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
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 / 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

17. ALLISON

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
ALLISON

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?