parental training ohad hershkovitz, psy.d director, cbt institute of israel

Parental TrainingOhad Hershkovitz, Psy.D

Director, CBT Institute of Israel

Parental Training

What is it?

Interventions focusing on the parents (or responsible environment) instead of the child

The primary and stated goal is to cause change in the child

The secondary and sometimes unstated goal is to cause change in the parents

Child Therapy Alone: Is It Enough?

Child Therapy without Parental Intervention

Environmental factors may continue to influence child and possibly sabotage therapy

Child’s maturity may limit extent of ability to affect change

Changes may be strictly symptom-based (e.g. behavioral), and not schematic (e.g. core beliefs)

Parental Training vs. Child Therapy

Parameters to consider when deciding who to target?

Age of child – take responsibility for therapy

Cognitive maturity of child

Willingness to undergo therapy

Other children in household/environment similarly affected

Location of problems (e.g. home/school)

Relationship status of parents

Receptiveness of parents

Emotional maturity of parents

Personal beliefs of therapist

Comparison of treatment models

Parental Training Doesn’t require minimum child

cognitive/emotional maturity Doesn’t require child

participation Can address problem at root

(schematic level) Can address parents’ personal

issues as well Short interventions can lead to

significant schematic changes in child

Can improve environment for other children

Child Therapy Doesn’t require parents to take

responsibility (or does it?) Doesn’t require parent

participation (or does it?) Often symptomatic, not schematic

(dependent on age/maturity) Parental inclusion usually

superficial Schematic changes usually require

significantly longer therapy than Parental Training

May not affect general home environment

Review of Parenting Styles and their Effects

AuthoritativeAuthoritarianPermissiveNeglectful

Parenting Styles

Authoritative

Warmth – demonstration of love and affection

Results in development of social skills and self conception

Demandingness – rules and consistent discipline

Results in development of self-control and social responsibility

Respect for child/adolescent’s autonomy/opinions

Results in development of independence and competence

Parenting Styles

Authoritarian

Lacking in Warmth

Detrimental to social skills and self conception

Lacking in Respect for Autonomy

Detrimental to independence and competence

Overuse of Demandingness

Parenting Styles

Permissive

Lacking in Demandingness

Detrimental to self control and social responsibility

Provides warmth

Provides respect for autonomy

Parenting Styles

Neglectful

Lacking in Demandingness

Detrimental to self control and social responsibility

Lacking in Warmth

Detrimental to social skills and self conception

Provides Respect for Autonomy

Most problematic parenting style

Research indicates most behavioral problems: delinquency, sexual promiscuity, drug/alcohol abuse

Problematic Parenting Styles

Problematic Parenting Style - Pathway

Conditioning

Behavioral Conditioning

Parental Attention due to Noncompliance = Positive Reinforcement for child

Angry parent = Increased attention to child

Child Compliance = Positive Reinforcement for parent’s anger

Cognitive Conditioning

Lingual schema = “90% is not good enough”

Evolutionary survival instinct = accept parental authority/guidance

Rationalization of parental attitudes…

Problematic Parenting Style: Rationalization

Parental message:

We need to protect/correct/punish/neglect/over-empower you

Child Rationalization:

I have no external proof (or internal confidence) to believe otherwise, so it must be true

Child Conclusion:

I must be weak/flawed/bad/worthless/overly responsible

Problematic Parenting Style - Example

Parenting Style: Overprotective

Core belief: “I must be in danger, I’m not strong enough to cope”

Anxiety, Avoidance, Dependent


Parenting Style: Intrusive/Over-controlling

Core belief: “I need to rely on them, I cannot rely on myself”

Dependent, Avoidant, OCD, Eating Disorders


Parenting Style: Critical/Judgmental

Core belief: “There is something inherently deficient in me”

Depression, Phobia, Panic Disorder, CD/ODD


Parenting Style: Belittling, Degrading

Core belief: “I don’t deserve love”

Social Phobia, Jealousy, Personality D/O, CD/ODD


Parenting Style: Histrionic/Repressive

Core belief: “Emotions are dangerous or proof that something is wrong”

Avoidant, OCD, Eating Disorders, Phobia, Panic


Parenting Style: Spanking

Core belief: “Bad behavior must be forcibly punished”

Anger, IED, Personality D/O

Poor ParentingChild therapy without parental training can be a superficial band-aid solution

Research on Parenting Styles & Training Poor Parental Style highly correlated with non-organic psychiatric/behavioral problems in

children Severe ODD highly correlated with development of CD ODD children 4x more likely to develop psychiatric issues ODD children with comorbid psychiatric issues 25x more likely to exacerbate psychiatric

issues later in life

Parental Training correlated with significant improvement in behavioral disorders Parental Training sometimes* correlated with significant improvement in psychiatric

conditions Limited research in this field makes generalizations difficult

Parental Training follow-up (years later) correlated with no significant difference between initially non-compliant children and psychiatrically healthy adults on following measurements:

Relationship with parents

Delinquency (crime, substance abuse)

Emotional Adjustment

Academic Achievement

Research on Parenting Styles & TrainingChildhood: Noncompliance, Temper tantrums

Adolescence: Aggression, Stealing, Substance abuse

Overt: Defiance, Fighting

Covert: Lying, Stealing

Specific Setting: Home

General Setting: School, Broader Community

Poor Parenting – Examples of Causes Behavioral Conditioning from parents’ parents

Repeating faulty behaviors

Cultural Norms e.g. emotionally intolerant society, expressively anxious society

Parents’ mental health issues and fears Anxiety leads to anxious parenting

Inconsistency between parents e.g. strict vs permissive

Relationship inequality Delegitimization of partner mimicked by children

Conflict between parents Inconsistent structure and rules, manipulation

Resistance to change Responsibility for child’s health/behavior = blame for problems

Fear of making mistakes = perfectionism, over-controlling

Fear of rejection by child = permissive

Anger at child = neglect, over-demandingness

Parental Training vs. Parental Therapy

Therapists often make mistake of losing focus or crossing boundary of parental training to parental therapy

When should parental training become parental therapy?

Parent shows willingness to change but inability due to own personal issues

e.g. Parent’s behavior dictated by anxiety, addiction, depression, etc.

Couple preoccupied with marital problems, unable to work together for child

e.g. ongoing divorce proceedings, active conflict, etc.

Parental Training vs. Parental Therapy

Parental Training Brief: 1-3 months

Primary Goal: Child’s improvement

Target: Parental Behavior

Scope: Limited focus on parent’s experience

H&N: Highly structured

Responsibility: Placed primarily on parent

Parental Therapy Longer: 3-6 months

Primary Goal: Parent’s improvement

Target: Parental Mental Health

Scope: Primary focus on parent’s experience

H&N: Varies by therapy/therapist

Responsibility: Shared with therapist

Parental Training: Recruiting


Overview

Inquire

Reflect

Identify & Reinforce

Identify & Challenge


Inquire (parent’s experience)

Why have you chosen your particular parenting style? Or why do you feel it is the right one?

What goals do you hope to achieve in parenting the way you do?

How effective is your parenting style in achieving these goals?

What would you like to see happen differently?

Allow parents to express frustration and hopefully realization that parenting style is ineffective


Reflect (child’s experience)

What does child hear/see from parents?

How does child interpret these events?

How does child feel as a result?

Is there an identifiable cycle?

What might break the cycle? What might lead the child to interpret events more positively? (Target parenting behavior)…

*Use visual aids, e.g. pathways, charts


Identify + Reinforce (Motivation to change) What might break the cycle? What might lead the child to interpret events

more positively? (Target parenting behavior)…

Do you think trying (target parenting behavior) might bring about a different interpretation and subsequently reaction from your child?

Why or why not?

Have you tried? How often? What happened?

Do you feel you want to commit the time and energy necessary to helping your child via making certain changes in the structure and discipline that the child experiences?

How important is it to help your child feel and behave better?

Do you feel it would be acceptable to leave the situation as it is?

How do you see your child developing as an adolescent/adult if there is no change or things continue to get worse?


Identify + Challenge (Resistance to change) Fear of blame

Does the fact that we can better match your parenting to your child’s needs mean you are to blame for doing something wrong?

Fear of mistakes

Have parenting mistakes in the past by you or others led to irrevocable damage?

Fear of taking responsibility from the child for change

Does your contributing to change mean the child will not learn to take responsibility?

Fear of giving unconditional love

Does expressing love regardless of behavior mean the child will not respond to discipline?


Use Encouraging Language

Focus on child, not on parent

e.g. “What can we do to help the child feel less shy?” instead of “Can you stop criticizing your child?”

Talk in shades of grey, not black and white

e.g. “What can we try doing to increase the chances of compliance?” instead of “If you want your child to listen, say X, not Y.”

Reinforce positive beliefs and behaviors

e.g. “Sounds like you have good intuition and some really good ideas and reactions. We probably don’t need to make too many changes.”

Parental Training: Challenges

Special Circumstances

Divorced/In-conflict parents

ADHD/Neurological problems

School-specific behavioral problems

Recruiting: Practice

Groups of 3

1 therapist, 2 parents

Review Recruiting steps

Inquire (parent’s experience)

Reflect (child’s experience)

Identify & Reinforce (Motivation to change)

Identify & Challenge (Resistance to change)

Parental TrainingTechniques

Parental Training: Behavioral Techniques

PET – Parent Effectiveness Training (Gordon)Child seen as equalChild seen as decision-maker; Parents express needsParent does not express authority


STEP – Systematic Training for Effective Parenting (Dinkmeyer, McKay)Identify and reflect child needsAllow child to choose alternative

actions for need


Behavioral MethodsReward & PunishmentPositive Reinforcement


Parenting Skills (Abidin) Combines parental experience with

strict behavior changes

HNC: Helping the Noncompliant Child(Forehand, McMahon) Primarily used on children aged 3-8 Stages

Attending Rewarding Ignoring

Effective with CD, ADHD, developmental problems Effective for parents at risk for child abuse/neglect

or substance abuse Contraindicated for autism, parental psychosis or

other severe mental illness, severe substance abuse

Training: Attending

Training: Rewarding

3 typesPhysical Rewards – hug, kiss, pat on

the backUnlabeled verbal rewards – “Great!”,

“Nice job!”Labeled verbal rewards – “Thank you

for picking up the toys like I asked”

Training: Rewarding

Guidelines for using rewardsBe specificGive immediatelyFocus on ImprovementUse consistently

Training: IgnoringAttention-seeking behaviors

WhiningNaggingTemper tantrumsInterrupting

Behaviors potentially harmful to people/property (e.g. fighting) should NOT be ignored

Training: Ignoring Ignoring is an ACTIVE process

Decide ahead of time which inappropriate behaviors to ignore

When ignoring, actively avoid giving attention to childNo eye contact or verbal cues (“Don’t

look!”)No verbal contact (“Don’t talk!”)No physical contact (“Don’t touch!”)

Training: Ignoring

Ignoring starts as soon as inappropriate behavior begins

Ignoring stops soon after (10-15 seconds) inappropriate behavior stops

Inappropriate behavior must be ignored EVERY time it appears, otherwise it will get worse instead of better.

Training: Ignoring

Ignoring is never used alone, should always be combined with positive attention (attends, rewards) for the alternate appropriate behavior

Training: Reward/Punishment

Training: Giving Instructions

Get child’s attentionMove closeSay the child’s name (maximum of 2

times)Establish eye contact


State the instruction clearlyGive ONE instruction at a timeUse firm voicePhrase as “Do” commandUse simple languageUse gestures as appropriateRationale (if given) precedes the

instruction


Wait 5 secondsCount silentlyNo verbalization to child

Training: Instructions for Noncompliance

Issue a single clear instruction“Please pick up your toys now”

Training: Instructions for Noncompliance If the child displays compliance to the

instruction within 5 seconds, provide positive attentionRewardsAttends

e.g. “Thank you so much for playing quietly, I really appreciate it when you do what I ask”

Training: Instructions for Noncompliance If the child does not display

compliance to the instruction within 5 seconds, give warning“If you do not X, you will have to go to time

out”

Training: Instructions for Noncompliance If the child displays compliance to the

warning within 5 seconds, give positive attentionRewardsAttends

Training: Instructions for Noncompliance If the child does not display

compliance to the warning within 5 seconds, without lecturing, scolding, or arguing.

Tell the child “Because you did not X, you have to sit in the chair until I say you can get up.”

Training: Instructions for Noncompliance Ignore child’s shouting, protesting, and

promises to complyLeave child in time out for 3 minutes,

including being quiet for last 15 seconds

Training: Instructions for Noncompliance When time out is completed, return

child to situation which resulted in noncompliance

Restate original clear instructionRepeat positive attention or

warning/time-out as necessary

Training: Procedure

Procedure and rationale for each skill are explained

Underlying social learning principle for each skill are briefly presented

Training: Procedure

Therapist demonstrates skill via modeling and role playing

Parent practices skill with therapist, who role plays as child

Training: Procedure

If child is included in therapy, teach child skill as well

Parent and therapist provide developmentally appropriate explanation

Child repeats procedure verbally and role plays relevant situations

Training: Procedure

If child is included in therapy:Parent practices with child in therapy

setting, therapist observes and coaches

Parent practices with child in therapy setting, therapist observes and coaches

Training: Procedure

Parent is given daily homework Practice specific situations with child

(initiated by parent)e.g. “Pick up your toys”

Practice with naturally occurring situationse.g. When child cries

Training: Procedure

Parent is given handouts with explanations specific to each skill to take home

Parent is given data sheets to practice and records interventions at home

HNC: Practice Groups of 2 1 parent, 1 therapist Resistant child (e.g. stops doing homework, asks

to play instead) Practice HNC steps separately (as with parents)

AttendingRewardingIgnoringGiving InstructionsInstructions for Noncompliance

Self-EsteemA deeper look behind the scenes

Rationalization: ReviewParental message:




Child Conclusion:


Rationalization: Development of Mental Health Problems

Parental belief:

I need to be strong/correct/right/perfect/accepted/in control



Child Conclusion:

The world must be dangerous/punishing/evil/mean/ungratifying/intolerant/lonely


Parental message:

“I need to be make sure everything is under control at all times”


“Lack of control is dangerous” “I need to be in control too”

Child Symptoms:

GAD, OCD, Phobia


Parental message:

“I need to think about every possible risk otherwise something will go horribly wrong”


“Mistakes are catastrophic” “I can’t relax, I must always be vigilant”

Child Symptoms:

GAD, PTSD (post-incident)


Parental message:

“The world (Society/Partner) will never accept or elevate fat/ugly individuals”


“I must be in control of my body”

Child Symptoms:

OCD, BDD, Eating Disorders


Parental message:

“My body must always be in control”


“I must not experience (negative) emotion or physical discomfort”

Child Symptoms:

Phobia, Panic Disorder, Hypochondria, Tourette’s, Trichotillomania


Parental message:

“The world is fair, justice will always prevail, I only have to follow the rules”


“If something bad happens, I’m at fault or I was completely wrong about the world”

Child Symptoms:

PTSD, Phobia (e.g. Driving), Depression

Focus of ChangeParental message:




Child Conclusion:


Focus of Change Address parental fears regarding giving up

current strategy Construct exercises to practice more flexible

approach Control = Let child make minor decisions even if you don’t

agree with choices

Perfectionism = Reinforce effort regardless of result

Over-demandingness/Punishment = Express noncritical dissatisfaction without punishment

Neglect = Schedule positive attention independent of behaviors

Over-empowering = Limit responsibility given to child, restrict detailed responses to anxious questions (e.g. “Mommy, do we have enough money?” after loss of parental employment)

Focus of Change: Practice

Groups of 21 therapist, 1 parentAddress fears of parental changeConstruct exercise for practicing

positive parenting

Training: Active Listening

Active ListeningEmphasize attentive listening with body,

gaze, reflective wordsNo judgment/criticism/correctionAcknowledge child’s experienceBreaks cycle of increasing frustration and

therefore increasing problematic behavior

Training: Active Listening Listen with all of your senses

Look directly at your child when they are speaking to you

Don't allow other things going on to distract you from giving the conversation your full attention

Observe body language; notice if they are acting "closed" or "open" as they talk

Avoid listening with the goal of preparing a response to the initial communication; listen all the way through your child's comments until he or she is done

Training: Active ListeningCommunicate with your whole self

Squarely face the personOpen your postureLean toward the person speakingEye contact throughout the messageRelax while listening

Training: Active ListeningReflect the message

"It sounds to me like you are saying...."

"What do you mean when you say...?"

"What I am hearing you say is....""I gather than you felt _____

when ...."


Let the message get all the way outAvoid jumping to conclusionsAvoid interrupting the flow of

thoughts except to reflect and clarifyAvoid passing judgment and then

tuning out


Respond with respectAcknowledge that your children have

real feelingsRespond to their concerns

respectfully even if you disagreeAvoid making them feel incapable or

discounting their very real feelings

Active Listening: PracticeGroups of 21 parent, 1 childPractice Active Listening skills

Listen with all of your sensesCommunicate with your whole selfReflect the messageLet the message get all the way outRespond with respect

Training: Role PlayingAllows to reenact and practice

alternative reactions to actual scenariosDiffuses “perceived threat” due to

theoretical constructProvides simple, concrete responses to

everyday situationsAllows practical assimilation of new skills

during therapy instead of attempting to translate theory into practice at home

Training: Role PlayingFocus of Change

Angry discipline = Have alternate responses ready instead of getting angry

Permissive = Provide boundaries regardless of child response

Neglectful = Provide positive attentionAuthoritarian = Engage in healthy

discussion with child

Role Playing: PracticeGroups of 21 parent, 1 therapistPractice Role Playing

First parent as childThen therapist as childReview Repeat as necessary

Training: Modeling Provides child with better coping skills

Teaches healthy behavior in both parent and child

Results in change in parents without “threat” of therapy (blame, guilt, etc.)

Targets underlying fear of change by observing non-catastrophic results

Useful for teaching

Healthy expression of emotion (e.g. “I feel…”)

Healthy interpretation of events (e.g. “I’m frustrated, but I can cope”)

Healthy discussion of possible reactions (e.g. “I should tell them how I feel”)

Healthy coping with distress (e.g. “I’ll go for a walk/listen to music/write”)

Training: Guiding Coping skills: Provides child with healthy options Child learns to choose responsibly instead of

automatically Teaches healthy behavior in both parent and child Use with lists for daily practice, refer child to list

when upsetRelaxation techniquesDefusing techniquesVerbalization techniquesTime/space distancing techniques

Training: Behavioral Correction Techniques Positive Reinforcement (immediate)

e.g. “Good job!” Better for small children

Reward Systems (cumulative) e.g. points system, stickers Better for older children

Time-out and Time-in Time-out – cool off (instead of punishment) Time-in – reward for cooling off

Withholding Privileges (or Response Cost) e.g. “No TV/computer for an hour” Check for accidental secondary punishments: withholding praise, limiting social

activities

Token Economy (cumulative)

Training: General Structure Maintain Routines

Set times for meals, chores, homework, breaks, etc.

Make rules/punishment clear and consistent Review rules and consequences beforehand with

partner and then child Share responsibility with partner for enforcing

rules and consequences Stay calm

Better to model losing control calmly than regaining control in distress

Training: Language Specific, not vague

“Stop doing X” instead of “Stop being a bad child”

Targeted, not general“You did X and that is not allowed” instead

of “You’re always doing something wrong” Behavioral, not personal

“You did X and that is not allowed” instead of “You’re such a bad child”

Training: Language Clarify, don’t justify

“You can have a cookie after dinner, not before” instead of “it can ruin your appetite and then you won’t finish your dinner”

Short, don’t elaborate “Goto your room” instead of “How many times do

I have to tell you not to hit your sister? What is wrong with you? Are you trying to make me crazy? Do you want me to punish you? If you hit her again I’ll tell your father and he’ll beat you until you cry!”

Speak calmly, not angrily (see previous example)

Training: Language

Positive reinforcementEfforts (e.g. “Good job studying your

best”)Abilities (e.g. “You draw very nicely”)Passions (e.g. “You really know your

computers”)Opinions (e.g. “That’s an interesting

view”)

Training: Language

Use simple statements and repeat themCognitive conditioning = positive

self-esteeme.g. “You dealt with that very well”

Training: Language

Avoid focusing mainly on single values/achievementse.g. “You’re a great student, you’re

going to be a doctor”Avoid focusing mainly on external

appreciatione.g. “Everybody loves you because

you’re so funny”

Language: PracticeRespond to the following behaviors:

“I don’t want to do homework!”“I’ll do it later, I’m watching TV!”“But I want a cookie now! I promise I’ll

eat my dinner.”“You can’t make me!”“Stay out of my room/stuff! Respect my

privacy!”Child is hitting younger sibling

Final Parenting Tips for 2 parents Back each other up in front of the child Disagree later, you can always apologize to the

child (great example) Share authority, don’t split Don’t negate or undermine other’s authority Don’t use child in an argument Don’t dictate rules as way to retain control in a

relationship Be consistent with each other Plan rules and consequences together beforehand Agreement on rules is less important than

consistency!

Mirror Dynamics: Here and Now

Mirror Dynamics Therapist-Parent relationship mirrors Parent-Child relationship

Parent expresses emotions behaviorally

Resistance

Tardiness/Cancellations

Accusations

Hopelessness

Lack of practice

Therapist reflects parental mistakes

Judgment/Criticism/Forces homework (Authoritarian)

Poor boundaries: Doesn’t address misbehaviors (Permissive)

Doesn’t show empathy for parents’ frustration (Neglectful)

Therapist emotion: Threatened, hopeless, annoyed, anxious

Mirror DynamicsSet example in therapy room

Maintain boundaries & Enforce rulesShow empathy for parents’ difficultiesAllow parents to take responsibility for

actions and possible alternative actionsModel tolerance for lack of

control/perfection/knowledge, including owning/reflecting own emotions

Seek out supervision

Review

Additional exercisesCase ConsultationsQ & A

parental training ohad hershkovitz, psy.d director, cbt institute of israel

Documents

problematic parenting

poor parenting child

autonomy slide

dependent slide

child child compliance

competence slide

cdodd slide

panic slide