We’ve all seen a child’s outburst in the grocery store, at school or in the home. Often the adult will try to deflect the flare-up by ignoring it temporarily, or attempt to encourage or enforce compliance through the promise of a reward or the threat of punishment. But for millions of kids, the inability to cope flexibly with life’s problems can trigger explosive behaviors that are unmanageable and harmful.

A Problem of Skills, Not Will

The common view suggests these kids behave badly to “have their way,” and need incentives — or disincentives — to conform to adult wishes and expectations. The Think:Kids program at Massachusetts General Hospital takes a different approach. “Think:Kids promotes the understanding that ‘challenging kids’ — kids with social, emotional and behavioral problems — lack the skills, not the will, to behave well,” says J. Stuart Ablon, PhD, director of Massachusetts General Hospital’s Think:Kids program and associate clinical professor of Psychology in the Department of Psychiatry at Harvard Medical School.

Originally started in 2003 as the Collaborative Problem Solving Institute, Think:Kids is gaining momentum because of persuasive evidence that its Collaborative Problem Solving (CPS) approach works across a broad range of circumstances, geographies and age groups.

Teaching Flexibility

Unlike traditional models of discipline, Think:Kids addresses challenging behaviors using an approach that avoids the use of power, control or motivational incentives. It focuses instead on teaching the thinking skills kids need to solve problems flexibly and to handle frustration. Teaching these skills takes place by helping children and their adult caregivers learn to resolve disagreements collaboratively. This involves three basic steps: providing empathy/reassurance, defining the problem and inviting the child to brainstorm.

“Moderate to severe behavioral problems cross all geographical and socio-economic boundaries,” says Dr. Ablon.

Dr. Ablon estimates that fully 10 to 20 percent of young people exhibit challenging behaviors. In addition, “moderate to severe behavioral problems cross all geographical and socio-economic boundaries,” says Dr. Ablon. “Kids with these issues are found in homes and schools across America, from inner cities to affluent suburbs. It’s a massive problem with staggering costs.”

Opened in 2009, the Think:Kids clinic has helped hundreds of families in the Boston area. Boston also serves as the nerve center for what has become a much broader effort. Here, Dr. Ablon heads up a team of mental health professionals who train more than ten thousand parents, educators and clinicians annually, and who consult with schools and treatment programs across the globe. Portland, Oregon and Ottawa, Ontario, are major hubs for Think:Kids programs. Other programs are sprinkled around the United States and as far away as Singapore. Implementation has just been launched in New York City schools. Through a collaboration with the Department of Education, Think:Kids has begun training 1,500 NYPD school safety agents and officers.

Extending the Model

In Oregon, CPS principles were first introduced in 2003 at an in-patient psychiatry unit for adolescents at Legacy Emanuel Hospital in Portland, under the supervision of Dr. Ablon. In the first year, the approach was credited with a 70 percent decline in the use of seclusions and restraints.

In 2007, the methodology was extended statewide by the Oregon Addictions and Mental Health Services Division of the Department of Human Services. Through their training, all the adults and systems concerned with the care of a particular child — parents, foster parents, schools, residential programs, hospitals, doctors and others — became acquainted with CPS principles and developed a common language for collaboration. Many have adopted these practices and are working to fully implement them.

“The CPS model succeeds as a new approach that people with minimal psychological training can absorb, that doesn’t assign blame to kids or adults, and that focuses on diminishing the extraordinary behavioral meltdowns that keep kids from being with the people they need the most,” observes Ajit N. Jetmalani, MD, director of Child Psychiatry at Oregon Health & Science University (OHSU) Doernbecher Children’s Hospital and Child Psychiatric Consultant to Oregon AMH. Kairos, an organization that provides intensive mental health services at nine settings in Oregon at the direction of CEO Robert E. Lieberman, MA, LPC, was among the first of 40 organizations in the state to adopt the new approach. Of the nine Kairos settings, four have intensive treatment milieus in which restraint and seclusion are used. Implementation of the CPS model with assistance from Think:Kids is credited with cutting the number of emergency safety interventions — restraints, hospital trips or seclusions — from 861 in 2008 to 144 in 2012 through September.

Most recently, Drs. Ablon and Jetmalani have forged an alliance between Think:Kids and OHSU, aiming to establish a sustainable presence for the program in Oregon and beyond. Dr. Ablon is also working to establish more “hubs of activity” for Think:Kids across the country and around the world. Dr. Ablon is also working to establish more ‘hubs of activity’ for Think:Kids across the country and around the world.

And with some experts suggesting that pediatricians now spend 30 to 40 percent of their time dealing with developmental and behavioral challenges, broadly applying Think:Kids principles could be just what the doctor ordered.

Originally written for Mindscapes, a MGH Department of Psychiatry Newsletter