Impact Factor : 0.548
Received: June 05, 2017 Published: June 08, 2017
Corresponding author: Begum Engur, Istanbul Bilgi University, King’s College London, MSc Child Adolescent Mental Health, London, UK
Parent training is the treatment of choice for children with oppositional problems and known to be very effective for reducing behavioural problems. It also increases sensitive responding the primary mechanism for increasing secure attachments and improving child-carer relations. Individual-based parent-training/education programmes are recommended in the management of children with conduct disorders only in situations where there are particular difficulties in engaging with the parents or a family’s needs are too complex to be met by group-based parent-training/education programme [1-4].
Keywords: Parenting; Intervention; Parent-child relationship; Behavioral disorders; Child mental health
Parent training works by directly coaching parents in how to interact differently with their children. Parents are praised for things that they are already doing which effectively manage their children’s behavior and suggestions are made in those areas where they feel that they experience difficulties. Whilst the therapist brings ‘expert’ knowledge to the sessions, parents know their child best, so that the two work collaboratively in sessions. Parent training is an active process of learning new skills; in the clinic/ during the sessions parents practice these skills with a member of the team in an adjacent room [1-4].
The basic principles of parent training find its basis on Social Learning Theory. Accordingly, it is possible to claim that much of a child’s difficult behavior is learned, therefore, difficult behavior can also be unlearned. Thus, the children’s behavior can be improved by; increasing their friendly/co-operative behavior and decreasing their unfriendly/uncooperative behavior. It also implies that we as human beings learn by modelling, observation, motivation and imitation. All behaviours are shaped by the environment around us and the interactions with each other [1-4].
PIPT is an adapted version of a parent training, majorly based on Kazdin’s and McMahon & Forehand’smodel [5,6] by South London and Maudsley NHS Foundation Trust, Conduct Adoption and Fostering Team. It is a 1:1 intervention for children with complex conduct disorder, primarily aimed at children aged 3-8. It is designed to promote positive child/parent relationships, to improve pro-social behavior and to reduce undesirable behavior. During the intervention process, parents identify own treatment goals and the sessions include modelling, role play and home practice/work. 6 different skills are practiced/delivered through PIPT; attending, praise/rewards, selective ignoring, clear/calm commands, consequences and time-out. Overall, the parenting intervention takes 6 to 8 sessions with 1-hour duration each and the structure of sessions include; review, introducing new skills (rehearse and role-play is done where necessary), live coaching (therapist through ear bug or within the same room if there aren’t a separate one way mirror room available), feedback and home practice given [5,6].
The first stage in the parent training process is called ‘the child game’. This aims to increase child’s friendly and co-operative behavior. Thus, it helps children learn how good it is to get undivided attention and for parents to see how powerful their attention can be in reinforcing children’s good behavior. It is also a meaningful opportunity for the parents to see how ignoring their children’s less desirable behaviors can decrease those behaviors. The first phase includes the sessions of attending, praise/rewards and selective ignoring [5,6].
The second phase of the programme is called ‘The Parent’s Game’, which includes the sessions of clear/calm commands, consequences (natural and logical) and time-out. In this part, parents find a chance to learn essential skills that will decrease their child’s undesirable behavior. Basically, in sessions parents learn how to get their children to do things that they tell them to do (compliance) and stop doing things that they find undesirable or uncooperative. During the ‘Parent’s Game’, parents learn to give clear commands one at a time; to praise their children for obeying their commands (being compliant); to give effective/calm warnings and to use a punishment technique called ‘Time Out from Positive Reinforcement’. Throughout the process, it is highly significant to continue to praise the child’s good behavior, to ignore minor behavioral problems and be consistent with the behaviors being ignored [5,6].
The first session of part one is Following & Attending. During this session, parents are coached to learn/enhance their skills to follow and imitate child’s behaviour; notice and then describe emotion, cognition, action; let child use their imagination; ignore minor misbehaviour; and encourage child to do their own problem solving. The following session is Praise & Rewards. Praising and rewards extend the previous session on attending. Used consistently, praise and rewards can also increase children’s selfesteem. The three types of praises are handled during the session; labelled verbal praise (the statements of exactly what the child did that the parents liked), unlabelled verbal praise (statements of general praise, still rewarding although they are not specific) and physical rewards (i.e. hugs, kisses, pats). The essential point is to use these immediately after the child engages in any behaviour aimed to increase and to praise the child in an enthusiastic and sincere manner. Moreover, rewards must always be clear, consistent, immediate and contingent. The third and last session of part one is Ignoring.
Ignoring is a major way to decrease the child’s unwanted behaviour and when the parents ignore, they completely remove their attention from the child. Most parents find ignoring incredibly difficult, however it is an extremely effective form of discipline which allows the parent to maintain self-control whilst the children learn that there is no value to the misbehaviour. It is essential to know that the ideology is to ignore the misbehaviour, not the child him/herself. Types of behaviour that the parents may prefer to ignore include tantrums, screaming, pouting, arguing back. During the session, parents learn to give no eye contact or expressions of disapproval; make no verbal contact; make no physical contact; stop ignoring as soon as the inappropriate behaviour stops; and do something distractive to help them ignore [5,6].
The first session of part two, the Parent’s Game, is Clear/ Calm Commands. During the second part, unlike the Child’s Game, parents should structure the activity and have their child do what they want. This is an artificial situation however it gives parents the chance to practise delivering clear commands to their children. On average adults give 17 instructions every half-hour. This increases to around 40 with children who are more defiant or who have poor concentration. The way parents give instructions has a great impact on how the child responds. When giving commands it is highly important to make commands simple and direct; to give 1 command at a time and to give child a chance to comply (around 5 secs).In addition, it is very significant to praise immediately if the child complies or to give consequence if the child does not (as it is introduced in the following session). The following session is called Giving Consequences.
It is a major opportunity for children to learn. Both Natural and Logical consequences are thought/coached to parents; where a natural consequence is whatever would result from the child’s action if there were no adult intervention (i.e. child walks to school if he/she misses the school bus) and a logical consequence, on the other hand, is designed by the parents as punishment to fit the misbehavior or disruptive behavior (i.e. the child refuses to eat the dinner, no desert given). At this point, it is momentous to make consequence immediate; make consequence age-appropriate; make consequence natural, not punitive; be friendly/ positive; and use short & to the point consequences. The last session of both part 2 and the parent training is the Time Out from Positive Reinforcement. This is a very powerful and effective punishment if the child does not comply with parents’ commands. However, punishment should be seen as a last resort. Accordingly, if it is used too frequently then it will become less effective.
Time out is an extreme form of ignoring, where the child is removed from all sources of attention for a specified period of time. It also gives parents a chance to cool down if they need it. Moreover, as the parents will learn to respond calmly, they will be able to use Time Out consistently and effectively. Furthermore, this technique is one of the most respectful ways for managing serious and challenging behaviour. The carer models a calm nonviolent approach in the knowledge that they have explained this consequence to their child beforehand. At a time when they may be highly emotionally dysregulated, the child will witness their carer remaining in control of their own emotional state. This can enable a child to feel safe, contained and secure. During the session, when parents apply time out through the therapist coaching/support, they learn not to talk; not to show any emotion and/or attention towards the misbehaviour. The time-out places can include; sitting on stair, on a chair, in the corner of the room etc. In addition, it is also highly important to explain what time out means to the children before the parents start implementing the technique [5,6].
Even though PIPT is designed primarily for the parents who have children with disruptive behavior or behavioral disorder, all of the techniques included in the programme can be implemented by any parent as they are all convenient/practical for children’s social, emotional, behavioral, cognitive, psychological development & well being.
A. J.S., 8 years old boy, referred to the unit as presenting challenging and oppositional behaviors towards both his friends and family. He had difficulty controlling her anger, was acting out-running out of school and throwing objects at other students. He found it very difficult to engage throughout the assessment and to separate from his mother. He hardly listened the explanations or commands. After couple of PIPT sessions, from the middle towards the end of the program, he was more compliant, more engaging, motivated with rewards/praises and overall a happy child. His misbehaviors both at home and school decreased significantly. His parents reported that home practices did really help.
B. M.T, 10 years old adopted boy, was referred by Somerset Children’s Social care following concerns regarding his behavior. He is reportedly defiant and non-compliant, doesn’t enjoy affection and seeks to be in control of his parents. M.T. had extremely severe temper tantrums for his developmental level at home, in which his behaviour could be very dramatic. He often argued with adults, actively refusing adults’ requests and did things that annoy other people. He was blaming others for his misbehaviour. M.T. often lied and had used a weapon to threaten parents. He deliberately destroyed the property of others and had stolen money from his mother’s purse. After his participation in PIPT sessions with his parents, he became more compliant, was able to control his anger, his relationship with both parents & peers improved. Not only his adoptive parents but also his teachers were much more satisfied of his behaviour & attitude in general.