1. 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

2. 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 BC)

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

5. 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

6. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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)

15. 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

16. 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)

17. 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.

18. 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?

19. 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

20. 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

21. 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

22. 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.

23. 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

24. 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)

25. 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.

26. 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

27. 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

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

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

30. SCHOOL
Low achievement
Truancy
Low commitment to school

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

32. Individual Factors Antisocial behavior Mental health problems
Low social conformity

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

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

39. 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

40. 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.

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

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

48. Joshua Leblang System Supervisor QUESTIONS? jleblang@uw.edu