Meme Hieneman, Kristin Knapp-Ines, & V. Mark Durand
For further information, contact Meme Hieneman at ENO@spadmin.usf.edu Behavioral parent training (BPT), and more specifically BPT in positive behavior support (PBS), has proven effective in reducing childrens problem behavior and improving family life when implemented completely by willing participants (Dunlap, Newton, Fox, Benito, & Vaughn, 2001; Frea & Hepburn, 1999; James & Scotti, 2000; Maughan, Christiansen & Jensen, 2005; Serketich & Dumas, 1996). Unfortunately, parents do not always complete the training and/or follow through with implementation. Estimates indicate that between 40 and 60 percent of parents drop out of parent education programs (Kazdin, 1996).
A number of factors have been suggested as affecting the success or failure of community-based interventions such as BPT, including the characteristics and needs of the children and families, availability of resources, time, and social support, and the relevance and practicality of the interventions (Hieneman & Dunlap, 2000, 2001). Whereas these factors may explain some attrition, another important explanation may have been overlooked and neglected. Durand (2001) completed a longitudinal investigation of variables associated with the escalation of problem behavior in young children and found that the most important predictor of future problems was parental pessimism. In other words, when parents feel unable to make meaningful change in their childs challenging behavior, these behaviors become progressively more severe over time.
In order to better understand and address this phenomenon, we have initiated a program of research combining parent education in positive behavior support with optimism training (Seligman, 1998), a cognitive-behavioral approach to overcoming negative self-talk. This combined approach is referred to as positive family intervention (Durand, 2007; Durand & Hieneman, 2008 a&b; Durand, Hieneman, Clarke, & Zona, in press). The purpose of this article is to provide an overview of this program, illustrating its process and components through a case example.
Positive Family Intervention
The PFI research program is designed to compare outcomes (e.g., changes in child behavior, attrition) for parents participating in PBS-only sessions with those who also receive optimism training. Regardless of the condition, all parents attend eight weekly sessions individually with a trained therapist. The sessions are 90 minutes in length and follow a consistent protocol that includes key concepts, case examples, practice and feedback, and homework to apply the information to their own child. The PBS curriculum covers the following content:
1.Introduction and goal setting (e.g., identifying target behaviors)
2.Gathering information through watching, talking, and recording
Analysis of patterns and preliminary intervention selection
Preventing behavior problems by manipulating the environment
Managing consequences to reinforce positive, not problem behavior
Replacing problem behavior with more appropriate alternatives
Implementing the interventions (e.g., developing a written behavior plan)
Monitoring outcomes and adjusting the interventions over time
In the PBS-plus condition, optimism training is integrated within the sessions. Parents are asked to share successful and challenging situations they face throughout the week between the sessions and to identify what they are thinking during those situations. They are then prompted to consider the consequences of those thoughts in terms of both their own behavior and the impact of those reactions on their children. If their beliefs are unproductive (e.g., they result in the parent giving up or giving in), the therapist guides parents to dispute their thoughts in terms of their accuracy and usefulness and to substitute more productive self-talk.
Peter and Linda learned about the Positive Family Intervention (PFI) project through a local non-profit agency serving children with autism while attending a training seminar. They enrolled in the program as soon as their son, Julian, turned three. Linda was a stay-at-home parent and Peter worked for a communications company, traveling extensively at times. Both parents were highly-educated and sought out information and services to support Julian. They had no family in the area and therefore rarely had breaks from their childcare responsibilities; however, they were able to arrange respite for the sessions and attended together on all but two occasions when Peters travel interfered with his attendance.
Peter and Lindas son, Julian, had been diagnosed with autism just prior to his second birthday. He communicated using some words such as eat, drink, and cuddle; however, more commonly he used his problem behavior in order to get his needs met. Julian was not dressing, brushing his teeth, feeding himself, or using the toilet independently. In addition to his developmental and behavioral challenges, Julian also had a digestive disorder that interferes with the absorption of nutrients and results in malnourishment, diarrhea, fatigue, constipation, and muscle cramps. A complete revision of Julians nutritional plan under the supervision of a dietician was underway.
Julian attended a pre-school five times per week for 4 hours a day. He received speech and occupational therapy daily during regular school hours, and speech and physical therapy at home several times per week. Julian had a very strong bond with his parents and often expressed dissatisfaction when either one of them attempted to leave a home therapy session.
Julians problem behaviors included tantrums that involved hitting and running into objects and people; throwing food, clothes, and toys; and crying and screaming. The tantrums lasted up to an hour with brief periods of quiet interspersed. In addition to tantrums, Julian also would scratch his mothers stomach, causing discomfort and sometimes abrasions, while sitting on her lap or being held. A final behavior of concern to Julians parents was sticking his finger in his eye while sitting in his car seat and riding in the car. In general, Julians problem behaviors were interfering with his education and progress in therapy, creating stress for his parents, and making it difficult for babysitters and extended family to care for him.
At the beginning of their work with our project, Peter and Linda felt that Julians problem behaviors occurred primarily because he had autism. Because of that perspective, Peter and Linda accepted Julians inappropriate behaviors as unchangeable and, therefore, their efforts consisted primarily of trying to distract and sooth Julian by holding him, talking to him, or offering him a variety of toys or food items. Lindas response to belly scratching varied based on Lindas stress level during that particular moment. When she was relaxed or distracted (e.g., having a conversation), she allowed it to occur until it became painful, however, if she was stressed, she told Julian immediately to stop in an annoyed manner. Even though Peter and Linda realized that their responses to Julians problem behavior were not effective and could have even been serving to maintain his problem behavior, they were unsure of how to address his behavior effectively and consistently.
Positive Family Intervention with Julians parents was facilitated by a therapist with a Ph.D. in clinical psychology and board certification in applied behavior analysis. The sessions were organized around the basic principles of positive behavior support (as described previously). The overall goal of the program was to help Julians parents develop individualized strategies through functional behavioral assessments and integrating those strategies into a comprehensive written behavior plan that could be used at home, school, and in the community. Throughout the sessions, the therapist guided Peter and Linda to identify positive and negative thought patterns or self-talk triggered by every day situations associated with Julians behavior. At the beginning of each session, she asked the parents to share a successful and a challenging situation that occurred over the past week and to describe exactly what they were feeling and thinking. She also prompted them to consider their beliefs as they discussed events and strategies throughout the sessions. Once they were able to articulate their self-talk, the therapist gradually guided the parents through optimism training steps distraction, disputation, and substitution. As homework, the therapist asked Peter and Linda to keep a weekly diary referred to as a self-talk journal.
Session 1. The therapist helped Peter and Linda identify members of Julians support team. All professionals involved in Julians daily therapy and teaching regimen participated, as well as his grandparents who came for overnight visits on a regular basis. Between each meeting, Peter and Linda were asked to communicate with the team about what they learned in the sessions and to obtain input. They identified long-term goals for Julian that included using utensils to feed himself while sitting at the table, toileting independently, communicating his needs in a more productive manner, and calming himself rather than having tantrums all of which would allow him to be more self-sufficient. The therapist helped Peter and Linda define Julians tantrums (i.e. running into walls or mother; throwing food, clothes, or toys; crying; screaming; and hitting furniture, himself, or his mother), belly scratching, and eye poking objectively, and asked them to collect simple frequency data.
In addition to introducing PBS and getting the family started with goal setting, team building, and data collection; the therapist helped Peter and Linda identify their self-talk associated with Julians behavior during particular situations. Important themes were that Peter and Linda thought that Julian was unable to learn due to his disability. Linda often became overwhelmed to the point that she thought the situation was hopeless. She felt that she had to do it all with very little help from others, including Peter. Peter was frustrated at his inability to effectively manage Julians behavior and believed that he was not capable of making a difference.
Session 2. Peter and Linda learned how to gather information through semi-structured interviews and observations to identify events (i.e., antecedents, consequences) surrounding Julians behavior. They also completed the Motivation Assessment Scale, a rating scale designed to aid identification of behavioral functions (Durand & Crimmins, 1992). As homework, they interviewed his preschool teacher, therapists, and other care providers. They conducted observations when Julians problem behavior was most likely, such as during meals, transitions, and while at the play ground. As their information gathering progressed, Julians behavior of sticking his finger into his eyes rapidly diminished and therefore was no longer recorded. Instead, his parents focused on tantrums and belly scratching.
The therapist helped Linda and Peter recognize the consequences of their thinking on their responses to Julian (and one another) and the short-term and long-term outcomes of those reactions. Due to their belief that Julian was unable to learn readily, Linda and Peter tended to be extremely accommodating - finding ways to sooth Julian, giving in to his requests (e.g., allowing Julian to stay up after bedtime), or exiting difficult situations (e.g., leaving a store without getting needed items). When particularly frustrated, Linda would overreact by yelling at Julian or Peter and blaming them. Peters feeling that he was incompetent led him to take a passive parenting role, withdrawing from child care responsibilities and reducing his expectations of Julian. Understandably, these thought patterns and consequences were creating incredible stress on the marriage.
Session 3. The therapist guided Peter and Linda to use the data from interviews and observations to develop summary statements or hypotheses to articulate consistent behavior patterns. It became apparent that Julians problem behaviors served a variety of functions based on different circumstances in which they occurred. For example, when Julian was tired and relaxed, unoccupied for extended periods, or engaged in mealtimes, he was more likely to scratch his mothers stomach in order to get her attention and experience the sensory input of the behavior. Regarding the tantrums, the data revealed that Julian was more likely to tantrum between his return home from school and bedtime than any other time of the day. His parents learned that Julian used tantrums to communicate that he either did not want to cooperate with a request (e.g., brush teeth, leave park), to gain access to an item or activity (e.g., TV, food) and/or to get intensive 1:1 interaction from an adult.
During this session, Julians parents were then taught to distract themselves when faced with unproductive thinking and to dispute their thoughts by considering whether their beliefs were accurate and helpful. Peter and Linda came to realize that, although Julian had a disability, he was still capable of responding to them and his environment. They saw that Julian learned more quickly when they were consistent and held their ground and that feeling sorry for him was a major impediment to their progress. Linda became aware that her perspective that she had to do everything was not entirely true. She had assistance available to her, but rarely asked for it. She often assumed that Peter was unconcerned when instead he was either unaware of her need for help, busy with work requirements, or feeling incompetent to assist her effectively. Peter came to realize that, even if he wasnt entirely sure how to manage Julians behavior, he had been able to teach Julian some play skills and could apply those strategies and what he was learning in the sessions to effect change in Julians behavior. Both parents recognized that their thinking was impeding creative problem-solving with Julian.
Sessions 4-6. Based on the patterns identified during the functional assessments, the therapist guided Peter and Linda to identify and design intervention strategies to prevent challenging behavior, manage consequences of Julians tantrums and belly scratching, and teach alternative appropriate behavior to replace problem behavior during sessions 4, 5, and 6 respectively. The strategies developed are summarized below:
Linda purchased and made available toys that allowed Julian to meet his sensory need of moving his fingers across surfaces. These were given to Julian to occupy him while his mother was talking with other people in person or on the phone (which tended to precipitate belly scratching). Linda also began wearing tighter fitting clothes or tucking her shirt into her pants to prevent Julian from putting his hand under her shirt.
Linda guided Julian to stroke her shoulders or back rather than touch her stomach, or she directed him to play with his sensory toys when he reached for her. If Julian did place his hand under her shirt, Linda clearly stated no, Julian, removed his hand, and redirected him.
Linda and Julians other support providers planned out transitions and prepared Julian so that events would proceed more quickly and smoothly. For example, Linda would facilitate his exit from pre-school by gathering Julians belongings and talking to the teacher prior to telling Julian it was time to leave. Once Linda was ready, she briefly reviewed her expectations (e.g., to walk to the car while holding her hand). Peter and Linda started setting up Julians next activity while he was still engaged in a previous activity, having snacks ready after playing on the playground, and informing him how much time was left when an activity was coming to an end.
Linda purchased shelves and bins to organize the toys in the living room, putting the toys into bins sorted by category (e.g., vehicles, stuffed animals). She placed lids on the bins so that Julian had to communicate when he wanted access to the toys thereby increasing his functional language. An added benefit of using the bins (or placing toys out of the way) was to prevent Julian from throwing them during tantrums.
Peter and Linda taught Julian to say no in order for him to delay transitions (and extend desired activities for a couple minutes) and to say cuddle in order to request attention from his parents. They responded appropriately and quickly to Julians efforts to communicate and rewarded successful transitions with toys, snacks and/or special toys (e.g., kept in the glove compartment).
Peter and Linda learned to always be one step ahead of Julian, meaning that they positioned their bodies so that he could not escape their demands. They also learned not to react outwardly to his tantrums. Peter and Linda would wait to interact with Julian until he had been calm and quiet for 20 seconds. If Julians tantrum had been to avoid a request, Peter and Linda guided Julian gently, but firmly through the expectation. If holding Julian did become necessary to prevent him from hurting himself, his parents minimized soothing words and physical contact.
During these sessions, the therapist taught Peter and Linda to replace unproductive thinking with more positive self-talk and to continually monitor and adjust their thinking in difficult circumstances. They were encouraged to take credit for successes and to view them as evidence that they were making progress with Julian. Both parents identified specific statements they could use to replace their negative thoughts, such as I can be successful if I plan events carefully, I can teach Julian the skills he needs to be successful, or it will be difficult, but I can follow through when faced with problems. Linda began to acknowledge that although it was difficult to handle Julian at times, she could get help from Peter (when at home), family, or service agencies if she asked for it. As Peter gained knowledge and skills through his participation in the program, he also gained confidence and realized he could be successful in managing Julians behavioral challenges.
Session 7-8. The therapist helped Julians parents develop a written behavior support plan integrating these intervention strategies to facilitate their continued implementation and monitoring. They discussed how to insure ongoing communication between team members, action steps needed to put the plan in place (e.g., obtaining bins, setting aside time to plan), and methods for monitoring the progress using a weekly journal. As the behavior plan was established, Peter and Linda tried to follow-through between sessions. They found that some of the strategies were easy to use (e.g., prevention methods) while others, especially those that required them to change interaction (and thought) patterns, took more focus and energy. Peter and Linda found managing their reactions to Julians tantrum behavior to be the most difficult. They were accustomed to trying to calm Julian down in order to relieve his distress during tantrums. Having to withdraw their attention and support during these times was hard, but over time they were able to be more consistent.
Outcomes for Julian and Family
As a result of their participation in the program, Peter and Linda were able to design and implement a behavior plan that produced important improvements for both Julian and the family. During the sessions, the parents initially reported that Julians tantrums were increasing in severity and length (while they were beginning to implement strategies), but rapidly decreased as strategies were implemented consistently. All intervention methods worked well for the family. As a result, his parents reported that Julian had learned new words in order to gain attention from his parents such as come, cuddle, and look. He also learned to say a minute in order to let his parents know that he needed a delay before he was ready for a transition. Julian learned to use a picture schedule, supporting him during transition time, and he was taught to touch other people gently, making belly scratching unnecessary.
A post assessment conducted by project staff a few weeks following the final session confirmed these improvements. On the standardized measure of problem behavior (SIB-R), Julians maladaptive behavior decreased from -46 (very serious) to -18 (marginally serious). Direct observation data collected via videotaping of targeted family routines before and after the sessions showed that his disruptive behavior decreased from 72% to 8% of the intervals. Julians parents reported satisfaction with the program.
Through their participation in the program, Peter and Linda were able to interrupt and replace negative thinking that interfered with their ability to implement Julians behavior plan consistently. They began to express more positive perspectives such as our efforts are showing, there is hope, which lead them to challenge Julian to try new things (e.g., ride a tricycle). They were able to catch themselves when negative thinking did emerge and refocus. The most instrumental paradigm shift Julians parents experienced was the realization that Julian could express his needs appropriately instead of getting what he wanted through his tantrums - that he was capable of learning despite his disability.
Having similar perspectives about Julian allowed Peter and Linda to work in greater concert as parents. They agreed to address disagreements privately (since arguments tended to prompt Julians tantrums) and to identify creative ways to increase Peters involvement despite his travel responsibilities. Unfortunately, after years of stress and breakdowns in communication, their marriage had suffered. Given their commitment to Julian, however, even as the couple contemplated separation, they completed the sessions together while considering how to maintain consistency in Julians intervention.
Conclusions and Next Directions
Behavioral parent training can be effective and produce positive changes in child behavior and family functioning, however, we need to address issues that impede parents ability to participate, follow-through, and benefit from intervention. Infusing cognitive behavioral methods such as optimism training into parent education in positive behavior support appears to help families overcome barriers and may be an important element in the sustainability of intervention as it promotes the resilience of families when faced with the challenges of raising children with a disabilities and behavior problems. Our research in this area is producing promising results. We have established protocols (Durand & Hieneman, 2008 a&b) and are continuing to evaluate outcomes for families of young children. Future investigations will focus on a wider range of families (e.g., older children, other disabilities, more complex family circumstances).
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