Parent management training

Parent management training (PMT), sometimes referred to simply as parent training, is a family of treatment programs that teaches parents to handle their children's behavior problems (such as aggression, hyperactivity, temper tantrums, and difficulty following directions). PMT was initially developed in the 1960s by child psychologists who were responding to the lack of effective treatment for young children with acting-out behaviors. The model was inspired by principles of operant conditioning and applied behavioral analysis. Treatment, which typically lasts for several months, focuses on parents learning to provide positive reinforcement, such as praise and rewards, for children's appropriate behaviors while setting proper limits, such as removing attention, for inappropriate behaviors.

Various forms of PMT include such "brand-name" treatments as parent–child interaction therapy (PCIT), Incredible Years (IY), Positive Parenting Program (Triple P), and the Kazdin method. PMT is one of the most effective treatments available for disruptive behavior, particularly oppositional defiant disorder (ODD), conduct disorder (CD), and juvenile delinquency. Professional training in specific approaches is available to mental health agencies, graduate training programs, and individual mental health providers. A number of resources have also been developed to guide parents in learning more about PMT skills on their own.

History and theory

Parent management training was developed in the early 1960s in response to an urgent need in American child guidance clinics. Research across a national network of these clinics revealed that the treatments being used for young children with disruptive behaviors, who constituted the majority of children served in these settings, were largely ineffective. Several child psychologists, including Robert Wahler, Constance Hanf, Ivar Lovaas, Sidney Bijou, and Gerald Patterson, were inspired to develop new treatments based on behavioral principles of operant conditioning and applied behavioral analysis. Between 1965 and 1975, a behavioral model of parent training treatment was established, that emphasized teaching parents to positively reinforce prosocial child behavior (such as praising a child for following directions) while negatively incentivizing antisocial behavior (such as removing parental attention after the child throws a tantrum). Early studies of this approach showed that the treatment was effective in the short-term in improving parenting skills and reducing children's disruptive behaviors.

Much of the initial development and testing of PMT was centered at the Oregon Social Learning Center, led by Gerald Patterson; the group's specific approach has been branded the Parent Management Training-Oregon Model (PMTO). Patterson and colleagues theorized that adverse environmental contexts lead to disruptions in parent practices, which then contribute to negative child outcomes. Negative parenting practices and negative child behavior contribute to one another in a "coercive cycle", in which one person begins by using a negative behavior to control the other person's behavior. That person in turn responds with a negative behavior, and the negative exchange escalates until one person's negative behavior "wins" the battle. For example, if a child throws a temper tantrum in order to avoid doing a chore, the parent may respond by yelling that the child must do it, to which the child responds by tantruming even louder, at which point the parent may give in to the child to avoid further disruption. The child's tantrums are thereby reinforced; by throwing a tantrum, s/he has achieved the end goal of getting out of the chore. PMT seeks to break patterns that reinforce negative behavior by instead reinforcing positive behavior.

Following the initial development of PMT, a second wave of research from 1975 to 1985 focused on the longer-term effects and generalization of treatment to settings other than the clinic (such as home or school), larger family effects (such as improved parenting with siblings), and behavioral improvements outside of the targeted areas (such as improved ability to make friends). Since 1985, the literature on PMT has continued to expand, with various researchers exploring such topics as application of the treatment to serious clinical problems, dealing with client resistance to treatment, prevention programs, and implementation with diverse populations.

Description of treatment

PMT is usually delivered by trained therapists (e.g., psychologists, social workers) to individual families or groups of families. Typically, the therapist acts as a "coach" who teaches parents to replace negative, coercive parenting practices with more positive approaches. Parenting skills are taught first by the therapist explaining and modeling the skill, then by parents practicing the skill in session through role plays, and finally by assigning parents homework to practice the skill with their child at home. PMT is therefore conducted primarily with the parents rather than the child, although children can become involved as the therapist and parents see fit. A typical course of treatment consists of 12 core weekly sessions, each lasting approximately 45–60 minutes for individual families and 90 minutes for groups. However, length of treatment varies according to the particular treatment being used as well as the needs of the family, and additional sessions may be added to boost the desired parenting skills. For example, a typical course of PMT-Oregon Model for an individual family lasts 25–30 sessions, whereas the group format lasts 14 sessions.

The content of PMT treatments, as well as the sequencing of skills within the treatments, varies according to the particular approach being used. However, there are core skills that are shared among the various approaches. In most PMT treatments, parents are taught to define and record observations of their child's behavior, both positive and negative. This monitoring procedure provides useful information for the parents and therapist to set specific goals for treatment, as well as measure the child's progress over time. Parents also learn to give effective instructions to their children - that is, to give specific, concise instructions using eye contact while speaking in a calm manner.

Providing positive reinforcement for appropriate child behaviors is a major focus of PMT. Typically, parents learn to reward appropriate behavior through social rewards (such as praise, smiles, and hugs) as well as concrete rewards (such as stickers or points towards a larger reward as part of an incentive system created collaboratively with the child). During this stage, it is important that parents learn to provide genuinely positive rewards, rather than ones that send mixed messages (e.g., using mixed praise such as, "You cleaned your room so nicely! Why can't you always do that?"). In addition, parents learn to select simple behaviors as an initial focus and reward each of the small steps that their child achieves towards reaching a larger goal (this concept is called "successive approximations"). Incentive programs can be slowly phased out as the desired behaviors stabilize over time.

After mastering skills of positive reinforcement for good behavior, PMT treatments typically teach parents to appropriately set limits using structured techniques in response to their child's negative behavior. The different ways in which parents are taught to respond to positive versus negative behavior in children is sometimes referred to as differential reinforcement. For mildly annoying but not dangerous behavior, parents practice ignoring the behavior. Following unwanted behavior, parents are also introduced to the proper use of the time-out technique, in which parents remove attention (which serves as a form of reinforcement) from the child for a specified period of time. Parents also learn to remove their child's privileges, such as television or play time, in a systematic way in response to unwanted behavior. Across all of these strategies, the therapist emphasizes that consequences should be administered calmly, immediately, and consistently, and balanced with encouragement for positive behaviors.

In addition to positive reinforcement and limit setting in the home, many PMT treatments incorporate collaboration with the child's teacher in order to track behavior in school and link it to the reward program at home. This can be achieved through communication with the teacher as well as structured reports of specific behaviors. Another common element of many PMT treatments is preparing parents to manage problem behaviors in situations that are typically difficult for the child, such as being in a public place.

Specific treatments that can be broadly characterized as PMT include but are not limited to Parent-Child Interaction Therapy (PCIT), Incredible Years (IY), Positive Parenting Program (Triple P), Behavioral Parent Training, Defiant Children, Schools and Homes in Partnership (SHIP), and Parent Management Training-Oregon Model (PMTO).

Effects

PMT is one of the most extensively studied treatments for childhood mental health concerns. As of 2014, a review of scientific literature on PMT revealed that approximately 48 PMT treatments had reached the highest level of research support possible, and PMT treatments constituted the majority of best-supported evidence-based treatments for childhood disruptive behavior.

The following criteria were used to assess PMT treatments for the highest level of research support:

• At least two good between-group design experiments demonstrating efficacy in one or more of the following ways: (a) Superior to pill placebo, psychological placebo, or another treatment at post-treatment assessment, (b) Equivalent to an evidence-based treatment in experiments with adequate statistical power (average study group size of at least 30 participants).
• Experiments must be conducted with treatment manuals.
• Characteristics of the client samples must be clearly specified.
• Effects must have been demonstrated by at least two different investigators or teams of investigators.

Specifically, results of several meta-analyses have shown that behavior-based PMT programs have moderate to large effects on child disruptive behavior following treatment, as assessed by parent and teacher reports as well as third-party behavioral observations. PMT tended to have larger effects for younger children than older children, although the differences between age groups were not statistically significant. In addition to effects on child behavior, meta-analyses revealed moderate improvement in parental adjustment (including marital satisfaction, depression, stress, irritability, and anxiety) as well as parental behavior. In addition, data from four studies showed that improvements in child and parent behavior were maintained up to one year after PMT, although the effects were small. Families from economically disadvantaged backgrounds were less likely to benefit from PMT than their more advantaged counterparts; however, this difference was attenuated if the low-income families received individual rather than group treatment. Overall, group formats of PMT delivery were less effective than individual formats, and the addition of individual therapy for the child did not improve outcomes. Although the majority of research on PMT has focused on treatment of existing problems, a review of early childhood prevention programs suggests that PMT is also effective for preventing later antisocial behavior and delinquency.

Although there is a great deal of support for PMT in the research literature, several limitations of the research have been noted. Importantly, a common concern with implementing evidence-based treatments in community (as opposed to research) contexts is that the robust effects found in clinical trials may not generalize to complex community populations and settings. To address this concern, a meta-analysis of PMT studies coded across "real-world" criteria found no significant differences in the effectiveness of PMT when it was delivered to clinic versus study-referred populations, in routine service versus research settings, or by non-specialist versus specialist therapists (i.e., those with direct links to the program developers). Despite these findings, some have called for increased attention to the impact of cultural diversity on PMT outcomes - especially given that parenting practices are deeply rooted in culture. Other limitations of the existing research include that studies tend to focus on statistically significant rather than clinically significant change (i.e., whether the child's daily functioning actually improves), more data is needed on long-term sustainability of treatment effects, and little is known about the processes or mechanisms through which PMT improves client outcomes.

Although the bulk of the research on PMT examines its impact on disruptive behavior, researchers have also studied PMT as an intervention for other concerns. For instance, a review of several randomized controlled trials of PMT for attention-deficit hyperactivity disorder (ADHD) found some support for improving general child behavior and parental stress, but found limited effects on ADHD-specific behavior. The authors concluded that the existing evidence was not strong enough to form clear clinical guidelines with regard to PMT for ADHD.

Adaptations of PMT have also been studied for children with pervasive developmental or autism spectrum disorders. In a randomized controlled trial of PMT for problem behavior associated with Asperger's syndrome, both a one-day workshop and a six-session individual format of PMT resulted in fewer problem behaviors and greater social interactions in the short-term. Similarly promising results were found for a PMT-based approach for children with various forms of ASD, with improved child behavior and positive parenting.

Some PMT treatments have also been applied to children with comorbid intellectual disability (ID; formerly known as mental retardation), with some support for their effectiveness. For example, a randomized controlled trial of young children with comorbid oppositional defiant disorder and intellectual disability showed that parent-child interactions and child disruptive behaviors improved in the treatment group relative to the control group.

Professional training and practice

PMT training for therapists and other providers has been limited, thereby preventing it from being used widely in clinical practice.

Further reading

• Barkley, R.A. & Benton, C.M. (2013). Your Defiant Child (Second Edition): 8 Steps to Better Behavior. New York: Guilford Press.
• Barkley, R.A. & Benton, C.M. (2013). Your Defiant Teen (Second Edition): 10 Steps to Resolve Conflict and Rebuild Your Relationship. New York: Guilford Press.
• Furlong M, McGilloway S, Bywater T, Hutchings J, Smith SM, Donnelly M (2013). "Cochrane review: behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years (Review)". Evid Based Child Health. 8 (2): 318–692. doi:10.1002/ebch.1905. PMID 23877886. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
• Kazdin, A.E. (2009). The Kazdin Method for Parenting the Defiant Child. New York: First Mariner Books.
• Kazdin, A.E. (2014). The Everyday Parenting Toolkit: The Kazdin Method for Easy, Step-by-Step, Lasting Change for You and Your Child. New York: First Mariner Books.
• Maliken AC, Katz LF (2013). "Exploring the impact of parental psychopathology and emotion regulation on evidence-based parenting interventions: a transdiagnostic approach to improving treatment effectiveness". Clin Child Fam Psychol Rev. 16 (2): 173–86. doi:10.1007/s10567-013-0132-4. PMID 23595362. {{cite journal}}: Unknown parameter |month= ignored (help)
• Michelson D, Davenport C, Dretzke J, Barlow J, Day C (2013). "Do evidence-based interventions work when tested in the "real world?" A systematic review and meta-analysis of parent management training for the treatment of child disruptive behavior". Clin Child Fam Psychol Rev. 16 (1): 18–34. doi:10.1007/s10567-013-0128-0. PMID 23420407. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

External links

• Parent Management Training- Useful Links
• Yale Parenting Center