Reference Work Entry

Handbook of Clinical Psychology Competencies

pp 1329-1350

Conduct Disorder and ODD

  • Ross W. GreeneAffiliated withHarvard Medical School

Abstract:

Social, emotional, and behavioral challenges in children are best understood through transactional models of development emphasizing factors associated with the child and environment and their reciprocal influences. Along these lines, conduct problems – often categorized as oppositional defiant disorder (ODD) and conduct disorder (CD) – can be conceived as the byproduct of incompatibility between child and environment, or what can be referred to as “child-environment incompatibility.” The goal of assessment is to understand these incompatibilities; the goal of intervention is to address them. Numerous models of psychosocial treatment have been applied to conduct problems, many of them evidence-based. However, the fact that conduct problems remain a significant public health issue suggests that greater innovation in thinking and intervention are needed. The primary focus of this article was Collaborative Problem Solving, an innovative, “hybrid” psychosocial treatment model. The CPS model combines elements of social learning theory, systems theory, and research in the neurosciences, and its effectiveness has been examined in families, schools, inpatient psychiatry units, residential facilities, and juvenile detention facilities. CPS is a challenging model to implement, and effectiveness of a clinician in doing so hinges on experience and supervised practice.

Abstract:

Social, emotional, and behavioral challenges in children are best understood through transactional models of development emphasizing factors associated with the child and environment and their reciprocal influences. Along these lines, conduct problems – often categorized as oppositional defiant disorder (ODD) and conduct disorder (CD) – can be conceived as the byproduct of incompatibility between child and environment, or what can be referred to as “child-environment incompatibility.” The goal of assessment is to understand these incompatibilities; the goal of intervention is to address them. Numerous models of psychosocial treatment have been applied to conduct problems, many of them evidence-based. However, the fact that conduct problems remain a significant public health issue suggests that greater innovation in thinking and intervention are needed. The primary focus of this article was Collaborative Problem Solving, an innovative, “hybrid” psychosocial treatment model. The CPS model combines elements of social learning theory, systems theory, and research in the neurosciences, and its effectiveness has been examined in families, schools, inpatient psychiatry units, residential facilities, and juvenile detention facilities. CPS is a challenging model to implement, and effectiveness of a clinician in doing so hinges on experience and supervised practice.

48.1 6.1 Overview

Oppositional defiant disorder (ODD) refers to a recurrent childhood pattern of developmentally inappropriate levels of negativistic, defiant, disobedient, and hostile behavior toward authority figures (APA, 1994). Specific behaviors associated with ODD include temper outbursts, persistent stubbornness, resistance to directions, unwillingness to compromise, give in, or negotiate with adults or peers, deliberate or persistent testing of limits, and verbal (and minor physical) aggression. These behaviors are almost always present at home and with individuals the child knows well (APA).

The following are considered associated features of ODD (APA, 2000). As developed in this chapter, these features may have even greater implications for assessment and treatment of ODD than the specific behaviors comprising the disorder:

In males, the disorder has been shown to be more prevalent among those who … have problematic temperaments (e.g., high reactivity, difficulty being soothed) or high motor activity. … there may be low self-esteem (or overly inflated self-esteem), mood lability, low frustration tolerance, swearing … and a vicious cycle in which the parent and child bring out the worst in each other. ODD is more prevalent in families … in which harsh, inconsistent, or neglectful child-rearing practices are common (pp. 100–102).

The essential feature of conduct disorder (CD) is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated (APA, 1994). These behaviors fall into four main groupings: aggressive conduct that causes physical harm to other people or animals; non-aggressive conduct that causes property loss or damage; deceitfulness or theft; and serious violations of rules. Youth meeting diagnostic criteria for CD may bully, threaten, or intimidate others, initiate frequent physical fights, use a weapon that can cause serious physical harm, be physically cruel to people or animals, steal, force someone into sexual activity, destroy others’ property, lie or break promises, break curfew, run away from home overnight, and skip school. The following are the associated features of CD (APA, 2000); not surprisingly, they overlap to some degree with the associated features of ODD:

Individuals with Conduct Disorder may have little empathy and little concern for the feelings, wishes, and well-being of others. Especially in ambiguous situations, aggressive individuals with this disorder often misperceive the intentions of others as more hostile and threatening than is the case and respond with aggression that they then feel is reasonable and justified. They may be callous and lack appropriate feelings of guilt or remorse. … self-esteem may be low. … poor frustration tolerance, irritability, temper outbursts, and recklessness are frequent associated features (ppm. 93–98).

Although the validity of the taxonomy for CD has been questioned (see Tremblay, 2003), two subtypes (childhood-onset and adolescent-onset) of the disorder are presently recognized, both occurring in a mild, moderate, or severe form (APA, 2000). Youth meeting criteria for the former have more disturbed peer relationships, exhibit more persistent CD behaviors, and are more likely to develop adult anti-social personality disorder than those meeting criteria for the latter.

Two thirds of children diagnosed with ODD do not subsequently develop CD (Hinshaw, 1994; Hinshaw, Lahey, & Hart, 1993; Lahey & Loeber, 1994). Yet, CD rarely occurs outside the presence of ODD (Frick et al., 1991; Greene et al, 2002; Hinshaw et al., 1993; Lahey, Loeber, Quay, Frick, & Grimm, 1992; Loeber, Green, Lahey, Christ, & Frick, 1992), and ODD has been shown to be a significant predictor of family dysfunction and social impairment even when a wide range of other psychiatric conditions – including CD – are controlled (Greene et al., 2002). Such findings suggest that the central feature of ODD – noncompliance – confers particular risk for more serious outcomes, perhaps especially because of how it has traditionally been conceptualized and the corresponding manner to which it has been responded.

48.2 6.2 Assessment of Symptoms and Maintenance Factors

Now would probably be a good time for the author of this chapter to disclose his general lack of enthusiasm for using diagnoses to describe youth with social, emotional, and behavioral challenges. Coming to a definitive conclusion regarding a diagnosis is not the goal of assessment, and for several reasons. Diagnoses cannot possibly reflect the complex combination of individual and environmental factors that set the stage for disadvantageous patterns of behavior, and often serve only to “pathologize” one element of the equation (in this case, the child or adolescent). Thus, saying that an individual “has ODD” or “has CD” is, as a practical clinical matter, fairly meaningless (the need to satisfy managed care reimbursement requirements notwithstanding). As is made clear in the ensuing pages, the term “child–environment incompatibility” would be preferable. Nonetheless, for ease of exposition and the sake of familiarity, the term “conduct problems” will be the primary descriptor for the remainder of the chapter. Yet, all too often, a diagnosis is used as the litmus test for determining treatment selection (in clinical settings), for establishing that a sample in a study was selected with sufficient rigor (in research settings), or for certifying that a child qualifies for additional services (in schools). In the case of the latter, an individual’s failure to meet diagnostic criteria for a specific psychiatric disorder carries the risk of the determination that the individual “has no problems” and therefore “has no need for additional services.” In this chapter, it will be assumed that if a child or an adolescent is exhibiting conduct problems, then there is most assuredly “a problem” and that the need for additional help is abundantly clear.

Before turning our attention to mechanisms of assessment, it might be a good idea to ponder what is it exactly, that we are trying to assess. The theoretical orientation of this chapter derives from research underscoring the reciprocal nature of interactions between parents and their difficult offspring (Anderson, Lytton, & Romney, 1986; Dumas & LaFreniere, 1993; Dumas, LaFreniere, & Serketich, 1995) and from models emphasizing transactional or reciprocal influences (Bell, 1968; Belsky, 1984; Chess & Thomas, 1984; Cicchetti & Lynch, 1993, 1995; Gottlieb, 1992; see Sameroff, 1975, 1995). These models posit that a child’s outcome is a function of the degree of “fit” or “compatibility” between the characteristics of the child (e.g., temperament, neuropsychological profile, activity level, ability to inhibit impulses) and the characteristics of his or her environment (e.g., adult caregivers, socioeconomic status, neighborhood). Studies on the reciprocal nature of interactions between children and adults have primarily focused on children and their parents, but the model can also be applied to lesser-studied interactions between children and other important adult caregivers, such as teachers (see Greene, 1995, 1996; Greene et al., 1997). A higher degree of compatibility between child and environment is thought to contribute to optimal outcomes, whereas a lesser degree of compatibility is thought to contribute to less advantageous outcomes. From this perspective, conduct problems can be understood as one of many possible expressions of child–environment incompatibility. Indeed, it is these incompatibilities that give rise to conduct problems and these very same incompatibilities, left untreated, that further fuel and exacerbate conduct problems once they are set in motion.

Yet, much research on conduct problems (and aggression) in youth has focused on “main effects” rather than on the transactional interplay between child and environmental characteristics. An impressive, indeed daunting, array of child and environmental characteristics has been identified as contributing to the development of conduct problems. And while one could roughly summarize these characteristics as follows – “conduct problems are usually caused by the combination of a lot of really bad things” – greater specificity might be useful.

As for child characteristics, sometimes the focus has been on comorbid diagnoses. We know, for example, that it is extremely rare for conduct problems to occur outside the context of other psychiatric disorders. A majority of youth with ODD and CD has comorbid ADHD (Abikoff & Klein, 1992; Greene et al., 2002; Hinshaw et al., 1993; Lahey & Loeber, 1994). Mood and anxiety disorders (Angold & Costello, 1993; Greene et al., 2002) and language processing disorders (Beitchman, Hood, & Inglis, 1989; Beitchman, Hood, Rochon, & Peterson, 1990; Baker & Cantwell, 1987; Greene et al., 2002; Moffitt & Lynam, 1994) are common comorbidities as well.

Sometimes the focus has instead been on dimensional constructs. So it is also known that conduct problems are associated with executive skill and other neuropsychological and cognitive deficits, aggression, difficulties in emotion regulation and temperament, lack of empathy, recklessness/novelty-seeking, and poor tolerance for frustration (see Lahey & Waldman, 2003, for an excellent review), along with obsessiveness and cognitive rigidity (Garland & Weiss, 1996; Budman, Bruun, Park, & Olson, 2000).

A similarly impressive list has been compiled for environmental factors, and includes pregnancy complications (such as viral infections or mother’s poor nutrition), delivery complications (such as hypoxia or lack of oxygen to the fetus during labor; see Brennan, Grekin, & Mednick, 2003, for a review), parents who are neglectful or harsh and inconsistent disciplinarians (Moffitt & Caspi, 2001), and low socioeconomic status (SES) (see Harnish, Dodge, & Valente, 1995; Kilgore, Snyder, & Lentz, 2000). Psychosocial and medical interventions applied in individual cases should also be considered important environmental factors, but are not typically taken into account by studies examining causes of conduct problems. Yet, these interventions have the potential to function (when they are effective) in a protective capacity or (when they are ineffective) to confer greater vulnerability.

So, while it might be tempting to simply engage in a mechanical process of counting risk factors to explain a child’s developmental progression to conduct problems, or to identify one or two factors that seem to exert the greatest impact (in other words, true “main effects”), such an endeavor would move us further away from the ultimate goal of assessment: to achieve an understanding of the incompatibilities between characteristics of a child and his or her environment and, based on this understanding, to pinpoint potential factors to be addressed by intervention.

In other words, it is good to know that a child or adolescent has or had difficult temperament, high motor activity, mood lability or irritability, low frustration tolerance, a lack of empathy or concern for the feelings, wishes, and well-being of others, and/or misperceptions of the intentions of others (known as cognitive distortions or cognitive biases). But it is worth noting that, taken independently, these characteristics do not usually lead to serious conduct problems. Thus, there must be some other dynamic at work: namely, how these characteristics influence and are influenced by characteristics of the environment (parents’ marital discord, parents’ harsh and inconsistent parenting practices, access to quality mental health care, interventions that were or were not effective) in ways that increase or decrease incompatibility and thereby heighten or reduce the likelihood of advantageous or disadvantageous outcomes.

Child–environment incompatibility can begin even before a child is born (for example, if the mother is exposing the fetus to substances that are not conducive to optimal development), but it is at the point at which it exceeds the “threshold of adversity” that conduct problems (and other disadvantageous outcomes) can be expected to emerge. The earlier the threshold of adversity is reached, the more disadvantageous the long-term outcome is likely to be. Of course, as noted by Lahey and Waldman (2003), even in youth whose conduct problems appear in adolescence, these problems do not “come (from) out of nowhere.” Early child–environment incompatibility may be manifested in many different ways, but it is the onset of chronic child noncompliance – again, the core feature of ODD – that is perhaps the clearest signal.

Let us consider briefly why this might be the case. As I have written elsewhere (e.g., Greene & Doyle, 1999; Greene, Ablon, & Goring, 2003), the skill of compliance – defined as the capacity to defer or delay one’s own goals in response to the imposed goals or standards of an authority figure – can be viewed as one of many developmental expressions of a young child’s evolving capacities for self-regulation and affective modulation (also see Amsel, 1990; Hoffman, 1975; Kochanska, 1995; Kopp, 1982; Stifter, Spinrad, & Braungart-Rieker, 1999). Demands for self-regulation and affective modulation begin at birth, and more sophisticated mechanisms for these skills develop as children mature, but most dramatically during the toddler years, when children learn to use language to label and communicate their thoughts and feelings, develop cognitive schemas related to cause-and-effect, and generate and internalize strategies aimed at facilitating advantageous interactions with the environment (Kopp, 1989; Mischel, 1983). But these skills do not develop independently of environmental influences and environmental influences typically do not occur in a vacuum. Compliance can therefore be viewed not only as a complex skill and as a critical milestone on the trajectory of emerging self-regulation and affective modulation in a child (Hoffman, 1983; Kochanska & Askan, 1995; Kopp, 1989), but also as a primary indicator of compatibility between a child and his or her environment.

Thus, true to our definition of assessment – to achieve an understanding of the incompatibilities between the characteristics of a child and his or her environment and, based on this understanding, to pinpoint potential factors to be addressed by intervention – assessment should examine any and all incompatibilities between child and environment, with an emphasis on (but not limited to) factors known to contribute to the development of conduct problems.

A variety of assessment instruments would be useful (and others perhaps less useful) in this endeavor. A situational analysis provides indispensable information about the conditions under which child–environment incompatibility occurs. In other words, with whom (mother, father, peers, sibling, teacher, soccer coach), when (when hanging out with peers outside of adult supervision, when asked to perform a difficult academic task, when truant from school), and where (at a peer’s apartment, in his own home, between classes at school, in math class, on the school bus) are conduct problems occurring? Be forewarned: often those upon whom the assessor is relying for assessment information may not be highly skilled at thinking about behavior in situational terms (they may be more naturally inclined to view behaviors as reflective of unvarying “traits”). Sometimes asking reporters to recount (in story form) situations in which conduct problems occurred can be a useful device. More fair warning: the stories are likely to begin with a description of the behaviors themselves (understandable, since the behaviors are usually the primary concern of the reporters) rather than a description of the conditions that preceded the behaviors (this information should be much more important to assessors). Thus, it is often necessary to ask reporters to “rewind the tape” so as to uncover the actual circumstances leading up to the problematic behavior, which are usually more complicated than originally presented.

In gathering information about the contexts and conditions under which conduct problems occur, assessors gather information about the characteristics of the child and environment contributing to incompatibility. In other words, embedded within every “incompatibility episode” are clues about the temperament, expectations, cognitive biases and distortions, belief systems, frustration tolerances, problem-solving skills, flexibility, and social skills of the interaction partners, and disciplinary practices of the adult caregivers. Such clues provide opportunities to gather much more detailed information in these domains.

In an effort to capture the above assessment information, I have developed a “discussion guide” (regrettably, it does look a bit like a checklist) called the Assessment of Lagging Skills and Unsolved Problems (ALSUP), which is comprised of a list of the skills found lagging in children with social, emotional, and behavioral challenges, as well as a list of the unsolved problems that commonly precipitate incompatibility episodes. Note that the ALSUP has not been developmentally normed, for it is intended to serve as a means of taking a highly individualized look at the lagging skills and unsolved problems relevant to a specific child rather than coming to conclusions about whether the child “has a problem” based on comparison to individuals of the same age, grade, or gender. In other words, if a child is having difficulty communicating his needs or concerns to those around him, and if this difficulty is contributing to incompatibility episodes, then there is most assuredly “a problem,” whether the child is a 2-year-old female or a 17-year-old male. The ALSUP is shown in Table 6.1.
Table 6.1

Assessment of lagging skills and unsolved problems

Assessment of lagging skills and unsolved problems (Rev. 12/5/08)

 

Child’s Name    Date

 

LAGGING SKILLS

 

Difficulty handling transitions, shifting from one mind-set or task to another (shifting cognitive set)

 

Difficulty doing things in a logical sequence or prescribed order

 

Difficulty persisting on challenging or tedious tasks

 

Poor sense of time

 

Difficulty reflecting on multiple thoughts or ideas simultaneously

 

Difficulty maintaining focus for goal-directed problem-solving

 

Difficulty considering the likely outcomes or consequences of actions (impulsive)

 

Difficulty considering a range of solutions to a problem

 

Difficulty expressing concerns, needs, or thoughts in words

 

Difficulty understanding what is being said

 

Difficulty managing emotional response to frustration so as to think rationally (separation of affect)

 

Chronic irritability and/or anxiety significantly impede capacity for problem-solving

 

Difficulty seeing the “grays”/concrete, literal, black-and-white, thinking

 

Difficulty deviating from rules, routine, original plan

 

Difficulty handling unpredictability, ambiguity, uncertainty, novelty

 

Difficulty shifting from original idea or solution/difficulty adapting to changes in plan or new rules

 

Difficulty taking into account situational factors that would suggest the need to adjust a plan of action

 

Inflexible, inaccurate interpretations/cognitive distortions or biases (e.g., “Everyone’s out to get me,”  “Nobody likes me,”  “You always blame me,”  “It’s not fair,”  “I’m stupid”)

 

Difficulty attending to or accurately interpreting social cues/poor perception of social nuances

 

Difficulty starting conversations, entering groups, connecting with people/lacks other basic social skills

 

Difficulty seeking attention in appropriate ways

 

Difficulty appreciating how his/her behavior is affecting other people

 

Difficulty empathizing with others, appreciating another person’s perspective or point-of-view

 

Difficulty appreciating how s/he is coming across or being perceived by others

 

UNSOLVED PROBLEMS

 

HOME

 

Waking up/getting out of bed in the morning

 

Completing morning routine/getting ready for school

 

Sensory hypersensitivities

 

Starting or completing homework or a particular academic task

 

Assessment of lagging skills and unsolved problems (Rev. 12/5/08)

 

UNSOLVED PROBLEMS (cont.)

 

Food quantities/choices/preferences/timing

 

Time spent in front of a screen (TV, video games, computer)

 

Going to/getting ready for bed at night

 

Boredom

 

Sibling interactions

 

Cleaning room/completing household chores

 

Taking medicine

 

Riding in car/wearing seatbelt

 

SCHOOL

 

Shifting from one specific task to another (specify)

 

Getting started on/completing class assignment (specify)

 

Interactions with a particular classmate/teacher (specify)

 

Behavior in hallway/at recess/in cafeteria/on school bus/waiting in line (specify)

 

Talking at appropriate times

 

Specific academic tasks/demands, e.g., writing assignments (specify)

 

Handling disappointment/losing at a game/not coming in first/not being first in line (specify)

 

OTHERS (list)

 

©Center for Collaborative Problem Solving, 2008

Because conduct problems do not occur in a vacuum, a developmental history is the mechanism through which information about all these domains can be placed in an historical context and a general sense can be obtained of duration of child–environment incompatibility. What was the child like as an infant? What were the subjective and overt responses of the adult caregivers? When did the caregivers first notice “behavior problems” in their child? What was their understanding of, and response to, these behavior problems? Were there any extenuating circumstances affecting the caregivers or family at the time behavior problems emerged or at any other point in the child’s development?

Along these lines, a school history will also be crucial. Anecdotally, children and adolescents whose conduct problems occur cross-situationally (i.e., at home and at school) tend to have a more difficult behavioral profile and tend to be more difficult to treat than children whose difficulties are confined to the home environment. Are conduct problems occurring at school? Under what conditions and with what interaction partners are these problems occurring? To what degree do “incompatibility episodes” coincide with particular academic demands, or in unstructured situations, or with certain peers or teachers? Is the child accessing the school discipline program, and to what degree has the program been effective (if, as is often the case, the child is accessing the school discipline program frequently, then the ineffectiveness of the program is probably self-evident)?

It will also be important to gather information about the treatment history of the child and key adult caregivers; as noted above, ineffective prior treatment can fuel alienation, hopelessness, and cynicism and can color an individual’s perspective on the prospects for current treatment and must be taken into account in formulating treatment plans (some of the most difficult-to-treat children have bounced from one treatment program to another, and have lost faith that the “system” will ever be helpful). What was the nature of the prior treatment? Individual therapy? Family therapy? Parent management training? Was the treatment effective or did it exacerbate or increase the frequency of incompatibility episodes? Why was it terminated? What does this tell us about the expectations of those involved and the degree to which they were able to participate in treatment and execute treatment recommendations? Have any diagnoses been rendered? How do the different interaction partners understand the meaning of the diagnoses? Has psychotropic medication ever been prescribed for any of the interaction partners? What were the target symptoms of the medication? Was the medication helpful?

Given the prior discussion as to cognitive factors contributing to the development of conduct problems, the assessor should also inquire about prior formal assessment that may have been conducted, both for the purposes of recommending such assessment (if it is needed) and for obtaining additional information about the general cognitive skills, executive skills, language processing skills, and other cognitive factors that may have bearing on interactions between a child and key people in his or her environment.

The behavior checklist is very common tool for assessing children, and many instruments are available for assessing conduct problems (see AACAP, 1997, 2007). While such “objective” instruments do provide an efficient overview of the problematic behaviors a child is exhibiting, there are important limitations to their use. They tend to focus on only one element of child–environment incompatibility (the child) and therefore tend to steer assessment in a direction that pathologizes children (rather than in the direction of examining incompatibilities between characteristics of a child and his environments). Thus, they tend to provide very little information about the expectations, biases, disciplinary practices, and other characteristics of the important adult caregivers doing the checking and how these characteristics influence, and are influenced by, characteristics of the child.

Another common assessment practice, perhaps especially in schools, is the “functional assessment,” which is based on the belief that a given behavior is “working” at (or serves the function of) getting a child something he wants (for example, attention) or enabling the child to escape or avoid something unpleasant, difficult, tedious, or uncomfortable (for example, homework). However, this definition of function tends to lead to interventions aimed at convincing a child that his behavior will not work (this is usually accomplished through use of punishment) or encouraging the performance of replacement behaviors that adults believe will work better (this is usually accomplished through use of incentives). Interestingly, such interventions are sometimes characterized as being reflective of transactional thinking, perhaps because they involve both interaction partners (the child, who is now on the receiving end of formal, imposed consequences, and the adults, who are now on the administering end). Yet, the logic of this form of intervention could well be called into question if the goal was to address the transactional processes known to contribute to the development of conduct problems.

Elsewhere (Greene, 2008), I have recommended a revised conceptualization of function, flowing from the following questions: If a child had the skills to go about getting, escaping, and avoiding in an adaptive fashion, then why is she or he going about getting, escaping, and avoiding in such a maladaptive fashion? The fact that the child is going about getting, escaping, and avoiding in a maladaptive fashion is evidence of the fact that she or he does not have the skills to go about getting, escaping, and avoiding in an adaptive fashion. As described below, this definition of function leads to interventions aimed at teaching skills and solving the problems that are giving rise to child–environment incompatibility in ways that are realistic and mutually satisfactory.

48.3 6.3 Evidence-Based Treatment Approaches

Diverse psychosocial treatment approaches have been applied to children’s conduct problems. Models known alternatively as “parent training” (PT) and “behavioral family therapy” have focused primarily on altering patterns of parental discipline that contribute to the development of oppositional behavior and problematic parent–child exchanges (McMahon & Wells, 1998). Skills typically taught to parents in such models include positive attending use of appropri-ate commands contingent attention and reinforcement and use of a time-out procedure (see McMahon & Wells). In general, research has documented the efficacy of these procedures (see Brestan & Eyberg, 1998, for a comprehensive review), and several intervention programs emanating from these models have been identified as either “well-established” (the Living with Children program [Patterson & Gullion, 1968] and videotape modeling parent training [Webster-Stratton, 1984, 1990, 1994]) or as “probably efficacious” (including parent–child interaction therapy [Eyberg, Boggs, & Algina, 1995]).

However, this same body of research has also documented various limitations of PT. First, parents receiving PT often do not fully comply with implementation or drop out of treatment altogether (e.g., Prinz & Miller, 1994), suggesting that this form of intervention may, in fact, not be well-matched to the needs and characteristics of many of those responsible for implementation. Most studies examining efficacy of PT have presented data only for those who remained in treatment rather than those who began treatment. Among those who remain in treatment, PT has been shown to produce statistically significant changes in oppositional behavior, but very few studies have reported clinically significant changes (Kazdin, 1997). Indeed, 30–40% of those children remaining in treatment continue to evidence behavior problems in the clinical range at follow-up (Webster-Stratton, 1990). Data have shown that a significant percentage of children – perhaps higher than 50% – are not functioning within the normal range when such treatment is completed (Dishion & Patterson, 1992). Finally, most studies examining efficacy of PT have not included clinically referred youth (Kazdin; Patterson & Chamberlain, 1994), and have typically failed to examine long-term treatment effects (Kazdin, 1993, 1997). In view of these limitations, it is reasonable to conclude the following about PT: (a) a meaningful percentage of children and parents do not derive substantial benefit from PT; and therefore (b) alternative treatments that more adequately address the needs of these children and parents must be developed and studied (Greene, 2005).

Alternative models of intervention have placed relatively greater emphasis on cognitive factors underlying ODD rather than on behavior per se (see Coie & Dodge, 1998; Crick & Dodge, 1996; Kendall, 1985; 1991; Kendall & MacDonald, 1993), and emanate from research highlighting the frustration and emotional arousal that often accompany externally imposed demands for compliance. As described above, a variety of factors may compromise a child’s skills in these domains, and these alternative models of intervention have focused on addressing the cognitive deficiencies and distortions of oppositional or aggressive children. Several such intervention models have been identified as “probably efficacious,” including problem-solving training (Kazdin, Esveldt-Dawson, French, & Unis, 1987; Kazdin, Siegel, & Bass, 1992), anger management programs (Feindler, 1990, 1991, 1995; Lochman, 1992; Loch-man, Burch, Curry, & Lampron, 1984; Lochman, Lampron, Gemmer, & Harris, 1987), and multisystemic therapy (Henggeler, Melton, & Smith, 1992).

A fairly recent addition to the array of evidence-based psychosocial treatment options for conduct problems is a model of care called Collaborative Problem Solving (CPS; Greene, 1998, 2001, 2005, 2008). The CPS model aims to help adults (1) conceptualize children’s social, emotional, and behavioral challenges as a byproduct of lagging cognitive skills and unsolved problems, in other words, as a form of developmental delay; (2) identify, in each child, the lagging skills underlying, and unsolved problems precipitating, incompatibility episodes; and (3) to begin using a collaborative approach to problem solving to address, in a realistic and mutually satisfactory manner, predictable, long-standing issues of disagreement so as to reduce the likelihood of incompatibility episodes and increase child–environment compatibility. Research has shown that the model is effective in both outpatient (Greene et al., 2004) and inpatient (Greene, Ablon, & Martin, 2006; Martin, Krieg, Esposito, Stubbe, & Cardona, 2008) settings. Because the mechanisms of change and basic competencies of clinicians in treating conduct problems differ across the different psychosocial treatment approaches, and because the CPS model is the expertise of the author, these mechanisms and competencies are discussed for the remainder of this chapter as they apply specifically to this model.

48.4 6.4 Mechanisms of Change Underlying the Intervention

From a transactional perspective, the goal of treatment is to improve child–environment compatibility. So, how can the CPS model be considered transactional if it primarily targets the lagging skills of the child? The answer: it could not, and the CPS model does not. So it might be instructive to distinguish between theory and good strategy. Adults who live or work with children with conduct problems are typically quite convinced that it is the “identified patient” (the child) who has “the problem.” Trying to dissuade adults from this perspective too quickly can cause them to precipitously abandon the therapeutic ship. While adult caretakers will doubtless need to be convinced of their role in incompatibility episodes, timing is everything. But let there be no doubt, the lagging skills listed on the ALSUP may be just as applicable to adults. Moreover, unsolved problems typically to involve two interaction partners, and the practice of collaboratively solving problems provides an opportunity for all interaction partners to participate in the problem-solving process and learn new skills.

This does not mean that all interaction partners must always receive direct treatment for child–environment incompatibility to be impacted. Some distinctly unidirectional interventions – pharmacotherapy being an obvious example – can have a significant impact on child–environment incompatibility, even though all of the interaction partners are not directly receiving treatment. For example, it is entirely possible that, by reducing a child’s hyperactivity and poor impulse control through use of stimulant medication, important elements setting the stage for child–environment incompatibility would be addressed and incompatibility episodes would be dramatically reduced. However, if it is also the case that adult caregivers have, for example, unrealistic academic and behavioral expectations or unrealistic notions about changes that will be achieved through administration of stimulant medication, then, even if a child had a positive response to the medication, child–environment incompatibility might not be sufficiently impacted and treatment would need to be expanded to factors unaffected by the initial intervention.

Let us consider in greater detail each of the three treatment components delineated in the last section, for each has implications for the mechanisms of change involved in the CPS model.
  1. 1.

    Conceptualize children’s social, emotional, and behavioral challenges as a byproduct of lagging cognitive skills and unsolved problems. For many adults, CPS involves a paradigm shift. Helping adults – parents, teachers, or staff in an inpatient, residential, or juvenile detention setting – understand how a child came to develop conduct problems so as to view the child through accurate, compassionate lenses, is an indispensable (and usually first) component of CPS treatment. This shift alone can have dramatic effects on adult–child interactions, but also sets the stage for subsequent intervention ingredients. Some adults do not readily abandon their pre-existing paradigms, and may need some evidence that the CPS model is going to improve their lives before they adjust their thinking.

    Parents often bring children and adolescents who are exhibiting conduct problems into treatment asking the question, “What should I do?” The first goal is to help parents shift, at least initially, to a different set of questions (“Why is my child acting this way and why is what seems to work with other children not working with this one?”), because it will be very difficult to answer the former without first considering the latter. In schools and treatment facilities, unidirectional explanations that imply intent (e.g., attention-seeking, manipulative, coercive, limit-testing, unmotivated), labels that imply fixed character (e.g., sociopath, psychopath, conduct disordered), and explanations that elevate some of the facts that are known about a child to “causal status” (“he was born addicted to cocaine,” “his parents are divorced,” “his mother’s crazy,” “his father’s in jail,” “you know what neighborhood he lives in,” “his brother’s the same way”) often color the perspectives of those responsible for intervention. Moreover, children who have evidenced conduct problems for many years often come with large “portfolios” filled with massive and overwhelming amounts of information, prior testing, and past treatment plans. In CPS, there are two important “filters” for sorting through this information: lagging skills and unsolved problems. While much of a child’s history is interesting as background information – typically providing countless sobering examples of child–environment incompatibility – the goal is to identify “actionable” information. The advantage of focusing on lagging skills and unsolved problems is that the skills can be taught and the problems solved; thus, these filters may be more likely to set the stage for productive, systematic intervention than focusing on past events about which the child, and those trying to help him, can do little to change.

     
  2. 2.

    Identify, in each child, the lagging skills underlying, and unsolved problems precipitating, incompatibility episodes. In CPS, treatment is highly individualized. Each child has a unique profile of lagging skills (in the parlance of CPS, lagging skills are the “why” of challenging behavior) and unsolved problems (the “who, what, where, and when” of challenging behavior), and it is crucial for the key adults who interact with a child to come to a consensus about his or her specific lagging skills and unsolved problems and, as part of this process, to establish priorities for what to begin working on first (because it will not be possible to “fix everything at once”). The ALSUP will be an important tool for these purposes. This process, and the consensus that emerges from it, propel CPS treatment into its next phase.

    Yet, this consensus can be particularly difficult to achieve in schools and treatment facilities, where communication can be challenging across classes and shifts and where, therefore, it can be extremely difficult to intervene in a cohesive, consistent manner in which the “left hand knows what the right hand is doing.” Of course, CPS is not the only model of treatment requiring good communication; any effective model of care has the same requirement. Thus, while the creation of mechanisms for effective communication is not an ingredient specific to the CPS model, it is typically an extremely important focal point when the model is being implemented.

    This treatment ingredient helps adults recognize that incompatibility episodes occur in the context of specific problems, and promotes the understanding that, if a problem can be solved, it will not precipitate challenging behavior any longer. Solved problems do not precipitate challenging behavior, only unsolved problems do.

     
  3. 3.

    Begin using a collaborative approach to problem solving to address, in a realistic and mutually satisfactory manner, predictable, longstanding issues of conflict or disagreement so as to reduce the likelihood of incompatibility episodes and increase child–environment compatibility. In most cases, this next phase involves working with children and their adult caretakers to solve the problems that are precipitating disadvantageous behavior. Adults are taught that the manner by which adults pursue unmet expectations and solve problems with a child is a major factor influencing the frequency and intensity of incompatibility episodes. Imposition of adult (in the parlance of CPS, this approach is referred to as “Plan A”) is one way to pursue unmet expectations and solve problems, but is also the most common precipitant of acute (but highly predictable) incompatibility episodes. Removing an expectation (known as “Plan C”) is effective at reducing tension between the child and the adult, but not effective at helping adults pursue unmet expectations. Collaborative Problem Solving (“Plan B”) is an effective way to pursue expectations without increasing the likelihood of incompatibility episodes while simultaneously training and practicing emotion regulation, frustration tolerance, problem solving, flexibility, and a host of other lagging skills (in both interaction partners). The three Plans can serve as useful “shorthand” for helping adults communicate and think about how they are approaching problems. The ultimate goal, of course, is to help adults reduce their use of Plan A (thereby reducing incompatibility episodes), set priorities (this is where Plan C comes in), and dramatically increase their use of Plan B so that problems are resolved in a realistic, mutually satisfactory, durable manner. This combination of ingredients sets the stage for new interaction patterns in which adult caregivers are imposing their will a lot less, collaboratively solving problems a lot more, communicating more effectively, and fighting less.

     

The key to the creation of these new patterns is to help adults and children solve problems proactively rather than emergently. Adult caregivers (and many children) are surprised to learn that most of the problems precipitating incompatibility episodes are actually highly predictable and can therefore be discussed in a planned manner. The reality is that Emergency Plan B tends to be far less productive than Proactive Plan B, the former being more of a crisis management tool and the latter a crisis prevention mind-set. The primary disadvantage of emergent Plan B is heat (as in “the heat of the moment”), which makes solving problems far more challenging. Incompatibility episodes are merely a signal that there is a problem that has not yet been solved (proactively). Upon reflection, it is almost always the case that the problems causing incompatibility episodes were already highly predictable.

Plan B consists of three ingredients. The first, historically referred to as the “empathy step,” involves having adult caregivers gather information from a child so as to achieve the clearest possible understanding of the child’s concern or perspective on a given problem. The second ingredient, known as the “define-the problem” step, involves having the adult be highly specific about his or her concern or perspective on the same problem. There are now two concerns (but no solutions, yet) that have been entered into consideration. The third ingredient, called the “invitation”, is where the adult and the child brainstorm solutions that will address the concerns of both parties.

Helping adult caregivers and the challenging children in their charge become proficient at these three ingredients is hard work. In outpatient work, an overview of the three ingredients is provided once the clinician has introduced the philosophical and theoretical underpinnings of the CPS model and a profile of lagging skills and unsolved problems has been established and priorities identified. Typically, treatment then continues with the clinician directly involved in the first few in-session Plan B discussions between parent(s) and child (focusing on items drawn from the list of unsolved problems), moves on with the parent(s) attempting Plan B in session, with guidance and feedback from the clinician, and continues with the parent(s) using Plan B outside of the clinical setting, with increasing independence and decreased reliance on the clinician for feedback. In schools and therapeutic facilities, it is equally important to begin with philosophical and theoretical underpinnings, but because the message is being delivered to many staff, unevenness in acceptance of the philosophy is to be expected. Thus, mechanisms must be in place to provide opportunities for staff to resolve philosophical differences and then to practice and receive feedback on their use of Plan B.

It is worth noting that the CPS approach differs from some other anger management and problem-solving training programs in its emphasis on helping adults and children develop the skills to resolve issues of disagreement collaboratively. I and others have argued that the equivocal effects of many interventions aimed at training cognitive skills to have likely been due, at least in part, to the manner in which such interventions were delivered (e.g., Greene & Barkley, 1996; Hinshaw, 1992). For example, in a majority of studies cognitive skills have been trained outside the settings where skills were actually to be performed. It has been suggested that training cognitive skills proximally to the setting(s) where, and the interactions partners with whom, new skills are to be performed might greatly enhance the maintenance and generalization of trained skills and would be more congruent with a transactional perspective (e.g., Greene & Doyle, 1999).

48.5 6.5 Basic Competencies of the Clinician

CPS is a process-oriented but directive form of psychosocial treatment drawing upon multiple lines of influence, including social learning theory, systems theory, and research in the neurosciences. Implementing CPS in an outpatient setting requires an array of skills, including: (a) the knowledge of the lagging skills setting the stage for challenging behavior; (b) the ability to transmit this knowledge to adult caregivers in a way that is persuasive but not dogmatic; (c) the ability to develop therapeutic alliances with adult caretakers and challenging kids so as to keep them engaged in the process (even when the going gets rough) and maintain a sense of realistic optimism; (d) the ability to empathize with each party about what they havee gone through and are going through (even when the child is not a willing participant in treatment) and deal effectively with each party’s misgivings and conceptions about this form of intervention; (e) the ability to take complex scenarios and reduce them to their basic ingredients: lagging skills and unsolved problems; (f) a capacity for neutrality, for it is not the role of the clinician to take sides or serve as judge and jury; (g) the ability to keep bringing participants back to the key themes of the intervention when they go astray, recognize when participants are having difficulty with key aspects of Plan B, and provide feedback and guidance on these aspects; (h) a sense of whether and when family members are able to converse directly with each other and the ability to prevent discussions from spinning out of control; (i) patience and persistence, because long-standing problems and conflictual patterns of interaction tend not to resolve quickly; (j) flexibility and creativity, because kids with conduct problems and their adult caretakers have been bumping up against inflexible systems for a very long time and have problems that often are not readily resolved through conventional solutions; and (k) energy, an “activist” mentality, and an understanding of how systems work, because the participants may well need someone to advocate on their behalf in a society where Plan A is still quite popular, especially as it relates to challenging kids.

Let us consider a few of these skills in greater detail, beginning with one aspect of item “d” (dealing effectively with misgiving and conceptions about the CPS model). It is quite common for adult caregivers – who have historically been relying heavily on consequences, have had only two options in their repertoires (Plan A and Plan C), and have therefore been engaged in the practice of “battle picking” – to conclude that Plan B is the equivalent of giving in to feel that they are relinquishing authority by using Plan B, and to believe that the CPS model involves dropping all adult expectations. The competent CPS clinician takes the time to inquire about these concerns and is skilled at helping caregivers talk about and move beyond them. Adults are pursuing expectations and “setting limits” with both Plan A and Plan B, and Plan B has significantly greater upside (and significantly less downside) than Plan A.

Let us think about item “f” (a capacity for neutrality) as well. As I have written elsewhere, this is one of the most important facets of the CPS model:

There is a temptation, in almost any form of therapy, to ally oneself with the “offended party.” Moreover, parents and children often come into therapy with the expectation that the therapist will be the arbiter of right and wrong. It is no accident that people have this mind-set, for (unfortunately) we live in an era where “winning” versus “losing” and rigid definitions of “right” versus “wrong” pervade many issues facing our society. Thus, when working with and their adult caretakers, the temptation can break in either direction, such that therapists can find themselves agreeing with the child when they feel that the adults are being unreasonable and agreeing with the adults when they feel that the child is being unreasonable.

In the CPS model, there are much more productive ways to insert oneself into a system than by taking sides. Indeed, it is actually counterproductive for the therapist to take sides. In succumbing to temptation, the therapist assumes the role of power broker. This is not an ideal role. If the therapist is busy meting out justice, when precisely do the parties learn to work things out with each other?

Indeed, the CPS model requires finely honed neutrality on the part of the therapist. The role of the therapist is to accurately represent both sides and to ensure that both concerns make it into the discussion. The best protection against taking sides is remaining focused on understanding and clarifying each person’s concerns (Greene & Ablon, 2006).

The competent CPS clinician adopts the stance that the concerns of both parties are legitimate and need to be addressed for a problem to be durably solved. Adults often find the clinician’s neutrality to be a bit disarming, as they may be accustomed to therapies (or general child-rearing trends in society) in which the goal is to give children the incentive to satisfy adult concerns. The adults are reassured that their concerns are legitimate and will be addressed through the process of collaboratively resolving problems. Kids tend to be receptive to finally having their concerns heard and legitimized, but have often had little practice at generating alternative solutions and contemplating the degree to which the solutions are mutually satisfactory. The clinician helps the child appreciate the legitimacy of the adult concerns (or at least take the adult concerns into account). The ultimate goal is to help kids and adults work toward mutually satisfactory solutions, and it is the child and the adults, rather than the therapist, who determine whether a proposed solution is indeed “mutually satisfactory.” A recurring point of emphasis along these lines is to help participants clearly distinguish between concerns and solutions.

Finally, a little more on item “g” (the ability to keep bringing participants back to the key themes of the intervention when they go astray, recognize when participants are having difficulty with key aspects of Plan B, and provide feedback and guidance on these aspects). There are some fairly typical ways in which participants struggle with the ingredients of Plan B. Adults tend to have an affinity for the emergent form Plan B, even if the clinician has expounded on the significant advantages of a more proactive approach to solving problems. The competent CPS clinician reminds participants that most unsolved problems are highly predictable, brings participants back to the list of unsolved problems generated early in treatment, provides opportunities (in sessions) for practicing Proactive Plan B, and monitors the continued effectiveness of solutions upon which they have agreed.

Adults also have a tendency to rush through the empathy step (a pattern I have referred to as “perfunctory empathy”) and often lack the ability to “drill” for greater specificity regarding a child’s concerns. Adults often fear that they are on the verge of capitulating if they should demonstrate a willingness to consider a child’s concerns (another misconception that would need to be addressed) or simply are not sure what to say in an effort to seek additional information. It is also quite common for adults to insert solutions (rather than concerns) into the define-the-problem step. This is often because adults are not exactly certain what their concerns are (this is often contrasted by their certainty over how a particular problem should be solved). The competent CPS clinician takes the time to help adults clarify their concerns. And many people new to Plan B struggle with the Invitation step because they have simply had very little practice at considering solutions that would address not only their own concerns but those of another person. The competent CPS clinician provides opportunities for such practice and, early on at least, potential ideas for realistic and mutually satisfactory solutions. Solutions that do not stand the test of time typically are not as realistic and mutually satisfactory as the interaction partners originally thought they were. And, in a majority of instances, the first solution seldom solves the problem durably; successful problem solving is an incremental process. The competent CPS clinician helps participants return to Plan B and formulate new solutions based on information gleaned from solutions that did not stand the test of time.

Implementation of CPS in schools and therapeutic facilities requires some additional skills, including: (a) knowledge of the politics of larger systems, an awareness of the need to understand the politics and hierarchy within each individual system prior to beginning training in CPS, and strategies for helping large systems bring people on board and deal effectively with the “politics of change”; (b) knowledge of the difficulties in communication inherent in large systems and of ways to help such systems establish optimal mechanisms for communication; and (c) recognition that things are likely to get worse before they get better.

Moreover, in such facilities, the individuals with whom (or situations in which) a child typically has difficulty in the outside world may not be readily accessible. This does not mean that Plan B cannot occur, but simply that staff may have to serve as the mouthpiece for those individuals. Fortunately, interactions and problems in restrictive facilities often imitate real life; the skills the children were lacking and problems they are having in the facility are the same as those that they were having in the “real world” (and that prompted their placement), so solving problems and teaching skills in the facility is not a pretense, it is the real deal.

CPS is not a passive model of intervention. Pre-existing belief systems and practices do not disappear quickly or easily. Adults have legitimate concerns about whether they will still be in control, whether they (and perhaps the children) will be safe, and whether chaos will ensue when one is implementing the CPS model. Fortunately, data from the studies cited earlier suggest that parents feel significantly more competent, set limits more effectively, and feel significantly better about their relationship with their child after CPS treatment. Conduct problems are significantly reduced in response to CPS; and, in restrictive facilities, use of chemical, physical, mechanical restraint and locked-door seclusion are significantly reduced (along with staff and patient injuries) when CPS is implemented.

Finally, the competent CPS clinician has an awareness of the potential benefits of pharmacologic intervention and of the factors such intervention can be effective in addressing. The target of medical intervention typically is not conduct problems or aggression per se, but rather the underlying or co-occurring factors – such as hyperactivity, poor impulse control, irritability, or emotional over-reactivity – with the intent of reducing oppositionality and aggression as associated symptoms (Connor & Steingard, 1996).

48.6 6.6 Expert Competencies of the Clinician

The primary factors setting the stage for expert status in CPS in a clinician are largely the same ones that set the stage for skilled application of the model in non-clinicians or with practically any other model: experience and supervised practice.

My experience is that many clinicians (and non-clinicians), on first learning about the CPS model, come to the fairly rapid conclusion that they are “already doing this” or that implementation will be fairly straightforward. As for the former, there is no question that CPS incorporates clinical ingredients that overlap with other models of care: empathy, relationship-building, talking, listening, clinical expertise, and so forth. However, as regards the latter, clinicians new to the model do tend to find it challenging in some characteristic ways: (a) maintaining neutrality while simultaneously protecting and strengthening therapeutic alliances; (b) being directive while simultaneously allowing the process of problem solving to unfold in individual cases; (c) spending too much time talking about the model in sessions and not enough time helping people practice; and (d) being enthusiastic about the model and eager for rapid acceptance and implementation while simultaneously appreciating that everyone has their own pace of change. It is also typical for clinicians new to the model to get pulled into dealing with the “hot” problem a family presents each week (rather than keeping track of unsolved problems and monitoring the degree to which they are durably solved), to focus primarily on Emergency Plan B (rather than Proactive Plan B), to struggle with kids who “won’t talk,” to become frustrated with parents and staff members who “just don’t get it,” to pontificate rather than clarify and validate concerns, or to become overwhelmed by the complexity of certain problems and personalities. Hearing or reading about these challenges is quite different than experiencing them first-hand. Let us consider a few of the above patterns in greater detail.

Among the many experiences that would move clinicians toward expert status is working with families in which it is clear that a child and an adult are not yet able to exchange ideas without a dramatic rise in hostilities. Under such circumstances, an important role for the therapist is that of mediator or conduit between the two parties, at least until the factions are better able to tolerate direct interactions:

The therapist explores possible solutions to conflicts between the two parties without the parties interacting directly with each other. Although this circumstance does not provide child and adult with any practice at directly talking things through, it does set the stage for some early successes with Plan B. Even when direct discussions are possible, the therapist is keeping a watchful eye on each family member’s capacity for remaining engaged without becoming emotionally overloaded and remaining sensitive to moments when one family member or another may need a break from the conversation …(when) there is the potential for all hell to break loose in the therapist’s office, the therapist is taking decisive action to prevent discussions from deteriorating past the point of no return, sometimes by interrupting, sometimes by asking someone to leave the office temporarily. There is nothing to be gained by watching a family discussion degenerate to the point that family members are at their worst. The therapist can gather relevant information about the factors setting the stage for deterioration well before the family hits the proverbial “brick wall” (Greene & Ablon, 2006).

Another essential experience is working with children who are having difficulty communicating their concerns; in other words, those who respond to inquiries about their concerns with either “I don’t know” or silence. The task for the clinician is to figure out what kind of “I don’t know” or silence it is. It turns out that silence and “I don’t know” could mean many different things. Some children simply do not have the communication skills to articulate their concerns (intervention would involve creating mechanisms for these skills to be trained). Some children have already forgotten the question (this is often evident from their facial expression). Some children really do not know what their concerns are, perhaps because they have never been asked (and therefore have never given the matter any thought). Plan B gives children the opportunity to give the matter some thought. Along these lines, some clinicians need to get comfortable with silence. For some clinicians, even some seasoned ones, silence is uncomfortable, and there is the strong temptation to fill the void with the sound of one’s own voice. Resisting this temptation not only facilitates the gathering of information, it also provides a crucial model for adult caregivers. If time to think does not accomplish the mission, the clinician would have an opportunity to model something else: hypothesis-testing and educated guessing. For some children, “I don’t know” or silence can be a sign that they do not yet trust the process, or the clinician, or that they fear there will be “hell to pay” when the session ends. Educated guessing would be helpful here as well; then, ways in which these concerns could be addressed can take place.

Finally – well, not really finally, but our last example – in some families, as well as in schools and other facilities, there are adults who dominate conversations, shoot down ideas, minimize the input of others, and prevent the free flow of ideas. There are other adults who are more passive and submissive and serve as spectators as the process of change unfolds. Handling these and other personality/communication patterns in an empathic, respectful, nonjudgmental, effective manner is a significant challenge, and one that tends to come more easily with experience.

Of course, experience is useful only if one is learning from it, and this typically requires supervised practice. As a relatively new model, opportunities for supervised practice are, at present, fairly limited. However, the author is working diligently to increase opportunities for such practice. Alas, it is, as of this writing, an unsolved problem, but not for long.

48.7 6.7 Transition from Basic Competence to Expert

Having now read of the author’s discomfort with diagnoses, then you probably will not be surprised to read that he is similarly uncomfortable with fixed designations such as “expert,” preferring instead to think in terms of levels of proficiency and comfort. The CPS model continues to evolve; presumably, clinicians practicing CPS do as well. So there are no formal criteria designating “expert” status in CPS, nor, at least at this point, any formal certification process.

But, as with any new skill, with experience and supervised practice clinicians implementing CPS become more comfortable and instinctive and less “mechanical” in their application of the model. They are still thinking and reflecting, but they are thinking and reflecting less about the formal, technical aspects of the model and more about how to tailor the model to a specific child, family, staff member, setting, or situation. Clinicians proficient in the model feel confident in their ability to handle the various bumps in the road that can occur during implementation, while relishing situations that will require a somewhat different tack than has been applied previously.

Here is a potentially useful analogy. The author of this chapter is an average athlete who had no experience in snow skiing until about 15 years ago. His spouse is a good athlete and has been skiing since childhood. The author has received some direct instruction in skiing and some supervised practice. He has gone skiing dozens of times in the past 15 years. Yet, when he is out on the slopes, he tends to stay on the easier trails and, if he does not think fairly continuously about what he is doing, has an outstanding likelihood of an embarrassing display. His spouse – who was interviewed for purposes of this chapter – thinks primarily about how much fun she is having when she is skiing; she tends to look at what is ahead only when she is skiing mogul courses and, even then, is in little danger of self-embarrassment or injury.

Transactional thinking is relevant here as well: a major determinant of treatment outcome is the degree to which intervention ingredients are well-matched to the needs and characteristics of individuals, or what could be referred to as “person–treatment compatibility”. While the CPS model is comprised of some specific ingredients, how it is presented and explained should differ depending on the specific needs of the individuals with whom a clinician is working.

Indeed, as I think on the matter, proficiency and comfort are constructs that tend to be model-specific. A different construct – effectiveness – is perhaps of greater importance. Effectiveness refers to the degree to which a clinician is actually improving lives, and presumably includes person variables that are not always trainable through experience and supervised practice. For example, there is an excellent chance that, no matter how much instruction and supervised practice the author receives in skiing, he may still never be highly skilled in the activity and at this point, he is attributing this unwelcome reality to advancing age.

48.8 6.8 Summary

Children and adolescents with conduct problems represent an enormous challenge, not only clinically but also societally. Their difficulties are best understood not through “main effects,” but rather through models of development emphasizing factors associated with the child and environment and their transactional influences. In this chapter, conduct problems were conceived as the byproduct of significant incompatibility between child and environment, or what was referred to as “child–environment incompatibility.” The goal of assessment is to understand these incompatibilities; the goal of intervention is to address them.

Numerous models of psychosocial treatment have been applied to conduct problems. The fact that conduct problems remain a significant public health issue suggests that greater innovation in thinking and intervention are needed. The primary focus of this article was a model called Collaborative Problem Solving, an innovative, “hybrid” psychosocial treatment. In many families, schools, and treatment facilities, this evidence-based model represents a significant departure from the traditional models of care. The CPS model combines elements of social learning theory, systems theory, and research in the neurosciences, and its effectiveness has been examined in families, schools, inpatient psychiatry units, residential facilities, and juvenile detention facilities. CPS is a challenging model to implement, and the effectiveness of a clinician in doing so hinges on experience and supervised practice.

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