Archives ofDisease in Childhood 1992; 67: 536-542

TYPES OF PSYCHIATRIC TREATMENT

Counselling parents in child behaviour therapy

R McAuley

This is the third of a series of articles on treatment of childpsychiatric disorders.

Over the past 21 years the field of behaviourtherapy with children has expanded consider-ably. Ollendick cites a 1968 report by Gelfandand Hartman in which only 70 studies relatingto child and adolescent behaviour therapy couldbe found in the literature.' By 1981 this figurehad expanded to 1000. This growth has contin-ued and so much so that it is now difficult for thepractising clinician to keep abreast of develop-ments within the now extensive literature.

In the late 1960s behaviour therapy wascharacterised by two main approaches. Directlyfrom the principles of operant conditioning,reinforcement procedures were developed forincreasing and decreasing behaviour and thesefound favour mostly in the fields of mentalhandicap and conduct disorders. The otherapproach derived its strategies from classical orrespondent conditioning and, in the main,included desensitisation techniques and thesewere used most often to treat children withphobic and emotional disorders.

In the 1970s interest in imitation learningexpanded the behaviour therapist's repertoirethrough the development of a new set ofprocedures collectively referred to as 'socialskills training'. Finally, the late 1970s and 1980ssaw the development of a set of techniquesderiving from an interest in cognitive processes.Included among these are self control tech-niques, self instructional training, coping andproblem solving strategies, and approaches forthe reversal of dysfunctional thinking. Thoughthese latter procedures have seen use with widegroups of child problems, they have not, as yet,been satisfactorily validated in their use withovert clinical disorders.One thread running right through the

development of child behaviour therapy hasbeen the idea that therapists, rather thantreating the problems exhibited by children,should educate the parents into this role.Inherently, this makes good sense as it is theparents who have the maximum 'therapeutic'contact with their children. The approach,which is often referred to as 'parent training',has enjoyed enormous success and attention,and especially so in the fields of conductdisorder and mental handicap. Traditionally,hallmarks of this approach include: (i) carefulfamily assessment through interviews andobservations of parent-child interactions: (ii)training parents to monitor and track child

behaviour; (iii) educating parents in reinforce-ment principles and a range of allied techniques,such as differential reinforcement, time out,contingency contracting and how to use pointincentive systems; and, finally, (iv) teachingparents to generalise their successes acrossbehaviours and over iime. In this paper theauthor examines some of the issues relevant toeach of these steps but, in particular, discussesaspects pertinent to the busy clinicians inroutine practice.When consulted about child behaviour

problems, such as tantrums, sleep difficulties,disobedience and aggressiveness, it is oftentempting to jump quickly to advice about firm,consistent management. However, betweencomplaint and successful resolution, severalaspects of our approach will influence thelikelihood of success. Firstly, our methods ofassessment and consequent understanding ofthe individuals, interactions, and developmentalissues may suggest factors other than the actualconsequences, which also require therapeuticattention. Secondly, as therapists the way inwhich we interact with the family will in manyinstances influence the treatment outcome.Thirdly, the manner in which treatment tech-niques are imparted will affect their utilisation,and finally, experience in the sorts of 'roadblocks' that may hinder treatment progress willbe important. Some aspects of each of theseissues is discussed below.

Assessment of child behaviour problemsA basic prerequisite to any treatment advice isan understanding of the behavioural problems,their antecedents, and consequences.

BEHAVIOURAL ANTECEDENTSTraditionally, parent trainers have concernedthemselves with what is observable, andthrough this have demonstrated a number ofimmediate and frequently occurring problemantecedents. These include vague instructions,frequently repeated instructions, inconsistencyin approach to the behaviour, failure to attendto prosocial behaviour, and attention to disrup-tive behaviour and sequences typified by esca-lating anger and aggression.2 The ramificationsfor treatment obviously include teaching theparent to observe more accurately, issue clearerand fewer instructions, and to act earlierand moreefficiency. However, this focus on immediateantecedents is often only part of the story.

Department of ChildPsychiatry,Royal Belfast Hospitalfor Sick Children,Belfast BT12 6BE,Northern IrelandCorrespondence to:Dr McAuley.

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The immediate interaction between parentand child is influenced by a wide range ofevents, including other interactions, the effectsof family and environmental stressors, and theattitudes and beliefs that parents hold aboutchild behaviour. Failure to attend to these willat worst result in unsuccessful treatment. Onthe other hand, careful consideration may sug-gest other and more appropriate approaches totreatment. Some of these aspects are discussedfurther.

Marital problems may lead to serious dis-agreements about child management, less timefor the child, and impose additional stress uponthe child.3 In the face of open conflict, childmanagement advice is ill advised until suchdifficulties are resolved or resolving. Perhapsthough, in dysfunctional marriages characterisedby apathy and disinterest, advice to one parentmay have beneficial effects. Problems betweenparents may also be expressed in more covertways. For instance, the child who sleeps with aparent may serve to mask parental sexualdifficulties. One way to test such a hypothesis isto question parents about the consequences forthem of successful child problem management.Other family interactional influences maypresentmore subtly, and only became appreciatedthrough careful investigation. Grandparents,for instance, may criticise and undermineparental efforts. This can often bemanaged eitherby appropriate parental assertion, ignoring, orat worst by grandparent exclusion. Finally,siblings who while not perceived as problematic,nevertheless often exhibit some problems andtherefore may require to be included in treat-ment.2 More subtly, if labelled 'good', suchchildren may, in maintaining their relativeposition, persist in covertly provoking thelabelled child. In such cases, if intersibling fight-ing is problematic, then parents may be bestadvised to ignore fighting in order to avoid beingdragged into a 'good'/'bad' labelling game.

Families may be exposed to a range ofstressors that have detrimental effects on childrearing. It has been established that in the yearor so after parental separation, mothers mayhave management difficulties especially withtheir sons.4 Here, rather than focusing interven-tion on child management, it may be far moreappropriate to support and advise the motherwith regard to the enormous adjustment she ishaving to make. Other stresses, such as parentaldepression, illness, or child illness, also requireappropriate consideration before child manage-ment advice is contemplated.An inquiry into parent day to day coping may

reveal ways in which child difficulties canindirectly be alleviated. At the simplest level forinstance, adjustments in parents' daily time-table can create more space and thus reducestress around areas of child management. Forexample, in one of the author's cases, a youngmother habitually attempted to dress threeyoung children, make breakfast, get them out toschool, and complete some household tasks-allin the space of one hour. In situations whereorganisation is more chaotic, then variousproblem solving and coping skills strategies maybe required.

Multiproblem families pose the greatest chal-lenge for parent trainers. Not only are theymultistressed, but also they frequently exhibit abroad range of poor coping skills. Also it isoften assumed that they are deficient in parent-ing skills. However, this is not usually thecomplete story. Research has demonstrated thatthese parents can 'learn' and successfully usebehavioural management techniques, but un-fortunately such improvements are often notmaintained.' It would appear that their problemslie more within dysfunctional attributions andexpectations about their children and their lifecircumstances. In any case, efforts to improvechild management in such families will at leastrequire prolonged and diverse treatment.

In the early days of parent training an implicitassumption that attitude change would followbehaviour change existed. This was a naivegeneralisation. At initial interviews, one is oftenstruck by the strength of parental belief state-ments such as, 'I've tried everything andnothing works', 'He's just like his father', 'Hedoesn't learn', etc. No doubt, in milder cases,direct behavioural advice with successful appli-cation may extinguish these beliefs. However,in more difficult cases the belief may hinderprogress from the beginning. Take for example,a mother who feels that nothing works, thinksshe is a bad parent, and sees her child as failingto learn, and consider how she approaches herchild when trying to get him to bed. She islikely to feel fed up and/or angry, and inconsequence her approaches to the child willoften convey a lack of belief in her ownmanagement ability. Frequent failure will re-inforce such dysfunctional beliefs, and perhapsalso lead to inconsistency of effort and ruleapplication. Also, other adults may reinforcethe beliefs either by taking over the manage-ment, or more directly, by criticising themother. If the therapist is to avoid failure, thensome preliminary work with dysfunctionalbeliefs will often be necessary. Basically, suchwill involve identifying the beliefs, teaching theparent to monitor them, then learning toexamine them according to reality and finally,in consequence, learning to establish moreappropriate ones in their place. For example, ifthe parent considers that 'nothing works', thenan in-depth examination ofbehavioural incidentsto which this is linked is required. Often thiswill reveal that what was thought not to work,was not in the first instance applied appropriately.Equally, other behavioural incidents will illus-trate that the techniques appropriately applieddid work. In cases where dysfunctional thinkingis intense and associated with significantemotional distress, then treatment lasting manysessions may be required. First the dysfunc-tional thinking will need modifying, nextrelaxation training and coping strategies may berequired for the emotional components, andfinally, problem solving approaches may beadvocated in order to substitute more appro-priate and constructive thinking. Such ap-proaches have shown some promise in a numberof difficult areas, such as child abuse.6When significant child behaviour problems,

parent dysfunctional thinking, and emotional

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problems coexist, then it is likely that familyrules governing child behaviour may becomeloose and inconsistently applied. It is of coursedifficult to track behaviour when the generalrules are unclear. As already hinted, it istherefore important in early therapy to spendtime discussing rules. For instance, what are theabsolute 'don'ts' (for example, no throwingthings around, no verbal abuse to parents, etc),what behaviour is expected at mealtimes, home-work times, and so on.One very important area of parent thinking

centres on expectations about child behaviour.Are the expectations of the child, given his orher particular developmental level, appropriate?The child abuse literature frequently refers tothe inappropriate expectations that such parentshave of their children.7 For instance, they mayexpect the child to exhibit high levels of selfcontrol at very young ages, or they might expecttheir baby. to respond exclusively to themwithout being able to appreciate the need forinteractional sensitivity and flexibility. Someyears ago the author treated an 18 month oldchild who presented with a six month history ofpersistent crying. Being behaviourally orien-tated, an interactional understanding of theproblem was sought in terms of attention versusnon-attention. Within this framework theresults of a prolonged observation failed toproduce answers. However, when conceptssuch as maternal sensitivity to the child wereconsidered, the nature of the problem becameclear. Observation showed that the mother wasattending to the child indiscriminantly in thesense that she failed to respond to social cuesemitted by the child. Some simple parentcoaching on such issues produced a dramaticresolution within 24 hours! Thus behaviouralassessments in general are incomplete unless theparents' complaints of the child behaviour areseen within the context of normal child develop-ment. In some cases then, it may be the parents'expectations which require modification andnot the child's behaviour.An early exploration of parent expectations

about treatment and about the future is alsooften useful. Understanding what they expectfrom the treatment may reveal useful informationabout motivation. Generally parents pushedinto therapy by outside agencies may view suchnegatively and as unhelpful. If this can beaddressed early on, then it may be possible-tobring about a more positive attitude to therapy.An exploration of the future may be beneficialin two ways. Firstly looking at what mayhappen if the problems persist may help generatefurther motivation to attempt change now.Secondly looking at the future ramifications ofpositive change for the child and parent maynot only help motivation, but may also suggestfuture actions that might solidify change. Forinstance, given positive changes, what will youand your child be able to do in the future thatyou can't do now?

THE PROBLEM BEHAVIOURAsk a number of people to define what theymean by child tantrums, and you will find that

the definitions vary considerably from person toperson. Such a simple test clearly illustrates theimportance ofgathering very specific informationabout the occurrence of the problem behaviour,its frequency, and where it occurs. Thisbecomes even more important when parentalcomplaints are vague. For instance, with com-plaints such as, 'she is anxious', one would wantclear episodic data about what she does, says,and what emotions are expressed. Informationof this type may reveal that the parents'concerns about the problem are justified, or thattheir perception of the behaviour is in some wayerroneous. For instance, depressed parentsoften perceive child behaviour as more prob-lematic than it is,8 or multidistressed parentsmay exhibit inappropriately high standardswhen making judgments about child behaviour.7Clearly, such findings have ramifications for thetreatment focus. In other instances informationmay reveal that the parents have not actuallyobserved the problem of interest and typicalexamples of this include intersibling fighting asalready discussed. Finally, accurate descriptionsof the behaviour will, where appropriate,facilitate the therapist in making judgmentsabout what opposite prosocial behaviour mightlater be reinforced.

BEHAVIOURAL CONSEQUENCESKnowledge of the consequences of problembehaviour will obviously increase our under-standing about why the problems persist.Interest in consequences will, in most instances,focus upon exactly what they are, how fre-quently they occur, how appropriate they are,and how consistently they are applied. Spread-ing the inquiry into common positive andnegative consequences employed by the parentwill also hint at what ones may, with or withoutmodification, be utilised later. Finally, infor-mation on the relative density of negative orpositive ones will be important as this too mayrequire later therapeutic consideration. Toillustrate: research in families with aggressivechildren has shown that often parents use apreponderance of negative to positive conse-quences.

Previous reference was made to the parentbelief that nothing works. In such cases, carefulinquiry into what rewards and punishmentsthey consider don't work may actually revealthat these techniques (as the parents see them)have paradoxical effects. In other words, whenthe smack is applied the child behaviourworsens, or when the parent praises, the appro-priate behaviour decreases. Clearly, in thesecases the techniques are not being employed atsufficient intensity or their timing is inappro-priate. In treatment, appropriate corrections orother consequences will need to be found.

There is a frequent tendency in therapists toconsider immediate consequences and to ignoreones occurring more distandy. For example,when a mother gives in to a child's refusal to goto school, the child ceases his distress and themother's giving in is reinforced. However, laterwe may find the child watching television andenjoying his mother's company. Here the child

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receives further and later reinforcement (some-times referred to as secondary gain) for hisrefusal behaviour. Such important consequentialarrangements require attention and can only beaddressed if we proceed in our exploration ofthe problems with questions such as, 'and thenwhat happened next'.

Assessment methodsParent trainers have employed a range ofassessment techniques and these have includedinterviews, direct observation, various ques-tionnaires, and parent records. Here the focusof attention is on interviews and parent records.A perusal of many texts on parent training

written over five to 10 years ago reveals anoverwhelming preoccupation with observationalmethods of assessment. No doubt this resultedconsiderably from an interest in achievingobjectivity. Also, much of the parent trainingdevelopment occurred within research settings,where the luxury of careful and painstakingobservation of interaction was feasible. Clini-cians in the service sector are frequently unableto spare such time, and therefore, must rely onmethods that are less time consuming. Fortu-nately, in recent years, parent trainers have for anumber of reasons shown an increased interestin interviewing.9 Firstly the recognition thatevents not readily observable, such as parentaldisputes and what they thought, are importanthas resulted in more attention. Secondly, therealisation that success is not only about observ-able changes, but also about changes in beliefsand attitudes (which are less immediatelyobservable) has been influential in shapingassessment methods.

Research into interviewing methods hasclearly demonstrated that it is possible to obtainhigh quality factual information about familylife, without necessarily hindering the impor-tant development of the therapist/client relation-ship (see later).' 0 This author would go furtherand state (on the basis of teaching experience),that many therapists do not realise that inter-viewers can gain clear interactional information.Practically speaking, a careful inquiry intorecent behavioural episodes, sequence bysequence, can be achieved if the intervieweradopts an attitude that he would like to be ableto visualise the episode in the manner of a videorecording. Obviously, while such interviewingskills can never completely override the potentialvalue of observing events, for the serviceclinician they can function satisfactorily as amajor assessment method.

Parent observational records of behaviouralepisodes serve several purposes. Further infor-mation about the problem is gained, theparents' attention is focused more specificallyon the problems, and finally in consequence theycan begin to observe more accurately as wasmentioned earlier. Unfortunately, clinicalexperience indicates that parents are poor atkeeping detailed records-and this is despitecare-ful instruction and training. On visits to theclinic it is often readily apparent that theirrecords lack detail or were completed shortlybefore the appointment. One can improve this

by telephone checks between appointments, orby asking for audio recordings of episodes madeat home, and finally the therapist can use thescanty records as a starting point for furtherfocused interviewing as already discussed.

Some thoughts on treatmentCareful assessment will in most instances sug-gest the most appropriate treatment techniques.Such will include ensuring that the situationsare maximally conducive to behaviour changethrough encouraging clear rules, ensuring timeis available to manage the problems, optimisingthe parents' general approach, and coaching inthe use of a variety of techniques such aspositive reinforcement, differential attention,time out, and point or star systems. Somediscussion has already taken place with regardto things that might be changed in order toincrease the probability of appropriate be-haviour. The specific techniques of change arenot discussed here. Rather, in this section somegeneral and important issues relating to theirapplication are examined.

THERAPIST SKILLSA number of research reports over the past 15years have drawn attention to the importance oftherapist skills in bringing about positivechange. For instance, Alexander et al, in work-ing with delinquent families, demonstrated thata therapist's ability not only to empathiseaccurately, but also to direct families clearly,contributed significantly to the likelihood ofsuccessful outcome.' Wahler and Dumas, intreating multiproblem families, have drawnattention to the importance of adopting afriendly, non-coercive style.5 Finally, Pattersonand colleagues (cited in Twardosz and Nord-quist) have begun to examine therapist skillsmainly as a consequence of inconsistent resultsin some of their parent training programmes.'2Obviously the requisite therapist skills will varyfrom case to case. In those where problems aremild and parents highly motivated, straight-forward direct quickly given advice may besufficient. However, in more difficult cases, thetherapist will often need to create an atmospherein which the client feels acknowledged, sup-ported, and encouraged to consider the resolu-tion of their problems in a positive light. Earlydirecting and teaching may simply drive someof these parents away. In the end, failure to givecredence to the importance of therapist skillswill result in resistance in therapy and possiblesubsequent treatment failure.

LEARNING THERAPY TECHNIQUESPopular books such as Toddler Taming containmuch sound practical advice that could benefitmany of the parents seen at busy outpatientclinics. 13 However, and unfortunately, manyseem unable to transfer the information intoaction. Clearly, the distance between the writtenword and successful application is vast, and alsosuch material frequently fails to address theindividualistic nature ofparent-child difficulties.

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How then can parents best learn to effectivelyapply behavioural techniques?A number of studies have demonstrated that

parents learn most effectively when techniquesare role played or rehearsed and least well whenthe knowledge is imparted didactically.'4 Theformer teaching methods are time consuming,and thus in busy clinical practice one has to findsome kind of reasonable balance. One possiblesolution is to train small groups of six to sevenparents. This has been done and would appearsuperficially to address the time problem.'5Additionally, working with parents in groupscan in itself be facilitative, because it offers aforum in which parents can discuss and com-municate their problems and solutions. Unfor-tunately, arranging convening and administeringgroup sessions can be costly in terms of time,and this is something that is often inadequatelyaddressed in the literature. Another approach isto employ prepared film and video demonstra-tions.'2 Though this has received some atten-tion, this author would suggest that it has notbeen explored in this country to its full potential.Overall, one could argue that further research isrequired into each of these different trainingmethods. However, the reality probably is thatthe different training methods are each in theirown ways effective, but that their use needs tobe matched carefully to the varying needs ofdifferent clinical samples.

ANTICIPATING ROADBLOCKS IN TREATMENTAs has been indicated, careful assessmentshould hint that at the optimal treatmentapproach and thus help reduce problems thatmight occur in therapy. However, there are anumber of commonly recurring themes withintreatment which are worth addressing.Many parents do not readily appreciate that

behavioural change in themselves and child istime consuming, and that in consequence (as isthe case with learning any new skill) space andtime requires to be created. For instance, inattempting to help a child develop homeworkskills, it is advisable as far as is possible toensure that other household tasks occurring atthe specified time take a secondary role. In allbehavioural management applications it isimportant to discuss this with the parents with aview to encouraging maximum effort and, inconsequence, reduce the negative influence ofother competing events.

Secondly, standard techniques and approacheswill never suit all parents. For instance, someparents might prefer to use a bedroom for timeout and others prefer a kitchen corner. Similarly,when managing disruptive mealtime behaviour,some parents may have no difficulty in remov-ing food until the next mealtime, but othersmay be unwilling to go this far. In all cases,therefore, the treatment techniques require tobe presented, discussed, and then tailored tosuit individual needs. Throughout such dis-course one of the therapist's functions will be toensure that what is being applied fulfills thetherapeutic requirements, for example, that thepositive reinforcement really is reinforcing tothe child.

Thirdly, parents require to be made awarethat the behavioural problems may, in earlytreatment, increase and intensify before theyimprove. This is important as some parents mayread the worsening as a sign, that the techniquesare not working, or worse still are damagingtheir child. Once this point is understood thenparents may hopefully read the worsening signswith encouragement and thus muster furthereffort.

Fourthly, experience teaches us of some ofthe manipulative craft which children canexhibit during behavioural programmes. Forinstance, the child may adopt an, 'I don't careattitude', or may elicit parental guilt throughstatements such as, 'you don't love me', 'you'recruel to me', etc. Viewed from a distance, themanipulative repertoires of some children canbe both creative and amusing. Parents oftenrequire to be warned.

Finally, throughout treatment therapistsrequire continually to hold the question, 'Iwonder what might prevent successful appli-cation', at the back of their minds. For example,how do we manage interfering adults, thepresence of siblings, and the fact that parentaltiredness may create difficulties in managingproblems in the middle of the night.

COURSE OF TREATMENTIf one is to modify successfully parent-childbehaviour, then contact requires to be quitefrequent. There is little use in initially seeingparents and children on a monthly basis. Notonly do parents require frequent encouragementand support, but also they require help withearly teething problems, and some of these havebeen referred to in the sections immediatelyabove. At first sight, this may appear timeconsuming, however much of this early workcan be conducted by telephone. In fact, in manymilder cases treatment may work very well withone or two clinic visits and the remainder ofcontact made by telephone. Once treatment hasbegun to succeed, then follow up at lessfrequent intervals is advisable for up to oneyear, as research findings have demonstratedthat many families require booster treatmentthroughout this period.2

EFFECTIVENESS OF TREATMENTBoth clinical experience and research haveshown that training parents to manage theirchildren's behavioural problems is effective.The treatment approach would appear to workbest when problems are mild, are of the actingout type, are of short duration, and where thegeneral family background is shown to berelatively stable. Conversely, when problemsare extensive, have been present for years, andoccur in a context of multiple other problems,then treatments show little in the way of durableeffects.'6 Of those cases that fall between thesetwo extremes, the question of success is muchmore difficult to answer.The issue of determining success rates is

further compounded by a host of variables thatinclude the specific types of problems, the

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Counselling parents in child behaviour therapy 541

duration and intensity of the therapy, thequality of therapy (for example, were thetherapists experienced or just newly trained),and finally what it is that actually constitutedsuccess. With regard to the latter point anumber of issues arise. Many single case studiesand reports concentrate on reductions in difficultbehaviour, and neglect whether or not the childshows significant increases in prosocial skills,generalisations of changes across environmentsand relationships, and changes in internal statessuch as might be reflected in measures of selfesteem. Equally, success must be allied to howparents think, perceive, and view the situationas in the first instance they have often beenresponsible for the referral.

Perhaps it is unrealistic to expect much moreat this time. After all the social learning theoriesunderpinning parent training are still largelyhypothetical, and secondly, our knowledge ofhow family events such as marital problemseffect and interact with the individual child overtime is still largely in its infancy. Finally, thereis a feeling that much of the literature's use ofthe word success is synonymous with cure.Kendall quite rightly asserts that the notion thatpeople can be 'fixed' is unreasonable andunhelpful.'7 For instance, if our successfullytreated school refuser returns with furtherproblems three years later, this is not necessarilyindicative of past failure, but rather indicatesthat more therapy is required. The conclusionwe can draw is that if we can be helpful at onemoment in time then our function becomesmore realistic, credible, and healthy.

Concluding remarksThis brief examination of parent training inbehavioural child management has focused onlyon some aspects considered important by apractising clinician. Many areas have not evenbeen considered. These, among others, includeobservational methodology, common treatmenttechniques such as time out and differentialattention, contingency contracting procedures,coping and problem solving strategies, and arange of adjunctive treatment proceduresdesigned to improve and enhance outcome.For further information the reader is referred toa number of useful source books listed in theappendix.The majority of developments in parent

training have taken place in research settings,and while such development continues there isan urgent need to conduct efficacy studies in theroutine clinical sector in order to establish howthe technology will stand up when time is shortand caseloads are large. Hopefully, the newemphasis on medical and clinical audit willserve as well in this direction over the nextdecade and beyond.

1 Ollendick TH. Child and adoleacent behaviour therapy. In:Garfield JL, Bergin AE, eda. Handbook of psychotherapyand behavior change. New York: Wiley, 1986: 525-64.

2 Patterson GR, Reid JB, Jones RR, Gouger RE. A. sociallearning approach to family interventions: families with aggres-sive children. Eugene Oregon: Castalia, 1975.

3 Jenkins JM, Smith MA. Marital disharmony and children'sbehaviour problems: aspects of a poor marriage that affectchildren adversely. J Child Psychol Psychiatry 1991 ;32:793-810.

4 Wallerstein J, Corbin SB, Lewis JM. Children of divorce: aten-year study. In: Hetherington EM, Arasteh J, eds.Impact of divorce, single parenting and step-parenting onchildren. Hillsdale, New Jersey: Erlbaum, 1989: 202-14.

5 Wahler RG, Dumas JE. Changing the observational codingstyles of insular and noninsular mothers: a step towardsmaintenance of parent training effects. In: Dangel RF,Polster RA, eds. Parent training: foundations of research andpractice. New York: Guilford, 1984: 379-416.

6 Wolfe DA. Child abuse. In: Hersen M, Hasselt VB, eds.Behavior therapy with children and adolescents. New York:Wiley, 1987: 385-415.

7 Wolfe DA. Child abuse. London: Sage, 1987.8 Webster-Stratton C, Hammond M. Maternal depression and

its relationship to life stress, perceptions and child behaviorproblems, parenting behaviors, and child conductproblems. J Abnorm Child Psychol 1988;16:299-315.

9 Mash EJ, Terdal LG. Behavioral assessment of child andfamily disturbance. In: Mash EJ, Terdal LG, eds. Behaviourassessment of childhood disorders. New York: Guilford,1988: 3-65.

10 Cox A, Rutter M. Diagnostic appraisal and interviewing. In:Rutter M, Hersov L, eds. Child and adolescent psychiatry:modem approaches. Oxford: Blackwell, 1985: 233-48.

11 Alexander JF, Barton C, Schiavo RS, Parsons BV. Systemsbehavioral intervention with families of delinquents:therapist characteristics, family behavior and outcome.J Consult Clin Psychol 1976;44:656-64.

12 Twardosz S, Nordquist VM. Parent training. In: Hersen M,Van Hasselt VB, eds. Behavior therapy with children andadolescents. New York: John Wiley, 1987.

13 Green C. Toddler taming. London: Doubleday, 1990.14 O'Dell SL, O'Quin JA, Alford BA, O'Briant AL, Bradlyn

AS, Giebenhain JC. Predicting the acquisition of parentingskills via four training methods. Behavior Therapy 1982;13:194-208.

15 O'Dell SL. Progress in parent training. In: Hersen M, EislerRM, Miller PM, eds. Progress behavior modification. NewYork: Academnic Press, 1985: 57-108.

16 Wahler RG, Graves MG. Setting events in social networks:ally or enemy in child behavior therapy. Behavior Therapy1983;14: 19-36.

17 Kendall PC. The generalization and maintenance of behaviorchange: comments, considerations, and the 'no-cure' criti-cism. Behavior Therapy 1989;20:357-64.

AppendixThe child behaviour therapy books listed areones that the author has found most useful.This list is by no means exhaustive, but shouldprovide readers with a fairly broad coverage ofthe field of child behaviour therapy.

CHILD BEHAVIOUR ASSESSMENTThe one text listed here, which is now in itssecond edition, is authoratative and has becomea standard bench book. In addition to chapterson conduct, emotional and developmentalproblems, there are also ones on brain injury,chronic pain, obesity, anorexia nervosa,eneuresis, encopresis, child abuse, and others.The breadth of coverage has hitherto beenunusual in behaviourally oriented textbooks.

1 Mash EJ, Terdal LG, eds. Behavioral assessment of childhooddisorders. New York: Guilford, 1988.

THERAPIST HANDBOOKSThe two books here provide therapists withdetailed guidelines for conducting child be-haviour therapy assessment, treatment planning,treatment implementation, and outcome evalu-ation. Both texts are practical and contain awealth of clinical experience.

1 Herbert M. Behavioural treatment of problem children.London: Academic Press, 1981.

2 Herbert M. Working with children and their families.London: Routledge, 1988.

CHILD BEHAVIOUR THERAPY HANDBOOKSThe two books listed deal with a wide range of

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different childhood disorders and problems.The author prefers the second text, mainlybecause of its masterly coverage of vast areas ofbehaviour therapy literature. Unfortunately thistext is now rapidly becoming rather dated.

1 Hersen M, Van Hasselt VB, eds. Behavior therapy withchildren and adolescents. New York: Wiley, 1987.

2 Ross AO. Child behavior therapy: principles, procedures andempirical basis. New York: Wiley, 1981.

CHILD BEHAVIOURAL MANAGEMENT MANUALSThe three books listed provide basic information

on the management of a range of child be-havioural problems. Generally they are fairlystraightforward and not too laden with technicaljargon. The author prefers the first book, as notonly does it contain much about practicalmanagement advice, but also it addresses manyof the practical problems encountered incounselling parents.

1 Barkely RA. Defiant children. New York: Guilford, 1990.2 Green C. Toddler taming. London: Doubleday, 1990.3 Patterson GR. Families. Champaign, Illinois: Research Press,

1977.

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hild: first published as 10.1136/adc.67.4.536 on 1 April 1992. D

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