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 Defiant Children: A Clinician's Manual for Assessment and Parent Training - Russell A. Barkley Chapter 4: An Overview of the Parent Training Program © Before reviewing in detail the specific methods to be taught in each step of the program, it is necessary to examine the basic concepts upon which the training program is built, the rationale for the sequence of the steps, and the schedule of activities occurring within each session. Concepts Underlying Child Management Training Several important principles of child management are interwoven throughout the training sequence. To grasp fully the program's orientation and potential power, practitioners should know these concepts in advance.
Consequences for child behavior, be they positive or negative, must be provided immediately if parents are to gain effective control over inappropriate behavior. You should repeatedly stress that parents need to provide consequences for a child immediately after the occurrence of the targeted behavior, rather than waiting until several minutes or hours later to confront the problem or reward the appropriate behavior. Because of the hectic lifestyles of many families, most parents delay dealing with behaviors, especially positive or appropriate ones. They are often much quicker to attend to undesirable or especially intrusive behaviors. But, even with these, they often wait until after the fourth or fifth repetition of a command before providing consequences for their children's noncompliance. In short, the more quickly a parent can provide consequences to a child, the greater the control they will exert over that child's behavior. Make Consequences Specific Parents are also instructed that consequences, especially verbal or social ones, should be quite specific. Both praise and criticism should refer to the behavior at issue, instead of being vague, general, or nebulous references to the children themselves, their general behavior, or their personal integrity. Similarly, with punishment, the consequences should be tailored to fit the transgression and not be based on the parents' level of impatience or frustration over this or prior episodes of misbehavior. Make Consequences Consistent Virtually all behavioral approaches to parent training stress the concept of consistency of consequences as a key to greater control of child behavior. This refers to consistency across settings, over time, and between parents. Consistency across settings simply means that if a behavior occurs that is generally punished in one environment, say the home, then it is also punished in other environments, such as stores. Although there may be occasional exceptions to this rule, it is generally a good policy for parents to respond to child behaviors similarly across various social contexts. This is often contrary to the practice of many parents who handle a problem one way while at home and a different way when in public places where others may observe them. Such a practice directly trains the child as to which situation will prove successful for the display of misbehavior. Consistency over time simply refers to the fact that parental standards about acceptable and unacceptable behavior in children should not vary too greatly from one moment to the next. Although these standards will change as a function of developmental changes in the child, over more immediate time periods it is necessary for parents to provide consequences for behavior as consistently as possible. Child behavior that is defined as unacceptable on one day should not be arbitrarily tolerated or even reinforced on another. For instance, punishing a child for "raiding" the refrigerator because a parent has a headache, while ignoring or actually assisting a visit to the refrigerator at a future time is a ludicrous practice, which only greatly reinforces such rule violations in the home. The converse is also true in that a behavior that is rewarded today should be so in the future and should certainly not be subjected to punishment later. Consistency between parents in the rules they establish for children and the consequences they employ for their adherence or violation is also important. Quite frequently, mothers tend to manage the problems they experience with a child in ways very different from those of the fathers; this often leads to conflicts not only in the development of a consistent set of rules for the children but also in the marital relationship. Establish Incentive Programs before Punishment Another concept is that punishment for inappropriate behavior should not be introduced in the home unless the parents have established a specific program for rewarding the appropriate alternative behavior. Most parents phrase their concerns about child behavior in the negative, specifying what it is they dislike about a child. This naturally leads to a consideration of punishment methods to suppress the unwanted behavior. As a result, punishment is the major type of interaction in the family and children rarely receive reinforcement for whatever acceptable behavior may be shown. Furthermore, punishment appears to lose its effectiveness in such circumstances where the family environment is devoid of positive incentives for appropriate conduct. By teaching parents to rephrase their complaints about child behavior into their prosocial or appropriate alternatives, the natural response is then one of thinking of incentives to encourage an increase in this behavior. Only then should consideration be given to punishment methods for reducing the unacceptable behavior by the child. This is especially true in those sessions where punishment is being taught, lest parents perceive the therapist as advocating the use of punishment as a primary response to misconduct by children. Anticipate and Plan for Misbehavior The experienced clinician recognizes that many parents are as impulsive in their reactions to child misbehavior as their children are in reacting to various events. This results in parents spending tremendous amounts of time in managing misbehavior while investing minimal, if any, time in analyzing, anticipating, and possibly preventing those situations in which the children are likely to create problems. If parents were to anticipate problematic encounters, they might develop methods that would reduce the probability of those problems developing. Perhaps this apparent lack of forethought or anticipation is merely the result of being so overwhelmed with incorrigible behavior that it is difficult to "take the offensive" and try to anticipate and ward off future problems in a particular setting. Or, perhaps, it results from some parents having forms of psychopathology similar to those of their children (i.e., ADHD and ODD), making the parent more impulsive and immature compared to other parents, just as the children are relative to their own peers. Regardless of the reasons, such lack of forethought contributes to many of the difficulties parents have in dealing with children in particular places, such as in stores, restaurants, and so forth. It is necessary periodically to discuss with parents this issue of thinking ahead about problem situations and preparing a plan of behavior management for the child before entering the potential problem situation. This is certainly contrary to the more typical situation of waiting until the disruptive or unmanageable behavior occurs and then trying to determine what to do about it; that strategy amounts to being "too little, too late" in dealing with defiant children. Recognize That Family Interactions Are Reciprocal Another concept conveyed to parents throughout the program is that of reciprocity of interactions within families. Parents often have a unilateral view of the causes of child behavior problems-either they caused the problem or it is all the child's fault. You must periodically emphasize that interaction patterns within families are quite complex and not especially well understood at this time. However, there are strong indications that parents' behavior toward a child is partly a function of that child's behavior toward them; the child's temperament, physical characteristics, and abilities; and prior experiences with that child (Bell & Harper, 1977; Patterson, 1982). Similarly, the child's behavior is partly a function of how the parent treats the child; the parent's own temperament, physical characteristics, and abilities; and prior experiences with that parent. Because of this bidirectional influence between parent and child, it is difficult to assign blame to either party for the current state of conflict. Hence, no time in this program is spent in blaming parents or children for interaction problems, a practice that is of no constructive worth in overcoming those problems. Instead, all parties to the problematic interaction bear some responsibility for its resolution. That parents are chosen as the major focus of change has more to do with convenience and their motivation to alter the problem interactions than it does with finding fault with their child management skills. In summary, the following general concepts concerning child management deserve periodic emphasis throughout the course of therapy: (1) making consequences immediate and specific; (2) making consequences consistent across settings, over time, and between parents; (3) establishing incentive programs for appropriate behavior before implementing punishment methods to suppress its unacceptable alternative; (5) anticipating potential problem situations and preparing a plan of action ahead of time; and (6) emphasizing that interaction patterns in families are reciprocal systems, thus making fault finding with parents or children of little constructive value. There are 10 steps to the core parent training program. The program can be taught as one self-contained unit with therapy terminating after the final session, or it can be integrated into an ongoing family therapy or parent counseling program designed to address other difficulties in the family, marriage, or parent's own personal life. In some cases, it may be necessary to change to other forms of therapy after these steps are completed in order to address other problems of the child, such as enuresis or encopresis, noncompliance with medical treatments, or school performance issues. In any case, the sequence of the procedures within this core program should remain essentially the same. Much research and clinical experience have been invested in constructing the steps of the program and their sequence, and they are deliberately presented in this order for significant reasons. Although it is possible that some families may not require all steps of the program due to the mild nature of the child's noncompliance, the training chosen for any particular case should follow this order. The justification is that the initial sessions emphasize the development of positive behavior management methods within the family, especially the use of incentives for compliance with rules and commands, while later sessions deal specifically with punishment techniques. Inverting the sequence such that punishment is taught first may result in an excessive reliance by parents on punishment throughout the entire program and, perhaps, ultimately to a lessened effectiveness of such techniques. By establishing a home environment rich with incentives for appropriate behavior, the subsequent introduction of selective, mild punishment appears to go more smoothly and effectively. In cases of only minor noncompliance by a child, a therapist may choose to train the parents only in the use of praise for acceptable compliance and appropriate child behavior and then skip to the use of the time out procedure for the occasional noncompliance by the child. In such instances, parents will generally find these two procedures to be sufficiently effective, and they will not need the more intense contingency management procedures and discussions of the causes of child misbehavior. Here, even the time out procedure need not be as dramatic or intense as it is in the usual approach because the minor level of noncompliance does not warrant such intensity. Occasionally, the therapist may wish to implement the home poker chip or point systems to augment the enhanced use of praise with these children, which is often very successful. Nonetheless, even in such mild cases, the sequence remains the same-positive reinforcement and incentive methods are taught first, before the punishment procedures are introduced. In most cases, the complete sequence of steps should be taught, as follows:
Other than the first step, the sessions follow a standard pattern of events. Whether group or individual family training is selected as the teaching format, each session begins with a review of the previous week's homework assignment and any other events the family may wish to share with you (or the group). Problems that may have arisen in implementing prior instructions are discussed and resolved. In individual family training, should parents fail to have done the homework, this issue is addressed, as discussed above, and the parents are reassigned this homework for the next week. When this occurs, no new material would be discussed in the session. In a group training format, the therapist would schedule a separate individual session with any family failing to do the homework so as to discuss this issue privately and determine whether this family should proceed further with training. That family remains in the group for this session, however. If homework was done satisfactorily, the new material, concepts, and methods are introduced, regardless of which teaching format is employed. Where appropriate, you should model or demonstrate these methods. Some therapists may choose to use videotaped demonstrations of the techniques to enhance the parents' acquisition of the method (see Webster-Stratton, 1984; Webster-Stratton et al., 1989). If the training is being done with an individual family, then at this stage of the session some practice of the methods within the sessions is encouraged. The parent and child can go to a playroom and the parent would practice the methods with the child under your supervision, usually using a one-way mirror if available. Any of several transmitter devices may be used for this purpose. These usually involve a small transmitter and microphone installed in the observation room connected to an antennae in the adjacent playroom. The parent is given direct and immediate feedback during practice using a small hearing aid (receiver) worn by the parent, which receives voice transmissions from the adjoining observation room. Should this resource not be available, simply observing the parents and child in a portion of your office for 15 minutes and then discussing with the parent the impressions of the performance can serve the same purpose. You would then discuss any problems the parents might envision in implementing the technique in their home during the coming week. In a parent group, no practice need occur at this point. Instead, group discussion of the methods and any problems each family anticipates encountering when implementing this procedure at home would be the focal points of the group activity at this time. Subsequently, the homework for the coming week is assigned and questions regarding it are resolved. Ample praise, encouragement, and positive feedback are provided throughout each session for the parents' participation in discussions, compliance with the instructions and homework, and general cooperation with the training program. Summary This chapter briefly describes the important concepts or principles upon which the treatment methods are founded, as well as the 10 steps of the program and their sequence. Emphasis is placed on adhering to the particular pattern of training, as it is important in its own right, beyond simply the methods being taught. Which methods are introduced in what sequence is often crucial to enhancing the effectiveness of the total program. A method for organizing the material to be taught within each step is also presented.
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