Davranışsal Konsültasyon Sağaltımı İçinde Bilişsel Davranışçı Oyun Terapisi: Down Sendromunda İçten Başlayan Dışa Yönelik Davranışsal Değişiklikler Yapma

Bu makale, hafif zihinsel özürlülüğe eşlik eden Down Sendromuna (DS) sahip bir öğrencinin sözel ve fiziksel saldırganlık ile ortaya çıkan duygu kontrolünü hedefleyerek gerçekleştirilen bireyselleştirilmiş Bilişsel Davranışçı Oyun Terapisi (CBPT) müdahalesini sunmaktadır. Bu müdahale, Ankara'da bulunan gelişimsel ve fiziksel engelli çocuklar için kurulmuş özel bir klinikte (özel eğitim ve rehabilitasyon merkezi) gerçekleştirilmiştir. Araştırmada yer alan müdahaleyi değerlendirmek için tek denekli araştırma modellerinden davranışlar arası çoklu başlama düzeyi modeli kullanılmıştır. Down sendromu tanısına eşlik eden hafif zihinsel yetersizliğe sahip hem duygu durum hem de davranış bozukluğu gösteren 14 yaşındaki bir kız öğrencidir. Katılımcının duygu düzenlemedeki zorlukları, diğerlerine zarar vermek, tekmelemek ve bağırmak gibi fiziksel ve sözlü saldırgan davranışlar da dahil olmak üzere, yüksek seviye problem davranışlardır ve hızla artma potansiyeline sahiptir. Müdahaleyi değerlendirmek için tek denekli araştırma modeli olan davranışlar arası çoklu başlama düzeyi modeline yer verilmiştir. Bilişsel Davranışçı Oyun Terapisi (BDOT) içindeki dinamik süreç, değişimleri içten, bilişsel süreçlere müdahale ile başlatarak dışa doğru yani açıkça görülen olumlu davranış değişikliklerinin ortaya konmasına hizmet eden bir yapı şeklinde araştırmada yer almıştır. Sonuçlar katılımcının yıkıcı davranış sıklığında azalma ve iletişim becerilerinde artış şeklinde yorumlanmıştır. Bu çalışma, DS ve hafif zihinsel yetersizliği olan bireylerle çalışan danışmanlar için, özellikle uyum davranışlara yönelik etkin müdahalelerin geliştirilmesi ve onaylanmasına yönelik önemli bir adım teşkil etmektedir. BDOT gibi hibrid yöntemlerin dışavurum davranış sorunları için, farklı yetersizliğe sahip gruplarda davranışsal konsültasyon süreçleri içerisinde araştırılmasına ihtiyaç vardır.

Anahtar Kelimeler:

Bilişsel davranışçı oyun terapisi, Down sendromu, Hafif zihinsel yetersizlik

Cognitive Behavioral Play Therapy in Behavior Consultation Treatment: Making Behavior Changes from the Inside Out in Down Syndrome

This article presents an individualized Cognitive Behavioral Play Therapy (CBPT) intervention, to target emotion dysregulation in verbal and physical aggression with Down syndrome (DS) concurrent with mild intellectual disabilities (ID). A female student participated in this pilot individual and clinic-based CBPT intervention. This intervention was implemented within a private clinic (special education and rehabilitation center) for children with developmental and physical disabilities located in Ankara, Turkey. K is a 14-year-old female student diagnosed with DS with a mild ID and co-occurring mood and behavioral disturbances. Participant’s emotion regulation difficulties had the potential to quickly escalate to severe behaviors, including physically and verbally aggressive behavior like threating to harm others, kicking and shouting. Single-subject methodology utilizing a multiple-baseline design across behaviors was used to evaluate the intervention. The dynamic process in Cognitive Behavioral Play Therapy (CBPT) has been investigated as a structure that serves to reveal positive behavioral changes, by intervening internally, starting from cognitive processes to outside by observing behavioral changes. The results were interpreted as a decrease in the frequency of destructive behavior of the participant and an increase in communication skills. This study represents an important step toward the development and validation of effective interventions for counselors working with individuals with DS and ID to specifically address adaptive behaviors. Further research needs to be conducted to fully determine the effects of the use of hybrid methods like CBPT for extrovert behavior problems, in different disability groups, within behavioral consultation procedures.

Keywords:

Cognitive behavioral play therapy, Down syndrome, Mild intellectual disabilities,

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American Association on Intellectual and Developmental Disabilities (AAIDD). (2010). Intellectual Disability: Definition, Classification, and Systems of Support. American Association on Intellectual and Developmental Disabilities, Washington, DC.Blackburn, I.M., James, I. A., Milne, D. L., Baker, C., Standart, S., Garland, A., Reichelt, F. K. (2001). The Revised Cognitive Therapy Scale (CTS-R): Psychometric Properties. Behavioural and Cognitive Psychotherapy, 29, 431–446.
Boratav, C. (2003). Boratav Depresyon Tarama Ölçeği (Bordepta): Epidemiyolojik çalışmalar ve birinci basamak sağlık hizmetinde depresyonu tanımaya duyarlı bir ölçek. Psikiyatri Dergisi; 14(3), 172-183.
Borthwick-Duffy, S. A., Lane, K. L., & Widaman, K. F. (1997). Measuring problem behaviors in children with mental retardation: Dimensions and predictors. Research in Developmental Disabilities, 18, 415–433.
Boumparis, N., Karyotaki, E., Kleiboer, A. Hofmann, S.G., & Cuijpers, P. (2016). The effect of psychotherapeutic interventions on positive and negative affect in depression: A systematic review and meta-analysis. Journal of Affective Disorders, 202, 153-162.
Carr, J. E. (2005). Recommendations for reporting multiple-baseline designs across participants. Behavioral Interventions, 20, 219–224.
Christ, T. J. (2007). Experimental control and threats to internal validity of concurrent and nonconcurrent multiple baseline designs. Psychology in the Schools, 44(5), 451–459.
Collacott, R. A., Cooper, S. A., & McGrother, C. (1992). Differential rates of psychiatric disorders in adults with Down’s syndrome compared with other mentally handicapped adults. The British Journal of Psychiatry: The Journal of Mental Science, 161, 671–674.
Cooper, S. A., & Collacott, R. A. (1993). Prognosis of depression in Down’s syndrome. Journal of Nervous and Mental Disease, 181, 204–205.
Cooper, S. A., Smiley, E., Morrison, J., Williamson, A., & Allan, L. (2007). An epidemiological investigation of affective disorders with a population-based cohort of 1023 adults with intellectual disabilities. Psychological Medicine, 37, 873–882.
De Bildt, A., Sytema, S., Kraijer, D., Sparrow, S., & Minderaa, R. (2005). Adaptive functioning and behaviour problems in relation to level of education in children and adolescents with intellectual disability. Journal of Intellectual Disability Research, 49, 672–681.
Dennhag, I., Gibbons, M. B. C., Barber, J. P., Gallop, R., & Crits-Christoph, P. (2012). How many treatment sessions and patients are needed to create a stable score of adherence and competence in treatment of cocaine dependence? Psychotherapy Research, 22, 475–488.
Dierssen, M. (2012). Down syndrome: the brain in trisomic mode. Nature Reviews Neuroscience, 13, 844-858.
Dykens, E. M., Hodapp, R. M., & Evans, D. W. (2006). Profiles and development of adaptive behavior in children with Down syndrome. Down Syndrome, Research and Practice, 9(3), 45–50.
Ehrlich, M. E., & Kratochwill, T. R. (2002). Behavioral Consultation Therapy. Encyclopedia of Psychotherapy, 1, 191–205.
Eyberg, S. M. (2005). Tailoring and adapting parent–child interaction therapy to new populations. Education and Treatment of Children, 28(2), 197–201.
Felce, D., & Emerson, E. (2001). Living with support in a home in the community: Predictors of behavioral development and household and community activity. Mental Retardation and Developmental Disabilities Research Reviews, 7, 75–83.
Foley, K. R., Jacoby, P., Girdler, S., Bourke, J., Pikora, T., Lennox, N., and Leonard, H. (2013). Functioning and post-school transition outcomes for young people with Down syndrome. Child: Care, Health and Development, 39, 789–800.
Harrison, P. L., & Oakland, T. (2003). Adaptive Behavior Assessment System-Second Edition. San Antonio, TX: Harcourt.
Harvey, M. T., May, M. E., & Kennedy, C. H. (2004). Nonconcurrent multiple baseline designs and the evaluation of educational systems. Journal of Behavioral Education, 13 (4), 267–276.
Hawkins, B. A., Eklund, S. J., James, D. R., & Foose, A. K. (2003). Adaptive behavior and cognitive function of adults with Down syndrome: Modeling change with age. Mental Retardation, 41(1), 7–28.
Hofmann, S. (2011). Introduction to modern CBT: Psychological solutions to mental health problems. Oxford, UK: Wiley-Blackwell.
Holland, A. J., Hon, J., Huppert, F. A., & Stevens, F. (2000). Incidence and course of dementia in people with Down’s syndrome: Findings from a population-based study. Journal of Intellectual Disability Research, 44, 138–146. Holland, A.J., Hon, J., Huppert, F.A., Stevens, F., & Watson, P. (1998) A population-based study of the prevalence and presentation of dementia in adults with Down's syndrome. British Journal of Psychiatry, 172, 493-498.
Horner, R. H., Carr, E. G., Strain, P. S., Todd, A. W., & Reed, H. K. (2002). Problem behavior interventions for young children with autism: A research synthesis. Journal of Autism and Developmental Disorders, 32, 423–446.
Hughes, C., & Ensor, R. (2011). Individual differences in growth in executive function across the transition to school predict externalizing and internalizing behaviors and self-perceived success at 6 years of age. Journal of Experimental Child Psychology, 108, 663–676.
Janatian, S., Nouri, A., Shafti, A., Molavi, H., & Samavatyan, H. (2008) Effectiveness of play therapy on the bases of cognition behavioral approach of symptoms of attention deficit/hyperactivity disorder (ADHD) among primary school male students aged 9–11. J Res Behav Sci, 2,110–112
Kırcaali-İftar, G., & Tekin, E. (1997). Tek denekli araştırma yöntemleri. Türk Psikologlar Derneği Yayınları.
Landreth, G. (2002). Play therapy: The art of the relationship (2nd ed.). Philadelphia, PA: Brunner-Routledge.
Lee, N. R., Fidler, D. J., Blakeley-Smith, A., Daunhauer, L., Robinson, C., & Hepburn, S. (2011). Caregiver-report of executive functioning in a population-based sample of young children with Down syndrome. American Journal on Intellectual and Developmental Disabilities, 116(4), 290–304.
Lott IT, Dierssen M. (2010). Cognitive deficits and associated neurological complications in individuals with Down syndrome. Lancet Neurol; 9, 623-33.
Lindsay, W.R., Howells, L., & Pitcaithly, D. (1993). Cognitive therapy for depression with individuals with intellectual disabilities. British Journal of Medical Psychology, 66, 135-141. Loveland K. A, & Kelley M. L. (1988). Development of adaptive behavior in adolescents and young adults with autism and Down syndrome. Am J Ment Retard, 93(1), 84–92.
Matson, J. L., Dixon, D. R., & Matson, M. L. (2005). Assessing and treating aggression in children and adolescents with developmental disabilities: A 20 year overview. Educational Psychology, 25, 151–181.
McCabe, M.P., McGillivray, J.A., & Newton D.C. (2006). Effectiveness of treatment programs for depression among adults with mild/moderate intellectual disability. Journal of Intellectual Disability Research, 50, 239-247.
Nadel, L. (2003). Down’s syndrome: A genetic disorder in biobehavioral perspective. Genes Brain and Behavior, 2, 156–166. Kahveci, G. 320
Nicham, R., Weitzdorfer, R., Hauser, E., Schubert, M., Wurst, E., Lubec, G., & Seidi, R. (2003). Spectrum of cognitive, behavioural and emotional problems in children and young adults with Down syndrome. Journal of Neural Transmission, 67 (Suppl.), 173–191.
Nota, L., Ferrrari, L., Soresi, S., & Wehmeyer, M.L. (2007). Self-determination, social abilities, and the quality of life of people with intellectual disabilities. Journal of Intellectual Disability Research, 51, 850-865.
Pennington B. F., & Ozonoff S. (1996) Executive functions and developmental psychopathology. Journal of Child Psychology and Psychiatry, 37, 51–87.
Parent, V., Birtwell, K. B., & Lambright, N. (2016). Combining CBT and Behavior-Analytic Approaches to Target Severe Emotion Dysregulation in Verbal Youth With ASD and ID Journal of Mental Health Research in Intellectual Disabilities, 9, (1-2), 60-82.
Perepletchikova, F. (2011). On the topic of treatment integrity. Clinical Psychology: Science and Practice, 18, 148–153.
Prasher, V. P., & Hall, W. (1996). Short-term prognosis of depression in adults with Down’s syndrome: Association with thyroid status and effects on adaptive behaviour. Journal of Intellectual Disability Research, 40, 32–38.
Pujol, J., Hoyo, L., Blanco-Hinojo, L., Sola, S., Macia, D., Martinez-Vilavella, G., Amor, M., Deus, J. Rodriguez, J., Farre, M., Dierssen, M., & Torre, R. (2015) Anomalous brain functional connectivity contributing to poor adaptive behavior in Down syndrome. Cortex, 64, 148-156.
Reaven, J. A. (2009). Children with high-functioning autism spectrum disorders and co-occurring anxiety symptoms: Implications for assessment and treatment. Journal for Specialists in Pediatric Nursing, 14(3), 192–199.
Rosner B. A., Hodapp R. M., Fidler D. J., Sagun J. N., & Dykens E. M. (2004) Social competence in persons with Prader-Willi, Williams and Down syndromes. Journal of Applied Research in Intellectual Disabilities, 17, 209–17.
Sheppard, L., & Unsworth, C. (2011). Developing skills in everyday activities and self-determination in adolescents with intellectual and developmental disabilities. Remedial and Special Education, 32, 393– 405.
Su, C.Y., Lin, Y.H., Wu, Y.Y., & Chen, C.C. (2008). The role of cognition and adaptive behavior in employment of people with mental retardation. Research in Developmental Disabilities, 29, 83–95.
Sung, H., Hawkins, B.A., Eklund, S.J., Kim, K.A., Foose, A., May, M.E., et al. (1997). Depression and dementia in aging adults with Down syndrome: A case study approach Mental Retardation, 35, 27-38.
Tau, G. Z., & Peterson, B. S. (2010). Normal development of brain circuits. Neuropsychopharmacology, 35(1), 147–168.
Van Gameren-Oosterom, H. B., Fekkes, M., Buitendijk, S. E., Mohangoo, A. D., Bruil, J., & Van Wouwe, J. P. (2011). Development, problem behaviour, and quality of life in a population based sample of eight-year-old children with Down syndrome. PLos One, 6. doi:10.1371/journal.pone.0021879
Van Gameren-Oosterom, H. B., Fekkes, M., van Wouwe, J. P., Detmar, S. B., Oudesluys-Murphy, A. M., & Verkerk, P. H. (2013). Problem behavior of individuals with Down syndrome in a nationwide cohort assessed in late adolescence. Journal of Pediatrics, 163(5), 1396–1401.
Warren, A. C., Holroyd, S., & Folstein, M. F. (1989). Major depression in Down’s syndrome. British Journal of Psychiatry, 155, 202–205.
Weck, F., Hilling, C., Schermelleh-Engel, K., Rudari, V., & Stangier, U. (2011). Reliability of Adherence and Competence Assessment in Cognitive Behavioral Therapy: Influence of Clinical Experience. The Journal of Nervous and Mental Disease, 199 (4), 276-279.
Whitaker, S. (2001). Anger control for people with learning disabilities: A critical review. Behavioural and Cognitive Psychotherapy, 29, 277–293.
Willner, P. 2005. The effectiveness of psychotherapeutic interventions for people with learning disabilities: A critical overview. Journal of Intellectual Disability Research, 49, 73-85.