family therapy concepts process and practice phần 7 potx

366 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS Belief Systems The coercive behaviour pattern just described is associated with problem- atic belief systems. Children come to expect that, if they persist with ag- gressive behaviour long enough, their parents will stop hassling them. Parents come to believe that, if they give in to their children’s aggression, they will leave them in peace. Two other sets of beliefs common in fami- lies where conduct problem are the main concern also deserve mention. Parents of children with conduct problems may treat them punitively because they attribute their children’s misbehaviour to negative inten- tions rather than to situational factors. That is, they may hold the belief that their children are intrinsically bad or deviant rather than seeing the misbehaviour as a transient response to a particular set of circumstances from a child who is intrinsically good. Children with conduct problems, probably because of their chronic ex- posure to punishment (albeit ineffective punishment) develop a belief that threatening social interactions are highly probable. Thus, they become bi- ased in the way they construe ambiguous social situations such that they are more likely to interpret these as threatening than benign. Because of this they are more likely to respond negatively to their parents, teachers and peers. Predisposing Factors A wide variety of developmental, contextual and constitutional factors may predispose parents and children to become involved in behaviour patterns and to develop belief systems that maintain conduct problems. These include early parent–child relationship factors; characteristics of the child and the parent; characteristics of the marriage and the family; and features of the school, peer group and wider community. Early Parent–Child Relationship Factors Abuse, neglect and lack of opportunities to develop secure attachments are important aspects of the parent–child relationship that place young- sters at risk for developing conduct disorder. Disruption of primary attachments through neglect or abuse may prevent children from devel- oping internal working models for secure attachments. Without such in- ternal working models, the development of prosocial relationships and behaviour is problematic. With abuse, children may imitate their parent’s behaviour by bullying other children or sexually assaulting them. Child Factors Youngsters wit h diffi cult temperaments and attention or overactivity problems are at particular risk for developing conduct disorder because CONDUCT PROBLEMS 367 they have diffi culty regulating their strong negative emotions and so re- quire very consistent and fi rm parenting coupled with warmth to help them sooth their negative mood states. Providing this type of parenting would be a challenge even for a resourceful and well-supported parent. Parental Factors Youngsters who come from families where parents are involved in crimi- nal activity, have psychological problems, who abuse alcohol, or who have limited information about child development are at risk for developing con- duct problems. Parents involved in crime may provide deviant role mod- els for children to imitate. Psychological diffi culties, such as depression or borderline personality disorder, alcohol abuse, inaccurate knowledge about child development and management of misconduct, may constrain parents from consistently supporting and disciplining their children. Marital Factors Marital problems contribute to the development of conduct problems in a number of ways. First, parents experiencing marital confl ict or parents who are separated may have diffi culty agreeing on rules of conduct and how these should be implemented. This may lead to inconsistent disci- plinary practices and triangulation of the child. Second, children exposed to marital violence may imitate this in their relationships with others and display violent behaviour towards family, peers and teachers. Third, par- ents experiencing marital discord may displace anger towards each other onto the child in the form of harsh discipline, physical or sexual abuse. This in turn may lead the child, through the process of imitation, to treat others in similar ways. Fourth, where children are exposed to parental confl ict or violence, they experience a range of negative emotions, includ- ing fear that their safety and security will be threatened, anger that their parents are jeopardising their safety and security, sadness that they can- not live in a happy family, and confl ict concerning their feelings of both anger towards and attachment to both parents. These negative emotions may fi nd expression in antisocial conduct problems. Fifth, where parents are separated and living alone, they may fi nd that the demands of social- ising their child through consistent discipline in addition to managing other domestic and occupational responsibilities alone, exceeds their per- sonal resources. They may, as a result of emotional exhaustion, discipline inconsistently and become involved in coercive problem-maintaining pat- terns of interaction with their children. Family Disorganisation Factors Factors that characterise the overall organisation of the family may predis- pose youngsters to developing conduct problems. Middleborn children, 368 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS with deviant older siblings in large, poorly organised families, are at par- ticular risk for developing conduct disorder. Such youngsters are given no opportunity to be the sole focus of their parents’ attachments and at- tempts to socialise them. They also have the unfortunate opportunity to imitate the deviant behaviour of their older siblings. Overall family disor- ganisation with chaotic rules, roles and routines; unclear communication and limited emotional engagement between family members provides a poor context for learning prosocial behaviour, and it is therefore not sur- prising that these, too, are risk factors for the development of conduct problems. School-based Factors A number of educational factors, including the child’s ability and achievement profi le and the organisation of the school learning environ- ment, may maintain conduct problems (Rutter, Maughan, Mortimore & Ouston, 1979). In some cases, youngsters with conduct problems truant from school, pay little attention to their studies and so develop achieve- ment problems. In others, they have limited general abilities or specifi c learning diffi culties and so cannot benefi t from routine teaching prac- tices. In either case, poor attainment, may lead to frustration and dis- enchantment with academic work and this fi nds expression in conduct problems, which in turn compromise academic performance and future employment prospects. Schools that are not organised to cope with attainment problems and conduct problems may maintain these diffi culties. Routinely excluding or expelling such children from school allows youngsters to learn that if they engage in misconduct, then all expectations that they should con- form to social rules will be withdrawn. Where schools do not have a pol- icy of working cooperatively with parents to manage conduct diffi culties, confl ict may arise between teachers and parents that maintains the child’s conduct problems through a process of triangulation. Typically the parent sides with the child against the school and the child’s conduct problems are reinforced. The child learns that if he misbehaves, and teachers object to this, then his parents will defend him. These problems are more likely to happen where there is a poor over- all school environment. Such schools are poorly physically resourced and poorly staffed so that they do not have remedial tutors to help youngsters with specifi c learning diffi culties. There are a lack of consistent expecta- tions for academic performance and good conduct. There may also be a lack of consistent expectations for pupils to participate in non-academic school events such as sports, drama or the organisation of the school. There is typically a limited contact with teachers. When such contact oc- curs there is lack of praise-based motivation from teachers and a lack of interest in pupils developing their own personal strengths. CONDUCT PROBLEMS 369 Peer-group Factors Non-deviant peers tend to reject youngsters with conduct problems and label them as bullies, forcing them into deviant peer groups. Within devi- ant peer groups, antisocial behaviour is modelled and reinforced. Community Based Factors Social disadvantage, low socioeconomic status, poverty, crowding and social isolation are broader social factors that predispose youngsters to developing conduct problems. These factors may increase the risk of con- duct problems in a variety of ways. Low socioeconomic status and poverty put parents in a position where they have few resources on which to draw in providing materially for the family’s needs and this in turn may increase the stress experienced by both parents and children. Coping with material stresses may com- promise parents’ capacity to nurture and discipline their children in a tolerant manner. The meaning attributed to living in circumstances characterised by low socioeconomic status, poverty, crowding and social isolation is a sec- ond way that these factors may contribute to the development of conduct problems. The media in our society glorify wealth and the material ben- efi ts associated with it. The implication is that to be poor is to be worth- less. Families living in poverty may experience frustration in response to this message. This frustration may fi nd expression in violent antisocial conduct or in theft as a means to achieve the material goals glorifi ed by the media. Stressful Life Events and Lifecycle Transitions Conduct problems may have a clearly identifi ed starting point associated with the occurrence of a particular precipitating lifecycle transition or stress, or they may have an insidious onset where a narrow pattern of normal defi ance and disobedience mushrooms into a full-blown conduct disorder. This latter course is associated with an entrenched pattern of ineffective coercive parenting, which usually occurs within the context of a highly disorganised family. Major stressful life events, particularly changes in the child’s social net- work, can precipitate the onset of a major conduct problem through their effects on both children and parents. Where youngsters construe the stress- ful event as a threat to safety or security, then conduct problems may occur as a retaliative or restorative action. For example, if a family move to a new neighbourhood this may be construed as a threat to the child’s security. The child’s running away may be an attempt to restore the security that has been lost by returning to the old peer group. Where parents fi nd that life 370 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS stresses, such as fi nancial problems, drain their psychological resources, then they may have insuffi cient energy to consistently deal with their chil- dren’s misconduct and so may inadvertently become involved in coercive patters of interaction that reinforce the youngster’s conduct problems. The transition to adolescence may precipitate the development of con- duct problems largely through entry into deviant peer groups and asso- ciated deviant recreational activities, such as drug abuse or theft. With the increasing independence of adolescence, the youngster has a wider variety of peer-group options from which to choose, some of which are involved in deviant antisocial activities. Where youngsters already have developed some conduct problems in childhood, and have been rejected by non-deviant peers, they may seek out a deviant peer group with which to identify and within which to perform antisocial activities, such as theft or vandalism. Where youngsters, who have few pre-adolescent conduct problems, want to be accepted into a deviant peer group they may conform to the social pressure within the group to engage in antisocial activity. Outcome Children who become involved in coercive family processes with their parents by middle childhood develop an aggressive relational style which leads to rejection by non-deviant peers. Such children, who often have specifi c learning diffi culties, typically develop confl ictual relationships with teachers and consequent attainment problems. In adolescence, rejec- tion by non-deviant peers and academic failure make socialising with a deviant delinquent peer group an attractive option. Conduct problems are the single most costly child-focused problem (Kazdin, 1995). For more than half of all children with conduct problems, the delinquency of adolescence is a staging post on the route to adult antisocial personality disorder, criminality, drug abuse and confl ictual, violent and unstable marital and parental roles, and progeny with con- duct problems (Burke et al., 2002; Farrington, 1995; Kazdin, 1995; Loeber et al., 2000; Rutter et al., 1998). The greater the number of systemic risk factors mentioned in the preceding sections, the poorer the prognosis. In addition, youngsters who fi rst show conduct problems in early childhood and who frequently engage in many different types of serious misconduct in a wide variety of social contexts including the home, the school and the community have a particularly poor the prognosis. Protective Factors For conduct problems, protective factors within the family system include positive parent–child and marital relationships, and good communica- tion and problem-solving skills. For children, an easy temperament and CONDUCT PROBLEMS 371 the capacity to make and maintain new friendships are important per- sonal protective factors. A supportive and well-resourced educational placement that can deal fl exibly with youngsters’ special needs, such as learning diffi culties or school-based conduct problems, may be seen as protective educational factors. A non-deviant support network and pro- social role model are important peer group protective factors. Low stress and a high level of social support within the extended family and social network are protective factors also. Good interprofessional and inter- agency communication and coordination is a protective factor insofar as it may lead to a more positive response to treatment. FAMILY THERAPY FOR CONDUCT PROBLEMS For pre-adolescent conduct problems, parent training, where parents are coached to use reward systems and behavioural control programmes, has been shown in many studies to be a particularly effective treatment (Behan & Carr, 2000). For adolescent conduct problems, the results of em- pirical studies show that functional family therapy, multisystemic family therapy, and combining family therapy with temporary treatment foster care are the most effective available treatments (Brosnan & Carr, 2000). The specifi c guidelines for clinical practice when working with youngsters with conduct problems using these approaches outlined in the remainder of this chapter should be followed within the context of the general guide- lines for family therapy practice given in Chapters 7, 8 and 9. Contracting for Assessment Contracting for assessment with families containing a pre-adolescent with home-based conduct problems is relatively straightforward, since it is commonly the parents who are the customers for change. It is suffi cient in such instances for the parents and child to attend the initial contract- ing session. In some instances, the school is the main customer, and the parents have been advised to secure counselling for their child or the child will either be excluded from school or not permitted to return if the child has already been excluded. In these instances, a representative of the school, the parents and the child may be invited to the contracting meeting. In cases where an adolescent has been involved in serious acts of delinquency and has been placed in care because he is beyond the control of his parents, contracting is a more complex process. In such cases, in the contracting meeting it is important to include the referring agent, a statu- tory professional from the child protection or juvenile justice agency since these are potential agents of social control representing the state; foster parents or childcare workers from the youngsters temporary care place- ment; the parents; and the child. 372 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS Within the contracting meeting, the therapist invites the main custom- ers to outline what the main conduct problems are that need to be resolved and why they think family therapy is necessary. The possible positive out- comes of family therapy deserve discussion and these may be framed in different ways depending on the customer and the context of the referral. With cases where the parents are the customer, the parents and child may fi nd it useful to see family therapy as a way of helping everyone in the family to get along better. Where the school is the main customer, family therapy may be offered in cooperation with school staff to prevent a child from being excluded from school or to enable an excluded child to return. Where a statutory child protection or juvenile justice agency is the cus- tomer and the child is in temporary care, family therapy, when conducted in cooperation with the statutory agency, may provide an avenue for the child to be reunited with the family. The more complex the case, the more likely it will be that contracting may take a couple of sessions. If families cannot reach a decision about whether to make a contract or not, then it is preferable to invite them to take a week to think about it and come back and discuss it again. Proceed- ing to conduct a family assessment without a clear contract is a recipe for resistance. It is also unethical. Assessment The fi rst aim of family assessment is to construct three-column formula- tions, such as those presented in Figures 12.2. and 12.3, of a typical epi- sode in which a conduct problem occurs and an exceptional episode in which a conduct problem is expected to occur but does not. When enquir- ing about conduct problems and family interaction patterns that maintain these, the coercive family process is a useful hypothesis with which to start. Belief systems that underpin action in this cycle may then be clari- fi ed. These in turn may be linked to predisposing risk factors, which have been listed above in the systemic model of conduct problems. With multi- problem families where there is multiagency involvement, assessment is typically conducted over a number of sessions and involves meetings or telephone contact with family members, foster parents or care staff who have regular contact with the referred child, involved school staff, and other involved professionals. Contracting for Treatment When contracting for treatment, following assessment, if the assessment has proceeded without cooperation problems then only the family need to attend the session in which a contract for treatment is established. How- ever, in complex cases where there have been cooperation problems such CONDUCT PROBLEMS 373 as failure to attend for appointments, then school staff, statutory child- protection or juvenile justice professionals, foster parents and care staff, or other key customers for change, should be invited to the contracting meeting. A summary of the family’s strengths and a three-column formu- lation of the family process in which the conduct problems are embedded should be given. Specifi c goals, a clear specifi cation of the number of treatment sessions and the times and places at which these sessions will occur should all be specifi ed in a contract. In statutory cases, such contracts should be written and formally signed by the parents, the family therapist and the statu- tory professional. Many families in which conduct problems occur have organisational diffi culties. Non-attendance at therapy sessions associated with these problems can be signifi cantly reduced by using a home visiting format wherever possible or organising transportation if treatment must occur at a clinic. The central aim of family therapy should be preventing the occurrence of coercive cycles of interaction and promoting positive exchanges between the parents and children. Sessions addressing these issue are the core of family therapy in cases where the main contract focuses on the reduction of conduct problems. It is less confusing for clients if child-focused family therapy sessions that have this overriding aim are defi ned as distinct from supplementary adult-focused or marital therapy sessions, in which the focus is on improving parental adjustment or couples enhancing their re- lationship, so that they can support each other in caring for their child. In some instances it may be appropriate for some sessions to be held which involve the parents with their own parents to help resolve family-of-origin diffi culties and foster support from the extended family. Treatment For most cases where conduct problems are the main concern, a chronic- care rather than an acute-care model is the most appropriate to adopt. Epi- sodes of treatment should be offered periodically over an extended time period (Kazdin, 1995). Effective family-based treatments are tailored to the developmental stage of the child and the complexity of the family dif- fi culties with the most intensive therapy being offered to complex families with multiple problems (Behan & Carr, 2000; Brosnan & Carr, 2000). For home-based conduct problems, occurring within the context of a family with few risk factors, weekly sessions over two or three months may be suffi cient. For pervasive severe conduct problems, occurring within the context of a family with multiple risk factors, two or three sessions per week with the family and members of the professional network over a period of year may be required, and in the most sever cases it may be necessary to combine this with treatment foster care (Chamberlain, 1994). 374 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS In all cases, treatment should involve interventions that help families to develop new belief systems about conduct problems and alter the pattern of interaction around the problem. These include: monitoring and refram- ing; externalising and building on exceptions; coaching in supportive play and scheduling special time; and developing reward systems and behavioural control systems. Where defi cits in communication and prob- lem-solving skills compromise the family’s capacity to follow through with these types of tasks then communication and problem-solving skills training in these areas may be appropriate. Where the problems occur in multiple contexts, such as the home, the school, and a residential care placement, it is important to hold network or liaison meetings involv- ing the family and staff in these other settings to ensure that reward and behaviour control programmes are being well coordinated and run consistently across multiple contexts. In circumstances where marital or personal diffi culties, high extrafamilial stress and low support prevent parents following through on child-focused therapeutic tasks, parent- focused interventions may be necessary. These include couples therapy, parent counselling, referral to support groups and advocacy. For severe conduct problems occurring within the context of families with multiple risk factors and few protective factors, family therapy may be conducted within the context of treatment foster care. All of these interventions have been described in detail in Chapter 9, and so will only be briefl y recapped here with particular reference to conduct diffi culties. Monitoring and Reframing Parents may be helped to shift towards more useful ways of viewing their children’s misconduct by observing and monitoring the impact of anteced- ents and consequences on their child’s behaviour. A form for monitoring tar- get behaviour problems is given in Chapter 9 (Figure 9.1). Through reframing, parents are helped to move from viewing the child’s conduct problems as proof that he is intrinsically bad to a position where they view the youngster as a good child with bad habits that are triggered by certain situations and rein- forced by certain consequences. When parents bring their child to treatment, typically they are exasperated and want the psychologist to take the child into individual treatment and fi x him. Through reframing the parents are helped to see that the child’s conduct problems are maintained by patterns of interaction within the family and wider social network, and therefore family and network members must be involved in the treatment process. Externalising and Building on Exceptions Externalising the conduct problem involves personifying the conduct problem as an external agent (such as Angry Alice or the Hammerman), CONDUCT PROBLEMS 375 which the parents and child must work together to defeat. Ideas about how to do this may come from an exploration of those exceptional cir- cumstances in which the conduct problem was expected to occur but did not. Such explorations may lead to solutions such as: eliminating or reducing the conditions that commonly precede aggressive behaviour; reducing children’s exposure to situations in which they observe aggres- sive behaviour; and reducing children’s exposure to situations which they fi nd uncomfortable or tiring, since such situations reduce their capacity to control aggression. In practice, such solutions often involve helping par- ents to plan regular routines for managing daily transitional events, such as: rising in the morning or going to bed at night; preparing to leave for school or returning home after school; initiating or ending leisure activi- ties and games; starting and fi nishing meals; and so forth. The more pre- dictable these routines become, the less likely they are to trigger episodes of aggression or other conduct problems. Within therapy sessions or as homework, parents and children may develop lists of steps for problem- atic routines, write these out and place the list of steps in a prominent place in the home until the routine becomes a regular part of family life. Supportive Play and Special Time Parents and young children may be coached in the principles of sup- portive play (described in Chapter 9) and with older children and ad- olescents, parents may be invited to schedule special time with their youngsters. Both of these interventions allow parents and children to replace negative interaction with regular periods of positive interaction. Where fathers have become peripheral to childcare tasks, inviting them to schedule regular periods of special time or supportive play with their children has the positive effect of both increasing positive interaction with the child and reducing childcare demands on their partners. Par- ents need to be coached in how to fi nish episodes of supportive play and special time by summarising what the parent and child did together and how much the parent enjoyed it. It is productive to invite parents to view these episodes as opportunities for giving the child the message that they are in control of what happens and that the parent likes being with them. Advise the parent to foresee rule-breaking and prevent it from happening. Finally, invite parents to notice how much they enjoy being with their children. Reward Systems Reward systems, which are described in detail in Chapter 9, involve agreeing a small number of target positive behaviours and a system for [...]... at risk of drug abuse and, once drug taking occurs, particular family behaviour patterns and family beliefs and narratives may maintain drug abuse Predisposing Family- based Risk Factors Poor relationship with parents, little supervision from parents and inconsistent discipline, parental drug abuse, and family disorganisation with unclear rules, roles and routines are some of the family factors that may... 376 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS Table 12.1 Points chart for an adolescent For these target behaviours you can earn points Points that can be earned Up by 7. 30 am 1 Washed, dressed and finished breakfast by 8.15 1 Made bed and standing at door with school bag ready to go by 8.30 1 Attend each class and have teacher sign school card 1 per... problems; for improving overall family functioning; and for preventing relapse Effective family- based treatment programmes for adolescent drug abuse has been shown to involve the following processes: contracting and engagement; becoming drug free; facing denial and creating a context for a drug-free lifestyle; family reorganisation; and disengagement (Stanton and Heath, 1995) These processes are central to... chapter for clinical practice when working with cases of drug abuse should be followed within the context of the general guidelines for family therapy practice given in Chapters 7, 8 and 9 DRUG ABUSE IN ADOLESCENCE 395 Contracting for Assessment In cases of chronic adolescent drug abuse, engagement and contracting for treatment is a process that may span a number of sessions and involve contact with... homework non-completion, theft, destruction of property and so forth To alter interactional patterns around drug abuse and drug-related deviant behaviour, family members must be helped to set very clear, observable and realistic goals both with 400 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS respect to the adolescents behaviour and with respect to the parents’ behaviour Broadly speaking,... Relapse Prevention and Disengagement Once a stable drug-free period has elapsed and new routines have been established within the family, which disrupt drug-abuse maintaining family patterns, disengagement may occur Relapse prevention is central to the disengagement process It involves identifying situations that may precipitate relapse, and helping the youngster and family members identify and develop confidence... precede problemsolving skills training and negotiation of rules and consequences It is not uncommon for such families to have no system for turn-taking, speaking and listening Rarely is the distinction made between talking about a problem so that all viewpoints are aired and negotiating a solution that is acceptable to all parties 380 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS The aim of... Class 4 Class 5 Class 6 Class 7 Class 8 Paying attention Completing classwork Following rules Other Teacher's initials Figure 12.4 Daily report card 382 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS and control over their conduct problems Where youngsters also have academic underachievement problems, it is important for the therapist to advocate for the family and take the steps necessary... clinical features are defiance, aggression and destructiveness; anger and irritability; and pervasive relationship difficulties within the family, school and peer group A systemic model of conduct problems highlights the role of relationships and characteristics of members of the family and the wider social connunity in the development and maintenance of conduct problems Treatment of conduct problems should... help families to develop new belief systems about conduct problems and alter the pattern of interaction around the problem Where deficits 384 FAMILY THERAPY PRACTICE WITH CHILD AND ADOLESCENT PROBLEMS in communication and problem-solving skills compromise the family s capacity to follow through with therapeutic tasks then communication and problem-solving skills training in these areas may be appropriate . problems, the results of em- pirical studies show that functional family therapy, multisystemic family therapy, and combining family therapy with temporary treatment foster care are the most effective. resolved and why they think family therapy is necessary. The possible positive out- comes of family therapy deserve discussion and these may be framed in different ways depending on the customer and. patterns of interaction within the family and wider social network, and therefore family and network members must be involved in the treatment process. Externalising and Building on Exceptions Externalising