Treating Explosive Kids

Part 2

The Collaborative

Problem-Solving Approach

Drew Burkley Psy.D.

Center of Excellence

Clinical Psychology Fellow

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.

Review

“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

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

The Plans

When a problem arises, there are three ways

to deal with it

Plan A: Imposing of parents Will

Plan C: Removing Expectations

Plan B: Collaborative Problem Solving.

Why Plan B?

Parents often chose Plan A.

Works for about 95% of children

Doesn’t account for lagging skills

Lagging skills, such as poor frustration

tolerance, poor executive functioning, etc.

may be influencing compliance

Typically seen in the “explosive” children

Plan B helps address skills and increase child

compliance

Plan B Basics

Plan B Basics

Plans A and C do not help children learn

needed skills

Developmentally, children are not equipped to

handle explosive episodes alone.

Two types of Plan B: Proactive and

Emergency

Parent does thinking for the child

Surrogate Frontal Lobe

Frontal lobes

Executive functioning

Impulse Control

Planning

Not fully developed until mid 20’s

Caregiver becomes surrogate frontal lobe

Thinks for child

Surrogate Frontal Lobe

The caregiver functions as a surrogate frontal

lobe by:

Walking child through the situation

Precipitating explosive episodes

After multiple repetitions, child will increase their

thinking-through ability

Something Caregivers already do

Teaching baseball or how to cross the street

Models creativity and flexibility

Rudimentary Plan B

Key Ingredients for a successful Plan B are Both parties (are at

a place at which they can begin calm and rational.

Ensure concerns of are clearly defined

Brainstorm All Ideas considered

Creative problem solving for all concerns

Steps Necessary for

Successful execution

of Plan B

Empathy (plus

reassurance)

“I’ve noticed you’ve

had problems with

X, what’s up?”

Define the problem

Invitation

Step 1: Empathy

Empathy Information Gathering to Understand Acknowledges the concerns of the child and

defines that concern Starts with “I’ve noticed”

Highly specific definition is essential for successful empathy

Feeling heard helps people feel understood

Step 2: Define the Problem

Plan A: The concern of the adult Plan C: The concern of the child Plan B: Reconciling the concerns of

the child with that of the adult

To Main purpose adult get’s their concern on the table. Recognize the pathways that are interfering with the

ability to the child to respond to Plan A Clearly define the concerns of the child through

Empathy Clearly define the concerns of the ADULT through

appropriate investigation

Step 3: The Invitation

Invite the child to brainstorm.

For example:

Let’s think about how we can solve this problem together.

Let’s see what we can figure out or do about this together.

Assess the ability of the child to develop alternative solutions.

Do they have the skills to generate alternative solutions? Do these solutions take both adult and child concerns into account?

If not, the care giver may have to serve as the surrogate frontal lobe.

Step 3: The Invitation

The burden is upon both members (child and adult) of the problem solving team to solve the problem. What matters now is that a solution is developed that is feasible and mutually satisfactory.

The invitation appears to many parents to be a dissolution of their power rather than a sharing and development of responsibility with their child.

The Litmus test for a good solution is that it is realistic, doable, and mutually satisfactory.

Emergency Plan B

Versus Proactive Plan B

Emergency Plan B De-escalation technique. Most parents and caregivers don’t realize

that the problems are highly predictable Proactive Plan B

Solve the problem before it occurs Teaching tool Helps child ID triggers Know for future occurences

Easy Living Through Plan B

Prior to explaining Plan B to caregivers, we

should:

Explain the pathways that are causing issues

identify the triggers (i.e., problems that have yet

to be solved) that commonly precipitate

explosive episodes.

Easy Living Through Plan B

Two forms of Plan B:

Focusing on resolving the triggers for the

explosion (Problem-focused Plan B)

Focusing on developing the lagging skills that

are causing the explosions (Skills-focused Plan

B)

Common Mistakes

Forgetting to Invite the child to problem solve

Skipping steps

Not clearly identifying the two concerns

Providing alternative solutions (two Plan A’s or a Plan A and a Plan C)

Common Mistakes

As a clinician, forgetting to examine and identify ADULT pathway problems before entering this step.

Caregivers trying to make Problem Solving Unilateral rather than collaborative.

Caregivers trying to make Plan B a clever form of Plan A!

Relying too much on Emergency Plan B and not using Proactive Plan B

Beyond the Basics

Skills Needed for Plan B

Identify and articulate concerns

Consider these generating alternative

solutions

Anticipate outcomes of potential solutions

Therapist Roles

Identify lagging skills

Assist family in strengthening them

Facilitate therapeutic process

Therapist Roles

Establish alliances with each participant

Maintain neutrality

Prevent discussion from spinning out of control

Be vigilant to hindrances to full investment

Therapist Roles

Help participants stay on track during

discussions

Identify any impediments to progress

Address within the family system

What is the single

greatest predictor

of therapeutic

change?

Establishing the therapeutic alliance

Establishing Alliances

Therapeutic relationship is vital

Communication of empathy is key

Validate

Convey understanding

Establishing Alliances with Adults

Adults need: To be heard and understood

To see the clinician as competent

To see the clinician has the capacity to help relieve distress

Establishing Alliances with Children

Children need to know: Things may be better this time around

That the clinician does not believe that negative behaviors are intentional

That the clinician views the situation as a “family problem”

Maintaining Neutrality

Ensure that all participants’ concerns make it

into the discussion

Remaining focused

Understanding

Clarifying

Maintaining Neutrality

Remain focused on process vs. outcome

***HOWEVER***

Solutions need to be“mutually satisfactory”

Taking Control of the Case

Therapist Roles

Mediate

Assess “temperature”

Remain vigilant

Taking Control of the Case

Therapist Roles (cont...)

Actively calculates the pace of therapy

Keeps the discussion on track

Remains mindful of other treatments being delivered

Pathways Extended

The Therapist as a Salesperson

Beginning therapy focused on child skill deficits:

Maintains congruence with many parents’ expectations about the process of therapy

Helps alter/reframe parent perceptions of their child’s outbursts

Pathways ExtendedThe Therapist as a Salesperson

A Good “Pitch” from original definition of the referral problem to more

systemic perception.

Address both child and parent skill deficits

Feasible when therapeutic alliance is secure.

Pathways Extended

Defining the problem

Executive struggles

Generating alternative solutions

Disorganized/unsystematic approach

Language-processing issues

Emotional regulation deficits

Concrete thinkers

Skills Trained

with Plan B

Identifying &Articulating Concerns and

Problems

Language Processing Skills– Using and Practicing Adaptive Vocabulary

– Using Reminders

– Talking about the incident later, away from the heat of the moment.

– Teach Pragmatic vocabulary with problem identification

Video Clip

Considering Possible Solutions

Mutual process between parent and child

Some children have never been given the

opportunity

Repetition and exposure to adults showing

this skill helps to build it in some cases

In other cases a structured model can help

Reflecting on Likely Outcomes and How

Feasible/Satisfactory They Are

Therapist may express skepticism about solutions that may not be realistic/feasible

model for the family

Child may not develop a solution based on both concerns

difficulty with perceptive taking

Parent’s Execution of Plan B

Step 1- Empathy Calming affect

Acknowledge their concern

Step 2 Defining Problem Help child to take your concern into account when working toward a

solution

State concern in a calm, tentative manner

Reminder of problems solved prior

Final Thoughts

Advantages of Plan B:

Training can occur in the environments in which the skills are to be utilized

Collaborative in nature

Child is more likely to think about a problem

More likely to take ownership of the problem and the solution

Teaching adaptive social functioning is built in

Questions and Wrap Up!