• By Dartington SRU
  • Posted on Thursday 07th August, 2014

How to get disruptive kids to turn up to therapy

Cognitive behavioural programmes can help children learn better behaviour, especially when their parents are involved. But services that target parents of kids with disruptive behaviour often have astonishingly high dropout rates. School-based interventions are a good alternative for hard-to-reach children.

In a Dutch trial, 97% of children in a school-based programme for kids with disruptive behaviour completed the ten-session treatment. This unusually high completion rate compares to typical dropout rates of a third or more for parent-focused programmes. The programme had positive, though modest, effects on behavior.

“Although treatment of disruptive behavior problems appears more effective when parents are the agents of change, catching and keeping these parents and their children for treatment is problematic,” the study’s authors say. So school-based programmes – where children are a captive audience – may be a strong second-best approach.

Finding ways to reach children with disruptive behaviour matters because challenging behavior in elementary school often foreshadows serious problems in the teenage and adult years. These issues include dropping out of school, poor relationships with family and peers, and being involved in crime.

Disruptive behaviour is an umbrella term for defiant behaviour, conduct problems and antisocial behaviour. It can include actions such as lying, aggression and stealing. Cognitive behavioural therapy (CBT) has been shown to reduce these behaviours in children by changing the way they think and act.

Many intervention programmes target behaviour problems in childhood. Parent-focused CBT treatments tend to be more effective than child-focused treatments. It seems that when parents learn to improve their parenting skills, better child behavior often follows.

However, this type of treatment faces a crucial problem: attracting and retaining families. Parents of children with disruptive behaviour problems often do not want to take part in treatment, have difficulty accessing treatment, and frequently drop out of programmes. This is especially true for parents and children from poorer backgrounds, deprived neighborhoods, and ethnic minorities.

One approach to this problem is to try to design programmes that will be more appealing and accessible to these parents. Another is to look for places where getting good attendance is easier – like schools.

Interventions that take place in schools have the added value of teacher involvement. Teachers can be educated about the programme and trained to support the children’s CBT, which may increase the overall effectiveness of the intervention. Teachers can also develop skills around classroom management, building positive peer relationships among children, and promoting children’s social skills.

Researchers from the University of Amsterdam set out to investigate the effectiveness of a school-based, targeted CBT programme for disruptive behaviour. They found that it was modestly effective – about as effective as other targeted approaches. According to reports from parents, teachers, and peers, children in the CBT programme fared better than children in the control group.

In total, 173 children aged between 8 and 12 years were selected to take part in a randomised control trial. The sample was taken from 17 schools from low or low-to-middle socio-economic status in the Netherlands. Altogether, 70 children received CBT, while the remaining children (103) were placed into a waitlist control condition and were treated afterwards. Most of the children were boys (79%) and had a low-to-middle class socio-economic status (87%). The sample was also ethically diverse (63% of children were of non-Western origin).

The ten-session programme, called “Keep Cool… Start at School,” ran for three years. The sessions aimed to help children set goals, change the way they think, and change the way they react to situations. This was achieved through role-playing, positive reinforcement, goal setting, and modeling. Parents were invited to one session mid-intervention.

Teachers also received five sessions of training. Some were trained in an active style of support, where they were taught how to help children with their programme workbooks and to model behaviour in class. Others were given strictly psycho-educational training about the content of the children’s programme.

Reports from teachers, parents, and peers were used to assess behaviour problems including defiant behaviour, conduct disorders, hyperactivity and attention problems. Measures were taken before the programme, immediately afterward, and at a later follow-up.

The researchers found that the intervention significantly reduced children’s disruptive behaviour in several areas. These included oppositional behaviour problems, conduct problems, and externalising problems. Interestingly, no difference was found between the two styles of teacher training at the post-intervention assessment.

The results also suggested that children at schools with a higher proportion of children at risk of disruptive behaviour may benefit more from this type of intervention than children at schools where the proportion of disruptive children is lower.

Despite interesting results, the current research does have limitations. First, some ratings were provided by teachers, who were directly involved in the trial. This could potentially lead to bias if the teachers are expecting to see improvements. Second, the lack of difference in results between the two types of teacher training is also a puzzle that would benefit from further research. But overall, the trial results point to schools as a useful location for interventions, especially when parents are hard to reach.

Liber, J., De Boo, G., Huisenga, H., & Prins, P. (2013). School-Based Intervention for Childhood Disruptive Behavior in Disadvantaged Settings: A Randomised Control Trial With and Without Active Teacher Support. Journal of Consulting and Clinical Psychology. DOI: 10.1037/a0033577

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