Specifically in adolescents, low levels of parental control, parental monitoring (defined has parental knowledge of general aspects of their children's lives and child disclosure of information), and parental supervision (defined as the active conduct parents develop in order to be knowledgeable of child-whereabouts, relationships, and performance in school) are associated with breaking rules, drug and alcohol abuse, and delinquency [80–83]. Furthermore, emotional neglect, lack of parental warmth, and absence of parental support are associated with emotional internalization problems, such as depression, anxiety, and suicidal ideation [84, 85]. Kerr and Stattin [86] deduced that it is the adolescent's willingness to disclose information and not the active monitoring by the parent that ultimately affects the quality and scope of parental knowledge and influence regarding the adolescent's behavior. In this sense, the positive outcome from parental involvement decreases significantly when a parent has to resort to surveillance and control of the child in order to gather information.

The more knowledge parents have about what happens in their children's lives, the less problem behavior the adolescents display. Specifically, the more informed parents are, the less adolescents engage in delinquency [87], illegal substance use and risky sexual activities [83], and the fewer deviant friends they have [88]. In a recent study on a sample of juveniles from the community, Silva and Stattin [6] found that increased levels of parental knowledge and youth-disclosure of everyday activities decreased the likelihood of self-reported delinquent behavior even for those youths who rated high in psychopathy. Youths and parents who find the time to meet and discuss events and activities the child is involved in when they stay out at night, how school was when they got home, how they perform in exams, their relationship with peers and friends, etc., develop a parent-child relationship based on mutual understanding and trust that provides strong support for the adolescent's transition into adulthood.

Problematic behavior may occur within the framework of normal development and minor delinquency is frequent in teenagers, mainly in boys [89]. Rule breaking confined to the adolescent stage is in many situations an expression of recently acquired autonomy, and causal factors are very likely specific to this period of development. For example, delinquent individuals inside the peer group, the experimentation with alcohol and drugs, and for girls dating delinquent boys, are risk factors closely related to deviancy that can emerge during both early and late adolescence [90]. Controlling these risk factors presents a great challenge for parents who fight to keep their children under supervision and control. Delinquent peers are a stronger predictor of delinquency than factors such as family, school, and community characteristics. In girls, for whom causes of delinquency are clearly relationship-oriented, dating a delinquent boy greatly influences her decision to engage in antisocial behavior [91] and is closely related to risky sexual behavior [92].

Adolescents' engagement in delinquent behavior inevitably leads to frequent confrontational parent-child interactions. In the context of relationships that had previously been warm and based on an authoritative parenting style, the restoration of trust and prosocial behavior can easily be accomplished. On the other hand, in relationships that developed in the context of harsh parenting and authoritarian or permissive parenting styles, the conflict produced by the adolescent's delinquent behavior can progress in four negative directions: (1) adolescents start to be more secretive, avoiding contact with their parents and lie, (2) there is an escalation of the conflict with the risk of violent behaviors from both parents and youths, (3) parents may increase their tolerance of delinquent behavior and decrease their monitoring efforts to avoid conflict and tension [93], and (4) parents respond by being less supportive and eventually reject the youth emotionally [94]. In such situations, adolescents might find it difficult to return to a more prosocial lifestyle trajectory, counting only on the guidance and counseling of peers who in many situations are developing delinquent behaviors themselves.

In contrast to the group of adolescents whose delinquent behavior emerges during, and is limited to, the adolescent period, there are some individuals to whom adolescent delinquency is merely a continuation of an antisocial behavioral pattern that emerged early in life [89]. The persistent antisocial behavior in such cases is believed to originate in the interaction between children's neurophysiological vulnerabilities and criminogenic environments. In this group it is very likely to find children who during childhood presented with difficult temperaments, disruptive behavior and/or CU traits. Parenting is affected by the children's delinquent behavior in a different manner depending on whether CU traits are present. Parents are more likely to be unsuccessful in acquiring knowledge from youths high on CU traits who are not willing to answer their questions or chooses to deceive them. Parents are forced to rely on what youths spontaneously decide to disclose. Studies suggest that youths with CU traits are less likely to freely give information to their parents [95] and greater behavior control does not allow parents to gain more knowledge either [73]. As a consequence, parents oftentimes reduce their monitoring behaviors, display surveillance efforts that are less stable, and exhibit monitoring behaviors that are less synchronous over time. In this way, youths find few restrains within the family. No one corrects them and they might feel invincible until they are caught by the juvenile justice system.

In families with inadequate parental guidance, the adolescent sometimes assumes a totally self-autonomous role that goes beyond age appropriate levels, often resulting in violence when parents attempt to step in and correct antisocial child behavior. In such cases, the adolescent strikes back in rage when his/her inflated expectation of entitlement is not realized or when the parent attempts to exert discipline. Similarly, in the case of parents who are unable to fulfill their role, children sometimes feel forced to shoulder the responsibilities of the unable parent. This burden can be overwhelming, resulting in frustration, and leading to violence toward parents as a means of rejection of the adult role. Similarly, when parents are overprotective and controlling, adolescent's violent behavior can originate as he/she struggles to gain age-appropriate levels of autonomy and power. Finally, the exposure to intrafamilial violence (e.g., child maltreatment and domestic violence witnessing) can establish a pattern of violent behavior as the norm in social interactions [96], and represents the genesis in the theory of intergenerational transmission of violence [43, 97]. The parental role is severely disturbed when parents feel threatened, intimidated, or controlled by the child's behavior or when parents believe they must adjust their own behavior to accommodate demands or avoid violence by the child [98]. This extreme case of coercive behavior from adolescent toward parents is also the most difficult to manage. Parental competence has most likely been low during the developmental years for this situation to develop.

#### **7. Intervention**

Adolescents' engagement in delinquent behavior inevitably leads to frequent confrontational parent-child interactions. In the context of relationships that had previously been warm and based on an authoritative parenting style, the restoration of trust and prosocial behavior can easily be accomplished. On the other hand, in relationships that developed in the context of harsh parenting and authoritarian or permissive parenting styles, the conflict produced by the adolescent's delinquent behavior can progress in four negative directions: (1) adolescents start to be more secretive, avoiding contact with their parents and lie, (2) there is an escalation of the conflict with the risk of violent behaviors from both parents and youths, (3) parents may increase their tolerance of delinquent behavior and decrease their monitoring efforts to avoid conflict and tension [93], and (4) parents respond by being less supportive and eventually reject the youth emotionally [94]. In such situations, adolescents might find it difficult to return to a more prosocial lifestyle trajectory, counting only on the guidance and counseling

of peers who in many situations are developing delinquent behaviors themselves.

caught by the juvenile justice system.

70 Parenting - Empirical Advances and Intervention Resources

In contrast to the group of adolescents whose delinquent behavior emerges during, and is limited to, the adolescent period, there are some individuals to whom adolescent delinquency is merely a continuation of an antisocial behavioral pattern that emerged early in life [89]. The persistent antisocial behavior in such cases is believed to originate in the interaction between children's neurophysiological vulnerabilities and criminogenic environments. In this group it is very likely to find children who during childhood presented with difficult temperaments, disruptive behavior and/or CU traits. Parenting is affected by the children's delinquent behavior in a different manner depending on whether CU traits are present. Parents are more likely to be unsuccessful in acquiring knowledge from youths high on CU traits who are not willing to answer their questions or chooses to deceive them. Parents are forced to rely on what youths spontaneously decide to disclose. Studies suggest that youths with CU traits are less likely to freely give information to their parents [95] and greater behavior control does not allow parents to gain more knowledge either [73]. As a consequence, parents oftentimes reduce their monitoring behaviors, display surveillance efforts that are less stable, and exhibit monitoring behaviors that are less synchronous over time. In this way, youths find few restrains within the family. No one corrects them and they might feel invincible until they are

In families with inadequate parental guidance, the adolescent sometimes assumes a totally self-autonomous role that goes beyond age appropriate levels, often resulting in violence when parents attempt to step in and correct antisocial child behavior. In such cases, the adolescent strikes back in rage when his/her inflated expectation of entitlement is not realized or when the parent attempts to exert discipline. Similarly, in the case of parents who are unable to fulfill their role, children sometimes feel forced to shoulder the responsibilities of the unable parent. This burden can be overwhelming, resulting in frustration, and leading to violence toward parents as a means of rejection of the adult role. Similarly, when parents are overprotective and controlling, adolescent's violent behavior can originate as he/she struggles to gain age-appropriate levels of autonomy and power. Finally, the exposure to intrafamilial violence (e.g., child maltreatment and domestic violence witnessing) can establish a pattern of violent behavior as the norm in social interactions [96], and represents the genesis in the In general, interventions have been designed to target parenting styles and strategies to modify those factors which are contributing to the child's behavioral dysfunction. With varying efficacy, the success of such interventions shows that changes in children's behavior are possible to achieve through changes in parental behavior [99]. If we frame the problem in the context of the parent-child dynamic then parents must be the primary target for change. However, the bidirectional influence of the parent-child dyad, the characteristics of the child's temperament and psychopathology are of critical importance to be considered for the clinical treatment. Parenting behavior is strongly influenced by the child's behavior and therefore intervention programs would benefit from a systemic approach that target parents, children, and the interaction they establish in their day to day relationship. The overall direction of influences does highlight the importance of seeking to affect changes in the child's behavior in addition to parenting behaviors, working with the child directly and to include adjustments in the child's environment.

Any type of intervention should aim to reduce problem behavior displayed by the child by developing competent parenting skills. When parents develop the ability to react to their children's negative emotionality in an adaptive way, parent-child interactions become more enjoyable, the occurrence of problematic behavior decreases and the development of more serious behavioral problems later in life is prevented [100, 101]. Successful interventions emphasize that parents must maintain consistency in their parenting behavior and to minimize the display of hostility. Teaching parents how to stimulate and encourage their child to develop appropriate emotional regulation may have several benefits by preventing the coercive cycles to develop during parent-child interactions and facilitate the child's process of positive socialization [30]. Therefore, parenting programs should include the practice of providing cognitive strategies aimed at helping parents learn how to control their own negative emotional arousal [102]. Similarly, parents must learn to avoid entanglement in any defiant and challenging behavior the child may display, thereby reducing the likelihood that an episode of negativity intensifies into a coercive parent-child interactional exchange [103, 104].

By making parents knowledgeable about how to reduce children's episodes of unregulated emotional arousal, the risk for future coercive parent-child interactions should diminish for two reasons [30]. First, if parents are taught how to read their child's reactions to environmental stimulation they have the necessary tools to anticipate emotional reactions to any novel situation. Second, if the child's emotional arousal is restricted to levels that allow the possible acquisition of internal regulatory strategies, the child has the opportunity to learn regulatory strategies that can be utilized in the future without the help of their parents. Thus, disrupting children's reliance on intensifying negative emotional arousal should reduce the reciprocal influences of emotion regulation through harsh parenting. Following Scaramella and Leve [30], parents need to learn (1) what are the indicators that the child is becoming emotionally over-aroused, (2) which types of situations produce emotional over-arousal, (3) how to avoid the occurrence of emotional over-arousal episodes, and (4) how to proceed when their children becomes emotionally over-aroused.

Cognitive-behavioral management training for parents has shown to be effective in improving parent-child relationships and parenting skills and is therefore regarded as suitable intervention for reducing child externalizing behavior problems [103–107]. Most of these parent management training programs include information on child development and care, instructions on how to build a positive parent-child relationship, and behavior management skills to reduce negative parenting. The increases in positive parenting, parental warmth, and parental feelings of self-efficacy are necessary components (but not enough by themselves) to improve child behavior [108]. A reduction in negative parenting in difficult parenting situations seems to have similar importance [103]. And finally, parents must avoid any reluctance to engage in disciplinary strategies out of a fear of the child's behavioral reaction, or they will likely see an increase in the child's opposition and defiance in response to any future effort of discipline [50].

The efficacy of the parent-training programs differs depending on the child disruptive condition [109]. Individual differences in difficult temperament, disruptive behavioral problems and the presence of CU traits predicate that treatment plans must be individually based. Multicomponent interventions that integrate behavioral parenting training, behavioral classroom management, and child skills training have shown to be effective in children with ADHD and conduct problems [110, 111]. While pharmacotherapy is considered by psychiatrist as the first-line treatment for ADHD [112], the core symptoms of ODD are not responsive to current medication and behavioral modification is the main target for intervention [113]. In children with CU traits, the risk for poor treatment outcomes is high. In such cases, social learningbased training has shown to be effective particularly when delivered early in childhood [114]. The clinical approach should target the specific reactivity problems of the child, the specific resources of parents and the current state of the parent-child relationship. It is important to consider ways of maintaining optimal parenting, especially when the child displays a difficult temperament. Parents frequently report that they are emotionally stressed, physically tired, harboring feelings that they do not know what to do and that they do not have any options about how to respond [115]. Promoting parents' psychological well-being, as well as enhancing their knowledge and understanding of their child's behavior, should be considered key components in the prevention and management of dysfunctional parent-child interactions [37].

And finally, what options are there for a parent with low competence who is facing a violent adolescent? The models that address coercive parent-child relationships [30, 116, 117] share several aspects. First, respect by both the parent and the adolescent is expected and must be given. This can be difficult as there are many layers of negativity, often created by years of coercive interactions, to work through, but this step is essential to the restorative process. If violence is present in the relationship, parental competence must be increased as the parent is expected to manage the level of conflict during parent-child communications [98]. The parent has to learn to recognize the child's warning signals indicating that violence is imminent. When the parent notices these signals, s/he must firmly end the confrontation and create a separation until both parties are fully under control and the communication can resume. Second, the mutual understanding that collaboration is necessary for conflict resolution is needed. In order for improvements to take place, all parts must share the responsibility for existing problems. The adolescent has most likely developed an attitude of autonomy and will be resistant to give up this position, but it is necessary for the parent to reclaim authority of being head of the household. Thirdly, participants in the restoration process must feel that they are fairly treated and a desired part of the family. When a participant's actions are challenged, it should be done in a firm and noninflammatory fashion. In addition to these basic recommendations, there are a multitude of individual factors that must be taken into consideration when relationship restorations are attempted. Therefore, most intervention programs operate with a therapist/counselor who identifies problem-causing criteria and then designs a customized intervention [96, 118, 119]. Positive practices to reduce intrafamilial confrontations will be able, over time, to convert adversarial and coercive communication styles into supportive and respectful behavior on behalf of both parents and adolescents.

#### **Author details**

acquisition of internal regulatory strategies, the child has the opportunity to learn regulatory strategies that can be utilized in the future without the help of their parents. Thus, disrupting children's reliance on intensifying negative emotional arousal should reduce the reciprocal influences of emotion regulation through harsh parenting. Following Scaramella and Leve [30], parents need to learn (1) what are the indicators that the child is becoming emotionally over-aroused, (2) which types of situations produce emotional over-arousal, (3) how to avoid the occurrence of emotional over-arousal episodes, and (4) how to proceed when their chil-

Cognitive-behavioral management training for parents has shown to be effective in improving parent-child relationships and parenting skills and is therefore regarded as suitable intervention for reducing child externalizing behavior problems [103–107]. Most of these parent management training programs include information on child development and care, instructions on how to build a positive parent-child relationship, and behavior management skills to reduce negative parenting. The increases in positive parenting, parental warmth, and parental feelings of self-efficacy are necessary components (but not enough by themselves) to improve child behavior [108]. A reduction in negative parenting in difficult parenting situations seems to have similar importance [103]. And finally, parents must avoid any reluctance to engage in disciplinary strategies out of a fear of the child's behavioral reaction, or they will likely see an increase in the child's opposition and defiance in response to any future effort

The efficacy of the parent-training programs differs depending on the child disruptive condition [109]. Individual differences in difficult temperament, disruptive behavioral problems and the presence of CU traits predicate that treatment plans must be individually based. Multicomponent interventions that integrate behavioral parenting training, behavioral classroom management, and child skills training have shown to be effective in children with ADHD and conduct problems [110, 111]. While pharmacotherapy is considered by psychiatrist as the first-line treatment for ADHD [112], the core symptoms of ODD are not responsive to current medication and behavioral modification is the main target for intervention [113]. In children with CU traits, the risk for poor treatment outcomes is high. In such cases, social learningbased training has shown to be effective particularly when delivered early in childhood [114]. The clinical approach should target the specific reactivity problems of the child, the specific resources of parents and the current state of the parent-child relationship. It is important to consider ways of maintaining optimal parenting, especially when the child displays a difficult temperament. Parents frequently report that they are emotionally stressed, physically tired, harboring feelings that they do not know what to do and that they do not have any options about how to respond [115]. Promoting parents' psychological well-being, as well as enhancing their knowledge and understanding of their child's behavior, should be considered key components in the prevention and management of dysfunctional parent-child interactions [37]. And finally, what options are there for a parent with low competence who is facing a violent adolescent? The models that address coercive parent-child relationships [30, 116, 117] share several aspects. First, respect by both the parent and the adolescent is expected and must be given. This can be difficult as there are many layers of negativity, often created by years of

dren becomes emotionally over-aroused.

72 Parenting - Empirical Advances and Intervention Resources

of discipline [50].

Teresa Silva\* and Peter Sandström

\*Address all correspondence to<EMAIL_ADDRESS>
Mid Sweden University, Sundsvall, Sweden

#### **References**

[17] Roustit C, Campoy E, Chai B, Chauvin P. Exploring mediating factors in the association between parental psychological distress and psychosocial maladjustment in adolescence. European Child and Adolescent Psychiatry. 2010;**19**:597-604. DOI: 10.1007/ s00787-010-0094-8

[5] Pasalich DS, Waschbusch DA, Dadds, MR, Hawes DJ. Emotion socialization style in parents of children with callous-unemotional traits. Child Psychiatry and Human

[6] Silva TC, Stattin H. The moderating role of parenting on the relationship between psychopathy and antisocial behavior in adolescence. Development and Psychopathology,

[7] Fontaine NM, McCrory EJ, Boivin M, Moffitt TE, Viding E. Predictors and outcomes of joint trajectories of callous-unemotional traits and conduct problems in childhood.

[8] Byrd AL, Hawes SW, Loeber R, Pardini DA. Interpersonal callousness from childhood to adolescence: developmental trajectories and early risk factors. Journal of Clinical Child and Adolescent Psychology. 2016. Advanced online publication. DOI:

[9] Jessor R., Turbin MS. Parsing protection and risk for problem behavior versus prosocial behavior among US and Chinese adolescents. Journal of Youth and Adolescence.

[10] Maccoby EE, Martin JA. Socialization in the Context of the Family: Parent-Child Interaction. In: Mussen PH, Hetherington EM, editors. Handbook of Child Psychology: Vol.4. Socialization, Personality and Social Development. New York: Wiley; 1983. pp.

[11] Campbell SB. Behavioral problems in preschool children: a review of recent research. Journal of Child Psychology and Psychiatry and Allied Disciplines. 1995;**36**:113-149

[12] Paulussen-Hogeboom MC, Stams GJ, Hermanns, JM, Peetsma TT, van den Wittenboer GL. Parenting style as a mediator between children's negative emotionality and problematic behavior in early childhood. The Journal of Genetic Psychology. 2008;**169**:209-

[13] Rollins BC, Thomas DL. Parental Support, Power, and Control Techniques in the Socialization of Children. In Burr WR, Hill R, Nye FI, Reiss IL, editors. Contemporary

[14] Coplan RJ, Hastings PD, Lagace-Seguin DG, Moulton CE. Authoritative and authoritarian mothers' parenting goals, attributions and emotions across different child rearing

[15] van IJzendoorn MH, Bakermans-Kranenburg MJ. Maternal Sensitivity and Infant Temperament in the Formation of Attachment. In Bremner G, Slater A, editors. Theories

[16] Hafen CA, Laursen B. More problems and less support: early adolescent adjustment forecasts changes in perceived support from parents. Journal of Family Psychology.

Theories about the Family: Vol. 1. London: Free Press; 1979. pp. 317-364

contexts. Parenting: Science and Practice. 2002;**2**:1-26

of Infant Development. Oxford: Blackwell; 2004. pp. 233-257

Journal of Abnormal Psychology. 2011;**120**:730-742. DOI: 10.1037/10022620

Development. 2014;**45**:229-242

74 Parenting - Empirical Advances and Intervention Resources

10.1080/15374416.2016.1144190

226. DOI: 10.3200/GNTP.169.3.09-226

2009;**23**:193-202. DOI: 10.1037/a0015077

2014;**43**:1037-1051. DOI: 10.1007/s10964-014-0130-y

2016;**28**:505-515

1-101

[43] Widom CS. The cycle of violence. Science. 1989;**244**:160-166

[30] Scaramella LV, Leve LD. Clarifying parent-child reciprocities during early childhood: the early childhood coercion model. Clinical Child and Family Psychology Review.

[31] Shaw DS, Winslow EB, Owens EB, Vondra JI, Cohn JF, Bell RQ. The development of early externalizing problems among children from low-income families: a transforma-

[32] Loeber R, Farrington DP. Young children who commit crime: epidemiology, developmental origins, risk factors, early interventions, and policy implications. Development

[33] Dishion TJ, Patterson GR. The Development and Ecology of Antisocial Behavior. In: Cicchetti D, Cohen DJ, editors. Developmental Psychopathology: Vol 3. Risk, Disorder,

[34] Campbell SB, Shaw DS, Gilliom M. Early externalization behavior problems: toddlers and preschoolers at risk for later maladjustment. Development and Psychopathology.

[35] Dishion TJ, Véronneau MH, Myers MW. Cascading peer dynamics underlying the progression from problem behavior to violence in early to late adolescence. Development

[36] Dodge KA, Malone PS, Lansford JE, Miller S, Pettit GS, Bates JE. A dynamic cascade model of the development of substance-use onset: early peer relations problem factors.

[37] Laukkanen J, Ojansuu U, Tolvanen A, Alatupa S, Aunola K. Child's difficult temperament and mothers' parenting styles. Journal of Child and Family Studies. 2014;**23**:312-

[38] Walling BR, Mills RSL, Freeman WS. Parenting cognitions associated with the use of

[39] Archer T, Oscar-Berman B, Blum K. Epigenetics in developmental disorder: ADHD and endophenotypes. Journal of Genetic Syndromes and Gene Therapy. 2011;**104**:1-33 [40] Nadder TS, Rutter M, Silberg JL, Maes HH, Eaves LJ. Genetic effects of the variation and covariation of attention deficit-hyperactivity disorder (ADHD) and oppositional-defiant disorder/conduct disorder (Odd/CD) symptomatologies across informant and occasion

[41] Martel MM, Nikolas M, Jernigan K, Friderici K, Waldman I, Nigg JT. The dopamine receptor D4 gene (DRD4) moderates family environmental effects of ADHD. Journal of

[42] Ashlea M, McGue M, Iacono WG, Alexandra S. The association between parent-child conflict and adolescent conduct problems over time: results from a longitudinal adoption study. Journal of Abnormal Psychology. 2011;**120**:46-76. DOI: 10.1037/a0021350

Abnormal Child Psychology. 2015;**39**:1-10. DOI: 10.1007/s10802-010-9439-5

psychological control. Journal of Child and Family Studies. 2007;**16**:642-659

of measurement. Psychological Medicine. 2002;**32**:39-53

Monographs of the Society for Research in Child Development. 2009;**74**:51-54

tional perspective. Journal of Abnormal Child Psychology. 1998;**26**:95-107

2004;**7**:89-107

2009;**12**:467-488

and Psychopathology. 2000;**12**:737-762

76 Parenting - Empirical Advances and Intervention Resources

and Psychopathology. 2010;**22**:603-619

323. DOI: 10.1007/s10826-013-9747-9

and Adaptation. New York, NY: Wiley; 2006. pp. 503-541

[68] Larsson H, Viding E, Plomin R. Callous-unemotional traits and antisocial behavior: genetic, environmental, and early parenting characteristics. Criminal Justice and Behavior. 2008;**35**:197-211. DOI: 10.1177/0093854807310225

[56] Räikkönen K, Pesonen AK, Heinonen K, Lahti J, Kajantie E, Forsén T, Osmond C, Barker DJ, Eriksson JG. Infant growth and hostility in adult life. Psychosomatic Medicine.

[57] Räikkönen K, Pesonen AK, Heinonen K, Komsi N, Järvenpää AL, Strandberg TE. Stress parents: a dyadic perspective on perceived infant temperament. Infant and Child

[58] Theule J, Wiener J, Tannock R, Jenkins JM. Parenting stress in families of children with ADHD: a meta-analysis. Journal of Emotional and Behavioral Disorders. 2010;**21**:3-17.

[59] Johnston C. Parent characteristics and parent-child interactions in families of nonproblem children with ADHD children with higher and lower levels of oppositional-defiant

[60] Befera MS, Barkley RA. Hyperactive and normal girls and boys: mother-child interactions, parent psychiatric status and child psychopathology. Journal of Child Psychology

[61] Frick PJ, Cornell AH, Barry CT, Bodin SD, Dane HE. Callous-unemotional traits and conduct problems in the prediction of conduct problem severity, aggression, and self-report

[62] Viding E, Larsson H. Genetics of Child and Adolescent Psychopathy. In Salekin RT, Lynam DT, editors. Handbook of Child and Adolescent Psychopathy. New York:

[63] Dadds MR, Cauchi AJ, Wimalaweera S, Hawes DJ, Brennan J. Outcomes, moderators, and mediators of empathic-emotion recognition training for complex conduct problems

[64] Hyde LW, Shaw DS, Gardner F, Cheong J, Dishion TJ, Wilson M. Dimensions of callousness in early childhood: links to problem behavior and family intervention effectiveness. Development and Psychopathology. 2012;**25**:347-363. DOI: 10.1017/

[65] Kolko DJ, Dorn LD, Bukstein OG, Pardini D, Holden EA, Hart J. Community vs. clinicbased modular treatment of children with early-onset ODD or CD: a clinical trial with

[66] Dadds MR, Perry Y, Hawes DJ, Merzs S, Riddell AC, Haines DJ, Solak E, Abeygunawardane AI. Attention to the eyes and fear-recognition deficits in child psychopathy. The British

[67] Hawes DJ, Dadds MR, Frost ADJ, Hasking PA. Do childhood callous-unemotional traits drive change in parenting practices? Journal of Clinical Child and Adolescent

3-year follow-up. Journal of Abnormal Child Psychology. 2009;**37**:591-609

Journal of Psychiatry. 2006;**189**:280-281. DOI: 10.1192/bjp.bp.105.018150

of delinquency. Journal of Abnormal Child Psychology. 2003;**31**:457-470

behavior. Journal of Abnormal Child Psychology. 1996;**24**:85-104

2008;**70**:306-313

Development. 2006;**15**:75-87

78 Parenting - Empirical Advances and Intervention Resources

DOI: 10.1177/1063426610387433

and Psychiatry. 1985;**26**:439-452

Guilford Press; 2010. pp. 113-134

S0954579412001101

Psychology. 2011;**40**:507-518

in childhood. Psychiatry Research. 2012;**199**:201-207

[94] Huh D, Tristan J, Wade E, Stice E. Does problem behavior elicit poor parenting? A prospective study of adolescent girls. Journal of Adolescent Research. 2006;**21**:185-204. DOI:10.1177/0743558405285462

[80] Clark DB, Kirisci L, Mezzich A, Chung T. Parental supervision and alcohol use in adolescence: developmentally specific interaction. Journal of Developmental and Behavior

[81] Green AE, Bekman NM, Miller EA, Perrott JA, Brown SA, Aarons GA. Parental awareness of substance use among youths in public service sectors. Journal of Studies on

[82] Laird RD, Criss MM, Pettit GS, Bates JE, Dodge KA. Parents' monitoring knowledge attenuates the link between antisocial friends and adolescent delinquent behavior.

[83] Ryan J, Roman NV, Okwany A. The effects of parental monitoring and communication on adolescent substance use and risk sexual activity: a systematic review. The Open

[84] Bacchini D, Miranda M, Affuso G. Effects of parental monitoring and exposure to community violence on antisocial behavior and anxiety/depression among adolescents. Journal of Interpersonal Violence. 2011;**26**:269-292. DOI: 10.1177/0886260510362879 [85] Parker JS, Benson MJ. Parent-adolescent relations and adolescent functioning: self-

[86] Kerr M, Stattin H. What parents know, how they know it, and several forms of adolescent adjustment: further support for a reinterpretation of monitoring. Developmental

[87] Eaton NR, Krueger RF, Johnson W, McGue M, Iacono WG. Parental monitoring, personality, and delinquency: further support for a reconceptualization of monitoring. Journal

[88] Keijsers L, Branj S, Hawk ST, Schwartz SJ, Frijns T, Koot HM, van Lier P, Meeus W. Forbidden friends as forbidden fruit: parental supervision of friendship, contact with

[90] Piquero NL, Gover AR, MacDonald JM, Piquero AR. The influence of delinquent peers

[91] Cauffman E, Farruggia SP, Goldweber A. Bad boys or poor parents: relations to female

[92] Dishion TJ. Cross-setting consistency in early adolescent psychopathology: deviant friendships and problem behavior sequelae. Journal of Personality. 2000;**68**:1109-1126

[93] Dishion TJ, Nelson SE, Bullock BM. Premature adolescent autonomy: parent disengagement and deviant peer process in the amplification of problem behavior. Journal of

on delinquency: does gender matter? Youth and Society. 2005;**36**:251-275

juvenile delinquency. Journal of Research on Adolescence. 2008;**18**:699-712

deviant peers, and adolescent delinquency. Child Development. 2012;**83**:651-666 [89] Moffitt TE. Adolescent-limited and life-course-persistent antisocial behavior: a develop-

mental taxonomy. Psychological Review. 1993;**100**:674-701

esteem, substance abuse, and delinquency. Adolescence. 2004;**39**:519-530

Pediatrics. 2008;**29**:285-292. DOI: 10.1097/DBP.0b013e31816e22bd

Journal of Abnormal Child Psychology. 2008;**36**:299-310

Family Studies Journal. 2015;**7**(Suppl 1: M3):12-27

Alcohol and Drugs. 2011;**72**:44-52

80 Parenting - Empirical Advances and Intervention Resources

Psychology. 2000;**36**:366-380

Adolescence. 2004;**27**:515-530

of Research in Personality. 2009;**43**:49-59

**Parenting-based Interventions**

[106] Reid MJ, Webster-Stratton C. The incredible years parent, teacher and child intervention: targeting multiple areas of risk for a young child with pervasive conduct problem using a flexible, manualized, treatment program. Journal of Cognitive and Behavior

[107] Michelson D, Davenport C, Dretzke J, Barlow J, Day C. Do evidence-based interventions work when tested in the "real world?" A systematic review and meta-analysis of parent management training for the treatment of child disruptive behavior. Clinical

[108] Deković M, Asscher JJ, Hermanns J, Reitz E, Prinzie P, van den Akker AL. Tracing changings in families who participated in the Home-Start parenting program: parental sense of competence as mechanism of change. Prevention Science. 2010;**11**:263-274.

[109] Webster-Stratton C. Combining parent and child training for young children with ADHD. Journal of Clinical Child and Adolescent Psychology. 2011;**40**:191-203. DOI:1

[110] Azevedo A, Seabra-Santos MJ, Gaspar MF, Homem T. A parent-based intervention program involving preschoolers with AD/HD behaviours: are children's and mothers' effects sustained over time? European Child and Adolescent Psychiatry. 2014;**23**:437-

[111] Jones K, Daley D, Hutchings J, Bywater T, Eames C. Efficacy of the Incredible Years basic parent training program as an early intervention for children with conduct problems and ADHD. Child: Care, Health and Development. 2007;**33**:749-756. DOI:

[112] Shiner RL. How shall we speak of children's personalities in middle childhood? A pre-

[113] Hood BS, Elrod MG, DeWine DB. Treatment of childhood Oppositional Defiant Disorder. Current Treatment Opinions in Pediatrics. 2015;**1**:155-167. DOI: 10.1007/

[114] Hawes DJ, Price MJ, Dadds MR. Callous-unemotional traits and the treatment of conduct problems in childhood and adolescence: a comprehensive review. Clinical Child and Family Psychology Review. 2014;**17**:248-267. DOI: 10.1007/s10567-014-0167-1 [115] Williams NJ, Harries M, Williams AM. Gaining control: a new perspective on the parenting of children with AD7HD. Qualitative Research in Psychology. 2014;**11**:277-297

[118] Holt A, editor. Working with Adolescent Violence and Abuse Toward Parents:

[119] Routt G, Anderson L. Adolescent Violence in the Home: Restorative Approaches to Building Healthy, Respectful Family Relationships. London: Routledge; 2015

liminary taxonomy. Psychological Bulletin. 1998;**124**:308-332

[116] Patterson GR. Coercive Family Process. Eugene, OR: Castalia; 1982

[117] Patterson GR, Reid JB, Dishion TJ. Antisocial Boys. Eugene OR: Castalia; 1992

Approaches, and Contexts for Intervention. London: Routledge; 2016

Child and Family Psychology Review. 2013;**16**:18-34

Practice. 2001;**8**:377-386

82 Parenting - Empirical Advances and Intervention Resources

DOI:10.1007/s11121-009-0166-5

0.1080/15374416.2011.546044

450. DOI: 10.1007/s00787-013-0470-2

10.1111/j.1365-2214.2007.00747.x

s40746-015-0015-7

**Provisional chapter**

#### **The Relationship between Parenting and Internalizing Problems in Childhood The Relationship between Parenting and Internalizing Problems in Childhood**

DOI: 10.5772/intechopen.73540

Simona Scaini, Sara Palmieri and Marcella Caputi Simona Scaini, Sara Palmieri and Marcella Caputi Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.73540

#### **Abstract**

Several types of stress factors are likely to be implied in the development, maintenance, and transmission of internalizing symptomatology: genetic/temperamental factors, cognitive factors, family factors, and societal/cultural factors. Nonetheless, family factors especially those related to parenting—seem to be crucial during childhood, because children are nested within their families and family factors are able to indirectly influence other factors as well. The current chapter focuses on the relationship between parental style and internalizing symptoms in childhood. In the first part of the chapter, the most important studies on the topic are reviewed in detail and differences in parenting behaviors between mothers and fathers are illustrated. A discussion on the cognitive and metacognitive factors as possible pathways of the relation between parenting and childhood symptoms is also proposed. The last part of the chapter reviews studies investigating the efficacy of parental involvement in cognitive behavior therapy for children who exhibit internalizing symptoms.

**Keywords:** childhood internalizing symptoms, parenting, anxiety, depression, metacognition, cognitive behavior therapy

#### **1. Introduction**

Internalizing problems in childhood and adolescence are a significant, persistent, and debilitating problem, undermining social and school functioning [1–3].

Epidemiological and clinical studies suggest that these disorders persist into adulthood and may contribute to an increased risk of suicide attempts, alcohol use, depression, and severe social restrictions [4–6].

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

Since these symptoms tend to manifest early in life, and are chronic and persistent, early recognition and treatment are especially desirable. However, surprisingly, internalizing disorders in children are still often overlooked and, consequently, underdiagnosed [7].

Although theoretical models suggest that family processes and parenting are important factors in the development, maintenance, and transmission of internalizing symptomatology [8, 9], metaanalytic and review contributions have provided mixed support for this association. In particular, previous studies identified a linkage between childhood anxiety and the broad parenting dimensions of rejection and control. Parental rejection is hypothesized to undermine children's emotion regulation by weakening self-esteem, promoting a sense of helplessness, and prompting development of negative self-schemas, leading to heightened sensitivity toward anxiety and depression [10, 11]. Parental control involves excessive parental regulation of children's life and activity, instructing the children on how to think or feel [12, 13]. Moreover, high control exerted by parents in contexts in which it would be developmentally appropriate for children to act independently, can induce decreased level of self-efficacy and perceived helplessness, thus increasing levels of anxiety and depression [10, 11, 14, 15]. Contrariwise, some parental practices encouraging children's autonomy and independence may increase children's perceptions of mastery over the environment.

Interestingly, several retrospective studies concluded that anxious adults generally remember their parents as being rejecting and controlling [16–18].

Nonetheless, the recent controversy over the theoretical models pointing out that parental practices are associated with child psychological problems have led to questions about the link between parenting and children's psychological health. Twin studies [19–23] have suggested that additional genetic effects account for a small portion of variance in children's trait anxiety and depression compared to non-shared environment (i.e. non-parenting factors). On the other hand, these kinds of studies have shown that, albeit small, the role of the shared environment factors in explaining children's differences for anxiety traits and depression symptoms is present, and it can include parenting influences. However, it is important to note that certain aspects of parenting (e.g. controlling parenting) could make children within a family alike, hence acting as a shared environmental influence for anxiety [24].

Two meta-analytic studies [25, 26] reported that parenting accounted for 4 and 8% of the variance in childhood anxiety and depression, respectively. Therefore, parenting behaviors—albeit not having an overall big impact—show stronger associations with depressive symptoms than with anxiety symptoms. It has been suggested that the observed stronger associations of parenting with depressive rather than anxiety symptoms may indicate that parenting is more likely to have an impact on children's mood compared to their fears (see below).

The intergenerational transmission of internalizing symptoms has been confirmed by both "top-down" studies, which have consistently demonstrated increased risk of anxiety disorder in children of affected parents, and by "bottom-up" studies, which have shown increased rates of disorder in the parents of affected children [27]. In a recent review, Eley and colleagues [28] suggest that maternal control may contribute more to the maintenance than to the onset of childhood anxiety, and that the association between maternal control and anxiety symptoms is significantly influenced by genetic factors.

Etiological models of anxiety underlined the mutual relationship between parents and children in the development and maintenance of childhood anxiety. Several authors [14, 29] highlighted the importance of recognizing that both the parent and the child play a role in creating a shared dynamic of maternal control and childhood anxiety. Familiarity for anxiety can follow two distinct pathways, often interacting with each other: a direct biological/genetic vulnerability pathway and learning experiences. Specific learning experiences implicated in the development and/ or the maintenance of anxiety in children could include directly experiencing aversive events (direct conditioning) and learning while observing experiences happening to others (observational or vicarious learning). In addition, children may increase their anxiety or fears through negative information or beliefs transmitted by others (e.g. parents, teachers, or peers). Thus, modeling of negative responding from parents, as well as moderating the effects of how children experience aversive events or fears when having a direct experience, observing others, or receiving fear relevant information from adults, can reinforce information-processing bias in children.

Since these symptoms tend to manifest early in life, and are chronic and persistent, early recognition and treatment are especially desirable. However, surprisingly, internalizing disorders in

Although theoretical models suggest that family processes and parenting are important factors in the development, maintenance, and transmission of internalizing symptomatology [8, 9], metaanalytic and review contributions have provided mixed support for this association. In particular, previous studies identified a linkage between childhood anxiety and the broad parenting dimensions of rejection and control. Parental rejection is hypothesized to undermine children's emotion regulation by weakening self-esteem, promoting a sense of helplessness, and prompting development of negative self-schemas, leading to heightened sensitivity toward anxiety and depression [10, 11]. Parental control involves excessive parental regulation of children's life and activity, instructing the children on how to think or feel [12, 13]. Moreover, high control exerted by parents in contexts in which it would be developmentally appropriate for children to act independently, can induce decreased level of self-efficacy and perceived helplessness, thus increasing levels of anxiety and depression [10, 11, 14, 15]. Contrariwise, some parental practices encouraging children's autonomy and independence may increase children's perceptions of mastery over

Interestingly, several retrospective studies concluded that anxious adults generally remember

Nonetheless, the recent controversy over the theoretical models pointing out that parental practices are associated with child psychological problems have led to questions about the link between parenting and children's psychological health. Twin studies [19–23] have suggested that additional genetic effects account for a small portion of variance in children's trait anxiety and depression compared to non-shared environment (i.e. non-parenting factors). On the other hand, these kinds of studies have shown that, albeit small, the role of the shared environment factors in explaining children's differences for anxiety traits and depression symptoms is present, and it can include parenting influences. However, it is important to note that certain aspects of parenting (e.g. controlling parenting) could make children within a family alike,

Two meta-analytic studies [25, 26] reported that parenting accounted for 4 and 8% of the variance in childhood anxiety and depression, respectively. Therefore, parenting behaviors—albeit not having an overall big impact—show stronger associations with depressive symptoms than with anxiety symptoms. It has been suggested that the observed stronger associations of parenting with depressive rather than anxiety symptoms may indicate that parenting is more

The intergenerational transmission of internalizing symptoms has been confirmed by both "top-down" studies, which have consistently demonstrated increased risk of anxiety disorder in children of affected parents, and by "bottom-up" studies, which have shown increased rates of disorder in the parents of affected children [27]. In a recent review, Eley and colleagues [28] suggest that maternal control may contribute more to the maintenance than to the onset of childhood anxiety, and that the association between maternal control and anxiety

likely to have an impact on children's mood compared to their fears (see below).

children are still often overlooked and, consequently, underdiagnosed [7].

86 Parenting - Empirical Advances and Intervention Resources

their parents as being rejecting and controlling [16–18].

hence acting as a shared environmental influence for anxiety [24].

symptoms is significantly influenced by genetic factors.

the environment.

In addition to these two pathways, interactional mechanisms such as gene-by-environment interplay and active/passive/evocative correlations can complicate the framework. Child and parent behaviors and beliefs may reinforce or moderate each other in a feedback loop [30]. For example, young children's inhibited behaviors have been shown to evoke overprotective parental behavior, which potentially increases the level of children's inhibition across development, putting them at a higher risk for anxiety disorders [17]. Individual differences in temperament, behavior, and cognitive characteristics can influence parental behaviors and parenting in general.

However, investigating the role of parenting in relation to anxiety and depression remains difficult for several reasons [27]. Firstly, studies' methodology influences the degree of association between parenting and youth reported anxiety/depressive symptoms. Observational assessments of parenting and diagnostic interviews for anxiety/depressive disorders are typically associated with stronger effects compared to parent or child reports. Secondly, studies vary in the operational definitions of parenting. Finally, the importance of parental factors is likely to vary according to the different stages of children's development. Since published studies have considered children and adolescents of different age ranges, generalizable and conclusive results are far from being reported.

#### **2. Parenting and internalizing symptoms in childhood**

Overall, four types of stress factors are likely to be implied in the development, maintenance, and transmission of internalizing symptomatology: genetic/temperamental factors, cognitive factors, family factors, and societal/cultural factors [31–39].

Nonetheless, family factors—especially those related to parenting—seem to be crucial during childhood, because children are nested within their families and family factors are able to indirectly influence the other factors as well.

According to Pinquart [40], parenting dimensions can be described in terms of either a dimensional or a categorical approach. The first approach, on the one hand, focuses on individual dimensions of parental behaviors, such as responsiveness (i.e. being accepting, nurturing, supportive, sensitive, and warm) and demandingness (i.e. control). Parental demandingness, in turn, can be employed through behavioral/harsh/psychological control and autonomy granting. Parental responsiveness and all the forms of parental demandingness have a different impact on child outcomes, mainly based on the frequency of their use and on the child characteristics. The second approach, on the other hand, defines four parenting styles (i.e. authoritative, authoritarian, permissive, and neglectful) according to the combinations of responsiveness and demandingness. Considering both the dimensional and the categorical approach in describing the relationship between parenting and internalizing problems can be useful, since different researchers often use different approaches and methodologies. Therefore, including both approaches—as in Pinquart's meta-analysis [40]—facilitates a clear and complete portrait of the possible associations.

Internalizing problems are those encompassing anxiety, depressive symptoms, somatic complaints, and social withdrawal [41]. The prevalence of internalizing symptoms, after the transition to formal schooling, is higher in girls than in boys [42]. Hundreds of studies have addressed the relation between parenting and one or more internalizing problems. Moreover, many reviews and meta-analyses tried to systematize the results deriving from all of the published researches [25, 26, 30, 43–45]. However, most of existing reviews and meta-analyses considered few studies; reported associations without distinguishing among different parenting behaviors/child outcomes; did not control for initial levels of internalizing symptoms; did not distinguish among results derived from different research designs and failed to describe possible moderators of the link between parenting dimensions and internalizing problems.

Recently, Pinquart [40] was able to overcome the abovementioned problems and found small concurrent and longitudinal associations between parenting dimensions/styles and internalizing symptoms. Specifically, harsh and psychological control were found to predict increases of internalizing symptoms over time; while parental warmth, behavior control, autonomy granting, and authoritative parenting were found to predict decreases of internalizing symptoms over time. At the same time, internalizing symptoms were predictive of parental psychological control. Moreover, the association between parenting and internalizing symptoms appeared to be moderated by effects of sampling, child age and gender, dependent variable (i.e. anxiety or depressive symptoms), parental gender, rater of parenting and internalizing symptoms, quality of measures, and publication status. Overall, controlling for such variables, a small amount of variance in internalizing symptoms remains to be explained by parenting, this leading to small effect sizes. Interestingly, significant gender differences emerged when comparing studies conducted on parenting and male versus female child anxiety. Pinquart's meta-analysis [40] reported stronger associations of parental warmth with internalizing symptoms in studies with more girls, attributing this result to gender differences in the prevalence of internalizing symptoms [42] and to girls' higher sensitivity to the quality of daily interpersonal relationships [46]. Moreover, stronger negative associations emerged between behavioral control and internalizing symptoms in studies with more boys, possibly indicating that parental monitoring is more important for neutralizing internalizing symptoms among boys [47].

Among internalizing disorders, social anxiety disorder represents the most studied condition so far. Parenting traits such as overcontrol, lack of warmth or rejection, and overprotection have been consistently described as predictors of social anxiety disorder [17, 31–33, 37, 48–51]. However, Brook and Schmidt's review [52] contributed to better specify all of the negative rearing practices associated with social anxiety disorder: practices of control, overprotection, rejection, neglect, lack of warmth or affection, anxious parenting, insensitivity, restrictiveness, social isolation, criticism, shame tactics, behavioral rigidity, and concern with the opinions of others. Moreover, Brook and Schmidt [52] explained the mechanisms through which the parenting practices most frequently observed in association with children's anxiety would promote it. On the one hand, overcontrol exerted by parents is likely to diminish a child's ability to explore the environment autonomously, possibly promoting anxiety in situations of perceived fear. On the other hand, rejecting parents usually establish an insecure attachment with their children, which is in turn related to the development of anxiety disorders and depression.

sensitive, and warm) and demandingness (i.e. control). Parental demandingness, in turn, can be employed through behavioral/harsh/psychological control and autonomy granting. Parental responsiveness and all the forms of parental demandingness have a different impact on child outcomes, mainly based on the frequency of their use and on the child characteristics. The second approach, on the other hand, defines four parenting styles (i.e. authoritative, authoritarian, permissive, and neglectful) according to the combinations of responsiveness and demandingness. Considering both the dimensional and the categorical approach in describing the relationship between parenting and internalizing problems can be useful, since different researchers often use different approaches and methodologies. Therefore, including both approaches—as in Pinquart's

88 Parenting - Empirical Advances and Intervention Resources

meta-analysis [40]—facilitates a clear and complete portrait of the possible associations.

more important for neutralizing internalizing symptoms among boys [47].

Among internalizing disorders, social anxiety disorder represents the most studied condition so far. Parenting traits such as overcontrol, lack of warmth or rejection, and overprotection have been consistently described as predictors of social anxiety disorder [17, 31–33, 37, 48–51]. However, Brook and Schmidt's review [52] contributed to better specify all of the negative rearing practices associated with social anxiety disorder: practices of control, overprotection, rejection, neglect, lack

Internalizing problems are those encompassing anxiety, depressive symptoms, somatic complaints, and social withdrawal [41]. The prevalence of internalizing symptoms, after the transition to formal schooling, is higher in girls than in boys [42]. Hundreds of studies have addressed the relation between parenting and one or more internalizing problems. Moreover, many reviews and meta-analyses tried to systematize the results deriving from all of the published researches [25, 26, 30, 43–45]. However, most of existing reviews and meta-analyses considered few studies; reported associations without distinguishing among different parenting behaviors/child outcomes; did not control for initial levels of internalizing symptoms; did not distinguish among results derived from different research designs and failed to describe possible moderators of the link between parenting dimensions and internalizing problems. Recently, Pinquart [40] was able to overcome the abovementioned problems and found small concurrent and longitudinal associations between parenting dimensions/styles and internalizing symptoms. Specifically, harsh and psychological control were found to predict increases of internalizing symptoms over time; while parental warmth, behavior control, autonomy granting, and authoritative parenting were found to predict decreases of internalizing symptoms over time. At the same time, internalizing symptoms were predictive of parental psychological control. Moreover, the association between parenting and internalizing symptoms appeared to be moderated by effects of sampling, child age and gender, dependent variable (i.e. anxiety or depressive symptoms), parental gender, rater of parenting and internalizing symptoms, quality of measures, and publication status. Overall, controlling for such variables, a small amount of variance in internalizing symptoms remains to be explained by parenting, this leading to small effect sizes. Interestingly, significant gender differences emerged when comparing studies conducted on parenting and male versus female child anxiety. Pinquart's meta-analysis [40] reported stronger associations of parental warmth with internalizing symptoms in studies with more girls, attributing this result to gender differences in the prevalence of internalizing symptoms [42] and to girls' higher sensitivity to the quality of daily interpersonal relationships [46]. Moreover, stronger negative associations emerged between behavioral control and internalizing symptoms in studies with more boys, possibly indicating that parental monitoring is The apparently robust relation between maternal/paternal overcontrol and child anxiety, though, is not found in early childhood. Needlessly helping or interfering with the child's behavior or feelings thus seems to be salient for the development of anxiety only when children grow older [43]. The same can be said for maternal autonomy granting, which is associated to anxiety in children older (but not younger) than 5 years [26, 43]. On the other hand, parental overprotection, which is characterized by excessively protective and cautious behaviors, is significantly associated with child anxiety even in early childhood [43]. Such a finding confirms that distinguishing between these two dimensions of overinvolvement is crucial at this age. Another interesting result regarding very young children is that the lack of paternal challenging behavior is associated with more anxiety. This speaks to the importance of investigating both mothers' and fathers' parenting, as parents have different roles within the family and dysfunctionality of the role of one of them might have specific consequences (see also the following paragraph of the present chapter).

As noted by Moller and colleagues [43], the association between parenting behavior and child anxiety is rather complex and several variables have been found to moderate it, at least in early childhood. Among the significant moderators of such relationship, there is the number of observational tasks that were used to measure child anxiety, so that higher effect sizes were found for studies with fewer observational tasks. Measurement method of parenting behavior also emerged as a significant moderator, with higher effect sizes for studies using multiple assessment measures. In the same vein, measurement method of child anxiety emerged as another significant moderator. Indeed, studies using questionnaires to measure child anxiety lead to opposite results compared with studies using observations to assess child anxiety. This counterintuitive finding has important implications for future research, as the unique aspects of child anxiety measured by questionnaires and observations suggest the importance of using multiple methods when assessing such a complex construct. Another moderator of the relationship between parenting behavior and child anxiety is represented by study design, as the studies which allow to catch a significant link are typically prospective or longitudinal, suggesting a low concurrent association between the two constructs (at least in early childhood). Nevertheless, very few longitudinal studies have been conducted on this topic, leaving the question regarding the direction between parenting behavior and child internalizing problems open. Two further research questions that need to be addressed by future researches concern the possibility that some children are more susceptible to effects of parenting than others and the generalizability of the results to single parent families or families with parents of the same gender. So far, studies were mostly conducted on two-parent families with a father and a mother present, who were generally non-anxious individuals of Caucasian origin and middle-high socioeconomic backgrounds [43]. Under these specific conditions, parenting seems to affect emotionally reactive children to a larger extent than other children [53, 54]. In addition, even in the cases in which both maternal and paternal behaviors were assessed, simultaneous interactions among the child and both parents were not observed, thus limiting our comprehension of the full picture.

It is noteworthy to remember that we are far from being able to report conclusive knowledge on the association between parenting and internalizing symptoms, because a limited numbers of studies have been so far published on cross-lagged associations and in particular on cross-lagged effects of parenting styles [40]. Nonetheless, these are not the unique reasons, as the operationalization of both constructs—parenting and internalizing problems—is likely to be different in every study; multiple informants are often missing; experimental designs are rare, as well as researches conducted on ethnic minorities or atypical populations.

#### **3. Differences in parenting behaviors between mothers and fathers**

Research on parenting and internalizing symptomatology has primarily focused on the child and his/her mother. Thus, the father's contribution to parenting is encapsulated in the 'parent' response, implying both father and mother have identical parenting styles [52]. In order to increase knowledge on father behaviors and anxious symptoms, Greco and Morris [55] investigated the association of father behavior with child social anxiety. The results suggested that fathers were more controlling with socially anxious children during the collaborative task, but no more rejecting than fathers of non-socially anxious children. Thus, authors conclude that including fathers in psychopathology research is important for future investigations of anxiety, especially since it is probable that mothers and fathers make unique and individual contributions to the family environment.

However, very few studies have directly compared anxiety/depression-promoting parenting behaviors between mothers and fathers A few years ago, Hudson and Rapee [56] examined the use of parental control by mothers and fathers during interactions with their anxious and non-anxious children. Specifically, parents were asked to work together with their anxious child to complete a series of difficult puzzles and together with their other (non-anxious) child in a challenging task. Results indicated that fathers of clinically anxious children were more controlling during the task compared to mothers.

In contrast with Hudson and Rapee [56], Rork and Morris [57] did not find differences in the levels of parental warmth or control between mothers and fathers during a multi-family interaction task. Whereas another study, by Bögels and Van Melick [58], investigating differences in parental report of rejecting behavior and psychological control in mothers and fathers of non-anxious children, found that fathers rated themselves as more psychologically controlling and rejecting than mothers.

The recent study of Teetsel et al. [59] revealed that anxious fathers reported higher control compared to anxious mothers; and anxious mothers reported higher use of punishment and reinforcement of children's dependence in anxiety provoking situations compared to fathers.

Moller and colleagues [43] examined the associations between parenting and child anxiety, and investigated—by means of two meta-analyses—whether maternal and paternal parenting behaviors have different effects on the development and maintenance of child anxiety. The analysis of 31 studies published between 1997 and 2014 showed that, besides the overall small role played by parenting behaviors in early childhood anxiety, fathers' (and not mothers') challenging parenting behavior is associated with less child anxiety.

seems to affect emotionally reactive children to a larger extent than other children [53, 54]. In addition, even in the cases in which both maternal and paternal behaviors were assessed, simultaneous interactions among the child and both parents were not observed, thus limiting

It is noteworthy to remember that we are far from being able to report conclusive knowledge on the association between parenting and internalizing symptoms, because a limited numbers of studies have been so far published on cross-lagged associations and in particular on cross-lagged effects of parenting styles [40]. Nonetheless, these are not the unique reasons, as the operationalization of both constructs—parenting and internalizing problems—is likely to be different in every study; multiple informants are often missing; experimental designs are rare, as well as researches conducted on ethnic minorities or atypical populations.

**3. Differences in parenting behaviors between mothers and fathers**

Research on parenting and internalizing symptomatology has primarily focused on the child and his/her mother. Thus, the father's contribution to parenting is encapsulated in the 'parent' response, implying both father and mother have identical parenting styles [52]. In order to increase knowledge on father behaviors and anxious symptoms, Greco and Morris [55] investigated the association of father behavior with child social anxiety. The results suggested that fathers were more controlling with socially anxious children during the collaborative task, but no more rejecting than fathers of non-socially anxious children. Thus, authors conclude that including fathers in psychopathology research is important for future investigations of anxiety, especially since it is probable that mothers and fathers make unique and individual

However, very few studies have directly compared anxiety/depression-promoting parenting behaviors between mothers and fathers A few years ago, Hudson and Rapee [56] examined the use of parental control by mothers and fathers during interactions with their anxious and non-anxious children. Specifically, parents were asked to work together with their anxious child to complete a series of difficult puzzles and together with their other (non-anxious) child in a challenging task. Results indicated that fathers of clinically anxious children were more

In contrast with Hudson and Rapee [56], Rork and Morris [57] did not find differences in the levels of parental warmth or control between mothers and fathers during a multi-family interaction task. Whereas another study, by Bögels and Van Melick [58], investigating differences in parental report of rejecting behavior and psychological control in mothers and fathers of non-anxious children, found that fathers rated themselves as more psychologically controlling

The recent study of Teetsel et al. [59] revealed that anxious fathers reported higher control compared to anxious mothers; and anxious mothers reported higher use of punishment and reinforcement of children's dependence in anxiety provoking situations compared to fathers.

our comprehension of the full picture.

90 Parenting - Empirical Advances and Intervention Resources

contributions to the family environment.

controlling during the task compared to mothers.

and rejecting than mothers.

The study by Milevsky et al. [60], conducted on a sample of adolescents, aimed at investigating the effect of parenting on self-esteem, life-satisfaction, and depression in adolescence. The authors found that, although the advantage of authoritative mothering over permissive mothering is evident for each assessed outcome, such an advantage is less defined for fathers and only evident for depression.

Interestingly, the findings of the study conducted by McKinney and Renk [61] suggest that different combinations of maternal and paternal parenting (e.g. a permissive father with an authoritarian mother) are related to late adolescents' emotional adjustment. Specifically, late adolescents having at least one authoritative parent would show better adjustment.

### **4. The role of cognitive and metacognitive factors in the relationship between parenting and symptoms**

Although a relationship between parental style and psychopathology in childhood has been established, few studies have explored in deep this relationship also considering possible link factors. Some studies proposed cognitive and metacognitive factors as possible pathways of the relation between parenting and childhood symptoms.

McGinn et al. [62], exploring the aforementioned variables, did not find a relationship between care or control from parents and anxiety in children. On the other hand, they found that negative cognitive schema mediated the relationship between abusive or neglectful parenting and depression [62].

Gallagher and Cartwright-Hatton [63] reported that a punitive, harsh, or inconsistent discipline is associated with trait anxiety. This parental discipline style was associated with both cognitive distortions and metacognition, which in turn partially mediate the relationship between parenting and anxiety. Moreover, children of over-reactive parents showed more dysfunctional beliefs about worry.

Another study, conducted on young adults (aged 18–23 years), found that intolerance of uncertainty mediated the relation between perceived anxious rearing behaviors and anxiety and worry [64].

A recent study by Nanda et al. [65] showed that parental psychological control was a predictor of child anxiety symptoms. Furthermore, the relationship between parental psychological control and anxiety is mediated by cognitions regarding perceived control.

Other authors have suggested that controlling parents prevent their children from developing independence, which in turn may contribute to feelings of helplessness or uncontrollability which are associated with symptoms of anxiety [66–68].

#### **5. Parental involvement in cognitive behavior therapy for internalizing symptoms**

Cognitive behavior therapy (CBT) has been found to be efficient for the treatment of anxiety disorders in children and youth [69–72]. Literature showed that CBT reaches an efficacy with an average of 60% remission at post-treatment [73].

In order to improve the efficacy of the treatment, a parental involvement has been considered. Principal aims for parental involvement are: removal of parental reinforcement of anxious child behavior, teaching anxiety management skills to parents, and reduction of family conflicts [74]. Specific components of protocols are: Psychoeducation, Parenting Training, Parental Modeling of Coping, Contingency Management, Cognitive Restructuring, Parental Anxiety Management, Collaborative Problem Solving, Communication skills, and Relapse Prevention [75].

Reviews [74, 76, 77] and meta-analyses [73, 78–80] have suggested that family-based CBT is efficient for the treatment of childhood anxiety; on the other hand, there are no differences in the outcomes among individual, group, or family-based treatment [75].

Studies comparing CBT treatments with parental involvement and control conditions (e.g. waiting list), showed a higher effect of the first condition, even if inconsistent findings derive from studies comparing parent-involved CBT and child-focused CBT [75]. Barrett et al. [81] and Wood et al. [82] (2006) showed that both family anxiety management (in addition to child-focused CBT) and family CBT produced greater efficacy than child-focused CBT alone. Other studies did not find differences between parent-involved CBT and child-focused CBT [69, 83, 84].

Although existing results are variegated, the efficacy of the treatment seems to be affected by children's age and gender, and presence versus absence of parental anxiety [85]. Some studies highlighted a positive effect of involving parents in the treatment when children are young [81, 86] or male [87], and when a parent has an anxiety disorder [85, 86]. Other studies did not find these results or found that parental involvement was less effective when parents suffered from anxiety disorders [83].

#### **6. Conclusions**

The purpose of this chapter was to integrate theoretical and empirical knowledge regarding the association between parenting and childhood internalizing problems. A strong body of evidence supports the relationship between these two constructs. Meta-analytic analyses, in particular, revealed that parental control is more strongly associated with child anxiety than parental rejection and that various sub-dimensions of parenting are differentially associated with childhood depression, especially parental hostility toward the child.

Although the literature on the topic suggests there may be a role of parenting in the development of internalizing disorders, many questions about the direction and mechanisms underlying the link also stay on [88]. For example, few studies have explored the role of temperament in children's reactivity to different types of parenting or in influencing the type of parenting. Additionally, more studies are needed on the role of shared genetic factors in the association between parenting, parents and child personality/temperament, and risk for anxiety pathology [30].

Moreover, the great majority of studies include a single parent, who is almost always the mother. Thus, it is hard to generalize results to the caregivers in general, or understand if they are specific to parents of a particular sex or in a particular childcare role. More studies exploring differences in parenting styles and child-rearing outcomes in different cultures, ethnicities, and socioeconomic status are necessary to extend the results to diverse populations.

As reported by McLeod et al. [25, 26], a very modest association between parenting and child internalizing symptoms exists. This could derive from the fact that many studies focused on the role of single factors in association with anxiety and depression. Future researches should therefore investigate interactional mechanisms between parenting and a range of other variables, including biological vulnerability and life events/lifestyle factors [89] in order to fully understand this complex relationship.

Based on the literature, it is clear that a shared genetic risk factor contributes to a general vulnerability for anxiety, and that unique individual characteristics and environmental experiences may mediate the specific expression of this vulnerability. In addition, parenting characteristics such as modeling of negative responding, as well as moderating the effects of how children experience aversive events or fears when having a direct experience, observing others, or receiving fear relevant information from adults, can reinforce information-processing bias in children.

Although parenting *per se* may not be the strongest predictor of internalizing disorders, identifying children who present a combination of vulnerability factors (e.g. problematic parenting and difficult temperament) may address the development of timely interventions. In addition, tailoring interventions focused on parenting behaviors associated with childhood depression and anxiety, may represent an important goal for future research in order to improve clinical care of children affected by internalizing disorders and to prevent the full-blown manifestation of such conditions.

### **Author details**

**5. Parental involvement in cognitive behavior therapy for**

Cognitive behavior therapy (CBT) has been found to be efficient for the treatment of anxiety disorders in children and youth [69–72]. Literature showed that CBT reaches an efficacy with

In order to improve the efficacy of the treatment, a parental involvement has been considered. Principal aims for parental involvement are: removal of parental reinforcement of anxious child behavior, teaching anxiety management skills to parents, and reduction of family conflicts [74]. Specific components of protocols are: Psychoeducation, Parenting Training, Parental Modeling of Coping, Contingency Management, Cognitive Restructuring, Parental Anxiety Management,

Reviews [74, 76, 77] and meta-analyses [73, 78–80] have suggested that family-based CBT is efficient for the treatment of childhood anxiety; on the other hand, there are no differences in

Studies comparing CBT treatments with parental involvement and control conditions (e.g. waiting list), showed a higher effect of the first condition, even if inconsistent findings derive from studies comparing parent-involved CBT and child-focused CBT [75]. Barrett et al. [81] and Wood et al. [82] (2006) showed that both family anxiety management (in addition to child-focused CBT) and family CBT produced greater efficacy than child-focused CBT alone. Other studies did

Although existing results are variegated, the efficacy of the treatment seems to be affected by children's age and gender, and presence versus absence of parental anxiety [85]. Some studies highlighted a positive effect of involving parents in the treatment when children are young [81, 86] or male [87], and when a parent has an anxiety disorder [85, 86]. Other studies did not find these results or found that parental involvement was less effective when parents suffered

The purpose of this chapter was to integrate theoretical and empirical knowledge regarding the association between parenting and childhood internalizing problems. A strong body of evidence supports the relationship between these two constructs. Meta-analytic analyses, in particular, revealed that parental control is more strongly associated with child anxiety than parental rejection and that various sub-dimensions of parenting are differentially associated

Although the literature on the topic suggests there may be a role of parenting in the development of internalizing disorders, many questions about the direction and mechanisms underlying the link also stay on [88]. For example, few studies have explored the role of temperament

with childhood depression, especially parental hostility toward the child.

Collaborative Problem Solving, Communication skills, and Relapse Prevention [75].

not find differences between parent-involved CBT and child-focused CBT [69, 83, 84].

the outcomes among individual, group, or family-based treatment [75].

**internalizing symptoms**

92 Parenting - Empirical Advances and Intervention Resources

from anxiety disorders [83].

**6. Conclusions**

an average of 60% remission at post-treatment [73].

Simona Scaini1 \*, Sara Palmieri1,2 and Marcella Caputi3

\*Address all correspondence to<EMAIL_ADDRESS>

#### **References**

[14] Rapee RM. The development of generalized anxiety. In: Vasey MW, Dadds MR, editors. The Developmental Psychopathology of Anxiety. London: Oxford University Press; 2001, 2001. pp. 481-503

**References**

chc.2012.05.001

94 Parenting - Empirical Advances and Intervention Resources

[1] Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, et al. Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry. 2010;**49**(10):980-989. DOI: 10.1016/j.jaac.2010.05.017 [2] Beesdo-Baum K, Knappe S. Developmental epidemiology of anxiety disorders. Child and Adolescent Psychiatric Clinics 2012;**21**(3):457-478. DOI: http://dx.doi.org/10.1016/j.

[3] Ramsawh HJ, Chavira DA, Stein MB. Burden of anxiety disorders in pediatric medical settings: Prevalence, phenomenology, and a research agenda. Archives of Pediatrics &

Adolescent Medicine. 2010;**164**(10):965-972. DOI: 10.1001/archpediatrics.2010.170

Psychiatry. 1998;**55**(1):56-64. DOI: 10.1001/archpsyc.55.1.56

Psychology. 2001;**69**(1):135. DOI: 10.1037/0022-006X.69.1.135

1183. DOI: 10.1111/j.1469-7610.2007.01812.x

Oxford University Press; 2001

10.1111/j.1467-8624.1989.tb04014.x

[4] Pine DS, Cohen P, Gurley D, Brook J, Ma Y. The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Archives of General

[5] Bittner A, Egger HL, Erkanli A, Jane Costello E, Foley DL, Angold A. What do childhood anxiety disorders predict? Journal of Child Psychology and Psychiatry. 2007;**48**(12):1174-

[6] Bolton JM, Cox BJ, Afifi TO, Enns MW, Bienvenu OJ, Sareen J. Anxiety disorders and risk for suicide attempts: Findings from the Baltimore epidemiologic catchment area follow-

[7] Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive–behavioral treatment of anxiety disorders in children: Long-term (6-year) follow-up. Journal of Consulting and Clinical

[8] Fox NA, Henderson HA, Marshall PJ, Nichols KE, Ghera MM. Behavioral inhibition: Linking biology and behavior within a developmental framework. Annual Review of

[9] Vasey MW, Dadds MR, editors. The Developmental Psychopathology of Anxiety. Oxford:

[10] Garber J, Flynn C. Predictors of depressive cognitions in young adolescents. Cognitive

[11] Kaslow NJ, Deering CG, Racusin GR. Depressed children and their families. Clinical

[12] Steinberg L, Elmer JD, Mounts NS. Authoritative parenting, psychosocial maturity, and academic success among adolescents. Child Development. 1989;**60**:1424-1436. DOI:

[13] Barber BK. Parental psychological control: Revisiting a neglected construct. Child

up study. Depression and Anxiety. 2008;**25**(6):477-481. DOI: 10.1002/da.20314

Psychology. 2005;**56**:235-262. DOI: 10.1146/annurev.psych.55.090902.141532

Therapy and Research. 2001;**25**(4):353-376. DOI: 10.1023/A:1005530402239

Psychology Review. 1994;**14**(1):39-59. DOI: 10.1016/0272-7358(94)90047-7

Development. 1996;**67**(6):3296-3319. DOI: 10.1111/1467-8624.ep9706244861

[41] Achenbach TM. Integrative Guide for the 1991 CBCL/4±18, YSR, and TRF Profiles. Burlington: University of Vermont, Department of Psychiatry; 1991

[27] Creswell C, Murray L, Stacey J, Cooper P. Parenting and child anxiety. In: Silverman WK, Field AP, editors. Cambridge: Cambridge University Press; 2011. pp. 299-322

[28] Eley TC, Napolitano M, Lau JY, Gregory AM. Does childhood anxiety evoke maternal control? A genetically informed study. Journal of Child Psychology and Psychiatry.

[29] Barlow DH. Anxiety and its Disorders: The Nature and Treatment of Anxiety and Panic.

[30] Wood JJ, McLeod BD, Sigman M, Hwang WC, Chu BC. Parenting and childhood anxiety: Theory, empirical findings, and future directions. Journal of Child Psychology and Psy-

[31] Chavira DA, Stein MB. Childhood social anxiety disorder: From understanding to treatment. Child and Adolescent Psychiatric Clinics of North America. 2005;**14**:797-818. DOI:

[32] Hudson JL, Rapee RM. The origins of social phobia. Behavior Modification. 2000;**24**:102-

[33] Hidalgo RB, Barnett SD, Davidson JRT. Social anxiety disorder in review: Two decades of progress. International Journal of Neuropsychopharmacology. 2001;**4**:279-298. DOI:

[34] Manassis K, Hudson JL, Webb A, Albano AM. Beyond behavioral inhibition: Etiological factors in childhood anxiety. Cognitive and Behavioral Practice. 2005;**11**:3-12. DOI: 10.1016/

[35] Merikangas KR. Vulnerability factors for anxiety disorders in children and adolescents. Child and Adolescent Psychiatric Clinics of North America. 2005;**14**:649-679. DOI:

[36] Muris P. Freud Was right…about the origins of abnormal behavior. Journal of Child and

[37] Ollendick TH, Hirshfeld-Becker DR. The developmental psychopathology of social anxiety disorder. Biological Psychiatry. 2002;**51**:44-58. DOI: 10.1016/S0006-3223(01)01305-1

[38] Rapee RM, Spence SH. The etiology of social phobia: Empirical evidence and an initial model. Clinical Psychology Review. 2004;**24**:737-767. DOI: 10.1016/j.cpr.2004.06.004

[39] van Brakel AML, Muris P, Bögels SM, Thomassen C. A multifactorial model for the aetiology of anxiety in non clinical adolescents: Main and interactive effects of behavioural inhibition, attachment, and parental rearing. Journal of Child and Family Studies

[40] Pinquart M.Associations of parenting dimensions and styles with internalizing symptoms in children and adolescents: A meta-analysis. Marriage & Family Review. 2017;**53**:613-

Family Studies. 2006;**15**:1-12. DOI: 10.1007/s10826-005-9006-9

2006;**15**:569-579. DOI: 10.1007/s10826-006-9061-x

640. DOI: 10.1080/01494929.2016.1247761

2010;**51**(7):772-779. DOI: 10.1111/j.1469-7610.2010.02227.x

chiatry. 2003;**44**(1):134-151. DOI: 10.1111/1469-7610.00106

New York: Guilford press; 2004

96 Parenting - Empirical Advances and Intervention Resources

10.1016/j.chc.2005.05.003

10.1017/S1461145701002504

S1077-7229(04)80003-8

10.1016/j.chc.2005.06.005

129. DOI: 10.1177/0145445500241006

[67] Rubin KH, Mills RS. Conceptualizing developmental pathways to internalizing disorders in childhood. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement. 1991;**23**(3):300-317. DOI: 10.1037/h0079019

[55] Greco LA, Morris TL. Paternal child-rearing style and child social anxiety: Investigation of child perceptions and actual father behavior. Journal of Psychopathology and Behavioral

[56] Hudson JL, Rapee RM. Parent-child interactions in clinically anxious children and their siblings. Journal of Clinical Child and Adolescent Psychology. 2002;**31**(4):548-555. DOI:

[57] Rork KE, Morris TL. Influence of parenting factors on childhood social anxiety: Direct observation of parental warmth and control. Child and Family Behavior Therapy.

[58] Bögels, S. M., van Melick, M. The relationship between child-report, parent self-report, and partner report of perceived parental rearing behaviors and anxiety in children and parents. Personality and Individual Differences 2004;**37**(8):1583-1596. DOI: 10.1016/j.paid.

[59] Teetsel RN, Ginsburg GS, Drake KL. Anxiety-promoting parenting behaviors: A comparison of anxious mothers and fathers. Child Psychiatry and Human Development.

[60] Milevsky A, Schlechter M, Netter S, Keehn D. Maternal and paternal parenting styles in adolescents: Associations with self-esteem, depression and life-satisfaction. Journal of

[61] McKinney C, Renk K. Differential parenting between mothers and fathers: Implications for late adolescents. Journal of Family Issues. 2008;**29**(6):806-827. DOI: 10.1177/0192513

[62] McGinn LK, Cukor D, Sanderson WC. The relationship between parenting style, cognitive style, and anxiety and depression: Does increased early adversity influence symptom severity through the mediating role of cognitive style? Cognitive Therapy and

[63] Gallagher B, Cartwright-Hatton S. The relationship between parenting factors and trait anxiety: Mediating role of cognitive errors and metacognition. Journal of Anxiety

[64] Zlomke KR, Young JN. A retrospective examination of the role of parental anxious rearing Behaviors in contributing to intolerance of uncertainty. Journal of Child and Family

[65] Nanda MM, Kotchick BA, Grover RL. Parental psychological control and childhood anxiety: The mediating role of perceived lack of control. Journal of Child and Family Studies.

[66] Chorpita BF, Barlow DH. The development of anxiety: The role of control in the early environment. Psychological Bulletin. 1998;**124**(1):3-21. DOI: 10.1037/0033-29<IP_ADDRESS>

Child and Family Studies. 2007;**16**(1):39-47. DOI: 10.1007/s10826-006-9066-5

Research. 2005;**29**(2):219-242. DOI: 10.1007/s10608-005-3166-1

Disorders. 2008;**22**(4):722-733. DOI: 10.1016/j.janxdis.2007.07.006

Studies. 2009;**18**(6):670-679. DOI: 10.1007/s10826-009-9269-7

2012;**21**(4):637-645. DOI: 10.1007/s10826-011-9516-6

Assessment. 2002;**24**(4):259-267. DOI: 10.1023/A:1020779000183

2009;**31**(3):220-235. DOI: 10.1080/07317100903099274

2014;**45**(2):133-142. DOI: 10.1007/s10578-013-0384-8

10.1207/S15374424JCCP3104\_13

98 Parenting - Empirical Advances and Intervention Resources

2004.02.014

X07311222

**Provisional chapter**

#### **Parent Training Interventions for Children and Adolescents with Aggressive Behavioral Problems Parent Training Interventions for Children and Adolescents with Aggressive Behavioral Problems**

DOI: 10.5772/intechopen.73541

Pietro Muratori, Valentina Levantini, Azzurra Manfredi, Laura Ruglioni and Furio Lambruschi Azzurra Manfredi, Laura Ruglioni and Furio Lambruschi Additional information is available at the end of the chapter

Pietro Muratori, Valentina Levantini,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.73541

#### **Abstract**

[79] Ishikawa S, Okajima I, Matsuoka H, Sakano Y. Cognitive behavioural therapy for anxiety disorders in children and adolescents: A meta-analysis. Child and Adolescent Mental

[80] Scaini S, Belotti R, Ogliari A, Battaglia M. A comprehensive meta-analysis of cognitivebehavioral interventions for social anxiety disorder in children and adolescents. Journal

[81] Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology. 1996;**64**(2):333-342. DOI: 10.1037//

[82] Wood JJ, Piacentini JC, Southam-Gerow M, Chu BC, Sigman M. Family cognitive Behavioral therapy for child anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry. 2006;**45**(3):314-321. DOI: 10.1097/01.chi.0000196425.88341.b0

[83] Bodden DHM, Bögels SM, Nauta MH, De Haan E, Ringrose J, Appelboom C, et al. Child versus family cognitive-Behavioral therapy in clinically anxious youth: An efficacy and partial effectiveness study. Journal of the American Academy of Child and Adolescent

[84] Waters AM, Ford LA, Wharton TA, Cobham VE. Cognitive-behavioural therapy for young children with anxiety disorders: Comparison of a child + parent condition versus a parent only condition. Behaviour Research and Therapy. 2009;**47**(8):654-662. DOI:

[85] Simon E, Dirksen C, Bögels S, Bodden D. Cost-effectiveness of child-focused and parent-focused interventions in a child anxiety prevention program. Journal of Anxiety

[86] Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the treatment of childhood anxiety. Journal of Consulting and Clinical Psychology. 1998;**66**(6):893-905.

[87] van der Bruggen CO, Bögels SM, van Zeilst N.What influences parental controlling behaviour? The role of parent and child trait anxiety. Cognition & Emotion 2010;**24**(1):141-149.

[88] Silverman WK, Kurtines WM, Jaccard J, Pina AA. Directionality of change in youth anxiety treatment involving parents: An initial examination. Journal of Consulting and

[89] Murray L, Creswell C, Cooper PJ. The development of anxiety disorders in childhood: An integrative review. Psychological Medicine. 2009;**39**(9):1413-1423. DOI: 10.1017/S0033

Psychiatry. 2008;**47**(12):1384-1394. DOI: 10.1097/CHI.0b013e318189148e

Disorders. 2012;**26**(2):287-296. DOI: 10.1016/j.janxdis.2011.12.008

Clinical Psychology. 2009;**77**(3):474. DOI: 10.1037/a0015761

Health. 2007;**12**(4):164-172. DOI: 10.1111/j.1475-3588.2006.00433.x

0022-006X.64.2.333

100 Parenting - Empirical Advances and Intervention Resources

10.1016/j.brat.2009.04.008

DOI: 10.1037//0022-006X.66.6.893

DOI: 10.1080/02699930

291709005157

of Anxiety Disorders. 2016;**42**:105-112. DOI: 10.1016/j.janxdis.2016.05.008

Children who display early disruptive and aggressive behavior are also at greater risk for delinquency, mood and anxiety disorders, and substance use in the long term. As is the case for many forms of childhood psychopathology, a number of factors are associated with the emergence of aggressive and disruptive behavior, including family factors. Indeed, conduct problems during childhood are usually associated with peculiar parenting practices, such as increasingly coercive cycles of harsh parenting and noncompliance exhibited by child; insensitive and nonresponsive parenting; inconsistent, severe discipline and vague commands and directions; lack of parental warmth and involvement; and absence of parental monitoring and supervision. That is why behavioral parent trainings (BPTs) represent one of the gold standard interventions for conduct problems. The main goal of BPT is to decrease coercive interchanges and, consequently, children aggressive problems by teaching parents strategies in order to apply a more effective discipline. Therefore, the putative mechanism for change in youth behavior in BPT is change in parent behavior. Some of the most employed parent training interventions for aggressive behavior problems are presented.

**Keywords:** child aggressive problems, family contextual factors, parenting practices, treatment, behavioral parent training

#### **1. Introduction**

Children who display early disruptive and aggressive behavior are also at greater risk for delinquency, mood and anxiety disorders, and substance use in the long term. Moreover,

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

longitudinal studies indicated that children with conduct problems initiated in childhood are at heightened risk for exhibiting persistent criminal behavior into adulthood. The presence of neurological deficits, which lead to difficulties managing peer conflicts, regulating emotions, and controlling impulses, and families with longstanding history of antisocial behavior prevents these youth from making important life transitions serving to further entrench them into a criminal lifestyle [1].

As for many forms of childhood psychopathology, a number of factors are associated with the emergence of aggressive and disruptive behavior. A contextual social-cognitive model has been employed to summarize the empirically identified risk factors for conduct problems in children [2, 3]. A set of neurobiological, family, peer, and social risk factors appear to be involved in the etiology of aggressive behavior problems.

There are several prenatal factors that can have an effect on a child's developing brain and result in later conduct problems, including in utero drug and tobacco exposure and severe maternal nutritional deficiencies [4, 5].

Furthermore, child temperaments characterized by a "lack of control" (e.g., short attention span, negativism, restlessness, and emotional lability [6]), high emotional reactivity levels, difficult temperaments in general, and fearful and highly active children [7] are associated with behavior problems. Besides, genetic effects on children's development of conduct problems are primarily manifested in interaction with environmental risk factors, such as child maltreatment, marital problems, and parental substance abuse [8].

The contextual social-cognitive model also focuses on children's sequential cognitive processing and on contextual parenting processes; it assumes that aggressive children have distortions in their social-cognitive appraisals and deficiencies in their social problem-solving skills and that their parents have deficiencies in their parenting behaviors.

Aggressive children have cognitive distortions and deficiencies at two stages: appraisal and problem solution. Firstly, children have difficulty encoding incoming social information and in accurately interpreting social events and others intentions. Aggressive children tend to approach social situations with a hostile attribution bias: they assume the intention of others' behavior is provocative and hostile in nature [9]. Furthermore, aggressive children tend to generate maladaptive solutions for perceived problems and have nonnormative expectations for the likelihood of success of aggressive and nonaggressive solutions to their social problems. Specific deficiencies have been noted in the solutions aggressive children offer in social situations: they often generate aggressive strategies because they expect that aggressive behavior will lead to the desired outcome.

Conduct problems have been shown to be influenced by the social context around the child, and the manifestations of the conduct problems directly affect family members, peers, and other persons in the children's social context [10].

### **2. The role of family contextual factors in aggressive behavior problems**

longitudinal studies indicated that children with conduct problems initiated in childhood are at heightened risk for exhibiting persistent criminal behavior into adulthood. The presence of neurological deficits, which lead to difficulties managing peer conflicts, regulating emotions, and controlling impulses, and families with longstanding history of antisocial behavior prevents these youth from making important life transitions serving to further entrench them

As for many forms of childhood psychopathology, a number of factors are associated with the emergence of aggressive and disruptive behavior. A contextual social-cognitive model has been employed to summarize the empirically identified risk factors for conduct problems in children [2, 3]. A set of neurobiological, family, peer, and social risk factors appear to be involved in the

There are several prenatal factors that can have an effect on a child's developing brain and result in later conduct problems, including in utero drug and tobacco exposure and severe

Furthermore, child temperaments characterized by a "lack of control" (e.g., short attention span, negativism, restlessness, and emotional lability [6]), high emotional reactivity levels, difficult temperaments in general, and fearful and highly active children [7] are associated with behavior problems. Besides, genetic effects on children's development of conduct problems are primarily manifested in interaction with environmental risk factors, such as child

The contextual social-cognitive model also focuses on children's sequential cognitive processing and on contextual parenting processes; it assumes that aggressive children have distortions in their social-cognitive appraisals and deficiencies in their social problem-solving skills

Aggressive children have cognitive distortions and deficiencies at two stages: appraisal and problem solution. Firstly, children have difficulty encoding incoming social information and in accurately interpreting social events and others intentions. Aggressive children tend to approach social situations with a hostile attribution bias: they assume the intention of others' behavior is provocative and hostile in nature [9]. Furthermore, aggressive children tend to generate maladaptive solutions for perceived problems and have nonnormative expectations for the likelihood of success of aggressive and nonaggressive solutions to their social problems. Specific deficiencies have been noted in the solutions aggressive children offer in social situations: they often generate aggressive strategies because they expect that aggressive behavior

Conduct problems have been shown to be influenced by the social context around the child, and the manifestations of the conduct problems directly affect family members, peers, and

maltreatment, marital problems, and parental substance abuse [8].

and that their parents have deficiencies in their parenting behaviors.

into a criminal lifestyle [1].

etiology of aggressive behavior problems.

102 Parenting - Empirical Advances and Intervention Resources

maternal nutritional deficiencies [4, 5].

will lead to the desired outcome.

other persons in the children's social context [10].

A wide range of family contextual factors lead to elevated risk of child conduct problems. Conduct problems during childhood are usually associated with characteristic family features. Particularly, they have been linked to poverty [11]; parent criminality; parental psychopathology, such as substance use, paternal antisocial personality disorder, or maternal depression [11]; marital conflict [12]; single and teenage parenthood [13]; stressful life events [11]; as well as insecure attachment in infancy and in preschool age, particularly disorganized attachment and avoidant attachment [14–16]. These familial risk factors can exert an effect on parenting practices, which in turn can exert an effect on child behavior.

The presence of parental psychopathology influences how parents perceive their child behavior and their educational practices. For example, mothers who suffer from depression see their child behavior as more upsetting during the worst period of depression [17]. Higher levels of maternal depression also predict caregivers' use of inconsistent discipline, and the use of inconsistent discipline predicts aggressive behavior in children [18]. Studies demonstrated that maternal psychopathology is associated to a change of the perception of child behavior that is interpreted as deliberate and malevolent, and this could lead to the greater use of harsh discipline, which aggravate children behavioral problems.

Disruptive and aggressive behavior problems are associated with peculiar parenting practices. Parenting practices that have been associated with conduct problems in childhood include, as described by Patterson [19], increasingly coercive cycles of harsh parenting and noncompliance exhibited by child, beginning in the preschool/toddler years, particularly for children who display challenging and difficult temperament styles. It is common in insensitive and nonresponsive parenting at age 1, with reliability and pacing of parental reactions not adequately meeting the child's needs. Inconsistently, severe discipline, as well as confusing or vague commands and directions, also characterizes parenting practices. Distinct lack of parental warmth and involvement and absence of parental monitoring and supervision represent risk factors for aggressive problems especially as children mature into adolescence [20]. Besides, the associations between child conduct problems and parenting factors are bidirectional, as the behavior and temperament displayed by the child can also affect the behavior the parent adopts [21]. For example, Patterson's coercion model suggests that both parent and child are active participants in their interactions [22], and the model proposes a four-step process of escape conditioning [23].  Then, the child responds to the parent's request with an aversive behavior. Step 3 is the stage where the negative parent-child interaction can occur: if the parent stops the request, the child has escaped from the parent's request. Lastly, the child withdraws their aversive behavior almost immediately after the parent terminates their request, thus reinforcing the parent's withdrawal of the request.

Several studies point out that affective quality of parenting affects the quality of development on a prosocial, moral, and educational level [24, 25].

In an interesting recent longitudinal study [26], the development of aggressive behavior at the age of 8 was predicted by the appearance of similar early manifestations during early childhood, and this relationship was clearly mediated by the ways in which the mother tried to modulate and handle this child's behavior since its onset, at around 2 years of life. In the insecure dyads, the mother tended to assert her power and control through coercive educative methods in order to manage the child's disruptive behavior. In the secure dyads, instead, in the face of similar dysregulated behavior of the child, the mother activated responsive behaviors, without the need to take control of them or to assert her power in a coercive way.

The ability to give rules, structures, and boundaries, linked to a good affective sensitivity and responsiveness (sensitive discipline), is the focal component of parenting: connected to each other, they contribute to the development of a harmonious self-organization of the child, interacting with his temperament and his basic resources. As confirmed by several studies [27, 28], the individual and environmental factors interact with each other, and the context in which the child grows can act as a detonator or as a protective factor against possible neurobiological vulnerabilities. A "difficult" temperament does not necessarily negatively affect the quality of development, but acts in interaction with the environment by increasing child's permeability to the influences of his context [29].

The task of developmental clinic psychology, with the strict contribution of the research, is intervening to reduce these possible escalations, in the interaction between the neurobiological vulnerability of the child and the parent's mental state, with appropriate programs of proven effectiveness.

#### **3. Behavioral parent training**

Parent training programs, which represent one form of parental intervention, are based on the premise that parenting practices contribute to the genesis, progression, and maintenance of both externalizing and internalizing problems. Competencies related to the self-regulation of emotion, cognition, and goal-directed behavior are shaped through repeated transactions between children's biological characteristics and the social contexts in which they develop [30], especially the parent-child relationship. It is thought that parenting practices control variables for child behavior patterns and may serve to potentiate the expression of biological vulnerabilities and in doing so enhance risk that is carried forward across the life span [31].

From a theoretical perspective, BPT descends from the social interactional model, which was proposed by Patterson and his colleagues to explain how parents can shape externalizing problems of their children and adolescents [32].

As highlighted by Kaminski and colleagues in a review [33], BPTs often share a range of common contents. They usually focus on child development knowledge and care, in order to give parents information about how to provide appropriate physical care and environment and information about typical child behavior and development. Another crucial component concerns the importance of positive and non-disciplinary interaction with children: parents are taught to use adequate strategies to promote positive parent-child interactions, such as demonstrating enthusiasm, following child's interest, and providing appropriate attention. During BPTs, parents also learn how to respond sensitively to child's emotional and psychological need and to provide developmentally appropriate physical contact and affection; emotional communication is an important component too: parents are trained to use communication skills (e.g., active listening), to help children identify and express emotions. Parent training interventions largely focus on disciplinary communication and behavior management: so, parents learn to give clear and developmentally appropriate directions, to set limits and rules, and to state behavioral expectations and consequences; they are also taught to use adequate discipline strategies, monitoring and supervision practices, specific reinforcement, and punishment techniques. Parents should be trained to teach children to share and cooperate, use good manners, and get along with parents, siblings, and adults. Finally, BPTs focus on promoting children's cognitive and academic skills.

Several studies point out that affective quality of parenting affects the quality of development

In an interesting recent longitudinal study [26], the development of aggressive behavior at the age of 8 was predicted by the appearance of similar early manifestations during early childhood, and this relationship was clearly mediated by the ways in which the mother tried to modulate and handle this child's behavior since its onset, at around 2 years of life. In the insecure dyads, the mother tended to assert her power and control through coercive educative methods in order to manage the child's disruptive behavior. In the secure dyads, instead, in the face of similar dysregulated behavior of the child, the mother activated responsive behaviors, without the need to take control of them or to assert her power in a coercive way. The ability to give rules, structures, and boundaries, linked to a good affective sensitivity and responsiveness (sensitive discipline), is the focal component of parenting: connected to each other, they contribute to the development of a harmonious self-organization of the child, interacting with his temperament and his basic resources. As confirmed by several studies [27, 28], the individual and environmental factors interact with each other, and the context in which the child grows can act as a detonator or as a protective factor against possible neurobiological vulnerabilities. A "difficult" temperament does not necessarily negatively affect the quality of development, but acts in interaction with the environment by increasing child's

The task of developmental clinic psychology, with the strict contribution of the research, is intervening to reduce these possible escalations, in the interaction between the neurobiological vulnerability of the child and the parent's mental state, with appropriate programs of proven

Parent training programs, which represent one form of parental intervention, are based on the premise that parenting practices contribute to the genesis, progression, and maintenance of both externalizing and internalizing problems. Competencies related to the self-regulation of emotion, cognition, and goal-directed behavior are shaped through repeated transactions between children's biological characteristics and the social contexts in which they develop [30], especially the parent-child relationship. It is thought that parenting practices control variables for child behavior patterns and may serve to potentiate the expression of biological vulnerabilities and in doing so enhance risk that is carried forward across the life span [31].

From a theoretical perspective, BPT descends from the social interactional model, which was proposed by Patterson and his colleagues to explain how parents can shape externalizing

As highlighted by Kaminski and colleagues in a review [33], BPTs often share a range of common contents. They usually focus on child development knowledge and care, in order to give parents information about how to provide appropriate physical care and environment and

on a prosocial, moral, and educational level [24, 25].

104 Parenting - Empirical Advances and Intervention Resources

permeability to the influences of his context [29].

problems of their children and adolescents [32].

**3. Behavioral parent training**

effectiveness.

Behavioral parent trainings are usually group interventions. The group setting allowed parents not to feel alone, blamed, criticized, or judged; they feel accepted and supported, which enable them to reflect upon their parenting approaches and to be open to new parenting practices. The group offers behavioral strategies and provides a collaborative, supportive context within which parents can express themselves and change. The group process promotes the parents' ability to reflect on their histories and on their particular parenting styles. It invited them to disclose their thoughts, feelings, and behaviors about parenting and examine those of their children as they discussed various aspects of their parenting and of their parent-child relationships [34].

Therapeutic alliance is crucial for successful parent training interventions, and group's leader behavior plays a key role. Indeed, leader's positive behaviors predicted change in parent's positive behaviors toward children [35]. Specifically, leader praise and reflective behaviors are demonstrated as important categories because of their impact on the very same parent behaviors. The level of leader praise significantly predicts change in the parental use of praise: the more praise modeled by the leader to parents in the group, the more likely parents use praise with their children at home [36]. Especially when parents are sharing their experiences, the group leader should highlight and praise parents' improvements, even if they are small, in order to create a supportive context and let parents be able to express themselves.

#### **4. Parent training interventions for disruptive and aggressive behavior problems**

Behavioral parent training (BPT) has been studied with rigorous research designs and is recognized as the leading intervention strategy for disruptive and aggressive behaviors (for a review see [37]). Some of the most employed parent training interventions for aggressive behavior problems are presented below.

#### **4.1. Coping Power Program**

The Coping Power (CP) Program is a multicomponent treatment program, delivered in a group setting, and was developed using a contextual social-cognitive model as a conceptual framework for identifying intervention objectives [3]. The contextual social-cognitive model focuses on the contextual parenting practices and on children's sequential cognitive processing in the development and rise of children's behavioral problems. The CP Program includes a CP-child component, which consists in 36 group sessions and 16 parents' sessions, both delivered over 12 months. Parents are met in groups of five families; typically, only one parent per family joins the groups. The child and his/her parent received the treatment on the same day.

Researches on risk factors within the contextual social-cognitive model have led to the development of specific modules within the CP Program, with a structured manual. The CP-child component focuses on children's ability to pursue long-term and short-term goals and their academic and study abilities. Children learn to recognize the emotions and their physiological and cognitive features, mainly anger, and to manage anger arousal (using selfstatements, distractions, and relaxation). Children also improve their perspective talking skills, attribution retraining, and social problem-solving skills. Finally, children are couched to use strategies in order to cope with peer pressure and make new friend, avoiding deviant peer groups.

The CP-parent component aims to increase positive parental attention and reward appropriate child behaviors. Parents learn to ignore minor disruptive behaviors, to give effective instructions, and to establish adequate rules and expectations for their children at home. Parents are also taught to use efficient consequences to negative child behaviors. The CP Program aims to empower family communication and reduce parental stress. Specifically, parents are taught principles of social learning theory and a description of how continuous exposure to negative social information maintains unhelpful emotion and negative behavior patterns. Instruction is provided as to cognitive approaches to track and alter dysfunctional thoughts that contribute to negative parenting patterns and to functional thoughts that may contribute to alternative positive parenting approaches to emotion regulation. Moreover, parents are instructed on skills to effectively ignore minor disruptive behavior, give effective instructions, and establish rules and expectations; they are instructed on approaches to punishment that facilitate appropriate social and emotional development. Information and rationale to devalue physical punishment are provided and discussed. Parents learn strategies to implement time-out, privilege removal, work chores, and "total reward shutdown" for negative child behavior. Finally, parents of children with aggressive/disruptive behavior experience high degrees of stress and disproportionate life challenges. The development of effective strategies to manage stress and cope with life challenges provide a "base" from which parenting strategies can be developed. In these sessions parents are taught strategies to regulate their emotions, ways to relax, and approaches to organize their time.

Numerous studies demonstrated the efficacy of the Coping Power Program in reducing disruptive and aggressive behaviors in children and that this reduction is maintained at followup evaluations [38–40].

#### **4.2. Incredible years**

**4.1. Coping Power Program**

106 Parenting - Empirical Advances and Intervention Resources

same day.

peer groups.

relax, and approaches to organize their time.

up evaluations [38–40].

The Coping Power (CP) Program is a multicomponent treatment program, delivered in a group setting, and was developed using a contextual social-cognitive model as a conceptual framework for identifying intervention objectives [3]. The contextual social-cognitive model focuses on the contextual parenting practices and on children's sequential cognitive processing in the development and rise of children's behavioral problems. The CP Program includes a CP-child component, which consists in 36 group sessions and 16 parents' sessions, both delivered over 12 months. Parents are met in groups of five families; typically, only one parent per family joins the groups. The child and his/her parent received the treatment on the

Researches on risk factors within the contextual social-cognitive model have led to the development of specific modules within the CP Program, with a structured manual. The CP-child component focuses on children's ability to pursue long-term and short-term goals and their academic and study abilities. Children learn to recognize the emotions and their physiological and cognitive features, mainly anger, and to manage anger arousal (using selfstatements, distractions, and relaxation). Children also improve their perspective talking skills, attribution retraining, and social problem-solving skills. Finally, children are couched to use strategies in order to cope with peer pressure and make new friend, avoiding deviant

The CP-parent component aims to increase positive parental attention and reward appropriate child behaviors. Parents learn to ignore minor disruptive behaviors, to give effective instructions, and to establish adequate rules and expectations for their children at home. Parents are also taught to use efficient consequences to negative child behaviors. The CP Program aims to empower family communication and reduce parental stress. Specifically, parents are taught principles of social learning theory and a description of how continuous exposure to negative social information maintains unhelpful emotion and negative behavior patterns. Instruction is provided as to cognitive approaches to track and alter dysfunctional thoughts that contribute to negative parenting patterns and to functional thoughts that may contribute to alternative positive parenting approaches to emotion regulation. Moreover, parents are instructed on skills to effectively ignore minor disruptive behavior, give effective instructions, and establish rules and expectations; they are instructed on approaches to punishment that facilitate appropriate social and emotional development. Information and rationale to devalue physical punishment are provided and discussed. Parents learn strategies to implement time-out, privilege removal, work chores, and "total reward shutdown" for negative child behavior. Finally, parents of children with aggressive/disruptive behavior experience high degrees of stress and disproportionate life challenges. The development of effective strategies to manage stress and cope with life challenges provide a "base" from which parenting strategies can be developed. In these sessions parents are taught strategies to regulate their emotions, ways to

Numerous studies demonstrated the efficacy of the Coping Power Program in reducing disruptive and aggressive behaviors in children and that this reduction is maintained at followThe Incredible Years (IY; [41, 42]) includes three different but linked evidence-based programs: the parents, the teachers, and the children's series. Their goal is the promotion of social and emotional skills, as well as the prevention and treatment of conduct problems.

The IY BASIC Parent Programs [43] are addressed for parents of children of different ages, from babies (6 weeks–1 year) to school-age (6–12 years). All these programs include ageappropriate examples of culturally diverse families and children with different temperamental features. The IY BASIC Parent Programs train parents in child-directed play skills, praise, and rewards, limit setting, and how to handle misbehavior. Parents are trained to increase the use of positive and consistent strategies in order to strengthen children's prosocial behaviors and social skills. These programs are offered weekly for 9–20 sessions to groups of 8–12 parents; they emphasize developmentally age-appropriate parenting skills that help children accomplish key developmental milestones. The main goals of the programs include the promotion of parent skills and the empowerment of family's relationship by increasing positive parenting, parent-child attachment, and confidence about nurturing; parents also learn to use child-directed play interactions to increase children's social-emotional, academic, verbal, and persistence skills. The program proposes to reduce harsh and physically violent discipline and increase positive discipline strategies such as ignoring and redirecting, logical consequences, time-out, and problem-solving. The IY BASIC Parent Programs highlight the importance of increasing family assistance systems, as well as the empowerment of home-school alliance and parents' participation in school-related activities.

Furthermore, there are two additional parenting programs addressed for specific populations [44]. The ADVANCE parenting program delivered after conclusion of the BASIC preschool or school-age programs was developed for particular high-risk and designated populations and focuses on parents' interpersonal risk factors. The School Readiness Program for children aging 3–5 years is a brief prevention program designed to teach parent's academic, social, and emotional coaching and strategies to help children develop preliteracy competencies.

The efficacy of the IY BASIC Parent Programs for children with aggressive behavior problems has been demonstrated in a large number of studies [45, 46]. Other studies [47] also indicated the additive benefits of the ADVANCE parenting program on children's prosocial solution generation and parents' marital interactions. Several studies have also shown that IY treatment effects are durable 1–3 years posttreatment [48].

#### **4.3. Triple P: Positive Parent Program**