The 8th World Congress of Behaviour and Cognitive Therapies - June 22-25 2016
This was held at the huge Melbourne Convention-Exhibition Centre, and attended by thousands. Most of those active in establishing Behavioural and Cognitive -Behavioural Psychology in Australia were there, giving the welcome party the feel of an old school reunion. There was also a large number of well-known presenters from overseas, many of whom had offered workshops in the past to the AACBT, and were leaders in the field - possibly best known to the younger practitioners as the authors of textbooks and manualised therapies.
Arron Beck, the founding father of CBT, presented the opening address which was pre-recorded specifically for the conference and introduced by his daughter Judith Beck, given he is now much too old to travel, but not too old to make some insightful comments. He talked about his latest work, applying CBT principles when working with Schizophrenia and even Autism. He described CBT as reformulating the disorder by figuring out what negative symptoms develop based on specific toxic beliefs, which then need to be targeted with new experiences, thus modifying these same beliefs. He argued the need to get past the medical model and recreate a normal setting, providing natural experiences leading to some satisfaction and meaningfulness. He did not see it as a behaviour but as a connection with something in the past – activating old memories and returning them into their meaningful place. The reactivating of a sense of meaningfulness allows the ignoring of any unsatisfactory present state, such as depression. Beck was putting emphasis on emotional matters and commented on the need to teach the next generation of practitioners to understand emotions. For a moment I thought we were going down the path of psychoanalysis, but he was talking about activities and environment, and it shows just how far CBT has come over the years. Hearing him developing and redefining his theory, taking it to more complex levels after all those years was indeed uplifting, and indicated that our science is really a living entity – constantly evolving,
ISADD was represented by Emina and Emily from Perth, and Renee and Jura from Victoria. Emina presented a paper “Behavioural Strategies to Extinguish Undesirable Ritualistic Responses to a Specific Stimulus in a Four Year Old Boy with Autism”. This was a neat single subject study, the sort that made behavioural psychology a powerful tool of behaviour change. Renee, who is doing her PhD at Monash University, presented “Mindfulness, Stress and Well Being in Parents of Children with ASD”. This topic is an area we need to know more about, given the growing awareness that to achieve change in the child, techniques alone are not sufficient, as we first need to reach the parents and work with the total family. Given the stress ASD generates in families, this often requires counselling, and our counselling role has been growing steadily. ISADD can be very proud of the work of these two young psychologists.
In general, however, there was surprisingly little on Autism per se, but lots on managing behaviours and working with families. At least in the sessions I chose of the many concurrent sessions offered.
I will report on several that particularly impressed, as well as suggested strategies that could be very helpful to us.
There was a session comparing behavioural Parent Management Training (PMT) with the Collaborative Treatment approach, when dealing with children with Oppositional Defiance Disorder. Tom Ollendick was the first speaker. He commented that the Triple P (Positive Parenting Programs) have been successful, but working with the ‘negative temperament’ child raised parent stress and often ended in escalation. He saw Collaborative Treatment as more effective when dealing with youths with Oppositional Defiance Disorder. PMT is manualised and well support by data. Improving parenting skills leads to consistency and reinforcement, and strategies such as Time Out and response cost are only used as a last resort. CPS on the other hand is collaborative and seeks proactive solutions. Based on the work of Ross Green (2010) it places emphasis on the problem, collaboratively solving it, and trying to understand what is happening to the child. A sample group of youths with ODD were also high on both Anxiety and ADHD. With intervention Anxiety was reduced but ADHD was not.
Ross Green himself presented data from schools and juvenile detention centres where emphasis was placed on the problem, on collaborative solving and proactive solutions. Figuring out why and when behaviours are exhibited lets us see them as a child’s communication of difficulties experienced and a lack of skills to meet expectations. This allows solving them coactively and proactively in partnership between child and adult. He quoted data from 15 schools, which were having serious behavioural issues; large numbers of children were expelled and discipline included restraints, locks, and corporal punishment (Yes, it is still legal in 19 states of the USA!). Teachers were trained and used Collaborative Problem Solving and all improved; in three years there were significantly fewer suspensions and detentions. The claim was made that the ‘school to prison pipeline’ was being addressed. (It may shock some to find out that currently it is possible to predict imprisonment at ages of 3 & 4.) This Collaborative approach was introduced with a core group of workers in the Maine youth detention system, which reportedly was quite rough. In time this resulted in reduced injuries, reduced recidivism (from 65% - 15%) and hence 50 empty beds! ($120,000 per annum per bed). One of the two facilities was closed. Policy and procedures were revised.
Louise Redmond, of the University of Technology Sydney, presented a case study as an example. This was an adolescent with Autistic traits, language issues, ODD, Social Phobia and generalised Anxiety. Missing skill and expectations were mapped, lagging skills assessed followed by showing empathy and interest in talking to the adolescent (I’ve noticed….. what’s up?). This display of adult concerns was an invitation to brain storm solutions together.
Her colleague, Rachael Murrihy, noted a 24% attrition rate in parents after training in behaviour management strategies, indicating motivational conflicts, and asked what gets in the way? Anna Wallace, also from UTS, tried to answer this also noting that parent training did not work long term for 50% of parents and she suggested subgroups based on parenting style and a spectrum of responsiveness – demandingness, or authoritativeness – permissiveness. She postulated that the permissive parents find it difficult to shift to monitoring the child but are quite willing to mediate solutions, and for them CPS would suit more.
All this was very relevant to our work at ISADD, and it justifies the move towards a more collaborative approach which we have been taking. It also places a new meaning on our oft quoted “parents as partners”. It is important to see negative behaviours as an expression of skill deficit and remember that ASD is just that.
Tom Ollendick’s work continues to be relevant. He has pioneered using CBT to manage Anxiety in children, using comic booklets to assist communication. His invited address on Children’s Anxiety – Fears and Phobias was therefore a must to attend. He postulated that childhood anxiety leads to adult issues, and the early specific phobias we see in children are a gateway disorder. He indicated that parental overprotection was a major contributor. CBT was certainly more effective than placebo and 56% of children with anxiety improved; however, of those only 46% were symptom free in six years. So only about a third do well and that was not good enough. “The odds need to improve”. That is the challenge.
To date there have been no consistent predictors to identify those who will do well; primary anxiety, based on parent anxiety, was most severe but the process is not understood though cognitive change may be implicated. New directions are needed to manage phobias, and he outlined a few. Brief CBT, low intensity, picture, comics followed by some advice over 12 – 16 short sessions brought some improvement. Another option was a 45 minute Cognitive Behaviour analyses followed by a three hour session including catastrophic beliefs, graded exposure, and modelling to raise self efficacy (”I can do this”). This was more effective than just an educational approach and brought 80% relief. Interestingly, parent involvement tended to reduce the children’s self efficacy, and children gave comments like ”they made me do it”. He concluded that it was best to work with children directly away from parents (“in this case parents were a safety issue”). He also noted that fixing the phobias greatly reduced general anxiety.
More on the topic of working with families was a brilliant presentation by Mark Dadds, another pioneer who put Australia on the map for his work on behavioural family therapy. The small auditorium was crowded out, attesting to Mark’s reputation as a lively, entertaining, and above all informative presenter.
Mark emphasised rapid engagement as change had to be achieved in ten sessions; he listed four elements for success
1. A sound grasp of learning theory was needed to enable the therapist to adapt to individual cases; the sequence of events helps determine their effect on behaviour.
2. An attachment rich connection was needed, as demonstrated by modulation of speech, eye contact, closeness, touch, shared time, love, security, and rewards need to be attachment rich and synergistic. Be aware that children can be driven to elicit harmful parental attention. Discipline needs to be attachment neutral, using descriptive praise words. Script what to say when rewarding, and with Time Out if that is needed. Beware that emotions will impact on attachment. All the needed information for working with the family can be elicited with interview.
3. Attributions of self and other, giving meaning to the problem behaviour, where either internal causes are blamed for a behaviour, or external attributions. Statements like “he can’t help it” do not address the problems and there will be no progress; they can even lead to relapses, and CBT will not work. It is important to get them out on day one, with questions such as “what are your darkest thought about this child?”
4. Family structure: Parent systems vary, find the parenting team, engage and correct the problem. The parent team needs to work well - it is the executive parenting system. Disengaged parent will make it very difficult. Who is the team – they need to see it themselves. In some cases extended family and friends are involved, and parents may give way. Or dad may be gone with mum and child oriented to where some children end up parenting the parents.
I should also mention a number of papers on Triple P and its adaptation to adolescence and disabilities such as ASD and Epilepsy. They emphasised the challenge to parenting routines and beliefs by bringing in uncertainty, and thus a need to recreate some certainties, some rules. How do families reconstruct a life as near normal possible after an ASD diagnosis? After realising that what they have is what they have, dreams fade. This reality check in itself can be traumatic, and new reality, a new parent role, is needed. Certainly this gives food for thought as to how we need to organise parent support. To me, the reality was emphasised by case studies of families supporting children with Type 1 Diabetes and Acute Lymphoblastic Leukaemia, where the present moment becomes more actual than education and the future.
More on families: a paper on coercive family processes showed that many parents used persuading with threats, shaming, and punishing, creating a Coercive parenting cycle. This is an aversive experience which can lead to regression, mental health issues, and even altered brain development. Unfortunately it is common, with 43% of parents likely to give a single smack. Disability involves more emotional issues and thus tends to lead to more coercion. Of 367 parents (73% were parents of children with ASD), 80% shout or get angry with the child at least some of the time, and 50% admitted to making the child feel bad. Parents were often depressed and not confident in their parenting skills leading to poor relationships with their child. The Triple P Program or its version for disability, Stepping Stones, reduced the risks with skills improved in communication and positive encouragement of the child. Child behaviour also improved.
All in all the conference was a useful reminder that parent training and family support work is central to success, and CBT has a lot to offer families bringing up children with ASD. I was impressed by the fine tuning of working with families, and the need to adapt to parenting styles which seems critical to success. To me, the conference emphasised the need to move from manualised and prescriptive approaches to a more individualised approach, tailoring the intervention to the client while still using the basic elements of learning theory.
Jura Tender