Evidence-Based Practices for Externalizing Behavior

ProblemsParenting Interventions

Suzanne Kerns, Ph.D.University of Washington

Division of Public Behavioral Health and Justice Policy

Nature and Significance of Child Behavior Problems

15% of boys and 14% of girls aged 4-12 years have emotional or behavioral problems in the ‘clinical’ range (Sawyer et al, 2000).

31% of children aged 4-12 years were reported by their parents to have a behavioral or emotional problem in last six months (Child Health Survey, 2001)

Treatment for behavior problems

Only 1 in 10 parents participate in parent education (Sanders et al, 1999)

Only 1 in 4 children, whose behavioral or emotional problem is in the clinical range, access a specialized support service (Sawyer et al, 2000)

Overview of components of evidence-based approaches for treatment of externalizing behavior problems• General theoretical approaches• Therapeutic strategies

Boiling down Evidence-Based Practices (EBPs) for behavior problemsMost EBPs for child and adolescent

externalizing behavioral health problems are:Cognitive Behavioral Therapies (CBT)Behavioral Therapy (BT) Systemic or Ecological interventions

For kids, evidence-based interventions for externalizing behaviors often require work with the caregiver and the child

Boiling down EBPsCognitive Behavioral Therapy (CBT) Addresses behavior that is problematic, or getting in the way Addresses thoughts and feelings that are problematic, or getting in the

way

Behavioral Therapy (BT) Addresses behavior that is problematic, or getting in the way

Systemic Interventions Broad Interventions: Address multiple factors in the youth’s

environment contributing to problem behavior (e.g., parental monitoring, increasing social support)

Often include some behavioral therapy and cognitive behavioral therapy

Overview of Behavior Therapy Assumptions

• All behavior is learned (adaptive and maladaptive)

• Maladaptive behavior can be changed by altering some aspect of the context in which it occurs

General Behavioral Strategies Positive and negative reinforcement

• Schedules of reinforcement important! Positive and negative punishment Shaping (i.e., successive

approximations) Generalization Maintenance

Behavior Behavior ap

ply

rem

ove

Positive Reinforcement

Positive Punishment

Negative Reinforcement

Negative punishment

The Cognitive Behavioral Therapy Model

BEHAVIOR COGNITION

EMOTION

CBT: Topics Covered in CBT Interventions

Education• Teaching about why symptoms developed and how maintained

(e.g., lying, hoarding)Connecting thoughts, feelings, and behavior

• Analyzing and ‘correcting’ inaccurate or unhelpful thoughts to feel better (e.g., “It’s my fault I’m in foster care.”)

Parenting skills/Behavior management• Rewards, ignoring, consequences

Coping Strategies• Breathing, relaxation, coping statements (“Stay calm. Take 5 deep

breaths.” “Its not my fault.”)

CBT: Qualities of CBT InterventionsManual that guides the therapist Usually upfront assessmentShort-term treatment• Less than 6 months in most cases

Therapist is directive• Sets agendas and plan for treatment, though

client has inputClear goals • Reduce temper tantrums

CBT: Qualities of CBT InterventionsPresent focusedSkills taught and practiced in session Homework assigned (practice outside

session)• To child and parent or caregiver, if involved• Try new skills at home, school

Common Strategies for Parenting Interventions Didactic instruction

Modeling

Role playing

Behavioral rehearsal

Homework

Qualities Inconsistent with CBT and other EBPs

Letting the child or parent direct the session• “Tell me where we should start today.”

The relationship between the therapist and youth as treatment• The relationship is important, but isn’t

‘treatment’Play therapy• Play as therapy, as opposed to a vehicle of

treatment• ‘Play therapy’ as treatment is ineffective

Qualities Inconsistent with CBT and other EBPsLong-term therapy (unless module-based)Therapy overly focused on the cause of the

problem, or the past, without a focus on now

Taking a year or more to see improvementTaking months to build a relationship,

before starting treatment

Why are so many of the EBPs CBT Interventions? CBT works!Focuses on current behaviors, problems, and

thoughtsDesigned to teach skills and provide

opportunities to practice and receive feedback Inherently strengths-focused: Teaching youth and

their caregivers the skills to help themselvesOften, best fit for range of cultures and

ethnicities

Diverse Cultural Groups and EBPs: A GOOD FIT New evidence that EBPs and Cultural

Competence may be more complementary than disparate (Whaley & Davis, 2007; Huey & Polo, 2008).

CBT approaches, specifically, have the strongest evidence.

Ethnic minority youth respond best to txs that are highly structured, time-limited, pragmatic, & goal-oriented (Ho, 1992).

Adaptations: Risky if core components are substituted or compromised in favor of untested adaptations (Huey & Polo, 2008).

Suggestion: Maintain EBPs in original form, apply culturally-responsive elements already incorporated into protocol (Huey & Polo, 2008).

Overview of Parent Training (McMahon & Wells, 1998: in Treatment of Childhood Disorders)

Parents/caregivers as primary change agents• Less focus on therapist-child interactions

Altering parental focus on challenging behaviors to emphasizing prosocial goals

Programs typically focus on principles of• Social Learning• Monitoring and/or tracking behaviors• Positive reinforcement• Extinction and mild punishment (away from physical

punishment)• Giving clear instructions• Problem solving

Parent Training as Prevention Meta-analysis (A Study of Studies) CDC: Valle, Wyatt, Filene & Boyle (2006)

presentation; paper forthcoming Examined:

• What is happening in these programs?• What is happening that works?

Only programs focused on active acquisition of skills; not parent education

Parents of kids 0-7 Examples: PCIT, TIY, Healthy Families

Summary of findings Little impact sharing information related

to child development Knowledge & information and parenting

self-efficacy improved through:• Recreation and play• Disciplinary communication• Positive reinforcement• Use of time-out

Parent attitudes and values improved by:• Appropriate responding• Emotional communication

Parent-child interaction improved by:• Recreation and play• Emotional communication

Positive child outcomes associated with • Parenting consistency• Modeling• Practice with own child• Problem solving

Take Home Message Some “cherished” components may be less

valuable overall than typically believed• Ex., developmental knowledge

Certain components positively associated with many outcomes• Parents: Practice with own child, parenting consistency,

disciplinary skills/communication, recreation and play• Children: Practice with own child, recreation and play

Evidence-based Parent Training Programs Helping the Noncompliant Child Parent-Child Interaction Therapy The Incredible Years Parent Management Training Oregon Model Triple P (Positive Parenting Program) Multisystemic Therapy Multidimensional Foster Care

Parent Training Programs Derived from Hanf Model Helping the Noncompliant Child Parent-Child Interaction Therapy The Incredible Years Parent Management Training Oregon

Model (Patterson et al.)

Barkley program (Defiant Child) also similar (though not in Eyberg review)

Helping the Noncompliant Child Robert McMahon & Rex Forehand (University of Washington;

University of Vermont) Ages 3 – 8 Parent and child seen together About 10 sessions (75-90 minutes); 1 or 2x a week Taught positive attention for appropriate behaviors, ignoring for

minor negative behaviors, and praise or time out for compliance/non compliance• Giving attends (e.g., You’re stacking the blue blocks on top of that big red one.”)

• Giving rewards (praise)• Use of active ignoring• Issuing clear instructions• Implementing time outs

Skills taught via modeling, role playing, and in vivo training Progress as each skill is mastered

Helping the Noncompliant Child Homework: 10-15 minute Child’s Game or Parent’s

Game session to practice skills learned in the clinic Two phases: Differential Attention (Phase I) and

Compliance Training (Phase II)• Behavioral criteria for moving from Phase I to Phase II

Agenda for sessions Clear instructions sequence Time out procedures for commands Standing rules Move skills outside the home

www.pcit.phhp.ufl.edu

Parent-Child Interaction Therapy

PCIT Kids age 2-7 Weekly 1 hour sessions for an average of 12-

16 sessions Two phases: Child Directed Interaction

(relationship enhancement) & Parent Directed Interaction (listening and minding)

Modeling and role plays, key is use of bug-in-the-ear in vivo coaching

Progress as each ‘set’ of skills is mastered

Time OutChair

Coach

Dad

Co-Therapist

Timeout RoomWindow

Two-wayMirror

Child Mom

Structure of PCIT Assessment

sessions• Pre-treatment• Post-treatment• Follow-up

Coaching sessions• Check in - review of week• Parent plays with child in

playroom• Therapist codes from

observation room• Therapist coaches parent

through bug-in-ear• Two parents take turns• Check out - homework plan

Teaching sessionsDescribingModelingRole-playing

The Incredible Years

www.incredibleyears.com

Incredible Years Parent Training Carolyn Webster-Stratton, University of Washington,

School of Nursing Group format 13 sessions For parents of kids age 2-10 Parents view videotape vignettes

• Stimulus for discussion and problem solving Focuses 1st on parent-child interactive play skills

then effective discipline (monitoring, ignoring, commands, logical consequences, & Time Out)

Parents also taught how to teach children problem solving

Triple P

TRIPLE P—Positive Parenting Program

Triple P based on 25 years of research and implementation Developed by Dr. Matt Sanders and colleagues at the

Parenting and Family Support Centre (U of Queensland) Designed from the outset as a public health strategy

created for broad-scale dissemination California Evidence-Based Clearinghouse for Child

Welfare: • Triple P Scientific Rating= Level 1 Well-supported, effective

practice (highest rating). • Relevance to Child Welfare= Level 1 (Highest rating)

Levels of InterventionUniversal Triple PUniversal Triple P

Level OneLevel One

Primary Care Triple PLevel three

Selected Triple PLevel Two

Standard Triple PLevel four

Enhanced Triple PLevel five

Core Principles of Positive ParentingSource: Sanders, M.R., Markie-Dadds, C., & Turner, K.M.T. (1997). Positive Parenting. Brisbane: Families International Publishing

Core principles

1Safe engaging environment

2Responsive

learning environment

3Assertive discipline 4

Reasonable expectations

5Taking care

of self

17 Specific Parenting SkillsPromoting a

positive relationship•Brief quality time

•Talking to children•Affection

Teaching new skills and behaviors

•Modeling•Incidental teaching

•ASK, SAY, DO•Behavior charts

Encouraging desirable behavior

•Praise•Positive attention

•Engaging activities

Managing misbehavior•Ground rules

•Directed discussion•Planned ignoring

•Clear, calm instructions•Logical consequences

•Quiet time•Time out

Specific skills

Other programs with strong parenting components that you may hear about Programs

• Multisystemic Therapy• Functional Family Therapy• Family Integrated Transitions• Multidimentional Treatment Foster Care• HOMEBUILDERS

These programs often require specialized staff – you may interact with practitioners from these programs

Summary Effective treatment of externalizing behaviors for younger

children (under 10) MUST include the parents as a primary focus. For older children, parents must be involved for effective treatment, although there are some effective interventions that directly involve the youth.

More commonalities than differences across evidence-based parenting programs

Consideration to your treatment population and practice set-up may influence decision to choose one program over another• Many programs can be implemented within traditional settings but

some require more significant investment Parenting interventions have the potential to provide a

significant public health benefit