Implementing Aggression Replacement Training At River Oak Center for Children

1. Implementing Aggression Replacement Training At River Oak Center for Children Gary Suits, MSW Clinical Program Manager, Wraparound ART Team Leader Curtis Bond, BS Psychology Program Services Clinician, Outpatient ART Group Leader Karen Thompson, BS Psychology Family Facilitator, Wraparound ART Group Leader

2. About River Oak Center for Children • Client base of approximately 800, from ages birth to 21 • Approximately 300 clinical and support staff, including Psychologists, Psychiatrists, Social workers, Marriage and Family Therapists, and paraprofessionals • Various programs include Outpatient, Intensive In-Home, Residential Services, Birth and Beyond, Differential Response, and Day School

3. Before ART…Fall 2005 • Anger Management Group for Boys 9-12, based on Rational-Emotive Therapy, the writings of William Pollack, and materials from Boys Town • First group: one group leader and three boys • Four complete groups for boys, 12 sessions each, between Fall 2005 and Fall 2006 • Girls group added Summer 2006; led by male-female team • Clients were referred with just a phone call to the group leader

4. ART…Fall 2006 • ROCC asked that ART be developed and implemented. Skillstreaming was already in place by this time • A proposal was submitted to Executive Management

5. January 2007 • Presentation to Board of Directors • A call for volunteers to attend ART training was put forth; 10 ROCC staff attended the 2-day training and 1-day Booster

6. February 2007 • Dates and locations for three groups were announced via inter-office email and printed flyers • Two other “internal” groups were requested for Residential clients age 9-12. • Groups advertised as Anger Management Groups, rather than ART

7. Referral Criteria • Any boy or girl age 13 and up, currently receiving mental health services through River Oak Center for Children, is eligible, regardless of program or diagnosis. • We believe that any client can benefit from the anger management groups. • Groups are “closed.” Clients may not join after the second session.

8. Modifications for our population • Maintaining even weekly attendance had been an issue in past. • Chose to hold groups 1x weekly rather than 3x weekly. • Outpatient model. • Maintained similar schedule to previous groups for familiarity, ease of transition to new curriculum, etc.

9. How To Graduate From An Anger Management Group • Group members must complete 8 out of 10 sessions in order to get credit for having completed the course • With approval of the Team Leader, “make ups” can be done on an individual basis, if missing group was beyond the control of the client

10. The Strike System • Breaking a group rule will result in earning one strike (x on the board) • If a client earns three strikes in one session, he or she is asked to leave. The client may return the next week. • If a client is asked to leave three sessions, he or she is dropped from the group with no opportunity for make-up

11. The Strike System Clients are rarely, if ever, removed from the group.

12. Modifications for our population • Need to condense, agreed anger control and moral reasoning most important. • Why control anger if you don’t care about right vs. wrong? • Focus similar to previous groups. • Groups 90 min long, with anger control for first portion, and moral reasoning for second portion.

13. Modifications – Hassle Logs • For teens, were able to utilize standard hassle logs. • For residential population, had some poor reading skills • Utilized “Non-readers Hassle Log” (pictorial format).

14. Modifications – Teaching new skills • For teens, able to stick to book pretty well. • Utilized their examples (from logs, from discussion etc.) to maintain engagement and “keeping it real.”

15. Modifications – Teaching new skills • For residential population, had to simplify, use a lot of role modeling by trainers, repetition, etc. • Utilized their examples (from logs, from discussion etc.) to maintain engagement and “keeping it real.” • Review sessions earlier in 10 week course.

16. Modifications – Role Plays • Girls loved this part • Teens – able to do with little or no modification. • Both populations, used a lot of reinforcement of acting skills, made it fun by making it “movie time”, etc.

17. Modifications – Role Plays • Residential: much harder time remembering “chain sequence” • Needed sequence written on board, trainer pointing and prompting, etc. • Repeated role plays to help improve performance without prompts. • Some struggled with evaluation assignments – took pre-coaching.

18. Modifications – Moral Reasoning • Challenges: • Shorter time frame • Need to keep discussion structured and on task • Hoped to give them skills to make good moral decisions.

19. Modifications – Moral Reasoning • Utilized “SODAS” model from Boys’ Town. • This model provided a structured decision-making tool the kids could use outside of group. (taught moral reasoning and problem solving at same time). • Helped to keep discussion focused and on track.

20. Modifications – Moral Reasoning • Teens able to “get it” with SODAS model, and apply to various moral dilemmas. • Residential had harder time identifying moral problems, and tended to go off topic more. • Required frequent prompts and visual cues to stay on task.

21. What worked well? – Teaching Skills • Use of “hand on head” for self-talk – kids really seemed to get this. • Hassle log for cuing memory. • ABC model to simplify for younger kids. “B” is where skills were used. • Role modeling vs. lecture. • Holding “review week” earlier in the 10 week cycle.

22. What worked well – role plays • Making it fun “movie time.” • Written cues on the board for sequence • Repetition for younger kids.

23. What worked well – Moral Reasoning • Structured discussion / decision-making model on board. • Repetition of this model week after week. • Teens able to use to solve real world problem.

24. Challenges • Some of the material too abstract for younger / residential population. • Keeping the younger kids focused and on task for 90 min. • Keeping some of the older kids focused and on task for 90 min. • Getting the boys to talk • Getting the girls to stop talking

25. Behavioral challenges • Had “3 strikes” system in place • For teens, rarely utilized strikes. Just encouraged them to take break outside if unable to redirect.

26. Behavioral Challenges • Multiple challenges for residential population. • Girls lived together, so brought issues into group (Group therapy). • Trainers not part of residential program. • Behavior not tied to residential program. • Residential staff not always available when needed.

27. Strategies for maintaining model adherence • Written cues, for trainers and trainees. • Being attentive to participants, and creative with teaching methods. • Making sure that skills are practiced in role plays (action more important than discussion). • Repetition and review.

28. Currently at River Oak… • Eight groups completed by mid-November 2007 • Skillstreaming currently in place as the behavior model for individual work • Adding Anger Control and Moral Reasoning for individual work • Will likely start Skillstreaming groups at Residential in spring 2008

29. Ongoing Challenges • Getting enough referrals at the beginning to sustain a group through completion (10/2/2 rule) • Middle management support • Overcoming the bias towards individual therapy as the answer to everything  • Transportation • Staff Turnover

30. Success Stories • The 12yo boy who came from a financially-challenged family. He wanted to continue in the group so badly that he went door-to-door in his neighborhood, doing odd jobs to earn enough money to buy gas

31. Success Stories • Another boy shared a story that at home, instead of getting upset and hitting or throwing things when asked to clean his room, he went to his happy place at home and sat until he was calm. This was a huge improvement for the client and a pleasant surprise for his mother

32. Success Stories • The group of teen girls who, after completing a Moral Reasoning problem having to do with a relationship triangle, decided that preserving friendships was more important than “some boy.”

33. Questions?

34. About The Presenters Gary Suits, MSW has been with River Oak Center for Children since 2002. Prior to coming to ROCC, Gary worked at Child and Family Institute as a member of the Homeless Outreach Team, providing in-home support services to homeless children and their families. He has also been a Family Teacher at Father Flanagan’s Home for Boys, Boys Town, Nebraska, where he operated a foster home for four boys age 9 to 12. Gary also holds the degree Master of Music from Northwestern University. A horn player, Gary has played in orchestras in Kansas, Missouri, Arkansas, and South Carolina, as well as a tour of Austria and Germany. He currently plays with several orchestras in the Sacramento area. Gary is also a United States Marine.

35. About The Presenters Curtis Bond, B.S. Psychology has been with River oak Center for Children for the past four years. He has extensive experience in child welfare, to include Boulder Creek Academy, a wilderness program for wayward teens; residential counselor with Paradise Oaks, and four years experience with Oregon Child Protective Services in Oregon. Curtis is an avid musician as well, taking every opportunity to play the guitar. He also enjoys hiking and photography.

36. About The Presenters Karen Thompson, BS Psychology, spent 15 years as a counselor in River Oak’s residential facility before coming to Wraparound as a Family Facilitator in the spring of 2006. She has taken on some of the most challenging cases that the program has encountered. Karen has enjoyed considerable success as an ART Group Leader, and is on track to become a certified trainer, with the ultimate goal of becoming a Master Trainer.