Treating Externalising Disorders

Question 1

What are the 4 guiding principles for effective treatment?

Answer 1

1. Target the ecology of the child - family, school, peers, work, etc
2. Target the developmental perspective - what is their age? Eg: in adolescence they may form gangs outside school
3. Be formulation/hypothesis driven - what are the maintaining/causal factors for THIS child?
4. Form a strong therapeutic team

Question 2

In early to middle childhood _____ ______ is the preferred treatment. In late childhood/adolescence ____ _______ is used, as well as anger _______, social ______, and ____ for the ______.

Answer 2

parent training
parent training 
management
skills
BCT
child

Parental training is very important - they are part of the causal/maintaining factors - they are both victim and architect of the system
After age 8 - child can do some form of CBT

Question 3

What is the effectiveness of the treatment in early childhood and how does this change later on?

Answer 3

60-70% do not have a diagnosis at the end of treatment. It becomes more difficult to treat in middle childhood and adolescence.

Question 4

In parent training, the main target of treatment is _______ attention. We do this by targeting _______ patterns.

Answer 4

differential, coercive

Question 5

What do we add to descriptive praise during treatment? Aka treatment involves operant conditioning and…?

Answer 5

1. Attachment theory - sweetness, touching, looking in someone’s eyes, hugs, mushy stuff - what we’re biologically wired for
   “that was so great bud, come here…you want to spend some time together? It’s so great we’re in a family together”
2. Structural family changes

Question 6

Structural systems are important in treatment. How is it most effective for a family to be organised?

Answer 6

Parents form a strong, separate team. They have executive action and authority. Children form a separate team and have less power.

Question 7

What changes are made during differential attention?

Answer 7

Positive behaviour is rewarded with strong attention, attachment-rich behaviour (instead of being ignored, or attachment neutral).

Attachment-rich rewards

Negative behaviour is ignored or responded to in a calm way, attachment-neutral (instead of attention and attachment-rich)

Attachment-neutral discipline

Question 8

Why is it important to vary rewards, be intermittent, unpredictable, etc?

Answer 8

Eventually we want children to be self-driven. So we don’t want them to become reliant on the rewards. Sometimes praise, hugs, parental time, “lets have some special time together” or “lets go and get a special treat together”

Question 9

What consists of effective discipline?

Answer 9

1. Get their attention
2. Say what you don’t like - what not to do
3. Say what you want - what to do instead

E.g: go up to them, put your arm around them, “hey, don’t speak to me in that voice please, if you want something speak to me in a nice voice”

QUIET NINJA VOICE

Question 10

If they comply with discipline or don’t comply with discipline, what are the next steps?

Answer 10

Comply - go straight into reward mode - thank you for speaking to me in a nice voice - hugs, etc

Don’t comply - repeat again ONCE

Then - immediate effective consequence - time out or logical consequence. This is pre-decided upon with the child beforehand, can be given quickly without emotion

Question 11

What does time out consist of?

Answer 11

Time out from positive reinforcement

• no access to rewards they want
• quiet time
• separate room, safe, neutral, boring
• as soon as they calm down –> back to time in –> lots of love and fun and attention

Question 12

What are the main traps parents fall into when following this behaviour?

Answer 12

1. Parents often know what to do but have issues with performance due to emotions getting the better of them. Time out is full of emotion - “GO TO TIME OUT!”
2. Praise is calm and neutral - “that’s nice how you did that drawing”

Which bucket is full of more stuff? Time out. This is not helpful for changing behaviour.

Question 13

In adolescence what is added to treatment (considering parent training is increasingly more difficult)?

Answer 13

Emergence of cognitive resources means they can engage in therapy as well - meta-cognition, abstract reasoning, etc

Keep them busy and know what they’re doing - sport clubs, music, etc. You can still give them freedom in these frameworks.

Question 14

Why is it important to be formulation driven? And continue to hypothesis test?

(Clinician/researcher model)

Answer 14

Broader, family-type program might be necessary if it’s not working (marital problems, anger management, financial struggles, etc)

Question 15

What is the success rate and what contributes to poor treatment outcomes?

Answer 15

About 60%

uneducated, low SES, minority groups, younger parental age, parental mental disorders, high CU traits