2. WHAT IS PMTO?
Created by Gerald R. Patterson, Research scientist;
Founder of Oregon Social Learning Center
PMTO is THEORY-BASED:
Social Interaction Learning Theory:
Emphasizes the influence of the social
environment on behavioral outcomes.
http://www.youtube.com/watch?v=YI5Tylind9E
Coercion Theory
Hypothesis:
One person engages in a negative behavior to get what he/she wants
The other person responds in an equally negative fashion.
The exchange between the two individuals increases in intensity-
Until one of them finally gives in.
3. REINFORCEMENT
A consequence following a behavior that attempts to
increase that behavior
Positive Reinforcement (PMTO):
Presenting something good
following a behavior you
want to increase
Negative Reinforcement:
Removing something bad
following behavior you want to increase
4. PUNISHMENT
A consequence followed by a behavior that attempts to
decrease that behavior
Positive Punishment:
Presenting something bad
following a behavior you
want to decrease
Negative Punishment:
Removing something good
following a behavior you want to decrease
5. WHO IS PMTO FOR?
TARGET POPULATION:
Parents (caregivers) of children 2-18
years of age with disruptive behaviors:
• Conduct Disorder
• Substance Abuse
• Oppositional Defiant
Disorder
• School Failure
• Anti Social Behaviors
• Covert/overt anti-social
behaviors
• Neglected/maltreated children
• Parents with anti social issues
• http://www.cebc4cw.org/program/the-oregon-model-parent-management-training-pmto/
6. WHAT’S SO SPECIAL ABOUT PMTO?
Based on these theories, PMTO addresses two social contexts:
Negative reinforcement
(within the family)-
Family coercive behaviors
overt antisocial behaviors.
Not accepted by peers
Positive Reinforcement
(from deviant peer groups)
Covert behaviors such as
lying, stealing and truancy.
7. PARENT MANAGEMENT TRAINING
EMPOWERING PARENTS AS AGENTS OF
CHANGE FOR THEIR CHILDREN
Group ( Michigan: Parenting Through Change)
14 weeks, standard
Individual PMTO: 18-22 sessions
(more flexible, customized)
Active (not pedantic) teaching
Role-play; home practice assignments
Based on simple routine tasks, then move
on to limit setting behaviors
First sessions- Intro to Change:
Identify and build on family strengths
and resources
Practitioner observation
Assessment of child’s functioning
Parent’s goals for change
8. PMTO OVERVIEW
FIVE CORE PARENTING SKILLS:
1) Skill Encouragement through
positive reinforcement
Pro social behavior
2) Limit Setting
decrease deviant behavior
3) Monitoring & Supervision
to ensure behavior stays on
track
4) Family Problem Solving
prevent conflict/manages
stress
5) Positive Parent Involvement
9. CHANGING OLD PARENTING HABITS
Parents- learn to identify positive parenting, use mild and
consistent discipline and identify / avoid harsh discipline:
Avoid negative reinforcement- identify coercion- no “giving in” to
child after initiating discipline.
No negative reciprocity- aversive
response to child’s aversive
behavior
No more inept discipline- anger,
coercive discipline, irritability,
indecisiveness, inconsistent discipline.
13. CASCADING EFFECTS of PMTO
Nine Year Follow-up study (Patterson, Forgatch & DeGarmo, 2010)
Possible enduring effects of PMTO intervention that generalize
through and beyond the family:
• Less deviant peer association
• Positive maternal adjustment:
Improved parenting
Increase in standard of living
(education, income, occupation)
• These effects increased
throughout 9-year follow up
Reduced deviant behavior = reduced maternal depression?
14. History and Implementation of PMTO
• Created by Dr. Gerald Patterson (1960s) and his colleagues at
Oregon Social Learning Center (OSLC)
• Implemented in:
• Norway: First wide range implementation
(national), 1999
• Later (2001) Iceland, the Netherlands,
Denmark
• Statewide programs in Michigan and Kansas
• Some implementations in Utah
• Military families in Minnesota
• Prevention program in Mexico City
15. PMTO: CULTURAL ADAPTATIONS
• Latino families-( Mexico City) Utah, Minnesota, Michigan)
• Norway- Studies with Somali and Pakistani immigrant and refugee
populations
Adaptations:
• Translation of all materials
• Cultural adaptations of PMTO
handbook
• Use of trained bilingual
• “link workers” from the population
• Gender separation
Somali/Pakistani- no fathers
• Results show fidelity across cultures
16. ENSURING FIDELITY
Fidelity of Implementation Rating System (FIMP)
Team of PMTO specialists – reliability checks
Database used by all PMTO sites
Used across all implementation sites
Certification – every three years
Trainees -narrow range of excellence
- more homogeneous as they
work toward certification
Monitored by ISII coaches
to be sure standard is sustained
Regular meetings in supervision
Fidelity should cross generations- linger to their children, etc.
“Competent adherence”
17. LIMITATIONS and FUTURE RESEARCH
Managing fidelity in large-scale implementation
Better efficiency with older children
Need additional recruitment
strategies to reach ethnic minorities
Need more research with
ethnic minority families
(Pakistani/Somali- validity?)
Cascading Effects:
Why? Can we do more?
18. PMTO in MICHIGAN
2004
SED population only- referred to CMH
Training/certification is only for CMH
agency employees (Free)
Funded through block grants
50,000.00 per region
In long run, saves money
2013:
35 agencies with PMTO practitioners in
the state community mental health
system
83 certified PMTO practitioners
97 currently in training and providing
services to families on individual basis
19. CERTIFICATION and TRAINING
• Advancement to PMTO certification candidacy is based on ISII
and onsite mentor feedback
• Free (must be CMH agency worker)
• 12-18 months, workshops
• Practice with real and simulated cases
with feedback- children age 4-12
• Coaching- at least 12 sessions based on
video observation of therapy
• Must achieve passing scores when
tested each session
• Certification period- 3 years
• Must renew certification through documentation of cases, seminars,
observation and supervision
20. FURTHER INFORMATION ON THE WEB:
• Implementation Sciences International, Inc. (ISII):
http://www.isii.net
• Oregon Social Learning Center:
http://www.oslc.org
• PMTO in MICHIGAN:
https://michiganpmto.com
•Two day workshops- informational, for anyone (parents)
•State seminar coaching day- End of March: Lansing, MI.
•Five-day training sessions (February, January)
21. References
Bjorknes, R., Kjobli, J., Manger T., & Jakobsen, R. (2012). Parent training among ethnic
minorities: Parenting practices as mediators of change in child conduct
problems. Family Relations, 61, 101-114,
Forgatch, M. S., Patterson, G. R., & Gewirtz, A. H. (2013). Looking forward: The promise of
widespread implementation of parent training programs. Perspective on
Psychological Science, 8(6), 682-694.
Kjobli, J., Hukkelberg, S., & Ogden, T. (2013). A randomized trial of group parent training:
Reducing child conduct problems in read-world settings. Behaviour Research and
Therapy, 51, 113-121.
Ogden T., Hagen, A. K., Askeland E., & Christensen, B. (2009). Implementing and
evaluating evidence-based treatments of conduct problems in children and
youth in Norway. Research on Social Work Practice, 19 (5), 582-591.
Patterson, G. R., Forgatch, M. S., & DeGarmo, D. S. (2010). Cascading effects following
intervention. Development and Psychopathology, 22, 949-970.
Reed, A., Snyder, Staats, S., Forgatch, M. S., DeGarmo, D. S., Patterson, G. R., . . . Schmidt,
N. (2013). Duration and mutual entrainment of changes in parenting practices
engendered by behavioral parent training targeting recently separated mothers.
Journal of Family Psychology, 27(3), 343-354.
Solholm, R., Kjobli, J., & Christiansen, T. (2013). Early initiative for children at risk:
Development of a program for the prevention and treatment of behavior
problems in primary services. Prev Science, 14, 535-544.
Hinweis der Redaktion
Cartoon- Coercion- negative reinforcement
Child learns to use coercive means to get what he/she wants- parent reacts in a coercive manner as well- but then finally gives in, giving the child what he/she wanted- reinforcing the behavior to continue in the future.
Difference between PMTO and other PMT:
PMTO is Theory based. coercion theory (created by Patterson)
Gerald R. Patterson, Ph.D., OSLC founder and Senior Scientist Emeritus, is well known for his pioneering work in three major areas in psychology:
a theory of aggression,
parent-training forms of intervention,
and multiple-method measurement with emphasis on direct observation of family interaction.
onlineacademy.org/modules/a205/support/glossary/coercion.html
Books: Families, Living with Children,
Coercive Family Process,
Families with Aggressive Children,
Parents and Adolescents,
Antisocial Boys, and
Antisocial Behavior.
Based on Reinforcement Theory:
John Watson- Operant Conditioning
Negative reinforcement-
mother says no- child gets angry (tantrum); mother gives in- increases child’s aversive behavior next time
But could also take away chores for one night for good behavior?
FOCUS OF PMTO: Positive reinforcement: praise, treats, etc.
So- PMTO focuses on the use of Positive reinforcement and Negative punishment.
Positive punishment (spanking, screaming, humiliation)
Negative Punishment (take away affection, love)
BUT-
Less harsh discipline- Negative Punishment- Take away television time
Ages vary depending on source- some say 2-18;
Manual says 4-12 since training involved only parents of these ages- can widen age gap after certification when customizing treatment
Delinquency and deviant peer association
Internalizing problems
Often comes with multi-problem families: Parents with mental illness or legal issues
Poverty, unsafe neighborhoods,
Other stresses that can cause problems:
Stressful changes such as Divorce, remarriage
Moves, new births, deaths
Focus can start with the children or with the parents- parents with problems
PMTO has been successful for parents with chronic mental health problems (e.g. depression, anxiety or antisocial behaviour), parents living in poverty, parents undergoing a major transition, such as a divorce or close relative death, and domestic violence.
Neglected or maltreated children
Reinforcement Theory:
Negative reinforcement takes place within the family until
No supervision- no monitoring; withdraw; consequences are withdrawn; kids fade away
Positive reinforcement occurs in the peer context
Anti social behaviors- Temper Tantrums/physical aggression.
This behavior is typically not accepted by their peers.
More time spent outside of family-
Children drift to deviant peer groups who provide positive reinforcement
PMTO emphasizes reducing resistance to change.
Therapists must not teach or confront- this only increases resistance to changing behavior.
- Intervention replaces pedantic teaching with active teaching (role play and problem solving) while delivering the core content
Parents are child’s best teachers
Active teaching – avoids resistance to change
First sessions: Intro to change-
Typically, the practitioner will observe the child and parent interacting together with the Family Interaction Task.
The child’s functioning is also assessed through the Child and Adolescent Functional Assessment Scale, which collects information on the child’s strengths and well as his or her difficulties.
During the first session, parents identify goals for change and consider ways in which these goals can be achieved within the context of the family and child’s strengths and resources.
The parents and practitioner then monitor the parent and child’s progress towards these goals throughout the duration of the programme.
Also can just do a 2-day supplimentary parent group course
Skills Training:
Using active teaching such as role play and problem solving- rather than pedantic teaching.
Positive parenting skills- then terminating coercive interactions through effective discipline (may happen in reverse, however)
Skill Encouragement: Teaching children new behavior through the use of praise and incentives. reinforcement and scaffolding-
Break tasks down- give effective directions to your child - reinforce success, prompt desired behavior, correction in non-aversive way.
2) Limit Setting and emotional regulation: Responding to problem behavior with negative, nonphysical consequences (negative punishment).
FLEXIBILITY- tailor intervention through wightin of the different components:
More flexible skill components (vary from case to case):
3) Monitoring & Supervision: Checking on children’s behavior at home and away from home.
4) Family Problem Solving: An organized method of making decisions with family input., promoting school success
5) Positive Parent Involvement: Parents demonstrating interest, caring and attention. – empathy, support, affection, respect.
http://www.northcare-up.org/pmto.html
Teach parents how to ID positive PMTO
(Images) and use mild and consistent discipline to stop unwanted behavior.
-Good Directions, ideas for Encouragement
Token system of encouragement
Components of PMTO:
Observing and recording behavior
Regulating emotions
Fostering communication through cooperation
Play with kids- with toys
Then look at “Can do chart” with Goals:
Pick up toys, ,make bed, etc beat the clock (time limit) Help kid clean
Positive reinforcement when completed (hug, proud, etc)
GROUP PMTO:
Typically less severe cases
Maximum number of 16 participants (caregivers of eight children)
12 weekly sessions, 2 ½ hours each
Two group leaders (at least one PMTO therapist)
PMTO is based on the SIL model.
From 2011 Presentation Terje Ogden, U of Oslo
Forgatch, Eugene (OSLC- oregon social learning center)
Flexibility (may not include)
Can be tailored for specific clinical problems, such as antisocial behavior, conduct problems, theft, delinquency, substance abuse, and child neglect and abuse.
Returning Military families dealing with the effects of PTSD
Stepfamilies
Single parents
Can be used as a preventative
program and a treatment program
Formats vary widely- can include
parent groups, individual family
treatment, books, audiotapes
and video recordings.
http://www.cebc4cw.org/program/the-oregon-model-parent-management-training-pmto/
Not just reducing anti-social behavior- but other benefits- why?
Decreasing rigidity/ coercive interactions
(The longer the time after PMTO, greater the difference between experimental and control groups)
Reduced deviant behavior- and also reduced maternal depression
Helping children through parent training can impact a mother’s world outside the family and thus lead to spread of intervention effects that go behond the home? -- one person changes and that change leads to change in another- happier; less depression on both sides-
OSLC- research center of anti-social behavior in children Oregon Social Learning Center (founded by Patterson)
International program implementation in Norway: to reduce long-term foster care- children 3-12 with conduct problems- psychiatric health care and child welfare
Kansas: Statewide child welfare system implementation
Michigan- statewide in the children’s community mental health system (SED – severly emotionally disabled)
Detroit- for parents who have lost custody due to abuse
Other PMTO Researchers:
John Reid
Patricia Chamberlan
Marion Forgatch
Thomas Dishion
Cultural adaptations- to consider/show more ethnically homogeneous groups
LINK WORKERS: function both as translators and culture builders- strengthen relationship between therapist and participants
Expansion of other components- large sibling groups and emotion control
Role playing- versions of the parent material
Harsh discipline and positive parenting may have differential effects on child conduct problems in different ethnic groups-varies
But here, the adaptation seems to work- was effective in reducing conduct problems- reduced harsh discipline and increased positive parenting was linked to this.
Mothers who attended more than 50% had best results
Seems flexible- can adapt without sacrificing the core components of PMTO
Seems to generalize well across cultures
Somali/ Pakistani populations- change in deviant behavior at home; not at school- why?
Perhaps school still using coercive measures of discipline? --future: combined parent training with teacher training
Based on Parents self-report of behavior outcomes (biased?)
Database- for adherence to PMTO based on direct observation FIMP is also observation based.
FIMP reliability checks – against the ISII FIMP raters- also involved in cultural adaptations- in these cases- idea is to achieve “competent adherance” rather than 100% fidelity
Implementation Sciences International, Inc. (ISII) is a research-based, non-profit organization providing training for community practitioners in Parent Management Training – the Oregon Model (PMTO™).
An affiliate organization of Oregon Social Learning Center (OSLC) based in Eugene, Oregon.
Shown to work across generations with little drift-
Even when adapted for diverse groups
High fidelity rates- with coaching and better when implemented across the child’s institutions
Moving interventions from controlled settings to community implementation is always a challenge.
Fidelity Norway/Iceland some drift after 8 years- harder to manage in large-scale implementation, but WEB technology helps
Need to better understand what policy changes are required to install evidenced based implementations in communities
When service system could break down- or sustainability changes due to changes in policy, how can we monitor the outcomes of implementation?
Encourage organizational use of evidence based practice- can promote fidelity within organizations- reward like additional funding, services, free training opportunities
OLDER CHILDREN:
PMTO most successful when children are below 8 years of age
- need to develop a design of PMTO interventions better suited for older chlldren- Future research
More research on group PMTO to consider more group intervention in the future
CULTURAL adaptations- Somali/Pak studies– self report- no check of translations
a way to include fathers?
Cascading effects- we don’t know exactly why mothers do better after PMTO- and the longer they go, the better-
we don’t know why peer deviant behavior goes down-
Perhaps if we knew more, we could do more in these directions and learn more ways to expand the research that we may not have thought about.
Luann Gray- State rep for PMTO
2004 PTMO in Michigan: Need for change for children in the mental health system (SED
SED- Severely emotionally disabled
CMH- Community of Mental Health
Norway first- they put tons of money into their children
Michigan- shoe string budget
Long run- reduced crisis calls, etc- saving money
27 practitioners providing Group PMTO
families are seen in community
treatment centers or at home
20 trainers
30 coaches
13 reliable fidelity raters
Medicaid accepted
Successfully implemented program- were initially some political and logistical issues
Some angry about the behavioral theory (rewarding children for what they ought to do in the first place)
Other problems- pitching the program to parents (experimental therapy)
childcare arrangements at the treatment centers
Policy issues: child has to receive direct services in order for agencies to receive third party payments- had to change this policy
Source: #4
Website:
Michiganpmto.com
lgray@kazoocmh.org
Hegira
Westland, MI
http://www.hegira.net/ChildrenSED.htm
Programs
Outpatient Therapy
Case Management
Home-Based
Wraparound
We feature the following evidence-based treatment interventions:
Parent Management Training-Oregon (PMTO)
Adolescent Multi-Family Group (MFG)
ALSO:
Arab American and Chaldean Council
Detroit (Not specifically on the website, however)
In LANSING:
Several other evidence-based practices are also used by specially-trained FGS (Family guidence services) therapists to address specific emotional and behavioral needs of children.
Parent Management Training – Oregon Model: a structured in-home intervention to help parents manage their children’s behavior
COSTS: Our services may be covered by health insurance, including Medicaid. Fees are assessed based on the client’s ability to pay. A coverage determination will identify a person's ability to pay along with any public funding that might be available. No one is ever denied services due to their inability to pay.
Arbor Circle, Grand Rapids: Arbor Circle provides many services for children, families and teens. Home Based services are offered in your home and other convenient locations. Services are often free of charge. Certain income levels require some ability to pay based on a sliding fee scale.
Typical training program includes six three-day workshops (18 workshop days)
Covering essential and supporting components, practice with cases
Candidates for certification required to video record their sessions with families
Coaching based on FIMP (Fidelity of Implementation Rating System):
Knowledge of PMTO principles, practice and theoretical models
Structure proficiency, leading without dominating
Teaching: verbal and active teaching strategies that promote parents mastery of PMTO skills
Process: proficiency of sophisticated therapeutic skills
Overall development- incorporating contextual and family circumstances that may interfere with the intervention of PMTO
Assessment of your local agency, funding, caseload, target pop, - have to assess all to achieve sustained implementation with high fidelity
FIMP: NO scores below four on a nine-point scale.
Following certification, monthly PMTO coaching within local community is required
Coaching from ISII at regular intervals to sustain fidelity
Need an additional 2 family PMTO cases- not training families
