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Errorless compliance training with physically abusive mothers: a single-case approach
Pergamon Child Abuse & Neglect 6 (2001) 855– 868
Errorless compliance training with physically abusive mothers: a single-case approach夞 Joseph M. Ducharmea,*, Leslie Atkinsonb, Lori Poultonb a
Department of Human Development and Applied Psychology, University of Toronto (OISE), 252 Bloor Street West, Toronto, Ontario, M5S 1V6, Canada b Child Psychiatry Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada Received 7 March 2000; received in revised form 22 November 2000; accepted 29 November 2000
Abstract Objective: “Errorless compliance training” is a recently developed, success-based approach for teaching children to comply with parental requests without the use of coercive consequences. Two mothers were trained to use this intervention to reduce severe child defiance that was precipitating mother/child confrontations and physical abuse. Method: To determine probability of child compliance to specific requests, we observed mothers delivering requests to their child. We then developed a hierarchy of compliance probabilities for each child. Mothers were trained to deliver a high density of Level 1 requests (those that typically yielded compliance), and provide praise for child compliance. Lower probability request levels were introduced gradually, at a slow enough pace to preclude noncompliant responses, reducing the need for mothers to respond aversively to child behavior. Results: At treatment completion and follow-up, both children demonstrated substantial improvements in compliance. Conclusions: The errorless approach may be well suited to managing parenting deficits and child opposition commonly associated with family violence. © 2001 Elsevier Science Ltd. All rights reserved. Keywords: Child abuse; Compliance training; Oppositional behavior; Parent training; Treatment
夞 Funding for this project was provided by the Family Violence Initiative, Health Canada. * Corresponding author. 0145-2134/01/$ – see front matter © 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 1 4 5 - 2 1 3 4 ( 0 1 ) 0 0 2 4 3 - 5
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Introduction In contrast to historical notions of abusive parents as deviant and disturbed, most researchers currently view child maltreatment from a more ecological perspective (Wekerle & Wolfe, 1996). According to this viewpoint, physical abuse can result from difficult parent/ child interactions, affected by parenting skill deficits, the child’s behavior, and a host of other environmental stress factors (Azar, 1989; Isaacs, 1982; Wolfe & Wekerle, 1993). Parenting skill deficits are commonly noted in violent families (e.g., Azar, 1989; Azar, Ferraro, & Breton, 1998). Abusive parents usually resort to power assertion over more constructive approaches to management of child oppositional responses (e.g., Bousha & Twentyman, 1984; Trickett & Kuczynski, 1986). In a study by Burgess and Conger (1978), abusive and neglectful parents focused more on negative child behavior, and demonstrated lower rates of interaction with their children than control parents. Oldershaw, Walters, and Hall (1986) found that abusive parents were much less likely to use positive consequences for child compliance, and consistently employed power assertive strategies for noncompliance. The effects of child behavior on the abusive interaction have been examined by several investigators. Herrenkohl, Herrenkohl, and Egolf (1983) found that child factors such as noncompliance and fighting with siblings accounted for the greatest amount of child physical abuse by parents. This finding is particularly discouraging in view of the commonly observed tendency of abused children to exhibit higher levels of noncompliant, aggressive, and other oppositional behaviors than control children (Bousha & Twentyman, 1984; Oldershaw et al., 1986; Wekerle & Wolfe, 1996). Trickett and Kuczynski (1986) found that, in addition to being less compliant, abused children were more likely to accompany noncompliance with overt verbal and physical opposition, and were more negativistic in response to parental intervention attempts than nonabused youngsters. Notwithstanding the wide range of factors contributing to problem behavior in children from violent homes, such responses can be highly frustrating for parents, and present extreme management difficulties to those with inadequate disciplinary skills. Given that parenting skill deficits and child oppositional responses are central to abusive interactions, parent training for increasing child compliance may be an essential direction for intervention in abusive families. Compliance training procedures have been demonstrated to produce broad improvements in child behavior, and are included in most empirically supported interventions for child conduct difficulties (e.g., Barkley, 1997; Eyberg & Boggs, 1998). Along with several other components, most compliance training approaches include a consequence for noncompliance, typically timeout. Of concern in violent families, however, is the level of confrontation that can occur when children resist parental attempts to implement such consequences (Roberts, 1982), and when parental misapplication of techniques such as timeout result in further abusive interaction (Azar, 1989). “Errorless” compliance training (Ducharme, Atkinson, & Poulton, 2000; Ducharme, 1996; Ducharme, Popynick, Pontes, & Steele, 1996; Ducharme et al., 1994), which is based on learning principles similar to those used in errorless discrimination training (e.g., Lancioni & Smeets, 1986), was developed to preclude decelerative consequences
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in the treatment of child conduct problems. With errorless compliance training, parent/ child interactions are observed to assess child compliance probability to a range of parental requests. Requests are then categorized into four probability levels, from requests that almost always yield compliance (Level 1), to those that rarely do (Level 4). In treatment, parents initially deliver only Level 1 requests and provide enthusiastic praise for compliance. Requests from succeeding probability levels are gradually introduced slowly enough to maintain high compliance and opportunities for reinforcement of child prosocial behavior. Because of this graduated introduction of difficult requests, noncompliance occurs at low levels, greatly reducing the need for decelerative consequences. In the case of maltreating parents, decreased child noncompliance would likely lead to reduced potential for abusive parental attempts at controlling child problem behavior. By treatment completion, children typically continue to comply at high rates even to previously low probability requests, and exhibit reduced levels of other maladaptive behaviors (e.g., Ducharme et al., 1994). In light of the nonintrusive and success-based nature of errorless compliance training, we hypothesized that this approach would be well suited to abusive parents who require strategies for managing conduct problems in their children. We piloted the errorless approach with two mothers who were referred because of abusive attempts at managing child behavior. Our goals were to increase parenting skills by teaching a noncoercive disciplinary approach, and to reduce child oppositional behavior, thereby eliminating a prominent trigger for maltreatment.
Method Participants Participants were two mothers who were using physical punishment (hitting) to manage the behavior of their children. Protective concerns necessitated child welfare agency involvement with both families and precipitated referral to our project. Both mothers had been verbally and physically abused by a previous partner, and the children had witnessed this abuse. Mothers were 23 and 27 years of age, and had less than grade 8 education. Both mothers scored above the 99th percentile on the Total Stress Score of the Parenting Stress Index (Abidin, 1983). Both were unemployed, and receiving welfare support. Children were 3- and 4-year-old males with severe behavior problems including noncompliance, aggression, and property destruction. The study was approved by ethical review committee, and mothers signed informed consent to participate. Setting and therapists All parent training and observation sessions took place in the family home. Home-based sessions were conducted by parents from 2 to 6 times per week. Parents collected data for all of these sessions. Approximately 35% of these sessions were attended, observed, and
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videotaped by a research therapist as an independent source of data and for inter-observer agreement purposes. The two research therapists had several years of experience with clinical issues, and received several days of training specific to the present clinical protocol. One had a university degree, the other a community college diploma. Research therapists and parents could not be kept blind to experimental conditions because of their ongoing involvement. Research design The research design was a multiple baseline across subjects. Observations were initiated at approximately the same time in the two family homes, and were collected regularly throughout pretreatment, treatment, and follow-up phases. The treatment phase was delayed for the second mother/child dyad, in multiple baseline fashion. With intensive repeated measurement, clinically significant treatment effects can be assessed through visual analysis of graphed changes in level and variability of data from pretreatment to treatment (Barlow, Hayes, & Nelson, 1986). Dependent measures Observational measure of compliance. Event recording of compliance was used during observations. Compliance was defined as the appropriate child response to a maternal request initiated within 10 s of the request, and completed within 40 s. During visits to the family home, we trained mothers to collect data on child compliance. Research therapists collected data and videotaped approximately 30% of the sessions from each phase of treatment to enable assessment of inter-observer agreement on mothers’ data, and provide an independent observational measure of treatment efficacy. The two independent measures (parents, therapists), and the absence of the therapist from the home for some of the parent data collection, controlled for the possibility that effects were related to presence of the therapist/observer. We predicted that both children would demonstrate consistent increases in compliance to Level 4 requests in Phase 4 of treatment, with less variability in responses than during pretreatment. Maternal report measures. Supplementary measures were used to assess breadth of change, and to socially validate the results (Wolf, 1978). The Parenting Stress Index (PSI, Abidin, 1983), which assesses child and parent variables affecting maternal stress, was administered to mothers during pretreatment and follow-up. Alpha reliability estimates for domain scores are high and concurrent and construct validity are strong for this questionnaire (Abidin & Brunner, 1995). A goal of this intervention involved reduction of behaviors that contributed to a high Child Characteristics Domain score (122 or above— denoting child behavior that makes parenting difficult, Abidin, 1983). We also collected data on the Parent Characteristics Domain to provide contextual information on the mother/child environment. High scores (153 or above) indicate that parent dysfunction related to issues such as depression and isolation are contributing to high stress levels. Intervention was not aimed at reducing characteristics associated with this domain.
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We administered the Compliance Probability Checklist (e.g., Ducharme et al., 1994) to mothers to provide a basis for request selection and a pre/post measure of maternal perception of child compliance. The checklist comprises 120 requests involving everyday tasks from different domains, including hygiene, dressing, and leisure. Mothers rated requests according to perceived compliance probability. The four probability levels included: “almost always” (76 –100%), “usually” (51–75%), “occasionally” (26 –50%), and “rarely” (0 –25%). We predicted mothers would perceive improvement in their child’s compliance levels after treatment. Our consumer satisfaction questionnaire has been used in several previous studies (e.g., Ducharme et al., 1994; 1996). The questionnaire comprised 14 items rated on a 5-point Likert scale, and was administered with other measures after treatment. This questionnaire provided a subjective measure of parental satisfaction with the intervention and the therapist. Inter-observer agreement We calculated inter-observer agreement for observational measures from event recording of compliance sessions attended and videotaped by research therapists. Agreement was defined as observers independently corresponding on occurrence of child compliance or noncompliance after request delivery by the mother. Three different categories of interobserver agreement were calculated for each mother/child dyad, as follows. Mother/therapist agreement. This category involved agreement between compliance data coded by the mother and those coded by the research therapist. Inter-observer agreement was obtained on 34% of the sessions conducted by mothers. Overall agreement averaged 97% for pretreatment and 98% for treatment, generalization, and follow-up sessions. Videotape/therapist agreement. This category involved comparison between videotape of compliance sessions conducted by the mother, as coded by an independent observer, and data collected by the therapist. Inter-observer agreement was obtained for 91% of the sessions videotaped by the therapist. Overall agreement averaged 91% for pretreatment and 90% for treatment, generalization, and follow-up sessions. Videotape/mother agreement. We also compared videotapes of compliance sessions, as coded by an independent observer, with data collected by the mother. Inter-observer agreement was obtained for 31% of parent-conducted sessions. Overall agreement averaged 91% for pretreatment and 89% for treatment, generalization, and follow-up sessions. Pretreatment assessment of compliance probabilities Checklist probability analysis. We asked mothers to complete the Compliance Probability Checklist to determine specific requests to include in treatment. Mothers rated each request according to perceived probability of child compliance.
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Observational probability analysis. To empirically assess probability of child compliance to specific requests, mothers conducted sessions in the home. They delivered approximately 24 requests from the completed Compliance Probability Checklist (6 requests from each of the 4 compliance probability levels, as selected by the therapist). Requests were printed on individualized data sheets provided to mothers before sessions. Before the first session, therapists taught mothers to deliver requests in the imperative, in a polite but firm tone, and to avoid repetition. This training ensured consistent request delivery across all phases. Given that children continued to exhibit high rates of noncompliance after this training, this procedure confirmed that they had severe noncompliance problems and were not simply hindered by poor request delivery. Additionally, mothers were trained to collect child compliance data. Request delivery and data collection training were completed using modeling, rehearsal, and performance feedback procedures. Training for this phase was completed in approximately 30 min. Parents conducted almost daily pretreatment sessions in the home with their child. During the approximately 90 min sessions, mothers presented each request once per session, embedding request delivery into the normal daily routine to ensure natural presentation. Hierarchical categorization of requests. After completion of the observational probability analysis, we calculated probability of compliance for each request, and categorized requests into four compliance probability levels: Level 1 (approximately 76 to 100%); Level 2 (51 to 75%); Level 3 (26 to 50%); and Level 4 (0 to 25%). Four of the six requests from each probability level were used for treatment. The other two requests in each level were reserved to assess generalization (see Generalization Probes, below). During each phase of treatment, we provided parents with a data sheet listing requests from the applicable probability level (i.e., Level 1 requests in Phase 1). Three repetitions of each request were listed on each sheet. Treatment procedures Phase 1 (Level 1 requests). Before the first treatment session, research therapists conducted home-based training sessions (about 45 min) with mothers, using modeling, rehearsal, and performance feedback. Mothers were taught to provide enthusiastic praise and physical contact after each compliant response. They also learned to provide no consequence for noncompliance other than to continue with ongoing household activities. The therapist also reviewed request delivery and data collection procedures. Therapists provided mothers with data sheets listing Level 1 requests for their child. During treatment, therapists monitored treatment data (in person or by phone) to ensure that subsequent request probability levels (and data sheets) could be introduced at the appropriate time. Request presentation was identical to the previous phase, with the exception that only Level 1 requests were issued. Each of the four requests from Level 1 was delivered three times. While interacting with children outside of sessions, mothers were taught to do one of two things: (1) avoid delivering requests from untrained probability levels, or (2) do tasks for the child that correspond to requests from untrained levels. With these procedures, mothers maintained the graduated nature of the intervention and decreased use of demands that, at this point, would likely lead to noncompliance and potential confrontation.
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Transition sessions. After consistently high compliance (over 75%) to Level 1 requests, a transition session, in which mothers delivered requests from both adjoining probability levels, was conducted to make the shift from one treatment phase to the next less abrupt. Phase 2, 3, and 4 (Level 2, 3, and 4 requests). These phases were conducted exactly as in Phase 1, except that mothers issued only Level 2 requests during Phase 2 sessions, Level 3 requests in Phase 3 sessions, and Level 4 requests in Phase 4 sessions (see Fig. 1). Mothers were informed that, outside of sessions, they can continue to use requests from any previous phase of treatment, but should avoid requests from subsequent phases. Generalization probes We observed each mother/child dyad during the observational probability analysis, and at completion of Phase 4 to evaluate generalization of child compliance to requests not included in treatment. During these probes, mothers issued the two requests that had been reserved for generalization assessment from each of probability Levels 3 and 4 (i.e., four requests in total per child). We used only Level 3 and 4 requests during generalization probes, because generalization is clinically relevant only for requests that were problematic for parents before treatment. Follow-up Mother conducted follow-up sessions at 1, 3, and 6 months after treatment completion.
Results Observational data Pretreatment. Therapist and parent data across all phases are graphed in Fig. 1. As in previous errorless compliance studies, graphed pretreatment data represent compliance to Level 4 requests, as child responses to these requests presented severe difficulties to parents. Because parent and therapist data correlated highly and parent data were more extensive and naturalistic, we used the latter for summary statistics. Mean percentage of compliance across children in pretreatment (i.e., during the observational probability analysis) was 92% for Level 1, 71% for Level 2, 49% for Level 3, and 27% for Level 4 requests (see shaded areas in Fig. 1). Treatment. As seen in Fig. 1, compliance to Level 1 requests in Phase 1 was similar to pretreatment responses to Level 1 requests. Mean percentage of compliance in Phase 1 across both children was 87%. Mean compliance to Level 2 requests in Phase 2 was 81%, a slight improvement of 10 percentage points over pretreatment responses to Level 2 requests. Mean percentage of compliance to Level 3 requests in Phase 3 was 70%, an
Fig. 1. Child compliance across all phases of treatment. Graphed pretreatment data represent compliance to Level 4 requests, since these were the primary targets of intervention. Graphed treatment data represent compliance to requests delivered in each specific phase. Shaded areas represent mean pretreatment compliance levels to requests for the probability level being trained in that phase. Closed squares represent parent-collected data; open circles represent therapist-collected data.
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increase of 21 percentage points over pretreatment responses to Level 3 requests. In Phase 4, mean percentage of compliance to Level 4 requests was 75%, a substantial mean increase of 48 percentage points over pretreatment responses to Level 4 requests. Visual analysis of pretreatment and Phase 4 data demonstrate almost no overlap between the two data sets, with most data points in pretreatment well below 50%, and almost all points above 60% after treatment. Generalization. To determine generalization to requests not included in treatment, we assessed compliance to untrained Level 3 and 4 requests. Generalization results showed substantial improvement from pretreatment to treatment. Mean compliance to generalization requests increased from 47% to 79% for Level 3, and from 27% to 83% for Level 4 requests. Follow-up. Follow-up data represent compliance to Level 4 treatment requests during follow-up sessions conducted 1, 3, and 6 months after treatment termination. Mean percentage of compliance during all follow-ups across both children was 80%. Mean percentage of compliance for Follow-up 1 was 63%, for Follow-up 2 was 88%, and for Follow-up 3 was 88%. Maternal report measures Parenting Stress Index. Hypotheses related to this measure were confirmed. In pretreatment, both parents reported scores above the clinical cutoff of 122 for the Child Characteristics domain (mother 1–161; mother 2–165). These scores dropped below the clinical range after treatment (mother 1–103; mother 2–117). In pretreatment, both parents reported scores well above the clinical cutoff of 153 for the Parent Characteristics domain (mother 1–198; mother 2–225). As expected, these scores continued at clinical levels post-treatment (mother 1–166; mother 2–205). Compliance Probability Checklist. Pre/post results for this checklist are presented in Fig. 2. As predicted, mothers’ ratings of child compliance to specific requests indicated that children were considerably more compliant after intervention, and that most of their post-treatment requests resulted in appropriate child responses. The first mother rated 27% of the requests on the checklist as Level 1 or 2 (high probability of compliance) before treatment, and 84% of the requests in these levels after treatment. The second mother rated 54% of the requests as Level 1 or 2 before treatment, and 95% of the requests in these levels after treatment. Consumer satisfaction. These results were substantially different for each mother. The first mother reported a high degree of satisfaction with the program (mean ⫽ 4.9 out of 5), and with the therapist (5.0 out of 5). The second mother reported a comparatively low satisfaction rating of 3.0 for the program and 4.2 for the therapist.
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Fig. 2. Maternal responses to the Compliance Probability Checklist before and after intervention for the two children. Of about 120 requests listed on the checklist, each bar represents the number of requests reported by parents as Level 1 (child almost always complies), Level 2 (child usually complies), Level 3 (child occasionally complies), and Level 4 (child rarely complies).
Discussion We trained two mothers, who were physically abusive with their children, to use errorless compliance training to reduce child opposition and increase compliance. Time-series observational data indicated that the children, who were extremely oppositional before treatment, became highly cooperative with parental requests throughout and after intervention. Gains generalized across untrained requests and were maintained at 6 month follow-up. Maternal report measures provided social validation for treatment gains. Because of the frequent delivery of high probability requests at treatment initiation, and the graduated introduction of more demanding requests at a rate that could be easily tolerated by the children, high rates of child compliance occurred throughout and after intervention. The increase in cooperation resulted in high levels of positive parental attention for prosocial child behavior, inasmuch as mothers were trained to immerse their children in praise and affection after each compliant response. In light of the fact that physically abusive parents are “less supportive and direct fewer positive behaviors toward their child; are less responsive to child initiations and express less positive affect toward the child than comparison parents” (Belsky, 1993), this increase in positive responsiveness may be essential to effective intervention with this population. Moreover, the decrease in child noncompliance appeared to obviate the need for mothers to respond to the child with punitive consequences, coercion, or abuse. Thus, from the beginning of treatment, the role of child behavior in the abuse equation was diminished. Maternal responses to the Compliance Probability Checklist provided supplementary
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support for observed improvements in child compliance. Mothers reported substantial positive change in child compliance after treatment. Additionally, they documented decreases in stress on the Child Characteristics Domains of the Parenting Stress Index. It is important to note, however, that the Total Stress Score for both mothers was still above the clinical cutoff for families in need of supports. Thus, although child behavior was perceived to be a much less potent influence on parenting dysfunction after treatment, other factors continued to burden the mothers. One surprising finding involved maternal responses to the Consumer Satisfaction Questionnaire, with one mother reporting a comparatively low level of satisfaction with our involvement. This finding appeared to be related to other life stressors, as her score on the Life Stress Scale of the Parenting Stress Index indicated that she was experiencing extremely high levels of stress outside of the parent-child relationship (Abidin, 1983). The generalization findings were equivalent to previous studies evaluating the effects of errorless compliance training (e.g., Ducharme et al., 1994), suggesting generalized compliance to most requests delivered by the mother. Follow-up results were also comparable to past research (Ducharme et al., 1996; Ducharme et al., 2000), demonstrating that compliance gains maintained at least 6 months after treatment. No reports of maltreatment or child injury concerns were raised by child welfare agencies or the mother throughout the intervention and follow-up period. Beyond this, however, we had no direct means of measuring child abuse occurrences during treatment and follow-up. Considering the private nature, low frequency, and illegality of maltreatment, however, researchers have noted that observational measures of abuse are likely to be invalid (Isaacs, 1982; Wolfe & Sandler, 1981). Isaacs (1982) recommended using higher frequency responses that correlate with maltreatment and can be readily observed to gauge occurrence of abuse, such as parenting skills (e.g., praise, attention to child prosocial responses), and child aversive behaviors (e.g., noncompliance). Desired changes in these parent and child behaviors in the present study provide indirect evidence that abuse was no longer a salient concern. Notwithstanding the large number of observation sessions conducted for research purposes in the present study, the demand on the practitioner using this intervention for clinical purposes is actually quite modest. As discussed in Ducharme et al. (1994), errorless compliance training, without intensive research evaluation, requires only about five or six clinic visits by the parent, or a similar number of visits to the home by the therapist. Thus, the approach compares favorably with other parent training programs in terms of intensity of clinician involvement. The most obvious limitation of this study involves sample size. Generalizability of results could be enhanced through randomized clinical trials comparing this strategy with other treatments or no-treatment controls. Additional measures, such as observations of parent/ child relationship variables, would provide evidence regarding breadth of change with the intervention. In summary, we taught mothers, who had been abused by partners and were abusing their children, to improve parent/child interactions using errorless compliance training. Through this intervention, we provided mothers with skills to improve child behavior without the use of coercive consequences that could potentially lead to further abusive interactions. The decrease in child noncompliance during and after treatment reduced child behavioral triggers
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for maltreatment. Although further studies are required, the errorless approach appears to have some potential for remediation of both parenting skill deficits and child opposition that play a substantial role in child maltreatment. Acknowledgments The authors would like to thank Edite Pontes, Jennifer Coolbear, Joanna Henderson, Carla Granger, and Tina Pecile for assistance with data collection, coding, summary, and graphics. References Abidin, R. R. (1983). Parenting Stress Index manual. Charlottesville, VA: Pediatric Psychology Press. Abidin, R. R., & Brunner, J. F. (1995). Development of a parenting alliance inventory. Journal of Clinical Child Psychology, 24, 31– 40. Azar, S. T. (1989). Training parents of abused children. In C. E. Schaefer, & J. M. Briesmeister (Eds.), Handbook of parent training (pp. 414 – 441). New York: John Wiley and Sons. Azar, S. T., Ferraro, M. H., & Breton, S. (1998). Intrafamilial child maltreatment. In T. Ollendick, & M. Hersen (Eds.), Handbook of child psychopathology, 3rd Ed. (pp. 483–504). New York: Plenum. Barlow, D. H., Hayes, S. C., & Nelson, R. O. (1986). The scientist practitioner: research and accountability in clinical and educational settings. New York: Pergamon. Barkley, R. A. (1997). Defiant children: a clinician’s manual for assessment and parent training (2nd ed.). New York: Guilford Press. Belsky, J. (1993). Etiology of child maltreatment: a developmental-ecological analysis. Psychological Bulletin, 114, 413– 434. Bousha, D. M., & Twentyman, C. T. (1984). Mother/child interaction style in abuse, neglect and control groups: naturalistic observations in the home. Journal of Abnormal Psychology, 93, 106 –114. Burgess, R. L., & Conger, R. D. (1978). Family interaction in abusive, neglectful, and normal families. Child Development, 49, 1163–1173. Ducharme, J. M. (1996). Errorless compliance training: optimizing clinical efficacy. Behavior Modification, 20, 259 –280. Ducharme, J. M., Atkinson, L., & Poulton, L. (2000). Success-based, non-coercive treatment of oppositional behavior in children from violent homes. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 995–1004. Ducharme, J. M., Pontes, E., Guger, S., Crozier, K., Lucas, H., & Popynick, M. (1994). Errorless compliance to parental requests II: increasing clinical practicality through abbreviation of treatment parameters. Behavior Therapy, 25, 469 – 487. Ducharme, J. M., Popynick, M., Pontes, E., & Steele, S. (1996). Errorless compliance to parental requests III: group parent training with parent observational data and long-term follow-up. Behavior Therapy, 27, 353–372. Eyberg, S. M., & Boggs, S. R. (1998). Parent-child interaction therapy: a psychosocial intervention for the treatment of young conduct-disordered children. In J. M. Briesmeister, & C. E. Schaefer (Eds.), Handbook of parent training: parents as co-therapists for children’s behavior problems, 2nd Ed. (pp. 61–97). New York: John Wiley & Sons. Herrenkohl, R. C., Herrenkohl, E. C., & Egolf, B. P. (1983). Circumstances surrounding occurrence of child maltreatment. Journal of Consulting and Clinical Psychology, 51, 424 – 431. Isaacs, C. D. (1982). Treatment of child abuse: a review of the behavioral interventions. Journal of Applied Behavior Analysis, 15, 273–294. Lancioni, G. E., & Smeets, P. M. (1986). Procedures and parameters of errorless discrimination training with developmentally impaired individuals. International Review of Research in Mental Retardation, 14, 135–164.
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Oldershaw, L., Walters, G. C., & Hall, D. K. (1986). Control strategies and noncompliance in abusive motherchild dyads: an observational study. Child Development, 57, 722–732. Roberts, M. W. (1982). Resistance to timeout: some normative data. Behavioral Assessment, 4, 237–246. Trickett, P. K., & Kuczynski, L. (1986). Children’s misbehaviors and parental discipline strategies in abusive and nonabusive families. Developmental Psychology, 22, 115–123. Wekerle, C., & Wolfe, D. A. (1996). Child maltreatment. In E. J. Mash, & R. J. Barkley (Eds.), Child psychopathology (pp. 492–537). New York: Guilford. Wolf, M. M. (1978). Social validity: the case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11, 203–214. Wolfe, D. A., & Sandler, J. (1981). Training abusive parents in effective child management. Behavior Modification, 5, 320 –335. Wolfe, D. A., & Wekerle, C. (1993). Treatment strategies for child physical abuse and neglect: a critical progress report. Clinical Psychology Review, 13, 473–500.
Re´sume´ Objectif: Former a` “l’obe´issance sans erreur” est inspire´ par une approche re´cemment mise au point, base´e sur le succe`s et destine´e a` enseigner a` l’enfant a` accepter les demandes parentales sans utiliser la coercition comme conse´quence. Deux me`res ont e´te´ forme´es a` utiliser ce mode d’intervention de fac¸on a` re´duire la grande provocation de leur enfant qui pre´cipitait la confrontation me`re-enfant et les se´vices physiques. Me´thode: Pour de´terminer la probabilite´ d’obe´issance de l’enfant a` des demandes spe´cifiques, nous avons observe´ des me`res qui les e´mettaient. Nous avons ensuite de´veloppe´ une hie´rarchie de probabilite´s d’obe´issance pour chaque enfant. Les me`res ont e´te´ forme´es a` e´mettre des demandes a` haute teneur en niveau 1 (celles qui typiquement amenaient l’acquiescement) et a` fe´liciter l’enfant pour avoir obe´i. Des demandes de niveau de probabilite´ infe´rieur furent introduites graduellement, a` un rythme assez lent pour empeˆcher les re´ponses de non-acquiescement, de fac¸on a` re´duire le besoin pour les me`res de re´pondre de fac¸on hostile au comportement de l’enfant. Re´sultats: Pendant le traitement et le suivi, les deux enfants ont montre´ une ame´lioration dans leur acceptation des demandes. Conclusion: Cette approche peut eˆtre indique´e pour re´ussir a` traiter de´ficits parentaux et opposition des enfants commune´ment associe´s a` la violence familiale.
Resumen Objetivo: “El entrenamiento en la obediencia sin errores” (“Errorless compliance training”) es un enfoque recientemente desarrollado, basado en el cumplimiento de metas, para ensen˜ar a los nin˜os a satisfacer las demandas parentales sin el uso de consecuencias coercitivas. Dos madres fueron entrenadas para que hicieran uso de esta intervencio´n con el objetivo de reducir las situaciones severas de desobediencia de los nin˜os que desencadenaban conflictos madre/hijo y maltrato fı´sico. Me´todo: Para determinar la probabilidad de obediencia del nin˜o a demandas especı´ficas, se observo´ a madres haciendo demandas a sus hijos. Se desarrollo´ una jerarquı´a de probabilidades de obediencia para cada nin˜o. Las madres fueron entrenadas para hacer demandas de Nivel 1 (las que habitualmente producen obediencia) y ası´ elogiar la conducta de obediencia del nin˜o/a. Los niveles superiores de demandas fueron introducidos gradualmente, con un ritmo lo suficientemente suave para excluir las
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respuestas de no obediencia, reduciendo ası´ la necesidad de las madres de responder aversivamente a la conducta infantil. Resultados: Con el desarrollo y continuacio´n de este tratamiento ambos nin˜os demostraron mejoras sustanciales en la obediencia. Conclusiones: “El entrenamiento en la obediencia sin errores” puede ser conveniente en el tratamiento de padres con de´ficits en la conducta parental y con problemas de conductas de oposicio´n en sus hijos/as, que se suelen asociar habitualmente a la violencia familiar.
Errorless compliance training with physically abusive mothers: a single-case approach夞 Joseph M. Ducharmea,*, Leslie Atkinsonb, Lori Poultonb a
Department of Human Development and Applied Psychology, University of Toronto (OISE), 252 Bloor Street West, Toronto, Ontario, M5S 1V6, Canada b Child Psychiatry Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada Received 7 March 2000; received in revised form 22 November 2000; accepted 29 November 2000
Abstract Objective: “Errorless compliance training” is a recently developed, success-based approach for teaching children to comply with parental requests without the use of coercive consequences. Two mothers were trained to use this intervention to reduce severe child defiance that was precipitating mother/child confrontations and physical abuse. Method: To determine probability of child compliance to specific requests, we observed mothers delivering requests to their child. We then developed a hierarchy of compliance probabilities for each child. Mothers were trained to deliver a high density of Level 1 requests (those that typically yielded compliance), and provide praise for child compliance. Lower probability request levels were introduced gradually, at a slow enough pace to preclude noncompliant responses, reducing the need for mothers to respond aversively to child behavior. Results: At treatment completion and follow-up, both children demonstrated substantial improvements in compliance. Conclusions: The errorless approach may be well suited to managing parenting deficits and child opposition commonly associated with family violence. © 2001 Elsevier Science Ltd. All rights reserved. Keywords: Child abuse; Compliance training; Oppositional behavior; Parent training; Treatment
夞 Funding for this project was provided by the Family Violence Initiative, Health Canada. * Corresponding author. 0145-2134/01/$ – see front matter © 2001 Elsevier Science Ltd. All rights reserved. PII: S 0 1 4 5 - 2 1 3 4 ( 0 1 ) 0 0 2 4 3 - 5
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Introduction In contrast to historical notions of abusive parents as deviant and disturbed, most researchers currently view child maltreatment from a more ecological perspective (Wekerle & Wolfe, 1996). According to this viewpoint, physical abuse can result from difficult parent/ child interactions, affected by parenting skill deficits, the child’s behavior, and a host of other environmental stress factors (Azar, 1989; Isaacs, 1982; Wolfe & Wekerle, 1993). Parenting skill deficits are commonly noted in violent families (e.g., Azar, 1989; Azar, Ferraro, & Breton, 1998). Abusive parents usually resort to power assertion over more constructive approaches to management of child oppositional responses (e.g., Bousha & Twentyman, 1984; Trickett & Kuczynski, 1986). In a study by Burgess and Conger (1978), abusive and neglectful parents focused more on negative child behavior, and demonstrated lower rates of interaction with their children than control parents. Oldershaw, Walters, and Hall (1986) found that abusive parents were much less likely to use positive consequences for child compliance, and consistently employed power assertive strategies for noncompliance. The effects of child behavior on the abusive interaction have been examined by several investigators. Herrenkohl, Herrenkohl, and Egolf (1983) found that child factors such as noncompliance and fighting with siblings accounted for the greatest amount of child physical abuse by parents. This finding is particularly discouraging in view of the commonly observed tendency of abused children to exhibit higher levels of noncompliant, aggressive, and other oppositional behaviors than control children (Bousha & Twentyman, 1984; Oldershaw et al., 1986; Wekerle & Wolfe, 1996). Trickett and Kuczynski (1986) found that, in addition to being less compliant, abused children were more likely to accompany noncompliance with overt verbal and physical opposition, and were more negativistic in response to parental intervention attempts than nonabused youngsters. Notwithstanding the wide range of factors contributing to problem behavior in children from violent homes, such responses can be highly frustrating for parents, and present extreme management difficulties to those with inadequate disciplinary skills. Given that parenting skill deficits and child oppositional responses are central to abusive interactions, parent training for increasing child compliance may be an essential direction for intervention in abusive families. Compliance training procedures have been demonstrated to produce broad improvements in child behavior, and are included in most empirically supported interventions for child conduct difficulties (e.g., Barkley, 1997; Eyberg & Boggs, 1998). Along with several other components, most compliance training approaches include a consequence for noncompliance, typically timeout. Of concern in violent families, however, is the level of confrontation that can occur when children resist parental attempts to implement such consequences (Roberts, 1982), and when parental misapplication of techniques such as timeout result in further abusive interaction (Azar, 1989). “Errorless” compliance training (Ducharme, Atkinson, & Poulton, 2000; Ducharme, 1996; Ducharme, Popynick, Pontes, & Steele, 1996; Ducharme et al., 1994), which is based on learning principles similar to those used in errorless discrimination training (e.g., Lancioni & Smeets, 1986), was developed to preclude decelerative consequences
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in the treatment of child conduct problems. With errorless compliance training, parent/ child interactions are observed to assess child compliance probability to a range of parental requests. Requests are then categorized into four probability levels, from requests that almost always yield compliance (Level 1), to those that rarely do (Level 4). In treatment, parents initially deliver only Level 1 requests and provide enthusiastic praise for compliance. Requests from succeeding probability levels are gradually introduced slowly enough to maintain high compliance and opportunities for reinforcement of child prosocial behavior. Because of this graduated introduction of difficult requests, noncompliance occurs at low levels, greatly reducing the need for decelerative consequences. In the case of maltreating parents, decreased child noncompliance would likely lead to reduced potential for abusive parental attempts at controlling child problem behavior. By treatment completion, children typically continue to comply at high rates even to previously low probability requests, and exhibit reduced levels of other maladaptive behaviors (e.g., Ducharme et al., 1994). In light of the nonintrusive and success-based nature of errorless compliance training, we hypothesized that this approach would be well suited to abusive parents who require strategies for managing conduct problems in their children. We piloted the errorless approach with two mothers who were referred because of abusive attempts at managing child behavior. Our goals were to increase parenting skills by teaching a noncoercive disciplinary approach, and to reduce child oppositional behavior, thereby eliminating a prominent trigger for maltreatment.
Method Participants Participants were two mothers who were using physical punishment (hitting) to manage the behavior of their children. Protective concerns necessitated child welfare agency involvement with both families and precipitated referral to our project. Both mothers had been verbally and physically abused by a previous partner, and the children had witnessed this abuse. Mothers were 23 and 27 years of age, and had less than grade 8 education. Both mothers scored above the 99th percentile on the Total Stress Score of the Parenting Stress Index (Abidin, 1983). Both were unemployed, and receiving welfare support. Children were 3- and 4-year-old males with severe behavior problems including noncompliance, aggression, and property destruction. The study was approved by ethical review committee, and mothers signed informed consent to participate. Setting and therapists All parent training and observation sessions took place in the family home. Home-based sessions were conducted by parents from 2 to 6 times per week. Parents collected data for all of these sessions. Approximately 35% of these sessions were attended, observed, and
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videotaped by a research therapist as an independent source of data and for inter-observer agreement purposes. The two research therapists had several years of experience with clinical issues, and received several days of training specific to the present clinical protocol. One had a university degree, the other a community college diploma. Research therapists and parents could not be kept blind to experimental conditions because of their ongoing involvement. Research design The research design was a multiple baseline across subjects. Observations were initiated at approximately the same time in the two family homes, and were collected regularly throughout pretreatment, treatment, and follow-up phases. The treatment phase was delayed for the second mother/child dyad, in multiple baseline fashion. With intensive repeated measurement, clinically significant treatment effects can be assessed through visual analysis of graphed changes in level and variability of data from pretreatment to treatment (Barlow, Hayes, & Nelson, 1986). Dependent measures Observational measure of compliance. Event recording of compliance was used during observations. Compliance was defined as the appropriate child response to a maternal request initiated within 10 s of the request, and completed within 40 s. During visits to the family home, we trained mothers to collect data on child compliance. Research therapists collected data and videotaped approximately 30% of the sessions from each phase of treatment to enable assessment of inter-observer agreement on mothers’ data, and provide an independent observational measure of treatment efficacy. The two independent measures (parents, therapists), and the absence of the therapist from the home for some of the parent data collection, controlled for the possibility that effects were related to presence of the therapist/observer. We predicted that both children would demonstrate consistent increases in compliance to Level 4 requests in Phase 4 of treatment, with less variability in responses than during pretreatment. Maternal report measures. Supplementary measures were used to assess breadth of change, and to socially validate the results (Wolf, 1978). The Parenting Stress Index (PSI, Abidin, 1983), which assesses child and parent variables affecting maternal stress, was administered to mothers during pretreatment and follow-up. Alpha reliability estimates for domain scores are high and concurrent and construct validity are strong for this questionnaire (Abidin & Brunner, 1995). A goal of this intervention involved reduction of behaviors that contributed to a high Child Characteristics Domain score (122 or above— denoting child behavior that makes parenting difficult, Abidin, 1983). We also collected data on the Parent Characteristics Domain to provide contextual information on the mother/child environment. High scores (153 or above) indicate that parent dysfunction related to issues such as depression and isolation are contributing to high stress levels. Intervention was not aimed at reducing characteristics associated with this domain.
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We administered the Compliance Probability Checklist (e.g., Ducharme et al., 1994) to mothers to provide a basis for request selection and a pre/post measure of maternal perception of child compliance. The checklist comprises 120 requests involving everyday tasks from different domains, including hygiene, dressing, and leisure. Mothers rated requests according to perceived compliance probability. The four probability levels included: “almost always” (76 –100%), “usually” (51–75%), “occasionally” (26 –50%), and “rarely” (0 –25%). We predicted mothers would perceive improvement in their child’s compliance levels after treatment. Our consumer satisfaction questionnaire has been used in several previous studies (e.g., Ducharme et al., 1994; 1996). The questionnaire comprised 14 items rated on a 5-point Likert scale, and was administered with other measures after treatment. This questionnaire provided a subjective measure of parental satisfaction with the intervention and the therapist. Inter-observer agreement We calculated inter-observer agreement for observational measures from event recording of compliance sessions attended and videotaped by research therapists. Agreement was defined as observers independently corresponding on occurrence of child compliance or noncompliance after request delivery by the mother. Three different categories of interobserver agreement were calculated for each mother/child dyad, as follows. Mother/therapist agreement. This category involved agreement between compliance data coded by the mother and those coded by the research therapist. Inter-observer agreement was obtained on 34% of the sessions conducted by mothers. Overall agreement averaged 97% for pretreatment and 98% for treatment, generalization, and follow-up sessions. Videotape/therapist agreement. This category involved comparison between videotape of compliance sessions conducted by the mother, as coded by an independent observer, and data collected by the therapist. Inter-observer agreement was obtained for 91% of the sessions videotaped by the therapist. Overall agreement averaged 91% for pretreatment and 90% for treatment, generalization, and follow-up sessions. Videotape/mother agreement. We also compared videotapes of compliance sessions, as coded by an independent observer, with data collected by the mother. Inter-observer agreement was obtained for 31% of parent-conducted sessions. Overall agreement averaged 91% for pretreatment and 89% for treatment, generalization, and follow-up sessions. Pretreatment assessment of compliance probabilities Checklist probability analysis. We asked mothers to complete the Compliance Probability Checklist to determine specific requests to include in treatment. Mothers rated each request according to perceived probability of child compliance.
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Observational probability analysis. To empirically assess probability of child compliance to specific requests, mothers conducted sessions in the home. They delivered approximately 24 requests from the completed Compliance Probability Checklist (6 requests from each of the 4 compliance probability levels, as selected by the therapist). Requests were printed on individualized data sheets provided to mothers before sessions. Before the first session, therapists taught mothers to deliver requests in the imperative, in a polite but firm tone, and to avoid repetition. This training ensured consistent request delivery across all phases. Given that children continued to exhibit high rates of noncompliance after this training, this procedure confirmed that they had severe noncompliance problems and were not simply hindered by poor request delivery. Additionally, mothers were trained to collect child compliance data. Request delivery and data collection training were completed using modeling, rehearsal, and performance feedback procedures. Training for this phase was completed in approximately 30 min. Parents conducted almost daily pretreatment sessions in the home with their child. During the approximately 90 min sessions, mothers presented each request once per session, embedding request delivery into the normal daily routine to ensure natural presentation. Hierarchical categorization of requests. After completion of the observational probability analysis, we calculated probability of compliance for each request, and categorized requests into four compliance probability levels: Level 1 (approximately 76 to 100%); Level 2 (51 to 75%); Level 3 (26 to 50%); and Level 4 (0 to 25%). Four of the six requests from each probability level were used for treatment. The other two requests in each level were reserved to assess generalization (see Generalization Probes, below). During each phase of treatment, we provided parents with a data sheet listing requests from the applicable probability level (i.e., Level 1 requests in Phase 1). Three repetitions of each request were listed on each sheet. Treatment procedures Phase 1 (Level 1 requests). Before the first treatment session, research therapists conducted home-based training sessions (about 45 min) with mothers, using modeling, rehearsal, and performance feedback. Mothers were taught to provide enthusiastic praise and physical contact after each compliant response. They also learned to provide no consequence for noncompliance other than to continue with ongoing household activities. The therapist also reviewed request delivery and data collection procedures. Therapists provided mothers with data sheets listing Level 1 requests for their child. During treatment, therapists monitored treatment data (in person or by phone) to ensure that subsequent request probability levels (and data sheets) could be introduced at the appropriate time. Request presentation was identical to the previous phase, with the exception that only Level 1 requests were issued. Each of the four requests from Level 1 was delivered three times. While interacting with children outside of sessions, mothers were taught to do one of two things: (1) avoid delivering requests from untrained probability levels, or (2) do tasks for the child that correspond to requests from untrained levels. With these procedures, mothers maintained the graduated nature of the intervention and decreased use of demands that, at this point, would likely lead to noncompliance and potential confrontation.
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Transition sessions. After consistently high compliance (over 75%) to Level 1 requests, a transition session, in which mothers delivered requests from both adjoining probability levels, was conducted to make the shift from one treatment phase to the next less abrupt. Phase 2, 3, and 4 (Level 2, 3, and 4 requests). These phases were conducted exactly as in Phase 1, except that mothers issued only Level 2 requests during Phase 2 sessions, Level 3 requests in Phase 3 sessions, and Level 4 requests in Phase 4 sessions (see Fig. 1). Mothers were informed that, outside of sessions, they can continue to use requests from any previous phase of treatment, but should avoid requests from subsequent phases. Generalization probes We observed each mother/child dyad during the observational probability analysis, and at completion of Phase 4 to evaluate generalization of child compliance to requests not included in treatment. During these probes, mothers issued the two requests that had been reserved for generalization assessment from each of probability Levels 3 and 4 (i.e., four requests in total per child). We used only Level 3 and 4 requests during generalization probes, because generalization is clinically relevant only for requests that were problematic for parents before treatment. Follow-up Mother conducted follow-up sessions at 1, 3, and 6 months after treatment completion.
Results Observational data Pretreatment. Therapist and parent data across all phases are graphed in Fig. 1. As in previous errorless compliance studies, graphed pretreatment data represent compliance to Level 4 requests, as child responses to these requests presented severe difficulties to parents. Because parent and therapist data correlated highly and parent data were more extensive and naturalistic, we used the latter for summary statistics. Mean percentage of compliance across children in pretreatment (i.e., during the observational probability analysis) was 92% for Level 1, 71% for Level 2, 49% for Level 3, and 27% for Level 4 requests (see shaded areas in Fig. 1). Treatment. As seen in Fig. 1, compliance to Level 1 requests in Phase 1 was similar to pretreatment responses to Level 1 requests. Mean percentage of compliance in Phase 1 across both children was 87%. Mean compliance to Level 2 requests in Phase 2 was 81%, a slight improvement of 10 percentage points over pretreatment responses to Level 2 requests. Mean percentage of compliance to Level 3 requests in Phase 3 was 70%, an
Fig. 1. Child compliance across all phases of treatment. Graphed pretreatment data represent compliance to Level 4 requests, since these were the primary targets of intervention. Graphed treatment data represent compliance to requests delivered in each specific phase. Shaded areas represent mean pretreatment compliance levels to requests for the probability level being trained in that phase. Closed squares represent parent-collected data; open circles represent therapist-collected data.
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increase of 21 percentage points over pretreatment responses to Level 3 requests. In Phase 4, mean percentage of compliance to Level 4 requests was 75%, a substantial mean increase of 48 percentage points over pretreatment responses to Level 4 requests. Visual analysis of pretreatment and Phase 4 data demonstrate almost no overlap between the two data sets, with most data points in pretreatment well below 50%, and almost all points above 60% after treatment. Generalization. To determine generalization to requests not included in treatment, we assessed compliance to untrained Level 3 and 4 requests. Generalization results showed substantial improvement from pretreatment to treatment. Mean compliance to generalization requests increased from 47% to 79% for Level 3, and from 27% to 83% for Level 4 requests. Follow-up. Follow-up data represent compliance to Level 4 treatment requests during follow-up sessions conducted 1, 3, and 6 months after treatment termination. Mean percentage of compliance during all follow-ups across both children was 80%. Mean percentage of compliance for Follow-up 1 was 63%, for Follow-up 2 was 88%, and for Follow-up 3 was 88%. Maternal report measures Parenting Stress Index. Hypotheses related to this measure were confirmed. In pretreatment, both parents reported scores above the clinical cutoff of 122 for the Child Characteristics domain (mother 1–161; mother 2–165). These scores dropped below the clinical range after treatment (mother 1–103; mother 2–117). In pretreatment, both parents reported scores well above the clinical cutoff of 153 for the Parent Characteristics domain (mother 1–198; mother 2–225). As expected, these scores continued at clinical levels post-treatment (mother 1–166; mother 2–205). Compliance Probability Checklist. Pre/post results for this checklist are presented in Fig. 2. As predicted, mothers’ ratings of child compliance to specific requests indicated that children were considerably more compliant after intervention, and that most of their post-treatment requests resulted in appropriate child responses. The first mother rated 27% of the requests on the checklist as Level 1 or 2 (high probability of compliance) before treatment, and 84% of the requests in these levels after treatment. The second mother rated 54% of the requests as Level 1 or 2 before treatment, and 95% of the requests in these levels after treatment. Consumer satisfaction. These results were substantially different for each mother. The first mother reported a high degree of satisfaction with the program (mean ⫽ 4.9 out of 5), and with the therapist (5.0 out of 5). The second mother reported a comparatively low satisfaction rating of 3.0 for the program and 4.2 for the therapist.
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Fig. 2. Maternal responses to the Compliance Probability Checklist before and after intervention for the two children. Of about 120 requests listed on the checklist, each bar represents the number of requests reported by parents as Level 1 (child almost always complies), Level 2 (child usually complies), Level 3 (child occasionally complies), and Level 4 (child rarely complies).
Discussion We trained two mothers, who were physically abusive with their children, to use errorless compliance training to reduce child opposition and increase compliance. Time-series observational data indicated that the children, who were extremely oppositional before treatment, became highly cooperative with parental requests throughout and after intervention. Gains generalized across untrained requests and were maintained at 6 month follow-up. Maternal report measures provided social validation for treatment gains. Because of the frequent delivery of high probability requests at treatment initiation, and the graduated introduction of more demanding requests at a rate that could be easily tolerated by the children, high rates of child compliance occurred throughout and after intervention. The increase in cooperation resulted in high levels of positive parental attention for prosocial child behavior, inasmuch as mothers were trained to immerse their children in praise and affection after each compliant response. In light of the fact that physically abusive parents are “less supportive and direct fewer positive behaviors toward their child; are less responsive to child initiations and express less positive affect toward the child than comparison parents” (Belsky, 1993), this increase in positive responsiveness may be essential to effective intervention with this population. Moreover, the decrease in child noncompliance appeared to obviate the need for mothers to respond to the child with punitive consequences, coercion, or abuse. Thus, from the beginning of treatment, the role of child behavior in the abuse equation was diminished. Maternal responses to the Compliance Probability Checklist provided supplementary
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support for observed improvements in child compliance. Mothers reported substantial positive change in child compliance after treatment. Additionally, they documented decreases in stress on the Child Characteristics Domains of the Parenting Stress Index. It is important to note, however, that the Total Stress Score for both mothers was still above the clinical cutoff for families in need of supports. Thus, although child behavior was perceived to be a much less potent influence on parenting dysfunction after treatment, other factors continued to burden the mothers. One surprising finding involved maternal responses to the Consumer Satisfaction Questionnaire, with one mother reporting a comparatively low level of satisfaction with our involvement. This finding appeared to be related to other life stressors, as her score on the Life Stress Scale of the Parenting Stress Index indicated that she was experiencing extremely high levels of stress outside of the parent-child relationship (Abidin, 1983). The generalization findings were equivalent to previous studies evaluating the effects of errorless compliance training (e.g., Ducharme et al., 1994), suggesting generalized compliance to most requests delivered by the mother. Follow-up results were also comparable to past research (Ducharme et al., 1996; Ducharme et al., 2000), demonstrating that compliance gains maintained at least 6 months after treatment. No reports of maltreatment or child injury concerns were raised by child welfare agencies or the mother throughout the intervention and follow-up period. Beyond this, however, we had no direct means of measuring child abuse occurrences during treatment and follow-up. Considering the private nature, low frequency, and illegality of maltreatment, however, researchers have noted that observational measures of abuse are likely to be invalid (Isaacs, 1982; Wolfe & Sandler, 1981). Isaacs (1982) recommended using higher frequency responses that correlate with maltreatment and can be readily observed to gauge occurrence of abuse, such as parenting skills (e.g., praise, attention to child prosocial responses), and child aversive behaviors (e.g., noncompliance). Desired changes in these parent and child behaviors in the present study provide indirect evidence that abuse was no longer a salient concern. Notwithstanding the large number of observation sessions conducted for research purposes in the present study, the demand on the practitioner using this intervention for clinical purposes is actually quite modest. As discussed in Ducharme et al. (1994), errorless compliance training, without intensive research evaluation, requires only about five or six clinic visits by the parent, or a similar number of visits to the home by the therapist. Thus, the approach compares favorably with other parent training programs in terms of intensity of clinician involvement. The most obvious limitation of this study involves sample size. Generalizability of results could be enhanced through randomized clinical trials comparing this strategy with other treatments or no-treatment controls. Additional measures, such as observations of parent/ child relationship variables, would provide evidence regarding breadth of change with the intervention. In summary, we taught mothers, who had been abused by partners and were abusing their children, to improve parent/child interactions using errorless compliance training. Through this intervention, we provided mothers with skills to improve child behavior without the use of coercive consequences that could potentially lead to further abusive interactions. The decrease in child noncompliance during and after treatment reduced child behavioral triggers
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for maltreatment. Although further studies are required, the errorless approach appears to have some potential for remediation of both parenting skill deficits and child opposition that play a substantial role in child maltreatment. Acknowledgments The authors would like to thank Edite Pontes, Jennifer Coolbear, Joanna Henderson, Carla Granger, and Tina Pecile for assistance with data collection, coding, summary, and graphics. References Abidin, R. R. (1983). Parenting Stress Index manual. Charlottesville, VA: Pediatric Psychology Press. Abidin, R. R., & Brunner, J. F. (1995). Development of a parenting alliance inventory. Journal of Clinical Child Psychology, 24, 31– 40. Azar, S. T. (1989). Training parents of abused children. In C. E. Schaefer, & J. M. Briesmeister (Eds.), Handbook of parent training (pp. 414 – 441). New York: John Wiley and Sons. Azar, S. T., Ferraro, M. H., & Breton, S. (1998). Intrafamilial child maltreatment. In T. Ollendick, & M. Hersen (Eds.), Handbook of child psychopathology, 3rd Ed. (pp. 483–504). New York: Plenum. Barlow, D. H., Hayes, S. C., & Nelson, R. O. (1986). The scientist practitioner: research and accountability in clinical and educational settings. New York: Pergamon. Barkley, R. A. (1997). Defiant children: a clinician’s manual for assessment and parent training (2nd ed.). New York: Guilford Press. Belsky, J. (1993). Etiology of child maltreatment: a developmental-ecological analysis. Psychological Bulletin, 114, 413– 434. Bousha, D. M., & Twentyman, C. T. (1984). Mother/child interaction style in abuse, neglect and control groups: naturalistic observations in the home. Journal of Abnormal Psychology, 93, 106 –114. Burgess, R. L., & Conger, R. D. (1978). Family interaction in abusive, neglectful, and normal families. Child Development, 49, 1163–1173. Ducharme, J. M. (1996). Errorless compliance training: optimizing clinical efficacy. Behavior Modification, 20, 259 –280. Ducharme, J. M., Atkinson, L., & Poulton, L. (2000). Success-based, non-coercive treatment of oppositional behavior in children from violent homes. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 995–1004. Ducharme, J. M., Pontes, E., Guger, S., Crozier, K., Lucas, H., & Popynick, M. (1994). Errorless compliance to parental requests II: increasing clinical practicality through abbreviation of treatment parameters. Behavior Therapy, 25, 469 – 487. Ducharme, J. M., Popynick, M., Pontes, E., & Steele, S. (1996). Errorless compliance to parental requests III: group parent training with parent observational data and long-term follow-up. Behavior Therapy, 27, 353–372. Eyberg, S. M., & Boggs, S. R. (1998). Parent-child interaction therapy: a psychosocial intervention for the treatment of young conduct-disordered children. In J. M. Briesmeister, & C. E. Schaefer (Eds.), Handbook of parent training: parents as co-therapists for children’s behavior problems, 2nd Ed. (pp. 61–97). New York: John Wiley & Sons. Herrenkohl, R. C., Herrenkohl, E. C., & Egolf, B. P. (1983). Circumstances surrounding occurrence of child maltreatment. Journal of Consulting and Clinical Psychology, 51, 424 – 431. Isaacs, C. D. (1982). Treatment of child abuse: a review of the behavioral interventions. Journal of Applied Behavior Analysis, 15, 273–294. Lancioni, G. E., & Smeets, P. M. (1986). Procedures and parameters of errorless discrimination training with developmentally impaired individuals. International Review of Research in Mental Retardation, 14, 135–164.
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Oldershaw, L., Walters, G. C., & Hall, D. K. (1986). Control strategies and noncompliance in abusive motherchild dyads: an observational study. Child Development, 57, 722–732. Roberts, M. W. (1982). Resistance to timeout: some normative data. Behavioral Assessment, 4, 237–246. Trickett, P. K., & Kuczynski, L. (1986). Children’s misbehaviors and parental discipline strategies in abusive and nonabusive families. Developmental Psychology, 22, 115–123. Wekerle, C., & Wolfe, D. A. (1996). Child maltreatment. In E. J. Mash, & R. J. Barkley (Eds.), Child psychopathology (pp. 492–537). New York: Guilford. Wolf, M. M. (1978). Social validity: the case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11, 203–214. Wolfe, D. A., & Sandler, J. (1981). Training abusive parents in effective child management. Behavior Modification, 5, 320 –335. Wolfe, D. A., & Wekerle, C. (1993). Treatment strategies for child physical abuse and neglect: a critical progress report. Clinical Psychology Review, 13, 473–500.
Re´sume´ Objectif: Former a` “l’obe´issance sans erreur” est inspire´ par une approche re´cemment mise au point, base´e sur le succe`s et destine´e a` enseigner a` l’enfant a` accepter les demandes parentales sans utiliser la coercition comme conse´quence. Deux me`res ont e´te´ forme´es a` utiliser ce mode d’intervention de fac¸on a` re´duire la grande provocation de leur enfant qui pre´cipitait la confrontation me`re-enfant et les se´vices physiques. Me´thode: Pour de´terminer la probabilite´ d’obe´issance de l’enfant a` des demandes spe´cifiques, nous avons observe´ des me`res qui les e´mettaient. Nous avons ensuite de´veloppe´ une hie´rarchie de probabilite´s d’obe´issance pour chaque enfant. Les me`res ont e´te´ forme´es a` e´mettre des demandes a` haute teneur en niveau 1 (celles qui typiquement amenaient l’acquiescement) et a` fe´liciter l’enfant pour avoir obe´i. Des demandes de niveau de probabilite´ infe´rieur furent introduites graduellement, a` un rythme assez lent pour empeˆcher les re´ponses de non-acquiescement, de fac¸on a` re´duire le besoin pour les me`res de re´pondre de fac¸on hostile au comportement de l’enfant. Re´sultats: Pendant le traitement et le suivi, les deux enfants ont montre´ une ame´lioration dans leur acceptation des demandes. Conclusion: Cette approche peut eˆtre indique´e pour re´ussir a` traiter de´ficits parentaux et opposition des enfants commune´ment associe´s a` la violence familiale.
Resumen Objetivo: “El entrenamiento en la obediencia sin errores” (“Errorless compliance training”) es un enfoque recientemente desarrollado, basado en el cumplimiento de metas, para ensen˜ar a los nin˜os a satisfacer las demandas parentales sin el uso de consecuencias coercitivas. Dos madres fueron entrenadas para que hicieran uso de esta intervencio´n con el objetivo de reducir las situaciones severas de desobediencia de los nin˜os que desencadenaban conflictos madre/hijo y maltrato fı´sico. Me´todo: Para determinar la probabilidad de obediencia del nin˜o a demandas especı´ficas, se observo´ a madres haciendo demandas a sus hijos. Se desarrollo´ una jerarquı´a de probabilidades de obediencia para cada nin˜o. Las madres fueron entrenadas para hacer demandas de Nivel 1 (las que habitualmente producen obediencia) y ası´ elogiar la conducta de obediencia del nin˜o/a. Los niveles superiores de demandas fueron introducidos gradualmente, con un ritmo lo suficientemente suave para excluir las
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respuestas de no obediencia, reduciendo ası´ la necesidad de las madres de responder aversivamente a la conducta infantil. Resultados: Con el desarrollo y continuacio´n de este tratamiento ambos nin˜os demostraron mejoras sustanciales en la obediencia. Conclusiones: “El entrenamiento en la obediencia sin errores” puede ser conveniente en el tratamiento de padres con de´ficits en la conducta parental y con problemas de conductas de oposicio´n en sus hijos/as, que se suelen asociar habitualmente a la violencia familiar.