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Defining parent training for practice and research
J o u r n a l o f the A m e r i c a n P s y c h i a t r i c N u r s e s A s s o c i a t i o n
Continuing Education Defining Parent Training for Practice and Research Jennifer Harrison Elder, RN, PhD Parent training is a f a m i l i a r t e r m in nursing a n d o t h e r social sciences. Yet, the c o n c e p t r e p r e s e n t e d by the t e r m in the l i t e r a t u r e is ambiguous. In this article the a u t h o r def i n e s a n d o p e r a t i o n a l i z e s the c o n c e p t o f p a r e n t training, e m p h a s i z i n g its relevance in p r o v i d i n g c a r e to children w i t h c o m p l e x p s y c h i a t r i c d i s o r d e r s . The d i s c u s s i o n is ill u s t r a t e d w i t h c a s e e x a m p l e s a n d p r o v i d e s an o p e r a t i o n a l definition o f the c o n c e p t o f p a r e n t training to f a c i l i t a t e a link among t h e o r e t i c concept, clinical p r a c t i c e , a n d emp i r i c research. (JAm P s y c h i a t r N u r s e s A s s o c [199 7]. 3~ 103-110)
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esearchers and clinicians have written extensively about the concept of parent training over the past 2 decades. Yet, the term p a r e n t t r a i n i n g has b e e n given numerous and varied meanings, and the concept is not clearly presented in the literature. Given this conceptual ambiguity, many potentially useful studies are difficult to understand, seldom appear to interface with existing theories, and cannot be replicated in such a way as to facilitate sound empiric assessment and scientific inquiry. Furthermore many professionals describe parent training in jargon that Kuhn (1970) refers to as "the language of experts." The purpose of this article is to clarify the concept of parent training by offering an operational definition, determining critical attributes of the concept, and analyzing cases for goodness of fit with the proposed operational definition.
Jennifer Harrison Elder is an Assistant Professor at the University o f Florida in Gainsville. Reprint requests: Jennifer Harrison Elder, RN, PhD, Box I O0187JHMI-IC, Gainesville, FL 32610. Copyright © 199 7 by the American Psychiatric Nurses Association. 1078-3903/9 7/$5.00 + 0 6 6 / 1 / 8 3 3 70
August 1997
PARENT TRAINING IN NURSING Parent training is not a new concept in nursing. On the contrary, nurses have long upheld traditions of training parents in ways that maximize the health and general welfare of their children. Nursing practice is a direct service that is goal-directed and adaptable to the needs of the individual, family, and community during health and illness. The provision of behavior management training for parents and families of children with behavioral and developmental disabilities is a nursing role (Elder, 1995). Parent training may be viewed as a second-order or middle-range concept and fits well within nursing's metaparadigm, which contains four central concepts: person, environment, health, and nursing. These concepts are connected in a major proposition stating that nursing addresses the wholeness and health of humans while recognizing that humans are continually interacting with their environments (Fawcett, 1989).
DEFINING THE PARENT TRAINING The following operational definition of parent training reflects nursing theory, current literature, clinical practice, and research findings: Parent training is a dynamic, interactive and instructional process by which a caretaker (parElder
103
J o u r n a l o f the A m e r i c a n P s y c h i a t r i c N u r s e s A s s o c i a t i o n
ent) is taught to perceive, assimilate, and utilize knowledge about his\her child in such a way as to: (a) modify maladaptive and/or deficit child behaviors, (b) promote health and general wellbeing of the child and family, and (c) facilitate the child's learning and successful current and future environmental adaptation within the home and community.
CRITICAL ATTRIBUTES OF THE PARENT
active participants in all levels of the training process (LaVigna & Donnellon, 1986). Furthermore individualized assessment is considered to be a critical attribute of effective behavioral management, particularly with multiply handicapped children. The parent training most often described in the literature focused only on implementing and evaluating specific interventions. These reports offered little information regarding the development of assessment and intervention procedures, which is critical for successful replication in research and clinical practice (Elder, 1995).
TRAINING CONCEPT This definition suggests several critical attributes of PARENTTRAINING MODEL the parent training concept. Historically there is wide The parent training model presented addresses the variation regarding which attributes are most imporpreviously stated concerns. The model contains four rant and the emphasis that each should receive during components: assessment, intervention development, clinical practice and in research. In the early 1970s the intervention implementation, and evaluation. These focus was on parent education, for example, teaching components proceed in the order in which they are childhood development and assisting parents to unpresented. That is, assessment must precede intervenderstand and apply behavioral techniques, such as timetion development, intervention development precedes out. During the 1970s there was also an emphasis on intervention implementation, and implementation prefamily systems, and many interventions included some cedes evaluation. form of family counseling or therapy (Patterson & Assessment. A s s e s s m e n t is the first and perhaps Fleishman, 1979). most important component in this model. The assessThese earlier definitions of parent training reflect ment includes a thorough client description that evaluthe characteristics of the children who most often reates personal likes and dislikes, temperament, comceived parent training, such as those with conduct dismunicative intent of behavior, cognitive and orders or hyperactivity. More recently, there has been developmental level, physical health status, current a trend toward increasing parental involvement in edueducational placement, and client role within the ramcation and treatment, and ily and community (Elder, parent training has been ex1996). A second assesspanded to include treatment The parent training most often ment is needed to evaluof multiply handicapped children, for example, those with autism or other com-
described in the literature focused only on implementing and evaluating specific interventions,
plex developmental disabilities. It is likely that this shift is in response to Public Law 94-142 and Public Law 99-457 (Cole, 1989), which mandate that children be provided educational opportunities regardless of their disabilities. Children with these psychiatric disorders vary considerably in symptoms, so there is also a need to tailor parent training programs to meet these varied needs of the individual children because what is effective for one may not be effective for another (Elder, 1996; LaVigna & Donnellon, 1986). The literature suggests a trend away from didactic teaching and family therapy models and a move toward a more interactive approach where parents are 104 Elder
ate parental beliefs regarding the child that are thought to influence child
learning (Miller, 1988). Family s t r e n g t h s and weaknesses, interactions with the child, availability and need for community support and advocacy, financial stability, and how well the home environment is suited to the needs of the child also warrant evaluation. Intervention Development. Once the assessment of the client and family have been conducted, intervention d e v e l o p m e n t can occur. This process involves the parent, child, and nurse working together to develop interventions based on the individual needs of the child, his or family, and his or her environment. Parents are trained to perform functional analyses of child behavior, observe antecedent and consequent Vol. 3, No. 4
J o u r n a l o f the American P s y c h i a t r i c N u r s e s Association
events (i.e., what occurs just before and immediately after the behavior of concern), and record behavior in a systematic manner (Coucouvanis, 1997). When parents are able to perform adequate behavioral assessments as indicated by information they obtain and present to the parent trainer, they are helped to set realistic behavioral and educational goals for their children (Rickert et al., 1988). Intervention Implementation. In the intervention implementation phase parents are taught to use appropriate interventions while continuously assessing effectiveness and adapting procedures as n e e d e d to obtain maximum benefit (Sanders & Plant, 1989). Ideally, intervention implementation should occur in the child's natural environment, such as home or school, because many children have difficulty generalizing across settings (Laski, Charlop, & Screibman, 1988). Evaluation. Finally, an evaluation of parent proficiency, child behavioral progress, and social validity occurs. Social validity, also referred to as consumer satisfaction, is critical if there is to be continued intervention implementation and maintenance of treatment effects once formal instruction is completed (Forehand, Wellsl & Greist, 1980). Ideally, this evaluation process uses behavioral data recorded by the parents and parent trainer, a written consumer satisfaction questionnaire, and w h e n possible, a review of videotaped parent-child sessions to illustrate p r e t r e a t m e n t and posttreatment effects (Elder, 1995).
parents found individual and family therapy to be of little use and discontinued attendance after two sessions. This type of child and parent treatment is problemoriented, does not include thorough assessment, and does not involve any form of parent training. Furthermore the unsaid message is that professionals, rather than parents, are best equipped to "fix" the child. This may place u n d u e burden on professionals while not equipping parents to manage their own children.
Related Case A related case contains attributes that appear like those found in the concept, but the defining characteristics differ or are unclear. For example, Mr. and Mrs. Seitz were having difficulty managing their 8 yea>old son, Jon, w h o had been given the diagnosis of mental retardation and a severe language disorder. He was dis-
Once the assessment of the client and family have been conducted, intervention development can occur.
Contrary Case
ruptive in public, lacked appropriate social skills, and had few friends. Mr. and Mrs. Seitz enrolled in a 6w e e k parent training class offered in their community, where they learned about normal childhood dev e l o p m e n t , first aid, h o w to teach their child to complete household chores, and ways to stimulate creativity. The instructor cited articles in parenting magazines and popular lay psychology magazines and described vignettes from her o w n experiences raising three "difficult children." Although the Seitzs thought the classes were interesting, they also found them to be of little help in managing their son. This case is related to parent training but does not illustrate the concept. This is an example of what has b e e n referred to as "parenting classes," a concept often confused with parent training.
The following contrary case contains attributes that are clearly unsupportive of the concept. Frances, a 9year-old girl with autism, was brought to a child psychiatrist by her parents, w h o could no longer control her extreme hyperactivity and self-abuse. The psychiatrist prescribed haloperidol (Haldol) and told the family to make a follow-up appointment for individual and family therapy. Haldoperidol effectively calmed Frances's behavior and made her very drowsy. Her
The following borderline case illustrates instances of the concept that are inconsistent. For example, Mr. and Mrs. Harris contacted a local child guidance clinic and reported that their 10-year-old daughter, Julie, diagnosed with autism, "does not listen to what we say, disobeys us constantly, and bites her little brother." Mr. and Mrs. Harris enrolled in a parent training group
CASES ILLUSTRATING CRITICAL ATTRIBUTES Walker and Avant (1994) assert that various types of cases (e.g., contrary cases, related cases, borderline cases, model cases) can help define and operationalize concepts for nursing practice and research. Each of these types of cases will be illustrated, and the final case, a model or paradigm, will fully illustrate the proposed parent training concept.
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Borderline Case
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that met once a w e e k at the clinic. The group was c o m p o s e d of parents w h o had "problem children." Parents were instructed in the use of time-out and other punishment procedures. They were told that most problematic behaviors are attention-seeking and will be extinguished if consistently punished or ignored. The Harrises faithfully applied what they had learned, but their daughter's behavior became even more problematic. Discouraged at the lack of progress, the Harrises discontinued their group meetings and sought help from their pediatrician, who prescribed thioridazine (Mellaril) to "calm Julie down." Several months later the Harrises received a call from Julie's school reporting that she had a seizure. She was hospitalized, and plans were made for an institutional placement because the family could no longer cope with her behavior and medical problems. This represents a borderline case in that it does not sufficiently illustrate the concept for several reasons. First, no individual client and family assessment was conducted. Had an adequate assessment and medical evaluation been done, it likely would have b e e n clear that Julie's lack of attention was not due to noncompliance but petit mal seizures. Lacking an adequate assessment, the Harrises attempted to implement procedures with their daughter that might have b e e n effective with children with conduct disorders but were totally inappropriate in this case. Second, they received no individualized instruction or follow-up. Finally, out of desperation they consulted a pediatrician, w h o prescribed thioridazine. The medication calmed Julie but, because of its sedating effect, prevented her from fully attending to her environment, which is essential for learning. In addition, the thioridazine lowered Julie's seizure threshold and likely precipitated her seizure. It is not surprising that this "parent training" was unsuccessful.
Model Case The following case is a model, or paradigm, because it contains all of the critical attributes. Charlie Dunn, a 12-year-old boy, was referred for evaluation and treatment of his autistic-like symptoms including severe school tantrums, limited social interactions, ritualistic behavior, delayed expressive language, and head-banging. His parents stated that they had exhausted all community resources including Charlie's school. School personnel could no longer manage his disruptive behavior and suggested a "homebound educational placement." The parents' primary goal was to control their son's behavior so that he could remain in school. 106 Elder
Assessment (Child). Charlie's parents described him as an "easy-going kid" w h o preferred to be left alone to rock in his chair, eat Oreo cookies, w a n d e r about the backyard, and listen to country music on his headset. During the outpatient assessment he sat quietly in the room, periodically going to the door to indicate his desire to leave. He communicated with two- to three-word phrases that were almost incomprehensible except by his parents, w h o served as interpreters. Cognitive and developmental evaluation indicated that Charlie was functioning in the range of trainably mentally retarded. His parents reported that he could successfully perform activities of daily living such as toileting, dressing, and grooming. His medical history revealed grand mal seizures in early childhood, but the parents described his current health as excellent. These reports were validated by past medical records and a physical examination. At the time of the evaluation Charlie was taking no medications, although he had r e c e i v e d previous trials of m e t h y l p h e n i d a t e (Ritalin), thioridazine (Mellaril), and h a l o p e r i d o l (Haldol). The parents reported that Ritalin made him "bounce off the walls," whereas Mellaril and Haldol produced "zombie-like states." Charlie attended a selfcontained special education classroom of 10 children with varying diagnoses. The class had one teacher and one teacher's aide. Recently he had been participating in activities to prepare him to perform clerical skills. Assessment (Family). Mrs. Dunn is a 45-year-old legal secretary. She and her husband have three other children in their early twenties. She tearfully admitted that she was faced with difficult decisions regarding h o w to care for her son at h o m e without forfeiting her work position, which she had maintained for 20 years. She acknowledged that Charlie was an unplanned pregnancy that occurred "too late in life." She stated that she was exhausted, bewildered, and unable to cope with the situation. Mr. Dunn, w h o voiced sympathy for his wife and son, offered little assistance, stating that his job demands required much travel and inconsistent schedules. Both parents believed that their son would probably never improve and feared institutionalization. Noting that the family was in crisis with a limited support system and resources, the psychiatric nurse arranged temporary respite care for Charlie. The parents, w h o had experienced little time to themselves, were encouraged to use the respite time for recreation. Plans were made to meet the next w e e k to beVol. 3, No. 4
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gin parent training in stress management, behavioral assessment, and intervention planning. Mrs. Dunn was amazed at the effect the respite had on her, her husband, and their relationship. The next w e e k both were more relaxed and eager to learn. Mr. and Mrs. Dunn had discussed pros and cons of Mrs. Dunn's leaving her job and compromised on emergency leave until the current crisis was resolved. Mrs. Dunn's supervisor agreed to this plan. Both parents were instructed regarding stress management and conducting a thorough, systematic behavioral analysis. They were taught to examine antecedents and consequences of problematic behaviors, record observations, and mutually set attainable goals. Mrs. Dunn contacted Charlie's teacher, w h o facilitated classroom observations. Mrs. Dunn conducted a behavioral analysis as instructed. She noted that Charlie exhibited tantrums w h e n asked to perform tasks that required him to pick up paper clips, put them in e m velopes, empty the envelopes, and repeat the activity. She assessed that her son was objecting to the activity
Cognitive and developmental evaluation indicated that Charlie was functioning in the range of trainably mentally retarded. by saying "go outside" and "go bathroom." The teacher did not interpret this behavior correctly and told Charlie "not now, do your work." On one occasion Charlie threw the paper clips and fell to the floor in a tantrum. He was taken to a "time-out" chair in the corner of the room by the teacher, where he remained for 15 minutes. Mrs. Dunn recognized that her son was voicing his opinion in much the same way that he did at home but was frustrated and angered by the fact that the teacher did not understand and respond to his communication attempts. Intervention Development. An intervention plan was d e v e l o p e d by the nurse and parents that focused on attending and consistently responding to the communicative intent of Charlie's behavior. Also, Charlie was allowed to engage in some of his preferred activities (reinforcers) w h e n he had periods void of tantrums and head-banging. Intervention Implementation. Alterations were made in the home environment, making it more interesting
August 1997
for Charlie. Both parents began to consistently implement what had b e e n d e v e l o p e d and to keep simple behavioral records. Mr. Dunn, encouraged by the resuits, began spending more time with his son. Mrs. Dunn scheduled a school meeting, where Charlie's teacher agreed to discontinue the paper clip activity and try some of Mrs. Dunn's behavior management suggestions. Evaluation. The efficacy of the behavioral plan was evaluated 1 month later. Charlie was exhibiting no self-abuse or tantrums at home and was behaving more appropriately in school. Behavioral data collected by the parents, nurse, and teacher supported this assessment. After viewing pretreatment and posttreatment videotapes, both parents were greatly encouraged by their son's improvement and d o c u m e n t e d the value (social validity) of the parent training they received. Two months later Mrs. Dunn telephoned the nurse, stating that Charlie's behavior had deteriorated. The parents were advised to conduct a follow-up functional analysis, which revealed that the behavior was in response to a change in their h o m e routine. With minimal consultation they were able to help their son with the adjustment, and the problematic behaviors decreased. Model Case Analysis. This model case illustrates not only the proposed parent training model but also the operational definition. The parent training process was dynamic, interactive, and instructional. In addition, by conducting thorough child and family assessments, the psychiatric nurse was able to develop and implement an effective behavioral plan, leading to improved child and family well-being while facilitating child learning at h o m e and school.
SUGGESTIONS FOR THEORY-BASED RESEARCH AND NURSING PRACTICE The parent training discussion and case vignettes presented suggest several implications for future develo p m e n t of the concept of parent training concept and subsequent research. First, it is clear that current parent training research is fragmented and, as a result, has limited usefulness in building a solid base for future research. There is a need to further develop and test the parent training model that has been presented. Second, more emphasis should be placed on assessment, an essential element of parent training, particularly w h e n related to children with diverse and complex disabilities. Third, once developed, parent training interventions should be empirically evaluated with
Elder
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appropriate research methods (e.g., single subject experimental designs) that focus on individual characteristics rather than groups and can be easily incorporated in clinical practice (Elder, 1997; Hersen & Barlow, 1976). In conclusion, psychiatric nurses are well equipped by tradition, education, and experience to address theoretic ambiguity, conduct parent training, and empirically evaluate outcomes. By defining and operationalizing parent training, psychiatric nurses can lead the way in bridging theoretic gaps and developing a solid base for effective clinical practice and future research. References Cole, M. (1989). Principles of family-centered care under PL 99457. Early Childhood Update, 5, 4-5. Coucouvanis, J. (1997). Behavioral intervention for children with autism. Journal of Child and Adolescent Psychiatric Nursing, 10, 37-46. Elder, J. H. (1996). Behavioral treatment of children with autism, mental retardation and related disabilities: Ethics and efficacy. Journal of Child and Adolescent Psychiatric Nursing, 9, 3- 12. Elder, J. H. (1995). In-home communication intervention training for parents of multiply handicapped children. Scholarly Inquiry for Nursing Practice, 9, 71-92. Elder, J. H. (1997). Single subject experimentation for psychiatric nursing. Archives of Psychiatric Nursing, 11, 1-7.
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Fawcett, J. (1989). Analysis and evaluation of conceptual models of nursing. Philadelphia: Davis. Forehand, R., Wells, K., & Greist, D. (1980). An examination of the social validity of a parent training program. Behavior Therapy, 11, 488-502. Hersen, M., & Barlow, D. (1976). Single-case experimental design: Strategies for studying behavior change. New York: Pergamon Press. Kuhn, T. S. (1970). The structure of scientific revolutions. Chicago: University of Chicago. Laski, K., Charlop, M., & Screibman, L. (1988) Training parents to use the natural language paradigm to increase their autistic children's speech. Journal of Applied Behavior Analysis, 2I, 391-400. LaVigna, G., & Donnellon, A. (1986). Alternatives to punishment: Solving behavior problems with nonaversive strategies. New York: Irvington Publishers, Inc. Miller, S. A. (1988). Parents' beliefs about children's cognitive development. Child Development, 59, 259-285. Patterson, G., & Fleishman, M. (1979). Maintenance of treatment effects: Some considerations concerning family systems and follow-up data. Behavior Therapy, 10, 168-185. Rickert, V., Sottolano, D., Parrish, J., Riley, A., Hunt, F., & Pelco, L. (1988). Training parents to become better managers. Behavior Modification, 12, 475-496. Sanders, M., & Plant, K. (1989). Programming for generalization to high and low risk parenting situations in families with oppositional developmentally disabled preschoolers. BehaviorModification, 13, 283-305. Walker, L., & Avant, K. (1994). Strategiesfor theory construction in nursing (3rd ed.). East Norwalk, CT: Appleton & Lange.
Vol. 3, No. 4
Continuing Education Defining Parent Training for Practice and Research Jennifer Harrison Elder, RN, PhD Parent training is a f a m i l i a r t e r m in nursing a n d o t h e r social sciences. Yet, the c o n c e p t r e p r e s e n t e d by the t e r m in the l i t e r a t u r e is ambiguous. In this article the a u t h o r def i n e s a n d o p e r a t i o n a l i z e s the c o n c e p t o f p a r e n t training, e m p h a s i z i n g its relevance in p r o v i d i n g c a r e to children w i t h c o m p l e x p s y c h i a t r i c d i s o r d e r s . The d i s c u s s i o n is ill u s t r a t e d w i t h c a s e e x a m p l e s a n d p r o v i d e s an o p e r a t i o n a l definition o f the c o n c e p t o f p a r e n t training to f a c i l i t a t e a link among t h e o r e t i c concept, clinical p r a c t i c e , a n d emp i r i c research. (JAm P s y c h i a t r N u r s e s A s s o c [199 7]. 3~ 103-110)
R
esearchers and clinicians have written extensively about the concept of parent training over the past 2 decades. Yet, the term p a r e n t t r a i n i n g has b e e n given numerous and varied meanings, and the concept is not clearly presented in the literature. Given this conceptual ambiguity, many potentially useful studies are difficult to understand, seldom appear to interface with existing theories, and cannot be replicated in such a way as to facilitate sound empiric assessment and scientific inquiry. Furthermore many professionals describe parent training in jargon that Kuhn (1970) refers to as "the language of experts." The purpose of this article is to clarify the concept of parent training by offering an operational definition, determining critical attributes of the concept, and analyzing cases for goodness of fit with the proposed operational definition.
Jennifer Harrison Elder is an Assistant Professor at the University o f Florida in Gainsville. Reprint requests: Jennifer Harrison Elder, RN, PhD, Box I O0187JHMI-IC, Gainesville, FL 32610. Copyright © 199 7 by the American Psychiatric Nurses Association. 1078-3903/9 7/$5.00 + 0 6 6 / 1 / 8 3 3 70
August 1997
PARENT TRAINING IN NURSING Parent training is not a new concept in nursing. On the contrary, nurses have long upheld traditions of training parents in ways that maximize the health and general welfare of their children. Nursing practice is a direct service that is goal-directed and adaptable to the needs of the individual, family, and community during health and illness. The provision of behavior management training for parents and families of children with behavioral and developmental disabilities is a nursing role (Elder, 1995). Parent training may be viewed as a second-order or middle-range concept and fits well within nursing's metaparadigm, which contains four central concepts: person, environment, health, and nursing. These concepts are connected in a major proposition stating that nursing addresses the wholeness and health of humans while recognizing that humans are continually interacting with their environments (Fawcett, 1989).
DEFINING THE PARENT TRAINING The following operational definition of parent training reflects nursing theory, current literature, clinical practice, and research findings: Parent training is a dynamic, interactive and instructional process by which a caretaker (parElder
103
J o u r n a l o f the A m e r i c a n P s y c h i a t r i c N u r s e s A s s o c i a t i o n
ent) is taught to perceive, assimilate, and utilize knowledge about his\her child in such a way as to: (a) modify maladaptive and/or deficit child behaviors, (b) promote health and general wellbeing of the child and family, and (c) facilitate the child's learning and successful current and future environmental adaptation within the home and community.
CRITICAL ATTRIBUTES OF THE PARENT
active participants in all levels of the training process (LaVigna & Donnellon, 1986). Furthermore individualized assessment is considered to be a critical attribute of effective behavioral management, particularly with multiply handicapped children. The parent training most often described in the literature focused only on implementing and evaluating specific interventions. These reports offered little information regarding the development of assessment and intervention procedures, which is critical for successful replication in research and clinical practice (Elder, 1995).
TRAINING CONCEPT This definition suggests several critical attributes of PARENTTRAINING MODEL the parent training concept. Historically there is wide The parent training model presented addresses the variation regarding which attributes are most imporpreviously stated concerns. The model contains four rant and the emphasis that each should receive during components: assessment, intervention development, clinical practice and in research. In the early 1970s the intervention implementation, and evaluation. These focus was on parent education, for example, teaching components proceed in the order in which they are childhood development and assisting parents to unpresented. That is, assessment must precede intervenderstand and apply behavioral techniques, such as timetion development, intervention development precedes out. During the 1970s there was also an emphasis on intervention implementation, and implementation prefamily systems, and many interventions included some cedes evaluation. form of family counseling or therapy (Patterson & Assessment. A s s e s s m e n t is the first and perhaps Fleishman, 1979). most important component in this model. The assessThese earlier definitions of parent training reflect ment includes a thorough client description that evaluthe characteristics of the children who most often reates personal likes and dislikes, temperament, comceived parent training, such as those with conduct dismunicative intent of behavior, cognitive and orders or hyperactivity. More recently, there has been developmental level, physical health status, current a trend toward increasing parental involvement in edueducational placement, and client role within the ramcation and treatment, and ily and community (Elder, parent training has been ex1996). A second assesspanded to include treatment The parent training most often ment is needed to evaluof multiply handicapped children, for example, those with autism or other com-
described in the literature focused only on implementing and evaluating specific interventions,
plex developmental disabilities. It is likely that this shift is in response to Public Law 94-142 and Public Law 99-457 (Cole, 1989), which mandate that children be provided educational opportunities regardless of their disabilities. Children with these psychiatric disorders vary considerably in symptoms, so there is also a need to tailor parent training programs to meet these varied needs of the individual children because what is effective for one may not be effective for another (Elder, 1996; LaVigna & Donnellon, 1986). The literature suggests a trend away from didactic teaching and family therapy models and a move toward a more interactive approach where parents are 104 Elder
ate parental beliefs regarding the child that are thought to influence child
learning (Miller, 1988). Family s t r e n g t h s and weaknesses, interactions with the child, availability and need for community support and advocacy, financial stability, and how well the home environment is suited to the needs of the child also warrant evaluation. Intervention Development. Once the assessment of the client and family have been conducted, intervention d e v e l o p m e n t can occur. This process involves the parent, child, and nurse working together to develop interventions based on the individual needs of the child, his or family, and his or her environment. Parents are trained to perform functional analyses of child behavior, observe antecedent and consequent Vol. 3, No. 4
J o u r n a l o f the American P s y c h i a t r i c N u r s e s Association
events (i.e., what occurs just before and immediately after the behavior of concern), and record behavior in a systematic manner (Coucouvanis, 1997). When parents are able to perform adequate behavioral assessments as indicated by information they obtain and present to the parent trainer, they are helped to set realistic behavioral and educational goals for their children (Rickert et al., 1988). Intervention Implementation. In the intervention implementation phase parents are taught to use appropriate interventions while continuously assessing effectiveness and adapting procedures as n e e d e d to obtain maximum benefit (Sanders & Plant, 1989). Ideally, intervention implementation should occur in the child's natural environment, such as home or school, because many children have difficulty generalizing across settings (Laski, Charlop, & Screibman, 1988). Evaluation. Finally, an evaluation of parent proficiency, child behavioral progress, and social validity occurs. Social validity, also referred to as consumer satisfaction, is critical if there is to be continued intervention implementation and maintenance of treatment effects once formal instruction is completed (Forehand, Wellsl & Greist, 1980). Ideally, this evaluation process uses behavioral data recorded by the parents and parent trainer, a written consumer satisfaction questionnaire, and w h e n possible, a review of videotaped parent-child sessions to illustrate p r e t r e a t m e n t and posttreatment effects (Elder, 1995).
parents found individual and family therapy to be of little use and discontinued attendance after two sessions. This type of child and parent treatment is problemoriented, does not include thorough assessment, and does not involve any form of parent training. Furthermore the unsaid message is that professionals, rather than parents, are best equipped to "fix" the child. This may place u n d u e burden on professionals while not equipping parents to manage their own children.
Related Case A related case contains attributes that appear like those found in the concept, but the defining characteristics differ or are unclear. For example, Mr. and Mrs. Seitz were having difficulty managing their 8 yea>old son, Jon, w h o had been given the diagnosis of mental retardation and a severe language disorder. He was dis-
Once the assessment of the client and family have been conducted, intervention development can occur.
Contrary Case
ruptive in public, lacked appropriate social skills, and had few friends. Mr. and Mrs. Seitz enrolled in a 6w e e k parent training class offered in their community, where they learned about normal childhood dev e l o p m e n t , first aid, h o w to teach their child to complete household chores, and ways to stimulate creativity. The instructor cited articles in parenting magazines and popular lay psychology magazines and described vignettes from her o w n experiences raising three "difficult children." Although the Seitzs thought the classes were interesting, they also found them to be of little help in managing their son. This case is related to parent training but does not illustrate the concept. This is an example of what has b e e n referred to as "parenting classes," a concept often confused with parent training.
The following contrary case contains attributes that are clearly unsupportive of the concept. Frances, a 9year-old girl with autism, was brought to a child psychiatrist by her parents, w h o could no longer control her extreme hyperactivity and self-abuse. The psychiatrist prescribed haloperidol (Haldol) and told the family to make a follow-up appointment for individual and family therapy. Haldoperidol effectively calmed Frances's behavior and made her very drowsy. Her
The following borderline case illustrates instances of the concept that are inconsistent. For example, Mr. and Mrs. Harris contacted a local child guidance clinic and reported that their 10-year-old daughter, Julie, diagnosed with autism, "does not listen to what we say, disobeys us constantly, and bites her little brother." Mr. and Mrs. Harris enrolled in a parent training group
CASES ILLUSTRATING CRITICAL ATTRIBUTES Walker and Avant (1994) assert that various types of cases (e.g., contrary cases, related cases, borderline cases, model cases) can help define and operationalize concepts for nursing practice and research. Each of these types of cases will be illustrated, and the final case, a model or paradigm, will fully illustrate the proposed parent training concept.
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Borderline Case
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that met once a w e e k at the clinic. The group was c o m p o s e d of parents w h o had "problem children." Parents were instructed in the use of time-out and other punishment procedures. They were told that most problematic behaviors are attention-seeking and will be extinguished if consistently punished or ignored. The Harrises faithfully applied what they had learned, but their daughter's behavior became even more problematic. Discouraged at the lack of progress, the Harrises discontinued their group meetings and sought help from their pediatrician, who prescribed thioridazine (Mellaril) to "calm Julie down." Several months later the Harrises received a call from Julie's school reporting that she had a seizure. She was hospitalized, and plans were made for an institutional placement because the family could no longer cope with her behavior and medical problems. This represents a borderline case in that it does not sufficiently illustrate the concept for several reasons. First, no individual client and family assessment was conducted. Had an adequate assessment and medical evaluation been done, it likely would have b e e n clear that Julie's lack of attention was not due to noncompliance but petit mal seizures. Lacking an adequate assessment, the Harrises attempted to implement procedures with their daughter that might have b e e n effective with children with conduct disorders but were totally inappropriate in this case. Second, they received no individualized instruction or follow-up. Finally, out of desperation they consulted a pediatrician, w h o prescribed thioridazine. The medication calmed Julie but, because of its sedating effect, prevented her from fully attending to her environment, which is essential for learning. In addition, the thioridazine lowered Julie's seizure threshold and likely precipitated her seizure. It is not surprising that this "parent training" was unsuccessful.
Model Case The following case is a model, or paradigm, because it contains all of the critical attributes. Charlie Dunn, a 12-year-old boy, was referred for evaluation and treatment of his autistic-like symptoms including severe school tantrums, limited social interactions, ritualistic behavior, delayed expressive language, and head-banging. His parents stated that they had exhausted all community resources including Charlie's school. School personnel could no longer manage his disruptive behavior and suggested a "homebound educational placement." The parents' primary goal was to control their son's behavior so that he could remain in school. 106 Elder
Assessment (Child). Charlie's parents described him as an "easy-going kid" w h o preferred to be left alone to rock in his chair, eat Oreo cookies, w a n d e r about the backyard, and listen to country music on his headset. During the outpatient assessment he sat quietly in the room, periodically going to the door to indicate his desire to leave. He communicated with two- to three-word phrases that were almost incomprehensible except by his parents, w h o served as interpreters. Cognitive and developmental evaluation indicated that Charlie was functioning in the range of trainably mentally retarded. His parents reported that he could successfully perform activities of daily living such as toileting, dressing, and grooming. His medical history revealed grand mal seizures in early childhood, but the parents described his current health as excellent. These reports were validated by past medical records and a physical examination. At the time of the evaluation Charlie was taking no medications, although he had r e c e i v e d previous trials of m e t h y l p h e n i d a t e (Ritalin), thioridazine (Mellaril), and h a l o p e r i d o l (Haldol). The parents reported that Ritalin made him "bounce off the walls," whereas Mellaril and Haldol produced "zombie-like states." Charlie attended a selfcontained special education classroom of 10 children with varying diagnoses. The class had one teacher and one teacher's aide. Recently he had been participating in activities to prepare him to perform clerical skills. Assessment (Family). Mrs. Dunn is a 45-year-old legal secretary. She and her husband have three other children in their early twenties. She tearfully admitted that she was faced with difficult decisions regarding h o w to care for her son at h o m e without forfeiting her work position, which she had maintained for 20 years. She acknowledged that Charlie was an unplanned pregnancy that occurred "too late in life." She stated that she was exhausted, bewildered, and unable to cope with the situation. Mr. Dunn, w h o voiced sympathy for his wife and son, offered little assistance, stating that his job demands required much travel and inconsistent schedules. Both parents believed that their son would probably never improve and feared institutionalization. Noting that the family was in crisis with a limited support system and resources, the psychiatric nurse arranged temporary respite care for Charlie. The parents, w h o had experienced little time to themselves, were encouraged to use the respite time for recreation. Plans were made to meet the next w e e k to beVol. 3, No. 4
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gin parent training in stress management, behavioral assessment, and intervention planning. Mrs. Dunn was amazed at the effect the respite had on her, her husband, and their relationship. The next w e e k both were more relaxed and eager to learn. Mr. and Mrs. Dunn had discussed pros and cons of Mrs. Dunn's leaving her job and compromised on emergency leave until the current crisis was resolved. Mrs. Dunn's supervisor agreed to this plan. Both parents were instructed regarding stress management and conducting a thorough, systematic behavioral analysis. They were taught to examine antecedents and consequences of problematic behaviors, record observations, and mutually set attainable goals. Mrs. Dunn contacted Charlie's teacher, w h o facilitated classroom observations. Mrs. Dunn conducted a behavioral analysis as instructed. She noted that Charlie exhibited tantrums w h e n asked to perform tasks that required him to pick up paper clips, put them in e m velopes, empty the envelopes, and repeat the activity. She assessed that her son was objecting to the activity
Cognitive and developmental evaluation indicated that Charlie was functioning in the range of trainably mentally retarded. by saying "go outside" and "go bathroom." The teacher did not interpret this behavior correctly and told Charlie "not now, do your work." On one occasion Charlie threw the paper clips and fell to the floor in a tantrum. He was taken to a "time-out" chair in the corner of the room by the teacher, where he remained for 15 minutes. Mrs. Dunn recognized that her son was voicing his opinion in much the same way that he did at home but was frustrated and angered by the fact that the teacher did not understand and respond to his communication attempts. Intervention Development. An intervention plan was d e v e l o p e d by the nurse and parents that focused on attending and consistently responding to the communicative intent of Charlie's behavior. Also, Charlie was allowed to engage in some of his preferred activities (reinforcers) w h e n he had periods void of tantrums and head-banging. Intervention Implementation. Alterations were made in the home environment, making it more interesting
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for Charlie. Both parents began to consistently implement what had b e e n d e v e l o p e d and to keep simple behavioral records. Mr. Dunn, encouraged by the resuits, began spending more time with his son. Mrs. Dunn scheduled a school meeting, where Charlie's teacher agreed to discontinue the paper clip activity and try some of Mrs. Dunn's behavior management suggestions. Evaluation. The efficacy of the behavioral plan was evaluated 1 month later. Charlie was exhibiting no self-abuse or tantrums at home and was behaving more appropriately in school. Behavioral data collected by the parents, nurse, and teacher supported this assessment. After viewing pretreatment and posttreatment videotapes, both parents were greatly encouraged by their son's improvement and d o c u m e n t e d the value (social validity) of the parent training they received. Two months later Mrs. Dunn telephoned the nurse, stating that Charlie's behavior had deteriorated. The parents were advised to conduct a follow-up functional analysis, which revealed that the behavior was in response to a change in their h o m e routine. With minimal consultation they were able to help their son with the adjustment, and the problematic behaviors decreased. Model Case Analysis. This model case illustrates not only the proposed parent training model but also the operational definition. The parent training process was dynamic, interactive, and instructional. In addition, by conducting thorough child and family assessments, the psychiatric nurse was able to develop and implement an effective behavioral plan, leading to improved child and family well-being while facilitating child learning at h o m e and school.
SUGGESTIONS FOR THEORY-BASED RESEARCH AND NURSING PRACTICE The parent training discussion and case vignettes presented suggest several implications for future develo p m e n t of the concept of parent training concept and subsequent research. First, it is clear that current parent training research is fragmented and, as a result, has limited usefulness in building a solid base for future research. There is a need to further develop and test the parent training model that has been presented. Second, more emphasis should be placed on assessment, an essential element of parent training, particularly w h e n related to children with diverse and complex disabilities. Third, once developed, parent training interventions should be empirically evaluated with
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appropriate research methods (e.g., single subject experimental designs) that focus on individual characteristics rather than groups and can be easily incorporated in clinical practice (Elder, 1997; Hersen & Barlow, 1976). In conclusion, psychiatric nurses are well equipped by tradition, education, and experience to address theoretic ambiguity, conduct parent training, and empirically evaluate outcomes. By defining and operationalizing parent training, psychiatric nurses can lead the way in bridging theoretic gaps and developing a solid base for effective clinical practice and future research. References Cole, M. (1989). Principles of family-centered care under PL 99457. Early Childhood Update, 5, 4-5. Coucouvanis, J. (1997). Behavioral intervention for children with autism. Journal of Child and Adolescent Psychiatric Nursing, 10, 37-46. Elder, J. H. (1996). Behavioral treatment of children with autism, mental retardation and related disabilities: Ethics and efficacy. Journal of Child and Adolescent Psychiatric Nursing, 9, 3- 12. Elder, J. H. (1995). In-home communication intervention training for parents of multiply handicapped children. Scholarly Inquiry for Nursing Practice, 9, 71-92. Elder, J. H. (1997). Single subject experimentation for psychiatric nursing. Archives of Psychiatric Nursing, 11, 1-7.
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Fawcett, J. (1989). Analysis and evaluation of conceptual models of nursing. Philadelphia: Davis. Forehand, R., Wells, K., & Greist, D. (1980). An examination of the social validity of a parent training program. Behavior Therapy, 11, 488-502. Hersen, M., & Barlow, D. (1976). Single-case experimental design: Strategies for studying behavior change. New York: Pergamon Press. Kuhn, T. S. (1970). The structure of scientific revolutions. Chicago: University of Chicago. Laski, K., Charlop, M., & Screibman, L. (1988) Training parents to use the natural language paradigm to increase their autistic children's speech. Journal of Applied Behavior Analysis, 2I, 391-400. LaVigna, G., & Donnellon, A. (1986). Alternatives to punishment: Solving behavior problems with nonaversive strategies. New York: Irvington Publishers, Inc. Miller, S. A. (1988). Parents' beliefs about children's cognitive development. Child Development, 59, 259-285. Patterson, G., & Fleishman, M. (1979). Maintenance of treatment effects: Some considerations concerning family systems and follow-up data. Behavior Therapy, 10, 168-185. Rickert, V., Sottolano, D., Parrish, J., Riley, A., Hunt, F., & Pelco, L. (1988). Training parents to become better managers. Behavior Modification, 12, 475-496. Sanders, M., & Plant, K. (1989). Programming for generalization to high and low risk parenting situations in families with oppositional developmentally disabled preschoolers. BehaviorModification, 13, 283-305. Walker, L., & Avant, K. (1994). Strategiesfor theory construction in nursing (3rd ed.). East Norwalk, CT: Appleton & Lange.
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