Diana Joyce, Ph.D. NCSP Douglas Jones, B.A. Angela Dobbins, M.Ed.

1. Diana Joyce, Ph.D. NCSP Douglas Jones, B.A. Angela Dobbins, M.Ed. djoyce@coe.ufl.edu djonesnd2000@ufl.edu dobbinad1@ufl.edu University of Florida Counseling Techniques for School Psychologists Delivering RtI InterventionsNASP Conference, Chicago, IL: March 3rd 2010 All Presentation Materials Including Sample Reports are Available at http://www.nasponline.org/

2. RtI Tiered Behavioral InterventionsCounseling Applications Tier I Universal – All Students Positive Behavioral Support: Frequent recognition for appropriate behaviors, proximity control, cueing, build-in appropriate movement opportunities (e.g., Kagan Brain Ex.), predictable structure, positively-phrased and highly visible behavioral expectations. Embedded Social Curriculum: Instruction in prosocial behavior/attitudes. Data Screening: School-wide climate survey, ISS/OSS data, incidence mapping, rating scales for emotional risk and social skills (SSIS, BESS, SOS) Tier II Supplemental, Targeted, Short-Term Observations, FBAs, Behavior Plans: Classroom observations to determine environmental contributors, antecedents, sustaining factors, frequency, patterns across subjects or time-of-day and task demands, self-monitoring or reinforcement plans, DRCs Counseling: Social Skills, Anger Mgmt, Test Anxiety, Friendship Groups Data Progress Monitoring: Tier II data Behavior Plans & Counseling Therapy: Individualized, greater frequency and intensity, often addressing multiple issues simultaneously Multi-agency Plans: Coordinate w/out-side agencies on counseling, behavioral plans, meds, family therapy, juvenile justice, etc. Data Progress Monitoring: Psychological assessment, Tier III data Tier III Intensive, Individual, Long-Term

3. (Kendall & Hedtke, 2006)

4. Three Counseling Approaches • Three Counseling Approaches • Solution-Focused • Conflicts, personal goals • Psychoeducational • E.g., Teach social skills, teach study skills • Cognitive Behavioral Therapy • Anxious behaviors, anger management, grief management

5. Basic Protocol Formats • First Session • Intro, Rapport-Building, Confidentiality, Rules • Core Sessions Targeted Skills Curriculum • Last Session, Closure • Booster or Follow-up

6. Progress Monitoring Data Sources(Pre/Post/Weekly) • Behavioral Observations • FBA Data • Knowledge Surveys • Rating Scales • BASC-2 Self-report • BECK Youth Inventory • RCMAS • Outcome Rating Scales; Session Rating scales, etc. • Discipline Referral Rates • Work Completion Rates • Improved Grades • Absence/Tardy Rates • Single Subject Design • Daily Behavior Report Cards • SUDS

7. Solution-Focused Brief Therapy(SFBT) • Focus on what want to achieve (not past) • Focus how to obtain goal • Positive stated goals, measurable • Case study • Male, 6th grade, good grades • Prior counseling aggression, anxiety • Weekly sessions, 1 month CBT, 5 month SFBT (Sklare, 2005)

8. Solution Focused Brief Therapy (SFBT) 1. Miracle Question • If you woke up & miracle happened, all of your problems were fixed… 2. What is 1st sign miracle occurred? • What would be different? 3. If we videotaped you after the miracle happened • What would you be doing? (Sklare, 2005)

9. SFBT Cont’d • Miracle = Areas needing remediating • First sign of miracle = guides goal development • Discussed when the “miracle” has occurred • Builds positive thinking and reflection on when the student made behavioral changes (Sklare, 2005)

10. SFBT Cont’d Scaling Questions: • Rate progress of goals on Likert scale • Use scaling as discussion point • When score high--What is preventing you from lower score? When score low– What need to do to allow that to happen? Coping Questions: • Strengths - Actions - Goals • “Things must be difficult for you. How do you manage to do so well in school?” (Sklare, 2005)

11. Progress Monitoring Data

12. Social Skills Protocol:Psychoeducational Approaches • Basic Components: • Teach & Model Skill (Knowledge Deficit) • Role Play w/Feedback (Performance Deficit) • Practice-Practice (Fluency Deficit) • Review • Generalization (NASP, 2004)

13. Social Skills Protocol: Select Skill Deficits for Core Sessions • Four skill areas: • Survival Skills (respect, listening, following directions, boundaries) • Interpersonal Skills(express feelings, manners, sharing, turn-taking, nonverbal cues) • Problem-solving Skills (asking for help, apologizing, generate solutions) • Conflict Resolution Skills (dealing with teasing, peer pressure, assertion) (NASP, 2004)

14. Second-Step Program • Unit I: Empathy Training • Focus on building feeling vocabulary • Identifying physical and situational cues • Unit II: Emotion Management • Focus on three strategies: • Self-coaching (“Stay Calm”) • Deep (Belly) Breathing, • Cognitive Distractions (Counting)

15. Second-Step Program • Unit III: Problem-Solving • Step 1 - How do I feel? • Step 2 - What is the problem? • Step 3 – What can I do? • Prosocial behaviors and assertive “I” statements reinforced

16. Case Example • 3 Kindergarten Males Identified • Referral Concerns: • Impulsive • Inattentive • Oppositional • Pre-intervention Data • BASC-2 Behavioral and Emotional Screening System (BESS) Parent Rating Scales • Teacher Interviews

17. Case Example • Group Focus: • Empathy Training • Impulse Control • Problem-Solving • Weekly, 30 Minute Sessions

18. Case ExampleProgress Monitoring Data: Calming Strategies

19. Main CBT Components • Relaxation Training • Diaphragmatic (deep) breathing • Progressive muscle relaxation (PMR) • Cognitive Strategies • Reducing negative self-talk • Challenging unrealistic and dysfunctional thoughts • Considering different perspectives • Behavior Strategies • Behavioral exposures • Successive approximation • Problem-Solving Techniques

20. CBT for Childhood OCD

21. Anxiety-Reductive Compulsive Disorders • Marked by obsessive thoughts or impulses (i.e., intrusive thoughts, feelings that produce anxiety) and anxiety-reductive behaviors (compulsions). • Negative reinforcement (i.e., the removal of something aversive) reinforces compulsive behaviors

22. The Obsessive-Compulsive Cycle Obsessions Fear/Anxiety Reduction in Distress Compulsions Negative Reinforcement (Piacentini et al, 2006)

23. Ritual Cycle S U D S SUDS = Subjective Units of Distress (0-100) Storch, 2006

24. CBT Treatment Strategies • Psychoeducation • Conceptualization of OCD • Rationale for Treatment • Creation of Symptom Hierarchy • Exposure plus Response Prevention • Addressing Obsessions • Contingency Management (Piacentini et al, 2006)

25. Symptom Hierarchy Storch, 2006

26. OCD Thermometer • Make a OCD Thermometer (Subject Units of Distress Scale [SUDS]) • Create a list of events that cause rituals (easiest to hardest) • Be creative and ‘intense’ • Progress up that list slowly where the person does not engage in rituals. • Tackle things one at a time. • Don’t leave the situation until anxiety drops. • SUDS = Subjective Units of Distress (0-100 or 0-10) Storch, 2006

27. Exposure and Response Prevention • Patients are gradually exposed to anxiety-provoking stimuli while refraining (or prevented) from engaging in anxiety-reductive compulsive behaviors. • Avoid providing the child with reassurance (e.g., you wont get sick) or accommodating anxiety driven behaviors (e.g., I’ll open the door for you). • CBT with exposure and response prevention (ERP) is the best established psychological treatment for OCD (Abramowitz et al., 2005; Chambless et al., 1998)

28. Relevance of ERP in the schools • Can collaborate with other mental health professionals to facilitate treatments • Schools provide many opportunities to conduct exposures • For more information see: Sloman, G. M., Gallant, J., & Storch, E. A. (2007). A School-Based Treatment Model for Pediatric Obsessive-Compulsive Disorder. Child Psychiatry and Human Development, 38, 303-319.

29. Case Example • 10 yr-old male • Learning Disorder • ADHD • Autism Spectrum Disorder • OCD • Referral concerns: • Frustration • Compulsive Behaviors • Touching / Retouching • Cloth Picking

30. Case Example • Weekly CBT Sessions • Coping Strategies • Role Plays • Frustration Exposures • ERP for OCD symptoms • Graduated Exposures • Behavioral Management • Compliance Training • Contingency Reinforcement

31. Touching Exposures

32. Questions? ? ? ? ? ?

33. Resources: CBT Manuals CBT Free Online Treatment Manuals https://trialweb.dcri.duke.edu/tads/manuals.html Christner, R. W., Forrest, E., Morley, J., & Weinstein, E. (2007). Taking cognitive-behavior therapy to school: a school-based mental health approach. Journal of Contemporary Psychotherapy, 37, 175-183. Kendall, E C., Choudhury, M. A., Hudson,J, & Pc'ebb, A. (2002). The C.A.T. Project Manual Ardmore, PA: Workbook Publishing. Kendall, P. & Hedtke, K. (2006). Cognitive-Behavioral Therapy for Anxious Children: Therapist Manual (3rd ed). Ardmore, PA: Workbook Publishing. Nelson III, M. W., Finch, A. J., & Ghee, C. (2006). Anger management with children and adolescents. In P. Kendall (Ed.). Child and adolescent therapy: cognitive-behavioral procedures. New York, NY: Guilford. Stallard, P. (2002). Think good- Feel good: A cognitive behavioral therapy workbook for children and young people. Hoboken, NJ: John Wiley & Sons.

34. ResourcesCounseling Interventions & Curricula • ACHIEVE: A Collaborative School-based Reform Process, Howard Knoff, Social Skills, Conflict Resolution, Self Regulation, Positive School Climate, www.stopandthinksocialskills.com • Aggression Replacement Training, Mark Amendola, Anger Control, Aggression, Moral Reasoning Training www.aggressionreplacementtraining.org • I Can Problem Solve, Myrna Shure, Aggression, Emotionality, Withdrawal, Rejected www.researchpress.com • Intervention Central, Jim Wright, ADHD, Bullying, Defiance http://www.interventioncentral.org/ • Life Skills Training, Gilbert Botvin, Self-esteem, Social Skills, Substance Abuse, Social Anxiety, Peer Pressure, www.lifeskillstraining.com • On-Line Graphing Resources http://www.interventioncentral.org • PeaceBuilders, Michael Krupnick, Positive School Climate, Prosocial Behaviors, Conflict, Sibling Fighting, School Attachment, Peer Rejection www.peacebuilders.com • Peace Education Foundation, Conflict Resolution Programs, Peer Mediation, Crisis Management, http://www.peaceeducation.com/ • Primary Mental Health Project, Deborah Johnson, Mild Aggression, Withdrawal, Shyness, Anxious, Poor Classroom Adjustment, www.childrensinstitute.net • Second Step Prevention Curriculum, Committee for Children http://www.cfchildren.org/programs/ssp/overview/ • Skill Streaming, A. Goldstein & E. McGinnis, Prosocial Skills, Stress Coping, Friendship Building, Sharing http://www.skillstreaming.com/

35. References • Abramowitz, J. S., Whiteside, S. P., and Deacon, B. J. (2005). The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 36, 55-63. • Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits-Christoph, P., et al. (1998). Update on empirically validated therapies, II. Clinical Psychologist, 51, 3-16. • Kendall, P. C. (Ed.). (2006). Child and adolescent therapy: Cognitive–behavioral procedures (3rd ed.). New York: Guilford Press. • National Association of School Psychologists. (2004). Social skills: Building skills for success in school and life. Bethesda, MD: Author. • Piacentini, J., March, J., & Franklin, M. (2006). Cognitive–behavioral therapy for youth with obsessive−compulsive disorder. In P. C. Kendall (Ed.), Child and adolescent therapy: Cognitive–behavioral procedures (3rd ed., (pp. 297–321). New York: Guilford Press. • Sklare, G. B. (2005). Brief counseling that works: A solution-focused approach for school counselors and administrators . Thousand Oaks, CA: Corwin Press. • Sloman, G. M., Gallant, J., & Storch, E. A. (2007). A School-Based Treatment Model for Pediatric Obsessive-Compulsive Disorder. Child Psychiatry and Human Development, 38, 303-319. • Storch, E. A.(2006). Treatment of a patient with Obsessive-Compulsive Disorder. Journal of Family Practice, 55, 329-333.