ispa 2016 slidesispa2016.org/images/handouts/saturday/armstrong.pdf · 6/23/2016 2 university of...

6/23/2016

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UNIVERSIT Y OF SOUTH F LORIDA

MORSANI COLLEGE OF MEDICINE

Effective Parenting for School Improvement

23 July 20169-10:30 AM

University of AmsterdamInternational School Psychology Association



Early Childhood Behavior Problems

• Disruptive behaviors (DB)– Non-compliance

– Aggression

– Temper loss

– Low concern for others



Typical versus Atypical

• Early aggression (18 months)

• Recalcitrant hostility

• Intense temper tantrums

• Low concern for others’ needs & feelings

• Lack of empathy

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DB Prevalence for Preschoolers

• According to DSM 5 (2013) & CDC (2012) – 12% Attention Deficit Hyperactivity Disorder

(ADHD)

– 11-16% Oppositional Defiant Disorder (ODD)

– 4-6% Conduct Disorder (CD)

– 46% co-morbid ODD and ADHD



DB Outcomes• Poor academic achievement• Special education placement• Delinquency• Substance abuse• Early pregnancy• Increased mental health disorders• Increased health problems• Other negative life outcomes



DB Medical Management

• Increased referral rates for children ages 2–5

• 75% are prescribed stimulant medication

• Poor children (Medicaid) twice as likely to receive medication compared to peers

• Less than 50% receive any psychological services

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Prevention and Early Intervention• DB emerge during toddler years

• Emotional regulation and social skills are critical to healthy development

• Parents and teachers are key protective factors

• Intervention should be evidence-based



Prevention Model

Tertiary

(clinical)

Secondary

(targeted)

Primary

(universal)



Two Treatment Options for Preschoolers

• DOCS Parenting Programs– Helping Our Toddlers, Developing Our Children’s Skills

(HOT DOCS; Armstrong, Agazzi, Childres, & Lilly, 2012)

– DOCS for Success (DOCS; Shaffer, Ogg, & Armstrong, 2012)

• Parent Child Interaction Therapy – PCIT; Eyberg & Funderburk, 2011

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• Helping Our Toddlers, Developing Our Children’s Skills (HOT DOCS)– Developed by Armstrong, Lilly, & Curtiss (2006)

• Development funded by– US Department of Education– Children’s Board of Hillsborough County– Participant materials & fees

• Current 2nd Edition-Revised– Target population- caregivers of children 0-5

• English and Spanish versions• DOCS for Success-2012 (children 6-12)

DOCS Parenting Programs



– Published studies (6 to date)– USF Dissertations and Theses (4 to date)– Standardized measures

• Child Behavior Checklist (CBCL)• Adaptive Behavior Assessment System (ABAS-2)• Sleep Disorders Inventory for Students-C (SDIS-C)• Parenting Stress Index

– Pre-Post measures• Eyberg Child Behavior Inventory (ECBI)• Knowledge Test

– Satisfaction measures– Progress monitoring tools

• Tip trackers

HOT DOCS Evaluation



• Results in improved behavioral outcomes– Significant reduction in challenging behaviors– Improved prosocial, emotional, and adaptive skills– Reduced parenting stress

• Effective with children experiencing wide-range of developmental needs

– Typical, global delays, medically-fragile, ADHD, ASD

• Appropriate for culturally diverse caregivers– Report decreased stress, improved skills, improved

caregiver-child relationships, and empowerment

HOT DOCS OUTCOMES

Wil l iams, Armstrong, Agazz i , & Brad ley-Klug , 2010

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Implementation Sites• Hillsborough County, Florida

– USF Pediatrics• Orange County, Florida

– Early Steps• Cambridge, MA

– Community Mental Health• Broward County, Florida

– Broward County School District and Early Steps

• Portland, Oregon– Providence Child Center

• Quito, Ecuador– Universidad San Francisco de Quito



HOT DOCS Curriculum

Module 1 – Early Childhood Development

Module 2 – Routines, Rituals and Development

Module 3 – Development and Behavior

Module 4 – Preventions that Guide Development

Module 5 – Teaching New Skills

Module 6 – Developing New Responses

Module 7 – Reducing Stress the HOT DOCS way



Trainer’s Manual• Slides and video examples• Learning Objectives• Activities• Materials• Instructions for Facilitators• Key Points• Parenting Tips*• Class activities and role plays• Special Play Activity

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HOT DOCS Problem Solving Chart

Triggers Behavior Consequences

Describe events just before the behavior:

•Where was the child?•What was the child doing?•Who else was present?•What were they doing?

Specifically describe the behavior:

What did the child do?

What happened following the problem behavior:•How did other(s) respond to the child’s behavior?

Preventions New Skills New Responses

•Visual schedule•Transition cue•Social Stories•Warning Time: Timers•Natural Endings•First/Then Boards•Offering Choices•“I want” board•Busy Bags

Teach positive opposite behaviorCommunication skills (gestures, signs, or words)Calm VoiceFeelings WordsWaitingFollowing DirectionsTurn Taking

Specific PraiseValidate & RedirectTime Out for Aggression

Function?To GET or GET OUT OF



Example Lesson: HOT DOCS 1: The Developing Brain

• Brain Development– The early childhood years– How neural connections

form– Influences on the

developing brain• Experiences &

Relationships• Impact of Stress

– Typical and atypical development

– Preparing your child for school

Example Parenting Tip:Give Clear Directions

• Providing child with explicit directions– Clearly and simply states expectations – Tells child what to do– Includes developmentally appropriate

language– Uses polite tone– Incorporates developmentally appropriate

expectations– Reinforced with attention and praise

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Example Class Activity: Give Clear Directions

• Don’t run!

• Stop climbing!

• Don’t touch!

• Stop whining!

• Don’t stand on the couch!

• Don’t hit!

• Stop pulling the dog’s tail!

• Stop playing with your food!

• Stop splashing the water!

• Don’t get out of bed!

• No biting!

• Don’t spit!



Example Homework Activity: Special Play

• Uses Play-doh and plastic mat to teach children to play within defined boundary

• Caregivers use “Clear Directions” to prepare children for activity

• Caregiver uses timer to signal beginning and ending of activity

• Caregivers praise child for following directions



Setting Rules: Play-doh Activity

Playdoh on mat No Playdoh on floor

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monday tuesday wens thursday friday saturday sunday

How Hard1234

How Hard1234

How Hard1234

How Hard1234

How Hard1234

How Hard1234

How Hard1234

Did notuse skill

Did notuse skill

Did notuse skill

Did notuse skill

Did notuse skill

Did notuse skill

Did notuse skill

How hard was it to Give Clear Directions to your child:

Directions: For each day of the week decide how hard it was for you to remember to use short, simple statements to tell your child what TO DO instead of what NOT to do. Circle your response below:

1 = very difficult 2 = difficult 3 = neither difficult 4 = easynor easy

HOT DOCS Tip Tracker: Give Clear Directions



ECBI Documenting Class Outcomes



HOT DOCS Case Study

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Julie’s Sleep Routine

• Julie plays energetically right up until bedtime at 8 PM

• She says she is hungry, and wants a peanut butter & jelly sandwich, and chocolate milk

• Parents turn on her favorite videos to help her relax• Julie insists on a bright nightlight in her room• Julie comes out several times for water, bathroom

and hugs• Julie finally falls asleep at 11 PM but climbs in bed

with parents at 2 AM• No one sleeps well, and the alarm goes off at 6 AM• Julie refuses to get up and ready for school

HOT DOCS Problem Solving Chart

Triggers Behavior Consequences

•Where was Julie‐in the living room•What was the Julie doing‐playing•Who else was present‐parents•What were they doing‐trying to get Julie to go to sleep

Plays energetically

Asks for food

Demands night light

Comes out of room

Climbs in bed with parents

Parents get her a sandwichParents turn on TVParents turn on night lightParents give her hugs and return her to bedParents give in and Julie sleeps with them

Preventions New Skills New Responses

•Visual schedule•Timer to signal end of playtime•Consistent sleep routine•Make room “sleep only” zone•Limit screen time•Use a sleep pass

Teach positive opposite behaviorCommunication skills (gestures, signs, or words)Calm VoiceFeelings WordsWaitingFollowing DirectionsTurn Taking

Specific Praise for following routineIgnore requests for food, drink, etc.Redirect Julie to bedSticker or token for maintaining sleep pass

Function?To GET or GET OUT OF



Parent Child Interaction Therapy• Active coaching of parent with their child• Grounded in developmental theory• Emphasis on restructuring interaction

patterns• Assessment-driven• Not time-limited • Empirically supported

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PCIT: A Model Program• Society of Clinical Child and Adolescent Psychology,

APA Division 53 (www.effectivechild therapy.com)

• The National Child Traumatic Stress Network (SAMHSA, 2005; http://www.nctsn.org)

• Chadwick Center for Children and Families (http://www.chadwickcenter.org)

• National Crime Victims Research and Treatment Center (U.S. Department of Justice; http://musc.edu/ncvc)

• The California Evidence-Based Clearinghouse for Child Welfare (2006; http://www.cebc4cw.org)

• Youth Violence: A Report of the Surgeon General (www.surgeongeneral.gov/library/youthviolence)



Efficacy of PCIT• Two well-conducted randomized trials

– United Sates (Schuhmann et al., 1998)

– Australia (Nixon et al., 2003)

• Participants– Preschool age (3 to 6 years)– Disruptive behavior disorders– Primarily Caucasian– No significant developmental/cognitive delay

• Improvements in (compared to waitlist)– Child behavior– Parenting practices and stress



Efficacy of PCIT

(Schuhmann et al., 1998)

p < .001d = 1.40

EC

BI

Inte

nsity

Sca

le

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PCIT Effect Size

(Connor et al., 2002)

(Schuhmann et al., 1998)

(Rosenthal et al., 1990)

Coh

en’s

d



Two Treatment Phases

• Child Directed Interaction (CDI)

• Parent Directed Interaction (PDI)

Child-Directed Interaction (CDI)“DO” SKILLS

Praise

Reflect

Imitate

Describe

Enthusiasm

“DON’T” SKILLS

Ask Questions

Give Commands

Criticize

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Parent-Directed Interaction (PDI)• Giving effective commands• Providing specific, immediate praise• Using a structured time-out sequence• Generalizing commands into everyday

routines• House Rules• Setting rules for public outings



PCIT Case Study: Braxton• 4-year-old boy with disruptive behavior

– Hitting, spitting, running away, poor self-regulation• Dx: SI, ADHD, ODD, & ASD• Expelled from community preschool• Receiving speech & occupational therapies• Medical management: Adderall (amphetamine-

dextroamphetamine) for inattention/hyperactivity & Intuniv (guanfacine extended release) for behavior and inattention

• PCIT: 14 weeks



Data Collection: CDI Skills (10 weeks)

3 3

10

4

22

8

3

10

4

10

5

2

76

14

4

16

8

25

11

21

5 5 5

15

9

6

1011

10

1 12 2 2

0 01

01

3

10 0

1 10

10 0 0 0 0 0 0 0 0 00

5

10

15

20

25

30BD Behavior Description RF Reflection LP Labeled Praise

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Data Collection: ECBI T-Scores (14 weeks)

77

6263

6466

67

6362

67

6361

62 6264

62

57

73 73

62

68

63

59

62

59

56 5655

56 56

5251 51

40

45

50

55

60

65

70

75

80

C‐T

C‐1

C‐2

C‐3

C‐4

C‐5

C‐6

C‐7

C‐8

C‐9

C‐10

P‐T

P‐1

P‐2

P‐3

P‐4

Series1 Series2

Pre-post Behavior RatingsPre-test

Tool T-scoreCBCL • PDD 77• ADHD 77• ODD 80• Anxiety 73

ECBI 77SESBI-R 82

Post-testTool T-scoreCBCL • PDD 60• ADHD 67• ODD 63• Anxiety 60

ECBI 57SESBI-R 50



Summary

• DB are common in young children

• Early onset DB lead to poor outcomes

• Prevention and early intervention with parents promote optimal development

• Evidence-based interventions work best

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Thank you!

Dank u!

University of South Florida

Kathleen Armstrong, [email protected]

Richard Downs, [email protected]

Handouts posted at:http://health.usf.edu/medicine/pediatri

cs/child_dev_neuro/Research.htm

ispa 2016 slidesispa2016.org/images/handouts/saturday/armstrong.pdf · 6/23/2016 2 university of...

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