Counseling Techniques for School Psychologists Delivering RtI Interventions NASP Conference, Chicago, IL: March 3rd 2010 Diana Joyce, Ph.D. NCSP Douglas Jones, B.A. Angela Dobbins, M.Ed. djoyce@coe.ufl.edu djonesnd2000@ufl.edu dobbinad1@ufl.edu University of Florida Hyatt-Crystal Ballroom, 280 Capacity, Wed March 3rd, 9:30-10:30am All clipart in this presentation is from Microsoft Office Suite ClipArt – for public use. All Presentation Materials Including Sample Reports are Available at http://www.nasponline.org/

RtI Tiered Behavioral Interventions Counseling Applications Tier I Universal – All Students Positive Behavioral Support: Frequent recognition for appropriate behaviors, proximity control, cueing, build-in appropriate movement opportunities (e.g., Kagan Brain Ex.), predictable structure, positively-phrased and highly visible behavioral expectations. Embedded Social Curriculum: Instruction in prosocial behavior/attitudes. Data Screening: School-wide climate survey, ISS/OSS data, incidence mapping, rating scales for emotional risk and social skills (SSIS, BESS, SOS) Tier II Supplemental, Targeted, Short-Term Observations, FBAs, Behavior Plans: Classroom observations to determine environmental contributors, antecedents, sustaining factors, frequency, patterns across subjects or time-of-day and task demands, self-monitoring or reinforcement plans, DRCs Counseling: Social Skills, Anger Mgmt, Test Anxiety, Friendship Groups Data Progress Monitoring: Tier II data Tier I: Focus on PREVENTION SOS = Signs of Suicide program SSIS = Social Skills Improvement System Rating Scales, 2008, Gresham & Elliott BESS = Behavioral and Emotional Screening System, 2007, Kamphaus & Reynolds Behavior Plans & Counseling Therapy: Individualized, greater frequency and intensity, often addressing multiple issues simultaneously Multi-agency Plans: Coordinate w/out-side agencies on counseling, behavioral plans, meds, family therapy, juvenile justice, etc. Data Progress Monitoring: Psychological assessment, Tier III data Tier III Intensive, Individual, Long-Term

Internalizing Externalizing Disorder Effective Interventions Internalizing Anxiety CBT, family anxiety management Depression CBT, coping skills training, behavioral self-control therapy Fears/ Phobias Graduated exposure, modeling, reinforced practice, In-vivo exposure, CBT, imaginal desensitization, self-calming techniques OCD CBT with exposure and response prevention, parent training Externalizing ADHD Behavior modification, reinforcement of other behaviors, organizers, parent training, medication ODD/CD Behavioral modification, anger management, CBT, REBT, time-out, problem-solving training, parent-child therapy, parent training (Kendall & Hedtke, 2006)

Three Counseling Approaches Solution-Focused Conflicts, personal goals Psychoeducational E.g., Teach social skills, teach study skills Cognitive Behavioral Therapy Anxious behaviors, anger management, grief management

Basic Protocol Formats First Session Intro, Rapport-Building, Confidentiality, Rules Core Sessions Targeted Skills Curriculum Last Session, Closure Booster or Follow-up

Progress Monitoring Data Sources (Pre/Post/Weekly) Behavioral Observations FBA Data Knowledge Surveys Rating Scales BASC-2 Self-report BECK Youth Inventory RCMAS Outcome Rating Scales; Session Rating scales, etc. Discipline Referral Rates Work Completion Rates Improved Grades Absence/Tardy Rates Single Subject Design Daily Behavior Report Cards SUDS

Solution-Focused Brief Therapy (SFBT) Focus on what want to achieve (not past) Focus how to obtain goal Positive stated goals, measurable Case study Male, 6th grade, good grades Prior counseling aggression, anxiety Weekly sessions, 1 month CBT, 5 month SFBT (Sklare, 2005)

Solution Focused Brief Therapy (SFBT) 1. Miracle Question If you woke up & miracle happened, all of your problems were fixed… 2. What is 1st sign miracle occurred? What would be different? 3. If we videotaped you after the miracle happened What would you be doing? (Sklare, 2005)

SFBT Cont’d Miracle = Areas needing remediating First sign of miracle = guides goal development Discussed when the “miracle” has occurred Builds positive thinking and reflection on when the student made behavioral changes (Sklare, 2005)

SFBT Cont’d Scaling Questions: Coping Questions: Rate progress of goals on Likert scale Use scaling as discussion point When score high--What is preventing you from lower score? When score low– What need to do to allow that to happen? Coping Questions: Strengths - Actions - Goals “Things must be difficult for you. How do you manage to do so well in school?” (Sklare, 2005)

Progress Monitoring Data

Social Skills Protocol: Psychoeducational Approaches Basic Components: Teach & Model Skill (Knowledge Deficit) Role Play w/Feedback (Performance Deficit) Practice-Practice (Fluency Deficit) Review Generalization (NASP, 2004)

Social Skills Protocol: Select Skill Deficits for Core Sessions Four skill areas: Survival Skills (respect, listening, following directions, boundaries) Interpersonal Skills (express feelings, manners, sharing, turn-taking, nonverbal cues) Problem-solving Skills (asking for help, apologizing, generate solutions) Conflict Resolution Skills (dealing with teasing, peer pressure, assertion) (NASP, 2004)

Second-Step Program Unit I: Empathy Training Focus on building feeling vocabulary Identifying physical and situational cues Unit II: Emotion Management Focus on three strategies: Self-coaching (“Stay Calm”) Deep (Belly) Breathing, Cognitive Distractions (Counting) Steps in the problem solving approach: How do I feel? What is the problem? What can I do?

Second-Step Program Unit III: Problem-Solving Step 1 - How do I feel? Step 2 - What is the problem? Step 3 – What can I do? Prosocial behaviors and assertive “I” statements reinforced

Case Example 3 Kindergarten Males Identified Referral Concerns: Impulsive Inattentive Oppositional Pre-intervention Data BASC-2 Behavioral and Emotional Screening System (BESS) Parent Rating Scales Teacher Interviews

Case Example Group Focus: Weekly, 30 Minute Sessions Empathy Training Impulse Control Problem-Solving Weekly, 30 Minute Sessions

Case Example Progress Monitoring Data: Calming Strategies During imaginal exposure, each of the students can identify and correctly use belly breathing as a strategy at the end of the intervention, but Student 1 is able to identify an additional way to calm himself (counting backwards). Qualitative data: student 1 has shown growth in his ability to wait his turn and adjust when things are not going his way ( no more tantrums). Has the ability to apply self-calming strategies during real life situations and can assist others in doing these. (Deep breathing and counting). Making gains, but still could benefit from more sessions in order to promote generalization across settings. Student 2 has shown limited growth in regulation of behaviors. Concerns with influencing/distracting other group members. Student 2 often causes Student 3 to loose focus during the sessions. Teacher reports seeing limited improvement for this student. Can identify deep breathing as a strategy, but does not actively use it during situations. Make gains, but could benefit from higher level of service. Student 3 has shown moderate growth in using cues to identify feelings of others and himself, but still lacks the generalization of skills from imaginal exposure to classroom. Has ability to identify deep breathing as a strategy, but does not generalize from imaginal/role play to real situations. Teacher reports social skills/ peer interactions have shown positive improvements. Make gain, but needs higher level of service.

Main CBT Components Relaxation Training Cognitive Strategies Diaphragmatic (deep) breathing Progressive muscle relaxation (PMR) Cognitive Strategies Reducing negative self-talk Challenging unrealistic and dysfunctional thoughts Considering different perspectives Behavior Strategies Behavioral exposures Successive approximation Problem-Solving Techniques

CBT for Childhood OCD

Anxiety-Reductive Compulsive Disorders Marked by obsessive thoughts or impulses (i.e., intrusive thoughts, feelings that produce anxiety) and anxiety-reductive behaviors (compulsions). Negative reinforcement (i.e., the removal of something aversive) reinforces compulsive behaviors

The Obsessive-Compulsive Cycle Obsessions Fear/Anxiety Reduction in Distress Compulsions Negative Reinforcement (Piacentini et al, 2006) 22

Ritual Cycle SUDS = Subjective Units of Distress (0-100) S U D Storch, 2006 23

CBT Treatment Strategies Psychoeducation Conceptualization of OCD Rationale for Treatment Creation of Symptom Hierarchy Exposure plus Response Prevention Addressing Obsessions Contingency Management if the child has an urge to perform a compulsion, the child would be prompted to recognize that those urges are the ‘‘OCD talking.’’ ‘‘Leave me alone OCD’’ or ‘‘I am not going to let OCD control my life’’ (Piacentini et al, 2006)

Symptom Hierarchy Step SUDS 10. Bathing with toilet water 10 9. Putting hand in public toilet w/o washing – 1 day 9 8. Flushing public toilet w/o washing – 12 hr 8 7. Flushing public toilet w/o washing – 30 min 7 6. Standing near urinal w/o washing 6 5. Flushing home toilet w/o washing 5 4. Touching public sink w/o washing 3. Touching sink in house w/o washing 4 2. Touching floor w/o washing 3 1. Touching doorknob w/o washing 2 Storch, 2006 25

OCD Thermometer Make a OCD Thermometer (Subject Units of Distress Scale [SUDS]) Create a list of events that cause rituals (easiest to hardest) Be creative and ‘intense’ Progress up that list slowly where the person does not engage in rituals. Tackle things one at a time. Don’t leave the situation until anxiety drops. SUDS = Subjective Units of Distress (0-100 or 0-10) Storch, 2006

Exposure and Response Prevention Patients are gradually exposed to anxiety-provoking stimuli while refraining (or prevented) from engaging in anxiety-reductive compulsive behaviors. Avoid providing the child with reassurance (e.g., you wont get sick) or accommodating anxiety driven behaviors (e.g., I’ll open the door for you). CBT with exposure and response prevention (ERP) is the best established psychological treatment for OCD (Abramowitz et al., 2005; Chambless et al., 1998) if the child has an urge to perform a compulsion, the child would be prompted to recognize that those urges are the ‘‘OCD talking.’’ ‘‘Leave me alone OCD’’ or ‘‘I am not going to let OCD control my life’’

Relevance of ERP in the schools Can collaborate with other mental health professionals to facilitate treatments Schools provide many opportunities to conduct exposures For more information see: Sloman, G. M., Gallant, J., & Storch, E. A. (2007). A School-Based Treatment Model for Pediatric Obsessive-Compulsive Disorder. Child Psychiatry and Human Development, 38, 303-319.

Case Example 10 yr-old male Referral concerns: Frustration Learning Disorder ADHD Autism Spectrum Disorder OCD Referral concerns: Frustration Compulsive Behaviors Touching / Retouching Cloth Picking

Case Example Weekly CBT Sessions Coping Strategies Role Plays Frustration Exposures ERP for OCD symptoms Graduated Exposures Behavioral Management Compliance Training Contingency Reinforcement

Touching Exposures

Questions? ? ? ? ? ?

Resources: CBT Manuals CBT Free Online Treatment Manuals https://trialweb.dcri.duke.edu/tads/manuals.html Christner, R. W., Forrest, E., Morley, J., & Weinstein, E. (2007). Taking cognitive-behavior therapy to school: a school-based mental health approach. Journal of Contemporary Psychotherapy, 37, 175-183. Kendall, E C., Choudhury, M. A., Hudson,J, & Pc'ebb, A. (2002). The C.A.T. Project Manual Ardmore, PA: Workbook Publishing. Kendall, P. & Hedtke, K. (2006). Cognitive-Behavioral Therapy for Anxious Children: Therapist Manual (3rd ed). Ardmore, PA: Workbook Publishing. Nelson III, M. W., Finch, A. J., & Ghee, C. (2006). Anger management with children and adolescents. In P. Kendall (Ed.). Child and adolescent therapy: cognitive-behavioral procedures. New York, NY: Guilford. Stallard, P. (2002). Think good- Feel good: A cognitive behavioral therapy workbook for children and young people. Hoboken, NJ: John Wiley & Sons.

Resources Counseling Interventions & Curricula ACHIEVE: A Collaborative School-based Reform Process, Howard Knoff, Social Skills, Conflict Resolution, Self Regulation, Positive School Climate, www.stopandthinksocialskills.com Aggression Replacement Training, Mark Amendola, Anger Control, Aggression, Moral Reasoning Training www.aggressionreplacementtraining.org I Can Problem Solve, Myrna Shure, Aggression, Emotionality, Withdrawal, Rejected www.researchpress.com Intervention Central, Jim Wright, ADHD, Bullying, Defiance http://www.interventioncentral.org/ Life Skills Training, Gilbert Botvin, Self-esteem, Social Skills, Substance Abuse, Social Anxiety, Peer Pressure, www.lifeskillstraining.com On-Line Graphing Resources http://www.interventioncentral.org PeaceBuilders, Michael Krupnick, Positive School Climate, Prosocial Behaviors, Conflict, Sibling Fighting, School Attachment, Peer Rejection www.peacebuilders.com Peace Education Foundation, Conflict Resolution Programs, Peer Mediation, Crisis Management, http://www.peaceeducation.com/ Primary Mental Health Project, Deborah Johnson, Mild Aggression, Withdrawal, Shyness, Anxious, Poor Classroom Adjustment, www.childrensinstitute.net Second Step Prevention Curriculum, Committee for Children http://www.cfchildren.org/programs/ssp/overview/ Skill Streaming, A. Goldstein & E. McGinnis, Prosocial Skills, Stress Coping, Friendship Building, Sharing http://www.skillstreaming.com/

References Abramowitz, J. S., Whiteside, S. P., and Deacon, B. J. (2005). The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 36, 55-63. Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits-Christoph, P., et al. (1998). Update on empirically validated therapies, II. Clinical Psychologist, 51, 3-16. Kendall, P. C. (Ed.). (2006). Child and adolescent therapy: Cognitive–behavioral procedures (3rd ed.). New York: Guilford Press. National Association of School Psychologists. (2004). Social skills: Building skills for success in school and life. Bethesda, MD: Author. Piacentini, J., March, J., & Franklin, M. (2006). Cognitive–behavioral therapy for youth with obsessive−compulsive disorder. In P. C. Kendall (Ed.), Child and adolescent therapy: Cognitive–behavioral procedures (3rd ed., (pp. 297–321). New York: Guilford Press. Sklare, G. B. (2005). Brief counseling that works: A solution-focused approach for school counselors and administrators . Thousand Oaks, CA: Corwin Press. Sloman, G. M., Gallant, J., & Storch, E. A. (2007). A School-Based Treatment Model for Pediatric Obsessive-Compulsive Disorder. Child Psychiatry and Human Development, 38, 303-319. Storch, E. A.(2006). Treatment of a patient with Obsessive-Compulsive Disorder. Journal of Family Practice, 55, 329-333.