Treatment and Prevention of Conduct and Behavior-Related Disorders: - PowerPoint Presentation

1. Treatment and Prevention of Conduct and Behavior-Related Disorders: Behavioral Parent TrainingR. C. Cramer, Psy.D., BCBA-D/LBA, LPC-SCoastal Bend Psychological AssociatesMarch 25, 2023Texas A & M University – Corpus Christi

2. Introduction Housekeeping Info +Who are you?Who am I?

3. OutlineConduct and Behavior-Related DisordersSymptoms, Onset, Prevalence, Causative Agents, Risk Factors, Outlook, and Prognosis of these disordersReview Treatment OptionsParent Training - Treatment and PreventionHistory of Parent TrainingEvidence-Based & Empirically-Supported ProgramsApplied Behavior AnalysisConverting Research into Practice

4. Course ObjectivesParticipants will be able to state and discuss Conduct and Behavior-Related DisordersParticipants will be able to state and discuss commonalities amongst Evidence-Based & Empirically-Supported ProgramsParticipants will be able to state and discuss the use of a parent training framework from a behavioral perspective

5. Conduct and Behavior-Related DisordersDSM-5 Category - Disruptive, Impulse-Control, and Conduct DisordersOppositional Defiant DisorderIntermittent Explosive DisorderPyromaniaKleptomaniaConduct DisorderAntisocial Personality Disorder (commentary)

6. Other Behavior-Related Disorders(that a true behaviorist would consider…)Attention-Deficit/Hyperactivity DisorderObsessive-Compulsive and Related DisordersFeeding and Eating DisordersElimination DisordersSleep-Wake DisordersSubstance-Related and Addictive DisordersEVERYTHING IS A BEHAVIOR!!!

7. Oppositional Defiant DisorderA. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms of the following categories, and exhibited during interaction with at least one individual who is not a sibling:Angry/Irritable Mood1. Often loses temper2. Is often touchy or easily annoyed3. Is often angry and resentfulArgumentative/Defiant Behavior4. Often argues with authority figures or, for children and adolescents, with adults5. Often actively defies or refuses to comply with requests from authority figures or with rules6. Often deliberately annoys others7. Often blames others for his or her mistakes or misbehaviorVindictiveness8. Has been spiteful or vindictive at least twice within the past 6 months.Note: The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion AB). For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months. Unless otherwise noted (Criterion AB). While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual’s developmental level, gender, and culture.

8. Oppositional Defiant Disorder (Continued)B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues) or it impacts negatively on social, educational, occupational, or other important areas of functioning,C. The behavior does not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also the criteria are not met for disruptive mood dysregulation disorder.Specify current severity:Mild: Symptoms are confined to only one setting (e.g., at home, at school, at work, with peers).Moderate: Some symptoms are present in at least two settingsSevere: Some symptoms are present in three or more settings.

9. Intermittent Explosive DisorderRecurrent behavioral outburst representing a failure to control aggressive impulses as manifested by either of the following:1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.2. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period.B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors.

10. Intermittent Explosive Disorder (Continued)C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation).D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences.E. Chronological age is at least 6 years (or equivalent developmental level).F. The recurrent aggressive outbursts are not better explained by another mental disorder (e.g., Major Depressive Disorder, Bipolar Disorder, Disruptive Mood Dysregulation Disorder, a Psychotic Disorder, Antisocial Personality Disorder, Borderline Personality Disorder) and are not attributable to another medical condition (e.g., head trauma, Alzheimer’s disease) or to the physiological effects of a substance (e.g., a drug of abuse, a medication). For children ages 6 to 18 years, aggressive behavior that occurs as part of an Adjustment Disorder should not be considered for this diagnosis.Note: This diagnosis can be made in addition to the diagnosis of ADHD, Conduct Disorder, ODD, or ASD when recurrent impulsive aggressive outbursts are in excess of those usually seen in these disorders and warrant independent clinical attention.

11. PyromaniaDeliberate and purposeful fire setting on more than one occasion.Tension or affective arousal before the act.Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences).Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment (e.g., major neurocognitive disorder, intellectual disability, substance intoxication).The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.

12. Kleptomania A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.B. Increasing sense of tension immediately before committing the theft.C. Pleasure, gratification, or relief at the time of committing the theft.D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.E. The stealing is not better explained by Conduct Disorder, a manic episode, or Antisocial Personality Disorder.

13. Conduct Disorder *A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: Aggression to People and Animals 1. Often bullies, threatens, or intimidates others. 2. Often initiates physical fights. 3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). 4. Has been physically cruel to people. 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). 7. Has forced someone into sexual activity.

14. Conduct Disorder (Continued)Destruction of Property 8. Has deliberately engaged in fire setting with the intention of causing serious damage. 9. Has deliberately destroyed others’ property (other than by fire setting). Deceitfulness or Theft 10. Has broken into someone else’s house, building, or car. 11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others). 12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery). Serious Violations of Rules 13. Often stays out at night despite parental prohibitions, beginning before age 13 years. 14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period. 15. Is often truant from school, beginning before age 13 years

15. Conduct Disorder (Continued)B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder. Specify whether: 312.81 (F91.1) Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years. 312.82 (F91.2) Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10 years. 312.89 (F91.9) Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years.

16. Conduct Disorder (Continued)Specify if: With limited prosocial emotions: To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at least 12 months and in multiple relationships and settings. These characteristics reflect the individual’s typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations. Thus, to assess the criteria for the specifier, multiple information sources are necessary. In addition to the individual’s self-report, it is necessary to consider reports by others who have known the individual for extended periods of time (e.g., parents, teachers, co-workers, extended family members, peers). Lack of remorse or guilt: Does not feel bad or guilty when he or she does something wrong (exclude remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules. Callous—lack of empathy: Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring. The person appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others, even when they result in substantial harm to others. Unconcerned about performance: Does not show concern about poor/problematic performance at school, at work, or in other important activities. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for his or her poor performance. Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions “on” or “off” quickly) or when emotional expressions are used for gain (e.g., emotions displayed to manipulate or intimidate others)

17. Conduct Disorder (Continued)Specify current severity: Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others (e.g., lying, truancy, staying out after dark without permission, other rule breaking). Moderate: The number of conduct problems and the effect on others intermediate between those specified in “mild” and those in “severe” (e.g., stealing without confronting a victim, vandalism). Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering)

18. OnsetThe DSM-5 notes that Conduct Disorder can appear as early as the preschool years, with ODD (Oppositional Defiant Disorder) a common premorbid condition, which may progress to Conduct Disorder. Middle childhood to middle adolescence is the time frame where Conduct Disorder symptoms are most apparent, and come to parental/educational/clinical attention. Rejection by more prosocial peers and association with delinquent peers with reinforcement of conduct disordered behaviors my occur (American Psychiatric Association, 2013).Theravive

19. PrevalenceAccording to the DSM-5, the annual prevalence of Conduct Disorder is 2% to 10%, with a median of 4%. It is more common in boys, or at least more apparent and more frequently diagnosed, due to boy's tendency to act out violently, while girls tend to act out in interpersonal relationships –e.g., social rejection of disliked peers, non-confrontation of a victim through malicious postings on a social networking site (American Psychiatric Association, 2013).Theravive

20. Causative Agents & Risk FactorsWhat causes conduct disorder in a child?Experts believe that many factors play a role in Conduct Disorder. These are:Brain damageA traumatic eventGenesChild abusePast school failureSocial problemsSome children with Conduct Disorders seem to have a problem in the frontal lobe of the brain. This interferes with a child’s ability to plan, stay away from harm, and learn from negative experiences.Some experts believe that a series of traumatic experiences occurs for a child to develop a conduct disorder. These experiences then often lead to depressed mood, behavior problems, and involvement in a deviant peer group.

21. Causative Agents & Risk Factors (Continued)A Conduct Disorder is more common in boys than in girls. It is also more likely to develop in children or teens who come from homes that are:DisadvantagedDysfunctionalDisorganizedChildren with these mental health problems are also more likely to have conduct disorder:Mood or anxiety disordersPosttraumatic Stress Disorder (PTSD)Substance Use DisorderAttention-Deficit/Hyperactivity Disorder (ADHD)Learning problemsChildren or teens who are considered to have a difficult temperament are more likely to develop behavior problems.Johns Hopkins

22. Causative Agents & Risk Factors (Continued)What causes Conduct Disorder?Researchers aren’t sure what exactly causes Conduct Disorder (CD), but they think it’s a complex combination of genetic/biological and environmental factors.Genetic/biological factors:Various studies show that certain characteristics of CD can be inherited, including antisocial behavior, impulsivity, temperament, aggression and insensitivity to punishment.High testosterone levels are associated with aggression.Traumatic brain injury, seizures, and neurological damage can contribute to aggression.Parental, familial and environmental factors:Parents of adolescents with CD often have engaged in substance use and antisocial behaviors. They’re also frequently diagnosed with ADHD, mood disorders, schizophrenia or antisocial personality disorder.A home environment that lacks structure and adequate supervision with frequent conflicts between parents can lead to maladaptive behavior in children, which can lead to CD.Children exposed to frequent domestic violence are more likely to develop CD.Living in low social and economic environments with overcrowding and unemployment leads to economic and social stress with a lack of adequate parenting. CD affects more children living in low economic environments than not.Availability of drugs and increased crime in a child’s neighborhood increases their risk of developing CD.It’s important to note that conduct disorder can occur in children from high-functioning, healthy families.Cleveland Clinic

23. Causative Agents & Risk Factors (Continued)What causes Conduct Disorder?Genetic and environmental factors may contribute to the development of conduct disorder.Genetic causesDamage to the brain’s frontal lobe has been linked to conduct disorder. The frontal lobe is the part of your brain that regulates essential cognitive skills, such as problem-solving, memory, and emotional expression. It’s also home to your personality.The frontal lobe in a person with conduct disorder may not work correctly, which can cause, among other things:a lack of impulse control, a reduced ability to plan future actions, and a decreased ability to learn from past negative experiencesThe impairment of the frontal lobe may be genetic or inherited, or it may be caused by brain damage due to an injury. A child may also inherit personality traits commonly seen in conduct disorder.Environmental factorsThe environmental factors that are associated with Conduct Disorder include:child abuse, a dysfunctional family, parents who abuse drugs or alcohol, and povertyHealthline

24. Outlook & PrognosisWhat is the prognosis (outlook) for Conduct Disorder?The prognosis (outlook) for Conduct Disorder depends on how early the condition developed and if it was treated.Usually, the disruptive behaviors of conduct stop during early adulthood, but in about one-third of cases, they continue. Many of these cases meet the criteria for antisocial personality disorder.Early onset of the condition (before 10 years of age) is associated with a poorer prognosis and is strongly associated with a significant decline in school performance.Some children and adolescents with conduct disorder develop other mental health conditions, including:Mood or anxiety disorders.Somatic symptom disorder.Alcohol Use disorder and/or substance use disorder.Early adult-onset psychotic disorders.Depression and Bipolar Disorder may also develop in the teen years and early adulthood. Suicidal ideation can be a complication of these conditions. It’s important to get your child immediate medical care if they’re talking about or threatening suicide.Cleveland Clinic

25. Outlook & Prognosis (Continued)What is the long-term outlook for children with Conduct Disorder?The long-term outlook for Conduct Disorder depends on the severity and frequency of your child’s behavioral and emotional problems.Children who continuously display extremely aggressive, deceitful, or destructive behavior tend to have a poorer outlook. The outlook is also worse if other mental illnesses are present. However, getting a prompt diagnosis and receiving comprehensive treatment can significantly improve your child’s outlook.Once treatment for Conduct Disorder and any other underlying conditions are received, your child has a much better chance of considerable improvement and hope for a more successful future.Parents and caregivers must seek treatment as well. Learning how to manage a conduct disordered child can be helpful to the child and adolescent and reduce stress within the family or social environment.Without treatment, your child could have ongoing problems. They may be unable to adapt to the demands of adulthood, which can result in relationship problems and an inability to hold a job. They’re also at an increased risk of substance misuse and problems with law enforcement.Your child may even develop a Personality Disorder, such as Antisocial Personality Disorder, when they reach adulthood. This is why early diagnosis and treatment are critical. The earlier your child receives treatment, the better their outlook for the future.Healthline

26. Treatment OptionsPsychotherapy & CounselingCognitive-Behavioral Therapy (and derivatives)Peer Group Therapy (Peer Group Supports)Anger Management TrainingImpulse-Control StrategiesFamily TherapyMedication Community-Based Treatments (Therapeutic Schools, RTCs)However, recidivism is between 35% - 70%!

27. PreventionWhat are the preventative steps?Audience impressions?

28. Parent TrainingWhat is the topic?What to train parents?Nuts and Bolts of parenting; Skills; What to do? What not to do?How to train parents?Follow the “Good Enough” ModelAdopt an Efficacious Approach; Best Practices

29. IntroductionParentsWorking with parents is a fact of life if working with children“Effective parenting has been found to predict positive behavioral, social, emotional, and academic adjustment, whereas ineffective parenting has been found to be predictive of later dysfunction and anti social behavior” (Borkowski, Landesman Ramey, & Bristol-Power, 2002)Training Parents vs Training TrainersVast literature base, manuals, workshops, seminars, conferences by professionals across the mental health spectrum“Parent training is defined as active, targeted teaching of specific parenting skills with the goal positively affecting child behavior” (Shriver & Allen, 2008)

30. Major Reference MaterialWorking With Parents of Noncompliant Children: A Guide to Evidence-Based Parent Training for Practitioners and Students (Shriver & Allen, 2008)

31. HistoryWhy focus on parents?Parents who demonstrate effective parenting behavior or practices are more likely to have children considered to be well adaptived, socially-functioning adolescents and adults. However, ineffective parenting practices are predictive of delinquency, school failure, antisocial behavior, and adult psychopathology (Borkowski, Landesman, Ramey & Bristol-Power, 2002; Patterson, Reid & Dishionj, 1992; Wade, 2004)

32. History (Continued)Theories of Behavior and Parenting:Parenting advice was dominated by philosophers, religious leaders, and physicians (Holden, 1997)Psychodynamic Theory (Freud – Id, Ego, Superego, Psychosexual Stages; Adler – Inferiority)Humanistic Theory (Maslow, Rogers, May; aware, conscious, choice, intention, meaning)Developmental and Cognitive Theory(Piaget – Intelligence, Maturation; Vygotsky – Zone of Proximal Development; Ainsworth, Bowlby – Attachment)Behavioral Theory(Skinner – External, Environmental Influences on Behavior, Observable, Measurable)

33. History (Continued)Research on ParentingParenting Attributes and Characteristics (intelligence, health, education, inclination to substance abuse)Parenting Style (authoritarian, authoritative +, permissive/permissive-indulgent, permissive-negligent -)Environmental VariablesSociocultural VariablesCulture, Ethnicity, SES, Education, Religion, CommunityFamily VariablesStructure, Type, Size, Involvement/InclusionParent-Child InteractionContingencies of Reinforcement, P>C & C>P

34. History (Continued)History of Parent Training1st Psychology Clinic for Children in US at University of Pennsylvania, 1896Child Guidance Clinics, Program for Prevention of Delinquency, 1922Expansion of Mental Health Services to SchoolsPsychodynamic – Uninvolved ParentsBehaviorism – Increasingly Involved Parents, 1950sUniversity-Based Research, 1960sTraining Parents as Part of Treatment for Children, 1970s & 1980sBehavioral Family Interventions, 1990sParenting is a complex topic that can encompass a wide range of skills, behaviors, attitudes, cognitions, and emotions

35. Evidence-Based & Empirically-Supported ProgramsWhat Comprises an Empirically-Supported, Evidence-Based, Well-Established, Exemplary Program?DataPeer ReviewExperimental Design – Compare to Treatment, ABABReplication – Multiple Between Group StudiesOutcomes Measured – Ratings v. Observation

36. Empirically-Supported Parent Training ProgramsLiving with Children (Patterson, 1968)Incredible Years (Webster-Stratton, 1984)Helping the Noncompliant Child (Forehand & McMahon, 1981)Parent-Child Interaction Therapy (Eyberg, 1982)

37. Living With Children ProgramTarget Population: Children ages 3-14 with significant social aggression (i.e. noncompliance, tantrums, crying, arguing, hitting, teasing, and stealing)Setting: Individual families or group formatLength: 90 min intake followed by approximately 12 treatment sessions and 6-10 brief 25 min in home observationsEmphasizes teaching parents to understand behavioral theory behind techniques, high level of contact between parent and practitioner and using point systems, teach data collection, extensive research, positive impact on parent and child behavior

38. The Incredible Years—Basic ProgramTarget Population: Young children ages 3-8 with behavior problems such as disobedience, bedtime problems, stealing, lying, bed-wetting, meal-time problems, and sibling rivalry.Setting: Parent groups of 8-12 individuals in a clinical setting.Length: 2 hour sessions for 10-14 weeks.Emphasizes videotaped modeling, collaboration between parents and practitioners, Natural and Logical Consequences, relies on parents to teach problem-solving strategies to children.

39. Helping the Noncompliant Child ProgramTarget Population: Children ages 3-8 exhibiting noncompliance.Setting: Intensive, clinic-based format with individual families.Length: 60-90 min sessions for 12 weeks with parents and children.Emphasizes child inclusion in sessions and participation in training, however, children are not in the decision-making process of how the program is implemented, skills teaching to child and parents, prevention and treatment focused, follows a scholarly text

40. Parent-Child Interaction Therapy (PCIT)Target Population: Young children ages 2-8 exhibiting disruptive behaviors such as defiance, verbal and physical aggression, and over-activity.Setting: Individual families in an intensive, clinic-based treatment format.Length: 60-90 min sessions over 8-14 weeks, with flexibility.Emphasizes developmental and behavioral elements in conceptualizing effective treatments, offers direct coaching of parent-child dyads, practices compliance as a skill, high teaching of skills, highly directive, uses technology

41. Commonalities between Efficacious ProgramsFoundations firmly rooted in behavioral and social learningEmphasizes positive interactions by praising, attending, and rewarding and by reducing reactivity to minor problemsHighlight importance of reducing unnecessary demands but being clear when demands are required and when compliance is expected.Use of immediate consequences and punishment when necessaryClearly establishing contingencies ahead of time with contracts, practice, or negotiation.Use well-established teaching techniques that include instruction, modeling, and homework

42. Parent Training AlternativesEmpirically supported programs are not necessarily the most popular; manuals, workshops, seminars, conferences, web-based support Parent Effectiveness Training (Gordon, 1975)Systematic Training for Effective Parenting (Dinkmeyer & McKay, 1983)Active Parenting program (Popkin, 1983)Love and Logic program (Fay, Fay & Cline)Putting Kids First (http://www.puttingkidsfirst.org)Nurturing Parenting Programs (Bavolek)Common Sense Parenting (Burke, Herron & Schuchmann, 2004)Triple P - Positive Parenting Program (Sanders, 1999)Critical balance of program & clinician expertise/competence!

43. Applied Behavior AnalysisAntecedentsEstablishing Operations Discriminative StimuliConsequencesPositive ReinforcementNegative ReinforcementExtinctionPositive PunishmentNegative Punishment

44. AntecedentsEstablishing OperationsEstablish the value of consequencesInfluence how much people want somethingGoing without food/cold, makes food/warmth more valuableDiscriminative StimuliSignal the best time to engage in certain behaviors to gain the valued consequencesSignal when certain responses will be most effective in achieving a desired consequenceAsking GM (not M) for a cookie; wrestling your sister (not brother) if you want to win

45. Consequences Positive ReinforcementPresented contingent on Bx; Inc. likelihood of Bx; Adding something desiredPraise, Touch, Treats, TangiblesNegative ReinforcementRemoved contingent on Bx; Inc. likelihood of Bx; Removing/Preventing something undesirableEscape or AvoidM stops nagging w/ clean room; CH stops tantrum when parent gives inExtinctionRemoval of reinforcer for a specific Bx; Bx no longer gets same resultsExtinction Burst, Planned Ignoring, Stop attending to attn-seeking tantrumsPositive PunishmentPresented contingent on Bx; Dec. likelihood of Bx; Adding something undesirableReprimands, spanks, threats, choresNegative PunishmentRemoved contingent on Bx; Dec. likelihood of Bx; Removing something desirableRestrict TV, Grounding, sit child in corner for T/O with no contact/attention

46. Conditions Affecting ConsequencesImmediacyDeliver reinforcers immediately whenever possibleMagnitudeGive enough to make it worthwhile for the childQualityConsider individual preferencesFrequencyBegin with frequent reinforcement, then use it more intermittently EffortMake sure the task, initially, is not too difficultChoiceConsider competing reinforcers and adjust the other five conditions accordingly

47. Application of Behavioral PrinciplesUse Reinforcement to Increase Desired BehaviorsCatch them being good; use praise, touch, points; schedule nondirective playUse Extinction to Decrease Minor Disruptive BehaviorsUse ignoring whenever possibleUse Antecedents Effectively; Stimulus Control to Increase Command ComplianceUse direct, simple commands (consistent, expected voice/tone)Use Punishment to Decrease Disruptive Behavior as NecessaryUse time-out and response cost

48. Behavioral Skills TrainingManuals typically assist the practitioner by providing specific guidance about which behaviors (skills) to teach and in which order to teach them.Success depends upon (a) whether the practitioner knows how to teach the critical skills, and (b) whether the practitioner can motivate parents to use the skills taught.

49. Behavioral Skills Training (Continued)Teaching parents the skills they need to be effective parents typically requires four components:InstructionModelingPracticeFeedback (Miltenberger, 2001)

50. Instruction“Explaining the lesson”Analyze components.Start with the simple skills; use chaining for more complex skills.Describe skill to be taught.Provide a rationale for why the skill is important to teach.Use written description (i.e., protocols) as aid.

51. Modeling “Seeing the skills in action, allow for questions, provide clarification”Match the model to the parent(s).Demonstrate each skill.Model correct and incorrect.Model learning as you go.

52. Rehearsal “Practice, Practice, Practice and get comfortable doing it”Practice easy skills first.Do partial-task, if necessary, then whole-task practice.Practice outside the clinic (i.e., homework).

53. Feedback “Shaping the appropriate acquisition of the skill”Use encouragement more than critique.Be descriptive more than general.Be immediate with feedback.Use prompting if necessary.

54. Enhancing Parent Motivation Develop Rationales“Fix my child, I’ll be back in 45 minutesConvincing the parent of the necessity of these actionsChoosing Language CarefullyUse non-technical terminology for childrenSocial implications

55. Overcoming Barriers to Treatment Adherence“Looking at contingencies that control the parent, not just the child”Rational for BSTParent(s) are part of the solution. It is important to learn new skills. Practice is important to success.Language in sessionUse nontechnical terms. Value child responsibility and independence. Translate principles into pictures, ideas, examples.Predict outcomesPredict extinction bursts. Predict social disapproval. Success with skill development may take timeProvide remindersEngage in frequent contact with practitioner. Use partners and relatives. Post checklists of skills. Train in different settings. Teach general principles of behavior.

56. Overcoming Barriers to Treatment Adherence (Continued)Build rapportConnect with parent. Use reflection and empathy. Schedule practices to avoid likely conflicts. Use self-disclosure and humor. Balance expert versus collaborative model. Use incentivesReimburse parents for adherence. $$$. Use spousal support.Use technologyConsider use of electronic monitors. Use resourcesOffer group format as support group. Add sessions on communication training. Refer for marital or drug counseling. Teach problem solving and self-management.Incorporate flexibilityAdjust performance criteria. Modify skills and sequences as needed.

57. Cultural Issues“practitioners must recognize that all individuals, including themselves, are influenced by historical, ecological, sociopolitical, and disciplinary aspects of culture” (APA, 2003;http://www.apa.org/pi/multiculturalguidelines.pdf) “information and recommendations grounded in religious, social, educational, familial, and legal contexts shape the experiences and beliefs of Asian American, African American, Native American, European American, and Latino American individuals and the practitioners who serve them” (p.140)

58. Beyond NoncompliancePractitioners face a wide range of child problems (inattention and hyperactivity, sleep problems, feeding problems, toileting problems, academic problems, adolescent-parent conflict, internalizing problems, plus more).Child noncompliance has received most of the attention in the parent training literature and research because it is one of the most common problems that practitioners will face regardless of whether they work in mental health outpatient clinics, primary care, or schools (e.g., Arndorfer, Allen & Aljazireh, 1999; Bear, 1998; Schroeder, Gordon, Kanoy & Routh, 1983).Noncompliance is a predictor of poor developmental outcomes and is considered a keystone behavior in the development of other childhood problems (McMahon & Forehand, 2003; Nelson & Hayes, 1986).There are no empirically supported parent training programs in the treatment of child problems other than noncompliance!

59. Developing a FrameworkPractitioners NEED to review the research literature on interventions for particular child problems; a means to remain current.However, these data need to be incorporated into a viable method, or framework, to decipher and organize the research literature on interventions to identify what and how to teach parents.What to TeachWhy it WorksHow to Teach: Parent Training

60. Developing a Framework (Continued)What to Teach – Begin with a review of the literature to formulate a plan of what to teach to start to remediate some of the components of the child problem behavior and to work towards the parent goal behavior.Why it Works – Identify whether intervention components derived from the literature are designed to increase a desired behavior through reinforcement, decrease behavior through extinction, prompt a behavior through stimulus control, or decrease a problem behavior through punishment.How to Teach: Parent Training – Sequence training (as above); Use BST sequence for each principle

61. Parent Training for Child NoncomplianceWTT – Teach parent social attention skills (praise, positive touch, descriptions, reflections) contingent on compliant and appropriate behavior.WIW – Reinforcement: Social attention delivered contingent on compliance or other desired child behaviors increases the probability of the behavior recurring.HTT – Instruction: Described and provide rationale for using social attention. Present information orally and provide handouts. Modeling: Demonstrate with the child or parent how to provide praise, descriptions, and reflections. Rehearsal: Have the parent practice providing praise, descriptions, and reflections with the child. Have parents practice social attention skills daily at home during the child-directed interaction. Feedback: Provide positive and corrective feedback during rehearsal to shape parents’ behavior towards the desired goal.

62. Parent Training for Child Noncompliance (Continued)WTT – Teach parents to ignore minor behaviors.WIW – Extinction: Removal of social attention contingent on noncompliance or other defined misbehavior reduces probability of the behavior recurring.HTT – Instruction: Describe and provide rationale for ignoring minor behaviors, particularly in relation to the use of social attention for compliance (i.e. differential social attention). Modeling: Demonstrate use of ignoring during activity with the child. Rehearsal: Have the parent practice ignoring with the child during an activity. Have parents use ignoring at home daily during activity. Feedback: Provide immediate positive and corrective feedback to the parent during rehearsal.

63. Parent Training for Child Noncompliance (Continued)WTT – Teach parents how to provide direct, one-step, developmentally appropriate commands.WIW – Stimulus Control: A parent command that signals reinforcement is available for compliance (a discriminative stimulus).HTT – Instruction: Describe and provide rationale for giving effective commands. Modeling: Demonstrate giving effective commands with the parent or child. Rehearsal: Have the parent practice giving effective commands with the practitioner or child. Have the parent practice using effective commands at home daily and track practices and/or child responses. Feedback: Provide immediate positive and corrective feedback to shape parents’ commands.

64. Parent Training for Child Noncompliance (Continued)WTT – Teach parents how to apply time-out contingent on noncompliance or other target misbehavior.WIW – Punishment: The child is removed to a less reinforcing environment contingent on noncompliance decreasing the probability of noncompliance recurring.HTT – Instruction: Describe and provide rationale for using time-out. Provide step-by-step protocol or procedure. Modeling: Model with the child how to implement time-out. Rehearsal: Have the parent practice time-out in the clinic with the child. Have the parent begin using time-out at home, collecting data on the procedure and the child’s response. Feedback: Provide immediate positive and corrective feedback to parent to shape effective implementation of time-out.

65. Parent Training for Picky EatingWTT – Teach parents to identify preferred foods and nonpreferred foods. Teach parents to monitor food intake with a food diary. Teach parents to intersperse high preferred food with low preferred food. Teach parents to provide social attention contingent on complaint behavior and food intake. Teach parents to provide reward contingent on food intake.WIW – Reinforcement: Interspersing high preferred foods increases the rate of eating less preferred foods. Social attention and reward also increase the likelihood of non-preferred food intake.HTT – Instruction: Describe and provide rationale for identifying high and low preferred foods and monitoring food intake. Describe and provide for using interspersal, social attention, and rewards. Modeling: Demonstrate how to intersperse food and provide contingent social attention and reward with the child or parent. Rehearsal: Have parents practice with the child during role-play or actual meal. Feedback: Shape parents’ skills in the feeding intervention.

66. Parent Training for Picky Eating (Continued)WTT – Teach parents to ignore minor misbehavior during mealtime. Teach parents to delay delivery of preferred food in response to minor misbehavior.WIW – Extinction: Removal of reinforcement (both social and food) reduces the probability of the behavior recurring. May also briefly increase problem behavior via an extinction burst.HTT – Instruction: Describe and provide rationale for ignoring minor misbehavior as part of differential attention. Predict possible temporary increase in misbehavior. Modeling: Demonstrate use of ignoring during role-play or actual mealtime. Rehearsal: Have parent practice ignoring with the child during mealtime in session. Feedback: Shape effective use of ignoring and differential attention during meals.

67. Parent Training for Picky Eating (Continued)WTT – Teach parents to limit or eliminate food and drink between mealtimes. Teach parents how to provide direct, one-step, developmentally appropriate commands and expectations during meals.WIW – Stimulus Control: Decreasing access increases the reinforcement value of even nonpreferred food (i.e. establishing operations). Clear commands are discriminative for compliance.HTT – Instruction: Describe and provide rationale for reducing other food intake and for giving effective commands and clear expectations. Modeling: Demonstrate with parent or child how to give effective commands and set clear expectations. Rehearsal: Have parent practice how to give effective commands during role-play of mealtime with the practitioner or child. Feedback: Shape parents’ use of effective commands.

68. Parent Training for Picky Eating (Continued)WTT – Teach parents to apply time-out contingent on food refusal or other noncompliance or target misbehavior.WIW – Punishment: Removal from reinforcing environment (food and praise available) to less reinforcing environment decreases food refusal and other target behaviors.HTT – Instruction: Provide description and rationale for using time-out. Provide step-by-step protocol or procedure. Modeling: Model with the child how to implement time-out. Rehearsal: Have parent practice time-out in the clinic during role-play or actual meal with the child. Feedback: Shape parents’ effective implementation of time-out.

69. Practitioner CharacteristicsThe quality of a practitioner’s training, experience, and expertise plays an important role in evidence-based practice. Practitioners should consider the level of training and experience needed to implement an intervention in parent training successfully relative to their own training and level of expertise (McCabe, 2004).A practitioner’s clinical skills and expertise are largely determined by training and experience. Training includes formal graduate training (coursework, practicum, in-service workshops, participation in professional conferences, mentorship, collaboration, supervision). Experience influences practice. We learn from direct experiences with children and families, with collegues/peers within and outside the discipline, from both successes and failures.

70. Practitioner Characteristics (Continued)A practitioner’s training and experiences make each of us unique in how we interact with clients and implement interventions. It is the responsibility of practitioners to recognize the limits of their knowledge and skill base when working with children and families and to refrain from offering services that they are not trained to provide. This is an ethical issue, as well as a practical issue (APA, 2002).Knowledge alone is not sufficient. There are also specific skills in clinical decision making, conducting observations of child and parent interaction, interviewing, data collection, and other areas of clinical practice that require supervised training and experience.Important that practitioners consider the type of skill repertoire in behavioral parent training and whether this skill set is a good match for their unique personality characteristics and interaction style with children and adults.BST requires being relatively direct, assuming an expert role, actively modeling and role playing in vivo with the child and parent, collaboration to problem-solving and addressing barriers to implementation of interventions.

71. Setting, Practice & Associated FactorsAccess to equipment (one-way mirrors, bug-in-ear receivers, video cameras) for monitoring, training, and supervisionAccess to additional personnel for training of clinicians, supervision of practitioners, conducting phone calls to clients, making home visits, consulting with school personnel, attending community/school meetings, etc.More frequent sessions (individual, family, various dyads)Longer sessions (:45-:53 versus 1:30-2:00)Various locations (office, home, school)

72. Converting Research into PracticeComprehensive AssessmentOperationally Define BehaviorsTeach Parents to Monitor Target BehaviorIdentify and Develop the InterventionTrain ParentsMonitor Treatment Adherence and ProgressApply Data-Based Decision Making

73. Comprehensive AssessmentParent InterviewObservation of parent-child interaction in the clinic or homeChild interviewBehavior rating formsReview of relevant recordsUse of cultural sensitivity from first contact with parent and child

74. Operationally Define BehaviorsIn collaboration with the parentObservable, measurable, agreed uponDefine target problem behavior for the childe.g. noncompliance, attention-seeking tantrumsDefine goal behavior for the parente.g. what does the parent need to do, what is the successful outcome

75. Teach Parents to Monitor Target BehaviorUse behavioral skills teaching strategiesHave parents collect baseline data on target behavior and goal behaviorsParental demonstration of data collection Allow for a determination of efficacy

76. Identify and Develop the InterventionReview evidence-based programs and associated manuals for interventionsRely upon a skilled, experienced practitioner for interventionsCritically evaluate the research literatureDevelop an intervention package using the framework

77. Train ParentsUse behavioral skills training including instruction, modeling, rehearsal, and feedbackBarriers to intervention implementation may be overcome by using clinical skills such as proving rationale, choosing language carefully, predicting outcomes, using reminders, recognizing the competition, developing rapport, using tangible incentives, using technology, using resources, and being flexibleThis is the aforementioned topic!

78. Monitor Treatment Adherence and ProgressData CollectionData on Treatment AdherenceIntegrity with which the parent is implementing treatment recommendations.Data of ProgressChild outcomes or progress toward the identified goal

79. Apply Data-Based Decision MakingMake changes in the intervention (i.e., what parent is being taught) as needed.Make changes in the parent training (i.e., how the parent is being taught) as needed.Fade intervention or incorporate strategies as part of the family’s natural routine.

80. What’s Next? Research & PreventionResearch Directions for Parent TrainingEmpirically Supported Parent Training ProgramsExtensions to child problems other than noncomplianceHow to train parentsParent Training for PreventionFAST Track (Conduct Problems Prevention Research Group, 1992, 2000, 2004)Linking the Interests of Families and Teachers (LIFT; Eddy, Reid & Fetrow, 2000; Reid & Eddy, 2002)Adolescent Transitions Program (ATP; Dishion & Kavanagh, 2003)

81. The EndThanks for your time!Informative?Motivated?I hope that you all view working with parents as a critical component of working with any child or adolescent.

82. Coastal Bend Psychological Associates R. C. Cramer, Psy.D., BCBA-D/LBA, LPC-S Baylea Wagener Cramer, Ph.D., LPC Claudia Schmidt, Ph.D., LPC Angelica Barrera, Ph.D., LPC-S Monica Jimenez, M.S., LPC Everett Bush, MS, LPA, BCBA/LBA Mary Rangel Gomez, M.S., LPC Cristian Tovar, M.S., LPC4639 Corona Drive, Suite # 34, Corpus Christi, Texas 78411Office (361) 442-4024 Fax (361) 806-9491 www.cb-pa.comBehavioral, Cognitive-Behavioral, Family Systems, Solution-Focused, Plus MoreIndividual Psychotherapy Couples/Marital Counseling Family Therapy Group CounselingComprehensive Psychological Assessment & Evaluation Clinical Supervision Program DevelopmentProgram Consultation Parent/GrandParent Support Groups Practicum/Internship/Supervision Training Site