Kazdin Method®

Parent Management Training

 PMT Skills 4-12
1. Attending and Ignoring
2. Shaping
3. Low Rate
4. Reprimands
5. Negotiating and Compromise
PMT 4
Consequences of Behavior
Attending and Ignoring

When used together these skills are

useful in decreasing irritating behaviors
such as whining, complaining, noisiness
and so forth.
 Annoying Behaviors
 Whining
 Bad table manners
 Complaining
 Calling parent/unable to play alone
 Pleading to be bought things in stores
 Crying
 Noisiness
 Pouting
 Interrupting
 Attending

 Define behavior you want to increase

 Decide what type of attention to use
 Decide when to use it
 Attending

Anytime you give any behavior

attention, that behavior increases.
 Define the Behavior You Want to
Increase (Positive Opposite)
Annoying Behavior Positive Opposite

Whining Using a normal voice

Saying something nice

Complaining

Interrupting
Waiting quietly, playing in
other room
 Types of Attention
 Eye Contact
 Talking
 Playing
 Smiling
 Praising
 Ask Questions
 Touch on the back
 Thumbs up
 Okay sign
 When to Give Attention
 During the positive behavior
 Immediately after the positive behavior
 Ignoring

A mild punishment technique used to

decrease annoying behavior
 Ignoring

 Define the behavior you want to decrease

 Decide what type of ignoring to use
 Decide when to use it
 Decide what positive behavior to pay
attention to
Define the Behavior You Want to Ignore

Annoying Behavior Specific Definition

Whining asking for something in a

droning, irritating voice

Pleading for asking for something

Something over and over again

Interrupting disrupting conversation,

saying “excuse me”, asking
for things during a conversation
 Types of Ignoring
 Look away
 Talk to someone else
 Get on the phone
 Watch TV
 Look at a book
 Walk away
 Pretend to do something else
 Decide When to Ignore

 Immediately ignore annoying behavior

 Prompt once for positive opposite and
then ignore annoying behavior
Two Potential Side Effects of Ignoring

 Annoying behavior may escalate when a

parent first ignores – keep ignoring
 Annoying behavior turns aggressive –
use time-out
 Case Scenario
Your child has a major report due for school. A few nights before
the due date, you encourage your daughter to start her book
report, but she complains and states, “I don’t want to do it now,
I’ll do it later!” You calmly remind her that she can earn bonus
points on her point chart for working on it that night. She gets
her books and mumbles under her breath, “This is stupid, I hate
this class, and who cares about this topic?” She looks out the
window for a few minutes and begins working again. After
working on it for 20 minutes she looks up and yells, “This is all of
your fault, I wanted your help last week but you were too busy!”
Two minutes later she pulls the book back and begins reading. As
she continues her report, she starts to look confused and calmly
asks her mother for help.”
 Case Scenario

A family of four is at a restaurant for dinner. The six-

year-old girl is eating with her hands and making a
big mess. A moment later, she picks up her napkin
to wipe some food off of her face. After placing the
napkin down, she taps her fork on the plate and
complains about her food. A few minutes later she
takes another bite using her fork. Then she asks
calmly if she can get up from the table to look at the
fish tank.
 Case Scenario
You are in the grocery store with your child.
He wants you to buy a package of cookies
that you have said “no” to. He starts to cry.
His crying is getting louder and then
escalates to yelling. He throws himself on
the floor and continues to scream. Other
customers are beginning to stare
disapprovingly.
 Answers
This is a difficult situation!

The parent should:

 Prompt in the beginning to accept the answer calmly in order
to earn points.
 Ignore by looking away with no facial expression during
negative behavior. If the child takes a break, the parent
should attend by looking at or talking to the child at any calm
moment.
 If the tantrum becomes aggressive the parent should
implement a time-out with loss of privilege if necessary.
 Leave the store calmly if the parent is uncomfortable or the
child continues to escalate.
 Parent Concerns
 I cannot allow the behavior to continue.
 Child and/or siblings see this behavior as
acceptable if ignored.
 I feel as though I am purposely making
my child angry by ignoring.
 I feel as though I am being rude by
ignoring.
 Three Role Plays
 Attending alone
 Ignoring alone
 Attending and Ignoring together
PMT 5
 Shaping

An extremely useful technique for

behaviors that are:
 Inconsistent
 Non-existent
 Very complex
 Appropriate Behaviors to
Shape
 Speaking nicely
 Handling self calmly and respectfully when told
no, frustrated or upset
 Being kind to siblings
 Getting ready for school
 Homework
 Instrument
 Bedtime routine
 Cleaning bedroom
 Picking up toys
 Academic task at home (reading)
 Guidelines for Shaping
 Define beginning behavior and goal behavior
 Reinforce beginning behavior until it occurs
consistently
 Slowly increase the requirement for your child to
get the reinforcer
 If child is doing less than expected – Do not
reinforce, just acknowledge
 Once goal is reached, continue to reinforce
behavior
 Shaping Worksheet
FIRST STEP: ________________________________________________________________________
**REINFORCE THIS BEHAVIOR UNTIL IT OCCURS CONSISTENTLY (4-6 DAYS).
**THE REINFORCER I WILL USE IS: _____________________________________________________

SECOND STEP: ______________________________________________________________________

**REINFORCE THESE TWO STEPS CONSISTENTLY (4-6 DAYS).
**THE REINFORCER I WILL USE IS:
____________________________________________________________________________________

THIRD STEP: ________________________________________________________________________

**REINFORCE THESE THREE STEPS CONSISTENTLY (4-6 DAYS).
**THE REINFORCER I WILL USE IS:
____________________________________________________________________________________

FOURTH STEP: ______________________________________________________________________

**REINFORCE THESE FOUR STEPS CONSISTENTLY (4-6 DAYS)
**THE REINFORCER I WILL USE IS:
____________________________________________________________________________________

LAST STEP: _________________________________________________________________________

**REINFORCE THESE FOUR STEPS CONSISTENTLY (4-6 DAYS).
**THE REINFORCER I WILL USE IS:
____________________________________________________________________________________
 Shaping Worksheet Example
Talking Respectfully (Swearing)
FIRST STEP: Talking respectfully for the first half hour after school 3:00 to 3:30
**REINFORCE THIS BEHAVIOR UNTIL IT OCCURS CONSISTENTLY (4-6 DAYS).
**THE REINFORCER I WILL USE IS: 1 music download

SECOND STEP: Talking respectfully for the first hour after school 3:00 to 4:00.
**REINFORCE THESE TWO STEPS CONSISTENTLY (4-6 DAYS).
**THE REINFORCER I WILL USE IS: 1 music download

THIRD STEP: Talking respectfully for the first hour and a half after school 3:00 to 4:30.
**REINFORCE THESE THREE STEPS CONSISTENTLY (4-6 DAYS).
**THE REINFORCER I WILL USE IS: 1 music download

FOURTH STEP: Talking respectfully for the first 3 hours after school 3:00 to 6:00.
**REINFORCE THESE FOUR STEPS CONSISTENTLY (4-6 DAYS)
**THE REINFORCER I WILL USE IS: 1 music download

LAST STEP: Talking respectfully for the evening 3:00 to bedtime.

**REINFORCE THESE FOUR STEPS CONSISTENTLY (4-6 DAYS).
**THE REINFORCER I WILL USE IS: 1 music download
 Using Shaping for School
Problem Behaviors
Why it works:
 Minimal work required on teacher’s part
 Breaks the day down so that the child
will be successful
 Parent is in charge of reinforcement
 Teachers and parents tend to focus on
the positive because the program
surrounds the positive opposite
 Parents learn how to respond effectively
to both positive and negative reports
 Setting up School Program
 Call teacher before session
 Establish beginning behavior with
parent based on teacher feedback
 Create positive reinforcement plan
 Role-play 3 scenarios
 Teacher Phone Contact
 Call teacher to get feedback on the
behavior to work on
 Ask about positive and negative
behaviors
 Tell teacher the program will take time
and to focus only on specified behavior
with the intention to broaden time frame
 Send daily forms to teacher through
parent or mail
 School Program Form

Child’s Name: ____________________ Date: __________ Day: __________

Teacher Instructions: Please rate the child’s degree of compliance with the
following behavior in the classes listed below. Place your initials in one of the
three spaces provided which describes the child’s behavior the best and send
the sheets home to the parents’ daily.

Behavior: _______________________________________________________

Definition: ______________________________________________________
________________________________________________________________

Class or Time : _________________________

Teacher’s Initials:

( ) MOST OF THE TIME

( ) SOME OF THE TIME
( ) VERY LITTLE OF THE TIME
 School Program Example
Teacher Instructions: Please rate the child’s degree of compliance with the following
behavior in the classes listed below. Place your initials in one of the three spaces
provided which describes the child’s behavior the best and send the sheets home to
the parents’ daily.

Behavior: Being Respectful of school rules

Definition: Following directions from the teacher the first time asked, following
school rules without questions, saying nice things to others, using a calm tone of
voice, keeping hands and feet to self

Class or Time: First hour of school

Teacher’s Initials:

( ) MOST OF THE TIME

( ) SOME OF THE TIME

( ) VERY LITTLE OF THE TIME

Go to Shaping Programs for Common
Behavioral Problems
 Intermittent  Bedtime/Sleep Fairy
Reinforcement  Used for younger
Programs kids who struggle
 Doing HW calmly with falling asleep on
and productively their own, bedtime
 Riding in car nicely routine, or staying in
with siblings bed all night.
 Playing nicely with  This can be done for
friends-sharing older kids but they
taking turns would know parent is
leaving the reward
Two-Tiered Reward Shaping Programs
 Amazon program – Used to decrease
number of TO’s. Therefore decreasing
aggression if things aren’t where you want
them to be.
 Have child put items in shopping cart
 Parent should assign number of no TO days
to each item.
 School Program – Reward for certain number
of days with “Most of the Time”. Increase
days when you think child is ready.
PMT 8
Low-Rate Punishment
 Used for serious behaviors that occur no more than
once a week
 Better than typical parent response to serious
behaviors
 Giving a chore or loss of privilege
Low-Rate Behaviors
 Stealing
 Lying
 Fire setting and match play
 Destroying property
 Running away
 Alcohol and drug use
 Inappropriate sexual content found on phone
(inappropriate comments, nude selfies)
Low-Rate Rules

 Explain to the child

 Observe or (strongly suspect) the behavior
 Select a tedious chore
 Stay calm
 Use immediately
 Don’t threaten
 Don’t debate or argue
 Low-Rate Rules
 If he won’t do the chore, calmly tell him you won’t be
able to start the time until he starts the chore.
 If he still won’t go, give the choice of either doing the
chore or losing a privilege.
 If the child starts the chore but is angry or purposely
doing a terrible job, calmly stop the chore and take
away the privilege.
 Praise your child once he begins the chore and while
he is doing it.
 Continue to praise positive opposite.
Low-Rate Behavior Program
1. Define low-rate behavior.
2. Parent decides if behavior has occurred.
3. Set two levels of consequence.
4. All occurrences of the low-rate behavior should be
followed by the chore.
5. Positive reinforcement should be used for the
positive opposite.
6. The program should remain in effect for at least 6
months.
Low-Rate Speech
Example: Stealing
“I know there are times when you see something you really
want and may be tempted to take it. There are times when I
really want something too but instead of taking it there are lots
of things you can do instead. You can ask me for something,
you can ask to borrow something, you could save up for what
you want, or we could put it on your point chart. You are doing
some of these things already!!! However, if I find that you have
taken something – or suspect that you have taken something,
you will have a chore. If its small like taking your sister’s shirt
w/out permission or change off my dresser it will be a smaller
chore. If it is something more serious such as taking money out
of my wallet or something from a store, you will have a larger
chore. But you know what? I don’t want to give you any chores
and I am sure you don’t want to do any chores…so lets just
stay as far away from taking things as possible.”
Low-Rate (Fill in the Blank)
Speech
“I know that there are times when you want to ____________. There are
times I really [feeling or desire], but
instead of [low-rate behavior], there are many things you can do instead.
When this happens, you can always
____________, ____________, or ____________. Now you are already
doing many of these things. However,
when I find that you did [low-rate behavior] or suspect you of that, even if
you [trivial occurrence of low-rate
behavior], I will give you a chore. If it is something small like
____________, you will have a small chore. If
it something bigger like ____________, you will have a bigger chore. But
you know what? I know you don’t
want to do any chores, and I don’t want to give you any chores, so let’s stay
as far away from ____________
as possible.”
Parent
Session 9
Reprimands
 Mild punishment technique
 Can use nonverbal expressions of disapproval
 Used for behaviors that are not aggressive but are
inappropriate
 Reinforce positive opposite
 Use firm and calm tone
 Be close
 Be consistent – don’t ignore behavior if you have
decided to reprimand it
 Physically terminate dangerous behavior
 Use loss of privilege as a back up
Appropriate Behaviors to
Reprimand
 playing ball in the house
 running in the house
 jumping on furniture
 rough housing
 yelling or playing too loudly
 splashing water out of tub
Effective Reprimand
 What to stop: “Joe, stop bouncing the ball in
the house.”
 Why to stop: “You might break something.”
 What to do instead: “Please take it outside
to play.”
 If the child complies – praise
 If the child continues – loss of privilege
Sessions 10 and 11
Compromise
 Used for ages 7 and older
 Two sessions: 1st session with parents alone
2nd session with parents and child
 Scripted tool (see handout) to assist families in
calmly discussing and generating solutions about a
difficult issue or disagreement
Common Behaviors for Compromising
 Pets
 Curfew
 Makeup
 Hair color
 Dating
 Piercings
 Tattoos
 Going to parties
 R-rated movies
 Having a phone
Rules of Compromising
 Be calm
 Be objective
 Be a good listener
 Be respectful
 Stay on the subject
 Offer suggestions when you disagree
 Focus on the present
Steps of Compromising
1. Open the discussion and review rules
2. Gather information
3. Focus on common interests
4. Create options
5. Evaluate options and choose a solution
6. Write the agreement
Problem Behaviors – What are the most
effective and appropriate interventions?

1) Child who won’t sit for dinner

2) Aggression when told no
3) Won’t stay in bed
4) Throws a fit when asked to get off screens
5) Struggles to be to school on time
6) Refuses to take medication
7) Siblings fighting constantly
8) Brushing teeth
9) Taking a shower
10) Homework
11) Won’t buckle seat belt
12) Constant fighting in the car
13) Transitions are hard
14) Child struggles to share, take turns, and likes to tell kids what to
do on playdates and won’t participate is it isn’t what they want to
do
Challenging Questions/Situations
1. How do you advise parents of kids who get upset and have a ton
of negative self-talk (e.g., "I'm the worst kid, I'm so stupid, I
should never have been born") and actions (hitting self in the
head). These seem to be triggered when a child acts out/is in the
midst of an anger outburst.
2. Why is my child acting like this?
3. Time out isn’t working – he had a major meltdown after I tried it
the first time and he didn’t go. I only tried is a couple more times
and he just keeps losing a privilege so I stopped using it.
4. The program isn’t working. He is manipulating it and is only nice
to me during the shaping time.
5. Parent keeps interjecting during the session with complaints
about her child’s behavior.
6. There are days when the child hasn’t earned any
mindings/compliances
7. A parent (who is also a doctor) is frustrated and says he doesn’t
think this is working and that his son (who has a DMDD dx) must
have some sort of personality disorder or psychosis.
 Kazdin Method® PMT Certification

Train how Dr. Kazdin’s Certified Specialists were

trained at the Yale University Child Conduct
Clinic.

Certification entails approximately 20-25 intensive

training sessions via Zoom with a Certified Trainer
or through a home study program.

Please call or email us for details!

 Problem Solving Skills Training
PSST

Cognitive-Behavioral Treatment program developed by

Dr. Alan Kazdin to teach children to learn to "stop and
think about positive solutions to problems before
acting on them."
 When done in conjunction with PMT this evidence-
based treatment is proven to decrease behavioral
challenges even more effectively than PMT alone!
 Works with children ages 5-15.
 Professional Training in PSST available!
 Tracie Bush, M.A., CKPMT
Tracie worked at the Yale University Parenting
Center and Child Conduct Clinic with Dr. Alan
Kazdin for six years and is one of four clinicians
certified to train professionals in Kazdin’s PMT.
She also worked as a Research Coordinator at the
Attention Deficit Hyperactivity Disorder Clinic at
the University of Massachusetts Medical Center,
in Worcester, MA with Dr. Russell Barkley. She
received both her B.A. in Psychology and English
and her M.A. in Counseling Psychology from
Assumption College.
traciebush@gmail.com
203-848-7169
PMT 3 - Consequences
Kazdin Method® Parent Management Training
Part 2

PMT 3
Consequences
 Time-Out

Time out is a mild punishment used to eliminate

any reinforcement for behavior. When done
consistently time out has been proven to
decrease or eliminate negative behavior.
 Harsh Punishment

 Short-term success
 Emotional reaction in child
 Child may start to avoid the parent
 Cause child to become aggressive
 Does not teach child how to solve problems
 Punishment alone doesn’t teach new or appropriate
behaviors
 Time-Out
Myths and Facts
Myth - Child is sent to TO to think about what they did wrong.
Fact – We can’t control what a child is thinking about.

Myth – Child should stay in TO until they calm down.

Fact – Putting a child in TO for a long time creates an aversive environment which will lead
to worse behavior.

Myth – Parent should force a child to stay in TO by holding them there or locking them in a
room.
Fact – Touch is very reinforcing and locking a child in a room creates an aversive
environment and child will behave worse.

Myth – The length of time a child should be sent to TO depends on their age. If a child is 10
they should have a 10 min TO.
Fact – A 1 minute TO is just as effective as a longer TO.
Fact – An 8 minute TO is the longest a child should be in TO. Any longer and it becomes an
aversive environment and child will behave worse.
 Time-Out
Factors That Influence Its Effectiveness

 Contingent
 Immediate
 Consistent
 Eliminate all reinforcement for negative
behavior
 Reinforcement of positive opposite
behavior
 Time-Out
Contingent

 Parent should be fairly certain the behavior

happened before giving a TO.
 If parent is truly unsure then no TO should be
given
 If TO is given mistakenly the parent should
apologize and move on.
 Time-Out
Be Immediate

 TO should be given right away, immediately after

behavior occurs
 Don’t threaten TO, give it.
 There may be rare instances when TO has to be
given at a later time.
 Time-Out
Be Consistent

 TO should be given every time the behavior

occurs.
 Work on one group of behaviors at a time to
maintain consistency.
 Start with most egregious behavior – typically
physical and/or verbal aggression.
 Time-Out
Eliminate All Reinforcement For Behavior

 Pick a place for TO that is boring with nothing

for the child to do.
 Hallway
 Dining room
 Bottom of a staircase
 Never a bedroom or playroom
 Multiple places far from each other may need to
be used if there are more than two children.
 Parent should be close by, but not staring at
child.
 Time-Out
Reinforcement for Positive Opposite Behavior

 Punishment DECREASES negative behavior

 Praise and reinforcement INCREASE positive
behavior
 Chart

 Shaping

 Role-plays

 In the moment
 Setting Up a Time-Out Program

 Clearly and specifically define behavior-exactly

what will get the child into a TO.
 If child is physically aggressive much of the time
then use TO only for physical aggression until you
see a decrease and then add in verbal aggression.
 If there is no physical aggression then use TO for
verbal aggression.
 If there is no physical or verbal aggression decide
what behavior to use it for if needed.
 Four Types of Time-out

 Cooperative
 Resistant
 Noisy
 Refusal
 Cooperative Time-Out

 Be calm
 Briefly tell child exactly why and for how long
to go to TO
 Praise child for going (ignore all disruptive or
aggressive behavior on way to TO).
 Set time-walk away but not to far
 Praise child for sitting in TO after the timer
goes off and it’s over. Move on!
 Don’t force an apology
 No lectures
 Resistant Time-Out
 Be calm
 Briefly tell child exactly why and for how long to go to
TO
 When child becomes resistant
 Parent should ignore and silently count to 3
 At 3 no matter what child is doing, (parent shouldn’t
wait for child to stop yelling or yell over the child)
parent should calmly say. “You have a choice, either
go to TO calmly or you will lose (a privilege) dessert.”
 Child doesn’t want to lose dessert so goes to TO
 Praise for sitting down and then Praise for completing
time-out
 Noisy Time-Out
After Being Cooperative

 Same as Cooperative TO but…

 Once child is in TO child becomes noisy, getting up,
asking for things, yelling, hitting the wall, throwing
things etc.
 Parent should walk back to TO area and say, “You have
a choice, either sit here calmly and quietly or you will
lose (a privilege) dessert.”
 Child doesn’t want to lose dessert so becomes quiet.
 Parent should praise and walk away until time is up
 Once time is up Parent should walk back in and say, “Great job
finishing TO quietly and calmly. You are all set to go.”
 Child continues to be noisy or gets up.
 Parent should ignore and count to 3 silently
 Then say, “You made your choice no dessert for tonight. TO is over.”
 Noisy Time-Out
After Being Resistant

 Same as Resistant TO but…

 Once child is in TO child becomes noisy, gets
up, asks for things, yells, hits the wall, or
throws things etc.
 Since child was at first resistant, parent has
already given the choice once. So it isn’t given
again. Parent should walk back to TO area and
say, “You’ve made your choice, no dessert
tonight and TO is over. You can go.”
 Refusal Time-Out

 Same steps as Resistant TO but…

 Child still isn’t going after being given the choice
and may be yelling or continuing to hit.
 Parent should ignore and silently count to 3
again.
 At 3 parent should say, “You have made your
choice. No dessert tonight and TO is over.”
 Privilege Loss

 Doesn’t have to be lengthy to be effective

 Never take anything away for over 24 hours
 Make a list with parent of possible privilege losses
 Only take away things parent can control without a power
struggle
 Don’t take away rewards or points
 Screen time that is given as “free time” on the chart can be
used
 Don’t take away sports, birthdays, vacations, or special
events.
 Don’t take away play dates unless child is very social
 After Time-Out is Over

 If the child broke something on the way to or

in TO, or made a mess, prompt child to clean
it up.
 Give minding points if complies. Let it go or
do it yourself if they don’t comply.
 Avoid lectures, discussion of behavior, and
prompts for apologies.
 Avoid punishment on top of punishment.
 Time-Out
Rules

 No TO on top of TO
If child is still aggressive after time-out is over or after
privilege loss parent should ignore
Parent has already punished this behavior it is just still
continuing
Punishment doesn’t stop behavior in its tracks. It
decreases it over time.
 Only 3 TOs allowed in a day
Giving a 4th or 5th TO causes an aversive environment
which can make behavior worse
Parent should instead ignore
 Guidelines for Explaining
Time-Out to Children

1. Select a time to talk when everyone is relaxed and in

good control.
2. Calmly explain procedure to the child – don’t debate or
argue with him about TO.
3. Have child practice (role-play) TO with you, at a time
when everyone is calm and relaxed.
* Be sure to praise him afterwards for cooperating
4. If child refuses to practice – drop the issue and just
start TO when needed.
 Variations of Time-Out

 Away from home

 In car
 TO for parent
 TO of toys
 Parent Concerns

 Before TO is explained in detail

 Punishment has never worked for my child
 Too much punishment was given randomly
 Child became satiated on punishment

 There is no way he will go to TO

 How to handle this is explained in detail during the role-plays
 Parent’s are typically very surprised when their child actually
goes. Which happens with the majority of kids.
 After TO has been tried
 Child flipped out the first couple of times when I used this
TO and lost a privilege so it didn’t work.
 It still works even if child always loses a privilege
 Tracie Bush MA, CKPMT

Tracie worked at the Yale University Parenting Center

and Child Conduct Clinic with Dr. Alan Kazdin for six
years and is one of four clinicians certified to train
professionals in Kazdin’s PMT. She also worked as a
Research Coordinator at the Attention Deficit
Hyperactivity Disorder Clinic at the University of
Massachusetts Medical Center, in Worcester, MA with
Dr. Russell Barkley. She received both her B.A. in
Psychology and English and her M.A. in Counseling
Psychology from Assumption College.
traciebush@gmail.com
203-848-7169
 Kazdin, A.E. (2017). Parent management training and problem-solving skills training for
child and adolescent conduct problems. In J.R. Weisz & A.E. Kazdin (Eds.). ​Evidence-based
Psychotherapies for Children and Adolescents ​(3rd ed., pp. 142-158). New York: Guilford Press.

CHAPTER 9
Parent Management Training and Problem-Solving
Skills Training for Child and Adolescent Conduct
Problems
Alan E. Kazdin

OVERVIEW OF THE CLINICAL PROBLEM

Our intervention work has focused on disruptive behavior disorders among children and
adolescents (ages 2-15) who are referred for inpatient or outpatient treatment. Our primary focus
has been with children referred for extreme physical aggression and property destruction, but
they evince the full range of behaviors include in the diagnosis of conduct disorder (CD; e.g.,
bullying and threatening others, lying, stealing, cruelty to animals, fire setting; American
Psychiatric Association, 2013) We have expanded our more recent work to include children
referred for stub​bornness, defiance, and unmanageable behaviors encompassed by the diagnosis
of oppositional defiant disorder (ODD). Children with either CD or ODD show significant
impairment in their functioning at home, at school, and in community settings (e.g., social and
athletic events).

A great deal is known about CD in terms of correlates, risk and protective factors,
long-term course, genetic influences, and characteristics of brain activity (e.g., Lahey &
Waldman, 2012; Moffitt & Scott, 2009). For example for CD, we know that there are untoward
long-term deleterious consequences that encompass mental and physical health, substance abuse,
criminal behavior, and maladaptive functioning in everyday life (e.g., employment, managing
finances). ODD also has a poo r long​ term prognosis, even though this disorder has been less
well studied than has CD (Nock, Kazdin, H ir ipi, & Kessler, 2007).

For both CD and ODD, fundamental questions related to etiology and processes through
which symptoms emerge remain to be resolved. Perhaps all the more encouraging is that at this
time, several evidence-based treatments have been devised (Kazdin, 2015). These interventions
span the full range of severity from stubbornness and defiance in young children to violence
among adjudicated adolescents. This chapter reports on our work on parent management training
(PMT) and cognitive problem-solving skills training (PSST).

CONCEPTUAL MODEL GUIDING THE TREATMENT

PROGRAM
Our default treatment has been PMT. However, in our early work with inpatient cases,
occasionally there was no parent available to participate in treatment (e. g., due to mental illness,
substance abuse, serving in prison). For such cases, we developed PSST and met only with the
child in treatment.

Our emphasis on PMT stems from two separate bodies of research: (1) the seminal
conceptual and empirical work of Patterson and his colleagues that focuses on coercive
sequences of parent- child interactions and how they can be altered (e.g., Patterson, 2016; Reid,
Patterson, & Snyder, 2002), and (2) advances in applied behavior analysis on how to change
behavior (e.g., use of establishing operations, functional analysis, differential reinforcement;
Cooper , Heron, & Heward, 2007; Kazdin, 2013). These lines of work can be translated into
multiple concrete techniques to alter both parent and child behavior.

PMT emphasizes changing how the child responds in interpersonal situations at home, at
school, and in the community and with teachers, parents, peers, siblings, and others. The
treatment uses learning -based procedures to develop behav​ ior and includes modeling,
prompting and fading, shaping, positive reinforcement, practice and repeated rehearsal,
extinction, and mild punishment. The treatment sessions develop skills that the parents use to
implement behavior change programs in the home.

PSST focuses on cognitive processes, a broad class of constructs that pertains to how
individuals perceive, code, and experience the world. Individuals who engage in conduct
problem behaviors, particularly aggression, show distortions and deficiencies in various
cognitive processes (e .g., Lochman, Powell, Whidby, & FitzGerald, 2012). Examples include
generating alternative solutions to interpersonal problems (e .g., different ways of handling social
situations), identifying the means to obtain particular ends (e.g., making friends) or consequences
of one's actions (e.g., what could happen after a particular behavior); making misattributions to
others of the motivation for their actions, perceiving how others feel, and expectations of the
effects of one's own actions. Deficits and distortion among these processes relate to teacher
ratings of disruptive behavior, peer evaluations, and direct assessment of overt behavior. Our
program initially drew heavily on the pioneering work of Shure and Spivack (e. g., Shure, 1992;
Spivack & Shure, 1982).

CHARACTERISTICS OF THE TREATMENT PROGRAM

Who Is Seen in Treatment

Our program began with an exclusive focus on CD among children ages 5- 12 referred
for inpatient care (Child Psychiatric Intensive Care Service, University of Pittsburgh School of
Medicine). The program expanded to outpatient treatment, which has been the focus for
approximately 25 years. Our current program, carried out at the Yale Parenting Center, provides
services for children and families (see Kazdin, 2011). Younger and younger clinical referrals and
pleas from mental health professionals and parents gradually expanded our age range (to ages 2-
15). We continue to focus on CD. However, referrals have increased among children (under 5
years of age) who are more likely to be referred for stubbornness, tantrums, and defiance at home
and other settings (preschool, day care).

The children are referred for oppositional, aggressive, and antisocial behavior, and
usually meet criteria for a primary diagnosis (using DSM criteria) of CD or ODD.
Approximately 70% of the children meet criteria for two or more disorders (range: zero to five
disorders). Most youth fall within the normal range of intelligence (e.g., mean Full-Scale IQ=
100-105; range from 60 to 140 on the Wechsler Intelligence Scale for Children-Revised). The
families we see are European American (-60-70% across projects), African American (-10-20%),
or Hispanic American (-1-7%), Asian and Native American (-1-2% each), with multiracial
fami​lies forming the remainder. The sex ratio of boys to girls in our projects is 3-4:1.
Approximately 50% of our cases come from two-parent families; the full range of
socioeconomic and educational status is represented.

Content of the PMT Sessions

Intervention with the Parent(s)

PMT ​is conducted primarily with the parent(s) or caregiver (s) . The core treatment
currently consists of five to 10 weekly sessions (45-60 minutes each). We have varied the
duration of treatment over the course of projects. Our current treatment includes a core set of
themes (see Table 9.1), each of which usually is covered in a single session. Optional sessions
(usually three or fewer, if needed) can be used to address emergent problems, to refine a
behavior change program, and or review content of a prior session. The individual sessions
usually begin with a discussion of the general concept and technique for that session and how it
is to be implemented. Most of the treatment session consists of modeling by the therapist and
role playing and rehearsal of the parent.

For example, in a session on attending and ignoring, parents engage in several role plays
with the therapist. Parent and therapist may alternate the role of the child and the parent. The
"child's behavior" is modeled by the therapist, who is demanding something, especially after
being told "no." The therapist whines, follows the parent who is walking away, and is demanding
to be heard and to have some parental decision overturned; the parent ignores. Once the child
calms down or begins to ask something nicely, the parent attends to the child and, depending on
the behavior, may even praise the child for calming down quickly. This is rehearsed multiple
times to help the parent practice ignoring and walking away, then return calmly to reinforce
behavior that is more appropriate on the child's part. The therapist sculpts parental behavior with
antecedents (verbally and nonverbally before and during the enactments), feedback and praise
(for small or large components of what the parent is doing), shaping, and moving to more
complex and unreasonable child behavior that mimic worst-case scenarios of the child.

TABLE 9.1. Parent Management Training Sessions: Overview of the Core Themes and
Sessions

1. Introduction and Overview. ​This session provides the parents with an overview of the
program and outlines the demands placed upon them and the focus of the intervention.

2. Defining ana Observing. ​This session trains parents to pinpoint, define, and observe
behavior. The parents and trainer define specific problems that can be observed, and
develop a specific plan to begin observations.

3. Positive Reinforcement (Point Chart and Praise). ​This session focuses on learning the
concept of positive reinforcement, factors that contribute to the effective application, and
rehearsal of applications in relation to the target child. An incentive ( oken/point_) chart
is devised , and _the delivery praise of the parent is developed through modeling ,
prompting, feedback , and praise by the therapist.

4. Time-Out from Reinforcement. ​Parents learn about time out and the factors related to its
effective application. Delivery of time out is extensively role-played and practiced.

5. Attending and Ignoring. ​Parents learn about attending and ignoring and choose
undesirable behavior that they will ignore and a positive opposite behavior to which they
will attend. These procedures are practiced within the session.
 6. Shaping/School Intervention. ​Parents are trained to develop behaviors by reinforcement
of successive approximations and to use prompts and fading of prompts to develop
terminal behaviors. Also, in this session, plans are made to implement a home-based
reinforcement program to develop school-related behaviors based on consultation of the
therapist with the school.

7. Review of the Program. ​Observations of the previous week , as well as application of the
reinforcement program, are reviewed. Details about the administration of praise, points,
and backup reinforcers are discussed and enacted so the therapist can identify how to
improve parent performance. The parent practices designing programs for a set of
hypothetical problems.

8. * ​Family Meeting. ​At this meeting, the child and parent(s) are brought into the session.
The programs are discussed along with any problems. Revisions are made as needed to
correct misunderstandings or improve implementation.

9. and 10.* ​Negotiating, Contracting, and Compromising. ​The child and parent meet
together to negotiate new behavioral programs and to place these in contractual form. The
therapist shapes negotiating skills in the parent and child, reinforces compromise, and
provides less and less guidance as more difficult situations are presented.

11. Reprimands and Consequences for Low-Rate Behaviors. ​Parents are trained in effective
use of reprimands and how to deal with low-rate behaviors such as fire setting, stealing,
or truancy.

12. Review, Problem Solving , Practice, Role Reversal. ​Parents practice designing new
programs, revising ailing programs, and responding to a complex array of situations in
which principles and practices discussed in prior sessions are reviewed. Also, parents
pretend to be the therapist and "train" the therapist pretending to be a parent.
_____________________________________________________________________________________________________________________

Note.​ ​The complete manual and supporting materials are provided elsewhere (Kazdin, 2005). Our sessions have varied in number in different
projects. Rather than number of sessions, the content areas of this table are more critical. Those sessions with an asterisk (*) are the ones we have
not included in our recent versions of treatment.

In some of our clinical trials, the child has been brought into the PMT sessions to reenact
situations that have occurred in the home and handle new situations. With the child present, one
can directly observe parent execution of procedures and child behavior in reenactments of
situations that transpired at home. Also, we can ask the child questions that corroborate parental
report of the program in the home or suggest inconsistencies. Currently, we do not include the
child in the sessions; effective intervention has not required that. Also, scheduling children to be
part of the sessions has raised more challenges in treatment delivery, because sessions can only
be conducted after school or by taking the child out of school to attend the session.

Program Components Worth Emphasizing

PMT includes three critical components to effect behavior change in the parent and child,
namely, the use of antecedents, behaviors, and consequences (see Kazdin, 2013). ​Antecedents
(what comes before the behavior) increase the likelihood of obtaining child behaviors we seek
(i.e., prompts, establishing operations) and include instructions, calm or playful tone of voice,
supportive gestures and glances, and allowing choices when possible. We also train parents to
omit harsh comments, nagging, threats, appeals to authority, and punitive physical contact (e.g.,
pulling a child) that are likely to decrease compliance or prosocial behavior (i.e., abolishing
operations).

Behavior ​refers to ways of crafting and obtaining the behaviors of interest and includes
three strategies. First and most straightforward is "shaping," which refers to developing goal
behavior in steps or small increments until the final goal is achieved. Second, we use simulations
in which the parent and child enact the desired behaviors under game-like circumstances. For
example, the parent and child may play something called the "tantrum game," in which the
parent pretends to deny an activity or privilege (e.g., "You cannot use the computer tonight"), the
child enacts a controlled tantrum (e .g., no hitting of the parent, breaking things, or shouting),
and then is praised for the result. This "game" can be used for many different behaviors when
shaping is not likely to be a viable option, because initial small increments of the behavior are
not present or evident with enough frequency. The "game" is a superb venue for combining
antecedents and consequences, and can readily achieve the main goal of the intervention,
repeated practice. As in other "simulations" (e.g., used by commercial airline pilots, by collegiate
and professional athletic teams) the practice carries over to everyday circumstances and may
then be directly fostered (reinforced) there. Finally, we use the game component to real-life
situations that are not quite simulations. For example, to speak nicely or without swearing, we
have used a game and challenge at the dinner table in which some contingency is in place for the
entire family. It is a game in once sense (playful, artificial, and a challenge) but also part of a
genuine everyday situation (eating dinner together). Shaping can be incorporated into the game
as needed to develop behavior gradually.

The third component, ​consequences, ​focuses primarily on praise. We distinguish the

praise that parents normally use (and encourage continuation of that) from strategic and special
praise designed to alter behavior. With young ch ild ren, usually this is effusive praise, a
statement of precisely what is being praised, then some non verbal gesture (e.g., patting the
child's back or shoulder). With adolescents, the three components (verbal praise, statement,
nonverbal gesture) are all included but are altered to be more "cool" and teen-friendly (e.g., no
effusiveness-maybe praise and a statement that is whispered or privately conveyed, and a
high-five hand gesture in the air). Use of other consequences are trained as well, based on
extinction (non attending, walking away) and mild punishment (brief time-out, response cost,
brief loss of privilege).

Consequences also include a token reinforcement or point system in the home to provide
a structured way of implementing the reinforcement contingencies. Our use of tokens is not so
much for the child as it is for the parents. Parents are more likely to carry out the praise program
when the structure and requirements of a point chart are used (e.g., monitoring delivery,
accumulation, and use of points). Also, tokens facilitate tracking of reinforcement exchanges
between parent and child (earning and spending the tokens). If behavior changes are needed at
school (e.g., deportment, homework completion), we consult with teachers. A home-based token
reinforcement system is devised in which child performance at school is monitored (e.g., via
e-mail, phone) with consequences provided at home by the parents (see Kazdin, 2013).

Initial Goals of the Program Pertain to Parent Behavior

The overall goal of treatment is to develop prosocial behaviors and eliminate or
drastically reduce disruptive behaviors, so the child can function well in the multiple situations
and contexts that have been problematic. Yet, at the beginning of ​PMT, ​the goal is to develop
parent competencies in concrete behaviors. Developing parent behavior is greatly facilitated by
focusing on simple and arguably clinically irrelevant child behaviors (e.g., child room cleaning,
table setting, helping with some task). We begin by ensuring that the parents reliably have the
skills (e.g., delivering praise in a way that is qualitatively different from what they usually do)
and can apply them. Then we move to changing child behaviors that were the basis for clinical
referral.

Content of the PSST Sessions

PSST consists of weekly sessions with the child , with each session usually lasting 30- 50
minutes. The core program (12 sessions; see Table 9.2) may be supplemented with optional
sessions, if the child requires additional assistance in grasping the problem-solving steps (early in
treatment) or their application in everyday situations (later in treatment).

Central to treatment is developing the use of ​problem-solving steps ​that serve as verbal
prompts the children deliver to themselves to engage in thoughts and actions that guide behavior.
The steps or self-statements include (1) "What am I supposed to do?"; (2) and (3) "I need to
figure out what to DO and what would HAPPEN"; (4) "I need to make a choice"; and (5) "I need
to find out how I did." Combining steps 2 and 3 requires the child to identify a solution (what to
DO) and then the consequence (what would HAPPEN), and to do this with three or more
solutions before proceeding to step 4. Using the steps, identifying and selecting prosocial
solutions, and enacting these solutions in the sessions, are modeled and practiced extensively.
Over the course of treatment, the steps move from overt (made aloud) to covert (silent, internal)
statements.

The early sessions use simple tasks and games to teach the problem-solving steps and to
help to deter impulsive responding. The content moves to individualized problem domains of the
child (e.g., interactions with peers, parents, siblings, teachers, and others), with multiple
instances and varied situations to help to promote generalization and maintenance. Throughout,
the therapist prompts the child verbally and nonverbally to guide performance, provides a rich
schedule of praise, delivers concrete feedback for performance, and models improved ways of
performing.

TABLE 9.2. Problem-Solving Skills Training: Overview of the Core Sessions

1. Introduction and Learning the Steps. ​This initial session teaches the problem-solving
steps in a game-like fashion in which the therapist and child take turns learning the
individual steps and placing them together in a sequence .

2. and 3. ​Applying the Steps. ​The child applies the steps to simple problem situations
presented in a board game in which the therapist and child alternate turns. A series of
super solvers (homework assignments) begins at this point, in which the steps are used in
increasingly more difficult and clinically relevant situations as treatment continues.

4. Applying the Steps and Role Playing. ​The child applies the steps to identify solutions and
consequences in multiple problem situations. Then the preferred solution, based on the
likely consequences, is selected and then enacted through repeated role-plays.

5. Parent - Child Contact. The parent(s), therapist, and child are seen in the session. The
child enacts the steps to solve problems. The parents learn more about the steps and are
trained to provide attention and contingent praise for the child's use of the steps and for
selecting and enacting prosocial solutions.

6. through 11. ​Continued Applications to Real-Life Situations . ​The child uses the
problem-solving steps to generate prosocial solutions to provocative interpersonal
problems or situations . Each session concentrates on a different category of social
interaction that the child might realistically encounter (i.e. , peer s, parents , siblings,
teachers ). Real-life situations, generated by the child, parent, or from contacts with
teachers and others, are enacted; hypothetical situations are also presented to elaborate
themes and problem areas of the child (e.g ., responding to provocation, fighting, being
 excluded socially, being encouraged by peers to engage in antisocial behavior). The
child's super solvers also become a more integral part of each session; they are reenacted
with the therapist beginning in session in order to better evaluate how the child is
transferring skills to his or her dai ly environment.

12. Wrap -Up and Role Reversal. ​This "wrap-up " session is included (a) to help the therapist
generally assess what the child has learned in the session, (b) to clear up any remaining
confusions the child may have concerning the use of the steps, and (c) to provide a final
summary for the child of what has been covered in the meetings. The final session is
based on role reversal in which the child plays the role of the therapist and the therapist
plays the role of a child learning and applying the steps.

____________________________________________________________________________

As an illustration, a typical situation might occur when a child is teased or threatened by

a peer at school. In the session , the therapist presents the problem to the child and the child is
asked to use her steps. The child asks step 1, answers it ("I am supposed to solve this problem
without hitting or getting into any trouble"), then proceeds to the other steps. At step 2, the child
identifies one alternative (e.g., "I could ignore and walk away") and immediately goes to step 3
to note the likely effect of that action ("That might work because the child might stop teasing,
and I would not get into a fight"). The child then goes back to steps 2 and 3 for another solution
and consequence (e.g., "I could go to the teacher"; "What would happen is that she could help
stop it and know that I was being picked on and did not do anything"). This continues for at least
three prosocial solutions. The child proceeds to step 4 to make a choice and explains why she
selected this. Then the child moves to the final step to say how she did ("I used the steps, I came
up with good solutions, the one I chose did not get me into trouble; I did GREAT!"). The
therapist too provides effusive praise, noting what components of the process were done well,
feedback (if further changes are necessary), then the sequence is enacted in role play in a
seamless and uninterrupted way and with the selected prosocial solution.

Children begin each session with tokens (small plastic chips) that can be exchanged for
small prizes at a "store" after each session . During the session, children can lose chips (response
cost) for misusing or failing to use the steps or gain a few additional chips, although this rarely
occurs. Social reinforcement and extinction are relied on more than token reinforcement to alter
child behavior. The chips present opportunities to address special issues or problems with the
child, such as encouraging a particular type of prosocial solution that the child might find
difficult.

In vivo ​practice, referred to as "super solvers," consists of systematically programmed

assignments designed to extend the child's use and application of problem-solving skills to
everyday situations . As available, parents are brought into sessions over the course of treatment
to learn the steps and practice joint super​ solver assignments that will be carried out at home.
Prompting, shaping, and praise are used by the therapist to develop the parent's' behavior. Over
time, the super solvers increase in complexity and encompass problem domains that led to the
child's referral to treatment. As part of training in the sessions, children practice situations in
which prosocial solutions they have selected do not work and they have to move to other
alternatives (e.g., seeking the teacher's assistance).

Manual and Supporting Materials

For PMT, we have a treatment manual for professionals, with dialogue and supporting
materials for each session (Kazdin, 2005; ​www.ou p.com/ us/ pmt ). ​The underpinnings of the
treatment procedures are elaborated in a textbook (Kazdin, 2013) used as part of therapist rather
than parent training. We also have several materials available for parents including trade books
(Kazdin & Rotella, 2008, 2013), videos of specific techniques ​(y aleparentingcenter.yale.edu /
kazdin -method-sessions ), ​and a set of pa rent-friendly articles on specific procedures to promote
behavior change (use of reinforcement schedules to eliminate behavior, shaping, time-out from
reinforcement) and to caution against the use of other procedures (e .g., spanking, repri​ mands)
that can impede prosocial functioning, if not actually do harm (see
www.slate.com/authors.alan_kazdin.html​).

For PSST, we have provided a summary of the treatment sessions and key steps in
developing use of the problem-solving skills steps, how these are applied and enacted within the
sessions, how they are faded over time, and homework assignments as children apply the skills
in everyday life ​( http:// yalepa ren tingcenter.yale.edu/ store). ​We have not published a detailed,
session-by-session manual or supporting materials beyond what is conveyed in the overview.
Among the reasons has been our emphasis on PMT within our clinical service.
EVIDENCE ON THE EFFECTS OF TREATMENT

Research from Our Program

We have evaluated both PMT and PSST in randomized controlled trials (RCTs; see Table 9.3). Our key findings may be highlighted by noting four
interrelated domains.

TABLE 9.3. Main Studies to Evaluate Treatment Outcome and Therapeutic Change

Investigation Sample Design and objective Main Findings

Kazdin et al. (1987a) Inpatient children (ages 7- 13, ​N = ​56) Randomized controlled trial PSST led to significantly greater decreases than did the other
(RCT}: PSST, relationship treatment and control conditions in externalizing and other behavioral
therapy, and treatment contact problems at home and at school, and greater increases in prosocial
control behavior ; the effects remained at a 1-year follow-up assessment.

Kazdin et al. (1987b) Inpatient children (ages 7- 12, ​N ​= 40) RCT: PSST+PMT combined Combined treatment showed significantly greater changes in
and treatment contact control externalizing and prosocial behaviors, and as in the prior study, the
(where both parents and child effects were maintained at a 1-year follow-up .
were seen as in the combined
treatment}

Kazdin et al. (1989) Inpatient and outpatient children (ages RCT: Compared PSST, PSST Both PSST conditions showed significant changes on measures of
7- 13, ​N ​= 112) with ​in vivo ​practice, and problem and prosocial behavior compared to relationship therapy;
relationship therapy PSST with ​in vivo ​practice led to greater improvements in behaviors
at school than did PSST alone, but these differences were no longer
evident at 1-year follow-up.
Kazdin, Siegel, & Bass Outpatient children (ages 7-13, ​N= RCT: Evaluated effects of All treatments improved child functioning on measures of
(1992) 97) PSST, PMT, and PSST+PMT externalizing symptoms and prosocial behavior; the combined
combined treatment led to significantly greater changes immediately after
treatment and at 1-year follow-up, and placed more children within
the nonclinical (normative range) in levels of functioning.

Kazdin, Mazutick, & Outpatient children (ages 4- 13, ​N = Evaluated therapeutic change of At the end of treatment, children who terminated prematurely showed
Siegel (1994) 75) completers and dropouts and greater impairment at home, at school, and in the community
factors that account for their compared to children who completed treatment. However, these
different outcomes differences were accounted for primarily by severity of impairment at
pretreatment rather than by receiving less treatment.

Kazdin (1995) Outpatient children (ages 7- 13, ​N ​= Evaluated of moderators of Child severity and scope of dysfunction, parent stress, an<l family
105) change among families that dysfunction predicted symptoms and prosocial functioning at the end
received PMT or PSST+PMT of treatment, but the effects varied by outcome (at home or at school).
combined The proposed moderators, even when significant, were not stro ng ly
1·related to outcome.

Kazdin & Crowley (1997) Outpatient children (ages 7- 13, ​N= Examined relation of Children more deficient in cognitive/ academic skills and more
120) intellectual functioning and severely impaired improved significantly with treatment but less than
severity of symptoms on their less impaired counterparts.
responsiveness to PSST

Kazdin & Wassell (1998) Outpatient children (ages 3-13, ​N ​= Examined the relation of Treatment completion was strongly related to therapeutic change,
304) treatment completion and with greater change among those who completed treatment. However,
therapeutic change among 34% of those who dropped out early made significant improvement
children who received PSST, compared to those who remained in treatment (78%). Predictors for
PMT, or PSST+PMT combined improvement did not vary as a function of whether individuals
dropped out or completed treatment.
Kazdin & Wassell (1999) Outpatient children (ages 3-13, ​N= Examined predictors of Perceived barriers to participation in treatment were related to
200) therapeutic change therapeutic changes in the children. Greater barriers were associated
with less change; the findings could not be explained by several child,
parent, and family variables.

Kazdin & Wassell (2000a) Outpatient children (ages 2- 14, ​N ​= Examined relation of parent Greater parent psychopathology and lower quality of life at
169) psychopathology and quality of pretreatment predicted therapeutic changes, controlling for
life as moderators of therapeutic socioeconomic status (SES) and child severity of dysfunction .
change in children who Greater perceived barriers to treatment by parents were associated
received PSST, PMT, or with less therapeutic change on the part of the children.
PSST+PMT combined

Kazdin & Wassell (2000b) Outpatient children (ages 2- 14, ​N = Examined therapeutic changes Child, parent, and family functioning improved over the course of
250) in children, parents, and treatment. Moderators of treatment varied as a function of child,
families and the predictors of parent, and family outcomes.
these change among children
who received PSST, PMT, or
PSST+PMT combined

Kazdin & Whitley (2003) Outpatient children (ages 6-14, ​N ​= RCT: All families received Treatment with the component to address parental stress was
127) PSST+PMT; half were assigned associated with greater therapeutic change among the children and
to receive a supplementary reduced barriers to treatment perceived by the parents.
component to address parental
stress

Kazdin, Marciano, & Outpatient children (ages 3-14, ​N ​= Evaluated child-therapist and A more positive therapeutic alliance (for either child or parent) was
Whitley (2005) 138) parent​ therapist alliance as a associated with greater therapeutic change, fewer experienced barriers
predictor of therapeutic change to treatment, and greater acceptability of treatment. SES, parent
among families that received dysfunction and stress, and pretreatment child dysfunction did not
account for the findings.
 PMT alone or PSST+PMT
combined

Kazdin, Whitley, & Outpatient children (ages 6- 14, ​N= Evaluated child-therapist and Both alliances predicted therapeutic changes of the children. The
Marciano (2006) 77) parent​ therapist alliance as a parent- therapist alliance predicted improvements in parenting
predictor of therapeutic change practices in the home; effects were not explained by SES, parent and
among families that received child dysfunction, and or parental stress.
PSST+PMT combined

Kazdin & Whitley (2006a) Outpatient children (ages 2- 14, ​N ​= Evaluated parent-therapist Alliance predicted parent improvements over the course of treatment;
218) alliance, pretreatment parent alliance was partially mediated by pretreatment parent social
social relations, and parenting relations.
practices developed with PMT
among families that received
PMT alone or PSST+PMT.

Kazdin & Whitley (2006b) Outpatient children (ages 3-14, who Evaluated comorbidity (0, 1, or Children's outcomes did not differ as a function of comorbidity or
met criteria for ODD or CD; N = 315) more comorbid disorders case complexity; greater change (pre- to posttreatment) was
separately for ODD and CD associated with more dysfunction (multiple comorbidities and greater
cases and case complexity family complexity) but the end points (post treatment) were not
(SES, scope of child different. Barriers to treatment moderated treatment outcome; greater
dysfunction, parent and family barriers were associated with less change in the children
stress and dysfunction, barriers
to treatment).Children received
PSST, PMT, or PSST-PMT

Kazdin & Durbin (2012) Outpatient children (ages 6- 13, Evaluated predictors of alliance Child-therapist alliance contributed to therapeutic change. The
referred for oppositional, aggressive, and whether they could account stronger the alliance, the greater the change. Pretreatment social
or antisocial behavior; ​N ​= 97) for the relation of alliance to competence of the child and level of intellectual functioning predicted
 therapeutic change. All cases the quality of alliance but did not account for or explain the
received PSST + PMT. alliance-outcome connection.

Rabbitt e t al. (2016) Outpatient children (ages 6- 13, RCT: Evaluated two variations The two treatments were equally effective in the degree of therapeutic
referred for oppositional, aggressive, of computer delivered treatment change among the children. The changes of the two groups were at
or antisocial behavior; ​N ​= 60) of PMT that varied in the the level of in-person treatment using the benchmark group for
amount of contact and guidance comparison. The two computer-delivered treatments were no different
with the therapist. A third group in the parent-therapist alliance, despite greatly reduced contact with
of participants, ​n ​= 60) was the therapist in one of the group. On the other hand, parents in the
matched to the children in the group with the therapist present and helping with each session
other two groups ​(n ​= 60) and evaluated their treatment as more acceptable than did parents in the
drawn from the clinic database reduced contact group.
involving in-person treatment
and used to benchmark the
changes with the computer
-delivered treatment.

________________________________________________________________________________________________________________________

Note. ​The table includes studies that had treatment outcome as the major focus. Many of our other studies are cited in the text on related topics (e.g.,
participation in treatment) and are not included here.
Outcome Effects
PMT and PSST alone or in combination produce reliable and significant reductions in
oppositional, aggressive, and antisocial behavior, and increases in prosocial behavior among
children. Parent dysfunction (depression, multiple symptom domains) and stress decline and
family relations improve (Kazdin, Bass, Siegel, & Thomas, 1989; Kazdin, Esveldt-Dawson,
French, & Unis, 1987a, 1987b; Kazdin, Siegel, & Bass, 1992). The effects of PMT can be
enhanced by providing supplementary sessions that focus on parent sources of stress (Kazdin &
Whitley, 2003). Also, a motivational enhancement intervention can improve parent motivation
for, adherence to, and attendance of treatment (Nock & Kazdin, 2005). Computer​ based delivery
of PMT and reduced contact with a therapist have been as effective as PMT delivered in person
(Rabbitt et al., 2016).

The Therapeutic Alliance

Child-therapist (in PSST) and parent-therapist (in PMT and PSST) alliances relate to
several outcomes. The more positive the child-therapist and parent-therapist alliance during
treatment, the greater the therapeutic change of the child and improvements of the parents in
parenting practices, the fewer barriers parents experience during the course of treatment, and the
more favorably parents rate the acceptability of the treatment (Kazdin & Durbin, 2012; Kazdin,
Marciano, & Whitley, 2005; Kazdin & Whitley, 2006b; Kazdin, Whitley, & Marciano, 2006),

Moderators of Treatment
Several characteristics of parents and children, beyond alliance, moderate therapeutic
change, including severity of child dysfunction, child IQ, parent stress, parent psychopathology,
and others. The most robust moderator of our treatment has been parental report of barriers to
participation in treatment. These barriers reflect four areas: stressors that compete with
participating in treatment, perceived treatment demands, perceived relevance of treatment, and
obstacles in relation to the therapist. The higher the perceived barriers, whether evaluated by
parents or therapists, the less the therapeutic change among the children, a relation not accounted
for by other factors, such as severity of parent or child dysfunction, stress in the home, or parent
attendance to treatment (Kazdin, 1995; Kazdin & Crowley, 1997; Kazdin, Holland, & Crowley,
1997; Kazdin, Holland, Crowley, & Breton, 1997; Kazdin & Wassell, 1999, 2000a, 2000b;
Kazdin & Whitley, 2006a).
Participation in Treatment
Parent dysfunction, family stress, and the experience of barriers to participation in
treatment are among the more robust predictors of canceling and not showing up for sessions,
and dropping out early. Dropping out early does not necessarily mean failure in treatment.
Among those who drop out of treatment very early, 34% report large improvements in the
behavior of their children (Kazdin, 1990; Kazdin & Mazurick, 1994; Kazdin, Mazurick, & Bass,
1993; Kazdin, Mazurick, & Siegel, 1994; Kazdin, Stolar, & Marciano, 1995; Kazdin & Wassell,
1998 ). Indeed , in many instances, individuals convey that they are dropping out because they
perceive no need to continue and complete our planned regimen.

Overall, our work has shown that ​PSST ​and PMT can effect significant change in
severely disturbed children referred for inpatient or outpatient treatment. Effects of treatment are
evident in performance at home, at school , and in the com mu nit y, both immediately after
treatment and up to a I-year follow-up assessment. Symptoms levels at the end of treatment often
fall within a sex- and age-based normative range.

Evidence Beyond Our Program: Briefly Noted

The evidence base for PMT is remarkable in scope and strength. First, there are several
variations of PMT and programs of research, many of which are included in this book (e.g., The
Incredible Years, Parent-child interaction therapy, Parent Management Training- Oregon Model ,
and Triple P-Positive Parenting Program). These programs have included multiple RCTs, tests in
different venues (home , school), and in the context of treatment and prevention.

Second, core procedures that are used in PMT have been applied widely to other domains
of clinical dysfunction in children and adults (e.g., autism spectrum disorders, anxiety disorders,
addictive behaviors, psychoses) and well beyond clinical work. For example, the procedures
have been effectively applied to diverse domains of functioning (e.g., classroom behavior,
reading and writing , athletic performance, recycling and energy conservation, basic training in
the military, gambling, engaging in social activities, adhering to medical regimens, engaging in
exercise), to a wide age range (from toddlers through older adults), and in multiple contexts (the
home, schools, colleges, business and industry, hospitals, the community) (Cooper et al., 2007;
Kazdin, 1977, 2013).

Finally, basic human and nonhuman animal research spanning decades has elaborated
operant conditioning principles and techniques from which PMT procedures draw. Seminal
nonhuman animal research has provided extensive data on core facets of learning and
performance (e.g., schedules of reinforcement, extinction , punishment) that are central to PMT
(e.g., Azrin & Holz, 1966; Ferster & Skinner, 1957). With only broad brush strokes here, it is
might be reasonable to claim that PMT and the techniques on which it is based are without peer
in the supportive evidence from which they can draw.

FUTURE DIRECTIONS
There is an enormous treatment gap (i.e., the gap between how many people are in need
of treatment [prevalence] and those who actually receive treatment). This applies to not only
disruptive behavior disorders, which has been the focus of this chapter, but also to psychiatric
disorders more generally. The vast majority of individuals (children, adolescents, and adults)
who are in need of services receive no services at all. Consequently, a high priority for future
research is to extend treatments to reach more people in need of services. One area worth special
research emphasis in ​PMT ​might be greater use of technology and social media (apps, the Web,
texting, Facebook) to extend the intervention on a much larger scale than what is being
accomplished now. The use of the Web, as one option, provides huge potential in extending the
reach of evidence-based psychotherapies. An exemplary illustration was a large-scale Web-based
intervention for smoking cessation that reached over 290,000 individuals from 168 countries
(Munoz et al., 2016). A research priority would be to extend ​PMT ​to more people in need and to
evaluate whether favorable outcomes can be achieved at that scale.

Another priority area would be to deliver and evaluate PMT as a tool for parenting in
general rather than, or at least in addition to, a clinical intervention. "Normal" parenting often is a
challenge , and PMT provides tools that can help with these challenges (e.g ., children eating
vegetables, practicing a musical instrument, doing homework, or teens communicating without
sarcasm, eye rolling, and visible disgust because they are in the presence of a parent). Broad
application may prevent or reduce deleterious parenting practices (e.g., use of corporal
punishment). Making PMT more widely available to all parents in a user-friendly fashion would
be a major contribution to treatment, prevention, and family harmony.

CONCLUDING COMMENTS
We have evaluated PMT and PSST with a range of child samples, including inpatient and
outpatient cases. Among all of our samples, children show multiple disorders and usually
multiple risk factors for continued dysfunction. As might be expected , the child problems often
are embedded in contexts that include parent sources of dysfunction, stress, and family issues
(e.g., domestic violence, socioeconomic disadvantage). Our interventions have produced reliable
changes in child behavior at home, at school, and in the community, even among the most
severely impaired cases and in complex family situations. In addition, we find decreases in
parent depression and stress, and improvements in family relations. Making concrete changes in
how the children function in everyday life appears to have positive collateral effects on the
parents and family.

Our most recent work has focused on making PMT more accessible and applicable
clinically by reducing the amount of professional therapist time that is required and delivering
treatment online. Our initial evidence suggests no loss of treatment efficacy with these changes.
These findings are in keeping with those of others who have extended PMT in ways that go
beyond individual, in-person treatment. From the work of many researchers, including those with
chapters in this book, PMT is one of the more well-studied interventions with a strong
experimental and applied research base. The challenges are extending this on a scale that makes
a difference in society, in addition to the lives of individual children and their families.

ACKNOWLEDGMENTS
Research reported in this chapter was facilitated by support from Research Scientist
Devel​ opment and Research Scientist Awards (Nos. K02, KOS MH00353), a MERIT Award
(No.

R0l MH35408), and other project grants (Nos. ROI MH59029, R34 MH093326) from the
National Institute of Mental Health and grants from the Jack Parker Foundation, Leon
Lowenstein Foundation, the Rivendell Foundation of America, the William T. Grant Founda​ tion
(No. 98-1872-98), Community Foundation of New Haven, and Yale University. No less essential
to the work has been the remarkable staff, pre- and postdocs, students, and interns who have
served at the Yale Parenting Center over the years.

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DOI 10.1007/s10802-011-9518-2

The Relation Between Maternal ADHD Symptoms

& Improvement in Child Behavior Following Brief
Behavioral Parent Training is Mediated by Change
in Negative Parenting
Andrea Chronis-Tuscano & Kelly A. O’Brien & Charlotte Johnston & Heather A. Jones &
Tana L. Clarke & Veronica L. Raggi & Mary E. Rooney & Yamalis Diaz & Jessica Pian &
Karen E. Seymour

Published online: 3 May 2011

# Springer Science+Business Media, LLC 2011

Abstract This study examined the extent to which maternal this relationship. Innovative approaches combining evidence-
attention-deficit/hyperactivity disorder (ADHD) symptoms based treatment for adult ADHD with parent training may
predict improvement in child behavior following brief therefore be necessary for families in which both the mother
behavioral parent training. Change in parenting was examined and child have ADHD. Larger-scale studies using a full
as a potential mediator of the negative relationship between evidence-based parent training program are needed to
maternal ADHD symptoms and improvement in child replicate these findings.
behavior. Seventy mothers of 6–10 year old children with
ADHD underwent a comprehensive assessment of adult Keywords Attention-deficit/hyperactivity disorder . Parent
ADHD prior to participating in an abbreviated parent training training . Parenting . Parent–child interactions . Adult
program. Before and after treatment, parenting was assessed ADHD
via maternal reports and observations and child disruptive
behavior was measured via maternal report. Controlling for Evidence-based behavioral and pharmacological treatments
pre-treatment levels, maternal ADHD symptomatology pre- for childhood attention-deficit/hyperactivity disorder
dicted post-treatment child disruptive behavior problems. The (ADHD) rely on parents to obtain and consistently
relation between maternal ADHD symptomatology and administer treatment (Pelham et al. 1998). In particular,
improvement in child behavior was mediated by change in behavioral parent training requires parents to modify
observed maternal negative parenting. This study replicated environmental antecedents and consequences in order to
findings linking maternal ADHD symptoms with attenuated manage child behavior. Although the empirical evidence
child improvement following parent training, and is the first to supports classification of behavioral parent training as an
demonstrate that negative parenting at least partially explains evidence-based treatment for children with ADHD (Pelham
and Fabiano 2008), not all families benefit equally from
these programs. Efforts to understand factors which predict
parent training response have identified parental psychopa-
This research was supported by a grant from the National Institute of thology as a robust predictor of outcomes (for reviews, see
Mental Health (R03MH070666–1) to the first author.
Chronis et al. 2004; Miller and Prinz 1990), presumably
A. Chronis-Tuscano (*) : K. A. O’Brien : H. A. Jones : because parental psychopathology interferes with effective
T. L. Clarke : V. L. Raggi : M. E. Rooney : Y. Diaz : J. Pian : implementation of behavior management skills.
K. E. Seymour
Department of Psychology, University of Maryland, ADHD has a strong genetic component, with most
College Park, MD 20742, USA heritability estimates exceeding .80 (Faraone et al. 2005). In
e-mail: achronis@psyc.umd.edu particular, mothers of offspring with ADHD are at 24 times
increased risk for ADHD compared to mothers of non-
C. Johnston
Department of Psychology, University of British Columbia, disordered children, with approximately 17% of mothers of
Vancouver, BC, Canada children with ADHD meeting criteria for ADHD themselves
1048 J Abnorm Child Psychol (2011) 39:1047–1057

during childhood (Chronis et al. 2003). Several studies have The present study extends the literature by adding
now documented impaired parenting and family functioning measures of parenting as well as child outcomes, and by
associated with adult ADHD (Biederman et al. 2002; Chronis- including both observational and maternal report measures.
Tuscano et al. 2008; Murray and Johnston 2006). These We used a multi-method approach to examine the relation-
studies suggest that mothers with either diagnosed ADHD or ship between maternal ADHD symptoms and child out-
elevated ADHD symptoms, compared to mothers with lower come following a brief group behavioral parent training
levels of ADHD symptoms, tend to be more permissive and program for mothers of children with ADHD. We took an
overreactive; less positive, involved, and consistent; and analogue approach, using a brief training program, given
poorer at planning, monitoring, and problem solving. the preliminary state of the evidence in this area. We
Moreover, studies which have attempted to improve parent- hypothesized that: (1) maternal ADHD symptoms would be
ing deficits by treating mothers with ADHD with stimulants associated with attenuated improvements in child behavior
have found that, despite reductions in adult ADHD symp- following parent training, and (2) that the link between
toms, parenting remains unchanged (Chronis-Tuscano et al. maternal ADHD symptoms and a failure to show expected
2010). Given that both parental psychopathology and improvements in parenting would at least partially explain
parenting behavior have been identified as important the relationship between maternal ADHD symptoms and
environmental risk or protective factors in developmental limited improvements in child disruptive behavior follow-
outcomes for children with ADHD (Chronis et al. 2007; ing behavioral parent training.
Johnston and Mash 2001), behavioral parenting interventions
may be particularly important for mothers with ADHD.
At the same time, effective implementation of behavior Method
management skills requires planning, forethought, persis-
tence, and consistency as well as the inhibition of negative Participants
emotional reactions on the part of parents—all of which are
impaired in adults with ADHD. In the single empirical Participants included 70 mother-child dyads recruited via
study to examine the relation between parental ADHD mailings and presentations to local schools and health
symptoms and child outcomes following behavioral parent professionals (including pediatricians, family practice
training, it was reported that mothers who had the highest physicians, child psychologists and child psychiatrists) in
self-reported ADHD symptoms (i.e., those in the highest the Washington, DC metropolitan area. For inclusion in the
third of the sample on an adult ADHD measure) reported study, children: (1) met full Diagnostic and Statistical
no child symptom reduction following a parent training Manual of Mental Disorders, Fourth Edition (American
program for their preschool-aged children with ADHD Psychiatric Association [DSM-IV-TR], 2000) criteria for
(Sonuga-Barke et al. 2002). Thus, the evidence from this ADHD according to well-validated parent and teacher
one study suggests that maternal ADHD symptoms may be report instruments and parent diagnostic interviews; (2)
associated with attenuated parent training outcomes for had an estimated IQ above 70; (3) were between the ages of
children with ADHD. 6 and 10; and (4) resided with their biological mothers.
Data from the Multimodal Treatment Study for ADHD Children taking stimulant medications were included, but
(MTA) demonstrate that the success of ADHD treatments is were rated by parents and teachers while off medication for
mediated by reductions in negative/ineffective discipline 1–2 days. In order to increase variability in observed child
(Hinshaw et al. 2000). One would hypothesize that adult behavior, parent–child interactions were conducted while
ADHD symptoms may impede a mother’s ability to make children were unmedicated. Medicated children also were
the necessary changes in her parenting, which would required to remain on a stable dose of medication
ultimately result in a diminished impact of behavioral throughout their participation in the study, unless clinically
parent training on child behavior. In particular, parents with contraindicated.
elevated ADHD symptomatology likely have more diffi- Mothers were not selected on the basis of an ADHD
culty inhibiting negative reactions to child behavior in favor diagnosis, but were expected to display a broader range of
of the behavioral skills taught in parent training programs. ADHD symptoms than would be present in the general
However, Sonuga-Barke et al. (2002) did not examine the population given the strong heritability of ADHD (Faraone et
extent to which maternal ADHD symptoms were associ- al. 2005). In order to isolate relationships between maternal
ated with treatment-related improvements in parenting— ADHD symptomatology and parenting, mothers who met
the more proximal outcome in behavioral parenting current DSM-IV criteria for any Axis I disorder other than
programs. Moreover, all constructs were measured via ADHD were excluded from participation. Efforts to screen
maternal report in their study, raising the possibility that out mothers on the basis of current psychopathology were
shared method variance could explain these results. made prior to the laboratory assessment. Mothers taking
J Abnorm Child Psychol (2011) 39:1047–1057 1049

stimulant medication were also excluded, as stimulant Table 1 Participant characteristics

medication has the potential to minimize or mask ADHD- Child characteristics
related deficits in parenting.
Eighty-one mothers met screening criteria and were Variable Mean (SD) %
assessed. Eleven were deemed ineligible: 5 were excluded
Age (years) 8.06 (1.2)
because the child did not meet full DSM-IV criteria for
Sex (Male) (n=66) 71
ADHD; 3 were excluded because the child had an
WISC-III verbal (Scaled score) 11.20 (3.9)
estimated IQ below 70; and 3 were excluded on the basis
of the mother’s current Axis I disorder that was identified WISC-III performance (Scaled score) 9.61 (3.8)
during the laboratory assessment. Participant characteristics Race/Ethnicity
are presented in Table 1. As depicted in Table 1, the sample Caucasian 36.2
was racially and socioeconomically diverse; total family African-American 40.6
income ranged from $32,500 to $385,000 and approxi- Hispanic 4.3
mately 64% of the sample was non-white. Native American 1.4
Mixed 7.2
Procedure Other 1.4
Refused 8.7
Mothers expressing interest in the study completed a brief ADHD diagnosis
telephone interview in which the family’s appropriateness Combined type 78.9
for the study was assessed according to the criteria Inattentive type 15.5
described above. When families appeared appropriate based Hyperactive/Impulsive type 5.6
on the telephone screen, parent and teacher measures were Comorbidity
mailed to the home, and mothers were instructed to return Oppositional defiant disorder 47.9
the completed measures prior to the assessment session. Conduct disorder 19.7
Mothers and children attended a 2.5-hour pre-treatment Medication status
assessment session, during which diagnostic interviews On medication 65.7
were administered and a parent–child observation was Mother characteristics
conducted. Upon arrival at the assessment session, mothers Age 38.6 (6.1)
were provided with a detailed explanation of the procedures Marital status (n=66)
and provided written informed consent. Mothers and Married 71
children were paid $40 for this visit. Divorced/Separated/Other 29
Mothers who were deemed eligible based on this labora- Education level (n=66)
tory assessment were invited to attend an abbreviated 5- High school 24.2
session behavioral parent training program, which included Some college/Associate’s degree 10.6
the following topics: Psychoeducation regarding ADHD, Bachelor’s or graduate degree 65.2
special time, differential attention (i.e., attending to/rewarding Family income (n=59)
prosocial behaviors and planned ignoring of minor/irritating 0–40,000 16.9
behaviors), effective commands, and time out. Groups were 40,001–70,000 23.7
comprised of 6–8 mothers and were facilitated by a single 70,001–100,000 27.1
group leader. Therapists included a Ph.D.-level psychologist >100,000 32.2
and an advanced doctoral student in clinical psychology, both Race/Ethnicity
of whom had extensive experience in the delivery of Caucasian 45.6
evidence-based behavioral parenting interventions for African American 45.6
ADHD. The advanced doctoral student was very closely Hispanic 7.4
supervised by the principal investigator, who watched all of Other 1.5
the tapes and provided extensive feedback on a weekly basis.
Session content was derived from the parent training manual n=70 unless indicated. WISC-III Weschler intelligence scale for
used in the Multimodal Treatment Study for ADHD (Abikoff children, Third Edition; ADHD Attention-deficit/hyperactivity disor-
der; ODD Oppositional defiant disorder; CD Conduct disorder
et al. 1994), which was based on evidence-based parent
training programs for children with ADHD and disruptive
behavior disorders (Barkley 1997; McMahon and Forehand provided for the target child and his/her siblings, and
2003; Patterson 1974). To encourage attendance, reminder mothers who attended all 5 sessions were paid $25 as an
calls were made prior to each session, childcare was extra incentive.
1050 J Abnorm Child Psychol (2011) 39:1047–1057

Following the completion of the 5-session parenting ADHD were considered present if they were endorsed by
program, mothers completed questionnaires assessing their either the participant or the collateral informant (i.e., the
parenting and children’s symptoms of ADHD and the “or rule”) as present to a clinically significant degree on the
disruptive behavior disorders and associated impairment, as modified K-SADS. Maternal KSADS ADHD symptoms in
well as a second parent–child interaction. Families who this sample ranged from 0 to 17 (inattention: 0–9;
completed this post-treatment assessment were paid $25. hyperactivity/impulsivity: 0–8). Mean ADHD symptoms
These study procedures were approved by the University reported on the KSADS for the sample based on the “or
Institutional Review Board. rule” were: 2.83 (SD=2.79) for inattentive symptoms, 2.81
(SD=2.22) for hyperactive/impulsive symptoms, and 5.64
Assessment of Maternal ADHD Symptoms (SD=4.45) for Total ADHD symptoms.
Although the main analyses use a dimensional composite
Consistent with best practice guidelines for the assessment score (described below), diagnoses were made for descriptive
of adult ADHD (McGough and Barkley 2004), mothers purposes only. Diagnoses were made based on ≥ = 6 past
were assessed using multiple instruments (diagnostic, symptoms and ≥ = 4 current symptoms reported on the
dimensional) with available normative data, multiple KSADS using maternal and collateral report (McGough and
informants (e.g., self, parent, spouse), and tools for Barkley 2004); however, since an adult ADHD impairment
differential diagnosis. They were administered the Struc- measure was not utilized, these “diagnoses” were based on
tured Clinical Interview for the DSM-IV, Non-Patient symptom criteria only. Fourteen percent (n=10) of mothers
Edition (SCID; First et al. 1996) to assess other psychiatric met symptom criteria for ADHD according to these
disorders that may co-occur with or better account for their procedures. Nine of these participants met symptom criteria
ADHD symptoms. for ADHD based on self-report alone and five met criteria
The SCID was supplemented with modified modules based on collateral report alone.
from the Schedule for Affective Disorders for School-Aged Mothers also completed the Conners Adult ADHD Rating
Children (K-SADS) assessing mothers’ past and current Scale (CAARS; Conners et al. 1999; Erhardt et al. 1999), a
symptoms of ADHD, oppositional defiant disorder (ODD), dimensional measure of current ADHD symptoms in a form
and conduct disorder (CD) in adults (Biederman et al. 2002; suitable for adults. The CAARS is a 93-item, reliable and
Faraone et al. 1995, 2000). Interviewers were trained to valid measure of ADHD symptoms that assesses the core
reliability on the SCID and modified K-SADS by the first features of ADHD as seen in children and adolescents, while
author and carefully supervised throughout the study. adding content unique to the adult expression of ADHD. The
Interviews were videotaped and 20% of the interviews individual completing the form must indicate if he or she
were coded by an independent rater. Kappas were 1.00 for experiences the ADHD symptom on a scale ranging from
ADHD, 1.00 for anxiety disorders, 1.00 for mood disorders, Not at all, never to Very much, very frequently. The CAARS
and 1.00 for all other disorders. has excellent psychometric properties and provides essential
Given concerns about individuals’ ability to accurately normative data. The Total ADHD Symptom (CAARS-
report their own ADHD symptoms, our assessment of adult ADHD) subscale was used in the current study (Cronbach’s
ADHD utilized information about past and current symp- alpha=.92).
toms gathered from collateral informants in addition to
mothers’ own reports (McGough and Barkley 2004). Thus, Assessment of Child ADHD
whenever possible, past and current collateral reports of
ADHD symptoms were obtained from individuals who The diagnosis of child ADHD was made using the K-SADS
lived with or were in close contact with the mothers during parent interview (Ambrosini 2000; Orvaschel and Puig-
the period in question and felt confident about their ability Antich 1995) and parent and teacher forms of the
to accurately rate the mothers’ ADHD symptoms. Fifty-one Disruptive Behavior Disorders (DBD) symptom checklist
collateral informants were contacted and provided reports: (Pelham et al. 1992). Twenty percent of the K-SADS parent
36 were spouses/significant others, 10 were close friends, 3 interviews were coded by an independent rater. Kappas
were siblings, 1 was a co-worker, and 1 was of unknown were .86 for ADHD, 1.00 for ODD, and 1.00 for CD. The
relationship to the participating mother. Research assistants DBD symptom checklist is a 45-item parent and teacher
interviewed mothers’ collateral informants via telephone report measure of the DSM-IV symptoms of ADHD, ODD,
using the modified K-SADS. Detailed analysis of collateral and CD. Symptoms are rated on a 4-point scale as
data is presented elsewhere (cite omitted to maintain describing the child not at all to very much (not at all=0
anonymity). Consistent with the recommendations of to very much=3). A total disruptive behavior score is
McGough and Barkley (2004) and with procedures used calculated by summing all responses rated as pretty much or
in our prior studies (cites omitted), DSM-IV symptoms of very much. In this study, Cronbach’s alpha for the pre-
J Abnorm Child Psychol (2011) 39:1047–1057 1051

treatment parent-reported DBD symptom checklist total and were indeed associated with maternal ADHD symptoms
was .92; the post-treatment alpha was .94. Symptoms for in this sample (cite omitted to maintain anonymity). Alphas
the child ADHD diagnosis were considered present if they for these subscales at pre- and post- treatment (respectively)
were endorsed by either the parent or teacher as occurring in this sample were: 0.79 and 0.79 for Involvement; 0.86 and
to a clinically significant degree on any of these measures 0.85 for Positive Parenting; and 0.76 and 0.78 for Inconsis-
(Piacentini et al. 1992). tent Discipline.
Cross-situational impairment necessary for a DSM-IV The present study also utilized observed parent–child
diagnosis of ADHD was evaluated using parent and teacher interaction tasks commonly employed in the ADHD literature
forms of the Children’s Impairment Rating Scale (CIRS; (Danforth et al. 1991): (1) a 5-minute free play; and (2) a
Fabiano et al. 2006). On the CIRS, raters assess impairment 10-minute homework task in which the child completed a
and need for treatment across multiple domains on a 7-point math worksheet while the mother was instructed to provide
scale, with scores above the midpoint indicating clinically assistance “as you see fit.” Mother-child interactions during
significant impairment (Fabiano et al. 2006). Alphas at pre- these tasks were coded using a revised version of the Dyadic
and post- treatment (respectively) in this sample were: 0.86 Parent–child Interaction Coding System (DPICS; University
and 0.84. of Washington Parenting Clinic 2000). The DPICS was
The Vocabulary and Block Design subtests of the developed by Eyberg and colleagues (Robinson and Eyberg
Weschler Intelligence Scale for Children, Third Edition 1981; most recent edition is Eyberg et al. 2009). The validity
(Wechsler 1991), were administered to exclude children of the DPICS has been documented in studies examining
with an estimated IQ below 70. This estimated IQ has been treatment outcome (Eyberg and Matarazzo 1981) and
used in several studies (e.g., Seguin et al. 2004; Todd et al. comparisons between non-disordered children and those
2002), and is correlated 0.92 with full scale IQ (Campbell referred for oppositional/aggressive behaviors (Aragona and
1998). Eyberg 1981; Robinson and Eyberg 1981).
Approximately 30% of children (n=23) had received a Discrete parenting behaviors were coded continuously with
diagnosis of ADHD by a medical or mental health a resulting total frequency for each behavior. We utilized the
professional prior to enrollment in the study, per parent following composite categories that are commonly reported in
report during the telephone screen. Parents reported that the literature: Positive Parenting (DPICS-PP; includes praise,
approximately 66% (n=42) of children were treated with positive affect, and physical positive); and Negative Parenting
medication and 17% (n=12) of children had received prior (DPICS-NP; includes negative command, critical statements,
psychosocial (i.e., non-medication) treatment for mental and physical negative; Eyberg et al. 2001; Webster-Stratton
health problems. 1998; Webster-Stratton and Spitzer 1992). In addition, we
included the “No Opportunity for Child to Comply” category
Child Behavior Outcomes (DPICS-NOCC), which is counted each time the mother gives
a command, but reissues another command before 5 s have
The DBD symptom checklist (Pelham et al. 1992) and the elapsed, regardless of whether the child has begun complying
CIRS were administered to mothers before and after the or not. These categories were selected on the basis of their
abbreviated parent training program to evaluate treatment hypothesized relationship to maternal ADHD symptoms
effects on child DBD symptoms and associated impairment. (Chronis-Tuscano et al. 2008).
A team of two undergraduate coders was trained by a
Parenting doctoral student in the use of the DPICS until 80% agreement
was attained. After studying the coding manual, coders
The Alabama Parenting Questionnaire (APQ; Shelton et al. participated in six full days of training to review and discuss
1996) is a 42-item measure on which parents indicate the coding procedures and to practice coding videotapes of the
frequency with which they implement the following parent- mother-child interactions. Throughout the course of the study,
ing practices: Involvement, Positive Parenting, Poor Moni- coders participated in weekly face-to-face meetings to identify
toring/Supervision, Inconsistent Discipline, and Corporal areas of disagreement, recode difficult tapes together, and
Punishment. Items are rated on a 5-point scale, ranging from discuss behaviors within each category to improve reliability
1 (never) to 5 (always). Internal consistency for all scales is for future coding. Reliability checks were conducted through-
moderate to high (Shelton et al. 1996), and test-retest out the study in order to maintain an acceptable level of
reliability across a 3-year interval averages 0.65 (McMahon agreement. The primary coder coded all of the tapes and
et al. 1997). The current study focused on treatment-related approximately 30% of these tapes were coded by a second
change in the Involvement, Inconsistent Discipline, and coder to assess inter-rater reliability. Both coders had no
Positive Parenting subscales, as these subscales were knowledge of mother and child assessment information or
hypothesized to be most likely impacted by maternal ADHD time of assessment (i.e., pre- or post-treatment). Consistent
1052 J Abnorm Child Psychol (2011) 39:1047–1057

with prior studies using the DPICS, overall reliability was listwise nor pairwise deletion was appropriate. Thus, we
computed by calculating percent agreement (Agreements/ used maximum likelihood estimation and all available data
Agreements+Disagreements; Eyberg et al. 2009; University to impute missing data for parenting and child behavior
of Washington Parenting Clinic 2000). Inter-observer agree- measures. This approach allowed us to test our hypotheses
ment coefficients for DPICS parenting categories at pre- and with improved power over listwise deletion and less biased
post- treatment (respectively) across situations were 0.89 and parameter estimates than other techniques including listwise
0.69 for Positive Parenting; 0.83 and 0.85 for Negative deletion, mean substitution, and multiple regression estimation
Parenting; and 0.86 and 0.82 for No Opportunity to Comply. (Graham 2009).

Results Prediction of Child Behavior Treatment Outcome

Preliminary Analyses Child DBD total symptom scores improved significantly from
pre- (M: 15.43, SD: 6.39) to post- treatment (M: 10.98, SD:
Maternal ADHD Symptoms Given that CAARS-ADHD 6.36) for the sample, t(69)=6.47, p<0.001. Child CIRS total
and KSADS-ADHD scores were highly correlated (r= scores also improved significantly from pre- (M: 23.58, SD:
0.67, p<0.001), a composite maternal ADHD variable was 8.61) to post- treatment (M: 20.69, SD: 9.32) for the sample, t
created for treatment outcome analyses. Use of a composite (51)=2.80, p=0.007. Regression analyses were conducted to
maternal ADHD variable served to reduce the overall examine whether the maternal ADHD symptom composite
number of analyses and thus the possibility of a Type I predicted DBD and CIRS total scores at post-treatment,
error. This composite was created using the total number of controlling for pre-treatment scores. Maternal ADHD signif-
symptoms reported by the mother herself or the collateral icantly and negatively predicted post-treatment DBD scores,
informant on the modified KSADS interview and on the controlling for pre-treatment DBD scores (see Table 2). Thus,
CAARS self-report. Standardized values (z-scores) for mothers with higher ADHD symptoms reported attenuated
CAARS-ADHD and KSADS-ADHD were averaged to effects of parent training on their children’s DBD symptoms.
compute the maternal ADHD composite variable. Thus, However, maternal ADHD did not significantly predict post-
this maternal ADHD composite variable combined self- and treatment CIRS total scores.
collateral-report data.
Prediction of Parenting
Treatment Attendance The mean number of sessions
attended was 3.58 of 5 (SD=1. 72). Approximately 17% of Given that both the APQ and DPICS included scales
mothers (n=12) attended no sessions and more than 75% of measuring the Positive Parenting construct, we examined
mothers attended at least 4 of the 5 sessions. Mothers who correlations between the APQ-PP scale and DPICS-PP
attended at least one session did not differ from non- during play and homework. At pre-treatment, APQ-PP and
attenders on the maternal ADHD composite variable, t(68) DPICS-PP during play were significantly positively corre-
=0.35, p=0.72, or child DBD total score, t(67)=1.70, p lated, r(68)=0.40, p=0.004, but not during homework,
=0.10. The maternal ADHD symptom composite was not r(68)=0.20, p=0.144. No significant correlations were
significantly related to attendance, r(68)=−0.001, p=0.992. found at post-treatment, thus we did not control for shared
variance between measures in our outcome analyses.
Missing Data Of the 58 families who attended at least Regression analyses were conducted to examine whether
one session, complete observational data at pre- and the maternal ADHD symptom composite predicted changes
post- treatment were available for 32 families due to a in parenting behavior at post-treatment, controlling for pre-
range of technical difficulties with the digital recording. treatment scores. As presented in Table 2, maternal ADHD
For the total sample, self-report measures of child predicted APQ Inconsistent Discipline and Involvement
behavior and parenting were missing for 6 families pre- subscale scores at post-treatment, indicating that mothers
treatment (8.6%) and 18 families post-treatment (25.7%). with higher ADHD symptoms reported less improvement in
There were no differences in pre-treatment DBD, t(67)= Inconsistent Discipline and Involvement after the brief
1.012, p=0.21, or maternal KSADS Total scores, t(67)= parent training program. Maternal ADHD symptoms did
−1.345, p=.16 for those who were and were not missing not significantly predict change in the APQ Positive
post-treatment data. However, Little’s MCAR was signif- Parenting subscale.
icant, MCAR test, χ2 [145]=179.880, p=0.03, which Maternal ADHD predicted DPICS-Negative Parenting
indicates that data were not missing completely at random during both the free play and homework segments at post-
(MCAR). Given that data were not MCAR, neither treatment after controlling for pre-treatment frequencies,
J Abnorm Child Psychol (2011) 39:1047–1057 1053

Table 2 Results of regression analyses predicting child behavior and parenting at post-treatment from maternal ADHD symptom composite

Maternal-reported child behavior and impairment

DBD CIRS
df F rΔ
2
β df F r2Δ β
Step 1 1, 68 36.79 0.35 1, 50 38.61 0.44
Pre 0.593** 0.660**
Step 2 1, 67 27.21 0.10 1, 49 19.73 0.01
Pre 0.500** 0.635**
M-ADHD 0.325** 0.105
Dyadic Parent Child Interaction Coding System (DPICS) parenting
Play negative parenting Play positive parenting Play-no opp to comply
df F r2Δ β df F r2Δ β df F r2Δ β
Step 1 1, 68 0.407 0.00 1, 68 0.306 0.00 1, 68 1.14 0.02
Pre 0.077 −0.067 −0.128
Step 2 1, 67 14.77 0.30 1, 67 1.61 0.04 1, 67 6.83 0.15
Pre −0.043 −0.050 −0.074
M-ADHD 0.561** −0.204 0.395**
Homework negative parenting Homework positive parenting Homework-no opp to comply
Step 1 1, 68 0.134 0.00 1, 68 0.001 0.00 1, 68 11.04 0.14
Pre 0.044 0.004 0.431*
Step 2 1, 67 13.78 0.29 1, 67 1.34 0.04 1, 67 16.47 0.19
Pre −0.039 −0.032 0.326*
M-ADHD 0.544** −0.200 0.332**
Alabama Parenting Questionnaire (APQ)
Inconsistent discipline Positive parenting Involvement
Step 1 1, 68 44.11 0.39 1, 68 38.42 0.36 1, 68 37.17 0.35
Pre 0.627** 0.601** 0.594**
Step 2 1, 6 26.03 0.04 1, 67 1.69 0.01 1, 67 22.26 0.05
Pre 0.540** 0.634** 0.654**
M-ADHD 0.227* 0.101 0.222*

n=70. M-ADHD Maternal attention-deficit/Hyperactivity disorder composite variable. DBD Disruptive behavior disorder rating scale. CIRS Child
impairment rating scale. No Opp to Comply Command with no opportunity for child to comply
** p<0.01, * p<0.05

also indicating that mothers with higher ADHD symptoms Mediation

demonstrated less improvement in observed negative
parenting across situations. Maternal ADHD did not Given that maternal ADHD predicted change in six of nine
significantly predict DPICS-Positive Parenting at post- parenting measures at post-treatment and change in maternal-
treatment for the play or homework segments. reported child disruptive behavior at post-treatment, the
Maternal ADHD predicted maternal repetition of potential mediating role of parenting in the association
commands before 5 s had elapsed, regardless of whether between maternal ADHD and child outcomes was examined.
the child had begun complying or not (DPICS-NOCC) Analyses were conducted in accordance with the model for
during both the play and homework segments at post- mediation proposed by Baron and Kenny (1986) and
treatment after controlling for pre-treatment scores. This reviewed by Kenny (2009). Conditions 1 and 2 as outlined
finding suggests that mothers with higher ADHD by Baron and Kenny’s model were already demonstrated in
symptoms displayed less improvement in reducing the analyses presented above: (1) the predictor variable
repeated commands without allowing the child an (maternal ADHD composite) is significantly associated with
opportunity to comply. the outcome variable of “change in child behavior” (i.e.,
1054 J Abnorm Child Psychol (2011) 39:1047–1057

maternal-report child disruptive behavior at post-treatment ment in child disruptive behavior following behavioral parent
controlling for pre-treatment score) and (2) the predictor training, and is the first to demonstrate that the relationship
variable (maternal ADHD composite) is significantly asso- between maternal ADHD and child behavior outcomes is
ciated with the mediator of “change in parenting” (i.e., mediated by reductions in observed negative parenting. That
parenting measures at post-treatment controlling for pre- is, the relationship between maternal ADHD symptoms and
treatment scores). Thus, linear regressions were conducted to attenuated response to parent training can be explained by the
examine conditions 3 and 4 of mediation: (3) that the failure of mothers with elevated ADHD symptoms to reduce
mediators (change in parenting) are significantly associated their use of negative parenting behaviors.
with the outcome variable (change in child behavior), and (4) Consistent with the one published study on this topic
that the association between maternal ADHD symptoms and (Sonuga-Barke et al. 2002), maternal ADHD symptomatology
child outcome was reduced when the parenting variables predicted change in child DBD scores following brief parent
were entered into the models. training, suggesting that mothers perceive less change in their
Conditions 3 and 4 of mediation were supported for 3 of 6 children’s disruptive behavior when they themselves have
parenting mediators, specifically maternal-reported Inconsis- higher levels of ADHD symptoms. Moreover, this study was
tent Discipline and DPICS-NP during play and homework. the first to show that maternal ADHD symptoms were
Both maternal ADHD and APQ-ID were significant when associated with the degree of change in self-reported and
entered together, suggesting partial mediation. However, observed parenting, the most proximal outcome in behavioral
maternal ADHD was no longer significant when entered with parenting interventions. We found that mothers’ ADHD
DPICS-NP during play and homework, suggesting full symptomatology predicted change in observed negative
mediation. See Table 3 for standardized regression coeffi- parenting, observed repeated commands without providing
cients for hierarchical regressions examining mediation. the child an opportunity to comply, and maternal reports of
Sobel tests were then performed to evaluate the inconsistent discipline following behavioral parent training.
statistical significance of the mediation effects, condition 4 These parental behaviors seem to characterize the adult with
of Baron and Kenny’s model (MacKinnon et al. 2002; ADHD, who tends to be emotionally reactive and to have
Sobel 1982). Sobel test results indicated that observed difficulty inhibiting her responses.
negative parenting during play and homework were signif- Perhaps most notably, we found that reductions in
icant mediators (z=2.03, p=0.04 and z=2.00, p=0.045, observed negative parenting mediated improvement in
respectively) of the relationship between maternal ADHD mother-reported child disruptive behavior. This finding is
symptoms and change in child behavior following brief consistent with MTA results suggesting that success
parent training. That is, the previously significant relation- resulting from evidence-based ADHD treatments is related
ship between maternal ADHD symptoms and change in to the degree of change in negative/ineffective discipline
child behavior was reduced significantly when the effects of (Hinshaw et al. 2000). The results of the present study
observed negative parenting was controlled. The Sobel test support the notion that mothers with significant ADHD
was not significant for APQ Inconsistent Discipline as a symptoms may have more difficulty inhibiting negative
mediator, however (z=1.52, p=.13). reactions to child behavior in favor of behavioral skills
taught in parent training programs, and that this failure to
inhibit negative parenting behaviors may explain the
Discussion attenuated reduction in child behavior problems following
treatment. Given that we utilized not only self-report data,
This study replicated prior findings suggesting that mothers but also observational data in an effort to avoid shared
with higher levels of ADHD symptoms report less improve- method variance and any potential biases in mothers’

Table 3 Summary of standardized regression coefficients from hierarchical regression analyses testing change in parenting as mediator of the
relationship between maternal ADHD symptoms and change in child disruptive behavior

Parenting measure Predictor-Mediator Mediator-Outcome Predictor-Outcome Mediator-Outcome (Controlling for predictor)

NP-Play 0.561** 0.343** 0.325** 0.231*

NP-Homework 0.544** 0.322** 0.325** 0.231*
APQ-ID 0.227* 0.338** 0.325** 0.247*

Parenting and child behavior measure pre-treatment scores are controlled in all analyses. NP DPICS observed negative parenting. APQ-ID
Alabama parenting questionnaire-inconsistent discipline
** p<0.01, * p<0.05
J Abnorm Child Psychol (2011) 39:1047–1057 1055

perceptions of their own or their children’s behavior, we appropriate given the preliminary state of the evidence in
have more confidence that the lack of change in observed this area. Our use of a brief parenting program was also
parenting indeed resulted in less change in child symptoms. consistent with recent evidence indicating that such programs
Prior research has both found that mothers with ADHD may be effective (Axelrad et al. 2009; Nixon et al. 2003). It is
(or elevated ADHD symptoms) engage in more negative certainly possible that results might be different had a typical
parenting practices toward their offspring with ADHD than 8–12 week program been implemented. In particular, mothers
mothers without ADHD symptoms (Biederman et al. 2002; with ADHD symptomatology may require more repetition or a
Chronis-Tuscano et al. 2008; Murray and Johnston 2006) larger “dose” of treatment before meaningful change can be
and that parenting is an important predictor of negative documented. Whether the results of the present report hold for
long-term outcomes for children with ADHD (Chronis et al. a full evidence-based parent training program awaits further
2007; Johnston and Mash 2001). Therefore, findings research. Next, we considered exclusively maternal ADHD
suggesting that behavioral parent training is less effective symptoms, rather than symptoms in both mothers and fathers.
at changing negative and inconsistent parenting when We made this design decision because it remains the case that
mothers experience elevated ADHD symptoms themselves mothers are most often responsible for the organizational
have potentially serious implications. In particular, these aspects of parenting (Furstenberg 1988; McBride and Mills
findings suggest that offspring of mothers with higher 1993; Parke 1995). The majority of the parent training
levels of ADHD symptoms may be at increased risk for literature focuses on mothers, as mothers most often present
negative developmental outcomes, both as a result of to treatment for their children’s attention and behavior
maladaptive parenting and poor behavioral treatment problems (Fabiano 2007). Nevertheless, fathers of children
response. However, this awaits empirical examination using with ADHD also are at increased risk of having ADHD
larger samples and prospective longitudinal designs. (Chronis et al. 2003) and many do take an active role in their
Contrary to our hypotheses, maternal ADHD symptoms children’s treatment. For these reasons, future studies should
were not significantly associated with the degree of change in also consider the impact that paternal ADHD may have on
positive parenting following intervention. This may reflect the behavioral treatment outcomes.
fact that adults with ADHD, perhaps due to their own Finally, the sample size was limited, particularly for
exuberance or their enhanced understanding of their children’s observational outcomes, and a fair amount of data were
symptoms (Psychogiou et al. 2007, 2008), have less difficulty missing. The fact that we found significant mediation effects
displaying positive parenting. It may be the case that their despite the small sample is quite promising, however. Still, the
ADHD symptoms interfere to a greater extent with their limited sample size prevented us from considering potentially
ability to inhibit negative reactions to child misbehavior. important variables, such as child medication status. Thus,
Several limitations of this study must be considered. replication is required with a larger sample using standard
Mothers who participated in this study were not diagnosed (rather than abbreviated) evidence-based behavioral parenting
with ADHD or clinically referred for adult ADHD; rather, programs, and considering ADHD symptoms in both mothers
we examined the extent to which continuously-distributed and fathers. Future studies should also carefully measure
levels of maternal ADHD symptoms were related to treatment participation, including implementation of behavior
treatment participation and outcomes. Unfortunately, an management skills outside of the session (e.g., at home) so
adult ADHD impairment measure was not available at the that we can further understand the mechanisms related to
time this study was initiated. Future studies should utilize attenuated treatment outcomes for this population.
an impairment measure relevant to adults with ADHD so Despite these limitations, this study replicated results
that diagnostic status of mothers can be obtained. Also, a from the single study suggesting that maternal ADHD
clinically-referred sample of mothers with ADHD would symptomatology is associated with attenuated response to
likely have high levels of comorbidity with depression and parent training, and is the very first to show that degree of
other disorders, which could certainly impact the findings. improvement in negative parenting mediates change in
Future studies will therefore need to examine whether the child behavior. Given that negative and inconsistent
same results are found with a clinical sample of mothers parenting predict poor long-term child outcomes, these
with ADHD. It is very likely that the effects would be even findings suggest that maternal ADHD symptomatology
stronger for mothers who are more impaired. may negatively impact both the developmental and treat-
This study included a 5-week behavioral parent training ment outcomes of children with ADHD. Assessment and
program which was abbreviated from the typical 8–12 week treatment of maternal ADHD, when present, may therefore
programs which have established efficacy (Weisz 2004). be recommended to increase the likelihood that children
Although ideally this question would be examined using a with ADHD will derive maximum benefit from evidence-
full-scale parent training program, we felt that a more based behavioral treatment. In particular, treating maternal
analogue approach, using a brief training program was ADHD (either with stimulant medication or evidence-based
1056 J Abnorm Child Psychol (2011) 39:1047–1057

psychosocial treatment) prior to her participation in Conners, C., Erhardt, D., Epstein, J., Parker, J., Sitarenios, G., &
Sparrow, E. (1999). Self-ratings of ADHD symptoms in adults: I.
behavioral parenting interventions may impact maternal
Factor structure and normative data. Journal of Attention
behavior in treatment and subsequent child behavior gains. Disorders, 3, 141–151.
Danforth, J., Barkley, R., & Stokes, T. (1991). Observations of parent-
Acknowledgments The authors would like to acknowledge Brandi child interactions with hyperactive children: research and clinical
Stupica, M.S. who provided statistical consultation. implications. Clinical Psychology Review, 11, 703–727.
Erhardt, D., Epstein, J., Conners, C., Parker, J., & Sitarenios, G. (1999).
Self-ratings of ADHD symptoms in adults: II. Reliability, validity,
and diagnostic sensitivity. Journal of Attention Disorders, 3, 153–
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 Parent Management Training:
Evidence, Outcomes, and Issues
ALAN E. KAZDIN. PH.D.

ABSTRACT
ObJective: To describe and evaluate parent management training (PMT) as a treatment technique for oppositional,
aggressive, and antisocial behavior. Method: Recent research is reviewed on the efficacy of PMT; factors that contribute
to treatment outcome; the range of outcomes related to child, parents, and family; and variations of treatment currently in
use. Limitations are also discussed related to the impact of treatment, clinical application, and dissemination of treatment.
Results and Conclusions: PMT is one of the more well·lnvestigated treatment techniques for children and adolescents.
Notwithstanding the large number of controlled studies attesting to its efficacy, fundamental questions remain about the
magnitude, scope, and durability of impact. J. Am. Acad. Child Ado/esc. Psychiatry, 1997, 36(10) :1349-1356. Key Words:
parent management training, child and adolescent therapy, opposit ional and conduct disorder.

Parent management training (PMT) refers to treatment cations. PMT research is worth highlighting because it
procedures in which parents are trained to alter their is one of the more well-investigated treatments in child
child's behavior at home. The procedures are based on and adolescent therapy in general. The strengths and
social learning principles that are used to develop posi- limitations of PMT research bring into sharp focus
tive, prosocial behaviors and to decrease deviant behav- broader issues regarding treatment development and
iors. PMT has been applied widely to many problem delivery of child and adolescent services.
domains (e.g.• child compliance, tantrums, enuresis,
tics, eating disorders, hyperactivity. adherence to med- OVERVIEW OF TREATMENT
ical regimens) and populations (e.g., preschool children
Background and Underlying Rationale
through adolescents; youths with a diagnosis of autism,
mental retardation. learning disability, conduct disorder, Although the development of PMT can be traced to
attention-deficit/hyperactivity disorder [ADHD], and several influences, two are particularly noteworthy.
others) (e.g.• Graziano and Diament, 1992; Schaefer First. operant conditioning, elaborated by B.P. Skinner
and Briesmeister, 1989). Among clinical problems, (1938), describes and explains how behavior can be
greatest attention has focused on youths with opposi- acquired and influenced by a variety of stimuli and con-
tional defiant disorder and conduct disorder and juve- sequences. Operant conditioning encompasses extensive
nile offenders. This article describes PMT in the context basic (e.g., in animal laboratory) and applied research
of conduct problems among children and adolescents, (e.g., extensions to diverse populations, including clini-
examines advances and limitations of current research, cal samples) and serves as a foundation of the tech-
and provides information that can foster clinical appli- niques that comprise PMT. Applications have
encompassed multiple settings (psychiatric hospitals,
Acctpud March 20. 1997. rehabilitation facilities, nursing homes, special edu-
Dr. Kazdin is Professor of Psychology and Proftssorof Child Study at Yak cation and regular classrooms. the military, business,
University, Neui Haven. CT.
and industry) (Kazdin, 1994). Experimental demonstra-
This work was faci/itaud by support of a Research Scientist Award
(MH00353) from NIMH and by theJohn D. and Catherine T. MacAnhur tions have shown that persons (e.g.• parents, teachers,
Foundation Research Network on Psychopathology and Development. peers, hospital and institutional staff) directly in contact
Reprint rtquests to Dr. Kazdin, Department of Psychology. Yak UnivN'Sity. with others (e.g., patients, students, residents, inmates)
RO. Box208205. NeuiHaven. CT 06520-8205.
0890-8567/97/3610-1349/$O.300/0iC> 1997 by the American Academ y of can be trained to administer consequences for behavior
Child and Adolescent Psychiatry. and to achieve therapeutic changes.

J. AM . ACAD. CHILD ADOLESC . PSYCHIATRY. 36:10. OCTOBER 1997 1349

KAZOIN

Second, research over the past 30 years has elaborated stealing, arguing), the focus is on developing prosocial
the role of parent discipline practices on child aggressive behaviors or positive behaviors that reduce the likeli-
behavior (Patterson, 1982; Patterson et al., 1992). hood of the undesired behaviors. Consequences refer to a
Parental attention to deviant behavior, interactions in range of events that can follow behavior and that can be
which increasingly aggressive child behavior is rein- used to alter the likelihood of such behavior in the
forced, inattention to prosocial behavior, coercive pun- future. Positive reinforcement is the key concept and
ishment, poor monitoring of child activities, and failure consists of providing social (attention, praise) and
to set limits, referred to as inept discipline practices, sometimes token reinforcers (points or stars with
unwittingly develop and exacerbate aggressive child backup value) for behavior. Mild punishment is also
behavior (Dishion er aI., 1992; Patterson et al., 1992). used as a consequence (e.g., brief time-out, loss of
Observations of family interaction in the home have tokens or privileges), although for several reasons (e.g.,
permitted careful evaluation of exchanges and how they deleterious side effects of punishment), these playa sub-
escalate over time (e.g., yelling, threats, throwing servient role to positive reinforcement (see Kazdin,
objects, physical aggression). Other influences (e.g., 1994).
parental stress, marital discord) on family interaction Many procedures can be derived from the general
patterns and the progression from child aggression to principles (e.g., reinforcement, punishment, extinction)
other problems (e.g., poor peer relations, academic fail- (see Cooper et al., 1987; Kazdin, 1994). These include
ure, and adolescent deviance and substance use) have diverse types of prompts, ways of scheduling con-
also been elaborated empirically (see Forgatch, 1991; sequences, types of consequences, means of involving
Patterson et al., 1992). Several studies, involving clinic the child in the program, and individual and group pro-
and nonclinic samples, cross-sectional and longitudinal grams (e.g., for siblings). How the procedures are imple-
designs, and randomized controlled clinical trials, mented is critical. For example, positive reinforcement
showed that inept parenting practices predict deviant at the beginning of a behavior-change program is opti-
child behavior and that changing these practices has sig- mally effective when it is administered contingently
nificant impact on child functioning (see Dishion and (only when the behavior occurs), frequently, and imme-
Andrews, 1995; Dishion et al., 1992; Forgatch, 1991). diately and usually for small increments of behavior.
Overall, this line of research found that parenting prac- These and related parameters influence the magnitude
tices playa significant role in the development and and durability of behavior change and are relevant in
amelioration of aggressive and antisocial behavior. Of the treatment sessions, as the therapist develops skills of
course, we know that this does not mean that inept par- the parents, and at home, as the parents develop behav-
enting practices are the cause of aggressive behavior, the iors of the child.
only cause of these behaviors, or even a necessary or suf There is a progression in the complexity of behavior
jicient cause of the behaviors nor the only influence that that is developed in the parents and child. Early in
might be mobilized to change these behaviors. Even so, PMT, simple behaviors are selected (e.g., child compli-
these and other such studies provided empirical under- ance in nonprovocative situations). The goal is to
pinnings of PMT. develop abilities in the parent and child and, only when
these are developed, to progress to more complex inter-
Key Principles and Techniques
actions. Agents other than the parents (e.g., relatives or
Antecedents, behaviors, and consequences, some- other adults at home , teachers, siblings) and perform-
times referred to as the ABCs, are key ingredients of ance outside of the home (e.g., school, playground) are
PMT and are used to alter behaviors of the parents and usually integrated into treatment, but the initial focus is
child. Antecedents consist of setting events and stimuli on developing skills of the parents. The programs often
that occur prior to behavior and that can be used to are "artificial" insofar as they introduce consequences
promote and directly facilitate behavior. Examples (e.g., special incentives such as tokens or points) that are
include verbal and physical aides (prompts), instruc- not normally present. Initial programs are temporary
tions, and modeling. Behaviors refer to the positive, pro- and can be gradually reduced (faded) and eliminated so
social behaviors that are to be developed. Even when that behaviors are maintained and transfer to settings
the primary goal is to eliminate behaviors (e.g., fighting, other than the home (Kazdin, 1994).

1350 j, AM. ACAD. CHILD ADOLES C . PSYCHIATRY, 36:10, OCTOBER 1997

 PARENT MANAGEMENT TRAINING

Characteristics of Treatment OVERVIEW OF CURRENT EVIDENCE

Treatment is conducted primarily with the parenrls) , Outcome Studies

who implement several procedures at home. The par- PMT has been evaluated in scores of randomized,
ents meet with a therapist, who teaches them to use spe- controlled outcome trials with youths varying in age
cific procedures to alter interactions with their child, to
(e.g., 2 to 17 years old) and severity of oppositional and
promote prosocial behavior, and to decrease deviant
conduct problems (for recent reviews, see Graziano and
behavior. Parents are trained to identify, define, and
Diarnenr, 1992; Miller and Prinz, 1990; Patterson et al.,
observe problem behaviors in new ways. Careful speci-
1993; Serketich and Dumas, 1996). By the mid-1980s,
fication of the problem is essential for the delivery of
several outcome studies had compared PMT to no-
reinforcing or punishing consequences and for eval-
treatment or waiting-list control conditions and to
uating whether the program is achieving the desired
other viable treatments (e.g., community-based treat-
goals. The treatment sessions provide concrete oppor-
ment, family therapy, individual therapy). Several
tunities for parents to see how the techniques are imple-
research programs (e.g., Eyberg, University of Florida;
mented, to practice and refine use of the techniques
Forehand, University of Georgia; Patterson, Oregon
(e.g., through extensive role-playing), and to review the
Social Learning Research Center; Webster-Stratton,
behavior-change programs used at home. Parent-man-
University of Washington) made special inroads in
aged reinforcement programs for child deportment and
developing the treatment (see Eyberg and Boggs, 1989;
performance at school, completion of homework, and
McMahon and Wells, 1989 ; Patterson et al., 1993 ;
activities on the playground are routinely included , with
Webster-Stratton, 1996). The outcome studies support
the assistance of teachers, as available.
several conclusions:
In most PMT programs, only one parent (usually the
mother) comes to treatment because of scheduling • PMT has led to marked improvements in child
issues (e.g., employment of the other parent) but also behavior on parent and teacher reports of deviant
because of the high rate of single-parent families among behavior, direct observation of behavior at home and
youths with conduct problems . Requiring two parents at school, and institutional records (e.g., school tru-
to attend treatment is not essential for therapeutic ancy, police contacts, arrest rates, institutionaliza-
change and has not led to enhanced outcomes . tion) .
However, this has not been thoroughly studied. Also, • The magnitude of change has placed conduct prob-
participation of both parents , rather than just one, is lem behaviors to within nonclinic levels of function-
confounded with many other variables (e.g., marital ing at home and at school, based on normative data
conflict, stress, family income) that do contribute to from nonreferred peers (e.g., same age, sex).
clinical outcomes, as discussed later. As treatment is • Treatment gains have been maintained in several
implemented, concrete efforts usually are made to inte- studies 1 to 3 years after treatment, although one pro-
grate the parent who does not attend sessions in the gram reported maintenance of gains 10 to 14 years
program carried out at home. later (Long et al., 1994).
Duration of treatment has varied depending on the • Improvements in child behaviors not directly focused
severity of child dysfunction. Programs for young, on in treatment, improvements in behaviors of sib-
mildly oppositional children usually last from 6 to 8 lings at home, and improvements in maternal psy-
weeks. With clinically referred youths with conduct dis- chopathology, particularly depression, have also been
order, the programs usually last from 12 to 25 weeks. It documented. Occasionally, marital satisfaction and
is difficult to provide a firm statement of the required family cohesion improve after treatment, but data on
duration of treatment because of two competing trends, these outcomes are sparse.
namely, efforts to develop more abbreviated and more
Factors That Contribute to Treatment Outcome
cost-effective variations of treatment, on the one hand
(e.g., Thompson et al., 1996), and to combine PMT Considerable attention has been devoted to identify-
with other treatment modalities (multi modal treat- ing parent and family characteristics that contribute to
ments), on the other hand (e.g., Webster-Stratton, outcome. Family socioeconomic disadvantage, marital
1996). discord, high parental stress and low social support,

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KAZDIN

single-parent families, harsh punishment practices, and when supplemented with therapist-led discussions,
parent history of antisocial behavior predict (1) who leads to clinically significant changes at posttreatment
remains in treatment; (2) the magnitude of change and that these changes are maintained at follow-up 1
among those who complete treatment; and (3) the and 3 years later. The opportunity to disseminate
extent to which changes are maintained at follow-up research findings to clinical practice, based on empiri-
(e.g., Dadds and McHugh, 1992; Dumas and Wahler, cally tested videotapes, is unique within child and ado-
1983; Kazdin, 1995a; Webster-Stratton and Hammond, lescent therapy research.
1990). Those families at greatest risk often respond to PMT has been extended to community settings to
treatment, but the magnitude of effects is attenuated as bring treatment to those persons least likely to come to
a function of the extent to which these factors are pres- or remain in treatment. PMT is effective and very cost-
ent. Among child characteristics, more severe and effective when provided in small parent groups in
chronic antisocial behavior and comorbidity predict neighborhoods where the families reside (e.g .,
reduced responsiveness to treatment (e.g., Kazdin, Cunningham et al., 1995; Thompson et al., 1996).
1995a; Ruma et al., 1996). Most studies have focused Occasionally,community-based has been more effective
on childhood-onset conduct problems, so the current than clinic-based treatment. Of course, it is not clear
interest in childhood- versus adolescent-onset subtypes that one form of treatment can replace another for all
has not been addressed systematically. youths . Yet, community applications may permit dis-
Characteristics of treatment also contribute to out- semination of treatment to families that otherwise
come. Providing parents with in-depth knowledge of might not attend the usual mental health services.
social learning principles, rather than just teaching Youths with conduct problems and their families
them the techniques, improves outcomes . Also, often present multiple problems. No single treatment
including mild punishment (e.g., brief time-out from modal ity, however beneficial , may be sufficient.
reinforcement) along with reinforcement programs in Consequently, efforts have been made to combine
the home enhances treatment effects (see Kazdin, treatment with other procedures. Supplementing PMT
1985). These components are now standard in most with sessions that address parent and family stressors
PMT programs. Processes within treatment have also and conflict, compared with PMT alone, has reduced
been studied to identify who responds to treatment. dropping out of treatment, improved clinical outcomes
Measures of parent resistance (e.g., parents saying, "I of the children, and increased positive communication
can't," "I won't") correlate with parent discipline and collaboration between the parents (e.g., Dadds
practices at home; changes in resistance during therapy et al., 1987; Prinz and Miller, 1994; Webster-Stratton,
predict changes in parent behavior. Moreover, specific 1994). Also, combining PMT with cognitively based
therapist ploys during the sessions (e.g., reframing, problem-solving skills training (for the child) is more
confronting) can overcome or contribute to resistance effective than PMT alone (Kazdin et al., 1992;
(Patterson and Chamberlain, 1994). This line of work Webster-Stratton, 1996). PMT occasionally comprises
advances our understanding of PMT greatly by one module of a multimodal treatment package, as, for
relating in-session interactions of the therapist and example, in multisystemic therapy (Henggeler and
parent to child functioning and treatment outcome. Borduin, 1990) and foster care treatment (Chamber-
lain, 1996) for delinquent youths.
Combined treatments are not always positive or
Variations of Treatment
neutral in their effects. For example, PMT supple-
In much of the outcome research, PMT has been mented with adolescent group treatment led to worse
administered to families individually in clinic settings. outcomes at follow-up than PMT alone (Dishion and
Group administration has been facilitated greatly by the Andrews, 1995), a finding possibly due to the unto-
development of videotaped materials that present ward peer influences (e.g., engaging in substance use)
themes, principles, and procedures to the parents of such groups may foster. An insufficiently explored issue
children with conduct problems (see Webster-Stratton, is who can profit from single modality treatments such
1996). Randomized, controlled trials have shown that as PMT and who requires a combined treatment
video-based treatment, particularly in group format and approach.

1352 J. AM . ACAD . CHILD ADOLESC. PSYCHIATRY, 36 :10, OCTOBER 199 7

 PARENT MANAGEMENT TRAINING

ISSUES AND LIMITATIONS family factors often associated with conduct problems
Treatment Outcome Effects (e.g., socioeconomic disadvantage, younger mothers,
single-parent families, high levels of stress, low social
Several basic questions can be raised about the mag- support, and parent history of antisocial behavior) are
nitude, scope, and durability of therapeutic changes risk factors for dropping out of treatment (Kazdin et al.,
among oppositional, aggressive, and antisocial children. 1994). High dropout rate may be exacerbated because
In relation to magnitude of change, PMT studies show of the demands PMT places on the parents to master
statistically significant improvements (e.g., "pre" to key concepts and implement treatment procedures at
"post" improvements) and that these improvements home. At this point, there is no clear evidence that
typically surpass those of other treatment and control PMT increases dropout rates over and above other
procedures. The clinical significance of change, i.e., treatments. Even so, for some families, the demands
whether the impact of treatment makes a difference in may be too great to begin or to continue treatment.
everyday functioning, includes many ways of examining The concern about demands of treatment on family
the data that go well beyond statistical significance (see participation has been addressed in different ways. First,
Jacobson, 1988; Kazdin, in press). In several studies , within the approach of PMT, specific procedures (e.g.,
PMT has been shown to produce clinically significant shaping parent behavior through reinforcement) are
changes. However, the very large body of empirical lit- used to develop parent skills in a graduated and highly
erature on PMT is considerably reduced if this crite- individualized fashion. The initial goal is to develop
rion is invoked. special skills in the parents, and the rate at which these
In relation to scope of therapeutic changes, many skills are developed can be systematically varied, as
outcome domains have been neglected, including peer needed. Second, supplementing PMT with time during
relations, social competence, participation in activities, treatment to discuss parental stressors decreases dropout
and academic functioning. These domains are likely to rates (Prinz and Miller, 1994). Finally, conducting PMT
be impaired among youths with conduct problems and in community settings decreases many of the logistical
also to influence long-term prognosis. The impact of obstacles among families who otherwise could not par-
PMT on comorbid conditions also is rarely measured. ticipate in treatment (Cunningham er al., 1995).
ADHD, for example, is likely to be one of the comor-
bid conditions. Although PMT can reduce con- Neglected Areas of Research
duct problems among youths with ADHD (e.g., Many areas of research can be identified in which
Anastopoulos et al., 1996) and ADHD symptoms much more information is needed, but two lacunae
among youths with behavioral problems (e.g., Strayhorn stand out. First, there is a paucity of studies that focus
and Weidman, 1991), few regard PMT as sufficient on adolescents with conduct problems. Most PMT
treatment for ADHD. A broad spectrum of clinically studies focus on youths 3 to 10 years of age. Within this
relevant outcomes warrant evaluation. age range, day-to-day influences utilized in PMT (e.g.,
Finally, in relation to durability, the poor prognosis of parent delivery of praise, attention, privileges) can have
conduct problems raises the question of the extent to significant impact on child behavior. As the child enters
which treatment will make a difference in the long term. adolescence, peers take on a salient role in general and
Antisocial children are at risk for dysfunction in in the promotion and maintenance of antisocial behav-
adolescence (e.g., substance abuse, criminal activity) and ior (Elliott et al., 1988; Newcomb and Bentler, 1988).
adulthood (e.g., criminal behavior, antisocial personality Controlled studies have shown PMT to reduce offense
disorder in males, depression in females) (see Kazdin , rates among delinquent adolescents (Bank et al., 1991)
1995b). Conclusions about the impact of PMT must be and school behavioral problems and substance use
tempered until long-term follow-up data are available. among adolescents at risk for serious conduct problems
(Dishion and Andrews, 1995).
Obstacles to Clinical Application
Research suggests that adolescents respond less well
In child and adolescent therapy in general, 40% to to PMT than do children (Dishion and Patterson,
60% of families that begin treatment terminate prema- 1992), although this effect seems to be accounted for by
turely (see Kazdin, 1996) . Many of the parent and severity of symptoms (Ruma et al., 1996). Adolescents

J. AM. ACAD . CHILD ADOLES C. PSYCHIATRY. 36:10 . O CTOBER 1997 1353

KAZDIN

referred for treatment tend to be more severely and ious techniques. Already mentioned were videotapes
chronically impaired than preadolescents; once severity that can also be used by professionals to guide group
is controlled, age does not influence outcome. Yet, in PMT. In short, although formal training opportunities
light of limited applications with adolescents, the are few, resources are available to familiarize oneself
strength of conclusions about the efficacy of PMT app- with the treatment and how it is applied.
lies mainly to preadolescent youths. This is important in Conceptual Clash. Several facets of PMT may gener-
its own right, given that childhood-onset conduct prob- ate in many mental health professionals the equivalent
lems may be enduring and are often recalcitrant to of conceptual "sticker shock." Many of us were trained
treatment. in some variation of psychodynamic, relationship-based
A second area that has been neglected within PMT is psychotherapy in which talk, play, the therapeutic rela-
consideration of ethnic and cultural issues (Forehand tionship, and intrapsychic processes serve a central role.
and Kotchick, 1996). Variation in parenting practices The conceptual underpinnings of PMT may seem
and family values among ethnic groups may influence bereft, simplistic, and indeed outright misguided, when
receptivity to changes in parent-child interaction pat- compared with the conceptual orientations on which
terns. The use of corporal punishment, the role of we may have imprinted. It is not that PMT ignores
extended family members in raising children, and emotions, cognitions, and nuances of relationships,
expectations for self-control and obedience on the part both in the sessions and more generally. Rather, the
of the child could readily influence the effectiveness and view embraces a broader conceptual position, namely,
indeed applicability of PMT. Diverse ethnic groups are that one of the best ways to alter psychological and
included in studies of PMT, but the effects of ethnic interpersonal domains is by having individuals behave
and cultural factors on disserninabiliry, treatment imple- differently. (The view that changing overt behavior is an
mentation, and clinical outcomes of PMT remain to be effective means to alter intrapsychic and interpersonal
investigated. processes is not unique to behavioral approaches. In the
early 1940s, the psychoanalyst A. Herzberg [1945]
Professional Issues
maintained that the best way to alter intrapsychic proc-
Limited Training Opportunities. The application of esses was to change behaviors in everyday situations. He
PMT is greatly limited by the paucity of training required patients to perform a graduated series of tasks
opportunities in child psychiatry, clinical psychology, outside of the therapy sessions related to their clinical
social work, and nursing. Continuing education pro- problems [e.g., anxiety, depression, sexual dysfunction,
grams and conference workshops can certainly familiar- and many others].) Although PMT focuses on concrete
ize professionals with the intervention, but they cannot behaviors, child functioning, and the family environ-
be expected to provide the necessary background and ment, the impact affects parent expectations, despair,
application skills. PMT requires mastery of social learn- conflict, family dynamics, and attitudes (see Thompson
ing principles and multiple procedures that derive from et al., 1996; Webster-Stratton and Spitzer, 1996). As
them (Cooper et al., 1987; Kazdin, 1994). The princi- with any treatment technique, the scope of changes one
ples are quite straightforward, but the range of applica- seeks extends beyond the specific foci of the sessions.
tions that follow from them and the requisite therapist Even so, the focus on concrete behaviors of the parents
skills in shaping parent behavior require more than and children is alien to many approaches that dominate
passing familiarity. clinical training.
Several resources are available to facilitate use of Related activities conducted within the treatment ses-
PMT clinically and in research. Treatment manuals are sions are also quite different from what many expect of
available for clinicians and convey the structure, con- therapy. Treatment sessions include a great deal of active
tent, and flow of treatment sessions (e.g., Forehand and role-playing, practice, feedback, and therapist modeling
McMahon, 1981; Forgatch and Patterson, 1989; and guidance to develop the skills that will be used at
Patterson and Forgatch, 1987; Sanders and Dadds, home. Learning by doing rather than by understanding
1993). Books and pamphlets are also available for par- is a reasonable way to characterize the sessions, even
ents (e.g., Forehand and Long, 1996; Patterson, 1976) though, of course, doing is enhanced by understanding
that convey basic concepts and show how to apply var- what to do, why to do it, and how it is to be done.

1354 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 36:10, OCTOBER 1997

 PARENT MANAGEMENT TRAINING

Therapist sensitivity, empathy, insight, and the thera- treatments, based on the number of independent rep-
peutic relationship are critically important because fam- lications demonstrating favorable outcomes. Even so,
ilies bring a range of problems to treatment (e.g., the research still leaves questions open about the mag-
conflict, ambivalence, and personal and family issues), nitude, scope, and durability of outcome effects. One of
no matter what the conceptual view of the clinician. the challenges is discussed as moving from efficacy (dem-
The professional obstacles raised by PMT do not onstration of treatment effects in well-controlled situ-
derive merely from our lack of familiarity with the treat- ations) to effectiveness (demonstrations in clinical
ment or its conceptual departure from more "tradi- applications) (e.g., Hoagwood and Hibbs, 1995). Many
tional" therapies with children and adolescents. In of our efficacy studies have not addressed central ques-
general, we have learned to be appropriately skeptical tions about what treatments work for whom, the dura-
and cautious about any single treatment approach to bility of treatment effects, and how these effects
multifaceted clinical problems. Conduct disorder influence long-term developmental trajectories. It is still
reflects a heterogeneous group of symptoms, and it is important to move what we have learned from lab-
unlikely that any single approach will address all of the oratory to clinic and community settings. PMT has
pertinent facets or associated features (e.g., comorbid made inroads in community-based extensions of treat-
diagnoses, family dysfunction). No doubt this view ment, as highlighted previously. At the same time, even
underlies efforts to include PMT in various combined with PMT, one of the more well-investigated treat-
and multimodal treatment packages mentioned pre- ments, further development is still needed to address
viously. central questions of clinical relevance.

CONCLUSIONS
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