AGGRESSION REPLACEMENT TRAINING--IN ACTION
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AGGRESSION REPLACEMENT TRAINING--IN ACTION
Rose Jenkins ConferenceImplementing Evidence-Based Practices:
Early Lessons LearnedOctober 3-4, 2006
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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’
Aggression Replacement Training
Across 3 Settings:Community Mental Health Clinic
Public and Non-Public School EnvironmentsJuvenile Hall
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Aggression Replacement Training
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
Weekly Clinical GS, ART-specific GS,
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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Aggression Replacement Training
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
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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
Axis 4 Stressors (Mild, Moderate or Severe)
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
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StaffingDay Treatment
Yuba County
Specialty MH Services
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
Group Facilitation Skills(Beginner, Intermediate, or Advanced)
Intermediate,
Beginner
Advanced, Advanced
All
Advanced
Support Staff None Instructional Aids Instructional Aids
Model AdherenceDay Treatment
Yuba County
Specialty MH Services
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)
Weekly Clinical GS, 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
Specialty MH Services
Sutter County
Day Treatment
Non-Public School
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,
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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Aggression Replacement Training
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
Axis 4 Stressors (Mild, Moderate or Severe)
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
Group Facilitation Skills(Beginner, Intermediate, or Advanced)
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
Frequency Session Duration Frequency Session Duration
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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