Effective Ecological Interventions Oppositional Defiant Disorder & Conduct Disorder Effective Ecological Interventions Joshua Leblang,Ed.S. Lecturer Public Behavioral Health & Justice Policy Department of Psychiatry 1

Our youth now love luxury Our youth now love luxury. They have bad manners, contempt for authority, they show disrespect for their elders … they contradict their parents …and tyrannize their teachers." Socrates (c. 470-399 BC)

What is it? Disruptive disorders, such as oppositional defiant disorder and conduct disorder, are characterized by antisocial behavior.

Oppositional Defiant Behavior as a DSM IV Diagnostic Category Oppositional Defiant Disorder (ODD), is defined as "a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures". The disorder is reflected in behaviors such as frequent temper tantrums, arguing, defiance, non-compliance, externalizing blame, vindictiveness, and a range of other problem behaviors. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author 5

Specific DSM IV ODD Criteria For at least 6 months, shows defiant, hostile, negativistic behavior; (4 or more of the following): -Losing temper -Arguing with adults -Actively defying or refusing to carry out the rules or requests of adults -Deliberately doing things that annoy others -Blaming others for own mistakes or misbehavior -Being touchy or easily annoyed by others -Being angry and resentful -Being spiteful or vindictive 6

DSM IV ODD Criteria The symptoms: cause clinically significant distress or impair work, school or social functioning. do not occur in the course of a Mood or Psychotic Disorder. do not fulfill criteria for Conduct Disorder. If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder. *Characteristics should occur more often than expected for age and developmental level. 8

Conduct Disorder as a DSM IV Diagnostic Category The essential features of Conduct Disorder (CD) involve "a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated“, resulting in a clinically significant impairment in functioning. This includes aggressive behaviors, behaviors that result in property loss or damage, deceitfulness or theft, other serious rule violations (e.g., running away from home, truancy). 9

DSM IV Conduct Disorder Criteria For 12 months or more has repeatedly violated rules, age-appropriate societal norms or the rights of others. Shown by 3 or more of the following, with at least one of the following occurring in the past 6 months: Aggression against people or animals Frequent bullying or threatening Often starts fights Used a weapon that could cause serious injury Physical cruelty to people Physical cruelty to animals Theft with confrontation Forced sex upon someone 10

DSM IV Conduct Disorder Criteria Property destruction -Deliberately set fires to cause serious damage -Deliberately destroyed the property of others (except fire-setting) Lying or theft -Broke into building, car or house belonging to someone else -Frequently lied or broke promises for gain or to avoid obligations ("conning") -Stole valuables without confrontation (burglary, forgery, shoplifting) 11

DSM IV Conduct Disorder Criteria Serious rule violation - Beginning by age twelve, frequently stayed out at night against parents' wishes - Runaway from parents overnight twice or more (once if for an extended period) - Frequent truancy before age 13 These symptoms cause clinically important job, school or social impairment. If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder. 12

DSM IV Conduct Disorder Criteria Childhood-Onset Type: at least one problem with conduct before age 10 Adolescent-Onset Type: no problems with conduct before age 10 Severity: Mild (both are required): There are few problems with conduct more than are needed to make the diagnosis, and Problems cause little harm to others. Moderate. Number and effect of conduct problems is between Mild and Severe Severe. Many more conduct symptoms than are needed to make the diagnosis, or symptoms cause other people considerable harm. 13

Family Factors that Promote Resiliency 􀂾 Parent and family connectedness 􀂾 Parent/Adolescent activities 􀂾 Parental presence 􀂾 Parental school expectations 􀂾 Parents involvement and awareness of sexual behaviors 􀂾 Limit access to substances and weapons 􀂾 Seek help for parental and familial problems/concerns 􀂾 Seek support from other parents 􀂾 Know community resources (National Resilience Resource Center, 2001)

Program characteristics that support positive youth development 1. Comprehensive, time-intensive 2. Earliest possible intervention 3. Timing is important 4. High structure is better 5. Fidelity to model is key to effectiveness

Positive Youth Development (con’t) 6. Need adult involvement 7. Active, skills-oriented programs are more effective 8. Programs that target multiple systems are most effective 9. Programs that are sensitive to the individual’s community and culture are best 10. Programs based on strong theoretical constructs and proven effective by evidence are best Connecticut Center for Effective Practice (From meta-analysis published in 2005)

CD/ODD presents as collection of behaviors rather than a coherent pattern of mental dysfunction. As such, there is no “magic bullet” to fix the problem.

How would you work with? 15 year old who refuses to go to school? 15 year old who refuses to go to school due to bullying? 15 year old who refuses to go to school because s/he was the babysitter for his/her baby brother 15 year old who refused to go to school because s/he was dealing drugs? 15 year old who refused to go to school because s/he wasn’t getting up in the morning --going to bed late at night playing video games --Parents having parties late at night?

Three treatments top the list for adolescents ALL focus on family/ caregivers Functional Family Therapy Multidimensional Treatment Foster Care Multisystemic Therapy Blueprints for Violence Prevention

What usually happens to youth? Youth gets in trouble Sent to treatment Meets other anti-social peers No changes at home CYCLE CONTINUES Returns home

An ecological approach Work with the entire ecology. By addressing the multiple systems, it is possible to make longer lasting changes for families. Community School Peers Family Youth Bronfenbrenner, 1979

MULTISYSTEMIC THERAPY Youths’ behaviors are influenced by their families, friends, and communities (and vice versa). Families are the key to success, so all aspects of treatment are designed with full collaboration from the family. Change can happen quickly, but it demands daily and weekly efforts from the youth and all the important people in his/her life. Families can live successfully without involvement in social service agencies. www.mstservices.com

How is MST Different? Discipline: Offers a combination of “best practice” treatments within a disciplined structure Accountability: At all levels, providers are held accountable for outcomes through MST’s rigorous quality assurance system Ecological validity: Working in the youth’s natural environment with existing family supports, thereby ensuring cultural sensitivity Focus on long-term outcomes: Empowerment of caregivers to manage future difficulties; focus on sustainability

How Does MST “Work?” Intervention strategies: MST draws from research-based treatment techniques Behavior therapy Parent management training Cognitive behavior therapy Pragmatic family therapies Structural Family Therapy Strategic Family Therapy Pharmacological interventions (e.g., for ADHD)

How is MST Implemented? Single therapist working intensively with 4 to 6 families at a time “Team” of 2 to 4 therapists plus a supervisor 24 hr/ 7 day/ week team availability 3 to 5 months is the typical treatment time (4 months on average across cases) Work is done in the community: home, school, neighborhood, etc.

How is MST Implemented? (continued) MST staff deliver all treatment – typically no services are brokered/referred outside the MST team Never-ending focus on engagement and alignment with the primary caregiver and other key stakeholder (e.g. probation, child welfare, etc.) MST staff must be able to have a “lead” role in clinical decision making for each case Highly structured weekly clinical supervision and Quality Assurance (QA) processes

Condensed Longitudinal Model of Youth Antisocial Behavior Family Prior antisocial behavior Low Monitoring Low Affection High Conflict Antisocial Peers Antisocial behavior School Explaining delinquency and drug use, by D.S. Elliott, D. Huizinga and S.S. Ageton. Beverly Hills, CA: Sage Publications, 1985, 176 pp Low School Involvement Poor Academic Performance

FAMILY Poor monitoring Ineffective discipline Low warmth High conflict Parental drug use/abuse

PEER Association with drug-using peers, Low association with prosocial peers

SCHOOL Low achievement Truancy Low commitment to school

Neighbors who use drugs COMMUNITY FACTORS High crime Neighbors who use drugs Transience

Individual Factors Antisocial behavior Mental health problems Low social conformity

MST Treatment Principles Nine principles of MST intervention design and implementation Treatment fidelity and adherence is measured with relation to these nine principles

Principles of MST 1. Finding the Fit The primary purpose of assessment is to understand the “fit” between the identified problems and their broader systemic context. 2. Positive & Strength Focused Therapeutic contacts should emphasize the positive and should use systemic strengths as levers for change.

Principles of MST (continued) Increasing Responsibility Interventions should be designed to promote responsibility and decrease irresponsible behavior among family members. Present-focused, Action-oriented & Well-defined Interventions should be present-focused and action-oriented, targeting specific and well-defined problems.

Principles of MST (continued) 5. Targeting Sequences Interventions should target sequences of behavior within and between multiple systems that maintain identified problems. 6. Developmentally Appropriate Interventions should be developmentally appropriate and fit the developmental needs of the youth.

Principles of MST (continued) 7. Continuous Effort Interventions should be designed to require daily or weekly effort by family members. 8. Evaluation and Accountability Intervention efficacy is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.

Principles of MST (continued) 9. Generalization Interventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering care givers to address family members’ needs across multiple systemic contexts.

MST Analytical Process Referral Behavior MST Analytical Process Desired Outcomes of Family and Other Key Participants Overarching Goals Environment of Alignment and Engagement of Family and Key Participants MST Conceptualization of “Fit” Re-evaluate Prioritize Assessment of Advances & Barriers to Intervention Effectiveness Intermediary Goals Measure Intervention Implementation Do Intervention Development

Where is MST Being Used? Over 30 states in the U.S. and in 10 countries Statewide infrastructure in Connecticut, Georgia, Hawaii, New Mexico, Ohio and South Carolina Nationwide program in Norway (25+ teams) Other international replications: Australia, Canada, Denmark, Ireland, England, Sweden, Switzerland, the Netherlands, and New Zealand.

MST: 25+ Years of Science Other randomized trials are in progress 14 Randomized Trials and 1 Quasi-Experimental Trial Published (>1300 families participating) 7 with serious juvenile offenders 2 independent randomized trials by Ogden and Timmons-Mitchell 2 with substance abusing or dependent juvenile offenders 2 with juvenile sexual offenders 2 with youths presenting serious emotional disturbance 1 with maltreating families 1 with adolescents with poorly controlled diabetes (independent: Ellis) Other randomized trials are in progress

Long-term Outcomes Long-term follow-up to the Missouri Delinquency Project: 14-year post-treatment outcomes Individuals who had been involved in MST as a youth (average age at follow-up = 28.2 years): 54% fewer arrests 64% fewer drug-related arrests 57%fewer days in adult confinement 43% fewer days on adult probation

Adult Days Confined 1357 days/ 3.72 years 582 days/ 1.59 years 14-Year Follow Up 1357 days/ 3.72 years 582 days/ 1.59 years 57% reduction MST Individual Therapy

MST Quality Assurance System Organizational Context Youth/ Family Supervisor Therapist Manualized Manualized Manualized Manualized Supervisory Adherence Measure Therapist Adherence Measure Consultant/ MST Expert Consultant Adherence Measure

Why is MST Successful? Treatment targets known causes of delinquency: family relations, peer relations, school performance, community factors Treatment is family driven and occurs in the youths’ natural environment Providers are accountable for outcomes Staff are well trained and supported Significant energies are devoted to developing positive interagency relations

16 year old male Case Example Hx of truancy (missing school 2-3 days/week) Runaway (usually 1-2 nights but as long as a week) Defiant/oppositional –refuses to follow household rules

Involved with negative peers Case Example 2 14 year old female Involved with negative peers Reportedly gang-involved Alcohol/marijuana usage Stealing/shoplifting charges

Joshua Leblang System Supervisor QUESTIONS? jleblang@uw.edu 206 685-2254