1. Treating Explosive Kids Part 2
The Collaborative
Problem-Solving Approach
Drew Burkley Psy.D.
Center of Excellence
Clinical Psychology Fellow

2. Authors Ross W. Greene, PhD J. Stuart Ablon, 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,

3. Location Collaborative Problem Solving Institute
Department of Psychiatry of Massachusetts General Hospital

4. Thanks to... Gloria Jones, Psy.D. Sasha Ahmed, M.S.
Scott Browning, Ph.D.
To be written by Dr. Browning

5. Review

6. “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

7. 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

8. The Plans When a problem arises, there are three ways to deal with it
Plan A: Imposing of parents Will
Plan C: Removing Expectations
Plan B: Collaborative Problem Solving.
Neither Plan A nor Plan C teaches the child how to negotiate their world using their lagging cognitive skills.
Parents and clinicians must first recognize and be aware of the lagging cognitive skills of their child and how they are attributed to the explosive episodes before they are able to move from Plan A or C to Plan B.

9. Why Plan B? Parents often chose Plan A.
Works for about 95% of children
Doesn’t account for lagging skills
Lagging skills, such as poor frustration tolerance, poor executive functioning, etc. may be influencing compliance
Typically seen in the “explosive” children
Plan B helps address skills and increase child compliance
Neither Plan A nor Plan C teaches the child how to negotiate their world using their lagging cognitive skills.
Parents and clinicians must first recognize and be aware of the lagging cognitive skills of their child and how they are attributed to the explosive episodes before they are able to move from Plan A or C to Plan B.

10. Plan B Basics

11. Plan B Basics Plans A and C do not help children learn needed skills
Developmentally, children are not equipped to handle explosive episodes alone.
Two types of Plan B: Proactive and Emergency
Parent does thinking for the child
Neither Plan A nor Plan C teaches the child how to negotiate their world using their lagging cognitive skills.
Parents and clinicians must first recognize and be aware of the lagging cognitive skills of their child and how they are attributed to the explosive episodes before they are able to move from Plan A or C to Plan B.

12. Surrogate Frontal Lobe
Frontal lobes
Executive functioning
Impulse Control
Planning
Not fully developed until mid 20’s
Caregiver becomes surrogate frontal lobe
Thinks for child
The Frontal Lobes of the brain are the areas in the brain that function to implement executive planning, motor planning, and impulse control.
In Plan B, the parent or care giver is doing the thinking (i.e. frontal lobe activity) for the child due to lacking cognitive skills or relative inexperience in performing the acts.
Similar to parents or care givers who teach their child or children how to ride a bike, hit a baseball, or learn to read (all frontal lobe activities), parents and care givers using Plan B will teach their child the crucial skills of flexibility, frustration tolerance, and problem solving.

13. Surrogate Frontal Lobe
The caregiver functions as a surrogate frontal lobe by:
Walking child through the situation
Precipitating explosive episodes
After multiple repetitions, child will increase their thinking-through ability
Something Caregivers already do
Teaching baseball or how to cross the street
Models creativity and flexibility
Walking a child through a frustrating situation in the present (thereby preventing explosive episodes in the present).
Solving problems routinely precipitating explosive episodes in a durable way
After multiple Plan B repetitions, training lacking thinking skills so that the child won’t need the surrogate frontal lobe for the rest of their life.

14. Rudimentary Plan B Steps Necessary for Successful execution of Plan B
Empathy (plus reassurance)
“I’ve noticed you’ve had problems with X, what’s up?”
Define the problem
Invitation
Key Ingredients for a successful Plan B are
Both parties (are at a place at which they can begin calm and rational.
Ensure concerns of are clearly defined
Brainstorm
All Ideas considered
Creative problem solving for all concerns
Ensure concerns of are clearly defined and are at least considered
Entertain the wide range of possibilities that could address BOTH sets of concerns.

15. Step 1: Empathy
Empathy
Information Gathering to Understand
Acknowledges the concerns of the child and defines that concern
Starts with “I’ve noticed”
Highly specific definition is essential for successful empathy
Feeling heard helps people feel understood
being aware of, and being sensitive to the feelings, thoughts, and experiences of another without actually sharing the feelings and experiences of another.
Observations have to be neutral. Not “I’ve noticed your trying to ruin my life”. I”ve noticed you’ve been terrorizing your brother lately, what’s up? I’ve noticed you’re being disruptive lately, what’s up? Shuts kid up.
Coming to a highly specific definition of the concern of the child is absolutely essential for this model and successful empathy.
Many adults or care givers will need specific models of how to empathize and what is not empathy. Many caregivers make an educated guess at this stage, but need instead to patiently work with their child.
Some parents have difficulty with the first step of Plan B (Empathy) because they fear that they are about to capitulate to the wishes of their child. In fact, what you are doing is clearly defining the problem.

16. Step 2: Define the Problem
Plan A: The concern of the adult
Plan C: The concern of the child
Plan B: Reconciling the concerns of
the child with that of the adult
To Main purpose adult get’s their concern on the table.
Recognize the pathways that are interfering with the ability to the child to respond to Plan A
Clearly define the concerns of the child through Empathy
Clearly define the concerns of the ADULT through appropriate investigation
What are your concerns about this specific behavior?
A common mistake at this step is that many caregivers attempt to provide TWO SOLUTIONS instead of defining TWO CONCERNS that Define the Problem.
Both child and adult concerns must be clearly specified before we can define the problem and an effective collaboration can begin! Usually adult’s concern’s fit into 1 of 3 categories Learning, Safety, how beh affects themselves or others.

17. Step 3: The Invitation Invite the child to brainstorm. For example:
Let’s think about how we can solve this problem together.
Let’s see what we can figure out or do about this together.
Assess the ability of the child to develop alternative solutions.
Do they have the skills to generate alternative solutions? Do these solutions take both adult and child concerns into account?
If not, the care giver may have to serve as the surrogate frontal lobe.
The child must be invited in to a collaborative brainstorming session in a way that is feasible and mutually satisfying
--End point
help the child learn how to develop alternative solutions to their problems

18. Step 3: The Invitation
The burden is upon both members (child and adult) of the problem solving team to solve the problem. What matters now is that a solution is developed that is feasible and mutually satisfactory.
The invitation appears to many parents to be a dissolution of their power rather than a sharing and development of responsibility with their child.
The Litmus test for a good solution is that it is realistic, doable, and mutually satisfactory.

19. Emergency Plan B Versus Proactive Plan B
De-escalation technique.
Most parents and caregivers don’t realize that the problems are highly predictable
Proactive Plan B
Solve the problem before it occurs
Teaching tool
Helps child ID triggers
Know for future occurences
Most parents and caregivers do not think about outbursts in situational terms so they don’t realize that the problems are highly predictable and wait until they are in the throes of a problem before attempting Plan B.
Emergency Plan B is when you are waiting until you are right in the middle of a disagreement or a problem to use Plan B. It is then a de-escalation technique.
We find that most outbursts tend to occur repetitively in response to the same circumscribed set of problems or triggers.
This is Emergency Plan B and it is the least opportune time to attempt a durable solution, but it can be a productive form of crisis intervention.
Over-reliance on Plan B as a de-escalation technique will decrease its effectiveness as a teaching technique because repeated crises and explosions have now become associated with the steps of Plan B (e.g., Empathy, Defining the Problem, Invitation).
Proactive Plan B is when you are trying to solve a predictable problem before it returns. Proactive Plan B is a teaching tool.
Proactive Plan B serves to help the child identify triggers to their explosive behaviors without shame to help them learn to solve the problem before it happens again.

20. Easy Living Through Plan B
Prior to explaining Plan B to caregivers, we should:
Explain the pathways that are causing issues
identify the triggers (i.e., problems that have yet to be solved) that commonly precipitate explosive episodes.
explain the pathways (i.e., skills that need to be trained) that may be interfering with the capacity of the child for flexible frustration tolerance and problem solving
We should also have achieved an informal sense of the ability of the caregiver to digest and absorb this alternative view toward their problem with their child.
Care givers must agree that it is crucial to teach their child their lacking thinking skills through collaborative solutions to problems and that consequence based programs are unlikely to accomplish these goals.
The level of hostility between the caregiver and the child must be at a SAFE level prior toward the implementation of any of these steps.

21. Easy Living Through Plan B
Two forms of Plan B:
Focusing on resolving the triggers for the explosion (Problem-focused Plan B)
Focusing on developing the lagging skills that are causing the explosions (Skills-focused Plan B)
If a majority of episodes deal with getting ready for school or doing homework, then therapist might consider a Problem focused Plan B
If outbursts are due to lagging skills, then Plan B might focus on skill building.

22. Common Mistakes Forgetting to Invite the child to problem solve
Skipping steps
Not clearly identifying the two concerns
Providing alternative solutions (two Plan A’s or a Plan A and a Plan C)
WARNING: IT IS VERY COMMON FOR ADULTS TO SUCCESSFULLY MAST ER THE FIRST TWO STEPS (EMPATHY AND DEFINING THE PROBLEM) BUT NEVER INVITE THEIR CHILD INTO THE PROBLEM SOLVING DEPARTMENT.
like Assessing Pathways, Empathy, Defining the problem, or giving the Invitation along the way. Also, not buying in.
(adult and child) and clearly defining the Problem but instead providing two Alternative solutions (e.g., Two Plan A’s or a Plan A and a Plan C).

23. Common Mistakes
As a clinician, forgetting to examine and identify ADULT pathway problems before entering this step.
Caregivers trying to make Problem Solving Unilateral rather than collaborative.
Caregivers trying to make Plan B a clever form of Plan A!
Relying too much on Emergency Plan B and not using Proactive Plan B

24. Beyond the Basics

25. Skills Needed for Plan B
Identify and articulate concerns
Consider these generating alternative solutions
Anticipate outcomes of potential solutions
For Plan B to be utilized and implemented effectively both parents and their children need to possess certain skills.
These are intricate skills that are not always developed in the families we serve. But Plan B discussions can provide us with meaningful (directly observable) information about each family member’s relational skills in these areas and others.

26. Therapist Roles Identify lagging skills
Assist family in strengthening them
Facilitate therapeutic process
(((Read Slide First!!!!)))
The goal of facilitating is that Plan B can be modeled, practiced, fine-tuned, and eventually implemented by the family without assistance
To achieve these goals, therapist must first [next slide]

27. Therapist Roles Establish alliances with each participant
Maintain neutrality
Prevent discussion from spinning out of control
Be vigilant to hindrances to full investment

28. Therapist Roles Help participants stay on track during discussions
Identify any impediments to progress
Address within the family system

29. What is the single greatest predictor of therapeutic change?

30. Establishing the therapeutic alliance

31. Establishing Alliances
Therapeutic relationship is vital
Communication of empathy is key
Validate
Convey understanding
((Read first two lines))
CPS requires hard work and a shift in mindset for participants
Things often get worse before getting better
Validate where the parent is coming from– ask questions that communicate an understanding of explosive children.

32. Establishing Alliances with Adults
Adults need:
To be heard and understood
To see the clinician as competent
To see the clinician has the capacity to help relieve distress

33. Establishing Alliances with Children
Children need to know:
Things may be better this time around
That the clinician does not believe that negative behaviors are intentional
That the clinician views the situation as a “family problem”
vs. “child’s problem”

34. Maintaining Neutrality
Ensure that all participants’ concerns make it into the discussion
Remaining focused
Understanding
Clarifying

35. Maintaining Neutrality
Remain focused on process vs. outcome
***HOWEVER***
Solutions need to be“mutually satisfactory”
Solutions eventually developed are not as important as the process (family interaction) by which they were developed.
Solutions, or outcomes....Family decides what is “mutually satisfactory” not the therapist.

36. Taking Control of the Case
Therapist Roles
Mediate
Assess “temperature”
Remain vigilant
Mediates between family members in conflict
Can predict when family may not be capable of direct interactions with each other
Remain vigilant during direct discussions of family members’ ability to remain emotionally regulated.

37. Taking Control of the Case
Therapist Roles (cont...)
Actively calculates the pace of therapy
Keeps the discussion on track
Remains mindful of other treatments being delivered
especially if conflicting guidance is being offered.

38. Pathways Extended The Therapist as a Salesperson
Beginning therapy focused on child skill deficits:
Maintains congruence with many parents’ expectations about the process of therapy
Helps alter/reframe parent perceptions of their child’s outbursts
Child- primarily focused on up to now; while parent may interfere with the implementation of plan B

39. Pathways Extended The Therapist as a Salesperson
A Good “Pitch”
from original definition of the referral problem to more systemic perception.
Address both child and parent skill deficits
Feasible when therapeutic alliance is secure.

40. Pathways Extended Defining the problem Executive struggles
Generating alternative solutions
Disorganized/unsystematic approach
Language-processing issues
Emotional regulation deficits
Concrete thinkers
The above are some potential parental pathway difficulties
Exec- refers to anticipation of problems before they occur

41. Skills Trained with Plan B

42. Identifying &Articulating Concerns and Problems
Language Processing Skills
Using and Practicing Adaptive Vocabulary
Using Reminders
Talking about the incident later, away from the heat of the moment.
Teach Pragmatic vocabulary with problem identification
Video Clip
A.V.- using emotion words- happy sad angry, instead of saying “this sucks” identify emotion
Reminder- When a child say’s I don’t want to, or has an outburst- it is helpful to remind them of the feeling that surfaces. EG. “you’re feeling frustated, or angry.”
In this clip, we’ll see an example of a child with some difficulty with language processing and how the therapist approaches that. start at 3:35 End at 7:47
So at this point, the therapist is trying to work with the family to develop an outcome which addresses everyone’s concerns.

43. Considering Possible Solutions
Mutual process between parent and child
Some children have never been given the opportunity
Repetition and exposure to adults showing this skill helps to build it in some cases
In other cases a structured model can help
never given..... and need parent/therapist to suggest solutions.
Structured model --- Ask for help, Meet halfway/give a little, Do it a different way

44. Reflecting on Likely Outcomes and How Feasible/Satisfactory They Are
Therapist may express skepticism about solutions that may not be realistic/feasible
model for the family
Child may not develop a solution based on both concerns
difficulty with perceptive taking

45. Parent’s Execution of Plan B
Step 1- Empathy
Calming affect
Acknowledge their concern
Step 2 Defining Problem
Help child to take your concern into account when working toward a solution
State concern in a calm, tentative manner
Reminder of problems solved prior
(((Watch clip from 8:30....)) parent’s try to work plan b with therapist as a support...
(((Stop when needed for time!!))) probably around 12:00 minutes....
Isn’t easy. Realistically, kids are not going to immediately change their perspective and regulate, however; this approach truly improves family discussion, problem solving, and healthy approaches.....

46. Final Thoughts Advantages of Plan B:
Training can occur in the environments in which the skills are to be utilized
Collaborative in nature
Child is more likely to think about a problem
More likely to take ownership of the problem and the solution
Teaching adaptive social functioning is built in

47. Questions and Wrap Up!