Effectively Working with
Disruptive Behaviors
Amy Gallagher, Psy.D., Program/Training
Director Psychology Internship
As presented by:
The Integrated Psychotherapy Consortium
TODAY’S AGENDA
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Welcome/ Introductions
EBP Background
Logistically….how? (EMR/ CCARs/ Etc.)
Orientation to Model
Breakout Sessions for Role Play
Supervision and Post Training
Wrap-up
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
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)
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
SESSION STRUCTURE
• Engagement
• Review
– Homework
– Parent O Meter
• Set Agenda
• Complete Skill
– Discussion
– Practice
– Role Play
• Assign therapeutic homework
• Check-out
SETTING IT UP
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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
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Write agenda items on chart
Cover session topic
Assign therapeutic homework
Check-out
SESSION 1: RAPPORT BUILDING
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Rapport Building
Trauma and Behaviors
Introduction to Intervention
Practice Goal Setting (Goal Worksheet)
Homework Expectations
• Helpful Hint- you are already doing this!
SESSION 2
Basic Social Learning, Tracking and
Improving the Parent-Child Relationship
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
SESSION 2:GOAL SETTING WITH
CHILDREN
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Children constantly set goals
“What would make your life better?”
Goals need to make sense
Focus on Long and Short Term goals
THE GOAL LINE
POINTS SYSTEM FOR GOALS: PRICE
LIST
Item
Points
Pencils, markers
2
Stickers
2
Toys
4
Baseball cards
8
Video games
12
ITunes Download
15
Cool shoes/clothes
30
• Have a set of small,
changing items to
provide quick rewards
for behavior change
• Have larger rewards
to encourage delay of
gratification and
planning
COMMON GOAL SETTING
CHALLENGES WITH CHILDREN
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Forgetting about goal
Not taking responsibility
Lacking motivation
Sense of failure
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
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
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!
SESSION 2: PRAISE
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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
HOMEWORK/HANDOUTS
HOMEWORK/HANDOUTS
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
PARENT-O-METER
SESSION 3
The Parent-Child Relationship, Ignoring
Minor Disruptive Behavior
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
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
Keeping Special Time Special
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
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
Session 3: IGNORING
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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
HANDOUT/HOMEWORK
SESSION 3: WRAP UP
• Summarize main points from session
• Assign homework:
– Behavior Tracking Form
– Scheduling Special Time
• Encourage “catch your child being good”
SESSION 3: HANDOUTS
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Keeping Special Time Special
Special Time Worksheet
Ignoring: An Effective Strategy
Techniques of Praise and Ignoring
Behavior Tracking Form: Praise and
Ignoring
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
SESSION 4
Giving Effective Instructions to Children
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”)
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
SESSION 4: HANDOUTS
• Giving Good instructions to your Children
• And Life Can be Humorous… Really Funny
Instructions that Won’t Work (I and II)
SESSION 5
Establishing Rules and Expectations
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
SESSION 5: HANDOUTS
• Behavior Rules and Expectations
• Establishing Behavior Rules and
Expectations
• Household Rules and Expectations
• Behavior Tracking Forms
– Behaviors Rules
– Expectations
Session 6
Anger Management (could be presented in
multiple sessions)
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
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
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
ANGER THERMOMETER
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”
ANGER WORDS
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
COPING STATEMENTS
ANGER THERMOMETER RECORD
SESSION 6: HANDOUTS
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Feeling Chart
Anger Thermometer
Words of Anger
Coping Statements
Anger Thermometer Record Forms
SESSION: 7
Problem Solving:
PICC Model
SESSION 7: PICC MODEL
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PI= Problem Identification
C= Identify Choices
C= Identify Consequences
Choose Solution
PROBLEM SOLVING- PICC MODEL
PROBLEM SOLVING WORKSHEET
PROBLEM SOLVING- THE BASICS
SESSION 7: HANDOUTS
• Problem Solving- PICC Model
• Problem Solving Worksheet
• Problem Solving- The Basics
YOUR TURN
• Use the PICC Model to solve a problem
based on one of your current clients
• Use the worksheet to identify basic
problem solving skills
PHASE II
• Check-in about progress
• Make decisions about next few sessions
– Which ones?
– Which order?
– Explore other issues (e.g., depression,
assertiveness, relaxation, learning)
– Discuss graduation (termination)
• Indications for further treatment
• Discuss w/ clients, parents, supervisors
PHASE II
• Child-focused sessions include:
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Social Problem Solving I (Session 8a)
Social Problem Solving II (Session 8b)
Anger Management II (Session 9)
Organizational & Study Skills (Session 10)
• Parent/ Family-focused sessions include:
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Use of Consequences: Discipline and Rewards (Session 11)
Introducing a Token Economy System (Session 12)
Home Token Economy II (Session 13)
Response Cost Program (Session 14)
SESSION 8
Social Problem Solving I & II
SESSION 8
• These Boys Have a Problem Worksheet
– Discuss how to solve the social problem using
the PICC method
– Help child solve relevant social problems
– Continue working on problem solving if
needed through other methods until skill is
solidified
SESSION 9
Anger Management & Abdominal Breathing
SESSION 9
• Review of physiological signs of anger
• Review use of Anger Thermometer
• Practice Abdominal Breathing (worksheet)
– May be enhanced by other breathing methods
• Could be conducted directly after Session
6
SESSION 10
Organizational & Study Skills
SESSION 10
• Help child & family understand the
importance of organization & study skills
• Assess knowledge of both through
experiential games
– Category Game
– Positive/Negative Study Skills
• Decide upon positive study skills for child
SESSION 10: HANDOUTS
• Study Skills for School
• Homework Contract
• Alternative Contract
SESSION 11
Use of Consequences, Discipline, & Rewards
SESSION 11
• Designed to be “parent only”
• Could be follow-up/adjunct to earlier
sessions
• Defines punishment & when to use it
• Provides rules for “good punishment”
• Includes Time-Out Guidelines
SESSION 11: HANDOUTS
• Punishment Concepts
• Time-Out
• Time-Out Worksheet
SESSION 12
Family Problem Solving
SESSION 12
• Uses the PICC model within the family
• Expands the PICC worksheet to include a
family commitment for implementation
SESSION 13
Family Communication: Building &
Adapting Structures for Long-Term
Planning Needs
SESSION 13
• Provides structure for positive family
communication
• Assists with organizing a family meeting
• Utilizes positive communication skills to
negotiate the logistics of family meetings
• Provides support to create a contract for
social outings (Four W’s & an H!)
– Who, What, Where, Where, How
SESSION 14
Family Communication: Building &
Adapting Structures for the Long-Term
Planning Needs
SESSION 14: TERMINATION
• Graduation
– Finish Line Handout
– Reactions & feelings about the program and about
ending
– Skill Review
– Improvements noted?
– How was the child supported?
– What did the child learn?
– Advise parents to keep all handouts for future use
– Share final regards, regrets, and appropriate
feelings
GRADUATION & BEYOND
• Discuss skill maintenance
• Discuss (expected) setbacks
– What can you do? (e.g., problem solving,
outside help, therapy, etc.)
• Identify community/school resources
THE NEXT STEP
• Choose 2 cases to use Model
• Set up Supervisory or Group Consultation
• Create method for tracking progress
– PGQ
Parent Guardian Questionnaire
CWRMH IMPLEMENTATION
• Registered in Program in ECR
– Multimodal Therapy Program
• Onset, Quarterly, & Graduation
– CCARs completed
– PGQ Completed and Scanned
• Monthly phone call supervision/consult
– Discussed engaging difficult families,
brainstorming ideas, successes
WRAP-UP
• Final discussion
• Final questions
Thanks for participating!!
CONTACT INFORMATION
Amy Gallagher, Psy.D
Program/Training Director Psychology
Internship
Colorado West Regional Mental Health, Inc.
515 28 ¾ Road, Bldg. A
Grand Junction, CO 81501
– (970) 683-7078
– agallagh@cwrmhc.org