Evidence-Based Psychosocial Treatment of Disruptive Behavior Disorders – Practice Elements Developed by the Center for School Mental Health with support provided in part from grant 1R01MH A1 from the National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services

Disruptive Behavior Disorder: Practice Components

Specific interventions to help the DBD student Parent praise Parent praise Commands/limit setting Commands/limit setting Tangible rewards Tangible rewards Response cost Response cost Parent monitoring Parent monitoring Time out Time out Psycho-education with parent Psycho-education with parent Problem solving Problem solving

Parent praise Training parents to praise correctly increases compliance in youth with Disruptive Behavior Disorders Training parents to praise correctly increases compliance in youth with Disruptive Behavior Disorders Praise can include Praise can include Verbal praise, Encouragement Verbal praise, Encouragement Attention Attention Affection Affection Physical proximity Physical proximity

Giving effective praise Be honest, not overly flattering Be honest, not overly flattering Be specific Be specific No “back-handed compliments” (i.e., “I like the way you are playing quietly, why can’t you do this while I’m on the phone?”) No “back-handed compliments” (i.e., “I like the way you are playing quietly, why can’t you do this while I’m on the phone?”) Give praise immediately Give praise immediately

Training parents to praise children Barkley manual, Step 2 (Defiant Children) Barkley manual, Step 2 (Defiant Children) Teach parents to set up “special time” to pay attention to their child during play Teach parents to set up “special time” to pay attention to their child during play Teach parents to narrate their child’s play Teach parents to narrate their child’s play Teach parents not to ask questions nor give any commands Teach parents not to ask questions nor give any commands Teach parents to ignore misbehavior during this playtime Teach parents to ignore misbehavior during this playtime Teach parents how to praise and praise lavishly during this time Teach parents how to praise and praise lavishly during this time

Training parents to praise teens Barkley manual, Step 3 (Defiant Teens) Barkley manual, Step 3 (Defiant Teens) Encourage parents to set aside 15 minutes a few times a week to pay attention to their adolescent Encourage parents to set aside 15 minutes a few times a week to pay attention to their adolescent Teach parents to pay attention to what their teen is doing, and show interest in a relaxed way Teach parents to pay attention to what their teen is doing, and show interest in a relaxed way Teach parents not to ask questions nor give any instructions Teach parents not to ask questions nor give any instructions Teach parents to ignore if the teenager reacts with sarcasm, coolness or suspicion Teach parents to ignore if the teenager reacts with sarcasm, coolness or suspicion Teach parents to praise well and often Teach parents to praise well and often

Improving commands/limit setting Training for parents and teachers to give commands in the most effective way Training for parents and teachers to give commands in the most effective way Effective commands increase compliance in children and adolescents with Disruptive Behavior Disorders (and in others, too!) Effective commands increase compliance in children and adolescents with Disruptive Behavior Disorders (and in others, too!)

Improving commands/limit setting with children Barkley Step 3 (Defiant Children) Barkley Step 3 (Defiant Children) Teach parents and teachers: Teach parents and teachers: To only give commands that they intend to back up with consequences (positive and negative) To only give commands that they intend to back up with consequences (positive and negative) Not to present commands as questions or favors Not to present commands as questions or favors Not give too many commands at once Not give too many commands at once

Improving commands/limit setting with children Teach parents and teachers: Teach parents and teachers: To make eye contact with the child before giving command To make eye contact with the child before giving command To reduce other distractions while giving commands To reduce other distractions while giving commands To ask the child to repeat the command To ask the child to repeat the command To watch the child for one minute after giving the command to ensure compliance To watch the child for one minute after giving the command to ensure compliance To immediately praise child when s/he starts to comply To immediately praise child when s/he starts to comply

Improving commands/limit setting with adolescents Barkley, Defiant Teens, Step 4 Barkley, Defiant Teens, Step 4 Teach parents and teachers: Teach parents and teachers: To consider the intent of their command To consider the intent of their command Do they have the time/energy to follow through? Do they have the time/energy to follow through? Do they have consequences for noncompliance? Do they have consequences for noncompliance? To avoid ambiguity when issuing commands To avoid ambiguity when issuing commands To not respond to compliance with gratitude To not respond to compliance with gratitude

Improving commands/limit setting with adolescents Teach parents and teachers: Teach parents and teachers:  To praise teens for appropriate behavior  To tell teen what to do, rather than what not to do  To eliminate other distractions while giving commands  To break down multi-step commands  To use aids for commands that involve time

Tangible rewards Children and adolescents with Disruptive Behavior Disorders do not respond to natural (intrinsic) rewards as well as typical youth Children and adolescents with Disruptive Behavior Disorders do not respond to natural (intrinsic) rewards as well as typical youth The training of parents and teachers in the use of tangible rewards is effective in increasing desired behaviors The training of parents and teachers in the use of tangible rewards is effective in increasing desired behaviors Can use token systems, behavior charts, or immediate rewards Can use token systems, behavior charts, or immediate rewards

Setting up a reward system for children at home Barkley, Defiant Children, Step 4 Barkley, Defiant Children, Step 4 Determine family’s readiness to implement Determine family’s readiness to implement Tailor the program to family’s ability-simplify it for overwhelmed or stressed families Tailor the program to family’s ability-simplify it for overwhelmed or stressed families Use poker chip system with younger children (4-7), point system with older children (8 and up) Use poker chip system with younger children (4-7), point system with older children (8 and up)

Setting up a reward system for children at home Set a positive tone for the program Set a positive tone for the program “We are going to make sure that you get rewarded for all of the good stuff you do at home” “We are going to make sure that you get rewarded for all of the good stuff you do at home” Parent(s) buys chips and makes a bank, or sets up a chart or notebook for tracking points Parent(s) buys chips and makes a bank, or sets up a chart or notebook for tracking points The parent(s) and child together (with your help) make up a list of rewards The parent(s) and child together (with your help) make up a list of rewards There should be everyday rewards, like TV or computer time, and longer term rewards, like going to a movie or earning a new video game) There should be everyday rewards, like TV or computer time, and longer term rewards, like going to a movie or earning a new video game)

Setting up a reward system for children at home Help the parent(s) and child make a list of jobs or problem areas Help the parent(s) and child make a list of jobs or problem areas Determine how much each is worth Determine how much each is worth Add up how much the child might earn in a day Add up how much the child might earn in a day Harder jobs should earn more Harder jobs should earn more Bigger rewards should cost more Bigger rewards should cost more Make sure the child has some success in the beginning Make sure the child has some success in the beginning

Setting up a reward system for children at home Discuss the concept of bonus chips to reward helpful or other positive behaviors, even if they aren’t on the list Discuss the concept of bonus chips to reward helpful or other positive behaviors, even if they aren’t on the list Chips and points are only given if the child complies after the first command Chips and points are only given if the child complies after the first command Don’t take away chips or points (response cost) in the beginning Don’t take away chips or points (response cost) in the beginning All caregivers should use the same system All caregivers should use the same system Remind parents to praise while giving the points Remind parents to praise while giving the points

Setting up a reward system for children at school Barkley, Defiant Children, Step 8, Daily School Report Card Barkley, Defiant Children, Step 8, Daily School Report Card The teacher tracks the child’s behavior and reports it to the parent daily, who rewards the child The teacher tracks the child’s behavior and reports it to the parent daily, who rewards the child Pretty easy for the teacher Pretty easy for the teacher This is particularly effective because both the parent and teacher are involved This is particularly effective because both the parent and teacher are involved If the parent can’t be involved, the rewards may be given at school If the parent can’t be involved, the rewards may be given at school

Setting up a reward system for children at school Choose a few target behaviors at school Choose a few target behaviors at school Choose one that the child will be successful with most of the time Choose one that the child will be successful with most of the time Set up a system for school report card or school/home note system Set up a system for school report card or school/home note system See samples on page See samples on page Pick from the targets given, or create your own with the blank samples Pick from the targets given, or create your own with the blank samples

Setting up a reward system for adolescents at home Barkley, Defiant Teens, Step 5 Barkley, Defiant Teens, Step 5 Use a point system (see previous slides) for 13/14 and under Use a point system (see previous slides) for 13/14 and under Set up basically the same way as with children Set up basically the same way as with children Warn parents to expect resistance, their teen is used to getting all of their privileges for free! Make sure parents don’t give in. Warn parents to expect resistance, their teen is used to getting all of their privileges for free! Make sure parents don’t give in. Make sure parents only choose privileges they can control Make sure parents only choose privileges they can control

Setting up a reward system for adolescents at home Barkley, Defiant Teens, Step 5 Barkley, Defiant Teens, Step 5 Use a behavior contract for teens 14/15 and older Use a behavior contract for teens 14/15 and older See sample contract on page 208 See sample contract on page 208 Begin with only “do” behaviors (clean up room, set table, get ready for school on time) Begin with only “do” behaviors (clean up room, set table, get ready for school on time) “Don’t” behaviors are dealt with under response cost in next section “Don’t” behaviors are dealt with under response cost in next section

Setting up a reward system for adolescents at school Barkley, Defiant Teens, Step 9 Barkley, Defiant Teens, Step 9 Establish a homework contract (see sample on page 121) Establish a homework contract (see sample on page 121) This can be adapted for other behavioral goals This can be adapted for other behavioral goals Can also set up guidance counselor, tutor or peer as “coach” for organizational skills or other targets Can also set up guidance counselor, tutor or peer as “coach” for organizational skills or other targets Rewards for teen’s participation can be made part of the home contract, or part of a school reward system Rewards for teen’s participation can be made part of the home contract, or part of a school reward system

Response Cost Using a point or token system in which negative behaviors result in the loss of points or tokens. Using a point or token system in which negative behaviors result in the loss of points or tokens. Training parents and teachers to use response cost is effective in reducing undesired behavior and noncompliance Training parents and teachers to use response cost is effective in reducing undesired behavior and noncompliance

Response Cost with Children Barkley, Defiant Children Step 4 & 8 Barkley, Defiant Children Step 4 & 8 Train parents and teachers: Train parents and teachers: To develop list of undesirable behavior to be fined by reward system To develop list of undesirable behavior to be fined by reward system To deduct points/chips for undesirable behavior To deduct points/chips for undesirable behavior Parent and child have chosen to reduce whining Parent and child have chosen to reduce whining If child whines, parent deducts three points If child whines, parent deducts three points Penalties increase based on severity of behavior Penalties increase based on severity of behavior

Response Cost with Children Train parents and teachers: Train parents and teachers: To avoid “punishment spiral” To avoid “punishment spiral” When parent fines child for misbehavior, the child may respond with more misbehavior When parent fines child for misbehavior, the child may respond with more misbehavior Child continues to lose points, then loses motivation for the point system Child continues to lose points, then loses motivation for the point system Rule: Parent fines child once through point system, then sends child to time out if undesirable behavior continues Rule: Parent fines child once through point system, then sends child to time out if undesirable behavior continues

Response Cost with Adolescents Barkley, Defiant Teens Step 6 Barkley, Defiant Teens Step 6 To train parents and teachers: To train parents and teachers: To now use behavioral contract with the teen for “fines” To now use behavioral contract with the teen for “fines” Teen agrees to not swear Teen agrees to not swear If teen swears, teen loses Internet privilege If teen swears, teen loses Internet privilege

Response Cost with Adolescents Train parents and teachers: Train parents and teachers: To begin with 1 week “training period,” during which parents labels misbehavior every time it happens and warns of new fines To begin with 1 week “training period,” during which parents labels misbehavior every time it happens and warns of new fines To avoid “punishment spiral” To avoid “punishment spiral” When parent fines teen for misbehavior, the teen responds with more misbehavior When parent fines teen for misbehavior, the teen responds with more misbehavior Teen continues to lose privileges, then loses motivation Teen continues to lose privileges, then loses motivation Rule: Parent fines teen no more than twice, then directs teen to “cool off” away from the situation Rule: Parent fines teen no more than twice, then directs teen to “cool off” away from the situation

Response Cost with Adolescents Encourage parents to act as “judge and jury” when teen lies Encourage parents to act as “judge and jury” when teen lies The teen should remain above suspicion The teen should remain above suspicion Response cost allows parents to discipline/educate instead of just punish Response cost allows parents to discipline/educate instead of just punish Emphasis of response cost is on Emphasis of response cost is on “Warm” – positive, loving “Warm” – positive, loving “Firm” – specific, immediate, and consistent “Firm” – specific, immediate, and consistent

Parent Monitoring Give parents a structured way to monitor their child’s behavior Give parents a structured way to monitor their child’s behavior Measurement of the target behavior should be repeated Measurement of the target behavior should be repeated Can use either informal or formal measures Can use either informal or formal measures

Parent Monitoring Informal measures Informal measures Daily homework log Daily homework log Behavior chart as part of a reward system Behavior chart as part of a reward system Home Situations Checklist (Barkley, Defiant Children) Home Situations Checklist (Barkley, Defiant Children)

Parent Monitoring Formal measures Formal measures Vanderbilt Scales (from your Resource Toolkit or on the web) Vanderbilt Scales (from your Resource Toolkit or on the web) Disruptive Behavior Disorders Scale (in Barkley or on the web) Disruptive Behavior Disorders Scale (in Barkley or on the web)

Time Out Time out is the removal of a child or adolescent from all reinforcement for a specified period of time after a targeted misbehavior Time out is the removal of a child or adolescent from all reinforcement for a specified period of time after a targeted misbehavior It is an effective intervention, but only if it is used correctly and is not used too often It is an effective intervention, but only if it is used correctly and is not used too often

Using Time Out with Children at Home Barkley, Defiant Children, Step 5 Barkley, Defiant Children, Step 5 Teach parents to give an effective command (Step 3) Teach parents to give an effective command (Step 3) Teach parents to count out loud (initially) from 5 to 1 Teach parents to count out loud (initially) from 5 to 1 Teach parents to give a time out warning if the child has not complied Teach parents to give a time out warning if the child has not complied After warning, count from 5 to 1 again After warning, count from 5 to 1 again

Using Time Out with Children at Home Teach parents to guide child to time out chair IMMEDIATELY Teach parents to guide child to time out chair IMMEDIATELY Teach parents to place the child in the chair “Stay there until I tell you to get up” Teach parents to place the child in the chair “Stay there until I tell you to get up” Teach parents not to argue or interact with the child in any way Teach parents not to argue or interact with the child in any way Teach parents to not come back until the child is calm. Once the child is calm and the time is served, the child must correct the misbehavior Teach parents to not come back until the child is calm. Once the child is calm and the time is served, the child must correct the misbehavior

Using Time Out with Children at Home Teach the parents that the child should now go and comply with the previous command, or correct the misbehavior Teach the parents that the child should now go and comply with the previous command, or correct the misbehavior Teach the parent to now praise compliance, and to praise the next behavior that the child does well Teach the parent to now praise compliance, and to praise the next behavior that the child does well

Time Out Tips with Children The first time out may be a killer The first time out may be a killer Prepare parents for a worst case scenarios Prepare parents for a worst case scenarios Reassure parents that this is not damaging their child Reassure parents that this is not damaging their child Make sure the time out area is away from anything interesting or fun Make sure the time out area is away from anything interesting or fun Remind parents not to “make up for” the time out (i.e., saving dessert for them) Remind parents not to “make up for” the time out (i.e., saving dessert for them)

Using Time Out with Adolescents Barkley, Defiant Teens, Step 8 Barkley, Defiant Teens, Step 8 “Grounding” = “house arrest” “Grounding” = “house arrest” NO access to privileges (phone, TV, etc) NO access to privileges (phone, TV, etc) Parent must be home to enforce Parent must be home to enforce Most effective with younger teens Most effective with younger teens May include “work detail” (cleaning out basement, scrubbing bathroom floor) May include “work detail” (cleaning out basement, scrubbing bathroom floor)

Parent Psychoeducation Engage and empower parents by teaching them about Disruptive Behavior Disorder Engage and empower parents by teaching them about Disruptive Behavior Disorder Establish relationship with parents as partner in treatment process Establish relationship with parents as partner in treatment process Look at how DBD influences parent-child interaction (bi-directional) Look at how DBD influences parent-child interaction (bi-directional)

Parent Psychoeducation Review information about Disruptive Behavior Disorders Review information about Disruptive Behavior Disorders Symptoms Symptoms Causes Causes Diagnostic criteria Diagnostic criteria Treatment modalities Treatment modalities

Emphasize caretaker role in development and treatment of DBD Emphasize caretaker role in development and treatment of DBD Problems in parenting and parenting styles may make DBD worse Problems in parenting and parenting styles may make DBD worse Establishing behavioral interventions at home or at school require caretaker involvement Establishing behavioral interventions at home or at school require caretaker involvement Knowledge enables parents to more effectively advocate for better services Knowledge enables parents to more effectively advocate for better services Parent Psychoeducation

 More effective if therapist devotes more than one session to psychoeducation More effective if therapist educates parents about DBD across multiple settings (home, school, playground, etc) More effective if therapist educates parents about DBD across multiple settings (home, school, playground, etc)

Resources for Parent Psychoeducation Center for Children and Families Center for Children and Families “Supporting Children with Challenging Behaviors: Relationships Are the Key ” “Supporting Children with Challenging Behaviors: Relationships Are the Key ” American Academy of Child & Adolescent Psychiatry American Academy of Child & Adolescent Psychiatry Fact sheets Fact sheets

Resources for Parent Psychoeducation National Initiative for Children’s Healthcare Quality National Initiative for Children’s Healthcare Quality “How to Establish a School-Home Daily Report Card” “How to Establish a School-Home Daily Report Card” Vanderbilt Assessment Scales (parent and teacher version) Vanderbilt Assessment Scales (parent and teacher version) DBD Resources Available on the Internet DBD Resources Available on the Internet “Working with Your Child’s School” “Working with Your Child’s School”

Differential reinforcement Teach parents and teachers how and when to differentially reinforce desirable behavior Teach parents and teachers how and when to differentially reinforce desirable behavior Step One: Ignore (stop reinforcing) the child’s undesirable behavior Step One: Ignore (stop reinforcing) the child’s undesirable behavior Step Two: Reinforce the child’s desirable behavior in a systematic manner Step Two: Reinforce the child’s desirable behavior in a systematic manner The desirable behavior should be a behavior that is incompatible with the undesirable behavior The desirable behavior should be a behavior that is incompatible with the undesirable behavior

Differential reinforcement Define the behavior of concern (target) Define the behavior of concern (target) Determine how often the target behavior occurs Determine how often the target behavior occurs Determine how often to reward the child for alternative behavior Determine how often to reward the child for alternative behavior Fixed interval – reward every X minutes Fixed interval – reward every X minutes Determine how to reward the child for alternative behavior Determine how to reward the child for alternative behavior Praise, attention, points or chips Praise, attention, points or chips

Reinforcement of target behavior Target behavior: Interrupting Target behavior: Interrupting Alternative behavior: Playing by himself Alternative behavior: Playing by himself Reward schedule: 5 minutes Reward schedule: 5 minutes If child goes 5 minutes without interrupting, the child receives reinforcement If child goes 5 minutes without interrupting, the child receives reinforcement If child interrupts before 5 minutes is up, the child does not receive reinforcement If child interrupts before 5 minutes is up, the child does not receive reinforcement Re-set schedule once child interrupts Re-set schedule once child interrupts

Problem solving Teaches children how to “use their heads before using their fists” Teaches children how to “use their heads before using their fists” Problem solving steps Problem solving steps Define the problem Define the problem Identify response options Identify response options Evaluate response options Evaluate response options Parents trained to help their children use problem solving steps Parents trained to help their children use problem solving steps

Problem Solving Extensive use of applied behavior analysis Extensive use of applied behavior analysis Prompt appropriate behavior Prompt appropriate behavior Shape behavior Shape behavior Deliver reinforcement for appropriate behavior Deliver reinforcement for appropriate behavior Extinguish inappropriate behavior Extinguish inappropriate behavior

Problem Solving Central Goals of Problem Solving Central Goals of Problem Solving Improve how children reason when confronted with interpersonal problems Improve how children reason when confronted with interpersonal problems Increase the number of prosocial solutions considered and employed Increase the number of prosocial solutions considered and employed

Problem Solving Skills Training Designed for aggressive and antisocial behavior Designed for aggressive and antisocial behavior Children ages 7-13 Children ages sessions (40-45 minutes) 20 sessions (40-45 minutes) Individual sessions with parent contact Individual sessions with parent contact

Problem Solving Skills Training Therapist Steps 1. Teach 5 problem solving steps 1. Identify the problem 2. List possible solutions 3. Evaluate them 4. Choose one 5. Try it 6. Evaluate the outcome

Problem Solving Skills Training 2. Practice steps on games (e.g., Checkers) 3. Apply steps to real-life problems 4. Teach parent to prompt and praise the use of steps

Problem Solving Skills Training 5. Child continues applying to real-life situations; re-enact solutions w/therapist 6. Wrap-up, review what has been learned, role-reversal (child teaches skills to therapist)

Problem Solving Psychotherapy for Children and Adolescents: Evidence-Based Treatments and Case Examples John R. Weisz (2004)