Effectively Working with Disruptive

BehaviorsAmy Gallagher, Psy.D.,

Program/Training Director Psychology Internship

As presented by:The Integrated Psychotherapy

Consortium

TODAY’S AGENDA• Welcome/ Introductions• EBP Background• Logistically….how? (EMR/ CCARs/ Etc.)• Orientation to Model• Breakout Sessions for Role Play• Supervision and Post Training• Wrap-up

EBP VS. REALITY• Differences between Evidence

Based Practice AND Practice Based Evidence

• Making it fit…• Being Creative…– 90 minutes vs. 60 minutes– Kiddos vs. Parents vs. Both

TARGET POPULATION• Ages 6 to 16• Mild to Moderate distress and symptomology• Oppositional Defiant, ADHD, Disruptive Bx

Spectrum• Behaviorally focused for parents and youth• Contraindicated:– Severe trauma – Severe mental illness– Lower functioning Autistic Spectrum Disorders

(ASDs)

INTERVENTION DESIGN & STRUCTURE

• Phase I (Sessions 1-7)– Introduction– Basic skills development – Problem solving

• Phase II (Sessions 8-14-ish)– Enhancing skills and strategies– Addressing additional situations & difficulties– Graduation

SESSION STRUCTURE• Engagement• Review

– Homework– Parent O Meter

• Set Agenda• Complete Skill

– Discussion– Practice– Role Play

• Assign therapeutic homework• Check-out

SETTING IT UP• Welcome parents and youth to session• Assess reactions to last meeting• Review goals briefly• Create Agenda– What issues would you like to discuss?– Any experiences you’d like to share

• Write agenda items on chart• Cover session topic• Assign therapeutic homework• Check-out

SESSION 1: RAPPORT BUILDING

• Rapport Building• Trauma and Behaviors• Introduction to Intervention• Practice Goal Setting (Goal

Worksheet)• Homework Expectations

• Helpful Hint- you are already doing this!

SESSION 2

Basic Social Learning, Tracking and Improving the Parent-Child

Relationship

Session 2: AGENDA• Skills Building/Practice with Parent

and Child• Goal Setting with the Child• Basic Social Learning: The ABC

Model• Positive Consequences for Positive

Behavior• Tracking and Labeling Behavior

SESSION 2:GOAL SETTING WITH CHILDREN

• Children constantly set goals• “What would make your life better?”• Goals need to make sense• Focus on Long and Short Term goals

THE GOAL LINE

POINTS SYSTEM FOR GOALS: PRICE LIST

Item PointsPencils, markers 2

Stickers 2

Toys 4

Baseball cards 8

Video games 12

ITunes Download

15

Cool shoes/clothes

30

• Have a set of small, changing items to provide quick rewards for behavior change

• Have larger rewards to encourage delay of gratification and planning

COMMON GOAL SETTING CHALLENGES WITH CHILDREN

• Forgetting about goal• Not taking responsibility• Lacking motivation• Sense of failure

COMMON GOAL SETTING CHALLENGES FOR ADULTS

• Believing goals are too easy– Difficulty understanding the importance

of shaping new behavior in small steps• Believing child is reinforced for

negative behaviors• Disrupting home/school tasks

GOAL SETTING: SOLUTIONS• Use reminder cards or stickers• Provide positive social reinforcement

and feedback• Set less challenging goals• Ask for suggestions from parents (&

kiddos!)• Encourage parent comments

SESSION 2: BASIC SOCIAL LEARNING THEORY

• The ABC model:– A=Antecedents– B= Behavior– C= Consequences

• Behavior is influenced by:– Antecedents – Consequences

• Becoming aware of how parents provide A’s and C’s is important!

SESSION 2: PRAISE• Positive Consequences for Good

Behavior• Ask parents to provide examples• “Catch your Child Being Good”• Types of Praise– Labeled Praise- identifies specific child

Bx–Unlabeled Praise- is positive but not

specific

HOMEWORK/HANDOUTS

HOMEWORK/HANDOUTS

HOMEWORK/HANDOUTS• Social Learning Theory• Tracking and Labeling Behavior– Parent Report of Child’s Behaviors– Behavior Tracking Form

• Praise– The Power of Praise– Tracking & Praising Your Child’s Behavior

• Parent-O-Meter

PARENT-O-METER

SESSION 3

The Parent-Child Relationship, Ignoring Minor Disruptive Behavior

SESSION 3: PARENT CHILD RELATIONSHIPS

• Engagement/Check in • Review homework/handouts & Set

Agenda– ABC Model, Behavior Tracking, & Praise– Goal Line and rewards– Parent-O-Meter

• Discuss any challenges with tracking • Teach & practice skills• Wrap-up

SESSION 3: SPECIAL TIME• Present Parent – Child Special Time

Handout– To maintain close positive contact– To have a protected positive time together

• Brainstorm ideas about a special time activity• Spend 10-15 min. a day in Special Time• Do not criticize or discuss problems during Special

Time• Praise child often during Special Time• Allow child to choose the activity-parents participate

with child• Record on Special Time worksheet

Keeping Special Time Special

SESSION 3: IGNORING• Ignoring Minor Disruptive Behavior– Behavior that is annoying Not dangerous– Substitute for “overreactions” by parent– Scolding and reprimanding is Not ignoring– Ignoring means stopping all communication– Avoid speaking or looking at the child–Negative child behavior may escalate

initially– After ignoring, “catch your child being

good” and praise the next good behavior

SESSION 3: IGNORING• Role Play Ignoring– Clinician plays “Parent” & parent plays

“Child”– Role-play “Parent” pulled into an

argument– Role-play “Parent” ignoring child’s

argument– Validate difficulty ignoring escalating

child

Session 3: IGNORING• Ask parents what they thought of

role-play• Handout: Tracking Praise &

Ignoring• Parent identifies 3 Bx to ignore on

sheet• Ask Parent to track for 2 weeks

HANDOUT/HOMEWORK

SESSION 3: WRAP UP• Summarize main points from session• Assign homework:– Behavior Tracking Form– Scheduling Special Time

• Encourage “catch your child being good”

SESSION 3: HANDOUTS• Keeping Special Time Special• Special Time Worksheet• Ignoring: An Effective Strategy• Techniques of Praise and Ignoring• Behavior Tracking Form: Praise and

Ignoring

YOUR TURN!• Each group will be assigned a

session– Learn a skill from Sessions 4 or 5–Understand the worksheets– Create a short role play to present

SESSION 4

Giving Effective Instructions to Children

SESSION 4: GIVING EFFECTIVE INSTRUCTIONS

• Instructions that Work– “Instructions” are Antecedents in the ABC

Model. They precede the child’s behavior, compliance, or noncompliance

– Considerations in giving good instructions• Is the instruction important?• Are you willing to follow through if the child

noncomplies?• Consider the timing of instructions• Treat children with respect (pleasant tone of

voice; saying “Please”)

SESSION 4: INEFFECTIVE INSTRUCTIONS

• Misguided Instructions– Buried or Interrupted Instructions-

• The adult keeps talking – Question Instructions-

• Instruction is given as a question– Chain Instructions-

• Too many instructions given once– Repeated Instructions-

• Repeating the same instruction over, and over, and over again– Vague Instructions-

• The instruction is unclear– Let’s Instructions-

• The instructions begins with “Let’s”– Distant Instructions-

• The instruction is shouted from a distance

SESSION 4: HANDOUTS• Giving Good instructions to your

Children• And Life Can be Humorous… Really

Funny Instructions that Won’t Work (I and II)

SESSION 5

Establishing Rules and Expectations

SESSION 5: RULES & EXPECTATIONS

• Rules vs. Expectations• Rules– Decrease Bx (hitting, fighting, swearing)– Always followed–No warnings, just consequences

• Expectations– Good behaviors/chores– Age appropriate

SESSION 5: HANDOUTS• Behavior Rules and Expectations• Establishing Behavior Rules and

Expectations• Household Rules and Expectations• Behavior Tracking Forms– Behaviors Rules– Expectations

Session 6

Anger Management (could be presented in multiple sessions)

SESSION 6: ANGER CONTROL

• Identify physiological cues of anger & other feelings

• Identify anger levels the child experiences

• Discuss triggers for anger and introduce idea of learning to cope with anger

• Brainstorm with child coping skills for each level of anger

SESSION 6: CLINICIAN HINTS• Children may have difficulty seeing a range of

emotional arousal• Children may become highly emotionally

aroused when thinking about their anger triggers

• Children may have difficulty identifying triggers• Anger may be masking other emotional states

(anxiety; depression)• Children may have very limited sense of coping

responses

ANGER AWARENESS: PHYSIOLOGICAL CUES

• Awareness of Signs of Anger– Facial expression– Tone of voice– Body Position/ Movement– Internal Body States• Increased Heart rate, Rapid Breathing• Feeling Flush, Sweating Palms • Tight Muscles, Clenched Fists

ANGER THERMOMETER

ANGER AWARENESS• Using thermometers,

children label own levels of anger and triggers at each level

• Can better problem solve at low to moderate levels of anger

• Aggressive children tend to report their anger in “on-off” terms as “angry” or Not-angry”

ANGER WORDS

ANGER MANAGEMENT TRAINING

• Key points:– Easier to cope if we don’t feel so angry–How can we reduce our feelings of

anger?• Distraction- Focusing attention in

something else (e.g., fun things to do later in the day)• Deep breathing• Self instruction or self- statements

COPING STATEMENTS

ANGER THERMOMETER RECORD

SESSION 6: HANDOUTS• Feeling Chart• Anger Thermometer• Words of Anger• Coping Statements• Anger Thermometer Record Forms

SESSION: 7

Problem Solving:PICC Model

SESSION 7: PICC MODEL

• PI= Problem Identification• C= Identify Choices• C= Identify Consequences• Choose Solution

PROBLEM SOLVING- PICC MODEL

PROBLEM SOLVING WORKSHEET

PROBLEM SOLVING- THE BASICS

SESSION 7: HANDOUTS• Problem Solving- PICC Model• Problem Solving Worksheet• Problem Solving- The Basics

YOUR TURN• Use the PICC Model to solve a

problem based on one of your current clients

• Use the worksheet to identify basic problem solving skills

PHASE II• Check-in about progress• Make decisions about next few

sessions–Which ones?–Which order?– Explore other issues (e.g., depression,

assertiveness, relaxation, learning)– Discuss graduation (termination)• Indications for further treatment• Discuss w/ clients, parents, supervisors

PHASE II• Child-focused sessions include:

– Social Problem Solving I (Session 8a)– Social Problem Solving II (Session 8b)– Anger Management II (Session 9)– Organizational & Study Skills (Session 10)

• Parent/ Family-focused sessions include:– Use of Consequences: Discipline and Rewards (Session 11)– Introducing a Token Economy System (Session 12)– Home Token Economy II (Session 13)– Response Cost Program (Session 14)

SESSION 8

Social Problem Solving I & II

SESSION 8 • These Boys Have a Problem

Worksheet– Discuss how to solve the social problem

using the PICC method–Help child solve relevant social

problems – Continue working on problem solving if

needed through other methods until skill is solidified

SESSION 9

Anger Management & Abdominal Breathing

SESSION 9• Review of physiological signs of

anger• Review use of Anger Thermometer• Practice Abdominal Breathing

(worksheet)–May be enhanced by other breathing

methods• Could be conducted directly after

Session 6

SESSION 10

Organizational & Study Skills

SESSION 10• Help child & family understand the

importance of organization & study skills

• Assess knowledge of both through experiential games– Category Game– Positive/Negative Study Skills

• Decide upon positive study skills for child

SESSION 10: HANDOUTS• Study Skills for School• Homework Contract• Alternative Contract

SESSION 11

Use of Consequences, Discipline, & Rewards

SESSION 11• Designed to be “parent only”• Could be follow-up/adjunct to earlier

sessions• Defines punishment & when to use it• Provides rules for “good

punishment”• Includes Time-Out Guidelines

SESSION 11: HANDOUTS• Punishment Concepts• Time-Out• Time-Out Worksheet

SESSION 12

Family Problem Solving

SESSION 12• Uses the PICC model within the

family• Expands the PICC worksheet to

include a family commitment for implementation

SESSION 13

Family Communication: Building & Adapting Structures for Long-Term

Planning Needs

SESSION 13• Provides structure for positive family

communication• Assists with organizing a family

meeting • Utilizes positive communication

skills to negotiate the logistics of family meetings

• Provides support to create a contract for social outings (Four W’s & an H!)–Who, What, Where, Where, How

SESSION 14

Family Communication: Building & Adapting Structures for the Long-

Term Planning Needs

SESSION 14: TERMINATION• Graduation– Finish Line Handout– Reactions & feelings about the program and

about ending– Skill Review– Improvements noted?– How was the child supported?– What did the child learn?– Advise parents to keep all handouts for future use– Share final regards, regrets, and appropriate

feelings

GRADUATION & BEYOND• Discuss skill maintenance• Discuss (expected) setbacks–What can you do? (e.g., problem

solving, outside help, therapy, etc.)• Identify community/school resources

THE NEXT STEP• Choose 2 cases to use Model• Set up Supervisory or Group

Consultation• Create method for tracking progress– PGQ

Parent Guardian Questionnaire

CWRMH IMPLEMENTATION• Registered in Program in ECR–Multimodal Therapy Program

• Onset, Quarterly, & Graduation – CCARs completed– PGQ Completed and Scanned

• Monthly phone call supervision/consult– Discussed engaging difficult families,

brainstorming ideas, successes

WRAP-UP• Final discussion• Final questions

Thanks for participating!!

CONTACT INFORMATIONAmy Gallagher, Psy.DProgram/Training Director Psychology

InternshipColorado West Regional Mental

Health, Inc.515 28 ¾ Road, Bldg. AGrand Junction, CO 81501– (970) 683-7078– agallagh@cwrmhc.org