Effectively Working with Disruptive Behaviors

1. Effectively Working with Disruptive Behaviors Amy Gallagher, Psy.D., Program/Training Director Psychology Internship As presented by: The Integrated Psychotherapy Consortium

2. TODAY’S AGENDA • Welcome/ Introductions • EBP Background • Logistically….how? (EMR/ CCARs/ Etc.) • Orientation to Model • Breakout Sessions for Role Play • Supervision and Post Training • Wrap-up

3. EBP VS. REALITY • Differences between Evidence Based Practice AND Practice Based Evidence • Making it fit… • Being Creative… • 90 minutes vs. 60 minutes • Kiddos vs. Parents vs. Both

4. TARGET POPULATION • Ages 6 to 16 • Mild to Moderate distress and symptomology • Oppositional Defiant, ADHD, Disruptive Bx Spectrum • Behaviorally focused for parents and youth • Contraindicated: • Severe trauma • Severe mental illness • Lower functioning Autistic Spectrum Disorders (ASDs)

5. INTERVENTION DESIGN & STRUCTURE • Phase I (Sessions 1-7) • Introduction • Basic skills development • Problem solving • Phase II (Sessions 8-14-ish) • Enhancing skills and strategies • Addressing additional situations & difficulties • Graduation

6. SESSION STRUCTURE • Engagement • Review • Homework • Parent O Meter • Set Agenda • Complete Skill • Discussion • Practice • Role Play • Assign therapeutic homework • Check-out

7. SETTING IT UP • Welcome parents and youth to session • Assess reactions to last meeting • Review goals briefly • Create Agenda • What issues would you like to discuss? • Any experiences you’d like to share • Write agenda items on chart • Cover session topic • Assign therapeutic homework • Check-out

8. SESSION 1: RAPPORT BUILDING • Rapport Building • Trauma and Behaviors • Introduction to Intervention • Practice Goal Setting (Goal Worksheet) • Homework Expectations • Helpful Hint- you are already doing this!

9. SESSION 2 Basic Social Learning, Tracking and Improving the Parent-Child Relationship

10. Session 2: AGENDA • Skills Building/Practice with Parent and Child • Goal Setting with the Child • Basic Social Learning: The ABC Model • Positive Consequences for Positive Behavior • Tracking and Labeling Behavior

12. SESSION 2:GOAL SETTING WITH CHILDREN • Children constantly set goals • “What would make your life better?” • Goals need to make sense • Focus on Long and Short Term goals

13. THE GOAL LINE

14. POINTS SYSTEM FOR GOALS: PRICE LIST • Have a set of small, changing items to provide quick rewards for behavior change • Have larger rewards to encourage delay of gratification and planning

15. COMMON GOAL SETTING CHALLENGES WITH CHILDREN • Forgetting about goal • Not taking responsibility • Lacking motivation • Sense of failure

16. COMMON GOAL SETTING CHALLENGES FOR ADULTS • Believing goals are too easy • Difficulty understanding the importance of shaping new behavior in small steps • Believing child is reinforced for negative behaviors • Disrupting home/school tasks

17. GOAL SETTING: SOLUTIONS • Use reminder cards or stickers • Provide positive social reinforcement and feedback • Set less challenging goals • Ask for suggestions from parents (& kiddos!) • Encourage parent comments

18. SESSION 2: BASIC SOCIAL LEARNING THEORY • The ABC model: • A=Antecedents • B= Behavior • C= Consequences • Behavior is influenced by: • Antecedents • Consequences • Becoming aware of how parents provide A’s and C’s is important!

19. SESSION 2: PRAISE • Positive Consequences for Good Behavior • Ask parents to provide examples • “Catch your Child Being Good” • Types of Praise • Labeled Praise- identifies specific child Bx • Unlabeled Praise- is positive but not specific

20. HOMEWORK/HANDOUTS

21. HOMEWORK/HANDOUTS

22. HOMEWORK/HANDOUTS • Social Learning Theory • Tracking and Labeling Behavior • Parent Report of Child’s Behaviors • Behavior Tracking Form • Praise • The Power of Praise • Tracking & Praising Your Child’s Behavior • Parent-O-Meter

23. PARENT-O-METER

24. SESSION 3 The Parent-Child Relationship, Ignoring Minor Disruptive Behavior

25. SESSION 3: PARENT CHILD RELATIONSHIPS • Engagement/Check in • Review homework/handouts & Set Agenda • ABC Model, Behavior Tracking, & Praise • Goal Line and rewards • Parent-O-Meter • Discuss any challenges with tracking • Teach & practice skills • Wrap-up

26. SESSION 3: SPECIAL TIME • Present Parent – Child Special Time Handout • To maintain close positive contact • To have a protected positive time together • Brainstorm ideas about a special time activity • Spend 10-15 min. a day in Special Time • Do not criticize or discuss problems during Special Time • Praise child often during Special Time • Allow child to choose the activity-parents participate with child • Record on Special Time worksheet

27. Keeping Special Time Special

28. SESSION 3: IGNORING • Ignoring Minor Disruptive Behavior • Behavior that is annoying Not dangerous • Substitute for “overreactions” by parent • Scolding and reprimanding is Not ignoring • Ignoring means stopping all communication • Avoid speaking or looking at the child • Negative child behavior may escalate initially • After ignoring, “catch your child being good” and praise the next good behavior

29. SESSION 3: IGNORING • Role Play Ignoring • Clinician plays “Parent” & parent plays “Child” • Role-play “Parent” pulled into an argument • Role-play “Parent” ignoring child’s argument • Validate difficulty ignoring escalating child

30. Session 3: IGNORING • Ask parents what they thought of role-play • Handout: Tracking Praise & Ignoring • Parent identifies 3 Bx to ignore on sheet • Ask Parent to track for 2 weeks

31. HANDOUT/HOMEWORK

32. SESSION 3: WRAP UP • Summarize main points from session • Assign homework: • Behavior Tracking Form • Scheduling Special Time • Encourage “catch your child being good”

33. SESSION 3: HANDOUTS • Keeping Special Time Special • Special Time Worksheet • Ignoring: An Effective Strategy • Techniques of Praise and Ignoring • Behavior Tracking Form: Praise and Ignoring

34. YOUR TURN! • Each group will be assigned a session • Learn a skill from Sessions 4 or 5 • Understand the worksheets • Create a short role play to present

35. SESSION 4 Giving Effective Instructions to Children

36. SESSION 4: GIVING EFFECTIVE INSTRUCTIONS • Instructions that Work • “Instructions” are Antecedents in the ABC Model. They precede the child’s behavior, compliance, or noncompliance • Considerations in giving good instructions • Is the instruction important? • Are you willing to follow through if the child noncomplies? • Consider the timing of instructions • Treat children with respect (pleasant tone of voice; saying “Please”)

37. SESSION 4: INEFFECTIVE INSTRUCTIONS • Misguided Instructions • Buried or Interrupted Instructions- • The adult keeps talking • Question Instructions- • Instruction is given as a question • Chain Instructions- • Too many instructions given once • Repeated Instructions- • Repeating the same instruction over, and over, and over again • Vague Instructions- • The instruction is unclear • Let’s Instructions- • The instructions begins with “Let’s” • Distant Instructions- • The instruction is shouted from a distance

38. SESSION 4: HANDOUTS • Giving Good instructions to your Children • And Life Can be Humorous… Really Funny Instructions that Won’t Work (I and II)

39. SESSION 5 Establishing Rules and Expectations

40. SESSION 5: RULES & EXPECTATIONS • Rules vs. Expectations • Rules • Decrease Bx (hitting, fighting, swearing) • Always followed • No warnings, just consequences • Expectations • Good behaviors/chores • Age appropriate

41. SESSION 5: HANDOUTS • Behavior Rules and Expectations • Establishing Behavior Rules and Expectations • Household Rules and Expectations • Behavior Tracking Forms • Behaviors Rules • Expectations

42. Session 6 Anger Management (could be presented in multiple sessions)

43. SESSION 6: ANGER CONTROL • Identify physiological cues of anger & other feelings • Identify anger levels the child experiences • Discuss triggers for anger and introduce idea of learning to cope with anger • Brainstorm with child coping skills for each level of anger

44. SESSION 6: CLINICIAN HINTS • Children may have difficulty seeing a range of emotional arousal • Children may become highly emotionally aroused when thinking about their anger triggers • Children may have difficulty identifying triggers • Anger may be masking other emotional states (anxiety; depression) • Children may have very limited sense of coping responses

45. ANGER AWARENESS: PHYSIOLOGICAL CUES • Awareness of Signs of Anger • Facial expression • Tone of voice • Body Position/ Movement • Internal Body States • Increased Heart rate, Rapid Breathing • Feeling Flush, Sweating Palms • Tight Muscles, Clenched Fists

46. ANGER THERMOMETER

47. ANGER AWARENESS • Using thermometers, children label own levels of anger and triggers at each level • Can better problem solve at low to moderate levels of anger • Aggressive children tend to report their anger in “on-off” terms as “angry” or Not-angry”

48. ANGER WORDS

49. ANGER MANAGEMENT TRAINING • Key points: • Easier to cope if we don’t feel so angry • How can we reduce our feelings of anger? • Distraction- Focusing attention in something else (e.g., fun things to do later in the day) • Deep breathing • Self instruction or self- statements

50. COPING STATEMENTS