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'''Parent management training (PMT)''', sometimes referred to simply as '''parent training''', is a family of treatment programs that teaches parents to effectively handle their children's behavior problems (such as aggression, hyperactivity, [[temper tantrums]], and difficulty following directions). PMT can be used for youth of all ages with a variety of behavioral problems, including those with diagnoses of [[oppositional defiant disorder]] (ODD), [[conduct disorder]] (CD), [[attention-deficit hyperactivity disorder]] (ADHD), [[pervasive developmental disorders]] (PDD)/[[autism spectrum disorders|autism spectrum]] (ASD), and [[intellectual disability]] (ID). PMT was initially developed in the 1960's by child psychologists who were responding to the lack of effective treatment for young children with acting-out behaviors.<ref name="PMTO chapter" />{{rp|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.
'''Parent management training''' (PMT) is a programme that trains parents to manage their children's behavioural problems at home and at school. PMT works to correct maladaptive parent-child interactions especially as they apply to discipline. PMT utilizes social learning techniques based upon [[Behaviour analysis of child development|behaviour analysis]] and [[operant conditioning]] to alter both the parents' and the child’s behaviour to decrease the child’s oppositional or antisocial behavioural patterns. PMT has been used as an adjunct therapy in [[autism spectrum disorder]], [[conduct disorder]], [[Down syndrome]], [[attention-deficit hyperactivity disorder]], and [[oppositional defiant disorder]] (ODD).


Various forms of PMT include such "brand-name" treatments as [[Parent-Child Interaction Therapy (PCIT)]], Incredible Years (IY), [[Triple P (parenting program)|Positive Parenting Program]] (Triple P), and the [[Alan Kazdin|Kazdin]] method. Results of many controlled studies of PMT treatments have shown that PMT is one of the most effective treatments available for disruptive behavior, particularly [[oppositional defiant disorder]] (ODD), [[conduct disorder]] (CD), and [[juvenile delinquency]].<ref name="PW">PracticeWise, LLC (2014). Evidence-Based Youth Behavioral Health Services Literature Database. Retrieved from http://www.practicewise.com/pwebs_2/About.aspx</ref><ref name="Kazdin review">Kazdin, A.E. (1997). Parent management training: Evidence, outcomes, and issues. ''Journal of the American Academy of Child & Adolescent Psychiatry, 36''(10), 1349-1356. doi:http://dx.doi.org/10.1097/00004583-199710000-00016</ref><ref name="Serketich">Serketich, W. J., & Dumas, J. E. (1996). The effectiveness of behavioral parent training to modify antisocial behavior in children: A meta-analysis. ''Behavior Therapy, 27''(2), 171–186. doi:10.1016/S0005-7894(96)80013-X</ref><ref name="Lundahl">Lundahl, B., Risser, H., & Lovejoy, M. (2006). A meta-analysis of parent training: Moderators and follow-up effects. ''Clinical Psychology Review, 26''(1), 86–104. doi:10.1016/j.cpr.2005.07.004</ref> 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.
The Oregon Social Learning Group developed and conducted most of the early research on parent management training in the late 1960s.<ref>Patterson, G.R. (2002) Etiology and Treatment of Child and Adolescent Antisocial Behaviour. ''The Behaviour Analyst Today, 3 (2),'' 133 -143 [http://www.baojournal.com]</ref> Off shoots of the model were similarly developed by Conne Hamf and such models led to the development of a hybrid model known as [[Parent–child interaction therapy]].<ref>McNeil, C. B., Filcheck, H. A., Greco, L. A., Ware, L. M. & Bernard, R. S. (2001) Parent-Child Interaction Therapy: Can a Manualised Treatment Be Functional? The Behaviour Analyst Today, 2 (2), 106 -125</ref> PMT was elaborated on in the 1980s and applied to children up to the age of 14 with severe aggressive and antisocial behavior by [[Alan E. Kazdin]], Ph.D. The work began at the [[University of Pittsburgh School of Medicine]] and continued from 1989 at the [[Yale Parenting Center and Child Conduct Clinic]] at [[Yale University]], where it is currently ongoing.<ref>"Vita: Alan E. Kazdin, Ph.D." http://www.alankazdin.com/pdfs/updated_vita_kazdin.pdf. Accessed 29 January 2012.</ref> The model follows applied behavior analysis with emphasis on antecedents, behaviors, consequences and repeated practice.<ref>Kazdin, A.E. (2005). Parent management training: Treatment for oppositional, aggressive, and antisocial behavior in children and adolescents. New York: Oxford University Press.</ref>


==History and Theory==
Treatment sessions include instruction in social learning principles and techniques.<ref>Patterson, G.R. (2002) Etiology and Treatment of Child and Adolescent Antisocial Behaviour. ''The Behaviour Analyst Today, 3 (2),'' 133 -143 [http://www.baojournal.com]</ref> The therapist instruct the parents on how to define, observe, and record their children's behaviour such as fighting and having [[temper tantrums]] and then how to apply appropriate methods of positive reinforcement and punishment.
Parent management training was first developed in the early 1960's 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. As a result, 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]]. From 1965-1975, a behavioral model of parent training treatment was established. The model 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).<ref name="PMTO chapter">Forgatch, M. S., & Patterson, G. R. (2010). Parent management Training—Oregon model: An intervention for antisocial behavior in children and adolescents. ''Evidence-based psychotherapies for children and adolescents (2nd ed.),'' 159-178. New York: Guilford Press.</ref>{{rp|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. <ref name="encyclopedia">Forehand, R., Kotchick, B. A., Shaffer, A., & McKee, L. G. (2010). Parent management training. ''Corsini encyclopedia of psychology.'' Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/9780470479216.corpsy0639/full
</ref>


Much of the initial development and testing of PMT was centered at the Oregon Social Learning Center, led by Gerald Patterson, and 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. <ref name="PMTO chapter"/>{{rp|161}} 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.
Positive reinforcement, the key element of PMT, is given to the child via various techniques such as giving the child increased attention and praise and awarding points for positive behaviour. Punishment for negative behaviour is meted out via methods such as giving time outs, verbal reprimands and loss of privileges such as watching television or playing video games.


Following the initial development of PMT, a second wave of research from 1975-1985 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).<ref name="encyclopedia"/> 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.<ref name="PMTO chapter"/>{{rp|170-174}}
Contingencies are indirectly affected as well by training parents to communicate better about contingencies and problem solve troubled situations <ref>Robert G. Wahler (2004): Direct and Indirect Reinforcement Processes in Parent Training, - JEIBI 1 (2), Pg. 120 -128 [http://www.baojournal.com]</ref>


==Description of Treatment==
==Research==
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.<ref>McMahon, R.R. & Forehand, R.L. (2003). ''Helping the noncompliant child.'' New York: Guilford Press.</ref> PMT is therefore conducted primarily with the parents rather than the child, although children can become involved as the therapist and parents see fit.<ref name="PMTO chapter"/>{{rp|162}} A typical course of treatment consists of 12 core weekly sessions,<ref name="Kazdin chapter">Kazdin, A.E. (2010). Problem-solving skills training and parent management training for oppositional defiant disorder and conduct disorder. ''Evidence-based psychotherapies for children and adolescents (2nd ed.),'' 211-226. New York: Guilford Press.</ref>{{rp|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.<ref name="PMTO chapter"/>{{rp|162}}
Parent management training has been very successful in treating children with conduct problems.<ref>Cautilli, J.D., & Tillman, T.C. (2004): Evidence Based Practice in the Home and School to Help Educate the Socially Maladjusted Child . ''JEIBI 1 (1),'' Pg. 28 -48 [http://www.baojournal.com]</ref><ref>Patterson, G.R. (2002) Etiology and Treatment of Child and Adolescent Antisocial Behaviour. ''The Behaviour Analyst Today, 3 (2),'' 133 -143 [http://www.baojournal.com]</ref> The programs have been found to generalize.<ref>Cautilli, J.D., Tillman, T.C. (2004): Evidence Based Practice in the Home and School to Help Educate the Socially Maladjusted Child . ''JEIBI 1 (1),'' Pg. 28 -48 [http://www.baojournal.com]</ref> and to be maintained for several years post the program being discontinued.<ref>Cautilli, J.D. & Tillman, T.C. (2004): Evidence Based Practice in the Home and School to Help Educate the Socially Maladjusted Child . ''JEIBI 1 (1),'' Pg. 28 -48 [http://www.baojournal.com]</ref> Meta analytic studies of children with ADHD have found the effect size to be large (.87) for parent management training.<ref>Chronis, A. M., Jones, H. A., & Raggi, V. L. (2006). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Clinical Psychology Review, 26, 486-502.</ref> Parent management training in the treatment of conduct disorder can be enhanced by simultaneously training the child in problem solving skills with the combined treatment even showing continued and greater improvement one year after the treatment occurred.<ref>Kazdin, A.E., Siegal, T., & Bass, D.(1992). Cognitive problem solving skills training and parent management training in the treatment of antisocial behaviour in children. ''Journal of Consulting and Clinical Psychology, 60,'' 733-747.</ref> This success occurs even if children and parents are trained in a group format <ref>Listug-Lunde, L., Bredemeier, K. & Tynan, W.D. (2005). Concurrent Parent and Child Group Outcomes for Child Externalizing Disorders: Generalizability to Typical Clinical Settings. ''IJBCT, 1(2),'' Page 124-129 [http://www.baojournal.com BAO]</ref>
Currently, efforts are underway to make the programs more effective by making it more culturally sensitive<ref>Shaffer, A Kotchick, B. A. Dorsey, St & Forehand R. (2001) The Past, Present and Future of Behavioural Parent Training: Interventions for Child and Adolescent Problem Behaviour. The Behaviour Analyst Today, 2 (2), 91 -105 [http://www.baojournal.com BAO]</ref> and improving cost effectiveness <ref>Olchowski, A.E., Foster, E.M. and Webster-Stratton, C.H. (2007). Implementing Behavioural Intervention Components in a Cost-Effective Manner: Analysis of the Incredible Years Program. ''Journal of Early and Intensive Behavioural Intervention, 3(4)-4(1),'' 284-304 [http://www.baojournal.com BAO]</ref>


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. <ref name="PMTO chapter"/>{{rp|166}}<ref name="Kazdin chapter"/>{{rp|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.<ref name="PMTO chapter"/>{{rp|167}}
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==Professional training==
The World Association for Behaviour Analysis offers a certification in behaviour therapy, which has considerable emphasis on behavioural parent training [http://www.baojournal.com/WCBA/WCBA.html]


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).<ref name="Kazdin chapter"/>{{rp|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?").<ref name="PMTO chapter"/>{{rp|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").<ref name="PMTO chapter"/>{{rp|162}}<ref name="Kazdin chapter"/>{{rp|216}} Incentive programs can be slowly phased out as the desired behaviors stabilize over time.<ref name="Kazdin review"/>{{rp|1350}}
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==References==
{{Reflist|2}}


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 (parenting)|time-out]] technique, in which parents remove attention (which serves as a form of reinforcement) from the child for a specified period of time.<ref name="Barkley">Barkley, R. A. (2013). ''Defiant children: A clinician's manual for assessment and parent training.'' New York: Guilford Press.</ref>{{rp|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. <ref name="PMTO chapter"/>{{rp|168}}
==External links==

* [http://www.yale.edu/childconductclinic The Yale Parenting Center and Child Conduct Clinic]
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.<ref name="Kazdin chapter"/>{{rp|216}}<ref name="Barkley" />{{rp|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.<ref name="Barkley" />{{rp|151}}
* [http://www.oup.com/us/companion.websites/0195154290/?view=usa Oxford University Press page for the book ''Parent Management Training'' by Alan E. Kazdin]

Specific treatments that can be broadly characterized as PMT include but are not limited to [[Parent-Child Interaction Therapy (PCIT)]], Incredible Years (IY), [[Triple P (parenting program)|Positive Parenting Program]] (Triple P), Behavioral Parent Training,<ref>van den Hoofdakker, B. J., van der Veen-Mulders, L., Sytema, S., Emmelkamp, P. M. G., Minderaa, R. B., et al. (2007). Effectiveness of behavioral parent training for children with ADHD in routine clinical practice: A randomized controlled study. ''Journal of the American Academy of Child and Adolescent Psychiatry, 46,'' 1263-1271.</ref> Defiant Children,<ref name="Barkley"/> Schools and Homes in Partnership (SHIP),<ref>Barrera, M., Biglan, A., Taylor, T. K., Gunn, B. K., Smolkowski, K., et al. (2002). Early elementary school intervention to reduce conduct problems: A randomized trial with Hispanic and non-Hispanic children. ''Prevention Science, 3''(2), 83-94. doi:10.1023/A:1015443932331</ref> and Parent Management Training-Oregon Model (PMTO).<ref name="PMTO chapter"/>

==Effects of Treatment==
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.<ref name="PW"/> 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.<ref name="PW"/>

Specifically, results of several meta-analyses have shown that behavior-based PMT programs have moderate<ref name="Lundahl"/> to large<ref name="Serketich"/> 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.<ref name="Lundahl"/>{{rp|95}} In addition to effects on child behavior, meta-analyses revealed moderate improvement in parental adjustment (including marital satisfaction, depression, stress, irritability, and anxiety)<ref name="Serketich"/>{{rp|178}} as well as parental behavior.<ref name="Lundahl"/>{{rp|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.<ref name="Lundahl"/>{{rp|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.<ref name="Lundahl"/>{{rp|95-96}} Overall, group formats of PMT delivery were less effective than individual formats,<ref name="Lundahl"/>{{rp|95}} and the addition of individual therapy for the child did not improve outcomes.<ref name="Lundahl"/>{{rp|95-96}} 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.<ref>Piquero, A. R., Farrington, D. P., Welsh, B. C., Tremblay, R., & Jennings, W. (2008). Effects of early family/parent training programs on antisocial behavior and delinquency: A systematic review. ''The Campbell Collaboration Library of Systematic Reviews, 4''(2). Retrieved from http://www.campbellcollaboration.org/lib/download/212/</ref>

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.<ref>Barrington, J., Prior, M., Richardson, M., & Allen, K. (2005). Effectiveness of CBT versus standard treatment for childhood anxiety disorders in a community clinic setting. ''Behaviour Change, 22'', 29–43. doi: http://dx.doi.org/10.1375/bech.22.1.29.66786</ref> 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).<ref name="Real world">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. ''Clinical Child and Family Psychology Review, 16''(1), 18–34. doi:10.1007/s10567-013-0128-0</ref>{{rp|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.<ref>Forehand, R. & Kotchick, B.A. (1996). Cultural diversity: A wake-up call for parent training. ''Behavior Therapy, 27'' 187-206. doi:http://dx.doi.org/10.1016/S0005-7894(96)80014-1</ref> <ref name="Kazdin chapter"/>{{rp|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,<ref name="Kazdin review"/>{{rp|1353}} and little is known about the processes or mechanisms through which PMT improves client outcomes.<ref name="Kazdin chapter"/>{{rp|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.<ref name="ADHD">Zwi, M., Jones, H., Thorgaard, C., York, A., & Dennis, J.A. (2012). Parent training interventions for attention deficit hyperactivity disorder. ''The Campbell Collaboration Library of Systematic Reviews, 8''(2). doi:10.4073/csr.2012.2 Retrieved from http://campbellcollaboration.org/lib/project/143/</ref> 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 disorder|pervasive developmental]] or [[autism spectrum disorders|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.<ref>Sofronoff, K., Leslie, A., & Brown, W. (2004). Parent manangement training and Asperger syndrome: A randomized controlled trial to evaluate a parent based intervention. (Parent Management Individual Sessions). ''Autism: The International Journal of Research and Practice, 8,''(3) 301-317. doi:10.1177/1362361304045215</ref> Similarly promising results were found for a PMT-based approach for children with various forms of ASD, with improved child behavior and positive parenting.<ref>Whittingham, K., Sofronoff, K., Sheffield, J., & Sanders, M. R. (2009). Stepping Stones Triple P: an RCT of a parenting program with parents of a child diagnosed with an autism spectrum disorder. ''Journal of Abnormal Child Psychology, 37''(4), 469-480. doi:10.1007/s10802-008-9285-x</ref>

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.<ref>Brightman,R.P, Baker, B.L, Clark, D.B., & Ambrose, S.A. (1982). Effectiveness of alternative parent training formats. ''Journal of Behavior Therapy and Experimental Psychiatry, 13,'' 113-117. doi:10.1016/0005-7916(82)90051-9</ref><ref>Roberts, C., Mazzucchelli, T., Studman, L., & Sanders, M. (2006). Behavioral family intervention for children with developmental disabilities and behavioral problems. ''Journal of Clinical Child and Adolescent Psychology, 35,'' 180-193. doi:10.1207/s15374424jccp3502_2</ref> 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.<ref>Bagner, D. M., & Eyberg, S. M. (2007). Parent–child interaction therapy for disruptive behavior in children with mental retardation: A randomized controlled trial. ''Journal of Clinical Child and Adolescent Psychology, 36''(3), 418–429. doi:10.1080/15374410701448448</ref>

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==Professional Training and Practice==
Despite its prominence in the world of research, PMT training for therapists and other providers has been limited, thereby preventing it from being used widely in clinical practice.<ref name="Kazdin chapter"/>{{rp|223}} Training in the form of treatment manuals, workshops, and online content is available for specific PMT approaches such as [[Parent-Child Interaction Therapy]]<ref>http://pcit.ucdavis.edu/training/,</ref> Incredible Years,<ref>http://incredibleyears.com/workshop-info/training-workshop-schedule/</ref> [[Triple P]],<ref>http://www.triplep.net/glo-en/getting-started-with-triple-p/</ref> the [[Alan Kazdin|Kazdin]] Method,<ref>http://yaleparentingcenter.yale.edu/professional-workshops)</ref> and Parent Management Training-Oregon Model.<ref>http://www.isii.net/2011SITEFILES/certification.html</ref> These forms of training are typically purchased by mental health agencies or training programs (e.g., clinical psychology graduate programs) rather than individual providers, and ideally agency-wide implementation support (such as supervision) is available. Providers may become certified in most of these evidence-based PMT practices.

==Resources for Parents==
Parents wishing to learn more about PMT approaches on their own can access several resources aimed at parents. These resources include books written by the developers of various PMT treatments,<ref>Kazdin, A.E. (2009). ''The Kazdin Method for Parenting the Defiant Child.'' New York: First Mariner Books.</ref><ref>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.</ref><ref>Barkley, R.A. & Benton, C.M. (2013). ''Your Defiant Child (Second Edition): 8 Steps to Better Behavior.'' New York: Guilford Press.</ref><ref>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.</ref> websites dedicated to parents,<ref>http://www.triplep-parenting.net/glo-en/home/</ref><ref>http://global.oup.com/us/companion.websites/0195154290/links/</ref><ref>http://yaleparentingcenter.yale.edu/parents</ref> and online workshops.<ref>http://yaleparentingcenter.yale.edu/parents/parent-workshops-0</ref>

For parents seeking PMT treatment, online provider directories are available for some specific approaches such as [[Parent-Child Interaction Therapy]],<ref>http://pcit.ucdavis.edu/find-a-provider/united-states/</ref>, Incredible Years,<ref>http://incredibleyears.com/parents-teachers/looking-for-incredible-years-groups/</ref> [[Triple P]],<ref>http://www.triplep-parenting.net/glo-en/get-help/find-a-triple-p-provider/</ref> and the [[Alan Kazdin|Kazdin]] method.<ref>http://yaleparentingcenter.yale.edu/certification-kazdin-parent-management-training-kpmt</ref> For general advice on finding the right therapist for a child, the [[American Psychological Association|American Psychological Association's]] Society of Clinical Child and Adolescent Psychology (Division 53) and the [[Association for Behavioral and Cognitive Therapies]] offer guidelines on their website, Effective Child Therapy.<ref>http://effectivechildtherapy.com/content/how-choose-child-therapist</ref>

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==References==


[[Category:Attention disorders]]
[[Category:Psychotherapy]]
[[Category:Childhood psychiatric disorders]]
[[Category:Childhood psychiatric disorders]]
[[Category:Educational psychology]]
[[Category:Special education]]
[[Category:Attention deficit hyperactivity disorder]]
[[Category:Attention deficit hyperactivity disorder]]
[[Category:Organizations for children with health issues]]
[[Category:Parenting skills organizations]]
[[Category:Parenting skills organizations]]
[[Category:Evidence-based medicine]]

Revision as of 07:09, 12 November 2014

Parent management training (PMT), sometimes referred to simply as parent training, is a family of treatment programs that teaches parents to effectively handle their children's behavior problems (such as aggression, hyperactivity, temper tantrums, and difficulty following directions). PMT can be used for youth of all ages with a variety of behavioral problems, including those with diagnoses of oppositional defiant disorder (ODD), conduct disorder (CD), attention-deficit hyperactivity disorder (ADHD), pervasive developmental disorders (PDD)/autism spectrum (ASD), and intellectual disability (ID). PMT was initially developed in the 1960's by child psychologists who were responding to the lack of effective treatment for young children with acting-out behaviors.[1]: 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.

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. Results of many controlled studies of PMT treatments have shown that PMT is one of the most effective treatments available for disruptive behavior, particularly oppositional defiant disorder (ODD), conduct disorder (CD), and juvenile delinquency.[2][3][4][5] 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 first developed in the early 1960's 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. As a result, 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. From 1965-1975, a behavioral model of parent training treatment was established. The model 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).[1]: 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. [6]

Much of the initial development and testing of PMT was centered at the Oregon Social Learning Center, led by Gerald Patterson, and 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. [1]: 161  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 1975-1985 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).[6] 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.[1]: 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.[7] PMT is therefore conducted primarily with the parents rather than the child, although children can become involved as the therapist and parents see fit.[1]: 162  A typical course of treatment consists of 12 core weekly sessions,[8]: 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.[1]: 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. [1]: 166 [8]: 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.[1]: 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).[8]: 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?").[1]: 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").[1]: 162 [8]: 216  Incentive programs can be slowly phased out as the desired behaviors stabilize over time.[3]: 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.[9]: 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. [1]: 168 

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.[8]: 216 [9]: 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.[9]: 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), Behavioral Parent Training,[10] Defiant Children,[9] Schools and Homes in Partnership (SHIP),[11] and Parent Management Training-Oregon Model (PMTO).[1]

Effects of Treatment

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.[2] 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.[2]

Specifically, results of several meta-analyses have shown that behavior-based PMT programs have moderate[5] to large[4] 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.[5]: 95  In addition to effects on child behavior, meta-analyses revealed moderate improvement in parental adjustment (including marital satisfaction, depression, stress, irritability, and anxiety)[4]: 178  as well as parental behavior.[5]: 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.[5]: 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.[5]: 95–96  Overall, group formats of PMT delivery were less effective than individual formats,[5]: 95  and the addition of individual therapy for the child did not improve outcomes.[5]: 95–96  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.[12]

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.[13] 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).[14]: 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.[15] [8]: 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,[3]: 1353  and little is known about the processes or mechanisms through which PMT improves client outcomes.[8]: 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.[16] 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.[17] Similarly promising results were found for a PMT-based approach for children with various forms of ASD, with improved child behavior and positive parenting.[18]

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.[19][20] 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.[21]

Professional Training and Practice

Despite its prominence in the world of research, PMT training for therapists and other providers has been limited, thereby preventing it from being used widely in clinical practice.[8]: 223  Training in the form of treatment manuals, workshops, and online content is available for specific PMT approaches such as Parent-Child Interaction Therapy[22] Incredible Years,[23] Triple P,[24] the Kazdin Method,[25] and Parent Management Training-Oregon Model.[26] These forms of training are typically purchased by mental health agencies or training programs (e.g., clinical psychology graduate programs) rather than individual providers, and ideally agency-wide implementation support (such as supervision) is available. Providers may become certified in most of these evidence-based PMT practices.

Resources for Parents

Parents wishing to learn more about PMT approaches on their own can access several resources aimed at parents. These resources include books written by the developers of various PMT treatments,[27][28][29][30] websites dedicated to parents,[31][32][33] and online workshops.[34]

For parents seeking PMT treatment, online provider directories are available for some specific approaches such as Parent-Child Interaction Therapy,[35], Incredible Years,[36] Triple P,[37] and the Kazdin method.[38] For general advice on finding the right therapist for a child, the American Psychological Association's Society of Clinical Child and Adolescent Psychology (Division 53) and the Association for Behavioral and Cognitive Therapies offer guidelines on their website, Effective Child Therapy.[39]

References

  1. ^ a b c d e f g h i j k l Forgatch, M. S., & Patterson, G. R. (2010). Parent management Training—Oregon model: An intervention for antisocial behavior in children and adolescents. Evidence-based psychotherapies for children and adolescents (2nd ed.), 159-178. New York: Guilford Press.
  2. ^ a b c PracticeWise, LLC (2014). Evidence-Based Youth Behavioral Health Services Literature Database. Retrieved from http://www.practicewise.com/pwebs_2/About.aspx
  3. ^ a b c Kazdin, A.E. (1997). Parent management training: Evidence, outcomes, and issues. Journal of the American Academy of Child & Adolescent Psychiatry, 36(10), 1349-1356. doi:http://dx.doi.org/10.1097/00004583-199710000-00016
  4. ^ a b c Serketich, W. J., & Dumas, J. E. (1996). The effectiveness of behavioral parent training to modify antisocial behavior in children: A meta-analysis. Behavior Therapy, 27(2), 171–186. doi:10.1016/S0005-7894(96)80013-X
  5. ^ a b c d e f g h Lundahl, B., Risser, H., & Lovejoy, M. (2006). A meta-analysis of parent training: Moderators and follow-up effects. Clinical Psychology Review, 26(1), 86–104. doi:10.1016/j.cpr.2005.07.004
  6. ^ a b Forehand, R., Kotchick, B. A., Shaffer, A., & McKee, L. G. (2010). Parent management training. Corsini encyclopedia of psychology. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/9780470479216.corpsy0639/full
  7. ^ McMahon, R.R. & Forehand, R.L. (2003). Helping the noncompliant child. New York: Guilford Press.
  8. ^ a b c d e f g h Kazdin, A.E. (2010). Problem-solving skills training and parent management training for oppositional defiant disorder and conduct disorder. Evidence-based psychotherapies for children and adolescents (2nd ed.), 211-226. New York: Guilford Press.
  9. ^ a b c d Barkley, R. A. (2013). Defiant children: A clinician's manual for assessment and parent training. New York: Guilford Press.
  10. ^ van den Hoofdakker, B. J., van der Veen-Mulders, L., Sytema, S., Emmelkamp, P. M. G., Minderaa, R. B., et al. (2007). Effectiveness of behavioral parent training for children with ADHD in routine clinical practice: A randomized controlled study. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 1263-1271.
  11. ^ Barrera, M., Biglan, A., Taylor, T. K., Gunn, B. K., Smolkowski, K., et al. (2002). Early elementary school intervention to reduce conduct problems: A randomized trial with Hispanic and non-Hispanic children. Prevention Science, 3(2), 83-94. doi:10.1023/A:1015443932331
  12. ^ Piquero, A. R., Farrington, D. P., Welsh, B. C., Tremblay, R., & Jennings, W. (2008). Effects of early family/parent training programs on antisocial behavior and delinquency: A systematic review. The Campbell Collaboration Library of Systematic Reviews, 4(2). Retrieved from http://www.campbellcollaboration.org/lib/download/212/
  13. ^ Barrington, J., Prior, M., Richardson, M., & Allen, K. (2005). Effectiveness of CBT versus standard treatment for childhood anxiety disorders in a community clinic setting. Behaviour Change, 22, 29–43. doi: http://dx.doi.org/10.1375/bech.22.1.29.66786
  14. ^ 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. Clinical Child and Family Psychology Review, 16(1), 18–34. doi:10.1007/s10567-013-0128-0
  15. ^ Forehand, R. & Kotchick, B.A. (1996). Cultural diversity: A wake-up call for parent training. Behavior Therapy, 27 187-206. doi:http://dx.doi.org/10.1016/S0005-7894(96)80014-1
  16. ^ Zwi, M., Jones, H., Thorgaard, C., York, A., & Dennis, J.A. (2012). Parent training interventions for attention deficit hyperactivity disorder. The Campbell Collaboration Library of Systematic Reviews, 8(2). doi:10.4073/csr.2012.2 Retrieved from http://campbellcollaboration.org/lib/project/143/
  17. ^ Sofronoff, K., Leslie, A., & Brown, W. (2004). Parent manangement training and Asperger syndrome: A randomized controlled trial to evaluate a parent based intervention. (Parent Management Individual Sessions). Autism: The International Journal of Research and Practice, 8,(3) 301-317. doi:10.1177/1362361304045215
  18. ^ Whittingham, K., Sofronoff, K., Sheffield, J., & Sanders, M. R. (2009). Stepping Stones Triple P: an RCT of a parenting program with parents of a child diagnosed with an autism spectrum disorder. Journal of Abnormal Child Psychology, 37(4), 469-480. doi:10.1007/s10802-008-9285-x
  19. ^ Brightman,R.P, Baker, B.L, Clark, D.B., & Ambrose, S.A. (1982). Effectiveness of alternative parent training formats. Journal of Behavior Therapy and Experimental Psychiatry, 13, 113-117. doi:10.1016/0005-7916(82)90051-9
  20. ^ Roberts, C., Mazzucchelli, T., Studman, L., & Sanders, M. (2006). Behavioral family intervention for children with developmental disabilities and behavioral problems. Journal of Clinical Child and Adolescent Psychology, 35, 180-193. doi:10.1207/s15374424jccp3502_2
  21. ^ Bagner, D. M., & Eyberg, S. M. (2007). Parent–child interaction therapy for disruptive behavior in children with mental retardation: A randomized controlled trial. Journal of Clinical Child and Adolescent Psychology, 36(3), 418–429. doi:10.1080/15374410701448448
  22. ^ http://pcit.ucdavis.edu/training/,
  23. ^ http://incredibleyears.com/workshop-info/training-workshop-schedule/
  24. ^ http://www.triplep.net/glo-en/getting-started-with-triple-p/
  25. ^ http://yaleparentingcenter.yale.edu/professional-workshops)
  26. ^ http://www.isii.net/2011SITEFILES/certification.html
  27. ^ Kazdin, A.E. (2009). The Kazdin Method for Parenting the Defiant Child. New York: First Mariner Books.
  28. ^ 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.
  29. ^ Barkley, R.A. & Benton, C.M. (2013). Your Defiant Child (Second Edition): 8 Steps to Better Behavior. New York: Guilford Press.
  30. ^ 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.
  31. ^ http://www.triplep-parenting.net/glo-en/home/
  32. ^ http://global.oup.com/us/companion.websites/0195154290/links/
  33. ^ http://yaleparentingcenter.yale.edu/parents
  34. ^ http://yaleparentingcenter.yale.edu/parents/parent-workshops-0
  35. ^ http://pcit.ucdavis.edu/find-a-provider/united-states/
  36. ^ http://incredibleyears.com/parents-teachers/looking-for-incredible-years-groups/
  37. ^ http://www.triplep-parenting.net/glo-en/get-help/find-a-triple-p-provider/
  38. ^ http://yaleparentingcenter.yale.edu/certification-kazdin-parent-management-training-kpmt
  39. ^ http://effectivechildtherapy.com/content/how-choose-child-therapist
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