Family interactive rating scale: an assessment and treatment tool for children and their parents in therapy.
Cognitive therapy (Methods)
Cognitive therapy (Social aspects)
|Publication:||Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 American Psychotherapy Association ISSN: 1535-4075|
|Issue:||Date: Summer, 2010 Source Volume: 13 Source Issue: 2|
|Topic:||Event Code: 200 Management dynamics; 290 Public affairs Canadian Subject Form: Cognitive-behavioural therapy; Cognitive-behavioural therapy Computer Subject: Company business management|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Concrete, visual, hands-on therapy tools appear to help children participate and understand the therapy process better than more abstract methods. Different forms of rating scales are used by many of us, and the Family Interactive Rating Scale (FIRS) is one way to engage children in therapy, gain their perspective, and at the same time include parental participation. This scale consists of a 1-10 rating scale, with 10 being the most positive and 1 being the most negative. It is used to assist children and parents to rate success and struggles the child may be experiencing within the family and school setting, whether it is behaviors, emotions, or cognitions. Also, the scale utilizes both the child's and parent's ratings, identifies different perceptions, helps identify goals to focus on in therapy, and allows for opportunities to praise the child when positive behaviors are met. In addition, the FIRS can be used with most children second grade and older, as long as they are able to understand and utilize a continuum of a 1-to-10 rating scale. The scale may also be used with a variety of childhood problems presenting in the therapy office.
Family Interactive Rating Scale
The Family Interactive Rating Scale (FIRS) can provide concrete discussions in therapy with children, provides an effective way to measure problems or successes, and is a method to discuss difficulties simply and understandably while still including parental involvement.
Family cognitive-behavioral therapy has been used to treat a variety of childhood disorders, although traditionally cognitive behavioral therapy has focused more on the individual, offering little involvement with the family. More recently, the importance of including the family in the treatment of the child is being recognized (Friedberg, 2006; Linares, Scott and Feeny, 2006; Pavuluri, Graczyk, Henry, Carbray, Heidenreich, and Miklwitz, 2004; Wood, 2006). Solution-focused brief therapy also focuses on helping change various behaviors by targeting present issues and utilizing rating scales from 0 to 10 (Iverson, 2002).
This article focuses on family cognitive-behavioral therapy utilizing the FIRS to guide the therapy process and can be used for a variety of disorders and difficulties such as ADHD, and other behavior disorders, mood and anxiety disorders, dealing with a divorce, school problems, etc., and with children approximately second grade and older.
Therapists have used various rating forms such as the Likert scale in therapy with children, especially to help quantify successes or struggles. I have been using scales to help children better explain how they were behaving, feeling, and thinking. Over time I used the scale more frequently with client families as a method to measure how the child was functioning at the initial diagnostic assessment, as well as an ongoing therapy tool.
Eventually, the scale was modified to include numerals 1-10 written on the left side of a large whiteboard in the office, and a smiley-face added above number 10 and a frowny-face added below number 1. With children--although this can be used with some adolescents and adults, too--the scale was developed as a method to help explain in a measured, concrete, and visible manner how the child is functioning on a variety of issues, such as behavior at school and home, friendships and other social skills, academic progress, appetite, sleep, handling anger, handling anxiety, general state of happiness, self-esteem, getting along with siblings and/ or parents, following directions, completing chores, bus behavior, etc.
With continued use, I formalized this scale into the development of the FIRS, replicating what was on my whiteboard to a handout on a clipboard for the child to complete during the therapy sessions while I would write on the whiteboard. Also, I may use some abbreviations next to each number on the scale to make it easier for the child to copy, for example: school behavior = SB, school work = SW, home behavior = HB, appetite = APE self-esteem = SE, homework = HM, etc.; otherwise I use the entire word like Dad, Mom, Anger, Trust, Mood, Sleep, Bus, Brother, Sister, and Friends. With these words I want the child to rate how he is functioning in each of these areas. Having the child copy this down on the FIRS form is another way to engage the child in therapy, and it can be used as a record when writing the therapy progress note, as well as in future therapy sessions, allowing date comparison. Sometimes with continued use I will allow the child to go to the whiteboard and write the words next to the scale while I copy it on the FIRS form. The FIRS can be used as often as a therapist finds it helpful and focus the ratings to whatever areas of concern they may have for the child.
The following are suggested steps to effectively utilize the FIRS in therapy with children and their parents.
1. Bring the child into your therapy office while the parent(s) stays in the waiting room. This can also be done with child and parent(s) at the same time if seeing the child separately seems to not work as well, although I prefer to start separately. This might also best be used after you have collected the necessary data for your initial diagnostic assessment, which might include seeing the parents first.
2. In your office will be a large whiteboard with the scale 1-10 down the left hand side, with 1 being most negative and 10 being most positive.
3. Hand the child a clipboard with the same FIRS form. As you interact with the child, he will simply copy what you write on the whiteboard. This information will reflect how the child rates himself on how he is functioning (this involves the child in the process and gives you a paper record of the discussion).
4. Now, you and the child begin rating, on a scale of 1-10, how she/he is performing on a variety of issues (I usually like to start with the least sensitive areas).
5. Abbreviations can be used to simplify the recording, slashes are used to separate ratings, arrows up and down can be used to indicate progress and declines, and comments from the parent(s) and child can be separated by color or circling parent ratings.
6. Bring the parent(s) into the therapy office and review with them and the child the issues that you and the child have identified on the whiteboard. Also, adding parent's ratings alongside the child ratings, especially if parent's comments are different from their child's, can be very helpful.
7. Continue the therapy session by discussing discrepancies or similarities between parent's and child's ratings, identifying problem areas, and developing plans to increase scores on these behaviors. Be sure to praise positive scores, both to reward the child and model appropriate behaviors for the parent(s).
8. This scale is always completed by the child and parent(s), with the therapist involved to elicit and discuss rating differences/similarities and thus utilizing the therapy relationship in this process. It allows for a very visual, concrete way to involve the child in the therapy process and allows for perceptual differences between child and parent/s to be easily identified and discussed.
9. The completed scale and therapy progress note are placed in the client's chart for the next family therapy session.
10. At the next family therapy session, the FIRS can again be completed by the therapist and child to help identify how the rating may or may not have changed. Parents are again brought into the therapy office to give their feedback, successes are praised and struggles are again identified, along with plans to increase ratings in these problem areas. These plans may be discussed with the family and may also be practiced during the therapy session.
Consistent with the CBT concept of socializing clients to the therapeutic process (Beck, 1995), once children and parents become familiar with the FIRS, they appear to quickly grasp the concept, and with ongoing sessions will easily volunteer how they rate themselves. The concrete, visual quality of this scale allows children and parents to discuss more precisely how they are functioning and helps the therapist to better understand how the child and parent(s) view these behavioral, emotional, and thinking areas. In addition, the FIRS helps to better clarify for parents how the child perceives himself and vice versa, aids in therapy sessions to identify problem areas, and more clearly measures successes or struggles in treatment.
Beck, J. (1995) Cognitive Therapy Basics & Beyond. Guilford Press.
Friedberg, R.D. (2006) A Cognitive-Behavioral Approach to Family Therapy. Journal of Contemporary Psychotherapy, 36, 159.
Iverson, C. (2002) Solution-focused Brief Therapy. Advances in Psychiatric Treatment, 8, 149-156
Linares Scott, T.J., & Feeny, N. (2006). Relapse Prevention Techniques in the Treatment of Childhood Anxiety Disorders: A Case Example. Journal of Contemporary Psychotherapy, 36(4), 151.
Pavuluri, M.N., Graczyk, P.A., Henry, D.B., Carbray, J.A., Heidenreich, J., & Miklowitz, D.J. (2004). Child-and Family-Focused Cognitive-Behavior-al Therapy for Pediatric Bipolar Disorder: Development and Preliminary Results. Journal of American Academy of Child and Adolescent Psychiatry, 43, 528.
Wood, J.J.(2006) Family Involvement in Cognitive-Behavioral Therapy for Children's Anxiety Disorders. Psychiatric Times, 23.
By Nate Larsen, PhD, DAPA
Nate Larsen, PhD, DAPA, and licensed psychologist, is employed at Lakeland Mental Health Center in Fergus Falls, Minnesota, where he has been providing a variety of therapy and program supervision services to children and their families for more than 20 years. In addition, he has been teaching psychology and counseling courses at area colleges for the past 12 years.
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