further review. Sources include the National Child Traumatic Stress
Network (nctsnet.org), the California Evidence-Based Clearinghouse for Child Welfare (cebc4cw.org), and the
Association for Child and Adolescent Counseling (acachild.com). Counselors interested in learning more about
this issue can review these online resources.
Conict of Interest and Funding Disclosure
The authors reported no conict of
interest or funding contributions for
the development of this manuscript.
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Yahnong Liu, NCC, is a doctoral student at the Pennsylvania State University. Richard J. Hazler, NCC, is a Professor and the Program
Coordinator of Counselor Education at the Pennsylvania State University. Correspondence may be addressed to Yahnong Liu, 317
Cedar Building, The Pennsylvania State University, University Park, PA 16802, [email protected].
Yanhong Liu
Richard J. Hazler
All Foreign-Born Adoptees Are Not the Same:
What Counselors and Parents Need to Know
International adoption provides U.S. families with parenting opportunities as well as with challenges accompanying
adoptees’ post-adoption adjustment. The literature indicates differences in adjustment outcomes between Chinese
and other international adoptees. Differences are found in behavioral adjustment, attachment formation and social-
emotional development. Pre-adoption circumstances, including the political and cultural reasons for adoption,
institutionalization experiences, and family stress, are relevant factors for adoptees’ post-adoption adjustment.
A closer look at Chinese adoptees offers insights on components that may prohibit or contribute to post-adoption
adjustment outcomes. Each component provides implications for professional counselors and the adoptive families
they serve for nurturing the growth of international adoptees.
Keywords: international adoption, international adoptees, Chinese adoptees, post-adoption adjustment, professional
counselors, adoptive families
International adoption, involving transferring children from a country of origin to a host country, creates
a unique set of circumstances where adoptive parents and adopted children meet across lines of differences
in biology, race, cultural heritage, nationality, socioeconomic status and more (Bartholet, 2006). World
circumstances of war, poverty and lack of social welfare have created multiple scenarios in which countries
now provide U.S. couples with additional parenting opportunities, while increasing infertility rates and other
difculties have reduced U.S. domestic adoption opportunities. These increases in international adoptions have
both global signicance and local importance for related countries, societies and communities (Hoshman, Gere,
& Wong, 2006). Many advantages and challenges accompany the adoption process that counselors increasingly
need to face in their schools, communities and private practices.
International adoption provides many opportunities for the countries involved, for the individuals wanting
to adopt and for the children needing adoption; however, the post-adoption process is accompanied by multiple
challenges for adoptive parents, professional counselors and human service agencies. A meta-analysis by Juffer
and van IJzendoorn (2005) showed that internationally adopted children exhibit more behavioral problems
and receive more mental health services than non-adopted children. Higher rates of attachment and social-
emotional problems also were found among internationally adopted children when compared to non-adopted
and domestically adopted peers. As such, this group needs to be considered an at-risk population deserving of
specic attention (Barcons et al., 2011; van den Dries, Juffer, IJzendoorn, & Bakermans-Kranenburg, 2010).
Professional counseling journals currently provide little help to their readers about international adoptees
and the resources needed to work effectively with them. Journal articles from psychology, social work, children
and youth services, adoption, and sociology (e.g., Bruder, Dunst, Mogro-Wilson, & Tan, 2010; Cohen & Farnia,
2011; Pugliese, Cohen, Farnia, & Lojkasek, 2010) provide more information on these issues, and their ndings
The Professional Counselor
Volume 5, Issue 2, Pages 238–247
http://tpcjournal.nbcc.org
© 2015 NBCC, Inc. and Affiliates
doi:10.15241/efh.5.2.238
The Professional Counselor/Volume 5, Issue 2
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can be utilized to meet the needs of professional counselors. This article will utilize the ndings from related
disciplines to demonstrate how professional counselors can more effectively support children and parents
among this population.
International adoptees from China have been shown to have better adjustment outcomes in comparison with
international adoptees as a whole, making them an important subgroup to examine (Cohen & Farnia, 2011; Tan,
Camras, Deng, Zhang, & Lu, 2012; Tan & Marfo, 2006). China also is the largest country of origin of children
for international adoption, accounting for over one fourth of the 242,602 U.S. international adoptions between
1999 and 2012 (U.S. Department of State, 2012). The post-adoption adjustment of international adoptees from
China and the wealth of literature regarding them provide important sources of information on what inuences
an international adoption. Consequently, this article gives signicant focus to Chinese adoptees and, where
possible, compares that information to studies of adoptees from other countries. This article transforms the
information into practical implications for counselors and parents with international adoptees and those who are
considering an international adoption.
A Closer Look at Chinese Adoptees
Chinese adoptees deserve particular research attention because they show more positive post-adoption
outcomes in areas such as personal-social development, problem-solving skills, behavioral adjustment,
child–parent attachment patterns and academic achievement (Cohen & Farnia, 2010; Tan, Marfo, & Dedrick,
2010; Welsh & Viana, 2012). Cohen and Farnia (2010, 2011) found a common trend in that Chinese adoptees
display rapid growth in overall development within the rst 6 months after adoption and increased attachment
2 years later. Their preschool years contain fewer behavioral problems compared even to U.S. preschool-age
non-adopted girls from the normative sample (Tan et al., 2012). Behaviors exhibited by Chinese adoptees
are comparable to those of U.S. non-adopted peers, which means Chinese adoptees demonstrate no more
internalizing (directed toward oneself), externalizing (directed toward the environment) or total problem
behaviors than all children in a similar age range (Tan et al., 2012). Internalizing problems, externalizing
problems and overall behavior problems are the three subscales of the Child Behavior Checklist that Tan et al.
(2012) used to measure preschool-age Chinese girls’ behaviors.
A study from another Western culture compared the academic achievement of 77 Chinese adoptees with
those of 77 Norwegian-born children of similar age and found no signicant difference between the two
samples (Dalen & Rygvold, 2006). These results differ from results of studies on international adoptees from
other countries, in which these adoptees have been shown to exhibit lower academic performance than non-
adoptees (e.g., Miller, Chan, Tirella, & Perrin, 2009; van IJzendoorn, Juffer, & Poelhuis, 2005). The combined
results consistently indicated better post-adoption results for Chinese children. These results raise the following
question: What is it about Chinese children and the process of their adoptions that might account for such
differences?
Politics and Culture
More than 90% of Chinese adoptees are female infants, a fact inuenced by China’s political and cultural
characteristics. Adoption from China to the United States was greatly affected by China’s one-child policy, rst
implemented in 1979. The policy was designed to control population growth by only allowing one child per
couple. This policy, along with China’s cultural emphasis on sons over daughters, has caused the abandonment
of many infant girls (Johnson, 2004). This abandonment practice is one way for a family to have a second child
but still be a one-child family. Most of the abandonments happen in rural areas of China where households
without a son are likely to experience discrimination for potentially losing their family name in following
generations (Chen & Li, 2009). Family name has great cultural importance throughout China, but rural
240
populations are the most concerned about these issues, making female children most vulnerable and more likely
to be put up for international adoption.
The one-child policy impacts more than the number and gender of adoptees. It is believed that this policy
is an indirect factor in Chinese adoptees’ better physical and experiential conditions when adopted (Kreider &
Cohen, 2009). The one-child policy, along with the cultural preference for male infants, indicates that healthy
parents abandon the majority of Chinese children put up for adoption for poverty-related, political or cultural
reasons, and not for health or disability reasons, as is often the case in other countries. Adoptees from Eastern
Europe and Russia, for example, consistently experience pre-adoption adversities such as poverty and birth
mothers’ alcohol and substance use during pregnancy (Kreider & Cohen, 2009; Welsh &Viana, 2012). The
physical and emotional pre-adoption environments for non-Chinese children understandably make a signicant
difference for their potential to successfully develop as they meet the multiple demands of the adoption process.
Pre-Adoption Institutionalization Experience
Approximately 85% of international adoptees have some level of institutionalization experience in their birth
countries (Gunnar, van Dulmen, & the International Adoption Project Team, 2007). Along with pre-adoption
parental quality and biological factors, the institutionalization experiences were found to be a signicant factor
in predicting post-adoption behavioral problems (Hawk & McCall, 2010; van den Dries et al., 2010). The
quality of institutional care received by adoptees varies from country to country. The psychological aspect
of institutional care is better in China because of the family-like atmosphere within institutions (Neimetz,
2010; Shang, 2002). A case study by Neimetz (2010) found that the director, codirector and other caregivers
were called father, mother and siblings, respectively. This family-style psychological emphasis demonstrates
recognition of a quasi-family environment aimed at counterbalancing the effects of the large number of children
in an institution, which does not seem to appear in many other countries.
Risk Factors for Adoptee Adjustment
Cognitive Development
The status of adoptees’ cognitive development at the time of adoption has been noted as predictive of
attachment outcome and social-emotional reactivity. Recent literature has indicated a positive relationship
between international adoptees’ post-adoption adjustment and their cognitive level when they arrived in the
host country (Cohen & Farnia, 2010). Cohen and Farnia (2011) found that mental development index scores are
signicant predictors of Chinese adoptees’ later social-emotional activities and attachment outcomes, which in
turn affect cognitive development. After 6 months, adoptees with higher mental development index scores were
associated with better social-emotional adjustment and faster rates of forming attachment relationships with
their adoptive mothers. Cohen and Farnia (2010) speculated that a lack of cognitive resources is associated with
adoptees’ difculty in post-adoption adjustment.
Behaviors at Time of Adoption
Positive relationships have been found between rejection behaviors at the time of adoption and both
internalizing and externalizing behavioral problems of preschool-age and school-age Chinese adoptees (Tan &
Marfo, 2006). Rejection behaviors are adoptees’ resistant behaviors toward adoptive parents during the initial
period after adoption (Tan & Marfo, 2006). Tan and Marfo (2006) found that the behaviors present at the time
of adoption were better predictors of later adjustment outcomes than adoptees’ age on arrival. Therefore, initial
behaviors are more inuential for adoption outcomes than the maturity that comes with age (Tan et al., 2010).
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241
Family Stress
Tan et al. (2012) studied the post-adoption adjustment of 133 preschool-age Chinese adoptees and found that
the level of stress in the adoptive family positively correlated with the child’s presenting behavioral problems.
The higher the level of stress that a family encounters, the more behavioral problems are identied in the child.
Maternal depression prior to adoption, as well as high parental expectations of problems (i.e., expecting a high
rate of occurrence of the child’s behavioral problems), were signicant predictors for post-adoption family
stress (Viana & Welsh, 2010). Familial stress is a signicant factor in child–parent relationships and a risk factor
for overall child psychopathology (Deater-Deckard, 1998).
Parental Sensitivity and Authoritative Parenting
Parental sensitivity refers to parents’ ability to sense various cues that an infant exhibits and to respond
to those cues consistently (Karl, 1995). Sensitive parenting provided by adoptive parents is related to better
developmental growth following adoption (Palacios & Brodzinsky, 2010). Parents who are consistently
sensitive in caregiving develop more secure attachment with adoptees, and changing from insensitive to
sensitive caregiving results in a transition from insecure to secure attachment (Beijersbergen, Juffer, Bakermans-
Kranenburg, & van IJzendoorn, 2012).
Parental sensitivity in the literature refers generally to parents’ responsiveness to infants, but the concept
of parenting styles takes on greater signicance when it concerns young children. Baumrind (1978) proposed
three primary parenting approaches: authoritative parenting, authoritarian parenting and permissive parenting.
Authoritative parenting was highlighted positively for its emphasis on parents’ setting up reasonably high
expectations while showing support for children’s interests. Tan et al. (2012) studied the role of authoritative
parenting in adoptive families with Chinese children and found that authoritative parenting was associated with
fewer behavioral problems in Chinese adoptees in the study.
A closer look at Chinese adoptees’ pre-adoption circumstances and post-adoption protective factors offers
insights about the critical components that may prohibit or contribute to positive adjustment outcomes. Political
and cultural inuences, institutionalization experiences prior to adoption, adoptees’ cognitive development
level, and parents’ sensitive care and authoritative parenting in post-adoption all appear to be important factors
in post-adoption adjustment. Each component provides implications for professional counselors and the
adoptive families they serve in facilitating adoptees’ development.
Implications for Parents and Counselors
Post-adoption protective factors such as parental sensitivity and appropriate parenting approaches can
mitigate adoptees’ adverse experiences and promote resilience (Barcons et al., 2011; Scroggs & Heiteld, 2001;
van den Dries et al., 2010). The impact of pre-adoption conditions diminishes as the inuence of the adoptive
family becomes more salient (Gagnon-Oosterwaal et al., 2012). Studies showing signicantly better results
for Chinese adoptees’ adjustment provide insights related to key issues deserving attention from professional
counselors and their parent clients. Examining pre-adoption conditions and experiences of international
adoptees can be a challenging issue due to the distance from countries of origin and condential nature of the
information.
Awareness of Gender Differences and Health Status
The availability of more female than male infants for adoption, created by China’s one-child policy and
cultural emphasis on males over females, is related to a healthier status of most adopted Chinese children
(Kreider & Cohen, 2009). These gender and health differences provide insights into caregiving by adoptive
parents and the counseling services offered to adoptive families. Designing and implementing preventative
242
and intervening approaches should be carefully examined and adapted based on considerations of male versus
female adoptees, and of healthy children versus children with special needs.
Implications for parents. Parents need to understand the context of countries from which they wish to
adopt a child. Families differ in their reasons for adoption, the countries they choose from which to adopt and
characteristics of the child whom they wish to adopt. These differences make it important for parents to conduct
a self-analysis and rationalize the adoption choice by specifying characteristics of an adopted child such as
gender, age, race and health conditions prior to the international adoption process (Gunnar, Bruce, & Grotevant,
2000). Becoming familiar with the context of countries of origin facilitates the family’s matching process with
a potential child. For example, parents may choose to adopt from a country with more female infants on the
waiting list, such as China, if they prefer adopting a female child and have no specic restrictions on other
characteristics.
Parents also need to be aware of potential relationships between abandonment and the gender or health of the
child so as to provide appropriate post-adoption care. Obtaining pre-adoption information about the child and
the country of origin is an important step (Gunnar et al., 2000). Additionally, adoptive parents should understand
that health and medical information, including family and prenatal history, is probably more comprehensive for
a child from some countries than others. Families may follow up with the adoption agency by making specic
requests for information that is more detailed than the standard information provided (Bledsoe & Johnston,
2004).
Implications for counselors. When considering the gender and health of the adoptee, two main types of
services are suggested for professional counselors working with internationally adoptive parents and adopted
children—information interpretation (Gunnar et al., 2000) and pre- and post-adoption counseling services
(Welsh, Viana, Petrill, & Mathias, 2007). The connection between the adoption process and the individual
characteristics of the child to each country’s policy and culture make it necessary for counselors to take into
consideration the context of the country of origin and to help families interpret adoption-related information
(Gunnar et al., 2000). Quality interpretation increases the likelihood of the child’s positive post-adoption
development. At the same time, the interpretation of information also has the potential to prevent a child
from being adopted due to possible physical and mental health concerns of the child, expenses involved, and
additional requirements about parents’ age, income or sexual orientation regulated by specic countries of
origin (Gunnar et al., 2000).
Counselors may utilize pre-adoption information (e.g., health and behavioral information, diagnosis) in
designing interventions for adopted children. Most counselors do not receive professional training in adoption
or working with adoptive families and children, so establishing a professional network with adoption agencies,
social workers and psychologists becomes essential. This network will provide more accurate information
and ensure necessary referrals, access to available medical and health data, appropriate consultation, and
professional collaboration that will best serve adoptees and families.
Recognizing Adoption-Point Behaviors
Tan et al. (2010) reported in a longitudinal study of preschool-age Chinese adoptees that behaviors exhibited
at the time of adoption predict adjustment outcomes regardless of the age at adoption. Risk indicators were
identied as refusal/avoidance and crying/clinging behaviors, and more internalizing and externalizing
behavioral problems were found in children exhibiting more physical risk indicators at the time of adoption
(Tan et al., 2012).
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Implications for parents. International adoptive parents should be aware of the behaviors exhibited at the
time of adoption by adoptees, which can be particularly helpful for recognizing potential adjustment issues.
To deal with noncompliance and clinging related to problem behaviors and social-emotional learning, it is
suggested that parents provide timely comfort and be attuned to the child’s needs (Brennan, 2013). Parents also
are encouraged to recognize changes from the environment of the adoptee’s origin to a U.S. environment and
consider preparing resources to help with children’s transitions. These can include music or stories in languages
of birth countries along with toys and other sources of origin environment comfort.
Implications for counselors. Professional consultation with adoption agencies can provide the basis for
understanding specic behaviors that the child presents and how the behaviors can affect development. Some
behaviors displayed by an adoptee may be related to his or her developmental stage, and frequently avoidance
and clinging behaviors are identied as major symptoms of separation anxiety disorder in children (Ehrenreich,
Santucci, & Weiner, 2009). Counselors may work with parents to track the frequency of the behaviors during
the initial period after adoption. Appropriate interventions can then be designed and implemented according to
the presentation of behaviors and/or specic diagnosis made by qualied professionals.
Facilitating Secure Attachment Development
Understanding the mutually inuential factors of social-emotional reactivity and attachment security of
adopted children are of practical signicance (Cohen & Farnia, 2010). According to attachment theory, children
with secure attachment are more likely to develop strong internal working models with salient self-efcacy,
enabling them to be empathic and more capable of maintaining relationships, whereas children with insecure
attachment may develop weak internal working models that lack social competency in relationships (Bowlby,
1969). Internationally adopted children experience a variety of transitions in culture, language and living
environment, which present as separation and loss, adding difculty to the development of attachment to new
caregivers (Bowlby, 1969).
Implications for parents. Parental sensitivity, or providing appropriate, timely and consistent responses, is
a major contributor to secure child–parent attachment. It is a protective factor for international adoptees and can
counteract otherwise problematic pre-adoption risk factors. Parents can increase their sensitivity by utilizing
a form of mind-mindedness as an effective strategy for helping infants form secure attachments (Meins,
Fernyhough, Fradley, & Tuckey, 2001). The technique involves naming children’s feelings, wishes, intentions
and thoughts in situationally appropriate ways. The act of naming encourages active recognition of the need
to respond to the child and the time to do so, thereby building a pattern of productive, sensitive, parental
behaviors.
Implications for counselors. Counselors may emphasize adoptee–parent relationships in which trust is
a fundamental element (Barcons et al., 2011; Tan & Camras, 2011). Parent training and psychoeducation
based on individual family needs can help establish the necessary parental desire and skills required. Trust-
Based Relational Intervention is one sample of a program developed for adoptive families of children with
social-emotional needs (Purvis, Cross, & Pennings, 2009). This program emphasizes the following two main
principles in developing a family-based program: (a) awareness (i.e., understanding adoptees’ responses and
feelings) and (b) engagement (i.e., interacting with adoptees in a way that makes them feel safe). Modeling
eye contact and imitating the child’s body position are recommended for working with internationally adopted
children for whom extreme changes in culture, environment and other factors can make developing trust more
difcult. Counselors should be cautious when using these strategies before getting to know the child and parents
in-depth. Active eye contact and body gestures may intimidate children due to cultural reasons or previous
traumatic experiences (Becker-Weidman, 2006).
244
Coping With Family Stress
Numerous studies have demonstrated a positive correlation between family stress and child psychopathology
(Grant, Compas, Thurm, McMahon, & Gipson, 2004; Tan et al., 2012), and have shown that a signicant sign
of parental stress is maternal depression prior to adoption (Viana & Welsh, 2010). Parents must consider the
parenting role differences in balancing family stress because parenting is not just the responsibility of a single
parent.
Implications for parents. Parents must evaluate the impact of family stress that can inhibit family function,
thereby increasing children’s behavioral problems, and the family’s ability to deal with those problems. In two-
parent households, parents are encouraged to participate in a parenting process in which one parent provides
more emotional support to children by encouraging them to be independent and to explore unknown things (i.e.,
proactive approach), while the other provides emotional support through sensitive caring and responding to
the child’s distress (i.e., reactive approach; Grossmann, Grossmann, Winter, & Zimmermann, 2002). Adoptive
parents must consider a self-check on overall mental health as individuals, as a couple and as a family. Seeking
support from a pre-adoptive preparation program focusing on evaluating self-wellness and promoting family
resilience is an extremely valuable step (Viana & Welsh, 2010).
Implications for counselors. Meeting the needs of adoptive families often requires implementing techniques
to help recognize and deal with the sources of family stress. Parents must have an understanding of the family
stress issues before they can effectively move on to developing and implementing interventions for adoptees’
behavioral problems, which can be exacerbated or even created by the stress. Counseling services for parental
depression, anxiety, and other relevant feelings and symptoms are critical (Viana & Welsh, 2010).
Conict within a couple’s relationship is a key factor that predicts family stress because low-conict couples
are positively associated with satisfying parent–child interactions (Krishnakumar & Buehler, 2000). A variety
of psychoeducational programs focus specically on improving couple relationships for new parents (Halford
& Petch, 2010). Counselors must consider the importance of parents’ focusing on conict management and pre-
parental anxieties of internationally adopting prior to the child’s arrival.
Cultivating Authoritative Parenting
Parenting and attachment are two parallel behavioral systems that facilitate effective caregiving and
attachment relationships in adopted children (Roberson, 2006). Results of hierarchical multiple regression
analyses by Kriebel and Wentzel (2011) indicated that adoptees’ cumulative risk from pre-adoption
circumstances is a negative predictor for later adaptive behaviors, whereas authoritative parenting is a positive
predictor of children’s adaptability. Authoritative parenting also was found to be associated with fewer
behavioral problems in Chinese adoptees, whereas authoritarian and permissive parenting styles were correlated
with more behavioral problems exhibited by the children (Tan et al., 2012).
Implications for parents. Cultivating authoritative parenting refers to promoting parents’ supportive role
accompanied by consistent rather than harsh discipline. Parents with an authoritative parenting style tend to
show warmth, affection and responsiveness and support children’s interests, but they also set up reasonably
high demands and expectations for children (Baumrind, 1978). Inconsistent, overly harsh or emotionally
vacant parenting has deleterious effects on children’s development. A lack of parental control or consistency in
discipline is associated with greater behavioral problems at all child developmental stages.
The concept of parenting styles is the same in all cultures, but its application may vary by race, culture or
socioeconomic status. For example, Kisilevsky et al. (1998) maintained that parenting methods of Chinese
parents differ substantially from those of U.S. parents, so adopted children from China experience different
The Professional Counselor/Volume 5, Issue 2
245
parenting before and after they are adopted. Parents with internationally adopted children are encouraged to take
all social and cultural variables of parenting into consideration (Kotchick & Forehand, 2002), while using an
authoritative parenting style as the principal guideline.
Implications for counselors. Psychoeducational programs can be intervention strategies for counselors to
better serve adoptive families’ parenting needs. Programs may include a miniature of Baumrind’s (1978) work
with emphasis on how current parent themes align with the parenting typologies (i.e., authoritative, authoritarian
and permissive). Counselors also may consider providing parenting examples; specically, as suggested
by Morris, Cui, and Steinberg (2013), they may provide examples related to intercultural parenting. Group
counseling is another option that counselors can consider for families. Parental networks of families with children
adopted from the same country of origin were found to be an effective intervention for post-adoption adjustment
of families (Welsh et al., 2007), as international adoptive parents tend to listen to and seek help from informal
networks whose participants have experienced similar challenges. Focus can be on feedback or experiences that
families can gain from each other, while lessening the facilitating role of the counselor.
Conclusion
A close review of the unique international circumstances related to adoption from China draws attention to risk
and protective factors of post-adoption adjustment. Parents of all international adoptees and counselors working
with adopted children and adoptive families may want to take the multicultural characteristics of each child into
consideration. There are vast differences within international adoptees as a group. Children’s health, attachment
and adjustment patterns vary based on their countries of birth, and each individual differs from others in the post-
adoption adjustment process due to personal reasons other than cultural factors.
Conict of Interest and Funding Disclosure
The authors reported no conict of
interest or funding contributions for
the development of this manuscript.
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Carl Sheperis, NCC, is the Chair of the Department of Counseling and Special Populations at Lamar University. Donna Sheperis, NCC,
is an Associate Professor at Lamar University. Alex Monceaux is an instructor at Lamar University. R. J. Davis and Belinda Lopez are
Assistant Professors at Lamar University. Correspondence may be addressed to Carl Sheperis, Box 10034, Beaumont, TX 77710,
csheperis@lamar.edu.
Carl Sheperis
Donna Sheperis
Alex Monceaux
R. J. Davis
Belinda Lopez
Parent–Child Interaction Therapy for Children
With Special Needs
Parent–Child Interaction Therapy (PCIT) is an evidence-based method for reducing disruptive behavior in
children and improving parent management of behavior. PCIT is a form of behavioral intervention that can be
used in clinical, home and school settings. Although initially designed for intervention related to oppositional
deant disorder and conduct disorder, PCIT has been found to be a promising intervention for addressing
behavioral issues among children with special needs. We present methods, research-based instructions and a case
example of PCIT with a child diagnosed with autism. This article is intended to assist professional counselors in
designing appropriate interventions for both children and parents.
Keywords: autism, parent–child interaction therapy, special needs, behavioral intervention, case example
Counseling techniques for children stem from a myriad of theoretical perspectives, and professional
counselors are often in the unique position to provide systems intervention and training to families when
a child has disruptive behavior. Despite the seniority of behaviorism in the eld of psychology, behavioral
family approaches have only recently been acknowledged as an effective practice in professional counseling.
According to Gladding (2011), the following three premises underlie behavioral family counseling: (a) all
behaviors are learned, (b) maladaptive behaviors are the target for change and (c) not everyone in the family has
to be treated for change to occur. With these assumptions, it is easily deduced that the following also are true:
(a) behavior can be unlearned and that new behaviors can be taught, (b) underlying, unresolved issues are not
the key components of treatment, and (c) positive changes for one family member will impact the entire family
system and surrounding ecology.
When working with children of preschool or early elementary age, it is important to directly involve
the child’s caregivers. Parents’ inuence on their children is signicant and some parenting practices may
exacerbate some children’s problems (McNeil & Hembree-Kigin, 2010). Behavioral family counseling
models recognize the relationship between the child’s behavior and the family system. One behavioral family
counseling technique, Parent-Child Interaction Therapy (PCIT), helps families work together with their
children in reaching therapeutic goals. PCIT involves teaching parents some fundamental relationship-building
strategies, including therapeutic play techniques for parents to use in the home environment (Johnson, Franklin,
Hall, & Prieto, 2000). The clinician typically teaches and models PCIT techniques for the parents over the
course of 8–10 weeks.
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Volume 5, Issue 2, Pages 248–260
http://tpcjournal.nbcc.org
© 2015 NBCC, Inc. and Affiliates
doi:10.15241/cs.5.2.248
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The purpose of this article is to demonstrate the practicality of PCIT as a component of behavioral family
counseling, to facilitate the professional counselor’s understanding of the model through a review of PCIT and
to illustrate the utility of this model for children with special needs through a case study.
An Overview of PCIT
PCIT (Neary & Eyberg, 2002) is an assessment-driven form of behavioral parent training designed for
families with preschool-aged children. We present a brief overview of PCIT, dene the key components integral
to the process, provide the framework for implementation and discuss the application of PCIT to special
populations. The core of PCIT is twofold—to create nurturing parent–child relationships and to model prosocial
behaviors while increasing a child’s appropriate, compliant behaviors (Eyberg & Boggs, 1989). Play therapy
skills are introduced to parents within the PCIT model to enhance the relationship between the parent and child.
Additionally, PCIT cultivates problem-solving skills with parents who can then generalize gains made in the
therapeutic milieu into the family environment. Similar to other models of family counseling, PCIT begins with
the assessment process. Counselors using PCIT collect psychosocial information from the family through either
structured or semistructured clinical interviews. Because PCIT is a behavioral model, family dynamics also are
assessed through direct observation of clients. Once clinical interview and observational data are collected and
evaluated, the counselor can explore family relationship dynamics.
PCIT counselors attempt to identify family roles, interactions and maladaptive disciplinary techniques (e.g.,
yelling, lack of follow-through, unrelated consequences) inherent in the system. The ultimate goal of these
observations is to derive methods for replacing current ineffective parenting strategies with more adaptive ones,
thus creating greater stability in the family system. Similar to other parenting approaches, family counselors
using PCIT offer support and assistance in improving parent–child relationships without placing blame on the
child or the parents (Webster-Stratton & Herbert, 1993).
The Benets of PCIT
There are many benets to PCIT; it is a brief, short-term family counseling procedure that teaches effective
parenting skills and helps parents interact better with their children on a daily basis. Fundamentally, PCIT’s
two-tailed approach benets both parents and children (Asawa, Hansen, & Flood, 2008) by reducing the
internalization of problems and parent–child stress. Additionally, PCIT empowers parents through teaching
positive interactive techniques that build parent–child rapport. PCIT fosters creativity and increases child self-
esteem, decreases noncompliance or disruptive behavior, and increases the quality of parent-provided positive
regard through developmentally appropriate play (Eyberg et al., 2001). These positive interactions effectively
decrease problem behavior, resulting in a reduction or elimination of emergency counseling visits. One PCIT
study reported that only 19% of participants in a randomized controlled trial with physically abusive parents re-
reported physical abuse more than 2 years after the implementation of the PCIT model (Chafn et al., 2004).
While PCIT sessions may focus on home and play, the behavioral skills that the parent learns can be
generalized to other children and additional settings, building stronger interactions across a spectrum of familial
and social settings. According to Urquiza and Timmer (2012), PCIT focuses on the following three essential
non-xed elements: (a) increased positive parent–child interaction and emotional communication skills, (b)
appropriate and consistent discipline methods, and (c) direct scaffolding for parent training in the interventions.
Thus, once the parent has mastered these skills in the session with the child and therapist, the parent is able to
transfer the skills to any location or setting to maintain positive interactions, emotional communication and
disciplinary consistency with the child.
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The Effectiveness of PCIT
Eyberg and her colleagues have researched and published extensively on the efcacy of PCIT and have
empirically supported the effectiveness of PCIT with children exhibiting a range of behavioral and emotional
problems (Neary & Eyberg, 2002). Specically, PCIT has proven effective with problems including attention-
decit/hyperactivity disorder (ADHD), conduct disorders, separation anxiety, depression, postdivorce
adjustment, self-injurious behavior and abuse (Eyberg et al., 2001; McNeil & Hembree-Kigin, 2010). For
example, Nieter, Thornberry, and Brestan-Knight (2013) conducted a pilot study with 17 families completing
PCIT treatment and found a signicant decrease in disruptive child behaviors as well as a decrease in
inappropriate parent behaviors over the 12-week group program. This study was the rst to deliver PCIT via
group sessions. The researchers found that treatment effects remained in place for more than 6 months after the
group’s completion.
Eyberg et al. (2001) investigated long-term treatment outcomes of PCIT for families of preschoolers with
conduct disorders over a period of 1–2 years, and found that treatment effects were sustained over time.
According to the researchers, the study was the rst of its kind to include long-term follow-up with families
receiving PCIT treatment (Eyberg et al., 2001). Hood and Eyberg (2003) established further evidence in another
follow-up study on PCIT treatment effects over a period of 3–6 years. In the study of treatment effects on
families with young children diagnosed with oppositional deant disorder, the researchers found that treatment
effects and behavioral change were again sustained over time. Thomas and Zimmer-Gembeck (2007) conducted
a review of behavior outcomes in 24 studies on PCIT and another parenting intervention, Triple P—Positive
Parenting Programs. All of the studies involved children aged 3–12 and their caregivers. Meta-analyses revealed
positive effects for PCIT as well as the other intervention, adding support within the literature on the efcacy of
PCIT.
To demonstrate the effectiveness of PCIT for treating ADHD, Guttmann-Steinmetz, Crowell, Doron, and
Mikulincer (2011) examined the interactions of children with ADHD and their mothers. Their ndings suggest
that while Behavior Parent Training is useful in managing ADHD, PCIT may be highly effective in impacting
the attachment-related processes during the child’s later developmental stages. These researchers suggested that
parents’ successful adaptation of PCIT’s verbal and behavioral skills during interaction with their child might
increase the child’s sense of security.
The effectiveness of PCIT has been expanded to other disorders such as separation anxiety. For example,
Choate, Pincus, Eyberg, and Barlow (2005) conducted a pilot study involving three families with children 4–8
years of age diagnosed with separation anxiety disorder. The researchers found that the child-directed activities
fostered children’s sense of control and reduced separation anxiety symptomology to normative levels by the
conclusion of treatment. Again, the treatment effects were shown to persist long after treatment ceased. This
study was replicated by Anticich, Barrett, Gillies, and Silverman (2012), providing further support of PCIT’s
effectiveness in alleviation of separation anxiety disorder symptomology.
Individuals or populations with special needs also appear to respond positively to PCIT. Bagner and Eyberg
(2007) found that mothers of young children diagnosed with mental retardation and oppositional deant
disorder reported a reduction in disruptive behaviors, increased compliance and less parenting stress after
participating in a randomized, controlled trial study utilizing PCIT. PCIT also has been cited as a promising
evidence-based intervention for autism (Agazzi, Tan, & Tan, 2013). Solomon, Ono, Timmer, and Goodlin-Jones
(2008) conducted a randomized trial of PCIT for treating autism and found the same results as researchers
studying other disorders have. PCIT was shown to reduce behavioral disruptions, increase adaptability and
increase positive parental perceptions of child behavior. While PCIT was originally developed to address
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behavioral disorders, it clearly serves as an intervention for various other disorders that impact parent–child
interactions.
The impact of PCIT on parents. PCIT has been shown to have equally effective outcomes for parent-
related issues as it does for child behavioral disruptions. For example, Luby, Lenze, and Tillman (2012) reported
highly favorable results for using PCIT to reduce behavioral disruptions and improve executive function among
preschoolers. However, PCIT also showed signicant effects for parents. Specically, PCIT interventions
helped to reduce depression severity and parenting stress while increasing emotion recognition. Furthermore,
Urquiza and Timmer (2012) found that parental depression decreases the likelihood that the child will
complete the treatment course. However, if the parents are persuaded to continue until completion, their own
psychological symptoms may be relieved.
PCIT has been shown to have positive effects on parents in a variety of circumstances. For example, Baker
and Andre (2008) suggested that PCIT might offer a unique and promising advantage in the treatment of
postdivorce adjustment issues in children. PCIT also has been found to be effective in working with abusive
parents, many of whose histories included depression, substance abuse and violent behavior (Chafn et al.,
2004). Although still effective in reducing parenting stress and child behavior problems, Timmer et al. (2011)
found that PCIT was less effective in foster parent homes than in non-foster parent homes. While PCIT is
clearly an effective intervention for both children and parents, in cases with complex systems like foster care
placement and abuse, PCIT could be used in conjunction with other interventions. The same is true for clients
with special needs.
Diverse population efcacy. Although we recognize that one size does not t all, PCIT has shown
signicant results with ethnic minorities and underserved populations. Different cultural and ethnic group
parenting styles (strict vs. relaxed styles) vary across the United States. In addition to effectively increasing
positive parenting behaviors and deceasing behavioral problems in children, treatment outcomes and efcacy
studies support the notion that PCIT is culturally effective and produces robust modications among diverse
groups (see Bagner & Eyberg, 2007; Borrego, Anhalt, Terao, Vargas, & Urquiza, 2006; Matos, Torres, Santiago,
Jurado, & Rodríguez, 2006; McCabe & Yeh, 2009). Additional literature and empirical research is available for
review regarding work with specic populations such as African Americans and Asians. There also is promising
evidence pointing to PCIT’s efcacy in populations exhibiting neurological and behavioral disorders such as
autism (Tarbox et al., 2009).
Efcacy through translation. Matos et al. (2006) conducted research in Puerto Rico with parents of
children aged 4–6 with ADHD. The manual and handouts were translated into Spanish with a few modications.
Results showed signicant decreases in behavior problems and hyperactivity. A recent follow-up study using
the culturally adapted version further revealed that signicant and robust outcome measures resulted from large
treatment effect sizes. Mothers reported reductions in “hyperactivity-impulsivity, inattention, and oppositional
deant and aggressive behavior problems, as well as a reduced level of parent-child related stress and improved
parenting practices” (Matos, Bauermeister, & Bernal, 2009, p. 246). Additionally, in a single-case study with a
Spanish-speaking foster mother and a 3-year-old Mexican-Chilean-Filipina child, PCIT proved to be effective;
reports from other family members noted substantive behavior improvement (Borrego et al., 2006). Thus, we
can deduce that PCIT can be used effectively across cultural groups.
Key Components
There are three main components of PCIT: child-directed interaction (CDI), parent-directed interaction (PDI)
and cleanup. Depending on the session being held, the components are presented in 5-minute segments with
varying degrees of parent control required. CDI is characteristically the rst stage in PCIT. Similar in approach
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to lial play therapy, this rst stage creates an opportunity to strengthen the parent–child relationship. Because
PCIT is utilized in the context of dyadic play, it is conducted in a room conducive to play (McNeil & Hembree-
Kigin, 2010). Thus, a room designated for CDI should contain a variety of toys, crayons, paper, modeling
compounds and other developmentally appropriate activities for a child. As with other play techniques, in order
to give children the opportunity to determine the rules by which they will play, games with rules are generally
excluded from a CDI playroom. Children engaged in CDI should be allowed to play with any or all of the
items in the room. Encouraging free play indicates to the child that he or she is the creator of the play, not the
caregiver. This approach allows the time to truly be child-directed.
Within CDI, the establishment of a positive therapeutic relationship is a crucial step in building a foundation
for the introduction of compliance training. Compliance training is simply teaching a child to mind or comply
over a period of time, through small compliance goals set by the parents. To lay the groundwork for this process
during CDI, the parents are instructed to praise, reect, imitate and describe their child’s play, while not asking
questions, placing demands or criticizing the activities that transpire unless harmful to the child (McNeil,
Eyberg, Eisentadt, Newcomb, & Funderburk, 1991).
Another essential concept introduced during CDI, includes fostering the enthusiasm and willingness of the
parent. Although responding positively to a child’s free play during CDI may appear simple, parents often
need considerable practice to master this response set. For example, one of the toys in our clinic is a Mr. Potato
Head. Young children can be very creative in their placement of the various accessories that come with the
toy. Often they will place an arm on top of the head, lips on the ear hole or eyes over the mouth hole. In PCIT,
we view this action as an expression of creativity. However, when we observe parents in free play with their
children, we often witness the parents limiting their children’s creativity by redirecting the placement of the
appendages on Mr. Potato Head. Parents often say, “No, honey, the lips go here,” or “That’s not where the arms
go.” Instructing parents to refrain from making such comments is generally all that a PCIT counselor needs to
do. PCIT counselors understand that this is a difcult skill for most parents to master, and they teach parents
the acronym PRIDE for use during CDI as well as other elements of PCIT. PRIDE simply stands for praise,
reection, imitation, description and enthusiasm (Eyberg, 1999). Table 1 provides some practical examples of
desired responses from parents during CDI using the PRIDE approach.
Table 1
Responses Using PRIDE model
Element Example
Praise Parent: “Thank you for putting away the toys.”
Reection
Child: “I’m drawing a dinosaur.”
Parent: “I see. You are drawing a dinosaur.”
Imitation Child is playing with a car. Parent gets a similar car and begins playing in the same manner.
Description Child is playing with a toy airplane. Parent says, “You are making the airplane y.”
Enthusiasm Parent: “Wow. Your drawing is very creative.”
In the second stage of PCIT, PDI usually is initiated once parents master CDI. Mastery is evidenced during
the child’s play by the parents exhibiting proper implementation of the PRIDE responses. PDI also is conducted
in the playroom or room selected for CDI. PDI consists of teaching parents how to manage their child’s
behavior and promoting compliance with parental requests (Bahl, Spaulding, & McNeil, 1999). Parents should
understand that PDI is more difcult for children than CDI and will likely be challenging for both the child and
parent. When beginning PDI, parents must understand the importance of appropriate discipline techniques and
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receive training in giving clear directions to their children. Because children require a great deal of structure,
professional counselors emphasize the importance of consistency, predictability and follow-through in this
training (McNeil & Hembree-Kigin, & 2010). In order to initiate compliance training, parents practice giving
effective instructions to their child. McNeil and Hembree-Kigin (2010) offered several rules for giving good
instructions as part of the parent training element of PDI that can be conceptualized in the following ways:
Command Formation, Command Delivery and Command Modeling:
Command Formation
A. Give direct commands for things you are sure the child can do. This increases the child’s opportunity
for success and praise.
B. Use choice commands with older preschoolers. This fosters development of autonomy and decision
making. (e.g., “You can put on this dress or this dress” rather than “What do you want to wear?” or
“Wear this”).
C. Make direct commands. Tell the child what to do instead of asking whether they would like to
comply (e.g., “Put on your coat”).
D. State commands positively by telling child what to do instead of what not to do. Avoid using words
such as “stop” and “don’t.”
E. Make commands specic rather than vague. In doing so, the child knows exactly what is expected
and it is easier to determine whether or not the child has been compliant.
Command Delivery
A. Limit the number of commands given.
• Some children are unable to remember multiple commands. The child’s opportunity for success
and praise increases with fewer, more direct instructions given at a time.
• When giving too many commands, parents have difculty following through with consequences
for each command. Additionally, the parent’s ignoring some minor behaviors may be best.
B. Always provide a consequence for obedience and disobedience. Consequences are the quickest ways
to teach children compliance. Consistency when providing consequences is the key to encouraging
compliance.
C. Use explanations sparingly. Some children would rather stall than know the answer. Avoiding the
explanation trap prevents children from thinking they have an opportunity to talk their way out of it.
Command Modeling
A. Use a neutral tone of voice instead of pleading or yelling. Interactions are more pleasant in this
manner and the child learns to comply with commands that are given in a normal conversational
voice.
B. Be polite and respectful while still being direct. This models appropriate social skills and thus
interactions are more pleasant.
After teaching parents to deliver effective instructions and allowing time for in vivo practice, professional
counselors introduce appropriate discipline strategies to be used in PDI. The in vivo coaching model utilizes an
observation room with a two-way mirror and the ability to for the counselor to communicate with the parent via
microphone. The focus on training includes communication and behavior management skills with additional
homework sessions (Urquiza & Timmer, 2012). In a study by Shanley and Niec (2010), parents who were
coached via a bug-in-ear receiver with in vivo feedback during parent–child interactive play demonstrated
rapid increases in positive parenting skills and interactions. Of these strategies, timeout is the most common as
it is “a brief, effective, aversive treatment that does not hurt a child either physically or emotionally” (Eaves,
Sheperis, Blanchard, Baylot, & Doggett, 2005, p. 252). Furthermore, Eaves et al. (2005) wrote that timeout
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benets both children with problematic behaviors and those who view the technique being used on other
children, in addition to those children and adolescents demonstrating developmental delays, psychiatric issues
and deance. However, for the parent to experience timeout’s full benet, the technique must be appropriately
and consistently administered. Eaves et al.’s (2005) article, “Teaching Time-Out and Job Card Grounding
Procedures to Parents: A Primer for Family Counselors” is an excellent article on timeout and why it is an
effective intervention.
All aspects of timeout are reviewed with the parents, such as the rationale for timeout, where timeout should
take place in the home, what to do when the child escapes timeout, what to do if the child does not comply
with timeout, the length of timeout, what should happen right before timeout and what should happen right
after timeout. Parents receive written instructions illustrating each step of timeout and offering guidance on
how to implement the procedure. These discipline strategies may not be necessary if a child is motivated to be
compliant. Determining compliance is often a very hard decision for parents to make. According to McNeil and
Hembree-Kigin (2010) there are several rules used to help parents determine compliance or noncompliance.
1. Parents must be sure that the instructions are developmentally appropriate for the child. If the child is
asked to bring the orange cup to the parent, one must know that the child can determine which cup is
actually orange.
2. Parents should know that the request is completely understood by the child. If there are any questions
about this the parents should point or direct the child to help him or her fully understand the request.
3. Parents should allow the child approximately 3 seconds to begin to attempt the task. If the child has not
begun to attempt the task by this time it should be considered noncompliance.
4. Parents should state the request only once. If the child pretends not to hear the request, this should be
considered noncompliance.
5. Parents should not allow the child to partially comply with instructions. If parents accept half-
compliance then children will often repeat the negative behavior because they know they can get away
with it.
6. Parents should not respond to a child’s bad attitude in completing a request. As long as he or she
completes the instruction, it is compliance.
7. Parents should consider it compliance if a child does what is asked and then undoes what is asked.
Compliance is compliance no matter how long it lasts.
When a parent determines that a child is compliant, verbal praise should be provided. This praise should be
given immediately and focus on the child’s compliance.
Parents are encouraged to practice the skills of giving good directions by delivering multiple commands to
the child. These commands are given during the playtime and may include requests to hand things to the parent
(e.g., “Give me the red block”) or play with certain toys (e.g., “Place the blue car in the box”). This activity
allows the child to practice following directions, while also affording the parent the opportunity to practice
praise (McNeil & Hembree-Kigin, 2010). The child begins to learn that when he or she follows directions, his
or her parents are very appreciative and excited. After the small tasks are accomplished, parents begin to place
demands on the child that are less desirable, such as cleaning up the toys or moving on to another task (McNeil
& Hembree-Kigin, 2010). By assigning less desirable tasks, parents nd themselves in a position to practice a
timeout procedure with the child. The professional counselor is there to model timeout and coach the parents
when practicing timeout.
The third and nal component to consider is called cleanup, which occurs as part of PDI. This time during
the PCIT process is exactly what one might think; it is intended to teach the child to clean up the toys at the
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255
end of the parent–child interaction in both the counseling and home milieus. Cleanup should be done without
the parents’ help but with the parents’ direction. Although this component may seem simple, it tends to be a
challenging situation, as signicant behavior problems often are displayed during this phase. The expectation is
that this phase lasts 5 minutes, but time varies depending upon the behavior of the child (McNeil & Hembree-
Kigin, 2010). Cleanup occurs only at the end of parent-directed play, not at the end of child-directed play, to
avoid confusing the child about the role of parental help during cleanup. All three components—CDI, PDI and
cleanup—are opportunities for behavioral observation and data collection.
Implementing PCIT
According to McNeil and Hembree-Kigin (2010), there are six steps in conducting PCIT with a family.
These authors have briey described the contents of each step as well as provided guidelines for the number of
sessions typically devoted to completing the tasks within each step. Step 1 requires one to two sessions for the
intake process, Step 2 requires one session to introduce and teach parents CDI skills, and Step 3 requires two
to four sessions in which the parents are coached on these skills. Steps 4 and 5 introduce and coach the PDI
and may take up to six sessions. The nal session is the follow-up session. These six steps complete a 10- to
15-session triadic training program.
Step 1 is the initial intake and can be accomplished in one to two counseling sessions, unless classroom
or other observations are warranted. These sessions consist of assessing family dynamics, obtaining the
family’s perception of the presenting problems, probing for insights into the current disciplinary beliefs and
methods held by the parents, and observing the natural interactions between parents and child. In addition to
the information-gathering component, the clinician denes the parameters of the sessions as well as the rules
and expectations. Certain parameters involve an understanding by the parents that this CDI time is designated
for the child to lead and for the parent to follow—a time often described to the parents as time-in for the child.
Thus, time-in is dened as a time when the child facilitates play by selecting the type of play and initiating all
play interactions.
The initial informal observation usually takes place in a sitting area while the family is waiting to visit with
the counselor. In this informal observation, the counselor looks for “the child’s ability to play independently,
strategies the child uses to engage the parent’s attention, parental responsiveness to child overtures, parental
limit-setting, warmth of parent-child interactions, and evidence of clinging and separation anxiety” (McNeil
& Hembree-Kigin, 2010, p. 20). After this stage of observation, a more formal observation is completed using
the Dyadic Parent–Child Interaction Coding System (DPICS; Eyberg & Robinson, 1983). This observation is
typically accomplished in three 5-minute increments in which behaviors and verbalizations are marked on the
DPICS sheet. The formal observation occurs over the three PCIT stages previously described—CDI, PDI and
cleanup. Following the initial observations, a third observation may be executed as a classroom observation.
This type of observation is done with students who attend day care, preschool or elementary school, and allows
one to see the child interact within his or her daily environment. Observation occurring in an alternate setting
increases the chances of obtaining normative behavior (McNeil & Hembree-Kigin, 2010).
In Steps 2 and 3, the counselor presents and provides coaching on the CDI skills. Step 2 typically requires
one counseling session. During this time the parents are taught the behavioral play therapy skills of CDI. The
third step, coaching the CDI skills, may take two to four sessions depending on how the family adopts these
principles into their daily interactions with their child. Coaching is described as modeling the behavior for the
family, allowing the family to practice in session with feedback and prompts as needed, assigning the family
homework to practice, and then repeating these steps until the parents are comfortable and uent in the process.
256
In Steps 4 and 5, respectively, the counselor teaches and coaches the parents about discipline skills. These
skills include both PDI and compliance training. Step 4 is typically accomplished in one session. Coaching may
last from four to six sessions. Again, coaching is described as modeling, in-session practice with feedback and
prompts, assigning homework, and evaluating success.
Step 6 consists of having a follow-up counseling session. This session is an opportunity to assess the
family’s progress with proper implementation of each component of the PCIT model, gauge the strides made
in compliance and assess the overall family satisfaction gained throughout the journey. Finally, one should
use boosters to help parents maintain learned skills as they face new challenges with their children. Table 2
delineates the steps to implementing PCIT over a typical 10–15-session treatment plan.
Table 2
Implementing PCIT
Step Number of sessions Process
1 1–2 Informal and formal observation
2 1 CDI
3 2–4 Coaching CDI skills
4 1 Teaching discipline skills via PDI and compliance training
5 4–6 Coaching
6 1 Follow-up
Case Study
PCIT was selected for use in the treatment of Manny, a 6-year-old Hispanic male diagnosed with autism
and noncompliant to his mother. Like many children with autism, Manny had difculty with unpredicted
changes and verbalization of concerns. As Manny’s frustration with communication increased, he demonstrated
stereotypies such as hand apping and eventually progressed to tantrum behavior. The two goals of treatment
were to increase the frequency of appropriate verbalizations and to decrease the frequency of inappropriate
behavior including physical aggression, noncompliance and making noises. Manny was experiencing other
issues related to autism, but his mother indicated that the behavioral problems were preventing him from
making progress in other area.
As a result, we decided to conduct a functional behavior analysis prior to beginning treatment. This
assessment of Manny’s behavior indicated that some of the behavior disruptions were a means of seeking
attention, and therefore it was determined that PCIT would teach the mother to provide more consistent
attention for appropriate behavior and to encourage appropriate communication more effectively. If needed,
the addition of the timeout component was available after the mother began adequately attending to Manny’s
appropriate behavior and ignoring inappropriate behavior.
Session 1
The counselor explained the procedure and rationale for PCIT to the mother, including CDI, PDI and
timeout. CDI was modeled and demonstrated with Manny. The mother was uncomfortable about being judged
on her parenting skills, so it was decided that she would practice the skills at home using the Child’s Game
nightly with Manny. The Child’s Game is simply dened as any free play activity the child chooses. The family
would return to the clinic in 1 week.
The Professional Counselor/Volume 5, Issue 2
257
Session 2
The counselor reviewed CDI and had the mother conduct the Child’s Game for 5 minutes. During CDI, the
counselor observed and noted the mother’s responses. The mother included 13 questions, one criticism and one
demand in the 5-minute session. The mother praised Manny frequently, but did not use the other desired skills
often. Manny was compliant with the demand that the mother gave and did not exhibit any of the disruptive
behaviors. Following the CDI, feedback was given to the mother about increasing descriptions, reections,
imitations and praises, and reducing questions. The mother also was encouraged to recognize and praise
communication attempts. Overall, the mother was directed to allow Manny to lead the play. When queried
about CDI practice at home, the mother reported that the activity the family had used for the Child’s Game was
watching television. Because there is no inherent interaction in television viewing, the mother was directed to
provide a choice to play with action gures or art materials, both indicated as reinforcing by Manny, in place of
video games or television. The Child’s Game was again given as homework.
Session 3
The professional counselor reviewed CDI and viewed the family during the Child’s Game. The mother
showed improvement using descriptions (16), reections (3), imitations (1) and praises (15). She also limited
her use of questions (6), criticisms (0) and demands (0). However, Manny exhibited disruptive behavior in 23%
of the observed intervals. The mother also reported that Manny continued to be noncompliant and make noises
at home. The professional counselor introduced PDI and timeout. Each was modeled with Manny, and his
mother was allowed to practice and receive feedback. Homework was to continue the Child’s Game, issue 10
demands throughout the day and follow through with the brief timeout procedure. Also, the mother was asked to
develop ve house rules to bring the following week. To keep a record of the number of instructions with which
Manny complied before going to timeout, and the number of timeouts per day, the mother received a homework
compliance worksheet to keep for 1 week. This log allows the parent to record the homework—in this case,
using the Child’s Game daily, issuing 10 demands throughout each day and recording the Manny’s compliance
to each, and using timeout as indicated.
Session 4
The counselor reviewed PDI, giving effective instructions and timeout to begin the session. The counselor
then observed the family during CDI/PDI. The mother gave clear, concise instructions six out of nine times,
only failing to wait before reissuing instructions when Manny did not immediately comply. Manny complied
with all issued demands except when the mother reissued the demands too quickly. The mother followed
Manny’s compliant behavior with praise statements four out of nine times. Manny was put in timeout for
disruptive behavior and the mother used the procedure correctly. Manny demonstrated disruptive behavior
during 33% of the observed intervals. A review of the homework compliance worksheet from the previous week
indicated that Manny complied with 10 out of 10 instructions on 5 out of 9 days, and nine out of 10 instructions
the remaining 2 days. The mother was encouraged to continue generalizing the skills she had learned throughout
the day. The house rules developed by the family over the previous week were discussed and worded in positive
statements and then introduced to Manny. The rules were explained and both examples and non-examples were
modeled. Homework was given to continue incorporating the Child’s Game, issuing 10 demands in a brief
period of time, using timeout as needed and recording compliance rates for 1 week.
Session 5
The counselor reviewed PDI, EID, timeout and the homework compliance worksheet. The mother indicated
that Manny had been compliant before timeout 10 out of 10 times for 6 days and nine out of 10 times for 1 day.
The mother also noted that Manny had been placed in timeout for breaking house rules. The mother reported
that Manny’s behavior had improved and he had had fewer tantrums related to schedule changes. She was
encouraged to continue using the PCIT skills and adapting them to more situations. Because compliance was
258
increasing, it was not necessary to continue CDI and PDI in this session. The family was given homework to
continue the Child’s Game, PDI, using timeout as needed and recording compliance rates. This time, the family
was to work at home for 2 weeks before the next session.
Session 6
The counselor reviewed the family’s progress and addressed further generalization and concerns about
daycare. The mother indicated that the child had been compliant before timeout on 10 out of 14 days. Two
of the other days Manny had been placed in timeout 10 times and six times for violating house rules. The
zero out of 10 compliance rating occurred during his birthday party, and the six out of 10 compliance rating
was primarily the result of an unexpected trip to the grocery store. The family was again given homework
to continue practicing generalizing CDI, PDI, using timeout as needed and recording compliance rates for 2
weeks.
Session 7
The counselor addressed concerns including the beginning of school in a few weeks and provided
suggestions to ease the transition. While the mother indicated that Manny had been compliant before timeout on
only 4 of the previous 14 days, a review of the compliance rates revealed that on the other 10 days, Manny was
compliant no less than 80% of the time. These compliance rates from various family settings were indicative of
behaviors being generalized across settings. The mother also showed evidence of her generalization of skills by
adapting the house rules to address new problematic behaviors. The family was encouraged to begin reviewing
material learned in the previous session and work on behavioral skills such as sitting for appropriate lengths of
time. The mother was instructed to continue both the use of her attending skills in order to reinforce appropriate
behavior, as well as the use of the timeout procedure to diminish inappropriate behaviors.
Session 8
For the nal follow-up session, the counselor reviewed the family’s progress and determined that treatment
goals were met. Concerns about how to get other family, friends and teachers to use PCIT skills with Manny
were addressed in this nal session. The family noted the improvements made as a result of PCIT and felt
equipped to maintain the behavioral changes gained as a result of this counseling approach. Termination of the
PCIT intervention was appropriate at this time; the case provided clear evidence of the application and utility
of the PCIT model. Manny’s mother was offered the opportunity to continue interventions related to the other
autism-specic issues that Manny was experiencing.
Conclusion
Professional counselors, whether working with children who have disruptive behavior or providing parenting
training to families, should be knowledgeable of the application of various behavioral techniques in order
to utilize them effectively and to teach them to parents. Researchers have proven that when implemented
appropriately, PCIT procedures are effective in reducing undesirable and problematic behaviors in children and
adolescents. Furthermore, it is clear that PCIT can be effectively applied to behavioral issues faced by children
with special needs. We suggest that counselors who are interested in PCIT seek additional training to develop
mastery of the techniques.
PCIT is a complex process that is often mistakenly viewed as simplistic. Thus, counselors who use PCIT
without appropriate training will likely provide ineffective parental coaching. This point is especially poignant
when working with children who have special needs. These children often present with numerous signicant
issues and deserve appropriate application of evidence-based intervention. We strongly suggest that counselors
complete the web-based training provided by the University of California at Davis Children’s Hospital. The
The Professional Counselor/Volume 5, Issue 2
259
training is free and can be accessed at http://pcit.ucdavis.edu/pcit-web-course//. Given that PCIT is an effective
approach and that the effectiveness of the model increases with appropriate education, professional counselors
who further educate themselves on PCIT’s uses and applications can benet their practices and the families they
serve through the correct use of this empirically validated method of behavioral family counseling.
Counselors who are interested in PCIT also should consider advancing research related to counseling
applications. While PCIT has been shown to be an effective intervention for autism and other disorders, more
research is needed. We encourage counselors to consider implementation of studies that determine outcomes of
PCIT for various child disorders and to conduct program evaluation for PCIT-based clinics.
Conict of Interest and Funding Disclosure
The authors reported no conict of
interest or funding contributions for
the development of this manuscript.
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The Professional Counselor
Volume 5, Issue 2, Pages 261–272
http://tpcjournal.nbcc.org
© 2015 NBCC, Inc. and Affiliates
doi:10.15241/ml.5.2.261
Monica Leppma, NCC, is an Assistant Professor at West Virginia University. Judit Szente is an Associate Professor at the University
of Central Florida. Matthew J. Brosch is a master’s student at West Virginia University. Correspondence can be addressed to Monica
Leppma, Allen Hall 502-F, PO Box 6122, Morgantown, WV 26506, [email protected].
Monica Leppma
Judit Szente
Matthew J. Brosch
Advancements in Addressing Children’s Fears:
A Review and Recommendations
Media and societal conditions affect fear development in youth; thus, counselors must remain current in their
understanding of these fears in order to meet children’s health, educational and developmental needs. Because of
the changing content and course of children’s fears, it is imperative that treatment approaches evolve concurrently.
Therefore, there is a need for a review and expansion of the current understanding of children’s fears and anxiety
and related treatment considerations. This article aims to connect research and literature regarding children’s
fears with current conceptions of emotions, affect regulation and resilience in order to advocate for a holistic and
modern approach for addressing fear in children.
Keywords: affect regulation, anxiety, children, fears, resilience
More than a century of research conrms the need for professional counselors to remain current in their
understanding and treatment of the fears of children and adolescents (Burnham, 2009; Hall, 1897; Jersild
& Holmes, 1935). When discussing youths’ fears, the literature includes the terms fear, anxiety and anxiety
disorders. Fear is dened as a distressing emotion resulting from a real or perceived threat, and anxiety is
the anticipation (i.e., fear) of a potential future threat (American Psychiatric Association [APA], 2013). The
terms fear and anxiety are often used interchangeably or in tandem in the literature as they appear to reect
similar underlying neurobiological processes. Anxiety disorders are included in the discussion because they are
psychological disorders that are viewed as developmentally inappropriate or as reecting pathological levels of
fear and anxiety (APA, 2013; Klein, 2009).
While the content and severity of children’s fears varies greatly, the evidence is clear that as society
changes, approaches to treating children’s fear and anxiety must be adapted (Burnham, 2009). Burnham (2009)
concluded that contemporary fears of today’s youth are inuenced by global events (such as natural disasters,
war and terrorism), societal changes, and television and media exposure. Stress and negative events contribute
to heightened fear responses in children (Ollendick, Langley, Jones, & Kephart, 2001). Any stressful incidents
that children experience have the potential to generate fear-related disorders (Robinson, Rotter, Robinson,
Fey, & Vogel, 2004). Because of the ever-changing nature of society, it is essential for counselors to remain
cognizant of the impact that current events might have on the children with whom they work, particularly in
relation to their fears and coping mechanisms.
Current literature points to positive emotions and affect regulation as means of increasing resilience
(Fredrickson, 2001; Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008; Hannesdottir & Ollendick, 2007).
Resilience, or the ability to overcome adversity, is an essential component of coping with fears and anxiety
effectively (Masten, 2001). The increase in adversities during the past decade, such as terrorist attacks, war,
262
hurricanes and school shootings (Burnham, 2005, 2007, 2009), warrants a renewed focus on children’s fears and
the promotion of resilience (Burnham, 2009; Tugade, Fredrickson, & Barrett, 2004).
Fears, worries and other stressors (e.g., academic issues, conict, change) are typical aspects of human
development; however, children often do not learn effective or appropriate skills to help them cope with these
challenges (Robinson et al., 2004). Although children may develop coping mechanisms in the absence of direct
instruction, these are often avoidant mechanisms that lead to poorer outcomes (Abei, Giger, Plattner, Metzke,
& Steinhausen, 2013). Maladaptive fear responses can lead to the development of anxiety disorders (Kiel &
Buss, 2014). Anxiety is the most prevalent childhood disorder and a strong predictor of adult psychopathology
(Weems & Silverman, 2006). Thus, teaching children helpful ways to cope with fears can promote healthy
development.
The need for developing effective coping skills in children is most evident during times of natural disasters
and global crises (Burnham, 2009). During these periods, children are at increased risk for developing situation-
specic fears. For instance, children who witnessed the September 11
th
attacks became more fearful of war and
terrorism as a result (Burnham, 2007). This increased fearfulness also is the case for children who experience
natural disasters such as earthquakes, wildres and even lightning strikes (Dollinger, O’Donnell, & Staley,
1984).
In addition to dealing with global crises or natural disasters, counselors must be able to help children with
everyday problems such as graphic media coverage of war and disasters, teasing, bullying, family conict,
economic problems, and academic failure (Burnham, 2009). For example, Robinson, Robinson, and Whetsell
(1988) found that children’s fears of people and of being alone have increased since early research began
on children’s fears in the 1900s. While the causality behind this change is unknown, the authors suggested
possible associations with increased exposure to violent media coverage, changes in family structure and the
rise in programs teaching about stranger danger. There is increasingly more evidence that television and other
media contribute to children’s fears (Burnham, 2009; Burnham & Hooper, 2008; Lahikainen, Kraav, Kirmanen,
& Taimalu, 2006). Furthermore, children’s fears are not relegated only to realistic or plausible events.
Elementary school-aged children, in particular, have a limited conception of the world and tend to confuse
reality and fantasy, which can lead to unnecessary fears and distorted assumptions (Moses, Aldridge, Cellitti, &
McCorquodale, 2003). This conuence presents children with a vast range of potential fears, and their inability
to cope with such fears can have devastating effects.
It follows, then, that counseling approaches for fear-related problems in children should evolve
commensurately with contemporary society, and professional counselors must improve their current practices
for the treatment of children’s fears. The rst step in this process is to identify areas that can be improved
in order to accentuate current treatment modalities. The purpose of this article is to provide an overview of
the emerging research relevant to the fear and anxiety experienced by school-aged children and adolescents.
More specically, this article aims to bring together new research and theory on positive emotions that can aid
professional counselors in cultivating resilience and affect regulation in the children with whom they work.
To this end, the following article explores the following: factors related to fear development in children and
adolescents (children throughout this paper refers to children and adolescents), issues related to treatment, and
implications for counselors.
Fear Development
Considerable literature exists outlining the normative progression of fear development in children (e.g.,
Burnham, 2005, 2009; Driessnack, 2006; Elbedour, Shulman, & Kedem, 1997; Lahikainen, Kirmanen, Kraav,
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& Taimalu, 2003; Lahikainen et al., 2006; Robinson, Rotter, Fey, & Robinson, 1991; Robinson et al., 2004;
Sayfan, 2008). Research over the decades has indicated that common fears of children include the broad
categories of animals, darkness, death and the supernatural. However, research also demonstrates that the
content of youth’s fears changes along with the advancement of technology, incorporating elements that have
become socially relevant and discarding those that have become obsolete (Burnham, 2009).
The fear response consists of three components: thoughts, emotions and physical sensations (Hannesdottir &
Ollendick, 2007; Robinson et al., 2004). Distressing events stimulate fear and anxiety in children, but fears also
can arise when a child anticipates possible risk of injury, pain or loss (Burnham, 2009; Robinson et al., 1991).
As an upsetting event proceeds from either a real or imagined threat, this anticipation of injury, pain or loss can
evoke a fear response in a child. Thus, fear can develop from actual events or from beliefs and perceptions.
While excessive childhood fears are correlated with adult psychopathology, it should be noted that fear is a
normative aspect of childhood development, so fears themselves are not considered the problem (Moses et al.,
2003; Robinson et al., 1988). In fact, there are positive aspects of fear, such as self-preservation, galvanizing
of internal coping resources, improved focus and an increased sense of vitality (Goud, 2005; Robinson et al.,
1988; Robinson et al., 1991), but the negative effects of children’s fears can be serious. Fears may disrupt sleep,
create exhaustion and hinder performance (Cartwright-Hatton, 2006; Robinson et al., 1991). Moreover, children
suffering from fear often exhibit diminished academic achievement because fear interrupts motivation and the
ability to concentrate (Moses et al., 2003; National Scientic Council on the Developing Child, 2010).
Researchers still do not completely understand the etiology of childhood fears and anxiety (Ollendick
et al., 2001). It is likely that fear development involves some hereditary predisposition and genetics (Eley,
Rijsdijk, Perrin, O’Connor, & Bolton, 2008; Klein, 2009). There is evidence that children’s characteristics and
temperaments inuence their fear development (Weems & Silverman, 2006). For example, Muris and Ollendick
(2005) found a link between fearful or inhibited temperament and childhood anxiety disorders. Overall, research
indicates that there is a moderate correlation between genetics and fear-related symptoms, but fear and anxiety
appear to arise from a complex interaction among a variety of factors (Weems & Stickle, 2005). Researchers
believe that behavioral (Ollendick et al., 2001; Weems & Stickle, 2005) and social learning also play a part.
Behavioral and Social Learning Factors
The behaviorally based factors in fear acquisition include (a) exposure to negative stimuli, (b) conditioning
through negative experiences, (c) social learning through others’ modeling or (d) exposure to upsetting
information (Muris, Merckelbach, Gadet, & Moulaert, 2000; Ollendick et al., 2001). For example, Dubi,
Rapee, Emerton, and Schniering (2008) found that toddlers indicated fear of objects based on their mother’s
positive or negative reaction to the object, regardless of the child’s temperament, which supports a social
learning aspect to fear acquisition. There is additional empirical evidence that fear acquired indirectly through
social observation, with no personal experience of the aversive event, engages similar neural mechanisms as
traditional behaviorally based stimulus-response fear conditioning (Olsson, Nearing, & Phelps, 2007). Field,
Lawson, and Banerjee (2008) found support for the effect of verbal information on persistent fear acquisition
in children. These studies reinforce the notion that fear can be acquired through behavioral and social learning
factors. Fears resulting from behaviorally based factors have been correlated with anxiety, phobias (fearful or
anxious responses to, or avoidance of, specic objects or situations; APA, 2013), and behavior problems in
children (Gao, Raine, Venables, Dawson, & Mednick, 2010).
Cognitive Factors
In addition to behavioral and social learning explanations of fear acquisition, there is evidence for cognitive-
based fear development. Research indicates that some fears are associated with maladaptive thinking patterns
264
(King, Muris, & Ollendick, 2005). Maladaptive thoughts can take the form of negative self-appraisal, negative
self-talk or dysfunctional evaluation of circumstances (King et al., 2005). Sayfan and Lagattuta (2008) found
that children between the ages of 3 and 7 are more aware than previously believed regarding the relationship
between fears, beliefs and knowledge. Fearful children experience numerous cognitive distortions such
as a tendency to doubt their ability to cope, overestimation of the likelihood of adverse consequences and
interpretation of threatening information in a distorted manner (Prins & Ollendick, 2003). This habitual negative
assessment of circumstances is associated with elevated fear and anxiety (Ollendick et al., 2001). Schell,
Dawson, and Marinkovic (1991) suggested that fear development is a complex process that includes autonomic
conditioned responses in addition to cognitive and emotional components. Cognitive factors, therefore, play a
clear role alongside behavioral and social learning explanations of fear development.
It is important to note that children’s fears can intensify over time if they are not addressed appropriately
(Moses et al., 2003). Gao et al. (2010) found 3 to 8 year olds’ fear conditioning increases with age, with
the most substantial increase occurring between the ages of 5 and 6. Unresolved childhood fears may have
deleterious effects on development and contribute to adult mental illness (Moses et al., 2003; Saavedra,
Silverman, Morgan‐Lopez, & Kurtines, 2010). This information suggests that addressing and treating fears in
childhood may be an effective means of preventing fear-related psychopathology in adulthood.
Treatment
Cognitive-behavior therapy (CBT) is the most widely used and empirically supported treatment for fear-
related disorders. Research demonstrates that CBT is effective for 60–70% of children, leaving about one-third
of the population who do not respond to CBT (Hannesdottir & Ollendick, 2007; Trosper, Buzzella, Bennett,
& Ehrenreich, 2009). Because a sizeable number of children do not appear to benet from CBT, it seems
worthwhile to examine additional approaches or adjuncts to traditional CBT that may be effective in treating
fearful children.
Affect Regulation
Awareness of emotions is the foundation of affect regulation (Suveg, Hoffman, Zeman, & Thomassin, 2009).
Affect regulation, as dened here, is the intentional process that an individual employs to modify emotional
states in order to achieve desirable social and individual goals (Eisenberg & Spinrad, 2004). This denition
refers to controlling both negative and positive emotions, and encompasses understanding and expressing
emotions (Hannesdottir & Ollendick, 2007; Ursache, Blair, & Raver, 2012). Research suggests that absence of
emotion regulation skills often lead to the development of anxiety disorders (Esbjørn, Bender, Reinholdt-Dunne,
Munck, & Ollendick, 2012; Hannesdottir & Ollendick, 2007; Weems & Silverman, 2006). This research on the
role of emotion regulation in fear development is relevant to counselors working with the contemporary fears of
children and adolescents.
Consequently, research indicates that the missing link in CBT approaches for working with fear-related
issues in youth is greater emphasis on affect regulation (Hannesdottir & Ollendick, 2007; Suveg & Zeman,
2004). In other words, children who do not respond successfully to traditional CBT may need a more extensive
education and greater focus on regulating emotions beyond feelings of anxiety. Children with fear-related issues
tend to experience more negative thoughts and feelings than neutral or positive ones. Learning to correctly
identify emotions across varying situations (both positive and negative) helps children gain a sense of control
over their feelings (Hannesdottir & Ollendick, 2007). Thus, as an adjunct to CBT techniques such as relaxation
training and cognitive restructuring, counselors can teach children and adolescents how to identify and manage
their full range of emotions.
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Emotional dysregulation is dened as a limited ability to control and modulate feelings in order to allow
successful functioning in social relationships and emotional well-being (Hannesdottir & Ollendick, 2007;
Ursache et al., 2012). Fearful children tend to avoid experiencing anxiety-provoking situations as well as
discussing the associated negative emotions. This avoidance behavior is believed to contribute to emotional
dysregulation because it denies opportunities for successfully managing triggered emotions (Hannesdottir &
Ollendick, 2007). As a consequence, anxious and fearful children lack a sense of mastery over their internal
emotional reactions (Weems, Silverman, Rapee, & Pina, 2003). Exposure therapy is an important and effective
component of CBT that addresses avoidance behavior by behaviorally desensitizing children via gradual
exposure to a hierarchy of fears until the fear response subsides (Hannesdottir & Ollendick, 2007; Trosper,
Buzzella, Bennett, & Ehrenreich, 2009). While exposure helps children acclimate to anxiety-provoking
situations or objects, it is unknown whether exposure improves children’s ability to cope with associated
emotions (Hannesdottir & Ollendick, 2007). In those cases where the child does not appear to respond
successfully to exposure therapy, or regresses to pathological reactions, counselors can consider additional
affect regulation strategies and interventions.
In one example of an affect regulation intervention, the counselor and client each choose an emotion they
are experiencing from a feelings chart. Next, the counselor models for the child a discussion of how he or she
knows they are feeling that way and why. Finally, the child is given the opportunity to do the same. This process
helps the child understand specic emotions, normalizes the experiencing of emotions and models effective
communication about emotions. Another suggestion is to utilize vignettes or stories to elicit specic emotions,
process these emotions with the client and then brainstorm ways to manage the emotions (Suveg, Kendall,
Comer, & Robin, 2006). Bibliotherapy also has been shown to be particularly helpful when working with
fearful children (Moses et al., 2003; Robinson et al., 2004).
Interventions such as these help children acquire a repertoire of emotion regulation skills (Suveg et al.,
2006). Fearful children must learn to become aware of their internal emotional states and then express or
discuss their emotions effectively (Ursache et al., 2012). Building upon children’s emotional awareness can be
a useful adjunct in enhancing other skills training that counselors provide in their sessions with fearful children
and adolescents. Suveg et al. (2006) suggested that treatment for fear-related issues should encompass all
emotions that children may have difculty regulating, not solely fear and anxiety. Learning to correctly identify
emotions helps children and adolescents gain a sense of control over their emotions and self-efcacy to change
their emotional state (Hannesdottir & Ollendick, 2007).
Researchers posit that explicitly targeting affect regulation would improve treatment outcomes for youth
with fear-related disorders (Hannesdottir & Ollendick, 2007; Trosper, Buzzella, Bennett, & Ehrenreich, 2009).
The ability to self-regulate emotion incorporates autonomy, self-efcacy, adaptability, positivity and prosocial
behavior (Hannesdottir & Ollendick, 2007; Ursache et al., 2012). In addition, current research suggests that
professional counselors should provide interventions and psychoeducation on positive emotions to promote
emotion regulation and resilience in children and adolescents (Gloria & Steinhardt, 2014; Hutchinson & Pretelt,
2010).
Positive Emotions
Fredrickson’s (1998, 2001) broaden-and-build theory of positive emotions provides a framework for
understanding the role of positive emotions in fostering resilience. Negative emotions, such as fear and anxiety,
narrow one’s focus and attention as a survival mechanism in preparation to either confront or avoid a perceived
threat. This is known as the ght or ight response. However, this type of narrow, focused response also can
cause people to become stuck by limiting exibility and creativity in nding new solutions (Hannesdottir
266
& Ollendick, 2007; Hutchinson & Pretelt, 2010; Tugade et al., 2004). Negative emotions are central in the
development of psychopathology because they tend to foster higher levels of arousal than positive emotions
(Suveg et al., 2009). This information is relevant to working with youth experiencing fear-related problems,
because “people have limited ability to think of and evaluate different solutions when they are overwhelmed by
negative emotions in a stressful situation” (Hannesdottir & Ollendick, 2007, p. 286).
The cultivation of positive emotions such as joy, gratitude, hope, serenity, interest and inspiration builds
resilience in the form of enduring internal and social resources that one can draw upon when necessary
(Fredrickson, 1998). Positive emotions help discard old negative patterns of thought and behavior to pursue
novel ideas and actions (Fredrickson, 2001; Isen, 2009). Positive emotions also are a source of human strength
that facilitates exibility, creative problem-solving and more efcient and open-minded thinking, all important
factors in resilience (Fredrickson, 2001; Isen, 2009). Experiencing positive emotions broadens individuals’
perspectives and reduces self-focus, allowing for a greater variety of behavioral responses (Isen, 2009).
Moreover, experiencing positive emotions creates an upward spiral wherein positive emotions build upon each
other to foster emotional and psychological well-being. Positive emotions also facilitate broad-minded and
exible thinking, which in turn, increases coping and problem-solving ability. Successful coping then leads to
more positive emotions (Tugade et al., 2004). Furthermore, successful coping and problem-solving cultivate
self-worth in children, which fosters a sense of self-efcacy and belief in their capacity to successfully handle
stressful situations (Cloitre, Morin, & Linares, 2010; Robinson et al., 2004).
Positive emotions build physical, social, emotional and intellectual capacity to confront and overcome
obstacles (Fredrickson, 2001; Tugade et al., 2004). For example, the positive emotion of joy prompts play,
motivation and exploration. There is evidence that play contributes a wide array of resources for children
(Trice-Black, Bailey, & Riechel, 2013). Imaginative play provides a safe environment for pretending and
experimenting with emotional expression, which is important to developing emotion regulation (Lester &
Russel, 2010). In fact, Hoffman and Russ (2012) found a relationship between imaginative play, positive affect
and emotion regulation in 5- to 10-year-old girls (n = 61). Furthermore, the pushing of limits and exploring
that occurs during play increases a child’s sense of self-efcacy and provides new information about the
environment (Lester & Russel, 2010). Play can build physical resources of agility, coordination and strength.
Play also promotes social resources such as connection, bonding and social skills (O’Connor & Stagnitti,
2011). In addition, play fosters the intellectual resources of problem-solving, creativity and the learning of
new information (Fredrickson, 2001; Lester & Russel, 2010; Trice-Black et al., 2013). Finally, play cultivates
psychological and emotional resources such as optimism, goal-orientation, a sense of identity (Fredrickson,
2000, 2001), and increased self-worth (Hippe, 2004). Thus, the positive emotions involved in play promote a
number of factors that build resilience.
The resources developed from joy and other positive emotions such as love, gratitude, awe, amusement,
interest and hope can become adaptive features that may enhance resilience in the face of future adversity.
Repeated experience of these positive emotions builds internal and social resources that accumulate over time
and can be drawn upon in times of need (Fredrickson, 2001). Positive emotion-based coping strategies, such as
positive reappraisal and infusing meaning into experiences, have been shown to buffer against stress (Folkman
& Moskowitz, 2000). There is additional evidence that cultivating positive emotions during times of adversity
also may replenish the ability to cope (Tugade et al., 2004).
In addition to buffering against stress, generating positive emotions seems to have an undoing effect. In
other words, positive emotions appear to serve as an antidote to the effects of negative emotions such as fear
and anxiety (Fredrickson, 2003) and therefore can reinforce resilience. For example, Fredrickson and Levenson
(1998) demonstrated that the elicitation of positive emotions increased the speed of cardiovascular recovery
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following a distressing event. This increased resilience to a distressing event is an encouraging sign that positive
emotions, which can be achieved through emotion regulation, have a benecial effect during times of distress.
Thus, cultivating positive emotions may improve youths’ responses to negative or stressful situations and
counteract the effects of chronic worry or fear (Hannesdottir & Ollendick, 2007).
The key for counselors is to ll their therapeutic toolboxes with interventions that directly target the
spectrum of emotions and affect regulation. It is important to remember that affect regulation requires the
ability to distinguish between all emotions. Interventions should include teaching skills for generating positive
emotions as a means of building internal and social resources. Fredrickson (2009) proposed a positivity ratio of
three positive emotions for every negative emotion to develop resilience. In other words, experiencing a greater
quantity of positive emotions over time helps to buffer against, and undo, the negative effects of stress.
Resilience and Emotions
Burgeoning research points to the importance of understanding the relationship between fear-related
disorders and emotions in order to promote resilience in children. Esbjørn et al. (2012) cited evidence of a link
between anxiety symptoms (e.g., overwhelming fear, worry, agitation, heart palpitations) and lack of emotion
regulation skills. Moreover, fearful children tend to have an even more limited understanding of emotions in
general than their normative peers (Hannesdottir & Ollendick, 2007; Suveg et al., 2009). Research ndings have
suggested that children diagnosed with anxiety disorders also report experiencing higher levels of emotional
intensity and somatic symptoms in response to emotions than children without anxiety disorders (Suveg et
al., 2009; Suveg & Zeman, 2004). Finally, there is evidence of a relationship between the inability to regulate
emotion and heightened levels of negative emotion (Esbjørn et al., 2012; Suveg & Zeman, 2004). Conversely,
research indicates that resilient people demonstrate greater positive emotionality (Tugade et al., 2004). These
ndings all suggest that emotions and emotion regulation play an integral role in the development, course and
potential modulation of fear-related disorders as well as the development of resilience.
In fact, Gloria and Steinhardt (2014) found, in a sample of 200 postdoctoral fellows, that positive emotions
were directly related to greater resilience. Their ndings suggested that positive emotions were positively
related to adaptive coping and negatively related to maladaptive coping. In addition, resilience moderated
the relationship between stress and trait anxiety and depressive symptoms. The authors concluded that
positive emotions may have the potential to build resilience in individuals experiencing stressful situations,
and resilience may in turn increase positive emotions, thus providing support for Fredrickson’s (1998, 2001)
broaden-and-build theory. These results further support the notion of emphasizing the cultivation of positive
emotions in helping children to build resilience.
Children develop resilience when they successfully manage stressors throughout daily life (Cloitre et al.,
2010). Resilience improves youths’ ability to cope with fear and anxiety and mitigates some of the adverse
effects of fear-related experiences (Burnham, 2009). As mentioned earlier, resilience is a set of qualities
that empowers people to successfully adapt or bounce back when facing some type of adversity (Burnham,
2009; Tugade et al., 2004). Examples of resilient qualities include self-efcacy, internal locus of control,
adaptability, exibility, self-worth, optimism, positivity and social connectedness (Burnham, 2009; Grotberg,
1995; Hutchinson & Pretelt, 2010; Robinson et al., 2004; Tugade et al., 2004). Research indicates that resilient
individuals possess a positive attitude toward life and are curious and open to new experiences (Masten, 2001).
Although the cultivation of resilience is a natural process in child development, it can be inhibited by traumatic
events, temperament, and societal or environmental conditions (Masten, 2001). Improving affect regulation
can help build resilience in youth, which may in turn minimize the negative effects of fearful or anxious
experiences.
268
Implications and Recommendations
We have provided an overview of the current landscape of children’s fears to help delineate a contemporary,
adaptive and holistic approach to treatment. Based on a review of the current literature, we recommend that
counselors incorporate interventions that specically teach emotional awareness when working with fearful or
anxious children. While many CBT interventions implicitly address emotions, we are suggesting that counselors
provide explicit psychoeducation concerning emotions, in order to explain the purpose, importance and range
of emotions. This approach promotes affect regulation skills by helping children to become more aware of how
they are feeling and why, and to adjust their emotional state to allow for a more benecial outcome. Affect
regulation is crucial as it provides children with tools that may be generalized across various situations and
stressors. The major implication is that this broad-based approach equips children with the ability to counteract
future stressors without the need for continued situation-specic interventions.
In addition to a direct emphasis on emotional awareness and regulation, we recommend incorporating
interventions that cultivate positive emotions. While CBT is generally inclusive of the way that thoughts and
feelings are interconnected, there is often little time devoted to the effects of positive emotions in relation
to fears and anxiety. The development of skills that cultivate positive emotions, in addition to challenging
negative thoughts and emotions, can improve resilience to future stressors. Developing skills related to positive
emotions can help fearful and anxious children to maintain an outlook that is more conducive to normative
functioning and resilience than techniques such as cognitive reframing can accomplish alone. This information
is particularly relevant as many CBT approaches focus on the specic presenting fear such as spiders, heights
or social situations. An approach that targets a wider range of emotions with the goal of creating more positive
emotions helps children not just overcome their immediate fears, but may prepare them to adequately confront
and manage future fears.
This focus on positive emotions has the intended benet of promoting resilience. As children learn how to
cumulatively produce positive emotional states, they build resilience that will buffer them against potentially
distressing stimuli. There is burgeoning evidence that generating positive emotions builds resources, broadens
one’s ability to respond to stressors and has an undoing effect on emotions such as fear and anxiety. Research
in the area of positive emotions and positive psychology provides a rich assortment of techniques for building
strengths and resilience (e.g., Seligman, Steen, Park, & Peterson, 2005). We recommend that counselors
incorporate this information into their work with fearful children.
The premise of this paper is that counselors can help ll the current gaps in treatment methodology with
a focus on developing increased resilience in children by teaching affect regulation and positive emotions.
Incorporating these constructs into a counselor’s current approach provides him or her with the widest range of
treatment options in a way that allows children to confront current and future fears in a holistic fashion that is
both specic and generalizable. Giving children access to these tools can prepare them for a range of potentially
fear-inducing experiences in a way that allows them to cope effectively and draw upon their internal resources.
This process continually expands client resilience and self-efcacy, preparing clients to confront a variety of
stressors effectively.
This concentration on affect regulation, resilience and positive emotions appears to be an effective means
of expanding upon current treatment approaches. Further research is recommended in the arena of adjunctive
counseling modalities that are inclusive of resilience, affect regulation and positive emotions in order to
determine their efcacy for those who are unresponsive to CBT. It also would be worthwhile to examine how
these concepts affect treatment when used alongside CBT for those who do respond well to traditional CBT.
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By focusing on these constructs in conjunction with other empirically supported treatments, it is our belief that
children’s outcomes will improve and they will be better prepared to confront not only specic fears in the
present, but myriad potential stressors in the future.
Conict of Interest and Funding Disclosure
The authors reported no conict of
interest or funding contributions for
the development of this manuscript.
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Emily Goodman-Scott, NCC, is an Assistant Professor at Old Dominion University. Simone F. Lambert, NCC, is the Counseling Department
Chair and Associate Professor at Argosy University. Correspondence may be addressed to Emily Goodman-Scott, 110 Education
Building, Old Dominion University, Norfolk, VA 23529, [email protected].
Emily Goodman-Scott
Simone F. Lambert
Professional Counseling for Children With
Sensory Processing Disorder
Sensory processing disorder is a complex neurological disorder affecting approximately 5–17% of the population,
yet professional counselors often misunderstand and misdiagnose this disorder. A child’s academic, emotional and
social functioning can be substantially impacted by sensory processing disorder; early diagnosis and treatment
is crucial. In this article, the authors describe the disorder, discuss its impact on children and their families, and
provide recommendations and resources for both mental health counselors and school counselors to utilize when
serving this unique population with special needs. A case study is included, in addition to suggestions for treatment
collaboration and advocacy on behalf of clients with sensory processing disorder.
Keywords: Sensory processing disorder, special needs, children, school counselors, mental health counselors
Children experience the world through their senses—the sound of the air conditioner running in their
classroom, the feel of a chair under their legs, the sight of a colorful wall, the smell of food cooking, the
muscle movement used to pick up a toy. The typical child can accurately perceive, process and respond to the
myriad stimuli in their environment, focusing on important stimuli, such as a parent’s voice, and ltering out
unimportant ones, such as a humming refrigerator. For other children, the same environment and accompanying
stimuli can be uncomfortable, overwhelming, unnoticeable and even frightening. Researchers estimate that
approximately 5–17% of the population has sensory processing disorder (SPD), a neurological disorder in which
sensory input is irregularly sensed, processed, organized, and responded to, creating sensory challenges that
negatively impact daily functioning (Ahn, Miller, Milberger, & McIntosh, 2004; Ben-Sasson, Carter, & Briggs-
Gowan, 2009). As a result of poor sensory processing, individuals with SPD may overreact or underreact to
stimuli (Byrne, 2009; Dunn, 1997, 2001; James, Miller, Schaaf, Nielsen, & Schoen, 2011; Katz, 2006; Miller,
Anzalone, Lane, Cermak, & Osten 2007; Walbam, 2013; Withrow, 2007). SPD is a lifelong disorder; while
typically developing children gain the ability to increasingly suppress stimuli with age, children with SPD tend
to struggle throughout their lifetime (Davies & Gavin, 2007), particularly if SPD is unidentied, misdiagnosed
or inaccurately treated.
Professional counselors are called to accurately diagnose and treat clients’ mental health and co-occurring
disorders (American Counseling Association [ACA], 2014). However, SPD is widely unrecognized and
misdiagnosed in the counseling eld (Collier & Falls, 2010; Katz, 2006; Murphy, 2011; Withrow, 2007). With
increasing research supporting the legitimacy of the SPD diagnosis (e.g., Chang et al., 2014; Davies & Gavin,
2007; Owen et al., 2013), counselors can be on the forefront of screening and providing counseling services
to children with SPD. This article will provide readers with background information on SPD, implications for
clinical mental health and school counseling practice, a case study example, and recommendations for future
professional education, advocacy and research. In the literature, SPD has been referred to by similar terms such
as sensory integration disorder or categorized by subtype (e.g., sensory modulation disorder). However, the term
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sensory processing disorder (SPD) will be utilized in this article, since SPD is the most prevalent term used in
recent years (Miller, Nielsen, Schoen, & Brett-Green, 2009). Similarly, we will use the term sensory processing
to also encompass sensory integration, as they are often used interchangeably in the literature.
Background
The most commonly known senses are auditory (sound), olfactory (smell), tactile (touch), visual (sight) and
gustatory (taste); two less known senses are proprioception and the vestibular sense (James et al., 2011; Katz,
2006; Withrow, 2007). Proprioception is a sense found in muscles, tendons and joints that deciphers bodily
awareness and coordinated movements. The vestibular sense is located in the inner ear and provides sensory
input regarding one’s balance and gravity. Sensory processing is a complex neurobiological process in which
individuals’ seven senses perceive information or stimuli from the environment, sending data to the brain
to interpret, process and respond to; the senses and brain are constantly engaged in a process of perceiving,
interpreting, processing, and responding to environmental stimuli (Byrne, 2009; Katz, 2006; Miller et al., 2009;
Parham & Mailloux, 2015; Walbam, 2013; Withrow, 2007). Sensory processing is a developmental process, and
thus especially crucial in the children’s rst 10 years of life (Ayres, 1979). In summary, a typically developing
child may easily and accurately perceive and process environmental stimuli, yet this is not the case for all
children.
Sensory processing has been well studied in the occupational therapy profession during the last 50 years,
beginning with the groundbreaking work of Dr. A. Jean Ayres, occupational therapist, psychologist and
neuroscientist (Parham & Mailloux, 2015). During the last several decades Ayres and others discovered patterns
of atypical sensory processing in children, which have collectively come to be labeled as SPD. “Sensory
processing disorder is a heterogeneous condition that includes a variety of subtypes. Individuals with the
disorder have impaired responses to, processing of, and/or organization of sensory information that effects
[sic] participation in functional daily life routines and activities” (Miller et al., 2009, p. 1). Further, Parham
and Mailloux (2015) described SPD as “patterns that emerge developmentally . . . and are thought to reect
subtle neural processing differences involving sensory and motor systems” (p. 266). Thus, children with SPD
struggle with the neurobiological cycle of receiving, sending, processing and responding to stimuli, and they
experience a severity that negatively impacts their daily functioning (Ayres, 1979; Davies & Gavin, 2007; Owen
et al., 2013; Parham & Mailloux, 2015). As a result of skewed sensory processing, individuals with SPD may
overreact or underreact to stimuli, perceiving stimuli to much greater or lesser degrees than peers (Byrne, 2009;
Dunn, 1997, 2001; James et al., 2011; Katz, 2006; Miller et al., 2007; Walbam, 2013; Withrow, 2007). For
example, a crowded indoor playground could be loud to one child, but frightening or even physically painful
for a child with auditory sensitivities. While a typical child may get dizzy from spinning around, a child with an
underdeveloped vestibular system may rarely become dizzy and seek spinning to feel soothed.
Although children with SPD may have neurological similarities, SPD is a highly individualistic disorder that
presents differently in each child and can be described by corresponding subtypes (Dunn, 1997, 2001; James et
al., 2011; Murphy, 2011; Walbam, 2013; Withrow, 2007). While there is consensus on an overarching denition
for SPD, there is not a consistent nosology for describing the subtypes (Miller et al., 2009). Proposed nosologies
of SPD subtypes typically include hyposensitivity, hypersensitivity and sensory-seeking subtypes (Ayres, 1979;
Dunn, 1997, 2001; Interdisciplinary Council on Developmental and Learning Disorders, 2012; James et al.,
2011; Katz, 2006; Miller et al., 2007; Walbam, 2013; Zero to Three, National Center for Infants, Toddlers and
Families, 2005).
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Subtypes
Those with hyposensitivities, one subtype of SPD, often have a high threshold for sensation, are under-
sensitive, and receive or process too few stimuli (Dunn, 1997, 2001; James et al., 2011; Katz, 2006; Walbam,
2013; Withrow, 2007). A child with hyposensitivities may seem to have poor social skills and miss social cues;
some behavioral examples include not hearing a teacher calling his or her name, being unaware of food on
the face, or lacking culturally appropriate personal space. Social skill decits can negatively impact children’s
friendships and group participation in both academic and social environments (Dunn, 1997; Kranowitz, 2005;
Withrow, 2007).
Children with hypersensitivities, a second subtype of SPD, have a low threshold for sensation and may
receive an overwhelming amount of stimuli, be unable to prioritize their sensory messages and be easily
overstimulated (Dunn, 1997, 2001; James et al., 2011; Katz, 2006; Walbam, 2013; Withrow, 2007). As a coping
technique against stimuli perceived as uncomfortable and even painful, children with hypersensitivies may have
heightened alertness, act aggressively toward others in response to perceived threats, and engage in behavioral
outbursts and rigid routines in attempts to avoid or escape stimuli (Dunn, 1997; Withrow, 2007). These children
may be described as generally anxious, aggressive, distracted or unfocused, or as picky eaters.
Lastly, some children with a third subtype of SPD crave and actively seek sensory input and increased
stimuli (Dunn, 1997, 2001). These children may seek constant movement to receive sensations from their
environment, and exhibit behaviors including running, jumping, chewing, tapping, humming and squeezing
(Dunn, 1997, 2001). Individuals with sensory-seeking behaviors may appear impulsive, unpredictable, and have
inappropriate personal space which may negatively impact academics and social relationships. Children who
seek sensations may be described as rambunctious, aggressive, or bouncing off the walls (sometimes literally).
They may seek spicy foods and not be bothered by intense avors.
Sensitivities and sensation seeking occur on a spectrum from mild to severe (James et al., 2011).
Furthermore, these variations can present differently in each of the seven senses (Dunn, 1997, 2001), and
children can even experience both hypersensitivities and hyposensitivities within the same sense (Withrow,
2007). This circumstance may bafe parents, who question how a child can watch a movie at a loud volume
at home, yet be unable to tolerate the noise of a crowded restaurant. Children and the adults around them may
need assistance recognizing children’s placement on the hyposensitivity, hypersensitivity and sensory-seeking
spectrums before, during and after an event which can facilitate children successfully coping and thriving in
various settings.
Prevalence
Researchers have estimated that SPD occurs in approximately 5–17% of children (Ahn et al., 2004; Ben-
Sasson et al., 2009). In one study examining the prevalence of SPD in children 4–6 years old, the parents
of incoming kindergarten students in one U.S. school district (N = 1,796) were asked to complete the Short
Sensory Prole, a parental-report screening tool used to determine parents’ perceptions of SPD correlates (Ahn
et al., 2004). Approximately 14% of those who completed the survey (with a 39% return rate) met the criteria
for SPD. However, researchers conservatively estimated that if all non-responders were free from meeting the
SPD criteria, then approximately 5% of this population would meet the screening criteria for SPD. Thus, the
number of incoming kindergarten students who met the criteria for SPD based on parental perceptions ranged
from 5–14%. Similarly, Ben-Sasson et al. (2009) used a longitudinal birth cohort sample of children to study
sensory over-responsivity (SOR) and related correlates. They found that nearly 17% of the 7–11 year olds in
their study (N = 925) had clinically signicant elevated SOR scores. However, these researchers believe the
number to be a conservative estimate of the population, as children with diagnosed medical and developmental
conditions were excluded from the study.
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Secondary Symptoms
All areas of a child’s life can be impacted by SPD (Walbam, 2013; Withrow, 2007). In addition to children
presenting primary symptoms of the disorder, they often face a host of secondary emotional and behavioral
difculties as a result of the disorder, such as frustration, loneliness, low self-esteem, a greater risk for strained
peer relationships, discouragement, and social, emotional and academic challenges (Champagne & Koomar,
2012; Katz, 2006; Miller, Nielsen, & Schoen, 2012; Walbam, 2013; Withrow, 2007). Also, those with SPD tend
to be more likely to struggle with depression and anxiety than their typically developing peers (Miller et al.,
2012) and may need assistance with self-regulation (Katz, 2006). These secondary symptoms may result from
attempted self-regulation due to negatively perceived sensory stimuli as well as feelings of isolation and being
misunderstood due to undiagnosed, untreated and mistaken symptoms (Miller et al., 2012; Withrow, 2007). In
this article, we describe the experiences of children with SPD as comparable to those of children with special
needs including disabilities and chronic illnesses.
Diagnosis and Treatment
Early SPD diagnosis and treatment is crucial in assisting children with both primary and secondary SPD
symptoms (Ben-Sasson et al., 2009; Byrne, 2009; Miller, 2006). SPD diagnosis and treatment early in life is
highly impactful on a child’s developing brain and behavioral symptoms (Ben-Sasson, et al., 2009; Miller,
2006). While occupational therapists (OTs) are charged with diagnosing and treating the primary symptoms and
underlying conditions associated with SPD, counselors need to be aware of SPD in order to appropriately screen
for, avoid misdiagnosing, make appropriate referrals for, and treat the secondary symptoms related to SPD.
Occupational therapy. Typically, OTs evaluate for and treat SPD (Castaneda, Olson, & Radley, 2013;
Champagne & Koomar, 2012; Katz, 2006; Parham & Mailloux, 2015; Walbam, 2013). Children are often
referred to OTs by parents, teachers and physicians (Parham & Mailloux, 2015); however, before making an OT
referral, physicians need to rule out medical conditions and medication side effects. OTs assist people with daily
living and occupational skills, and they are trained in mental and physical disorders (Castaneda et al., 2013).
Since school is “work” for children, OTs help children with SPD to function more effectively in their academic
work and social living skills. OTs can be school-based or work in community or hospital settings (Castaneda et
al., 2013).
OTs use several strategies to assess for SPD, including interviews and questionnaires, direct observations
(e.g., naturalistic and structured clinical) and standardized testing (Parham & Mailloux, 2015). SPD diagnoses
often begin with the use of a screening tool to determine the existence of symptoms signifying possible
sensory irregularities. The Sensory Prole 2 (Dunn, 2014) is a standardized, parental-report tool for evaluating
children’s sensory processing patterns in various environments and requires a B-level qualication to administer
(Dunn, 2014). The Sensory Integration and Praxis Tests (SIPT) is a popular, recommended and standardized
comprehensive test for measuring sensory integration and requires a C-level qualication to administer (Ayres,
1989). The SIPT was normed on approximately 2,000 children in North America and is considered a valid and
reliable assessment.
The sensory integration approach to occupational therapy is commonly used to treat SPD; the overarching
goal of this intervention is to enable a child’s nervous system to more efciently process and respond to
sensory information (Parham & Mailloux, 2015). Occupational therapy is highly specialized based on the
child’s unique needs and diagnosis. Further, occupational therapy also may include the use of a sensory diet—
an individualized program for children with sensory challenges including a specic combination of sensory
activities throughout the day (Parham & Mailloux, 2015). A sensory diet provides a wide range of sensory input;
for example, activities may evoke the senses through music, new smells, visual stimulus, as well as “movement,
heavy work, or tactile stimulation” (Hall & Case-Smith, 2007, p. 212).
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Clinical diagnosis. The occupational therapy profession has treated SPD for decades. Furthermore, the SPD
Scientic Work Group, including approximately 40 interdisciplinary research scientists from various specialties
(e.g., neurology, pediatrics, occupational therapy, psychiatry, autism, psychology) has regularly met since
2002 with the aim of studying SPD; members’ efforts have been funded through both the Wallace Research
Foundation and National Institutes of Health (SPD Foundation, 2014). However, much controversy has existed
regarding SPD as an independent disorder, particularly in the psychiatry and psychology professions, whose
members have raised the following criticisms: “(1) an absence of formal diagnostic criteria, (2) high prevalence
among children with developmental disorders such as autism spectrum disorders . . . (3) unknown etiology,
and (4) lack of epidemiological evidence related to this condition” (Ben-Sasson et al., 2009, p. 706). These
criticisms will be addressed in the subsequent paragraphs.
Diagnostic criteria. Sensory disorders are found both in the Diagnostic Manual for Infancy and Early
Childhood (Interdisciplinary Council on Developmental and Learning Disorders, 2012) and the Zero to Three’s
Diagnostic Classication of Mental Health and Developmental Disorders of Infancy and Early Childhood-
Revised (Zero to Three, 2005). For example, the Zero to Three was created by an interdisciplinary group
of researchers and clinicians to complement the American Psychiatric Association’s (APA) Diagnostic and
Statistical Manual of Mental Disorders (DSM) with a specic focus on the unique development of and disorders
found among infants and young children. This nosology includes two sensory-related disorders: Hyposensitive/
Underresponsive (420) and Sensory Stimulation-Seeking/Impulsive (430), describing the sensory reactivity
patterns, motor patterns and behavioral patterns of each disorder (Zero to Three, 2005).
The APA reviewed SPD for consideration in the DSM-5 (Levingston, 2014; Murphy, 2011) and groups such
as the SPD Scientic Work Group lobbied for its inclusion (SPD, 2012, 2014). The full diagnosis of SPD was
not included in DSM-5 reportedly due to lack of research (Levingston, 2014). However, the new Avoidant/
Restrictive Food Intake Disorder does recognize that sensory aspects of food can cause a signicant food
disturbance (e.g., texture, smell, spiciness; APA, 2013). Further, in the DSM-5 the APA recognized sensory
issues as a part of autism spectrum disorder (ASD), including: “hyper- or hyporeactivity to sensory input
or unusual interest in sensory aspects of the environment” (APA, 2013, p. 50). While the DSM-5 does not
recognize SPD as an individual disorder, we nd it promising that SPD was considered for inclusion and that
sensory issues were added to the most recent DSM. The DSM has evolved and will likely continue to evolve
based on research advances (APA, 2013) and we are hopeful that SPD will be considered for inclusion in the
next edition of the DSM, especially with recent research advances (e.g., Chang et al., 2014; Owen et al., 2013).
In addition to the DSM, the 10th revision of the International Statistical Classication of Diseases (ICD-
10; World Health Organization, 2013) and the ICD-9 (Centers for Disease Control and Prevention, National
Center for Health Statistics, 1991) are other commonly used nosologies. Although the ICD does not specically
identify sensory issues, OTs may use the following codes to diagnose clients: lack of normal physiological
development, unspecied (783.40; ICD-9); other symptoms involving nervous and musculoskeletal
systems (781.99; ICD-9), and unspecied lack of expected normal physiological development in childhood
(R62.50; ICD-10; E. Smolak, personal communication, January 15, 2015). Thus, professionals can use ICD
codes related to SPD.
SPD research. Researchers have determined distinct patterns among children with SPD varying from those
among their typically developing peers. Specically, when comparing children with clinically determined
atypical sensory processing to their typically developing peers, researchers found that the former exhibited
differences in their physiological responses to sensory stimuli (McIntosh, Miller, Shyu, & Hagerman, 1999),
parasympathetic nervous system functioning (Schaaf et al., 2010; Schaaf, Miller, Seawell, & O’Keefe, 2003),
and differences in both behavioral and physiological measures (Schoen, Miller, Brett-Green, & Nielsen, 2009).
278
Additionally, Davies and Gavin (2007) and Gavin et al. (2011) found differences in brain activity between
children with and without SPD using electroencephalography. In fact, “brain activity correctly distinguished
children with SPD from children who were typically developing with 86% accuracy” (Davies & Gavin, 2007,
p. 176). Finally, in a recent study (N = 40), Owen et al. (2013) found neurological differences in brain structure
between children with and without SPD, specically stating:
Children with SPD show specific reduction in the white matter microstructure primarily affecting
posterior cerebral tracts. . . . These findings suggest that children with SPD have a specific imaging
biomarker for their clinical disorder and the pattern of their shared structural difference. (p. 850)
Signicant sensory abnormalities (e.g., SPD) can be comorbid with several childhood clinical disorders
such as ASD, attention-decit/hyperactivity disorder (ADHD), anxiety disorders, depression, Fragile X
syndrome and obsessive-compulsive disorder (Ghanizadeh, 2011; Goldsmith, Van Hulle, Arneson, Schreiber,
& Gernsbacher, 2006; Tomchek & Dunn, 2007; Van Hulle, Schmidt, & Goldsmith, 2011). At the same time,
researchers are suggesting that SPD is a separate and distinct disorder. For example, when studying youth with
ASD and SPD, Schoen et al. (2009) demonstrated differences in sympathetic nervous system functions and
sensory-related behaviors between children in the two samples, while Chang et al. (2014) reported differing
patterns of brain connectivity in adolescents with the two separate diagnoses. In addition, Miller et al. (2012)
studied differences between youth with SPD, ADHD and the two dual diagnoses by using several parental-
report instruments and measuring physiological reactions to sensory stimuli by electrodermal response. They
found that participants with ADHD had greater inattention and participants with SPD had the most sensory
issues, while those with both diagnoses experienced inattention and fewer sensory issues than those who only
had SPD. Further, participants with SPD had greater physiological or electrodermal reactivity to sensory stimuli
than participants with ADHD (Miller et al., 2012). Overall, differences seem to exist between participants
with SPD and those with similar but varying clinical diagnoses (e.g., ADHD and ASD), suggesting SPD as an
individual disorder.
Etiology. While the etiology of SPD is still largely unknown, several researchers believe that SPD may have
a genetic basis (e.g., Goldsmith et al., 2006; Miller et al., 2009; Owen et al., 2013; Van Hulle et al., 2011). For
example, Goldsmith et al. (2006) studied the tactile and auditory defensiveness, temperament, and behavior
problems of toddler-aged twins as determined by parent reports. Researchers determined moderate genetic
inuences with tactile defensiveness, leading them to suggest more research investigating the heritability of
SPD and sensory issues.
Overall, although SPD is controversial, there is substantial evidence for SPD as a distinct disorder in
children. According to the APA (2013),
A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s
cognition, emotion regulation, or behavior that reects a dysfunction in the psychological, biological, or
developmental processes underlying mental functioning. Mental disorders are usually associated with
significant distress or disability in social, occupational, or other important activities. (p. 20)
Based on the literature review, we believe that SPD meets the APA’s criteria for a mental health disorder, due to
an irregular neurological pattern of receiving, sending, processing and responding to stimuli, which results in
impairment to an individual’s regular behavioral and emotional functioning.
Professional counseling. SPD has received some, albeit limited recognition in the counseling eld (e.g.,
Collier & Falls, 2010; Katz, 2006; Withrow, 2007), including an article featured in Counseling Today (Murphy,
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2011). However, SPD seems to be widely unrecognized in the counseling profession. Counselors may often
misdiagnose this neurological condition due to clients’ highly individualized presentations, as well as SPD
symptoms mirroring those of other disorders (Collier & Falls, 2010; Katz, 2006; Murphy, 2011; Walbam, 2013).
SPD can present as ADHD through impulsive and inattentive behaviors; ASD through social decits, rigidity
and sensory symptoms; and depression and anxiety through withdrawn and lethargic behaviors. Well-known
author and OT Carol Kranowitz wrote the following:
Many parents, educators, doctors, and mental health professionals have difculty recognizing SPD.
When they don’t recognize the problem, they may mistake a child’s behavior, low self-esteem, or
reluctance to participate in ordinary childhood experiences for hyperactivity, learning disabilities, or
emotional problems. Unless they are educated about SPD, few people understand that bewildering
behavior may stem from a poorly functioning nervous system. (2005, p. xxiv)
SPD and sensory challenges are often unrecognized, misdiagnosed and considered solely behavioral,
psychological or emotional issues (Parham & Mailloux, 2015).
An accurate diagnosis is imperative for client treatment and is included as follows in the 2014 ACA Code
of Ethics, section E.5.a.: “Counselors take special care to provide proper diagnosis of mental disorders”
(ACA, 2014, p. 11). Counselors are ethically required to thoughtfully consider mental diagnostic possibilities
and to accurately diagnose clients. However, medical and mental disorders can be commonly misdiagnosed,
especially when many disorders have similar symptoms and overlapping criteria (Pollak, Levy, & Breitholtz,
1999). Misdiagnoses may have long-term ramications for individuals, including ineffective treatment and
secondary concerns due to unmet needs, such as anxiety, depression, low self-esteem, and poor academic and
social functioning (Katz, 2006; Kinnealey & Fuiek, 1999; Miller, 2006, Miller et al., 2012; Withrow, 2007).
Lack of an accurate diagnosis also can lead to poor use of resources and harmful or even fatal client outcomes
(Pollak et al., 1999). In order to uphold the ACA’s ethical standards for accurately diagnosing clients, as well as
to meet clients’ needs, it is imperative that counselors are aware of SPD and work in tandem with other service
providers when warranted in order to ensure that each client receives an accurate diagnosis and treatment.
Counselor Implications
All Professional Counselors
Given the prevalence of SPD, counselors are likely already working with clients who have SPD. Thus,
counselors across settings need to be aware of SPD and related counseling implications. Since early intervention
is preferred, counselors who work with children should be at the forefront for recognizing and addressing
SPD in session. This section will focus on the following: awareness and education, screening and diagnosis,
treatment team, treatment goals, counseling strategies, and counseling accommodations.
Awareness and education. First and foremost, counselors must possess knowledge of SPD as a neurological
disorder and awareness of SPD characteristics in children. There is limited counseling-related SPD literature
(e.g., Collier & Falls, 2010; Katz, 2006; Murphy, 2011; Withrow, 2007), and in our experiences as counselor
educators and practitioners, we have seen very little SPD information in counseling textbooks or at counseling
conferences. Thus, counselors may need to seek educational and training opportunities outside the counseling
eld in order to stay abreast of SPD.
Screening and diagnosis. Counselors can screen for SPD through the process of differential diagnosis to
see if the symptoms (a) are part of a separate mental health diagnosis, (b) indicate SPD misdiagnosed as another
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disorder or (c) are co-occurring (Byrne, 2009). Screening and diagnosis are complicated due to SPD often
co-occurring with other mental health disorders (Walbam, 2013). Additionally, context is critically important
when counselors identify diagnostic criteria, as well as triggers and antecedents to emotional and behavioral
responses. For example, a child who presents characteristics of ADHD (e.g., impulsiveness and hyperactivity)
also should be considered for SPD, as this child could lack physical stimulation and seek sensory input to self-
modulate. Dr. Roianne Ahn, a licensed psychologist, SPD researcher and staff member at the Sensory Therapies
and Research Center provides training to mental health clinicians regarding recognizing SPD in clients. When
clinicians suspect that a child has sensory abnormalities, Dr. Ahn encourages them to use a parental-report
screening checklist (e.g., Appendix A: Sensory Processing Disorder Checklist or the Sensory Prole 2) to
initially screen for SPD symptoms and then recommend a formal occupational therapy evaluation (R. Ahn,
personal communication, November 7, 2014). With the high prevalence of SPD, professional counselors may
want to consider including a screening checklist in initial client paperwork.
Treatment team. Counselors can consult and collaborate with stakeholders through the use of a treatment
team (Katz, 2006; Murphy, 2011; Walbam, 2013). The purpose of the treatment team is to collaborate on
the child’s needs and treatment across various settings, gaining the perspectives of diverse stakeholders.
A treatment team can be comprised of the counselor (e.g., school counselor, mental health counselor), OT,
parents or caregivers, and teachers. The treatment team may include the child’s pediatrician and potentially a
nutritionist when appropriate. Counselors can play a vital role as part of a treatment team by coordinating the
interdisciplinary team. Also, family involvement is crucial—parents or caretakers often know their child best,
children are heavily impacted by their families, and parents or caretakers often advocate for their child on a
long-term basis.
Through the collaborative treatment team, counselors can identify and advocate for resources for children
with SPD and their families in order to improve their daily functioning (Walbam, 2013; Withrow, 2007).
Treatment teams can discuss children’s needs, accommodations and resources, ensuring that stakeholders are
working collaboratively to serve the child. For example, one function of the treatment team may be consultation
to discuss the child’s sensory diet in multiple settings, such as chewing gum to remain attentive in class or
receiving calming deep pressure before school in the morning (Parham & Mailloux, 2015).
Treatment goals. Counseling treatment goals can incorporate suggestions from the treatment team. For
instance, counseling treatment goals may focus on children’s emotions, cognitions and behaviors pertaining to
SPD (Kranowitz, 2005). Children with SPD may have a number of mental health concerns including anxiety,
depression, low self-esteem, poor social skills and frustration (Champagne & Koomar, 2012; Katz, 2006; Miller
et al., 2012; Walbam, 2013; Withrow, 2007). Similar to those with chronic illness (Cheu, 2013), children with
SPD may have additional concerns including fear, grief, shame, anger or frustration. Furthermore, children may
misunderstand SPD; thus, educating children and normalizing their experiences may be appropriate treatment
goals (Withrow, 2007).
Other treatment goals can include the child adjusting to the diagnosis of SPD and identifying strategies for
coping in social situations when SPD symptoms often occur (Murphy, 2011). For example, although home
environments may be easily controlled to meet the child’s sensory needs, children with SPD may need to cope
with uncontrolled environments, such as a crowded grocery store or an odorous and loud public restroom.
Thus, counseling treatment may include systematic desensitization—children increasingly coping with
uncomfortable stimuli through increased exposure. Counseling can assist with behavioral, social and emotional
symptoms related to SPD (Kranowitz, 2005), in addition to other disorders that may co-occur including anxiety,
depression, ASD, attention-decit disorder and learning disorders (Ostovar, 2009). Further, one disorder can
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exasperate another (i.e., the child may have difculty adjusting to a new environment if there is a change in
sensory input, such as street noise by the child’s bedroom window).
Counseling strategies. Counselors can provide individual, group and family counseling modalities
(Withrow, 2007) using solution-focused and cognitive-behavioral techniques to address children’s mental
health needs and co-occurring disorders. For example, through individual counseling, children may increase
their coping skills and self-esteem; through group counseling, children can improve their social skills.
Further, counselors can assist clients to understand their disorder (Withrow, 2007), adjust to their limitations
and capitalize on their strengths (Miller, 2006). Through the use of psychoeducation and bibliotherapy (see
Appendix B), counselors can educate children about SPD, normalizing their experience. Further, by focusing on
the child’s strengths, counselors can emphasize the positives of SPD. For example, children who seek sensory
input from spinning may excel in gymnastics or ice skating, while those who need physical input may thrive in
contact sports.
Some mental health issues, such as children’s anxiety, can be exacerbated by contextual factors like an
unpredictable environment that may occur in everyday life situations as well as at special events (Ostovar,
2009). Taking a systems approach, counselors can work with family members and other service providers
(e.g., teachers) to increase the predictability and children’s understanding of their environment (Withrow,
2007). Thus, counselors can assist in identifying sensory triggers and establishing accommodations, while
simultaneously addressing secondary emotional and behavioral symptoms that occur in various settings and
situations.
Counseling accommodations. In conjunction with the treatment team’s recommendations, counselors can
make a number of small accommodations during their counseling sessions to support children with SPD as they
engage in the counseling process (Withrow, 2007). First, counselors should be mindful of environmental stimuli
in their ofces, such as bright lights, highly decorated ofces or intense smells, which may be distracting
for a child with SPD. Counselors can keep smells to a minimum, for example, by not wearing perfume and
asking ofce mates to refrain from using incense or scented candles. Next, varied seating options can increase
children’s comfort, as their needs may vary from rm to soft cushions and from smooth to more textured
upholstery.
Similar to OTs (Kranowitz, 2005), counselors working with young children typically have numerous toys
and materials to use in therapy (Landreth, Ray, & Bratton, 2009). Counselors may nd that covering a shelf
and only displaying a couple of items at once reduces children’s feelings of being overwhelmed. Likewise,
many children may enjoy a variety of arts and crafts materials, yet some children with SPD may not be able to
tolerate getting glue or paint on their hands. Using a paintbrush for glue application and using hand wipes or a
nearby sink to clean their hands may allow children to fully engage in the activity. In consultation with an OT,
alternative materials can be selected. Based on the client’s needs, therapeutic putty could be substituted for a
regular modeling compound to provide more sensory input; a dry food box (e.g., uncooked rice, beans, pastas)
could be substituted for a traditional sand tray to provide more tactile input through different textures; and
markers with or without scents could be used as part of a child’s sensory diet.
In consulting with the treatment team, the counselor may learn of the child’s need to implement other
movement strategies as part of a sensory diet to increase his or her participation during counseling. These
movements may include use of a rocking chair, proprioceptive exercises or a dget. Balancing counseling
interventions with attending to sensory inputs may help the child best focus during counseling sessions.
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Mental Health Counselors
Play-based strategies. Children, particularly young children, express their emotions, thoughts and
experiences through the language of play (Trice-Black, Bailey, & Riechel, 2013). Children with SPD may have
qualitatively different playing styles, which may affect their social development (Cosbey, Johnston, Dunn, &
Bauman, 2012). Counselors can foster the achievement of social development therapeutic goals by examining
the nature of children’s play and the activities that children nd most fullling. Cosbey et al. (2012) reported
that children with SPD tend to participate in more solitary play, less complex play and greater overall conict
in play when compared to peers’ play. Therefore, social development and play strategies may be a focus of
counseling for children with SPD. Furthermore, Cosbey, Johnston, and Dunn (2010) recommended three
potential goals in working with children with SPD: (a) identify activities that bring joy and meaning to the
individual child, (b) strategize ways that the child can successfully engage in the activity, and (c) use these
activities to build his or her social circles with peers. Similarly, counselors may use such activities to assist
children with SPD in improving relationships and interactions with family members.
Family counseling strategies. A substantial aspect of serving a child with SPD involves working with
and supporting the people important in the child’s life, such as parents, siblings and other family members
(Parham & Mailloux, 2015). When working from a family systems perspective, counselors should recognize the
adjustment process for both parents and siblings. Just as children with SPD need to adjust to the diagnosis, so do
their family members. The SPD diagnosis may bring a sense of relief to parents who have spent a long journey
attempting to nd an accurate diagnosis for their child (Parham & Mailloux, 2015). Some parents may feel
grief and loss when their child is diagnosed with special needs, guilt for not obtaining the diagnosis sooner, and
overwhelmed by navigating a new world of treatment expenses and accommodations (Anderson & Davis, 2011;
Grossman & Okun, 2009; Marshak, Dandeneau, Prezant, & L’Amoreaux, 2010). Gourley, Wind, Henninger, and
Chinitz (2013) found that parental stress was positively correlated with SPD severity, and that parents whose
children had SPD had greater stress than those who had children without SPD. Thus, counselors can assist
parents in processing their emotions, learning coping strategies, developing a plan of action and gaining a better
understanding of SPD. Through psychoeducation (see suggestions in Appendix B), parents can learn about
SPD and counselors can teach parents how to advocate for their children in various settings and situations (e.g.,
birthday parties, classroom activities, family gatherings; Ostovar, 2009; Withrow, 2007).
Another of the counselor’s essential tasks may be providing support for parents (Cohn, May-Benson, &
Teasdale, 2011), which can be accomplished through a local support group for parents of children with SPD or
through family therapy. As the severity of SPD increases, so does the level of support needed by parents (Cohn
et al., 2011). Cohn et al. (2011) found a signicant correlation between an increase in a child’s SPD severity and
a decrease in parents’ perceived parental competence. Informing parents about the benets of proper treatment
may not only increase the likelihood of children receiving the needed treatment, but also decrease parents’ stress
and anxiety related to parenting a child with special needs. Finally, family counseling may include treatment
goals that center on establishing balance for the family system, as many families may have spent a large amount
of family time and resources seeking an accurate diagnosis for their child (Gladding, 2015).
Siblings of children with special needs such as SPD may be negatively impacted in various ways, including
greater likelihood of psychological or behavioral concerns, stressed relationships with parents, and missing
parental attention (Anderson & Davis, 2011; Cohen, 1999). Engaging siblings in counseling can assist all the
children in the family with adapting to the new family norms, routines and rules. For example, siblings can
benet from learning more about SPD (Parham & Mailloux, 2015) and processing their reactions to the SPD
diagnosis, treatment and changes to the family system. Depending on the siblings’ ages and developmental
levels, understanding SPD and the related issues may be difcult for them to comprehend. For example,
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siblings’ interactive play may change signicantly once triggers are identied for the child with SPD. Siblings
may need to process their emotions in their own space; thus, a referral to a sibling support group or individual
counseling may be warranted.
School Counselors
According to the American School Counselor Association (ASCA, 2013), school counselors are charged with
serving all students, including students with disabilities and special needs. School counselors can serve students
through increasing their own awareness of SPD, consulting and collaborating with stakeholders, advocating
for necessary student services and accommodations, and providing students with individual and small group
counseling (ASCA, 2013). Thus, school counselors can apply these strategies to their work with children who
have SPD.
Education, consultation and collaboration. To serve students with SPD, school counselors should educate
themselves about the disorder and be vigilant about the signs and symptoms. School counselors can consult with
other school professionals such as the OT and parents or caretakers if they suspect SPD. As teachers and family
members may possess little knowledge of SPD, school counselors can educate, consult and collaborate with
these stakeholders (ASCA, 2013) to increase their understanding of the disorder and to learn to best support the
child with SPD.
Accommodations. The 2008 amendments of Section 504 of the Rehabilitation Act of 1973 constitute a
“federal law designed to protect the rights of individuals with disabilities in programs and activities that receive
Federal nancial assistance from the U.S. Department of Education” (U.S. Department of Education, 2013,
Introduction, para. 2), including students in public schools. To be eligible under Section 504, students must
have a conrmed physical or mental impairment that substantially impacts their functioning (U.S. Department
of Education, 2013). If a student’s SPD signicantly impedes his or her school participation and learning, that
student may be eligible for Section 504, including relevant accommodations, supports and a documented plan.
School counselors can advocate for students receiving services under Section 504, as well as assist students and
parents in navigating the educational system as they seek services.
To promote academic performance and social and emotional functioning in schools, 504 services vary based
on the unique needs of each student. Accommodations should be individualized and based on information
gathered from the student, family, teacher and diagnosing professionals. Once the student’s sensory triggers
are identied, the school counselor can examine each aspect of the child’s day for potential triggers and
modications; small changes can make a signicant difference. SPD accommodations in the classroom may
include preferential seating, possibly with a larger personal space circumference (e.g., the student’s own table
for classroom work and testing), sensory breaks in the classroom, “heavy work” (e.g., delivering books to
the library), increased time for assignments and tests, and a quiet location for testing. Some students with
poor muscle coordination may require accommodations for underdeveloped ne motor skills, such as using
a mechanical pencil for short assignments, a computer for longer writing assignments and pencil grips. In
coordination with an OT, other accommodations may include a weighted vest or lap pillow, a balance ball chair
instead of a traditional seat, and dgets or stress balls to help increase attending behavior, reduce stress and
increase hand muscle strength. If available and as needed, students can meet with a school-based OT to further
address SPD symptoms in the classroom.
In addition to focusing on student accommodations for accessing the core curriculum, students with
SPD may struggle with the elective or “specials” classes, unplanned situations, transitions and unstructured
time outside of the classroom. While many children love playing tag during recess or physical education
(P.E.), a student who is sensory defensive may dread this and similar activities. Thus, a P.E. accommodation
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may be engaging in a different noncontact sport. Alternatively, children who need sensory input may have
accommodations to complete additional jumping jacks or wall pushes beyond P.E. class. In addition, a child
with gross motor skill challenges could receive accommodations to strengthen and develop those areas without
being penalized for failure to meet grade-level expectations. With any sport, an OT can assess a child’s physical
strengths and challenges, working with P.E. teachers, coaches and parents to select appropriate individual or
group activities based on the SPD presentation in each child (Kirkpatrick, 2012).
As previously mentioned regarding play-based techniques, some creative arts activities may be troublesome
for children with SPD. Accommodations in art class should ensure that students with SPD participate to the
best of their ability, and receive modied assignments and grading protocols (e.g., extra time to complete
assignments). Likewise, students in music class may need to utilize their noise reduction headphones. Finally,
school counselors should be mindful of students’ schedules, advocating for “specials” classes to be spaced
out and at the end of the day when possible, as children with SPD who have multiple triggers are apt to have
challenges concentrating once back in their regular classroom.
Children with SPD may be fearful of unexpected situations due to concern that a sensory trigger will occur.
Providing students with advance warning can assist them during these situations. For instance, students can
receive advance notice for re drills and prearranged substitute teachers. The school counselor can check
on the students during such triggering events to determine their reactions and ensure that accommodations
are implemented. The school counselor can coach children to advocate for themselves in these situations,
for example, by asking a substitute teacher to reduce the classroom noise level, or wearing noise-canceling
headphones during re drills.
Students with SPD may benet from accommodations assisting them with daily school transitions. For
example, a visual reminder (e.g., written schedule) may help reduce students’ anxiety surrounding transitions.
To preserve personal space when transitioning between classes, younger students can receive preferential order
in line, while older students can receive permission to walk in the hallways immediately before or after their
peers.
Children with SPD may nd unstructured school time to be difcult due to the magnitude of overwhelming
sensory input. School counselors can assist students with SPD by collaborating with them and other
stakeholders to create modications for unstructured school times (e.g., recess, lunch, school assemblies, class
parties, bathroom breaks, transportation to and from school). Accommodations may include preferential seating,
noise-canceling headphones and decreased time in such situations. Further, students should be provided a safe
place to decompress when overstimulated.
When annually reviewing 504 plans and adjusting accommodations, school counselors need to be aware that
students’ triggers and challenges may change at different developmental and chronological ages. For example,
high school students with SPD may require unique accommodations in various situations such as the following:
during driver’s education (e.g., not driving with other students in the car), while dissecting frogs in biology or
when using odorous chemicals in chemistry. Biological changes in adolescence produce new and potentially
triggering smells, such as the P.E. locker room at the secondary level. Thus, school counselors may need to (a)
advocate for accommodations to counter these scenarios that may emerge in middle and high school, and (b)
further address the emotions related to dealing with SPD symptoms in the classroom and in social situations
with classmates that may occur with the onset of adolescence.
Counseling. In addition to assisting with accommodations, school counselors can conduct individual and
small group counseling for students with SPD in order to help them succeed in school (Collier & Falls, 2010).
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School counselors can provide counseling to address students’ emotional and mental health concerns, which
may include anxiety, depression, low self-esteem, poor social skills and frustration (Champagne & Koomar,
2012; Katz, 2006; Miller et al., 2012; Walbam, 2013; Withrow, 2007). School counseling may address students’
anxiety about school transitions and school-related sensory reactions by teaching students coping skills. School
counselor-led counseling can normalize the experience of children with SPD, combating potential feelings of
self-consciousness and isolation. Through the use of bibliotherapy and psychoeducation (see Appendix B),
students can learn improved self-regulation and organization skills as well as self-advocacy and assertiveness.
For example, students can learn to advocate for themselves by participating in their 504 plan meeting, as well as
learn to develop strategies for communicating with teachers when becoming overwhelmed by sensory stimuli.
When students with SPD receive accommodations and counseling, classmates may express jealousy or
frustration, similar to siblings. The school counselor can help process these situations and role-play social
interactions in individual or group settings. Further, school counselors can assist teachers in offering sensory
modulation strategies for an entire class, in order to prevent the child with SPD from being singled out. The
following is a case study of how a counselor can intervene with a child who has SPD.
Case Study
Euna is a 6-year-old, second-generation Korean American attending her rst year of school as a rst-grade
student in public school. Her parents are professionals, and she is an only child who had an in-home nanny and
no formal preschool. At school, she shows little variation in affect and rarely speaks to peers. However, she and
her parents speak at home, often in quiet voices. Euna inches when touched and her parents describe her as a
picky eater and uncoordinated. She does not like school; at home she has daily outbursts prior to departing for
the school bus. Euna does not have reciprocal friendships in school and often sits alone in the cafeteria during
lunch. Often she requests to visit the nurse to avoid the cafeteria during lunch.
Euna visits a mental health counselor for anxiety; this counselor has basic awareness of SPD. After the
intake and initial counseling session with Euna, the mental health counselor suspects SPD and gathers
additional background information from Euna’s parents as well as a release of information to speak to Euna’s
teacher and school counselor. Next, the mental health counselor gathers background information from Euna’s
school counselor and teacher about her school functioning. After completing screening checklists (e.g.,
Appendix A: Sensory Processing Disorder Checklist or the Sensory Prole 2), the mental health counselor and
school counselor provide Euna’s parents with an OT referral for formal evaluation and recommend that her
parents rst speak to the pediatrician; the counselors obtain a release of information to be able to speak with
the OT and pediatrician. The OT determines that Euna does have SPD, and through the physical examination,
Euna’s pediatrician rules out other potential physiological causes for symptoms. The pediatrician also provides
a referral to a nutritionist who can ensure that Euna is obtaining proper nutrition and gradually increase the
types and textures of food in Euna’s diet.
After consulting with the OT and pediatrician, the school and mental health counselors work together to
provide bibliotherapy resources for the family, education for the teacher and school staff, and coping strategies
for Euna in school, at home and in the community. They collaborate with the OT to incorporate sensory
strategies that will enhance counseling sessions with Euna. Lastly, the school counselor invites the OT and
mental health counselor to participate in the development of the 504 plan to provide accommodations for Euna
to be successful in school.
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During the last several years, authors have presented variations of the Euna case study to audiences in
counseling classes and conferences, asking for participants’ thoughts on a preliminary diagnosis for further
exploration. Common participant responses include trauma, anxiety and school phobia; this is not surprising, as
SPD can be easily misdiagnosed as other disorders.
Summary and Recommendations
SPD is a neurological disorder that impacts the daily functioning of children across settings. Thus, to
advocate on behalf of children with SPD in mental health and school settings, counselors need to increase their
SPD-related education, advocacy, screening, treatment, stakeholder collaboration and research. First, counselors
should become increasingly knowledgeable about and advocate for an increased awareness of SPD within
the counseling profession. We recommend that counselors advocate for the inclusion of SPD in diagnostic
standards, such as the future edition of the DSM, and in counselor education, professional development and
counseling literature. By increasing the counseling profession’s knowledge of SPD, counselors can provide
children with more appropriate and earlier treatment interventions.
Next, counselors need to effectively screen for SPD and collaborate with parents and other professionals to
treat the primary and secondary needs of children with this disorder. Also, counselors can educate stakeholders
on SPD, including teachers and parents. By further demystifying and clarifying SPD for professionals and
family members, these stakeholders can best support children with SPD, improving their quality of life and
achieving treatment goals.
Conducting and publishing counseling-related SPD research can add professional credibility and recognition
of SPD. In the future, researchers should investigate the following: (a) counselors’ awareness of SPD; (b)
mental health, school, and family counseling interventions used for children with SPD; (c) consultation
practices with other service providers to serve children with SPD; and (d) perceptions and outcomes of
clients with SPD receiving counseling services in an effort to develop future evidence-based best practices.
Also, researchers can explore the psychometric properties of instruments used to screen for SPD, perceptions
regarding these instruments, and effectiveness of counselors using these instruments. Finally, counselors
can conduct interdisciplinary research with OTs, as future SPD research areas outlined by the American
Occupational Therapy Association (2014) are related to counseling treatment goals pertaining to SPD (e.g.,
social communication, anger management, academic performance, behavior issues). When counselors and
researchers engage in self-education and professional education, more accurate screening, evidence-based
counseling treatment strategies, stakeholder education and collaboration, and research, they advocate for
children with SPD across settings and have the potential to dramatically improve the lives of many children.
Conict of Interest and Funding Disclosure
The authors reported no conict of
interest or funding contributions for
the development of this manuscript.
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Appendix A
Sensory Processing Disorder Checklist
© Sensory Therapies And Research (STAR) Center, 2006
Retrieved from http://spdfoundation.net/library/checklist.html
Many of the symptoms listed in the following categories are common to that particular age group. Where more than a
few symptoms are found in a child, we recommend you talk to your doctor or check the SPD Foundation’s Treatment
Directory for a professional experienced with treating Sensory Processing Disorder.*
Infant/ Toddler Checklist:
____ My infant/toddler has problems eating.
____ My infant/toddler refused to go to anyone but me.
____ My infant/toddler has trouble falling asleep or staying asleep
____ My infant/toddler is extremely irritable when I dress him/her; seems to be uncomfortable in clothes.
____ My infant/toddler rarely plays with toys, especially those requiring dexterity.
____ My infant/toddler has difculty shifting focus from one object/activity to another.
____ My infant/toddler does not notice pain or is slow to respond when hurt.
____ My infant/toddler resists cuddling, arches back away from the person holding him.
____ My infant/toddler cannot calm self by sucking on a pacier, looking at toys, or listening to my voice.
____ My infant/toddler has a “oppy” body, bumps into things and has poor balance.
____ My infant/toddler does little or no babbling, vocalizing.
____ My infant/toddler is easily startled.
____ My infant/toddler is extremely active and is constantly moving body/limbs or runs endlessly.
____ My infant/toddler seems to be delayed in crawling, standing, walking or running.
Pre-School Checklist:
____ My child has difculty being toilet trained.
____ My child is overly sensitive to stimulation, overreacts to or does not like touch, noise, smells, etc.
____ My child is unaware of being touched/bumped unless done with extreme force/intensity.
____ My child has difculty learning and/or avoids performing ne motor tasks such as using crayons and
fasteners on clothing.
____ My child seems unsure how to move his/her body in space, is clumsy and awkward.
____ My child has difculty learning new motor tasks.
____ My child is in constant motion.
____ My child gets in everyone else’s space and/or touches everything around him.
____ My child has difculty making friends (overly aggressive or passive/ withdrawn).
____ My child is intense, demanding or hard to calm and has difculty with transitions.
____ My child has sudden mood changes and temper tantrums that are unexpected.
____ My child seems weak, slumps when sitting/standing; prefers sedentary activities.
____ It is hard to understand my child’s speech.
____ My child does not seem to understand verbal instructions.
School Age:
___ My child is overly sensitive to stimulation, overreacts to or does not like touch, noise, smells, etc.
___ My child is easily distracted in the classroom, often out of his/her seat, dgety.
___ My child is easily overwhelmed at the playground, during recess and in class.
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___ My child is slow to perform tasks.
___ My child has difculty performing or avoids ne motor tasks such as handwriting.
___ My child appears clumsy and stumbles often, slouches in chair.
___ My child craves rough housing, tackling/wrestling games.
___ My child is slow to learn new activities.
___ My child is in constant motion.
___ My child has difculty learning new motor tasks and prefers sedentary activities.
___ My child has difculty making friends (overly aggressive or passive/ withdrawn).
___ My child gets stuck on tasks and has difculty changing to another task.
___ My child confuses similar sounding words, misinterprets questions or requests.
___ My child has difculty reading, especially aloud.
___ My child stumbles over words; speech lacks uency, and rhythm is hesitant.
Adolescent/Adult:
___ I am over-sensitive to environmental stimulation: I do not like being touched.
___ I avoid visually stimulating environments and/or I am sensitive to sounds.
___ I often feel lethargic and slow in starting my day.
___ I often begin new tasks simultaneously and leave many of them uncompleted.
___ I use an inappropriate amount of force when handling objects.
___ I often bump into things or develop bruises that I cannot recall.
___ I have difculty learning new motor tasks, or sequencing steps of a task.
___ I need physical activities to help me maintain my focus throughout the day.
___ I have difculty staying focused at work and in meetings.
___ I misinterpret questions and requests, requiring more clarication than usual.
___ I have difculty reading, especially aloud.
___ My speech lacks uency, I stumble over words.
___ I must read material several times to absorb the content.
___ I have trouble forming thoughts and ideas in oral presentations.
*While this checklist can’t diagnose a child with SPD, it can be a helpful guide to see if additional testing should be done.
When lling out this checklist, think about the child’s behavior during the past six months.
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Appendix B
Abbreviated List of Sensory Processing Disorder Resources
Resources
for Parents, Teachers and Counselors
• Answers to Questions Teachers Ask about Sensory Integration: Forms, Checklists, and Practical Tools for Teachers and
Parents by
Jane Koomar, Carol Kranowitz, Stacey Szklut, Lynn Balzer-Martin, Elizabeth Haber, Deanna Iris Sava
• Building Sensory Friendly Classrooms to Support Children with Challenging Behaviors: Implementing Data Driven
Strategies! by Rebecca A. Moyes
• The Out-of-Sync Child Has Fun, Revised Edition: Activities for Kids with Sensory Processing Disorder by Carol Stock
Kranowitz
• The Out-of-Sync Child: Recognizing and Coping with Sensory Processing Disorder, Revised Edition by Carol Kranowitz
and Lucy Jane Miller
• Parenting a Child with Sensory Processing Disorder: A Family Guide to Understanding and Supporting Your
Sensory
-
Sensitive Child by Christopher R. Auer
• Raising a Sensory Smart Child: The Denitive Handbook for Helping Your Child with Sensory Integration Issues by
Lindsey Biel and Nancy Peske
• Sensational Kids: Hope and Help for Children with Sensory Processing Disorder by Lucy Jane Miller and Doris A.
Fuller
• Sensory Parenting, From Newborns to Toddlers: Everything is Easier When Your Child’s Senses are Happy! by Britt
Collins and Jackie Linder Olson
• Sensory Parenting, The Elementary Years: School Years Are Easier when Your Child’s Senses Are Happy! by Britt
Collins and Jackie Linder Olson
• Sensory Processing Disorder Foundation: http://www.spdfoundation.net/index.html
• Starting Sensory Therapy: Fun Activities for the Home and Classroom! by Bonnie Arnwine
• The Survival Guide for Travelling with a Sensory Kiddo: From Amusement Parks, to the Beach or a Weekend Road Trip
to Visit Relatives...Sensory Help is Here! by Angie Voss
• Too Loud, Too Bright, Too Fast, Too Tight: What to Do If You Are Sensory Defensive in an Overstimulating World by
Sharon Heller
• Understanding Your Child’s Sensory Signals: A Practical Daily Use Handbook for Parents and Teachers by Angie Voss
• Your Essential Guide to Understanding Sensory Processing Disorder: When You See a Child Through Sensory Goggles...
It ALL Makes More “Sense”! by Angie Voss
Sensory Processing Disorder Checklists
• http://www.sensory-processing-disorder.com/sensory-processing-disorder-checklist.html
• http://sinetwork.org/library/checklist.html
• http://www.sensationalbrain.com/sensory-activities-6-quick-ideas/
For Children
• The Adventures of Sensory Avoider Allie: Allie Only Eats Three Foods by Angie Voss and Dillon Seglem
• Arnie and His School Tools: Simple Sensory Solutions That Build Success by Jennifer Veenendall
• Ellie Bean the Drama Queen: A Children’s Book about Sensory Processing Disorder by Jennie Harding and Dave
Padgett
• I’m Not Weird, I Have Sensory Processing Disorder (SPD): Alexandra’s Journey (Growing with Love) by Chynna T.
Laird
• Meghan’s World: The Story of One Girl’s Triumph over Sensory Processing Disorder by Diane M. Renna and Regina
Stark
• Picky, Picky Pete by Michele Grifn
• Sensitive Sam: Sam’s Sensory Adventure has a Happy Ending! by Marla Roth-Fisch
• Squirmy Wormy: How I Learned to Help Myself by Lynda Farrington Wilson
• This is Gabriel Making Sense of School: A Book About Sensory Processing Disorder by Hartley Steiner
• Why Does Izzy Cover Her Ears? Dealing with Sensory Overload by Jennifer Veenendall
293
Cassandra A. Storlie, NCC, is an Assistant Professor at Kent State University. Eric R. Baltrinic is an Assistant Professor at the University
of Toledo. Correspondence may be addressed to Cassandra Storlie, 310 White Hall, PO Box 5190, Kent, OH 44242, [email protected].
Cassandra A. Storlie
Eric R. Baltrinic
Counseling Children With Cystic Fibrosis:
Recommendations for Practice and Counselor
Self-Care
Cystic brosis is a progressive, chronic disease that affects approximately 30,000 adults and children in the United
States. Counseling children with the special needs specic to cystic brosis can be overwhelming for mental health
professionals due to the progressive and deteriorating nature of the illness, long-term contact with clients, and
discouraging prognosis. Being exposed to long-term therapeutic relationships with chronically ill children and
witnessing treatment failure can contribute to burnout, compassion fatigue and vicarious trauma in counselors,
highlighting the need for targeted literature addressing holistic self-care strategies. The purpose of this manuscript
is to provide a review of the current literature illuminating the challenges facing children with cystic brosis and to
provide targeted self-care suggestions for professional counselors working with this population.
Keywords: children, chronic disease, compassion fatigue, cystic brosis, self-care
Cystic brosis (CF) is a chronic, terminal disease targeting most organ systems (Withers, 2012) and affects
approximately 30,000 children and adults nationwide (Cystic Fibrosis Foundation [CFF], 2014a). CF primarily
affects the gastrointestinal and respiratory systems (Withers, 2012), and although the life expectancy has greatly
improved, CF is fatal and there is no known cure (CFF, 2014a). Counseling children with chronic illnesses,
such as CF, presents special challenges for mental health professionals (Sidell, 1997), including professional
counselors. As the nature and severity of clients’ problems impact levels of counselor burnout or compassion
fatigue (Figley, 2002), it is essential that professional counselors working with children with CF maintain
healthy self-care practices.
There is an abundance of information examining the physiological aspects of CF that clients experience
throughout the disease progression (CFF, 2014a; Pearson, Pumariega, & Seilheimer, 1991; Sawicki, Sellers, &
Robinson, 2009; Sawicki & Tiddens, 2012). However, there is limited literature on the special considerations
that need to be taken when counseling children with CF. Furthermore, there is a paucity of counseling literature
targeting how professional counselors can foster personal self-care while working with young clients with
special needs and chronic conditions. The purpose of this manuscript is to provide a review of literature
that illuminates the challenges facing children with CF and provides a primer for self-care suggestions for
professional counselors who work with these children.
Special Needs of Children with Cystic Fibrosis
Physiological Challenges Facing Children with Cystic Fibrosis
Professional counselors need to be knowledgeable of chronic diseases affecting their clients in order to be
sensitive to the traumas experienced by children and families coping with illness (Thompson & Henderson,
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http://tpcjournal.nbcc.org
© 2015 NBCC, Inc. and Affiliates
doi:10.15241/cas.5.2.293
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2007). CF is most commonly diagnosed during newborn screening and severely affects the exocrine system
(CFF, 2014b). Within the exocrine system, there is a lack of appropriate enzymes available during digestion,
so children with CF are unable to properly digest their food and absorb essential nutrients for healthy growth
and development. They experience recurrent gastrointestinal distress such as issues of diarrhea and constipation
with foul-smelling stools due to poor absorption (CF Living, 2014). As such, children with CF often suffer from
malnutrition and an inability to maintain a healthy weight. However, the most notable signs and symptoms
affecting children with CF result from chronic lung and respiratory infections that lead to frequent coughing
spells to clear the lungs of thick mucus. This inability to clear the lungs requires multiple episodes of daily
chest physiotherapy (Berge & Patterson, 2004). Over time, the respiratory infections produce lung damage that
appears cyst-like, giving name to the disease cystic brosis (CFF, 2014a).
Children with CF can spend hours per day on medical treatments such as nebulizer treatments to improve
breathing, medications prior to meals to improve digestion, and oral, inhaled or intravenous antibiotics to treat
respiratory infections (CF Living, 2014). However, disabilities from CF are not often visibly apparent until later
stages of the disease. Decreased mobility and debilitating side effects from long-term medications, along with
decreased lung capacity, all contribute to clients with CF requiring oxygen therapy for survival (Withers, 2012).
The later stages of CF are inundated with frequent hospitalizations. Treatment during end-stage CF is palliative
rather than curative (Lowton & Gabe, 2003), and without lung transplantation, CF remains a fatal disease due to
respiratory failure (Hayes, Anstead, Warner, Kuhn, & Ballard, 2010). Nevertheless, medical breakthroughs have
increased the survival rate of children with CF (Blum, 1992) and now many children are living into adulthood.
Advanced clinical drug trials, aggressive antibiotic medications and innovative gene therapy research have
been successful with CF clients of all ages. In 1955, children with CF were not expected to live to attend grade
school. Children born with CF in this decade are projected to live into their 40s (CFF, 2014a). With this increase
in life expectancy, health care teams are faced with unique challenges specic to the turbulence of adolescence
and treatment compliance (Withers, 2012). Although there has been a predominant focus on treating CF based
on medical science (Chesson, Chisholm, & Zaw, 2004), there is a strong interconnection of the psychosocial
and physical challenges facing children and adolescents with CF. As such, professional counselors are called to
increase their knowledge, skill and awareness of not just the physical challenges affecting children with CF, but
also the emotional obstacles facing this population.
Psychosocial Challenges Facing Children with Cystic Fibrosis
Emotional and behavioral health disorders affect approximately 20% of all children and adolescents
nationwide (Canning, Haner, Shade, & Boyce, 1992), and children with chronic illness may exhibit even higher
incidences of mental health and psychosocial issues (Barnes, Eisenberg, & Resnick, 2010). For example,
children with CF may experience extreme psychological challenges (e.g., depression, hopelessness, suicidal
ideation) and physical complications (e.g., poor lung functioning, malnutrition) throughout the progression
of their chronic condition. Taken together, these comorbidities contribute to the complexity of supporting
an intense treatment modality (Anderson, Flume, & Hardy, 2001; Withers, 2012) that also promotes healthy
psychosocial development and family system functioning (O’Haver et al., 2010).
In order to provide evidenced-based practices to clients with CF, as well as their families and loved
ones, professional counselors need to be current on mental health research related to this special population.
Studies have identied that children with CF may be predisposed to psychological issues and attachment and
behavioral problems (Berge & Patterson, 2004) that may require additional training for professional counselors
to effectively and efciently counsel this population. When compared to healthy peers, children with chronic
health conditions also have been found to have a slightly higher risk of attempting suicide (Barnes et al.,
2010). Grief and loss, internal and external stress, negative body image, and difculty managing emotions are
common challenges experienced by children with CF (Berge & Patterson, 2004; Withers, 2012). In managing
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these difculties, internalizing behaviors and anxiety also have been found prominent among this population
(Berge & Patterson, 2004). Younger male children with CF have been found to exhibit higher levels of anxiety
(Bregnballe, Thastum, & Schiøtz, 2007) and female children with CF have demonstrated internalizing behaviors
by expressing less anger than female children without CF (Bregnballe et al., 2007).
Although research supports the idea that individuals with chronic illnesses are at increased risk for
depression (Quittner et al., 2008), studies conducted on individuals with CF have provided mixed results
(Pearson et al., 1991; Thompson, Hodges, & Hamlet, 1990). Berge and Patterson (2004) identied higher
incidences of depression among youth with CF, whereas Tluczek et al. (2014) found that patients with CF
report similar psychosocial functioning as their healthy peers. One possible factor affecting the mixed reports of
depression among children with CF may include the level of disease acceptance. Previous investigations have
identied that the level of disease acceptance among youth with CF can signicantly lessen levels of anxiety,
depression and disability in adolescents with CF (Casier et al., 2008). Nonetheless, depression and depressive
symptoms have been shown to impact the progression of chronic diseases, such as CF, by increasing the
likelihood that clients will be less compliant with treatment regimens and partake in risky behaviors (Quittner et
al., 2008; Withers, 2012). Hence, we recommend assessing and screening for depressive symptoms frequently
and examining the level of disease acceptance in clients with CF. Professional counselors working with children
with CF will need to further tailor interventions based on the client’s symptom patterns (Chesson et al., 2004),
while accounting for changes typical of childhood development.
Recently, scholars have researched the experiences of adolescents with CF in their transition to adulthood.
This turbulent time (Withers, 2012) may need special consideration by professional counselors. Qualitative
research on the experiences of adolescents with CF who were transitioning to adulthood generated the following
three emerging themes: treatment compliance, health-related problems and future outlook concerning their
disease (Berge, Patterson, Goetz, & Milla, 2007). Male participants described being more independent with
treatment compliance, whereas females desired an accountability partner for their treatment regimen. Female
participants expressed issues with depression, negative body image and fear of diabetes as a complication from
CF, whereas males only disclosed their fear of acquiring diabetes as the disease progressed. Interestingly, both
male and female participants expressed a positive outlook concerning CF regarding identity and acceptance of
the disease (Berge et al., 2007). Identifying and maintaining a positive outlook while dealing with a chronic
and debilitating illness can be a challenge for children with CF and their parents and families. Professional
counselors working with youth with CF need to consider these ndings. Special attention may be given to issues
of treatment compliance, further physical complications from CF and maintaining a positive outlook.
Regarding risky behaviors (Quittner et al., 2008), teenagers with CF have admitted to using alcohol and
drugs to seek relief from the challenges of CF (Vaeth & Martins, 2015). As such, professional counselors
working with children with CF need to tailor interventions to the individuals’ symptom-specic patterns
(Chesson et al., 2004) and be mindful of behaviors that may hasten the disease process. The use of alcohol
and drugs may hasten the disease’s progression because of the ways in which these substances can interact
with the client’s current prescription medication regimen. Alcohol use may result in pancreatitis and a
hypoglycemic reaction (Withers, 2012). Likewise, clients who smoke legal and illegal substances contribute to
the deterioration of lung functioning. We recommend frequently assessing and screening for substance abuse
and depressive symptoms and exploring the level of disease acceptance among youth with CF in creative,
developmentally appropriate ways. Importantly, professional counselors preparing counseling interventions for
children with CF need to account for the added psychosocial and developmental challenges that are typical in
childhood development.
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Special Considerations When Counseling Children with Cystic Fibrosis
Many children share similar psychological and developmental needs as they grow (Thompson &
Henderson, 2007). However, children with chronic illness may struggle to be emotionally mature, while
simultaneously managing the physical symptoms of their conditions (Dahlbeck & Lightsey, 2008). Furthermore,
the psychosocial complexities and the chronic nature of CF may create unique challenges for professional
counselors providing services to children and their families, such as the deteriorating nature of CF, frequent
hospitalizations and the life-threatening prognosis (Frels, Leggett, & Larocca, 2009; Morison, Bromeld, &
Cameron, 2003). Counseling professionals’ increased sensitivity to the progression and impact of this disease
can help guide their intervening efforts (Chesson et al., 2004) by leading them to consider the physiological and
psychological trauma caused by CF. Professional counselors must ensure that they have developed rapport with
the child as an individual, instead of a child with a disability (Thompson & Henderson, 2007).
Counseling interventions for children with CF begin with recognizing that children with CF are not adults
with CF. Therefore, treatment and counseling efforts need to allow for special consideration of childhood
development and understanding (Chesson et al., 2004; Geldard & Geldard, 2008). Chesson et al. (2004) offered
suggestions for meeting the needs of children with chronic illnesses through counseling. First, counselors need
to obtain the child’s understanding of counseling (e.g., what it is, how it will help, roles, communication).
Although parental support and involvement is important when counseling children (Geldard & Geldard,
2008; Morison et al., 2003), relying solely on parental reports is not a replacement for exploring the child’s
perspective of counseling (Geldard & Geldard, 2008). Chronic illnesses such as CF impact the whole family
system (Kirk et al., 2013). However, within the therapeutic counseling relationship, children with CF must feel
as if they are the experts on their lives and their mental health, regardless of age.
Second, counselors working with children should limit the amount of talking they do in session (Chesson
et al., 2004) in favor of engaging children through natural modes of expression such as play, drawing and
games. We recommend structuring counseling sessions to include discussions alongside an activity, versus
a sole reliance on face-to-face conversation, in order to improve rapport building within the therapeutic
relationship. Children engaging in healthy interdependent relationships with counselors can begin to develop
a sense of independence and trust (Juntunen & Atkinson, 2002) within the counseling process, despite the
tumultuous times during the disease progression. The adverse impact of chronic illness on social functioning
(Last, Stam, Onland-van Nieuwenhuizen, & Grootenhuis, 2007) can lead to social withdrawal (Dahlbeck &
Lightsey, 2008), which can be intensied when there is a concentrated focus on the child via adult approaches to
counseling (e.g., making the child the center of attention to discuss his or her illness). As such, we recommend
that professional counselors make age-appropriate and developmental adjustments to the counseling session
and consider instituting group counseling modalities to counter the regularity of social isolation among these
children.
Third, professional counselors developing a therapeutic relationship with a child experiencing CF must
incorporate interactions that address the traumatic impact of living with the illness. Children with CF undergo
physically stressful and painful experiences during medical treatment. Geldard and Geldard (2008) suggested
that professional counselors clarify the nature of counseling and differentiate it from medical treatments. They
also suggested maintaining an environment that provides acceptance and invites free disclosure. Professional
counselors are urged to explain the distinction between counseling and medical procedures (e.g., there are no
needles or painful medical procedures in counseling). Professional counselors also are encouraged to engage
children in activities and play to reduce their level of anxiety and guardedness (Chesson et al., 2004). These
targeted counseling strategies can promote resiliency factors such as self-efcacy and empowerment so that
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children may cope with adversity throughout the illness (Dahlbeck & Lightsey, 2008; Luszczynska, Gutiérrez-
Doña, & Schwarzer, 2005). Chesson et al. (2004) further suggested that counselors gradually establish the
therapeutic relationship over a number of shorter sessions in order to establish trust with the child. We caution
against rushing the counseling relationship-building process and encourage professional counselors to listen
openly in order to understand the child’s world.
As children struggle with chronic illnesses such as CF, acute emotional reactions are invariably triggered,
which may increase the propensity for children to act out in self-injurious ways (Vaeth & Martins, 2015). The
counseling process requires consistency and transparency when discussing how a child’s treatment progress
will be shared among adults. Accordingly, a fourth special consideration needs to be illuminated—the limits
of condentiality. Professional counselors must illustrate the circumstances when parents will be notied of
instances of self-harm or suicidal and homicidal ideation. Given the susceptibility of children with chronic
illnesses to depression (Quittner et al., 2008) and suicidal ideation (Barnes et al., 2010), coping with the
challenges and effects of CF are constantly in the minds of these children. Rebecca Mueller (2001) illustrated
this point as a young person struggling with the illness as follows:
All the information I have about my disease has been dispersed in small pieces over time. The idea that
[when] a child with CF reaches a certain age, truth and honest answers should suddenly be given is
awful. With the many different sides and aspects of CF or other diseases, the information needs to come
out over time, giving the person time to react and contemplate. (p. 43)
Professional counselors working with children with CF understand the need for a collaborative approach in
supporting individuals and families experiencing the trauma of chronic illness. Children with chronic diseases
are involved with multiple treatment professionals (e.g., dieticians, respiratory therapists, physicians, nurses,
case managers, mental health and school counselors). Chesson et al. (2004) recommended that counselors assist
children with understanding the decisions made by their parents, doctors and other professionals about their
treatment. This task can be done by assessing the child’s knowledge of the disease process and treatment and
initiating family sessions or sessions with other health care professionals when warranted. Ultimately, children
who protest treatment interventions can be overridden by a caregiver’s decision. When children have a history
of adult-driven decisions related to life-preserving medical treatments, this experience can make behavioral
counseling interventions difcult. We suggest that counselors make every effort to respect the feelings and
wishes of children with CF, including helping to “coordinate services, rearranging physical environments,
removing barriers and inconveniences, and securing special equipment and materials” (Thompson &
Henderson, 2007, p. 713). Professional counselors can further facilitate this supportive process by empowering
children to identify and articulate their perspectives on medical treatments, given their limited choices (Chesson
et al., 2004; Morison et al., 2003).
Family Involvement
Family involvement is critical to all aspects of treatment of children with CF, starting with diagnosis. Parents
and families are signicantly affected when their child is diagnosed with a chronic illness (Anderson et al.,
2001; O’Haver et al., 2010). Thompson and Henderson (2007) explained, “The demands for energy, time, and
nancial resources may add a heavy burden of stress to families” (p. 602). It is essential to note that families
and children face myriad stressors related to the “uncertainty and uncontrollability” of chronic illness, along
with “restrictions on their freedom” (Last et al., 2007, p. 102). However, family members (particularly parents)
are often responsible for providing an environment in which children can develop resiliency and independence.
Family members provide a supportive environment and help to promote children’s sense of self-worth and
ability to cope with challenging life situations (Juntunen & Atkinson, 2002). These tasks may be especially
difcult for parents of children with CF in that they too are more vulnerable to higher incidences of depression
298
(Quittner et al., 2008; Tluczek et al., 2014). Hence, we recommend that professional counselors working with
the family system ensure that parents of children with CF have access to the emotional supports necessary to
sustain family functioning and equilibrium, including participation in their own counseling as needed (Tluczek
et al., 2014). Similarly, professional counselors may nd it necessary to provide parent education about the
CF disease process in order to help parents identify strategies to enhance resiliency in their child (Juntunen &
Atkinson, 2002).
Counseling children with CF involves implementing prolonged and gradual approaches to relationship
building, increasing one’s knowledge of the illness, adapting treatment approaches to account for the impact of
invasive medical procedures, and involving parents, guardians and other professionals in the counseling process.
Above all, honoring the perspective of the child is central to success in counseling this population, which can be
easier said than done. The chronic and complex nature of CF and its treatment requires a great deal of effort and
presents additional clinical challenges for professional counselors. Over time, the challenges of working with
children with special needs can affect the wellness of professional counselors providing services. Therefore, it
is important for counselors to recognize the factors contributing to impairment and burnout, particularly among
counselors who work with children experiencing chronic illnesses like CF.
A Self-Care Primer for Professional Counselors
Professional counselors and other health professionals engaged in prolonged therapeutic contact with clients
with CF are vulnerable to burnout, compassion fatigue and vicarious trauma (Coady, Kent, & Davis, 1990;
Lewiston, Conley, & Blessing-Moore, 1981; Savicki & Cooley, 1987), potentially leading to impairment.
Counselors have an ethical obligation to recognize their state of wellness and potential impairment (American
Counseling Association [ACA], 2011), which may be impacted by burnout, compassion fatigue or vicarious
trauma while working with children experiencing chronic conditions (Angerer, 2003; Kalliath, O’Driscoll,
Gillespie, & Bluedorn, 2000; Najjar, Davis, Beck-Coon, & Doebbeling, 2009; Sexton, 1999) such as CF. Such
occupational risks may be heightened when professionals work with clients with a poor prognosis associated
with chronic illness, including CF (Coady et al., 1990).
Counselors and other mental health professionals experience occupational stressors such as long working
hours, work with challenging clients, poor interdisciplinary support and poor supervision (Coady et al., 1990).
Lewiston et al. (1981) examined burnout among health care providers working with clients experiencing CF.
They found high levels of emotional exhaustion and client depersonalization (i.e., a sense of inability to impact
clients’ improvement while watching clients’ illness progress), and a lower sense of accomplishment among
health care providers working with this population. The implications of these results are intensied because
“psychotherapists who work with chronic illnesses tend to disregard their own self-care needs when focusing on
the needs of clients” (Figley, 2002, p. 1433).
Children with CF and their families are survivors of both medical and psychosocial traumas. Frequent
trips to the emergency room, an inability to breathe, surgeries, and understanding the unpredictable and fatal
progression of CF are among the traumas endured by this special population. Professional counselors who
hear these traumatic stories within the therapeutic milieu must understand that vicarious trauma can occur for
even the most experienced counselor. Sommer (2008) claried that vicarious traumatization is not inadequacy
on behalf of the counselor or emotional damage of the client but can be considered an “occupational hazard”
(p. 52). Vicarious trauma, dened as “a traumatic reaction to specic client-presented information” (Trippany,
Kress, & Wilcoxon, 2004, p. 32), also may occur among professional counselors working with children who
have CF due to the erratic and terminal progression of the illness.
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Professional counselors serving the CF community must recognize their vulnerabilities to burnout,
compassion fatigue and vicarious trauma. Given the realities of clinical practice and responsibilities of
everyday living (e.g., busy schedules, high caseloads, supervision barriers, family responsibilities, maintaining
relationships), poor self-care and wellness may be easy to identify but difcult to change. In order to prevent
issues of burnout, compassion fatigue and vicarious trauma, the following self-care strategies are suggested for
professional counselors who work with this special population.
Self-Care Strategies for Professional Counselors
Although counselors are taught to utilize a developmental and wellness approach when working with clients
(Myers & Sweeney, 2005), they often neglect their own health and well-being. Self-care strategies embedded
in a wellness philosophy may help to prevent incidences of burnout among those working with the unique
emotional and psychosocial stressors affecting children with CF and their families. Myers and Sweeney (2005)
identied wellness as both a process and an outcome in that it is an “overarching goal for living and a day-by-
day, minute-by-minute way of being” (p. 9). Self-care strategies involve managing stress in ways that limit the
impact on the individual (Young, 2005). Within the counseling literature, wellness is depicted as incorporating
social, emotional, physical, intellectual and spiritual dimensions (Roscoe, 2009). Counseling wellness models
have been empirically supported in the counseling literature (Myers & Sweeney, 2005; Myers, Sweeney, &
Witmer, 2000; Sweeney & Witmer, 1991; Witmer & Sweeney, 1992) and inform individuals about methods to
limit their stress and maintain a healthy sense of well-being. Hence, we recommend that professional counselors
use multidimensional, holistic self-care strategies to maintain a sense of wellness when working with youth
experiencing special needs. The following section provides physiological, cognitive and spiritual wellness
strategies for professional counselors to use while working with children with CF and other chronic conditions.
Physiological self-care strategies. Professional counselors are accustomed to working with clients regarding
wellness and self-care but may not always practice their own healthy suggestions. Self-care strategies that are
body-focused may help alleviate the impact of stress (Young, 2005), particularly among those working with
children with special needs such as CF. Young (2005) recommended approaches such as progressive relaxation,
balanced exercise and nutrition, and adequate rest to assist with integrating a wellness focus and enhancing self-
care. A healthy diet and physical activity are readily known to prevent physical and mental health conditions,
while also increasing energy levels. Furthermore, “minding the body” and having adequate sleep and bodily
rest are additional suggestions for restoring self-care as a priority for professional counselors (Norcross &
Guy, 2007, pp. 64–65). Professional counselors interested in implementing physiological self-care strategies
to address potential issues of vicarious trauma while working with children diagnosed with CF may consider
simple tasks such as taking a brisk walk during their lunch break, joining a gym, or being more intentional
with their diet and bedtime routines. In addition to focusing on physical health and wellness, self-care in the
cognitive domain is equally important for fostering a sense of well-being.
Cognitive self-care strategies. Stress from occupational risks accumulated through working with youth
with special needs may be further prevented if counselors utilize cognitive approaches to support their own
self-care. Professional counselors interested in improving their self-care in cognitive ways may consider
cognitive restructuring to formulate new thinking patterns and assertiveness training to bring about direct
changes in behaviors that may have been impacted by stress (Young, 2005), which often accumulates during
the long-term therapeutic relationship with children and families affected by CF. Moreover, the use of guided
imagery may provide both cognitive and physical benets in helping to create a cognitive break from daily
stress inside and outside the workplace. Notably, cognitive self-care strategies begin with self-monitoring,
insight and self-awareness (Norcross & Guy, 2007). Despite counselors’ close therapeutic connection to clients
with CF and their families, healthy boundaries are imperative to prevent issues of burnout and compassion
fatigue. Norcross and Guy (2007) noted that “setting boundaries consistently emerges in the research as one of
300
the most frequently used and one of the most highly effective self-care principles” (p. 94). Due to counselors’
innate desire to help others, they often take on too many clients or are mandated to do so by agency policies.
Counselors may provide extra time to ancillary responsibilities and have unrealistic expectations of themselves.
As such, we recommend that professional counselors obtain good supervision to help manage and maintain
work–life balance, particularly when working with children with special needs. In addition to the benets of
physical and cognitive self-care strategies, spirituality also has been shown to enhance levels of wellness and
thus decrease the potential for burnout and compassion fatigue.
Spiritual self-care strategies. Spirituality comes in many forms and there is no nite denition of how one
engages in his or her spiritual self. Many counselors and psychotherapists identify their own career path as a
calling to care for others and commitment to growth and self- knowledge (Norcross & Guy, 2007). Research
supports that spirituality, prayer and meditation are positive manners in which to promote wellness and augment
self-care (Cashwell, 2005). Spiritual beliefs, practices and experiences are intricately connected and may
continue to foster support from communities and individuals, along with reinforcing healthy emotions. While
working with children experiencing the later stages of CF, professional counselors’ spirituality may help them
connect with clients on a more meaningful level. Taking a spiritual perspective can further shape counselors’
perspective on life events (Young, 2005), particularly when they are grieving the death of a child with CF.
In seeking a spiritual connection to a higher power, the negative responses to stressful events may be limited
(Young, Cashwell, & Shcherbakova, 2000), strengthening one’s wellness and ability to care for oneself. These
actions, along with discussing spirituality with the child and family affected by CF, may further model healthy
practices during difcult times in the disease process.
Spiritual self-care can include the use of mindfulness, which can be viewed as the nonjudgmental awareness
of one’s own inner suffering (Birnie, Speca, & Carlson, 2010) and reections on self-compassion (Neff, 2003).
Birnie et al. (2010) described self-compassion as the awareness of “feelings of caring and kindness towards
oneself in the face of personal suffering” and the “recognition that one’s suffering, failures, and inadequacies are
part of the human condition” (p. 2). When counseling children with CF, professional counselors may consider
routinely expressing self-compassion as part of their inner dialogue. The following mantra used by the second
author may be of assistance to professional counselors implementing spiritual self-care:
Suffering is part of life. My clients suffer, but did not choose this illness. They are walking in its wake
and I will walk alongside them. I will extend loving kindness in all the work I do, despite the pain and
suffering I experience and witness.
We highlight the following three essential components of self-compassion: (a) extending kindness and
understanding toward oneself rather than harsh judgments or criticism, (b) recognizing that suffering (even
chronic illness) is a part of the larger human condition, and (c) not overidentifying with the awareness of
one’s painful thoughts (Birnie et al., 2010; Neff, 2003). By engaging in self-compassion and mindfulness,
professional counselors may help to prevent incidences of compassion fatigue while working with children and
families affected by CF by recognizing that this illness has a role in their humanity.
Conclusion
Professional counselors working with children and families affected by CF should consider the physical
and psychosocial challenges facing this special-needs population. With the discouraging nature of the disease
progression, professional counselors must have a basic understanding of the client’s chronic condition
(Thompson & Henderson, 2007) and how the progression of the illness affects the child’s emotional state.
Professional counselors must further explore how to limit the impact of occupational stress that may lead
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to burnout, compassion fatigue and vicarious trauma. This article provides a primer on the physiological,
psychosocial and special needs specic to youth with CF and offers targeted self-care strategies for professional
counselors. Children with CF are a special population and professional counselors are called to implement
these special considerations in their thoughtful practice. There is an abundance of literature examining the
physiological aspects of CF (CFF, 2014a; Pearson et al., 1991; Sawicki et al., 2009; Sawicki & Tiddens, 2012).
However, more research is warranted to examine the salient factors that affect the therapeutic relationship
between professional counselors and children with CF. Meanwhile, professional counselors can develop and
implement individualized, multidimensional self-care strategies to counter the effects of this difcult yet
rewarding work.
Conict of Interest and Funding Disclosure
The authors reported no conict of
interest or funding contributions for
the development of this manuscript.
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Sherry Richmond-Frank
Because “Mama” Said So: A Counselor–Parent
Commentary on Counseling Children With
Disabilities
This article, written by a parent of an adult child with spina bida, invites counselors into the life experiences of
children with handicaps and their families. The description of these experiences highlights current problems with
the stigma this population experiences. The author describes the varying disability identities and orientations
that have evolved within the disability culture and wider society. Counselors are encouraged to use unbiased
terminology in both research and clinical work with children with disabilities. Solutions are offered for counselors
to implement in practice and research to further overcome stereotypes, develop disability awareness and provide
helpful counseling. The author provides practical interventions for a variety of challenges where counselors may be
useful to children with disabilities and their families.
Keywords: children, disabilities, stereotypes, stigma, handicaps
I am a counselor, a life coach and the parent of an individual with a disability. Since entering the disability
community 28 years ago with the birth of my daughter, I have attended both workshops and seminars designed
to assist parents concerning children with disabilities or chronic illness. In 2005, I attended eight monthly
sessions of Partners in Policymaking, a national leadership training program for people with developmental
disorders and family members of young children with disabilities, designed to achieve productive partnerships
between people needing and using services and those who make public policy and laws. In this article, I provide
information about children with disabilities and their family systems and offer recommendations for counselors
working with children with disabilities and their families.
Disability Identity and Orientation
I use the term disability in this article, while the preferable word to describe differences is variation, a more
neutral term that lacks negative connotations for children in society. Variations provide richness and diversity
in life that can be noted without being denigrated or overemphasized. Depending on how children or adults
identify with and orient themselves to the impact of their disabilities, both personally and with respect to society
at large, they may have varying preferences for acceptable terms. The reader can consult Gilson and DePoy
(2004) for a discussion on disability identities and orientations.
The saying “Nothing about us without us” is an informal one within the disability community. Hahn (1993),
a social scientist with over 10 years of research experience in the disability eld and personal experience using
crutches and a wheelchair since the age of 6, has spoken of a minority model of disability that has its origins
in a sociopolitical model. This model arose when individuals with non-transient or lifelong disabilities stated
that research using prior models did not seem relevant to their lived experience. Thus, policies and services
that arose from these models did not result in meaningful life improvements. Attitudinal variation has arisen
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within the disability subculture regarding identities and orientations toward disabilities. A sociological ideology
for conceptualizing individuals with disabilities and their families has emerged, which varies from the older
entrenched medical model that regards disability as illness, tragedy or a negative situation requiring treatment
and rehabilitation. Using the medical model, people with disabilities and their families are conceptualized based
on their acceptance of and adaptation to disabilities. The sociological model focuses on the larger society or
system and its reaction to the individual, rather than examining the person with the disability as the identied
patient. Impairment and dysfunction are conceptualized as part of the larger system, with its handicapping
environment and public attitudinal barriers, rather than within the individual who has varying abilities and is
referred to by this larger system as a person with a disability.
A wide range of models have evolved to the point that Darling (2003) proposed an exploration of disability
orientations that include normalization, crusadership, afrmation, isolated afrmation, situational identication,
resignation and apathy. Familiarity with these orientations will help counselors understand the disability
identities and orientations of their clients and their family members. It is benecial to acquire a clearer
understanding of disabilities and their actual rather than imagined impact on clients in order to improve one’s
diversity awareness.
Eliminating Ableism and Pity
Professionals entering the multilayered maze of counseling children with disabilities must honestly explore
their positive and negative preconceptions about people with disabilities. Counselors should understand and
confront ableism, dened as “the discrimination or prejudice against individuals with disabilities” (Ableism,
2015). Furthermore, counselors should examine and challenge their own disability stereotypes prior to entering
the counseling room with clients impacted by disability. Scope (2014), a disability-related charity in the United
Kingdom, challenges ableism in the initiative “End the Awkward” found on the their website (http://www.scope.
org.uk/awkward). This site allows readers to take an informal quiz to see if they are an “ambassador of cool”
or a “captain awkward” around people with disabilities and also a link to watch short television advertisements
designed to decrease awkwardness around individuals with disabilities. Helping professionals need to internally
clarify the distinction between empathy and sympathy. Counselors can invite open discussion about the
disability, as they would invite clients to share information about any subculture, so they feel free to clarify
pertinent aspects of their lives and disability in counseling that might otherwise go unaddressed.
Helping professionals also should use non-handicapping language to afrm the individuality and personhood
of clients. The Publication Manual of the American Psychological Association (American Psychological
Association, 2010) has provided the following recommendations for unbiased terminology in research and
academic writing:
The overall principle for “nonhandicapping language” is to maintain the integrity (worth) of all
individuals as human beings. Avoid language that objecties a person by her or his condition (e.g.,
autistic, neurotic), that uses pictorial metaphors (e.g., wheelchair bound or conned to a wheelchair),
that uses excessive and negative labels (e.g., AIDS victim, brain damaged), or that can be regarded as
a slur (e.g., cripple, invalid). Use people-rst language, and do not focus on the individual’s disabling
or chronic condition (e.g., person with paraplegia, youth with autism). Also use people-rst language
to describe groups of people with disabilities. For instance, say people with intellectual disabilities in
contrast to the retarded (University of Kansas, Research and Training Center on Independent Living,
2008).
Avoid euphemisms that are condescending when describing individuals with disabilities (e.g., special,
physically challenged, handi-capable). Some people with disabilities consider these terms patronizing
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and offensive. When writing about populations with disabilities or participants, emphasize both
capabilities and concerns to avoid reducing them to a “bundle of deciencies” (Rappaport, 1977). Do not
refer to individuals with disabilities as patients or cases unless the context is within a hospital or clinical
setting. (p. 76)
Children with Disabilities and the Family System
The family of a newborn diagnosed with a disability attempts to become acquainted with the infant and gain
parenting skills, while still in a bustling neonatal intensive care unit. The family may be experiencing what
McHugh (1968) called anomie, which is the idea that life is no longer normal, does not make sense, and is out
of one’s control. The family’s experience may include focusing on the physician’s words, hearing the startling
news that their child is receiving the diagnosis of lifelong disability, and considering what impact the disability
will have on their child and family. Simultaneously, numerous specialists and nurses may be verbally giving
the parents large amounts of vital, unfamiliar information in complex medical terminology, while evaluating
how the parents are adjusting. The parents may be asked to make urgent life-altering medical decisions about
surgeries that will affect their child’s well-being. Helping professionals must realize that parents need time to
adapt to this life-changing situation.
Normalization
Parents who have not lived with a disability as a part of their lives need time to absorb the impact of the
disability on their child and family as they move through anomie into the period that Seligman and Darling
(2007) called normalization and resume the activities that were punctuated by the adjustment to the disability.
Families acclimate to a new normal that contains a member with a disability. Gradually parents become
capable of a knowledgeable dialogue with the medical community and may even inform physicians of
promising treatments for their child, eventually realizing that they and their child(ren) are capably managing the
practicalities of the disability, gaining needed services, and coping when unexpected changes and challenges
arise.
During normalization, family members strive to help each other, and they build satisfying experiences and
memories as they travel through the family life cycle. This process is neither easy nor quick; it can be gut-
wrenchingly painful. However, it can produce much personal growth, the shifting of previously held values
and priorities, and the satisfaction of a job well done. The process of normalization is not, as some assume, an
insurmountable burden to bear, but rather a growth-producing challenge that can be met, sometimes joyfully.
Counselors should beware of assuming that all children with disabilities and their families contain pathology.
Many families have the internal and external resources to adapt to the disability over time without the need
for professional intervention. Helping professionals should avoid referring to these families and children as
special, as this term minimizes and unintentionally disrespects the effort required by ordinary people who face
extraordinary challenges while meeting the other demands of daily living.
Parents’ Adjustment to the Diagnosis
People assume that parents whose children receive a disability diagnosis at birth are grieving the loss of
an ideal perfect child. I suggest that the parents have grown to love the child prenatally and are grieving what
their actual child is experiencing or may experience throughout life. The parents may struggle with the pain
of relaying the diagnosis to siblings, grandparents and extended family members. Olshansky (1962), one of
the initial researchers of families of children who have cognitive disabilities, recommended that chronic grief
is an expected reaction of a caring parent to parenting a child with a disability and much more useful than the
oversimplied idea of acceptance or rejection.
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Some developmental disabilities are discovered prenatally or shortly after birth, or result from premature
birth. Some disabilities are diagnosed later in childhood, as parents notice missed developmental milestones or
the child loses previously-acquired skills through illness, accident or physical abuse. Other parents may suspect
a disability in their child prior to receiving an ofcial diagnosis. Counselors should remember that the pang of
sadness a parent may feel when his or her child misses a developmental milestone or experiences social stigma
is normal and does not mean that parents are coping poorly.
Parents who are trying to be hopeful are not necessarily denying the disability. Automatically applying
diagnoses from the fth edition of the Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association, 2013) to the parent’s reaction to an initial diagnosis of disability in their child can add
additional stress to the family system. Family members of children with disabilities may be inclined toward
mental health difculties that do not interfere with normal life functioning until the additional stress of the
disability and the requirements for managing it overload the person’s coping skills, either temporarily or over
time. The process of normalization takes time to unfold. Helping professionals should build a caring relationship
with the family at the time of diagnosis and be available later if mental health issues begin to interfere with
normal functioning. Counselors should use their clinical skills of differential diagnosis to understand and
unearth the interplay between the parent’s orientation to disability and his or her conceptualization of disability
identity to avoid framing a mindset as a mental health disorder.
The child’s parents or siblings may have psychiatric diagnoses or relational difculties that predate the
child’s disability diagnosis. Such issues may interfere with family resilience and the process of normalizing the
disability and promoting healthy child development. Addictions, anxiety, depression, adult attention-decit/
hyperactivity disorder and other diagnoses can impede parental well-being and effective parenting. Thompson
and Gustafson (1996) suggested that improved child development and adaptation to chronic childhood illness
are associated with parental social support, adjustment and decreased stress. Elman (1991) suggested the need
for counseling depressed family members. Crnic and Greenberg (1990) indicated that decreased competence in
children is related to parental personal stress that interferes with effective parent–child communication. After
many years of counseling families, I have come to believe that the family system can operate more smoothly if
the individual members address mental health issues that impede marital satisfaction, family cohesion, conict
resolution, stress management, child rearing, medical management and other positive coping skills.
The birth order of a child with a disability can change the future family structure as the parents contemplate
whether to have additional children. If the child with a disability is the parents’ rstborn and the disability
has a genetic component, additional children may share the same disability, in a milder or more severe form.
Parents may consult geneticists to explore the probabilities of a recurrence of the disability while they consider
their ability to incorporate various scenarios into their lives. Childhood disabilities have direct and indirect
psychosocial and nancial costs for families. Seligman and Darling (2007) discussed direct costs of adaptive
equipment, therapy and child care, and indirect costs like fees for housing modications, work absences, and
parental difculty for career advancement. Sometimes one parent chooses not to work outside the home in
order to be available for tasks related to managing the disability, a decision that reduces the family’s income.
Regardless of the counselor’s or geneticist’s viewpoints, the decision to pursue additional children can be a
complex, grueling decision for individuals whose convictions do not give them the option of attempting to
conceive and then terminating a life prenatally if a disability is detected, especially for parents who already love
a prior child with that or another disability.
Self-Concept Development among Children with Disabilities
The child with the disability develops opinions about the family and himself or herself. Children create a
sense of self from the reections they see in their interactions with others. Unfortunately, people with cognitive,
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emotional or physical differences encounter distorted mirrors daily. The communication they have with others
often is ltered through an unspoken screen of ableism and stigma. In Disability Is Natural: Revolutionary
Common Sense for Raising Successful Children with Disabilities, Snow (2001) described the Euro-American
history of disability and myths. When the child encounters a person who has not had close friendships with
anyone with disabilities, the person may display uncomfortable, awkward behavior around the child. The person
may stare, avoid eye contact, treat the child with pity, act like the child is “special,” speak to the parents instead
of the child or act in other confusing ways that pose barriers to intimacy. Children with disabilities sometimes
do not question the interpretations of others and may begin to believe that anomalies are bad and that they are
inherently bad, rather than just different. Children with disabilities also may not realize that the awkwardness in
the room arises from discomfort in the other person and may wonder what is wrong with them.
Though people with disabilities are a natural part of society, they continually encounter barriers to full
participation in society. In a society containing environmental and attitudinal barriers—for example, the lack of
ramps or curb cuts necessary for people in wheelchairs to navigate their community—the simplest of tasks can
be continually inconvenient.
Counselors must recognize that the disability is the child’s constant companion, 24 hours a day, 7 days a
week, which may include a complex medical condition that affects various parts of the body and its functions,
possibly resulting in pain. The vocabularies of children with disabilities may include medical terminology and
treatments that are complicated to understand and time consuming to accomplish. The child may have a visible
disability that is always on display for others’ comments and stares; alternatively, the child may have a disability
that is hidden and misinterpreted by people in the community. Until one accompanies a person with a visible
disability in public, one does not even realize what a luxury it is to go about daily tasks without others stopping
to look for extended amounts of time with expressions of wide-eyed shock or curiosity. Counselors can teach
children without disabilities to react less awkwardly around children who have disabilities.
Counselors should remember that each child and family is unique, but be aware that children with disabilities
are more like children without disabilities than they are different. They simply vary in some way. The child
may be in counseling because of internal challenges resulting from the disability or external emotional, social,
attitudinal, educational or physical barriers to inclusion. However, the child may be in counseling for a difculty
that would arise even if there were no disability. It is helpful for children with disabilities to realize that some of
the struggles they encounter are common to all children.
The Emotional Toll of Services
Community services, such as Respite Care and Individual Education Plans, are available to assist children
with disabilities and their families with some of the challenges presented by the disability. People are vetted to
see if they qualify for services and terms from the medical model of disability are utilized. Unfortunately, in
order to receive services designed to maximize potential, children with disabilities must interact with agency
staff members who discuss and emphasize decits and rehabilitation in their presence. Children with disabilities
may nd the language and terminology insulting and demoralizing, considering that they have not had an
accident and do not feel the need to be compared or repaired.
The disability subculture is not homogenous. Developmental disabilities include spina bida, cerebral
palsy, diseases of the muscles and bones, neurological disorders, craniofacial deformities, metabolic disorders,
endocrine disorders, seizure disorders, cleft palate, cleft lip, visual impairment and blindness, hearing
impairment and deafness, mental retardation, attention-decit/hyperactivity disorder, learning disabilities,
autism, chromosome and genetic disorders, and numerous others, including those that are extremely rare and
possibly unnamed. Children and families in these various subgroups have some experiences in common and
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other distinct differences due to the various traits, challenges, onset and societal reactions to their particular
disabilities.
Complex Client Group
Counseling children with developmental disabilities is like working a complex three-dimensional puzzle.
Each individual child is as distinctive as a ngerprint. The child is a member of a family that has its own
characteristics, rules and roles. The child and his or her family members’ temperaments affect reactions to a
disability. Within any given family, there may be varying opinions among members about how to handle the
disability or avoid dealing with it, which can impact family interactions. Children with handicaps come from
a variety of ethnic cultures and heritages that inuence the adjustment of the family members’ reactions to the
child’s differences.
Spirituality
Counselors should not underestimate the benets that some children with disabilities and their families
derive from strong connections to their faith or other forms of spirituality, if they are not part of a religious
community. Seligman and Darling (2007) wrote that some religious communities contribute a great deal of
support to the families of children with disabilities. Poston and Turnbull (2004) discovered that other families
have difculty nding a religious group that will incorporate their child and family into the faith community.
They reported that having a child with a disability, at times, is the precipitating factor to the development of
spirituality in family members. Schiele (2000) and Parham (2002) proposed that aspects of the Afrocentric
service models are benecial when working with African Americans since these models incorporate
interdependence, collectivity, affect and spirituality. These benets may be generalizable to other ethnic groups.
McCarthy (1995) encouraged counselors to explore and use spiritual ideas and techniques to benet the physical
and mental well-being of clients.
Belief in a benevolent power or ideological concept can sustain exhausted, discouraged individuals when
situations are beyond their control despite their sincere proactive efforts. During those moments when they
feel that they cannot continue without despair, they can let go and allow God, a higher power or whatever
spirituality they cling to for sustenance intervene. For example, when sending their day-old neonate into spinal
surgery, religious parents may draw comfort from the belief that a divine being continues with their infant and
the surgeon beyond the operating room doors that separate them from their child. Children whom physicians
predict will die continue against all scientic evidence to live and thrive; sometimes parents have supernatural
theories about these outcomes. Turnbull, Turnbull, Erwin, and Soodak (2006) referred to spirituality as the way
that people derive meaning in their lives and interact with the sacred. According to Skinner, Correa, Skinner,
and Bailey (2001), spirituality can inuence whether a family considers the addition of a member with a
disability to be a blessing or retribution for an offense (Chan, 1998; Chan & Lee 2004; Rolland, 2003). Frisco
(as cited in Seligman & Darling, 2007) indicated that the majority of the grandparents surveyed reported that
religion and belief in God helped them more comfortably accept a disability in their grandchild.
Multiple Interconnecting Systems
The child and his or her family have multiple interconnecting systems to navigate, while attempting to
achieve the normal activities of being a family and helping the child accomplish typical developmental tasks,
without reducing this goal to a tedious, life-draining behavioral chart that devalues the child’s personhood
and the spontaneity and freedom of childhood. Nichols (1984) considered an open system to be a group of
interconnected parts of a whole that interact with each other and the larger environment around information,
material and energy. General systems theory and cybernetics provide concepts that assist counselors in studying
the multiple elements that constitute the collective experience of living with a disability. These systems may
include physicians, therapists, schools, tutors, insurance companies, respite care services, disability advocacy
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and support groups, community activities, neighbors, playmates, extended family, and other groups of people
who make up the ever-evolving gears of an interacting environment that contains the child and his or her
nuclear family subsystem. Miller (1995) afrmed that a well-functioning psychosocial environment is vital to
the child’s healthy maturation, and counselors can work with children and their families to reduce feelings of
being overwhelmed.
Disabilities are not as inherently stressful as what parents go through while trying to help their child with
optimal growth and development. Acquiring adaptive equipment, services, educational accommodations and
community participation can be tedious and frustrating. Parents often are required to contact busy physicians,
educators, automated insurance provider telephone messages and agency coordinators to get documentation
for equipment that they need in order to accomplish simple tasks that the dominant culture takes for granted.
Normal activities like comfortable body positioning, eating, toileting, ambulating and being integrated into
school classrooms can be prolonged, inordinately exhausting, emotionally draining and time consuming.
Once services and equipment are acquired, the family unit may become part of a large, complex, constantly
evolving system including, depending on the particular disability, educators, adapted physical educators,
therapists (e.g., physical, occupational, speech, respiratory), tutors, dieticians and medical specialists (e.g.,
pediatricians, gastroenterologists, orthopedic surgeons, cardiologists, urologists, audiologists). Many disabilities
require adaptive equipment that is initially unfamiliar to the family. Medical professionals tell parents and
their children about assistive health devices that others with similar disabilities have found helpful. The family
may need time to adjust to the reality that their child has to use the device, to examine the risks and benets of
equipment and treatments for the disability, and to nd someone who provides the service locally.
Health devices are often expensive and must be paid for through insurance, government programs or private
payments. Obtaining the equipment may be a lengthy, convoluted process that involves repeated negotiation
with insurance providers and resubmitting payment requests or searching out alternative funding sources if
insurance payment is denied. Once the adaptive equipment arrives, there are often therapy appointments to
individualize the t of the equipment to the child, teach the parents and child how to use the product, coax the
child to use the aids, and check to see that the product is doing no harm to the child. It can take weeks of trial
and error to modify equipment that is problematic. This process may repeat often as the child grows older.
Children may want to participate in activities that are outside the realm of the Americans with Disabilities
Act. Parents may nd themselves having to reassure and encourage the people who run these programs to
include their child. This process may involve educating Scout leaders, religion teachers, preschool staff, parents
of the child’s classmates, camp staff and others about the disability and how to make modications to include
the child, and also may involve calming fears that it will be too difcult for the staff or the child to manage or
too dangerous for the child to participate. Most children with limitations want the same independent adventure
opportunities as other children; to try new experiences; risk, fail, try again and succeed; and sometimes surpass
others’ expectations for them.
It is important to help families see that their child needs to be surrounded by a support system that has
challenged negative assumptions about people with disabilities. Children with an observable disability do
not have the gift of anonymity that most people take for granted. They need comfortable places to just be
themselves, recharge emotionally and exist as a member of the group. They need the enduring support and
friendship from others who are easy, normal and natural in their interactions with the children, to inoculate
them against assaults to their worth that they can encounter in the larger society. On some level, children may
think that their parents are giving them afrmation because of their roles as parents. Children need to know that
people other than their parents also acknowledge their skills, temperament, accomplishments and personhood.
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Children need interactions with people who allow them to be authentic and respond genuinely and honestly;
thus, children learn how to be in healthy relationships.
Interventions to Disable Ableism and Promote Friendships
Parents of children without disabilities sometimes tell their children not to stare at children with disabilities
but may not make a suggestion for a replacement behavior, like saying, “hello.” Thus normal opportunities to
interact are missed and taboos that encourage shunning and bullying continue. This behavior can contribute to
unnecessary adjustment problems in adulthood that Cadman, Boyle, Szatmari, and Offord (1987) and Rutter,
Tizard, and Whitmore (1970) have suggested are related to experiencing social rejection early in one’s life. To
promote integration and change attitudes, it would be helpful for school counselors to offer diversity training
concerning disabilities for students and parents throughout the school population. Informational sheets could be
sent home in the beginning of the school year or brief presentations could be included at parent meetings. Some
of the child’s classmates may grow up and one day become parents of children with disabilities.
Social Skills Development
Miller (1995) reminded us that the peer social system is the main area where children develop and hone
relationship-building and social problem-solving skills. However, some children with disabilities have trouble
forming relationships with their peers for a variety of reasons. They may lack the opportunity to socialize
with peers in a regular setting or have trouble ambulating to where children are playing. They may have a
human aide who impedes normal peer interactions, tagging along to manage a healthcare issue. They may not
understand the social mores of others their age because of so much time spent with parents and adult health care
providers or due to aspects of their disability. In addition, service providers may talk to parents about the child
as if the child is not present. Parents can learn to redirect physicians, nurses and other service providers to speak
to the child in age-appropriate language.
Tovray and Wilson-Portuondo (1995) suggested that children may need formal help to learn social skills
for developing friendships if they do not notice or understand social cues and nonverbal messages from others.
Children with disabilities may struggle with nonverbal learning issues or characteristics on the autism spectrum,
making engaging or understanding others difcult. They also may have behavioral disabilities that alienate
other children or result in the continual loss of recess privileges. They may have medical therapies after school
and daily tasks to complete between visits. Children with disabilities may spend an unreasonable amount of
time trying unsuccessfully to complete homework assignments. Counselors can help a child with a disability
by making a referral to a neuropsychologist to determine strengths and weaknesses, and then the counselor,
parents, neuropsychologist, teachers and tutors can help the child develop more effective study and executive
functioning skills that match his or her temperament and learning style. Parents and counselors can work
together so that children with disabilities have opportunities to be and not just do activities.
Educating Peers to Reduce Isolation
Sometimes children ask questions undiplomatically. For example, a preschooler with spina bida might
be asked, “Why do you walk weird?” Some parents of children with disabilities visit the school on the child’s
rst day and speak to the child’s classmates in an attempt to decrease painful queries that can invite social
anxiety. Preparing the class as a group also frees peers from being preoccupied with unanswered questions. If
professionals help the child and family create and practice an elevator speech, perhaps these unhelpful questions
will occur less often. The elevator speech can be a few sentences to explain the disability when meeting new
people, which could prevent the disability from becoming a taboo subject. Talking openly can relieve other
children’s unrealistic fears of catching the disability.
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Returning to the previous example of a preschooler with spina bida, the child could introduce herself by
name and say something to let her classmates know what they have in common, like, “I am 5 years old. I have
a brother and sister, and two dogs. Who else has a brother and sister? Does anyone else have a dog? I like to
play, read books and eat ice cream. I am looking forward to being your friend.” After this joining statement,
she could then give a brief age-appropriate description naming her disability and saying how it affects her and
others, as follows: “I have spina bida, so some of the nerves in my back don’t talk to my legs to tell them to feel
or move. The other parts of my legs have to work harder, so I walk differently. I’ll pass around my old braces,
like the ones I wear to help me walk. Please don’t mess with my wheelchair unless I ask for help. You can’t
catch spina bida like you do a cold. I don’t run so please walk slower, so I can keep up. Let’s talk and see how
we can all play together.” Sometimes the child may not have the social or cognitive skills for public speaking
or may simply prefer that the parent give the elevator speech. However, the child can learn self-advocacy by
sharing some part of the elevator talk. After the elevator speech, the parent can ask if anyone has any questions.
Parents sometimes ask educators to send a letter home to the parents of their child’s typical classmates with a
brief description of the disability so that parents understand and include the child in after-school invitations that
are extended to the rest of the class. Then the child and peers can begin the school year ready to focus on getting
to know each other, forming friendships and learning classroom content.
This introduction could reduce the isolation of children with disabilities by demystifying their differences
and allowing them to assimilate into the group. Children with disabilities, their classmates, school staff and
families need practical skills for dealing with bullies. Parents can search for schools that take bullying and
violence prevention seriously and have a school strategy in place to discourage bullying. Bullies may try their
unacceptable behaviors on various class members; however, they tend to choose people who are alone to be
their victims of repetitive bullying. Children with disabilities can learn strategies for standing up to the bully.
Classmates of children with disabilities can acquire the information necessary to become friends and allies for
the student in areas where there may be less adult supervision such as the lunchroom, bathrooms, hallways, or
on the playground. They can help intervene to include the child with a disability in pleasant encounters with
children from other classrooms and also speak on behalf of their friend when others ask questions or make nasty
comments. Counselors can work with the school staff, parents and children to develop school-wide anti-bullying
campaigns that teach children to counteract bullying and become allies for one another.
Preventing Isolation by Building Peer Support
The child and family may share their culture, religion and other signs of unity and cohesion. However, if the
child’s exceptionality is not inherited, he or she may have the difcult experience of being the only member of
his family with the anomaly. The child may benet from the support of peers with the same disability to spend
time with and compare experiences; or just be with colleagues who are already familiar with the disability and
do not require explanations. Counselors can help parents nd camps and support groups for both the family and
child that include both children with disabilities and typical peers. Children need older, successful role models
with disabilities who inspire them to persevere when they are discouraged. They need mentors, with and without
disabilities, who challenge them to dream and make continual progress to accomplish their dreams.
Recommendations for Counselors
Counselors can be more aware of areas in which they can be quite helpful. Counselors can intervene in the
medical system to provide newborns with disabilities and their parents with natural settings that allow relaxed
time together to promote attachment and bonding. Counselors also can operate from a systemic, strengths-based
model in order to best respect and support the child and family. Throughout the child’s development, counselors
and families can collaborate to promote the development of age-appropriate skill acquisition, protective yet
permeable personal boundaries, self-awareness, positive self-esteem, social skills, relationship development, the
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ability to be resilient in the face of stigma, and the opportunity to transition to the adult roles of employment,
independent living, dating and family formation.
Systemic, Strengths-Based Counseling Models
Allen (1994) indicated that counselors and theorists operating from various individually oriented counseling
perspectives assume that the origin of dysfunction and self-destructive behaviors in an individual is an internally
defective self, psyche or physiological aw. Hahn (1993) noted that the medical understanding of disability
relates to organic pathology or impairment. Counselors who operate from a family systems model believe that
difcult individual behavior is best understood as one piece of a larger interacting whole, such as the family
or society, which is greater than the sum of its parts. The behaviors of individual members of the system are
considered reections of what is happening in the larger system. Rather than identifying the individual as
a patient to be xed, Nichols (1984) stated that the system should be explored to identify pathology in the
interactions between people. Oliver (1996) did not believe that disabilities are intrinsically bad, and Linton
(1998) reported that many people have disability pride. Disability pride refers to recognition that society is
enriched by the distinctive positive voices, identities, thoughts, awareness, lifestyle examples and literature
produced by individuals with disabilities. Seligman and Darling (2007) suggested that professionals who adopt
a medical model of pathology may presume that the birth of a child with a disability will lead to maladaptive
family functioning and therefore the implementation of intrusive, undesired interventions from service
providers. I advocate the use of a collaborative, systemic, strengths-based counseling model due to the complex
interconnected systems that make up the environment of children with disabilities and because it is more
respectful of the child and family’s disability orientations and ability to prosper within a complicated context.
It is erroneous, unkind and disrespectful to label a child who is capably using his resources to the best of his
ability as unhealthy simply because he varies from the norm.
A systemic, strengths-based counseling model also respects the inherent worth of the child with a disability
by not presuming that he or she is the identied patient. He or she is incredibly resilient in the face of daily
challenges that would make many adults cower and yet gets up each day with renewed hope and moves forward
into the future. Not only does this child face the same developmental tasks of childhood as his or her peers, but
he or she must use additional thought, energy and time to develop and implement strategies to compensate for
personal variations that may make the accomplishment of these tasks extremely difcult and time consuming.
One goal of counselors working with children with disabilities is to acknowledge the personhood and
accomplishments of the children and their incredible inner fortitude, without categorizing them as more
special than any other child. In a society where people are compared to a perceived norm, this child was either
born with or acquired a variation that has been characterized as less than the norm, and labeled a disability,
impairment, handicap or developmental disorder. The terms are pejorative; the connotations of the words just
mentioned are as follows: not able, broken, defective, of lesser quality and developing incorrectly.
Counselors might also wonder how separation experiences impact attachment and bonding from the child’s
perspective. Does the child experience feelings of abandonment and fear at a time when he or she lacks the
ability to conceptualize or express them? A question for counselors and researchers to consider is whether there
is an enduring impact from these experiences. Some parents initially reject the child with a disability or fear
that they will not be able to manage the infant’s medical needs. Family members who have access to each other
usually bond. Seligman and Darling (2007) reported that attachment can be difcult for some parents when
aspects of the child’s disability interfere with the baby responding positively to his or her parents’ overtures.
Parents and counselors can help children with disabilities develop a healthy sense of self and determine
what behavior is acceptable in others, and under what conditions. With so many people entering and leaving the
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child’s life, it is helpful for parents and counselors to help children understand different types of relationships
and what to expect from them. They need to be protected from physical, sexual and emotional abuse and learn
refusal skills in situations where their trust and cooperation are exploited.
Promoting Self-Awareness
Children with disabilities need self-awareness. Counselors have the opportunity to assist parents of young
children with disabilities by suggesting that parents play games with their toddlers to help them learn body parts
and their functions, including the terms that name their disability since it is also a natural part of them. It is not
a dening part, but rather an aspect of themselves that they can become aware of and discuss, such as being
adopted or having green eyes. Once the disability is assimilated into the family, family members go about the
business of life; their child with a disability is just another member of the family.
Helping Children with Disabilities, Siblings and Parents Deal with Stigma
Siblings can help children with disabilities begin to interact differently with peers by accustoming them
to the support, disagreements and jealously common between brothers and sisters. Children with disabilities
encounter people within the larger community who may not be familiar with disabilities or the concept that
disabilities occur among regular people. Children with disabilities and their siblings need to be prepared
ahead of time for ableism so that they are not surprised or heartbroken by the reactions they receive from
people outside their home. At home, no one stares at children with disabilities, mocks their disability-related
differences or calls them negative names. Unfortunately, well-adjusted children with disabilities may encounter
cruelty from other children whom they meet outside their homes and primary social networks. They need
to know that the dysfunction in these interactions does not originate in them, but rather are due to a lack of
knowledge in other people. Children, parents and siblings need help interacting with the larger society around
issues of being different and educating others about their disabilities. Sibling groups can be helpful for children
who sometimes feel torn between conicting emotions about their sibling with a disability. Goffman (1963) said
that family members of children with disabilities sometimes receive courtesy stigma when they are in public
with their family member who has a disability. Children have reported feeling embarrassed by their sibling or
guilty for excluding them or not defending them. At other times children have been shunned for standing up for
their sibling. Siblings may sometimes be jealous of the extra attention their sibling’s disability requires, assist
with their sibling’s care or operate independently.
The Importance of Being, While Also Acquiring Skills
Children need time for unstructured play to develop their imagination, gain independence, explore hobbies
and experience leisure. They need opportunities to develop the daily living skills necessary to achieve autonomy
by adulthood. In addition to learning to prepare food, clean, do laundry, manage money, monitor appointments
and keep a home from dissolving into chaos, they will need to gradually take over the medical management of
their disability if they intend to maintain their health. Children with disabilities and their families need extreme
time-management skills in order to accomplish this herculean task. Counselors or life coaches can help families
develop a long-term family vision. They also can help the child and family develop short-term and long-term
goals for the child with the disability and problem-solving skills to overcome obstacles to their vision and goals.
Parents and children may nd it helpful to learn assertiveness skills so they can coordinate homework tasks
assigned by support services and say no to excessive demands from numerous systems that add up to more than
a 24-hour day.
Helping Adolescents Progress to Adulthood
When a disability is added to the list of difculties Haley (1997) described, one may discover additional
requirements for launching a young adult with disabilities. Some states require adolescents with disabilities to
be evaluated before they can apply for a driver’s license, and their vehicles may need costly accommodations.
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Some people with disabilities are refused the opportunity to obtain a driver’s license and must make other
plans for transportation. A young person with a disability needs a plan for vocational career development, job
training, higher education or some means of nancial support. Plans for independent living, a group home, or a
nursing home, must be made prior to leaving the family home. Such plans often include meetings with a team
to develop an individual education transition plan during secondary school, and meetings with rehabilitation
counselors after high school to plan for college, vocational training or employment. Parents and students spend
additional time and energy to acquire the documentation required to obtain these services. Counselors and
life coaches can help the family members prioritize the various activities competing for their time, energy and
nancial resources. Professionals may encourage creativity around informal methods of achieving formal goals
that do not require the child and family to expend more energy acquiring and maintaining the services than
warranted by the potential relief obtained from the services.
Other Counseling Services
Counselors have so many tools to offer children with disabilities and their families throughout the family
life cycle. They can offer concepts and techniques to deal with grief and anomie at the initial diagnosis of a
disability, the chronic grief that emerges when a developmental milestone is missed, repeated encounters with
ableism, or unsuccessful operations and physical therapy. Some childhood disabilities and chronic illnesses end
in death at an early age. Counselors and hospice staff can help families prepare for this untimely departure.
Relaxation exercises can be helpful to families after a busy day of preoperative medical appointments,
immediately prior to a surgery or while waiting for a surgery to end. A child having a painful medical
procedure or frightening experience like Magnetic Resonance Imaging also can use relaxation as a method to
cope. Cognitive therapy can help children and families reframe complex medical issues and disabilities from
seemingly overwhelming tragedies to neutral manageable situations within their capabilities. Reframing can
allow parents who regret missing work to spend hours in physician’s ofces, X-ray labs or therapy appointments
to see the experiences as valuable times—opportunities to really get to know the child and bond around lived
experiences.
Learning to use communication skills allows parents to request that nonurgent operations and treatments be
scheduled at times that do not interrupt other activities, such as birthdays, weddings and exciting eld trips with
classmates. Counselors can teach communication skills that can be used within the family to explore rigid roles
that may not allow members the exibility to effectively cope with the added chores that accompany a disability
without sacricing the real needs of any one family member.
Counselors can assist families and children in learning vital time-management and decision-making skills.
They can help parents see that self-care is useful and that it is ne to ask for help from each other and use
resources outside the family to relieve caregiver stress. Counselors can help families learn to develop a stress
management plan that utilizes positive rather than negative coping skills during times of extreme stress. If
families and children learn assertiveness skills, they may be able to release passivity or aggression. Counselors
can help children and families reduce anxiety and depression throughout the lifespan, cultivate humor and
gratitude, and juggle a variety of activities and emotions in the pursuit of a balanced life. Counselors may use
their own creativity to generate original ideas for assisting children with disabilities and their families.
Conclusion
This article provides signicant ideas to consider when working with individuals with disabilities and
their families; there is much to learn through exploring relevant research and anecdotal information regarding
disability awareness. An understanding of systemic theory is invaluable when working with the complex
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interconnecting systems that make up the environment of a child with a disability. Counselors may explore
disability identities and orientations within the individual with a disability, the family and society. Professionals
can consider interventions concerning identity formation in the person with a disability by promoting self-
awareness, boundary development, and the understanding of and externalization of ableism for both the child
and family members. Mental health professionals have the opportunity to confront the stigma associated with
disabilities and service acquisition. Counselors can use reframing to normalize variations within students
and decrease pity. They can partner with the child and his or her parents to educate the child’s classmates
and their parents, school personnel, and community about the disability and inclusive practices that prevent
social isolation and encourage interactions that disarm bullying and myths about people with disabilities.
Counselors can offer practical help to children who may struggle with social skills, study skills, communication,
assertiveness, stress management, spirituality, transitioning from childhood to adulthood, and the importance of
being or experiencing one’s humanity rather than just accomplishing tasks. In addition to using the introductory
ideas provided in the article, counselors are invited to creatively adapt additional theories and techniques to
support children with disabilities and their families.
Conict of Interest and Funding Disclosure
The author reported no conict of
interest or funding contributions for
the development of this manuscript.
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National Board for Certified Counselors, Inc. and Affiliates
