Ohad Hershkovitz, Psy.D Director, CBT Institute of Israel

Ohad Hershkovitz, Psy.D Director, CBT Institute of Israel
Parental Training Ohad Hershkovitz, Psy.D Director, CBT Institute of Israel

Parental Training What is it?
Interventions focusing on the parents (or responsible environment) instead of the child The primary and stated goal is to cause change in the child The secondary and sometimes unstated goal is to cause change in the parents

Child Therapy Alone: Is It Enough?
Child Therapy without Parental Intervention Environmental factors may continue to influence child and possibly sabotage therapy Child’s maturity may limit extent of ability to affect change Changes may be strictly symptom-based (e.g. behavioral), and not schematic (e.g. core beliefs)

Parental Training vs. Child Therapy
Parameters to consider when deciding who to target? Age of child – take responsibility for therapy Cognitive maturity of child Willingness to undergo therapy Other children in household/environment similarly affected Location of problems (e.g. home/school) Relationship status of parents Receptiveness of parents Emotional maturity of parents Personal beliefs of therapist

Comparison of treatment models
Parental Training Child Therapy Doesn’t require minimum child cognitive/emotional maturity Doesn’t require child participation Can address problem at root (schematic level) Can address parents’ personal issues as well Short interventions can lead to significant schematic changes in child Can improve environment for other children Doesn’t require parents to take responsibility (or does it?) Doesn’t require parent participation (or does it?) Often symptomatic, not schematic (dependent on age/maturity) Parental inclusion usually superficial Schematic changes usually require significantly longer therapy than Parental Training May not affect general home environment

Review of Parenting Styles and their Effects
Authoritative Authoritarian Permissive Neglectful

Parenting Styles Authoritative
Warmth – demonstration of love and affection Results in development of social skills and self conception Demandingness – rules and consistent discipline Results in development of self-control and social responsibility Respect for child/adolescent’s autonomy/opinions Results in development of independence and competence

Parenting Styles Authoritarian Lacking in Warmth
Detrimental to social skills and self conception Lacking in Respect for Autonomy Detrimental to independence and competence Overuse of Demandingness

Parenting Styles Permissive Lacking in Demandingness Provides warmth
Detrimental to self control and social responsibility Provides warmth Provides respect for autonomy

Parenting Styles Neglectful Lacking in Demandingness Lacking in Warmth
Detrimental to self control and social responsibility Lacking in Warmth Detrimental to social skills and self conception Provides Respect for Autonomy Most problematic parenting style Research indicates most behavioral problems: delinquency, sexual promiscuity, drug/alcohol abuse

Problematic Parenting Styles

Problematic Parenting Style - Pathway

Conditioning Behavioral Conditioning Cognitive Conditioning
Parental Attention due to Noncompliance = Positive Reinforcement for child Angry parent = Increased attention to child Child Compliance = Positive Reinforcement for parent’s anger Cognitive Conditioning Lingual schema = “90% is not good enough” Evolutionary survival instinct = accept parental authority/guidance Rationalization of parental attitudes…

Problematic Parenting Style: Rationalization
Parental message: We need to protect/correct/punish/neglect/over-empower you Child Rationalization: I have no external proof (or internal confidence) to believe otherwise, so it must be true Child Conclusion: I must be weak/flawed/bad/worthless/overly responsible

Problematic Parenting Style - Example
Parenting Style: Overprotective Core belief: “I must be in danger, I’m not strong enough to cope” Anxiety, Avoidance, Dependent

Parenting Style: Intrusive/Over-controlling Core belief: “I need to rely on them, I cannot rely on myself” Dependent, Avoidant, OCD, Eating Disorders

Parenting Style: Critical/Judgmental Core belief: “There is something inherently deficient in me” Depression, Phobia, Panic Disorder, CD/ODD

Parenting Style: Belittling, Degrading Core belief: “I don’t deserve love” Social Phobia, Jealousy, Personality D/O, CD/ODD

Parenting Style: Histrionic/Repressive Core belief: “Emotions are dangerous or proof that something is wrong” Avoidant, OCD, Eating Disorders, Phobia, Panic

Parenting Style: Spanking Core belief: “Bad behavior must be forcibly punished” Anger, IED, Personality D/O

Poor Parenting Child therapy without parental training can be a superficial band-aid solution

Research on Parenting Styles & Training
Poor Parental Style highly correlated with non-organic psychiatric/behavioral problems in children Severe ODD highly correlated with development of CD ODD children 4x more likely to develop psychiatric issues ODD children with comorbid psychiatric issues 25x more likely to exacerbate psychiatric issues later in life Parental Training correlated with significant improvement in behavioral disorders Parental Training sometimes* correlated with significant improvement in psychiatric conditions Limited research in this field makes generalizations difficult Parental Training follow-up (years later) correlated with no significant difference between initially non-compliant children and psychiatrically healthy adults on following measurements: Relationship with parents Delinquency (crime, substance abuse) Emotional Adjustment Academic Achievement

Research on Parenting Styles & Training
Childhood: Noncompliance, Temper tantrums Adolescence: Aggression, Stealing, Substance abuse Overt: Defiance, Fighting Covert: Lying, Stealing Specific Setting: Home General Setting: School, Broader Community

Poor Parenting – Examples of Causes
Behavioral Conditioning from parents’ parents Repeating faulty behaviors Cultural Norms e.g. emotionally intolerant society, expressively anxious society Parents’ mental health issues and fears Anxiety leads to anxious parenting Inconsistency between parents e.g. strict vs permissive Relationship inequality Delegitimization of partner mimicked by children Conflict between parents Inconsistent structure and rules, manipulation Resistance to change Responsibility for child’s health/behavior = blame for problems Fear of making mistakes = perfectionism, over-controlling Fear of rejection by child = permissive Anger at child = neglect, over-demandingness

Parental Training vs. Parental Therapy
Therapists often make mistake of losing focus or crossing boundary of parental training to parental therapy When should parental training become parental therapy? Parent shows willingness to change but inability due to own personal issues e.g. Parent’s behavior dictated by anxiety, addiction, depression, etc. Couple preoccupied with marital problems, unable to work together for child e.g. ongoing divorce proceedings, active conflict, etc.

Parental Training vs. Parental Therapy
Brief: 1-3 months Primary Goal: Child’s improvement Target: Parental Behavior Scope: Limited focus on parent’s experience H&N: Highly structured Responsibility: Placed primarily on parent Longer: 3-6 months Primary Goal: Parent’s improvement Target: Parental Mental Health Scope: Primary focus on parent’s experience H&N: Varies by therapy/therapist Responsibility: Shared with therapist

Parental Training: Recruiting

Overview Inquire Reflect Identify & Reinforce Identify & Challenge

Inquire (parent’s experience) Why have you chosen your particular parenting style? Or why do you feel it is the right one? What goals do you hope to achieve in parenting the way you do? How effective is your parenting style in achieving these goals? What would you like to see happen differently? Allow parents to express frustration and hopefully realization that parenting style is ineffective

Reflect (child’s experience) What does child hear/see from parents? How does child interpret these events? How does child feel as a result? Is there an identifiable cycle? What might break the cycle? What might lead the child to interpret events more positively? (Target parenting behavior)… *Use visual aids, e.g. pathways, charts

Identify + Reinforce (Motivation to change) What might break the cycle? What might lead the child to interpret events more positively? (Target parenting behavior)… Do you think trying (target parenting behavior) might bring about a different interpretation and subsequently reaction from your child? Why or why not? Have you tried? How often? What happened? Do you feel you want to commit the time and energy necessary to helping your child via making certain changes in the structure and discipline that the child experiences? How important is it to help your child feel and behave better? Do you feel it would be acceptable to leave the situation as it is? How do you see your child developing as an adolescent/adult if there is no change or things continue to get worse?

Identify + Challenge (Resistance to change) Fear of blame Does the fact that we can better match your parenting to your child’s needs mean you are to blame for doing something wrong? Fear of mistakes Have parenting mistakes in the past by you or others led to irrevocable damage? Fear of taking responsibility from the child for change Does your contributing to change mean the child will not learn to take responsibility? Fear of giving unconditional love Does expressing love regardless of behavior mean the child will not respond to discipline?

Use Encouraging Language Focus on child, not on parent e.g. “What can we do to help the child feel less shy?” instead of “Can you stop criticizing your child?” Talk in shades of grey, not black and white e.g. “What can we try doing to increase the chances of compliance?” instead of “If you want your child to listen, say X, not Y.” Reinforce positive beliefs and behaviors e.g. “Sounds like you have good intuition and some really good ideas and reactions. We probably don’t need to make too many changes.”

Parental Training: Challenges
Special Circumstances Divorced/In-conflict parents ADHD/Neurological problems School-specific behavioral problems

Recruiting: Practice Groups of 3 1 therapist, 2 parents
Review Recruiting steps Inquire (parent’s experience) Reflect (child’s experience) Identify & Reinforce (Motivation to change) Identify & Challenge (Resistance to change)

Parental Training Techniques

Parental Training: Behavioral Techniques
PET – Parent Effectiveness Training (Gordon) Child seen as equal Child seen as decision-maker; Parents express needs Parent does not express authority

STEP – Systematic Training for Effective Parenting (Dinkmeyer, McKay) Identify and reflect child needs Allow child to choose alternative actions for need

Behavioral Methods Reward & Punishment Positive Reinforcement

Parenting Skills (Abidin) Combines parental experience with strict behavior changes

HNC: Helping the Noncompliant Child (Forehand, McMahon)
Primarily used on children aged 3-8 Stages Attending Rewarding Ignoring Effective with CD, ADHD, developmental problems Effective for parents at risk for child abuse/neglect or substance abuse Contraindicated for autism, parental psychosis or other severe mental illness, severe substance abuse

Training: Attending

Training: Rewarding 3 types
Physical Rewards – hug, kiss, pat on the back Unlabeled verbal rewards – “Great!”, “Nice job!” Labeled verbal rewards – “Thank you for picking up the toys like I asked”

Training: Rewarding Guidelines for using rewards Be specific
Give immediately Focus on Improvement Use consistently

Training: Ignoring Attention-seeking behaviors Whining Nagging
Temper tantrums Interrupting Behaviors potentially harmful to people/property (e.g. fighting) should NOT be ignored

Training: Ignoring Ignoring is an ACTIVE process
Decide ahead of time which inappropriate behaviors to ignore When ignoring, actively avoid giving attention to child No eye contact or verbal cues (“Don’t look!”) No verbal contact (“Don’t talk!”) No physical contact (“Don’t touch!”)

Training: Ignoring Ignoring starts as soon as inappropriate behavior begins Ignoring stops soon after (10-15 seconds) inappropriate behavior stops Inappropriate behavior must be ignored EVERY time it appears, otherwise it will get worse instead of better.

Training: Ignoring Ignoring is never used alone, should always be combined with positive attention (attends, rewards) for the alternate appropriate behavior

Training: Reward/Punishment

Training: Giving Instructions
Get child’s attention Move close Say the child’s name (maximum of 2 times) Establish eye contact

State the instruction clearly Give ONE instruction at a time Use firm voice Phrase as “Do” command Use simple language Use gestures as appropriate Rationale (if given) precedes the instruction

Wait 5 seconds Count silently No verbalization to child

Training: Instructions for Noncompliance
Issue a single clear instruction “Please pick up your toys now”

If the child displays compliance to the instruction within 5 seconds, provide positive attention Rewards Attends e.g. “Thank you so much for playing quietly, I really appreciate it when you do what I ask”

If the child does not display compliance to the instruction within 5 seconds, give warning “If you do not X, you will have to go to time out”

If the child displays compliance to the warning within 5 seconds, give positive attention Rewards Attends

If the child does not display compliance to the warning within 5 seconds, without lecturing, scolding, or arguing. Tell the child “Because you did not X, you have to sit in the chair until I say you can get up.”

Ignore child’s shouting, protesting, and promises to comply Leave child in time out for 3 minutes, including being quiet for last 15 seconds

When time out is completed, return child to situation which resulted in noncompliance Restate original clear instruction Repeat positive attention or warning/time- out as necessary

Training: Procedure Procedure and rationale for each skill are explained Underlying social learning principle for each skill are briefly presented

Training: Procedure Therapist demonstrates skill via modeling and role playing Parent practices skill with therapist, who role plays as child

Training: Procedure If child is included in therapy, teach child skill as well Parent and therapist provide developmentally appropriate explanation Child repeats procedure verbally and role plays relevant situations

Training: Procedure If child is included in therapy:
Parent practices with child in therapy setting, therapist observes and coaches

Training: Procedure Parent is given daily homework
Practice specific situations with child (initiated by parent) e.g. “Pick up your toys” Practice with naturally occurring situations e.g. When child cries

Training: Procedure Parent is given handouts with explanations specific to each skill to take home Parent is given data sheets to practice and records interventions at home

HNC: Practice Groups of 2 1 parent, 1 therapist
Resistant child (e.g. stops doing homework, asks to play instead) Practice HNC steps separately (as with parents) Attending Rewarding Ignoring Giving Instructions Instructions for Noncompliance

A deeper look behind the scenes
Self-Esteem A deeper look behind the scenes

Rationalization: Review
Parental message: We need to protect/correct/punish/neglect/over-empower you Child Rationalization: I have no external proof (or internal confidence) to believe otherwise, so it must be true Child Conclusion: I must be weak/flawed/bad/worthless/overly responsible

Rationalization: Development of Mental Health Problems
Parental belief: I need to be strong/correct/right/perfect/accepted/in control Child Rationalization: I have no external proof (or internal confidence) to believe otherwise, so it must be true Child Conclusion: The world must be dangerous/punishing/evil/mean/ungratifying/intolerant/lonely

Parental message: “I need to be make sure everything is under control at all times” Child Rationalization: “Lack of control is dangerous” “I need to be in control too” Child Symptoms: GAD, OCD, Phobia

Parental message: “I need to think about every possible risk otherwise something will go horribly wrong” Child Rationalization: “Mistakes are catastrophic” “I can’t relax, I must always be vigilant” Child Symptoms: GAD, PTSD (post-incident)

Parental message: “The world (Society/Partner) will never accept or elevate fat/ugly individuals” Child Rationalization: “I must be in control of my body” Child Symptoms: OCD, BDD, Eating Disorders

Parental message: “My body must always be in control” Child Rationalization: “I must not experience (negative) emotion or physical discomfort” Child Symptoms: Phobia, Panic Disorder, Hypochondria, Tourette’s, Trichotillomania

Parental message: “The world is fair, justice will always prevail, I only have to follow the rules” Child Rationalization: “If something bad happens, I’m at fault or I was completely wrong about the world” Child Symptoms: PTSD, Phobia (e.g. Driving), Depression

Focus of Change Parental message: We need to protect/correct/punish/neglect/over-empower you Child Rationalization: I have no external proof (or internal confidence) to believe otherwise, so it must be true Child Conclusion: I must be weak/flawed/bad/worthless/overly responsible

Focus of Change Address parental fears regarding giving up current strategy Construct exercises to practice more flexible approach Control = Let child make minor decisions even if you don’t agree with choices Perfectionism = Reinforce effort regardless of result Over-demandingness/Punishment = Express noncritical dissatisfaction without punishment Neglect = Schedule positive attention independent of behaviors Over-empowering = Limit responsibility given to child, restrict detailed responses to anxious questions (e.g. “Mommy, do we have enough money?” after loss of parental employment)

Focus of Change: Practice
Groups of 2 1 therapist, 1 parent Address fears of parental change Construct exercise for practicing positive parenting

Training: Active Listening
Emphasize attentive listening with body, gaze, reflective words No judgment/criticism/correction Acknowledge child’s experience Breaks cycle of increasing frustration and therefore increasing problematic behavior

Listen with all of your senses Look directly at your child when they are speaking to you Don't allow other things going on to distract you from giving the conversation your full attention Observe body language; notice if they are acting "closed" or "open" as they talk Avoid listening with the goal of preparing a response to the initial communication; listen all the way through your child's comments until he or she is done

Communicate with your whole self Squarely face the person Open your posture Lean toward the person speaking Eye contact throughout the message Relax while listening

Reflect the message "It sounds to me like you are saying...." "What do you mean when you say...?" "What I am hearing you say is...." "I gather than you felt _____ when ...."

Let the message get all the way out Avoid jumping to conclusions Avoid interrupting the flow of thoughts except to reflect and clarify Avoid passing judgment and then tuning out

Respond with respect Acknowledge that your children have real feelings Respond to their concerns respectfully even if you disagree Avoid making them feel incapable or discounting their very real feelings

Active Listening: Practice
Groups of 2 1 parent, 1 child Practice Active Listening skills Listen with all of your senses Communicate with your whole self Reflect the message Let the message get all the way out Respond with respect

Training: Role Playing
Allows to reenact and practice alternative reactions to actual scenarios Diffuses “perceived threat” due to theoretical construct Provides simple, concrete responses to everyday situations Allows practical assimilation of new skills during therapy instead of attempting to translate theory into practice at home

Training: Role Playing
Focus of Change Angry discipline = Have alternate responses ready instead of getting angry Permissive = Provide boundaries regardless of child response Neglectful = Provide positive attention Authoritarian = Engage in healthy discussion with child

Role Playing: Practice
Groups of 2 1 parent, 1 therapist Practice Role Playing First parent as child Then therapist as child Review Repeat as necessary

Training: Modeling Provides child with better coping skills
Teaches healthy behavior in both parent and child Results in change in parents without “threat” of therapy (blame, guilt, etc.) Targets underlying fear of change by observing non-catastrophic results Useful for teaching Healthy expression of emotion (e.g. “I feel…”) Healthy interpretation of events (e.g. “I’m frustrated, but I can cope”) Healthy discussion of possible reactions (e.g. “I should tell them how I feel”) Healthy coping with distress (e.g. “I’ll go for a walk/listen to music/write”)

Training: Guiding Coping skills: Provides child with healthy options
Child learns to choose responsibly instead of automatically Teaches healthy behavior in both parent and child Use with lists for daily practice, refer child to list when upset Relaxation techniques Defusing techniques Verbalization techniques Time/space distancing techniques

Training: Behavioral Correction Techniques
Positive Reinforcement (immediate) e.g. “Good job!” Better for small children Reward Systems (cumulative) e.g. points system, stickers Better for older children Time-out and Time-in Time-out – cool off (instead of punishment) Time-in – reward for cooling off Withholding Privileges (or Response Cost) e.g. “No TV/computer for an hour” Check for accidental secondary punishments: withholding praise, limiting social activities Token Economy (cumulative)

Training: General Structure
Maintain Routines Set times for meals, chores, homework, breaks, etc. Make rules/punishment clear and consistent Review rules and consequences beforehand with partner and then child Share responsibility with partner for enforcing rules and consequences Stay calm Better to model losing control calmly than regaining control in distress

Training: Language Specific, not vague
“Stop doing X” instead of “Stop being a bad child” Targeted, not general “You did X and that is not allowed” instead of “You’re always doing something wrong” Behavioral, not personal “You did X and that is not allowed” instead of “You’re such a bad child”

Training: Language Clarify, don’t justify
“You can have a cookie after dinner, not before” instead of “it can ruin your appetite and then you won’t finish your dinner” Short, don’t elaborate “Goto your room” instead of “How many times do I have to tell you not to hit your sister? What is wrong with you? Are you trying to make me crazy? Do you want me to punish you? If you hit her again I’ll tell your father and he’ll beat you until you cry!” Speak calmly, not angrily (see previous example)

Training: Language Positive reinforcement
Efforts (e.g. “Good job studying your best”) Abilities (e.g. “You draw very nicely”) Passions (e.g. “You really know your computers”) Opinions (e.g. “That’s an interesting view”)

Training: Language Use simple statements and repeat them
Cognitive conditioning = positive self- esteem e.g. “You dealt with that very well”

Training: Language Avoid focusing mainly on single values/achievements
e.g. “You’re a great student, you’re going to be a doctor” Avoid focusing mainly on external appreciation e.g. “Everybody loves you because you’re so funny”

Language: Practice Respond to the following behaviors:
“I don’t want to do homework!” “I’ll do it later, I’m watching TV!” “But I want a cookie now! I promise I’ll eat my dinner.” “You can’t make me!” “Stay out of my room/stuff! Respect my privacy!” Child is hitting younger sibling

Final Parenting Tips for 2 parents
Back each other up in front of the child Disagree later, you can always apologize to the child (great example) Share authority, don’t split Don’t negate or undermine other’s authority Don’t use child in an argument Don’t dictate rules as way to retain control in a relationship Be consistent with each other Plan rules and consequences together beforehand Agreement on rules is less important than consistency!

Mirror Dynamics: Here and Now

Mirror Dynamics Therapist-Parent relationship mirrors Parent-Child relationship Parent expresses emotions behaviorally Resistance Tardiness/Cancellations Accusations Hopelessness Lack of practice Therapist reflects parental mistakes Judgment/Criticism/Forces homework (Authoritarian) Poor boundaries: Doesn’t address misbehaviors (Permissive) Doesn’t show empathy for parents’ frustration (Neglectful) Therapist emotion: Threatened, hopeless, annoyed, anxious

Mirror Dynamics Set example in therapy room
Maintain boundaries & Enforce rules Show empathy for parents’ difficulties Allow parents to take responsibility for actions and possible alternative actions Model tolerance for lack of control/perfection/knowledge, including owning/reflecting own emotions Seek out supervision

Review Additional exercises Case Consultations Q & A

Ohad Hershkovitz, Psy.D Director, CBT Institute of Israel

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