September 22, 2018 Erin Schoenfelder Gonzalez, Ph.D.

Brief Evidence-Based Behavioral Treatment for Disruptive Behavior and Depression
September 22, 2018 Erin Schoenfelder Gonzalez, Ph.D. Nathaniel Jungbluth, Ph.D., Cari McCarty, Ph.D., & Bob Hilt, MD Erin Schoenfelder Gonzalez, Ph.D. Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine Seattle Children’s Hospital

Integrating Brief Behavioral Treatments with Primary Care
Child Disruptive Behaviors Adolescent Depression

Learning Objectives 1) Understand models for integrating mental health care with primary care 2) Determine which patients will benefit from a brief behavioral treatment approach for disruptive behavior or depression 3) Explain the rationale and value of a behavioral treatment approach for disruptive behavior or depression

Gaping Needs Depression and behavior problems create long-term risks, including: High school drop-out Involvement with the law Underemployment Suicide attempts Adult MH problems Chronic medical problems 4 of 5 children with MH problem receive no help (Soni, 2009) Most referrals to child mental health (MH) treatment are for disruptive behavior

Example: How Common is ADHD?
Clinical estimates: 6-9% of children Similar prevalence rates worldwide Clinical estimates for 4-8% 1-2 students per class 2003 CDC survey in US by parent report identified 14% and 6% of 10 year old boys and girls identified and 9% and 4%, respectively, taking stimulants Recent CDC data 2007 released that showed increased to average of 9.5 percent based on parent-report; as high as 10% in a 2013 study, but that’s not neccesarily following the diagnostic criteria. Rates may be higher in community samples Percent of Youth 4-17 ever Diagnosed with Attention-Deficit/Hyperactivity Disorder: National Survey of Children's Health, 2007

Primary Care & Pediatric Mental Health
PC is only point of contact for most MH concerns 25% of PC pediatric patients have a psychosocial problem 66% of PCPs say they cannot get outpatient MH care for their patients 2x the average of other services Barriers: Trained & available providers Patient time/transportation Insurance Referral/communication problems Stigma (Cunningham, 2009; Kolko, & Perrin, 2014; Rushton, Bruckman & Kelleher, 2002)

5 Models for Mental Health & Primary Care
1. External Coordination 2. Consultation 3. Training of PCPs 4. On-site Intervention (without coordination) 5. On-site Collaborative Care (Cohen et al., 2010; Kolko & Perrin, 2014) Care as usual. Communiation hard. About 1/3 usually referred back to PCP Specialist consults with PCP by phone, etc. Train PCPs in intervention skills Co-located services MH provider and PCP team members

External Coordination
The traditional referral model

Consultation PAL Line

Training of PCPs PCPs provide direct treatment

On-Site Intervention Co-located services in-house

Collaborative Care Behavior Health Provider works together with PCP
Specialist consultation if needed

Collaborative Care Principles
Patient-Centered Team Care Population-based care Measurement-based Treatment to Target Evidence-based care Accountable care Patient-Centered Team Care Primary care and behavioral health providers collaborate effectively using shared care plans that incorporate patient goals. The ability to get both physical and mental health care at a familiar location is comfortable to patients and reduces duplicate assessments. Increased patient engagement oftentimes results in a better health care experience and improved patient outcomes. Population-Based Care Care team shares a defined group of patients tracked in a registry to ensure no one falls through the cracks. Practices track and reach out to patients who are not improving and mental health specialists provide caseload-focused consultation, not just ad-hoc advice. Read how to identify a population-based tracking system in our Implementation Guide. Measurement-Based Treatment to Target Each patient’s treatment plan clearly articulates personal goals and clinical outcomes that are routinely measured by evidence-based tools like the PHQ-9 depression scale. Treatments are actively changed if patients are not improving as expected until the clinical goals are achieved. Sometimes called Stepped Care. Read more about Treatment to Target. Evidence-Based Care Patients are offered treatments with credible research evidence to support their efficacy in treating the target condition. These include a variety of evidence-based pyschotherapies proven to work in primary care, such as PST, BA and CBT, and medications. Collaborative Care itself has a substantial evidence base for its effectiveness, one of the few integrated care models that does. Accountable Care Providers are accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided. Read more about accountability in our Financing section. (UW AIMS Center, 2017; Bauer, Thielke, Katon, Unutzer, & Arean, 2014)

Stepped Care Model – AIMS Center
many of the practices we work with incorporate CoCM into a “blended” or stepped model that combines other behavioral health interventions and strategies. Blended models of care seen in successful integrated care practices frequently combine CoCM and the Primary Care Behavioral Health (PCBH) Model, also known as the Behavioral Health Consultant Model. The CoCM and the PCBH Models are sometimes erroneously viewed as competing models. In practice however, these two models are frequently blended in a very complementary way within the same practice setting. If clinician roles, workflows, and target populations are thoughtfully defined, then a stepped measurement-based model can address the varied behavioral health needs of a much larger segment of a clinic’s patient population. An example: HealthPOint – 12 clinics in King County compbines PCBH and CoCM in its integrated care model. Consultant provides brief visits for consultation/feedbnack to PCP. BHCM sees patients with higher needs

What Is Behavioral Treatment?
Behaviors occur in context/environment Behaviors are attempts to get needs met We can understand why behaviors occur Changing the environment can change behavior Patients can change behavior to improve mental health

Biopsychosocial Model
(Adapted from Based on Engle, 1977)

Who Needs Behavioral Treatment?
Levels of Complexity (AACAP Guidelines, 2012) 0. Preventive Services and Screening (all patients) 1. Early Identification & Routine Care Provision (identified but uncomplicated, high prevalence behavioral health problems. Management by PCP) 2. Specialty Consultation, Treatment & Coordination (intermediate risk, complexity or severity, requiring specialist) 3. Intensive MH Services for Complex Problems (Identified disorder, high risk, complexity or severity, multisystem service teams)

Behavioral Treatment Principles
Shape family understanding of problem Anticipate triggers/difficulties Alter environment and structure Learn skills Create contingencies Reinforce and practice

PAL Plus Goal: Support PCPs treating MH with behavior therapy services
Team: PAL Team 2 Psychologists: Train/supervise BHSPs 3 BHSPs: Provide therapy The Model One-step PCP/School referral for families with Behavior Problems (ages 5-11) or Depression (ages 12-17) Seattle Children’s psychologists trained BHSPs via Videoconference Psychologists provide weekly supervision with BHSPs PAL telehealth consultation re: meds as needed 9 instances of med consult

Two Programs: “First Approach Skills Training”
Disruptive Behavior Ages 5-11 Disruptive behavior related to attention, self-regulation, adjustment, oppositional behavior Rule outs: Trauma, Autism, severe aggression Depression Ages 12-17 Mild to moderate depression Adolescent wiling to participate Rule outs: Severe depression, active suicidal ideation After: Follow-up call 2 weeks later; Refer to intensive services PRN

PAL+ Outcomes Measures
Construct Disruptive Behavior Depression - Teen Depression - Parent Home Situations Questionnaire Disruptive Behaviors across situations X Pediatric Health Questionnaire – 9 Adolescent depression screener Short Moods & Feelings Questionnaire Parent-report depressive symptoms Weiss Functional Impairment Rating Scale Functional problems across domains Satisfaction with Program Acceptability, perceived helpfulness, open-ended feedback

PAL+ Referrals

PAL+ Enrollment

9 in DB track got a med review

PAL+ Enrollment Disruptive Behavior Depression Many more referrals
63% responded. Of those: 48% initiated 31% declined 21% referred elsewhere Of initiated: 63% completed all sessions, 11% on-going 26% dropped out Depression More severe cases referred 78% responded 19% Declined 47% Referred elsewhere Of initiated: 62% completed the program, 23% on-going 23% dropped out Similar to lg 2014 study – 67% of PCP accepted the referral, onl y18% completed a face-to-face encounter.. Hacker et al., 2014 Another found 30% to engage in services Hacker et al., 2014b. A third fround 45% Rushton et al., 2002

PAL+ Outcomes Disruptive Behavior Depression
24.7% reduced disruptive behavior 24.8% reduced impairment Depression 19% improved teen-report depression 42% improved parent-report depression 19.8% reduced impairment 18% improved anxiety HSQ (40.87 to 30.92) WFIRS (1.4 to 1.06) PHQ-9 (14.54 to 11.73) SMFQ (13.5 to 8) WFIRS 19.8% GAD-7 (10.3 to 8.4)

PAL+ Satisfaction Disruptive Behavior Depression
100% it helped “somewhat” or “a great deal” (71% a great deal) 100% mostly or very satisfied 100% would recommend 94% it met most or all of needs 88% were enough sessions Depression 100% parents: helped “somewhat” or “a great deal” 100% teens: “It helped somewhat” 84% were enough sessions 67% it met a few of my needs; 33% it met most of my needs HSQ (40.87 to 30.92) WFIRS (1.4 to 1.06) PHQ-9 (14.54 to 11.73) SMFQ (13.5 to 8) WFIRS 19.8% GAD-7 (10.3 to 8.4)

PAL+ Lessons Learned We struggle to stay on the radar for PCPs
External referrals: hard to connect Mild cases (depression) may be missed in Primary Care Without routine screening, hard to engage with specific programs 4 sessions sufficient for most behavior cases, not for most depression cases

Who Needs Behavioral Treatment?

Disruptive Behaviors Noncompliance with requests Arguing and back-talk
Trouble following through with routines and tasks Tantrums Aggressive behaviors Annoying or attention-seeking behaviors Negative parent-child relationship What are the types of behavior problems you see in practice? What are parents’ common complaints? What do you usually recommend?

Screening for Behavior Problems in PC
Behavior is not typical for child age/development Behavior causing distress or impairment Classroom Academic progression Home/caregiver relationships Personally for the child Screening Tools: PSC-17 Vanderbilt Rating Scale Home Situations Questionnaire Teacher Ratings

PSC-17 Brief screen for psychosocial problems ages 4-17, based on original 35item (Leiner et al., 2007) 17 items and 3 domains: Externalizing, Attn Problems, Internalizing. Clinical cutoffs

DB Screening Questions
“How long have you noticed these behaviors?” “How long have you been concerned about these behaviors?” “Do the behaviors get in the way of life activities – home routines, social relationships, participating in groups or class?” “Do you notice that child’s well-being is affected by these behaviors?” “What do other caregivers (relatives, other guardian, teacher, daycare teacher) say or notice about these behaviors?”

When is it something else?
Stressors and trauma Speech/language Neurodevelopmental Disorder: Developmental delays, ADHD, Autism Sleep Disorder Genetic Disorder Parent problem Abuse/neglect Medical diagnosis what kids of things would you want to rule out when beh issues are present…) Get them thinking about CONTEXT beyond just parent skill deficits off the bat. What medical diagnoses would you screen out? Seizures, thyroid, etc.

Parent Behavior Management Training
The research: “Well established” evidence base for disruptive behaviors Improves oppositional behavior, classroom behavior, compliance, family/parent stress The skills: Improving parent/child positive relationship: Special Time Labeled praise Effective Instructions Planned Ignoring Incentive Systems Time Out Privilege Removal

Child playing on DS told to stop and put on pajamas
Antecedent Behavior Consequence Child playing on DS told to stop and put on pajamas Child screams and throws toys Parent soothes, explains, gives 5 min warning

Child playing on DS told to stop and put on pajamas
Antecedent Behavior Consequence Child playing on DS told to stop and put on pajamas Child screams and throws toys Parent soothes, explains, gives 5 min warning Child and parent negatively reinforced (child escapes demand, parent escapes tantrum)

Anticipate and strengthen: Feedback: Immediate Consistent Frequent
Antecedent Behavior Consequence Anticipate and strengthen: Positive relationship Daily structure Clear expectations Incentive systems School supports Feedback: Immediate Consistent Frequent Meaningful Balanced

FAST Disruptive Behavior
Intake: Causes of Child Behavior Session 1: Improving relationships Session 2: Praise and Planned Ignoring Session 3: Commands and Rewards Session 4: Consequences

Parent Training: The Pitch
1 hour individual therapy doesn’t affect attention and compliance in other settings Parents: Are with the child across settings Can anticipate challenges and plan in advance Will learn to “coach” successful behaviors More likely to do their homework  Research support Parent Behavior Management Training as first-line treatment for ADHD and ODD

Who Needs Depression Treatment?
Elevated symptoms of depression Low/sad mood Lack of enjoyment Fatigue and/or sleep problems Rapid weight gain/loss Unexplained stomach/headaches/pain Symptoms causing distress or impairment Adolescent asking for help Measures: PHQ-9 Mood & Feelings Questionnaire Child Depression Inventory/Beck Depression Inventory Advantage of parent and child versions. Goes down to lower ages.

Depression Screening Questions
Do you feel like you often don’t enjoy things that used to be fun? Have you stopped doing things you used to enjoy, like hobbies or hanging out with friends? Do you often feel sad, or hopeless about the future? Do you feel tired often, even after a night of sleep? Have your eating or sleep habits changed? Do you ever wish you weren’t alive anymore? PHQ-2 (rate 0-3) Little interest or pleasure in doing things Feeling down, depressed, or hopeless

Behavioral Activation for Depression
The Research: Adapted from effective adult treatment Improves depression, global functioning, activation, and avoidance on par with other evidence-based depression tx The Concept: When life doesn’t feel rewarding, people have low motivation, avoidance, negative mood Patterns of avoidance and inactivity maintain low motivation and negative mood Guided activation through goal setting helps youth stop avoiding, re-engage, and improve motivation and mood Is there a paper on specific outcomes for adolescents? The only paper I found showed it was equivalent to other care (McCauley, Gudmundsen, Schloredt, Martell, Rhew, Hubley et al., 2016)

Activation/Avoidance Cycle

BA Model

Basic BA Skills Understand patterns of avoidance and depression
Observe how activation improves mood Schedule positive activities Set SMART Goals Engage parent support Address lifestyle factors: Sleep, exercise

FAST Depression Skills
Intake: Set goals, Tracking activities and moods Session 1: BA Model, Activity Scheduling Session 2: SMART Goals Session 3: Avoidance, Parent Support Session 4: Review What Works, Plan for Future

How could we make this a SMART goal?
Goal Setting How SMART is this goal?? “I will get in shape” How could we make this a SMART goal? Although goal setting will not be a focus of the parenting group, we wanted to spend some time introducing to this concept as it will be one of the primary skills taught to your teen in the teen group. BA uses the idea of setting SMART goals (Handout) Go over what SMART goal means Give example of poor SMART goal and see if parents can shape into a “SMARTer” goal I will work out Tuesday, Thurs, Sat (3x/week) for 30 mins each time I will walk the dog for 2 miles a day I will jog for 2 miles, 3x a week I will lift weights M/W/F after work for 45 minutes each time I will go to the 5:30pm yoga class T, Th and 11am Sunday

The Pitch Validate that teen is in a “stuck pattern”
Ask what they have already tried Point out the need for a “team” to support them Ask if they are willing to try an “experiment” of meeting with a therapist to observe how it goes Express confidence in programs to help Confirm privacy/confidentiality

Rolling with Resistance
Brainstorm all options Validate how stressful and challenging things are Avoid blame, but note that parents can be part of the solution Asked what they have already tried Point out that they are seeking more solutions Ask: What could be benefits of making this change?

Summary Many ways to integrate MH treatment in Primary Care
Behavioral treatments have far-reaching benefits Parent training for disruptive behavior Behavioral Activation for depression We struggle to get on the radar for PCPs Benefits of routine screening to catch kids in need early For program specifics, don’t touch that dial….

Questions?

References Soni A. The Five Most Costly Children’s Conditions, 2006: Estimates for the U.S. Civilian Noninstitutionalized Children, Aged 0– Medical Expenditure Panel Survey: Statistical Brief #242. Cunningham, P. J. (2009). Beyond parity: primary care physicians’ perspectives on access to mental health care. Health Affairs, 28(3), w490-w501. Kolko, D. J., & Perrin, E. (2014). The integration of behavioral health interventions in children's health care: Services, science, and suggestions. Journal of Clinical Child & Adolescent Psychology, 43(2), Rushton, J., Bruckman, D., & Kelleher, K. (2002). Primary care referral of children with psychosocial problems. Archives of pediatrics & adolescent medicine, 156(6), Cohen, J. A., Issues, T. W. G. O. Q., & AACAP Work Group on Quality Issues. (2010). Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 49(4), Bauer, A. M., Thielke, S. M., Katon, W., Unützer, J., & Areán, P. (2014). Aligning health information technologies with effective service delivery models to improve chronic disease care. Preventive medicine, 66, Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286),

References McCauley, E., Gudmundsen, G., Schloredt, K., Martell, C., Rhew, I., Hubley, S., & Dimidjian, S. (2016). The adolescent behavioral activation program: Adapting behavioral activation as a treatment for depression in adolescence. Journal of Clinical Child & Adolescent Psychology, 45(3),

Erin Schoenfelder Gonzalez, Ph.D.

Brief Evidence-based Treatment for Disruptive Behavior and Depression
Child Disruptive Behavior Depression

Learning Objectives 1) Explain the value of a behavioral treatment approach for disruptive behavior or depression 2) Teach evidence-based skills from Parent Management Training and Behavioral Activation 3) Troubleshoot common barriers to treatment engagement

Why Use Brief Behavioral Interventions
PROS Prevention Easier to engage families Cost effective Easier training Broad benefits Can be integrated Avoid over-treating CONS Hard sell if problems mild May be insufficient Lack of systematic screening Traditional behavioral treatments: 8-18 sessions Brief: 20 min to 6 sessions

What does Parent Training add?
Functioning rather than symptoms MTA Study Outcomes for Combo Treatment: Behavioral/combo superior for: Children with anxiety Families with adversity and stress Parent-child relationships Academic difficulties Social skills Anxiety symptoms Oppositional/aggressive behaviors Family satisfaction with treatment

Sequencing Treatment Pelham study: ages 5-12 with ADHD
Week Week 9-16 A Non responder? B B group: better classroom behavior Higher parent engagement/attendance Adding meds 2nd improved classroom behavior and parent/teacher-rated oppositional behavior BPT Meds Meds BPT (Pelham et al., 2016, JCCAP)

Parents have worse BPT attendance when child is treated with medication first
(Pelham et al., 2016)

Updated ADHD Treatment Guideline?

How does Brief Parent Training Work?

Parent-Child Disruptive Behavior Cycle
Parent Corrections -Negative attention -Too many commands -Inconsistency Child dysregulation, impulsivity, inattention Child Disruptive Bx -Off-task -Attention seeking -Arguing/resisting Coercive Parenting -Giving in -Withdrawing -NO FAMILY FUN Externalizing Dx -Defiance -Anger Internalizing Dx -Low self-esteem -Anxious Parent Stress -Negative affect -Expect the worst

How do we help families break the cycle?

Parent-Child Disruptive Behavior Cycle
Parent Corrections -Negative attention -Too many commands -Inconsistency Parenting Skills -Positive attention -Increase structure -Consistent consequences Child dysregulation, impulsivity, inattention Child Disruptive Bx -Off-task -Attention seeking -Arguing/resisting Child Engagement -Seek positive attention -Learn expectations Effective Parenting -Realistic expectations -Positive relationship -MORE FUN Coercive Parenting -Giving in -Withdrawing -NO FAMILY FUN Child Positive Bx -Success experiences -Self-efficacy -Positive relationships -School effort Externalizing Dx -Defiance -Anger Internalizing Dx -Low self-esteem -Anxious Parent Coping -Stop the Tug-O-War -Calm responses Parent Stress -Negative affect -Expect the worst

FAST Disruptive Behavior
Session 1: Causes of Child Behavior, Improving relationships Session 2: Praise and Planned Ignoring Session 3: Commands and Rewards Session 4: Consequences First Approach Skills Training

Session 1: Causes of Child Bx Problems

Session 1: Special Time 10-15 min per day (timed) Scheduled!
Child chooses and leads activity Parent pays special attention! Praise Reflect Imitate Describe Enjoy

Special Time Activities
Younger Legos, blocks Color/draw Craft project Play a game the child’s way Play with a pet together Build a fort Older Go for a walk Get a cup of tea/hot chocolate together Talk Practice a sport Let them teach you about a favorite topic Open it up to audience to brainstorm

**Demonstration**

Using Contingencies

Contingencies To increase behaviors To decrease behaviors
Catch ‘Em Being Good Attending to desired behaviors Incentives Immediate, consistent feedback (tokens) Premack Principle (If-Then) To decrease behaviors Planned ignoring Time Out Response Cost (losing privileges)

Session 2: Catch ‘Em Being Good
How to do it: Tell ‘em exactly what you like Catch ‘em in the act if you can Stay near them and keep describing while they are in action Include physical affection if it feels natural (high 5, hugs) Catch ‘em every chance you get! Examples: “I like the way you are playing nicely with your brother.” “You did a good job putting away your shoes when I asked.” “Great idea to get your homework done now so you can go out and play.” Avoid: Generic Praise Complements with a Kick

Session 2: Planned Ignoring

Session 3: Effective Instructions
Direct and specific Only one or two instructions at a time Instruction is followed by 10 seconds of silence Ineffective Instructions: Buried: Too much talking or explaining after a command makes it difficult for children to figure out what they are being asked to do Chain: Too many instructions one after the other makes it difficult for children to remember each step Question: Stating the instruction in the form of a question technically allows the child to say no Vague: Nonspecific commands that don’t state exactly what you want makes it difficult for child to comply Let’s: Gives the child the impression that you are going to help him/her Distance: Instructions are yelled from a distance which makes it more difficult for child to pay attention well Repeated: Repeating same instruction without reaching a limit

Session 3: Token System Target Behavior When Checked? Tokens
Out of bed with 1 reminder After 1st reminder 1 Dressed and teeth brushed in 10 min Timer goes off Put away shoes and backpack Arriving home TOTAL 3

Incentives Menu Small (daily) Medium (weekly) Large (long-term)
Screen time Treat with lunch or dinner Later bedtime Medium (weekly) Fun outing Friend get-together Spending money Large (long-term)

Consequences must be…. Immediate Frequent Specific Balanced Consistent
3:1 ratio positive:negative

Session 4: Time Out “Time Out from Reinforcement”
Most effective immediate consequence Tweaks Time Out spot MAX of 5 min Refusal to start: Add 1 min up to 9 Continued refusal: Drop T.O. and give privilege removal End: Reintegrate into family activities

Session 4: Privilege Removal
Remove privilege (e.g., screens, toy, social time, dessert) for shortest effective time (10 min–24 hours). This gives child a chance to try again. Behavior (specific) Privilege lost Length of time* Removal Plan Rushing through homework and guessing answers Screens (iPad + TV) 1 hour Rest of day if child does not carefully re-do HW Parent checks HW after complete. Remove iPad + TV remote to parents’ closet

Implementation Issues

Family Barriers “I shouldn’t have to praise or bribe my child for them to behave. They should do it on their own.” Motivational Interviewing is a helpful framework for addressing this common barrier, especially when the stressors or complicated factors are likely to be on-going. Discuss what signs would indicate to parent that it is time to make a change. Brainstorm a list of options with parents about how to proceed, including their ideas as well as “Try FAST-B skills” or return at a later time. A decisional balance exercise can help parents weigh the pros can cons of participating in FAST-B. For a helpful worksheet, see: Encourage a behavioral “experiment” of trying Special Time and observing how much time was spent, how disruptive it was, and parent and child’s response. Validate that behaviors can get briefly worse when things change and children test new limits. That is often a sign that the program is working and things will get better with consistent skill use. Ask parent to bring the child and try skills in session, observing whether they might be less burdensome than expected. If parent is willing, encourage parents to set a phone or calendar reminder for times when they think they could try implementing a skill.

Family Barriers “Things are too hectic right now to make a change in my parenting approach” Motivational Interviewing is a helpful framework for addressing this common barrier, especially when the stressors or complicated factors are likely to be on-going. Discuss what signs would indicate to parent that it is time to make a change. Brainstorm a list of options with parents about how to proceed, including their ideas as well as “Try FAST-B skills” or return at a later time. A decisional balance exercise can help parents weigh the pros can cons of participating in FAST-B. For a helpful worksheet, see: Encourage a behavioral “experiment” of trying Special Time and observing how much time was spent, how disruptive it was, and parent and child’s response. Validate that behaviors can get briefly worse when things change and children test new limits. That is often a sign that the program is working and things will get better with consistent skill use. Ask parent to bring the child and try skills in session, observing whether they might be less burdensome than expected. If parent is willing, encourage parents to set a phone or calendar reminder for times when they think they could try implementing a skill.

Family Barriers “We’ve tried parenting strategies like this before. They didn’t work.” “Our goal is for kids to do these things on their own, too, though it sounds like your child is needing help to get more independent right now. Think of our strategies like using supports to guide the growing limbs of a tree. The strategies will help your child learn new behaviors and habits, so eventually they will develop a new routine and won’t need as much extra support.” Isn’t it true that if you praise a child too much, they will become dependent on praise to do anything? “The research does not find that to be the case. Think about your own experiences at home or at work. If you go through the efforts to do something very well, like cook a special meal for your family, and no one comments or seems to notice, would you keep doing it? We all thrive on recognition and encouragement. Eventually, your child may see the inherent value in the task and find internal motivation as well.” I’ve heard that time out isn’t recommended anymore, and that you should…[talk to your child about what they did, use spanking, etc.] instead. “Though there has been some controversy about time out, it is still recommended by behavioral experts as the most effective consequence “in the moment” for child misbehaviors. It may need to be tweaked for certain children, such as those with a history of trauma. But we find the method that we use works well for most children. It sounds like [current method] hasn’t been working well for your family, and that you’re looking for another strategy.” Encourage parents to role play and practice with you in session to see how it feels.

When do you need more? Outcome measures: Continued Impairment
PSC-17 Home Situations Questionnaire Impairment Rating Scale Vanderbilt? Continued Impairment Developmental concerns? Academic needs

Same principles, Many programs
(Reitman & McMahon, 2013)

Parent Training Resources

Behavioral Activation Model of Change
When life doesn’t feel rewarding, people have low motivation, avoidance, negative mood Patterns of avoidance and inactivity maintain low motivation and negative mood Guided activation through goal setting helps youth stop avoiding, re-engage, and improve motivation and mood (Martell, Addis, & Jacobson, 2001) • Life events/daily hassles can lead to feeling unmotivated as well as having low energy and a generally negative mood. • Finding challenging work or work involving great cognitive effort as unrewarding common among teens with ADHD • Avoidance of work in response to these feelings is an attempt to cope

FAST Depression Skills
Intake: Set goals, Tracking activities and moods Session 1: BA Model, Activity Scheduling Session 2: SMART Goals Session 3: Avoidance, Parent Support Session 4: Review What Works, Plan for Future

What do you see teens doing in their personal lives that have ST payoff and LT consequences?
What does avoidance look like?

Negative Consequences
The BA Model Life Circumstances How did you feel? What did you do? Negative Consequences Treatment Rationale Emphasize relationships among environment, mood, and activity Highlight vicious cycle that can develop between depressed mood, withdrawal/avoidance, and worsened mood Suggest activation as a tool to break this cycle and support problem solving Emphasize a “goal-directed” approach: act according to a plan or goal rather than a feeling or internal state

Session 1: BA Cycle Example
Heavy school workload junior year, high expectations Low motivation, anxiety, sadness, frustration Procrastinate work until late night, surfed internet and played video games for hours Lack of sleep, grades slipping, arguments with parents Discuss example BA model what has their adolescent has done to feel better (e.g., avoid school, play video games, procrastinate)? Highlight behaviors that make motivation worse rather than better, and how these behaviors can become secondary problems, creating a “vicious cycle.” Like to normalize the behavioral response when describing this model- like it makes total sense to isolate, want to avoid difficult things like homework when mood is down, trouble comes when these behaviors stick around for long periods of time and get in the way of our lives- interfere with family and friend relationships and schoolwork

Session 1 HW

Increasing Goal Directed Behavior Acting from the “outside in”
Follow a written plan (e.g., activity schedule) Public commitment—share intention , public support can help to get a task done. Plan specific strategy for implementation (what, when, where, etc.) Highlight short/longterm consequences of increased activation Monitor progress Use of self-reinforcement Adopt a scientific/experimental attitude Be alert for the “just do it” approach Ultimate goal of treatment Patients modify their behavior to increase contact with sources of positive reinforcement Typical goals relate to changing avoidance patterns and routine disruption and to changing environmental context Goal is not to accomplish all parts of the activity—rather, to get started, increase activation, disrupt avoidance Completing one component will increase likelihood of completing others How do you do it? Break down activities into parts Assign simple to more complex tasks in a stepwise fashion Design assignments so that early success is guaranteed Focus on acting from the “outside in” or engaging in goal-directed behavior Set priorities for short and long-term goals Figure out what behaviors are needed to reach goal—what, when, where, etc. Be focused, specific, and concrete!

Goal Setting Although goal setting will not be a focus of the parenting group, we wanted to spend some time introducing to this concept as it will be one of the primary skills taught to your teen in the teen group. BA uses the idea of setting SMART goals (Handout) Go over what SMART goal means Give example of poor SMART goal and see if parents can shape into a “SMARTer” goal I will work out Tuesday, Thurs, Sat (3x/week) for 30 mins each time I will walk the dog for 2 miles a day I will jog for 2 miles, 3x a week I will lift weights M/W/F after work for 45 minutes each time I will go to the 5:30pm yoga class T, Th and 11am Sunday

**Demonstration**

Goal Setting How SMART is this goal??
“I will get better grades at school” How could we make this a SMART goal? Although goal setting will not be a focus of the parenting group, we wanted to spend some time introducing to this concept as it will be one of the primary skills taught to your teen in the teen group. BA uses the idea of setting SMART goals (Handout) Go over what SMART goal means Give example of poor SMART goal and see if parents can shape into a “SMARTer” goal I will work out Tuesday, Thurs, Sat (3x/week) for 30 mins each time I will walk the dog for 2 miles a day I will jog for 2 miles, 3x a week I will lift weights M/W/F after work for 45 minutes each time I will go to the 5:30pm yoga class T, Th and 11am Sunday

Session 2

Let’s Practice! SMART Goal Setting
Guiding Principles Break down goals into parts Assign simple to more complex tasks in a stepwise fashion Choose goals so that early success is likely (i.e., what does the teen value? what is realistic but also a impactful?) Learn to identify and problem-solve barriers Be focused, specific, and concrete! (i.e., What, where, when, who, how) Figure out what behaviors are needed to reach goal—what, when, where, etc. If you run into resistance or the steps aren’t being taken, it’s possible the goal wasn’t the right one to start with, you didn’t break it down into small enough steps, the goal or steps weren’t specific enough Increasing Goal Directed Behavior (acting from the “outside in”) Follow a written plan (e.g., activity schedule) Public commitment—share intention , public support can help to get a task done. Plan specific strategy for implementation (what, when, where, etc.) Highlight short/longterm consequences of increased activation Monitor progress Use of self-reinforcement Adopt a scientific/experimental attitude Be alert for the “just do it” approach

Session 3

Session 3: Avoidance

Session 3

Implementation Issues

Teen Barriers “I’ve got this. I don’t need help.”
Motivational Interviewing is a helpful framework for addressing this common barrier, especially when the stressors or complicated factors are likely to be on-going. Discuss what signs would indicate to parent that it is time to make a change. Brainstorm a list of options with parents about how to proceed, including their ideas as well as “Try FAST-B skills” or return at a later time. A decisional balance exercise can help parents weigh the pros can cons of participating in FAST-B. For a helpful worksheet, see: Encourage a behavioral “experiment” of trying Special Time and observing how much time was spent, how disruptive it was, and parent and child’s response. Validate that behaviors can get briefly worse when things change and children test new limits. That is often a sign that the program is working and things will get better with consistent skill use. Ask parent to bring the child and try skills in session, observing whether they might be less burdensome than expected. If parent is willing, encourage parents to set a phone or calendar reminder for times when they think they could try implementing a skill.

Family Barriers “My daughter needs an attitude adjustment. If she would stop being lazy, her problems would go away.” “Our goal is for kids to do these things on their own, too, though it sounds like your child is needing help to get more independent right now. Think of our strategies like using supports to guide the growing limbs of a tree. The strategies will help your child learn new behaviors and habits, so eventually they will develop a new routine and won’t need as much extra support.” Isn’t it true that if you praise a child too much, they will become dependent on praise to do anything? “The research does not find that to be the case. Think about your own experiences at home or at work. If you go through the efforts to do something very well, like cook a special meal for your family, and no one comments or seems to notice, would you keep doing it? We all thrive on recognition and encouragement. Eventually, your child may see the inherent value in the task and find internal motivation as well.” I’ve heard that time out isn’t recommended anymore, and that you should…[talk to your child about what they did, use spanking, etc.] instead. “Though there has been some controversy about time out, it is still recommended by behavioral experts as the most effective consequence “in the moment” for child misbehaviors. It may need to be tweaked for certain children, such as those with a history of trauma. But we find the method that we use works well for most children. It sounds like [current method] hasn’t been working well for your family, and that you’re looking for another strategy.” Encourage parents to role play and practice with you in session to see how it feels.

Teen Barriers “I have enough homework already. Therapy homework is just too much.” Motivational Interviewing is a helpful framework for addressing this common barrier, especially when the stressors or complicated factors are likely to be on-going. Discuss what signs would indicate to parent that it is time to make a change. Brainstorm a list of options with parents about how to proceed, including their ideas as well as “Try FAST-B skills” or return at a later time. A decisional balance exercise can help parents weigh the pros can cons of participating in FAST-B. For a helpful worksheet, see: Encourage a behavioral “experiment” of trying Special Time and observing how much time was spent, how disruptive it was, and parent and child’s response. Validate that behaviors can get briefly worse when things change and children test new limits. That is often a sign that the program is working and things will get better with consistent skill use. Ask parent to bring the child and try skills in session, observing whether they might be less burdensome than expected. If parent is willing, encourage parents to set a phone or calendar reminder for times when they think they could try implementing a skill.

When do you need more? Measures Continued impairment Co-morbidities?
PHQ-9 Short Moods & Feelings Questionnaire Continued impairment Co-morbidities? Anxiety/OCD Trauma Learning problems ADHD On-going navigation of stressors Treat anxiety or trauma first. Depression is much harder to treat.

Clinician Resources

Questions?

Summary Behavioral treatments improve functioning and break behavioral patterns/cycles Parent Training improves young child functioning Behavior Activation for moderate depression and stress

Case Example: Jack, age 11 PCP diagnosed ADHD
Family from Iran, father strict upbringing High impulsivity, low social reasoning Argues and negotiates impulsively Hyperfocus on his own interests Refuses to follow family rules

Behavior Management Plan
ISSUE PLAN Pos Behavior to Increase Neg Behavior to Decrease Antecedents Environmental Changes Needed Reward for Positive Consequence for Negative

ISSUE PLAN Pos Behavior to Increase Compliance with requests Neg Behavior to Decrease Arguing, refusing Antecedents Parent frustration, helplessness Low child insight/awareness Environmental Changes Needed Rules printed and reviewed Role-play “talking back” Reward for Positive Points toward electronics time Consequence for Negative Labeling of behavior Privilege removal with 10 warnings

Case Example: Mira, age 16 First generation Mexican-American
Has dropped out of volleyball Mostly lies in bed on screens Up until 3am, sleeps all day if she can Grades have consistently been low Parent told PCP they are worried she is sick She says, “Everyone annoys me.”

CONCEPTUALIZATION PLAN Environmental Factors What Does Avoidance Look Like? Positive Activities to Increase SMART Goals Parent Role Other Supports Needed

CONCEPTUALIZATION PLAN Environmental Factors Ethnic/cultural discrimination; Family stressors? School placement What Does Avoidance Look Like? Hyperfocus on screens; disengagement from social Positive Activities to Increase Sports; social; family; other? SMART Goals Schoolwork completion; exercise Parent Role Supportive listening, positive time together Other Supports Needed Special Education assessment? Diagnostic evaluation and/or med consult

Erin Schoenfelder Gonzalez, Ph.D.

September 22, 2018 Erin Schoenfelder Gonzalez, Ph.D.

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September 22, 2018 Erin Schoenfelder Gonzalez, Ph.D.

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Presentation on theme: "September 22, 2018 Erin Schoenfelder Gonzalez, Ph.D."— Presentation transcript:

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