An empirical "real world" comparison of two treatments with aggressive adolescent males.

This research study compares the efficacy of Mode Deactivation Therapy (MDT), an advanced form of Cognitive Behavioral Therapy based on Beck's theory of modes, and standard Cognitive Behavioral Therapy (CBT) for adolescent males in residential treatment. The results showed MDT was superior to CBT in reducing both physical and sexual aggression and reductions of external and internal psychological distress as measured by the Devereux Scale of Mental Disorder (DSMD) and Child Behavioral Checklist (CBCL).

Keywords: CBT, MDT, Conduct Disorder, Aggression.

Introduction

This study compares two effective treatments, Mode Deactivation Therapy (MDT) and Cognitive Behavioral Therapy (CBT) for adolescent males in residential treatment. CBT has had numerous publications regarding its efficacy with adolescents (Reinecke, Dattilio, Freeman, 1996, 2004). MDT has been demonstrated to be an evidenced based treatment for adolescents in numerous studies (Apsche, Ward 2004, Apsche Ward, Evile 2004; Apsche, Bass, Jennings, Murphy, Hunter and Siv, 2005, compared MDT to CBT and social skills training (SST) in reducing physical aggression and sexual aggression with adolescents. MDT is shown to be more effective than CBT or SST in reducing both physical and sexual aggression in these adolescents as measured by the Devereux Scale of Mental Disorder (DSMD) and Child Behavioral Checklist (CBCL).

Both CBT and MDT have been demonstrated to be effective treatments with difficult adolescents in numerous studies. CBT has a plethora of literature published in recent articles and books on its efficacy with adolescents. Reinecke, Dattilio, Freeman, 2004, Friedberg, Maclure, 2002. CBT has been demonstrated to be effective in treating adolescent depression, Rehm and Sharp, 1996, adolescent anxiety disorders, Kendall, 2004 and personality disorders, Beck, Freeman, Davis and Associates, 2004, aggression, Lochman, Whidby, Fitzgerald, 2000, and anger, Nelson and Finch, 2000.

MDT has had several recent articles that demonstrate it is an effective treatment with aggressive and abused or reactive adolescents (Apsche, Bass, Siv, 2005; Apsche, Ward Bailey 2004.MDT and CBT were compared together and with social skills training (Apsche, Bass, Jennings, Murphy, Siv and Hunter, 2005); Apsche, Bass, Siv, 2005). The results suggest that MDT was superior to CBT and SST in reducing both physical and sexual aggression in adolescents in a residential treatment center. The results of these studies suggest that MDT is effective in treating physical and sexual aggression in adolescent males. These results also suggest that MDT is more effective in treating these adolescents than standard CBT or SST. (Apsche et. al., 2005).

METHOD

Sample Characteristics

A total of 40 male adolescents participated in the study. All subjects were referred to the same residential treatment facility for the treatment of physical aggression and/or sexual aggression. In this study, subjects were randomly assigned to one of the two treatment conditions at the time of admission based on available openings in the caseload of the participating clinicians. Both treatment conditions showed similarity in terms of the frequency of Axis I and Axis II diagnoses, age, and racial background. To ensure consistency in the delivery of the two respective treatments, therapists were specifically trained in one of the two treatment curriculums/methods. The average length of residential treatment across all conditions was around 11 months.

Cognitive Behavioral Therapy (CBT) Participant: Nineteen male sexual offenders from a residential sex offender treatment program for adolescent males were assigned to the CBT condition. The group was comprised of 15 African Americans, 3 European Americans and 1 Hispanic American with ages between 11 and 18 years with an average age of 16.1. The principal Axis I diagnoses for this group included Conduct Disorder (15), Oppositional Defiant Disorder (4), and Post Traumatic Stress Disorder (9). Axis II diagnoses for the group included Mixed Personality Disorder (4), Borderline Personality Disorder (4), Narcissistic Personality Disorder (0) and Dependent Personality Disorder (1). All participants were first-time admissions to the program and had never participated

in a cognitive-behavioral based treatment program before. Their mean estimated length of stay was 18.3 months (SD=3.53, range 12-23), mean estimated number of victims was 2.4 (SD=3.4, range 1-12).

The particular CBT methodology used for this group employed a published treatment curriculum and workbook system for adolescent sex offenders called "Thought Change" (Apsche, 1999; Apsche, Evile and Murphy, 2004). This structured treatment program is specifically designed for personality disordered and conduct-disordered youth with psychosexual disturbances and high levels of aggression and violence. Components of this psycho-educational treatment curriculum included daily recording of negative thoughts, cognitive distortions, cognitive restructuring, sexual offense patterns and beliefs, aggressive patterns and beliefs, mood management, dysfunctional beliefs, taking responsibility, mental health maintenance, substance abuse issues, and victim empathy.

Mode Deactivation Therapy (MDT) Participants: A total of twenty-one male adolescents were assigned to the MDT condition. All participants were first-time admissions to the program and had never participated in a cognitive-behavioral or mode deactivation based treatment program before. The group was comprised of 17 African Americans, 3 European Americans and 1 Hispanic American with an average age of 16.5. The principal Axis I diagnoses for this group included Conduct Disorder (15), Oppositional Defiant Disorder (4), Post Traumatic Stress Disorder (8), and Major Depressive Disorder, primary or secondary (5). Axis II diagnoses for the group included Mixed Personality Disorder (6), Borderline Personality Traits (5), and Narcissistic Personality Traits (2). The MDT condition used the methodology described earlier in this paper. Their mean estimated length of stay is 16.36 (SD+1.73, range12-19), mean number of reported victims is 3 (SD=3.16, range 1-13). Types of offenses included flashing, fondling, vaginal and anal penetration, or a combination for both conditions of this study.

MEASURES

The key measures of physical and sexual aggression used in this study consisted of Daily Behavior Reports and Behavior Incident Reports. The Daily Behavior Reports were completed by all levels of staff, both professional and paraprofessional, across all settings of the residential treatment program (e.g., schoolroom, psychoeducational classes, treatment activities, residential dormitories, etc.). The Behavior Incident Reports were only completed by staff following the occurrence of serious or critical incidents, namely, acts of physical and/or sexual aggression. Inter-rater reliability in the use of these measures was determined by independently totaling the number of physical and sexual aggression incidents on both the Daily Behavior Report cards and the Behavior Incident Report forms and calculating the percentage of agreement. The agreement for this study was at the 98% level.

The baseline ("pre-treatment") measure of physical and sexual aggression consisted of the average number of incidents per week that occurred during the first 60 days following admission and the post-treatment measure was the rate of occurrence during the 60 day period prior to discharge.

Two assessments were used to measure the behavior of the residents, which included the Child Behavior Checklist (CBCL; Achenbach, 1991) and the Devereux Scales of Mental Disorders (DSMD; The Devereux Foundation, 1994).

The CBCL is a multi-axial assessment designed to obtain reports regarding the behaviors and competencies of 11 to 18 year olds. The means and standards are divided into three categories: internalizing (which measures withdrawn behaviors, somatic complaints, anxiety and depression), externalizing (which measures delinquent behavior and aggressive behavior), and total problems (which represent the conglomerate of total problems and symptoms, both internal and external).

The DSMD illustrates level of functioning in comparison to a normal group, via behavioral ratings. T scores have a mean of deviation of 10; a score of 60 or higher indicates an area of clinical concern.

[FIGURE 1 OMITTED]

Thus, the first analysis suggests that both types of treatment--Mode Deactivation Therapy and Cognitive Behavioral Therapy--had a positive effect of reducing rates of physical and sexual aggression over the course of treatment (see Figure 3).

The second analysis looked at significant differences in treatment effectiveness between the two treatment conditions. It was hypothesized that adolescent male aggressive sexual offenders would show greater improvements in terms of aggressive and sexual acting out behavior when treated with MDT as compared to CBT. To test this hypothesis, a one-way analysis of variance (ANOVA) was conducted on the baseline and post-treatment measures of physical and sexual aggression. Both post-treatment physical aggression and post-treatment sexual aggression were significantly affected by type of treatment, F(2, 36) = 8.32, p < .01 (post-treatment aggression); F(2, 36) = 10.02, p < .01 post-treatment sexual aggression).

To better elucidate between-group differences in magnitude of effect, independent factorial analyses on treatment model and variable were conducted.

With an overall percent reduction of 80.7% in rates of post-treatment physical aggression, Mode Deactivation Therapy was found to be superior to Cognitive Behavioral Therapy at 72.6%. The greater magnitude of effect for MDT was statistically significant compared to CBT. (Table 4)

The most dramatic difference between treatment groups was found in reduction of post-treatment rates of sexual aggression. In this instance, only Mode Deactivation Therapy showed a statistically significant reduction in rates of sexual aggression from baseline to post-treatment. MDT showed a reduction of 84.5% in sexual aggression compared to CBT at 72.0%. Post-treatment rates of sexual aggression were .30 for MDT and .42 for CBT. The differences were significant using an independent T-test comparing, CBT and MDT. The T-test showed T = 2.21, df = 39, p <.01. The results clearly show that MDT produced significantly superior results when compared to CBT. These differences in magnitude of effect are graphically represented in Table 4.

[FIGURE 2 OMITTED]

The CBCL is a multi-axial assessment designed to obtain reports regarding the behaviors and competencies of 11 to 18 year olds. The means and standards are divided into three categories: internalizing (which measures withdrawn behaviors, somatic complaints, anxiety and depression), externalizing (which measures delinquent behavior and aggressive behavior), and total problems (which represent the conglomerate of total problems and symptoms, both internal and external).

The DSMD uses T scores with a mean of 50 and a standard deviation of 10; any T-score over 60 is considered clinically significant. The means and standards are divided into four scales and analyzed: (1) Internalizing (which measures negative internal mood, cognition, and attitude), (2) Externalizing (which measures prevalence of negative overt behavior or symptoms), (3) Critical Pathology (which represents the severe and disturbed behavior in children and adolescents), and Total (which represent the conglomerate of all scores including general Axis I pathology, delusions, psychotic symptoms, and hallucinations).

At the time both CBCL and DSMD assessments, the two groups differed significantly. Residents who participated in MDT had lower scores on all measures than did residents who engaged in CBT.

The results indicate that the mean scores on both measures the internalizing factor, externalizing factor, critical pathology, and total score for the MDT group is at or near one standard deviation below the CBT group.

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

[FIGURE 5 OMITTED]

[FIGURE 6 OMITTED]

Results

This research study was initiated to compare the efficacy of two different treatment methods for male adolescents in residential treatment for physical and/or sexual aggression. We began the analysis by assessing weekly behavioral reports, which indicated a number of observed sexual or aggressive acts. Once reports were compiled, statistical analysis of the results ensued. It was found that all participants benefited from treatment regardless of theoretical orientation (see Table One). The baseline average rate of aggression across all groups was 1.56 with a total standard deviation of .501 and standard error of .065. There was a 74% reduction in rate of aggression to the post treatment mean of .41, with a standard deviation of .495 and standard error of .065. An independent T test was performed on the difference in means. The T-test found a significant difference between the baseline and post-treatment measures T = 18, df = 39, p <.01. A one-way ANOVA was computed and indicated a significant difference, F (2,36) 8.32, p<.01.

Further analysis was performed on the difference between baseline and post-treatment rates of sexual aggression. The baseline mean across both groups was 1.68 with a total standard deviation of .471 and standard error of .061. There was a 76% reduction in the rate of sexual aggression to the post-treatment mean of .41 with a standard deviation of .495 and standard error of .065. A one-way ANOVA was computed and indicated a significant difference, F (2,36) = 10.02, p < .01.

There was a significant difference of 1SD or better, across all domains of DSMD and CBCL for the MDT group. On the DSMD the MDT total score was reduced to less than 60. This indicates that MDT reduced the score to "not of the level of clinical concern."

Both CBT and MDT reduced both internal and external scores on the CBCL. MDT scores on the CBCL showed on 1 SD or more significance than the CBT scores across all individual measures. These results suggest that MDT might be effective in reducing symptoms of Axis I pathology as measured by the CBCL and DSMD.

Discussion

The data indicates that MDT was superior to CBT in reducing internal distress and psychological symptoms as measured by the CBCL and DSMD. Moreover, MDT was superior in reducing both physical aggression and sexual aggression in this study. It appears that MDT is superior in treating this typology of adolescents. It is also interesting to note that MDT was superior in reducing specific symptoms related to Post-Traumatic Stress Disorder. These findings might offer an additional methodology to the body of literature for treating PTSD in adolescents.

As in any real world study, it is always difficult to control for the levels of competence of the participating therapists and their adherence to the "purity" of the referenced treatment methods. Best efforts were made to control for this common problem by ensuring that therapists shared the same professional degree and level of clinical experience in each of the two methodologies and by providing training in the delivery of each model prior to the study. Training was provided by a doctorate level psychologist for both groups. The MDT group was trained by the first author and founder of MDT.

The strength of the outcomes could be further enhanced with the inclusion of additional outcome measures and, ideally, long-term follow-up of the youth who participated in the study. This study measured levels of psychological distress, including internal and external, as measured by the CBCL and DSMD. MDT demonstrated a significant decrease in all levels of behavior and Psychological distress.

It is important to note that the authors do not purport that MDT will generalize to any groups other than youngsters with conduct and personality disorders.

The authors hope that future research may use randomized trials in outpatient clinics and attempt to replicate these findings in other residential treatment facilities and with other relevant adult and adolescent populations, particularly for those with severe aberrant behaviors including personality disorders, conduct disorder and aggression. Thus, MDT might be considered in future studies as a consideration to reduce problems related to Axis I disorders and internal distress.

REFERENCES

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Author Information:

Jack A Apsche, Ed.D., ABPP, Apsche Center for Evidenced Based Psychotherapy

111 South Main Street

Yardley, PA 19067.

215-321-4072

[e-mail]

[e-mail]

Christopher K. Bass, Ph.D.

Dept of Psychology

Clark Atlanta University 

207 Knowles Hall

Atlanta, GA 30313

[e-mail]

Alexander M. Siv, M.A.

Brightside for Families and Children

2112 Riverdale Street

West Springfield, MA 01089

[e-mail]

Susan Matteson, LCSW, ACSW 

TheraCare

6981 North Park Drive

Pennsauken, NJ 08109

[e-mail]

Table  1. Demographic Characteristics of
Study Participants by Group

Axis I                               CBT    MDT
  Conduct Disorder                    15     13
  Oppositional Defiant Disorder        4      4
  Post Traumatic Stress Disorder       9      8
  Major Depression                     0      5
Axis II
  Mixed Personality Disorder           5      6
  Borderline Personality Traits        4      5
  Narcissistic Personality Traits      2      2
  Dependent Personality Traits         0      0
  Avoidant Personality Traits          0      0
Race
  African American                    15     17
  European American                    3      3
  Hispanic/Latino American             1      1
  Total                               19     21
Average Age                         16.1   16.5

Table 2. Descriptive Statistics of  Participants
pre and post mean scores by group

                     Tx                 Std.   Std.
Measure             Type    N    Mean   Dev.   Error

Baseline            CBT     19   1.53   .513    .118
Physical            MDT     20   1.55   .510    .114
Aggression
                    Total   39   1.56   .501    .065

Baseline            CBT     19   1.68   .478    .110
Sexual Aggression   MDT     20   1.65   .489    .109

                    Total   39   1.67   .471    .061

Post-Treatment      CBT     19   0.42   .507    .116
Physical            MDT     20    0.3   .470    .105
Aggression
                    Total   39   0.41   .495    .065

Post-Treatment      CBT     19   0.47   .513    .118
Sexual Aggression   MDT     20   0.25   .444    .099

                    Total   39   0.41   .495    .065

                         95%
                         confidence
                         Interval

                    Lower     Upper
Measure             bound     Bound    Min    Max

Baseline             1.28      2       1      2
Physical             1.31      2       1      2
Aggression
                     1.43      2       1      2

Baseline             1.45      2       1      2
Sexual Aggression    1.42      2       1      2

                     1.56      2       1      2

Post-Treatment       0.18      1       0      1
Physical             0.08      1       0      1
Aggression
                     0.28      1       0      1

Post-Treatment       0.23      1       0      1
Sexual Aggression    0.04      0       0      1

                     0.28      1       0      1

Table 3.  ANOVA--Difference in Outcomes Between MDT and CBT

                                      Sum of
     Measure                         Squares      Df

Baseline Physical   Between Groups     .707        2
Aggression          Within Groups     14.005      36
                    Total             14.712      38

Post-Treatment      Between Groups    3.299        2
Physical            Within Groups     11.108      36
Aggression          Total             14.407      38

Baseline Sexual     Between Groups     .537        2
Aggression          Within Groups     14.005      36
                    Total             14.542      38

Post-Treatment      Between Groups    3.483        2
Sexual              Within Groups     9.737       36
Aggression          Total             13.220      38

                         Mean
     Measure            Square          F       Signif.

Baseline Physical        .353
Aggression               .250         1.413      .252

Post-Treatment          1.649
Physical                 .198         8.316      .001
Aggression

Baseline Sexual          .269         1.074      .349
Aggression               .250

Post-Treatment          1.742         10.017     .001
Sexual                   .174
Aggression

Table  4. Post-Treatment Scores and Percent Reduction
in Types of Aggression across Treatments

                        Post-        MDT        Post-        CBT
                      Treatment    Percent    Treatment    Percent
                        Score     reduction     Score     reduction

Physical Aggression      .30       .80.7%        .42        72.6%
Sexual Aggression        .25       .84.5%        .47        72.0%

Table 5. T-scores, ranges, and standard deviations
in all measures for both groups

Measure          Scale                        CBT

Child Behavior   Internal           71.43 (Range = 66 - 84)
Checklist        External           73.74 (Range = 66 - 86)
(CBCL)           Total                       72.67
Pre-Treatment

Child Behavior   Internal        63.66 (Range = 55 - 80) SD =
Checklist                                    10.04
(CBCL)           External        65.63 (Range = 52 - 82) SD =
Post-Treatment                               10.76
                 Total               64 (Range = 52 - 84)
                                           SD = 9.24

DSMD             Internal            70.5 (Range = 62 - 84)
                 External            73.1 (Range = 64 - 86)
Pre-Treatment    Critical Path       68.7 (Range = 58 - 88)
                 Total                       70.77

DSMD             Internal           61.70 (Range = 52 - 74)
                 External           57.81 (Range = 52 - 72)
Post-Treatment   Critical Path      50.21 (Range = 46 - 66)
                 Total              58.00 (Range = 56 - 82)

Measure                                       MDT

Child Behavior                      72.57 (Range = 68 - 86)
Checklist                           72.94 (Range = 64 - 86)
(CBCL)                                       72.74
Pre-Treatment

Child Behavior                   51.75 (Range = 39 - 71) SD =
Checklist                                    12.10
(CBCL)                           50.04 (Range = 37 - 69) SD = 11.74
Post-Treatment
                                  51.00 (Range = 40 - 61) SD
                                            = 10.28

DSMD                                 71.3 (Range = 64 - 83)
                                     72.5 (Range = 67 - 84)
Pre-Treatment                        70.5 (Range = 60 - 86)
                                             71.50

DSMD                                49.70 (Range = 46 - 56)
                                    45.88 (Range = 41 - 54)
Post-Treatment                      46.15 (Range = 42 - 56)
                                    46.15 (Range = 40 - 56)