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, LiCSWSchool Based Manager

HCRS

Learning from Evidence Based Parent Training

Objectives

Review of behavioral principles Discussion of evidence based parent

management training programs Discussion of use of these skills in the school

setting

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

Review of Behavioral Principles

Antecedents, Behavior, Consequences Antecedents Behavior Consequences Behavioral work looks at all of these, not just

the consequences alone.

Antecedents

What comes before The general context including the relationship

and the environment. The setting. Immediately preceding events

- Clear instructions / Prompts

Behavior

Definition of behavior Tracking Monitoring Shaping

Consequences

What happens after the behavior Reinforcement “Punishment”

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.

Positive reinforcers Social reinforcers Attention Praise Touch- high five, hug Facial expressions Tangible reinforcers Things Privileges Tokens

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.

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

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.

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

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.

Making reinforcement effective Contingent! Immediate Continuous when first developing the

behavior Reinforcers valuable to the individual Vary and combine the reinforcers Shaping the behavior

Influences on childhood aggression Child factors Parent factors Level of family stress Parenting style

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

The coercion cycle

Parent makesrequest orsays no

Child refuses or

ignores

Parent gets Irritable and

yellsChild

escalatesrefusal with

tantrumMore circular

yelling or escalation to hitting

Parent gives up OR

succeeds

Gives up – for child- tantrum reinforced; for parent- giving up neg. reinforced by end of

tantrum Succeeds –escalation of

parent reinforced

Parent Management Training

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

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

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

Elements common to successful parent management training interventions

Teaching parents about the research behind the techniques

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

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

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

Staying focused Problem solving outlook Using handouts, notebooks,

support calls to support parents in making changes to their own behavior.

Strategies:Define and observe

Define the problem behavior very specifically

Define the behavior you do want to see

Get a baseline count

Stranger test

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

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

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

Helping the Noncompliant Child

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)

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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

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Outline of the HNCParenting Program

Phase I: Differential Attention• Attends• Rewards• Ignoring

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Outline of the HNCParenting Program

Phase II: Compliance Training• Clear Instructions SequenceClear instructionsConsequences for Compliance and

Noncompliance

• Standing Rules

Structure of Sessions

Observation (5 min.) – CG or PG Discuss homework and observation Teach parenting skill

Didactic instruction Modeling Role-playing Practice with child

Observation (5 min.) – CG or PG Handouts to parent Assign homework

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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

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Parent Management Trainingby Alan Kazdin, PhD Yale Child Study Center

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

• http://childconductclinic.yale.edu/

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

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

Skills

Skills: Defining Behavior

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

What are….

Laughing Having a bad attitude Talking in a nasty tone Swearing Feeling sad Hating the teacher

Define as specifically as possible Stranger test Define Oppositional Aggressive behavior Not following directions Acting disrespectful Not sitting still

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

What is the positive opposite?• Jumping on the couch• Biting fingernails• Not following directions• Off task behavior

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.

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

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

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

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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

The importance of clear instructions

http://www.youtube.com/watch?v=wPOgvzVOQig

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

Skills: Using Reinforcers

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

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

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?

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.

“OK” and “Not OK” behaviors OK” Behavior

“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

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

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Advantages

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

Rewards

Don’t smile until Christmas ?

“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

What makes rewards work

• Immediate!• Contingent!• Consistent! Use every time at the

beginning!• Focus on improvement• Specific

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

Skills: Planned Ignoring or Differential Attention

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

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http://www.youtube.com/watch?v=Gk-OfmmRaqs

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!

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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

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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!

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

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!

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)

Differential attention- completing school work during recessTeacher: 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?...

Skills: Shaping

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.

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…

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.

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.

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?