evidence-based psychosocial treatment of disruptive behavior disorders – practice elements...

Evidence-Based Psychosocial Evidence-Based Psychosocial Treatment of Disruptive Treatment of Disruptive

Behavior Disorders – Practice Behavior Disorders – Practice ElementsElements

Developed by the Center for School Mental Health with support Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1 from the provided in part from grant 1R01MH71015-01A1 from the

National Institute of Mental Health and Project # U45 MC00174 National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child from the Office of Adolescent Health, Maternal, and Child

Health Bureau, Health Resources and Services Administration, Health Bureau, Health Resources and Services Administration, Department of Health and Human ServicesDepartment of Health and Human Services

Disruptive Behavior Disorder: Disruptive Behavior Disorder: Practice ComponentsPractice Components

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0 20 40 60 80 100

Problem Solving

Parent Priase

Time Out

Commands/LimitSetting

Tangible Rewards

% of EBP w/PracticeComponent

Specific interventions to help Specific interventions to help the DBD studentthe DBD student

Parent praiseParent praise Commands/limit settingCommands/limit setting Tangible rewardsTangible rewards Response costResponse cost Parent monitoringParent monitoring Time outTime out Psycho-education with parentPsycho-education with parent Problem solvingProblem solving

Parent praiseParent praise

Training parents to praise correctly Training parents to praise correctly increases compliance in youth with increases compliance in youth with Disruptive Behavior DisordersDisruptive Behavior Disorders Praise can include Praise can include

Verbal praise, EncouragementVerbal praise, Encouragement AttentionAttention AffectionAffection Physical proximityPhysical proximity

Giving effective praiseGiving effective praise

Be honest, not overly flatteringBe honest, not overly flattering Be specificBe specific No “back-handed compliments” (i.e., No “back-handed compliments” (i.e.,

“I like the way you are playing “I like the way you are playing quietly, why can’t you do this while quietly, why can’t you do this while I’m on the phone?”)I’m on the phone?”)

Give praise immediatelyGive praise immediately

Training parents to praise Training parents to praise childrenchildren

Barkley manual, Step 2 (Defiant Children)Barkley manual, Step 2 (Defiant Children) Teach parents to set up “special time” to pay Teach parents to set up “special time” to pay

attention to their child during playattention to their child during play Teach parents to narrate their child’s playTeach parents to narrate their child’s play Teach parents not to ask questions nor give Teach parents not to ask questions nor give

any commandsany commands Teach parents to ignore misbehavior during Teach parents to ignore misbehavior during

this playtimethis playtime Teach parents how to praise and praise Teach parents how to praise and praise

lavishly during this timelavishly during this time

Training parents to praise Training parents to praise teensteens

Barkley manual, Step 3 (Defiant Teens)Barkley manual, Step 3 (Defiant Teens) Encourage parents to set aside 15 minutes a few Encourage parents to set aside 15 minutes a few

times a week to pay attention to their adolescenttimes a week to pay attention to their adolescent Teach parents to pay attention to what their teen Teach parents to pay attention to what their teen

is doing, and show interest in a relaxed wayis doing, and show interest in a relaxed way Teach parents not to ask questions nor give any Teach parents not to ask questions nor give any

instructionsinstructions Teach parents to ignore if the teenager reacts Teach parents to ignore if the teenager reacts

with sarcasm, coolness or suspicionwith sarcasm, coolness or suspicion Teach parents to praise well and oftenTeach parents to praise well and often

Improving commands/limit Improving commands/limit settingsetting

Training for parents and teachers to Training for parents and teachers to give commands in the most effective give commands in the most effective wayway

Effective commands increase Effective commands increase compliance in children and compliance in children and adolescents with Disruptive Behavior adolescents with Disruptive Behavior Disorders (and in others, too!)Disorders (and in others, too!)

Improving commands/limit Improving commands/limit setting with childrensetting with children

Barkley Step 3 (Defiant Children)Barkley Step 3 (Defiant Children) Teach parents and teachers:Teach parents and teachers:

To only give commands that they intend To only give commands that they intend to back up with consequences (positive to back up with consequences (positive and negative)and negative)

Not to present commands as questions Not to present commands as questions or favorsor favors

Not give too many commands at onceNot give too many commands at once

Improving commands/limit Improving commands/limit setting with childrensetting with children

Teach parents and teachers:Teach parents and teachers: To make eye contact with the child before To make eye contact with the child before

giving commandgiving command To reduce other distractions while giving To reduce other distractions while giving

commandscommands To ask the child to repeat the commandTo ask the child to repeat the command To watch the child for one minute after giving To watch the child for one minute after giving

the command to ensure compliancethe command to ensure compliance To immediately praise child when s/he starts to To immediately praise child when s/he starts to

complycomply

Improving commands/limit Improving commands/limit setting with adolescentssetting with adolescents

Barkley, Defiant Teens, Step 4Barkley, Defiant Teens, Step 4 Teach parents and teachers:Teach parents and teachers:

To consider the intent of their commandTo consider the intent of their command Do they have the time/energy to follow through?Do they have the time/energy to follow through? Do they have consequences for noncompliance?Do they have consequences for noncompliance?

To avoid ambiguity when issuing commandsTo avoid ambiguity when issuing commands To not respond to compliance with gratitudeTo not respond to compliance with gratitude

Improving commands/limit Improving commands/limit setting with adolescentssetting with adolescents

Teach parents and teachers:Teach parents and teachers: To praise teens for appropriate behaviorTo praise teens for appropriate behavior To tell teen what To tell teen what toto do, rather than what do, rather than what

notnot to do to do To eliminate other distractions while To eliminate other distractions while

giving commandsgiving commands To break down multi-step commandsTo break down multi-step commands To use aids for commands that involve To use aids for commands that involve

timetime

Tangible rewardsTangible rewards

Children and adolescents with Children and adolescents with Disruptive Behavior Disorders do not Disruptive Behavior Disorders do not respond to natural (intrinsic) rewards respond to natural (intrinsic) rewards as well as typical youthas well as typical youth

The training of parents and teachers in The training of parents and teachers in the use of tangible rewards is effective the use of tangible rewards is effective in increasing desired behaviorsin increasing desired behaviors Can use token systems, behavior charts, Can use token systems, behavior charts,

or immediate rewardsor immediate rewards

Setting up a reward system for Setting up a reward system for children at homechildren at home

Barkley, Defiant Children, Step 4Barkley, Defiant Children, Step 4 Determine family’s readiness to Determine family’s readiness to

implementimplement Tailor the program to family’s ability-Tailor the program to family’s ability-

simplify it for overwhelmed or stressed simplify it for overwhelmed or stressed familiesfamilies

Use poker chip system with younger Use poker chip system with younger children (4-7), point system with older children (4-7), point system with older children (8 and up)children (8 and up)


Set a positive tone for the programSet a positive tone for the program ““We are going to make sure that you get rewarded We are going to make sure that you get rewarded

for all of the good stuff you do at home”for all of the good stuff you do at home” Parent(s) buys chips and makes a bank, or sets Parent(s) buys chips and makes a bank, or sets

up a chart or notebook for tracking pointsup a chart or notebook for tracking points The parent(s) and child together (with your The parent(s) and child together (with your

help) make up a list of 10-15 rewardshelp) make up a list of 10-15 rewards There should be everyday rewards, like TV or There should be everyday rewards, like TV or

computer time, and longer term rewards, like going computer time, and longer term rewards, like going to a movie or earning a new video game)to a movie or earning a new video game)


Help the parent(s) and child make a list Help the parent(s) and child make a list of jobs or problem areasof jobs or problem areas

Determine how much each is worthDetermine how much each is worth Add up how much the child might earn in a Add up how much the child might earn in a

dayday Harder jobs should earn moreHarder jobs should earn more Bigger rewards should cost moreBigger rewards should cost more Make sure the child has some success in the Make sure the child has some success in the

beginningbeginning


Discuss the concept of bonus chips to Discuss the concept of bonus chips to reward helpful or other positive behaviors, reward helpful or other positive behaviors, even if they aren’t on the listeven if they aren’t on the list

Chips and points are only given if the child Chips and points are only given if the child complies after the complies after the firstfirst command command

Don’t take away chips or points (response Don’t take away chips or points (response cost) in the beginningcost) in the beginning

All caregivers should use the same systemAll caregivers should use the same system Remind parents to praise while giving the Remind parents to praise while giving the

pointspoints

Setting up a reward system for Setting up a reward system for children at schoolchildren at school

Barkley, Defiant Children, Step 8, Daily Barkley, Defiant Children, Step 8, Daily School Report CardSchool Report Card

The teacher tracks the child’s behavior The teacher tracks the child’s behavior and reports it to the parent daily, who and reports it to the parent daily, who rewards the childrewards the child Pretty easy for the teacherPretty easy for the teacher

This is particularly effective because both This is particularly effective because both the parent and teacher are involvedthe parent and teacher are involved

If the parent can’t be involved, the If the parent can’t be involved, the rewards may be given at schoolrewards may be given at school

Setting up a reward system for Setting up a reward system for children at schoolchildren at school

Choose a few target behaviors at Choose a few target behaviors at schoolschool Choose one that the child will be Choose one that the child will be

successful with most of the timesuccessful with most of the time Set up a system for school report card or Set up a system for school report card or

school/home note systemschool/home note system See samples on page 244-246See samples on page 244-246

Pick from the targets given, or create your Pick from the targets given, or create your own with the blank samplesown with the blank samples

Setting up a reward system for Setting up a reward system for adolescents at homeadolescents at home

Barkley, Defiant Teens, Step 5Barkley, Defiant Teens, Step 5 Use a point system (see previous slides) Use a point system (see previous slides)

for 13/14 and underfor 13/14 and under Set up basically the same way as with Set up basically the same way as with

childrenchildren Warn parents to expect resistance, their teen Warn parents to expect resistance, their teen

is used to getting all of their privileges for is used to getting all of their privileges for free! Make sure parents don’t give in.free! Make sure parents don’t give in.

Make sure parents only choose privileges they Make sure parents only choose privileges they can controlcan control

Setting up a reward system for Setting up a reward system for adolescents at homeadolescents at home

Barkley, Defiant Teens, Step 5Barkley, Defiant Teens, Step 5 Use a behavior contract for teens 14/15 Use a behavior contract for teens 14/15

and olderand older See sample contract on page 208See sample contract on page 208 Begin with only “do” behaviors (clean up Begin with only “do” behaviors (clean up

room, set table, get ready for school on room, set table, get ready for school on time)time)

““Don’t” behaviors are dealt with under Don’t” behaviors are dealt with under response cost in next sectionresponse cost in next section

Setting up a reward system for Setting up a reward system for adolescents at schooladolescents at school

Barkley, Defiant Teens, Step 9Barkley, Defiant Teens, Step 9 Establish a homework contract (see sample Establish a homework contract (see sample

on page 121)on page 121) This can be adapted for other behavioral This can be adapted for other behavioral

goalsgoals Can also set up guidance counselor, tutor or Can also set up guidance counselor, tutor or

peer as “coach” for organizational skills or peer as “coach” for organizational skills or other targetsother targets Rewards for teen’s participation can be made part Rewards for teen’s participation can be made part

of the home contract, or part of a school reward of the home contract, or part of a school reward systemsystem

Response CostResponse Cost

Using a point or token system in Using a point or token system in which negative behaviors result in which negative behaviors result in the loss of points or tokens.the loss of points or tokens.

Training parents and teachers to use Training parents and teachers to use response cost is effective in reducing response cost is effective in reducing undesired behavior and undesired behavior and noncompliancenoncompliance

Response Cost with ChildrenResponse Cost with Children

Barkley, Defiant Children Step 4 & 8Barkley, Defiant Children Step 4 & 8 Train parents and teachers:Train parents and teachers:

To develop list of undesirable behavior to To develop list of undesirable behavior to be fined by reward systembe fined by reward system

To deduct points/chips for undesirable To deduct points/chips for undesirable behaviorbehavior

Parent and child have chosen to reduce whiningParent and child have chosen to reduce whining If child whines, parent deducts three pointsIf child whines, parent deducts three points Penalties increase based on severity of behaviorPenalties increase based on severity of behavior

Response Cost with ChildrenResponse Cost with Children

Train parents and teachers:Train parents and teachers: To avoid “punishment spiral”To avoid “punishment spiral”

When parent fines child for misbehavior, the When parent fines child for misbehavior, the child may respond with more misbehaviorchild may respond with more misbehavior

Child continues to lose points, then loses Child continues to lose points, then loses motivation for the point systemmotivation for the point system

Rule: Parent fines child Rule: Parent fines child once once through point through point system, then sends child to time out if system, then sends child to time out if undesirable behavior continuesundesirable behavior continues

Response Cost with Response Cost with AdolescentsAdolescents

Barkley, Defiant Teens Step 6Barkley, Defiant Teens Step 6 To train parents and teachers:To train parents and teachers:

To now use behavioral contract with the To now use behavioral contract with the teen for “fines”teen for “fines”

Teen agrees to not swearTeen agrees to not swear If teen swears, teen loses Internet privilegeIf teen swears, teen loses Internet privilege


Train parents and teachers:Train parents and teachers: To begin with 1 week “training period,” during To begin with 1 week “training period,” during

which parents labels misbehavior every time it which parents labels misbehavior every time it happens and warns of new fineshappens and warns of new fines

To avoid “punishment spiral”To avoid “punishment spiral” When parent fines teen for misbehavior, the teen When parent fines teen for misbehavior, the teen

responds with more misbehaviorresponds with more misbehavior Teen continues to lose privileges, then loses Teen continues to lose privileges, then loses

motivation motivation Rule: Parent fines teen Rule: Parent fines teen no more than twiceno more than twice, then , then

directs teen to “cool off” away from the situationdirects teen to “cool off” away from the situation


Encourage parents to act as “judge and Encourage parents to act as “judge and jury” when teen liesjury” when teen lies The teen should remain above suspicionThe teen should remain above suspicion

Response cost allows parents to Response cost allows parents to discipline/educate instead of discipline/educate instead of justjust punish punish

Emphasis of response cost is onEmphasis of response cost is on ““Warm” – positive, lovingWarm” – positive, loving ““Firm” – specific, immediate, and consistentFirm” – specific, immediate, and consistent

Parent MonitoringParent Monitoring

Give parents a structured way to Give parents a structured way to monitor their child’s behaviormonitor their child’s behavior

Measurement of the target behavior Measurement of the target behavior should be repeatedshould be repeated

Can use either informal or formal Can use either informal or formal measuresmeasures


Informal measuresInformal measures Daily homework logDaily homework log Behavior chart as part of a reward Behavior chart as part of a reward

systemsystem Home Situations Checklist (Barkley, Home Situations Checklist (Barkley,

Defiant Children)Defiant Children)


Formal measuresFormal measures Vanderbilt Scales (from your Resource Vanderbilt Scales (from your Resource

Toolkit or on the web)Toolkit or on the web) Disruptive Behavior Disorders Scale (in Disruptive Behavior Disorders Scale (in

Barkley or on the web)Barkley or on the web)

Time OutTime Out

Time out is the removal of a child or Time out is the removal of a child or adolescent from all reinforcement for adolescent from all reinforcement for a specified period of time after a a specified period of time after a targeted misbehaviortargeted misbehavior It is an effective intervention, but only if It is an effective intervention, but only if

it is used correctly and is not used too it is used correctly and is not used too oftenoften

Using Time Out with Children Using Time Out with Children at Homeat Home

Barkley, Defiant Children, Step 5Barkley, Defiant Children, Step 5 Teach parents to give an effective Teach parents to give an effective

command (Step 3)command (Step 3) Teach parents to count out loud Teach parents to count out loud

(initially) from 5 to 1(initially) from 5 to 1 Teach parents to give a time out Teach parents to give a time out

warning if the child has not compliedwarning if the child has not complied After warning, count from 5 to 1 againAfter warning, count from 5 to 1 again


Teach parents to guide child to time out chair Teach parents to guide child to time out chair IMMEDIATELYIMMEDIATELY

Teach parents to place the child in the chair Teach parents to place the child in the chair “Stay there until I tell you to get up”“Stay there until I tell you to get up”

Teach parents not to argue or interact with Teach parents not to argue or interact with the child in any waythe child in any way

Teach parents to not come back until the Teach parents to not come back until the child is calm. Once the child is calm and the child is calm. Once the child is calm and the time is served, the child must correct the time is served, the child must correct the misbehaviormisbehavior


Teach the parents that the child should Teach the parents that the child should now go and comply with the previous now go and comply with the previous command, or correct the misbehaviorcommand, or correct the misbehavior

Teach the parent to now praise Teach the parent to now praise compliance, and to praise the next compliance, and to praise the next behavior that the child does wellbehavior that the child does well

Time Out Tips with ChildrenTime Out Tips with Children

The first time out may be a killerThe first time out may be a killer Prepare parents for a worst case scenariosPrepare parents for a worst case scenarios Reassure parents that this is not Reassure parents that this is not

damaging their childdamaging their child Make sure the time out area is away Make sure the time out area is away

from anything interesting or funfrom anything interesting or fun Remind parents not to “make up for” Remind parents not to “make up for”

the time out (i.e., saving dessert for the time out (i.e., saving dessert for them)them)

Using Time Out with Using Time Out with AdolescentsAdolescents

Barkley, Defiant Teens, Step 8Barkley, Defiant Teens, Step 8 ““Grounding” = “house arrest”Grounding” = “house arrest”

NO access to privileges (phone, TV, etc)NO access to privileges (phone, TV, etc) Parent must be home to enforceParent must be home to enforce Most effective with younger teensMost effective with younger teens May include “work detail” (cleaning out May include “work detail” (cleaning out

basement, scrubbing bathroom floor)basement, scrubbing bathroom floor)

Parent PsychoeducationParent Psychoeducation

Engage and empower parents by Engage and empower parents by teaching them about Disruptive teaching them about Disruptive Behavior DisorderBehavior Disorder

Establish relationship with parents as Establish relationship with parents as partner in treatment processpartner in treatment process

Look at how DBD influences parent-Look at how DBD influences parent-child interaction (bi-directional)child interaction (bi-directional)


Review information about Review information about Disruptive Behavior DisordersDisruptive Behavior Disorders SymptomsSymptoms CausesCauses Diagnostic criteriaDiagnostic criteria Treatment modalitiesTreatment modalities

Emphasize caretaker role in Emphasize caretaker role in development and treatment of DBDdevelopment and treatment of DBD Problems in parenting and parenting Problems in parenting and parenting

styles may make DBD worsestyles may make DBD worse Establishing behavioral interventions at Establishing behavioral interventions at

home or at school require caretaker home or at school require caretaker involvementinvolvement

Knowledge enables parents to more Knowledge enables parents to more effectively advocate for better serviceseffectively advocate for better services



More effective if therapist devotes More effective if therapist devotes more than one session to more than one session to psychoeducationpsychoeducation

More effective if therapist educates More effective if therapist educates parents about DBD across multiple parents about DBD across multiple settings (home, school, playground, settings (home, school, playground, etc)etc)

Resources for Parent Resources for Parent PsychoeducationPsychoeducation

Center for Children and FamiliesCenter for Children and Families ““Supporting Children with Challenging Supporting Children with Challenging

Behaviors: Relationships Are the Key ”Behaviors: Relationships Are the Key ”

American Academy of Child & American Academy of Child & Adolescent PsychiatryAdolescent Psychiatry Fact sheets Fact sheets

Resources for Parent Resources for Parent PsychoeducationPsychoeducation

National Initiative for Children’s National Initiative for Children’s Healthcare QualityHealthcare Quality ““How to Establish a School-Home Daily How to Establish a School-Home Daily

Report Card”Report Card” Vanderbilt Assessment Scales (parent Vanderbilt Assessment Scales (parent

and teacher version)and teacher version) DBD Resources Available on the InternetDBD Resources Available on the Internet ““Working with Your Child’s School”Working with Your Child’s School”

Differential reinforcementDifferential reinforcement

Teach parents and teachers how and Teach parents and teachers how and when to differentially reinforce when to differentially reinforce desirable behaviordesirable behavior Step One: Ignore (stop reinforcing) the Step One: Ignore (stop reinforcing) the

child’s undesirable behaviorchild’s undesirable behavior Step Two: Reinforce the child’s desirable Step Two: Reinforce the child’s desirable

behavior in a systematic mannerbehavior in a systematic manner The desirable behavior should be a behavior The desirable behavior should be a behavior

that is incompatible with the undesirable that is incompatible with the undesirable behaviorbehavior

Differential reinforcementDifferential reinforcement

Define the behavior of concern Define the behavior of concern (target)(target) Determine how often the target behavior Determine how often the target behavior

occursoccurs Determine how often to reward the child Determine how often to reward the child

for alternative behaviorfor alternative behavior Fixed interval – reward every X minutesFixed interval – reward every X minutes

Determine how to reward the child for Determine how to reward the child for alternative behavioralternative behavior

Praise, attention, points or chipsPraise, attention, points or chips

Reinforcement of target Reinforcement of target behaviorbehavior

Target behavior: InterruptingTarget behavior: Interrupting Alternative behavior: Playing by himselfAlternative behavior: Playing by himself Reward schedule: 5 minutesReward schedule: 5 minutes

If child goes 5 minutes without interrupting, If child goes 5 minutes without interrupting, the child receives reinforcementthe child receives reinforcement

If child interrupts before 5 minutes is up, the If child interrupts before 5 minutes is up, the child does not receive reinforcementchild does not receive reinforcement

Re-set schedule once child interruptsRe-set schedule once child interrupts

Problem solvingProblem solving

Teaches children how to “use their Teaches children how to “use their heads before using their fists”heads before using their fists”

Problem solving stepsProblem solving steps Define the problemDefine the problem Identify response optionsIdentify response options Evaluate response optionsEvaluate response options

Parents trained to help their children Parents trained to help their children use problem solving stepsuse problem solving steps

Problem SolvingProblem Solving

Extensive use of applied behavior Extensive use of applied behavior analysisanalysis Prompt appropriate behaviorPrompt appropriate behavior Shape behaviorShape behavior Deliver reinforcement for appropriate Deliver reinforcement for appropriate

behaviorbehavior Extinguish inappropriate behaviorExtinguish inappropriate behavior


Central Goals of Problem SolvingCentral Goals of Problem Solving

Improve how children reason when Improve how children reason when confronted with interpersonal problemsconfronted with interpersonal problems

Increase the number of prosocial Increase the number of prosocial solutions considered and employedsolutions considered and employed

Problem Solving Skills Problem Solving Skills TrainingTraining

Designed for aggressive and Designed for aggressive and antisocial behaviorantisocial behavior

Children ages 7-13Children ages 7-13 20 sessions (40-45 minutes)20 sessions (40-45 minutes) Individual sessions with parent Individual sessions with parent

contactcontact


Therapist StepsTherapist Steps1.1. Teach 5 problem solving stepsTeach 5 problem solving steps

1.1. Identify the problemIdentify the problem2.2. List possible solutionsList possible solutions3.3. Evaluate themEvaluate them4.4. Choose oneChoose one5.5. Try itTry it6.6. Evaluate the outcomeEvaluate the outcome


2.2. Practice steps on games (e.g., Practice steps on games (e.g., Checkers)Checkers)

3.3. Apply steps to real-life problems Apply steps to real-life problems

4.4. Teach parent to prompt and praise Teach parent to prompt and praise the use of stepsthe use of steps


5.5. Child continues applying to real-life Child continues applying to real-life situations; re-enact solutions situations; re-enact solutions w/therapistw/therapist

6.6. Wrap-up, review what has been Wrap-up, review what has been learned, role-reversal (child teaches learned, role-reversal (child teaches skills to therapist)skills to therapist)


Psychotherapy for Children and Psychotherapy for Children and Adolescents: Evidence-Based Adolescents: Evidence-Based Treatments and Case ExamplesTreatments and Case Examples

John R. Weisz (2004)John R. Weisz (2004)

evidence-based psychosocial treatment of disruptive behavior disorders – practice elements...

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