Treating Explosive Kids - Part 1

1. Treating Explosive Kids
Part 1
The Collaborative
Problem-Solving Approach
Drew Burkley Psy.D.
Center of Excellence
Clinical Psychologist
Andrew.Burkley@Cherokeehealth.com

2. Authors
 Ross W. Greene, PhD
 Director of the Collaborative Problem Solving Institute
 Associate Professor in the Department of Psychiatry, Harvard
Medical School
 J. Stuart Ablon, PhD
 Director of Think:Kids, Department of Psychiatry,
Massachusetts General Hospital,
 Associate Professor in the Department of Psychiatry, Harvard
Medical School

3. Location
 Collaborative Problem Solving Institute
Department of Psychiatry of Massachusetts General
Hospital
http://www.explosivechild.com

4. Thanks to...
 Gloria Jones, Psy.D.
 Sasha Ahmed, M.S.
 Scott Browning, Ph.D.

5. The Need For a
New Paradigm
Have you experienced this?

6. Typical Protocol
 Parent Management Training
 Teaches contingency and consistency
 Establishes a list of target behaviors with compliance as the
goal
 Establishes a menu of rewards and punishments
 Develops a currency system to track the child’s progress

7. Problems with
Parent Management
 Research supports this technique, however there are also
many limitations
 It may not be well suited to the needs of those
responsible, as evidenced by a high drop-out rate
and noncompliance
 Changes in oppositional behavior are not
statistically significant

8. Problems with
Parent Management
 Most studies have not included clinically referred
children
 As a result, the following can be concluded
 There is a low percentage of substantial gain from this
technique
 Alternative treatments that address the needs of
explosive children and caretakers are needed

9. How do we label children and
adolescents?
 Many labels have been used to describe “children”
 Defiant, aggressive, angry, non-compliant, challenging
 They have also been given a number of diagnoses
Oppositional defiant disorder, conduct disorder,
intermittent explosive disorder

10. “Explosive” children and
adolescents?
 The term “explosive” will be used in this presentation
because it is a common theme among all the
descriptions and diagnoses

11. Explosive children does not
mean exact children….
 Understanding the factors underlying a specific
child’s explosive behaviors directly influences the
selection of interventions employed to address
those behaviors.
 Intervention options are most effective when they are
designed with the needs of each individual are
considered.

12. What makes CPS different?
 Assumes that explosive children are poorly
understood and are often poorly addressed by
available therapies
 For close to fifty years, conceptualization and
treatment of explosive children have been
significantly influenced by the coercion or social
interactional model.
 There has been a focus on patterns of parental
discipline
 Inconsistent discipline
 Irritable explosive discipline
 Low supervision and involvement
 Inflexible rigid discipline

13. Characteristics & Behavior Link
 Lagging skills in the global domains:
 Flexibility and adaptability
 Frustration tolerance
 Problem-solving
 The CPS model aims to identify the specific
cognitive factors contributing to the development of
a child’s non-compliance and explosiveness

14. Executive Skills
 Transitions
 Sequences
 Difficulty staying on tasks
 Impulsivity
 Problem Solving
Range of solutions to a problem

15. Cognitive Flexibility Skills
 Concrete, black-and-white thinkers
 Insistence on sticking with rules, routine or original plans
 Difficulty with unpredictability, ambiguity, uncertainty
 Obsessive or Preservation
 Theory of Mind
 Situation-Person Dynamics
 Inaccurate interpretations/Cognitive distortions/Biases

16. Language Processing Skills
 Difficulty expressing thoughts, needs or concerns in
words
 Often appears not to have understood what was
said
 Long delays before responding to questions
 Difficulty knowing or saying how he or she feels

17. Emotion Regulation Skills
 Difficulty staying calm enough to think rationally
when frustrated
 Cranky, grouchy, grumpy, irritable outside the
context of frustration
 Sad, fatigued, tired, low energy
 Anxious, nervous, worried, fearful

18. Social Skills
 Difficulty attending to or misreading of social cues/
difficulty recognizing nonverbal social cues
 Seeks the attention of others in inappropriate ways;
 Seems unaware of how behavior is affecting other
people
 Lacks empathy
 Poor sense of how he or she is coming across or being
perceived by others
 Inaccurate self-perception

19. Transactional Theory
Three conceptual models for understanding children’s
developmental outcomes:
Unidirectional or Main Effect Model
Bidirectional or Interactional Model
Transactional or Reciprocal Model

20. Transactional Theory
 Unidirectional or Main Effect Model
 Child’s outcome is the product of either characteristics of
the child or characteristics of the caretakers
 Bidirectional or Interactional Model
 The combination of adult and child characteristics
produces a child’s outcome
 Transactional or Reciprocal Model
 Child’s outcome is a function of the degree of fit or
compatibility between child and adult characteristics
 The goal of treatment requires an understanding of both
child and adult

21. Situational Analysis
 Explosive level behaviors occur when there are
high levels of incompatibility between a child and
the environment
 Demands on the child exceed the child’s capacity to
respond
 The environment also includes the transaction with
other people

22. Identifying
Pathways and
Triggers

23. Identification of Pathways
 Executive Skills
 Emotional Regulation Skills
 Language Processing Skills
 Cognitive Flexibility Skills
 Social Skills

24. Identification of Triggers
 Sensory Hypersensitivities
 Transitions
 Academic Tasks
 Interaction with Peers, Adults, Family

25. Two Mechanisms for Identification
of Pathways and Triggers
 Clinical Interview
 Formal Assessment
 Developmental pediatricians
 Neuropsychologists

26. Goals of the Interview
 Assess safety
 Empathically support parents
 Need to be believed
 Assess Pathways and Triggers

27. Interview Questions
Child
 Why did your parents bring you in today?
 What difficulties do you see your family having?
 What’s the matter with your parents?
 How are things going with your friends?
 What is the hardest thing about _______ in school?
 Would you describe yourself as _______?
 Are there more stories?

28. Interview Questions
Caregivers
 Tell me about _________’s explosions.
 Do you think that _____is more bothered by _____
or______?
 Do they occur during certain times of the day?
 What goes on when______’s doing_______?
 How does he or she do with_______?
 How have you responded to/handled it when ____does
_____?

29. Interview Questions
Family
 Gain a Consensus
 “Would you all agree that _______is troublesome?”
 Emphasize Cognitive Difficulties
 Not Behavior

30. Putting the Information Together
 Meet with the Child/Adolescent Alone
 Generate hypothesis
 Meet with the Caregivers Alone
 Generate hypothesis
 Meet with the Family
 Generate hypothesis

31. Other Important Information to
Consider
 Developmental History
 Treatment History
 Family Stressors
 Pharmacology
 Educational History
 History of Adult Responses to Deficits

32. Questions
 What do you do when there are large numbers of items on the
Pathways Inventory?
 Prioritize and Organize, “triage” approach
 What do you do if you don’t get strong signals on the Pathways
Inventory?
 Keep Trying! Gather more “stories”
 What other factors not related to cognitive skills contribute to
explosions?
 Sleep, Trauma, Seizures, D&A, Allergies, other Medical Issues
 How do you know when to refer for formal testing?
 When interviews and observations do not provide enough
definitive information to identify the specific skill deficit or trigger.

33. Options for
Handling
Problems
Three Plans

34. Three Plans
 Plan A- Insistence
 Plan C- Reducing Expectations
 Plan B- The Collaborative Problem-Solving
Approach
 “Surrogate Frontal Lobe”

35. Plan A
In Typical Children
 Child motivated by insistence
 There is no extreme reaction to insistence
In The Explosive Child
 Adult expectations are pursued
 Adults add consequences for children
 Cognitive deficits prevent from meeting expectations
 Inflexibility increases the chances of an outburst
Plan A is easy on the front-end, but has
shortcomings long-term

36. Plan C
Reducing or Removing expectations
 Saying nothing
 Changing Demands
 Adults fear expectations will never be met or
children will capitalize on the giving in
 Adults fear children will not learn expectations
Goal is to reduce the overall number of
outbursts

37. Plan B Brief Overview
Working toward a mutually satisfactory
resolution
Goals
 Reduce frequency, intensity, and duration of explosive
episodes
 Help adults pursue expectations through collaborative
problem-solving
 Teach the cognitive skills that are lacking in the child
More efficient on the back end
Creates opportunities for long-term success

38. Goals Achieved By Each Plan
Pursue Expectations Reduce Outbursts Teach Skills
Plan A X
Plan B X X X
Plan C X

39. Questions and Wrap Up!