Collaborative Problem Solving with Explosive Children

Content from the Collaborative Problem Solving Institute, Department of Psychiatry at Mass General Hospital Harvard Medical School.

www.ccps.info

Presenter: Chris Poyzer, LSW

www.thinkkids.org

www.explosivechild.com

Challenging Times

• There are more kids with social, emotional, and behavioral challenges than ever before. Whether your a teacher, parent, foster parent, counselor or school psychologist, police officer , or daycare provider, these kids (between 5/10 percent of all children) present unique challenges that need a specialized approach. The old paradigm is not working…

Turnover Rate For Teachers: Why Teachers Get Out Of The Profession

•#1 Reason (60 percent of teachers) “dissatisfaction with working conditions due to student behavior” (The cost burden to Minnesota k-12, Wilder Research Development 2008).

•Teacher leaving the profession according to the Alliance for Excellent Education cost the United States about 7 billion dollars per year in recruitment and other factors…

Challenging Children are….

•A complex and grossly misunderstood group•In need of adult understanding of the factors underlining their challenging behaviors… that directly influence the selection of interventions employed by school staff, parents, clinicians, and even police to best address those behaviors.

Challenging Children…

•There is no “one size fits all approach to the caring of challenging children and their adult caretakers..•Interventions options (behaviorally based, reward based ect) are not as potent if not well matched with the child’s specific needs.

Old Methods: Behavioral Based Not Potent Enough…

B.F Skinner- “behavior is modified by type of reward and punishment, and focuses on the consequences (punishing events)”, Pavlov and Classical Conditioning, Patterson “the attention that hitting and teasing elicits from parents in the home often functions as a positive reinforce for child, and that time out (isolation) can help dimnish aggressive actions”……

Behavioral Based philosophy is not working…

• Most of the research on this theory was done on rats, mice, rabbits and of course Pavlov’s dog.

• What was missing was the critical gift called language, and the ample endowment of memory and reasoning abilities of the child (most remarkable from my experience)….

• Children are not static, they are dynamic, transient beings that need a approach that balances this…

Common Hypothesis/Conventional Wisdom: Children Explode and are

Challenging…

•Because of passive, permissive, inconsistent, non- contingent parenting, the kid has learned that challenging behavior is an effective means of getting something (e.g attention, control) or escaping or avoiding something (e.g., homework, math (not the case, many families I work with have children in their homes that are not explosive or even a bit challenging!) What does that tell you? Conventional wisdom is wrong…

Important Themes To Take Away

•Consequences are only positive if they are effective in decreasing the challenging behavior.•Usually adults, educators, and other providers first hypothesis of ‘the problem” is wrong, as well as the first solution to the problem (Case Example: Confused vs. Fear, child fearful of parent going back to prison).

Compassion First

•That is why using a more effective, durable, compassionate, and collaborative approach is important. It allows you to dig deeper, and may hit oil (core problem), that may be fueling the challenging behavior or skill deficit •Skills Based Problem vs. Problem Based (Motivation vs. skills deficit).•CPS is something you do “with the child” vs. “to the child”.

Children do well if they can...

…if they can’t, we adults need to figure out why, so we can

help

Old paradigm “children do well if they wanna”

Children I work with do not “wanna” be sent to residential homes, kicked out of daycare

for “ever”, suspended, or alienated by their peers…

Case Example: Jimmy, I was his staff…I was caring for this “challenging child” and

I failed that night.•8 year old boy in a inpatient psychiatric unit•Diagnosed with Fetal Alcohol Affect, multiple foster homes, abuse (Sexual, Physical, Emotional).•Problem: Did not “wanna go to bed”•Intervention: Behavioral based, threatened with taking away “privs” in the morning (room time, game time you name it).•2nd Intervention-Seclusion room and restraining Jimmy..•Hypothesis: Still not sure to this day, why he could not fall asleep or why he kept coming out of his room? Could have been numerous reasons (stress, anxiety, fear, moving target)

Other Themes of Collaborative Problem Solving

•Explosive children and their episodes are a by product of a learning disability..•These children lack the skills necessary to problem solve, self regulate, control their frustration, and learn how to practice being flexible.•Educators, parents, and caretakers are in a excellent position to assess (plan B is an effective assessment tool), remediate, and make accommodations….

Most Crucial Themes….

•In the midst of a child’s most frustrating moments, never consequence, ignore or minimize their experience. This is an excellent way to escalate their frustrations (kaboom!), or implode (isolate)…•Welcome it has an opportunity, with “crisis comes opportunity” to find out what is going on? And maybe even deepen your explanation to guide your next step/intervention…(Thesis to CPS)•These children’s episodes are highly predictable..

Lack of Motivation vs. Lack of Skills?

•Example of my hopes of making the PGA tour (Motivation is extremely high, although skills are lacking, my motivation will decrease naturally)•If a child has the requisite skills and is motivated (yes/yes) we should see adaptive behavior. If a child doe not possess the requisite skills and is unmotivated (No/No). We are unlikely to see adaptive behavior. Increase skills first and motivation will increase…

Your explanation guides your intervention...

Half baked explanation leads to a half baked intervention, that

do not work so well.Slow Down! Parents, teachers, social workers, are so eager to fix and solve the problem they fly by the problem that needs

fixing……

Definition of “Good Parenting,” “Good Teaching,” and “Good

Treatment”

Be responsive to the handyou’ve been dealt

Unconventional Wisdom:It’s a Learning Disability

The child is delayed in the development of the skills of flexibility/adaptability, frustration tolerance, and problem-solving, or has significant difficulty applying these skills when they are most needed.

Definition of an Explosive Outburst

An explosive outburst – like other forms of maladaptive behavior -- occurs when the cognitive demands being placed upon a person outstrip the person’s capacity to respond adaptively.

Neurological Defects

•Defects in the prefrontal area can facilitate violent behavior (explosive, challenging ect) because of the resulting inability to understand concepts such as right and wrong (Executive Functioning Domain Later will expand on this) or to appraise the consequences of the violent act.•* Most of the children I work with that are “violent” and “rage” fall under the Reactive Domain vs. Proactive in terms of violence and aggression..

Neurology Cont..

•Abnormalities in the association areas of the brain lead to distorted perception and evoke assaultive behavior when a stimulus is perceived as threatening . (Madoki, M.W, Sumner, G.S, Ferrari, K.M. Evaluation and Treatment of Rage in Children and Adolescents. University of Florida Health Science Center at Jacksonville. December, 1991)• That may explain why Crisis Intervention and rapid demands can trigger rage? The child perception is distorted or maladaptive and crisis intervention causes a recoil (kickback).

Teach the skills of flexibility, frustration tolerance, and problem-solving and reduce the likelihood of explosive outbursts, while maintaining adults as authority figures. Use Collaborative Problem Solving More Often (Empathy vs. Apathy).Assess Neurological Defects Referral (Neuropsychological Testing, MRI, PET, CT ect)

Logical Interventions (vs Consequences for having Neurological Deficits)..

Definition of “Authority Figure”

- Understands the problem- Fixes it- Kids do not respect adults who

continue to apply/impose Plan A to problems that Plan A has not fixed.

- Kids do respect adults who have reasonable expectations, listen to their problems, treat them with mutual respect and work toward finding solutions that are mutually satisfying.

What about Consequences?

•Usually children/students know the rules and learn what to do and not do pretty quick. The CPS model is not allergic to consequences. Like Penicillin only use is it when needed. Use it as the only medical intervention. Body resist it and it will no longer work. Consequences are similar with behavioral challenges, one tool in the tool box. •Consequences are only important for two things…

1. Formal Consequences: Teaching a child basic lessons don’t hit, don’t swear (all taught in Kindergarten or hopefully prior)

2. Giving a child incentive to behave…

Consequences cont…

•….adaptively (secondary gain is, we believe, greatly overrated as an explanation for why a child would “choose” to endure repeated punishment and informal consequences-social rejection, peer alienation ect).

•In the role of treatment or education of explosive children consequences should not be the only tool in the toolbox and if it is usually results in using it for everything and learning skills is never started.

True Fact

There is no cookie-cutter.CPS is a blameless model

100 percent nature and 100 percent nurture

Diagnosis provides very little (just where the child is on the

spectrum of lagging skills)

CPS Overview

Because the CPS model views explosive/ noncompliant behavior as a learning disability…• the emphasis is on entirely different assessment “raw material” (cognition, not behavior)• the emphasis is on entirely different goals of intervention (teaching lacking thinking skills and solving problems rather than teaching adults to be more effective at imposing their will and ensuring that kids have the incentive to comply)

CPS Treatment Ingredients

1. Answer the question, “What lagging thinking skills are contributing to this child’s learning disability in the domains of flexibility, frustration tolerance, and problem-solving?”

2. Be aware of options for responding to problems/ unmet expectations and of what each option accomplishes

3. Successfully execute Plan B

Three Plans(Common Approaches to

Problems/Unmet Expectations)

Plan A: Impose adult will

Plan B: Collaborative Problem Solving

Plan C: Drop it (for now, at least)

Or better described as “minimize”, remove it from the child’s radar. Is it worth it?

Plan A

•Imposition of Adult Will (could be also imposing/assumption of the child’s feelings and emotions as well)•When a child does not meet expectations, it is common for adults to insist MORE intensively. •In children who have the skills (“Children do well if they can, so children who can”) this imposition of adult will does not typically have major adverse ramifications….

Plan A Continued

•The main problem with Plan A (imposing adult will) lies in the fact that adult expectations are being pursued that greatly heightens the likelihood of explosive outburst in certain children.•Many adults respond to this incompatibility by further intensifying their application of Plan A, often by offering incentives or threatening punishment, with the aim of giving children additional motivation to respond…

Alternative of CPS vs. Plan A

• Provides adults with an opportunity to give matter more thought (discipline repertoires) and question these popular assumptions and exposes them to a different perspective to..

• (1) Understand that there are actually three options for responding to problems, a road map (2) Recognize that they have been approaching such problems with Plan A and (3) recognize that one of the other two response option may fit better with the child’s abilities and raw cognitions at the moment (Vapor Lock, Hot Zone)…

After the Plans

• Plan A: “He did what I said.”

• Plan B: “We worked it out…we solved the problem together.”

• Plan C: “Are you going to call my mom!”…”No I am not sure that you are ready to talk to your mom, you still look pretty angry…lets just slow down a little”. (Backburner)

Three Plans(Common Approaches to

Problems/Unmet Expectations)

Plan A: Impose adult will(e.g., “No,” “You must,” “You can’t”) or in academic settings “You need to go to the office.)

In the analysis of explosive episodes, the escalation usually begins with an adult using Plan A, or starting Plan A and shifting to Plan C (dropping it, or giving in).

Plan A Entry Phrases

“No”, “You must”, You can’t, “This is your final warning", "If you do not pull it together you are going to be suspended” (just escalated the probability of a blow up, anxiety now is amplified)•Be careful about IMPOSING what you think the child is feeling. “I know that you are angry…”. Frustration, sadness, confusion, and/or anxiety can present differently (mood incongruence). This can really set off a child. Explore a little, start small and then expand.

Plan A Cont..

•Plan A is very habitual, established and valued part of our culture (buck up), many are not aware they are imposing their will until they learn about CPS… Parent “I have been using Plan A all the time”.•“I was raised (with Plan A) that way, and I turned out fine”. (remember “children do well if they can”. Maybe you had the skills!

Plan C

•Involves reducing or removing a given expectation•Highly effective at reducing a child’s global level of frustration. This can take on many forms. Using “ok”, “I hear ya”, “gotcha”, “I like how you are using your words vs. stomping” ect. •Example: 2nd grade student banging his head against the wall yelling “I am not going to the office!” Plan C- I said “I agree…. going to the office would not help lets stay right here and figure out what is up? (Emergency Plan C).

Plan C as Giving In?

•When an adult begins with Plan C, the adult is merely indicating they have no expectations, maybe because it is unrealistic (at that time, such as trying to get him to the principals office).•Adult is choosing Plan C therefore it is not ignoring, but rather a behavioral tool to avoid explosive episodes…•Majority of time most adults start off using Plan A and then switch to Plan C anyway because of their own frustration, fatigue, or lack of a road map of what else to do.•.

Plan B- the intervention

•Engage (curious) the child in a process of working toward a mutually satisfactory resolution of adult and child concerns.•Top goal to reduce the frequency, intensity and duration of explosive episodes.

Plan B Cont…

•Second goal: to help adult pursue expectations (get there concerns on the table=epidemic of children not knowing their adult caregivers concerns!•Third (durable) is to teach cognitive skills that are lacking-neither Plan A and C achieve this goal.•More effective over the long haul (handouts of reduction of psychiatric seclusions and restraints…

Plan B

•Is more efficient, the time spent problem solving together is generally far less that what is required in dealing with a child who has spiraled out of control and become violent and destructive. •Plan A always consumes more time that spending time solving problems….

Plan B Basics

•Plan B is that of the surrogate frontal lobe (go back to slide `16-18 and Neuropsychiatric defects).•* walking the child through a frustrating situation in the moment (midst of the frustration).•Solving problems routinely before explosive episodes (Proactive Plan B)•After long term use of Plan B and being the surrogate, you are now training thinking skills and slowly the challenging behavior evaporates and the surrogate steps back…

Plan B Entry Steps

1. Empathy(+Reassurance)2. Define the Problem3. Invitation

Let’s Get It Started

•Two forms of Plan B– Proactive Plan B

• Used well before a challenging behavior occurs, remember these kids are highly predictable (change in environment, staff changes, Halloween!).

– Emergency Plan B• Used in the “midst of a challenging episode-child

is already into “vapor lock”• Proactive Plan B should be used 80 percent of

the time (really is Plan B).

Goals of Plan B Continued...

•Problems that are routinely precipitating their challenging episodes.•Goal is to resolve one by one so that after a period of time, they are not causing challenging episodes.•Solutions that do not stand the test of time usually fall flat, they fail to identify (inaccurate empathy) and resolve (unrealistic expectations) the concerns of both child and adult.

Empathy in-depth

• To achieve the best possible understanding of a kid’s concern or perspective, approval, hunger, fatigue, fear a desire to be liked, a tendency to avoid ect...

• Most kids are accustomed to having their concerns superseded by the concerns of adults (Professionals do this a lot also, therapist, educators, social workers)

• Gather information as much as possible…

Information Gathering

•Made difficult by the fact that some kids, and oh yes even adults are not highly specific about their concerns.•Adults are quick to throw out a solution rather than a concern (reflect back into your life this week or even today in which this is evident?, we are all guilty)

Surrogate Frontal Lobe

•Adult “walks the child” through and gives the child the opportunity (maybe never has happened) to demonstrate a capacity to generate solutions to problems.

•Child: “I do not like to get in trouble”•Me: “You do not like to get in trouble…tell me more” (Empathy, allowing her to be heard, staying neutral)•Child: “Sometimes when I get in trouble, I get scared”•Me: “sometimes you get scared when you get in trouble” (Exploring, expanding, goal accurate empathy).•This little bit of knowledge is helpful, this little girl would have meltdowns because of her sense of terror when disciplined (very internal process)

Feeling Heard

• Feeling heard and understood tends to be calming• Empathy alone is not enough, reassurance may be

needed. • Research shows that children that rage and have

meltdowns their IQ can drop 20 points, that is why some children do not remember all that took place during the episode

• Reassurance that you are not going to expect them to problem solve until they are calm is helpful…

Plan B Entry Steps

1. Empathy(+Reassurance)

2. Define the Problem3. Invitation

Define Problem

• Ensures that the adult’s concern is on the table

• Definition of a problem: two concerns that have yet to be reconciled

• Reminder: Solutions are not concerns• Good question: “What’s your concern

about that?”– What if child “doesn’t care” about your

concern?

Proactive Plan B with Stevie…

•Mother (Empathy, kicking off Proactive B) “I noticed that when you have a bad day at school, you always throw things when you come home?•Child: “So…I was angry, I told you why I was angry (getting a little irritated)”•Mother: “I know you did and I really appreciate you telling me (reassurance )about what was wrong”, but my concern is that I may not always know what is going on by you throwing things?

Invitation

• This is an invitation to brainstorm solutions together

• Lets the child know this is something you’re doing with him rather than to him (thesis to CPS).- e.g., “Let’s think of how we can work that

out;” “Let’s see if we can solve that problem”

• Should recap two concerns so as to reiterate problem to be solved

• Child is given the first opportunity to generate solutions (“Do you have any ideas?”) – but resolution of the problem is a team effort (collaborative)

Emergency Plan B vs. Proactive Plan B

Difference is timing and the wording . Emergency Plan B is just repeating the concerns back to him, sticking to his exact words (sounds simple, but rarely used, adults quit after once or twice, I have used it for 10 minutes straight one time and eventually shifted to the core problem).

• Usually called Reflective Listening

Q and A

• Are there some challenging kids who are so volatile and unstable that academics, demands at home, and other expectations need to be deemphasized until thing are calmer?

• Answer: Absolutely. Some are not available (IQ drop), neuropsychiatric symptoms are pronounced, academics may need to take a backseat, chores can wait if they trigger aggression. And even hospitalization.. Hierarchy of problems…

Q & A

•Should I reward a kid for successfully participating in Plan B?

Answer•No.•Making headway or getting a problem solved, learning a new skill (communicate), resolve difficulties without explosions or yelling and screaming are far more rewarding than any extrinsic reward you might offer.

Q & A

• It is a Plan A world. If we are doing Plan B with a kid, are we not setting him up for failure (buck up mentality)?

• Which skills is most important for life in the “real world”: the blind adherence to authority trained with Plan A, plus in the real world the child will need skills so he can handle problems he or she will face….

•BREAK TIME!

Collaborative Problem Solving

Pathways: The Hand You’ve Been Dealt

• Executive skills• Language processing skills• Emotion regulation skills• Cognitive flexibility skills• Social skills

Pathways: The Hand You’ve Been Dealt

Executive skills– shifting cognitive set (toughest

challenge for explosive children).• Efficiency and flexibility by which a

child shifts from the rules and expectations of one situation to the rules and expectations of another.

• Deficits in these domains have potential to severely compromise a child’s capacity to respond to directives in an adaptive (compliant) manner.

Aggression

•It has been shown that aggression rarely occurs outside the context of inattention and poor impulse control and this explains the significant overlap between disorders with executive deficits (ADHD) and disorders associated with explosive behavior (ODD/Conduct Disorder).•Children challenged in working memory or planning might have difficulty efficiently reflecting upon prior consequences of noncompliance (hindsight) and anticipation of consequences of actions.

Pathways: The Hand You’ve Been Dealt

• Executive skills

• Language processing skills• Emotion regulation skills• Cognitive flexibility skills• Social skills

Pathways: The Hand You’ve Been Dealt

Language processing skills– labeling and categorizing

emotions– Explosive children are

emotionally illiterate..so teach them how to be emotionally literate!

– Plan B will be ineffective if the child is unable to define a problem with you and verbalize how they are feeling.

Pathways: The Hand You’ve Been Dealt

• Executive skills• Language processing skills

• Emotion regulation skills• Cognitive flexibility skills• Social skills

Pathways: The Hand You’ve Been Dealt

Emotion regulation skills– separation of affect

• The ability to separate one’s emotional response to a problem from the thinking one must perform to resolve the problem

• Emotional arousal can cause cognitive debilitation, and can cause IQ to drop 20 points.

• Called the “affective storm”

Separation of Affect: Goals of Intervention

Goal #2: Think clearly in the midst of frustration

Goal #1: Stay calm enough to do Goal #2

Pathways: The Hand You’ve Been Dealt

Emotion regulation skills– chronic irritability, anxiety

Pathways: The Hand You’ve Been Dealt

• Executive skills• Language processing skills• Emotion regulation skills

• Cognitive flexibility skills• Social skills

Pathways: The Hand You’ve Been Dealt

Cognitive flexibility skills– concrete, literal, black-and-white

thinking– difficulty focusing on the “big picture” – difficulty handling the “grays” of the

world:• problem-solving• social skills• unpredictability/uncertainty/ambiguity

Pathways: The Hand You’ve Been Dealt

• Executive skills• Language processing skills• Emotion regulation skills• Cognitive flexibility skills

• Social skills

Pathways: The Hand You’ve Been Dealt

Social skills– Cognitive deficiencies

• Poor perspective-taking and appreciation of how one’s behavior is affecting other people

• Poor appreciation of how one is coming across

• Poor appreciation of social nuances• Poor social repertoire (e.g., starting

conversations, entering groups)• This Pathway causes most damage long-

term…why do you u think that is?

Pathways: The Hand You’ve Been Dealt

How are all these skills assessed?

Pathways: The Hand You’ve Been Dealt

Assessment Tools– Pathways Inventory– Situational Analysis– Formal Testing (sometimes)– Best Assessment tool is Accurate

Empathy by doing Plan B well…

Pathways Inventory

Provides a listing of the skills frequently found lagging in children with social, emotional, and behavioral challenges

Prioritization will be necessary!

Situational Analysis (Clues to Pathways)

Explosive outbursts provide rich information in two areas:

• Pathways– These are “skills that need to be trained”

• Triggers – These are “problems that have yet to be

solved” (e.g., homework, reading, recess, lunch, waking up in the morning, sensory hypersensitivities, sibling interactions, etc.)

Why the Emphasis on Pathways and Triggers?

Focusing on the pathways helps adults• understand that a child’s explosive

outbursts are not intentional, goal-oriented, manipulative, or attention-seeking

• identify cognitive skills that may need to be trained

Dead-End Explanations

“He has bipolar disorder” “He is off today” (Mr. Poyzer, 2007)

“He has fetal alcohol syndrome”“She’s adopted” “He was abused”“He just wants attention” “It is

behavioral”“He just wants his own way”“He just wants control”“He’s making bad choices”“He won’t cooperate”

Definition

Cooperate: collaborate, come together..(so when you say “he or she is not being cooperative….it takes two”.

Dead Explanations: A story about a child’s meltdown is just a story unless it identifies lagging skills in the domains of Executive Functioning, Cognitions, Social Skills, or Language Processing…

Additional Information/Resources

www.ccps.info

Center for Collaborative Problem Solving