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Parent Management Training for Oppositional

and Conduct Problem Children


Julie Feldman and Alan E. Kazdin
Yale University
Reprinted from:
Feldman, J. & Kazdin, A. E. (1995). Parent management training for oppositional and
conduct problem children. The Clinical Psychologist, 48(4), 3-5.

I. Description of Treatment
Parent management training (PMT) refers to programs that train parents to
manage their child's behavioral problems in the home and at school. PMT has
emanated from two lines of work. First, maladaptive parent-child interactions,
particularly in relation to discipline practices, have been shown to foster and to
sustain conduct problems among children. Second, social learning techniques,
relying heavily on principles of operant conditioning, have been extremely
useful in altering parent and child behavior. In PMT, parent-child interactions
are modified in ways that are designed to promote prosocial child behavior and
to decrease antisocial or oppositional behavior.
Treatment sessions include instruction in social learning principles and
techniques. The therapist provides a brief overview of underlying concepts,
models the techniques for the parents, and coaches parents in implementing
the procedures. Procedures and interaction patterns practiced in the sessions
are then used in the home. Parents usually are taught how to define, observe,
and record behavior at the beginning of treatment because once behaviors
(e.g. fighting, engaging in tantrums) are defined concretely, reinforcement and
punishment techniques can be applied. The PMT therapist details the concepts
and procedures derived from positive reinforcement (e.g., contingent delivery
of attention, praise, points) and punishment (e.g., time out from reinforcement,
loss of privileges, and reprimands). Reinforcement for prosocial and nondeviant
behavior is central to treatment. Parents are taught how to use reinforcement
and punishment techniques contingent on the child's behavior, to provide
consequences consistently, to attend to appropriate behaviors and to ignore
inappropriate behaviors, to apply skills in prompting, shaping, and fading, and
to use these techniques to manage future problems. There is an extensive
amount of practice and shaping of parent behavior within the sessions to
develop skills in carrying out the procedures.
Because the immediate goal of treatment is to develop parenting skills, the
therapist begins by having parents apply new skills to relatively simple
problems (e.g., compliance, completion of chores, oppositional behavior). As
parents become proficient using the initial techniques, the child's most serious
problem behaviors at home and in school are addressed (e.g., fighting, poor
school performance, truancy, stealing, firesetting). In most PMT programs, the
therapist maintains close telephone contact with the parents in-between
sessions. These contacts are used to encourage parents to ask questions about
the home programs, to provide an opportunity for the therapist to prompt
compliance with the behavior-change programs and reinforce parents' use of
the skills, to strengthen the therapeutic alliance, and to allow the therapist to
problem-solve when programs are not modifying child behavior effectively.

II. Summary of Studies Supporting Treatment Efficacy


PMT is one of the most extensively studied therapies for children and has been
shown to be effective in decreasing oppositional, aggressive, and antisocial
behavior (for reviews of research, see Dumas, 1989; Forehand & Long, 1988;
Kazdin, 1985; Miller & Prinz, 1990; Moreland, Schwebel, Beck, & Wells, 1982).
Randomized controlled trials have found that PMT is more effective in changing
antisocial behavior and promoting prosocial behavior than many other
treatments (e.g. relationship, play therapy, family therapies, varied community
services) and control conditions (e.g. waiting-list, "attention-placebo"). Follow-
up data have shown that gains are maintained from posttreatment to 1 and 3
years after treatment has ended. One research team found that noncompliant
children treated by parent training were functioning as well as nonclinic
individuals approximately 14 years later (Long, Forehand, Wierson, & Morgan,
1994). The benefits of PMT often generalize to areas that are not focused on
directly during therapy. For example, improvements in parental adjustment and
functioning, marital satisfaction, and sibling behavior have been found
following therapy. Overall, perhaps no other technique has been as carefully
documented and empirically supported as PMT in treating conduct problems.
A unique feature of PMT is the abundance of research on child, parent, and
family factors that moderate treatment effects. Moreover, PMT, either alone or
in combination with other techniques, has been applied with promising effects
to other populations including autistic children, mentally retarded children and
adolescents, adjudicated delinquents, and parents who physically abuse their
children. The principles and procedures on which PMT relies have also been
applied in many settings including schools, institutions, community homes,
day-care facilities, and facilities for the elderly.

III. References
A. Background Research
Reviews of the outcome evidence, as well findings related to moderators of treatment,
generalization, and maintenance of changes, can be obtained from the following sources:
Dumas, J.E. (1989). Treating antisocial behavior in children: Child family approaches.
Clinical Psychology Review, 9, 197-222.
Forehand, R., & Long, N. (1988). Outpatient treatment of the acting out
child: Procedures, long-term follow-up data, and clinical problems.
Advances in Behaviour Research and Therapy 10, 129-177.
Kazdin, A. E. (1985). Treatment of antisocial behavior in children and
adolescents. Homewood, IL: Dorsey Press.
Long, P., Forhand, R., Wierson, M., & Morgan, A. (1994). Does parent
training with young noncompliant children have long-term effects?
Behaviour Research and Therapy, 32, 101-107.
Miller, G. E., & Prinz, R. J. (1990). Enhancement of social learning family
interventions for child conduct disorder. Psychological Bulletin, 108, 291-
307.
Moreland, J. R., Schwebel, A.I., Beck, S., & Wells, R. (1982). Parents as
therapists: A review of the behavior therapy parent training literature -
1975 to 1981. Behavior Modification, 6, 250-276.
B. Clinical References
Materials that describe the procedures and methods used in training for oppositional and antisocial
children can be found in the following sources:
Forehand, R., & McMahon, R.J. (1981). Helping the noncompliant child: A clinician's guide
to parent training. New York: Guilford.
Sanders, M.R., & Dadds, M.R. (1993). Behavioral family interventions.
Needham Heights, MA: Allyn & Bacon.
Webster-Stratton, C., & Herbert, M. (1994). Troubled families-problem
children: Working with parents: a collaborative process. Chichester,
England: John Wiley.

IV. Resources for Training


We know of no formal programs where professionals can obtain training in PMT.
There are, however, research centers that have long-standing treatment
programs and a great deal of information on training. Two programs that have
made special contributions to the literature include those of:
Dr. Gerald Patterson
Oregon Social Learning Center
207 East 5th Avenue, Suite 202
Eugene, OR 97401
and
Dr. Carolyn Webster Stratton
Department of Parent and Child Nursing
University of Washington
Seattle, WA 98195
This latter research program has generated and evaluated video-taped
versions of PMT that can be used to train professionals and facilitate treatment
sessions with parents.
Stress Inoculation Training for Coping with
Stressors
Donald Meichenbaum, Ph.D.
University of Waterloo, Ontario
Reprinted from:
Meichenbaum, D. (1996). Stress inoculation training for coping with stressors. The Clinical
Psychologist, 49, 4-7.

I. Description of Treatment
Stress Inoculation Training (SIT) emerged out of an attempt to integrate the
research on the role of cognitive and affective factors in coping processes with
the emerging technology of cognitive behavior modification (Meichenbaum,
1977). SIT has been employed on a treatment basis to help individuals cope
with the aftermath of exposure to stressful events and on a preventative basis
to "inoculate" individuals to future and ongoing stressors.
SIT is a flexible individually-tailored multifaceted form of cognitive-behavioral
therapy. In order to enhance individuals' coping repertoires and to empower
them to use already existing coping skills, an overlapping three phase
intervention is employed. In the initial conceptualization phase a collaborative
relationship is established between the clients and the therapist (trainer). A
Socratic-type exchange is used to educate clients about the nature and impact
of stress and the role of both appraisal processes and the transactional nature
of stress (i.e., how clients may inadvertently, unwittingly, and perhaps, even
unknowingly, exacerbate the level of stress they experience). Clients are
encouraged to view perceived threats and provocations as problems-to-be-
solved and to identify those aspects of their situations and reactions that are
potentially changeable and those aspects that are not changeable. They are
taught how to "fit" either problem-focus or emotion-focus to the perceived
demands of the stressful situation (e.g., see Folkman et al., 1991). The clients
are taught how to breakdown global stressors into specific short-term,
intermediate and long-term coping goals.
As a result of interviewing, psychological testing, client self-monitoring, and
reading materials, the clients' stress response is reconceptualized as being
made-up of different components that go through predictable phases of
preparing, building up, confronting, and reflecting upon their reactions to
stressors. The specific reconceptualization that is offered is individually-tailored
to the client's specific presenting problem (e.g. anxiety, anger, physical pain,
etc.). As a result of a collaborative process a more hopeful and helpful model is
formulated; a model that lends itself to specific intervention.
The second phase of SIT focuses on skills acquisition and rehearsal that follows
naturally from the initial conceptualization phase. The coping skills that are
taught and practiced primarily in the clinic or training setting and then
gradually rehearsed in vivo are tailored to the specific stressors clients may
have to deal with (e.g., chronic illness, traumatic stressors, job stress, surgery,
sports competition, military combat, etc.). The specific coping skills may
include emotional self-regulation, self-soothing and acceptance, relaxation
training, self-instructional training, cognitive restructuring, problem-solving,
interpersonal communication skills training, attention diversion procedures,
using social support systems and fostering meaning-related activities.
The final phase of application and follow through provides opportunities for the
clients to apply the variety of coping skills across increasing levels of stressors
(inoculation concept as used in medical immunization or in social psychology to
prepare individuals to resist the impact of persuasive messages). Such
techniques as imagery and behavioral rehearsal, modeling, role playing, and
graded in vivo exposure in the form of "personal experiments" are employed. In
order to further consolidate these skills individuals may even be asked to help
others with similar problems (Fremouw & Harinatz, 1975; Meichenbaum, 1994).
Relapse prevention procedures (i.e., identifying high risk situations, warning
signs, and ways to coping with lapses), attribution procedures (i.e., ensuring
clients take credit for and appropriate ownership by putting into their own
words the changes that have taken place), and follow-through (i.e., booster
sessions) are built into SIT.
SIT also recognizes that the stress an individual experiences is often endemic,
institutional and unavoidable. As a result, SIT has often helped clients to alter
environmental settings and or worked with significant others in altering
environmental stressors (e.g., hospital staff for medical patients, Kendall, 1983;
coaches for athletes, Smith, 1980; drill instructors for recruits, Novaco et al.,
1983; and so forth). SIT recognizes that stress is transitional in nature and that
there is a need to not only work with clients to bolster and nurture flexible
coping repertoires, but it is also necessary, on some occasions, to go beyond
individual and group interventions and to adopt a community based focus.
SIT has been conducted with individuals, couples, small and large groups. The
length of intervention has varied from being as short as 20 minutes for
preparing patients for surgery (Langer et al., 1975) to 40 one hour weekly and
biweekly sessions administered to psychiatric patients or to individuals with
chronic medical problems (Meichenbaum, 1994; Turk et al., 1983). In most
instances, SIT consists of some 8 to 15 sessions, plus booster and follow-up
sessions, conducted over a 3-to-12-month period.

II. Summary of Studies Supporting Treatment Efficacy


SIT has been employed in the treatment of:
acute time-limited stressors
such as in preparation for medical examinations (Jay & Elliot, 1990; Kendall, 1983; Kendall
et al., 1979); surgery (Langer, et al., 1975; Ross et al., 1996; Wells et al., 1986) and
performance evaluation (athletic competition, public speaking - Altmaier et al., 1982;
Hussain & Lawrence, 1978; Jaremko, 1980, 1983; Smith, 1980);
chronic intermittent stressors
such as military combat (Meichenbaum, 1994; Novaco et al., 1983) and episodic physical
conditions like recurrent headaches (Holroyd et al., 1977);
chronic continual stressors
such as medical illness (asthma, hypertension, Type A behavior, chronic pain, cancer, burns,
rheumatoid arthritis - Moore & Altmaier, 1981; Randich, 1982; Roskies, 1983; Turk et al.,
1983) and psychiatric illness (Holcomb, 1986; Long, 1984); prolonged occupational stress
such as police work, teaching, combat (Forman, 1982; Meichenbaum, 1993; Novaco et al.,
1983; Wemick et al., 1981).
stressor sequence
that results from exposure to stressful events (e.g., divorce, unemployment, rape -
Meichenbaum, 1993; Foa et al., 1991; Vernon & Best, 1983). (With regard to SIT treatment
of rape victims: SIT produced significantly more improvement on PTSD symptoms
immediately after treatment but at follow-up prolonged exposure produced superior outcome
in PTSD symptoms.)
Another clinical problem that has yielded positive results is the application of
SIT to treatment of adolescents and adults who have problems with anger
control (Deffenbacher et al., 1988; Feindler & Ecton, 1986; Hains & Szyakowski,
1990). In a review Meichenbaum (1993) has provided a comprehensive
summary of how SIT has been used on a preventative and treatment basis and
how SIT can be viewed from a constructive narrative perspective
(Meichenbaum, 1994).

III. Clinical References Describing the Approach


Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon
Press.
Meichenbaum, D. (1994). A clinical handbook/practical therapist manual for
assessing and treating adults with post traumatic stress disorder. Waterloo,
Ontario: Institute Press.
Meichenbaum, D., & Deffenbacher, J. L. (1988). Stress inoculation training.
Counseling Psychologist, 16, 69-90.
Meichenbaum, D., & Jaremko, M. (Eds.) (1983). Stress prevention and
management: A cognitive-behavioral approach. New York: Plenum Press.
Turk, D. C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral
medicine: A cognitive-behavioral perspective. New York: Guilford Press.
Meichenbaum, D. (1977). Cognitive behavioral modification: An integrative
approach. New York: Plenum Press.

IV. Resources for Training


There are no formal programs where professional can obtain specific training in
SIT. Dr. Donald Meichenbaum often gives one, two and five day workshops on
SIT and related cognitive-behavioral interventions. For information contact him
at the
University of Waterloo
Department of Psychology
Waterloo, Ontario, Canada, N2L 3G I
e-mail: dmeich@watarts.uwaterloo.ca

V. References
Altmaier, E. M., Ross, S. L., Leary, M. R., & Thombrough, M. T. (1982). Matching
stress inoculation's treatment components to client's anxiety mode. Journal of
Counseling Psychology, 29, 331-334.
Deffenbacher, J., Story, D., Brandon, A., Hogg, J., & Hazeleus, S. (1988).
Cognitive and cognitive relaxation treatment of anger. Cognitive Therapy and
Research, 12, 167-184.
Feindler, E. & Ecton, R. (1986). Adolescent anger control: Cognitive-behavioral
techniques. New York: Pergamon Press.
Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. (1991). Treatment of
posttraumatic stress disorder in rape victims: A comparison between cognitive
behavioral procedures and counseling. Journal of Consulting and Clinical
Psychology, 59, 715-723.
Folkman, S., Chesney, M., McKusik, L., Ironson, G., Johnson, D. S., & Coates, T. J.
(1991). Translating coping theory into an intervention. In J. Eckenrode (Ed.).
The social context of coping. New York: Plenum Press.
Forman, S. (1982). Stress management for teachers: A cognitive-behavioral
program. Journal of School Psychology, 20, 180-187.
Fremouv, W. & Harmatz, M. (1975). A helper model for behavioral treatment of
speech anxiety. Journal of Consulting and Clinical Psychology, 43, 652-660.
Hains, A. A. & Szyakowski, M. (1990). A cognitive stress-reduction intervention
program for adolescents. Journal of Consulting and Clinical Psychology, 37, 79-
84.
Holcomb, W. R. (1986). Stress inoculation therapy with anxiety and stress
disorders of acute psychiatric patients. Journal of Clinical Psychology, 42, 864-
872.
Holroyd, K., Andrasik, F., & Westbrook, T. (1977). Cognitive control of tension
headaches. Cognitive Therapy and Research, 1, 121-133.
Hussain, R., & Lawrence, S. (1978). The reduction of test, state, and trait
anxiety by test specific and generalized stress inoculation training. Cognitive
Therapy and Research, 2, 25-37.
Jaremko, M. (1980). The use of stress inoculation training in reduction of public
speaking anxiety. Journal of Clinical Psychology, 36, 735-738.
Jaremko, M. (1983). Stress inoculation training for social anxiety with emphasis
on dating anxiety. In D. Meichenbaum and M. Jaremko (Eds.) Stress reduction
and prevention. New York: Plenum Press.
Jay, S. M. & Elliot, C. H. (1990). A stress inoculation program for parents whose
children are undergoing medical procedures. Journal of Consulting and Clinical
Psychology, 58, 799-804.
Kendall, P. (1983). Stressful medical procedures: Cognitive-behavioral
strategies for stress management and prevention. In D. Meichenbaum and M.
Jaremko (Eds.) Stress reduction and prevention. New York: Plenum Press.
Kendall, P. C., Williams, L., Pechachek, F. F., Graham, L. E., Shisslak, C., &
Herzoff, N. (1979). Cognitive-behavioral patient education intervention in
cardiac catheterization procedures: The Palo Alto Psychology Project. Journal of
Consulting and Clinical Psychology, 47, 49-58.
Langer, T., Janis, I., & Wolfer, J. (1975). Reduction of psychological stress in
surgical patients. Journal of Experimental Social Psychology, 11, 155-165.
Long, B. C. (1984). Aerobic conditioning and stress inoculation: A comparison of
stress management interventions. Cognitive Therapy and Research, 8, 517-
542.
Meichenbaum, D. (1993). Stress inoculation training: A twenty year update. In
R. L. Woolfolk and P. M. Lehrer (Eds.), Principles and practices of stress
management. New York: Guilford Press.
Moore, K., & Altmaier, E. (1981). Stress inoculation training with cancer
patients. Cancer Nursing, 10, 389-393.
Novaco, R. W. (1975). Anger control: The development and evaluation of an
experimental treatment. Lexington, Mass: Heath.
Randich, S. (1982). Evaluation of stress inoculation training as a pain
management program for rheumatoid arthritis. Unpublished doctoral
dissertation, Washington University, St. Louis.
Roskies, E. (1983). Stress management for Type A individuals. In D.
Meichenbaum and M. Jaremko (Eds.), Stress prevention and reduction. New
York: Plenum Press.
Ross, M. J., & Berger, R. S. (1996). Effects of stress inoculation training on
athletes' post surgical pain and rehabilitation after orthopedic injury. Journal of
Consulting and Clinical Psychology, 64, 406-410.
Smith, R. E. (1980). A cognitive-affective approach to stress management
training for athletes. In C. H. Nadeau, W. R. Halliwell, K. M. Newell, and G. C.
Roberts (Eds.), Psychology of motor behavior and sport. Champaign, IL: Human
Kinetics Press.
Vernon, L. J., & Best, C. L. (1983). Assessment and treatment of rape-induced
fear and anxiety. The Clinical Psychologist, 36, 99-104.
Wells, J. K., Howard, O. S., Nowlin, W. F., & Vargas, M. J. (1986). Presurgical
anxiety and postsurgical pain and adjustment: Effects of a stress inoculation
procedure. Journal of Consulting and Clinical Psychology, 54, 831-835.
Wemick, R. L., Jaremko, M. E., & Taylor, P. W. (1981). Pain management in
severely burned adults: A test of stress inoculation. Journal of Behavioral
Medicine, 4, 103-109.