Treating Explosive Kids

Part 1

The Collaborative

Problem-Solving Approach

Drew Burkley Psy.D.

Center of Excellence

Clinical Psychologist

Andrew.Burkley@Cherokeehealth.com

Authors

Ross W. Greene, PhD

Director of the Collaborative Problem Solving Institute

Associate Professor in the Department of Psychiatry, Harvard

Medical School

J. Stuart Ablon, PhD

Director of Think:Kids, Department of Psychiatry,

Massachusetts General Hospital,

Associate Professor in the Department of Psychiatry, Harvard

Medical School

Location

Collaborative Problem Solving Institute

Department of Psychiatry of Massachusetts General

Hospital

http://www.explosivechild.com

Thanks to...

Gloria Jones, Psy.D.

Sasha Ahmed, M.S.

Scott Browning, Ph.D.

The Need For a

New ParadigmHave you experienced this?

Typical Protocol

Parent Management Training

Teaches contingency and consistency

Establishes a list of target behaviors with compliance as the goal

Establishes a menu of rewards and punishments

Develops a currency system to track the child’s progress

Problems with

Parent Management

Research supports this technique, however there are also many limitations

It may not be well suited to the needs of those

responsible, as evidenced by a high drop-out rate

and noncompliance

Changes in oppositional behavior are not

statistically significant

Problems with

Parent Management

Most studies have not included clinically referred children

As a result, the following can be concludedThere is a low percentage of substantial gain from this

technique

Alternative treatments that address the needs of explosive children and caretakers are needed

How do we label children and

adolescents?

Many labels have been used to describe “children”

Defiant, aggressive, angry, non-compliant, challenging

They have also been given a number of diagnoses

Oppositional defiant disorder, conduct disorder,

intermittent explosive disorder

“Explosive” children and

adolescents?

The term “explosive” will be used in this presentation

because it is a common theme among all the

descriptions and diagnoses

Explosive children does not

mean exact children….

Understanding the factors underlying a specific

child’s explosive behaviors directly influences the

selection of interventions employed to address

those behaviors.

Intervention options are most effective when they are designed with the needs of each individual are considered.

What makes CPS different?

Assumes that explosive children are poorly understood and are often poorly addressed by available therapies

For close to fifty years, conceptualization and treatment of explosive children have been significantly influenced by the coercion or social interactional model. There has been a focus on patterns of parental

discipline Inconsistent discipline Irritable explosive discipline Low supervision and involvement Inflexible rigid discipline

Characteristics & Behavior Link

Lagging skills in the global domains:

Flexibility and adaptability

Frustration tolerance

Problem-solving

The CPS model aims to identify the specific cognitive factors contributing to the development of a child’s non-compliance and explosiveness

Executive Skills

Transitions

Sequences

Difficulty staying on tasks

Impulsivity

Problem Solving Range of solutions to a problem

Cognitive Flexibility Skills

Concrete, black-and-white thinkers

Insistence on sticking with rules, routine or original plans

Difficulty with unpredictability, ambiguity, uncertainty

Obsessive or Preservation

Theory of Mind

Situation-Person Dynamics

Inaccurate interpretations/Cognitive distortions/Biases

Language Processing Skills

Difficulty expressing thoughts, needs or concerns in

words

Often appears not to have understood what was

said

Long delays before responding to questions

Difficulty knowing or saying how he or she feels

Emotion Regulation Skills

Difficulty staying calm enough to think rationally

when frustrated

Cranky, grouchy, grumpy, irritable outside the

context of frustration

Sad, fatigued, tired, low energy

Anxious, nervous, worried, fearful

Social Skills

Difficulty attending to or misreading of social cues/ difficulty recognizing nonverbal social cues

Seeks the attention of others in inappropriate ways;

Seems unaware of how behavior is affecting other people

Lacks empathy

Poor sense of how he or she is coming across or being perceived by others

Inaccurate self-perception

Transactional Theory

Three conceptual models for understanding children’s developmental outcomes:

Unidirectional or Main Effect Model

Bidirectional or Interactional Model

Transactional or Reciprocal Model

Transactional Theory

Unidirectional or Main Effect Model Child’s outcome is the product of either characteristics of

the child or characteristics of the caretakers

Bidirectional or Interactional Model The combination of adult and child characteristics

produces a child’s outcome

Transactional or Reciprocal Model Child’s outcome is a function of the degree of fit or

compatibility between child and adult characteristics

The goal of treatment requires an understanding of both child and adult

Situational Analysis

Explosive level behaviors occur when there are

high levels of incompatibility between a child and

the environment

Demands on the child exceed the child’s capacity to

respond

The environment also includes the transaction with

other people

Identifying

Pathways and

Triggers

Executive Skills

Emotional Regulation Skills

Language Processing Skills

Cognitive Flexibility Skills

Social Skills

Identification of Pathways

Sensory Hypersensitivities

Transitions

Academic Tasks

Interaction with Peers, Adults, Family

Identification of Triggers

Clinical Interview

Formal Assessment

Developmental pediatricians

Neuropsychologists

Two Mechanisms for Identificationof Pathways and Triggers

Goals of the Interview

Assess safety

Empathically support parents

Need to be believed

Assess Pathways and Triggers

Interview Questions

Child

Why did your parents bring you in today?

What difficulties do you see your family having?

What’s the matter with your parents?

How are things going with your friends?

What is the hardest thing about _______ in school?

Would you describe yourself as _______?

Are there more stories?

Interview Questions

Caregivers

Tell me about _________’s explosions.

Do you think that _____is more bothered by _____ or______?

Do they occur during certain times of the day?

What goes on when______’s doing_______?

How does he or she do with_______?

How have you responded to/handled it when ____does _____?

Interview Questions

Family

Gain a Consensus

“Would you all agree that _______is troublesome?”

Emphasize Cognitive Difficulties

Not Behavior

Putting the Information Together

Meet with the Child/Adolescent Alone Generate hypothesis

Meet with the Caregivers Alone Generate hypothesis

Meet with the Family Generate hypothesis

Other Important Information to

Consider

Developmental History

Treatment History

Family Stressors

Pharmacology

Educational History

History of Adult Responses to Deficits

Questions

What do you do when there are large numbers of items on the Pathways Inventory?

Prioritize and Organize, “triage” approach

What do you do if you don’t get strong signals on the Pathways Inventory?

Keep Trying! Gather more “stories”

What other factors not related to cognitive skills contribute to explosions?

Sleep, Trauma, Seizures, D&A, Allergies, other Medical Issues

How do you know when to refer for formal testing?

When interviews and observations do not provide enough definitive information to identify the specific skill deficit or trigger.

Options for

Handling

ProblemsThree Plans

Plan A- Insistence

Plan C- Reducing Expectations

Plan B- The Collaborative Problem-Solving

Approach

“Surrogate Frontal Lobe”

Three Plans

Plan A

In Typical Children Child motivated by insistence There is no extreme reaction to insistence

In The Explosive Child Adult expectations are pursued Adults add consequences for children Cognitive deficits prevent from meeting expectations Inflexibility increases the chances of an outburst

Plan A is easy on the front-end, but has shortcomings long-term

Plan CReducing or Removing expectations

Saying nothing Changing Demands

Adults fear expectations will never be met or children will capitalize on the giving in

Adults fear children will not learn expectations

Goal is to reduce the overall number of outbursts

Plan B Brief Overview

Working toward a mutually satisfactory resolution

Goals Reduce frequency, intensity, and duration of explosive

episodes

Help adults pursue expectations through collaborative problem-solving

Teach the cognitive skills that are lacking in the child

More efficient on the back end

Creates opportunities for long-term success

Goals Achieved By Each Plan

Pursue Expectations Reduce Outbursts Teach Skills

Plan A X

Plan B X X X

Plan C X

Questions and Wrap Up!