Transcript Welcome Mentor International

Treating Explosive Kids
Part 1
The Collaborative
Problem-Solving Approach
Drew Burkley Psy.D.
Center of Excellence
Clinical Psychologist
[email protected]
Authors

Ross W. Greene, PhD



Director of the Collaborative Problem Solving Institute
Associate Professor in the Department of Psychiatry, Harvard
Medical School
J. Stuart Ablon, PhD


Director of Think:Kids, Department of Psychiatry,
Massachusetts General Hospital,
Associate Professor in the Department of Psychiatry, Harvard
Medical School
Location

Collaborative Problem Solving Institute
 Department of Psychiatry of Massachusetts General
Hospital
 http://www.explosivechild.com
Thanks to...
Gloria Jones, Psy.D.
 Sasha Ahmed, M.S.
 Scott Browning, Ph.D.

The Need For a
New Paradigm
Have you experienced this?
Typical Protocol

Parent Management Training

Teaches contingency and consistency

Establishes a list of target behaviors with compliance as the
goal

Establishes a menu of rewards and punishments

Develops a currency system to track the child’s progress
Problems with
Parent Management

Research supports this technique, however there are also
many limitations

It may not be well suited to the needs of those
responsible, as evidenced by a high drop-out rate
and noncompliance

Changes in oppositional behavior are not
statistically significant
Problems with
Parent Management

Most studies have not included clinically referred
children

As a result, the following can be concluded
 There
is a low percentage of substantial gain from this
technique
 Alternative treatments that address the needs of
explosive children and caretakers are needed
How do we label children and
adolescents?

Many labels have been used to describe “children”
 Defiant,

aggressive, angry, non-compliant, challenging
They have also been given a number of diagnoses
 Oppositional
defiant disorder, conduct disorder,
intermittent explosive disorder
“Explosive” children and
adolescents?

The term “explosive” will be used in this presentation
because it is a common theme among all the
descriptions and diagnoses
Explosive children does not
mean exact children….

Understanding the factors underlying a specific
child’s explosive behaviors directly influences the
selection of interventions employed to address
those behaviors.

Intervention options are most effective when they are
designed with the needs of each individual are
considered.
What makes CPS different?

Assumes that explosive children are poorly
understood and are often poorly addressed by
available therapies

For close to fifty years, conceptualization and
treatment of explosive children have been
significantly influenced by the coercion or social
interactional model.

There has been a focus on patterns of parental
discipline
Inconsistent discipline
 Irritable explosive discipline
 Low supervision and involvement
 Inflexible rigid discipline

Characteristics & Behavior Link

Lagging skills in the global domains:




Flexibility and adaptability
Frustration tolerance
Problem-solving
The CPS model aims to identify the specific
cognitive factors contributing to the development of
a child’s non-compliance and explosiveness
Executive Skills
 Transitions
 Sequences
 Difficulty
staying on tasks
 Impulsivity
 Problem
 Range
Solving
of solutions to a problem
Cognitive Flexibility Skills

Concrete, black-and-white thinkers

Insistence on sticking with rules, routine or original plans

Difficulty with unpredictability, ambiguity, uncertainty

Obsessive or Preservation

Theory of Mind

Situation-Person Dynamics

Inaccurate interpretations/Cognitive distortions/Biases
Language Processing Skills

Difficulty expressing thoughts, needs or concerns in
words

Often appears not to have understood what was
said

Long delays before responding to questions

Difficulty knowing or saying how he or she feels
Emotion Regulation Skills

Difficulty staying calm enough to think rationally
when frustrated

Cranky, grouchy, grumpy, irritable outside the
context of frustration

Sad, fatigued, tired, low energy

Anxious, nervous, worried, fearful
Social Skills

Difficulty attending to or misreading of social cues/
difficulty recognizing nonverbal social cues

Seeks the attention of others in inappropriate ways;

Seems unaware of how behavior is affecting other
people

Lacks empathy

Poor sense of how he or she is coming across or being
perceived by others

Inaccurate self-perception
Transactional Theory
Three conceptual models for understanding children’s
developmental outcomes:
Unidirectional or Main Effect Model
Bidirectional or Interactional Model
Transactional or Reciprocal Model
Transactional Theory

Unidirectional or Main Effect Model


Child’s outcome is the product of either characteristics of
the child or characteristics of the caretakers
Bidirectional or Interactional Model

The combination of adult and child characteristics
produces a child’s outcome

Transactional or Reciprocal Model
Child’s outcome is a function of the degree of fit or
compatibility between child and adult characteristics
 The goal of treatment requires an understanding of both
child and adult

Situational Analysis

Explosive level behaviors occur when there are
high levels of incompatibility between a child and
the environment


Demands on the child exceed the child’s capacity to
respond
The environment also includes the transaction with
other people
Identifying
Pathways and
Triggers
Identification of Pathways

Executive Skills

Emotional Regulation Skills

Language Processing Skills

Cognitive Flexibility Skills

Social Skills
Identification of Triggers

Sensory Hypersensitivities

Transitions

Academic Tasks

Interaction with Peers, Adults, Family
Two Mechanisms for Identification
of Pathways and Triggers

Clinical Interview

Formal Assessment
Developmental pediatricians
 Neuropsychologists

Goals of the Interview

Assess safety

Empathically support parents


Need to be believed
Assess Pathways and Triggers
Interview Questions
Child

Why did your parents bring you in today?

What difficulties do you see your family having?

What’s the matter with your parents?

How are things going with your friends?

What is the hardest thing about _______ in school?

Would you describe yourself as _______?

Are there more stories?
Interview Questions
Caregivers

Tell me about _________’s explosions.

Do you think that _____is more bothered by _____
or______?

Do they occur during certain times of the day?

What goes on when______’s doing_______?

How does he or she do with_______?

How have you responded to/handled it when ____does
_____?
Interview Questions
Family

Gain a Consensus


“Would you all agree that _______is troublesome?”
Emphasize Cognitive Difficulties

Not Behavior
Putting the Information Together

Meet with the Child/Adolescent Alone


Meet with the Caregivers Alone


Generate hypothesis
Generate hypothesis
Meet with the Family

Generate hypothesis
Other Important Information to
Consider

Developmental History

Treatment History

Family Stressors

Pharmacology

Educational History

History of Adult Responses to Deficits
Questions

What do you do when there are large numbers of items on the
Pathways Inventory?
 Prioritize and Organize, “triage” approach

What do you do if you don’t get strong signals on the Pathways
Inventory?
 Keep Trying! Gather more “stories”

What other factors not related to cognitive skills contribute to
explosions?
 Sleep, Trauma, Seizures, D&A, Allergies, other Medical Issues

How do you know when to refer for formal testing?
 When interviews and observations do not provide enough
definitive information to identify the specific skill deficit or trigger.
Options for
Handling
Problems
Three Plans
Three Plans

Plan A- Insistence

Plan C- Reducing Expectations

Plan B- The Collaborative Problem-Solving
Approach

“Surrogate Frontal Lobe”
Plan A
 In
Typical Children


 In
Child motivated by insistence
There is no extreme reaction to insistence
The Explosive Child



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Adult expectations are pursued
Adults add consequences for children
Cognitive deficits prevent from meeting expectations
Inflexibility increases the chances of an outburst
 Plan
A is easy on the front-end, but has
shortcomings long-term
Plan C
 Reducing or Removing
 Saying nothing
 Changing Demands
expectations
 Adults
fear expectations will never be met or
children will capitalize on the giving in
 Adults
 Goal
fear children will not learn expectations
is to reduce the overall number of
outbursts
Plan B Brief Overview
 Working
toward a mutually satisfactory
resolution
 Goals
Reduce frequency, intensity, and duration of explosive
episodes
 Help adults pursue expectations through collaborative
problem-solving
 Teach the cognitive skills that are lacking in the child

 More
efficient on the back end
 Creates opportunities for long-term success
Goals Achieved By Each Plan
Pursue Expectations Reduce Outbursts Teach Skills
Plan A
X
Plan B
X
Plan C
X
X
X
Questions and Wrap Up!