AGGRESSION REPLACEMENT TRAINING--IN ACTION

AGGRESSION REPLACEMENT TRAINING--IN ACTION

Rose Jenkins ConferenceImplementing Evidence-Based Practices:

Early Lessons LearnedOctober 3-4, 2006

Rose Jenkins 2006 Aggression Replacement Training--In Action

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Elijah McCauley, MAClinical Training Specialist

Stars Behavioral Health Group

Aggression Replacement TrainingOverview


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Stars Behavioral Health Group

• Starting in 1988, we now operate a wide variety of behavioral health programs for children, adolescents, and families.

• Our programs include treatment –intensive programs provided in homes, at schools, and residential/ community-based centers.


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Our ClientsConduct Disorder

Aggression toward others

Destruction of Property

Deceitfulness, lying, or stealing

Serious violations of rules


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The 3 AARRTT Components

• #1. Skill-Streaming #1. Skill-Streaming (behavioral)(behavioral)

• #2. Anger Control Training #2. Anger Control Training (emotional)(emotional)

• #3. Moral Reasoning #3. Moral Reasoning Training (values)Training (values)


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Skill-Streaming

50 social skills: examples– Expressing a Complaint

Constructively– Caring for Someone Who is Sad or

Upset – Dealing w /(-) Peer Pressure– Keeping Out of Fights– Helping Others– Responding Constructively to

Failure


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• Modeling– (Skill Demonstration by Trainers)

• Role-Playing– (Skill Rehearsal by Youth)

• Performance Feedback– (By Trainers and all Youth in Group)

• Generalization Training– (To Increase Both Transfer and Maintenance)

Skill-Streaming


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Anger Control Training

• Identify triggers (internal & external)

• Identify physiological cues of anger

• Identify anger reducers

• Reminders to decrease anger


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Problems I Had Today• Think bad about myself• Don’t care about others• Don’t care about myself• Problems with authority• Mess with other people• Get messed with alot• Make others mad• Steal stuff• Get mad easy• Want to use alcohol or drugs• Lie to people• “Punk” other people


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Thinking Problems

• Self-Centered (me, me, me)• Blaming Others (you, you, you)• Assuming the Worst (biggie, biggie, biggie)• Minimizing (no biggie)


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Anger Reducers: Chill-Out Skillz• Deep Breathing

• Count Backward from 10Count Backward from 10

• Put a “cool” picture in your head


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Moral Reasoning

The strength of this UNIQUE approach comes from

Positive Peer Influence


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Moral Reasoning

We want our clients to develop--

Moral Maturity

For this to occur they must develop mutual caring, respect & trust


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Anthony’s Problem Situation

Anthony is walking along a side street w/his friend Raymond. Noticing a purse in the backseat of a parked car, Raymond says, “Look! The car’s unlocked, & there’s a purse in the backseat. Let’s grab it!”

What should Anthony do?


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Anthony’s Problem Situation1.Should Anthony try to persuade Raymond not to steal the

purse? (circle one) Should persuade should let steal can’t decide

2. What if Raymond says to Anthony that the car owner can probably get insurance $ to cover the loss? (circle one)

Should persuade should let steal can’t decide

3. In general, how important is it for people not to take things that belong to others? (circle one)

Very important important not important

4. What if you found out the car belonged to your good friend Would Care a lot don’t care don’t know


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Santa Clara County

Aggression Replacement Training


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Purpose

• To implement an evidence based program into Juvenile Hall and the Ranch Programs in order to:– Enhance positive coping strategies – Reduce violence in custody and upon

release – Increase in sociably acceptable

behaviors


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Demographics

• Average daily population:Juvenile Hall 250 / Ranches 101

• Number of minors admitted annually: Juvenile Hall 2893 / Ranches 420

• Minors screened for Mental Health issues annually: 2888

• minors open to MH services while detained: Juvenile Hall 1010 / Ranches 312


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Accomplishments - Wave #1

• Seven Mental Health Therapists and Eleven Custodial Staff trained in ART Model.

• Two ten week groups consisting of 8 male minors completed in Juvenile Hall.

• Twelve minors complete ten weeks of training at the Boys Ranch.

• Three additional groups 2 male and 1 female started in Juvenile Hall.

• One additional group for males started at the Boys ranch.


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Comparison of Skillstreaming Checklist

Average Score, Maximum possible = 50

BeforeGroup Score Score VarianceHall Staff 39 47 21%Ranch Staff 31 39 26%Hall Youth 39 40 3%Ranch Youth 32 45 41%

After


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Satisfaction Questionnaires

Average score, Maximum possible = 30

Hall Pct Ranch PctSkillstreaming 20 68% 23 77%Anger Control 20 66% 24 80%Moral Reasoning 22 73% 25 83%


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Number of behavior Incident Reports

Before AfterJuvenile Hall 22 9Ranch 10 0

For Youth Completing ART Curriculum


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Facilitator Viewed Strengths

• Sessions build upon previous information.• Materials are easy for trainer to understand.• Materials are easy for minors to understand. • Different levels of material are given so that

subject matter can be modified to fit group.• Use of week 0 to do pretest and set ground

rules with minors.


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Facilitator Viewed Difficulties• Calls to master trainer not useful at the beginning• Scheduling meeting due to staff schedules can be

challenging• Amount of staff time needed to prepare sessions,

lead session and evaluate can place a burden on the staff

• High attrition in Juvenile Hall groups.• Turnover in members = challenge to group

dynamics


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Victor Community Support Services, Inc.Victor Treatment Centers, Inc.

North Valley Schools, Inc.

Observations and Conclusions of Victor Family of Programs’


Across 3 Settings:Community Mental Health Clinic

Public and Non-Public School EnvironmentsJuvenile Hall


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Community Mental Health Clinic Setting

Client DemographicsSummer 2004 Summer 2006 Summer 2006

Group Count 6 7 10

Age Range 12 to 15 14 to 18 12 to 15

Gender Male Male Male

Problem Behaviors Frustration Tolerance, Attention

Aggression, Stealing Frustration Tolerance, Hyperactivity

Acuity (Low, Moderate or High)

Moderate to High High Moderate

Diagnoses ADHD, PTSD PTSD, Anxiety, ADHD

ADHD, ODD

Axis 4 Stressors (Mild, Moderate or Severe)

Moderate Moderate to Severe Moderate

Probation Involvement 0% 3 of 7 on Probation 0%

Cognitive Functioning Average Average Most Average,

Several Borderline

Treatment Motivation Low to Moderate High Moderate


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StaffingSummer 2004 Summer 2006 Summer 2006

Education Level HS, MSW MS, MSW HS, MA

Years of Counseling Experience

10 years and

8 years

7 years and

5 years

12 years and

16 years

Group Facilitation Skills(Beginner, Intermediate, or Advanced)

Beginner, Intermediate

Advanced, Intermediate

Intermediate,

Advanced

Support Staff None None None

Model Adherence

Summer 2004 Summer 2006 Summer 2006

Initial Training 2 Hours, Read Book, Watched Videotape

3 Days

with Master Trainers

3 Days

with Master Trainers

Booster Training None None None

Group Supervision Weekly Clinical GS

(No ART-Specific GS)

Weekly Clinical GS, ART-specific GS,

Every Other Week


Every Other Week

Administrator Oversight High Moderate Moderate

Videotape Reviews None None None

Fidelity Measures(Questionnaires Developed by Master Trainers)

None None Yes

Overall Fidelity Moderate High High

ART Design

Summer 2004 Summer 2006 Summer 2006

Frequency

Per week

Session Minutes

Duration

In weeks

Frequency Session Duration Frequency Session Duration

Skillstreaming 1x 60 10 1x 90 10 2x 60 10

Pros Role Plays Role Plays Role Plays, Use of skills at home

Cons Youth became distracted Homework Compliance DD youth became confused

Anger Control 1x 60 10 1x 90 10 1x 60 10

Pros Youth Engagement Role Plays, Content Use of Hassle Logs

Cons Homework compliance,

Anger Intensity

Can be perceived as too Instructional / Didactic

Agitation / Anger Intensity made Behavior Mgmt difficult

Moral Reasoning 1x 60 10 1x 90 10

Not ImplementedPros Role Plays engaged the youth Full Engagement of Youth,

Positive Peer to Peer Influence

Cons “Over their heads” None

Incentives Daily Rewards,

Final outing

Weekly Rewards,

Final Outing

Daily Rewards

Enhancements None Oscars, Scene Clapper, Devil Glasses

Flip charts and visual aids


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School SettingsIntegrated Day Treatment Program in a Special

Day ClassSpecialty MH Services in a Special Day Class

Day Treatment Program in a Non-Public School


Client DemographicsDay Treatment

Yuba County

Specialty MH Services

Sutter County

Day Treatment

Non-Public School

Group Count 8 12 9

Age Range 14 to 18 14 to 18 14 to 18

Gender Coed Coed Coed

Problem Behaviors Aggression,

Anti-social Behavior

Impulse Control, Aggression,

Hyperactivity

Aggression, Running, Impulse Control,

Anxiety

Acuity (Low, Moderate or High) High High High

Diagnoses ADHD, PTSD, Mood Disorders

Conduct Disorder, ADHD, PTSD, Mood

Disorders

PTSD, Mood Disorders


Severe Severe Severe

Probation Involvement None 6 of 12 2 of 9

Cognitive Functioning 6 Average, 4 Borderline Borderline, some Average

7 Average, 1 DD

Treatment Motivation Moderate Low High

Rose Jenkins 2006

StaffingDay Treatment

Yuba County


Sutter County

Day Treatment

Non-Public School

Education Level MA, HS MS, MA MA, MA (for Skillstreaming Groups)

MFT, MSW / MA(for Anger Control and

Moral Reasoning Groups)

Years of Counseling Experience

2 years and

11 years

7 years and

5 years

Average of

10+ years


Intermediate,

Beginner

Advanced, Advanced

All

Advanced

Support Staff None Instructional Aids Instructional Aids

Model AdherenceDay Treatment

Yuba County


Sutter County

Day Treatment

Non-Public School

Initial Training 2 Hours, Read Book, Watched Videotape

1 Days with Master Trainer

3 Days with Master Trainers

Booster Training None 3 Days with Master Trainers

1 Days with Master Trainer

Group Supervision Weekly Clinical GS(No ART-Specific GS)

Weekly Clinical GS(No ART-Specific GS)


Week

Administrator Oversight Low Moderate High

Videotape Reviews None None Yes, 8 total

Fidelity Measures(Questionnaires Developed by Master Trainers)

None None Yes

Overall Fidelity Moderate to Low Moderate to High High

ART DesignDay Treatment

Yuba County


Sutter County

Day Treatment

Non-Public School

Frequency

Per week

Session Minutes

Duration

In weeks


Skillstreaming 1x 60 10 1x 90 10 2x 60 10

Pros Role Plays Role Plays Role Plays,

Youth applied their skills

Cons Youth became distracted Homework Compliance DD youth became confused

Anger Control 1x 60 10 1x 90 10 1x 60 10

Pros Youth Engagement Role Plays, Content Use of Hassle Logs

Cons Homework compliance,

Anger Intensity

Felt too Instructional Agitation / Anger Intensity made behavior mgmt difficult

Moral Reasoning 1x 60 10 1x 90 10 1x 90 10

Pros Role Plays engaged the youth Full Engagement of Youth, Positive Peer to Peer Influence

Full Engagement of Youth, Positive Peer to Peer Influence

Cons “Over their heads” None None

Incentives Rewards, Party at end Weekly Oscars, Rewards Snacks, Rewards

Enhancements None Reducers (putty, postcards) Youth running groups, Visual aids (color chalk)


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Juvenile Hall Setting

Five A.R.T. Group Curricula over 10 Months


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Client Demographics

Group Count 8 per group curriculum, 53 Youth total

Age Range 14 to 18

Gender Male Groups, Female Groups

Problem Behaviors Drugs, Aggression, Anti-Social Behavior,

Truancy, Impulse Control

Acuity (Low, Moderate or High)

High

Diagnoses PTSD, ADHD, Mood Disorders


Severe

Probation Involvement 100%

Cognitive Functioning Average to Borderline

Treatment Motivation High


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Staffing

Education Level MA, 2nd Year MSW Student

Years of Counseling Experience 20 years and 6 years


Both have Advanced skills

Support Staff None involved in Groups but all JH Staff were trained


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Model AdherenceInitial Training 2 Hours, Read Book,

Watched Videotape3 Days with Master Trainers

Booster Training 1 Day with Master Trainers

Group Supervision Weekly Conference Calls with Master Trainer

Weekly Clinical GS

Administrator Oversight High

Videotape Reviews None

Fidelity Measures Yes

Overall Fidelity Moderate to High

ART Design

Frequency

Per week

Session

Length

Duration

In Weeks


Skillstreaming Mon – M 90 mins

10 w

Mon - F 90 m 10 w

Pros JH Youth are clearly in need of Social Skills

Cons Youth turnover and need for staff consistency make this program very difficult for JH

Anger Control Wed – M 90 m 10 w Mon 90 m 10 w 3x – M 90 m 3 w

Wed – F 90 m 10 w Tues 90 m 10 w 3x - F 90 m 3 w

Pros Kids identify underlying reasons for anger, learn to reframe anger, learn acceptability of anger and new ways to express it, learn connection between anger and recidivism.

Cons Hassle Logs can be a compliance challenge

Moral Reasoning Fri – M 90 m 10 w Wed 90 m 10 w

Fri – F 90 m 10 w

Pros First time kids actually analyze their values and morals, need to look at morals, chance to look at motivation for crimes, as well as consequences

Cons Challenging with cognitively limited youth

Incentives Getting out of Room, Intermittent Rewards (pizza parties)

Enhancements Angel Wings, Pitchfork, Artwork, Gang Intervention (gang rivals in same groups)


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ConclusionsClient Demographics

• ART seems most effective for youth with higher Cognitive Functioning

• Single-sex groups assist with client focus and behavior management (other research indicates same gender groups also reduce female anti-social behavior)

• Youth with high motivation at the onset of the ART groups increase effectiveness

• ART seems appropriate for both moderate and higher level acuity


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Conclusions

Client Demographics

• ADHD symptoms seem to interfere with the acquisition of ART skills

• The intensity of Anger may increase during ART sessions, however:– Anger intensity during sessions does not seem to

increase aggression– Youth with intense anger experiences seem to apply

ART skills• Youth are most engaged in the Role Plays• The application and sustainment of ART skills is greatly

enhanced through collateral involvement (family members, teachers, milieu counselors)


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ConclusionsStaffing Characteristics and Training

• Increased supervision and fidelity monitoring appears to be as critical to ART efficacy as didactic training

• Experience running groups and comfort level with youth anger appear to increase ART success

• Group supervision and collegial support increase ART fidelity and efficacy

• Staff attitude and enthusiasm seem to be more essential than formal education or years of experience


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Conclusions

Staffing Characteristics and Training • Staff morale is consistently elevated through ART

applications• ART provides a vehicle for staff creativity and

application of their unique talents and skills • Staff must be comfortable with role plays; staff

consistently love role plays• Use of humor seems to be a very helpful skill with ART• It seems to work best for support staff (milieu

counselors) to remain outside of the group, due to the sensitivity of discussions


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Conclusions

ART Design

• ART is consistently reported as easy to learn and straightforward

• Role Plays are consistently reported as the most engaging and effective element of ART

• Skillstreaming seems most appropriate for environments with stable client populations and staffing, due to the need for youth to practice of their individualized plans


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ConclusionsART Design

• Anger Control seems to have the most long term impact (numerous clients remember Anger Control language years later)

• Moral Reasoning seems most appropriate for older youth (14 to 18) due to its cognitive demands

• Maintaining fidelity with Moral Reasoning can be a challenge with consistent reports of insufficient content

• ART enhancements assist with maintaining a fun atmosphere and youth engagement


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Sustaining ART in a Residential Program

Sean Schoneman, Ph.D. Assistant Clinical Director of Training

Casa Pacifica


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Steps to Sustaining

TrainingProgram Fidelity Staff InvolvementResponsibilityAccountabilitySupport from Senior ManagementResultsSetting Goals for the Future

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Training

• Medical Model: Observe, assist, lead• Placed immediately into groups after 3 day

training• “Expert Team” Meetings:

– Training– Implementation – Support


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Training3 Tiers of ART Training at Casa Pacifica

Tier 1: Expert ART Team– 3 Day Training in Sacramento– Weekly Expert ART Team Meetings– Training New Hires & People from their

Departments– Teleconferencing with National Trainer– Annual 3 Day Training from National

Trainers


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Training

3 Tiers of ART Training at Casa Pacifica

Tier 2: All Additional ART Group Facilitators– Annual 3 Day Training from National

Trainers

– Quarterly Refresher Trainings

– Supervision During Groups from Expert ART Team Co-leaders

– 2-Hour New Hire Training


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Training

3 Tiers of ART Training at Casa Pacifica

Tier 3: All other staff– 3 Day Training from National

Trainers and/or 2-Hour New Hire Training


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Program Fidelity Strategies

• Expert Team Leader Observations of Groups using ART Checklists

• Quarterly Refreshers for all ART Participants• “New” ART Trainings by Department• Weekly “Expert Team” Meetings• Video Taping• Teleconferencing with National Trainer


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Advantages to Being Part of Multi-agency Implementation

• Great Support in Getting Started• Able to Get ART Resources Cheaper• Other Agencies are Available to Share

Information• Data Base

– Assistance with Creating Own Data Base– Access to Aggregate Data from all

Participating Agencies• Program Fidelity


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Recent Changes to Our Expert ART Team

Leadership Responsibilities within the Team:Back-Up LeaderProgram LeadersPaperwork CzarTreasurerFour Trainer have been recognized as

“Proficient” and will begin training ART on campus


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Recent Changes to Our Expert ART Team

Leadership Responsibilities within the Team:Back-Up LeaderProgram LeadersPaperwork CzarTreasurerFour Trainer have been recognized as

“Proficient” and will begin training ART on campus


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Future Challenges

1. Budget1. 96 % of our current budget = Stipends2. Team wants to keep their stipends3. Increasing our funding

1. Grants2. Lobbying for a larger budget3. Producing revenue via teaching

2. Keeping the Team Together3. Opening a site in Santa Barbara, CA


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Future Goals for ART in Our Agency

Trainer of Trainers Training. Providing In-House Training of ART

. Providing Training for Other AgenciesTraveling to Learn and TeachLive Supervision via bug-in-the-earEvery Current Expert Team Member has the

Opportunity to be a Trainer of TrainersIncreased Collaboration with our LSCI Team


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AGGRESSION REPLACEMENT TRAINING--IN ACTION