1. Adolescent Externalizing Behaviors
Joshua Leblang, Ed.S., LMHC
Division of Public Behavioral Health and Justice Policy

2. Our youth now love luxury
Our youth now love luxury. They have bad manners, contempt for authority, they show disrespect for their elders … they contradict their parents…and tyrannize their teachers."
Socrates (c BC)

3. The number of boy burglars, boy robbers and boy murderers is so astoundingly large as to alarm all good men."
New York Times editorial in 1857

4. Disruptive disorders, such as oppositional defiant disorder and conduct disorder, are characterized by antisocial behavior.
It presents as collection of behaviors rather than a coherent pattern of mental dysfunction. As such, there is no “magic bullet” to fix the problem.

5. Normal Adolescent Development (AACAP, 2005)
Movement towards independence
More cohesive sense of identity
Ability to think ideas through
Conflict with parents begins to decrease
Increased ability for delayed gratification and compromise
Increased concern for others
Peer relationships important and take an appropriate place among other interests

6. Morals, Values, and Self-Direction
Greater capacity for setting goals
Interest in moral reasoning
Capacity to use insight
Increased emphasis on personal dignity and self-esteem
Social and cultural traditions regain some of their previous importance

7. For adolescents that you may encounter
It is rare that an adolescent self-refers themselves to counseling.
Externalizing youth are rarely interested in “insight”
Engagement with the youth is important, but equally important is parent/caregiver—
Ensure attendance at sessions.
Reinforcing any new behaviors
Provider of “reliable” information about behaviors.

8. What Evidence matters???

9. Why do we need to know what works?
First, many programs, despite their good intentions, are either ineffective or actually do more harm than good.
Second, ineffective or harmful programs are a waste of scarce resources.
Blueprints for Violence
Prevention

10. Biases against Evidence-based Practices
“They are too rigid and cookbook”
“Doesn’t apply to real world kids with real world, multi-problem histories”
“Developed in some lab”
“Overly simplistic”
“Too difficult to implement in community setting”
“Just a band-aid and doesn’t address underlying issues and concerns”
“Another passing fad”
“My training and expertise are not valued” 10

11. Why use EBT’s
Interventions showing beneficial effects in outcome research should be taught and used in preference to interventions that have not been tested and shown to be effective.
National Institute of Mental Health (National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention and Deployment, 2001),
Office of the Surgeon General (1999, 2004),
President’s New Freedom Commission on Mental Health (2003)

12. Rationale for Using Evidence-based Practices
Programs that are integrative in nature (practice, research, theory) and use systematic clinical protocols ”clinical maps”
Manual driven
Model congruent assessment procedures
Focus on adherence and treatment fidelity
Clinically responsive and individualized to unique “outcome” needs of the client/family
Models that have strong science/research support 12

13. Family Factors that Promote Resiliency (National Resilience Resource Center)
􀂾 Parent and family connectedness
􀂾 Parent/Adolescent activities
􀂾 Parental presence
􀂾 Parental school expectations
􀂾 Parents involvement and awareness of sexual behaviors
􀂾 Limit access to substances and weapons
􀂾 Seek help for parental and familial problems/concerns
􀂾 Seek support from other parents
􀂾 Know community resources

14. Program characteristics that support positive youth development
1. Comprehensive, time-intensive
2. Earliest possible intervention
3. Timing is important
4. High structure is better
5. Fidelity to model is key to effectiveness

15. Positive Youth Development (con’t)
6. Need adult involvement
7. Active, skills-oriented programs are more effective
8. Programs that target multiple systems are most effective
9. Programs that are sensitive to the individual’s community and culture are best
10. Programs based on strong theoretical constructs and proven effective by evidence are best
Connecticut Center for Effective Practice (From meta-analysis published in 2005)

16. 3 Treatments top the list for adolescents
ALL focus on family/ caregivers
Functional Family Therapy
Multidimensional Treatment Foster Care
Multisystemic Therapy

17. What is Functional Family Therapy?
Focus is to improve family communication and supportiveness while decreasing the intense negativity so often characteristic of these families.
Many of the targeted interventions, therefore, emphasize communication skills, family interaction, problem-solving and promoting constructive behaviors
Intervention ranges from, on average, 8 to 12 one-hour sessions up to 30 sessions of direct service for more difficult situations

18. What is Functional Family Therapy?
Conducted both in clinic settings as an outpatient therapy and as a home-based model
A treatment technique that is appealing because of its clear identification of specific phases, which organize intervention in a coherent manner, thereby allowing clinicians to maintain focus in the context of considerable family and individual disruption
Each phase includes specific goals, assessment foci, specific techniques of intervention, and therapist skills necessary for success

19. Functional Family Therapy A treatment technique
                                                                                       
Functional Family Therapy A treatment technique

20. Multidimensional Treatment Foster Care (MTFC)
Program Overview:
The goal of the MTFC program is to decrease problem behavior and to increase developmentally appropriate normative and pro-social behavior in children and adolescents who are in need of out-of-home placement. 20

21. MTFC MTFC treatment goals are accomplished by providing:
Close supervision; fair and consistent limits ; predictable consequences for rule breaking ; a supportive relationship with at least one mentoring adult; and reduced exposure to peers with similar problems.
The intervention is multifaceted and occurs in multiple settings. The intervention components include:
Behavioral parent training and support for MTFC foster parents;
skills training for youth;
supportive therapy for youth;
school-based behavioral interventions and academic support;
and psychiatric consultation and medication management, when needed.

22. MULTISYSTEMIC THERAPY
Youths’ behaviors are influenced by their families, friends, and communities (and vice versa).
Families are the key to success, so all aspects of treatment are designed with full collaboration from the family.
Change can happen quickly, but it demands daily and weekly efforts from the youth and all the important people in his/her life.
Families can live successfully without involvement in social service agencies.

23. How is MST Different?
Discipline: Offers a combination of “best practice” treatments within a disciplined structure
Accountability: At all levels, providers are held accountable for outcomes through MST’s rigorous quality assurance system
Ecological validity: Working in the youth’s natural environment with existing family supports, thereby ensuring cultural sensitivity
Focus on long-term outcomes: Empowerment of caregivers to manage future difficulties; focus on sustainability

24. How Does MST “Work?”
Intervention strategies: MST draws from research-based treatment techniques
Behavior therapy
Parent management training
Cognitive behavior therapy
Pragmatic family therapies
Structural Family Therapy
Strategic Family Therapy
Pharmacological interventions (e.g., for ADHD)

25. Why is MST Successful?
Treatment targets known causes of delinquency: family relations, peer relations, school performance, community factors
Treatment is family driven and occurs in the youths’ natural environment
Providers are accountable for outcomes
Staff are well trained and supported
Significant energies are devoted to developing positive interagency relations

26. 9 Principles of MST Finding the Fit Positive & Strength Based
Increasing Responsibility
Present focused, Action-orientated
Targeting Sequences
Developmentally/ Culturally Appropriate
Continuous Effort
Evaluation & Accountability
Generalization

27. An ecological approach
Work with the entire ecology. By addressing the multiple systems, it is possible to make longer lasting changes for families.
Community
School
Peers
Family
Youth
Bronfenbrenner, 1979

28. Condensed Longitudinal Model of Youth Antisocial Behavior
Family
Prior antisocial
behavior
Low Monitoring
Low Affection
High Conflict
Antisocial
Peers
Antisocial
behavior
School
Explaining delinquency and drug use, by D.S. Elliott, D. Huizinga and S.S. Ageton. Beverly Hills, CA: Sage Publications, 1985, 176 pp
Low School Involvement
Poor Academic Performance

29. Individual Factors Antisocial behavior Mental health problems
Low social conformity

30. FAMILY Poor monitoring Ineffective discipline Low warmth High conflict
Parental drug use/abuse

31. PEER Association with drug-using peers,
Low association with prosocial peers

32. SCHOOL
Low achievement
Truancy
Low commitment to school

33. Neighbors who use drugs
COMMUNITY FACTORS
High crime
Neighbors who use drugs
Transience

34. What usually happens to youth?
Youth gets in trouble
Sent to treatment
Meets other anti-social peers
No changes at home
CYCLE CONTINUES
Returns home

35. What usually happens to youth?
Sent to treatment / group
Youth uses drugs
Meets other drug-using peers
CYCLE CONTINUES
Now has greater access to negative peers, people to buy from

36. Case Example 16 year old male
Hx of truancy (missing school 2-3 days/week)
Runaway (usually 1-2 nights but as long as a week)
Defiant/oppositional –refuses to follow household rules

37. Case Example 2 14 year old female Involved with negative peers
Reportedly gang-involved
Alcohol/marijuana usage
Stealing/shoplifting charges

38. How can we best use this??? House Bill 1373
…up to twenty outpatient therapy hours per calendar year, including family therapy visits integral to a child's treatment
How can we best use this???