Dr. Young define's tantrums and what is considered developmentally appropriate versus atypical. Learn about brief interventions for tantrums that can be done in a primary care setting and community services and evidence-based interventions for problematic tantrums.
Well, let's go ahead and get started. First of all, good morning. Um, thank you for inviting me to Early bird rounds. My name is Rebecca Young. I'm an assistant professor in the child psychiatry department here at WSU. Today, we're gonna be discussing tantrums. Um, I feel like there's a lot of terminology for tantrums. They can be called meltdowns, emotional dysregulation, crash-outs. Um, but at the end of the day, all those things are extreme emotional reaction that is beyond what is warranted for the situation. And so for the use of this presentation, we will refer to any of these emotional reactions as tantrums. I have no financial disclosures. Objectives today, we're going to define tantrums and what's considered developmentally appropriate or typical versus atypical. Learn about brief interventions for tantrums that can be done in a primary care setting, and examine community services and evidence-based interventions for problematic tantrums. So let's go ahead and start with a case. Uh, Sam is a 4-year-old boy who presents to a pediatric clinic with his mom. Mom reports that their primary concern is that Sam got kicked out of daycare 3 months ago for tantrums, and he's on the verge of getting kicked out of his current daycare for the same behaviors. Sam has always been an emotional child, even as a baby. He frequently had meltdowns when he was 2 over the smallest of things, and mom thought he would grow out of it. Now his tantrums are worse, they're lasting up to an hour. He's been hitting and kicking uh peers, staff, and parents, and even bit a daycare staff member. Usually this happens when he has to transition away from the TV, get ready in the morning for daycare, or if he's asked to do something he doesn't wanna do. With this guy, mom Stacy usually gives up whenever he tantrums and allows him to do what he wants because, quote, it's just a fight all the time. All right. So I realize everyone is supposed to be muted, but I kinda want you to think about similar cases that you've seen in the clinic. And if uh this is something that you regularly um experience as a chief complaint in the clinic. And while we're going through these slides, I'm gonna have you think about what can be triggers for a tantrum, and then what's on your differential diagnosis. Is there a diagnosis that can be associated with tantrums? So a little bit about me. I'm a child psychiatrist at WU specifically in the Herman Center. Um, and this is, um, a clinical hat that I wear that is specific for infant and preschool mental health and focuses on assessment and treatment of our youngest population, so 0 to 6 years old. You may not be surprised, but the most common chief complaint I get in this age range is Tantrums, meltdowns, dysregulation, emotional outbursts. That's one of the most common chief complaints that we get. So how can we conceptualize tantrums? Um, kind of what I mentioned at the very beginning, it's, I think it's useful to think of tantrums as a reaction to a situation a child can't handle in a more grown-up way. Like, they have difficulty talking about how they feel, or making a case for what they want, or just doing what has to be asked of them. Instead, they're overwhelmed by emotion, and it's unleashed dramatically. Uh, tantrums in and of themselves is typical in development. Tantrums, um, as you probably know, mostly occur between ages 2 to 3 years, but can start to occur as young as 12 months. I think it's helpful to be able to understand like how generalized tantrums are for this age range. So 87% of 24 month olds, so 2-year-olds have tantrums, 91% of 30 to 36 month olds, and 59% of 42 to 48 year olds. So between the years of 2 to the 4th birthday, the vast majority of those children are gonna have tantrums. Um, one study showed that on average, children ages 18 months to 16 months old, so that's a pretty wide range, tantrums occur once a day with a medial duration of 3 minutes. Most commonly, tantrums last 30 minutes to 1 minute, with normalization of mood and behaviors between episodes. And as children get older, the severity, frequency, and length of events naturally decrease. So what is not typical tantrums, what makes them atypical. What makes them so that it's not developmentally appropriate. The rule of thumb that I use is going by the three P's, so persistent, pervasive, and impairing. Please give me that one. I realize it's not starting with a P, but Um, so persistent, um, atypical for children older than 5 years old to have repeated patterns of tantrums. Um, by the time you are in preschool, getting out of preschool, children tend to grow out of temper tantrums. Um, likewise, if it's lasting more than 15 minutes or occurring regularly, more than 5 times a day, like, that would be atypical as well. Um, kids can still get upset and angry, but kids should be learning better control of emotions at this point, like at 5 years of age of preschool. Pervasive. It's happening in more than one place, and happening more ubiquitously. So, think about it, if it's happening at home, it's also happening at school, it's happening with grandparents, um, it's happening out in public, a more pervasive displaying of tantrums would be a red flag. And then lastly, in pairing. So, what is it interfering with? I think there can be a couple of things. I think, um, atypical tantrums, especially can interfere with peer relationships. So think about the kids at school, they're like, I don't wanna invite that kid. Like, I don't wanna invite you to my birthday party. He just goes off the rails all the time. Uh, there can be concern for educational parents, so, um, kids are having to be sent home for their tantrums, so they're actually not able to be at school and learning, or it takes away the time that they're in the classroom to the point that they're not getting the full academic, um, time that they need. And then are there family disruptions as part of it? Like, what is the impact on the family? And then lastly, I'll kind of put as a side note, extreme aggression is not typical for toddler tantrums, uh, for like routine toddler tantrums. If a kid is like physically injuring themselves or others or destroying property, that's a big red flag. And these are all signs that it's probably time to get some help. Why do terrible tantrums occur? Um, I, the first bullet point I have is, uh, manipulative, because I have, I do hear parents talk about that with in reference to their kids and their behaviors, and kind of describing it as intentional, consciously willful on the kids's part. Um, I think it's important, especially when we're talking about why tantrums occur in the psychoeducation for parents, is that a lot of times these behaviors are less voluntary than parents realize, and I would probably better describe it as a learned behavior. If a kid unleashes their feelings in a dramatic way by crying, yelling, kicking the floor, punching the walls, or hitting a parent, like, it serves them to get what they want, or out of what they're trying to avoid. It's a and then it becomes a behavior that they come to rely on. And children learn um through caregiver reinforcement that tantrums get results, and it's a vicious cycle, because instead of honing and practicing adaptive skills that kids normally learn to solve problems collaboratively, these kids are learning maladaptive responses when they get frustrated. So by continuing to practice these maladaptive skills, they're strengthening these behaviors over time and use them in a greater number of situations. The other thing I usually hear from parents is, I've tried to correct the behaviors, I've tried to respond differently, nothing has worked. And that's what I think is really important for to understand the concept of intermittent reinforcement. For adults, I think a good example is gambling. But, right? Like you don't get the house every hand, it's difficult to predict when you're gonna get the payout, but it's that unpredictability plus knowing at some point the house is gonna lose, that reinforces the behavior, and people stay in for that one more hand again and again. Similarly, for a child who has a tantrum and gets their way. Half the time, 1/3 of the time, 1/10 of the time, they'll continue the behavior because at some point they have learned that the adult is going to cave. So the goal with a child prone to tantrums is to help them unlearn this response and instead learn other more mature ways to handle a problem situation. I think it's also helpful to put this in the context of what's the perspective of the toddler or preschool child. Um, well, what we're seeing is the screaming, the throwing toys, the hitting and kicking, there is more under the surface that is key to intervention. And to unlearn this response. I think the big question to ask and figure out is what's causing the tantrum and what is making it difficult for the child to respond more appropriately. And it's helpful to realize that coping skills are things that children learn. It's not something that necessarily comes naturally, it's seen through modeling and practice, um, and acquisition. And so some skills that a young child may be lacking and need to learn is impulse control, problem solving, delaying gratification, negotiating, communicating their wishes and needs, knowing what's appropriate or expected in a given situation, as well as self soothing. In a primary care setting, I think there's a lot of helpful questions that can be asked to be able to help delineate what is going on and figure out what are gonna be the intervention points. There's a very exhaustive long list, um, but I want to focus in on a couple specifically. Um, it's helpful to know what are the circumstances that are happening before the tantrum. If we conceptualize tantrums as an emotional reaction, what is it that that child is reacting to? Um, I think it's also really helpful to ask how caregivers respond both behaviorally and emotionally, so internally, externally, to tantrums, and, um, we'll kind of talk about that, why in a moment. And then helpful to ask about any big changes to any of their environments. What other symptoms are also going on? Is it just tantrums? Are we noticing that they're showing more anxiety, having a regression and developmental milestones? What are some of the other symptoms that may help us diagnostically? All right, I've put the standardized rating scales here to be a bit more thorough on how you as a provider could evaluate tantrums with more objective measures. I say this with a caveat, like, this is not necessary, um, in a primary care setting. Um, the, so the three that we have are the child behavior checklist, the preschool age psychiatric assessment, and the preschool feelings checklist. Uh, The CBCL health checklist, has two versions. There's one for 6 to 18 year olds, and there's also a version for 1.5 to 5 year olds. If you've ever seen the CBCL or had a parent um fill it out, you know that it's a 100 plus questionnaire, and parents hate it cause it takes so long and it's so time consuming. Um, so that's one of the downfalls of it. One of the helpful things from it, it actually provides more detail than just about tantrums, and so it can be really helpful if you're feeling diagnostically puzzled by a kid. The PAPA, um, is not something actually we even really use in child psychiatry setting from my experience, um, mainly because the big drawback is you have to be formally trained in it, and it is a regimented interview, and so it's also very time consuming. Lastly, the preschool feelings checklist is a validate screening tool in the primary care setting for preschoolers in need of mental health evaluation. And a quick shout out that um the preschool feelings checklist was in part created by our own Joe Luby, who is in our child psychiatry department at Washington. What are some of the causes of problematic tantrums that may be more clinical and pathological? Um, and I know this is this straightforward, but there is no such thing as a tantrum disorder or a meltdown disorder. I think it's helpful to liken it to fevers, where there can be, they can be triggered by so many different problems that we can't make them stop until we understand what is triggering them. Um, so let's talk about potentially, um, diagnostic underlying causes. So think ADHD, lack of focus, inability to complete work and tolerate boredom, amongst other symptoms. This can contribute to escalation towards explosive outbursts. Anxiety, whether it's an anxiety disorder or anxious traits, kids can still overreact to anxiety provoking situations and meltdown when they're stressed. Learning problems and learning behaviors, especially thinking about, um, do these do these tantrums occur when the child is um at school, during homework time, particular learning lessons, etc. Depression and irritability. A small portion of kids who have severe and frequent tantrums, um, also have underlying mood conditions like depression, and irritability can be one of those core signs of depression in childhood. Autism. Uh, children with ASD tend to be more rigid in their thinking behaviors and daily patterns as part of the diagnostic criteria. Um, and unexpected changes can trigger, uh, an emotional reaction. And then sensory processing issues and disorders. Kids can be overwhelmed by, um, stimulation or particular sensations that may be, um, neutral to other kids. Uh, going into some of the disruptive impulse control and conduct disorders, I have oppositional defiant disorder, um, and one of the, one of the symptoms that can be from that is like often losing their temper, uh, their temper. And for kids under the age of 5, losing temper should be most days over the age of 5, at least once a week. I did put DMDD in here. I realized it actually does not fall under the disruptive impulse control and conduct disorder, it falls under mood disorders, but I think it's helpful because I liken it to a more extreme version and more pervasive version of ODD. So, um, part of the criteria can be severe temper outbursts, uh, 3 or more times a week with baseline irritability. Like these are kids that parents are walking on eggshells around because they can respond with big outbursts of things. Intermittent explosive disorder. I will say that this technically can't be diagnosed before the age of 6, based on the criteria from the DSM, um, and it needs to be 6 years, um, chronologically or the developmental equivalent. And this is explosive outbursts characterized by verbal aggression and physical aggression at least twice a week, and or having a recurrent property damage or physical injury to others. Uh, think about trauma-related disorders. Um, one of the symptoms you can have with PTSD if we're thinking about it from, um, just like core criteria, uh, is, uh, irritable, irritable behavior and angry outbursts with little or no provocation. Um, typically expresses verbal or physical aggression towards people or objects. Um, I'm also gonna give the little footnote that trauma can look differently, um, between adults and kids, but I think it's safe to say that temper tantrums could definitely occur if a child has experienced a traumatic, um, experience and have signs and symptoms of PTSD. And then one that I really want to emphasize on is developmental delay. So, particularly thinking about speech delay, like trouble communicating their needs, social emotional uh development delay, as well as like motor delay, like how difficult is it for them to be independent and get their needs met for themselves, and how can that lead to tantrums. Um, there's a wide variety of There's a wide variety of medical concerns that could also lead to tantrums, uh, but I briefly want to highlight two things that are already essentially screened. Um, so think about visual and hearing deficits that can cause frustration, um, and so making sure that, like, are there any visual or hearing concerns that could be leading to this, as well as like lead neurotoxicity can be associated with aggressive behaviors, um, hence, like the lead screening that does occur. How do we as providers work with parents and children to manage these tantrums? Um, first and foremost, a good number of the cases in the pediatric setting that parents bring up will probably fall into the category of developmentally typical tantrums. Um, and so providers can provide reassurance that tantrums are part of the normal child development. I think that's key. And then when it comes to problematic tantrums or atypical tantrums, or even handling better, um, typical neurodevelopmental, uh, tantrums, prevention is the best way to handle it. And so attempting to mitigate common triggers, um, is gonna be vital. Um, school involvement can, uh, be paramount, especially if this is occurring in that setting, is causing academic, um, problems. And then some children and parents may need additional professional support, in which case it's good to know what the evidence-based treatments are, as well as what is available in the community. And then lastly, if in-home or in-school behavior modifications aren't sufficient, or the behaviors are very extreme, it's probably time to refer to a developmental pediatrician, child psychologist, or a child psychiatry. Um, all right. How can we teach parents how to respond to tantrums? I'm gonna say this at the outset, we don't blame parents for the child's tantrums because parents are only part of what goes into the child's behavior pattern, along with many other factors like the child's temperament, the child's behavior, uh, child's development. But parent behavior is an adjustable factor, and so it's actually one of our most powerful tools we have in helping young kids with tantrums. And I think it's important for adults to know that. When a tantrum occurs, caregiver's response affects the likelihood of the behavior happening again. There are a wide range of interventions and recommendations for how caregivers should respond, but there's a lot of commonalities between them that we're gonna talk about. One of them is to resist the temptation to end the tantrum by giving the child what they want when they tantrum. Um, for non-dangerous outbursts, the goal is to ignore the behavior, withdraw all parental attention. This also includes negative attention, like reprimanding or trying to persuade the child to stop. Both of which could be seen as possible reinforcement for the behavior from the child's side. On the flip side of that, there should be a lot of positive praise for desired behaviors. However, positive praise should be very specific. So instead of a parent saying, you were so good, like, that's very vague, and the kid may say, like, what did I actually do good at? Like, I don't actually know. I just know I did good. And instead, a parent could say, you did a great job using your indoor voice in the store. So the statement helps tell know what behaviors are expected and what is acceptable. Another important concept is that parents can't reason with a child who is upset. A child is throwing a tantrum, any bit of logical brain is offline, cause it's flooded by the emotional part of the brain. Um, a good rule of thumb is for parents and caregivers to wait until the child is calm to dissect what happened. Trying to dissect dissect what's happening and what's going on and trying to reason will probably lead to prolonged tantrums. And then, uh, it's key for caregivers and adults to, um, help build emotional regulation skills. Um, adults can ask a child about their feelings, can provide examples of feeling words, offer pictures of facial depictions, um, to associate the expression of feelings over acting out behaviors. And I put positive praise again at the end, mainly because that is such a big one, and, um, we'll kind of see how this principle falls into play with some of our evidence-based practices even. Um, in most cases, children who have frequent tantrums do it in a very predictable circumscribed situations, um, when it's homework time, bedtime, when it's time to stop playing. The trigger is usually being asked of them to do something that's adverse, or to stop doing something that's fun for them. Taking a closer look at the pattern of children's tantrums can reveal a trigger that needs attention, or is towards a diagnosis too. One of the goals of a functional assessment is to inquire about the antecedents. So what's happening immediately before the behavior, behaviors, what is the child's reaction? And usually this is some kind of measurable act. And the consequences, the result that happens immediately after the behavior, like, do they go on timeout? Do parents give them a toy to distract? Is immediate attention given? The functional assessment is to see if some tantrum triggers and consequences might be either eliminated or changed, so that they are not problematic for the child or perpetuating of tantrums. However, some things just can't be eliminated. So, say, for example, if the trigger is leaving for school, or putting on their shoes, these are things that kids just have to do. Um, but parents and caregivers can handle the situation differently. That's an adjustable factor, like giving pre-warnings for the task or allowing the child to control decisions by offering choices that are both acceptable, um, in the mind of the caregiver. Um, some of these adjustments can take trial and error of testing las environment can be changed, um, but the goal is to reduce the incidence of perpetuation of outbursts. The other consideration is, are the expectations for the child's behavior developmentally appropriate? Does the environment request need to be modified to match the child's ability and better foster development towards maturing? A lot has been said about the ins and outs of tantrums. Um, a quick way to psycho-educate family, um, is using the monic rid, as in, like, let's get rid of the tantrums. Um, so, our remaining calm, uh, quiet approach emphasizing redirection is useful, um, even if the parent is a Turk of aggressive behaviors, firmly stating, um, no hitting, no kicking, no biting, and a neutral tone models parental emotional regulation to their child. Um, I ignore the tantrum. Um, again, this is to not give any, uh, reinforcement for the behaviors, particularly if the tantrum is to gain adult attention. Uh, distract the child. The caregiver may need to leave with the child, um, to get out of the current environment in order to wait for it to stop. Uh, that can also help, especially if this is out in public or in a big classroom setting, where additional attention onlookers or an audience can perpetuate a tantrum as well. And then do say yes when meeting a child's physical and safety needs, um, but don't give in to demands. Um, parents can't ignore unsafe behaviors, um, but that doesn't mean giving in to demands. Rather, it's more, uh, guidance to provide, uh, physical safety during a tantrum. While you're working with parents, it's important to understand how tantrums impact environments outside the home, particularly school and daycare. So, the title of this presentation is getting kicked out of daycare, which is not, um, which is something I've definitely seen in the population that I work with. Um, and if behaviors are causing that third P, the impairment aspect in these areas, it's a good idea to get the school slash daycare involved, so that that environment and adults who care for the child in that environment can also be addressed. Um, first, I would say get input from school or daycare. Um, you can often, um, understand what is happening and what kind of impairment is, um, affecting the child, um, and what is needed for the child to continue to function appropriately in that setting. This can be done through direct communication with the daycare school through a release of information, in formal correspondence, or just having the parents bring it in like teacher reports. And the question is whether the child needs um something like an individualized education plan or a 504. Um, if there is impairment, this would be an appropriate request. It's a right for children to receive free and appropriate education, which includes alterations or accommodations for their needs. Um, and just briefly, I'm not gonna go into all the ins and outs of the differences between IEP and 504, but IEP students who need specialized instruction and relative services to make academic progress, while 504 plan provides accommodations to ensure equal access to education for students, usually with a broader range of disabilities, including medical needs. By starting this process, the school will determine if, uh, an IP evaluation is warranted. And if it's warranted, they'll likely conduct professional observations. And then these observations will happen, um, in a classroom daycare setting where an observer uses some kind of assessment tool or as a preset plan for how to measure the behaviors of interest in the child. Usually this is done over a period of a couple of weeks. The goal is to be able to have a more objective way to collect data. Um, and also be able to do it longitudinally as opposed to just a pop in the classroom where you may or may not see the, uh, behaviors at that point in time. Um, And then there is a formal meeting to determine if an IUD 504 is warranted, and what aspects should be included in the plan for the child to continue to receive their education or placement. Services in the community that I think it's helpful for pediatricians to know. Um, and you guys may already know about this, but I, it's just helpful to go through it. Um, thinking, especially for families, well, in addition to it, but also families that, um, kids that are, aren't in daycare or don't use daycare services or school, um, There are still interventions that can be given for them. So the Early Head Start program is a national program, at comprehensive health and mental health services, home visits, parent education. The purpose is to work with the entire family unit, so the child and the family, to promote, uh, children's growth and development, as well as support parents and guardians to fulfill their parental roles as caregivers, but also educators. Um, eligibility for this includes families that are in the prenatal stages up until the child's age of 3, and then the family must be at or below the federal poverty line. There we go. Um, alternatively, or in addition to, uh, First Steps is led by the Missouri Department of Elementary and Secondary Education. Uh, children who are eligible for these services, um, are ages birth to 36 months, who have been determined to have a diagnosed physical and mental condition associated with developmental disability, high probability of resulting in developmental disability or delay, or children who have a non-developmental delay. Each child found eligible for for steps gets an individualized family service plan that really works with the family to address concerns and priorities, um, in regards to their, their child's development. And then families partner with the planning and implementation of the um individualized family service plan. And then they get an early intervention team that is the individuals um that are involved in the interventions and collaborate with a coordinator as well as the primary provider to provide strategies um to support the child's development. As you see, some of the things that they do offer is PT, OT, speech language, hearing, um, autism spectrum disorder evaluation. Um, I put this up here. I just wanna briefly talk about this. Uh, so this is from the annual report for First Steps, um, and looking at who is like referring to First Steps. Um, and as you can see, medical providers do about half of the referrals. Um, but it's also good to know that there is actually a pipeline between early Head Start participants and First Steps as well. Another chart, um, from the annual First Steps report, um, looking into aspects that are provided for families and, um, efficacy, essentially. Um, wanted to highlight real quick early childhood outcomes, um, that show an impact on the program, uh, to make progress on social-emotional skills as well as appropriate behaviors. The other thing I want to highlight is, uh, transition planning, um, And especially since this programming only goes until the age of 3, as well as communication with the school district that the child resides in. It can be instrumental, especially in providing necessary services the child that the family may need, navigating the really confusing process that is the, uh, private sector as well as the school system. I'll go ahead and scoop over that. Um, what are the next steps after first steps? Um, part of the transition process that happens as children start to age out of first steps is evaluation for early childhood education. Uh, not everyone who receives first steps will automatically transition to early childhood special education, because they need to continue to meet the needs for services. Uh, but to be evaluated, there needs to be a referral or a parent request. And then this program runs for ages 3 to 5 years old, and it's run through the local school district. All right, let's transition into psychological therapy resources for tantrums. Um, one of the most commonly known one is parent-child interaction therapy or PCIT. It's been around for decades, considered by many as the gold standard treatment for a wide variety of things. It's a parent training program, and it uses a bunch of different components. So social learning theory, attachment theory, developmental theory, behavioral principles, as well as traditional play therapy. The nice thing is, a child does not need a specific diagnosis to receive this therapy. Rather, it can be like very non-specific diagnostic symptoms. So some of the examples that it is validated for is frequent temper tantrums, right, perfect for this talk, verbal aggression and physical aggression, destruction of toys and family belongings, whining or crying for no apparent reason, constantly seeking attention, and then difficulty with behaviors at school, preschool, and daycare. And that's actually just part of the list of things that it's validated for. The optimal age for PCIT to be effective is for children between the ages of 2 to 7, but there are versions that have been adapted for kids up to the age of 10, and even as young as 12 months old. There are 2 big phases. I think it's helpful to know just a little bit of detail about it, so that whenever you do the referral process, um, you can give a little bit of education on what the parents can expect. Um, so two phases, child-directed interaction phase. This is where parents develop child-centered interactions to enhance the parent-child relationship. And then the second part to it is parent-directed interaction phase, where caregivers learn behavioral management skills. Um, what I really like about it is it actually gives equal attention to both of these components. So strengthening of relationship, as well as, um, uh, behavior management skills. This should be done by someone who's certified in PCIT, meaning they did the formal training, they had supervision. Um, and so usually being able to be certified in, it takes about 2 years. Right, and applied behavioral analysis, or ABA, um, based on the science of learning and behavior, um, it's essentially using the ABC model in a very systematic way, as well as pos uh positive reinforcement. And can be used for a lot of different skill acquisition. Um, so one of the big ones is, uh, decreased problem behaviors like tantrums, but also can be used for acquisition of language and communication, improve attention and focus, social skills, etc. Um, it uses positive reinforcement as the main strategy, and it can be performed in different locations. So it can be done at home, it can be done at school, it can be done in the community. Uh, there is a functional behavioral assessment, and that assessment is looking at each individual skills and preferences. Um, and then this can be used to target tantrums through skill-based treatment. And then once the functional behavioral assessment is completed, there, the next step is to develop a behavioral intervention plan, which is really the structure of framework to um have the strategies and interventions to reduce the challenging behaviors while promoting positive alternatives. One of the drawbacks that can be from ADA is in order for insurance usually to approve of it, there usually needs to be an autism spectrum disorder diagnosis on file with usually formal testing. Um, so using like a CARS-I or an ADOS. Um, so ADA services can be given to the kids without autism disorder, but in terms of affordability, insurance coverage, that's a little bit more. Constrained. All right. And then I do have some additional info just in case that you are wanting to be able to look up um referral process or additional information, so early Head Start info as well as first steps. Um, early childhood special education info. I wanted to be able to give some PCIT resources. So that first link is what I really like to use whenever I'm talking with parents about what PCIT is. You can kind of print it off and use it as a, a handout. Um, as well as, uh, PCIT resources in the local area. Um, just fair warning, this is, I'm not endorsing anyone necessarily particularly. These are people who have been, um, verified and validated either through, um, people I've interacted with, as well as Psychology Today. Um, so there's a lot of individuals because it takes individual training. And then ABA resources also in the Saint Louis metro area. All right. Thank you.
