1. Evidence-Based Practices for Externalizing Behavior Problems Parenting Interventions Suzanne Kerns, Ph.D. University of Washington Division of Public Behavioral Health and Justice Policy

2. 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)

3. 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)

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

5. Boiling down Evidence-Based Practices (EBPs) for behavior problems Most 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

6. Boiling down EBPs Cognitive 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

7. 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

8. General Behavioral Strategies Positive and negative reinforcement Schedules of reinforcement important! Positive and negative punishment Shaping (i.e., successive approximations) Generalization Maintenance Behavior  Behavior  apply remove Positive Reinforcement Positive Punishment Negative Reinforcement Negative punishment

9. The Cognitive Behavioral Therapy Model BEHAVIOR COGNITION EMOTION

10. 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.”)

11. CBT: Qualities of CBT Interventions Manual that guides the therapist Usually upfront assessment Short-term treatment Less than 6 months in most cases Therapist is directive Sets agendas and plan for treatment, though client has input Clear goals Reduce temper tantrums

12. CBT: Qualities of CBT Interventions Present focused Skills taught and practiced in session Homework assigned (practice outside session) To child and parent or caregiver, if involved Try new skills at home, school

13. Common Strategies for Parenting Interventions Didactic instruction Modeling Role playing Behavioral rehearsal Homework

14. 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

15. Qualities Inconsistent with CBT and other EBPs Long-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 improvement Taking months to build a relationship, before starting treatment

16. Why are so many of the EBPs CBT Interventions? CBT works! Focuses on current behaviors, problems, and thoughts Designed to teach skills and provide opportunities to practice and receive feedback Inherently strengths-focused: Teaching youth and their caregivers the skills to help themselves Often, best fit for range of cultures and ethnicities

17. 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).

18. 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).

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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)

26. 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

27. 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

28. www.pcit.phhp.ufl.edu Parent-Child Interaction Therapy

29. 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

30. Time Out Chair Coach Dad Co-Therapist Timeout Room Window Two-way Mirror Child Mom

31. 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 sessions Describing Modeling Role-playing

32. The Incredible Years www.incredibleyears.com

33. 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 1 st 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

34. Triple P

35. 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)

36. Levels of Intervention Universal Triple P Level One Primary Care Triple P Level three Selected Triple P Level Two Standard Triple P Level four Enhanced Triple P Level five

37. Core Principles of Positive Parenting Source: Sanders, M.R., Markie-Dadds, C., & Turner, K.M.T. (1997). Positive Parenting. Brisbane: Families International Publishing Core principles 1 Safe engaging environment 2 Responsive learning environment 3 Assertive discipline 4 Reasonable expectations 5 Taking care of self

38. 17 Specific Parenting Skills Promoting 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

39. 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

40. 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