Intensive Behavioral Parent Training for a Child Abusive Mother
Intensive Behavioral Parent Training for a Child Abusive Mother
A direct parent training technique (bug-in-the-ear) was used to reduce abuserelated
behaviors in a low-functioning child abusive mother who displayed very
high rates of aversive behavior towards her three children. Using a multiple
baseline design, parent training decreased hostile parent behaviors and increased
positive behaviors during simulated problematic parent-child interactions in the
clinic. The mother’s hostile verbal and physical prompts were reduced by prompting
and feedback by the therapist. The mother’s positive behavior also improved
when training was introduced, although these changes were less clear. Improvements
in parent-child interaction were found in both the clinic and home settings
and were maintained in these settings following the withdrawal of the training
procedure and subsequent 2-month posttreatment follow-up. The importance of
This project was conducted while David Wolfe and Kathleen Brehony were psychology
residents at the University of Mississippi Medical Center. Portions of this study were
presented at the Association for Advancement of Behavior Therapy Annual Convention,
Toronto, November, 1981. Requests for reprints should be sent to David Wolfe, Department
of Psychology, The University of Western Ontario, London, Ontario N6A 5C2, Canada,
or Jeffrey A. Kelly, Department of Psychiatry and Human Behavior, University of Mississippi
Medical Center, 2500 N. State Street, Jackson, MS 39216.
438 0005-7894/82/0438-045151.00/0
Copyright 1982 by Association for Advancement of Behavior Therapy
All rights of reproduction in any form reserved.
PARENT TRAINING FOR AN ABUSIVE MOTHER 439
assessing parenting skills and including intensive training in child management
with supportive agency services for abusive parents is discussed.
Recently, child abuse has received dramatically increased attention
among behavioral scientists and among the general public. Although several
studies of child abuse have been reported, most of these appear to
be largely descriptive in nature, focusing either on characteristics of abusive
parents and abused children or treatment program outlines (cf. Burgess
& Conger, 1978; Dubanoski, Evans, & Higuchi, 1978; Spinetta,
1978). Relatively few studies have empirically evaluated the effectiveness
of treatment to reduce abusive parenting (Isaacs, in press).
Parental attempts to control aversive child behavior have been recognized
as common antecedents to physical child abuse (Friedman, Sandler,
Hernandez, & Wolfe, 1981). From this perspective, abuse may occur
when the parent lacks the skills repertoire to effectively control child
misbehavior and to reinforce child-appropriate behavior in nonviolent
ways. Abusive individuals’ behavioral capabilities are often not adequate
to resolve everyday child conflicts, due to parents’ exposure to punitive
models in their own parents (Straus, Gelles, & Steinmetz, 1979), isolation
from appropriate child-rearing models and resources (Burgess & Richardson,
in press), and poor impulse control (Denicola & Sandier, 1980).
Training abusive parents in effective and nonviolent methods of child
management, therefore, has been the focus of recent behavioral research.
The efficacy of behavioral parent training with child abusers has been
investigated in several recent projects (Crozier & Katz, 1979; Denicola
& Sandier, 1980; Sandier, VanDercar, & Milhoan, 1978; Wolfe & Sandler,
1981). In each of these studies, didactic instruction, problem-solving,
behavior rehearsal, and/or self-control skills were taught to abusive
parents, and time-series experimental designs were employed. These
studies provided initial empirical support for the effectiveness of parent
training in modifying targeted “high risk” parent-child interactions.
Each study further clarified the special difficulties of providing services
to abusive families (for example, the parents’ adherence to harsh
corporal punishment, lack of family and economic stability, unrealistic
expectations of the child), as well as the types of improvements which
may result from parent training (such as increased child compliance, use
of more appropriate punishment techniques, reduced coerciveness).
The data presented in the above studies were inconclusive due to certain
methodological limitations. Carry-over effects of the treatment components,
inadequate experimental design and control of dependent variables,
inability to monitor family progress for a length of time, and similar
procedural difficulties related to the unique problems associated with
child abuse warrant continued investigation (Isaacs, in press). In view of
these concerns, Wolfe, Sandier, and Kaufman (1981) evaluated the combined
effectiveness of group and individual parent training with abusive
parents using a treatment-control group design. The three outcome measures
(observations of parenting skills in the home, parental report of
440 WOLFE ET AL.
child behavior problems, and caseworker report of family problems) converged
upon the finding that specific training in child management, child
development, and anger control was more effective in improving family
functioning than standard services provided by the state child welfare
department. The authors concluded that competency-based parent training
with child abusers can be conducted with a relatively small investment
of time and labor, and may add critical structure and direction for comprehensive
intervention planning.
The approach to intervention with child abusers supported by these
studies was derived from the social learning model of family dysfunction
and child abuse (see Burgess & Richardson, in press; Friedman, et al.,
1981; Patterson, Reid, Jones, & Conger, 1975), that is, training abusive
parents in appropriate child management, anger control, and similar skills
in order to develop an alternative to physical coercion. Current expansions
of this approach have also been reported which focus upon cognitive
distortions and parental mood changes which can impair parenting
effectiveness (Conger, Lahey, & Smith, Note 1), and upon critical community
supports for parents which appear to be necessary for maintaining
prosocial behavior among family members (Wahler, 1980). However, the
preliminary findings regarding the modification of high risk parent-child
interactions require continued investigation before concluding that these
behavioral approaches for treating child abusers are both necessary and
sufficient for the majority of parents who are referred for treatment (Starr,
1979).
The present study investigated the effect of a direct training technique
(bug-in-the-ear) for modifying abuse-related behaviors in a low-functioning
abusive mother who displayed high rates of physical punishment
and little ability to control the aversive behaviors of her children. A
multiple baseline design was employed to evaluate closely the effects of
this training technique on several positive and negative parenting behaviors.
METHOD
Subjects
The family in the present study was court ordered to the Child Behavioral
Psychology Clinic following adjudication for child abuse and neglect.
Court summaries documented one case of physical abuse, several occasions
of suspicious injuries, and multiple instances of neglectful behavior.
The family consisted of a 29-year-old epileptic unmarried black female,
two 9-year-old epileptic retarded twin boys and a 2-year-old girl. Prior to
their referral to the clinic, the family had been under supervision by child
welfare authorities for 5 years. Mother and daughter were both of low
intellectual functioning (maternal WAIS IQ = 78; child WlSC-R IQ =
73). The twin boys were essentially nonverbal with recorded Peabody
Picture Vocabulary Test IQ scores well within the retarded range. Medical
authorities had reported the family on multiple occasions for noncompliance
in treating the children’s epilepsy, while school authorities
PARENT TRAINING FOR AN ABUSIVE MOTHER 441
had reported welts and cuts on the boys’ faces and bodies. The mother
was unemployed and receiving public assistance payments. On initial
observation, the children were found to engage in high frequency running,
were noncompliant to the mother’s requests and were socially unresponsive.
The mother was easily frustrated managing her children and reported
relying upon verbal threats and physical punishment to control
her children.
Behavioral Observation Procedures
Through home and laboratory observation as well as discussion with
the mother and caseworker, two types of situations were identified as
being especially problematic for the family. When the mother wanted to
engage the children in a task, they were consistently noncompliant to her
requests. In addition, the family reported they spent very little time engaged
in joint cooperative activities. As a result of these initial discussions
and observations, child compliance and family cooperation were mutually
agreed upon as the initial priorities for treatment intervention.
The treatment team developed two structured activities which simulated
these problematic interactions and provided in-clinic tasks that
could serve as a basis for training: (1) Compliance interaction. At the
beginning of each compliance task, a therapist entered the treatment room
and scattered approximately 50 small toys from a large basket onto the
floor. The therapist then left the room, and the mother requested that the
children pick up the toys and place them in containers. This task was
selected because it required the mother to give directions to the children
and was likely to elicit noncompliance from the children rather quickly.
The task was considered completed when all the objects had been picked
up by the children. (2) Cooperative interaction. Family members reported
they did not engage in frequent joint cooperative activities in the home.
In the second task, the mother was provided with crayons and coloring
books and was asked to help the children color and draw pictures for a
period of 10 min. This task approximated a cooperative, play-based activity
in which the mother and children might engage.
Dependent Measures
Two types of parent behaviors were used as dependent measures: Hostile
parental prompts (both physical and verbal) were targeted for reduction,
while positive prompts (physical and verbal) were later targeted for
increase during each of the two interaction tasks described above.
Hostile physical prompts were recorded whenever the mother pushed
or grabbed a child during an interaction. This most often occurred when
a child had ignored one of the mother’s commands, and the parent physically
pushed at the child to elicit some behavior. A hostile physical
prompt was also recorded if the mother made a hand-raising motion toward
a child but did not actually make physical contact with the child.
Hostile verbal prompts were scored as occurring when the mother
threatened, labeled, or condemned a child during an interaction. Specific
442 WOLFE ET AL.
verbal examples include “I’m gonna hit you,” “Don’t be so stupid,”
“Stop that!” and so on.
Positive physical prompts were scored whenever the parent hugged,
patted, or touched a child when the child was engaging in appropriate
behavior (following a direction given by the mother, picking up blocks,
coloring in the book, etc.).
Positive verbal prompts were recorded when the parent specifically
praised a child’s behavior, thanked the child, or expressed other positive
verbalizations toward the child. Specific examples are “You are doing a
good job,” “I like the way you’re coloring,” or “That’s nice, Susan.”
The total number of times that each of these behaviors occurred during
a 10-min fixed interval for every compliance and cooperative task was
determined by a research assistant in the observation room who served
as the observer. In addition, a second observer was also present for
approximately 40% of all sessions and independently rated the interactions
for the same parent behaviors. The treatment outcome goals were
to reduce the frequency of hostile physical and verbal prompts and to
increase the frequency of positive physical and verbal parental prompts
to the children during the interaction tasks. Baseline and parent training
occurred during 13 60-min sessions. Sessions were generally held weekly.
Procedures
All parent training was conducted in a large playroom in the clinic.
Training was conducted using a multiple baseline design. Treatment staff,
consisting of the therapist and a research assistant observer, were in an
adjacent observation room and could view the family through a one-way
mirror. Following baseline assessment of the mother’s skills, parent training
was implemented using a bug-in-the-ear device (Stumphauzer, 1971).
The therapist communicated with the mother through a microphone in
the observation room to a miniature remote receiver worn in the mother’s
ear. Because therapist instruction and training of the mother took place
using the bug-in-the-ear device heard only by her during interaction sessions,
it was not evident to the children that an outside authority was
intervening in the family interaction. As far as the children knew, changes
in parental behavior and child management practices were generated by
their mother. While parent training sessions took place in the clinic, periodic
home probe observations were also made to assess the generalization
of training effects into the home setting.
Baseline. During baseline sessions the family was simply observed in
the playroom during both the compliance and cooperative interaction
tasks. The tasks were always presented twice in a session (5-min intervals
each) with the order of tasks counterbalanced. Following five baseline
observations of the mother’s behavior in each task, parent training was
instituted.
Training to decrease hostile parent behavior. Because hostile physical
and verbal parental prompts occurred quite frequently during both the
cooperative and compliance tasks of behavior, treatment attention was
first directed to reducing these negative behaviors. Using the bug-in-thePARENT
TRAINING FOR AN ABUSIVE MOTHER 443
ear device while the parent was interacting with the children, the therapist
instructed the mother in strategies to deal with child noncompliance and
noncooperation other than by hostile verbalizations or physical threats.
For example, when one of the children misbehaved during a task, the
mother was verbally prompted to withdraw attention from that child for
20 sec. If a child more seriously misbehaved (e.g., yelled “no” to one of
her directions), the mother was instructed to implement a modified timeout
procedure by placing the child in a chair in the corner of the room
for one min and directing her attention to the other children who were
behaving appropriately. If the child left the chair during time out, he or
she was physically returned to it, with the 1-min period restarted. The
therapist praised the parent whenever she correctly applied the instructed
procedure.
Directions giving the mother alternatives to hostile physical and verbal
behavior were provided while the family was engaged in both interaction
tasks. This phase of training took place over six different clinic visits,
with two trials on the compliance and cooperation task per session. The
mother’s behavior during each practice task was rated on the four target
behaviors to determine whether her frequency of hostile physical and
verbal prompts decreased while she was receiving training.
Training to increase positive parent behavior. For the next five clinic
visits, the same form of training focused on increasing the parent’s use
of positive physical and verbal comments to the children during each
practice task. During each of the instructions in this phase, the therapist
instructed the mother in the use of positive verbal and physical attention
to maintain the children’s appropriate behavior. For example, the therapists
prompted the mother to praise a child when that child complied
with her direction, to praise the children periodically for their on-task
behavior (picking up objects or coloring), and to hug, pat, or gently touch
the children to provide physical affection contingent on their good behavior.
As in the previous phase, the parent’s behavior was rated during
each of the practice interactions to assess the extent to which those behaviors
occurred.
Following the practice interactions during each session, the therapist
also met individually with the parent to discuss implementing and using
behavioral parenting techniques at home. During the phase which focused
on reducing her hostile behaviors, the mother was instructed in the use
of time out at home and the use of selective inattention to extinguish
child misbehaviors. When the focus of parent training turned to the use
of reinforcement-based child control techniques in the clinic practice interactions,
the therapist and parent also developed “homework” assignments
which called for her to use praise and positive physical attention
during specific daily interactions with the children at home (such as an
after-dinner period each day when she would read to the children).
Fading bug-in-the-ear training. After hostile prompts had been decreased,
and other positive verbal and physical parent behaviors increased
with bug-in-the-ear training during the practice interactions, the
use of the device was withdrawn during each of the tasks. In one clinic
