Presentation on theme: "Effective Ecological Interventions"— Presentation transcript:
1Effective Ecological Interventions Oppositional Defiant Disorder & Conduct DisorderEffective Ecological InterventionsJoshua Leblang,Ed.S.LecturerPublic Behavioral Health & Justice PolicyDepartment of Psychiatry1
2Our 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)
3What is it?Disruptive disorders, such as oppositional defiant disorder and conduct disorder, are characterized by antisocial behavior.
5Oppositional Defiant Behavior as a DSM IV Diagnostic Category Oppositional Defiant Disorder (ODD), is defined as "a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures".The disorder is reflected in behaviors such as frequent temper tantrums, arguing, defiance, non-compliance, externalizing blame, vindictiveness, and a range of other problem behaviors.American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author5
6Specific DSM IV ODD Criteria For at least 6 months, shows defiant, hostile, negativistic behavior; (4 or more of the following): -Losing temper -Arguing with adults -Actively defying or refusing to carry out the rules or requests of adults -Deliberately doing things that annoy others -Blaming others for own mistakes or misbehavior -Being touchy or easily annoyed by others -Being angry and resentful -Being spiteful or vindictive6
8DSM IV ODD Criteria The symptoms: cause clinically significant distress or impair work, school or social functioning.do not occur in the course of a Mood or Psychotic Disorder.do not fulfill criteria for Conduct Disorder.If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder.*Characteristics should occur more often than expected for age and developmental level.8
9Conduct Disorder as a DSM IV Diagnostic Category The essential features of Conduct Disorder (CD) involve "a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated“, resulting in a clinically significant impairment in functioning.This includesaggressive behaviors,behaviors that result in property loss or damage,deceitfulness or theft,other serious rule violations (e.g., running away from home, truancy).9
10DSM IV Conduct Disorder Criteria For 12 months or more has repeatedly violated rules, age-appropriate societal norms or the rights of others.Shown by 3 or more of the following, with at least one of the following occurring in the past 6 months:Aggression against people or animalsFrequent bullying or threateningOften starts fightsUsed a weapon that could cause serious injuryPhysical cruelty to peoplePhysical cruelty to animalsTheft with confrontationForced sex upon someone10
11DSM IV Conduct Disorder Criteria Property destruction -Deliberately set fires to cause serious damage -Deliberately destroyed the property of others (except fire-setting)Lying or theft -Broke into building, car or house belonging to someone else -Frequently lied or broke promises for gain or to avoid obligations ("conning") -Stole valuables without confrontation (burglary, forgery, shoplifting)11
12DSM IV Conduct Disorder Criteria Serious rule violation- Beginning by age twelve, frequently stayed out at night against parents' wishes- Runaway from parents overnight twice or more (once if for an extended period)- Frequent truancy before age 13These symptoms cause clinically important job, school or social impairment.If older than age 18, the patient does not meet criteria for Antisocial Personality Disorder.12
13DSM IV Conduct Disorder Criteria Childhood-Onset Type: at least one problem with conduct before age 10Adolescent-Onset Type: no problems with conduct before age 10Severity:Mild (both are required): There are few problems with conduct more than are needed to make the diagnosis, and Problems cause little harm to others.Moderate. Number and effect of conduct problems is between Mild and SevereSevere. Many more conduct symptoms than are needed to make the diagnosis, or symptoms cause other people considerable harm.13
14Family Factors that Promote Resiliency 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(National Resilience Resource Center, 2001)
15Program characteristics that support positive youth development 1. Comprehensive, time-intensive2. Earliest possible intervention3. Timing is important4. High structure is better5. Fidelity to model is key to effectiveness
16Positive Youth Development (con’t) 6. Need adult involvement7. Active, skills-oriented programs are more effective8. Programs that target multiple systems are most effective9. Programs that are sensitive to the individual’s community and culture are best10. Programs based on strong theoretical constructs and proven effective by evidence are bestConnecticut Center for Effective Practice (From meta-analysis published in 2005)
17CD/ODD presents as collection of behaviors rather than a coherent pattern of mental dysfunction. As such, there is no “magic bullet” to fix the problem.
18How would you work with? 15 year old who refuses to go to school? 15 year old who refuses to go to school due to bullying?15 year old who refuses to go to school because s/he was the babysitter for his/her baby brother15 year old who refused to go to school because s/he was dealing drugs?15 year old who refused to go to school because s/he wasn’t getting up in the morning--going to bed late at night playing video games--Parents having parties late at night?
19Three treatments top the list for adolescents ALL focus on family/ caregiversFunctional Family TherapyMultidimensional Treatment Foster CareMultisystemic TherapyBlueprints for Violence Prevention
20What usually happens to youth? Youth gets in troubleSent to treatmentMeets other anti-social peersNo changes at homeCYCLE CONTINUESReturns home
21An ecological approach Work with the entire ecology. By addressing the multiple systems, it is possible to make longer lasting changes for families.CommunitySchoolPeersFamilyYouthBronfenbrenner, 1979
22MULTISYSTEMIC 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.
23How is MST Different?Discipline: Offers a combination of “best practice” treatments within a disciplined structureAccountability: At all levels, providers are held accountable for outcomes through MST’s rigorous quality assurance systemEcological validity: Working in the youth’s natural environment with existing family supports, thereby ensuring cultural sensitivityFocus on long-term outcomes: Empowerment of caregivers to manage future difficulties; focus on sustainability
24How Does MST “Work?”Intervention strategies: MST draws from research-based treatment techniquesBehavior therapyParent management trainingCognitive behavior therapyPragmatic family therapiesStructural Family TherapyStrategic Family TherapyPharmacological interventions (e.g., for ADHD)
25How is MST Implemented?Single therapist working intensively with 4 to 6 families at a time“Team” of 2 to 4 therapists plus a supervisor24 hr/ 7 day/ week team availability3 to 5 months is the typical treatment time (4 months on average across cases)Work is done in the community: home, school, neighborhood, etc.
26How is MST Implemented? (continued) MST staff deliver all treatment – typically no services are brokered/referred outside the MST teamNever-ending focus on engagement and alignment with the primary caregiver and other key stakeholder (e.g. probation, child welfare, etc.)MST staff must be able to have a “lead” role in clinical decision making for each caseHighly structured weekly clinical supervision and Quality Assurance (QA) processes
27Condensed Longitudinal Model of Youth Antisocial Behavior FamilyPrior antisocialbehaviorLow MonitoringLow AffectionHigh ConflictAntisocialPeersAntisocialbehaviorSchoolExplaining delinquency and drug use, by D.S. Elliott, D. Huizinga and S.S. Ageton. Beverly Hills, CA: Sage Publications, 1985, 176 ppLow School InvolvementPoor Academic Performance
28FAMILY Poor monitoring Ineffective discipline Low warmth High conflict Parental drug use/abuse
29PEER Association with drug-using peers, Low association with prosocial peers
30SCHOOLLow achievementTruancyLow commitment to school
31Neighbors who use drugs COMMUNITY FACTORSHigh crimeNeighbors who use drugsTransience
32Individual Factors Antisocial behavior Mental health problems Low social conformity
33MST Treatment Principles Nine principles of MST intervention design and implementationTreatment fidelity and adherence is measured with relation to these nine principles
34Principles of MST1. Finding the FitThe primary purpose of assessment is to understand the “fit” between the identified problems and their broader systemic context.2. Positive & Strength FocusedTherapeutic contacts should emphasize the positive and should use systemic strengths as levers for change.
35Principles of MST (continued) Increasing ResponsibilityInterventions should be designed to promote responsibility and decrease irresponsible behavior among family members.Present-focused, Action-oriented & Well-definedInterventions should be present-focused and action-oriented, targeting specific and well-defined problems.
36Principles of MST (continued) 5. Targeting SequencesInterventions should target sequences of behavior within and between multiple systems that maintain identified problems.6. Developmentally AppropriateInterventions should be developmentally appropriate and fit the developmental needs of the youth.
37Principles of MST (continued) 7. Continuous EffortInterventions should be designed to require daily or weekly effort by family members.8. Evaluation and AccountabilityIntervention efficacy is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.
38Principles of MST (continued) 9. GeneralizationInterventions should be designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering care givers to address family members’ needs across multiple systemic contexts.
39MST Analytical Process ReferralBehaviorMSTAnalyticalProcessDesired Outcomesof Family and OtherKey ParticipantsOverarchingGoalsEnvironment of Alignment and Engagementof Family and Key ParticipantsMST Conceptualizationof “Fit”Re-evaluatePrioritizeAssessment ofAdvances & Barriers toIntervention EffectivenessIntermediaryGoalsMeasureInterventionImplementationDoInterventionDevelopment
40Where is MST Being Used?Over 30 states in the U.S. and in 10 countriesStatewide infrastructure in Connecticut, Georgia, Hawaii, New Mexico, Ohio and South CarolinaNationwide program in Norway (25+ teams)Other international replications: Australia, Canada, Denmark, Ireland, England, Sweden, Switzerland, the Netherlands, and New Zealand.
41MST: 25+ Years of Science Other randomized trials are in progress 14 Randomized Trials and 1 Quasi-Experimental Trial Published (>1300 families participating)7 with serious juvenile offenders2 independent randomized trials by Ogden and Timmons-Mitchell2 with substance abusing or dependent juvenile offenders2 with juvenile sexual offenders2 with youths presenting serious emotional disturbance1 with maltreating families1 with adolescents with poorly controlled diabetes (independent: Ellis)Other randomized trials are in progress
42Long-term OutcomesLong-term follow-up to the Missouri Delinquency Project: 14-year post-treatment outcomesIndividuals who had been involved in MST as a youth (average age at follow-up = 28.2 years):54% fewer arrests64% fewer drug-related arrests57%fewer days in adult confinement43% fewer days on adult probation
43Adult Days Confined 1357 days/ 3.72 years 582 days/ 1.59 years 14-Year Follow Up1357 days/ 3.72 years582 days/ 1.59 years57% reductionMSTIndividual Therapy
44MST Quality Assurance System Organizational ContextYouth/FamilySupervisorTherapistManualizedManualizedManualizedManualizedSupervisoryAdherenceMeasureTherapistAdherenceMeasureConsultant/MST ExpertConsultantAdherenceMeasure
45Why is MST Successful?Treatment targets known causes of delinquency: family relations, peer relations, school performance, community factorsTreatment is family driven and occurs in the youths’ natural environmentProviders are accountable for outcomesStaff are well trained and supportedSignificant energies are devoted to developing positive interagency relations
4616 year old male Case Example 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
47Involved with negative peers Case Example 214 year old femaleInvolved with negative peersReportedly gang-involvedAlcohol/marijuana usageStealing/shoplifting charges
48Joshua Leblang System Supervisor QUESTIONS? firstname.lastname@example.org