Changing Destructive Behavior

As more educators become concerned about the use of powerful psychiatric drugs on children, there is growing interest in counseling techniques for troubled kids that aim to change destructive behavior.

Counseling therapies are getting a push because they have been shown to be effective on kids with severe behavioral problems, often in cases where other approaches have failed. The techniques take a practical approach, often using a specific curriculum to teach new behaviors, rather than trying to discover the underlying emotional problem with a particular student. In an interesting twist, much of this new counseling is often directed at parents.

Developed mostly in the past decade at a few major universities, the therapies target kids with diagnoses like "conduct disorder," "oppositional defiant disorder" or "bipolar disorder," who are at risk of getting kicked out of school. Some educators estimate there are 1.4 million to 4.2 million children who meet the criteria for "conduct disorders" alone.

Unfortunately, today many of these kids are placed on powerful psychiatric medications. The drugs are often ineffective, and parents worry about side effects, especially with some talk about the potential link between antidepressants and suicidal tendencies in teens. These newer behavioral therapies, including Parent Management Training at Yale University and the Incredible Years program at the University of Washington, Seattle, can reduce the need for drugs, or be effective where drugs alone have not, say the programs' developers.

The techniques are often called "evidence-based" therapies because their effectiveness has been demonstrated in a number of experiments. The more traditional forms of talk therapy haven't been studied as extensively because they vary so widely by individual therapists and are therefore quite difficult to quantify.

Among efforts to expand access to these therapies, experts at Columbia University's Center for the Advancement of Children's Mental Health have compiled a selection of techniques into a course and workbooks to make it easier to train mental-health practitioners. Six hundred therapists from Florida's state-funded mental-health clinics have taken the course, and others from New York are also enrolling. Another course teaches parents about the therapies.

Professional organizations such as the American Psychological Association, and government agencies including the Substance Abuse and Mental Health Services Administration, have put together lists of therapies with the strongest scientific evidence behind them.

These approaches are still little known outside of the universities where they were developed. Unlike drugs, which are backed by pharmaceutical companies' marketing and numerous TV ads, no system exists for informing parents and educators of effective psychotherapies.

The therapies can also be expensive; one approach costs $4,500 for a three-to-five-month program. Mental-health services aren't always covered by insurance, and insurers that do pay for it typically don't require that practitioners use evidence-based approaches.

Here is a closer look at three of the most well known evidence-based therapies for children.

Parent Management Training

Developed by Alan Kazdin, a child psychologist at the Parenting Center and Child Conduct Clinic at Yale University, the program treats children ages two to 13 who display aggressive and antisocial behavior. During the typical program of five to 15 weeks, therapists train parents how to manage their children's behavior through role- playing exercises and a disciplined system of rewards and punishments that is implemented in specific steps.

Parent Management Training has been widely studied in the past 20 years. Dr. Kazdin cites over 50 controlled studies that support use of the technique, and has done 10 major studies himself that ranged in size from 50 to 250 kids.

At the Yale clinic, each session costs $20-$100 on a sliding scale based on need, and may be paid for by insurance that covers mental- health visits. PMT is currently done at a handful of university medical centers outside of Yale, including the University of Washington at Seattle and the Oregon Social Learning Center, in Eugene, Ore.

The Incredible Years

The Incredible Years program is intended for parents who have children, age two to 8, with conduct problems. Usually the parent attends about three months of group sessions led by a therapist, which are structured around videos depicting difficult situations with children. The section that targets children uses a character called Dina Dinosaur to teach kids to manage anger, practice conversational skills and behave appropriately in class. School districts have used another module of the program to train teachers to handle disruptive kids in the classroom.

Seven studies over the past 20 years support the Incredible Years approach, according to Carolyn Webster-Stratton, the clinical psychologist who developed the program at the University of Washington. The therapy was associated with better parent-child interactions, reduced child-conduct problems at home and school, and reduced reliance on critical or violent forms of discipline.

The therapy is free at Dr. Stratton's clinic, which is funded largely by the National Institutes of Health. The center also markets training materials to government health-care agencies, mental-health clinics, hospitals and schools, and fees vary at those facilities. Training modules have been sold in 49 states. Dr. Stratton maintains a database of 8,826 professionals who have been trained in the Incredible Years programs for parents, children, and schools in the past eight years.

Multi-systemic Therapy

Developed at Medical University of South Carolina, MST is used primarily for juvenile offenders ages 12 to 17. Adolescents are usually referred to the treatment by a court because they are at high risk of being incarcerated or sent to a residential facility or foster care. The intense intervention, lasting three to five months, focuses on changing the factors that make the adolescent prone to risky behavior. The therapist looks at all areas of the teen's life: family, school, peer group and probation officer. The therapist comes to the home or school, often multiple times a week, and is available by phone 24 hours a day.

MST trains the caregiver in much the same way Parent Management Training does, setting defined rules for the adolescent's behavior, monitoring compliance with the rules, and doling out punishments or rewards. But MST also addresses problems the parent may have, such as substance abuse, a psychiatric condition or a stressful full-time job. The therapist seeks practical solutions like finding childcare or keeping parents on their psychiatric medications. At school, the therapist might try to decrease the teenager's association with deviant friends, while encouraging him to make other friends.

Fourteen clinical trials of MST have been published in scientific journals. In three trials with violent and chronic juvenile offenders, MST produced 25% to 70% decreases in the long-term rates of re-arrest, and 47% to 64% decreases in long-term rates of out-of-home placements. While MST typically costs about $4,500 a person, proponents say it can produce significant savings by keeping the teens out of jail or psychiatric facilities, and from committing crime.

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