Premier’s Special Education Scholarship
2009
THE PURPOSE OF THE SCHOLARSHIP
The reason for my visit was to investigate the Collaborative Problem Solving Model,
(CPS) a cognitive/ behavioural approach to working with young people with
Collaborative
Problem
Solving Model:
“kids do well if they can”……..
a different way of
understanding & working
with young people with
challenging behaviour
challenging and aggressive behaviour in the United States of America and Canada.
The scholarship allowed me to investigate the model directly with its founder Dr Ross
Greene as well as in a number of Child & Adolescent Inpatient Psychiatric Units,
Specialised Schools for students with Emotional and Behaviour Disorders and Health
Systems which have adopted and applied the model.
Another prime motivation for the visit was to gain an insight into the CPS model and
to
Keith Marshall, Principal Caldera School
NSW Department of Education & Training Scholarship 2009
follow up on recommendations that Ross Black, Principal of Rivendell SSP (1990 2009) made in his 2007 Churchill Scholarship. In particular Black’s recommendations
2 & 3;


staff in interdisciplinary facilities be trained in a common approach that
enhances collaboration and communication from the perspectives of each
discipline;
the need for ongoing monitoring and review of the processes, communication
structures and philosophy in interdisciplinary facilities if the culture is to be
maintained.
THE BACKGROUND TO THE COLLABORATIVE PROBLEM SOLVING
MODEL (CPS)
The Collaborative Problem Solving Model (CPS) was developed by Dr Ross Greene
over 10 years ago and has been articulated comprehensively in The Explosive Chid
and in his recent publication Lost at School.
Greene’s model is a cognitive behavioural approach and was first developed as a
treatment plan for young people and their families in an outpatient setting. Greene
found that in his clinical practice traditional cognitive/behavioural methods were
being driven from a clinical perspective and were not involving enough the young
person who was displaying social, emotional or behaviour problems.
The Collaborative Problem Solving Model (CPS) has continued to be developed and
conducted in a number of different settings throughout the USA, Canada and Sweden.
The underlying philosophy of The Collaborative Problem Solving Model (CPS) is
that“Kids do well if they can”. In essence it proposes that if young people have the
capacity/skills to cope with the demands of their environment they will adapt in a
functional manner. CPS proposes that if the child lacks the capacity /skills to cope
with the demands placed upon them, they are likely to display more maladaptive and
problematic behaviours.
The CPS model challenges the ‘motivational perspective’ that “kids do well if they
want to”. This ‘motivational perspective’ is based on a common perception that young
people with social, emotional and behavioural challenges have learnt to behave
inappropriately, to seek attention or to coerce adults into giving into their demands.
Typically the terminology applied to these young people is ‘manipulative’, ‘attention
seeking’, ‘unmotivated’, ‘disrespectful’, ‘coercive’ or ‘testing the limits’. As a
consequence interventions and strategies applied to these individuals have in the main
been ‘reward and punishment’ models, which aim to teach the young people to
behave appropriately and provide them with the necessary motivation to do so.
In the education sector this is delivered using strategies such as detention, suspension,
exclusions and level/reward systems. In therapeutic settings, such as Inpatient
Psychiatric Units, Residential Care and Juvenile Detention, strategies such as
confinement, seclusion and restraint (physical and chemical) have been used. Within
the family environment generally monetary or materialistic rewards or losses,
groundings and even corporal punishment are applied.
2
This ‘motivational perspective’ that “kids do well if they want to” currently underpins
the policy and procedure of many services, in particular in their behaviour
management practice and welfare procedures, which are based upon social leaning
theory and operant principles as a means of motivating the young person. (Mohr,
Olson, Martin & Pumareiga 2009).
THE COLLABORATIVE PROBLEM SOLVING MODEL (CPS)
The model, as developed by Greene, proposes that young people with challenging
social, emotional and behavioural issues should be viewed as presenting with a
disability in the same way others present with learning disabilities in reading, writing
and mathematics.
Greene emphasises that most people prefer to do well, as it is a better option than
doing poorly. However if a person lacks the skills to cope with the demands placed
upon them, they will act in a maladaptive and possibly challenging manner.
The CPS model conceptualises that aggressive and challenging behaviour of some
young people is characterised by lagging cognitive skills in the global domains of
flexibility, frustration, tolerance and problem solving.
The model provides a framework to understand the aggressive outbursts, as stemming
from impairments in one of the five non-mutually exclusive pathways:
 Executive functioning (including inattention, disorganised thinking and poor
handling of transitions);
 Language processing (such as expressive or receptive impairments including
difficulty in expressng feelings);
 Emotional regulation (including irritability, anxiety and distorted self
perception);
 Cognitive flexibility (such as concrete thinking & insistence on sameness and
rigid routines);
 Social skills (such as misreading interpersonal nuances and difficulty
appreciating the views of others)
(Martin, Kreig, Esposito, Stubbe & Cardona 2008
The Collaborative Problem Solving Model offers a distinct teaching and learning
framework of working with young people with challenging behaviour. Greene
believes that the key feature of the CPS model is for adults to assess the young
person’s lagging skills impairments and to ultimately teach specific skills to address
these issues, through working collaboratively with them. In CPS, working
collaboratively with the young person allows adults to listen to their views and
concerns, and in turn allows young people to become aware of the adult’s concerns.
Greene proposes that this method helps to develop a trust relationship between the
individuals as well as an agreed process of solving issues, particularly explosive
challenges, or at the very least, it will result in an improved mutual understanding.
This in turn will improve outcomes not only for the young person but for the services
providing them with support.
3
CPS has the potential to influence the way front line workers who manage young
people with challenging behaviour view a young person’s problems/issues.
Importantly CPS involves a common set of assumptions and language to understand
and work/teach with young people with challenging behaviour thus allowing multiple
professionals to converse through this approach as there is a similar language and
focus.
The approach may also have significant implications in providing young people and
staff with a safer working environment by reducing serious incidents, injury and
Occupational Health and Safety issues. The approach can offer a more humane way to
solve problems and teach the skills necessary to participate in a modern world, outside
of the support setting of the unit, school or community care, where negotiation is
paramount and valued.
THE STAGES OF THE COLLABORATIVE PROBLEM SOLVING MODEL
Stage One: Assessment
The CPS model has an assessment tool; Assessment of Lagging Skills and Unsolved
Problems (ALSUP).This tool focuses attention on the issues surrounding the young
person’s unsolved problems as well as their skills deficit. This assessment phase is the
key to understanding why the challenging behaviour is occurring.
Stage Two: Intervention
The Collaborative Problem Solving model offers a proactive and individualised
approach in working with challenging young people as it is tailored to take into
account each young person’s needs and ability to learn. This model moves away from
an adversarial atmosphere to an alliance of trust, in which mutual understanding can
be fostered.
The three steps of CPS are:
 Empathy: the adult develops an understanding of the young person’s
concerns and perspective on an unsolved problem. This requires engaging the
young person in talking about unsolved problems and the issues surrounding
those problems.

Defining the problem: the adult puts their concerns on the table for the young
person to hear. Adult concerns tend to revolve around safety issues and
learning issues and how the problem is impacting on others as well as the
young person themselves. At this stage only concerns are being discussed and
no plans or solutions are made.

Invitation: the adult invites a collaborative process so that both views can be
addressed and solutions generated with the young person’s concerns having
equal weighting to the adult’s.
4
Success in CPS takes time and it is critically important both that the young person
participates throughout the process and that this process takes place well before and
not during a challenging episode.
APPLICATION OF THE COLLABORATIVE PROBLEM SOLVING MODEL
CASE STUDY ONE
Child Assessment Unit at Cambridge Hospital Boston Massachusetts
The Child Assessment Unit at Cambridge Hospital is a 13 bed, locked inpatient
psychiatric unit for patients aged 3 -14 yrs. Approximately 80% of the patients
admitted have a significant trauma history and 95% were admitted for severe out of
control behaviour. Staffing consists of psychiatrists, psychologists, social workers,
occupational therapists, nursing and milieu counsellors. The average length of
admission in 2009 was 2 weeks.
The unit adopted the CPS model in 2001 as a result of the work of the unit Medical
Director, Dr Bruce Hassauk and Nursing Manager, Kathy Regan. The prime goal for
the adoption of the CPS model in the unit was to reduce the use of more restrictive
practices, such as restraint.
The Cambridge unit was the first to adopt the CPS model and it involved
comprehensive training of all staff, establishing
1. a common set of assumptions about the factors underlying young people’s
aggressive or unsafe behaviour,
2. an understanding of the manner in which limits are set and expectations
pursued by adults and how these in turn can precipitate such behaviour;
3. an emphasis being placed on crisis prevention rather than crisis management.
Research, undertaken by Greene, Ablon & Martin in 2006, indicated a significant
decrease in the rate of restraint and seclusion after the implementation of the CPS
model (9 months prior to training there were 281 episodes of restraint compared to 1
in the 15months after training). The use of physical holds under 5 minutes also
reduced. Injuries in the unit for both patients and staff also showed a dramatic
decrease dropping from 10.8 per month to 3.3 post training.
As well as visiting the day school during my visit, I also attended clinical meetings,
planning meetings, an occupational therapists’ session and had individual and group
discussions with key multidisciplinary personnel, including Kathy Regan.
In the course of these discussions it became clear that one of the most unexpected
outcomes of the adoption of the CPS model was staff dynamics. Kathy Regan
explained, “The culture of the unit itself became more collaborative.”
CPS has also resulted in staff having a similar set of assumptions and language
regarding the factors underlying aggressive outbursts. This allows for very practical
assessment and ongoing communication during a patient’s short admission and allows
for the commencement of skills training for the young person within the unit and the
5
development of a comprehensive and clear discharge plan for that young person into
the community.
CASE STUDY TWO
The Yale-New Haven Children’s Hospital and Study Center, Connecticut USA
The Yale-New Haven Children’s Hospital is part of Yale University School of
Medicine and has an inpatient psychiatric unit of 15 beds for students from 4 - 14 yrs
of age. Attached to this unit is the Yale Child Study Center which provides
educational programs to students in the unit as well as to students attending the Partial
Hospital Program as day patients. The unit has a large multidisciplinary team
consisting of psychiatrists, psychologists, social workers, occupational therapists,
nursing and milieu counsellors as well as teaching and support staff from the Yale
Study Center. The Inpatient Psychiatric Unit has about 200 admissions in a year with
an average length of stay of between 3-4weeks.
With growing concerns about the use of restraint and other restrictive practices in
Psychiatric Inpatient Units following the death of a young patient in Connecticut, The
Yale-New Haven Hospital Inpatient Psychiatric Unit decided in September 2005 to
adopt the CPS model primarily as a means of decreasing restrictive interventions.
Although CPS was not designed specifically for this purpose it was thought that the
experiences at the Cambridge Unit in Boston would see fewer and shorter restraints
and seclusions and no compromise in patient safety.
The Model was implemented over a six month period with comprehensive staff
training and follow up video supervision sessions with the developers of the CPS
model twice per week for 90mins. Research undertaken over a 5 year period on the
adoption of the CPS model by Martin, Kreig, Esposito, Stubbe and Cardona, showed
a significant reduction in the use of restraint. In fact there was a 37.6 fold reduction in
restraint and 3.2 fold reduction in seclusion while the mean duration of restraint also
decreased substantially.
Discussions during my 5 day visit reinforced the findings of research undertaken by
Martin et al, which found that the CPS model has merit in being adapted to a variety
of settings that deal with aggressive and volatile young people including paediatric
wards, special schools, residential schools, juvenile justice settings or paediatric
emergency services
CASE STUDY THREE
The Children’s Hospital of Eastern Ontario Canada (CHEO)
The CHEO Mental Health Services provides a wide range of clinical services
including:



A centralised intake process to provide a single point of entry
Specialised Outpatients & Outreach Service
Regional Psychiatric Emergency services for Children and Youth
6





Eating Disorders program Inpatient/Outpatient
Inpatient Psychiatric Units
Partnership Day Programs with both English & French School Boards
Health promotion and Early Intervention Services
Telepsychiatry Services.
The CHEO partnership programs with the English & French School Boards are
designed to support young people with severe mental health needs which interfere
with attendance and functioning at their regular schools. These day treatment
programs are delivered in partnership with the various school boards and are usually
located within a mainstream school.
I visited three of these programs during my five day visit including the Steps to
Success program (pre and primary school), ack on Track program (high school) and
the Brookfield’s Day program (senior high school). These programs have a
multidisciplinary approach with the staff including psychiatrists, psychologists, milieu
counsellors, teachers and allied education staff.
The Collaborative Problem Solving model has also been adopted by the Mental
Health Patient Service Unit at the CHEO both the 6 North Psychiatric Inpatient Unit,
an 8 bed facility for young people aged 5-11 yrs and the Steps to Success treatment
program, based in a community school for students aged 4-13yrs with complex
behaviour and emotional problems. In late 2009 the 6 East Psychiatric Inpatient Unit,
a 12 bed facility for young people aged 12-15, completed CPS training and is
currently in the process of embedding the model in the program. In 2010 the inpatient
services at the Royal Ottawa Mental Health Care Centre a 10 bed psychiatric unit for
young people aged 15-18 and the Francophone Day treatment program will both
receive training.
CASE STUDY FOUR
The Community of Practice Model for Collaborative Problem Solving, Ottawa
Community of Practice partners includes Crossroads Children's Centre, Children's
Hospital of Eastern Ontario/Royal Ottawa Hospital, Roberts/Smart Centre,
Coordinated Access, Youth Services Bureau, Cornwall Hospital, Christie Lake Camp,
Algonquin College Child and Youth Worker Program, and the Ottawa District School
Board (Safe Schools Program).
In 2007 the Child and Youth Mental Health Network in Ottawa (CYMHN) set out to
evaluate how they were progressing as a system of care for the complex needs
children and families. After completing the System of Care Practice Review
(SOPCR), the network identified a number of areas of practice and delivery that
needed to be addressed. In particular they identified the need to create a more
common treatment approach across providers so that the transition between services
for the children and families was more effective and less confusing. They also wanted
to introduce a common communication model for all providers using similar
language, focus and goals.
7
Observing what had occurred in Oregon USA, where a State funded and sponsored
training in the CPS model resulted in it being utilised in a number of care facilities,
CYMHN adopted the CPS model in 2009 across all services.
CASE STUDY FIVE
The Provincial Centre of Excellence for Child and Youth Mental Health at
CHEO
The Provincial Centre of Excellence for Child and Youth Mental Health at CHEO is
an innovative response to the challenges facing Mental Health Services. There is a
high incident of mental health disorders among young people and very few of these
young people access services. The centre identifies and builds on existing pockets of
excellence across the state of Ontario and services these programs and communities
with training and financial support, including work with the remote indigenous
communities and with range of newly arrived immigrants. The centre provides a
foundation on which a more cohesive and effective system can be developed through
quality research to respond to the needs of the community.
OTHER VISITS
Collaborative Problem Solving Seminar Concord New Hampshire (One day)
A one day workshop conducted by Dr Ross Greene, which highlighted the philosophy
and the process of the CPS model. The workshop was primarily attended by primary
and junior high school staff. However there were a number or special schools and
clinicians in attendance.
Walker Programs Boston USA (One day visit)
Walker is a network of facilities and professionals that provides world-class mental
health services, state-of-the-art special education, expert professional training and
consultation, and child welfare advocacy.
Each year, Walker provides intensive services for hundreds of the most troubled
children, youth and families in Boston (USA). Walker's multidisciplinary programs
extend specialised therapeutic environments beyond the classroom and into family
homes, public schools and community settings.
Beacon High School Boston USA (One day visit)
Beacon High School is a co-educational therapeutic alternative high school that
provides academic and specialised therapeutic programs. The programs include
individual and group sessions for 70 students aged between 15-20yrs in the greater
Boston area and is associated with the Walker programs. The staff includes teachers,
teaching support staff, psychologists, psychiatrists and career counsellors.
The students at Beacon High suffer serious emotional problems or mental illness,
mainly anxiety or depression based. Students spend approximately 2 years in the
program with many students progressing onto college programs. The program
8
maintains a student retention rate of 80% and a graduation rate of 80%. There is a
strong emphasis on the creative and performing arts within the school.
Think: Kids Center Boston USA (One day visit)
Think: Kids is a program in the Department of Psychiatry at the non-profit
Massachusetts General Hospital. It provides clinical services to families and
training, consultation, support and outreach to parents, educators, and clinicians using
the Collaborative Problem Solving approach. The centre is providing the training and
ongoing supervision to the Ottawa Community of Practices as well as in the state of
Oregon.
CONCLUSION
The Collaborative Problem Solving model provides an alternate means of viewing,
understanding and supporting young people with social, emotional and behavioural
challenges. This approach challenges some of the conventional views and systems of
management that exist in our society.
The CPS model has been actively researched and the empirical data and research
published in mental health journals across a variety of settings and locations show
promising results. The CPS model is of potential value to facilities providing care,
support and education to young people including Education, Health, Community
Services, and Juvenile Justice as well as to parents.
Within Education it has been well documented that students with significant social,
emotional and behaviour issues impact on the school system causing disruption; on
the school environment; on their own learning and engagement; as well as on staff
and other students.
The New South Wales Department of Education and Training has been responsive to
these issues in various ways and has developed a number of innovative strategies and
programs to support these young people including Specialised Schools and Tutorial
programs and recently the Positive Behaviour and Learning program for staff.
However the Collaborative Problem Solving model offers a new and researched
approach which potentially could be of relevance to the teaching profession in
working with young people with challenging behaviours.
9
References
Greene, R. W. (2001) The explosive child: A new approach for understanding &
parenting easily frustrated, chronically inflexible children (3rd ed.).New York: Harper
Collins.
Greene, R. W. (2009) Lost at School: Why our kids with behavioural challenges are
falling through the cracks & how we can help them (Revised 2nd edition). New York:
Scribner.
Greene, R. W., & Ablon J.S. (2006) Treating explosive kids: The collaborative
problem solving approach. New York: The Guilford Press.
Greene, R.W., & Ablon J.S., & Goring, J.C., (2003) A transactional model of
oppositional behaviour: Underpinnings of the collaborative problem solving
approach. Journal of Psychosomatic Research, 55, 67-75.
Greene, R.W., Ablon J.S., Hassuk B., Regan K., & Martin A., (2006). Use of
collaborative problem solving to reduce seclusion & restraint in child & adolescent
inpatient units. Psychiatric Services 57, 610-612.
Greene, R.W., Monuteaux, M., C., Goring, J. C., Henin, A., Raezer-Blakely, L.,
Edwards, G., Markey, J., & Rabbitt, S., (2004). Effectiveness of Collaborative
Problem Solving in affectively Dysregulated Children with Oppositional- Defiant
Disorder: Initial Findings. Journal of Consulting and Clinical Psychology 72, No 6,
Martin, A., Kreig, H., Esposito, F., Stubbe, D., & Cardona, L., (2008). Reduction of
Restraint and Seclusion through Collaborative Problem Solving: A Five-Year
Prospective Inpatient Study. Psychiatric Services 59, No 12, 1406-1412
Mohr, W.K., Martin, A., Olson, J. N., Pumariega, A.J., Branca, N., (2009). Beyond
point and level systems: Moving towards child-centred programming. American
Journal of Orthopsychiatry 79 No1, 8-18.
Regan, C., (2006).Opening our arms: Helping troubled kids do well. Boulder, CO:
Bull Publishing.
Acknowledgement
Premier of New South Wales
John Brown, Tourism Foundation
Staff of the Scholarship Directorate NSW Department of Education and Training
Dr Ross Greene, Founder of the Collaborative Problem Solving Model
Mr Ross Back, Principal Rivendell SSP (1990-2009)
Ms June Simpson, School counsellor Rivendell SSP
Dr Andres Martin, Director Inpatient Psychiatric Unit Yale New Haven Hospital
Dr Mary Gunsalus, School Director Yale Child Study Center School
Dave Murphy, Case Coordinator, 6 North Inpatient Psychiatric Unit CHEO
Michael Hone, Director Clinical Services Cross Roads Program Ottawa
10