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Learning from Evidence Based Parent Training

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Presentation on theme: "Learning from Evidence Based Parent Training"— Presentation transcript:

1 Learning from Evidence Based Parent Training
Allison Y. Hall, M.D. Assistant Professor of Psychiatry and Pediatrics University of Vermont College of Medicine Vermont Center for Children Youth and Families Karen McMahon, LiCSW School Based Manager HCRS

2 Objectives Review of behavioral principles
Discussion of evidence based parent management training programs Discussion of use of these skills in the school setting ALLISON - NOTE HOW BEHAVIOR AFFECTS RELATIONSHIPS -ABRAMS?

3 Four Factor Model of Child Aggression
Child Factors Parent (Adult) Factors Stress Parenting (Teaching) Style

4 Review of Behavioral Principles

5 Antecedents, Behavior, Consequences

6 Antecedents What comes before
The general context including the relationship and the environment. The setting. Immediately preceding events - Clear instructions / Prompts Behavioral theory focuses on what affects the likelihood of a certain behavior and how often it will occur. It divides the factors affecting this this u into three parts, what comes immediately before the behavior, the antecedant, the behavior itself, and what comes immediately after the behavior, the consequence. Now there are obviously a large number of things that come before the behavior which affect it, trauma being one example. Behavioral approaches tend to focus on events which are close to the behavior and which can be changed.

7 Behavior Definition of behavior Tracking Monitoring Shaping kAREN
Behavioral approaches are based on close observation. This means getting a clear definition of behavior. Tracking - basing plans on detailed observation of behavior so as to counteract human tendency to simplify life through stereotyping. Gives parents a baseline awareness of good and bad behavior and helps them be aware of change. This is why HNC has actual observations in sessions Monitoring- becoming aware of what teenagers are doing with their free time

8 Consequences What happens after the behavior Reinforcement
“Punishment” karen

9 Consequences -Reinforcers
Reinforcers- defined by how they affect the chance of the behavior occurring again. You don’t know whether something is a reinforcer until you test it out with a particular individual Positive reinforcer –an event or thing which, when it immediately follows the behavior, increases the chance of the behavior occurring again. Negative reinforcer –an aversive event or thing which, when it is removed following the behavior, increases the chance of the behavior occurring again. KAREN The idea of a reinforcer is that its presence or removal increases the chance of the behavior occurring again. By definition, if it doesn’t increase the behavior, it isn’t a reinforcer! Behavior programs are dynamic Positive example - treat for the dog Negative example - whining which stops when parent gives in

10 Positive reinforcers Social reinforcers Attention Praise
Touch- high five, hug Facial expressions Tangible reinforcers Things Privileges Tokens KAREN Can work even if intermittant

11 Negative reinforcers Not used in parent management training but important in how oppositional behavior develops. Classic example is a child whining for candy who stops whining when his parent gives him the candy. Because the unpleasant whining stops the parent is more likely to give in in the future. ALLISON

12 Extinction The elimination of behavior through eliminating previous positive reinforcement Ignoring is an example of this. You are removing a positive reinforcer, attention, to behavior such as whining

13 Consequences –”Punishment”
A word which is a technical term within behavioral theory An event or thing which, when applied immediately after a behavior, decreases the chance of that behavior occurring again What is punishment to one individual may not be punishment to another. SOUNDS OLD FASHIONED. NOT THE SAME AS “BREAK THEIR SPIRIT” -GOAL IS BEHAVIOR CHANGE

14 Risks of punishment Harsh punishment has side effects
May stop the immediate behavior but not lessen the chance of its recurring Physical punishment increases the chance of aggression May cause the child to avoid the parent Harsh punishment can include not only physical punishments but excessively long time outs or grounding

15 Mild Punishments in Parent Management Training
Brief, immediate, mild punishment works best Time out Privilege removal Chores No yelling or hitting in PMT Always coupled with positive reinforcement of the desired behavior.

16 Making reinforcement effective
Contingent! Immediate Continuous when first developing the behavior Reinforcers valuable to the individual Vary and combine the reinforcers Shaping the behavior Comment from Karen on tying in to relationship


18 Influences on childhood aggression
Child factors Parent factors Level of family stress Parenting style COMMENT from Karen on experience with Brazelton, different types of babies and fit between parent and child

19 Aspects of parenting which affect childhood aggression
Poor monitoring of child activities Parental attention to deviant behavior Reinforcement of increasingly aggressive behavior Inattention to prosocial behavior Coercive punishment Failure to set limits

20 The coercion cycle Parent makes says no request or Child refuses or
ignores Parent gets Irritable and yells refusal with tantrum escalates Child yelling or escalation to hitting More circular gives up OR succeeds Parent Gives up – for child- tantrum reinforced; for parent- giving up neg. reinforced by end of tantrum Succeeds –escalation of parent reinforced

21 Parent Management Training

22 What is Parent Mangement Training?
A systematic way of helping parents understand and practice behavioral management skills to escape from the coercive cycle- to change their own behavior and their child’s behavior Positive reinforcement of good behavior Minimize attention to negative behavior Mild punishment

23 Parent Management Training Evidence Based Programs
Behaviorally based programs working either with parents alone or parents and children together Manualized Several programs developed with similar basic features

24 Forms of Parent Management Training
Parent Management Training - Patterson Parent Management Training -Kazdin Helping the Noncompliant Child – McMahon and Forehand The Incredible Years – Webster Stratton Triple P –Positive Parenting Program Parent Child Interaction Therapy - Eyeberg Defiant Children/ Defiant Teens -Barkley

25 Elements common to successful parent management training interventions

26 Teaching parents about the research behind the techniques

27 Strong emphasis on increasing the positive reinforcement, much less on the punishment

28 Actual practice through role plays and sometimes rehearsal with the child in session

29 Use of those same reinforcement strategies, especially strong positive reinforcement and shaping, in the work with the parents

30 Staying focused Problem solving outlook Using handouts, notebooks, support calls to support parents in making changes to their own behavior.

31 Strategies: Define and observe
Define the problem behavior very specifically Define the behavior you do want to see Get a baseline count Stranger test

32 Strategies: Reinforce the desired behavior
Reinforce the behavior you want through attention and other social rewards, privilege rewards, tangible rewards, token rewards or contracts Shape complex behavior over time

33 Strategies: “Punish” the undesired behavior
Ignore minor misbehavior Use mild punishment for bigger misbehavior Time out Privilege removal Work chore

34 Reminders about punishment
The definition of punishment = a consequence which decreases the likelihood of a behavior occurring in the future. Punishments do not have to be harsh to be effective Harsh punishments have side effects: harsh physical punishments increase childhood aggression, lectures make the parent aversive Effective punishment is mild and used in the context of abundant positive reinforcement of desired behavior

35 Helping the Noncompliant Child

36 Helping the Noncompliant Child
Program for 3-8 year olds Identified as a leading evidence-based program Eyberg et al. (J of Clin Child and Adol Psychology, 2008) Brestan and Eyberg (J of Clin Child Psychology, 1998) Office of Juvenile Justice and Delinquency Prevention (OJJDP) Substance Abuse and Mental Health Services Administration (SAMHSA)

37 Core Elements of HNC Presenting problem: Excessive noncompliance
Child age: 3 to 8 Participants: Parent(s) and child Program: Sequence of parenting skills Active teaching methods, including home practice Competency based

38 Outline of the HNC Parenting Program
Phase I: Differential Attention Attends Rewards Ignoring

39 Outline of the HNC Parenting Program
Phase II: Compliance Training Clear Instructions Sequence Clear instructions Consequences for Compliance and Noncompliance Standing Rules

40 Structure of Sessions Observation (5 min.) – CG or PG
Discuss homework and observation Teach parenting skill Didactic instruction Modeling Role-playing Practice with child Handouts to parent Assign homework

41 Effectiveness of HNC Studies over 30 years support changes in:
Short and long term parent and child behavior Parent attitudes toward child Untargeted behaviors Siblings Maternal depression Studies from our clinic and others over the past 30+ years indicate that the program: Leads to change in parent and child behavior in the clinic and the home Leads to long-term (3.5 years) child behavior changes and behavior comparable to “normals” (non-referred) 11 years (during adolescence) and 16 years (during young adulthood) later Leads to parent attitude change toward child

42 Parent Management Training by Alan Kazdin, PhD Yale Child Study Center

43 Core Elements of PMT-Kazdin
Presenting problem: externalizing behaviors Child age: studied for ages 2-14 Participants: predominantly parents Program: Sequence of parenting and communication skills Active teaching methods, including home practice Further training and certification is available through the Yale Parenting Center

44 Outline of the PMT-Kazdin Program
Defining, Observing and Recording Behavior Positive Reinforcement- Praise and Token System Time Out from Reinforcement Attending and Planned Ignoring Shaping and School Program Low Rate Behaviors Reprimands Compromising Skills

45 Format of sessions Welcome/ review of homework
Outline objectives of session Initial presentation of the concepts and skills of the session Therapist demonstrates the skill by role playing as the parent Parent practices by role playing as the parent Assignment of homework

46 Skills

47 Skills: Defining Behavior

48 Defining, Observing and Recording Behavior
The first step in addressing any problem behavior is defining it. Behavior – an action that can be seen and heard Not a feeling, attitude or thought Session one’s focus is on defining, observing and recording behavior as well as some initial comments on being positive. Defining behavior is important because we can’t begin to carefully observe it or talk to the child about it until we have a good definition. So the first thing you go over is What is a behavior. An action that can be seen and heard

49 What are…. Laughing Having a bad attitude Talking in a nasty tone
Swearing Feeling sad Hating the teacher

50 Define as specifically as possible
Stranger test Define Oppositional Aggressive behavior Not following directions Acting disrespectful Not sitting still Aggression- hitting , kicking, spitting, throwing objects

51 The “Positive Opposite”
The behavior you would like to see instead of the behavior you do not want. Slamming the door -Closing the door quietly Tantrum when told no -Accepting no calmly Not following directions Doing what you are told right away Raising your hand to ask for more information if you don’t understand the direction KAREN

52 What is the positive opposite?
Jumping on the couch Biting fingernails Not following directions Off task behavior Karen can you give me some good school examples?

53 The role of observing behavior
Getting a baseline count of behaviors is extremely helpful to evaluating the effectiveness of your plan. Our brains tend to expect the same behavior we are used to. By counting behaviors, we will be able to notice small changes and see whether our interventions are working.

54 Prompting (PMT) Research demonstrates that effective prompts increase the likelihood of a behavior occurring Specific Calm Close, without touch Immediate Statement rather than a question Use only once Avoid chain commands Avoid too much rationale Role play with Eliza telling a 17 year old to go get gas for the car.

55 Effective Instructions/Prompts
Be positive! State what you want the child to do rather than want you want the child not to do Use an assertive, but not angry tone Verbal praise as soon as the child starts

56 Clear instructions (HNC)
Get child’s attention Move close Say the child’s name (max. two times) Establish eye contact State the instruction clearly Give one instruction at a time Use firm voice Phrase as a “do” command Use simple language Use gestures as appropriate Rationale (if given) precedes the clear instruction Wait 5 seconds Count silently No verbalization to child

57 Effective Instructions
Ineffective instructions Chain commands Vague commands Question commands “Let’s” commands Rationale after the command Effective instructions One at a time Specific Assertive tone, no questions If need for rationale, state before the instruction

58 The importance of clear instructions

59 Role Play – Give a Clear Instruction
To a 15 year old to open up his book To a 12 year old who is chatting with his neighbor in the middle of class To an 8 year old who is off task

60 Skills: Using Reinforcers

61 To address an undesired behavior….
Define the negative behavior in your mind Define the positive opposite Be sure to reinforce the positive opposite when it happens spontaneously Prompt for the positive opposite with a clear, effective prompt/ instruction Reinforce positive response to the prompt

62 Behaviors are strongly affected by consequences
A behavior will occur more frequently if it is positively reinforced Social reinforcers –smiles, attention, thumbs up, pat on the back, specific praise - are free and can be used frequently

63 Common questions Why should you have to attend to or praise behavior that is only what is expected for that child’s age? Why should you have to reinforce behavior that the child can do perfectly well some of the time? Is too much praise bad?

64 How to use reinforcers Reinforcement needs to happen immediately after the behavior At first, the reinforcer should happen every time the behavior occurs If no behavior, no reinforcer! By definition, a positive reinforcer increases behavior. If you are providing the reinforcer liberally and the behavior is not increasing, you need to choose a different reinforcer.

65 “OK” and “Not OK” behaviors
“Is this something I’d like to stay the same or see more of?” If “yes,” this is an “OK” behavior “Not OK” Behavior “Is this something I’d like to see less frequently or not at all?” If “yes,” this is a “Not OK” behavior

66 Attends Follows, rather than leads, the child’s activity (by a running verbal commentary) Used only to reinforce “OK” behaviors Describe overt behavior (“You are getting out your pencil; you have your book out” Emphasize desired prosocial behavior (“You’re talking in a regular voice.”) “Volume control” feature allows an observer to raise or lower the intensity and frequency of the positive attention

67 Advantages Can increase desired behaviors
Complements the use of praise Helps with “volume control” 67

68 Rewards Don’t smile until Christmas ? KAREN

69 “Rewards” -Social reinforcers
Three types Physical rewards Pat on the back Unlabeled verbal rewards Great! Nice job! Labeled verbal rewards Good work writing your homework down

70 What makes rewards work
Immediate! Contingent! Consistent! Use every time at the beginning! Focus on improvement Specific

71 A few thoughts on point charts
The reinforcers need to be valuable to the child so the child needs to be part of planning them. The reinforcers should be small so you can give a lot of them If it is not working, you need to see if the reinforcer is still motivating for the child Expect to have to refresh the chart from time to time

72 Skills: Planned Ignoring or Differential Attention

73 Ignoring Focus on attention-seeking behaviors (e.g., whining, nagging, temper tantrums, interrupting) Behaviors that are potentially harmful to people or property (e.g., fighting) should not be ignored Ignoring is an active process Decide ahead of time which “not OK” behaviors to ignore When ignoring, actively avoid giving attention to the child


75 Ignoring (cont.) Three components No eye contact or nonverbal cues
Don’t look! No verbal contact Don’t talk! No physical contact Don’t touch!

76 Ignoring (cont.) Ignoring starts as soon as the undesired behavior begins. Ignoring stops when the undesired behavior ceases. The undesired behavior must be ignored every time that it occurs; otherwise the behavior will become worse instead of better. Ignoring is never used alone Always combine with positive attention (attends and rewards) for the alternative appropriate behavior

77 Commonly Encountered Situation
“Extinction burst” – The child’s disruptive behavior increases initially Ignoring is especially difficult then Critical not to give in – will make matters worse!

78 Behaviors to target with differential attention
Whining Complaining Pouting Other annoying behaviors

79 Differential attention-
Reinforce behavior you want to see more of through attention and rewards If you see a negative behavior choose a positive to replace it. Ignore minor, annoying misbehavior Only works well when you are reinforcing the good behavior!

80 Differential attention: child wanders off in gym class because he is frustrated with his performance
Jimmy: Bounces basketball hard without hitting anyone and stomps off Teacher: Looks at the rest of the class and says to them, “Let’s leave Jimmy alone right now and play with him as soon as he is ready to come back” (Ignoring Jimmy, attending to the class behaving well) Jimmy: “This game is stupid!” ( Ignore) Jimmy: Comes back and stands quietly on the sidelines (Attend)

81 Differential attention- completing school work during recess
Teacher: Please complete these two work sheets. Child “I hate these stupid work sheets”. Child –gets her pencil out and starts the page muttering, “This is stupid.” …She looks out the window for a few minutes and begins working again.…. After five minutes she says, “I hate this class” …but a minute later starts working. …. After another five minutes she says calmly, “I don’t understand how to do this problem, can you help me?...

82 Skills: Shaping KAREN

83 Shaping Getting to a major goal by defining and reinforcing small steps toward the goal Start by defining the long term goal and the first step.

84 School Based Example: Major Long Term Goal – Decrease aggressive behavior on the playground Define the Positive Opposite Long Term Goal eg. Child will play calmly with others or by himself during recess Then.. Think of the small steps that are part of the child’s progress toward decreased aggressive behavior…

85 Small Steps to Shape Behavior
Decreasing aggressive behavior…. What does the beginning of this change look like? Visualize each small step Child walks over and stays close to the teacher Child walks around quietly by himself Child says “Hi” to other kids Child plays calmly with other kids We attend to and reinforce these small steps. This is not what we hope for as the final outcome. However, these steps are the beginning of a changed recess for this child.

86 Trouble shooting behavior plans
1) Are the reinforcers immediate, contingent, adequate and given all or most of the time when the behavior occurs. 2) Can more social reinforcement be brought in- attention 3) Are there enough opportunities for the behavior- Practice opportunities can be brought in. ALLISON

87 Trouble shooting behavior plans
5) Enhance the prompts through more specific instructions, helping, modeling 6) Are the demands too difficult? 7) Are there other reinforcers which are maintaining the negative behavior?

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