Cognitive Behavioural Therapy: Oppositional Defiant Disorder
Evidence-Based Intervention for ODD- EDPS 674 Alicia Marchini, Sarah Juchnowski & Lindsay Birchall
Agenda ● ● ● ● ● ● ●
Description of the Intervention - Alicia Review of Research Basis - Alicia Overview of the Theoretical Basis - Sarah General Application - Lindsay Cognitive Change Tasks - Lindsay Behavioural Change Tasks - Sarah Critical Thought of Practical Application - Sarah & Lindsay
Description of the Intervention
Description of the Intervention -
CBT for child conduct problems was developed with the notion that children display disruptive behavior because of
(a) learned cognitive distortions (b) cognitive deficiencies (c) a related tendency to respond impulsively to both external and internal stimuli
Description of the Intervention Target Areas: - To reduce aggressive behaviour - To increase prosocial interactions - To correct the cognitive deficits, distortions and inaccurate self-perceptions - To reduce emotional outbursts, impulsivity, and explosiveness, and ultimately enabling the child to be more reflective and considerate of how best to respond
Description of the Intervention Age Range: -
Initially used with school-age children (5-13 years old)
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Adults
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More recently used with preschool children
Delivery Format & Accompanying Costs: -
One-on-One -
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between $120 and $250 for sessions that are 50 minutes or longer
Group -
between $120 and $170 for sessions that are hour to an hour and a half long
Description of the Intervention Training Requirements: The therapist must be adequately trained in... -
cognitive behavioural therapy
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cognitive restructuring
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various therapy techniques to explore personal issues that might be contributing to the child’s defiant behaviour
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communication skills
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problem solving skills
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emotional regulation and anger management
Review of Research Basis
Review of Research Basis -
Meta-analytic studies show medium to large effect sizes (between 0.47 and 0.90) for CBT for children with conduct problems
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CBT has proven to be more effective than comparison groups
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Typically, those who had CBT are more likely to be in the normal functioning range after the therapy compared to those in other conditions
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Limitation of Studies: Often relied solely on parent and teacher report
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Kendall and Braswell (1982): Compared CBT, behavioural treatment, and an attention control condition -
found that CBT and behavioural treatment were superior to the control condition and that CBT was slightly more effective
Review of Research Basis -
CBT leads to an increase in problem-solving skills and self-control, and a decrease in cognitive distortions and hostile attributions -
Hypothesized to cause the change in the child’s behaviour after the treatment is completed
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However, no studies have shown that these changes are completely accounted for by the CBT treatment
Review of Research Basis -
Children of older age (11-13 years old) and with greater cognitive ability are more likely to benefit from CBT than younger children (5-7 years old) and less cognitively developed children
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Child is less likely to respond to CBT if: -
s/he has a higher number of conduct disorder symptoms
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parent has higher levels of parenting stress, depression, or detrimental child-rearing practices
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the child lives in a single-parent home or is of low socio-economic status
Review of Research Basis -
No relationship between the length of the treatment and the therapeutic outcome for children with conduct problem
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One study found that a longer CBT program (18 sessions) was associated with significantly improved behaviour in comparison to a shorter version of the same program (12 sessions)
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Most of the approaches that are examined in studies are typically within a short time frame (8 and 10 weekly sessions) that are typically an hour long
Review of Research Basis -
No difference between the outcome of individual and group therapy formats of CBT and family therapy approaches -
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time and cost advantages of group treatment = might be favoured over individual treatment
Contradictory Evidence: Group treatment with children and adolescents with conduct problems may actually cause the problems to become worse
Review of Research Basis -
Many of the studies include children who are referred by teachers, parents, or peers, or have only mild, undiagnosed behaviour problems
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CBT for mild child conduct problems can work, but it has been argued that they don’t actually provide evidence that it does work with actual clients
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Suggested that the nature, severity, and number of behaviour problems of children who are in many of these studies are not significantly different from those seen in clinical samples
Review of Research Basis -
CBT has demonstrated beneficial effects with children from outpatient and inpatient clinical populations, who have multiple diagnoses and are from diverse ethnic and socioeconomic backgrounds, in various settings
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Positive effects were maintained up to a year after the treatment was completed
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This level of generality has not been proven with the many different kinds of CBT treatment approaches
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Evidence for long-term effects (> one year after treatment) is limited
Review of Research Basis -
Research supports the efficacy of CBT for children with conduct disorders
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Influences on CBT:
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child’s motivation
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adherence to treatment
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level of knowledge
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communication skills
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therapists’ warmth and likeability
Not yet clear which aspects of CBT are effective agents of change and which are not as effective
Overview of the Theoretical Basis
History Behaviourism: Precedes the 1900: Pavlov, Skinner, Little Albert. Focuses on current, emphasizes overt behaviour, treatment is objective, treatment is based on empirical research Cognitive: Derived from the limitations of behaviourism. Began to include thoughts, beliefs, assumptions, attitudes, memories and fantasies in to therapy. Bandura (1969) developed the social learning theory, connected our environment and consequences with cognitive processes. Albert Ellis (1950) derived from Rational Emotive Therapy, thoughts mediate our behaviour. CBT: Aaron Beck (1960) developed CBT incorporating both cognitive and behavioral components. Beck put great importance into one’s internal dialogue.
Rationale and Change Process Behaviourism: • Follows scientific method, • Belief that behaviour is observable, measurable and easily evaluated, • Talk is not valuable • Change comes through stimulus control and reinforcement Cognitive: • We make sense of our situations through thoughts, which affects how we behave and feel • Dysfunctional thinking causes dysfunctional behaviour • By identifying new ways of thinking • Change comes through analyzing, organizing and reframing thoughts
Cognitive Behavioural Therapy • • • • •
Combinations of Cognitive and Behavioural therapy Cognition, emotion, behaviour, and physiology all interact together with the environment By examining all these aspects you can in turn develop the best treatment plan CBT is dynamic and all-encompassing Many change tasks under CBT makes it the most popular and empirically researched mode of psychotherapy.
Application
Symptom Review ★ Angry/Irritable Mood ★ Argumentative/Defiant Behaviour ★ Vindictiveness ○ Developmentally inappropriate ○ Noncompliance, defiant and disruptive behaviours ○ Actively refusing to comply with adult requests and rules ○ Oppositionality-disobedient behaviours toward authority ○ Negativistic and hostile behaviours ○ Aggression (verbal threats and physical acts) ○ Excessive arguing with adults ○ Poor Emotional regulation ○ Deliberately trying to annoy others or upset others, or being easily annoyed by others ○ Blaming others for your mistakes ○ Being spiteful and seeking revenge ○ Swearing and using obscene language-saying mean or hateful things when upset ○ Property destruction (APA, 2013; Hamilton, 2008; Steiner & Remsing, 2007; webmed.com)
Implications of Symptoms ● ● ● ● ● ● ● ● ● ●
Individuals typically do not recognise symptoms in themselves ○ instead they justify their behaviours as a response to unreasonable circumstances or demands Significant disturbance in social, academic or occupational functioning Problematic relationships and interactions with others ○ Circular Causality of dysfunctional interactions Dysfunctional family interactions Difficulty making and keeping friends-peer rejection Difficulty at work with supervisors and authority figures Poor school work and performance - school dropout Antisocial behaviours Suicide, anxiety, depression, substance use Impulse control problems
(APA, 2013; Hamilton, 2008; Steiner & Remsing, 2007; webmed.com)
Etiology ● Single cause is unknown and unlikely ● Symptoms increase with age ● The gradual stacking of factors contributes to the development of ODD
Risk Factors: SES, culture, prenatal (smoking, toxin exposure, poor nutrition, neglect), familial cluster of disruptive behaviour disorders, unresponsive parenting practices, attachment related, parents likely to have similar difficulties with self-control, emotional regulation, mood stability, one parent diagnosed with psychiatric disorder, marital difficulties)
(Steiner & Remsing, 2007)
Early Intervention & Prevention ●
Early Intervention: the earlier the intervention process can begin, the more likely it is to succeed
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Possible prevention of more problematic behaviours and the typical progression of ODD (e.g. later developed CD)
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Early interventions can minimize the damage to relationships (e.g. child and family distress)
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More intensive treatment is necessary if the onset is early and the severity is great
(Steiner & Remsing, 2007; Baker & Scarth, 2002)
Individualized Intervention Plan ● Multiple change tasks within Cognitive and Behavioural Therapy ● Tasks should be chosen based on individual symptom presentation and individual capacities ● Plan should target all domains of dysfunction ● Skills should be as developmentally and age appropriate as they can be
(Steiner & Remsing, 2007)
Cognitive-Change Tasks Identifying and Testing Automatic Thoughts Decatastrophizing Reattribution Redefining Decentering Thought Stopping Distraction Three-column technique Maladaptive Assumptions
Cognitive Change Processes Awareness of client’s cognitive content or stream of thought in their reaction to an upsetting event View thoughts as hypothesis-rather than facts-so clients can recognize dysfunctional or irrational thought patterns Substitute accurate judgements for inaccurate judgements Gather feedback to inform clients of whether the changes they made have resulted in the desired outcome Self-Management/Problem-Solving/Awareness of Cognitive Schemas
(Tuscott, 2010, Wedding & Corsini, 2014)
CBT & ODD Focus on ● Communication ● Problem Solving Skills ● Impulse Control ● Anger Management Main Skills ● Problem Solving ● Cognitive Restructuring
★ Children often have cognitive skill gaps and cognitive distortions affecting these areas (Baker & Scarth, 2002)
Problem Solving ● May be collaborative: involving others who the challenging behaviour arise with (parents, peers, teachers) ● May be group: students presenting with similar symptoms and difficulties in similar areas ● May be individual (Bierman, Miller, & Stabb, 1987; Frey, Hirschstein, & Guzzo, 2000; Green et al., 2004, Linseisen, 2008)
Group Problem Solving:Second Step Second Step problem Solving Model 1. Identify the problem 2. Brainstorm solutions 3. Evaluate solutions by asking, “Is it safe? Is it fair? How might people feel? Will it work?” 4. Select, plan, and try the solution 5. Evaluate if the solution worked and what to do next
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Social Learning Theory & Modeling Ideal for practicing social problem solving in school settings Students practice problem solving model using hypothetical situations Role Plays, Dramas & Comedic scenes: offers emotional distance ○ Video clips ○ Puppets, character play (younger children) Ideal size 4-8 members Same sex membership is better 2x a week for 5 weeks: 50 min training sessions Use of contingency-based systems
(Bierman, Miller, & Stabb, 1987; Frey, Hirschstein, & Guzzo, 2000)
Group Problem Solving:Second Step ●
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Watch video clip ○ Characters demonstrating positive and negative behaviours Ask group questions/discussion ○ “What set the character off?” “What did you see happen?” “What were the consequences?” Identify details: voice tones, facial expressions, hand gestures, defensiveness, hostile posturing, angry eye contact Children with ODD often do not see all the consequences of their actions ○ especially with peer relationships ○ or issues of respect and trust
Group Problem Solving: Second Step Use group process to help in sticky situations For example: “What do you think we need to do about Joey’s behavior, guys?” “What do you think our choices are?” “If Joey continues to break Rule #2, our group can’t [pick something positive that is planned or a group reward that could be given]. I’m wondering how the group can help?” Give verbal praise to the suggestions that are beneficial, while trying to ignore or minimize the negative or threatening comments. (Linseisen, 2008, p.9)
Group Problem Solving: Second Step Use humor to defuse negative comments or actions “Well, Freddy, punching Joey in the face is an option. However, then, you would be in even more trouble with the group than Joey is. Great idea?”
(Linseisen, 2008, p.10)
Cognitive Restructuring Redefining a problem: can facilitate change when our conceptualization of the problem was preventing change ● Mobilize a patient who believes a problem is beyond their control ● Stating problems in terms of behaviours over which we have control ○ Can make a problem more concrete and specific ○ Stating problems in terms of the patient's behaviors
★ODD ●Individuals often attribute their problem to the actions of others - The problem is out of their control May teach individuals with ODD that the problem can be navigated if they redefine it-take accountability and responsibility for their behaviours (Truscott, 2010; Wedding and Corsini, 2014)
Cognitive Restructuring Automatic Thoughts ●Thoughts are accessible, powerful and habitual ●Gather data on specific thoughts ●Test validity and meaning through direct evidence and logical analysis ●Identify cognitive distortions ●May uncover logical inconsistencies, contradictions, errors in thinking
Thought Stopping ● ● ● ●
Part of Automatic Thought process Breaking a chain of thoughts that tend to escalate into distress, particularly anxiety Client identifies sequence of thoughts- then attends to those early in the process Anxiety or frustration provoking activity is undertaken, to practice interrupting the chain
(Truscott, 2010; Wedding and Corsini, 2014)
Cognitive Restructuring ★ODD ● Identifying thoughts that contribute to escalation. Breaking a chain of thoughts using thought stopping. Stop anger, frustration, anxiety that may escalate into aggressive or hostile behaviours. Building tolerance through practice. Pair with redefining the problem and taking responsibility for one’s actions.
Behavioural - Change Tasks Homework Hypothesis testing Exposure Therapy/Interventions Behavioural Rehearsal/Role Play Diversion Techniques Activity Scheduling Graded-Task Assignment Relaxation Based Interventions
Response Prevention Operant Strategies Social Skills Training Time-Out Successive Approximation (Shaping) Contingency Based (Token Economies) Modeling
Token Economy Systems Token Economy Systems (TES) • • •
Individualized programs in which the child receives tokens in return for appropriate behaviour. These tokens include a range of reinforcers (money, privileges, or objects) TES are among the most successful programs in applied psychology TES can help to improve academic and social skills, attention, speech, drug addiction, self-care, and disruptive behaviours
ODD • • • • • •
Typically used to increase compliance, disruptive behaviour and academic Contingent teacher praise or reprimands Token economy systems Response cost Time out from positive reinforcement Self-management
Relaxation Based Interventions Relaxation Interventions • Techniques include: breathing, refocusing attention, increasing body awareness, exercises, meditation, progressive muscle relaxation, visual imagery, and variations of these. ODD • Typically used to target anger and tantrum like behaviour • Decreases physiological arousal • Techniques include relaxation, distraction and self-instruction
Behavioural Change Processes
Reinforcement Prompting Stimulus Control Setting Events
Critical Thought: Practical Application
Age of Application Younger clients •
May need more concentration on behavioural techniques • Do not have as rich language • Developmentally Egocentric (trouble taking other’s perspectives) • Lack of insight
Older Clients • • •
May need more concentration on cognitive techniques Have more cognitive abilities for verbal techniques May not buy into behaviour techniques
Cognitive and Language Issues •
CBT assumes the client has strong understanding of language. Clients must be able to analyze and process their own thoughts to a certain extent for cognitive therapy to be affective.
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Links between behaviours and feelings are more easily recognized by individuals with higher IQs and verbal ability.
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CBT is feasible in some of these circumstances EX) for individuals with cognitive impairments with specific modifications. Such modifications may include: drawings, visuals, repetition, slowing down sessions, over teaching and an increase in explicit teaching.
Cultural Issues Aspects to consider: • Socio-economic status • Ethnic groups • Family dynamics
Lack of Insight Blame game • Do not hold themselves accountable • Blame others for their circumstance ex) They MADE me mad. • Believe their actions are warranted based on what they see as unrealistic expectations • Theory of mind difficulty • Often manipulative, quick to exploit others • Strong need to gain power, therefore power is the ultimate reinforcer
Co-Morbidities
(Hamilton, 2008; APA, 2013 p.466)
ODD is highly comorbid with other disorders: ● Attention-deficit/hyperactivity disorder (ADHD) ● Mood Disorders ○ Depression ○ Anxiety ● Conduct Disorder ● Substance use problems ● Specific Learning Disorders
★ Symptoms of ODD can be difficult to distinguish from other problems ★ Treating other mental health conditions may help improve ODD symptoms ★ It may be more difficult to treat ODD if these other conditions are not evaluated and treated appropriately (may worsen ODD symptoms) ★ CBT strategies should fit individual symptoms (e.g. impulse control, attention)
Non Compliance (Linseisen, 2008) ● ● ●
Interventions that increase compliance are imperative ○ lead to decreased disruptive behaviours “Bottom step on the ladder” Without compliance, motivation and willing participation you will not be able to work on helpful change tasks, no matter how evidence based they are
Considerations: ● ● ● ●
Children that are non compliant and oppositional may “sabotage” your efforts to help them If they are forced to engage in the intervention process, their participation will be low If they do not believe their behaviour is a problem, their participation will be low Children with ODD often crave and thrive on negativity and conflict ○ Oppositional behaviours may be reinforced by adult and peer attention, contributing to non-compliance
Compliance Building (Linseisen, 2008) ● ● ● ● ● ●
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Give commands and provide consequences effectively Delivery of requests using a firm but quiet tone of voice, using statement form (not question form) Requests should be specific and delivered within 3 ft of the student Establish eye contact before making requests Post 4 or 5 positively behaviourally stated rules for the student Teacher movement in the classroom provides more supervision in the classroom ○ promotes detection of problem behaviours earlier ○ Increased potential for rewarding positive behaviours more frequently Use of Mystery Motivators as positive reinforcers in the classroom Recognize and praise children for good behaviour
Relationship Building ●
Relationship building is imperative ○ Therapist must build an alliance with the child ○ Building a relationship with youth with ODD can take time and require great patience
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Often youth are disliked and disregarded by adults ○ Identified as “problematic” or “defiant” within the system The older the youth, the more challenging
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We need to meet youth where they are at ○ without pushing to make changes in their behaviour or to connect with the worker faster or more intimately than the youth can manage ○ By working with the youth at their own pace the worker can gain trust and promote security and stability in the relationship. After a relationship is established: work on skills (Linseisen, 2008; Steiner & Remsing, 2006)
Parent Participation Considerations: ● Parents of children with ODD may be contributing to the problem behaviours (parental mental health issues, dysfunctional family dynamics, substance use problems, inconsistent discipline, lack of supervision, harsh discipline, poor emotional regulation, neglect, abuse, etc.)
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Children with ODD are relentless and relationships with parents are strained Interventions should involve positive family interactions
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Adherence to recommendations may be low: consider CBT models including homework
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Parents will likely need ongoing supports to maintain their mental health: Counselling, Parent Training, support groups
(mayoclinic;Linseisen, 2008; Hamilton, 2008; Steiner & Remsing, 2006)
Parent Training Should Include: ● Mental Health provider experienced in treating ODD ● Parent-Child Interaction Therapy or Systemic Family Therapy ● Individual and Family Therapy ● Behaviour Modification Therapy ● Collaborative & Cognitive Problem Solving Training ● Social Skills Training ● Building Resiliency
(mayoclinic;Linseisen, 2008; Hamilton, 2008; Steiner & Remsing, 2006)
Possible Behavioural Parent Training Tasks ● ● ● ● ● ● ● ● ● ●
Recognize and praise positive behaviours Model positive behaviours Avoid power struggles Set limits and enforce consistent reasonable consequences Set up a routine Build in quality time together Work with your partner: ensure consistent and appropriate discipline procedures Enlist supports from teachers, coaches and other adults Be prepared for challenges early on: Extinction bursts Replace empty threats with clear, calm, concise instructions
(mayoclinic;Linseisen, 2008; Hamilton, 2008; Steiner & Remsing, 2006)
References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th. Arlington, VA: American Psychiatric Association; 2013:265-70. Baker, L., L. & Scarth, K. (2002). Cognitive Behavioural Approaches to Treating Children and Adolescents with Conduct Disorder, Children’s Mental Health Ontario, retrieved from: http://www.kidsmentalhealth.ca/documents/Cognitive_Behavioural_Conduct_Disorder.pdf Bierman, K. L., Miller, C. M., & Stabb, S. (1987). Improving the social behavior and peer acceptance of rejected boys: Effects of social skill training with instructions and prohibitions. Journal of Consulting and Clinical Psychology, 55, 194–200. Frey, K. S., Hirschstein, M/, K. & Guzzo, B. A. (2000) Second Step: Preventing Aggression by Promoting Social Competence, Journal of Emotional and Behavioral Disorders, 8(2): 102 - 112 Greene R. W. et al., (2004) Effectiveness of collaborative problem solving in affectively dysregulated children with oppositional-defiant disorder: initial findings. J Consult Clin Psychol, 72: 1157-1164
Hamilton, S. S. & Armando, J., (2008). Oppositional Defiant Disorder. American Family Physician, 78(7):861-866, 867868 Linseisen, T. (2008), Effective Interventions for Youth With Oppositional Defiant Disorder. In Franklin, C., Harris, M. B.& Allen-Meares, P. (Eds.), The School Practitioners Concise Companion the Mental Health (pp.1-15). Oxford University Press, Oxford Scholarship Online: April 2010. doi:10.1093/acprof:oso/9780195370584.001.0001
Maggin, D. M., Chafouleas, S. M., Goddard, K. M. & Johnson, A. H. (2011). A systematic evaluation of token economies as a classroom management tool for students with challenging behavior. Journal of School Psychology, 49:529-554. doi:10.1016/j.jsp.2011.05.001 mayoclinic.com. Oppositional Defiant Disorder, Retrieved from: http://www.mayoclinic.org/diseases-conditions/oppositional-defiant-disorder/basics/definition/con-20024559, retrieved
March 15th, 2015 Oppositional and Defiant Behavior in Children and Teens. (2014). In GoodTherapy.org. Retrieved March 2, 2015, from http://www.goodtherapy.org/therapy-for-oppositional-and-defiant-disorder.html#Therapy%20for%20Oppositional%20 Behavior
Scott, S. (2007). An update on interventions for conduct disorder. Advances in Psychiatric Treatment, 14(1), 61-70. doi: http://dx.doi.org/10.1192/apt.bp.106.002626 Steiner, H. & Remsing, L. (2007). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Oppositional Defiant Disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(1), 126-141. doi: 10.1097/01.chi.0000246060.62706.af Sütcü, S. T., Aydın, A., & Sorias, O. (2010). Effectiveness of a Cognitive Behavioral Group Therapy Program for Reducing Anger and Aggression in Adolescents. Turk Psikoloji Dergisi, 25(66), 68-72. Truscott, D. (2010). Becoming an effective psychotherapist: Adopting a theory of psychotherapy that’s right for you and your client. Washington, DC: American Psychological Association. Wedding, D. & Corsini, R. J. (2014). Current psychotherapies (10th ed.). Belmont, CA: Brooks/Cole. webmd.com. Oppositional Defiant Disorder, retrieved from: http://www.webmd.com/mental-health/oppositional-defiant-disorder, March 20, 2015
