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![Page 1: Effectively Working with Disruptive Behaviors Amy Gallagher, Psy.D., Program/Training Director Psychology Internship As presented by: The Integrated Psychotherapy.](https://reader038.fdocuments.in/reader038/viewer/2022110321/56649cf95503460f949ca5d8/html5/thumbnails/1.jpg)
Effectively Working with Disruptive
BehaviorsAmy Gallagher, Psy.D.,
Program/Training Director Psychology Internship
As presented by:The Integrated Psychotherapy
Consortium
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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
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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
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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)
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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
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SESSION STRUCTURE
• Engagement• Review
– Homework– Parent O Meter
• Set Agenda• Complete Skill
– Discussion– Practice– Role Play
• Assign therapeutic homework• Check-out
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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
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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!
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SESSION 2
Basic Social Learning, Tracking and Improving the Parent-Child
Relationship
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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
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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
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THE GOAL LINE
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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
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COMMON GOAL SETTING CHALLENGES WITH CHILDREN
• Forgetting about goal• Not taking responsibility• Lacking motivation• Sense of failure
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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
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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
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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!
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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
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HOMEWORK/HANDOUTS
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HOMEWORK/HANDOUTS
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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
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PARENT-O-METER
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SESSION 3
The Parent-Child Relationship, Ignoring Minor Disruptive Behavior
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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
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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
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Keeping Special Time Special
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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
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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
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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
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HANDOUT/HOMEWORK
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SESSION 3: WRAP UP
• Summarize main points from session• Assign homework:– Behavior Tracking Form– Scheduling Special Time
• Encourage “catch your child being good”
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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
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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
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SESSION 4
Giving Effective Instructions to Children
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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”)
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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
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SESSION 4: HANDOUTS
• Giving Good instructions to your Children
• And Life Can be Humorous… Really Funny Instructions that Won’t Work (I and II)
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SESSION 5
Establishing Rules and Expectations
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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
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SESSION 5: HANDOUTS
• Behavior Rules and Expectations• Establishing Behavior Rules and
Expectations• Household Rules and Expectations• Behavior Tracking Forms– Behaviors Rules– Expectations
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Session 6
Anger Management (could be presented in multiple sessions)
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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
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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
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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
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ANGER THERMOMETER
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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”
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ANGER WORDS
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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
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COPING STATEMENTS
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ANGER THERMOMETER RECORD
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SESSION 6: HANDOUTS
• Feeling Chart• Anger Thermometer• Words of Anger• Coping Statements• Anger Thermometer Record Forms
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SESSION: 7
Problem Solving:PICC Model
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SESSION 7: PICC MODEL
• PI= Problem Identification• C= Identify Choices• C= Identify Consequences• Choose Solution
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PROBLEM SOLVING- PICC MODEL
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PROBLEM SOLVING WORKSHEET
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PROBLEM SOLVING- THE BASICS
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SESSION 7: HANDOUTS
• Problem Solving- PICC Model• Problem Solving Worksheet• Problem Solving- The Basics
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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
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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
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PHASE II
• Child-focused sessions include:– 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:– 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)
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SESSION 8
Social Problem Solving I & II
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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
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SESSION 9
Anger Management & Abdominal Breathing
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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
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SESSION 10
Organizational & Study Skills
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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
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SESSION 10: HANDOUTS
• Study Skills for School• Homework Contract• Alternative Contract
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SESSION 11
Use of Consequences, Discipline, & Rewards
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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
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SESSION 11: HANDOUTS
• Punishment Concepts• Time-Out• Time-Out Worksheet
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SESSION 12
Family Problem Solving
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SESSION 12
• Uses the PICC model within the family
• Expands the PICC worksheet to include a family commitment for implementation
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SESSION 13
Family Communication: Building & Adapting Structures for Long-Term
Planning Needs
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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
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SESSION 14
Family Communication: Building & Adapting Structures for the Long-
Term Planning Needs
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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
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GRADUATION & BEYOND
• Discuss skill maintenance• Discuss (expected) setbacks–What can you do? (e.g., problem
solving, outside help, therapy, etc.)
• Identify community/school resources
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THE NEXT STEP
• Choose 2 cases to use Model• Set up Supervisory or Group
Consultation• Create method for tracking progress– PGQ
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Parent Guardian Questionnaire
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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
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WRAP-UP
• Final discussion• Final questions
Thanks for participating!!
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CONTACT INFORMATION
Amy Gallagher, Psy.DProgram/Training Director Psychology
InternshipColorado West Regional Mental
Health, Inc.515 28 ¾ Road, Bldg. AGrand Junction, CO 81501– (970) 683-7078– [email protected]