= Behavioral Pa rent Training Linda J. Pfiffner, Ph.D. Nina M. Kaiser, Ph.D. Theoretical Underpinnings and Key Concepts Behavior therapy has a long history of success in treating childhood problems. This approach is based on several core assumptions that highlight methodolog- ical rigor, empirical evaluation, a focus on observable behaviors as the most ben- eficial targets of intervention, and the importance of behavioral assessment in both design and ongoing evaluation of treatment plans. Behavior therapy approaches emphasize the importance of environmental and social contingencies in fostering and maintaining problem behavior—that is, contingency theory (Patterson 1982), Contingency-based behavioral interventions involve one or more of four key concepts: behavior is increased either by following it with something desirable (positive reinforce- ment) ot by removing, something unde- Sirable (negative reinforcement); behavior is decreased either by following it with Something undesirable (punishment) or 901 by removing something desirable (extinc- tion). Current behavioral treatments also draw from social learning theory (Ban- dura 1977), which incorporates contin- gency theory into a more general model that also includes modeling and imita- tion and cognitive factors (e.g., cognitive appraisals and attributions). Behavioral interventions usually begin with a functional behavior analysis, which involves specifying behaviors (positive behaviors to increase or nega- tive behaviors to decrease) and then identifying each behavior’s antecedents (variables setting the stage for or preced- ing the behavior) and consequences (variables maintaining the behavior).On the basis of this analysis, specific strate- gies for modifying antecedents and con- sequences are selected for a behavioral intervention plan with the goal of reduc- ing problem behavior and promoting desired behavior. Maximally effective behavioral interventions consider the function of the problem behavior when attempting to reduce it. For example, if a child exhibits disruptive behavior in order to gain parental attention, a behav- ioral intervention might teach the child902 to gain attention through more appro- priate behavior and reinforce this appro- priate behavior when it occurs. Generally, the behavioral approach to intervention selects target behaviors for treatment that cause impairment in daily living (e.g., academic, social behavior) rather than targeting diagnos- tic symptoms per se, although it is important to note that these interven- tions often do have powerful direct and indirect effects on diagnostic symptoms. A behavioral approach can be very effec- tive in modifying behavior and improv- ing overall adjustment, whatever the underlying disorder. Behavior therapy has been applied to a wide variety of childhood problems and within multiple different settings. Our main focus in this chapter will be on behavioral parent training (BPT), one of the most widely used forms of behavior therapy for disruptive behavior prob- Jems (also variously referred to as parent management training, parent training, or behavioral family therapy). In this approach, the therapist teaches parents skills to improve the quality of family relationships, promote positive child behaviors, and decrease child deviant behaviors. We include information about core components of parent train- ing as well as adjunctive interventions used to address problems at school, with peers, and in the family system. Rationale for Using Parent Training With Disruptive Behavior Disorders Parent training programs are based largely on theory and data showing that families with a child displaying behav- ior problems tend to exhibit dysfunc- ty Dulcan's Textbook of Child and Adolescent Psychiatry, Second Edition tional parent-child interaction patterns. One prominent pattern, described by Patterson (1982), is referred to as the coercive process and specifies that fami- lies with children having behavior problems learn to control one another through negative reinforcement. More specifically, children exhibit negative behaviors to the parent and the parent responds aversively to this behavior; this type of response from the parent in turn leads to an escalation of the child’s negative behavior and so on until either the parent or the child gives in to the demands of the other, thereby reinfore- ing the other’s negative behavior. One example of this type of pattern might be achild learning that unwanted parental demands (e.g., to do chores or home- work) might be withdrawn if he or she provides a counterattack (e.g., arguing, refusing, exhibiting high levels of nega- tive affect). Alternatively, a parent who discovers that the child complies when the parent engages in yelling or other extremely aversive behavior is more likely to employ this type of behavior in the future. Observational studies of family interaction (Dishion et al. 1991; Patterson et al. 1992) show that dis- rupted family management skills, most notably parent discipline and monitor- ing, appear to be key factors in antiso- cial behavior development. Subsequent studies consistently have found that problematic parenting practices (e.g. overly negative and controlling, lacking in warmth and positive involvement) are strongly related to disruptive behavior disorders (Johnston and Mash 2001). The importance of maladaptive parenting practices in perpetuating dis- tuptive behavior problems is under- scored by findings that the adverse effects of contextual factors on children such as stress, social disadvantage, divorce, and/or parent depression are ——Lo Behavioral Parent Training mediated largely by these practices (Patterson et al. 1992). Child behavior problems most com- monly addressed by parent training map onto the DSM-5 diagnoses of attention- deficit hyperactivity disorder (ADHD; classified under neurodevelopmental disorders) and oppositional defiant dis- order and/or conduct disorder (classi- fied under disruptive, impulse-control, and conduct disorders). For this chapter, we refer to this triad of disorders as dis- ruptive behavior disorders (DBDs). Par- ent training for DBDs is supported by extensive data that children with these problems show dysfunctional responses to usual contingencies that disrupt these children’s ability to regulate behavior according to typical consequences (for a review, see Luman et al. 2005). More spe- cifically, because of a weak inhibition system, children with DBDs display a lack of sensitivity to partial reinforce- ment, elevated reward thresholds, a marked aversion to delays in reinforce ment, and less avoidance of or caution toward cues of punishment or nonre- ward. Children with conduct disorder have a reward-dominant style, in which their behavior is motivated more by the Possibility of gaining a reward than avoiding punishment. Together, these findings suggest that the families of chil- dren with DBDs are likely to benefit from Parent training precisely because of this approach’s focus on modification of external contingencies, such as use of consistent, salient, and immediate rewards; well-delivered negative conse quences; clear rules and directions; and Predictable routines. Parent training prog} : address attachment deficiencies between children and their parents. Lower Jevels of attachment are theo Fized to lead to emotional dysregulation and a lack-of mutual responsiveness rams also can 903 between parent and child (Harwood and Eyberg 2004; Herschell et al. 2002). Parent training addresses these emo- tional factors by fostering responsive- ness, communication, and nurturance between parent and child. These pro- cesses in turn enable the child to develop secure attachments with others and improved emotional regulation. Models of Parent Training Models for delivering parent training involve a therapist working with par- ents to teach a variety of behavioral strategies; the parents then apply these strategies at home. Troubleshooting the use of each strategy occurs within the context of each individual family during each therapy session. Parent training may be offered in combination with behavioral school consultation and/or with child-focused interventions, such as skill-building groups or cognitive- behavioral interventions. Parent training can be administered individually with parents, with families (parents and children together), or in groups of parents. The group format may be especially useful for parents who would benefit from receiving sup- port from and/or sharing ideas with other parents. Reluctant parents often become more open to using a strategy after hearing firsthand about the success another parent has had with that partic- ular strategy. However, not all parents benefit equally from a group experience. Groups seem to be most useful when members share very similar problems, Working with the individual family is indicated when more intensive and tai- lored interventions are needed; this may be the-case when there are very severe child: problems, for parents who have904 Dulcan’s Textbook of Child and Adolescent Psychiatry, Second Edition interpersonal styles that would be diffi- cult for a group, or when a slower pace is desirable. In some cases, individual sessions interspersed with the group meetings are helpful. Parent training is intended to be time limited. The number of sessions typi- cally varies from 6 to 12, with some pro- grams lasting as long as 20-25 weeks; duration generally depends on the severity of the problems and develop- mental level of the child (Kazdin 1997; McMahon and Forehand 2005; Webster- Stratton et al. 2004). During sessions, the therapist presents specific strategies, discusses their rationale, has parents practice the skills (e.g., via role-plays), and instructs parents to implement the skills at home with their child between sessions. If therapists opt to have par- ents practice skills in vivo with their child(ren), parents can be observed and coached by having the parents wear a “bug-in-the-ear” (wireless ear piece with radio transmission) while the ther- apist is behind a one-way mirror; alter- natively, in-room coaching can be effective with young children. Programs in which parents observe videotaped examples of effective and ineffective parenting strategies with opportunity for discussion of the strategies also have substantial research support for efficacy (Webster-Stratton et al. 2004). Parent training has been successfully delivered remotely via weekly telephone coaching sessions (McGrath et al. 2011) and video- conferencing (Reese et al. 2012). Recent innovations in smartphone technology also have been applied to parent training. For example, Jones et al. (2014) developed a technology-enhanced version of Helping the Noncompliant Child (McMahon and Forehand 2005) that incorporated videos of parenting skills, tracking of daily skill use, video call check-ins, videotaped home practice for review and feedback, and text mes- sage reminders of home practice Enhancements like these appear to improve the parent’s engagement in treatment and, as a result, improve child outcomes. Baseline Assessments Prior to Starting Treatment Initial assessments typically include the usual diagnostic work-up and gathering of information about functional impair- ment at home, at school, and with peers. This information ideally is obtained from. the child’s parents and teachers using a combination of empirically based and standardized rating scales, as well as more qualitative measures, including direct observation of the family interac- tions or school functioning (if possible). However, it is important to emphasize that behavioral forms of treatment are guided more by functional analysis of behavior and less by a diagnosis or symptoms per se. Therefore, parents typ- ically are asked questions at the initiation of parent training about the frequency and specific types of behaviors of con- cern, as well as the antecedents (e. when they occur) and consequences (e.g., what happens after they occur) of each problem behavior. Parents often keep a chart of these behaviors during the first week or two prior to starting a behavior plan. This chart can then serve as a baseline for comparison after spe- cific strategies are implemented in order to determine if the program is having its intended effect. Assessment of target behaviors continues throughout behav- ioral treatment as an important guide to decision making about which strategies are most effective for each family.Behavioral Parent Training Setting Treatment Goals In behavioral approaches, setting goals for treatment is an individualized and collaborative process between parent and therapist. Usually, the parents’ ini- tial goal simply involves modifying the child’s behavior. However, in parent training, treatment goals include the parents changing, their own behavior. Although this goal does not always need tobe explicitly stated, some discussion of this issue usually is helpful. It is import- ant that the therapist communicates to the parents that they are not being blamed for their child’s difficulties. Instead, parents are told that children’s difficulties are multiply determined (including biological and environmental factors) and that children with behav- ioral challenges are more difficult to par- ent. The goal is to find the best ae between their child’s personality and their parenting practices. We often tell parents of children having behavioral concerns that there is a need to become “superparents,” providing a structured “superenvironment” that is more demanding than what average parents need to manage their children. Initial treatment goals are set at levels that ensure that both the child and the Parent experience some success at the outset (and consequently are motivated to continue). Thus, initial target behav- iors and parenting strategies taught are relatively simple and easy to change (@-B Positive attention during noncontronta- tional situations, compliance with non Provocative commands). At treatment onset, parents typically are encouraged to target only one or two behaviors fof change. A shaping process }5 then use So that as initial goals are reached, ne difficult or complex behaviors and skills are added, Behaviors important te the i 905 child’s family, social, and academic func- tioning generally are included as pri- mary goals (e.g., following directions the first time asked, completing chores, com- pleting homework, playing well with siblings), and both prosocial and antiso- cial behaviors are included. After parents have obtained some success with home- based targets, treatment goals may be expanded to incorporate problem behav- ior outside the home or with other adults. Core Session Topics Although a number of different approaches to parent training exist, all approaches generally involve some combination of the core topics we describe in Appendix 41-1 at the end of this chapter. Different approaches vary somewhat in the session time that is allo- cated to each topic, the order in which topics are presented, and/or supple- mental topics that are also covered by the treatment package. In addition, we note that clinicians may pick and choose specific topics to be covered on the basis of differences in the problems with which a given child and family present. For example, we have found that par- ents of children who are particularly impulsive or oppositional tend to need more instruction on effective discipline than do parents of children with mostly attentional problems. For each topic, we discuss and troubleshoot common parental concerns and questions. Please note that we intend our descriptions of session topics to serve as an educational overview of each topic rather than step-by-step instructions, We reference a variety of excellent treat- ment manuals throughout this chapter that provide more explicit information on conducting BPT, and we encourage those interested in implementing this906 Dulcan’s Textbook of Child and Adolescent Psychiatry, Second Edition type of intervention to consult these manuals for further guidance. Psychoeducation and Background Information Overview ‘The first session of BPT generally involves providing parents with background infor- mation and psychoeducation regarding childhood behavior problems, family interactions, and behavior therapy (see Appendix 41-1). In addition, parents are introduced to the antecedent-behavior- consequence (ABC) model of behavior that sets the framework for alll topics pre- sented in this chapter. Troubleshooting As mentioned in the subsection “Setting, Treatment Goals,” one question that often arises relates to why parents (as opposed to the child) participate in treat- ment, as the child is the identified patient. In response to these concerns, therapists typically acknowledge that the temperaments of children with exter- nalizing problems make these children more difficult to parent; consequently, parent training is presented as a way for parents to obtain additional strategies for their parenting toolboxes that will help them more effectively manage their child’s behavior. In addition, it may be helpful to briefly describe research liter- ature suggesting that parent-focused intervention is more effective than are child-focused treatments alone, likely at least in part as a result of core skill defi- cits underlying child behavior problems. Attending and Ignoring Overview The focus of this session is on improving the parent-child relationship, under the assumption that 1) this relationship has been impaired by negative parent-child interaction cycles and 2) children are more likely to comply with parental instructions in the context of a positive parent-child relationship. Parents thus are taught to spend “special time” with their child during which they actively attend to their child’s behavior (see Appendix 41-1). After parents master this skill, they learn to generalize the attending skill and differentially attend to positive behaviors they would like to see increase and ignore negative behav- iors that they aim to decrease. Troubleshooting During discussion of attending and ignoring, parents may raise the follow- ing concerns: © Why shouldn't I ask questions, praise my child, or be directive during special time? Parents are encouraged to let the child direct the activity to the greatest extent possible in order for the child to feel that the activity is most pleas- ant and validating. Asking questions, praising, and redirecting the child all are subtle ways of controlling the sit- uation and consequently are to be avoided during the attending/special time exercise. How should I deal with misbehavior? Parents are encouraged to ignore mild misbehavior during special time. Obviously, however, it is inappropri- ate to ignore behaviors that are unsafe, and parents should employ their usual system of consequences to cope with any such behaviors that occur. How will I find time? What about my other kids? Parents are encouraged to practice attending even if the special time lasts only for brief periods of time (5-10 min- utes) or in the context of an activity that the child already is doing. Often, look- =Behavioral Parent Training ing for opportunities to practice attend- ing (rather than scheduling attending as aseparate event) feels more manage. able to parents. Parents with multiple children may find that all children are eager to have parents do attending with them; if this is the case, parents may choose to do special time with one child on one day and another child the next day. I'm ignoring, but my child’s behavior is getting worse! It is important to warn parents that with ignoring, behaviors generally get worse before they get better; because the child often escalates in an attempt to obtain the parents’ attention, the most unbearable behavior often occurs immediately before the child gives up. Once the child begins to behave appropriately, the parent is directed to resume attending. Praise and Positive Reinforcement Overview As negative behavior generally is much more salient to parents than positive behavior, parents often unintentionally ignore positive behaviors when these behaviors do occur. Session content con- sequently focuses on reinforcing and tewarding positive behavior with praise and tangible reinforcers such as activi- ties or token prizes (see Appendix 41-1). Troubleshooting The following issues or concerns may Come up during a discussion of praise and positive reinforcement: * Giving rewards feels ike bribing my child for things that he or she should be doing anyway. Therapists may wish to point out that the child is not doing, the task at 907 the moment and that use of positive reinforcement can be helpful in get- ting the child to complete the task {and can consequently be faded out over time). It also may be useful to draw a parallel between this type of positive reinforcement and that expe- rienced by parents in the workforce, few of whom likely would go to work if they were not paid. My child is upping the ante and saying things like “I'll do it if you get me..." Parents are encouraged to provide rewards only in the context of struc- tured reward programs, as opposed to spontaneous rewards (particularly in situations in which the child is try- ing to manipulate the situation in order to obtain a reward). Giving in to this kind of request makes it more likely to happen in the future. Token Economy or Point System Overview A crucial component of parent training programs for parents of school-age chil- dren involves working with parents to establish a home reward system in which the child earns tokens, points, or privileges for positive behavior; the child then can cash in earned tokens or points for activities or token reinforcers (see Appendix 41-1 and Figure 41-1). Case Example 1: Token Economy/Shaping and Fading/integrating Home Challenge and Classroom Challenge Melissa, a 7-year-old girl, was brought in to the clinic by her pare ents, Mr. and Mrs, Smith. The Smiths’ primary concern was Melissa's need908 Behavioral Parent Training “Bssijayy 405 AwoUod LOO) OWES *h-by SUNOS sow 04 09, od 0 dey, 40 seuuig, — =spuomay Apo, unt Ale ouupeg 0f:8. wood yum 2u0g, —spromay Ayog syed o7 = sBunu0g 40g as504 Aopug Aopssoyy,Behavioral Parent Training for excessive supervision when com- pleting morning routine tasks, which made the entire family late to school and work on almost a daily basis; the Smiths indicated that they currently were giving Melissa four or more reminders for each task she needed to accomplish in the morning. In ad tion, Melissa’s teacher reported that Melissa had difficulty completing her work independently in the classroom and that she required reminders to stay seated appropriately during class time. Mr. and Mrs. Smith set up a token economy system with five specific target behaviors for Melissa to accomplish during morning rou- tine (see Figure 41-1). Melissa could earn 5 points for each behavior that she completed with two or fewer reminders from her parents, for a total of 25 points per day. In addition, Melissa’s teacher agreed to imple- ment a daily behavior report card (Figure 41-2) in the classroom to help Melissa complete her work inde- pendently, remain seated during class time, turn in completed home- work, and remember to bring the report card to the teacher each day (awarded with a bonus point). Melissa could earn an additional 15 points for successfully performing these behaviors. Before beginning the program, the Smiths developed a reward menu with Melissa’s assistance; as Melissa could earn up to 40 points each school day (for a total of 200 points per week), the Smiths assigned point values to each reward accordingly (Gee Figure 41-1). After posting the morning routine checklist and imple- menting the token economy, Mr. and Mrs, Smith reported an immediate improvement in Melissa's compli- ance with the morning routine. After 2 weeks, Melissa needed only one to two reminders for each moming rou" tine behavior and consequently was regularly earning all 25 possible points every morning. At this point, Mr. and Mrs. Smith decided that because Melissa now was doing $? well, they would change the crite- 909 rion; now, Melissa would need to complete each task with one or fewer reminders in order to earn her points. ‘After Melissa met this goal regularly, the Smiths then required Melissa to complete each morning routine behavior without any reminders in order to earn her points. The Smiths were able to phase out the token econ omy once Melissa was regularly com- pleting the morning routine checklist independently, although they contin- ued to praise her every morning for getting the checklist done on her own. Melissa’s teacher continued to imple- ment the daily behavior report card in the classroom throughout the remain- der of the school year. Troubleshooting For clinicians, it is important to be aware that token economies are somewhat sen- sitive interventions, with minor differ- ences in intervention structure often resulting in vastly different outcomes and efficacy (Table 41-1). Consequently, if a token economy is not initially effec- tive, it is important to troubleshoot the intervention rather than to deem it inef- fective and discontinue it. One frequent challenge is that parents often want to address a large number of behaviors and end up developing complicated pro- grams that are difficult for the child to understand and for the parents to imple- ment consistently (Table 41-1). It is best for parents to start with a simple system. that focuses on increasing three or four positive behaviors and then revise the system as the child responds to the ini- tial demands. Inaddition, parents must set the crite- ria for earning the tokens or rewards low enough that the child is able to regularly obtain rewards; if the behaviors are too. difficult relative to the child’s current functioning, the child likely will become discouraged and the system will not work,910 Dulcan's Textbook of Child and Name: Melissa Date: —, Adolescent Psychiatry, Second Edition MY CHALLENGE TIME TARGET BEHAVIORS Completed classwork independently Followed class rules Tuned in completed homework oO} Gave challenge to teacher T bonus point DAILY TOTAL POINTS Point Scale 1 = Okay 2= Super Job Teacher signature: (O=Needs Improvement Figure 41-2. Sample daily report card for Melissa. Giving Effective Instructions Overview Discussion of effective instructions shifts the focus from the consequences of behaviors to the antecedents of those behaviors. More specifically, parents dis- cuss how to give instructions in a man- ner that maximizes the chance that the child will comply (see Appendix 41-1). Troubleshooting © What do I do when my child does not comply? Parents often want to jump ahead to a discussion of punishment, partic- ularly in the context of this module, but it is important for them to master giving instructions in a maximally effective manner prior to implement- ing a punishment for noncompliance. To this end, parents are encouraged simply to practice giving effective instructions and to praise compliance without implementing any particular consequences for noncompliance. Time-Out Overview Time-out, or time away from positive reinforcement (e.g., parental attention, another enjoyable activity) can be a powerful consequence for negative behavior. This session involves review- ing parents’ past experiences with time- ‘out, as well as discussion of mechanical and logistical issues of the time-out pro- cedure (see Appendix 41-1 and Figure 41-3). Case Example 2: Time-Out/Integrating Strategies Kyle is a 10-year-old boy whose par- ents, Mr. and Mrs. Miller, reported concerns including aggressive behavior toward his younger sister and noncompliance with parental commands. The Millers decided to employ a time-out procedure to address both of these problem behav- iors. They selected a time-out loca- tion (in the living room on the sofa, away from any distractions such asont Behavioral Parent Training “sawoayno jeurdo 403 a>eId 1u1 9q 0} poou seaaye Avur sazsuatunues auros yey adxq quoUr aanisod vse pyiyp ayy 01 payuasaid ag pinoys pur (spueatat 40) syuourosinbax ur sasvas2ut jenpeld via “$'a) ssaooad jenpea8 e st wea8oud e Surpey Aqyryssaoong yioddns uv puv wei8ord ayy spurysiapun auodsoaa yeu 0s (s10HISK -qvq/suiasedpueid “3'0) sjuared ayy 0} uo ppe Ur suyerareD yim ayerTUMUTLOD, -aoejd uy wesSord ayy Surdaay ur yuD}sqsU09 9q 0} 3Ng |ySUE -uvout zou 8unypatuos oj sasuanbasuo) SuiSueyp s9p1su09 o} sjuored aSesn0IUy “Appamip su019e Sunadusos Aue ssouppy “ToIAeYag ay AYE LOS pur jaw axe sjeo8 aunsua of Aressadau se uayo Se 1230 0} spadu JUOUIDOFU!Y ‘roooputaz ayy SyueM PIryD amp amns rey -wes8ord ayy doys 0} squared ayy 108 0} papuoyu 514151 Sururejdwios s, pjry> aup az0u8 pur y>ea s,PEYD axp UMIM axe s[eo8 auns axe, suaoxoputas pur s]e08 Surpnpout ‘wes8oud ayy jo sdays ype yeadax py ayy 2acH1 -pousva uayar [uo y1 98 UeD pue sasTOJUTaN aM SjUB PILYD ay ams axepY “fjaiepauran njssazons aq 0} PIEYD ayy SMOITE ILA [>A9q BI [208 19g epapey Surag seas weifoid puemar ayy way swajgosd azous Survey 12e)S PLY 8G PIL quiesSoad ayy Susoddns siayejo1e9 YF az apESpeA OF WEIS UHL PUK 9] BJO} [9M OP PRP IMD PIG gQaay JO uMNY 40] FOP OF asja auoawos Suna 410m Supop Jo no Fun}98 ‘uonuD)e sad Sin “108 “8.0) so1seyaq woiqosd ayy SuruTeHUTEU SIOWDe] FOYIO aI9KD 92V {Xpuanbay pue Apayerpounat uaa saDs0puTO2 ong 5} qaosuopuad 9yy Uy poysasmaUL PINP 9S] EPIEY OOF St wey SuTUTe;dusos so wresBord ayy jnoge snorwue A[19A0 PLP Aw SL qunesZoid arg purysiapun pip ayy Seog, ai Surwsea ynoyprn yf aavyo} a}qe10U pur zad10jUIaX at Aq PHAHOW PNP] 2u81y 001 195 jvo8 aug 5 -suiuay aanisod “ajqearasqo ut sorneyog 19830} aUYOq, ¢Apeap Asa pauyap s01veyoq 39818) a1p S] uonnjos uonsanp ‘Sa]WIOUDSe UDYHO} Buyooysajqnoyy “b-EY FIEVLSEE eee 912 Dulcan’s Textbook of Child and Adolescent Psychiatry, Second Edition Parent issues instruction. Parent waits 10 seconds for child to comply. —_— Child does not Child complies eal | = Parent praises child Parent issues for compliance. worning Sear nen Child does not Child complies ack 1 x Parent praises child Parent issues for compliance. warning Child serves timeout Child must comply with the original instruction after time- out is served Figure 41-3. Time-out flowchart. TV or toys) and decided that Kyle’s time-outs would be 10 minutes long (1 minute for each year of his age). The Millers sat down with Kyle and explained that from now on, every time he displayed aggressive behav- ior toward his sister (e.g., hitting, kicking, pinching), he would earn an automatic time-out. In addition, Kyle now would be expected to follow parental instructions with only one reminder; if he did not follow the instructions after a warning was pro- vided, he would earn a time-out. If Kyle chose not to serve this time-out, he would not be able to play video games or watch TV for the remainder of the day. Mr. and Mrs. Miller posted these rules on the refrigerator. Later that day, Kyle was playing, video games when Mr. Miller instructed him to pick up his shoes and put them away. Kyle ignored the instruction. After waiting 10 seconds for kyle to comply, Mr. Miller stated, “I've asked you to pick up your shoes and put them away. If you do not pick up your shoes now, you will earn a 10-minute time-out.” Kyle continued to ignore his father. Mr. Miller then informed Kyle that he had earned a 10-minute time-out and should proceed directly to the living room sofa to serve his time-out. When Kyle refused to do so, Mr. Miller calmly reminded Kyle that if he did not serve his time-out, he would be choosing to lose video games and TV for the remainder of the day. Although Kyle grumbled under his breath on his way to time- ut, he served the time-out appropri- ately. At the end of the 10 minutes, Mr. Miller allowed Kyle to leave time-out and instructed him to pick up his shoes, Kyle complied, and then he was able to return to playing video games,Behavioral Parent Training Troubleshooting The following concerns often come up during a discussion of time-out. © I've tried time-out before and it did not work, Discussion about the mechanics of time-out used in the past and how the time-out being recommended may differ from the procedure employed in the past likely will address these concerns. However, therapists should be prepared to troubleshoot the time- out procedure with parents as they implement this strategy at home. What if my child refuses to go to time- out? Parents may handle time-out refusal in one of two ways. First, parents can modify the time-out procedure and use either an escalating or escalating- reducible time-out. In an escalating time-out, the child earns additional time in time-out for each refusal to go to time-out. In an escalating-reducible time-out, the duration of the child’s time-out increases each time that he or she refuses to go to time-out, but the child has the chance to earn half off his or her time-out by proceeding to time- out and serving the time-out appropri- ately. An alternative way to handle time-out refusal involves implement- ing a back-up consequence, suich as removal of a favorite activity, should the child choose not to go to time-out. Response-Cost Procedures Overview Parents also are taught punishment Strategies that involve removing tokens, points, or privileges after the child demonstrates target negative behaviors; these strategies can be 913 implemented either within the existing home reward system or separately (see Appendix 41-1). Troubleshooting Again, parents may get carried away with the number of behaviors that they want to address. Parents who employ response-cost procedures within the token economy must be cautioned to monitor the reward system in order to ensure that the child continues to earn rewards and remains motivated. Parents also must be warned about punishment spirals that result in the child losing all of his or her tokens or points or losing activities or toys for unreasonably long, periods of time. If a child continues to misbehave after the initial response-cost fine, the parent should implement a back-up conse- quence instead of continuing to fine the child tokens or points. Further, it may be helpful to discuss children’s difficulty estimating time (as well as the fact that if parents take away toys or activities for extended periods of time, they are limit- ing their future response-cost options should the behavior recur). Developing a Plan for Homework Overview Some programs include one or more ses- sions that specifically address home- work time in the home environment (see Power et al, 2001). Key points of this ses- sion generally are related to the develop- ment of a plan to increase the structure of the time set aside for homework by making rules for this time explicit, thinking ahead about potential prob- lems, and instituting consequences for specific homework target behaviors (see Appendix 41-1)914 Dulcan’s Textbook of Child and Adolescent Psychiatry, Second Edition Troubleshooting Children may not clearly record school homework assignments or may not bring home the needed materials. Using a homework assignment notebook con- taining daily assignments, materials, and due dates is advisable. Children and parents should be made aware of the teacher's procedure for assigning home- work, and children should be reinforced for using the homework notebook. The teacher may also sign the notebook each day to ensure accuracy. Parents also may be somewhat resis- tant to setting a specific and consistent time for homework in the context of other family activities. Although this is a valid concern, parents should be cau- tioned that children are likely to be most compliant with a homework hour that occurs at a routine time. Home-School Report Cards Overview Many parent training intervention pro- grams include a session teaching fami- lies to develop a daily behavior report card (DRC) targeting between one and four problem behaviors that the teacher fills out and sends home with the child each day (Kelley 1990) (see Appendix 41-1 and Figure 41-2). The child can earn daily rewards at home based on his or her behavior at school. This type of program encourages better communica- tion between parents and teachers and provides the child with incentives for positive behavior in the classroom. Degree of therapist involvement in developing these programs depends on the particular intervention model, as well as the type of service (i.e., group vs. individual treatment) being provided. Some programs include regular school consultation meetings for the duration of treatment, while other programs teach parents how to set up a classroom intervention with limited or no therapist contact with the school. The latter approach is more efficient in use of ther- apist time and is likely to be successful with reasonably skilled parents and with teachers who already are familiar with the approach. Troubleshooting Children may forget to bring home the DRC or fail to bring it home on days with negative ratings. Usually this can be addressed successfully by treating that day as if the target goals were not achieved, and therefore the daily home reward is not earned. Parents and teachers may select too many behaviors on which to focus or set the bar for rewards too high. As with home-based interventions, home-school report cards must have a manageable number of behaviors (typically between two and four) and permit the child some success. Finally, teachers may informally expand target behaviors to address more general misbehavior over the course of the intervention rather than adhering to the originally specified operational defi- nitions of DRC goals. Should this be the case, the child may not understand exactly what he or she needs to do in order to be considered successful. Spe- cific, concrete expectations should be set and then consistently adhered to, with any modification or expansion of goals formalized and explicitly explained to the child.Behavioral Parent Training Managing Behavior in Public Places Overview Parents often report child misbehavior in public places outside the home setting in which the strategies that they have learned to use at home are not immedi- ately available. Parents are encouraged to anticipate problem behavior by employing the ABC model before enter- ing the public place in order to alter antecedents and minimize the chance that the child will engage in problem behavior (see Appendix 41-1). Troubleshooting Parents often raise concerns about feel- ing embarrassed about their child’s mis- behavior or about implementing punishment techniques in public; dis- cussion of these concerns often may help parents to be more comfortable and less. self-conscious about using available strategies. In the end, however, parents must realistically select strategies that they are willing and able to implement consistently. When-Then Overview In addition to the formal rewards that parents have learned to use in their token economy systems, there are many activities that parents permit children to have for free that also can be used as rewards. During discussion of “Grandma's rule” or Premack contin« gencies, parents learn to use more desit- able activities as reinforcers for the completion of less desirable activities (see Appendix 41-1). Forexample, a par- ent might say, “If you do your home- work, then you can watch TV.” For families struggling to implement a more 915 structured token economy system, a less complex when-then contingency imple- mented consistently can serve as a more easily administered alternative to a token or point system (e.g., “If you are ready to leave for school by 7:45 A.M., then you can play the iPad in the car on the way to school.”). Troubleshooting Parents occasionally will attempt to use they are not willing to withhold (e.g., family vacations or other outings); it is important to remind parents that they should employ this strategy only when the desired activity is one that they are willing and able to withhold if the child fails to complete the less desirable task. Planning Anead During the final session, parents review the strategies that they have learned over the course of treatment and discuss ways to apply these strategies to future situations (see Appendix 41-1). Supplemental Topics Child Skills BPT can be combined with child- focused skill training treatments, such as social skills training, anger manage- ment, or organizational and study skills training, that permit direct skill instruc- tion and practice for children (e.g., Abikoff et al. 2013; Kazdin et al. 1992; Pfiffner et al. 2007, 2014). Parents also can be taught strategies, as part of BPT, for helping their child’s skills develop in these domains (e.g., Parental Friendship Coaching developed by Mikami et al. 2010). (Table 41-2 contains details on addressing social and organizationalDulcan’s Textbook of Child and Adolescent Psychiatry, Second Edition 916 LOZ Te 9 JUHA {2661 NOWENGIHY PUE JOU ‘SOOT ALAN PUR UELY “E10 TEP OLLAY As aseayd uOHCUUZOsUI [eUOH PPE 4O4 ON, quozed aif jo ed ayy uo iaiwosu0UIed pue SuLOyuouroIMbad anu “o> FTL paysy|qrise wais4s uoNeziUeSs0 Aue yng ‘au 1940 panpai9q, eo etp quazed ayy jo yred ayy uo jiawysa nun awe e sauinbas ARoWeAyS SIU, Aqinyssazons [pps yea Sursn x05 ppyp og Surpremoy ties aida eg TINS ypea asn oy Uys jnoge PEP ayy Buin PHYD aKa Buryse pur rare aig SurzTUeSostp uayp pur (Asap 10 x>edy>eq PINUD aD YEA SuPaLE I YeYM Pur |INYS yea Burssnosiq, 28.9) vase sypads & ut pry ayy 40) s|IP4s [euouezTuE0 Suyer}suoUD {SayDROD [YS Se as—s OF SUDIEd SuRDWD ) ase 2) PIM " ed i HYDRO, quased a1p oj ssavord jouoqeziueduo ayy Sunueydxg Jor acyaq aantsod premaz oy ayepdeyd ayy axojaq ueyd v dn Buniag :saypeod [[N4S Se aALAS o} Syuased Suryreay (samyoid pur si0j0> se ypns sand jensta pur ‘saafays’sjaqe] ‘soxog Sursn_ uiays4s e Sunuawayduy £q sdeysad) uowtuomava awoy ap SurziUeRIQ) INS TeuOHEZtUeRLO SuNapoyy Aolua tis uoapyyp yiog wey Guage ue SujUUEig, sug aepced ary Surdaoy SOX PIRP ayp saad pazsuLeUL-pinus 10 u1oFsea uv SuNooIag {PIMP 249 104 sasupadxa nyssazons sawp eid soyeur puv zoracyoq spoztueSio aiow 9q01 pI wojgoud jo suopaoaque sozrunut yy A;UUEU e U SoIepsetd SMBUS 3yy aSeanooua [IM Jey awWoY ye amNyongys [eUOALZIUL{O Ue SurYs! HLaae ur uoRedinsed pur sayepvjd auo-uo-au0 "8'a) sjfrys [es 39) Joraeypg poztuettosip sx pazrueio jo swuopaosjue urssauppy _aon>ead oysonrumoddo yptoa upp Suapracud joaouepodiay Surssnosiq, SUDIS 1eIOg SIMMS PMD ynoge syuased BulyseAL “Z-iy avy. SuIMS euoneZIUeBIQSe Behavioral Parent Training problems.) Session content generally includes two primary components. The first component involves working with the parents to address antecedents of skilled versus unskilled behavior on the part of the child and to structure the environment and provide the child with opportunities to be successful. Second, the parents also are taught to serve as skill coaches for their child by working with the child to focus on specific skills (e.g., engaging in discussion with the child about what a specific skill may mean, cuing the child about when to use the skill, rewarding the child for success- fully demonstrating the skill). Parent Stress Management Parents usually are receptive to the idea that their own stress levels affect their child’s behavior and that higher levels of parental stress are related to increased behavior problems on the part of the child (as well as increased relational stress between the child and the parent). Likewise, parents usually agree that when they are able to manage their own stress levels, they are better able to meet their child’s needs. Parents may be engaged in discussion about their values and priorities and how these correspond to the manner in which they allocate their time. Further, parents also may be taught specific coping strategies to use when they are feeling pressured; these strategies may include relaxation, par- ticipating in pleasurable leisure activ: ties, taking a time-out when they can feel themselves getting upset OF angry, engaging in good sleep hygiene and other healthy habits, and finding addi- tional sources of support (e.g. see Sand- ers et al. 2000; Webster-Stratton 1994) 917 Parent Cognitions and Emotion Management Chronis et al. (2004) note that parental psychopathology and/or emotional dysregulation is one major moderator of treatment response for those participat- ing in parent training. Clinicians recently have given more weight to the discussion of parents’ own cognitions and emotions, particularly as they per- tain to the child. These interventions may include teaching parents cognitive restructuring techniques to help them differentiate between unhelpful and helpful thoughts about the child or situ- ation (e.g., see Bloomquist 1996). Thera- pists generally make the point that some thoughts may cause the parents either to become angry with the child and esca- late the situation (e.g., age-inappropriate expectations or thoughts that the child is misbehaving intentionally) or to become discouraged and give up (e.g., thoughts that attempts to exert control over the child are hopeless or that the parents themselves are ineffective or inadequate parents), whereas other thoughts are more likely to help the parents remain calm and to deal with the child’s behav- ior in a more rational manner. Parents are taught to identify the first type of thought as well as ways to respond to this kind of thinking, that will be most effective in promoting calm and rational interactions with their child. These strategies may be especially useful adjuncts for depressed and/or multiply stressed parents (e.g., Chacko et al. 2009; Chronis-Tuscano et al, 2013) Inaddition, teaching parents mindful- ness strategies also may help in address- ing parent cognitions and emotions. More specifically, advocates of mindful- ness in parent training argue that parents and children become enmeshed in auto- matic cycles and that being mindful of918 Dulcan's Textbook of Child and Adolescent Psychiatry, Second Edition these interactions serves asa step toward altering them. Dumas (2005) describes the following key components of a mind- fulness approach: 1) teaching parents to accept where the child and they them- selves are in the moment without judg- ing; 2) teaching parents to distance themselves from situations that could induce negative emotion; and 3) collabo- rating with the parents to rationally develop and implement a plan to meet goals relevant to both parents and child. Monitoring Treatment Progress In behavior therapy, treatment progress is monitored each session by reviewing the data, such as the child’s progress on behavior charts and DRCs (if used). Writ- ten documents (e.g,, charts or graphs of point totals) can facilitate a more objec- tive appraisal of gains over time (although we note that gathering and constructing charts of such data can be time intensive for the parents and /or therapist). Objective data can be supple- mented with more qualitative parent impressions regarding treatment prog- ress (as well as teacher impressions regarding school-based interventions). To effectively monitor progress, parents should be asked specific questions about how they are implementing the pro- grams (e.g., Which behaviors did you praise this week? How often did you do special time? How often did you catch yourself giving effective vs. ineffective instructions? Did you use the point sys- tem? How calm were you when you gave the time-out?) and about how their child is responding (e.g., How much did your child seem to enjoy special time? How often did your child complete his or her target behaviors? What rewards did your child earn and how often? How often did he or she earn a time-out? How well did he or she take the time-out?). Brief behay- ior rating scales also can be used to track progress, as can questionnaires regarding parents’ understanding of social learning principles and effective parenting prac- tices. Consumer satisfaction ratings also can be very helpful for assessing parents’ understanding of and perceptions about the usefulness of content covered during each session. When such ratings are gath- ered each session, these data can alert the therapist to potential dissatisfaction that might lead to premature termination or failure to follow through on programs at home. In addition, observations of par- ent-child interactions can be extremely useful in determining whether parents are able to successfully implement the procedures and also in evaluating the child’s response. Potential Adverse Effects or Complications In general, this approach to treatment is associated with a very low risk for any serious adverse effects, making the risk- benefit ratio quite small. Instead, unwanted effects usually are mild and transient and result from parents using, skills taught in an inappropriate man- ner. These effects can be addressed by making modifications to the program. We discuss typical pitfalls in the earlier subsections on troubleshooting session content (see “Core Session Topics”) and in Table 41-1. The most serious compli- cations may occur around the topic of punishment, as overly critical or poten- tially violent parents may overuse these approaches to the exclusion of the more Positive ones. In these cases, an errorless learning approach may be particularly .Behavioral Parent Training helpful (Ducharme et al. 2000). Errorless learning is a success-based noncoercive intervention that involves the gradual introduction of more demanding requests so that child noncompliance and associated consequences for non- compliance are minimized throughout treatment. Another potential complica- tion is that children presenting with aggressive behavior may become aggressive toward parents or other authority figures when punishment is used. In these cases, reward-only pro- grams may be best, or there may be a need for additional intervention, such as collaborative family problem solving (Greene 2014) or medication. Misuse of rewards may also lead to untoward effects. Studies show that rewarding behaviors that already have intrinsic value will decrease their intrin- sic value (Deci et al. 1999). Also, reward- ing the termination of a problem behavior may inadvertently increase that behavior through negative rein- forcement (e.g., “If you stop the tantrum, you can have dessert” or in the case of children demanding rewards to com- plete tasks). In addition, studies show that children who receive ability- focused praise are more likely to become discouraged and give up during chal- lenging tasks, whereas effort-focused Praise is best for improving motivation and persistence on challenging tasks (see Dweck 2006). These studies high- light the need to carefully design and judiciously use praise and other reward- based programs. A common problem in behavior ther- apy (as in other forms of psychotherapy) is noncompliance or resistance to treat- ment, as indicated by failure to complete homework between sessions, poor atten- dance, or other resistance to using rec- ommended strategies. In these cases, itis important to determine the contributing 919 factors (e.g., the parent did not under- stand homework; he or she was too busy; it was too difficult). Research shows that the relationship between the therapist and parents greatly influences parental compliance with behavioral treatment in the same manner in which this type of relationship is important to the success of other forms of psychotherapy. Thus, even though a behavioral approach tends to be inherently directive, it is most effective in the context of a collab- orative parent-therapist relationship (see Webster-Stratton and Herbert 1993). The therapist's warmth, humor, support, optimism, and knowledge are key factors in establishing this type of relationship. A Socratic style of interaction in which the therapist asks parents questions to facili- tate their reaching desired conclusions often improves parent-therapist collabo- ration and can increase parents’ motiva- tion to change. It also is incumbent on the therapist to use the same reinforcement principles with parents that they are teaching parents to use with their chil- dren (eg., praise their efforts). Other pro- cedures that also can improve adherence to treatment include making reminder phone calls, holding sessions only after the parent has completed the homework, scheduling sessions at convenient times, offering child care, and addressing trans- portation needs. When to Expect Response Children typically respond to initial strategies within the first few weeks of the time that parents put these strategies into practice (i.e., within the first several sessions of treatment). Some parents are surprised by how much change occurs with their use of contingent positive attention. More serious problems usu-a 920 Dulcan’s Textbook of Child and Adolescent Psychiatry, Second Edition ally are not resolved until stronger reward-based and/or punishment pro- grams are used. With a well-conceived behavior plan, initial improvement in specific target behaviors is expected within 1 week of starting the program. Continued improvement toward long- term treatment goals is achieved via a gradual shaping process of both child and parent behavior. For example, when the child successfully earns a reward for initial target behaviors (e.g., brushes teeth with only one reminder), the requirements for earning the reward are gradually increased (e.g., dresses and brushes teeth with no reminders) until the final goal is achieved (e.g., completes entire morning routine with no reminders; see Case Example 1). However, it is common for children (and parents) to backslide about half- way through the program. Trouble- shooting usually can revamp a faltering program, and parents who had stopped using the program, thinking the child’s gains were going to be durable without it, often see the importance of maintain- ing consistency. When to Change to or Add a Different Treatment Insome cases, the ongoing weekly assess- ment of progress shows that desired effects are not being achieved. There are two critical areas to assess: 1) adherence to treatment (are the parents implement- ing the program consistently, or are the procedures only partially implemented, explaining the poor response to treat- ment?) and 2) what exactly is the child’s response, and how unsuccessful is the progress? In some cases, the treatment goals or behavioral criteria initially may have been too high and the child may display more success if the criteria are reduced to a more realistic level. Goals then can be increased more gradually via a shaping process. In other cases, unsuccessful programs may be helped by adding other strategies (e.g., adding response cost to a reward program) or adding a behavioral program in another setting for problems specific to that set- ting (e.g., school, peers). Parents may wish to consider adding medication if either severe behavior problems make it difficult to implement the program con- sistently or milder problems do not respond to tweaking of the behavioral program or cross-site implementation of the program. The combination of medi- cation and behavioral treatments is con- sidered the most potent intervention for many cases of ADHD, improving symp- toms and functioning across domains (Subcommittee on Attention-Deficit/ Hyperactivity Disorder et al. 2011). Other forms of treatment also may be needed in order to address problems with the family system (marital therapy, cognitive-behavioral therapy for paren- tal depression, treatment for parental ADHD); these adjunctive treatments can occur concurrently with BPT, or parent training can be paused temporarily until gains in alternative treatments are achieved. How Long to Continue Successful Treatment Fading and termination of treatment usually are a collaborative decision between therapist and family. Many programs involve a set number of ses sions, after which time a decision is made about whether additional treat- ment is needed. When most treatment— Behavioral Parent Training goals are met, the frequency of individ- ual sessions typically is reduced gradu- ally in order to best maintain treatment gains (e.g., from once per week to once every other week and then once per month). Parents often become less moti- vated to come to sessions when their child is having success; termination thus is often initiated by the parents. After termination, booster sessions may be provided (and often are encouraged) during predictable transitional periods (start or change of school) or at times of high stress. For more severe or chronic problems, a continued-care model may be necessary. For example, given that ADHD is considered a chronic disorder, it is likely that some sort of intervention may be needed throughout childhood, adolescence, and into adulthood. The precise nature and intensity of these interventions may vary somewhat depending on environmental circum- stances and developmental stage, but it seems reasonable to expect that mainte- nance of improvements following initial successful treatment will require contin- ued intervention and troubleshooting from time to time. Le Indications BPT is strongly indicated for opposi- tional and conduct problems and ADHD on the basis of numerous empit- ical studies and is recommended by the major professional organizations in psy- chiatry, pediatrics, and psychology (American Psychological Association Working Group on Psychoactive Medi- cations for Children and Adolescents 2006; Steiner et al. 2007; Subcommittee on Attention-Deficit /Hyperactivity Dis- order et al. 2011). Both boys and girls Spanning the full age range (toddler to adolescent) can benefit from this 921 approach, although developmental con- siderations may require modifications (see the section “Developmental Issues”). BPT also can be helpful for youth with comorbid internalizing problems such as anxiety or depression, although minor modifications may be made for children presenting primarily with these types of problems. Contraindications The demands of parent training can be substantial, as parents are required to learn specific procedures and complete homework each week to practice skills taught during group. Asa result, the pri- mary contraindications are parent psy- chopathology (ADHD, depression), marital discord, or some other type of family dysfunction that is sufficiently severe that it prevents parents from par- ticipating or making the necessary time investment. Alternatives would be to teach the skills in a more gradual man- ner, have the parents receive individual or couples counseling prior to parent training, or provide these interventions concurrently. Developmental Issues Parent training can be applied across developmental levels with various mod- ifications. For the preschool and early elementary school ages, parents and other caretakers assume dominant roles in socialization, and young children typ- ically are very responsive to parental and caretaker attention. Several behav- ioral programs have been developed for this age group. These interventions include The Incredible Years (Webster- Stratton and Reid 2010), Parent Child Interaction Training (Menting et al. eee ee meta ee eee oie922 2013), and Helping the Noncompliant Child (McMahon and Forehand 2005). Each of these programs follows a similar two-stage process. In the first, child- directed stage, parents are taught skills to foster a close, secure relationship with their child through use of traditional play therapy skills such as using attend- ing and praising without questions, commands, and criticisms. In the sec- ond, parent-directed stage, parents are taught specific techniques for giving effective commands, labeled (or specific) praise, selective attention (ignoring), and time-out for more serious problems (eg., hitting, tantrums). At the elementary school level, there are greater expectations placed on chil- dren for independent functioning, and children develop the ability to delay gratification for longer periods of time, to work toward specific goals over time, and to understand the relationship between their behavior and contingen- cies. As exemplified by programs devel- oped by Barkley (2013), Cunningham et al. (1995), Kazdin (2005), Sanders et al. (2000), and Webster-Stratton and Reid (2010; Webster-Stratton et al. 2004), interventions for this age group focus on daily and weekly reward programs or contracts as well as discipline tech- niques such as response cost (taking away privileges) and time-out. Treat- ment also often includes contact with schools and a focus on homework for the purpose of addressing academic problems. Parent training without the direct involvement of the child may be less effective during adolescence because of teens’ greater need for autonomy, increased risk-taking behaviors, reduced responsiveness to direct parent control, and greater influence of peer groups on values and behavior (relative to the influences of family or authority fig- i Dulcan’s Textbook of Child and Adolescent Psychiatry, Second Edition ures). For adolescents, contingency man. agement and discipline (response cost and restitution through chores rather than time-out) continue to be part of the treatment, but there is a need for greater involvement of the adolescent in the problem-solving process. Treatment focuses on teaching teens and their par- ents effective skills for communication, negotiation, and family problem solving (Barkley and Robin 2014; Dishion and Kavanagh 2003). Formal behavioral con- tracts typically are used. Treatment for adolescents also focuses on improving parental monitoring and oversight of their teen’s behavior. As with younger youth, treatment often includes consult- ing with the school to address academic and/or social problems in that setting. Research Evidence for Efficacy and Effectiveness Numerous outcome studies and meta- analyses show strong and clinically meaningful effects of BPT for the disrup- tive behavior disorders during preschool and elementary school (Evans et al. 2013; Fabiano et al. 2009; Menting et al. 2013; Pfiffner and Haack, in press). Gains occur in child compliance and reduction of problem behaviors, moving many chil- dren into the nonclinical range of func- tioning relative to their peers (Kazdin 1997). BPT also improves parenting skills, including use of effective commands, Praise, attending, ignoring, and monitor- ing, and decreases controlling and nega- tive parenting. The extent of changes in parenting usually predicts the extent of improvement in child behavior (Chronis- Tuscano et al. 2011; Dishion et al. 2003; Hinshaw et al. 2000). Gains made in par- ent training can be maintained severalBehavioral Parent Training years posttreatment (Nock 2003). During adolescence, family-centered behavioral interventions (including the teen in the treatment sessions) show positive effects (Barkley and Robin 2014; Dishion and Kavanagh 2003). BPT also has positive effects on par- ent functioning. Parents who participate in parent training often show reductions in parenting stress (Anastopoulos et al. 1993; Gerdes et al. 2012) and depression and greater confidence in their ability to manage their child’s behavior (Herschel et al. 2002). Treatment effects can extend to untreated siblings (Herschel et al. 2002). Parent training also can be effec- tive in alleviating marital distress that is caused by disagreements over childrear- ing, by unifying the parents’ approach (Beauchaine et al. 2005). Parent satisfac- tion for this form of intervention tends to be high (Herschell et al. 2002). The addition of components to address par- ents’ problem solving, stress, depres- sion, and marital discord increases effects of BPT on overall parent, child, and family functioning (Nock 2003). Multicomponent Behavioral Interventions BPT is likely to be most potent when combined with school- and/or child- focused interventions, as together these interventions can target the range of risk factors and settings contributing to child problems and synergize the effects of the individual components. The combina- tion of parent training with school- based interventions, such as those reviewed in Chapter 48, “School-Based Interventions” (see also Pfiffner et al. 2006), and/or child-focused interven tions, such as anger management train- | _E=™=™F;;E- -—,-- yx 923 ing, problem solving, and social skills, has been found to be effective in improv- ing attention and externalizing problem behavior, parent-child interactions, homework problems, and social skills in a number of studies across age groups (Kern et al. 2007; Langberg et al. 2010; Nock 2003; Pfiffner and McBurnett 1997; Pfiffner et al. 2007, 2014; Power et al. 2012; Webster-Stratton et al. 2011). Including a child component can reduce premature termination in BPT (Miller and Prinz 1990), suggesting that these adjunctive interventions exert a positive effect on parents’ motivation for treat- ment. In addition, when medication is needed, there is evidence that combin- ing behavioral and medication treat- ments may permit a lower dose of medication (Fabiano et al. 2007; Pelham et al. 2014). Factors Affecting Outcome A number of studies have evaluated under which conditions and for whom behavioral interventions work best. Gen- erally, the more difficult the living condi- tions and the more impaired the child functioning and parent functioning, the less favorable the outcome is. In particu- lar, past research suggests that low socio- economic status (SES) predicts poorer outcome (Eamon and Venkataraman 2003). It is likely that the limited resources of families from lower levels of SES con- tribute to these families’ greater likeli- hood of early termination from treatment. For example, transportation issues, need for daytime attendance (ie., during work- ing hours), lack of child care for siblings, and other such issues may present greater treatment barriers for these families rela- tive to more affluent families, For familiesly 924 Dulcan’s Textbook of Child and Adolescent Psychiatry, Second Edition facing financial disadvantage, an individ- ual approach to BPT that allows for more tailoring of treatment to individual family circumstances may be significantly more effective than group-based approaches (Harwood and Eyberg 2004; Lundahl et al. 2006). There is no evidence that low SES increases dropout differentially for behavior therapy versus other psychoso- cial treatments. There has been some question as to whether fathers need to attend parent training; outcome studies tend to show that having both parents attend may not affect posttreatment out- come but may improve maintenance of treatment gains (Fabiano et al. 2012; Miller and Prinz 1990). Recently, BPT has been adapted for fathers of children with ADHD (Fabiano et al. 2012). The adapted intervention integrates standard BPT with a recreational sports activity (e.g., soccer game) for fathers to practice newly learned parenting skills with their chil- dren. This approach has been shown to improve fathers’ engagement in the treat- ment. Generally, we advise that all care- takers attend sessions but require only the primary caretaker to attend every week. A number of other parent and family factors may affect outcomes. Single- parent families, high parent stress, and a lack of parent social support all predict less favorable outcomes (Harwood and Eyberg 2006; Nock 2003; Schneider et al. 2013). Parents’ beliefs about their child and his or her capacity to change can also affect outcome. Parents who think that their child is behaving badly on purpose or that their child is destined to display negative behavior (“There is nothing I can do”) often are less likely to feel motivated to implement new behav- ioral strategies. Further, perceived stigma about receiving mental health services may prevent parents from con- tinuing to receive services or from accessing them at all. A number of child factors also predict response to parent training, The Severity and nature of symptoms and problems likely are the strongest predictors of whether or not (or to what degree) treat ment produces desired change. For example, children with conduct disorder who are high on callous-unemotional traits show a poorer response to parent training in general than do children low on these traits, and these children show an especially poor response to time-out as compared with reward programs (Hawes and Dadds 2005). Children with very severe oppositional defiant disor- der or explosive behavior also may respond less well to traditional parent training approaches and require a more collaborative family problem-solving model (Greene 2014) relative to children presenting without these problems. For child-focused treatments, level of moti- vation and cognitive ability on the part of the child also are likely to be positively related to response. Cultural and racial backgrounds affect treatment-seeking behavior, in that members of minority groups are less likely to seek or obtain services, and therefore much of the existing treatment outcome research is based largely on white samples (Forehand and Kotchick 1996). For families completing treat- ment, past research typically shows few differences in response to interventions after controlling for SES (Butler and Eyberg 2006), and recently several cul- turally modified treatments for children. have been developed with positive results (McCabe and Yeh 2009). In light of differences in parenting across cul- tures, it seems important to take cultural factors into consideration. For example, in cultures involving the extended fam- ily in child care and emphasizing com- munal parenting, it may be important for nonparent providers to take part inBehavioral Parent Training or observe the training. In order to address cultural conceptions regarding behavior and psychological functioning (and particularly the increased stigma that may be associated with psychologi- cal disorders or participation in mental health services), the language used to describe the treatment may require modification (e.g., “understanding your child and resolving conflicts” or “parent coaching” instead of “parent training” [see Butler and Eyberg 2006}). Similarly, the types of reinforcers, activities, and privileges may need to be adapted depending on family and cultural val- ues. Response to treatment also may benefit from a cultural match between therapist and family. As noted earlier, there are a variety of process factors associated with imple- mentation of parent training that also can affect outcome. As with any inter- vention, the therapist-client relationship influences outcome in behavior therapy (Webster-Stratton and Herbert 1993). Therapist warmth, knowledge of social learning principles and disruptive behavior disorders, likability, and com- munication skills all are likely to contrib- ute to more positive outcomes. Helpful therapist behaviors include active listen- ing skills to guide and maintain parents’ responses to open-ended questions, whereas overly supportive statements early in therapy may reinforce feelings of client helplessness, which might con- tribute to dropout (Harwood and Eyberg 2004). Compliance with treat- 925 ment also can be enhanced using moti- vational strategies (Dishion et al. 2003; Nock and Kazdin 2005) and specific prompts (e.g., reminder phone calls between sessions that prompt parents to complete homework or to come to the next session). Active parental engage- ment and compliance with treatment as measured by parental adherence to between-session assignments (e.g., the extent to which they implement the strategies they are taught) and toa lesser extent attendance at sessions are import- ant predictors of child outcomes (Clarke et al. 2013). Cost-Benefit Issues Relative to long-term “traditional” indi- vidual therapy, behavior therapy is very cost-effective. The substantial gains of BPT can result from as few as 8-12 par- ent training sessions. The cost-benefit of parent training may be especially favor- able when it is administered in a group setting, which for many families is as effective as individual approaches (Chronis et al. 2004). Large community- based group parent training programs held in the child’s neighborhood also provide a cost-effective and perhaps less. stigmatizing approach than clinic-based services (Cunningham et al. 1995). Self- administered parent training (e.g., via workbooks, videos) does not appear to be sufficient for most families (Sanders et al. 2000; Webster-Stratton 1990),i 926 Dulcan's Textbook of Child and Adolescent Psychiatry, Second Editio, mn Summary Points Behavioral parent training (BPT) is a well-established and evidence-baseq treatment for a wide variety of child and adolescent behavior Problems that can be adapted across developmental levels and is also usetul for Prevention of behavior problems. The positive effects of BPT include reductions in chil dren's deviant behavior and symptoms; improvement in child compliance, Parenting skills, and the quality of parent-child interactions; and improvement in parents’ stress, self-confidence, and well-being. * BPT interventions employ functional behavior analysis—the antecedent-be- havior-consequence (ABC) model of behavior—in order to examine problem behaviors and identify potential antecedents and/or consequences of main- taining those behaviors. BPT programs then include some combination of Core topics that teach parents to alter either antecedents (attending, giving ef. fective instructions, managing behavior in public places, planning ahead) or Consequences (praise and positive reinforcement, time-out, token economy, when-then, response cost) to improve the behavior. * Behavioral interventions designed to target school-based problems such as homework completion or school behavior can be taught during BPT sessions and therapist consultation with the child's teacher. * Additional child problems, such as social or organizational skills deficits, can be addressed in additional parent sessions (often including the child) and in parallel skills-training group treatment for the child. * Sessions also can be added to address concurrent parent stress manage- ment or maladaptive cognitions or emotions on the part of the parents; these sessions typically employ combinations of behavioral, cognitive-behavioral, and/or mindfulness techniques. * Parent factors that often reduce positive outcomes include low SES, single- Parent status, severe marital discord, and parent psychopathology (depres- sion, ADHD, substance abuse). These issues may be addressed through ad- junctive treatments or (in the case of limited resources) some alteration of the parent training protocol. * Combinations of BPT with other cognitive-behavioral treatments and/or med- . ication likely produce the most potent outcomes for children and families hav- ing the most impairment. In some cases of ADHD, behavioral treatments add benefit to medication and may permit decreased medication use and dose. American Psychological Association Work- References ing Group on Psychoactive Medications for Children and Adolescents: Psycho pharmacological, Psychosocial, and Combined Interventions for Childhood Disorders: Evidence Base, Contextual Factors, and Future Directions. Report of the Working Group on Psychoactive Medications for Children and Adoles” Abikoff H, Gallagher R, Wells KC, et al: Re- mediating organizational functioning in children with ADHD: immediate and long-term effects from a randomized controlled trial. 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