case study of backward child

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Published: 11 September 2017

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

Magdalena Romanowicz ORCID: orcid.org/0000-0002-4916-0625 1 ,
Alastair J. McKean 1 &
Jennifer Vande Voort 1

BMC Psychiatry volume 17 , Article number: 330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table 1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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Acknowledgements

We are also grateful to patient’s legal guardian for their support in writing this manuscript.

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Correspondence to Magdalena Romanowicz .

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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DOI : https://doi.org/10.1186/s12888-017-1492-y

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Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

Identify disorders of childhood and adolescence in case studies

Case Study: Jake

A young boy making an angry face at the camera.

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

A girl sitting with a book open in front of her. She wears a frustrated expression.

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
Case Study: Childhood and Adolescence. Authored by : Chrissy Hicks for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
Angry boy. Located at : https://www.pxfuel.com/en/free-photo-jojfk . License : Public Domain: No Known Copyright
Frustrated girl. Located at : https://www.pickpik.com/book-bored-college-education-female-girl-1717 . License : Public Domain: No Known Copyright

The mentally backward child

Published: June 1976
Volume 43 , pages 178–180, ( 1976 )

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Clarke, A.D.B. and Clarke, A.M. (1954). Pseudofeeblemindedness. Amer. J. Ment. Def. 59 507.

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Guerton, W.H. (1949). Differential characteristics of pseudofeeble minded. Amer. J. Ment. D 54 , 394.

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Marfatia, J.C. (1971). Psychiatric problems children. Popular Prakshan , Bombay.

Takrani, L.B. (1969). Pseudo-mental retardation Indian J. Ment. Retard. 2 , 87

Teja, J.S. (1969) Problems in classifying retarded. Indian J. Ment. Retard. 2 , 66.

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From the Department of Paediatrics, Patna Medical College, Patna-4.

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Jha, S.K. The mentally backward child. Indian J Pediatr 43 , 178–180 (1976). https://doi.org/10.1007/BF02894343

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During your time at Manor, you will need to conduct a child case study. To do well, you will need to plan ahead and keep a schedule for observing the child. A case study at Manor typically includes the following components:

Three observations of the child: one qualitative, one quantitative, and one of your choice.
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A Narrative

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Qualitative and Quantitative Observation Tips

Remember your observation notes should provide the following detailed information about the child:

child’s age,
physical appearance,
the setting, and
any other important background information.

You should observe the child a minimum of 5 hours. Make sure you DO NOT use the child's real name in your observations. Always use a pseudo name for course assignments.

You will use your observations to help write your narrative. When submitting your observations for the course please make sure they are typed so that they are legible for your instructor. This will help them provide feedback to you.

Qualitative Observations

A qualitative observation is one in which you simply write down what you see using the anecdotal note format listed below.

Quantitative Observations

A quantitative observation is one in which you will use some type of checklist to assess a child's skills. This can be a checklist that you create and/or one that you find on the web. A great choice of a checklist would be an Ounce Assessment and/or work sampling assessment depending on the age of the child. Below you will find some resources on finding checklists for this portion of the case study. If you are interested in using Ounce or Work Sampling, please see your program director for a copy.

Remaining Objective

For both qualitative and quantitative observations, you will only write down what your see and hear. Do not interpret your observation notes. Remain objective versus being subjective.

An example of an objective statement would be the following: "Johnny stacked three blocks vertically on top of a classroom table." or "When prompted by his teacher Johnny wrote his name but omitted the two N's in his name."

An example of a subjective statement would be the following: "Johnny is happy because he was able to play with the block." or "Johnny omitted the two N's in his name on purpose."

Anecdotal Notes Form Form to use to record your observations.
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Tips for Writing Objective Observations
Objective vs. Subjective

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For this section, you will collect artifacts from and/or on the child during the time you observe the child. Here is a list of the different types of artifacts you might collect:

Potential Qualitative Artifacts

Photos of a child completing a task, during free play, and/or outdoors.
Samples of Artwork
Samples of writing
Products of child-led activities

Potential Quantitative Artifacts

Checklist
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Examples of Components of the Case Study

Here you will find a number of examples of components of the Case Study. Please use them as a guide as best practice for completing your Case Study assignment.

Qualitatitive Example 1
Qualitatitive Example 2
Quantitative Photo 1
Qualitatitive Photo 1
Quantitative Observation Example 1
Artifact Photo 1
Artifact Photo 2
Artifact Photo 3
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Case Study Narrative Example Although we do not expect you to have this many pages for your case study, pay close attention to how this case study is organized and written. The is an example of best practice.

Narrative Tips

The Narrative portion of your case study assignment should be written in APA style, double-spaced, and follow the format below:

Introduction : Background information about the child (if any is known), setting, age, physical appearance, and other relevant details. There should be an overall feel for what this child and his/her family is like. Remember that the child’s neighborhood, school, community, etc all play a role in development, so make sure you accurately and fully describe this setting! --- 1 page
Observations of Development : The main body of your observations coupled with course material supporting whether or not the observed behavior was typical of the child’s age or not. Report behaviors and statements from both the child observation and from the parent/guardian interview— 1.5 pages
Comment on Development: This is the portion of the paper where your professional analysis of your observations are shared. Based on your evidence, what can you generally state regarding the cognitive, social and emotional, and physical development of this child? Include both information from your observations and from your interview— 1.5 pages
Conclusion: What are the relative strengths and weaknesses of the family, the child? What could this child benefit from? Make any final remarks regarding the child’s overall development in this section.— 1page
Your Case Study Narrative should be a minimum of 5 pages.

Make sure to NOT to use the child’s real name in the Narrative Report. You should make reference to course material, information from your textbook, and class supplemental materials throughout the paper .

Same rules apply in terms of writing in objective language and only using subjective minimally. REMEMBER to CHECK your grammar, spelling, and APA formatting before submitting to your instructor. It is imperative that you review the rubric of this assignment as well before completing it.

Biggest Mistakes Students Make on this Assignment

Here is a list of the biggest mistakes that students make on this assignment:

Failing to start early . The case study assignment is one that you will submit in parts throughout the semester. It is important that you begin your observations on the case study before the first assignment is due. Waiting to the last minute will lead to a poor grade on this assignment, which historically has been the case for students who have completed this assignment.
Failing to utilize the rubrics. The rubrics provide students with guidelines on what components are necessary for the assignment. Often students will lose points because they simply read the descriptions of the assignment but did not pay attention to rubric portions of the assignment.
Failing to use APA formatting and proper grammar and spelling. It is imperative that you use spell check and/or other grammar checking software to ensure that your narrative is written well. Remember it must be in APA formatting so make sure that you review the tutorials available for you on our Lib Guide that will assess you in this area.
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http://orcid.org/0000-0001-5603-6959 Dina R Hirshfeld-Becker 1 , 2 ,
Aude Henin 1 , 2 ,
Stephanie J Rapoport 1 ,
Timothy E Wilens 2 , 3 and
Alice S Carter 4
1 Child CBT Program, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
2 Department of Psychiatry , Harvard Medical School , Boston , Massachusetts , USA
3 Division of Child and Adolescent Psychiatry, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
4 Department of Psychology , University of Massachusetts Boston , Boston , Massachusetts , USA
Correspondence to Dr Dina R Hirshfeld-Becker; dhirshfeld{at}partners.org

Anxiety disorders represent the most common category of psychiatric disorder in children and adolescents and contribute to distress, impairment and dysfunction. Anxiety disorders or their temperamental precursors are often evident in early childhood, and anxiety can impair functioning, even during preschool age and in toddlerhood. A growing number of investigators have shown that anxiety in preschoolers can be treated efficaciously using cognitive–behavioural therapy (CBT) administered either by training the parents to apply CBT strategies with their children or through direct intervention with parents and children. To date, most investigators have drawn the line at offering direct CBT to children under the age of 4. However, since toddlers can also present with impairing symptoms, and since behaviour strategies can be applied in older preschoolers with poor language ability successfully, it ought to be possible to apply CBT for anxiety to younger children as well. We therefore present two cases of very young children with impairing anxiety (ages 26 and 35 months) and illustrate the combination of parent-only and parent–child CBT sessions that comprised their treatment. The treatment was well tolerated by parents and children and showed promise for reducing anxiety symptoms and improving coping skills.

childhood anxiety disorders
preschoolers
cognitive behavioural therapy

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https://doi.org/10.1136/gpsych-2019-100156

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Introduction

Anxiety disorders affect as many as 30% of children and adolescents and contribute to social and academic dysfunction. These disorders or their temperamental precursors 1 are often evident in early childhood, with 10% of children ages 2–5 already exhibiting anxiety disorders. 2 Anxiety symptoms in toddlerhood 3 and preschool age 4 show moderate persistence and map on to the corresponding Diagnostic and Statistic Manual anxiety disorders. 5 6 Well-meaning parents, particularly those with anxiety disorders themselves, may respond to a child’s distress around separating from parents or being around unfamiliar children by decreasing the child’s exposure to these situations, for example, by not having the child start preschool or by not leaving the child with a childcare provider to go to work or socialise. In the short term, such responses may impair concurrent family function, strain the parent–child relationship, and reduce the child’s opportunity for increased autonomy, learning and social development. 7 These avoidant strategies may initiate a trajectory where the child takes part in fewer and fewer activities, leading to social and academic dysfunction. 8

Members of our research team began championing the idea of early intervention with young anxious children over two decades ago, with the aim of teaching children and their parents cognitive–behavioural strategies to manage anxiety before their symptoms became too debilitating. 8 Although cognitive–behavioural therapy (CBT) has since emerged as the psychosocial treatment of choice for treating and preventing anxiety, 9 10 at that time, most protocols that had been empirically tested were aimed at children ages 7 through early adolescence, with only a few enrolling children as young as age 6. 11 We developed and tested a parent–child CBT intervention (called ‘Being Brave’) and reported efficacy in children as young as 4 years. 12 13 The treatment involved teaching parents about fostering adaptive coping and implementing graduated exposures to feared situations, and modelling how to teach children basic coping skills and conduct exposures with reinforcement. In parallel, a growing number of investigators confirmed that anxiety in preschoolers could be treated efficaciously using CBT administered either by training parents to apply CBT strategies with their children or through direct intervention with children. 14 15 Early family-based intervention using cognitive–behavioural strategies was shown to reduce rates of later anxiety and to attenuate the onset of depression in adolescence in girls. 16

The question remains as to whether early intervention can be extended even younger. With few exceptions, 17 18 most investigators do not offer direct CBT for anxiety to children under age 3 or 4, 15 and none to our knowledge have treated anxiety disorders with CBT in children under age 2.7. 15 However, we reasoned that since toddlers can also present with impairing symptoms, and since behaviour strategies can be feasibly applied even in preschoolers with poor language ability, 19 it ought to be possible to apply family-based CBT for anxiety to toddlers as well. We therefore present two cases of anxious children, ages 26 and 35 months, treated with parent and child CBT.

Recruitment

Parents of children ages 21–35 months were recruited for a pilot intervention study (a maximum of three cases) using advertisements to the community. To be included, children had to be rated by a parent as above a standard deviation on the Early Childhood Behavior Questionnaire Fear or Shyness Scale 20 and could not have global developmental delays, autism spectrum disorder or a primary psychiatric disorder other than anxiety.

Children were evaluated for behavioural inhibition using a 45 min observational protocol. 21 Parents completed a structured diagnostic interview about the child (Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime) that has been used with parents of children as young as 2 years; 22 23 an adapted Coping Questionnaire, 24 in which parents assessed the child’s ability to cope with their six most feared situations; and questionnaires assessing child symptoms (Child Behavior Checklist 1-1/2-5 (CBCL), 25 subscales from the Infant Toddler Social Emotional Assessment (ITSEA) 26 ), family function (Family Life Impairment Scale 27 ) and parental stress (Depression Anxiety Stress Scale 28 ). These assessments were repeated following the intervention, with the exception of the behavioural observation for the child initially rated ‘not inhibited’. The clinician rated the global severity of the child’s anxiety on a 7-point severity scale (Clinician Global Impression of Anxiety 29 ) at baseline and rated global severity and improvement of anxiety postintervention. Participant engagement in session and adherence to between-session assignments were rated by the clinician at each visit, and parents completed a post-treatment questionnaire rating the intervention.

Children were treated by the first author, a licensed child psychologist, using the ‘Being Brave’ programme. 13 It includes six parent-only sessions, eight or more parent–child sessions and a final parent-only session on relapse prevention. An accompanying parent workbook reinforces the information presented. Parent-only sessions focus on factors maintaining anxiety; monitoring the child’s anxious responses and their antecedents and consequences; restructuring parents’ anxious thoughts; identifying helpful/unhelpful responses to child anxiety; modelling adaptive coping; playing with the child in a non-directive way; protecting the child from danger rather than anxiety; using praise to reinforce adaptive coping; and planning and implementing graduated exposure. Child–parent sessions teach the child basic coping skills; and focus on planning, rehearsing and performing exposure exercises, often introduced as games, with immediate reinforcement. All parent–child sessions were preserved from the original protocol, but two sessions teaching the child about the CBT model, relaxation and coping plans were omitted, as were two sessions in which the (older) child does a summary project and celebrates gains. Up to six child–parent sessions focusing on exposure practice were included.

In the cases that follow, identifying details are disguised to protect participants’ privacy. Parents of both children provided written consent for the publication of de-identified case reports.

Background information

‘J’ was a 35-month-old girl, the third of three children of married parents. She had congenital medical problems requiring multiple surgeries, and she continued to undergo regular follow-up procedures. J met the criteria for separation anxiety disorder with marked severity, mild social phobia and mild specific phobia. Although she was able to attend her familiar day care if handed directly to a teacher and attend a gymnastics class with a friend while her mother waited in the hall, J showed great distress if apart from her mother at home. If her mother left her sight (eg, to use the bathroom), J would sob, cry and try to open the door to get in. If her mother went out and left her with a family member, J would fuss, cry and try to come along, and would continually ask to video-call her, so her mother would cut her outings short. J also had fears of doctors’ visits, of riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was afraid to take part in gymnastics performances.

J also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say ‘ow, ow’ if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties.

‘K’ was a 26-month-old boy, the only child of married parents. He met the criteria for moderate separation anxiety disorder. Although able to go to a day care he had been attending since infancy, he showed distress at drop-off particularly at the start of each week, crying for 15 min. He feared being apart from his mother in the house: he could not tolerate his mother leaving the room even to change clothes and would cry if his mother left the playroom while K played with his father. He would get distressed if his father took him on outings without his mother. He could not be dropped off at a childcare centre at his parents’ gym, leading to their avoiding exercise. He slept in his own crib, rocked to sleep by a parent, but would wake in a panic (alert but distressed) two to three times per month, crying for over an hour until his parents took him into their bed. K also was very particular about where objects were placed in the playroom and would fuss if they were put in the wrong place. He got anxious about deviations in routine (eg, taking a different path on a walk) and had trouble throwing things away (eg, used Band-Aids).

Intervention Feasibility and Outcomes

To demonstrate feasibility, the application of the treatment protocol with both participants is summarised in table 1 . Both participants completed the treatment, in 11 and 10 sessions, respectively. For each, session engagement was rated ‘moderately’ or ‘completely engaged’ at all but one session, and homework adherence was rated as ‘moderate work’ to ‘did everything assigned’ at all but one session.

View inline

Application of treatment protocol with both participants

The quantitative results of the treatment are presented in table 2 . Both children were rated by the clinician as having shown ‘much improvement’ (Clinician Global Impression of Anxiety-Improvement 1 or 2), and both showed changes in quantitative measures of anxiety and family function. In both families, parents rated their satisfaction with the treatment as ‘extremely satisfied’, and felt that they would ‘definitely’ recommend the intervention to a friend. They rated all strategies introduced in the intervention as ‘very-’ or ‘moderately helpful’ and rated the change in their ability to help their child handle anxiety as ‘moderately-’ to ‘very much improved’.

Quantitative changes in diagnoses, coping ability, symptoms and family function in both participants

These pilot cases demonstrate the feasibility and acceptability of parent–child CBT for toddlers with anxiety disorders. The two participating families completed the treatment protocol and were consistently engaged with in-session exercises and adherent to between-session skills practice. The cases demonstrate that basic coping skills and exposure practice can be conducted with toddlers.

Although efficacy cannot be determined from uncontrolled case studies, the cases did show promising preliminary results. Both children showed a decrease in number of anxiety disorders, both were rated by the clinician (and parents) as either ‘moderately-’ or ‘much improved’ in their overall anxiety, and both showed increases in their parent-rated ability to cope with their most feared situations. Participant 2 improved on all symptom measures as well. Most significantly, his ITSEA general anxiety, separation distress, inhibition to novelty, negative emotionality, compliance and social relatedness scores and his CBCL total score, internalising score and somatic complaints scale score normalised from clinical to non-clinical range. Participant 1 had a more complicated clinical presentation, and whereas her diagnoses and coping scores improved, her parent-rated symptom scores were more mixed, perhaps related to medical problems which impacted sleep. Beyond changes in the children’s behaviour, family life impairment was reduced for both families, and parental stress was decreased out of clinical range for participant 1. Notably, both children also showed gains in areas of competence, including prosocial peer relations and mastery motivation.

This work extends previous research demonstrating that very young children experience impairing levels of anxiety that are amenable to CBT. Previous studies have found that CBT is as efficacious with older preschool-age children with anxiety disorders as it is with school-aged youth, 14 15 with approximately two-thirds of treated youth demonstrating clinically significant improvement. There is increasing recognition that anxiety disorders start early in childhood, and that there are significant advantages to intervening proximally to their onset, before anxiety symptoms crystallise and impairment accumulates. For example, one study of 1375 consecutive referrals (mean age 10.7) to a paediatric psychopharmacology clinic found that the median age of onset of a child’s first anxiety disorder was 4 years. 30 Children seeking treatment for anxiety often present in middle childhood, for symptoms which began much earlier, exposing the child and family to undue stress for years. By teaching parents and very young children skills to manage anxiety, we hope to give families important tools to navigate the developmental transitions inherent in this age range, and to help children develop a sense of mastery during a critical developmental period. Of course, a larger controlled trial is needed to further evaluate this intervention and its efficacy over time.

Assessing and treating toddlers require a developmentally informed approach. Anxiety and other symptoms may present differently in younger children, and because of limited language and cognitive abstraction capabilities toddlers are not as able to describe their fears and worries. Because some forms of anxiety (eg, separation anxiety, stranger anxiety) are normative, determination of clinically significant levels of anxiety requires an understanding of typical development in toddlerhood and the ability to conduct a detailed assessment with parents and the child using measures normed for this age group (such as the ITSEA and CBCL 1-1/2-5). Similarly, implementing CBT with toddlers and preschoolers requires age-appropriate modifications of empirically supported techniques. The adaptations we used included increased parental involvement in planning exposures, decreased focus on child cognitive restructuring (beyond framing the practice as ‘being brave’ and redirecting the child’s attention to rewarding aspects of the situation), and adaptations to exposure exercises to maximise child participation and motivation (practising at times when the child was rested and not irritable, incorporation of games and reinforcers, and allowing the child maximal choice about when/how to carry out the exposure). The cases we presented demonstrate that existing interventions can be effectively adapted and implemented with children as young as 2 years of age. By sharing the information gleaned from our research, we hope to inform providers who may be less familiar with treating children in this age range and increase their confidence in intervening with very young children.

Acknowledgments

The authors acknowledge Jordan Holmen for assistance with data checking.

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Dina Hirshfeld-Becker earned her undergraduate degree from Harvard and her doctorate in clinical psychology from Boston University, and completed post-doctoral training at Massachusetts General Hospital. Dr Hirshfeld-Becker is currently co-founder and co-director of the Child Cognitive Behavioral Therapy (CBT) Program in the Department of Psychiatry at MGH and an associate professor of psychology in the Department of Psychiatry at Harvard Medical School. The Child CBT Program offers short-term empirically supported CBT with youths ages 3-24, research in novel treatment adaptations, and clinical training in CBT, including on-line training courses. She pioneered the development and empirical evaluation of one of the first manualized cognitive-behavioral intervention protocols for anxiety in 4- to 7-year-old children, the “Being Brave” program, and has been exploring its use with children with autism spectrum disorder and with younger toddlers and their parents. Dr Hirshfeld-Becker has published numerous articles, reviews, and chapters. Her main research interests include the etiology, development, and treatment of childhood psychiatric disorders, particularly anxiety disorders, and in the study of early risk factors for these disorders.

Contributors DRHB designed the study with input from ASC, AH and TEW. DRHB developed the intervention and treated the cases, and DRHB, SJR and AH collected, scored, analysed and tabulated the data. DRHB wrote the first draft of the manuscript, SJR drafted parts of the Results section, and AH made significant additions to the Discussion section. AH, ASC and TEW revised the manuscript critically for important intellectual content. DRHB incorporated all of their edits and finalised the document. All authors approved the final version and are accountable for ensuring accuracy and integrity of the work.

Funding This work was supported by a private philanthropic donation by Mrs. Eleanor Spencer.

Competing interests DRHB and AH receive or have received research funding from the National Institutes of Health (NIH). ASC reports receipt of royalties from MAPI Research Trust on the sale of the ITSEA, one of the instruments included in the manuscript. TEW receives or has received grant support from the NIH (NIDA), and is or has been a consultant for Alcobra, Neurovance/Otsuka, Ironshore and KemPharm. TEW has published a book, Straight Talk About Psychiatric Medications for Kids (Guilford Press); and co/edited books: ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier), and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). TEW is co/owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire), and has a licensing agreement with Ironshore (BSFQ Questionnaire). TEW is Chief of the Division of Child and Adolescent Psychiatry, and (Co)Director of the Center for Addiction Medicine at Massachusetts General Hospital. He serves as a clinical consultant to the US National Football League (ERM Associates), US Minor/Major League Baseball, Phoenix House/Gavin Foundation and Bay Cove Human Services.

Patient consent for publication Parental/guardian consent obtained.

Ethics approval All procedures were approved by our hospital’s institutional review board (Partners Human Research Committee, 2018P000376), and parents provided informed consent for themselves and their child.

Provenance and peer review Not commissioned; externally peer reviewed.

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Backward Children

Contents in the Article

Backward children or backwardness is defined by various psychologists, and some of the popular definitions are given below:

Barton Hall (1947)- Backwardness is general, is applied to cases where there educational attainment falls below the level of their natural abilities.

Schnoell (1948)- Backward pupil is one who, compared with other pupils of the same chronological age, shows marked educational deficiency.

Burt (1950)- A backward child is one who in mid-school career is unable to do the work of the class next below that, which is normal for his age.

Characteristics of Backward Children

Backward children are slow learners and they find it difficult to keep pace with the normal school work.
They are not able to attain what they should and their educational attainment falls below their natural abilities.
They fall far behind other children of their age in matter of study. Usually such children are seen to be remained in the same class for a number of years.
They might show failure in the academic field and show educational impoverishment.
We cannot call a child backward merely on the basis of his low I.Q. Therefore backward child should not be misunderstood and labelled as mentally retarded.
A child may be both dull and backward but he is not necessarily backward because he is dull.

Types of Backwardness

Backwardness is basically of two types:

General – Such children are weak in all subjects of the school curriculum.
Specific – Child suffering from specific backwardness lags behind in one or two specific subjects only and in other remaining subjects he may perform good or extraordinary.

Causes of Backwardness

Although it is difficult to list the causes of backwardness of child but usually many factors lie behind a particular case of backwardness. Roots of backwardness generally lie within a child or in the outside factors, like his environment.

Some of the factors of Backwardness are detailed as follows:

Physical or Physiological factors-

The physiological and physical situation of a child affects his educational attainment at every stage. Majority of educationally backward children suffer from some kind of physical retardation of lacks proper development. Sometimes they are born with poor health, lack of vitality and physical deformities or sometimes poor environment leads them to suffer from physical ailments, chronic diseases and bodily defects. Such conditions affects child and results into poor eyesight, faulty hearing, defective speech etc. Such health condition may deteriorate his health to such extent that he may be unable to devote adequate time and energy in their studies and as a result become educationally sub-normal and termed as backward.

Intellectual factors-

Intellectually inferior children are also seen to be educationally backward but this is not always true. Some children are born with brain having some inherent defects or with some intellectual sub-normality. Such intellectually inferior or mentally handicapped children cannot keep pace with the normal school curriculum and are found to be slow in learning.

Environmental factors-

All the factors above were innate factors or inherent factors of backwardness but apart from that, environmental factors such as home, neighbourhood and school atmosphere significantly influence the educational attainment of an individual. Some of these environmental factors are:

Home influences-

The parents, family relationships and home atmosphere have a direct relationship with the child’s educational attainment. A privileged family is able to provide best amenities and basic necessities of life are fulfilled, whereas a poor family lacks even basic necessities and their health suffers with malnutrition and unhygienic conditions, they may not get proper educational opportunities. All these deprivation impairs their capacity of learning.

Family relationships and the behaviour of family members also contribute to the child’s achievement. The problem in family relationship may create emotional and social problems.

School influences-

Unfavorable and inappropriate school environmental conditions also contribute to the problem of backwardness. Some of the factors that may affect the educational attainment of the children could be- ineffective, defective teaching, lack of equipment, facilities and co-curricular activities, etc. defective curriculum and examination system, lack of guidance or wrong choice of subjects by student, improper attitude of teacher and interpersonal relationships among the staff and students may also lead to disinterest of children in learning.

Influence of neighbourhood and other social agencies-

The social environment of a child also includes neighbourhood along with home and school. The neighbourhood where the child lives, his peer group, the members of the society he comes in contact with, all these contribute to the problem of educational sub-normality.

Therefore, a child’s interest, attitude, habit of work and study, thought and reasoning processes, observation power, understanding, all these get affected by the kind and nature of environment in which he lives and gradually he attains what his environment allows him to attain.

Education of Backward Children

Backward children suffer from mental, emotional and social problems. Apart from this, a defective intelligence and inherited physical characteristics, this is the result of maladjustment and maltreatment.

Therefore, backward children need proper care and special attention. Wastage and stagnation of human resources and increase in the number of problem children should be checked.

Diagnosis of the cause of Backwardness-

Before planning for the education of backward children, it is important to diagnose the probable causes of a child’s backwardness. It can be done in following ways:

Assessment tests and attainment tests may be used to assess the extent and nature of backwardness of child in specific subjects.
The intellectual level of the backward child can be assessed by any standard test of intelligence.
Other psychological tests can be used to assess child’s special abilities.
Situational tests and observation tests can be performed to analyse the child’s overall behaviour and his behaviour in particular situation and his emotional qualities, social relationships and temperamental traits should be observed.
A complete physical and medical examination should be done to examine the physical and physiological condition of the backward child.
Socio-economic status of the child’s family, their living conditions, education of parents, relationship within family, his friend circle, etc. should also be carefully observed.
The school environment including curriculum, methods of teaching, facilities available for co-curricular activities and student-teacher interaction should be carefully analysed.

Educational guidance / Treatment of Backwardness

After the probable cause of backwardness is diagnosed, efforts should be made to help the child to get rid of his backwardness. The treatment of backwardness lies completely in its nature and extent as well as the causes of backwardness. Since, every case is different, different method is applied to different child. Some of the points have proven to be helpful in planning educational programmes as a remedial step for the backward children, they are as follows:

Regular medical checkup and necessary treatment- Regular medical checkup should be done in cases where cause of backwardness is due to physical defects and ill-health and accordingly necessary treatment should be given. The school authorities should cooperate with parents in correct treatment.
Readjustment in the home and the school- When backwardness is caused as a result of environmental factors, child should be helped to readjust in the home as well as at school. These children should be properly understood, their emotional insecurity should be helped with tender love, affection and security. Proper counselling is given to parents for proper handling of the child.
Provision of special schools or special classes – Provision of special schools or special classes is also an effective remedial step. In such schools, trained teachers are there to help the child with their specific needs.
Special curriculum, methods of teaching and special teachers- The children suffering from acute backwardness should have a special curriculum, special methods of teaching and trained teachers at their school.
Special coaching and proper individual attention- After the weakness of child is being identified through proper diagnostic tests in various subjects, special coaching and proper individual attention may be given in form of drill, practice, repetition, explanation etc.
Checking truancy and non-attendance- In some cases the cause of backwardness is due to irregular attendance, truancy or long absence from school. Such cases should be diagnosed and proper steps should be taken to remove them.
Provision of co-curricular activities, diversified course- In some cases cause of backwardness is lack of interest in the school studies. Therefore, adequate provision co-curricular activities, rich experiences should be given and diversified courses should be provided so that he gets the opportunity of doing the activity that he likes.
Rendering guidance services- Lack of guidance in making proper choices for selection of courses leads to disinterest of child in studies and it is considered to be one of the contributing factors of backwardness.
Maintenance of progress card- There should be a proper and regular maintenance of record of student. It can be maintained by keeping record of their progress in form of cumulative record cards and progress charts. This helps in tracking the attainment level and rate of progress of the child.
Controlling negative environmental factors- Negative environment of the child should be removed or reduced after diagnosing whether its school, home or his peer group.
Involving educational psychologists- Services of experiences educational psychologist might also be helpful in planning of the education of backward children.

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How to educate a backward child | psychology.

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“The Backward child is one who is unable to do the work of the class next below that which is normal for his age.” — Cyril Burt

One of the problems which every headmaster or teacher of the secondary school has to face in that of teaching backwards children — children who show inability to progress normally in school work. It is being increasingly realized that such children need special care at the hands of school authorities, parents and others. The problem of educating backward children has joined vast dimensions with the advent of democracy in most countries and the consequent acceptance of the principle of “education for all the children of all the people.”

Definitions of Backwardness:

(1) Schonnel, F.J.:

“Backward pupil is one who compared with other pupils the same chronological age shows marked educational deficiency.”

(2) Burton Hall:

“Backwardness in general, is applied to cases where their educational attainment falls below the level of their natural abilities.”

(3) Cyril Burt:

“The backward child is one who is unable to do the work of the class next below that which is normal for his age.”

Types of Backwardness:

Backwardness among children is of two types:

1. General backwardness:

When a child remains unsuccessful in every subject included in the curriculum, he is said to be a case of general backwardness.

2. Specific backwardness:

When the child exhibits lack of progress or backwardness in a particular subject or a specific area of knowledge, he is said to be suffering from specific backwardness.

Who is a Backward Child?

A backward child is a slow learner. He is unable to do the work of the class in which he is placed or even of the class below that. He does not respond satisfactorily to the ordinary school curriculum and to the usual methods and procedures of the classroom teaching. He is not up to the attainment levels in various subjects which are normal for his age or grade. Burt describes a backward Child as one who in mid-school career is unable to do the work of the class next below that which is normal for his age.

His educational ratio, which can be obtained by first ascertaining the average attainment level or age in all the subjects and then dividing it by his chronological age, is below 85 whereas a medium child has educational ratio or quotient between 85 and 155. The main feature of backwardness is educational impoverishment.

The educational impoverishment may be shown in one or two specific subjects or in all subjects or in general. Accordingly backwardness may be other specific or general. Slowness in arithmetic, spelling or history, in learning, reading, geography or science may be due to intellectual deficiency or dullness, but there are many children who are scholastically backward but not dull. Those who are generally backward are dull in all the subjects or intellectual activities, although not equally.

Although backwardness is primarily an intellectual or scholastic condition it is a psychological characteristic that arises from and affects the pupil’s entire personality. It results from a complex of innate equipment and environmental influences. It is tantamount to psychological failure of the total child.

Causes of Backwardness:

Burt, Schonnel and Segal have made very comprehensive studies in the causation of backwardness. One thing on which all agree is that it is a phenomenon of multiple causation.

1. Poor intellectual ability or low intelligence:

Poor intellectual ability or low intelligence in a major factor in 60 percent of cases. Some children are born with an inherited lack of vitality or a week developmental impulse which causes them to grow slowly.

2. Physical defects and diseases:

Physical defects and diseases contribute considerably to the causation of scholastic backwardness. These may be defective vision, impaired hearing, speech defects, left-backwardness, chronic catarrh, bronchitis, enlarged tonsils or adenoids, fever, digestive disorders and other glandular affections. Other physical conditions which cause debility, headache and mental fatigue and seriously interfere with the problems of attendance in school and study at home and result in sub-normal scholastic achievement are malnutrition, tuberculosis, epileploid conditions and chorea.

A child was referred to our child guidance clinic sometime back. His father and teacher complained that the boy was doing very unsatisfactory work in the classroom. He was failing in almost all the subjects for the last one year. He lacked concentration and his memory was poor. The case history and interviews were happy and conducive to successful adjustments. Tests of intelligence administrated placed him in the I.Q. range of 110-115.

But the medical examination showed that he was running temperature (which had evidentially gone unnoticed) due to chronic and septic tonsils and adenoids. These physical conditions affected his concentration and memory rather adversely leading to his scholastic backwardness.

3. Again, poverty, poor home condition:

Again, poverty, poor home condition such as over-crowding, insanitation, negative intellectual and emotional atmosphere may not enable the child to do his best in studies. Crowded homes, suffer from one serious defect apart from noise and lack of amenities-they provide very meagre parental contacts for encouragement and stimulation.

Other causes include frequent absence from school whether due to illness, truancy or other reasons, double promotion, change of school too often, unsympathetic, teachers, lack of individualized attention, discipline based on fear, lack of regular and intensive drill in skill subjects, and previous deficiencies which are carried over.

4. Emotional disturbance:

Our experience with such children tells us that one of the important factors is the emotional disturbance of the child on account of unhappy, interpersonal relationships at home or in school.

Recently, a girl was brought to our clinic by her father because she had failed to achieve anything scholastically inspite of his best efforts. He was desperate and wanted help. The girl was 12 year old and was still in class III. She had been sent to a good progress in school for a number of years. The parents had arranged for her a number of individual tuitions as well. Her health status was very satisfactory.

After a couple of interviews with her parents and with her, we administered a couple of intelligence tests on her and found to our surprise that her I.Q. was above 110. The case history material, the data collected from interviews and other teaching showed that the girl was suffering from a sense of terrible insecurity and inadequacy. The child was unwanted by both the parents.

The mother managed at her constantly and made invidious companions with her younger brother who was about 5 years old. Father did not take much interest in her studies and pursuits because of the nature of his job. The intra-parental conflicts over the method of discipline and other matters were frequent and took place in the presence of the children. The girl disliked the mother to such an extent that she turned disobedient and stubborn and resented all suggestions from her including that of studies.

5. The influence of neighbourhood:

The influence of neighbourhood is another factor which might contribute to the problem of educational sub-normality in children. Companions may colour their outlook on life, on work or studies. In some questions, for example, boys regard it as more manly to profess a distaste for books and lessons. They express scorn for the teacher and make fun if “learning” or “conscientiousness in studies”. Such attitudes will damp the enthusiasm of a conscientious student in his efforts to study.

Children who belong to rural areas are likely to acquire attitudes of indifference to matters of study from their parents whose motivations are not favourably inclined towards sending children to school.

All these causes are operative even in specific backwardness, although Schonnel has pointed out to specific causes explaining specific types of backwardness. Backwardness in reading, For example, may be attributed to weakness in perception of visual pattern of words, weakness in auditory discrimination of speech sounds, adverse emotional attitudes, defects of visual acuity, organic immaturity etc.

Similarly, backwardness in spelling has been ascribed to weak visual perception of verbal material, weak auditory perception of verbal material, visual defects, inattention, defective hearing, speech defects and others.

How Do We Discover and Diagnose Backwardness?

A teacher should be a keen observer to be able to say whether a particular child is backward or not. Besides the ability to observe, he needs to have an understanding of other diagnostic techniques. For ascertaining general intelligence we can depend on standardised, verbal and un-verbal individual tests of intelligence.

For assessing sensory acuity, span of perception, steadiness, speed and accuracy of head movements, other tests may be used. Tests of temperament and personality may be useful in ascertaining persistence, assertiveness, attention to details, concentration, attitudes to authority towards school work and emotional stability.

Even projective techniques of personality may be used for assessing conflictual situations and their causes. Standardised attainments tests in various subjects are found useful in forming a correct estimate of the child’s actual attainments in a particular subject as compared to other children.

Observation of the child’s mind at work under simple and controllable conditions in the classroom may be very much needed for diagnostic purposes. His recreational, occupational and extra-curricular interests may also be ascertained through observation and interviews.

A knowledge of his physical and medical check-up results, of home conditions, of family constellation, parental attitudes of the type of discipline prevailing, the cultural activities encouraged and the general moral tone of the home may also be useful in understanding the causes.

Educational Guidance of the Backward Child :

In order to help educationally a backward child, it is necessary to find out, at first, the cause or causes of his backwardness. Once the cause or causes have been discovered, we should plan an integrated course of action with a view to educating him.

The school doctor, parents, teachers, a visiting teacher, if any, a school social worker if any, the school counsellor or psychologist all should work together in order that the correct causes are discovered and remedies are made available.

Many of the lessons learned by children have to be unlearned, before they can understand the advanced subject-matter. For this “remedial teaching” is needed which can be done either with an individual or with a small group of children.

The following are some suggestions that have been found useful in guiding backward pupils in the learning-teaching process:

(1) Slow learners require short and simple methods of instruction based on concrete living experiences with concrete materials. Verbal instruction should be reduced in their case as much as desirable. The use of educational excursions, dramatisation, projects, play activities or games and other audio-visual materials will be very profitable along with appropriately graded material.

(2) Habits of success must be developed if the child is to retain that self- confidence which is so vital to him. The teacher should lead him very slowly, making sure that each step is thoroughly mastered before the next is introduced. Trying to cover ground too fast will only create confusion in the child’s mind and discourage him completely. This discouragement will make it practically impossible for him to learn even what is within his power.

(3) The desired outcomes should always be kept in mind. Interesting but unimportant matters may be given brief attention; more energy should be expended on that which is important and essential. Certain abstract technicalities which characterise each subject should be excluded for the backward child.

(4) They should be encouraged to participate in extracurricular activities of the school according to their interests and abilities.

(5) Individual attention should be paid to such matters as health, social conditions, school attention, and teaching methods.

(6) The class-work should stimulate all the senses-The class-teacher should seek the help of specialists if possible, to remedy the defects of speech, hearing and sight.

(7) There must be much more individual instruction than is necessary for normal children.

(8) The teacher must have great patience, and a firm determination. Never to be discouraged, while at the same time clearly recognising the child’s limitations. Moreover, the teacher must respect the child. If he or she looks down upon him as being inferior because he will not attain what the average child can, then he cannot give him what he needs and is likely to be doing him real harm. A backward child needs praise, continuous help, sympathetic consideration of his difficulties and sustained interest on the part of his teacher.

(9) When a number of backward pupils are found together, a class may be organised specially for such cases. Sometimes such children may be retained longer in lower grade or may be specially sent to lower grade for learning skills which they lack.

(10) In the education of backward children, discipline should be as free as possible. Character training rather than mere intellectual tuition should be given greater importance than is actually given.

(11) In the time-table for the backward class the old lines of demarcation between one subject and another should be dropped or cut across. The syllabus to a large extent, will have to be planned in terms of projects rather than of subjects. The same flexibility should characterise other aspects of school organisation. The school should be so organised that there is plenty of activity and reasonable freedom of movements of the backward pupils.

(12) A special medical checkup should be arranged at the outset and facilities should be available for remedying the ailments or defects so discovered.

(13) In the case of backward pupils who have temperamental and emotional difficulties, no effort should be spared to bring about their readjustment in the home or in the school. Parental education which aims at changing wrong parental handling, a system of social science which aims at improving the medical and social environment at home and outside, can go a long way in such cases. The child guidance clinics play a vital role in this area to help the backward child.

(14) In the case of specific backwardness in specific subject area, remedial teaching has proved profitable. The remedial programme has to be planned according to the deficiencies shown by the diagnostic tests in the various processes, steps of learning and the various elements constituting the subject.

To illustrate, let us take the example of a child who has difficulty in reading or who is found to be word-blind, correct usual habits have to be built up so that the particular difficulty is overcome. Correct speech sounds have top built up in the mind of a child whose spelling mistakes are due to “word-deafness” or to an inability to comprehend the symbolic meaning of spoken words.

A programme of remedial teaching develops each pupil to the limits of his or her potential ability rather than pulls him towards the similarity of achievement as attained by others. At best it is an individual matter with different standards of achievement to be attained for different individuals. The cooperation of the specialists is highly necessary in dealing with specific backwardness.

Relationship Between Education and Psychology
Characteristics of Gifted Children | Intelligence | Child Psychology
Specialised Methods of Training to Mentally Retarded Children | Psychology
How to Train a Mentally Retarded Child? | Psychology

Child Psychology , Educational Psychology , Backward Child

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Case Study on Backward Children

Backward children case study:.

Backward children are the children who have troubles with education and their capability of learning belongs to the lower level than it is required according to the general standards. In every country there is a problem with backward children and pedagogues work hard to create effective methods of teaching and improvement the chances for children to receive normal education.There are many factors which influence the problem of the child backwardness and they depend to the physical, genetic, psychological, social, economic and other fields. The first factor which can influence the child’s learning abilities is a disease or physical injures of the essential organs, primarily the brain. If the child has fallen ill with something and takes medicine for the disease, they can have a negative impact on their intellectual abilities. With the run of time the impact of remedies can reduce, but still this effect exists.

The learning abilities can be seriously damaged by severe headaches and megrim. The relation of backwardness and poverty is very close, because if the family is poor, the child will not have the chance to receive education and devote as much time to education as he requires.Then, psychological problems and stress can reduce the learning abilities, because the child lives under the constant pressure of parents or classmates and can not focus on studying. The process of learning requires healthy environment and minimum of stress, so the family scandals, threats and parent’s dominance can cause harm to the child’s intellect. So, backwardness depends on many factors and it is important to select the right methods and techniques to help the child cope with these obstacles.

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Backward children are the children who require specific approach towards education and the student is able to improve his knowledge on the issue and study the problem from all sides. It is better to reveal the problem on child backwardness on the definite example suggested by the professor and a case study will be a magnificent experience for every young professional. One should learn about the child as much as possible and find out about the cause of his backwardness and evaluate its effect on the quality of his education. Finally, one can create his own methodology of the defeat of the problem of the child’s backwardness in the selected case.The problem of a case study is the student’s poor experience and limits of his knowledge about the issue and the way of its research. So, it is impossible to succeed in writing without a free example case study on backward children written online.

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J Appl Behav Anal
v.44(4); Winter 2011

AN ASSESSMENT OF THE EFFICIENCY OF AND CHILD PREFERENCE FOR FORWARD AND BACKWARD CHAINING

Comparative studies of forward and backward chaining have led some to suggest that sensitivity to each teaching procedure may be idiosyncratic across learners and tasks. The purposes of the current study were threefold. First, we assessed differential sensitivity to each chaining procedure within children when presented with multiple learning tasks of similar content but different complexity. Second, we evaluated whether differential sensitivity to a chaining procedure during a brief task predicted differential sensitivity during the teaching of longer tasks. Third, we directly assessed children's preferences for each teaching procedure via a concurrent-chains preference assessment. Learners acquired all target skills introduced under both chaining conditions, but individual children did not consistently learn more efficiently with either procedure. Short-duration tasks were not predictive of performance in tasks of longer duration. Both chaining procedures were preferred over a baseline condition without prompting, but participants did not demonstrate a preference for either procedure.

Behavior analysts frequently employ response-chaining procedures to teach multistep tasks that range from food preparation ( Schuster, Gast, Wolery, & Guiltinan, 1988 ), family-style dining ( Wilson, Reid, Phillips, & Burgio, 1984 ), and self-feeding ( Hagopian, Farrell, & Amari, 1996 ) to Internet usage ( Jerome, Frantino, & Sturmey, 2007 ), playing a game of darts ( Schleien, Wehman, & Kiernan, 1981 ), making a corsage ( Hur & Osborne, 1993 ), and assembling bicycle brakes, meat grinders, and carburetors ( Walls, Zane, & Ellis, 1981 ). Response chaining involves breaking a task into its component parts via a task analysis and then sequentially teaching each individual component to mastery levels via prompting and differential reinforcement. Total task, forward chaining, and backward chaining are three variants of response chaining described in the literature ( Cooper, Heron, & Heward, 2007 ); the current study focuses on forward and backward chaining.

Forward chaining involves teaching the initial step in a task analysis to mastery and then sequentially teaching additional steps. After a step is mastered and subsequent steps are targeted for teaching, all previous steps along with the current step are required to be accurately completed to be considered correct and result in reinforcement delivery. For instance, in a hypothetical task that requires Steps A, B, C, and D to be demonstrated in order, an instructor would teach Step A; then Steps A and B; then Steps A, B, and C; and finally, Steps A, B, C, and D. Typically, an instructor would deliver reinforcement at the completion of each successful response (i.e., the temporal location of reinforcement delivery would vary depending on the required terminal step). Backward chaining involves teaching the final step of the task analysis initially and progressively teaching early components. As earlier steps are added, all previously taught steps and the current step are required to be accurately completed in order to be considered correct and result in reinforcement delivery. Again, using our hypothetical task requiring Steps A, B, C, and D, Step D would be taught first; then Steps C and D; followed by Steps B, C, and D; and finally, Steps A, B, C, and D. The instructor delivers reinforcement at the completion of the last step. Thus, regardless of the stage of training, reinforcement is delivered at the “natural” location (i.e., at the end of the task).

Given the success of both forward and backward chaining in teaching multistep tasks across a variety of populations, including persons with intellectual disabilities ( Hur & Osborne, 1993 ; Walls et al., 1981 ; Zane, Walls, & Thvedt, 1981 ) as well as persons of typical development ( Ash & Holding, 1990 ; Smith, 1999 ; Weiss, 1978 ), some researchers have sought to compare the relative efficiency of these teaching methods ( Ash & Holding, 1990 ; Hur & Osborne, 1993 ; Smith, 1999 ; Walls et al., 1981 ; Weiss, 1978 ). Weiss (1978) compared forward and backward chaining in the acquisition of response chains with undergraduate college students given a contrived task. Specifically, these authors developed an apparatus that consisted of six buttons and required participants to press different sequences of buttons to earn points. They taught each participant four six-step sequences using either forward or backward chaining and found forward chaining to result in fewer incorrect responses and more rapid acquisition.

In contrast, Walls et al. (1981) compared forward and backward chaining in assembling a bicycle brake, a meat grinder, and a carburetor with 22 people between the ages of 18 and 46 who had been diagnosed with mild to moderate intellectual delays and who were from a vocational rehabilitation center. The frequency of incorrect responses and total training time were similar across backward- and forward-chaining conditions. Hur and Osborne (1993) compared backward and forward chaining in teaching corsage making to children who had been diagnosed with moderate to severe mental retardation. Participants were assigned randomly to either a forward-chaining group or backward-chaining group, and both groups acquired this 18-step task in a similar number of trials.

Thus, neither forward nor backward chaining has been consistently more efficacious in promoting response acquisition. These outcomes led Spooner and Spooner (1984) in their review of chaining procedures to surmise, “it may be that different learners do better with different procedures, and when different tasks are used, different results are obtainable” (p. 123). This summary makes two fundamental assumptions: (a) All other things being equal, a given individual will consistently demonstrate differential sensitivity to one teaching procedure with a given task, and (b) although the histories that result in this differential sensitivity are highly idiosyncratic and potentially complex, we should be able to predict an individual's sensitivity to a teaching procedure given their demonstrated sensitivity to that procedure in the past. Researchers have not empirically validated these assumptions. If they are accurate, the identification of differential sensitivity to one teaching procedure should be valuable to teachers who are responsible for teaching complex skills, specifically in helping them to identify the most efficacious teaching procedure possible. If these assumptions are inaccurate, teachers and researchers may be expending their energy and resources unnecessarily in attempting to compare and predict the effectiveness and efficiency of these procedures. The initial purpose of this study was to determine if, by holding all other factors constant, children would indeed demonstrate a consistent sensitivity to one teaching procedure, and if so, if this sensitivity could be identified by presenting a brief assessment task that then could guide teachers' selections of efficient teaching procedures for longer response chains.

In addition to the relative efficiency of each procedure, teachers also may select teaching procedures by considering individual children's preferences for the available alternatives. Children, particularly those with disabilities, rarely are afforded the opportunity to voice their preferences for therapeutic programming. Providing such opportunities, in addition to respecting the individual's autonomy, may result in increased time on task and may limit the occurrence of problem behavior during instruction ( Hanley, 2010 ; Mason, McGee, Farmer-Dougan, & Risley, 1989 ; Powell & Nelson, 1997 ; Ringdahl, Vollmer, Marcus, & Roane, 1997 ).

Assessment of children's preferences for teaching strategies may be complicated, particularly when individuals have limited vocal repertoires. Hanley and colleagues described the use of a concurrent-chains procedure that offered a direct, nonverbal assessment of individuals' preferences and has been effective in determining preferences for behavioral interventions, classroom behavior-management strategies, and teaching strategies with individuals of both typical and atypical development ( Hanley, 2010 ; Hanley, Piazza, Fisher, Contrucci, & Maglieri, 1997 ; Heal & Hanley, 2007 ; Heal, Hanley, & Layer, 2009 ; Tiger, Hanley, & Heal, 2006 ). This procedure simply involves correlating salient stimuli with the interventions or teaching strategies and then allowing participants to select the correlated stimuli to gain brief access to the different interventions or teaching strategies.

We conducted our current study in two parts. The first involved an efficiency assessment in which participants were taught 3-, 6-, 9-, and 18-step motor sequences using both forward and backward chaining. We examined the outcomes of this assessment to determine (a) if children exhibited a consistent differential sensitivity to backward or forward chaining with similar tasks and (b) if we could predict differential acquisition of the 18-step tasks via learner performance with the tasks of shorter length (i.e., correspondence between the outcomes of the 3-, 6-, and 9-step comparisons with the outcome of the 18-step task). The second part involved a preference assessment using the concurrent-chains methodology of Hanley (2010) , in which we introduced a novel task and provided participants the opportunity to select whether the skill was taught using forward-, backward-, or no-chaining methods.

Participants and Setting

We recruited four participants from a local school for children with developmental and learning disabilities. Each class at this school offered small student-to-teacher ratios and some one-to-one instruction on a daily basis. All participants, except Daniel, were behind their peers in academic functioning and, according to teacher report, rarely followed two-step instructions. Further, teachers reported that none of the participants had experience with either chaining procedure prior to the study. Bella was a 10-year-old girl who had been diagnosed with attention deficit hyperactivity disorder (ADHD); her teacher reported that she was having trouble focusing during school instruction. Paul was an 11-year-old boy who had been diagnosed with ADHD; his teacher reported that he had trouble concentrating long enough to complete several steps of a task. Daniel was an 11-year-old boy with speech delays; his teacher reported that although he was within grade level on academic tasks, he had a stutter and displayed occasional slowed speech. Katie was a 12-year-old girl with learning deficits; her teacher reported she was behind grade level in almost every area of academics. We obtained parental consent and daily assent for each child; all study procedures were preapproved by the Institutional Review Board of Louisiana State University. The first author conducted all sessions in a vacant room in the school.

Preexperimental Preference Assessments

Prior to initiating the formal experiment, we conducted two preference assessments. First, we conducted a color preference assessment based on the procedures described by Heal et al. (2009) to eliminate bias in the colors associated with initial-link stimuli during our concurrent-chains preference assessment. We used 10 different-colored sheets of construction paper and presented each sheet to participants in pairs. We instructed participants to select the color they “liked more” on each trial and provided a brief statement of praise (e.g., “thanks”) after each selection. After we paired each colored sheet with each other colored sheet, we then ranked color preference based on selection percentages (i.e., number of times selected divided by the number of times presented). We selected three colors that were ranked similarly from the lower end of the preference hierarchy and randomly assigned each color to be correlated with each condition in our concurrent-chains preference assessment.

Next we conducted a leisure-item preference assessment based on the procedures described by Fisher et al. (1992) to identify activities to which access was delivered as a reinforcer during teaching conditions. We identified items to include via an interview with each participant's classroom teacher and presented items in paired arrays to identify highly preferred activities. We included access to the top three items to be used as reinforcers in the study. There were also instances in which participants requested an item not in their top three, and we allowed them to obtain that item as reinforcement for that day.

To develop our experimental motor sequences, we first selected six motor movements from which each motor sequence would be derived; these were touching one's nose, eye, and ear; patting one's head and lap; and clapping one's hands (we present operational definitions of these behaviors in Table 1 ). We then randomly selected from these movements to design pairs of motor sequences that included 3, 6, 9, and 18 steps (we made selections without replacement until all six movements were selected and then restarted for the 9- and 18-step motor sequences). We randomly assigned members of a motor sequence pair to either forward or backward chaining in a counterbalanced order across participants such that any unintended differences in motor sequence difficulty would be balanced across participants. For example, we assigned three-step Motor Sequence A to the forward-chaining condition and three-step Motor Sequence B to the backward-chaining condition for Daniel and Paul, and we assigned the three-step Motor Sequence B to the forward-chaining condition and the three-step Motor Sequence B to the backward-chaining condition for Bella and Katie. We then compared the efficiency of forward and backward chaining sequentially across each motor-sequence pair. That is, we taught one three-step sequence with forward chaining and one three-step sequence with backward chaining in alternating sessions. After both sequences reached mastery, we taught both six-step sequences, followed by both nine- and 18-step sequences. We compared backward and forward chaining across each sequence length in an adapted alternating treatments design.

Table 1 Operational Definitions of Motor Movements in Motor Chains

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Efficiency assessment

Prior to each pair of teaching sessions, the participant selected a leisure item from an array of preferred items; we delivered the selected item as a reinforcer during the next pair of sessions to ensure that the quality of reinforcement was identical across chaining conditions. We conducted one to six 10-trial sessions per day within a daily 45-min session block allocated to each participant, typically 4 days per week. Individual session duration depended on the number of steps in the motor sequence and participant responding during sessions (i.e., sessions that required prompting were longer than sessions with independent responding). Anecdotally, session durations ranged from about 5 min up to 25 min. In accordance with our experimental design, we alternated forward- and backward-chaining sessions in a random and counterbalanced order by flipping a coin to determine which would be conducted first.

At the onset of each comparison, we conducted a minimum of three baseline trials to ensure that participants could not engage in the motor sequence prior to instruction. During baseline trials, the teacher instructed the participant to complete a motor sequence (e.g., “Do the — dance”; we assigned each dance an arbitrary name to facilitate discrimination of the experimental conditions). The teacher did not provide any consequences for correct or incorrect responding, and after 5 s she instructed the participant to complete the motor sequence again, initiating a new trial. Following these baseline trials, we initiated instruction of the motor sequence.

During forward-chaining conditions, we initially targeted only the first step of the motor sequence. That is, after the instruction, “Do the — dance,” if the child completed the targeted steps of the motor sequence independently, the teacher delivered praise (e.g., “Great job!”), physically guided the participant to complete all untargeted steps, and delivered access to the preselected leisure item for 30 s. We provided physical guidance for untrained steps to equate exposure to these steps during this condition with the exposure experienced during backward-chaining sessions described below. If the child did not complete the required step independently within 5 s of the instruction or the engaged in an incorrect response, the teacher provided a model prompt that demonstrated the required step. If the child did not then complete the required step within 5 s, the teacher physically guided the child to engage in the targeted step and then all remaining untargeted steps. The teacher then waited 5 s after completion of the trial to deliver an instruction to initiate the next trial. This training continued for the first step until the participant correctly and independently engaged in that step on three consecutive trials (mastery criterion). After meeting this mastery criterion, the teacher then targeted Steps 1 and 2 together, then Steps 1, 2, and 3, and so on. Subsequent trials were similar except that both the targeted step and all previously mastered steps were then required to produce reinforcement. If the participant did not initiate the motor sequence, engaged in any incorrect responses, or delayed by more than 1 s between any previously mastered steps in the sequence, the teacher provided a model of all currently targeted components (i.e., the current step and any previously mastered steps) and provided the participant the opportunity to respond again. If the correct motor sequence was not emitted following the model, the teacher then physically guided the participant to complete the targeted and any previously mastered steps in the sequence.

Teaching trials were similar during backward-chaining conditions, except that we initially targeted only the terminal step of the motor sequence. That is, immediately after the instruction, the teacher physically guided the participant to complete all steps except for the last step in the sequence. Correct responding resulted in praise and access to a preferred leisure item, and incorrect responding or a failure to respond within 5 s resulted in the delivery of a model prompt of all steps. If the child did not engage in the correct response within 5 s of the model prompt, the teacher physically guided the child to complete the response. The mastery criterion for that step was identical to the criterion used in the forward-chaining condition (i.e., three consecutive, independently correct trials). After mastery on the terminal step had been achieved, the teacher initiated the next trial with the instruction and immediately physically guided the participant to complete all but the last two steps and provided a 5-s delay, and so on. Again, all previously mastered steps were required to be demonstrated with less than 1-s delay between responses to avoid more intrusive prompting. The teacher delivered praise and 30-s access to the identified preferred leisure item only after independent responses that included both the current and all previously mastered steps in the correct order.

In both forward- and backward-chaining conditions, we set the terminal mastery criterion as three consecutive trials of independently correct responding of the complete motor sequence following the initial instruction. After a participant met the terminal mastery criterion for a motor sequence, we continued to conduct training trials for the other motor sequence until it also met mastery. Each participant learned the 3-, 6-, 9-, and 18-step sequences in consecutive order. We determined the relative sensitivity to a chaining procedure based on the differential number of trials required to meet the terminal mastery criterion in each comparison. Following mastery of these motor sequences, we initiated the preference assessment.

Preference assessment

We presented three colored cards on a table in front of each participant to start the initial link of a preference assessment trial. Selections of (i.e., touching) one card completed the initial link and resulted in the onset of the terminal link of the chain in which the teacher taught a novel three-step motor sequence to completion using one of the two chaining procedures or a control procedure, depending on which card the participant selected. The teacher conducted backward- and forward-chaining terminal links similarly to those described during the efficiency assessments, except that teaching continued until participants met mastery criterion of independently completing the motor sequence following three consecutive instructions (i.e., sessions were no longer defined by 10-trial blocks; instead, terminal-link experiences continued until participants mastered the motor sequences). In this regard, the speed of each participant's acquisition of the motor sequence determined the number of trials and duration of exposure to each terminal link; participants required no more than 20 trials to master a task. The teacher conducted control terminal links similarly to baseline sessions, except that she terminated sessions based on time. Specifically, we measured the duration from the onset of the first instruction to the moment the mastery criterion was met during the forward- and backward-chaining terminal links and yoked the duration of control sessions to be equal to the mean of the previous two chaining terminal links. We initiated control sessions by providing the same initial instruction, “Do the — dance,” but did not provide any additional prompting. The teacher did not otherwise interact with the participant during these terminal links. Anecdotally, participants generally sat quietly during these periods and awaited the next initial-link opportunity.

We interspersed forced-choice sessions, in which the teacher presented only one initial-link card on each trial and physically guided the participant to complete the initial-link selection, in order to promote continued exposure to each of the terminal-link conditions. We began the preference assessment with three forced-choice exposure trials (one each for forward chaining, backward chaining, and the control condition) and included three additional forced-choice exposure trials following every five free-choice trials; we considered only selections during free-choice trials with all three colored cards present in determining preference. Between two and eight preference assessment trials were conducted per day, with no more than five free-choice trials in one day. The preference assessment duration ranged from 3 days to 9 days. Individual terminal-link experiences ranged from 2 min to 4 min. We terminated the preference assessment following free-choice selections of one initial link that totaled six selections greater than the next closest initial link or following 15 total free-choice trials.

Measures and Interobserver Agreement

Observers collected data on participant responding on a trial-by-trial basis using pencil-and-paper data sheets. During the efficacy assessment, observers coded a trial with an independently correct response if the participant initiated the motor sequence within 5 s of the instruction and completed the correct target step and all previously mastered steps in the correct sequence with no more than 1 s between each step. Observers coded a trial with a correct response following a model if the participant initiated the motor sequence within 5 s of the model prompt and completed the correct target step and all previously mastered steps in the correct sequence with no more than 1 s between each step. Observers coded a trial with a physically guided response if the teacher physically guided the participant to complete the target response sequence. During baseline trials only, observers coded a trial with no response or incorrect response if the participant failed to initiate the correct motor sequence within 5 s of the instruction or engaged in an incorrect response; these data were coded only during baseline because the programmed contingencies during teaching conditions resulted in additional prompting and the code captured this behavior in the other response categories.

A second observer simultaneously but independently collected data to provide an indicator of the reliability of measurement during 40%, 55%, 80%, and 64% of sessions during Paul's, Daniel's, Bella's, and Katie's teaching evaluations, respectively. For the teaching evaluations, we compared observers' records on a trial-by-trial basis; a trial was scored in agreement if both observers coded the same response category (i.e., independently correct, correct following a model, physically guided, or no response or incorrect) and in disagreement if the observers' records did not match. We then summed the number of trials scored in agreement, divided this sum by the total number of trials, and converted this to a percentage, resulting in mean interobserver agreement coefficients of 99% (range, 80% to 100%) for Paul, 97% (range, 80% to 100%) for Daniel, 99% (range, 80% to 100%) for Bella, and 99% (range, 90% to 100%) for Katie.

In addition, we collected data on participants' selections during the initial links of the preference assessment. On each trial, an observer noted the color of the selected card; selection was defined as contact of the participant's hand to a colored card. We compared observers' records of colored cards selected during 43%, 25%, 67%, and 25% of initial-link trials for Paul, Daniel, Bella, and Katie, respectively. Observers' records were scored in agreement if they both coded the same colored card selected and in disagreement if their records did not match; observers agreed on 100% of the selections across all participants.

Efficiency Assessment

We present a summary of each participant's acquisition of motor sequences in Figure 1 , which depicts the number of trials to mastery given forward- and backward-chaining conditions across each motor sequence comparison. None of the participants engaged in an independently correct response during baseline. Paul acquired the three-step motor sequence taught via backward chaining in 12 fewer trials than the three-step motor sequence taught with forward chaining (20 and 32 trials, respectively). We observed a similar pattern during the six-step motor sequence comparison in which Paul met the mastery criterion in 13 fewer trials given backward chaining (39 and 52 trials for the backward-chaining and forward-chaining motor sequences, respectively). However, we did not observe these differences during the nine-step motor sequence comparison; he acquired both motor sequences following exactly 78 trials. Paul acquired the 18-step backward-chaining motor sequence in seven fewer trials than the forward-chaining motor sequence (147 and 155 trials, respectively).

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Overall performance of all participants on the 3-, 6-, 9-, and 18-step motor tasks taught with forward and backward chaining.

Daniel demonstrated more variable performances across the different motor sequence lengths. He acquired the three-step backward-chaining motor sequence in nine fewer trials than the three-step forward-chaining motor sequence (11 and 20 trials for backward and forward chaining, respectively). Similarly, he met mastery criteria for the six-step backward-chaining motor sequence in three fewer trials than the six-step forward-chaining motor sequence (34 and 37 trials for backward and forward chaining, respectively). The reverse pattern was true for the longer motor sequences. During the nine-step motor-sequence comparison, Daniel met the mastery criterion during the forward-chaining condition in three fewer trials than the backward-chaining condition (60 and 57 trials for backward and forward chaining, respectively). During the 18-step comparison, Daniel reached mastery in nine fewer trials during the forward-chaining condition than during the backward-chaining condition (128 and 119 trials for backward and forward chaining, respectively).

Katie acquired both three-step motor sequences in the same number of trials with forward and backward chaining (14 trials). She mastered the six-step backward-chaining motor sequence in one fewer trial than the six-step forward-chaining motor sequence (29 and 30 trials for backward and forward chaining, respectively). We observed larger differences in her acquisition of the nine- and 18-step motor sequences. She mastered the nine-step forward-chaining motor sequence in 18 fewer trials than the backward-chaining motor sequence (88 and 70 trials for backward and forward chaining, respectively) and the 18-step motor sequence in 35 fewer trials (155 and 120 trials for backward and forward chaining, respectively).

The outcomes for Bella were the most consistent across comparisons; she always met mastery criterion in fewer trials given forward chaining, requiring three fewer trials in the three-step motor-sequence comparison (21 and 18 trials for backward and forward chaining, respectively), five fewer trials in the six-step motor sequence comparison (45 and 40 trials for backward and forward chaining, respectively), 10 fewer trials in the nine-step comparison (94 and 84 trials for backward and forward chaining, respectively), and five fewer trials in the 18-step comparison (175 and 170 trials for backward and forward chaining, respectively).

In summary of the aforementioned results, backward chaining was associated with fewer trials to mastery in three of four comparisons for Paul with an equal number of trials in the nine-step comparison. Backward chaining was associated with more rapid acquisition in two comparisons and slower acquisition in two comparisons for Daniel. Forward chaining was associated with more rapid acquisition in two comparisons, slower acquisition in one comparison, and equal acquisition in one comparison for Katie. Finally, forward chaining was associated with more rapid acquisition in all four comparisons for Bella.

We then examined the outcomes of the 3-step, 6-step, and 9-step comparisons to the 18-step comparison to determine the level of correspondence between the relatively shorter motor sequences and the longer motor sequences (i.e., would the determination of a “winner” from a brief comparison predict children's sensitivity in one of the longer duration comparisons?). These data are shown in Table 2 . The outcomes of the three-step and six-step comparisons corresponded with the outcomes of the 18-step comparison in only two of four cases (50%), which is equivalent to chance. The nine-step comparison may have been slightly more predictive, with correspondence in three of four cases (75%); however, the small number of participants prohibits any definitive conclusions.

Table 2 Correspondence Between Outcomes of the Short- and Long-Chain (18-Step) Motor Sequences

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Preference Assessment

We show each participant's cumulative initial-link selections from the preference portion of our study in Figure 2 ; these data represent responding only during free-choice trials. Daniel and Katie alternated between forward- and backward-chaining selections consistently. They both made seven selections of forward chaining and eight selections of backward chaining, and neither participant chose the control condition during the assessment. Bella similarly alternated between selections of forward chaining (six selections) and backward chaining (seven selections), but she selected the control condition on two trials. We terminated Daniel's, Katie's, and Bella's assessments after the 15-trial stop criterion with the determination that they each preferred backward and forward chaining similarly, and preferred both chaining conditions over the control condition. A preference for one chaining procedure emerged only for Paul. After choosing the control condition on the first trial, he then selected forward chaining in the next seven consecutive opportunities.

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Cumulative selections during free-choice trials of the concurrent-chains preference assessment.

We compared the acquisition of motor sequences across a sample of children with special needs using both forward and backward chaining. Across our four participants, this provided a total of 16 comparisons of forward and backward chaining. Forward chaining was associated with fewer trials to mastery in eight comparisons, backward chaining was associated with fewer trials to mastery in six comparisons, and no difference in trials to mastery was obtained in two comparisons. With the exception of the nine- and 18-step motor sequences for Katie, we observed marginal differences between backward and forward chaining ( M = 5.79 difference in trials to mastery; range, 0 to 13).

Only one of the four participants demonstrated a consistent differential sensitivity to a particular teaching condition in each of her four comparisons; Bella consistently met the mastery criterion more quickly under the forward-chaining conditions ( M = 5.75 trials difference). Paul met the mastery criterion more rapidly in the backward-chaining conditions for three of the four comparisons. Although Daniel and Katie met mastery more quickly in the backward-chaining conditions or in an equal number of trials for the shorter motor sequences, both met mastery criteria more rapidly during the forward-chaining conditions of the nine- and 18-step motor sequences. Thus, it did not appear that there were consistent differences in an individual's sensitivity to either teaching procedure, despite the use of similar tasks.

We also sought to determine if differentially rapid acquisition of a shorter motor sequence could serve as a behavioral assessment to predict differential sensitivity in acquisition of a longer motor sequence. We found correspondence between the three- and six-step motor sequences and the 18-step motor sequence for two of the participants (Paul and Bella), and the nine-step motor sequence was predictive for three of the participants (Daniel, Katie, and Bella). However, given the overall variability within each participant, it seems most appropriate to conclude that these correspondences were chance occurrences. That is, there were no consistencies in individuals' acquisition of motor sequences given forward and backward chaining, and thus any differences in the 18-step motor sequences could be predicted equally well by a coin flip or by previous performance.

In total, the results of our efficiency assessment ran contrary to Spooner and Spooner's (1984) assertion that there are idiosyncratic differences in sensitivity to chaining procedures that would be consistent in individual learners. In the current study, we assessed children's sensitivity to each teaching procedure repeatedly using highly similar tasks. Despite holding the task and the learner constant, we did not identify any consistencies in sensitivity to one teaching procedure beyond what would be expected by chance. Based on the variability in outcomes of comparisons in the literature and the results of the current study, it is likely safe to conclude that forward- and backward-chaining procedures are similarly effective in establishing behavior chains.

In addition to assessing the differential efficiency of these procedures, we also assessed participants' preferences for these procedures relative to a control condition. All participants preferred either chaining procedure over the no-chaining control, and three of the four participants displayed no preference for one chaining procedure over another. That is, similar to there being a lack of difference in the efficiency of these procedures, the children who experienced these teaching procedures were also indifferent regarding the procedure they received. The fourth participant, Paul, did meet our preference criteria for forward chaining. However, we believe that this may not be an accurate reflection of his preference; instead, his initial selection resulted in reinforcement and was strengthened immediately and differentially to the exclusion of the other options. For instance, at one point he asked the therapist, “Why would I switch to another color if I get my toy with purple [the color of the initial-link card associated with the forward-chaining condition]?”

These results draw attention to an important methodological feature of the concurrent-chains procedure, specifically the inclusion of the control condition. Had we included only the initial links from the backward- and forward-chaining conditions in the present assessment, we would have been unable to determine if the resultant data were indicative of indifference or of a failure to discriminate the contingencies associated with the initial links. By including a control condition that was unlikely to occasion selections, we can be fairly confident that our participants were indeed discriminating between the outcomes of their initial-link selections based on their minimal selections of the control condition; they were indifferent with regards to which chaining procedure they experienced.

The overall results of this evaluation suggest that (a) there is no consistent difference in task acquisition given instruction consisting of forward or backward chaining between or within participants, (b) it probably is not possible to use differential sensitivity during a brief task to predict differential sensitivity during longer tasks, and (c) these procedures are neither differentially efficient nor differentially preferred.

The lack of difference between these procedures, both in terms of efficiency and preference, is not an unimportant finding. Rather, these findings indicate that both procedures are effective at engendering complex chains of new behavior, and both are preferred by the consumers that experience them. From a practitioner's perspective, these results suggest that teachers and interventionists should be comfortable implementing either procedure with their clientele.

Our data did not completely rule out the possibility that some tasks may be taught more effectively with either forward or backward chaining. We chose to compare acquisition across similar motor tasks to rule out differences in task difficulty as a potential confounding effect. It may be that greater sensitivity to a particular chaining procedure would be identified for a different type of task. For instance, in making a sandwich, spreading peanut butter across one side of the bread creates a continuous visual discriminative stimulus to occasion the next response in the task (e.g., putting the knife down). It may be that such continuous stimuli exert stronger stimulus control than the presumably brief stimuli of a motor movement (e.g., one can no longer experience touching one's nose after that response has ended). These continuous discriminative stimuli may better set the occasion for a subsequent response, although it is unclear how this presentation would differentially favor one chaining procedure over the other.

It also may be the case that some tasks allow more natural or direct sources of reinforcement to result from the completion of the chain using backward chaining in lieu of socially contrived or indirect reinforcement when using forward chaining. For instance, in making a peanut butter sandwich, the immediate natural consequence of completing a targeted step with backward chaining would be access to the completed sandwich. By contrast, completing an early step via forward chaining (e.g., laying pieces of bread side by side) would not result in the same automatic consequence (i.e., complete sandwich), and thus teachers would need to rely on delivering another reinforcer (e.g., praise, edible item). Thompson and Iwata (2000) found that direct contingencies may result in more rapid acquisition. By arranging a reinforcement contingency that was not a direct product of the behavior (i.e., completion of a motor sequence resulted in the teacher delivering a toy), we may have obscured this benefit of backward chaining. The methods of the current study would be applicable to conducting additional comparisons of forward and backward chaining with disparate tasks and more natural reinforcement contingencies. It also would be interesting to compare the efficiency of and children's preferences for chaining methods relative to total-task presentation. During total-task presentation, all steps in a multistep task are targeted from the onset of instruction, and prompts are provided as needed to occasion each component response (e.g., Kayser, Billingsley, & Neel, 1986 ; McDonnell & McFarland, 1988 ).

In practice, it is common to physically guide learners through the early steps of a task with backward chaining. For instance, in teaching an individual to remove his or her sweater independently, it is common to guide pulling each arm out of its sleeve and placing hands under the collar to set the occasion for him or her to push the sweater over the head. To minimize the likelihood that this level of exposure to future targeted steps did not differentially favor backward chaining, we chose to include physical guidance on the untrained steps in both forward- and backward-chaining conditions. It is possible that this additional prompting and exposure to future targeted steps were in part responsible for the marginal differences between conditions by resulting in rapid acquisition in both conditions. If we had not prompted untrained steps prior to targeting them for instruction, differences between forward and backward chaining may have been more apparent. Future research may evaluate these procedures without additional prompting in place.

Finally, although the children did not demonstrate a preference for one of these teaching procedures, it is likely that teachers may have a distinct preference for one procedure over the other. If students are indifferent, then teachers' preferences certainly may be honored when instructional methods are selected. Future research may consider the systematic evaluation of teachers' preferences for these procedures.

Acknowledgments

This study was conducted as an undergraduate honors thesis by the first author. Sarah K. Slocum is now at the Psychology Department of the University of Florida.

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Case Studies and Scenarios

Case studies.

Each case study describes the real experience of a Registered Early Childhood Educator. Each one profiles a professional dilemma, incorporates participants with multiple perspectives and explores ethical complexities. Case studies may be used as a source for reflection and dialogue about RECE practice within the framework of the Code of Ethics and Standards of Practice.

Scenarios are snapshots of experiences in the professional practice of a Registered Early Childhood Educator. Each scenario includes a series of questions meant to help RECEs reflect on the situation.

Case Study 1: Sara’s Confusing Behaviour

Case study 2: getting bumps and taking lumps, case study 3: no qualified staff, case study 4: denton’s birthday cupcakes, case study 5: new kid on the block, case study 6: new responsibilities and challenges, case study 7: valuing inclusivity and privacy, case study 8: balancing supervisory responsibilities, case study 9: once we were friends, scenarios, communication and collaboration.

Barbara, an RECE, is working as a supply staff at various centres across the city. During her week at a centre where she helps out in two different rooms each day, she finds that her experience in the school-age program isn’t as straightforward as when she was in the toddler room. Barbara feels completely lost in this program.

Do You Really Know Who Your Friends Are?

Joe is an RECE at an elementary school and works with children between the ages of nine and 12 years old. One afternoon, he finds a group of children huddled around the computer giggling and whispering. Joe quickly discovers they’re going through his party photos on Facebook as one of the children’s parents recently added him as a friend.

Conflicting Approaches

Amina, an experienced RECE, has recently started a new position with a child care centre. She’s assigned to work in the infant room with two colleagues who have worked in the room together for ten years. As Amina settles into her new role, she is taken aback by some of the child care approaches taken by her colleagues.

What to do about Lisa?

Shane, an experienced supervisor at a child care centre, receives a complaint about an RECE who had roughly handled a child earlier that day. The interaction had been witnessed by a parent who confronted the RECE. After some words were exchanged, the RECE left in tears.

Duty to Report

Zoë works as an RECE in a drop-in program at a family support centre. She has a great rapport for a family over a 10-month period and beings to notice a change in the mom and child. One day, as the child is getting dressed to go home for the day, she notices something alarming and brings it to the attention of her supervisor.

Posting on Social Media

Allie, an RECE who has worked at the same child care centre for the last three years, recently started a private social media group to collaborate and discuss programming ideas. As the group takes a negative turn with rude and offensive comments, it’s brought to her supervisor’s attention.

Child Care and Early Education Research Connections

Beyond looking backward: child care and the hypothetical extraction method.

Description: Eight case studies examining the linkages from staff development, to teacher use of instructional strategies, to the performance of K-3 students in early literacy skills of phonemic awareness, phonics, vocabulary, fluency, and comprehension Resource Type: Other Author(s): Pratt James Edward ; Kay David Funder(s): United States. Child Care Bureau

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Study: 61% of the US to have cardiovascular disease by 2050

The American Heart Association is predicting 61% of Americans will have heart disease by 2050.

(CNN) – The American Heart Association is predicting about 61% of adults in the United States will have cardiovascular disease in the next two decades.

The group released research Tuesday, which found 45 million adults will have some form of cardiovascular disease or a stroke by 2050.

That number is up from 28 million in 2020.

Researchers said a big driver of the trend is the growing number of people likely to develop high blood pressure, which puts them more at risk for a heart attack or stroke.

An aging population is also a factor.

Heart disease is responsible for more than 800,000 deaths every year, making it the leading killer of Americans.

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Good Kids - Piano prodigy update

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Topeka development groups welcome summer interns to Top City

Watch CBS News

Trump was found guilty in his "hush money" trial. Here's what to know about the verdict and the case.

By Graham Kates

Updated on: May 31, 2024 / 11:57 AM EDT / CBS News

Former President Donald Trump was found guilty of 34 counts of falsifying business records by a jury in New York on Thursday, marking the end of a historic trial stemming from a "hush money" payment made to an adult film star before the 2016 election.

The trial lasted roughly six weeks, and the jury spent two days deliberating before returning a verdict. Trump denounced the decision as "rigged" and vowed to fight the conviction. His sentencing is scheduled for July 11.

Here are the basics of the charges, what happened during the trial and what comes next:

What were the charges?

Former President Donald Trump sits at the defense table with his defense team in a Manhattan court on April 4, 2023, in New York City, his first appearance after being charged with 34 felonies.

Trump was indicted on March 30, 2023, and charged with 34 state counts of falsifying business records in the first degree, a felony in New York.

What was the verdict?

Trump was found guilty on all charges on May 30, 2024. The jury returned a unanimous verdict in the Manhattan courtroom where the trial unfolded for six weeks.

What was needed for the jury to convict?

Justice Juan Merchan instructed jurors before they began deliberations that in order to find Trump guilty of falsifying business records in the first degree, they needed to unanimously conclude not only that he caused records to be falsified, but that he "conspired to promote or prevent the election of any person to a public office by unlawful means."

There were a few types of "unlawful means" that the jury heard evidence about, including: falsification of other business records, violations of campaign finance laws and violations of tax tax laws.

What exactly did prosecutors say Trump did?

Prosecutors from Manhattan District Attorney Alvin Bragg's office said Trump met with former National Enquirer publisher David Pecker and ex-fixer Michael Cohen in his Trump Tower in August 2015, and that the trio hatched a conspiracy to identify, purchase and squash stories that might harm Trump's reputation and presidential campaign.

Just days before the 2016 election, Cohen paid $130,000 to adult film star Stormy Daniels , who claimed she had sex with Trump in 2006. She agreed to keep her story under wraps in exchange for the money.

After Trump became president, Cohen was paid $35,000 a month for a year in a series of checks, most of which were signed by Trump. Prosecutors said the checks and associated business records were illegally portrayed as payments to Cohen for his legal work, when in fact they were intended to reimburse him for the Daniels deal, among other things.

What did Trump's lawyers say?

Defense attorney Emil Bove cross-examines David Pecker during former President Donald Trump's criminal trial in New York on Friday, April 26, 2024.

Trump's lawyers said the arrangement with Pecker and the National Enquirer was not atypical for political campaigns, which often try to influence media narratives about candidates. They said non-disclosure agreements like the one Cohen struck with Daniels are common, too.

As for the checks to Cohen, Trump's lawyers noted that Cohen's title at the time was "personal attorney to the president," and he actually was being paid for ongoing legal work. They said Cohen and Trump had a verbal retainer agreement, but not a signed one.

How about Trump himself?

Trump pleaded not guilty to the charges and denied all wrongdoing. He accused Bragg, a Democrat, of pursuing the case for political gain. Trump has called the case a "con job" and said the charges were "rigged" after the verdict came down.

Who were the key players?

Trump, Cohen and Pecker got top billing during the trial. Pecker was called to the stand by prosecutors first, and described the August 2015 Trump Tower meeting , as well as years of communications with Cohen and Trump about the scheme.

His testimony corroborated key moments relayed by Cohen, whose credibility the defense repeatedly sought throughout to undermine. Pecker's time on the stand was the lead-in to weeks worth of testimony from 18 others before Cohen, their final witness. Prosecutors sought to use those weeks to back up Cohen's story with corroborating evidence.

During the first day of their deliberations, the jury asked to hear portions of Pecker and Cohen's testimony related to the Trump Tower meeting.

What did Cohen say?

Cohen said Trump received regular updates on efforts to cover up salacious stories about him when he ran for president in 2016, and personally signed off on the scheme to falsify records related to them.

Cohen recounted three instances when he, Pecker and the editor of the National Enquirer worked to secure the rights to stories with salacious claims about Trump.

The jury heard a secret recording Cohen made of a conversation with Trump, in which Trump appeared comfortable with the purchase of a story told by another woman, named Karen McDougal.

"So, what do we got to pay for this? 150?" Trump can be heard saying on the tape.

Not long after the Enquirer paid for McDougal's story, Daniels' story hit the market. Her attorney approached the Enquirer about selling the rights one day after the release of the "Access Hollywood" tape in October 2016. On the recording, Trump was heard saying he could "grab [women] by the p****" and "make them do anything." The tape posed a major threat to his electoral prospects.

Cohen recounted intense negotiations in which everyone involved — Trump, Cohen, Daniels, her attorney and the Enquirer editor — were aware that Daniels' claim of a sexual encounter with Trump might have dire consequences for his campaign.

Cohen wired Daniels' attorney $130,000 of his own money on Oct. 28, 2016.

During his testimony, Cohen described how working for Trump for a decade was an "amazing" experience that turned sour after the "hush money" payment to Daniels became public in 2018.

He testified that he believed he was subject to a "pressure campaign" by Trump and his allies after the FBI raided his home and office that year, leading to a pair of guilty pleas to federal charges.

Under scathing cross-examination from defense attorney Todd Blanche, Cohen acknowledged that he's since made a living by loudly criticizing Trump.

He admitted wanting to see Trump imprisoned, and saying as much on his podcast.

Cohen also acknowledged lying under oath on multiple occasions, and, in a shocking moment, admitted for the first time to having stolen tens of thousands of dollars from the Trump Organization.

What did Daniels say on the stand?

Stormy Daniels testifies at former President Donald Trump's criminal trial in New York on May 7, 2024.

Daniels wasn't part of the scheme to influence the election. She never worked for Trump and had no involvement in any of the crimes alleged in the case.

Still, her story of sex with Trump in 2006 was the catalyst that sparked a series of events leading to this unprecedented criminal trial. Prosecutors said she was called to the stand because Blanche denied they ever had sex in his opening statement, an assertion they believed they had to rebut.

Daniels said she met Trump at a celebrity golf tournament in Nevada, and later was invited by Trump's bodyguard to a dinner with the famed businessman. She said they met up at a hotel suite she described in elaborate detail, right down to the tiles, and she was expecting to go to dinner when instead they began talking about business.

Daniels said Trump showed a keen interest in her industry, and seemed to value her insights. After some two hours of talking, with no dinner in sight, she excused herself to go to the bathroom. She recalled being surprised when she emerged to see that Trump had undressed down to a T-shirt and boxers. She described the sex that followed as, on her part, reluctant.

This part of her testimony caused the defense to demand a mistrial, a motion that was denied.

Daniels then described interacting with Trump frequently over the next year or so — including briefly meeting with him at Trump Tower — because he promised to advocate for her to get a spot on his reality television competition. When he told her it wouldn't happen, they stopped communicating.

Later, through a representative, she began shopping her story, seeking to sell the rights to it. When Trump's presidential candidacy gained steam in 2016, those efforts also became heated. They reached a fever in October of that year, when the "Access Hollywood" outtake surfaced.

Daniels said she realized her story was potentially more valuable, because it could be bad for his campaign. Cohen testified to frantic efforts to purchase it.

What comes next?

Trump's conviction kickstarts the sentencing portion of the case. Merchan, the judge, set a date of July 11 for Trump's sentencing hearing. He asked the defense to submit any motions they plan to request no later than June 13, and said prosecutors must respond by June 27.

Falsification of business records carries a maximum sentence of four years in prison and a $5,000 fine for each charge, but Merchan has broad leeway when determining the punishment. Some experts expect Merchan to use other options, like fines, probation or home confinement. But others say he could order Trump to serve some time behind bars.

Donald Trump

Graham Kates is an investigative reporter covering criminal justice, privacy issues and information security for CBS News Digital. Contact Graham at [email protected] or [email protected]

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US ranks highest in maternity deaths among high-income countries, study says

The U.S. ranks highest in maternal deaths out of 14 other high-income countries.

(CNN) – A new report shows the United States continues to have a higher rate of women dying in pregnancy, childbirth or postpartum compared with all other high-income nations.

These numbers are despite recent declines in the U.S. maternal death rate.

The report comes from the Commonwealth Fund, a private foundation focused on healthcare-related issues.

There were about 22 maternal deaths for every 100,000 live births in the U.S. in 2022, which is the most recent year with available data.

The rate was more than double, sometimes triple, those found in most other high-income countries that year.

The lead author notes the U.S. is the only nation in the analysis without universal healthcare and nearly 8 million women of reproductive age in the U.S. don’t have health insurance.

The author also said there aren’t enough midwives in the country and midwife care is not integrated enough into the healthcare system.

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Police say 15 people were arrested..

MOORESVILLE, N.C. (WBTV) - Mooresville Police Department officials recently wrapped up their largest child predator operation in the department’s history.

Operation Artemis ran from May 28-30 and led to the arrest of 15 people for various crimes against children.

“These are the faces of the boogeyman,” said Mooresville Police Chief Ron Campurciani.

One of the people arrested is an active service member and another worked driving school buses.

The ages of the people arrested ranged from 25- to 78-years-old and the minors they thought they were meeting for sexual activities ranged from 13- to 15-years-old.

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Taken into custody May 28

Brandon Cassiano, 30, of Mooresville: Felony solicitation of a child by computer and appearing. $50,000 secured bond.

Taken into custody May 29

Kenneth Lanning , 78, of Clayton: Felony solicitation of a child by computer and appearing, felony third-degree sexual exploitation of a minor, felony second-degree sexual exploitation of a minor. $150,000 secured bond.

Joshua Lara , 27, of High Point: Felony solicitation of a child by computer and appearing. $50,000 secured bond.

Thomas Trickett , 65, of Cornelius: Felony solicitation of a child by computer and appearing. $50,000 secured bond.

Dawson Davidson , 25, of Taylorsville: Felony solicitation of a child by computer and appearing $50,000 secured bond.

Taken into custody May 30

Paul Corkery , 45, of Concord: Felony solicitation of a child by computer and appearing. $50,000 secured bond.

Nien Eya Y , 45, of Charlotte: Felony solicitation of a child by computer and appearing and felony soliciting prostitution of a minor. $150,000 secured bond.

Elvin Rodezno Rodriguez , 39, of Charlotte: Felony soliciting prostitution of a minor. $50,000 secured bond.

Michael Smith , 55, of Charlotte: Felony solicitation of a child by computer and appearing. $50,000 secured bond.

Wilbur Cole III , 28, of Gretna, VA: Felony solicitation of a child by computer and appearing. $100,000 secured bond.

Aaron Mark Mayhew , 33, of Cherryville: Felony solicitation of a child by computer and appearing. $50,000 secured bond.

Christopher Bell , 29, of Mooresville: Misdemeanor solicitation of prostitution. $1,500 secured bond.

Eutiquio Chavez , 36, of Concord: Felony solicitation of a child by computer and appearing. $50,000 secured bond.

Daniel Yachnin , 28, of Cornelius: Felony solicitation of a child by computer and appearing. $50,000 secured bond.

Taken into custody June 1

Jose Beristain Solis , 39, of Mooresville: Felony solicitation of a child by computer. $10,000 secured bond.

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

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Early Childhood Education: How to do a Child Case Study-Best Practice

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Introduction

Recruitment

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Intervention Feasibility and Outcomes

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Characteristics of Backward Children

Types of Backwardness

Causes of Backwardness

Physical or Physiological factors-

Intellectual factors-

Environmental factors-

Home influences-

School influences-

Influence of neighbourhood and other social agencies-

Education of Backward Children

Diagnosis of the cause of Backwardness-

Educational guidance / Treatment of Backwardness

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AN ASSESSMENT OF THE EFFICIENCY OF AND CHILD PREFERENCE FOR FORWARD AND BACKWARD CHAINING

Participants and Setting

Preexperimental Preference Assessments

Efficiency assessment

Preference assessment

Measures and Interobserver Agreement

Efficiency Assessment

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Case Studies and Scenarios

Case Study 1: Sara’s Confusing Behaviour

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Conflicting Approaches

What to do about Lisa?