1. Persistent refusal to comply with rules or expectations in the home, school, or community.
2. Excessive fighting, intimidation of others, cruelty or violence toward people or animals, and destruction of property.
3. History of stealing at home, at school, or in the community.
4. School adjustment characterized by disrespectful attitude toward authority figures, frequent disruptive behaviors, and detentions or suspensions for misbehavior.
5. Repeated conflict with authority figures at home, at school, or in the community.
6. Impulsivity as manifested by poor judgment, taking inappropriate risks, and failing to stop and think about consequences of actions.
7. Numerous attempts to deceive others through lying, conning, or manipulating.
8. Consistent failure to accept responsibility for misbehavior accompanied by a pattern of blaming others.
9. Little or no remorse for misbehavior.
10. Lack of sensitivity to the thoughts, feelings, and needs of other people.
11. Multiple sexual partners, lack of emotional commitment, and engaging in unsafe sexual practices.
12. Use of mood-altering substances on a regular basis.
13. Participation in gang membership and activities.
| 1. Identify situations, thoughts, and feelings that trigger angry feelings, antisocial behaviors, and the targets of those actions. (1, 2) |
1. Using relevant verbal response modes (e.g., questioning, active listening, clarification, reflection, empathy), build rapport toward creating trust and a good working therapeutic alliance with the client.
2. Conduct clinical interviews with the client and parents focused on specifying the nature, severity, and history of the adolescent's misbehavior; thoroughly assess the various stimuli (e.g., situations, people, thoughts) that have triggered the client's anger and the thoughts, feelings, and actions that have characterized his/her antisocial responses; consult others (e.g., family members, teachers) and/or use parent/teacher rating scales (e.g., Child Behavior Checklist; Eyberg Child Behavior Inventory) to supplement the assessment as necessary. |
| 2. Parents identify major concerns regarding the child's misbehavior and the associated parenting approaches that have been tried. (3) |
3. Assess how the parents have attempted to respond to the child's misbehavior, what triggers and reinforcements there may be contributing to the behavior, the parents' consistency in their approach to the child, and whether they have experienced conflicts between themselves over how to react to the child. |
| 3. Parents and child cooperate with psychological assessment to further delineate the nature of the presenting problem. (4) |
4. Administer psychological instruments designed to assess whether a comorbid condition(s) (e.g., bipolar disorder, depression, ADHD) is contributing to disruptive behavior problems and/or objectively assess parent-child relational conflict (e.g., the Parent-Child Relationship Inventory); follow up accordingly with client and parents regarding treatment options; re-administer as needed to assess treatment outcome. |
| 4. Complete a substance abuse evaluation and comply with the recommendations offered by the evaluation findings. (5) |
5. Arrange for a substance abuse evaluation and refer the client for treatment if the evaluation recommends it. |
| 5. Provide behavioral, emotional and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship. (6, 7, 8, 9, 10) |
6. Assess the client's level of insight (syntonic versus dystonic) toward the “presenting problems” (e.g., demonstrates good insight into the problematic nature of the “described behavior,” agrees with others' concern, and is motivated to work on change; demonstrates ambivalence regarding the “problem described” and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledgment of the “problem described,” is not concerned, and has no motivation to change).
7. Assess the client for evidence of research-based correlated disorders (e.g., oppositional defiant behavior with ADHD, depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e.g., increased suicide risk when comorbid depression is evident).
8. Assess for any issues of age, gender, or culture that could help explain the client's currently defined “problem behavior” and factors that could offer a better understanding of the client's behavior.
9. Assess for the severity of the level of impairment to the client's functioning to determine appropriate level of care (e.g., the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g., the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment).
10. Assess the client's home, school, and community for pathogenic care (e.g., persistent disregard for the child's emotional needs or physical needs, repeated changes in primary caregivers, limited opportunities for stable attachments, persistent harsh punishment, or other grossly inept parenting). |
| 6. Cooperate with the recommendations or requirements mandated by the criminal justice system. (11, 12, 13) |
11. Assess the child's illegal behavior patterns and consult with criminal justice officials about the appropriate consequences for the client's destructive or aggressive behaviors (e.g., pay restitution, community service, probation, intensive surveillance).
12. Consult with parents, school officials, and criminal justice officials about the need to place the client in an alternative setting (e.g., foster home, group home, residential program, juvenile detention facility).
13. Encourage and challenge the parents not to protect the client from the natural or legal consequences of his/her destructive or aggressive behaviors. |
 7. Cooperate with a physician's evaluation for possible treatment with psychotropic medications to assist in anger and behavioral control and take medications consistently, if prescribed. (14) |
14. Assess the client for the need for psychotropic medication to assist in control of anger; refer him/her to a physician for an evaluation for prescription medication; monitor prescription compliance, effectiveness, and side effects; and provide feedback to the prescribing physician. |
| 8. Increase the number of statements that reflect the acceptance of responsibility for misbehavior. (15, 16, 17, 18) |
15. Use techniques derived from motivational interviewing to move the client away from externalizing and blaming toward accepting responsibility for his/her actions and motivation to change.
16. Therapeutically confront statements regarding the client's antisocial behavior and attitude, pointing out consequences for himself/herself and others (or assign “How My Behavior Hurts Others” or “Patterns of Stealing” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
17. Therapeutically confront statements in which the client lies and/or blames others for his/her misbehaviors and fails to accept responsibility for his/her actions; explore and process the factors that contribute to the client's pattern of blaming others (e.g., harsh punishment experiences, family pattern of blaming others).
18. Assist the client in identifying the positive consequences of managing anger and misbehavior (e.g., respect from others and self, cooperation from others, improved physical health); ask the client to agree to learn new ways to conceptualize and manage anger and misbehavior. |
| 9. Agree to learn alternative ways to think about and manage anger and misbehavior. (19, 20) |
19. Assist the client in making a connection between his/her feelings and reactive behaviors (or assign “Surface Behavior/Inner Feelings” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
20. Assist the client in conceptu-alizing his/her disruptive behavior as involving different components (cognitive, physiological, affective, and behavioral) that go through predictable phases that can be managed (e.g., demanding expectations not being met leading to increased arousal and anger which leads to acting out). |
| 10. Learn and implement calming strategies as part of a new way to manage reactions to frustration. (21) |
21. Teach the client calming techniques (e.g., muscle relaxation, paced breathing, calming imagery) as part of a tailored strategy for responding appropriately to angry feelings when they occur (or assign “Progressive Muscle Relaxation” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
| 11. Identify, challenge, and replace self-talk that leads to anger and misbehavior with self-talk that facilitates a more constructive reaction. (22) |
22. Explore the client's self-talk and beliefs that mediate his/her angry feelings and actions (e.g., demanding expectations reflected in should, must, or have to statements); identify and challenge biases, assisting him/her in generating appraisals and self-talk that corrects for the biases and facilitates a more flexible and temperate response to frustration (or assign “Journal and Replace Self-Defeating Thoughts” in the Adult Psychotherapy Homework Planner by Jongsma). |
| 12. Learn and implement thought-stopping to manage intrusive unwanted thoughts that trigger anger and acting out. (23) |
23. Assign the client to implement a thought-stopping technique on a daily basis between sessions (or assign “Thought-Stopping” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis); review implementation; reinforce success, providing corrective feedback toward improvement. |
| 13. Verbalize feelings of frustration, disagreement, and anger in a controlled, assertive way. (24) |
24. Use instruction, modeling, and/or role-playing to teach the client assertive communication; if indicated, refer him/her to an assertiveness training class/group for further instruction (see Anger Control Training for Aggressive Youths by Lochman et al.). |
| 14. Learn and implement problem-solving and/or conflict resolution skills to manage interpersonal problems constructively. (25) |
25. Teach the client conflict resolution skills (e.g., empathy, problem-solving, active listening, “I messages,” respectful communication, assertiveness without aggression, compromise); use modeling, role-playing, and behavior rehearsal to work through several current conflicts (consider assigning “Becoming Assertive” or “Problem-Solving Exercise” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
| 15. Practice using new calming, communication, conflict resolution, and thinking skills in session with the therapist and during homework exercises. (26, 27) |
26. Assist the client in constructing and consolidating a client-tailored strategy for managing anger that combines any of the somatic, cognitive, communication, problem-solving, and/or conflict resolution skills relevant to his/her needs.
27. Use any of several techniques, including relaxation, imagery, behavioral rehearsal, modeling, role-playing, or feedback of videotaped practice in increasingly challenging situations to help the client consolidate the use of his/her new anger management skills (see Problem-Solving Skills Training and Parent Management Training for Conduct Disorder by Kazdin). |
| 16. Practice using new calming, communication, conflict resolution, and thinking skills in homework exercises. (28) |
28. Assign the client homework exercises to help them practice newly learned calming, assertion, conflict resolution, or cognitive restructuring skills as needed (or assign “Anger Control” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis); review and process toward the goal of consolidation. |
| 17. Decrease the number, intensity, and duration of angry outbursts, while increasing the use of new skills for managing anger. (29) |
29. Monitor the client's reports of angry outbursts with the goal of decreasing their frequency, intensity, and duration through the client's use of new anger management skills (or assign “Alternatives to Destructive Anger” in the Adult Psychotherapy Homework Planner by Jongsma); review progress, reinforcing success and providing corrective feedback toward improvement. |
| 18. Increase verbalizations of empathy and concern for other people. (30) |
30. Use role-playing and role-reversal techniques to help the client develop sensitivity to the feelings of others in reaction to his/her antisocial behaviors. |
| 19. Identify social supports that will help facilitate the implementation of new skills. (31) |
31. Encourage the client to discuss and/or use his/her new anger and conduct management skills with trusted peers, family, or otherwise significant others who are likely to support his/her change. |
| 20. Increase the frequency of responsible and positive social behaviors. (32, 33, 34) |
32. Direct the client to engage in three altruistic or benevolent acts (e.g., read to a developmentally disabled student, mow grandmother's lawn) before the next session to increase his/her empathy and sensitivity to the needs of others.
33. Assign homework designed to increase the client's empathy and sensitivity toward the thoughts, feelings, and needs of others (e.g., “Headed in the Right Direction” from the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
34. Place the client in charge of tasks at home (e.g., preparing and cooking a special dish for a family get-together, building shelves in the garage, changing oil in the car) to demonstrate confidence in his/her ability to act responsibly. |
| 21. Parents learn and implement Parent Management Training skills to recognize and manage problem behavior of the client. (35, 36, 37, 38, 39) |
35. Use a Parent Management Training approach beginning with teaching the parents how parent and child behavioral interactions can encourage or discourage positive or negative behavior and that changing key elements of those interactions (e.g., prompting and reinforcing positive behaviors) can be used to promote positive change (e.g., Parents and Adolescents Living Together: Part 1, The Basics by Patterson and Forgatch; Parents and Adolescents Living Together: Part 2, Family Problem Solving by Patterson and Forgatch).
36. Ask the parents to read material consistent with a parent training approach to managing disruptive behavior (e.g., The Kazdin Method for Parenting the Defiant Child by Kazdin; Parents and Adolescents Living Together: Part 1, The Basics by Patterson and Forgatch).
37. Teach the parents how to specifically define and identify problem behaviors, identify their reactions to the behavior, determine whether the reaction encourages or discourages the behavior, and generate alternatives to the problem behavior.
38. Teach parents how to implement key parenting practices consistently, including establishing realistic age-appropriate rules for acceptable and unacceptable behavior, prompting of positive behavior in the environment, use of positive reinforcement to encourage behavior (e.g., praise), use of clear direct instruction, time-out, and other loss-of-privilege practices for problem behavior.
39. Assign the parents home exercises in which they implement and record results of implementation exercises (or assign “Clear Rules, Positive Reinforcement, Appropriate Consequences” or “Catch Your Teen Being Responsible” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis); review in session, providing corrective feedback toward improved, appropriate, and consistent use of skills. |
| 22. Increase compliance with rules at home and school. (40) |
40. Design a reward system and/or contingency contract for the client and meet with school officials to reinforce identified positive behaviors at home and school and deter impulsive or rebellious behaviors. |
| 23. Client and family participate in family therapy. (41) |
41. Refer family to an evidence-based family therapy such as Functional Family Therapy (see www.fftinc.com) or Brief Strategic Family Therapy (see Brief Strategic Family Therapy for Hispanic Youth by Robbins et al.) in which problematic interactions within the family system are assessed and changed through the use of family systems and social learning interventions to support more adaptive communication and functioning. |
| 24. Client and family participate in a Multisystemic Therapy program. (42) |
42. Refer client with severe conduct problems to a Multisystemic Therapy program with cognitive behavioral and family interventions to target factors that are contributing to his/her antisocial behavior and/or substance use in an effort to improve caregiver discipline practices, enhance family affective relations, decrease youth association with deviant peers and increase youth association with prosocial peers, improve youth school or vocational performance, engage youth in prosocial recreational outlets, and develop an indigenous support network (see Multisystemic Therapy for Antisocial Behavior in Children and Adolescents by Henggeler et al.). |
| 25. Verbalize an understanding of the difference between a lapse and relapse. (43, 44) |
43. Provide a rationale for relapse prevention that discusses the risk and introduces strategies for preventing it.
44. Discuss with the parent/child the distinction between a lapse and relapse, associating a lapse with a temporary setback and relapse with a return to a sustained pattern thinking, feeling, and behaving that is characteristic of conduct disorder. |
| 26. Implement strategies learned in therapy to counter lapses and prevent relapse. (45, 46, 47, 48) |
45. Identify and rehearse with the parent/child the management of future situations or circumstances in which lapses could occur.
46. Instruct the parent/child to routinely use strategies learned in therapy (e.g., parent training techniques, problem-solving, anger management), building them into his/her life as much as possible.
47. Develop a “coping card” on which coping strategies and other important information can be kept (e.g., steps in problem-solving, positive coping statements, reminders that were helpful to the client during therapy).
48. Schedule periodic maintenance or “booster” sessions to help the parent/child maintain therapeutic gains and problem-solve challenges. |
| 27. Parents verbalize appropriate boundaries for discipline to prevent further occurrences of abuse and to ensure the safety of the client and his/her siblings. (49) |
49. Explore the client's family background for a history of neglect and physical or sexual abuse that may contribute to his/her behavioral problems; confront the client's parents to cease physically abusive or overly punitive methods of discipline; implement the steps necessary to protect the client or siblings from further abuse (e.g., report abuse to the appropriate agencies; remove the client or perpetrator from the home). |
| 28. Identify and verbally express feelings associated with past neglect, abuse, separation, or abandonment. (50) |
50. Encourage and support the client in expressing feelings associated with neglect, abuse, separation, or abandonment (consider assigning “Letter to Absent or Uninvolved Parent” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
| 29. Establish and maintain steady employment. (51, 52) |
51. Refer the client to vocational training to develop basic job skills and find employment.
52. Encourage and reinforce the client's acceptance of the responsibility of a job, the authority of a supervisor, and the employer's rules. |
| 30. Identify and verbalize the risks involved in sexually promiscuous behavior. (53) |
53. Provide the client with sex education; discuss the risks involved with sexually promiscuous behaviors; and explore the client's feelings, irrational beliefs, and unmet needs that contribute to the emergence of sexually promiscuous behaviors (or assign “Connecting Sexual Behavior With Needs” or “Looking Closer at My Sexual Behavior” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
| 31. Parents participate in marital therapy. (54) |
54. Assess the marital dyad for possible substance abuse, conflict, or triangulation that shifts the focus from marriage issues to the client's acting-out behaviors; refer for appropriate treatment, if needed. |