8/12/2011

8

PRACTICE components PRACTICE components

P P sychoeducationsychoeducation and and Parenting skillsParenting skillsyy gg R R elaxationelaxation A A ffective expression and regulationffective expression and regulation C C ognitive coping ognitive coping T T rauma narrative development & processingrauma narrative development & processing I I n vivo gradual exposuren vivo gradual exposure C C onjoint parent child sessionsonjoint parent child sessions E E nhancing safety and future developmentnhancing safety and future development

Parenting SkillsParenting SkillsEngagement is the first interventionEngagement is the first intervention

Validate and take seriously caregiver concerns Validate and take seriously caregiver concerns about any issueabout any issue

Requires a lot of follow upRequires a lot of follow up

8/12/2011

9

Parenting SkillsParenting Skills

TFTF--CBT views parents as central therapeutic agent for CBT views parents as central therapeutic agent for change and establishes parent as the person the childchange and establishes parent as the person the childchange and establishes parent as the person the child change and establishes parent as the person the child turns to for help in times of troubleturns to for help in times of trouble

Explain the rationale for parent inclusion in treatmentExplain the rationale for parent inclusion in treatment

Not because parent is part of the problem but because Not because parent is part of the problem but because parent can be the child’s strongest source of healingparent can be the child’s strongest source of healing

Emph size positi e p renting skillsEmph size positi e p renting skills Emphasize positive parenting skills,Emphasize positive parenting skills,

enhance enjoyable childenhance enjoyable child--parent interactions, parent interactions,

maximize perception/reality effective parenting maximize perception/reality effective parenting

Common Parental Issues inCommon Parental Issues inChild TraumatizationChild Traumatization

I i lfI i lf bl d ilbl d il Inappropriate selfInappropriate self--blame and guiltblame and guilt

Inappropriate child blameInappropriate child blame

OverOver--protectivenessprotectiveness

OverOver--permissivenesspermissivenesspp

PTSD SymptomsPTSD Symptoms

8/12/2011

10

GoGo,, YieldYield,, oror StopStop??Bringing Parent & Child TogetherBringing Parent & Child Together

Emotionally stable & flexibleEmotionally stable & flexible Has reviewed trauma narrative Has reviewed trauma narrative

with therapistwith therapist Able to focus on experience of Able to focus on experience of

child/youth child/youth Poised for praisePoised for praise

h ll b hh ll b h

Emotionally unstable & rigid

Avoids trauma narrative with therapist

Preoccupied with their experience of pain – limited focus on child/youth.

Open to challenge by therapist as Open to challenge by therapist as unhelpful cognitions emerge.unhelpful cognitions emerge.

Communication is an honoring Communication is an honoring exchange between parent & child.exchange between parent & child.

Open to potential for growth from Open to potential for growth from narrative (strengths, resilience, & narrative (strengths, resilience, & hope)hope)

Has consistently attended sessionsHas consistently attended sessions

pain limited focus on child/youth.

Difficulty offering praise

Defensive to challenge by therapist as unhelpful cognitions emerge.

Communication is struggle between parent & child.

Closed to potential for growth from narrative (despair, impairment, lost)

What is Your FavoriteWhat is Your FavoriteWhat is Your Favorite What is Your Favorite Color?Color?

8/12/2011

11

Parenting Skills: 2 main prongsParenting Skills: 2 main prongs

Use PRAISEUse PRAISE when a parent wants MORE OF when a parent wants MORE OF ppa behavior; wants to INCREASE behavior (e.g., a behavior; wants to INCREASE behavior (e.g., saying “thank you”, using an inside voice, saying “thank you”, using an inside voice, picking up toys)picking up toys)

Use Time out, Ignoring, and Contingency Use Time out, Ignoring, and Contingency ManagementManagement when a parent wants to when a parent wants to DECREASE a behavior (e.g., screaming, nonDECREASE a behavior (e.g., screaming, non--compliance, whining)compliance, whining)

The Power of PraiseThe Power of Praise

Praise is a powerful reinforcer because kids want their Praise is a powerful reinforcer because kids want their parent’s attentionparent’s attentionpp

Offer “global” praise generously (i.e. I’m so proud to be Offer “global” praise generously (i.e. I’m so proud to be your parent; I love you)your parent; I love you)

Positive behaviors will become more frequent if praise is Positive behaviors will become more frequent if praise is given:given: ImmediatelyImmediately ConsistentlyConsistently Specifically Specifically Positively & EnthusiasticallyPositively & Enthusiastically By Focusing on Efforts and BehaviorsBy Focusing on Efforts and Behaviors

8/12/2011

12

Immediate PraiseImmediate Praise

Praise the desired behavior IMMEDIATELY after it Praise the desired behavior IMMEDIATELY after it occurs. Praise tends to be more powerful if it occurs occurs. Praise tends to be more powerful if it occurs l i til i ti t th b h i rt th b h i rcloser in timecloser in time to the behavior. to the behavior.

Hint:Hint: Parents often do not praise when they Parents often do not praise when they have have the the opportunity, instead waiting for a negative behavior opportunity, instead waiting for a negative behavior and then they “pounce” on it… giving the and then they “pounce” on it… giving the negativenegativebehavior the attention! behavior the attention!

Help parents “catch” their child with the positive Help parents “catch” their child with the positive behavior and behavior and immediately immediately praise it. (e.g., praise it. (e.g., “I really like how “I really like how you and your sister you and your sister are playing so quietly in here”)are playing so quietly in here”)

Consistent PraiseConsistent Praise

When first attempting to increase a desired behavior, When first attempting to increase a desired behavior, praise it each and every time it occurs. Oncepraise it each and every time it occurs. Oncepraise it each and every time it occurs. Once praise it each and every time it occurs. Once established, praise can come less frequently. established, praise can come less frequently.

Hint: To start, have parents choose Hint: To start, have parents choose oneone behavior to behavior to increase praise on in a given week; if possible, have increase praise on in a given week; if possible, have them tally the number of times they could praise it (use them tally the number of times they could praise it (use

f li k b h l f l)f li k b h l f l)of a clicker counter can be helpful) of a clicker counter can be helpful)

8/12/2011

13

Specific PraiseSpecific Praise

Specific praise Specific praise teachesteaches the child the child what parents want what parents want more ofmore of Instead of “good job” say: “Good jobInstead of “good job” say: “Good jobmore of.more of. Instead of good job , say: Good job Instead of good job , say: Good job putting your dishes in the sink”. putting your dishes in the sink”.

Teach parents some ways to begin specific Teach parents some ways to begin specific praises and practice this in the office: e.g., praises and practice this in the office: e.g., I like it when you…, Good girl for…I like it when you…, Good girl for… What a wonderful idea to…, Thank you for.., What a wonderful idea to…, Thank you for.., Nice job of…, You’re so polite to…Nice job of…, You’re so polite to…

Positive and EnthusiasticPositive and Enthusiastic

Always positive; avoid negative tags like “thank you Always positive; avoid negative tags like “thank you for being quiet while I talk with daddy; for being quiet while I talk with daddy; why can’t you why can’t you d h ll h i ?”d h ll h i ?”do that all the time?”do that all the time?”

Enthusiasm can be shown by warmth in the voice, a Enthusiasm can be shown by warmth in the voice, a gentle touch, eye contact, a cheerful voice, a gentle touch, eye contact, a cheerful voice, a smile… or any combo of these. smile… or any combo of these.

Hint: you might help parents see how they get all Hint: you might help parents see how they get all excited over negative behavior (e.g., yelling). Help excited over negative behavior (e.g., yelling). Help g ( g , y g) pg ( g , y g) pthem to see how getting excited over positive them to see how getting excited over positive behavior will give them more payoffbehavior will give them more payoff

8/12/2011

14

Focus on Efforts and BehaviorFocus on Efforts and Behavior

Help parents identify the work and effort put in: “you Help parents identify the work and effort put in: “you worked hard picking up all your toys”!worked hard picking up all your toys”!worked hard picking up all your toys !worked hard picking up all your toys !

Help parents avoid focusing too much on physical Help parents avoid focusing too much on physical characteristics (e.g., “you’re the prettiest little girl I characteristics (e.g., “you’re the prettiest little girl I know”). know”).

Avoid superlatives: (e.g., “you’re the smartest , the Avoid superlatives: (e.g., “you’re the smartest , the fastest, etc). Instead, “I could see you put a lot of fastest, etc). Instead, “I could see you put a lot of energy into that race!” Or, “I’m so pleased to see the energy into that race!” Or, “I’m so pleased to see the hard work you put into your book summary!” hard work you put into your book summary!”

Decreasing BehaviorsDecreasing Behaviors

IgnoringIgnoring

TimeTime--OutOut

Contingency ManagementContingency Management

8/12/2011

15

The Power of IgnoringThe Power of Ignoring

Along with praising positive behaviors that a Along with praising positive behaviors that a iiparent wants to increase…parent wants to increase…

Ignore the MILD behaviors that a parent wants Ignore the MILD behaviors that a parent wants to decrease.to decrease.

Kids LOVE attention; this is why ignoring Kids LOVE attention; this is why ignoring works!works!works! works!

The Power of IgnoringThe Power of Ignoring What to ignore?What to ignore?

Behaviors that are annoying, but not unsafe…Behaviors that are annoying, but not unsafe…y g,y g, Whining, cursing, banging, clinging, bragging, sulking, arguing, Whining, cursing, banging, clinging, bragging, sulking, arguing,

threatening, baby talk, sassing, screaming, etc threatening, baby talk, sassing, screaming, etc

What not to ignore?What not to ignore? Hitting, biting, kicking, breaking things, sexually intrusive Hitting, biting, kicking, breaking things, sexually intrusive

behaviors, etcbehaviors, etc

Child’s behavior will likely escalate before it diminishes… Child’s behavior will likely escalate before it diminishes… help parents understand that they will need to “hang in help parents understand that they will need to “hang in there” through that hard time!there” through that hard time!

8/12/2011

16

Giving effective commandsGiving effective commands

Cue child to pending command: “Sally, please…”Cue child to pending command: “Sally, please…”

M k i i lM k i i l Make it simpleMake it simple

Make it developmentally appropriateMake it developmentally appropriate

Phrase it positivelyPhrase it positively

Give it in a neutral tone of voiceGive it in a neutral tone of voice

Provide an explanation BEFORE command is givenProvide an explanation BEFORE command is givenp gp g

Give one command at a timeGive one command at a time

Praise immediately after compliancePraise immediately after compliance

When no compliance:When no compliance:

Limit warnings to ONE!!!!!Limit warnings to ONE!!!!!

“Sally, you have two choices. You can either “Sally, you have two choices. You can either do do this behaviorthis behavior or you can or you can take this consequencetake this consequence

8/12/2011

17

TimeTime--OutOut

Parents need a clear protocol and often quite a bit Parents need a clear protocol and often quite a bit of modeling and problem solving to manage time of modeling and problem solving to manage time

{{out {see out {see BarkleyBarkley or or Schroeder & Gordon Schroeder & Gordon (resource (resource list), or the PCIT manual found onlist), or the PCIT manual found on--line}. Follow line}. Follow such protocols carefully. such protocols carefully.

Before timeBefore time--out can be effective, a parent needs to out can be effective, a parent needs to have enough “timehave enough “time--in” relationship with a child.in” relationship with a child.

Time OutTime Out

Purpose: Interrupt child’s negative behaviors and allow Purpose: Interrupt child’s negative behaviors and allow him/her to regain controlhim/her to regain controlhim/her to regain controlhim/her to regain control

Explain to childExplain to child

Location: quiet, least stimulatingLocation: quiet, least stimulating

Quiet for at least a short time (few seconds) after the Quiet for at least a short time (few seconds) after the time limittime limit

Once in time out, parent should refrain from Once in time out, parent should refrain from comments and maintain calm demeanorcomments and maintain calm demeanor

Be consistent!Be consistent!

8/12/2011

18

Contingency ReinforcementContingency Reinforcement

Purpose: Decrease unwanted behaviors and Purpose: Decrease unwanted behaviors and i d i d b h ii d i d b h iincrease desired behaviors increase desired behaviors --(see Barkley, 1997 in resources)(see Barkley, 1997 in resources)

Select only one behavior to targetSelect only one behavior to target

Explain process to childExplain process to child

Involve child in decisions about rewardsInvolve child in decisions about rewards Involve child in decisions about rewardsInvolve child in decisions about rewards

Add stars and give rewards weekly and be Add stars and give rewards weekly and be consistentconsistent

Behavior ManagementBehavior Management

Reasonable developmental expectationsReasonable developmental expectations

Appropriate LimitAppropriate Limit--settingsetting

8/12/2011

19

How do you Teach Behavior How do you Teach Behavior Management to Caregivers? Management to Caregivers?

ModelingModeling

Role Plays with parentRole Plays with parent

The Feedback SandwichThe Feedback Sandwich

Repeated PracticeRepeated Practice with increasingly difficult with increasingly difficult child behavior/responseschild behavior/responses

Watch parent with the child to see the skills Watch parent with the child to see the skills in action and be able to problem solve with in action and be able to problem solve with the parentthe parent

8/12/2011

20

Parenting Wisely CurriculumParenting Wisely Curriculumhttp://www.familyworksinc.comhttp://www.familyworksinc.com

Caregiver Sensitivity– Capacity to attend to and interpret

Moretti & Obsuth (2009)

Attachment Based Family TherapyTHE CONNECT PROGRAM

behavior, including Implicit and explicit communication, in terms of attachment behavior needs.

Partnership and mutuality – Ability to organize care in relation

with their teen’s mood, interests and needs; readiness for negotiation and flexibility.

Reflective FunctionI t t i th it t fl t– Interest in the capacity to reflect on and understand their own psychological experiences and those of their teen.

Dyadic Affect Regulation– Capacity to hold, tolerate and

explore difficult emotional states in themselves and their teen.

8/12/2011

21

Common Parental Issues inCommon Parental Issues inChild Child TraumatizationTraumatization

I i lfI i lf bl d ilbl d il

1 Stressful I id

Youth’s Self Concept

BUILDING INTERACTIONAL AWARENESSBUILDING REFLECTIVE FUNCTIONING

Inappropriate selfInappropriate self--blame and guiltblame and guilt

Inappropriate child blameInappropriate child blame

Parental loss of control, incompetenceParental loss of control, incompetence

OverOver--protectivenessprotectiveness

THECONFLICT

CYCLE

Incident

Adult’s Reactions

Youth’s Feelings

pp

OverOver--permissivenesspermissiveness

PTSD SymptomsPTSD Symptoms Youth’s Observable Behavior

Long & Fecser. Life Space Crisis Intervention Conflict Cycle. http://www.air.org/cecp/interact/authoronline/april98/1.htm

Adult’s Feelings

ATTACHMENT, SELF-REGULATION, & COMPETENCY (ARC)

Offense/TraumaIntegration

Blaustein & Kinniburgh (2010)

Affect Modulation

Affect

Executive Functioning

Self Development

& Identity

Integration

CaregiverAffect

ManagementAttunement

Consistent Response

Routines & Rituals

IdentificationModulation

Expression

8/12/2011

22

Resources: General Behavioral Resources: General Behavioral ConcernsConcerns

Bloomquist, M.L. (2006). Bloomquist, M.L. (2006). Skills Training for children with Skills Training for children with q , ( )q , ( ) ggbehavior problems; A parent and therapist guidebookbehavior problems; A parent and therapist guidebook. .

Barkley, R. (1997). Barkley, R. (1997). Defiant Children, 2Defiant Children, 2ndnd edition: A clinician’s edition: A clinician’s manual for assessment and parent trainingmanual for assessment and parent training. NY: Guilford Press. NY: Guilford Press

Barkley & Benton (1998). Barkley & Benton (1998). Your Defiant Child: 8 steps to better Your Defiant Child: 8 steps to better behavior.behavior. NY: Guilford PressNY: Guilford Press

Barkley & Robins (2008). Barkley & Robins (2008). Your Defiant Teen: 10 Steps to Your Defiant Teen: 10 Steps to Resolve Conflict and Rebuild Your RelationshipResolve Conflict and Rebuild Your Relationship. NY: Guilford . NY: Guilford ppPress.Press.

Parent Child Interaction Therapy (PCIT) manual can be found at Parent Child Interaction Therapy (PCIT) manual can be found at http://pcit.phhp.ufl.edu/http://pcit.phhp.ufl.edu/

8/12/2011

23

Books with chapters on various problem Books with chapters on various problem behaviors (e.g., sleep problems)behaviors (e.g., sleep problems)

Christophersen & Mortweet, (2001). Christophersen & Mortweet, (2001). Treatments Treatments that Work with Children.that Work with Children. Washington, DC, APAWashington, DC, APA

Eisen, A (2008). Treating Childhood Behavioral and Eisen, A (2008). Treating Childhood Behavioral and Emotional Problems. NY: The Guilford PressEmotional Problems. NY: The Guilford Press

Schroeder, C.S. & Gordon, B.N. (2002). Schroeder, C.S. & Gordon, B.N. (2002). Assessment and Treatment of Childhood Assessment and Treatment of Childhood ProblemsProblems--second edition NY: Guilford Presssecond edition NY: Guilford PressProblemsProblems--second edition. NY: Guilford Press.second edition. NY: Guilford Press.