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Helping the Noncompliant Child Family-Based Treatment for Oppositional Behavior
By Robert J. McMahon Rex L. Forehand
The Guilford Press Copyright © 2003 The Guilford Press
All right reserved.
Chapter One Overview of the "Helping the Noncompliant Child" (HNC) Parent Training Program
In this chapter, we first present some of the necessary requirements for effective parent training, including characteristics of the training setting, who should attend sessions, the parenting skills that are taught, and the methods for teaching those skills. We then present overviews of the parent training program, the use of behavioral criteria to determine success in learning each parenting skill and the structure of sessions, and note the availability of additional training materials for the parent training program. Finally, we describe ethical considerations in the use of parent training to treat child noncompliance, engagement of families in the intervention, and therapist characteristics.
As noted in Chapter 1, we hypothesize that the child's noncompliant, inappropriate behavior is shaped and maintained through maladaptive patterns of family interaction, which reinforce coercive behaviors. As a logical outgrowth of this formulation, our intervention strategy involves teaching parents to change their behavior toward their child so as to incorporate more appropriatestyles of family interaction. In the initial part of this chapter, we delineate some of the basic requirements for our parenting program to be effective.
THE TRAINING SETTING
Parent training can occur either in the home or in a clinic setting. There are advantages and disadvantages to each approach. Intervention in the home prevents the need for generalization from the clinic to the home to occur. However, home-based intervention requires substantially more time and expense on the part of the therapist (e.g., travel time and gas expenses). It is also the case that third-party payers typically will not pay for services provided outside of a clinic. As noted earlier, our program is based on a clinic training model, as this appears to be more efficient and therefore most likely to be employed by most mental health professionals. We have also spent substantial time and effort in our research endeavors to examine and facilitate generalization from the clinic to the natural environment (see Chapter 10).
Intervention is initiated and carried out with individual families rather than in groups in a clinic playroom similar to the one used for clinic observations. However, our parent training program has been adapted for use in a group format by several clinical researchers (e.g., Baum, Reyna McGlone, & Ollendick, 1986; Breiner & Forehand, 1982; Long & Forehand, 2000b; McMahon, Slough, & the Conduct Problems Prevention Research Group, 1996; Pisterman et al., 1989).
There are a few fundamental considerations in setting up the clinic playroom in which the parent training program will be conducted. The room should have a chair for each person (i.e., the therapist, parent[s], and child), various sets of age-appropriate toys, and an additional chair that serves as the TO chair. Because children with conduct problems often engage in destructive behavior, we recommend that the furniture be basic, functional, and durable, and that the room be furnished as minimally as possible. If possible, the light switch should either be out of the child's reach or taped or locked in the "on" position.
Toys should be conducive to joint play and facilitative of imaginative play (Cavell, 2000). Examples of such toys are building materials (e.g., Legos, building blocks, Lincoln Logs), crayons or markers with paper and coloring books, a dollhouse with furniture and people, cars and trucks, and farm or zoo animals. Toys that should be avoided include board games, aggression-facilitating toys (e.g., guns), and messy toys (e.g., bubbles, paints) (Hembree-Kigin & McNeil, 1995).
The placement of furniture and toys is also important. Toys should be placed in that part of the room farthest from the door, with chairs for the therapist and parent(s) placed between the toys and the door (see Figure 3.1). This layout (1) provides separate areas for discussion among adults and for toy play and (2) prevents the child from having easy access to the playroom door should the child decide to leave during the session!
In an ideal situation, the playroom is equipped with a one-way window and a radio signaling device such as the "bug-in-the-ear" (a hearing-aid-like device converted to a radio receiver that the parent wears in his or her ear), giving the therapist the ability to unobtrusively talk to the parent from behind the window while the parent interacts with the child. However, these accoutrements are not necessary for the successful implementation of the program.
Sessions are optimally scheduled twice each week, with a session length of 75-90 minutes. We have found the more traditional format of weekly 50-minute sessions to be less successful. A 50-minute session usually does not permit adequate time for homework review, observation of parent-child interaction, and the extensive teaching and practice procedures employed in the program. In addition, weekly sessions increase the likelihood of an unacceptable level of performance decay. If parents are having difficulty implementing a procedure at home, they usually either stop using the skill or, worse, become proficient at using it incorrectly. By attending two sessions each week, parents receive a more constant level of feedback and training. When practical considerations (e.g., distance, insurance reimbursement, scheduling) prevent twice-weekly sessions, we strongly recommend that phone contact occur midway between the weekly sessions.
WHO SHOULD ATTEND SESSIONS
When two parents reside in the home, we encourage both to attend sessions. Two parents consistently implementing the program will be more effective than only one parent! In our clinical experience, both parents attend in about 50% of the cases. Not surprisingly, when only one parent is involved in treatment, it is usually the mother.
When only one parent attends sessions, we encourage that parent to share handouts with the second parent. The two parents also are encouraged to practice the skills together so that they both are using the skills.
In some cases, an extended family member (e.g., the child's grandmother) may be a coparent. In these cases, we encourage the involvement of that person. We have found particularly high levels of coparenting by extended family members in ethnic minority groups (e.g., African American) (Forehand & Kotchick, 1996; Kotchick et al., in press).
Which skills can parents most effectively use to modify child noncompliance and other inappropriate behavior? As noted in Chapter 2, parent training interventions have tended to employ a number of similar teaching procedures and parenting skills (Dumas, 1989; Kazdin, 1995; Miller & Prinz, 1990). For young (3- to 8-year-old) children presenting with noncompliance, our research and clinical experience support the teaching of five core skills: giving attends, giving rewards, use of active ignoring, issuing clear instructions, and implementing time outs. These parenting techniques are described in detail in subsequent chapters, and Chapter 10 presents the data from studies examining these skills.
Our clinical experience has indicated that these skills should be taught in a specific order. In particular, the attending and rewarding skills from Phase I should be taught prior to teaching clear instructions and TO from Phase II. We strongly believe that these positive attention skills are critical to providing a more positive social context for the child and thus increase the likelihood of cooperative behavior (see Chapter 1). In addition, we have found that parents who are first taught a disciplinary procedure such as TO (which is a type of punishment) may terminate prematurely, as they often will have reduced their children's problem behaviors (albeit temporarily). Unfortunately, these parents have not learned any positive skills for interacting with their children or for maintaining their children's positive behavior. Therefore, for both ethical reasons and overall intervention effectiveness, we believe that, in nearly all cases, it is important to teach punishment procedures to parents later in the intervention process. However, it may sometimes be necessary to introduce nonphysical punishment procedures (e.g., TO) earlier in the program, when the child is extremely out of control (see Chapter 6, p. 128) or when working with physically abusive parents (see Chapter 9, pp. 190-192).
METHOD OF TEACHING
An extensive body of research indicates that modeling and role playing are the most effective teaching procedures in parent training (see O'Dell, 1985, for a review). These findings support our model for training parenting skills. Although we employ other teaching methods, such as instructing parents in what to do and giving them handouts describing the skill, we particularly emphasize modeling and role playing. In addition, parents are given homework assignments to employ the skill at home with their child. In this gradual shaping procedure, parents are told, are shown, practice, and generalize to the home each new skill. Parents also must meet specific performance criteria for a parenting skill before proceeding to the next skill (see below). This active approach to teaching parenting skills may be especially effective with disadvantaged parents (e.g., low SES, single parents) (Knapp & Deluty, 1989).
Similarly, our research (e.g., Davies, McMahon, Flessati, & Tiedemann, 1984) indicates the importance of actively including the child in the learning process. The child is present in the clinic playroom throughout the session; more importantly, the therapist and parent explain, model, and role play the parenting skills with the child before they are implemented "for real." This parent training program is one of the only ones of its type to involve the child as an active participant to this extent.
The sequence of instructional procedures that we follow for teaching the parenting skills is presented in Table 3.1.
An additional part of the teaching procedures consists of the therapist, in interactions with the parent, shaping how the parent should interact with his or her child. For example, in providing feedback to the parent during the instructional sequence just described, the therapist can (1) provide positive reinforcement for appropriate parenting behavior ("Nice job of attending there!"), (2) provide corrective feedback ("Remember-no questions"), (3) prompt the parent as to what to say/do next ("Say, 'You're pushing the car up the tower'"), and (4) model a desired behavior ("You're pushing the car up the tower"). At other times, the therapist may ignore off-task comments by a parent. If such skills are good procedures to use with children, then they are also appropriate for the therapist to use with the parent!
OVERVIEW OF SKILLS TAUGHT IN THE PARENT TRAINING PROGRAM
The program consists of two phases: Differential Attention (Phase I) and Compliance Training (Phase II). In each phase a series of parenting skills is taught in a sequential manner. A synopsis of the skills that are taught in the parent training program is presented in Table 3.2.
During the Differential Attention phase of the intervention (Phase I), the parent learns to increase the frequency and range of social attention to the child and reduce the frequency of competing verbal behavior. A major goal is to break out of the coercive cycle of interaction by establishing a positive, mutually reinforcing relationship between the parent and child. In the context of the Child's Game, the parent is taught to increase the frequency and range of positive attention to the child; to eliminate verbal behaviors-commands, questions, and criticisms (Forehand & Scarboro, 1975; Johnson & Lobitz, 1974)-that are associated with inappropriate child behavior; and to ignore minor inappropriate behaviors. First, the parent is taught to attend to and describe the child's appropriate behavior. Moreover, the parent is required to eliminate all commands, questions, and criticisms directed to the child during the clinic training session. The second segment of Phase I consists of teaching the parent to use verbal (e.g., praise) and physical (e.g., hugs) attention contingent upon compliance and other appropriate behaviors (rewards). In particular, the parent is taught to use praise statements in which the child's desirable behavior is labeled (e.g., "You are a good boy for picking up the blocks"). Throughout Phase I, the therapist emphasizes the use of contingent attention to increase child behaviors that the parent considers desirable. The parent is also taught to actively ignore minor inappropriate behaviors. At home, the parent is required to structure daily 10- to 15-minute Child's Game sessions to practice the skills that were learned in the clinic. Near the end of Phase I, with the aid of the therapist, the parent formulates a list of child behaviors that he or she wishes to increase. The contingent use of attends and rewards to increase these behaviors is also discussed. The parent develops programs for use outside of the clinic to increase at least three child behaviors using the new skills.
In Phase II of the parent training program (Compliance Training), the primary parenting skills are taught in the context of the clear instructions sequence (see Table 3.2). The clear instructions sequence consists of three paths. The therapist first teaches the parent to use appropriate commands (clear instructions) to increase the likelihood of child compliance. In the context of the Parent's Game, the therapist teaches the parent to give direct, concise instructions one at a time and to allow the child sufficient time to comply. If the child initiates compliance within 5 seconds of the clear instruction, the parent is taught to reward and attend to the child within 5 seconds of the compliance initiation (Path A). If the child does not initiate compliance, the parent learns to implement a brief TO procedure involving the following event sequence. The parent gives a warning that labels the TO consequence for continued noncompliance (e.g., "If you do not pick up the toys, you will have to sit in the chair"). If the child initiates compliance within 5 seconds, the therapist instructs the parent to provide positive attention (i.e., rewards and attends) for the child's compliance (Path B). If compliance does not occur within 5 seconds following the warning, the parent learns to implement a brief TO procedure that involves placing the child on a chair facing a wall (Path C).
Excerpted from Helping the Noncompliant Child by Robert J. McMahon Rex L. Forehand Copyright © 2003 by The Guilford Press. Excerpted by permission.
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