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.:169 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.
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).:169–170 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.:161 For example, if a child throws a temper tantrum 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.:170–174
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.[page needed] PMT is therefore conducted primarily with the parents rather than the child, although children can become involved as the therapist and parents see fit.:162 A typical course of treatment consists of 12 core weekly sessions,:215 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.:162
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.:166:216 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.:167
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).:216 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?").:167 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").:162:216 Incentive programs can be slowly phased out as the desired behaviors stabilize over time.:1350
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.:128 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.:168
In addition to positive reinforcement and limit setting in the home, many PMT treatments incorporate collaboration with the child's teacher 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.:216:151 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.:151
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), and Parent Management Training-Oregon Model (PMTO).[medical citation needed]
PMT is one of the most extensively studied treatments for childhood mental health concerns. 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.:95 In addition to effects on child behavior, meta-analyses revealed moderate improvement in parental adjustment (including marital satisfaction, depression, stress, irritability, and anxiety):178 as well as parental behavior.:95 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.:97 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.:95–96 Overall, group formats of PMT delivery were less effective than individual formats,:95 and the addition of individual therapy for the child did not improve outcomes.:95–96
There is a great deal of support for PMT in the research literature, but 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).:26 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.:224 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,:1353 and little is known about the processes or mechanisms through which PMT improves client outcomes.:223
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 there was a risk of bias in the studies due to poor methodology, and that existing evidence was not strong enough to form clear clinical guidelines with regard to PMT for ADHD. A 2009 review of long-term outcomes in children with Tourette syndrome (TS) said that, in those children with TS who also have other comorbid conditions, PMT is effective in dealing with explosive behaviors and anger management.
Professional training and practice
PMT training for therapists and other providers has been limited, thereby preventing it from being used widely in clinical practice.:223
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