Effectively Working with Disruptive Behaviors Amy Gallagher Psy

Effectively Working with Disruptive Behaviors Amy 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 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 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 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 8 a) Social Problem Solving II (Session 8 b) 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 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, 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 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 – agallagh@cwrmhc. org