Ch 7: Parenting Skills

Parenting Skills

• Even the most competent parents may find it difficult to parent effectively when a child experiences a severely traumatic life event.
• Trauma can directly impact parental functioning, making it difficult to maintain normal routines and consistency in rules and expectations.
• Continued structure and predictability in the family environment promotes adaptive functioning in both children and adults.
• Gaining optimal parenting skills is essential, especially when children respond to traumatization with aggression, angry outbursts, or other negative behaviors.
• Parenting skills are equally important in addressing sadness in children.
• Parental functioning is critically important to children’s outcomes, especially for those children who have experienced multiple traumas.
• All participating parents should receive guidance and support in enhancing their parenting knowledge and skills.
• Parents often benefit from normative information concerning child traumatic stress reactions and general developmental expectations.
• Therapists can assist parents in understanding the development, persistence, and motivation for children’s problem behaviors by conducting functional analyses in relation to problematic parent–child interactions.
• Teenagers can also be quite responsive to functional analyses to better understand their own potentially trauma-related problematic behavioral reactions.

Functional Analyses

• When a parent reports repeated child behavior problems, it is helpful to gather information about:

  • Antecedents: Circumstances that may have preceded and/or triggered the behavior problem.
  • Behaviors: The specific problem behavior itself.
  • Consequences: What followed the child’s behavior problem.

• This approach to examining the ABCs for problem behaviors is referred to as a functional behavioral analysis.

• Such an analysis helps the therapist identify the function of the child’s problem behavior.

• Both positive and negative behaviors typically serve an important function and/or are motivated by basic human needs and desires.

• By examining several circumstances in which the child engaged in the problem behavior, the motivation for it often becomes clear.

• Behaviors are most often motivated by basic needs, including:

  • The need to escape or avoid pain/distress.
  • The need for attention.
  • A desire for feelings of control.
  • A desire for feelings of belonging.
  • A desire for positive physical sensations.
  • A desire for feelings of mastery.

• Children engage in behaviors that will most predictably assist them in achieving their desired outcomes.

• When children have suffered trauma, the behaviors in which they engage to meet natural needs may reflect the problematic behaviors and chaotic environments to which they were exposed.

• Parents often respond to their children’s problem behaviors in ways that inadvertently reinforce avoidant, fearful behaviors and/or provide negative parental attention to noncompliant and even aggressive behaviors.

• These types of reactions by parents serve to maintain the problem behaviors over time.

• By eliciting details from parents concerning the circumstances surrounding problematic behavioral reactions, therapists can often help parents reduce their occurrence by identifying the function of the behavior, altering the antecedents, and/or encouraging children’s efforts to engage in healthier coping or attention-seeking behaviors that similarly achieve their desired outcomes.

• Functional analyses can be conducted with teens as well to help them explore the factors motivating their problem behaviors, while also identifying and practicing healthier behaviors that will achieve their desired outcomes.

• Example:

  • A teenager cuts school on days she has gym due to anxiety.
  • Analysis: Identify replacement behaviors or environmental changes to manage the distress of participating in gym class.
  • Changes: Learning coping skills or attending study hall during gym until therapy helps her face traumatic memories.

• Functional Behavioral Analysis Diagram:

  • Antecedent: Loud voice.
  • Behavior: Anger, aggression.
  • Consequence: Foster mother yells, hits him.

• Once problem behaviors are identified through functional behavioral analyses, encourage parents to learn to practice effective parenting skills to encourage children’s positive replacement behaviors and to minimize the problem behaviors between sessions.

• These skills include the use of praise, reflective listening, selective attention, effective time-out procedures, and contingency reinforcement schedules (i.e., behavior charts).

• Parental skills can be introduced along with psychoeducation in the first few treatment sessions.

• These skills are beneficial whether or not children are exhibiting behavioral difficulties.

Praise

• Most people thrive on praise or positive attention.

• Many parents devote more time to correcting or criticizing their children for negative behaviors than to praising them for positive ones.

• Ask the parent what the child does right or well or what the parent is most proud of the child for doing.

• Ask the parent what percent of the time he/she provides positive feedback for those positive behaviors versus critical feedback for negative behaviors in the form of yelling, lecturing, etc.

• Instruct the parent to focus on increasing the frequency of actively praising the child for specific positive behaviors in the coming week and note the effect of this praise on the child’s mood and subsequent behavior.

• Follow the acronym PRAISE to offer praise effectively:

  • Provide purely positive praise.
  • Repeat praise consistently for new behaviors.
  • Acknowledge small steps toward positive behaviors.
  • Intermittently offer praise to maintain established positive behaviors.
  • Specify the type of behavior you are encouraging.
  • Enthusiastically praise specific behavior for optimal impact.

• Purely positive praise works best because it gives the child attention only for what he/she is doing right.

• Parents often need practice in keeping their praise purely positive.

• Have a parent identify the negative tag in a qualified praise such as “I’m so glad you took out the garbage when I asked. Why can’t you listen like that more often?”

• Reviewing parents’ efforts to praise between sessions is very important in terms of increasing positive parent–child interactions and helping parents to recognize missed opportunities to praise.

• Repeated and consistent praise is particularly important when encouraging a child to engage in a new behavior.

• Acknowledging small steps toward that new behavior with praise is a process referred to shaping.

• Therapists are in many ways shaping parenting behaviors when acknowledging and praising parents’ small efforts toward following through on parenting assignments and making changes in their style of communicating with their children between sessions.

• Intermittent praise then becomes important once new positive behaviors are established.

• Intermittent praise is more natural and is associated with more sustained positive behaviors because children continue to exhibit positive behaviors, even when the praise or attention is not immediate, because they learn to anticipate that at some point (i.e., intermittently) they will receive positive recognition for their efforts.

• Specific praise is always helpful whether the praise is in response to a new or an established behavior.

• This type of praise helps children understand exactly what behavior the parent, teacher, or therapist is encouraging.

• Enthusiasm is key to conveying effective praise.

• Encouraging parents to initially yell their purely positive praise with enthusiasm can help them to understand the importance of positive enthusiasm.

• Simultaneously, it is important to help parents minimize their yelling in response to the child’s negative behaviors as such negative attention only serves to maintain or increase the problem behaviors.

• Having parents role-play with the therapist various scenarios wherein they praise their child may help the therapist correct any errors the parents may be making in their attempts to praise.

• Childhood PTSD is sometimes manifested by irritable mood and angry outbursts, and parents may be focused, understandably, on these behaviors.

• The therapist should encourage such parents to “catch your child being good,” or at least to catch times when the child is exhibiting no overtly negative behaviors, and offer praise.

• When children respond to such comments with sullen responses (“Just leave me alone”), it is important for the parent to understand that an initial negative response to praise is not uncommon, as the child or teen may not know how to react and/or may not trust the sincerity of the praise.

• Parents whose children are exhibiting significant behavior problems often need additional help in identifying positive behaviors and offering specific praise.

• Brief conjoint sessions after the child’s and parent’s individual sessions during which the parent shares carefully prepared specific praise for their child allows the therapist to coach and observe the parent’s efforts to praise positive replacement behaviors.

• Once the parent demonstrates skill in expressing praise to the child, it can be valuable to help the child prepare specific praise for the parent.

• Therapists should encourage children to praise common or daily parent behaviors that don’t cost anything but often go unacknowledged.

• Parents are also encouraged to listen actively and participate with children when they engage in healthy conversation and/or positive behaviors.

• Parents may be encouraged to establish daily routines that allow for more opportunities for parents to praise their children for adaptive behaviors and reflectively listening.

• Examples of such routines include positive dinnertime rituals wherein each family member shares a positive experience of the day, thereby allowing parents to actively listen and praise specific achievements.

• Examining the pattern of child–parent interactions and helping parents increase their efforts to attend to positive behaviors via praise, listening, and participating with their children can dramatically reverse the escalation of problem behaviors.

Reflective Listening

• Reflective listening is another surprisingly challenging parenting skill that therapists can coach a parent to practice in a carefully planned conjoint session in which the child is encouraged to initially share a positive experience.
• Parents may be coached to actively listen to the child’s sharing of a negative experience.
• Learning to simply reflectively listen (while holding back from problem solving) is critical for parents given that some problems are unresolvable and teenagers often just want to be heard and gain greater feelings of mastery when they solve their own problems.

Selective Attention

• When a parent consciously makes a decision to not react to certain negative behaviors the child exhibits, he/she is using selective attention.
• This approach is based on the idea that children want focused, emotionally intense attention from their parents and others, and that they will continue to exhibit behaviors that get this type of attention even if the attention takes a negative form (e.g., yelling from the parent).
• Without realizing it, parents often attend and respond more to misbehavior in their children than to positive behavior.
• the parent cannot and should not ignore overtly dangerous behaviors.
• Examples of behaviors to which parents often respond negatively but which would be better selectively ignored include the following:
  • Temper tantrums or angry verbalizations directed at the parent.
  • Making nasty faces, rolling eyes, smirking at parent.
  • Mocking, taunting, mimicking the parent.
  • Provocative comments meant to be intentionally annoying.
• Ignoring such behaviors requires a great deal of active effort both in terms of ignoring the problem behaviors and identifying and repeatedly praising positive replacement behaviors.
• Over time, when parents actively ignore the types of negative behaviors will initially escalate.
• The parent will need support in minimizing their attention to such negative behaviors by remaining calm, turning away, and if the parent feels compelled to say something, making only a very brief comment such as, “that behavior is unacceptable.”
• Ultimately, children and teens recognize that their parents are not accepting or condoning the negative behaviors, but rather they are choosing not to allow the problem behaviors to negatively impact them or the rest of the family.
• Therapists can utilize functional analyses to identify positive replacement behaviors that can help the child achieve the outcomes desired (e.g., attention) that have been achieved previously by the problem behaviors.
• The therapist should point out to the parent that the above identified problem behaviors, although unpleasant, are not harmful and are most often the child’s effort to “get the parent’s goat,” that is, to provoke a negative response.
• The parent should practice walking away calmly, without commenting on such behaviors, and busy him/herself with another activity in another part of the room or in a different room.
• This technique may result in an escalation to even more provocative behaviors (known as an extinction burst), which should be taken as a sign that the parent is effectively withdrawing his/her negative attention.
• The parent should maintain a calm, dispassionate, controlled demeanor to avoid giving the child the reinforcing negative attention he/she is seeking.
• The next moment the child is behaving well, the parent should give positive attention (praise) for the positive replacement behavior.
• An added benefit of selective inattention is that the parent saves him/herself from emotional distress by remaining calm and unflustered despite the child’s negative behaviors.
• The coping skills (e.g., relaxation, cognitive coping), which the parent will be learning alongside the child, are often very valuable in helping the parent manage the stressors associated with applying these parenting skills.
• In addition to using praise, the foster mother might try to calmly validate the teen’s angry affect, for example, by saying, “I know you’re mad. You can talk to me about it if you want to.”

Time-Out

• The purposes of the time-out procedure are:
  • To interrupt the child’s negative behaviors and thus allow him/her to regain emotional and behavioral control.
  • To deprive the child of the opportunity to receive any type of attention.
• Time-out procedures are generally not effective for adolescents, so alternative strategies should be used.
• Ideally, the parent should explain the time-out procedure to the child before the first time it is used, stating that if the child does not comply with the parent’s request to stop a particular behavior, the parent will place the child in time-out.
• Time-outs should be located in the quietest, least stimulating room available, and should only last 1 minute for every year of age (e.g., a 7-year-old should receive no more than a 7-minute time-out).
• Before initiating the time-out procedure, the parent should calmly ask the child to stop the undesired behavior, specifying the undesired behavior exactly (e.g., “Please stop kicking the door” rather than “BEHAVE!”).
• If the behavior continues, the parent may remind the child once that he/she will go to time-out if the behavior does not stop.
• The parent should refrain from responding to the child’s protestations or further negative behaviors.
• The timer should be set when the child has stopped or dramatically reduced the screaming, banging on the walls, etc., in the time-out room.
• Once the time has elapsed, the parent should retrieve the child from time-out and proceed with normal activities.
• If the child is now acting in an appropriate manner, the parent should interact positively with the child, giving positive attention and refraining from showing annoyance or anger about the previous behavior problems.
• Parents who are able to implement time-out consistently often see rapid behavioral improvements in their children and feel more competent about their own parenting skills because they are not losing control, yelling, hitting, or engaging in other angry parenting responses.
• Parents may be reminded that despite the trauma endured, children benefit from the predictable and repeated use of time-out because it is much less guilt- and anxiety-provoking for children compared to inconsistent parental threats and yelling.

Contingency Reinforcement Programs

• Contingency reinforcement programs, which involve the utilization of behavior charts, are useful for decreasing unwanted behaviors and/or for increasing desired behaviors in many children.
• Behavior charts should adhere to the following guidelines:
  • Select only one behavior at a time to target for change.
  • Discuss with the child exactly how to earn a star on the chart (e.g., “Every day that you cooperate in the morning and get to school on time, you will get a star”).
  • Involve the child in decisions about what the reward will be (e.g., “I will go to a movie alone with Mom on Sunday if I have gotten five stars between Monday and Saturday”).
  • Add up stars and give rewards at least weekly.
  • Give stars and rewards consistently and with enthusiastic praise for the specific goals achieved.

Parenting Skills for Adolescents

• The above parenting principles apply for adolescents, modify these skills to be optimally developmentally appropriate and effective for older youth.
• Educate the parent about effectively negotiating with adolescents by using direct, streamlined requests, developing clear family rules, and consequences for breaking them.
• Engage the adolescent, during individual and brief joint sessions in some of these activities.
• The above parenting skills (e.g., praise, selective attention, and behavior charts) can then be applied for implementing these strategies.
• If the child is exhibiting significant behavioral problems, assess whether these are manifestations of the child’s PTSD symptoms or were present before the traumatic event.
• It is important in these cases to keep the focus of treatment with the parents on parenting skills before refocusing their attention, when clinically appropriate, on the review and discussion of the child’s narrative.
• In families where the children’s trauma involved the death of a parent or sibling or other trauma impacting the parent, even the most competent parents may experience difficulty in implementing optimal parenting practices.
• Maintaining normal routines and consistency in rules and expectations in the face of the stress of traumatic stress and grief promotes adaptive functioning for children even in these trying circumstances.
• Helping these parents utilize the coping skills to model healthy adaptive coping behaviors for their children.

Troubleshooting

• Parents sometimes blame themselves for their children’s exposure to abuse, violence, or other forms of trauma.
• Emphasize that no parent is able to protect a child from adverse events 100% of the time.
• Help children learn effective coping skills that will be valuable in recovering from the trauma endured as well as more effectively coping with whatever life brings their way in the years to come.
• When sharing parenting guidance, praise a parent’s effective use of specific skills as well as his/her overall dedication.
• Explain that it will be helpful to enhance their parenting skills to address the unanticipated trauma and to support their child’s full recovery.
• Children should understand that when they are instructed to go to time-out, they will not be allowed to have any privileges (e.g., TV, computer, phone) until the time-out is completed.
• A time-out room that contains toys, games, TVs, or other fun activities is overstimulating and does not provide the child with the atmosphere to regain control.
• If the parent is unable to take the child to a time-out location without a physical confrontation, the parent instead can put a prized toy or electronic device in the time-out location or remove him/herself to another room (effectively giving him/herself a time-out), thereby depriving the child of the parent’s attention for the designated time period.
• Modeling praising behavior by noticing and remarking on the parents’ positive actions may be helpful in this regard (in effect, “catch them” being good parents).
• It is not a matter of totally ignoring unacceptable, disrespectful behaviors; it is more a matter of rebalancing the amount of attention paid to those behaviors relative to more appropriate behaviors.
• The goal is to reverse the balance of attention so that the parent is giving much more praise and attention to the 10 minutes of decent behavior and withdrawing attention and praise when the problem behavior happens.
• The mother turning away, withdrawing, and quietly saying, “I don’t like that behavior” is a very potent punishment when the child has been getting lots of negative attention that inadvertently reinforced such behaviors in the past.
• The parent and therapist should work together to design an appropriate way to withdraw attention from the child’s negative behavior; it could be as simple as looking away from the child, very briefly explaining to the child that that was not a nice thing to do, that it hurt Mommy’s feelings, or that it was not a safe behavior.
• Most importantly, selective attention is not effective if it is not combined with efforts to provide more positive parental attention, particularly for prosocial behaviors that can replace the problem behavior (e.g., minimizing attention to whining while increasing praise to polite requests or efforts to use a pleasant tone of voice).
• All behavioral interventions must be individualized to fit the child and parent being treated.
• The ultimate goal is not to reduce parental attention overall but to rebalance how the child is able to obtain parental attention, such that approximately 80% of the time the child is receiving parental attention for positive behaviors and only 20% of the time for negative behaviors.