Data-Based Clinical Decision Making in the Treatment of an Adolescent with Severe Conduct Problems.

Data-Based Clinical Decision Making in the Treatment of an Adolescent with Severe Conduct Problems. Abstract This case illustrates the contributions of continuous datamonitoring to clinical decision making in the treatment of an adolescentwith severe conduct problems. Treatment began with a comprehensive pointsystem that required the continual monitoring of a range of targetbehaviors. Beginning each session with a review of graphs of themonitored behaviors helped keep the sessions focused and rewarded theclient and his parents with visual feedback of their progress. Asubjective rating system was also implemented in which the client'sparents quantified their evaluations of his overall behavior on a dailybasis. This system enhanced the clients parents' sensitivity to therelationship between his observable ob��serv��a��ble?adj.1. Possible to observe: observable phenomena; an observable change in demeanor.See Synonyms at noticeable.2. behavior and their subjectiveevaluations of him. It also helped the therapists determine when thepoint system had reached the peak of its effectiveness and conclude thata familybased treatment approach was needed. As part of family-basedtreatment, a rating scale was developed that assisted the therapist s inconducting family problem-solving training and allowed for continuedevaluations of the family's progress in learning key skills. The antisocial antisocial/an��ti��so��cial/ (-so��sh'l)1. denoting behavior that violates the rights of others, societal mores, or the law.2. denoting the specific personality traits seen in antisocial personality disorder. behaviors comprising conduct disorders Conduct DisorderDefinitionConduct disorder (CD) is a behavioral and emotional disorder of childhood and adolescence. Children with conduct disorder act inappropriately, infringe on the rights of others, and violate the behavioral expectations of (e.g.,aggression, stealing, destruction of property, serious rule violations)pose a significant challenge for mental health professionals. Suchconduct problems account for some 30% to 50% of all child and adolescentmental health clinic referrals (Herbert, 1987). Left untreated, thesebehaviors remain stable over the course of development and predict anumber of poor adult outcomes, such as psychopathology psychopathology/psy��cho��pa��thol��o��gy/ (-pah-thol��ah-je)1. the branch of medicine dealing with the causes and processes of mental disorders.2. abnormal, maladaptive behavior or mental activity. and criminality(Loeber) 1982; Patterson, 1982). Given the prevalence and predictivepower The predictive power of a scientific theory refers to its ability to generate testable predictions. Theories with strong predictive power are highly valued, because the predictions can often encourage the falsification of the theory. of antisocial behaviors, it is sobering to find that treatmentattempts are most often unsuccessful (Kazdin, 1987). One of the morepromising available treatment approaches appears to be behavioralfamily-based interventions (Kazdin, 1987). Behavioral family-basedinterventions typically take the form of parent training and are basedon the assumption that parenting skills deficits (and sometimesexcesses) are implicated im��pli��cate?tr.v. im��pli��cat��ed, im��pli��cat��ing, im��pli��cates1. To involve or connect intimately or incriminatingly: evidence that implicates others in the plot.2. in the development and/or maintenance of thechild's conduct problems. Parents are given instruction in basicbehavioral principles (e.g., reinforcement reinforcement/re��in��force��ment/ (-in-fors��ment) in behavioral science, the presentation of a stimulus following a response that increases the frequency of subsequent responses, whether positive to desirable events, or , punishment) and procedures(e.g., differential reinforcement, time out, response cost), and taughthow to use these principles and procedures to decrease the rates ofantisocial behaviors and increase the rates of prosocial behaviorsexhibited by their child. Although parent training appears to be effective with youngchildren, much less is known about its efficacy with adolescents.Patterson and his colleagues offer one of the few parent-traininginterventions specifically adapted for use with adolescents (Forgatch& Patterson, 1989; Patterson & Forgatch, 1987). Specificadaptations include the parental monitoring of a wider range ofbehaviors, especially those that put the adolescent at increased riskfor further delinquency delinquencyCriminal behaviour carried out by a juvenile. Young males make up the bulk of the delinquent population (about 80% in the U.S.) in all countries in which the behaviour is reported. (e.g., curfew curfew[O.Fr.,=cover fire], originally a signal, such as the ringing of a bell, to damp the fire, extinguish all lights in the dwelling, and retire for the night. The custom originated as a precaution against fires and was common throughout Europe in the Middle Ages. violations), increased overallparental monitoring and supervision (e.g., knowing "who, where,what, when"), and increased involvement of the adolescent in thetreatment process (Patterson & Forgatch, 1987). The second phase ofthe intervention involves teaching the parents and adolescent new waysto deal with problem behaviors and conflict through the use of familyproblem solving problem solvingProcess involved in finding a solution to a problem. Many animals routinely solve problems of locomotion, food finding, and shelter through trial and error. and negotiation (Forgatch & Patterson, 1989). The present case study describes the application of the Pattersonand Forgatch intervention in the treatment of a 15 year-old maleexhibiting severe conduct problems. A single-subject design evaluationof this case can be found in Nangle, Carr-Nangle, & Hansen (1994).The purpose of the present paper is to illustrate' thecontributions of continuous data monitoring to our clinicaldecision-making. As will be illustrated by this case, the use of ongoingdata collection described by Hawkins & Mathews (1999) as "Level1" research is actually a fundamental aspect of the Patterson andForgatch intervention (Forgatch & Patterson, 1989; Patterson &Forgatch, 1987). Method Participant Eric was a 15 year-old, lower middle-class, white male referred toour university-based outpatient clinic for the treatment of severeconduct problems, such as aggression, threatening family members with aknife, and destruction of property. He met DSM-IV DSM-IVDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States. (American PsychiatricAssociation The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. ,, 1994) criteria for both Attention-Deficit/Hyperactivityand Conduct Disorders. Eric was referred to us by a graduate studenttherapist treating him for behavior problems (e.g., verbal and physicalabuse of teachers, fighting with peers) through our clinic's schoolconsultation program. Eric had a history of psychiatric psy��chi��at��ricadj.Of or relating to psychiatry.psychiatricadjective Pertaining to psychiatry, mental disorders hospitalizationsfor problems associated with extreme temper outbursts and aggression(ages 2 and 13), as well as six years of outpatient counseling precedingthis referral. Eric lived at home with his mother, stepfather step��fa��ther?n.The husband of one's mother and not one's natural father.stepfatherNouna man who has married one's mother after the death or divorce of one's fatherNoun 1. , and three siblings siblingsnpl (formal) → fr��res et s?urs mpl (de m��mes parents)(one biological, two half). He rarely mentioned his biological fatherand had no contact with him. Eric attended a public school in a suburbansetting where he was enrolled in the behavior-disorders program, but wasalso enrolled in two advanced classes and participated in wrestling andtrack (with the continued prompting and support of hisbehavior-disorders teacher). Setting Intervention began with weekly therapy sessions that were held atour university-based outpatient clinic and usually attended by Eric andhis mother. Repeated scheduling difficulties and sporadic sporadic/spo��rad��ic/ (spo-rad��ic) occurring singly; widely scattered; not epidemic or endemic. spo��rad��icor spo��rad��i��caladj.1. Occurring at irregular intervals.2. attendancesoon prompted us to move the intervention into the home setting. Thehome visits typically involved two therapists meeting with Eric, hisparents, and sometimes his siblings, for weekly 90-minute sessions,usually held at the family's dining room table. Initiation of thehome visits allowed for a more objective assessment of Eric'ssituation, improvements in "attendance,' and increasedinvolvement of family members, especially Eric's step-father. Thetherapists also maintained frequent contact with Eric'sbehavior-disorders teacher. Data Collection Three types of data were collected. First, as part of theintervention, Eric's parents were asked to collect frequency dataon a number of target behaviors. Second, Eric's parents were askedto complete daily subjective ratings evaluating his behavior. Third, aspart of the family problem-solving training, the therapists developed arating scale that was used to monitor the family's progress inlearning key skills. Target behaviors. A fundamental part of the Patterson and Forgatch(1987) intervention is teaching parents how to define and track targetbehaviors. Using this approach, we worked collaboratively with Eric andhis parents to generate a list of target behaviors and define themspecifically. We have found that such collaboration enhances complianceby both the parents and the adolescent. Eric's parents, like mostparents, initially described his behavior in very global, nonspecific nonspecific/non��spe��cif��ic/ (non?spi-sif��ik)1. not due to any single known cause.2. not directed against a particular agent, but rather having a general effect.nonspecific1. terms (e.g., "He is mean"). They were then asked to listexactly what Eric did, in terms of observable behaviors, that led themto use the global descriptors (e.g., "He hits his sister,""He curses See Unix curses. curses - A set of subroutines in Unix for handling navigation on a terminal screen using the cursor. "). As the result of this process, we generated and defined an initiallist of target behaviors that the parents wanted to see Eric engage inmore frequently (helping, sharing, saying nice things to someone) andless frequently (aggression, cursing, destruction of property).Throughout intervention, we continued to refine and add to the list oftarget behaviors. As suggested by Patterson and Forgatch (1987), weadded target behaviors that might put Eric at risk for furtherdelinquency, such as homework completion and curfew violations. Inaddition, inconsistencies between the parents' subjective ratingsand Eric's recorded behavior often resulted from his engagement inbehaviors not targeted. Therefore, we periodically added targetbehaviors, such as compliance with parental requests and Eric'sinsistent in��sis��tent?adj.1. Firm in asserting a demand or an opinion; unyielding.2. Demanding attention or a response: insistent hunger.3. pestering when he did not get his way ("hounding hound?n.1. a. A domestic dog of any of various breeds commonly used for hunting, characteristically having drooping ears, a short coat, and a deep resonant voice.b. A dog.2. ").The target behaviors were defined specifically in terms of observableresponses so that we could all agree on instances of their occurrence ornonoccurrence. E xample definitions follow: compliance: Eric engages in a behavior or ceases to engage in abehavior that has been specified in a request by his parents. Eric has10 seconds to engage in the requested behavior (or in a period of timespecified by the parents for requests that take longer to comply with,such as taking out the garbage). Failure to comply with the parentalrequest within the specified time period will result in the coding ofnoncompliance noncompliancefailure of the owner to follow instructions, particularly in administering medication as prescribed; a cause of a less than expected response to treatment.noncompliance. aggression: Eric engages in a physical act that would usuallyresult in injury or pain to another person or restrict their movement(e.g., holds sister's arm to keep her from moving). Frequency recording of behaviors. Eric's parents began tonotice and record occurrences of these target behaviors continuouslyacross the day and evening. As we expected, Eric's mother assumedmost of the responsibility for this. She constructed simple recordingforms (see Patterson & Forgatch, 1987) that were displayed on therefrigerator door and initiated the use of a golf-shot counter(Lindsley, 1968) to assist in the recording of high-rate behaviors, suchas compliance. Upon the occurrence of a target behavior, Eric'smother immediately recorded a hash mark on the recording form next tothe name of the response. Recording continued throughout theintervention. Although interobserver agreement was not assessed formally, we usedin-home session time to informally assess agreement on the use of thedefinitions and immediately discuss any disagreements. Eric was verydetail oriented o��ri��ent?n.1. Orient The countries of Asia, especially of eastern Asia.2. a. The luster characteristic of a pearl of high quality.b. A pearl having exceptional luster.3. and learned the operational definitions quickly. Thiswas helpful in that he served as an informal interobserver agreementchecker check��er?n.1. a. One, such as an inspector or examiner, that checks.b. One that receives items for temporary safekeeping or for shipment: a baggage checker.2. , but detrimental det��ri��men��tal?adj.Causing damage or harm; injurious.detri��men in that he would purposefully pur��pose��ful?adj.1. Having a purpose; intentional: a purposeful musician.2. Having or manifesting purpose; determined: entered the room with a purposeful look. engage inantisocial behaviors that did not technically meet the target behaviordefinitions. Subjective ratings by parents. Across the initial 20 weeks ofintervention, we noted a disturbing pattern in which Eric'sparents' verbal evaluations of his progress were often verynegative despite his continued improvement on targeted behaviors. Toquantify this pattern, we incorporated subjective ratings of Eric'sbehavior into the daily data collection. Eric's parents were askedto agree on a daily subjective rating of his behavior (on a 0 to 100scale with higher ratings indicative of better behavior). Eric was askedto subjectively rate his own behavior using the same scale. The parents were instructed to meet with Eric at the end of eachday to discuss the subjective ratings and any disagreements. Thisprocedure served to quantify the parents' satisfaction withEric's behavior, facilitate family communication, and help us todecide when we needed to modify the intervention. Family problem-solving skills assessment. After approximately 39weeks, family problem-solving training (Forgatch & Patterson, 1989)was added to the intervention. We devised the Family Problem-SolvingRating Scale (FPSRS; see Figure 1) to help us monitor the family'sprogress throughout problem-solving training. The FPSRS is comprised ofa checklist of each task-analyzed step in the family problem-solvingtraining process (e.g., problem definition, solution generation,solution evaluation and implementation). Use of the FPSRS helps thetherapist monitor progress during the session, provide immediatefeedback, and keep the session focused. Intervention The intervention described was carried out in three phases: (1)contingency management For use in management theory, see Contingency theory.Contingency Management is a type of treatment used in the mental health or substance abuse fields. (condition A) comprised primarily of a pointsystem; (2) resumption RESUMPTION. To reassume; to promise again; as, the resumption of payment of specie by the banks is general. It also signifies to take things back; as the government has resumed the possession of all the lands which have not been paid for according to the requisitions of the law, and the of treatment, following the brief termination ofservices by parents, comprised of a more comprehensive contingencymanagement (condition A') program; and (3) contingency managementcombined with family problem-solving training (condition A' + B). Contingency management (A). The foundation of the Patterson andForgatch (1987) intervention is teaching parents to notice and recordselected target behaviors (see previous section). Eric's parentswere also given instruction on how to set house rules, how to issueeffective commands, the importance of using positive reinforcement positive reinforcement,n a technique used to encourage a desirable behavior. Also calledpositive feedback, in which the patient or subject receives encouraging and favorable communication from another person. , howto set up a point system, how to use response cost and the assignment ofextra chores to decrease behavior, and how to negotiate behavioralcontracts. Subsequent to the baseline phase, Eric's parents were taughthow to implement basic behavior management behavior managementPsychology Any nonpharmacologic maneuver–eg contingency reinforcement–that is intended to correct behavioral problems in a child with a mental disorder–eg, ADHD. See Attention-deficit-hyperactivity syndrome. principles through the use ofa point system in which Eric earned points for engaging in targetedprosocial behaviors and lost points for engaging in targeted antisocialbehaviors. Eric and his parents negotiated weekly contracts outlining"menus" of specific rewards that he could earn for favorable fa��vor��a��ble?adj.1. Advantageous; helpful: favorable winds.2. Encouraging; propitious: a favorable diagnosis.3. daily performances on the point system (e.g., extra money, junk food junk foodn.Any of various prepackaged snack foods high in calories but low in nutritional value.junk food,staying up later than usual), as well as specific penalties for poorperformances (e.g., loss of television time, going to bed early). Ericcould "save" points for special privileges or rewards (e.g.,trips to the mall, opportunities to cook his favorite dishes, extramoney). Therapy sessions began with a review of Eric's performance onthe point system for that week. One therapist immediately plotted thedata on a series of working graphs done in pencil, while the othertherapist discussed the week with Eric and his parents. When theplotting was completed, the focus of discussion turned to a review ofthe graphs. Making the data the central focus of the session appeared toenhance compliance with data collection and assisted the therapists inkeeping the sessions on track (e.g., not shifting attention to eachweek's crisis). Contingency management (A'). Following a brief period of notreatment due to a temporary termination of services by Eric'sparents, we implemented a more comprehensive contingency managementintervention. Target behaviors were added to the existing system (e.g.,compliance, noncompliance, stealing, temper tantrums temper tantrumPediatrics A prolonged anger reaction in an infant or child, characterized by screaming, kicking, noisy and noisome behavior, or throwing him/her self on the ground to get his/her way from a parent/caretaker/warden. Cf Adult temper tantrum. ). In return for ourcontinued involvement with the case, Eric's stepfather agreed tomuch more involvement in the therapy sessions and interventionimplementation. In addition, the therapists also consulted with theparents on the use of behavioral procedures (e.g., reward, time out)with Eric's younger stepbrother step��broth��er?n.A son of one's stepparent.stepbrotherNouna son of one's stepmother or stepfatherNoun 1. and stepsister, whose behaviorswere also becoming somewhat problematic and stressful for the parents. Family problem-solving training. Because the data still did notshow satisfactory results, family problem-solving training (Forgatch& Patterson, 1989) was added to the intervention after session 39.Eric, his parents, and 13 year-old sister were given instruction onbasic problem-solving steps: problem identification and definition,solution generation, solution evaluation, agreeing on a solution, andevaluating the outcome of the implementation of the agreed upon Adj. 1. agreed upon - constituted or contracted by stipulation or agreement; "stipulatory obligations"stipulatorynoncontroversial, uncontroversial - not likely to arouse controversy solution. In addition, the family was given instruction on keycommunication skills (e.g., active listening Active listening is an intent to "listen for meaning", in which the listener checks with the speaker to see that a statement has been correctly heard and understood. The goal of active listening is to improve mutual understanding. ) and how to use behavioralcontracts to implement agreed upon solutions (Forgatch & Patterson,1989). Training consisted of weekly homework assignments and readingsfrom the Forgatch & Patterson (1989) text, as well as live modelingby the therapists and review of videotaped family problem-solvingsessions conducted by Eric's family. As the family acquired the problem-solving skills, they wereinstructed to notice and record issues that resulted in family conflicts(e.g., messy mess��y?adj. mess��i��er, mess��i��est1. Disorderly and dirty: a messy bedroom.2. Exhibiting or demonstrating carelessness: messy reasoning. bathroom, delegation of house chores) and hold weekly"family forums" in which they engaged in the familyproblem-solving steps in order to negotiate solutions to specificconflicts. Each solution was spelled out in a behavioral contract (seeForgatch & Patterson, 1989) signed by each family member and loggedin a notebook by Eric's mother. These contracts were periodicallyreviewed by the family to determine whether or not the solutions worked. Contingency Management (A) When the parents started collecting data, they reported anoticeable improvement in Eric's prosocial behavior. Eric'srate of prosocial behaviors (i.e., helping, sharing, saying nice things)increased steadily during the initial intervention phase from an averageof 52 per week during the first 10 weeks to 79 per week during the last10 weeks (see Figure 2). The rate of physical aggression (and parentalverbal reports of severity) decreased over 60% per week from baselineand leveled off throughout the A phase. As we expected, the parents' subjective ratings were quitevariable across the initial weeks (see Figures 2 and 3; sessions 21through 27) and did not seem to be related to the points that Eric hadearned. The parents often felt frustrated frus��trate?tr.v. frus��trat��ed, frus��trat��ing, frus��trates1. a. To prevent from accomplishing a purpose or fulfilling a desire; thwart: because Eric would engage ininappropriate behaviors not targeted by the point system (an issuediscussed earlier in the Data Collection section). Discussion of suchinstances led to continual adjustments to the point system.As a result, the parents' subjective ratings became lessvariable and were more in line with Eric's point system earnings. Despite improvements in Eric's behavior, his parents continuedto voice their frustration with him and the intervention. We wereparticularly concerned about the deteriorating de��te��ri��o��rate?v. de��te��ri��o��rat��ed, de��te��ri��o��rat��ing, de��te��ri��o��ratesv.tr.To diminish or impair in quality, character, or value: relationship between Ericand his stepfather. As noted earlier, the stepfather left most of theresponsibility for implementing the point system to Eric's mother.He typically came to session visibly upset with Eric and often voicedhis belief that Eric ruined an otherwise happy family. The familyeventually terminated treatment, a termination that proved to betemporary. Shortly after termination, Eric was hit by the stepfatherduring an argument that resulted from the stepfather's accusation A formal criminal charge against a person alleged to have committed an offense punishable by law, which is presented before a court or a magistrate having jurisdiction to inquire into the alleged crime. that Eric had stolen batteries from him. Eric was removed from the homefor a one-week period by Child Protective Services child protective servicesSociology A state or county agency that addresses issues of child abuse and neglect . Immediately afterthis incident, the family called to request that our services beresumed. Contingency Management (A') Eric responded well to the expanded point system (see Figures 2 and3). For example, his frequency of compliance with parental requestsincreased dramatically. His parents' subjective ratings were quitefavorable and consistent (see Figures 2 and 3). However, theparents' subjective ratings soon began to decline (sessions 37-39)and Eric's frequencies of prosocial behavior remained rather low(see Figure 2). As often happens in cases like this, Eric continued tobe the focus of the parents' negativity. The parents attributed a number of marital and sibling sibling/sib��ling/ (sib��ling) any of two or more offspring of the same parents; a brother or sister. sib��lingn. problems toEric's behavior. We considered the possibility that the parents,especially the stepfather, might be "using" complaints aboutEric to draw themselves closer together, since they had significantmarital problems. Contingency Management and Family Problem-Solving Training (A'+ B) In view of the increasing negative focus on Eric, we decided toshift the focus more to the family unit as a whole by adding familyproblem-solving training (Forgatch & Patterson, 1989) to the ongoingcontingency management intervention. The addition of familyproblem-solving skills training resulted in further improvements inEric's behavior. There were improvements in his rate of prosocialbehaviors (47 per week during A' to 85 per week during A' + B)and in his frequency of compliance (see Figures 2 and 3). With thecombined intervention in place, these gains were maintained for a periodof over two months. We were particularly pleased with the improvementsin the relationship between Eric and his stepfather, and theparents' reported satisfaction with treatment. Unfortunately,despite these gains, Eric befriended a delinquent delinquent1) adj. not paid in full amount or on time. 2) n. short for an underage violator of the law as in juvenile delinquent. DELINQUENT, civil law. He who has been guilty of some crime, offence or failure of duty. adolescent, which ledto increasing parental concern because he began missing curfew (sessions60-61; see Figures 2 and 3). Within weeks, Eric and his new friend werearrested for s etting fire to a barn. Eric was removed from the home bythe courts and services were continued within a residential treatmentfacility. Interestingly, according to according toprep.1. As stated or indicated by; on the authority of: according to historians.2. In keeping with: according to instructions.3. the verbal report of Eric'smother via follow-up telephone conversations, the family continued touse structured family discussions and contracting long after thetermination of the case. Discussion This case illustrates the advantages of the using continuous datacollection in clinical decision making. As part of the Patterson andForgatch (1987) intervention, parents must learn to notice and recordoccurrences of a range of specific target behaviors. Beginning eachsession with a review of the data in graphic form helped keep sessionsfocused, and rewarded the family's efforts with visual feedback ofprogress. The addition of subjective ratings enhanced the parents'sensitivity to the relationship between Eric's observable behaviorand their subjective evaluations of him, and helped us to see the limitsof the point system's effectiveness. The use of the FPSRS allowedus to structure our training sessions, monitor the family'sprogress, and provide immediate and precise feedback. Continuation ofdata collection allowed us to assess the added effects of the familyproblem-solving training on Eric's behavior. References American Psychiatric Association (1994). Diagnostic and statisticalmanual of mental disorders Diagnostic and Statistical Manual of Mental Disorders/Di��ag��nos��tic and Sta��tis��ti��cal Man��u��al of Men��tal Dis��or��ders/ (DSM) a categorical system of classification of mental disorders, published by the American Psychiatric Association, that delineates objective (4th ed.). Washington: Author. Forgatch, M., & Patterson, G. R. (1989). Parents andadolescents living together-part 2: Family problem-solving. Eugene, OR:Castalia Publishing. Hawkins, R. P., & Mathews, J. R. (199). 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Child and Family BehaviorTherapy behavior therapyor behavior modification,in psychology, treatment of human behavioral disorders through the reinforcement of acceptable behavior and suppression of undesirable behavior. , 16, 65-76. Patterson, C. R. (1982). Coercive co��er��cive?adj.Characterized by or inclined to coercion.co��ercive��ly adv. family process. Eugene, OR:Castalia Publishing. Patterson, G. R., & Forgatch, M. (198?). Parents andadolescents living together-part 1: The basics. Eugene, OR: CastaliaPublishing. [Graph omitted] [Graph omitted]