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 PediatricsUniversity of Vermont College of MedicineVermont Center for Children Youth and FamiliesKaren McMahon, LiCSWSchool Based ManagerHCRS
2 Objectives Review of behavioral principles Discussion of evidence based parent management training programsDiscussion of use of these skills in the school settingALLISON - NOTE HOW BEHAVIOR AFFECTS RELATIONSHIPS -ABRAMS?
3 Four Factor Model of Child Aggression Child FactorsParent (Adult) FactorsStressParenting (Teaching) Style
5 Antecedents, Behavior, Consequences Behavioral work looks at all of these, not just the consequences alone.THESE INFLUENCES ARE HAPPENING WHETHER WE PAY ATTENTION TO THEM OR NOT. THE GOAL IS TO BE MORE THOUGHTFUL ABOUT HOW THESE ELEMENTS ARE AFFECTING BEHAVIOR AND USE THEM TOWARD THE BEHAVIOR WE WOULE LIKE TO SEE
6 Antecedents What comes before The general context including the relationship and the environment. The setting.Immediately preceding events- Clear instructions / PromptsBehavioral 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 sessionsMonitoring- 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 individualPositive 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.KARENThe 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 dynamicPositive example - treat for the dogNegative example - whining which stops when parent gives in
10 Positive reinforcers Social reinforcers Attention Praise Touch- high five, hugFacial expressionsTangible reinforcersThingsPrivilegesTokensKARENCan work even if intermittant
11 Negative reinforcersNot 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 ExtinctionThe elimination of behavior through eliminating previous positive reinforcementIgnoring 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 theoryAn event or thing which, when applied immediately after a behavior, decreases the chance of that behavior occurring againWhat 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 recurringPhysical punishment increases the chance of aggressionMay cause the child to avoid the parentHarsh 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 bestTime outPrivilege removalChoresNo yelling or hitting in PMTAlways coupled with positive reinforcement of the desired behavior.
16 Making reinforcement effective Contingent!ImmediateContinuous when first developing the behaviorReinforcers valuable to the individualVary and combine the reinforcersShaping the behaviorComment from Karen on tying in to relationship
18 Influences on childhood aggression Child factorsParent factorsLevel of family stressParenting styleCOMMENT 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 activitiesParental attention to deviant behaviorReinforcement of increasingly aggressive behaviorInattention to prosocial behaviorCoercive punishmentFailure to set limits
20 The coercion cycle Parent makes says no request or Child refuses or ignoresParent getsIrritable andyellsrefusal withtantrumescalatesChildyelling or escalation to hittingMore circulargives up OR succeedsParentGives up – for child- tantrum reinforced; for parent- giving up neg. reinforced by end of tantrumSucceeds –escalation of parent reinforced
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 behaviorPositive reinforcement of good behaviorMinimize attention to negative behaviorMild punishment
23 Parent Management Training Evidence Based Programs Behaviorally based programs working either with parents alone or parents and children togetherManualizedSeveral programs developed with similar basic features
24 Forms of Parent Management Training Parent Management Training - PattersonParent Management Training -KazdinHelping the Noncompliant Child – McMahon and ForehandThe Incredible Years – Webster StrattonTriple P –Positive Parenting ProgramParent Child Interaction Therapy - EyebergDefiant 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 focusedProblem solving outlookUsing handouts, notebooks, support calls to support parents in making changes to their own behavior.
31 Strategies: Define and observe Define the problem behavior very specificallyDefine the behavior you do want to seeGet a baseline countStranger 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 contractsShape complex behavior over time
33 Strategies: “Punish” the undesired behavior Ignore minor misbehaviorUse mild punishment for bigger misbehaviorTime outPrivilege removalWork 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 effectiveHarsh punishments have side effects: harsh physical punishments increase childhood aggression, lectures make the parent aversiveEffective punishment is mild and used in the context of abundant positive reinforcement of desired behavior
36 Helping the Noncompliant Child Program for 3-8 year oldsIdentified as a leading evidence-based programEyberg 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 8Participants: Parent(s) and childProgram:Sequence of parenting skillsActive teaching methods, including home practiceCompetency based
38 Outline of the HNC Parenting Program Phase I: Differential AttentionAttendsRewardsIgnoring
39 Outline of the HNC Parenting Program Phase II: Compliance TrainingClear Instructions SequenceClear instructionsConsequences for Compliance and NoncomplianceStanding Rules
40 Structure of Sessions Observation (5 min.) – CG or PG Discuss homework and observationTeach parenting skillDidactic instructionModelingRole-playingPractice with childHandouts to parentAssign homework
41 Effectiveness of HNC Studies over 30 years support changes in: Short and long term parent and child behaviorParent attitudes toward childUntargeted behaviorsSiblingsMaternal depressionStudies 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 homeLeads 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) laterLeads 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 behaviorsChild age: studied for ages 2-14Participants: predominantly parentsProgram:Sequence of parenting and communication skillsActive teaching methods, including home practiceFurther training and certification is available through the Yale Parenting Center
44 Outline of the PMT-Kazdin Program Defining, Observing and Recording BehaviorPositive Reinforcement- Praise and Token SystemTime Out from ReinforcementAttending and Planned IgnoringShaping and School ProgramLow Rate BehaviorsReprimandsCompromising Skills
45 Format of sessions Welcome/ review of homework Outline objectives of sessionInitial presentation of the concepts and skills of the sessionTherapist demonstrates the skill by role playing as the parentParent practices by role playing as the parentAssignment of homework
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 heardNot a feeling, attitude or thoughtSession 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 SwearingFeeling sadHating the teacher
50 Define as specifically as possible Stranger testDefineOppositionalAggressive behaviorNot following directionsActing disrespectfulNot sitting stillAggression- 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 quietlyTantrum when told no-Accepting no calmlyNot following directionsDoing what you are told right awayRaising your hand to ask for more information if you don’t understand the directionKAREN
52 What is the positive opposite? Jumping on the couchBiting fingernailsNot following directionsOff task behaviorKaren 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 occurringSpecificCalmClose, without touchImmediateStatement rather than a questionUse only onceAvoid chain commandsAvoid too much rationaleRole 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 doUse an assertive, but not angry toneVerbal praise as soon as the child starts
56 Clear instructions (HNC) Get child’s attentionMove closeSay the child’s name (max. two times)Establish eye contactState the instruction clearlyGive one instruction at a timeUse firm voicePhrase as a “do” commandUse simple languageUse gestures as appropriateRationale (if given) precedes the clear instructionWait 5 secondsCount silentlyNo verbalization to child
57 Effective Instructions Ineffective instructions Chain commands Vague commands Question commands “Let’s” commands Rationale after the commandEffective instructionsOne at a timeSpecificAssertive tone, no questionsIf need for rationale, state before the instruction
61 To address an undesired behavior…. Define the negative behavior in your mindDefine the positive oppositeBe sure to reinforce the positive opposite when it happens spontaneouslyPrompt for the positive opposite with a clear, effective prompt/ instructionReinforce positive response to the prompt
62 Behaviors are strongly affected by consequences A behavior will occur more frequently if it is positively reinforcedSocial reinforcers –smiles, attention, thumbs up, pat on the back, specific praise - are free and can be used frequently
63 Common questionsWhy 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 reinforcersReinforcement needs to happen immediately after the behaviorAt first, the reinforcer should happen every time the behavior occursIf 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 AttendsFollows, rather than leads, the child’s activity (by a running verbal commentary)Used only to reinforce “OK” behaviorsDescribe 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 praiseHelps with “volume control”67
69 “Rewards” -Social reinforcers Three typesPhysical rewardsPat on the backUnlabeled verbal rewardsGreat! Nice job!Labeled verbal rewardsGood work writing your homework down
70 What makes rewards work Immediate!Contingent!Consistent! Use every time at the beginning!Focus on improvementSpecific
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 themIf it is not working, you need to see if the reinforcer is still motivating for the childExpect to have to refresh the chart from time to time
72 Skills: Planned Ignoring or Differential Attention ALLISON
73 IgnoringFocus 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 ignoredIgnoring is an active processDecide ahead of time which “not OK” behaviors to ignoreWhen ignoring, actively avoid giving attention to the child
75 Ignoring (cont.) Three components No eye contact or nonverbal cues Don’t look!No verbal contactDon’t talk!No physical contactDon’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 aloneAlways combine with positive attention (attends and rewards) for the alternative appropriate behavior
77 Commonly Encountered Situation “Extinction burst” – The child’s disruptive behavior increases initiallyIgnoring is especially difficult thenCritical not to give in – will make matters worse!
78 Behaviors to target with differential attention WhiningComplainingPoutingOther annoying behaviors
79 Differential attention- Reinforce behavior you want to see more of through attention and rewardsIf you see a negative behavior choose a positive to replace it.Ignore minor, annoying misbehaviorOnly 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 offTeacher: 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?...
83 ShapingGetting to a major goal by defining and reinforcing small steps toward the goalStart by defining the long term goal and the first step.
84 School Based Example:Major Long Term Goal – Decrease aggressive behavior on the playgroundDefine the Positive Opposite Long Term Goaleg. Child will play calmly with others or by himself during recessThen..Think of the small steps that are part of the child’s progress toward decreasedaggressive behavior…
85 Small Steps to Shape Behavior Decreasing aggressive behavior….What does the beginning of this change look like? Visualize each small stepChild walks over and stays close to the teacherChild walks around quietly by himselfChild says “Hi” to other kidsChild plays calmly with other kidsWe 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- attention3) 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, modeling6) Are the demands too difficult?7) Are there other reinforcers which are maintaining the negative behavior?