Effective Intervention Strategies for Behavior Problems (page 3)
This article will describe empirically supported family and parenting interventions that can be offered by schools to reduce conduct problems and promote social and academic competence. "Empirically supported" interventions will be defined here based on the Chambless and Hollon criteria (1998), a standard that is generally accepted in the scientific community (APA Task Force on Psychological Intervention Guidelines, 1995). This standard relies on interventions being evaluated in randomized control designs, demonstrating changes in observations of behavior (not only in parent or teacher reports), replication by an independent research group, provision of detailed training manuals and intervention materials, and publication in peer-reviewed journals. These criteria promote selection of interventions that are based on evidence about what is proven to work for conduct problem children and their families.
Rationale for Parent Training. Parenting interactions are clearly the most well-researched and proximal causes of conduct problems in children. Research shows that some parents of children who are highly aggressive lack certain fundamental parenting skills (Patterson, 1982). For example, parents of such children may be less positive and more coercive, permissive, erratic, and inconsistent. They are less likely to monitor behavior and more likely to reinforce inappropriate and ignore prosocial behaviors (Chamberlain, Reid, Ray, Capaldi, & Fisher, 1997; Reid & Eddy, 1997). These parental constructs at age 10 predict later antisocial behavior and drug abuse (Patterson, Crosby, & Vuchinich, 1992). Many factors disrupt parenting, including family life stressors (often associated with socioeconomic disadvantage) (Forgatch, 1989; Forgatch, Patterson, & Skinner, 1988; Wahler & Sansbury, 1990; Webster-Stratton, 1990a); maternal insularity and lack of support (Wahler, 1980); parental psychopathology or substance abuse (Kazdin, 1987); and marital discord (Cummings & Davies, 1994; McMahon & Forehand, 1984; Webster-Stratton & Hammond, 1999). Low parent involvement in school also puts children at risk for academic failure and antisocial behavior (Reid & Eddy, 1997).
Parent training programs help counteract the parent and family risk factors by teaching positive, nonviolent discipline methods and supportive parenting that promotes children's self-confidence, prosocial behaviors, problem-solving skills, and academic success. Parent interventions help parents respond effectively to normal behavior problems so that these problems do not escalate. Parents learn to provide support for their children's cognitive, social, and emotional growth. Parent training programs can also help parents communicate effectively with teachers and advocate for their child's social and academic development. Group format parent training that also focuses on family issues such as communication and problem-solving skills addresses some of these family risk factors by facilitating parent support, decreasing parents' isolation, and providing strategies to cope with stressful life events.
Empirical Validation for Parent Training Programs. Extensive research indicates that parent training is the single most effective intervention available for reducing early conduct problems (Kazdin, 1985; Tanaka, 1987; Taylor & Biglan, 1998). In a review of 82 empirically tested psychosocial interventions for conduct problem children and adolescents (Brestan & Eyberg, 1998), the two found to be effective were parent training programs: a program derived directly from Patterson's social learning model (Patterson & Chamberlain, 1988) and a program based on videotape modeling developed by Webster-Stratton (Webster-Stratton, 1996; Webster-Stratton & Hancock, 1998). Of the 10 additional programs judged to be "probably efficacious," three were parent training or family therapy programs. Likewise, a review by Kazdin and Kendall (1998) of interventions for treating antisocial children found that two of four interventions showing the greatest promise emphasized the family.
The successful short-term outcome of parent training has been repeatedly verified by significant changes in parents' and children's behavior and adjustment (Dishion & Andrews, 1995; Eyberg, Boggs, & Algina, 1995; Kazdin & Kendall, 1998; Patterson & Narrett, 1990; Webster-Stratton & Hammond, 1997). Home observations indicate reductions in children's levels of aggression by 20% to 60% (Patterson, Chamberlain, & Reid, 1982; Webster-Stratton & Hammond, 1997). Researchers have found improvements in other outcomes, including school dropout and attendance, disruptive behavior, and criminal activity (Kazdin, Siegel, & Bass, 1992). Generalization of behavior improvements from the clinic setting to the home over reasonable follow-up periods (1–4 years) and to untreated child behaviors have also been demonstrated (Taylor & Bilan, 1998). Studies typically find that approximately two-thirds of children show clinically significant improvements, which means that their behavior falls in the normal range following the family intervention (Webster-Stratton, Hollinsworth, & Kolpacoff, 1989). There is mixed evidence on generalization of improvements from home to school; parent training studies have indicated that improvements in the child's behavior at home are not necessarily associated with improved peer relationships, particularly if teachers are not involved in the intervention. Evidence does indicate that early intervention has longer-lasting effects when parent programs incorporate a cognitive/academic component (Yoshikawa, 1994). Programs are also more likely to generalize when parent training is combined with child and teacher training (Kazdin, Esveldt-Dawson, French, & Unis, 1987; Kazdin et al., 1992; Webster-Stratton & Hammond, 1997; Webster-Stratton & Reid, 1999c).
For older adolescents with conduct disorders, an intensive parent component, as a part of a more comprehensive therapeutic program, is necessary for reducing violence. In addition to parent education program, research supports the effectiveness of multisystemic therapy (MST) (Henggeler, Melton, & Smith, 1992; Henggeler, Schoenwald, & Pickrel, 1995) and functional family therapy (Alexander & Parsons, 1982; Morris, Alexander, & Waldron, 1990). MST is a comprehensive, family-oriented program that has been effective in reducing a variety of antisocial and delinquent outcomes (Henggeler, Schoenwald, Borduin, & Rowland, 1998). Programs based on this model use individualized wraparound service plans for each child and family, an approach familiar to school psychologists (Eber & Nelson, 1997). See Eber and Nelson (1997) for an example of how schools can assume the lead role in a system of care. Although family therapy is critical for older students with chronic behavior problems, less intensive parent interventions are sufficient for most younger students. Christenson, Rounds, and Franklin (1992) and Sheridan, Kratochwill, and Bergan (1996) present thorough reviews of home–school collaboration strategies found to be effective in preventing and reducing children's academic and social problems.
School-Based Prevention Strategies
Rationale for Parent Training in School Settings. While parent training historically has not been seen as an essential element of school services, there are several advantages to offering parent training in a school-based preventive model rather than in a mental health setting. First, school-based programs are ideally placed to target multiple risk factors in the child, family, and school and build links between these three areas. Second, school-based programs are more accessible to families and eliminate the stigma associated with services offered in traditional mental health settings as well as some of the practical and social barriers to treatment access (e.g., lack of transportation, insurance, child care, or financial resources). Third, school interventions can be offered before low-level behavior problems have escalated into severe problems that require referral and extensive clinical treatment. Moreover, when intervention is offered in communities, these communities become natural sources of support for parents and teachers (Webster-Stratton, 1997). Lastly, on-site school interventions can provide services to high numbers of high-risk families and children at comparatively low cost.
Empirical Validation of School-Based Prevention. As indicated by the preceding review, there is extensive knowledge about the development and treatment of conduct disorders using parent training. Work in the area of prevention of conduct problems is also extremely promising. In the past decade several multifaceted, randomized control, longitudinal prevention programs have shown that rates of later delinquency and school adjustment problems can be lowered by early parent–school intervention. Tremblay and colleagues (Tremblay, Pagani, Masse, & Viatro, 1995; Tremblay et al., 1996) found that a combination of parent and child training for high-risk children in kindergarten and first grade reduced delinquency and school adjustment problems at age 12. Similar findings using child and parent training fourth- and fifth-grade students were reported by Lochman and Wells (Lochman & Wells, 1996). FAST TRACK, a large scale, multicenter, multicomponent program, provided ongoing services to children exhibiting conduct problems from first to fifth grade. The intervention included a classroom management component, social skills training called PATHS, (Kusche & Greenberg, 1994), academic tutoring, parent training (based on Forehand, Rogers, McMahon, Wells, & Griest, 1981), home visits, and friendship enhancement. Outcome at 1 and 3 years showed reductions in conduct problems and special education resource use (Group 1999a, 1999b). The LIFT project (Reid, Eddy, Fetrow, & Stoolmiller, 1999), another school-based prevention program, provided parent training, classroom social skills training, a behavioral playground program, and a parent–teacher communication program to all students in high-risk schools. Results showed intervention effects on physical aggression, behavior improvements in the classroom, and reductions in maternal aversive behavior at home (Reid et al., 1999). Two randomized prevention trials of Webster-Stratton's parent intervention program (The Incredible Years Training Series) produced positive change in Head Start parents and their 4-year-old children immediately at posttreatment and at 1-year follow-up. Intervention produced positive changes in parenting, parents' school involvement, children's levels of aggression, conduct problems, and social skills (Webster-Stratton, 1998b; Webster-Stratton & Reid, 1999c).
Prevention Programs That Include Teacher Training
To promote student's behavioral and academic success, teachers must be well trained in effective classroom management. Schoolwide approaches that provide consistent classroom discipline plans and individualized plans for children with conduct problems can be highly effective (Cotton & Wikelund, 1990; Gottfredson, Gottfredson, & Hybl, 1993; Knoff & Batsche, 1995). Specific teacher behaviors associated with improved classroom behavior include the use of high levels of praise and social reinforcement (Walker, Colvin, & Ramsey, 1995); proactive strategies such as preparation for transitions and clear, predictable classroom rules (Hawkins, Von Cleve, & Catalano, 1991); short, clear commands, warnings, reminders, and distractions (Abramowitz, O'Leary, & Futtersak, 1988; Acker & O'Leary, 1987); tangible reinforcement for appropriate social behavior (Pfiffner, Rosen, & O'Leary, 1985); team-based rewards (Kellam, Ling, Merisca, Brown, & Ialongon, 1998); mild but consistent response costs (time-out or loss of privileges) for aggressive or disruptive behavior (Pfiffner & O'Leary, 1987); and direct instruction in appropriate social and classroom behavior (Walker, Schwartz, Nippold, Irvin, & Noell, 1994) and problem-solving skills (Shure & Spivack, 1982).
Classroom management training is promising in demonstrating short-term improvements in disruptive and aggressive behavior in the classroom for approximately 78% of disruptive students (Stage & Quiroz, 1997). Programs such as ACHIEVE (Knoff & Batsche, 1995) and BASIS (Gotfredson et al., 1993) that focus on classroom management skills and discipline, social skills training, and home–school collaboration are effective in reducing teacher reports of antisocial behavior and improving academic achievement. However, these studies did not use randomized control designs or measure the programs' effects across settings and over time.
Several studies using randomized control designs have extended this teacher training research. Two large-scale prevention projects, the Seattle Social Development Project (Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999) and the Child Development Project (Battistich et al., 1991), emphasized training teachers in classroom management. Six-year follow-up of the Hawkins study (Hawkins et al., 1999) with children who received school-based intervention in first through fifth grades showed reduced violent delinquent acts, lower drinking age, less sexual activity, and fewer early pregnancies. Child Development Project results show improvements in prosocial and problem-solving skills (Battistich, Schaps, Watson, Solomon, & Schaps, 1989). A follow-up study of these children demonstrated intervention students were less likely to use alcohol and exhibited fewer delinquent behaviors (Battistich, Schaps, Watson, & Solomon, 1996). Webster-Stratton (Webster-Stratton & Reid, 1999b, 1999c) evaluated the combined effects of parent and teacher training in two randomized control studies, as prevention in Head Start and as treatment with a sample of diagnosed 4- to 8-year-old children. The teacher program significantly enhanced the effectiveness of parent and child training in terms of decreasing aggressive behavior in the classroom, promoting academic readiness, and increasing on-task work. Moreover, participating teachers were observed to use fewer inappropriate and harsh discipline strategies and to be more nurturing and positive than nonintervention teachers.
Key Features of Effective Parent Programs
Several excellent literature reviews indicate that cognitive-behavioral family interventions are helpful for prevention and treatment of conduct disorders and promotion of social competence (Brestan & Eyberg, 1998; Taylor & Biglan, 1998). These reviews can help schools evaluate the appropriateness of particular parenting programs for their needs. Based on research, schools are advised to use the following guidelines to select an effective parenting/teacher intervention.
Broad-Based Content. Program content and process must be relevant and sensitive to individual parent needs and circumstances. A focus on problem solving, communication with teachers, personal family issues, and other risk or protective factors in addition to parenting skills is more effective. Moreover, the combination of child and parent training results in better early peer interactions and later reductions in delinquent behavior and drug abuse (Kazdin, Bass, Siegel, & Thomas, 1989; Kazdin, Esveldt, French, & Unis, 1987; Kazdin et al., 1992; Webster-Stratton & Hammond, 1997). Although all these facets of interventions are not required for every family, the ability to integrate them into treatment clearly enhances the effectiveness of parent training, especially when parents are coping with issues such as serious depression, drug abuse, marital discord, or extreme poverty.
Cognitive, Behavioral, and Affective Components. Programs that emphasize parents' feelings and cognitions and promote self-management as well as teaching behavioral "principles" have higher consumer satisfaction and longer-lasting effects. Programs should include parent–child relationship building through positive parenting practices and child-directed play as well as behavioral strategies such as time-out and loss of privileges (rather than relying on exclusively one focus or the other).
Length Greater than 20 Hours. Programs that are at least 20 hours (extending to 50 hours) in length have more sustained and significant effects (Kazdin, 1987). Parenting programs offered in schools can be provided across key transition points such as entry to preschool, kindergarten, middle school, and high school. This approach provides a lengthier and more comprehensive approach and also provides parents with periodic "boosts" to keep up their efforts at home and to facilitate relationships with new teachers.
Early Intervention and Developmental Focus. The earlier intervention begins, the more positive the child's behavioral improvements. This does not mean that programs for parents of antisocial adolescents should be eliminated but that it is far easier to impact behavior problems when children are young. Parenting programs should focus on a particular developmental stage and age. Programs that attempt to address issues for all ages are likely to fail because different parenting strategies are appropriate for children of different ages, and parents may be confused and frustrated by strategies that do not apply their own child's developmental level.
Collaborative Process. Programs that are collaborative (i.e., parents are given responsibility for identifying their own goals and developing their own solutions with the guidance of the group leader) result in more parental engagement and fewer dropouts and are perceived as more culturally sensitive. When parents are involved in self-management (e.g., determining their priorities for home activities) and a coping or problem-solving model (vs. a mastery model) is used, programs are perceived as more meaningful and relevant to parents' needs and cultural traditions. This will result in greater parental attendance, retention, and behavior change (Webster-Stratton & Herbert, 1994).
Focus on Strengths. Programs that focus on parents' strengths (as opposed to their deficits), assuming that even highly stressed parents bring knowledge and expertise regarding their child and their needs, result in less dropout, more involvement, and more behavior change.
Building Family and Social Support. Programs that are offered in group format, encourage partners' involvement, and promote within-group relationships are more cost-effective. They also reduce parents' of isolation, increase their sense of support, reduce dropout rates, and result in lasting effects (Webster-Stratton, 1985).
Performance Training Methods. Training methods need to be responsive to a variety of parental learning styles and should utilize "performance-based" training methods such as videotape modeling, role playing, and home practice assignments. Direct feedback, instruction, and active practice of skills are more effective than "verbal-based" learning methods such as discussion and written handouts.
"Principles" Training. There is greater behavior improvement and generalization when parents are taught behavioral principles (not just specific strategies). Parents who understand the rationale behind parenting strategies and their long-term results are more motivated to implement them.
Parent–Teacher Partnerships. Parenting programs that promote skills in school collaboration and help parents and teachers develop consistent home–school behavior plans are more effective than programs offered in isolation from schools and teachers. Programs that include teacher training result in more generalization and consistency of behavior improvements across settings.
Group Leader Clinical Skills. Leaders who are warm, collaborative, nonhierarchical, nonblaming, and supportive and demonstrate a coping model are more effective than program leaders who are "expert," distanced, and prescriptive. A collaborative approach (i.e., leader acts as a "coach" to provide support and encouragement) will facilitate active parent participation and interaction. The "expert" model frequently fosters passive resistance on the part of parents. It is important that leaders receive appropriate training and ongoing supervision until they are proficient with intervention implementation. Many empirically validated programs have developed certification procedures for assuring that the program is delivered with integrity and a high level of quality.
Sensitivity to Barriers for Low-Income Families. Programs should be accessible and realistic about the practical constraints of low-income families. This may mean providing child care, transportation, food, flexible meeting times, and community meeting places (Webster-Stratton, 1998a). Weekly support calls from leaders and group "buddy systems" help engage families and result in lower dropout and higher attendance rates, particularly in highly stressed families. Leaders can also help parents make up missed group sessions in a home-visit format.
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