PMTO: An Evidence-Based Program

Marion S. ForgatchOregon Social Learning Center

Eugene, Oregon USA

Paper presented at the PMTO Working Conference, January 12, 2006, De Eenhoorn in Amersfoort, the Netherlands.

Support for this project was provided by Grant Nos. R01 MH38318 and R01 MH54703 from the Child and Adolescent Treatment and Preventive Intervention Research Branch, DSIR, NIMH, U.S. PHS; Grant No. R01 DA16097 from the Prevention Research Branch, NIDA, U.S. PHS; and Grant No. P30 MH 46690 from the Prevention and Behavioral Medicine Research Branch, Division of Epidemiology and Services Research, NIMH & ORMH, U.S., PHS.

What is PMTO?

Grandfather of theoretically grounded evidence-based practices

Developed mid 1960s by Gerald R. Patterson

Lineage: John B. Reid

Patricia Chamberlain

Marion Forgatch

Thomas Dishion

What is PMTO?Theory Driven Interventions—Principle Based

Emphasizes Clinical & Teaching Skills

Manualized & Flexible

Family & Group applications

Prevention & Clinical Programs

Fidelity Evaluation (Competent Adherence)

Evidence Based: Published findings

Positive Outcomes for Youth & Parents

What is PMTO?Tailored for serious behavior problems for youth from preschool through adolescence Overt antisocial behavior (noncompliance, aggression, defiance, hyperactivity, fighting)

Covert antisocial behavior (lying, stealing, truancy, fire setting)

Internalizing problems (depressed mood, peer problems, deviant peer association)

Delinquency

Substance abuse

School Failure

What is PMTO?Family intervention designed to empower parents Parents as primary treatment agents

Parents practice skills through role play

Identify and build on strengths in family

Agendas yet responsive to needs of family

Intervenes with family members and subsystems

Couples

Youngsters

Siblings

What is PMTO?

Suitable for multi-problem families

Parents with psychopathology (depression, anxiety, antisocial)

Family contextual problems (poverty, poor neighborhoods)

Family structure transitions (divorce, repartnering)

Marital conflict

What is PMTO?

Family intervention designed to empower parents

Skill Encouragement: Teaching new behavior through positive contingencies

Limit Setting: Discouraging deviant behavior through negative noncorporal sanctions

Monitoring/Supervision: Attending to children’s behavior at home and away from home

Family Problem Solving: Interpersonal planning, troubleshooting, contingency agreements

Positive Involvement: Demonstrating interest, attention, caring

Skills training in effective parenting practices

Social Interaction Learning Model

Sample Order of Topics

AssessmentIdentifying Strengths & ChallengesGiving Good DirectionsEncouragementLimit Setting(Problem Solving)(Monitoring and Supervision)(Positive Involvement)(Selected Topics Relevant for Family)

Typical PMTO Session: General Outline

Prior to Session Midweek Call (Check in; encourage; troubleshoot) Call Night Before (Confirm appointment)

Agenda for 1-Hour Session Approx. Time Arrival, Greetings 5 minutes Debrief Home Practice 10-15 minutes Session Content 25-30 minutes

Review previous skills Troubleshoot & brainstorm Introduce new skills Role plays & exercises Address family issues

Home Practice Assignment 10 minutes Closing 5 minutes

PMTO INTERVENTION PMTO INTERVENTION MODELMODEL

Experimental Manipulation

Address hypotheses:

• Do parenting practices change?

• Do child outcomes change?

• Does change in parenting produce change in child outcomes?

Contexts Parenting Child Practices Outcomes

Apply theory-based intervention in randomized controlled designs.

Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182.

Group

Change in Mediator

Change in Outcome

Potential Covariates:Age/GradeGenderSocioeconomic statusBaseline levels

Models of Mediated Effects

Preventing NoncomplianceMarriage and Parenting in StepfamiliesPI: Marion ForgatchStepfamilies: Boys & Girls; Kindergarten – 3rd GradeSelected Prevention: Recent Re-Marriage

CovariatesGender of ChildAge of ChildBaseline Couple ParentingBaseline Noncompliance

Group Noncompliance

CoupleParenting

1 year Change

.29**-.66***

Martinez, C. R., Jr., & Forgatch, M. S. (2001). Preventing problems with boys' noncompliance: Effects of a parent training intervention for divorcing mothers. Journal of Consulting and Clinical Psychology, 69, 416-428.

Parenting through ChangePI: Marion ForgatchSingle Mothers: Boys Kindergarten – 3rd GradeSelected Prevention: Recent Separation

Group

CovariatesBaseline Coercive ParentingBaseline Positive ParentingBaseline Noncomply

Observed

.20**

-.54***

N = 238

Growth Baseline-30 months5 Assessments

Observed

Noncompliance

Positive Parenting

Coercive Parenting

-.19**

-.19**

Preventing Noncompliance

Preventing Substance UseLinking Interests of Families & TeachersPI: John ReidMixed Family Structures; Fifth Grade Boys and GirlsUniversal Prevention: Schools in High-Crime Neighborhoods

CovariatesBaseline Problem SolvingBaseline Substance UseSocial DisadvantageChild Gender

Group6-year

Growth Substance

Use

Change Parent-Child

Problem Solving

6 Assessments

.12*

-.21*

5th- 11th Grade

Observed

BL-6 mos.

Youth Report

DeGarmo, D. S., Eddy, J. M., & Reid, J. B. (in preparation). Preventing growth in substance use and delinquency: Testing intervening mechanisms across early and late adolescence.

Eddy, J. M., & Chamberlain, P. (2000). Family management and deviant peer association as mediators of the impact of treatment condition on youth antisocial behavior. Journal of Consulting and Clinical Psychology, 68(5), 857-863.

Group

Multidimensional Treatment Foster CarePI: Patricia ChamberlainSample: Chronically Delinquent Adolescent BoysTreatment: Court-Referred Offenders

Change Delinquent Behavior

Mediators•Deviant Peers•Supervision•Discipline•Adult-Youth Relationships

Police Report

Youth Report

.88***

-.64**

N = 53

Treating Delinquency

Placement to 1 year post-exit

3 months in treatment

Agents MethodsCaretaker Direct InterviewYouth Phone Interview

Covariate:Antisocial Behavior for 6 months pre-baseline

DeGarmo, D. S., & Forgatch, M. S. (submitted). Preventing the “Early Start” within transitional divorce families: An experimental test of developmental precursors of antisocial behavior and delinquency.

Parenting through ChangePI: Marion ForgatchSingle Mothers: Boys Kindergarten – 3rd GradeSelected Prevention: Recent Separation

Group

CovariatesBaseline Effective ParentingBaseline Deviant Peer AssociationBaseline Delinquent Behavior

Teacher Report

Growth Baseline-36 months4 Annual Assessments

Observed

Delinquent Behavior

Deviant Peer Association

Effective Parenting

Preventing Delinquency

Boy Report

Growth Baseline – 30 Months

*

* **

52

54

56

58

60

0 1 2 3 4 5 6 7 8 9

ControlIntervention

Te

ach

er D

elin

qu

en

cy T

Sc

ore

Group by Time Mean Trajectories TRF Delinquency T Score

Years

TRF DELTBL

TRF DELT1 Yr

TRF DELT3 Yrs

TRF DELT4 Yrs

9 YearAverage

Delinquency

9 YearGrowth

Delinquency

cmin =111.828, df =77, p =.006, cmindf =1.452, cfi = .991

D2

TRF DELT7 Yrs

Intent toTreat

TRF DELT8 Yrs

TRF DELT9 Yrs

Boy AgeBL

Boy Age 1Yr

Boy Age3 Yrs

Boy Age 4 Yrs

Boy Age7 Yrs

Boy Age 8 Yrs

Boy Age9 Yrs

D1

.64

TRF DELTBL

TRF DELT1 Yr

TRF DELT3 Yrs

TRF DELT4 Yrs

9 YearAverage

Delinquency

9 YearGrowth

Delinquency

cmin =131.063, df =89, p =.002, cmindf =1.473, cfi = .989

D2

TRF DELT7 Yrs

Intent toTreat

TRF DELT8 Yrs

TRF DELT9 Yrs

Boy AgeBL

Boy Age 1Yr

Boy Age3 Yrs

Boy Age 4 Yrs

Boy Age7 Yrs

Boy Age 8 Yrs

Boy Age9 Yrs

D1

ParentingChange

BL to 1 Yre8

.64

0

0.125

0.250

0.375

0.500

Pro

bab

ilit

y o

f A

rres

ts

0 2.24 4.49 6.73 8.98

Years Since ODS Baseline

E_GROUP = 0

E_GROUP = 1

Control Group

Intervention Group

Probability of Arrests by Group (HLM Bernoulli estimation)Probability of Arrests by Group Average (HLM Bernoulli estimation)Group × Time ß11 = -.34, p.031

0.002

0.248

0.494

0.740

0.986

Pro

bab

ilit

y o

f A

rres

tsProbability of Arrests: ODS Official Arrest Data

0 3.24 6.48 9.71 12.95

Years Since ODS Baseline

E_GROUP = 0E_GROUP = 1

Control Group

Intervention Group

Probability of Arrests by Group Individuals (HLM Bernoulli estimation)

Group × Time ß11 = -.34, p.031

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3

Years from Baseline

Eff

ect

size

(d

)

Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

DeGarmo, Patterson, & Forgatch, 2004

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3

Years from Baseline

Eff

ect

size

(d

)

Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

DeGarmo, Patterson, & Forgatch, 2004

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3

Years from Baseline

Eff

ect

size

(d

)

Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

DeGarmo, Patterson, & Forgatch, 2004

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3

Years from Baseline

Eff

ect

size

(d

)

Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

DeGarmo, Patterson, & Forgatch, 2004

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3

Years from Baseline

Eff

ect

size

(d

)

Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

DeGarmo, Patterson, & Forgatch, 2004

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3 4 5 6 7 8 9

Years from Baseline

Eff

ect

Siz

e (d

)

Parenting

Youth Internalizing

Youth Externalzing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3 4 5 6 7 8 9

Years from Baseline

Eff

ect

Siz

e (d

)

Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3 4 5 6 7 8 9

Years from Baseline

Eff

ect

Siz

e (d

)

Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3 4 5 6 7 8 9

Years from Baseline

Eff

ect

Siz

e (d

)

Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

Youth Substance

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3 4 5 6 7 8 9

Years from Baseline

Eff

ect

Siz

e (d

)

Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

Youth Substance

Maternal Substance

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3 4 5 6 7 8 9

Years from Baseline

Eff

ect

Siz

e (d

)

Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

Youth Substance

Maternal Substance

Univariate Effect Sizes of ODS II and III Cohen’s d

PMTO Intervention

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0 1 2 3 4 5 6 7 8 9

Years from Baseline

Eff

ect

Siz

e (d

) Parenting

Youth Internalizing

Deviant Peer Association

Teacher Report Delinquency

Maternal Depression

Youth Substance

Maternal Substance

Per Capita Yearly Income

• When I was asked to join this program, I didn’t know much of what I was saying yes to. But today I’m very happy.

• I’ve learned the importance of being supportive and encouraging.

• Well, the first thing that came into my mind is this role play! And I still can’t believe that I’ve done that!

Norway certification ceremonies May 2000

• I’ve learned it’s important to have fun while you do therapy. I’ve never had so much fun as I have now.

• I’ve done therapy for many years, and have wanted to help these families. But it’s difficult and you get burned out. One of the things I’ve learned is the inspiration of these persons. It brings my inspiration and focus back. Actually, I was thinking of retiring as a therapist, and I’ve very glad I didn’t.

• It has given me hope on behalf of the children of Norway, especially this conduct disordered group, and it’s so much more fun to work with these families

• I’ve learned that no family is hopeless.

• It’s changed the way I am with my nearest family. I’m more encouraging.

• I’ve learned that this has been a very safe group of people. I have been a participant in very many groups in my life, but I have never felt so secure.

• Your method has challenged my thinking from backward to forward. I’m taking small steps, but I’m on the road to develop. And the reason for that is the way it’s been done and the beautiful support of the group.

• Using role play has really opened up a new world for me as a therapist. And I like the way PMT has allowed us to have answers and set up the families to discover those answers.

• The first workshop was overwhelming. I could barely breathe. But we went on.

• I had to climb down from the abstract and work with concrete details. Perhaps it has to do with role plays. I never used them before. It has been amazing.

• Well, let’s take the role play first. It’s very difficult for a serious person, but I’m trying and going along slowly.

• This therapy is in a humane frame, a very realistic frame.

• I like the role plays and having fun with the parents. I think I do a much better job with the kids I work with (in a residential center) and also being a mother.

• This therapy is hard work. I think I had a little resistance and was resistant. But we, all these beautiful people from Norway, we have learned a lot and we share this optimistic confidence and respect for you.

• It’s strange to be a student of 50 and come in to a new classroom. And it’s such a lovely class. There’s a focus on details, a focus on performance, a focus on patience, and persistence. I would also like to say it has helped me in my personal life. In this area I’ve had many losses.

• There is no shortcut to create a symphony.

References

Achenbach, T. M. (1991). Manual for the Teacher's Report Form and 1991 Profile. Burlington: University of Vermont.

Asher, S. R., & Wheeler, V. A. (1985). Children's loneliness: A comparison of rejected and neglected peer status. Journal of Consulting and Clinical Psychology, 53(4), 500-505.

Capaldi, D. M., & Dishion, T. J. (1985). Describing Friends Questionnaire.

Capaldi, D. M., Dishion, T. J., & Patterson, G. R. (1991). Assessment of families for the Oregon Youth Study (Technical report). Eugene, OR: Oregon Social Learning Center.

DeGarmo, D. S., & Forgatch, M. S. (2005). Early development of delinquency within divorced families: Evaluating a randomized preventive intervention trial. Developmental Science.

DeGarmo, D. S., Patterson, G. R., & Forgatch, M. S. (2004). How do outcomes in a specified parent training intervention maintain or wane over time? Prevention Science, 5(2), 73-89.

Dishion, T. J., & Owen, L. D. (2002). A longitudinal analysis of friendships and substance use: Bidirectional influence from adolescence to adulthood. Developmental Psychology, 38, 480-491.

Duncan, G. J., Brooks-Gunn, J., & Klebanov, P. K. (1994). Economic deprivation and early childhood development. Child Development, 65, 296-318.

Forgatch, M. S. (1994). Parenting through change: A programmed intervention curriculum for groups of single mothers. Eugene: Oregon Social Learning Center.

References

Forgatch, M. S., & DeGarmo, D. S. (2002). Extending and testing the social interaction learning model with divorce samples. In J. B. Reid, G. R. Patterson & J. Snyder (Eds.), Antisocial behavior in children and adolescents: A developmental analysis and model for intervention (pp. 235-256). Washington DC: American Psychological Association.

Forgatch, M. S., Knutson, N. M., & Mayne, T. (1992). Coder impressions of ODS lab tasks. Eugene: Oregon Social Learning Center.

Kovacs, M. (1985). The children's depression inventory (CDI). Psychopharmacology Bulletin, 21(4), 995-998.

Martinez, C. R., Jr., & Forgatch, M. S. (2001). Preventing problems with boys' noncompliance: Effects of a parent training intervention for divorcing mothers. Journal of Consulting and Clinical Psychology, 69, 416-428.

Patterson, G. R., DeGarmo, D. S., & Forgatch, M. S. (2004). Systematic changes in families following prevention trials. Journal of Abnormal Child Psychology, 32(6), 621-633.

Pearlin, L. I., & Schooler, C. (1978). The structure of coping. Journal of Health and Social Behavior, 19, 2-21.

Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.

Rusby, J. C., Estes, A., & Dishion, T. (1991). The Interpersonal Process Code (IPC) (unpublished manuscript): Oregon Social Learning Center, Eugene, OR.