Effectively Working with Disruptive Behaviors Amy Gallagher, Psy.D.,

Effectively Working with Disruptive Behaviors Amy Gallagher, Psy.D., Program/Training Director Psychology Internship As presented by: The Integrated Psychotherapy

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 Points Pencils, 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!)

SESSION 14 Family Communication: Building & Adapting Structures for the LongTerm 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 INFORMATION Amy Gallagher, Psy.D Program/Training Director Psychology Internship Colorado West Regional Mental Health, Inc. 515 28 ¾ Road, Bldg. A Grand Junction, CO 81501 – (970) 683-7078 – [email protected]