3/2/2015
Workshop Objectives
Evidence-Based Assessment and
Intervention for ODD and CD in
Children and Adolescents
Mark D. Terjesen, Ph.D
March 2015
Case Example
Joshua was referred to a clinic by his mother. She reported that
yesterday he threw a chair at her when she took away his video
game as a consequence for him lying about a poor test grade.
When the chair hit her, she reported he laughed aloud. She
reported that when Joshua does not get his way, he will often
tantrum. Tantrums include yelling, hitting, and throwing things.
During a tantrum, Joshua has hurt the dog and his mother when
he has thrown things. His mother reported she is scared for him
and does not know what to do. The school reports that although
Joshua does not engage in aggressive behavior towards his
teachers, he is very non-compliant, refuses to do work and will
argue with his peers or with the teacher to get what he wants.
He does not seemed bothered by consequences such as
detention like losing recess.
3 4
Why Study Conduct Problems?
One of most common reasons for referral
There is an increase in conduct problems across
gender, social class, & family types
Significantly impact quality of home life & school
performance
Societal Concern: Strongly associated with
delinquency & adult criminality
5 6
• Provide an overview of CD and ODD
• Present diagnostic information and comorbidity
and prognosis
• Discuss assessment strategies
• Review Empirically Supported Treatments
• PCIT practice
• Provide a model of CBT for intervention
• Individually
• Family Based
• Review Barkley’s Parent Training Model
2
Case Example
Greg, age 10, was referred because of excessive fighting, hyperactivity,
temper tantrums, and disruptive behavior at home and at school. At home,
Greg argues with his mother, starts fights with his siblings, and steals from his
parents. He threatens to set fires when he is disciplined. On three separate
occasions, Greg actually set fires to rugs, bedspreads, and trash in his home.
One fire led to several thousand dollars in damages. He also put a pillow over
his younger brother’s face and has broken windows on people’s cars and
houses at night.
Greg also lies frequently; at school his lying has gotten others into trouble and
caused frequent fights with peers. He denies all wrongdoing. Although his
intelligence is average, he is in a special class and his academics are below
grade level and that his behavior is overactive and disruptive. His parents
report that they do not know what to do. His mother reports that she is being
seen for depression and can not manage his behavior. His father is currently
unemployed and has had difficulty over the years maintaining a consistent job.
(Adapted from Mash & Wolfe, 2010)
Considerations
There is heterogeneity in the types & severity of
conduct problems; Broad range of behaviors (e.g.,
yelling to physical assault)
Conduct problems & comorbid problem in adjustment
Risks associated with conduct problems
Multiple developmental pathways
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Definitions
Definitions
Conduct Problems & Antisocial Behavior: Antisocial behavior is defined as behavior by
terms used to describe a wide range of age- which violates basic norms, rights and rules
inappropriate actions and attitudes of a child that – Lying: Violates norm of speaking the truth
violate family expectations, societal norms, and – Stealing: Violates the right of the
the personal or property rights of others protection of one’s property
(McMahon, Wells, & Kotler, 2006) – Disobedience: When children repeatedly
resist in response to requests, instructions
or corrections by adults
– Physical aggression : Violates right of
physical integrity
7 8

Conduct Problems: Heterogeneity

Heterogeneity in the types & severity of conduct Maladaptive Behavior
problems
Normative Oppositional/ Defiant Antisocial Behavior
Noncompliance Behavior
Definitions & frequently used terms: acting out, tantrums,
antisocial, etc
– Noncompliance:
Noncompliance that Excessive Behavior by which
• excessive disobedience to adults disobedience to adults
stems from a young basic norms, rights
• appears early in onset/progression
child’s self-assertion and rules are violated
• chronic in development and is driven by the
• related to academic & peer relationship problems & referrals desire to do something
– Aggression: autonomously.
• stable & difficult to treat Generally short lived Consistent and Consistent and
• Types include: Pervasive Pervasive
• retaliatory / hostile/reactive
• proactive /instrumental
• relational aggression
9 10

Heterogeneity in ODD Symptoms

1. Loses temper Emotional Dysregulation
2. Argues with adults Oppositional/ Defiant

3. Actively refuses to comply with adults’ Oppositional/ Defiant

requests or rules

4. Deliberately annoys people Provocativeness

Categorical & Dimensional
5. Blames others for his mistakes or
misbehavior
Hostility Systems
6. Is touchy or easily annoyed by others Emotional Dysregulation

7. Is angry and resentful Emotional Symptom

8. Is spiteful or vindictive Hostility

* Matthys and Lochman

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DSM-5: Oppositional Defiant Disorder DSM-5: Oppositional Defiant Disorder

(Continued)
A. A pattern of angry/irritable mood, argumentative B. Disturbance in disorder is associated with distress in
/defiant behavior, or vindictiveness lasting at least 6 the individual or others in his or her immediate social
months during which 4 of the following are present context, or it impacts negatively on social, educational,
– Angry / irritable Mood
• Often loses temper
occupational, or other important areas of functioning
• Is often touchy or easily annoyed C. Behaviors do not occur exclusively during the course of
• Is often angry or resentful
a psychotic, substance use, depressive disorder,
– Argumentative Defiant Behavior
• Often argues with authority, or children / adults
bipolar disorder, dysregulation disorder
• Often actively defies ore refuses to comply with adults’ rules
• Often deliberately annoys others
• Often blames others for their mistakes or misbehavior
– Vindictiveness
• Has been spiteful or vindictive at least twice within the past 6 months

13 14

DSM-5: Oppositional Defiant Disorder

(Continued) DSM-5: Oppositional Defiant Disorder
NOTE: The persistency and frequency of these (Continued)
behaviors should be used to distinguish a behavior Diagnostic Features
that is within normal limits from a behavior that is – Symptoms may be confined to one
symptomatic. setting; however cross setting symptoms
should be assessed as pervasiveness of
For children <5 behavior should occur for most days for a symptoms predicts severity
period for at least 6 months – Symptoms of ODD can occur to some
For children >5 behavior should occur at least once a week degree in individuals without the disorder
for at least 6 months – Symptoms often part of a pattern of
problematic interactions
15 16

DSM-5 Differential Diagnosis

DSM-5 Differential Diagnosis Intermittent Explosive Disorder
Conduct Disorder – IED show serious aggression toward others that ODD
– ODD behaviors less severe
does not
– ODD does not include aggression towards people or Intellectual Disability
animals, theft, etc – ODD is only also given if ODD behavior is greater than
– ODD includes emotional dysregulation
individuals of comparable mental age
ADHD Language Disorder
– Rule out that oppositional behaviors are not solely due to
situations that demand sustained attention – Must rule out failure to follow direction
Depressive / Bipolar Social Phobia
– Rule out if symptoms occur exclusively during the course – Rule out defiance due to fear of negative evaluation
of mood disorder
17 18

3

DSM-5: Conduct Disorder
A. A repetitive & persistent pattern of behavior in
which the basic rights of others or major age-
appropriate societal norms or rules are violated,
as manifested by the presence of 3 or more of the
following 15 criteria in the past 12 months, with at
least one criterion present in the past 6 months
DSM-5: Conduct Disorder (Continued)
B. Clinically significant impairment in social,
academic, or occupational functioning
C. 18 years of age and not APD
DSM-5: Conduct Disorder Specifiers
With limited pro-social emotions:
– Lack of remorse or guilt
– Callous – lack of empathy
– Unconcerned about performance
– Shallow or deficient affect
Severity
– Mild
– Moderate
– Severe
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DSM-5: Conduct Disorder (Continued)
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others
2. Often initiates physical fights
3. Has used a weapon that can cause physical harm
4.
5.
Has been Physically cruel to people
Has been physically cruel to animals
6.
7.
Has stolen while confronting a victim
Has forced someone into sexual activity
Destruction of property
8. Has deliberately engaged in fire setting
9. Has deliberately destroyed another person’s property
Deceitfulness or theft
10. Has broken into someone’s house, building, or car
11. Often lies to obtain goods
12. Has stolen items of nontrivial value without confronting a victim
Serious violation of rules
13. Often Stays out at night despite parent prohibition
14. Has run away from home at least twice
15. Often truant from school
19 20
DSM-5: Conduct Disorder (Continued)
Specify subtype
1. Childhood onset: one symptom prior to age 10
2. Adolescent onset: show no symptom prior to
age 10
3. Unspecified onset: criteria met but not enough
material to determine onset of first symptom
21 22
DSM-5: Conduct Disorder (Continued)
Males with CD frequently exhibit fighting, stealing,
vandalism, and school discipline problems /
physical and relational aggression
Females with CD are more likely to exhibit lying ,
truancy, running away, substance use, and
prostitution / relational aggression
23 24
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Dimensions
OVERT—COVERT Dimension
– Children who display more overt antisocial behavior tend to be negative,
irritable, and resentful in their reactions to hostile situations and to experience
higher levels of family conflict
– Children who display covert antisocial behavior are less social, more anxious,
and more suspicious of others, and come from homes that provide little family
support.

DESTRUCTIVE—NONDESTRUCTIVE
– Children who display overt-destructive behaviors, particularly persistent
fighting, are at high risk for alter psychiatric problems and impairment in
functioning (Brody et al., 2003)

Overt-destructive (physical aggression)

Overt-nondestructive (oppositional)
Covert- destructive (property violations)
Covert-nondestructive (status offenses)

Dimensions helpful for prognosis & align with legal system (Frick et al., 1993)
25

Epidemiology

 ODD: >1- < 20% ; 5-25% ; 2-16% ; 1-11% ; mean 3.3%

 Need more research, more prevalent in males before puberty, but may be equal rates afterwards.

 CD: >1 - <10% (2-9% girls, 6-16% boys)

 Lifetime prevalence: ODD 10%; CD 9%

Comorbidity, Prognosis, &  Prevalence relatively consistent across countries that differ in
race and ethnicity
Risk Factors  25 - 40% of adolescents with CD develop adult antisocial behaviors
 Gender differences exist in antisocial behavior
 Childhood: 2-4 times more common in boys than in girls
 Narrows greatly in early adolescence
 Increases again in late adolescence and beyond
 Girls more likely than boys to use indirect and relational forms of
aggression
(Merrell, 2008; APA, 2013)
28

Associated characteristics Comorbidity

• Verbal and language deficits despite normal intelligence What are the comorbid problems and why are they
• School difficulties including academic underachievement in important to know?
language and reading – Importance: for understanding child as well
• Antisocial behavior may be related to and inflated, unstable, as planning assessment and intervention
and tentative view of self
– Associated adjustment problems &
• Correlated to family disturbances
relationship among them:
• May engage in behaviors that put them at risk for health-
• Comorbid problem behaviors affect child’s context
related problems
and can result in anxiety and depression
• Interpersonal problems- including rejection & bullying; (mediation)
friendship with other antisocial children
• Comorbid problem behaviors are often the result
of other disorders (e.g., impulsivity)
• Mediators & Moderators impact assessment and
treatment
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Comorbidity (Continued)
ADHD Etiology & Risk Factors
▪ Most common comorbidity, 36% boys, 57% girls
▪ Related to more severe & chronic prognosis (i.e., delinquency, aggression)
▪ Aggression associated with impulsivity/hyperactivity Conduct problems result from a complex
▪ ADHD & CD displays greater amounts of physical aggression
Depression, Anxiety interaction of multiple factors
▪ Precede onset of CD (often), opposite also occurs (not sure if causal)
▪ Increased risk for suicide in youth (higher girls than boys)
• Biological
▪ Mixed findings with anxiety on level of impairment • Cognitive and Learning Styles
Substance Use
▪ Conduct problems and substance use = earlier onset & use of multiple drugs • Family Context
Language impairments
▪ A reaction to frustration • Physiological Differences
▪ Noncompliance could be a function of receptive difficulties (understanding
directions) • Peers
Academic Achievement
▪ 20-25%
• Broader Social Ecology
▪ Often a function of comorbid conditions

31 32

Biological Factors
Early temperament has been linked to conduct problems
in preschool, school-aged, & adolescents (Frick &
Morris, 2004)
Temperament alone does not cause CD; rather it
appears to interact with other factors like parent
management strategies to influence the outcome
• Emotion regulation (negative reactivity & effortful control)
• Inability to regulate anger related to conduct problems.
• Affective components of conscience
• Hostile attribution bias and deficits in social problem solving
skills
• Distortion of social cues
Cognitive Correlates
Conduct problems associated with: (bidirectional relationship )
• Poor academic performance
• Neuropsychological or cognitive impairments; Score lower on intelligence tests
More sensitive to rewards than punishment (reward-dominant response
style)
Deficit in social cognition (perceptions and interpretations of social cues)
• Important to consider in your assessments (interviews, observations) and
treatment
• Make more hostile attribution biases
• Errors in interpretation of social cues and encoding (lack of attention to
social cues)
• Deficient quantity and quality of generated solutions to social situations
• More likely to engage in aggressive behavior

33 34

Family : Parent Variables

Research has shown that the following are powerful predictors of the Family Context (cont)
development of aggressive and antisocial behavior in children: Familial discord
– Harsh and inconsistent discipline practices
• Marital distress
– Lax parental monitoring (low supervision and involvement)
– Coercive behavior in families (Patterson)/ Coercive parenting and • Insularity- high frequency of negative and adverse
interactions relationships
– Exposure to adult models of antisocial behavior • Little social supports
– Few positive parenting behaviors
– Parental psychopathology associated with conduct disorder • Marital adjustment  related to (-) parent behavior
• Maternal depression & perceptions of youth behavior/maladjustment
• Parental antisocial behavior Familial adversity
• History of parental abuse
• Life stressors such as poverty, unemployment
• Substance use

Merrell, K.W. (2008)

35 36

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Peers & Broader Social Ecology Developmental Course / Pathway

Peers
• Peer rejection  Conduct problems and
deviant peer group & delinquency
Broader social ecology
• SES – violence witnessed, poor housing, poor
schools, etc
• Insularity (negative pattern of social contacts
& interchanges within the community)
Developmental pathways
– Early onset (preschool/elementary---adolescents
CD)
– Later onset (symptoms of CD during adolescence
after a normal history)
Not all children with ODD develop a Conduct Disorder
Not all children with CD will develop Antisocial
Personality Disorder
Developmental Course: For many children antisocial
behaviors appear then decline during normal
development, but for children who are most aggressive
they often maintain over time

37 38

Developmental Course / Pathway Developmental Pathways

DSM-5
Early starter: • Child onset (before age 10): more severe conduct problems
– Onset of conduct problems in early childhood that in childhood & adolescence, antisocial in adulthood, greater
persist throughout adolescent association with biological/dispositional and contextual
correlates than adolescent
– 14 times more likely to be arrested before age 14. • Adolescent onset (after age 10): do not consistently show
risk factors; Exaggeration of normal adolescent identity
Later starter: formation encouraged by an antisocial peer group
– Conduct problems begin in adolescence and less More research needed:
likely to persist into adulthood.
• Developmental pathway with girls
– Often have poor parental monitoring, deviant peers,
conflict with parents.

Merrell, K.W. (2008)

39 40

Developmental Course Developmental Course (Continued)

Infancy: irritable, overactive, low tolerance
Toddler: overactive, inattentive, tantrums Adolescence
Preschool: noncompliant, aggressive, problems with peers – School truancy/ drop out/ delinquency
• Parents use physical punishment—modeling aggression – Violence
that may lead to negative behavior – substance abuse
Elementary (Average age of onset = 6 years of age): – promiscuity
– Conflict with authority
– Overt problems of aggression with peers Adult
– Parent-child conflict
– May develop Anti-Social Personality Disorder
– Covert problems including lying and stealing
– increased school complaints
– rejection by peers
– academic problems

41 42

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Prognosis of ODD/CD
Risk Factors • Aggressive children have an increased risk for being
rejected by peers (Coie, 1990) & abused by parents
Risk factors: (Reid et al., 1981)
• Early onset
• Aggression is stable over time
• Breadth of deviance
• School drop out
• Frequency and intensity of antisocial behaviors
• Family and parent variables • Alcoholism & drug abuse
• Child intelligence - verbal • Juvenile delinquency
• Marital dysfunction & interpersonal problems
• Poor physical health

43 44

Prognosis of ODD/CD
Anti-Social Personality Disorder
Stability of Aggression
– Olweus (1979) found that the stability of aggressive behavior was
almost as strong over 10 year period as intelligence. CD in childhood & adolescence to ASPD in
adulthood
The likelihood that children's aggressive behavior will persist into Adults with ASPD have almost always met criteria
adulthood increases with age.
– There is a modest probability that very young children (preschool) who
for CD; however small population of youth with CD
exhibit persistent patterns of aggression will exhibit aggressive go onto develop the chronic ASPD
behavior as adults

– If these same children are still aggressive by age 10 – 12 the chances

0f aggression in later childhood and adolescence increases
significantly

Merrell, K.W. (2008)

45 46

Assessing Externalizing Disorders

• The essential characteristics of this domain

include:
– Aggression
– Acting out
Assessment – Disruptive
– Defiant and oppositional
– Antisocial
– Hyperactive behaviors

• Comorbidity is common
Merrell, K.W. (2008)

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Assessment
Determine the appropriateness of the referral by
assessing the severity / significance of symptoms
Multi-stage assessment
– Developmentally appropriate, broad-band (provide
example) screening tools, & unstructured clinical interview
to identify behaviors & comorbid conditions
– More labor intensive measures to a) identify trajectory; b)
assess associated conditions in multiple settings and
assess level of functional impairment
– Use information to identify risk factors
Assessment Considerations
 Developmental appropriateness or clinically significant
 Young children with conduct problems are often not
accurate reporters
 Assessment of school and peer contexts become
increasingly important in middle childhood and adolescence
 Language and non-compliance (observations of parent-child
interaction)
 Female considerations

49 50

Methods of Assessing Externalizing

Assessment Method / Measures Problems

• Behavioral Observation
– Very useful, as overt behavior is easy to observe
Interviews
Behavior rating scales
– Can look at specific interactions with environmental
Behavioral observations variables (antecedents and consequences)
Assessment of functional impairment
Comorbid measures: Language, CBCL, BASC-2; – Can directly inform intervention
disorder specific rating scales
Risk measures (parenting measures: stress- • Behavior Rating Scales
practices, psychopathology measures)
– Very useful, can assess long term frequency, severity,
compared to norms
– Useful in monitoring effectiveness of interventions
Merrell, K.W. (2008)
51

Methods of Assessing Externalizing

Problems
•Interviewing Techniques
– Behavioral interviewing is particularly appropriate

– Should include multiple sources of information

•Sociometric Techniques
Empirically Supported Treatments
– E.g. Peer nominations, peer rating, sociometric ranking.
CD & ODD
– Effective for identifying children with externalizing problems, good for
research and screening

•Self Report Instruments

– Children with externalizing disorders are not always reliable reporters
of their own behavior

– Good to use these to gather data on the child’s perceptions of their

behavior
Merrell, K.W. (2008)
53

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Empirically Validated Interventions

Anger Control Training
Goals for Treatment
Group Assertive Training
Ameliorate primary & comorbid problems Helping the Noncompliant Child
Change outcome trajectory Incredible Years
Improve quality of family interactions Multisystemic Therapy
Parent-Child Interaction Therapy
Improve parenting skills
Parent Management Training Oregon Model
Improve social skills
Positive Parent Program
Triple P Standard Individual Treatment
Triple P Enhanced Treatment
Problem Solving Skills Training
PSST Practice / PSST Parent Management Training
55 56

Anger Control Training Parent Management Training

(Lochman, Barry & Pardini, 2003)
Goal: Changing how parents interact with their child will change the child’s
Cognitive Behavioral Intervention behavior. Change new skills

Elementary School Age Children
Takes place in school
Meet once per week for 40 to 50 minutes in small
groups (~6 children)
Discuss vignettes of social encounters with peers
Teach/learn problem solving for dealing with
anger-provoking social situations
Behavioral rehearsal with feedback, then practice
Premise: maladaptive parent-child interactions are at least partly
responsible for producing or sustaining the child’s antisocial behavior
Description:
– Minimal or no direct intervention with the child
– Learn skills and procedures to change parent0child interactions to promote
positive child behavior and decrease anti-social behavior
– Parents learn new ways to identify, define, and observe their child’s problem
behaviors
– Content: rules, praise, punishment, negotiations, contingency management,
contracting
– Homework and practice
– Progress monitoring

in situations designed to around anger

57 58

Helping the Noncompliant Child Parent Child Interaction Therapy (PCIT)

(Forehand & McMahon) (Brinkmeyer & Eyberg, 2003)

Preschool and Early School Aged Children (Ages Parenting skills training program for children
3 - 8) ages 2 - 7
Parent and child seen together for 10 weekly Aims to change the parent-child interaction
sessions patterns
Goal is to disrupt coercive cycle of parent-child 12 to 16 sessions / 1 hr per week
interactions Parent learns basic interaction patterns:
– Child Directed Interaction and Parent Directed
Interaction
Therapists coach parents as they interact with
child
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PCIT
Parent Child Interactive Therapy (PCIT) which
is:
– a manualized family-based intervention
– Effective alternative to traditional parent training
– Builds parent-child relationship and development
of parent’s behavior management skills
– Incorporates parents and child in treatment
http://www.dailymotion.com/video/xpmbbv_parent-child-
interaction-therapy-for-child-behavioral-
problems_lifestyle#.UYAp40p3vaI
61
Target Population
Children ages 2-7 years of age with disruptive
behavior disorders/externalizing behavior problems:
• Oppositional Defiant Disorder
• Conduct Disorder
• Disruptive Behavior Disorder, Not otherwise
specified
• Attention-Deficit Hyperactivity Disorder
62

Phases of PCIT
Child-Directed Interaction (CDI) One-hour session
– Focus on increasing positive interactions Parents alone
between Parent and child. Didactic presentation of skills
• Teaching Sessions, Coaching Sessions “Rules”
until mastery criteria is met Reasons
Parent-Directed Interaction (PDI)
Examples
– Parent structures environment. Consistent
Modeling/demonstration
consequences for compliance and non-
compliance Role-play with parents

• Teaching Sessions, Coaching Sessions

until mastery criteria is met
63 64

Child-Directed Interaction
Skills Taught in PCIT
DO
DON’T
PRIDE Skills – Praise – Give
– Praise – Reflect Commands
– Reflection – Imitate – Ask
– Imitation Questions
– Describe
– Description of Behavior – Criticize
– Enthusiasm
– Enthusiasm
IGNORE annoying behavior
STOP THE PLAY for dangerous or destructive
behavior
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CDI: The Don’t Rules Child Directed Interaction The Don’t Rules

No Commands
No commands  Direct
 Sit here

No questions  Indirect

Could you sit here?
No criticism Why no commands
Attempt to lead
Risk negative interaction

67 68

Child Directed Interaction

The Don’t Rules
No Criticism
No Questions
Questions ask for an answer • Examples
• You’re a bad girl
 Open • That doesn’t go that way
 Closed • No Stop Quit Don’t

• Points out mistakes rather than correcting them

Often hidden commands
– “That’s wrong” is a criticism
Take lead from the child
– “It goes like this” allows correction without criticism
Can suggest disapproval
• Lowers self-esteem
Can suggest not listening
• Creates unpleasant interaction
69 70

Child Directed Interaction

The Do Rules
So…if you take that away….what is left? Praise
“Do” Rules The PRIDE Skills
Unlabeled praise is nonspecific
– Good!

Praise – That's great!

Labeled praise tells child specifically what is

Reflect good
Imitate – Thank you for using your indoor voice.

Describe Increases the behavior it follows

Increases child's self-esteem
Enthusiasm!
Increases positive feeling between parent and child
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Reflection Imitation
Doing the same thing as the child
 Repeating or paraphrasing – Parallel play
“Parent, this is a funny thing on top of his head!” – Cooperative play
“Yes, his hat is very silly!” Lets the child lead
Allows child to lead the conversation
Teaches parent how to “play”
Shows that parent is listening
Shows approval of child’s activity
Shows that parent understands
Teaches child how to play with others
Improves and increases child’s speech – Sharing
– Taking turns

73 74

Behavioral Description Enthusiasm

Telling the child exactly what he or she is doing Conveying excitement by voice and gesture
– “You’re drawing a sun.”
– “Wow! You finished that so quickly!”
Lets the child lead
Shows you are interested and paying Lets child know the Parent enjoys being
attention with the child
Shows approval of child’s activity
Makes the play more fun for both Parent
Models speech and child
Teaches vocabulary and concepts Adds a quality of warmth to the interaction
Holds child’s attention to the task

75 76

Let’s Practice CDI

DPICS coding for 5 minutes CDI MASTERY CRITERIA
Criteria For Beginning PDI Phase of Treatment
10 labeled praises
In a 5-minute observation of CDI, at least:
10 behavior descriptions – 10 Behavioral Descriptions
10 reflections – 10 Reflections
– 10 Labeled Praises
And no more than a total of 3 of the following:
Questions, Commands, Criticisms
(And no commands,
questions, or criticisms)
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Parent -Directed Interaction Parent -Directed Interaction

Increasing compliance through reinforcement
Using effective commands
Increasing consistency in behavioral
contingencies.
Time-out procedure is taught, modeled, role-
played and carried out with child (if necessary).
Sessions begin with child-directed interaction and
move to Parent -directed interaction
Focus on small commands during play (“hand me
the blue block”).
As the child increasingly complies with
commands, more real life commands are
introduced (clean-up commands, opening book,
etc).

79 80

Parent-Directed Interaction
The Command ...
Effective Commands Command

Direct (telling, not asking)

Positive (what to DO, not stop doing) Disobey
No Opportunity
Single (one at a time) Obey

Specific (not vague)

Age-appropriate Whoops! Redirect/
(Start over) Labeled Consequence
Given in a normal tone of voice
Praise
Polite and respectful (Please... )
Explained before given or after obeyed
Used only when really necessary
81

Moving from CDI to PDI Effective Commands in PDI

“Our special time was fun! Now we are going Rule Reason Example

to practice listening and minding. I’m going to

Commands should be Leaves no question that Please hand me the
tell you lots of little things to do like “hand me a direct rather than indirect the child is being told to block.
block” or “draw with the red crayon.” It is very do something. Put the train in the box.
Does not imply a choice, Draw a circle.
important for nor suggest that the Instead of:
Parent might do the task Will you hand me the
you to listen and do what I ask fast. If you mind for the child. block?
quick-like-a-rabbit, I will be very proud of you, Reduces confusion for Let’s put the train in the
the young children. box.
and we can keep playing. If you don’t mind, Would you like to draw a
you will have to XXX” circle?

83 84

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Effective Commands in PDI

Effective Commands in PDI Rule Reason Example
Rule Reason Example Commands should be Permits children to know Get down off the chair
Specific rather than exactly what they’re Instead of
Commands should be Tells child what to do Come sit beside me. vague supposed to do. Be careful.
positively stated. rather than what Instead of Talk in a quiet voice.
not to do Don't run around the room Instead of
• Avoids criticism of the Behave
child’s behavior Put your hands in your
Commands should be Makes it possible for Put the blue Lego in the
• Provides a clear pocket.
age-appropriate. children to understand box.
statement of what the Instead of
the command and be Instead of
child can or should do Stop touching the
able to do what they are Change the location of
computer
told to do. the azure plastic block
Commands should be Helps child to remember Put your jacket in the from the floor to its
given one at a time the whole command. closet. container.
Helps parent to determine Instead of
if child Put your jacket in the Draw a square.
completed entire closet, put your books in Instead of
command. the desk, get out your Draw a hexagon
math book. 85 86

Effective Commands in PDI Effective Commands in PDI

Rule Reason Example Rule Reason Example

Commands should be Increases the likelihood Child: (banging block on Commands should be Avoids encouraging child Parent: Go clean your
given politely and that the child table). explained before they to ask “why” after a desk.
respectfully will listen better. Parent: (in a normal tone are given or after command as a delay Child: Why?
Teaches children to obey of voice) they are obeyed. tactic. Parent: (ignores, or uses
polite and Please hand me the Avoids giving child time-out warning if child
respectful commands. block. attention for not disobeys).
Avoids child learning to Instead of obeying.
obey only if Instead of
yelled at. Parent: (said loudly) Child: (obeys).
ƒ
Prepares child for Hand me that block this Parent: Now your hands
school. instant! look so clean! It is good
to be clean when you go
home.
87 88

Effective Commands in PDI

Rule Reason Example Let’s Practice PDI

Commands should be Decreases the child’s (Child is running around)

Use 4 Commands during the session
used only when frustration (and Please sit in this chair. Use Behavioral Descriptions, Reflections, and
necessary the amount of time spent (Good time to use
in the time- command) Praise) in between each command-obey-praise-
out chair). Instead of sequence
Please hand me my
iPAD from the counter.
(Not a good time to use
a direct command)

89 90

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Problem Solving Skills Training

(Kazdin, 2003)
PDI Mastery:
Behavioral Treatment
– During the 5-minute practice, Parents must
Children ages 7 to 13
• Give at least 4 commands, of which at least 20 to 25 sessions (40 - 50 minutes each) with
75% must be “effective,” (i.e., direct, child
positively-stated, single commands that Taught problem solving strategies
provide an opportunity for the child to
Encouraged to generalize these strategies to real-
comply or not comply) life problems
• Show at least 75% correct follow-through – Identifying problems, generating solutions, weighing
after effective commands pros and cons of each solution, decision making,
evaluating outcome
–labeled praise after obey
Role plays, corrective feedback, social
–warning after disobey. reinforcement, token response cost
91 92

Problem-Solving Skills Training 5 Steps to Problem Solving

Focus on the cognitive distortions and deficiencies displayed 1- What am I supposed to do?
by children and adolescents with conduct problems in
interpersonal situations (Kazdin, 2003) 2- I have to look at all my possibilities
Premise: child’s perceptions and appraisals of environmental 3- I had better concentrate and focus
events will trigger aggressive and antisocial responses
4- I need to make a choice
Description
– Uses modeling, practice, role playing, behavioral contracts,
reinforcement, punishment, loss of coins/tokens
– Used in conjunction with PMT
– During session child learns to appraise the situation,
identify self-statements and reactions, and alter their
attributions about other children’s motivations

93 94

Group Assertive Training Multisystemic Therapy

(Huey & Rank, 1984) (Henggeler & Lee, 2003)
• Adolescents with serious antisocial and delinquent
Based on verbal response model of assertiveness behavior
Used with adolescents • Three to five months in duration
8 hours of group assertive training in small groups • Contact with therapist more than once per week.
(~ 6) - 2x per week for 4 weeks • Combines treatments and procedures as needed to
Counselor Led Assertive Training and Peer Led provide intensive family and community based
Assertive Training intervention
• Goal of promoting responsive behavior and
preventing out-of-home placement
• Cognitive behavioral, behavior therapies, parent
training, pragmatic family therapy, pharmacological
95
interventions 96

16

Multi-systemic therapy
MST is based on social-ecological theory
(Brofenbrener, 1979)
Social-ecological theory views individuals as nested
within increasingly complex systems (family, school,
neighborhood)
Problem behavior is maintained by problem
interactions within & across systems
Influence may be direct or indirect
97
Principles of MST
Principle 1: The primary purpose of assessment is to
understand the fit between the identified problems &
their broader systemic context
Principle 2: Therapeutic contacts should emphasize
the positive and use of systemic strengths as levers
for change
Principle 3: Interventions are designed to promote
responsible behavior & decrease irresponsible
behavior among family members
Principle 4: Interventions are present focused & action
oriented, targeting specific & well-defined problems
Principle 5: Interventions target sequences of behavior
within and between multiple systems that maintain the
identified problem
99
Rational Emotive Mental Health Program
(Block, 1978)
Cognitive Behavioral School-Based program
11th and 12th graders
Meet daily for 45 minute sessions / 12 weeks
Cognitive restructuring through evaluating
irrational thoughts/beliefs, activity exercises
and group directed discussion.
Teach self-examination and self-questioning
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Multi-Systemic therapy
Views caregivers as the key to altering antisocial behavior
patterns
Goal is to strengthen relationships between caregivers &
indigenous resources (grandparents, etc), recognizing that that
caregivers will need significant support
Benefits of home-based treatment
• Avoids potential iatrogenic effects of placing delinquent youth
together
• Helps overcome common barriers like forgetting
appointments
• Provides information about relationships between youth ad
caregivers
• Helps to establish rapport & engage in therapeutic process
Strength-Based focus
Uses strategies such as positive reinforcement & problem solving
98
Principles of MST
Principle 6: Interventions are developmentally
appropriate & fit the developmental needs of youth
Principle 7: Interventions are designed to require daily
or weekly effort by family members
Principle 8: Intervention outcome is evaluated from
multiple perspectives with providers assuming
accountability for overcoming barriers to successful
outcome
Principle 9: Interventions are designed to promote
treatment generalization and long-term maintenance
of therapeutic change by empowering caregivers to
address family members’ needs across multiple
systemic contexts
100
Prevention Programs
Premise: CD problems can be treated more easily
and effectively at younger ages
Address risk factors and strengthen protective
factors can change developmental trajectory
Reduce financial and societal impact\
Incredible Years
Fast Track
102
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School-Based Issues

Peer-teacher interactions
A Word on Psychosocial Treatments
• Students who are aggressive or disruptive often become Earlier intervention is key
rejected by peers
• Also receive less support and nurturance in the school setting
Multi-disciplinary team with communication is
– More likely to get punished and less likely to get encouragement essential
from teachers in comparison to well-behaved peers Multi-faceted
School variables risk factor to conduct disorders (Rutter Integrity is key
1976)
• Teacher availability
• Teacher-student ratio
• Teacher use of praise
• Emphasis on individual responsibility

103 104

Pharmacological Interventions Medication for CD/ODD

Evaluations of medication treatments for ODD Primarily targets the aggression
and CD are less studied
Medications target symptom of aggression Atypical anti-psychotic
rather than other disruptive behaviors – Buspirone (Buspar)--reduction in irratibility, defiance, anger, &
aggression
Risperidone (atypical antipsychotic) effective – Carbamazepine (Tegretol)--reduction in impulsivity &
for reducing aggressive behavior in youth with aggression
CD with below average IQ – Guanfacine (Tenex)–reduction in overarousal & aggression
– Pemoline (Cylert)—reduction in aggression, defiance, anger, &
Stimulants effective in reducing aggression irriability
associated with ADHD and possibly CD – Risperidone (Risperdal)—reduction in impulsivity, aggression,
Lithium and Divalproex Sodium (Mood overarousal, & defiance
Stablizers) effective in reducing aggression in
children and adolescents with CD Some dosages not yet established for children &
105
adolescents 106

Medication for CD/ODD Mediators / Moderators

Side-effects Mediators:
• Dizziness • Parent management skills
• Drowsiness • Youth deviant peer association
• Nausea • Harsh parenting practices
• Vomiting Moderators:
• Sedation • Marital adjustment
• Appetite reduction • Maternal depression
• Sleep disturbances • Paternal substance abuse
• Weight gain • Child comorbid anxiety-depression

107 108

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Conclusions re: Psychosocial

treatments
Earlier intervention is key
Multi-disciplinary team with communication is
essential
Multi-faceted General Treatment Considerations when
Integrity is key working with youth with CD/ODD

109

Owning the problem A Model of the Development of

Chronic Conduct Problems
Problematic behaviors of youth may occur in multiple contexts
(home, school, peers) and may have multiple influences that Dodge, K. A., & Pettit, G. S. (2003). A biopsychosocial
may maintain them. model of the development of chronic conduct
problems in adolescence. Developmental Psychology,
39, 349 –371.
Parent/ Analogy to heart disease
Peers – Single causal agent will never be found
Family – Multiple diverse risk factors
– Risk factors also associated with other outcomes
School – Multiple pathways from distal risk factors to proximal processes
How do distal risk factors (e.g., temperament,
socioeconomic disadvantage) relate to proximal
processes (e.g., emotional reactions & cognitive
These behaviors may change how they are presented based on interpretations)?
context and often are sources of “blame” for the students problem
(“It’s not my fault! It’s…..
111 112

Dodge & Pettit’s Model

Rationale for Treating
Aggression/Noncompliance/
Defiance
Biological Predisposition
High Proportion of School & Clinic Referrals: frequent
complaint of referring families
Parenting High Levels of Family Conflict: noncompliance contributes
Mental Anger/Conduct
Processes Disorder/ODD/ to negative interaction within family
Peers Situational Pervasiveness: if noncompliant at home, likely
ADHD
to also be the case elsewhere
From:
Sociocultural Context Barkley, Russell A. (1997). Defiant Children: A Clinician’s
Manual for Assessment and Parent Training (2nd ed.).
New York: The Guildford Press

114

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Rationale for Treating Aggression/ Context and Background of Treatment for

Noncompliance/Defiance Childhood Disorders
Effects on Family Social Ecology: may have effect on
family functioning of the family, in turn impacting the
Special Challenges:
• Motivation for and Participation in Treatment
noncompliant child
– Focus of therapy may be on disturbing as opposed
Impact on the classroom/school climate: may impact peer to disturbed behavior
behaviors, teacher classroom management, teacher – Perceiving that “no problem” exists makes
stress treatment more challenging
Developmental Persistence: noncompliance/defiance is – Keeping families in treatment
stable over time » 40-60% of children who begin treatment drop
out prematurely
Prediction of Diverse Negative Developmental Outcomes: » Need to consider what factors (SES
precursor to other more problematic behavior disadvantage, high stress, parental
A prelude to Effective Treatment of Other Problems psychopathology, severity of dysfunction, etc)
that play a role in maintaining in treatment

115 116

Developing a Therapeutic Alliance in CBT:

The Challenge of REBT & CBT (or any other COMPONENTS OF THE THERAPEUTIC ALLIANCE
psychotherapy) with Aggressive Clients

• The biggest problem facing psychotherapists with
aggressive clients is that they are unmotivated for
treatment.
• Often they are referred not because they are disturbed
but because they are disturbing (referred by family,
parents, legal system).
• Most models of psychotherapy were developed on self
referred neurotic adults who desire to change.
• Most are referred against their will by others for
externalizing problems and do not wish to change.
117
1) Agreement on the goals of therapy.
2) Agreement on the tasks of therapy.
3) The relationship bond.
– Agreement on the goal may be easy to establish in
the population that most psychotherapies were
developed on, Adult self referred neurotic patient
are usually eager to change.
– What population of adults do we have the greatest
difficulty establishing the therapeutic relationship
with? Forced referred, externalized people (e.g..
Court referred or spoused coerced)
118

Building the Therapeutic Prochaska & DiClemente Stages of

Alliance/Working Relationship Change (1981)
DiGiuseppe & colleagues (DiGiuseppe, 1995; • Pre-contemplative stage
DiGiuseppe, Linscott, & Jilton, 1996) advocates
asking clients in a Socratic fashion to assess the • Contemplative stage
consequences of their emotional & behavioral
responses. • Action stage
Motivational syllogism can used to reach agreement • Maintenance stage
on the goals of therapy. The elements of motivational
syllogism are as follows:
(1) My present emotion is dysfunctional
(2) An acceptable alternative emotional script exists for this type of
activating event
(3) Giving up the dysfunctional emotion and working toward
feeling the alternative one is better for me
(4) My beliefs cause my emotions; therefore, I will work at
changing my beliefs to change my emotions
119 120

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Stages of Change Building An Alliance In Individual

Therapy with the Motivational
The type of therapy needs to match the client’s stage Syllogism Model
of change To help deal with these problems the following
strategies are suggested:
REBT designed for clients in the action stage
1) Assess the client’s goals.
Most children & adolescents enter therapy in the 2) Express empathy for the child client’s perception of the
pre-contemplative stage problem.
– Establish agreement on goals and tasks of therapy to 3) Agree on goal to explore.
build the therapeutic alliance before using active 4) Explore the consequences on the EMOTION.
approach of REBT
5) Explore alternative scripts.

121 122

Considerations When Stages of Change

Working with Angry Children
Most aggressive kids do not see their behavior as
problematic
– In therapy against their will
Initial goal of therapy- to motivate them for behavior change
– Agreement on the goals and tasks of therapy
Teach the Motivational Syllogism to children in pre-
contemplative stage
– My present emotion (anger) is dysfunctional
• Technique: Socratic questioning to help client
understand how the anger is dysfunctional.
• Assess consequences of their emotional and
behavioral responses.
• Help client identify negative consequences of their
maladaptive emotions and behaviors

123 124

Motivational Syllogism Continued Motivational Syllogism Continued

– An acceptable alternative emotional script
(annoyance) exists for this type of activating event
• Technique: through teaching and reviewing
acceptable models, help client understand that
there are alternative emotional scripts that are
more adaptive.
– Note- not to change the level of intensity, but to
replace the emotion with a qualitatively different one.
Explore the culturally acceptable alternative
emotional reactions with the client
– Giving up the dysfunctional emotion and working
toward feeling the alternative one is better for me
• Technique: through Socratic questioning have
client imagine feeling the new emotional script
and review the consequences for the new
emotion.
• This should accomplish agreement on the goals
of therapy

125 126

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Motivational Syllogism Continued Motivational Syllogism Continued

– My beliefs cause my emotion; therefore, I will work
at changing my beliefs to change my emotions
• Technique: teach the beliefs-consequences
connection (B->C). This should accomplish
agreement on the tasks of therapy.
• Do steps of motivational syllogism before discussion
of each new problem and before use of any
intervention
• Assess child/adolescent’s stage of change and
agreement on goals of therapy before proceeding with
any intervention

127 128

What is Rational Emotive Behavior

Therapy & Cognitive Behavioral
Therapy?
Cognitive Behavior Therapy (CBT) operates under
the premise that individuals engage in unhealthy,
REBT as a Treatment Model maladaptive ways of thinking and it is these
for CD/ODD thoughts that cause problematic emotions and
behaviors
– There are many variants of Cognitive
Behavior Therapy. The one that will guide
this talk is Rational Emotive Behavior
Therapy (REBT)
130

Emotion:
Depression Three Column Technique

Antecedent Event Thoughts Emotions

My teacher gave me an I will never be able to do Fear
Perception: Automatic assignment. this.
Negative I am bad at everything Depressed
“He didn’t like Thoughts: Attributions:
my work” “I fail at every thing” “I AM stupid” My friend asked me to X will be there, she Depressed
go to a party with her. doesn’t like me.
No one will like me there. Anxious
Once I went with her and
I felt bad. I will feel bad
again.
Core Schematic
Cognition

132

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Different Targets of Emotional Assessment Different Targets of Emotional Assessment

Typical questions that psychologists put to young
clients to assess their feelings include:
– When __________ happened, what did you feel?
– What else did you feel?
– Using your Emotional Thermometer, when was the
last time you got very angry/down/worried?
– What were you feeling inside when you felt very
angry/down/worried?
– When you were very __________, what did you do,
how did you behave?
– What happened to you after you behaved in that
way? What did other people say or do?
Unless you can identify a time when your student
was extremely upset (e.g., 8-10 on the Emotional
Thermometer) it is unwise to conclude that the
client has an emotional problem or harbors
irrational beliefs.
To “get at” a more extreme emotional reaction of
students, ask:
“When was the last time you got extremely upset (really
angry, anxious or down) – when you were close to the top
of the Emotional Thermometer?”

133 134

Different Targets of Emotional Assessment WHAT IS THE ESSENSE OF EMOTIONAL

DISTURBANCE?
In assessing dysfunctional cognitions in both
children & their parents & teachers, interpretations The Essence of Emotional Disturbance:
of reality as well as appraisals of interpretations DEMANDINGNESS
are examined. Demandingness takes the forms:
Waters (1982b) suggested 4 main problem areas – “I must” , “You must”, “It must’
to assess: – “I have to”, “You have to”, “It has to”.
1. Is the child distorting reality? – “I got to”
2. Is the child evaluating situations in a self-defeating – “I need”
way?
3. Does the child lack appropriate cognitions?
– “I should”
4. Does the child lack practical problem-solving skills?
135 136

THE ESSENSE OF ALL EMOTIONAL

DISTURBANCE (Continued)
ESSENSE OF ALL EMOTIONAL
DISTURBANCE (Continued)
THE ESSENCE OF
ALL EMOTIONAL The Self Others The World
DISTURBANCE:

DEMANDINGNESS “I “YOU “IT

MUST” MUST” MUST”
(And if I do not) (And if you do not) (And if it does not)
(One can put the demands on:)
1. IT IS HORRIBLE , 1. IT IS HORRIBLE , 1. IT IS HORRIBLE ,
TERRIBLE AND AWFUL! TERRIBLE AND AWFUL! TERRIBLE AND AWFUL!

2. I CAN’T STAND IT! 2. I CAN’T STAND IT! 2. I CAN’T STAND IT!

3. I AM NO GOOD! 3. YOU ARE NO GOOD! 3. IT IS NO GOOD!

The Self Others The World

137 138

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DERIVATIVES OF THE DEMANDS ESSENSE OF ALL EMOTIONAL

DISTURBANCE Summary
All serious emotional disturbance is caused (or
Catastrophising: “It’s Horrible, Terrible &
strongly influenced) by:
Awful”.
– Cognitions
Low Frustration Tolerance: “I Can’t Stand It”.
And these Cognitions take the form of:
Self/Other Rating: “I’m no good, rotten, bad,
worthless”. – A Demand (e.g. “I must be successful”
– And one of the Derivatives (“ It is Horrible”,
or “I Can’t Stand It”, or “I’m a Rotten
Person”.

139 140

ESSENSE OF ALL EMOTIONAL

DISTURBANCE Summary
WHAT ARE THE GOALS OF
REBT?
Given this model, emotional disturbance develops
because of one or two types of cognitive errors: Demand: • Preference: “ I’d really
“I Must” like to …. but no reason
1.empirical distortions of reality that occur (inferences)
Catastrophizing: I Must”
2.irrational, exaggerated & distorted appraisals of
inferences. “It’s Horrible” • “It’s bad, but not HTA”
According to REBT/CBT, it is primarily the appraisal Low Frustration Tolerance • “I don’t like it, but I can
that is necessary for emotional disturbance. “I Can’t Stand It” stand it”
Ellis has noted, however, that, many times, the
Self Rating: • “I’m a disadvantaged
“I am a Rotten Person” psn. But not RP”
appraisals are about distortions of reality.

141 142

Rational vs. Irrational Beliefs Defining “Beliefs”

In REBT/CBT, the terms belief and belief system refer to that
IRRATIONAL RATIONAL aspect of human cognition that is responsible for the mental
health & the psychological well-being of the individual.
Ellis has elaborated an ABC (DE) theory of emotional
Demandingness Preference disturbance that describes how a person becomes upset:
– REBT/CBT starts with an emotional & behavioral
consequence (C) and seeks to identify the activating event
Awfulizing Unpleasant (A) that appears to have precipitated (C).
– REBT/CBT steadfastly maintains that it is the individual’s
beliefs (B) about what happened at (A) that more directly
LFT Tolerance “create” (C).
– Disputation (D) involves challenging & questioning irrational
Self Downing beliefs
Self Acceptance – When individuals change their unsound assumptions, they
wind up with new cognitive (philosophical), emotive, &
Others Downing Accepting Others behavioral effects (E’s).

144

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Another “User” Friendly Model Different Targets of Emotional Assessment

Be thorough in eliciting absolutes and derivative
Happening → Thinking → Feeling → Behaving evaluations using inference chaining & deductive
John teases me. Everyone teases me. down (9/10) withdraw interpretation questioning.
I have no friends.
I'll never have friends.
Summarize & validate the information you have
gathered.
This is terrible.
I'm a loser. Say: “So let me get this straight, you have said that
John teases me. This is unfair. anger (10/10) fight when ___ happens and you think ___, & you get
He shouldn't do this.
very ___ (feeling) & you behave ___.” Is that right?
I can't stand this. If young client does not agree with your summary,
He's a real _____. return to conduct further assessment.
Note. The order of assessment questions using the HTFB framework is as follows: 1. Identify a specific Happening
(day, place, person, task). 2. Assess different feelings client had about the Happening and assess using the
Emotional Thermometer, the intensity of each. 3. Assess behavior reactions that accompany feelings.
145 146

Child and Adolescent Scale of Irrationality

Measuring Irrationality in Children Child and Adolescent Scale of Irrationality (CASI)
– Developed: Bernard & Laws (1988). Modified: Bernard & Cronan (1999)
– 49 items representing irrational beliefs
– Original factor structure was empirically derived

Terjesen, Kassay, and Smidt (2010) evaluated the CASI

– 1036 participants
Measuring irrationality is a part of data-based decision making – New factor structure based on expert consensus
– Intervention can be designed to target specific irrational beliefs Total Irrationality and 5 Irrational Belief scales
– Intervention is more direct and efficient – Internal consistency of the overall measure was high (α= .92)
– Change can be monitored over time – Convergent validity – all scales highly correlated with BASC-2 scales
– Discriminant validity – clinical sample higher than school-based sample
Fewer empirically supported measures of children’s irrational beliefs exist in Total Irrationality and 4 Irrational Belief scales
compared to those of adults
– Youth data has been collected on adult measures CASI-3 (Terjesen, Kassay, and Smidt, 2013)
– Four non-English measures have been developed for children – Clearly measures all irrational beliefs
– Child and Adolescent Scale of Irrationality (CASI) » Includes rational alternative beliefs
– Content of items balanced

147 148

Treatment Goals & Methods Empirical disputation

Involves an examination of evidence to determine whether
So….now we have identified these unhealthy the child’s inferences & evaluation are reality based:
thoughts…..NOW WHAT????There are 6 main
REBT/CBT intervention strategies used to restructure  “Where is the evidence to support your idea that no
one likes you?”
faulty inferences, absolutes & evaluations including:
 “Where is the evidence that you are an idiot because
empirical disputation you received a poor grade?”
logical disputation  “Where is it written that you must do everything
perfectly?”
semantic disputation  “Is it true that you must?”
Functional disputation
rational self-statements (with/without Empirical analysis is a common form of empirical
disputation & involves you & the young client designing a
disputing) simple experiment to gather data to test the client’s
rational emotive imagery interpretation of reality (conclusions, predictions).

149 150

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Logical disputation Semantic disputation

Involves an examination of whether the
conclusions the child is drawing & the expectations
clients formulate are sensible & logically follow
from the facts.
“Does it make sense to conclude you are never going to
be able to pass a math exam?”
“Does it follow that because someone acts badly towards
you from time to time that he is a totally bad person in
every respect?”
“Just because you want to succeed in your schoolwork,
does it follow logically that it must happen?”
Involves providing young clients with an objective definition
of the words & phrases they employ in thinking about &
evaluating their world.
For example, if you have determined through your
assessment that your child believes that “It is awful to be
thought badly of by my peers,” you can semantically
dispute this using a Socratic style as follows:
– “Well, ‘awful’ really means the very worst things that could
happen to you. Is being thought badly of by one or more of your
classmates really the worst thing that could happen to you?”

151 152

Bonus Disputation:
Functional disputation The Ross and Rachel Dispute
Involves challenging the belief in the sense that it O.k., not an official dispute according to Ellis,
is not helping one work towards their life but I like to use this and call this the “Friends”
goals. In fact, it is causing them great dispute.
difficulty. Simply, when we engage in harmful patterns of
– Does it help me to think this way? Does my thinking a question we may wish to ask
thought help me to achieve my goals and ourselves is:
manage my emotions? – “Would I tell my friend, that….
• He/she is a loser if they fail the exam
• That it would be AWFUL if they made a “social
mistake”

153 154

Case Study
Empirical, logical and semantic disputing can be used to Background
dispute both inferences & evaluations. Kevin is a 4th grade student enrolled at Bayside School. He has one younger
sister and lives with his biological parents who are very strict.
In teaching your young clients about the process of
disputing, you can explain that disputing involves asking
three questions about one’s thinking: Demandigness 79
1. Is what I am thinking true? Is there evidence to support what I Awfulizing 63
CASI scores
am thinking? LFT 60
2. Is my thinking logical? Does it make sense to think this way? Self Downing 55
3. Does it help me to think this way? Does my thought help me to Other Downing 50
achieve my goals and manage my emotions?

You can explain that when a child answers “No” to any one
of these questions, s/he should with your help, try to
change the thought to one that is true, sensible & helpful.
155
Presenting problem
Kevin was referred for evaluation by his teacher who claims that he is very
distracted and unfocused lately, and has some anger problems towards
peers and some defiance towards his teacher. Further, his grades dropped
compared to last semester and he is in danger of failing math.
156

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Demandingness Interventions Targeting Demandingness

Distinguish needs from wants
 What are things you really need? So is getting an A something you
CASI – 3 Items: really need or is it something you just really want?
“I need to be able to do what I want Where it is written?
when I want.”  Where is the law that teachers have to be fair all of the time?
“I must get good grades” Be a detective or scientist and look for the evidence
“I ABSOLUTELY need my friends to like me.”  How many times has your teacher given you a boring assignment?
If it has happened hundreds of times before then obviously it can and
I really want to get only good grades, but I
I must always get an “A”. don’t have to get them just because I does happen, so does how can you say that it must not happen?
want this to happen.  Ask the student to do a task in which you suspect he will not be
successful. Ask him to tell himself that he must do is successfully.
Acting out When he is unable to do it, ask him if what he was telling himself was
Anger Anxiety Disappointment Worry Sadness
behaviors helpful and if it made any sense to do it.
Magic wand
 If you had a magic wand, what would you change about what
happened with your friend? But, do you actually have a magic
wand?
157 158

Awfulizing Disputing “Awfulizing”

CASI - 3 Items:
“When a teacher treats me unfairly, it’s horrible.”
The tendency to blow things out of proportion is
“It would be the worst thing in the world if I made a characteristic of people of all ages.
mistake.” Make young clients aware that they are
“awfulizing”.
Use the “catastrophe scale” exercise:
 On a blackboard or large sheet of paper, have the young
client list all the catastrophes s/he can think of.
Failing a test it’s unpleasant but it’s not
Failing a test would be awful. the end of the world.
 After listing, bring up the child’s complaint.
 It may not be necessary to point out that the event, while
Social Positive Social
bad, does not belong on the same list.
Depression Anxiety Sadness Worry
Isolation Relationships

159 160

Interventions Targeting Awfulizing Interventions Targeting Awfulizing

Bad vs. Awful Catastrophe scale
BAD AWFUL

BAD Getting a bad grade. Losing my best friend. Earthquake

On a scale from 0 to 100 how

AWFUL is it? Adapted stories
How angry do you feel when you
think it is SO awful?
GOOD Using Puppets with younger children

Imagery

161 162

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Interventions Targeting LFT

Low Frustration Tolerance Break down the task
CASI - 3 Items: – Help the student see that even large, seemingly “unbearable” task can be
“I can’t stand having to follow rules at home.” broken down into smaller, more manageable steps. As she is accomplishing
the steps, ask her if the task was ever so “impossible” to begin with.
“I can’t stand my parents telling me what to do.”
Teach the “I Think I Can” story
– Will telling yourself that “you can’t do something” help you actually do it? How
about telling yourself “I can do it”?
Have you stood it before?
– Have you been grounded before? Did you survive the incident? Do you have
reason to believe that this time it is going to kill you?
Lose a game…and stand it
Even if I don’t like it, I’ll get through it – Play a game and let the student loss. When he loses ask him how he is
I can’t stand having too and it is worth it to do so. standing it. Help him, if necessary, learn strategies to cope with the
much homework. disappointment.
Is it worth it?
Anger Anxiety Procrastination Sadness Worry Productivity – Encourage the student to step out of the moment and list the pros/cons of
facing/avoiding a task. Then review the list to see if it would be worth
attempting. Ask her to write more rational evaluations of the task and their
163 ability to get through it. 164

Ratings of Self Worth Interventions Targeting Ratings of Self Worth

CASI - R Items: • Flat tire metaphor/ Fruit basket metaphor

“When my friends don’t ask me to do things with them I think • Self-worth circle (part not equal to whole)
I’m a loser.”
“I think I’m a total failure in everything when I don’t get good
• Behavior doesn’t equal the whole person
grades.”

• Friend test
If I don’t get good grades that Grades reflect just my performance
means I am a loser. and not myself as a person.
• How is it helping you to put yourself down?

Self • Shame Attack Exercise

Depression Guilt Shame Disappointment Regret Acceptance

165 166

Self Worth Circle Ratings of Others’ Worth

CASI – 3 Items:
“Parents who are usually too strict are total idiots.”
“Teachers who treat students differently are not bad
people.”

Just because somebody treats me

People that treat me bad are bad that doesn’t mean they loose
worthless. their worth as human beings.

Positive Self
Relationship Regret Acceptance
difficulties Guilt Shame Relationships

167 168

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Interventions Targeting Ratings of Others’ “Tips for Disputing”

Worth
Be animated when disputing.
• Behaviors not equal to person
For children 8–12 years old, make sure your
disputes are concrete & tied to specific events.
• Does a person’s “worth” go up and down?
Go over the same disputes over successive
sessions.
• Humans make mistakes
Be patient.
• Is anyone perfect? Check to make sure that your client is not just
agreeing with you for the sake of agreeing.
Ask clients to put in their own words their
understanding of one of your didactic disputes.
169 170

Rational self-statements Common IBs in CD/ODD

• Rational self-statements are generated through a
collaborative effort of the therapist & child & are provided Frustration Intolerance
to children for rehearsal & use in subsequent situations
Self and Other Ratings of Worth
that tend to occur with child high levels of emotionality.
• The use of rational self-statements is the preferred
Awfulizing or Catastrophizing
cognitive intervention for use with clients younger than 8. Demandingness of Self, Others, and World Conditions
• For young clients, you can use “green light” & “red light”
or “positive thinking” & “negative thinking” rather than
“rational thinking” & “irrational thinking.”
• For clients older than 8, rational self-statements also are
generated collaboratively between you & your client after
disputing has occurred & are the main technique for
developing in clients new rational Effects (beliefs).
171 172

Frustration Intolerance FI Continued

• “I can’t stand-it-it is” (Ellis & MacLaren, 1998) for
events
• Need for immediate gratification
• Short-term hedonism
• Present in extreme forms in academic and
social/interpersonal situations
• FI results in work avoidance and lack of successful
learning experiences which results in self-downing
and self-rating
• Children with FI tend to be overly focused on
gratifying whatever need they have in the
moment- less inclined to attend to other important
stimuli (verbal and non-verbal behaviors of other
children).
• Result- peer rejection- triggering further emotional
and behavioral difficulties

173 174

29

ABC Framework for FI: A scenario
A fight breaks out in the schoolyard
– A: Children playing ball in the yard
– B: I need to play right now
– C: Anger (emotional); pushing one’s way into
the game (behavioral)
175
Other-Rating
“They’re stupid”
Feelings of anger which hinders efforts to be
successful in their schoolwork and relationships
Focal Point of Therapy
– Teach Unconditional Self- and Other-
Acceptance
– Rate behaviors not self
177
Awfulizing
• Catastrophic thinking resulting in anxiety
• Is the anxiety of social or evaluative nature?
• What if I try and join in on the game and the
others reject me?--- That would be awful,
horrible, the end of the world- ?? ANXIETY
• What if I tried really hard and did poorly on my
test?---That would be horrible and terrible- ??
ANXIETY
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Self-Rating
I’m a loser. Nobody likes me. I’m stupid.
Feel chronic feelings of inferiority that interfere
with ability to adjust to and cope with ODD/CD.
• Depression, feelings of hopelessness,
withdraw, no opportunity to develop
appropriate social skills.
176
Demandingness
Self- “I should be a better student”
Others- “I shouldn’t be told what to do; They should
listen to me”
World- “Things should be different”
178
REBT with CD/ODD: Other considerations
• Establish session expectations and monitor therapy
assignment completion
• Perhaps consider incorporating an in-session token
economy to increase attention to the task at hand: make
the most out of the session.
180
30

REBT with ODD/CD: Other
considerations
The use of a game to teach the concept of frustration
tolerance has also been helpful for such children.
– For example, playing a board game, while at the
same time modeling for the child High Frustration
Tolerance self-statements such as “This is tough but I
can get through it!” assists the ADHD child in seeing
that there is another way of thinking about a problem.
181
Pre-Requisites to Disputation
• Insight into the B->C connection
• Teach a cognitive model of emotions and behaviors
• Emotional and behavioral responsibility is a primary
therapy goal
• Teach an emotional vocabulary
• Teach an emotional schema
• Conduct a thorough assessment of the child’s
cognitive and developmental level
183
In Between Session Assignments
• Crucial for reinforcing concepts
• Assessment driven (write down your thoughts and
feelings when you get upset this week)
• Behavioral/Experiential (start conversations 3 times
this week)
• Risk-taking (raise your hand in class when you are
not sure of the answer)
• Cognitive (practice disputing in front of the mirror
everyday this week)
185
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REBT with ODD/CD: Other considerations
Game playing allows for:
• Therapist modeling: especially helpful for children who
are cognitively or developmentally not able to engage
in more abstract and flexible thinking.
• Observation of deficits in social skills, inability to take
turns and impulsive play behaviors.
• Opportunity to provide feedback for the child on how
the therapist feels when he/she is interrupted or when
the child does not allow turn-taking, can be an
invaluable step in assisting the child to develop better
social skills.
182
Child Session Format
Treatment activities (hypothetical 45 minute session):
– Rapport Building/chat time (5 minutes)
– Goal Attainment Check-In (5-10 minutes)
• Evaluation of completion of prior session HW
– Establishing In Session Goal (5-10 minutes)
– Discussion of concrete & abstract ABCs related to the goal
(10-15 minutes)
– Role playing, disputing, effective coping statements, self-
help forms (10-15 minutes)
– Coping Skills Activity (5 minutes)
– Development of between session goal and evaluation of
barriers (5 minutes)
184
Social Problem-Solving
Children with CD/ODD often do not pause to entertain
alternative solutions to their problems
Teach the child problem-solving…and importance of
emotional regulation
Research does not support improved behavior when
using problem-solving alone
Difficulty generalizing problem-solving skills to different
situations
186
31

Self-Instructional Training
Meichenbaum & Goodman (1971)
Teach children to talk to themselves to help control
their behavior
Use reinforcement to augment SIT’s effects
Use games to teach SIT
187
CBT Approach to Working with families
Highly interactionist.
– Family members simultaneously influence and are
influenced by each other's thoughts, emotions, and
behaviors.
So, we need to look at this system and how within this
system individuals interact
– Family members will develop expectations about who
plays what role and this will guide affect and behavior
– When these expectations involves negative content, the
family dynamics may become more volatile and lead to
more conflict.
– Finally, as the number of family members increases, so
does dynamic complexity and the risk for further
escalation.
189
Family Therapy for Treatment of Families with
Children with Externalized Disorders
• Conduct thorough assessment of child’s difficulties
• Form therapeutic alliance with parents
• Choose target behavior and appropriate consequences
collaboratively with parents
• Assess parents’ ability to carry out interventions
• Change parents’ IBs and emotions that may interfere with
performing the new parenting strategies
191
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Family Therapy for Non-Compliant
and Aggressive Behavior
"The parents are the architects of the
family"
Virginia Satir (1967), (p. 83).
Family conflict resolution depends on:
– communication skills
– beliefs of family members about individual and
family functioning (Schemas)
– Family emotion and behavior
188
Family Therapy for Treatment of Families
with Children with Externalized Disorders
Goal- change parents’ IBs and emotional disturbance.
Necessary to accomplish the primary goal of changing the
child’s symptomatic behavior
Parents involved from start
– This can be a challenge in schools
– Also, be conscious of cultural variables that may impact
upon family involvement
190
Family Therapy for Treatment of Families with Children
with Externalized Disorders Continued
• Have parents predict what resistance they expect to
occur to their new parenting strategies from the identified
patient and generate solutions to confront these attempts
at resistance
• Assess parents’ ability to follow strategies they choose to
handle the resistance
• Intervene with parents again to change IBs and schema
that may prevent them from handling the resistance
• Continue to assess child’s progress and parent’s
compliance with the behavioral skills and modify
treatment plan as needed
• Begin individual therapy with child to internalize gains
made by the behavioral intervention
192
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Cognitive/
Family Schemas and IB’s Behavioral/Systemic Therapy
Very often we might have inferences that guide us DiGiuseppe discusses an integrative approach
individually within the family system. These inferences to help overcome the problem of no motivation
may have come from our own personal history and
may be non-evaluative
for treatment is to work with the family or some
– We handle difficulties like we did in my family
other system, (e.g. the school) to change the
It is when our inferences become evaluative and contingencies.
rigidly held that it becomes problematic within this This brings up the issues of:
system – “Undeclared War” Between Individual & Family
– We HAVE TO handle difficulties the way they were handled Therapy.
in my family
This….leads to conflict How does one decide what therapy to
use??
193 194

Advantages & Disadvantages Advantages & Disadvantages

of Types of Therapies of Types of Therapies
A: Individual therapy B: Family Systems Therapies

Pro: Individual therapy works at the intrapsychic level.
Establishes skills within the child.
Con: Less effective than therapies that work with
families.
195
Pro: More effective, works with the environment that
influences the child.
Con:
 No guarantee of transfer of skills to the child.
 Parents tend to drop out when asked to implement
an intervention. They often do not own the problem.
Often does not teach parents skills to use in the
future, rather it helps them overcome a present
practical problem.
 Negates the focus on personality, temperament or
skills of the individual.
196

Advantages & Disadvantages

of Types of Therapies Integration of Approaches
C: Behavioral Based on Paterson work with disruptive children we
can expect Coercive Family Process to operate in
Pro: most families of children with externalized disorders.
1) Most effective. More research supporting it than Coercive Family Process:
other therapies. Coercive Behavior of one family member is positively
2) teachable technology. reinforced by the compliance of another family
therapists who is negatively reinforced by the
interaction.
Cons: • What leads to coercive family process?
1) problem of generalization. • What cognitions support it?
2) parental failure to comply. • Is it innate?
3) lack of focus on parental emotions & pathology.

197 198

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Stages of the Therapy Stages of the Therapy

Stage 1 Stage 2:
Assessment: Engaging parents in the therapeutic alliance:
A) nature of psychopathology: developmental level of functioning. – If one parent is resistant to change uses motivational
Is the behavior really dysfunctional or does the referring agent syllogism as to the parents behavior first before you start
have unrealistic expectations of the child on the task of changing the child's behavior.
B) behavioral assessment - discriminative stimulus and
reinforcers.
C) family assessment:
1) structure of the family
2) roles of individual members
3) who will resist?
D) emotions, skills, and cognitions of each member.

199 200

Stages of the Therapy Stages of the Therapy

Stage 3: Stage 4
Behavioral Intervention: choosing target behavior & Assessing parents ability to carry out agreed
reinforcers which will be effective. intervention assess emotions, skill, cognitions.
Teaching parents problem solving by raising Possible parental interfering emotions:
alternatives and consequences of choices. guilt, anger, anxiety, discomfort anxiety
Some family therapies and behavior therapies assign Parents irrational beliefs
tasks and lose opportunity to teach problem solving. 1) demandingness
Note: Regardless of choice parents make research 2) catastrophizing
indicates that for externalized behavior disorders 3) frustration intolerance
response cost is most effective.
4) self downing
In this stage it is important to collaborate on reaching 5) projected frustration intolerance
a decision on an intervention. The intervention is not
assigned by the expert as in many family system 6) condemnation of the child
models.
201 202

Stages of the Therapy Stages of the Therapy

Stage 5
Therapy on the parents:
– Cognitive restructuring of their irrational beliefs
– Use all of the techniques that one would in adult REBT or CBT
focused on the emotions and cognitions identified in the previous
stage.
Stage 6
Predict resistance:
– Problem solving what they believe the child or others will do
sabotage their efforts. Problem solve how they can respond to
those attempts at sabotage.
– Again it is important that you use collaborative problem solving so
that the parents learn to problem solve independent of the
therapist. This will help them do it own their own after
termination.
203
Stage 7
Assessment of the parents’ ability to follow
intervention:
– Imagine themselves following through. What emotions &
beliefs will they have about this new action.
– What do they believe their emotional reactions will be to
these.
– Assess emotions and cogntions that will get in their way of
following on the intervention chosen to counteract the
sabotage.
Stage 8
Intervention with parents:
– Dispute the irrational beliefs that they will experience and
could encourage them to give into the resistance.
204

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Stages of the Therapy Stages of the Therapy

Stage 9 Stage 10
How will child respond to new action Individual therapy for the child or adolescent.
1) at the beginning of each session, assess the progress the
1) repeat assessment child and parents have made. If parents have followed their
2) redesign interventions through collaborative interventions remain in this stage. If the have not return to
problem solving. stage 8.
2) Use motivational syllogism to help child internalize the
3) continue to assess parent’s ability to carry out desirability of change and cooperation with the therapists.
the new interventions 3) Use all REBT and CBT methods to reduce the undesirable
4) continue to use cognitive restructuring to help target behaviors support the desired positive changes.
them follow through on the planned What of the therapeutic alliance in these Stage 10
interventions. sessions???

205 206

Effective Interventions for CD/ODD:

Stages of the Therapy
What Does It Take?
Stage 10
Individual therapy for the child or adolescent. Challenge assumptions about what maintains
1) at the beginning of each session, assess the progress the the behavior
child and parents have made. If parents have followed their
interventions remain in this stage. If the have not return to
stage 8. Be willing to experiment
2) Use motivational syllogism to help child internalize the
desirability of change and cooperation with the therapists. Be creative, not just artistically
3) Use all REBT and CBT methods to reduce the undesirable
target behaviors support the desired positive changes. Use all available resources
What of the therapeutic alliance in these Stage 10
sessions??? Parental Involvement!

207 208

Allied Behavioral Treatments as part of Clinical Behavior Therapy

family therapy
Chronic misbehavior? Behavior Modification • Most common application of behavioral procedures
Contingency management to children with disruptive and attentional problems
– Token economy rewards • Work with teacher/parent in a consultation model
– Time out • Daily report cards targeting specific individual
– Response cost problems
– Removal of privileges • Teacher monitors and provides feedback to the child
– Maneuvering of attention and to the parent
• Positive consequence delivered at home by parent
Requires intensive work on part of teacher/parent

209 210

35

Antecedent-Based Strategies
• Antecedent interventions are things done before the
target behavior occurs, preventing problems before
they occur
• Antecedent strategies alone are not enough! They
should be combined with consequence-based
strategies
• Here is where “data collection” by the parent or
teacher might be very helpful to “predict” when the
behaviors are to occur
• When possible, we can design an environment and
provide preventative actions that may be more suitable
to reduce the occurrence of the behavior.
• These are strategies you can use to try to prevent
problem behaviors from occurring
211
Functional Behavior Assessments
Often the first step in determining an appropriate reactive
intervention or consequence-based strategy
A process that includes interviews, observations, and data
collection
Environmental variables occurring directly before and after
the target behavior are examined
Patterns of these variables are examined to help determine
what function the behavior serves for the child (e.g.,
attention from teacher, escaping a difficult task)
Used to determine what interventions may be most
effective
215
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Antecedent-Oriented Daily Report Card
Consequence-based Strategies
Manipulation of events after a target behavior to:
1. Increase probability of adaptive responding
2. Decrease probability of problematic behavior
– Functional Behavior Assessments (FBAs)
– Token reinforcement programs
– Contingency contracting
– Response cost
– Time-out from positive reinforcement
– Daily Report Card
214
Token Reinforcement Programs
Behavioral strategies incorporating secondary reinforcers to
provide students the reward immediacy that is needed
Can help to improve academic productivity and appropriate
classroom behaviors
Usually considered too complicated for children <5
Steps to take in setting up a token economy:
1. Identify target behaviors
2. Identify tokens used (children <9 do better with tangible
objects like poker chips, otherwise, stickers, checkmarks)
3. Determine the value of target/goal behaviors.
 Number of tokens earned for completing each
behavior or subcomponent must be determined.
 Completion of more difficult or time-consuming tasks
warrants more tokens.
 More complex behaviors broken down into smaller
tasks.
216
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Token Reinforcement Programs (cont’d) Contingency Contracting

Steps to take in setting up a token economy (cont’d):
4. Work with student to develop a list of privileges or
• Involves the negotiation of a contract between the
activities for which tokens may be exchanged. student and parent/teacher
 Can get input from parents • Contract what the desired behaviors are and what
5. Teach the student the value of tokens through consequences will be earned for their performance
demonstration and ensure that initial target
behaviors are within the child’s capability to • Specific academic and behavioral goals are
ensure early success. identified
6. Tokens are exchanged for privileges at the very
least on a daily basis. Shorter delays will allow • Rewards can again be preferred activities
for more success.
• Usually unsuccessful with children <6
7. Monitor effectiveness of intervention and alter
delivery of tokens or timing of exchanges as • Early on in the process, start with a small number of
needed. goals and avoid extremely high standards of quality
8. Determine other target behaviors to be changed.
9. Fade out use of tokens in a gradual fashion. At
first, tokens after every step of a process and
later tokens when whole process is completed.
217 218

Response Cost Time-out from Positive Reinforcement

Mild punishment strategy
• Involves the combination of positive reinforcement for Should only be used in the context of ongoing
appropriate behaviors with small penalties for inappropriate positive reinforcement
behaviors Rules to follow:
• Can be used in conjunction with token reinforcement 1. Use only when there is a reinforcing environment
• In order to be effective, child must earn more reinforcers than # from which to remove the child
2. Use when the function of the behavior is to gain
lost
attention from teachers or peers
• Can involve chips in a cup, marks on a chart, etc. 3. Employ quickly after problematic behavior/ breaking
• One method involves giving children the maximum amount at of rules
the beginning of the day, and subtracting throughout the day 4. Apply consistently
for inappropriate behaviors 5. Use for smallest period of time that proves effective
(1-5 minutes)
• An alternate method involves positive behaviors weighted 6. Terminate when:
more heavily (5 points for appropriate behavior, -1 for inappr.) 1. A short period of calm is seen
• One must be careful that teacher’s presence in subtracting 2. The child has expressed willingness to change
points is not reinforcing for child behavior
219 220

Daily Report Card

• Child receives daily feedback about performance in several
areas of classroom functioning
• Can be used by teacher to provide student with reward at the
end of the day
• Alternately, can be sent home with child and the rewards are
given at home, based on performance
• Several behavioral goals are selected depending on presenting
problems in child
• Ratings from 1-5 are entered by teacher at different points
throughout the day for each goal
• Can be used by multiple teachers and can include comments
For home-based contingency:
• Must be signed and brought home each day & returned the next
• Child can earn rewards at home based on number of points
accumulated
• Requires advance communication with families involved and
their cooperation
221 222

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Why is Parenting Important?

So many parent variables –
• Prevalence Rates of mental illness with children: to what do we attend?
• Parenting variables have been identified as risk
factors in the developmental pathways of childhood  Parent Practices
and adolescent disorders / problems
– Parent practices  Parent Affect
– Parent affect  Parent Beliefs
– Parent beliefs
• Parent involvement in treatment has been shown to  Parent Satisfaction
improve treatment effectiveness of child problems
 Parent Self-efficacy
• Parent beliefs are related to adherence and
willingness to engage in treatment (Davidson &  Parent Self-esteem
Fristad, 2006)
223 224

Parental Beliefs Parental IBs

 Parental beliefs, especially irrational parenting

cognitions, are also important to consider as they may • Awfulizing about diagnosis
influence parenting stress and behaviors. • FI about parenting a child with CD/ODD*
 Research indicates that specific irrational beliefs are • Self-blame for causing CD/ODD
linked to particular emotions (Joyce, 1995) and in
parents, these emotions then inhibit effective parenting • Demandingness about parenting child with CD/ODD
and problem-solving (Bernard, 1990).
 The accuracy of parent’s beliefs about their child’s
behavior and illness influences the parent’s view on the
necessity for referral, treatment acceptability, and
ultimately, effective intervention implementation.
– It is crucial clinicians identify and provide parents
with accurate information about their child’s
condition as early as possible. 225 226

Parental Beliefs and Stress Parenting Cognitions

As emotions and beliefs interact, cognitions also play In both theoretical and empirical work, parents'
a role in stress development in parents (Abrams & cognitions have been recognized as playing an
Ellis, 1994). important role in parent-child interactions
– Parents’ negative affect has been linked to the (Bugental & Johnston, 2000; Dix & Grusec, 1985;
increased presence of stressors, extreme Johnston, 1996a).
cognitions, and distorted perceptions of child
One type of parental cognition that has received
behaviors.
increasing attention is parenting self-acceptance.
Witt (2005) found that parents with high irrational
beliefs rated their autistic child’s symptoms as more
stressful and reported higher overall levels of stress.

227 228

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Parenting Self-acceptance Parent Beliefs (REBT): Four Core

Categories
Parenting a child with behavioral problems may • DEMANDIGNESS
negatively impact a person's sense of effectiveness (“My child must behave well”)
and satisfaction as a parent;
– a parent with low satisfaction and efficacy is unlikely to
REBT: parents hold
irrational beliefs that are • AWFULIZING
be optimally responsive to a child's needs, which may related to extreme (It’s awful that Joe did this in public”)
fuel further behavior problems. emotional parental
responses (Joyce, 1990;
Parenting self-acceptance may also be reciprocally Bernard, 1990). • LOW FRUSTRATION
related to the style that parents use in interacting TOLERANCE
with their children. (“I can’t stand his screaming”)
Perhaps a parent who reacts with greater
attentiveness to his or her child engenders a • GLOBAL EVALUATION
responsive, secure child who is more pleasurable to (“I am the worst parent in the world”)
parent.

229 230

REBT: ABC Interventions Targeting Parent Irrational

A B
Activating Event
------------------------------
Child’s problems
He’s failing in school
She tantrums when
not getting her way
Irrational beliefs
------------------------------
“He should obey me”
“I am a bad parent, I
am no good”
“I can’t stand when my
child misbehaves”
“It’s too hard”
“It’s awful that he
behaves this way,
what will people think”
C
Beliefs
Consequences
Assessment tools helped identify ABC’s
------------------------------
– A: Activating Event
Unhealthy negative – B: Irrational Beliefs
emotions
– C: Consequences (unhealthy negative emotions &
Anger
Guilt
Behaviors)
Depression Belief – Consequence Connection
Anxiety
Dispute Irrational Beliefs
Ineffective parent
practices Replace with more adaptive rational beliefs
Behavioral Activities:
Poor parent-child
interactions – Role plays, homework, ABC log, handout

231 232

Parent Beliefs: Self-Worth

Parent Beliefs:
Low Frustration Tolerance (LFT) Self-Worth / downing & Depression
LFT: – Being inadequate as a parent reduces my worth
– I can’t take it when I’m under stress from my children; – “I am not able to deal with this b/c I am not a good parent
– I can’t deal with it when my children misbehave – “I am a horrible person”; “He says he hates me and therefore I am worthless”
– “I can’t take it when he yells and screams…It’s too hard”; “I can’t deal with him
hating or being mad at me.” Dispute IB’s
– Functional: How is it helping you to carry out these interventions and feel more
Disputes for LFT—Feelings are not facts competent, if you keep telling yourself you are no good?
– Functional: How is it helping me to follow the BIP if I tell myself I can’t take it..I can’t – Logical: Parenting is a part of you, is it all of you?; (1)
take it?; Sports/coaching metaphor • Activity: the self-acceptance exercise, the Friend Dispute; the Rating Game
– Empirical: Can you really not stand it? Have you stood it before? Haven’t there – Parent modeling IB’s for child
been things that you’ve stood before? – Point out validity and functionality in what the child says; when is he saying this;
– Short-term discomfort vs. long-term benefit; (explanation & metaphor) why is he saying this; what does he want
– Parenting is hard; how hard??? – Point out teachers don’t let him have anything he wants, does he hate them?
– Parent modeling LFT for child (Inelegant solution)
– Activity: Flat tire
Rational Beliefs
Rational Beliefs – “My mistakes as a parent does not define my worth as a person.”
– “I don’t like it, but I can stand it” , “I can put up with his tantrums”–annoyance/upset
– “I can get through it” “This will help us in the long run”
233 234

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Self-Acceptance Exercise
Disputation Work / Home
Does this rejection/failure take
away from my good qualities?
+ Example (excerpt):
-
Does it make sense to conclude - that you are a failure & this leads to your depression
that “I am totally hopeless”
because of one or more negative
things have happened? + say, Get out of my house you are a failure? Would you think of her
- +
Rest of life
Parent Behavior Management
 Contingency Management – positive
reinforcement in the absence of aggression and
for compliance
 Types of reinforcements & preference
assessments
 Prevent escape / avoidance
 Consistency of mother’s response
 Schedule of reinforcement
 Reinforcement of mother behavior
 Evaluation of treatment effectiveness –activity log
& discussion
Parent Training: Underlying Concepts
• Make Consequences Immediate, Specific, and
Consistent
• Establish Incentive Program before Punishment
• Anticipate and Plan for Misbehavior
• Recognize That Family Interactions are
Reciprocal
3/2/2015
Friend Dispute
Purpose: Help mom see that she has a more tolerant & compassionate
attitude toward her friend/ group member than she has toward herself
Goal: adopt same attitude toward self; Be your own best friend
– Therapist: So you can see that you are saying to yourself that b/c you _____
+
– Client: yes
- – Therapist: Now let’s suppose your friend was in your situation. Would you
as a failure?
– Client: No
– Therapist: How would you think of her?
NOTE: Do this activity after they have been exposed to the concept of self-worth
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Summary
• Parent beliefs should be a primary target of
intervention to increase treatment effectiveness
• Teach parenting skills through cognitive & behavioral modification
strategies
Parent • Acknowledge the differences in parent beliefs among the diverse
populations
• Use a multi-method &multi-source assessment approach
• Identify underlying irrational cognitions (CASI) and their
impact on behavior
Child • Use multiple contexts assessment (school, home, public)
• Develop SEL-school-based programs that integrate the
management of parent psychological problems
School
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Parent Training: The Steps
Defiant Children: Third Edition (Barkley, 2013)
A Clinician's Manual for Assessment and Parent
Training
1. Why Children Misbehave: Psychoeducation
2. Pay Attention: How to use attention effectively
3. Increasing Compliance and Independent Play: via attention
4. When Praise is Not Enough: Poker Chips and Points (Reward
training)
5. Time Out or Other Discipline
6. Extending Time-out
7. Anticipating Problems: Managing in Public
8. Improving School Performance at Home: Daily Behavioral report
9. Handling Behavior Problems
10. Booster Session & Follow-up Meetings
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Parent Training: Step 1
“Why Children Misbehave”
•Review events since the evaluation
•Brief reassessment of child disruptive behavior (rating
scales)
•Open discussion of parents’ views of the cause of
misbehavior
•Presentation of a model for understanding child
misbehavior -Child characteristics, the parents’
characteristics, situational characteristics, family stress
events, reciprocal interaction among factors
•Goal of therapy: Best fit between child, parent, and
family circumstances
•Some Handicaps are behavioral 241
•HOMEWORK: Inventory of family problems, child
proof home
Parent Training: Step 3
“Increasing Compliance and Independent
Play”
•Review Homework
•Explain extension of attending skills from play to compliance
•Review ways to make commands effective
•Discuss: use of compliance training at home, how children
disrupt their activities, and how to decrease disruption and
increase independent play
•Therapist model techniques and review client reactions to the
skill
•Increase monitoring of child behavior
•HOMEWORK: continue “special time,” begin praising and
attending to compliance, daily compliance practice time, give
effective commands, practice attending to independent play (and
monitor play)
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Parent Training: Step 5
“Time Out! And Other Disciplinary Methods”
•Review Homework – adjust token system
•Discuss use of token system for penalties – prepare parent for
importance of the session (difficult and requires consistency)
•Educate parents on time out and discipline
•Review time outs: how to use it, where it should be, length,
what if the child leaves it, child avoidance polys, managing
physical resistance
•Review restrictions to using time out this week
•Discuss parent reaction to procedure. Model the procedure
for parent
•HOMEWORK: implement behavioral penalties, use time out
for only 1-2 noncompliant behaviors, record time outs,
continue previously taught methods 245
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Parent Training: Step 2
“Pay Attention!”
•Review Homework
•Introduce rational for attending – importance of quality
attention, work supervisor example, how do the parents
attend to problems?
•Provide information on parent attending skills – what is the
reaction of the parents to these skills?
•Model attending for parents
•Have parents practice in session
•Determine when “special time” and attention will be done
at home
•HOMEWORK: Begin daily “special time” practice periods,
record information on “special time”
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Parent Training: Step 4
“When Praise is Not Enough: Poker Chips and
Points”
•Review Homework
•Reassess child disruptive behavior using rating scales
•Introduce need for special reward programs
•Explain advantages of home chip/point system
•Educate parent on token systems
•Establish the token system: choosing chips/points, list of
privileges, list of target behaviors, assigning prices/wages,
cautions on starting
•What is the parent reaction to the token system?
•HOMEWORK: continue previously taught methods,
implement chip/point system, Bring lists of privileges and jobs
to next session
244
Parent Training: Step 6
“Extending Time Out to Other Misbehavior”
•Review homework records on time out
•Reassess child disruptive behavior using rating scales
•Select two or more additional non-compliant behaviors
for use with time out
•HOMEWORK: Continue using and recording time out
method
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Parent Training: Step 7

Parent Training: Step 8
“Anticipating Problems: Managing Children
“Improving School Behavior from Home:
in Public Places”
The Daily School Behavior Report Card”
•Review homework
•Anticipating problem behavior = the key to success
•Educate parent on anticipating problematic behavior – •Review homework
setting rules before entering public, establish incentive for •Discuss with parents any school behavior problems
compliance and disciplinary response for noncompliance, •Teach parents the procedures to use in establishing a
assign child activity, monitor/attend/reward compliance in daily school behavior report card
public
•Can be used in: stores, restaurants, car, visiting others, •HOMEWORK: implement a daily school behavior report
church card, continue previously taught methods
•Review how to use methods for transitions between
major activities
•Discuss parental reactions to methods 247 248

•HOMEWORK: make two bogus shopping trips for

practice, record information on the trips, contact teachers
for update on school conduct

Parent Training: Step 9 Parent Training: Step 10

“Handling Future Behavior Problems” “Booster Session and Follow-Up Meetings”

•Review homework •Review parents’ continuing use of behavior management

•Review think aloud – think ahead method for in-home
misbehavior
•Education and review: Keeping records of problem
behaviors, review records for parent mistakes, correct
errors when needed, develop incentive system, design
disciplinary method, implement the new program,
evaluate program effectiveness
•Challenge parents with hypothetical behavior problems
methods
•Make corrections to management methods as needed
•Consider discontinuation of the token system
•Discuss when and how to phase out the daily school
behavior report card
•Consider child’s need for adjunctive
psychopharmacological treatment and make appropriate
referral for it, if needed.

•HOMEWORK: generally none

249 250

THANK YOU!
Key Points for Effective Interventions
Timing is everything!
– CD/ODD children often have problems with impulse
control, so reinforcers should be given immediately
after goal behavior
– Try to limit the delay between behavior and reward
Individualize it!
– All students are different – make sure you know what
is rewarding for the student you are working with
Stay positive!
– Target behaviors should always be stated in positive
terms – what do you want to see?
– Be consistent, and eventually you will see change
– Sometimes it gets worse before it gets better – don’t
give up!

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Any questions:
terjesem@stjohns.edu

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